Background :Pain after the excision of orthopaedic-oncologic lesions is intense, and its suppression requires special measures. Multimodal analgesia, the currently preferred methodology, consists of two or more drugs administered concurrently, an approach which induces better postoperative analgesia than if administered singly. Pregabalin is an analgesia adjuvant that is administered perioperatively. Its pre- versus post-incisional pharmacological capabilities have never been compared in orthopaedic-oncologic patients. Objectives :To assess postoperative analgesic requirements and numerical pain scoresof pre- vs . post-surgically administered pregabalin in patients undergoing bone tumour resection, and the levels of pre-surgery anxiety and quality of the night’s sleep. Design : Prospective, double-blinded and randomised, comparative and controlled trial. Setting :A single tertiary care, university-affiliated, medical centre. Patients :One-hundred patients allocated into two study groups. Interventions : Fifty patients received 150 mg pregabalin twice before surgery and placebo after surgery (the PRE group), and 50 received placebo before surgery and pregabalin after it (the POST group) twice daily. Each protocol continued up to 72 h. Main Outcome Measures : The effects of both protocols on pain, on postoperative consumption of analgesics, and the effects of preoperative pregabalin on preoperative anxiety and on night’s sleep. Results : Both groups had similar ASA class, age and weight values. Both protocols resulted in similar patient-rated pain scales during postoperative days 0-3. The total consumption of opioids and non-opioid analgesics was also similar. Preoperatively pregabalin-treated patients were less anxious and slept better the night before surgery compared to placebos. There were no significant adverse events. Conclusions : Two preoperative or six postoperative pregabalin 150 mg doses provided similar control of postoperative pain and usage of opioids/non-steroidal anti-inflammatory drugs in patients undergoing surgery for orthopaedic-oncologic lesions. Each protocol was similarly safe and tolerable. Pre-surgical pregabalin reduced preoperative anxiety and improved preoperative night’s sleep.

The article describes a unique clinical case of multifocal synchronous osteosarcoma patient 10 years old with the defeat of the right femur and humerus identified in a clinic in Israel in 2014. The patient was conducted a combined treatment including arthroplasty. At the time of this writing, the patient is alive without evidence of disease manifestations and can independently move without crutches.

ВВЕДЕНИЕ Остеосаркома — первично злокачественная опухоль костей, которая развивается из примитивных мезенхимальных стволовых клеток, способных дифференцироваться в костную, хрящевую или фиброзную ткани; составляет 3% всех злокачественных опухолей у детей и подростков. Частота встречаемости — 4 случая на 1 млн детского населения в год, что составляет 35–50% всех злокачественных опухолей костей в детском возрасте [1, 2]. DOI: 10.15690/onco.v2.i4.1467 А. Штернхайм , Д. Левин , М. Министерский , А. Ниркин , Дж. Бикелс , С. Дадиа , Е. Коллендер , Е. Гортзак , М.Ю. Рыков, Э.Р. Сенжапова, А.З. Дзампаев, В.Г. Поляков 4 1 Клинический центр педиатрии Дана-Дуэк, Тель-Авив, Израиль 2 Медицинский центр им. Э. Сураски, Тель-Авив, Израиль 3 Российский онкологический научный центр им. Н.Н. Блохина Минздрава России, Москва, Российская Федерация 4 Российская медицинская академия последипломного образования Минздрава России, Москва, Российская Федерация

