1/54. Epidural hematoma following epidural catheter placement in a patient with chronic renal failure.PURPOSE: We report a case of epidural hematoma in a surgical patient with chronic renal failure who received an epidural catheter for postoperative analgesia. Symptoms of epidural hematoma occurred about 60 hr after epidural catheter placement. CLINICAL FEATURES: A 58-yr-old woman with a history of chronic renal failure was admitted for elective abdominal cancer surgery. Preoperative laboratory values revealed anemia, hematocrit 26%, and normal platelet, PT and PTT values. General anesthesia was administered for surgery, along with epidural catheter placement for postoperative analgesia. Following uneventful surgery, the patient completed an uneventful postoperative course for 48 hr. Then, the onset of severe low back pain, accompanied by motor and sensory deficits in the lower extremities, alerted the anesthesia team to the development of an epidural hematoma extending from T12 to L2 with spinal cord compression. Emergency decompressive laminectomy resulted in recovery of moderate neurologic function. CONCLUSIONS: We report the first case of epidural hematoma formation in a surgical patient with chronic renal failure (CRF) and epidural postoperative analgesia. The only risk factor for the development of epidural hematoma was a history of CRF High-risk patients should be monitored closely for early signs of cord compression such as severe back pain, motor or sensory deficits. An opioid or opioid/local anesthetic epidural solution, rather than local anesthetic infusion alone, may allow continuous monitoring of neurological function and be a prudent choice in high-risk patients. If spinal hematoma is suspected, immediate MRI or CT scan should be done and decompressive laminectomy performed without delay.- - - - - - - - - - ranking = 1keywords = spinal (Clic here for more details about this article) |
2/54. Continuous spinal anaesthesia/analgesia for abdominal aortic aneurysm repair and post-operative pain management.The intra-operative management of two patients with chronic obstructive pulmonary disease and cardiovascular pathology, who underwent peripheral reconstructive vascular surgery under continuous spinal anaesthesia, is described. Furthermore, continuous intrathecal analgesia was also continued in the post-operative period and provided effective pain relief that was reflected by the favourable surgical outcome.- - - - - - - - - - ranking = 2.5keywords = spinal (Clic here for more details about this article) |
3/54. Neuropathic pain syndrome as an occult manifestation of injury of the spinal cord after surgical repair of aortic coarctation.Injury to the spinal cord injury with paraplegia, is a rare complication of surgical repair of aortic coarctation recognized immediately post-operatively. We present the case of a 41-year-old male undergoing surgery for restenosis at the site of a repair. Intra-operatively, he suffered inadvertent injury to an intercostal arterial branch during isolation of the aorta below the graft. Over the following months, he developed unusual symptoms involving the legs and genitourinary tract which, only after extensive investigations, were attributed to ischemic damage to the spinal cord related to the surgery. We suspect that similar syndromes reflecting injury to the spinal cord injury may be unrecognized following surgical repair of coarctation.- - - - - - - - - - ranking = 3.5keywords = spinal (Clic here for more details about this article) |
4/54. Intraspinal haematoma following lumbar epidural anaesthesia in a neonate.A neonate with chromosomal 9 abnormality and omphalocele received a lumbar epidural catheter after laparotomy. Several attempts were needed to establish this catheter. Bleeding occurred from the operative wound after surgery. Using an epidural infusion with ropivacaine 0.1% for 48 h postoperative pain relief was sufficient. Four days after epidural catheter removal, dysfunction of the sacral parasympathetic nerves was noted. Motor and sensor function of the lower limbs were unaffected. magnetic resonance imaging showed a localized intraspinal haematoma in the lower lumbar region.- - - - - - - - - - ranking = 2.5keywords = spinal (Clic here for more details about this article) |
5/54. Late operative site pain with isola posterior instrumentation requiring implant removal: infection or metal reaction?OBJECTIVES: To elucidate the cause of late operative site pain in six cases of scoliosis managed with Isola posterior instrumentation that required removal of the implants. METHOD: Microbiologic examination of wound swabs and enriched culture of operative tissue specimens was undertaken in all cases. Histologic study of the peri-implant membranes also was conducted. RESULTS: The presentation in all cases was similar: back pain appearing between 12-20 months after surgery, followed by a local wound swelling leading to a wound sinus. In only one of these cases was the discharge positive for bacterial growth. Implant removal was curative. Histologic examination of tissue specimens revealed a neutrophil-rich granulation tissue reaction suggestive of an infective etiology despite the failure to isolate organisms. Within the granulation tissue was metallic debris that varied from very sparse to abundant from fretting at the distal cross-connector junctions. A review of recent literature describing similar problems suggests that late onset spinal pain is a real entity and a major cause of implant removal. CONCLUSIONS: On reviewing the evidence for an infective etiology versus a metallurgic reaction etiology for these cases of late onset spinal pain, it was concluded that a subacute low-grade implant infection was the main cause. Histologic findings would seem to confirm low-grade infection. There may be more than one causative factor for late operative site pain, as it is possible that fretting at cross connection junctions may provide the environment for the incubation of dormant or inactive microbes.- - - - - - - - - - ranking = 1keywords = spinal (Clic here for more details about this article) |