Background Cryosurgery is a well established modality in the treatment of benign aggressive and low grade malignant tumours. In this setting it allows for intra-lesional resection and preservation of function without compromising oncological outcome. Here we present the outcome of 87 patients treated with cryosurgery for low-grade chondrosarcoma of bone. Materials and methods 87 patients were treated between 1988 and 2005. The mean age was 51 years (range, 8-77 years), and included 47 females and 40 males. Minimal follow-up was two years. Patients were treated for lesions of the distal femur (n = 30), proximal humerus (n = 33), proximal femur (n = 5), proximal tibia (n = 10), and the remaining sites included the iliac bone, distal tibia, forearm, carpal and tarsal bones (n=10). Patients were treated with intralesional curettage through a cortical window, adjuvant burr drilling, cryotherpay and reconstruction with cement or bone graft and hardware fixation when that was clinically indicated. Results Post operative pathology reports showed high grade sarcomas in two patients, which underwent subsequent wide resection and prosthetic replacement and are excluded from this report. No local recurrence was noted after minimal follow up of two years in the remaining 85 patients. Post-operative complications included; fractures (n=4) of which two needed surgical fixation, superficial wound infection (n=5), delayed wound healing due to “cold burns” (n=6), degenerative arthritis which necessitated joint replacement (n=3), all more than 10 years after initial tumour resection. Functional outcome was rated as good or excellent in 76 patients (89%). Five patients had moderate function (6%), all of them with tumours of the proximal humerus and no outcome was available for 4 patients (5%). Conclusions Low complication rates, good functional outcome and very low local recurrence rates can be obtained when cryoablative surgery is performed for low grade chondrosarcomas of bone.

Purpose Most children today with bone sarcomas undergo limb-sparing surgery. When treating children younger than 12 years of age, the result is significant limb length discrepancy (LLD). One of the solutions is the use of an expandable endoprosthesis.Methods A retrospective analysis of 38 skeletally immature patients with bone sarcoma of the lower limb in whom different types of expandable endoprostheses were used from January 1988 to December 2005 were included. All patients were under the age of 14 years. There were 26 osteosarcoma and 12 Ewing's sarcomas. The data collected included the tumor characteristics, the surgical and other treatment modalities, complications and their treatment, and the final LLD and functional results.Results Fifty-five percent of the patients survived and had a mean follow-up of 113 months. All survivors reached skeletal maturity at the time of last follow-up. Seventy-one percent of the survivors had satisfactory function and 29% had a poor result. There were three secondary amputations due to local recurrence. Complications were documented in 58% of patients; the most common was infection that was diagnosed 56 times (primary 16% and secondary 84%). A significant correlation was found between function and final LLD (greater than 5 cm = inferior function), the number of complications, and the number of surgical procedures performed other than prosthesis elongation. The younger the patient was at definitive surgery, the shorter the time it took for the prosthesis to fail.Conclusion In order to improve results, the number of operations must be reduced. This can be achieved by the use of novel non-invasive expandable endoprostheses or biological reconstruction.

Background: This summary of a single center's extensive cumulative experience in bone tumor cryosurgery assesses the long-term outcome of bone conservation surgery in which adjuvant cryosurgery plays a pivotal role.Materials and methods: We performed 440 cryosurgical procedures between January 1988 and December 2002. Two-thirds of the series comprised a variety of primary benign-aggressive and low-grade malignant lesions, and one-third were primary high-grade and metastatic bone tumors. The anatomical locations included almost every bone of the skeleton. Two methods of bone cryosurgery were used: Marcove's "open" direct-pour system using liquid nitrogen (1988-1997) and Meller's "closed" argon-based system (1998 to the present).Results: The study cohort consisted of 214 males and 191 females (age range 5-82 years). The median follow-up was 7 years (range 3-18). The overall local recurrence rate was 8%: fractures = 1%, infections = 2% and skin burns = 1.3%. There were three cases of transient nerve palsies in areas other than the sacrum, and four cases of late osteoarthritis of an adjacent joint. The functional outcome for the 372 patients with no evidence of disease was almost 100% "good" and "excellent" (American Musculo-skeletal Tumor Society System). Only two patients needed secondary amputations.Conclusions: Bone cryosurgery is a safe and effective limb-, joint- and even epiphysis-sparing surgical technique in suitable types of bone tumors, temporarily or permanently obviating the need for resection surgery. (c) 2007 Elsevier Ltd. All rights reserved.

Background: Postoperative pain in patients with bone and soft tissue cancer is different from that of other surgical patients due to the severity of the pain generated during surgery and because many of them have already been in pain preoperatively. The search for optimal intravenous pharmacologic management for this population is an ongoing one. We conducted a 10-month prospective, randomised, double blind study to compare the effects of a standard morphine dose to a 35%-lower dose plus a subanaesthetic dose of ketamine for postoperative pain control in patients undergoing bone and soft tissue cancer surgery under standardised general anaesthesia.Methods: After extubation, when objectively awake (>= 5/10 on a 0-10 visual analogue scale (VAS)) and complaining of pain (>= 5/10 VAS), patients were connected to an intravenous patient-controlled analgesia (IV-PCA) device that delivered 1.5 mg morphine/bolus (MO group) or 1 mg morphine + 5mg ketamine/bolus (MK group), with a 7 min lockout time. Rescue intramuscular diclofenac 75 mg was available Q4/day. Follow-up lasted 96 h.Results: Fifty-seven patients (24 males, aged 18-74 years) completed the study. Pain scores were lower in the MK group compared to the MO patients, although MO patients (n = 29) used 32.9 +/- 24.9 mg/patient morphine during the first 24 postoperative h compared to 14.6 +/- 11.4 mg/patient (P < 0.05) for the MK patients (n = 28). At that time point, 11 MO versus 4 MK patients still required IV-PCA (P < 0.05). Diclofenac was also used more in the MO group. All vital signs were similar between the groups. The physiotherapy score was 35% higher for the MK patients (P < 0.05). No patient had hallucinations. Postoperative nausea and vomiting rates were higher in the MO group.Conclusions: The use of subanaesthetic ketamine plus 2/3 the standard dose of morphine following bone and tissue resections results in 1) lower and more stable pain score, 2) similar to 60% morphine sparing effect, 3) a shorter period of postoperative IV-PCA dependence. Such therapy is also associated with better early physical performance. (c) 2008 Elsevier Ltd. All rights reserved.

Katznelson and Nerubay (1980) reported their experience with 5 cases of total femur endoprosthetic reconstruction in Acta Orthopaedica Scandinavica almost 3 decades ago. Their patients had primary ...

European Journal of PainVolume 10, Issue S1 p. S145-S145 549 POSTOPERATIVE INTRAVENOUS PATIENT-CONTROLLED ANALGESIA-ADMINSITERED KETAMINE PLUS MORPHINE SPARES MORPHINE USE IN ORTHOPEDIC ONCOLOGICAL PATIENTS S. Chazan, S. Chazan CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorN. Marouani, N. Marouani CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorL. Arbel, L. Arbel CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorJ. Bickels, J. Bickels CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorD. Stocki, D. Stocki CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorA. Gorodetzky, A. Gorodetzky CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorA. Nirkin, A. Nirkin CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorI. Meller, I. Meller CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorV. Rudick, V. Rudick CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorY. Kollender, Y. Kollender CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorA.A. Weinbroum, A.A. Weinbroum CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this author S. Chazan, S. Chazan CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorN. Marouani, N. Marouani CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorL. Arbel, L. Arbel CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorJ. Bickels, J. Bickels CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorD. Stocki, D. Stocki CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorA. Gorodetzky, A. Gorodetzky CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorA. Nirkin, A. Nirkin CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorI. Meller, I. Meller CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorV. Rudick, V. Rudick CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorY. Kollender, Y. Kollender CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorA.A. Weinbroum, A.A. Weinbroum CHU Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this author First published: 13 January 2012 https://doi.org/10.1016/S1090-3801(06)60552-1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume10, IssueS1September 2006Pages S145-S145 RelatedInformation