6/54. The role of laparoscopic biopsies in lumbar spondylodiscitis.The infection of an intervertebral disk is a serious condition. The diagnosis often is elusive and difficult to make. It is imperative to have appropriate microbiologic specimens before the initiation of treatment. We report the case of a 51-year-old woman with lumbar spondylodiscitis caused by infection after the placement of an epidural catheter for postoperative analgesia. A spinal magnetic resonance imaging (MRI) scan confirmed the diagnosis, but computed tomography (CT)-guided fine-needle biopsy did not yield adequate material for a microbiologic diagnosis. Laparoscopic biopsies of the involved disk provided good specimens and a diagnosis of propionibacterium acnes infection. We believe that this minimally invasive procedure should be performed when CT-guided fine-needle biopsy fails to yield a microbiologic diagnosis in spondylodiscitis.- - - - - - - - - - ranking = 0.5keywords = spinal (Clic here for more details about this article) |
7/54. Postoperative epidural analgesia and possible transient anterior spinal artery syndrome.BACKGROUND AND OBJECTIVE: We present an unusual complication of epidural analgesia used to facilitate postoperative pain relief while allowing mobilization of the patient. CASE REPORT: A 65-year-old woman with a history of chronic obstructive pulmonary disease, atherosclerotic cardiovascular disease, chronic renal failure, and degenerative vertebral anatomy underwent resection of the left ureter due to obstructing tumor. The day following surgery, mobilization to an armchair was started, followed by a decrease in blood pressure. Soon after, flaccid paralysis with sparing of sensory functions, consistent with anterior spinal artery syndrome (ASAS), was diagnosed. CONCLUSIONS: This complication should be taken into account, especially in patients at risk, when considering epidural analgesia techniques in the postoperative period. Reg Anesth Pain Med 2001;26:274-277.- - - - - - - - - - ranking = 2.5keywords = spinal (Clic here for more details about this article) |
8/54. Opioid-free analgesia following total knee arthroplasty--a multimodal approach using continuous lumbar plexus (psoas compartment) block, acetaminophen, and ketorolac.BACKGROUND AND OBJECTIVES: Traditionally, postoperative analgesia following total knee arthroplasty (TKA) has been provided by neuraxial or peripheral regional techniques with supplemental administration of opioids. We report an alternative method of postoperative pain management for patients undergoing TKA in whom the use of systemic or neuraxial opioids may result in significant side effects. CASE REPORT: A 74-year-old woman with a history of protracted nausea and vomiting after systemic and neuraxial opioid administration presented for left total knee arthroplasty. A spinal anesthetic with postoperative continuous lumbar plexus (psoas) analgesia was planned. A quadriceps motor response was elicited and a 20-gauge catheter was advanced through an 18-gauge insulated Tuohy needle into the psoas sheath. After 30 mL of bupivacaine 0.5% with 100 microg clonidine was administered through the psoas catheter, a spinal anesthetic (2 mL 0.5% bupivacaine at the L2-3 interspace) was performed. A continuous psoas infusion of 0.2% bupivacaine with 2 microg/mL clonidine at 8 mL/h was initiated in the recovery room. The psoas infusion was subsequently changed to 0.2% bupivacaine without clonidine and the rate increased to 10 mL/h. Supplemental analgesia with oral acetaminophen 1 g every 4 to 6 hours alternating with intravenous ketorolac 15 mg every 6 hours provided satisfactory analgesia, with visual analog scale (VAS) scores of 0 to 2 at rest and 3 to 4 with movement. The psoas catheter was removed 48 hours postoperatively because of prolongation of the prothrombin time. VAS scores remained 0 to 3 throughout the remainder of her hospitalization. CONCLUSION: A multimodal approach consisting of continuous lumbar plexus (psoas) block and nonopioid analgesics successfully provided postoperative pain relief in our patient and facilitated her physical rehabilitation after total knee arthroplasty.- - - - - - - - - - ranking = 1keywords = spinal (Clic here for more details about this article) |
9/54. Recurrent neurological symptoms in a patient following repeat combined spinal and epidural anaesthesia.A healthy woman developed neurological symptoms after two consecutive Caesarean sections under combined spinal and epidural anaesthesia. Amethocaine was used for spinal anaesthesia and mepivacaine for epidural anaesthesia on both occasions, and a combination of fentanyl and bupivacaine was continuously infused for pain relief after the second. Her symptoms on both occasions were similar, including pain in the buttocks of 7-11 days duration and numbness in the sacral area of 5-6 months.- - - - - - - - - - ranking = 3keywords = spinal (Clic here for more details about this article) |
10/54. Innovation and surgical techniques: endoscopic resection of cervical branchiogenic cysts.The recent advent of endoscopic procedures has compelled both plastic and neck and head surgeons to reconsider the conventional methods by which the excision of cervical congenital cystic is classically achieved.An endoscopic approach for excision of the cervical congenital cystic is described. This procedure is anatomically safe and can be made with minimal morbidity through a small transcervical incision.Both specific instruments and solid anatomical knowledge are necessary to perform a safe and efficient cystic endoscopic excision.The essential surgical steps are as follows: 1. Minimal incision placed in natural cervical wrinkle over the dome of the cyst; 2. Intracystic or extracystic dissection; 3. Identification and protection of the sternocleidomastoid muscle, spinal nerve, hypoglossi nerve, and posterior belly of digastric muscle; 4. Careful dissection of the posterior surface of the cyst, avoiding injury on the carotid vessels and internal jugular vein.Eight patients were operated on with this technique and they were very pleased with postoperative comfort and aesthetic results. Inconspicuous scars and no complications were registered.With advanced endoscopic instruments and the development of new surgical technique and surgeon experience, the endoscopic surgery can be the method of choice in cervical excision of branchiogenic cysts.- - - - - - - - - - ranking = 0.5keywords = spinal (Clic here for more details about this article) |
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