European Journal of PainVolume 10, Issue S1 p. S144c-S144 548 FREQUENCY OF APPLICATION OF THE INTRAVENOUS PATIENT-CONTROLLED ANALGESIA IS NOT AN OBJEECTIVE CORRELATOR WITH THE SUBJECTIVELY-RATED PAIN VISUAL ANALOGUE SCALE S. Chazan, S. Chazan Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorN. Marouani, N. Marouani Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorL. Arbel, L. Arbel Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorJ. Bickels, J. Bickels Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorD. Stocki, D. Stocki Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorA. Horodetzky, A. Horodetzky Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorA. Nirkin, A. Nirkin Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorI. Meller, I. Meller Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorV. Rudick, V. Rudick Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorY. Kollender, Y. Kollender Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorA.A. Weinbroum, A.A. Weinbroum Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this author S. Chazan, S. Chazan Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorN. Marouani, N. Marouani Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorL. Arbel, L. Arbel Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorJ. Bickels, J. Bickels Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorD. Stocki, D. Stocki Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorA. Horodetzky, A. Horodetzky Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorA. Nirkin, A. Nirkin Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorI. Meller, I. Meller Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorV. Rudick, V. Rudick Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorY. Kollender, Y. Kollender Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this authorA.A. Weinbroum, A.A. Weinbroum Tel Aviv Souraski Medical Center, Tel Aviv, IsraelSearch for more papers by this author First published: 13 January 2012 https://doi.org/10.1016/S1090-3801(06)60551-XRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume10, IssueS1September 2006Pages S144c-S144 RelatedInformation

Introduction: Diffused pigmented villonodular synovitis (PVNS) is a locally aggressive lesion for which surgery provides only marginal resection. An adjuvant treatment modality is therefore required to prevent local tumor recurrence. The authors describe their experience with intra-articular injection of Yttrium 90 (Y 90 ), a radioisotope, as an adjuvant for tumor resection. Materials and Methods: Between 1989 and 2002, 20 patients with diffuse PVNS were treated with post-operative, intraarticular injection of Y 90 . There were 15 male and 5 female patients who ranged in age from 13 to 67 years (mean, 35 years). Anatomic locations of the affected joints included: knee – 15, ankle – 4, hip – 1. Tumor resection was initially done in all patients: 13 patients required open arthrotomy, the remaining 7 underwent arthroscopic tumor resection. Ten patients were referred for treatment after having operation for a local tumor recurrence: 6 patients had one, 2 had two, 1 had three, and the remaining one had five local recurrences. Six to eight weeks after surgery, intraarticular injection of 15–25 mCi of Y 90 was done. These procedures were conducted in the operating room under local anesthesia and fluoroscopic guidance. All patients were followed for a minimum of two years (range, 25–168 months; mean, 65 months). Results: Following Y 90 injection, all patients reported mild pain around the affected joint. This pain was well controlled with the use of NSAID’s and typically resolved within a few days or weeks. Three patients had superficial skin inflammation and associated blisters around the site of injection, probably the result of Y 90 effect on the soft-tissues. All were treated conservatively with complete resolution of their symptoms. All patients gained their pre-injection range-of-motion within 4–6 weeks. At the most recent follow-up, five patients had transient post-radiation skin changes (discoloration of the skin and dry and scaly skin) and local recurrence occurred in only one patient (5%) with PVNS around the knee; additional Y 90 injections were unsuccessful and he eventually underwent knee arthrodesis. Conclusion: Y 90 injection is a reliable adjuvant for surgery in the management of diffused PVNS. Local tumor control and good function, associated with only mild morbidity are achieved in the majority of the patients.

Introduction: Cryosurgery of bone tumors using direct pour of liquid nitrogen has the advantage of joint preservation associated with good local tumor control. However, this technique does not allow accurate control of the temperature or of the overall time of freezing. Additionally, this is a gravity-dependent procedure that cannot be applied in all shapes and locations of tumor cavities. The authors report their experience with a novel cryosurgical technique that allows accurate determination of the temperature and freezing time as well as freezing of any geometry of tumor cavity. Materials and Methods: From 1997 to 2000, 58 patients who were diagnosed with 13 malignant and 45 benign-aggressive bone tumors underwent argon-based cryoablation. This technique included tumor removal by means of curettage and burr-drilling, filling the tumor cavity with a gel medium, insertion of metal probes into this medium, and computer-controlled delivery of argon gas through the metal probes, and reconstruction of the tumor cavity with cemented hardware. All patients were followed for more than two years. Results: None had skin necrosis, infection, thromboembolic complication, or neurapraxia. Fractures occurred in two patients (3.4%) and local tumor recurrence in two patients (3.4%), who were successfully treated with a second closed cryoablation. Conclusions: The current study focuses on the concept and surgical technique of argon-based and computer-controlled, closed cryoablation of bone tumors. The main advantages of this system are the ability to control the freezing temperature and overall freezing time and the use of a gel medium, which evenly conducts the cold temperature throughout the tumor cavity and allows cryoablation of various cavital geometry and positions. The current technique of argon-based cryoablation is simple and easy to perform. It achieves good local tumor control and is associated with a low rate of complication. The authors recommend its use as an alternative to the traditional direct pour technique of cryosurgery.

Introduction: Megaprosthetic failures around the knee and especially those who are infection-related are difficult to manage. Although most of these cases are effectively managed with a two-stage prosthetic revision, selected cases eventually require sacrifice of the knee joint. The authors present their experience with knee-arthrodesis using a vascularized fibula and allograft reinforcement. Materials and Methods: Between 1998 and 2002, eight patients with failed knee prosthesis were referred for resection-arthrodesis; all patients had at least two previous revision attempts using a spacer or a new implant. Knee-arthrodesis included resection of the distal femur and proximal tibia and reconstruction with a free micro-vascularized fibular graft and allograft reinforcement. Fibular grafts were harvested with a large musculocutaneous flap to facilitate soft-tissue coverage and monitor flap viability. Following surgery, patients were kept non-weight-bearing for 3 months. Radiographs were performed 6 and 12 weeks postoperatively to establish fibular graft incorporation. If healing had progressed satisfactorily, weight-bearing was gradually allowed. Results: At the most recent follow-up’ all eight patients had a stable and painless reconstruction, associated with radiological evidence of solid fibular graft union. The latter was typically observed between 6 to 12 weeks from surgery. Complications included one emergent surgery for anastamotic rupture in one patient and surgical debridement with skin grafting of musculocutaneous flap necrosis in another patient. Conclusions: Knee-arthrodesis using microvascularized fibula and allograft reinforcement is a safe and reliable salvage procedure in end-stage failures of megaprosthetic knee implants.

Competence of the extensor mechanism is the major determinant of functional outcome of patients after proximal tibia resection. A method of secondary reconstruction of the extensor mechanism using the middle third of the quadriceps tendon and the patellar retinaculum augmented with Gore-Tex strips and gastrocnemius flap is described. Between 1981 and 1997, 7 patients with extension lag greater than 20 degrees at least 1 year after the initial surgery underwent secondary reconstruction of the extensor mechanism. All patients were followed up for a minimum of 2 years. Full extension to an extension lag of 10 degrees was achieved in three patients, and an extension lag between 10 degrees and 20 degrees was achieved in 4 patients. All patients had good to excellent functional outcomes and reported no limitations in daily life activities.

UNLABELLED:Pain after bone malignancy surgery is intense and requires large amounts of analgesics. The augmented antinociceptive effects of dextromethorphan (DM), a N-methyl-D-aspartate receptor antagonist, were demonstrated previously. We assessed the use of postoperative patient-controlled epidural analgesia (PCEA) or IV patient-controlled analgesia (PCA) in patients undergoing surgery for bone malignancy under standardized combined general and epidural anesthesia with or without DM. Patients (n = 120) were randomly allocated to receive PCEA (ropivacaine 3.2 mg plus fentanyl 8 microg/dose) or IV-PCA (morphine 2 mg/dose) postoperatively, starting at subjective visual analog scale pain intensity >or=4 of 10 for up to 96 h. Placebo or DM 90 mg orally (30 patients/group/set) was given in a double-blinded manner before surgery and for 2 days afterwards. Diclofenac 75 mg IM was available as a rescue drug. DM patients used PCA and rated their pain >50% less than their placebo counterparts in each set, especially during the first 2 postoperative days (P < 0.01). Hourly and overall maximal pain intensity among PCEA patients was approximately 50% less than in the IV-PCA set (P < 0.01). Diclofenac was used 42% less (P < 0.01) by the PCA-DM patients compared with their placebo counterparts. Seven PCEA-DM and 11 IV-PCA-DM individuals reported having side effects compared with 44 in the PCEA-placebo and the IV-PCA-placebo groups (P < 0.01). Time to first ambulation was similar with both analgesia techniques but shorter among the DM-treated patients compared with the placebo recipients (1.5 +/- 0.8 versus 2.1 +/- 1.1 days, P = 0.02). Thus, DM afforded better pain control and reduced the demand for analgesics, augmented the PCEA effect versus IV-PCA, and was associated with minimal untoward effects in each analgesia set. DM patients ambulated earlier than placebo recipients. IMPLICATIONS:Patients undergoing bone-malignancy surgery under combined general and epidural anesthesia received randomly patient-controlled epidural analgesia (PCEA) or IV patient-controlled analgesia (PCA) postoperatively and dextromethorphan (DM) 90 mg or placebo double-blindly for 3 days (n = 30/group/set). The DM effect was recorded with minimal untoward effects: it afforded better pain control and reduced the demand for analgesics compared with the placebo, especially when associated with PCEA. DM patients ambulated earlier than placebo recipients.

BACKGROUND:Pain is mediated centrally by N-methyl-D-aspartate (NMDA) receptors. The antinociceptive effects of preincision dextromethorphan (DM), an NMDA antagonist, have been demonstrated in surgical patients under general or epidural anesthesia. The authors investigated the effects of DM on postoperative pain and other parameters in patients undergoing surgery for bone malignancy under standardized combined general and epidural anesthesia using patient-controlled epidural analgesia (PCEA) postoperatively. METHODS:Patients received placebo or DM 90 mg (30 patients per group) in a double-blind manner preoperatively and on each of the two following days. Postoperative PCEA consisted of 1.6 mg ropivacaine plus 4 microg/mL fentanyl both continuously and by demand up to 96 hours, starting when subjective pain intensity was greater than or equal to 4/10 (visual analog score). Rescue drugs on demand (paracetamol or dipyrone orally) were also available. RESULTS:The DM patients experienced about 50% (P < 0.01) less pain than their placebo counterparts for more than 2 postoperative days and they rated their overall maximal pain intensity by one-half that estimated by the placebo-treated patients (P < 0.01). The DM group also consumed 30-50% less epidural analgesics than the total amount consumed by the placebo-medicated group (P < 0.01) and demanded significantly (P < 0.05) fewer rescue drugs on the first postoperative day. They were less sedated (40-60%, P < 0.01) and reported 50% fewer overall side effects (P < 0.05). The groups were similar for the need for urinary catheterization, time of first ambulation, and/or discharge home. CONCLUSIONS:A 3-day DM administration is associated with better pain reduction in patients undergoing surgery for bone malignancy under combined general and epidural anesthesia with postoperative PCEA compared with placebo without increasing side effects.

BACKGROUND. Cryosurgery is an adjuvant surgical technique for the treatment of benign aggressive, low-grade malignant and metastatic tumors of long bones. It has been used rarely to treat sacral tumors, mainly because of potential damage to nerves, blood vessels, and intrapelvic organs. The authors described their experience with this procedure and provided medium and long-term follow-up results.METHODS. Fifteen procedures of cryosurgery of the sacrum were performed in 14 patients to improve the therapeutic outcome of a variety of tumors. The patient group included 7 males and 7 females with a mean age of 42 +/- 24 years. Three patients were younger than 20 years of age. The procedures were performed at the Tel Aviv Sourasky Medical Center between January 1991 and January 1999. There were seven benign aggressive lesions (four giant cell tumors and three aneurysmal bone cysts), one benign schwannoma, one low-grade chondrosarcoma, five metastatic carcinomas, and one high-grade Ewing sarcoma, all localized at level S-2 or higher. Eight of the bone tumors also involved significant anterior or posterior soft tissue. All patients had severe preoperative pain radiating to the buttocks, perineum, and lower limbs and 9 (64%) patients had bladder and/or rectal dysfunction. Invasive diagnostic procedures and radiation (if warranted) preceded surgery. Sacral posterior fenestration and burr drilling were followed by two-cycle cryosurgery using the open pour technique or the argon-helium-based heat-freeze system.RESULTS. All interventions were performed under combined general and regional anesthesia and concluded uneventfully with moderate blood loss. Thirteen patients were discharged home after 8 +/- 5 days (one patient remained hospitalized for 30 days). Only two patients experienced local disease recurrence during a 3-11-year follow-up period: one was retreated successfully by cryosurgery and the other underwent sacrectomy and radiotherapy elsewhere, with a subsequent loss of visceral functions. No patient suffered chronic pain, deep wound infections, or significant neurologic deficits and all were satisfied with the esthetic outcome.CONCLUSIONS. Cryosurgery is a conservative, feasible, and safe adjuvant technique in the treatment of sacral tumors. It is associated with minimal permanent neurologic and vascular injury compared with sacrectomy. (C) 2003 American Cancer Society.

Postoperative pain is mediated centrally by N‐methyl‐D‐aspartate (NMDA) receptors. The beneficial effects of preincision oral dextromethorphan (DM), which is an NMDA antagonist, on postoperative pain and intravenous patient‐controlled analgesia (IV‐PCA) morphine (MO) consumption have been examined in patients undergoing surgery. The authors investigated 75 patients who underwent surgery for bone and soft tissue malignancies, in whom postoperative pain is more severe compared with patients who undergo general surgery.

Study Design. Report of a patient with a carcinoid tumor of the coccyx. Objectives. To describe the clinical presentation, diagnosis, and treatment of a patient with a carcinoid tumor of the coccyx and to review the relevant medical literature in English. Summary of Background Data. No reports of a carcinoid tumor of the coccyx were found in the literature. Seven reports of carcinoid of the sacrum are described. Methods. Clinical history, magnetic resonance imaging studies, and light and electronic microscope micrographs are reviewed. Results. A coccygeal mass was detected during evaluation of coccygodynia in a 40-year-old woman. Four years after extended coccygectomy, there are no signs of local tumor recurrence. Conclusions. Carcinoid tumor of the coccyx is extremely rare. An extended coccygectomy may lead to a cure or at least to a prolonged disease-free interval.

Study Design. Report of a patient with a carcinoid tumor of the coccyx.Objectives. To describe the clinical presentation, diagnosis, and treatment of a patient with a carcinoid tumor of the coccyx and to review the relevant medical literature in English.Summary of Background Data. No reports of a carcinoid tumor of the coccyx were found in the literature. Seven reports of carcinoid of the sacrum are described.Methods. Clinical history, magnetic resonance imaging studies, and light and electronic microscope micrographs are reviewed.Results. A coccygeal mass was detected during evaluation of coccygodynia in a 40-year-old woman. Four years after extended coccygectomy, there are no signs of local tumor recurrence.Conclusions. Carcinoid tumor of the coccyx is extremely rare. An extended coccygectomy may lead to a cure or at least to a prolonged disease-free interval.