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  1. Imaging in spinal posterior epidural space lesions: A pictorial essay.

    PubMed

    Gala, Foram B; Aswani, Yashant

    2016-01-01

    Spinal epidural space is a real anatomic space located outside the dura mater and within the spinal canal extending from foramen magnum to sacrum. Important contents of this space are epidural fat, spinal nerves, epidural veins and arteries. Due to close proximity of posterior epidural space to spinal cord and spinal nerves, the lesions present with symptoms of radiculopathy and/or myelopathy. In this pictorial essay, detailed anatomy of the posterior epidural space, pathologies affecting it along with imaging pearls to accurately diagnose them are discussed. Various pathologies affecting the posterior epidural space either arising from the space itself or occurring secondary to vertebral/intervertebral disc pathologies. Primary spinal bone tumors affecting the posterior epidural space have been excluded. The etiological spectrum affecting the posterior epidural space ranges from degenerative, infective, neoplastic - benign or malignant to miscellaneous pathologies. MRI is the modality of choice in evaluation of these lesions with CT scan mainly helpful in detecting calcification. Due to its excellent soft tissue contrast, Magnetic Resonance Imaging is extremely useful in assessing the pathologies of posterior epidural space, to know their entire extent, characterize them and along with clinical history and laboratory data, arrive at a specific diagnosis and guide the referring clinician. It is important to diagnose these lesions early so as to prevent permanent neurological complication.

  2. Imaging in spinal posterior epidural space lesions: A pictorial essay

    PubMed Central

    Gala, Foram B; Aswani, Yashant

    2016-01-01

    Spinal epidural space is a real anatomic space located outside the dura mater and within the spinal canal extending from foramen magnum to sacrum. Important contents of this space are epidural fat, spinal nerves, epidural veins and arteries. Due to close proximity of posterior epidural space to spinal cord and spinal nerves, the lesions present with symptoms of radiculopathy and/or myelopathy. In this pictorial essay, detailed anatomy of the posterior epidural space, pathologies affecting it along with imaging pearls to accurately diagnose them are discussed. Various pathologies affecting the posterior epidural space either arising from the space itself or occurring secondary to vertebral/intervertebral disc pathologies. Primary spinal bone tumors affecting the posterior epidural space have been excluded. The etiological spectrum affecting the posterior epidural space ranges from degenerative, infective, neoplastic - benign or malignant to miscellaneous pathologies. MRI is the modality of choice in evaluation of these lesions with CT scan mainly helpful in detecting calcification. Due to its excellent soft tissue contrast, Magnetic Resonance Imaging is extremely useful in assessing the pathologies of posterior epidural space, to know their entire extent, characterize them and along with clinical history and laboratory data, arrive at a specific diagnosis and guide the referring clinician. It is important to diagnose these lesions early so as to prevent permanent neurological complication. PMID:27857455

  3. Roseomonas spinal epidural abscess complicating instrumented posterior lumbar interbody fusion.

    PubMed

    Maraki, Sofia; Bantouna, Vasiliki; Lianoudakis, Efstratios; Stavrakakis, Ioannis; Scoulica, Efstathia

    2013-07-01

    The first case of a spinal epidural abscess caused by Roseomonas mucosa following instrumented posterior lumbar fusion is presented. Although rare, because of its highly resistant profile, Roseomonas species should be included in the differential diagnosis of epidural abscesses in both immunocompromised and immunocompetent hosts.

  4. Posterior epidural migration of a sequestrated lumbar disk fragment: MR imaging findings.

    PubMed

    Chen, C Y; Chuang, Y L; Yao, M S; Chiu, W T; Chen, C L; Chan, W P

    2006-08-01

    We present a 75-year-old man who, for 2 weeks, had progressive pain in both of his thighs when standing straight. MR imaging showed a sequestrated disk fragment, which had a signal intensity similar to that of a herniated disk with a rim enhancement in the posterior epidural space and a ruptured outermost annulus of the intervertebral disk at L2-3. Awareness of these MR imaging findings can help in the diagnosis of posterior epidural disk migration.

  5. Horner's Syndrome Secondary to Epidural Anaesthesia Following Posterior Instrumented Scoliosis Correction

    PubMed Central

    Gunn, Lucinda; Madhavan, Pradeep

    2015-01-01

    An 11-year-old girl underwent T4 to L1 posterior instrumented scoliosis correction for adolescent idiopathic scoliosis. Postoperative clinical examination revealed left-sided Horner's syndrome which was preceded by left-sided C8 paraesthesia. The Horner's syndrome resolved after 14 hours following weaning and removal of the epidural catheter. Horner's syndrome following posterior instrumented scoliosis correction associated to epidural use is extremely rare. Surgeons must be aware of the risks of epidural placement and the need for close monitoring of associated complications. Alternative aetiology producing a Horner's syndrome must always be considered because of its devastating long term sequela if missed. PMID:25705345

  6. Acute posterior fossa epidural hematoma in a newborn infant with Menkes disease.

    PubMed

    Takeuchi, Satoru; Horikawa, Masahiro; Wakamatsu, Hajime; Hashimoto, Jyunya; Nawashiro, Hiroshi

    2014-02-01

    Epidural hematoma (EDH) in newborn infants is rare compared with other types of intracranial hemorrhages. Furthermore, posterior fossa EDH is extremely rare. We present a case of posterior fossa EDH in an infant with Menkes disease with accessory bones in the occiput. A male infant with a condition diagnosed with Menkes disease by prenatal testing was born at 39 weeks via vacuum extraction. The patient presented with a mild tremor at 2 days after delivery. A brain computed tomography (CT) scan showed an acute EDH in the posterior fossa, extending into the occipitoparietal area. Three-dimensional CT and bone window CT scan revealed several accessory bones, diastasis of 1 accessory suture, a communicated fracture, and a linear fracture in the occipital bone. Furthermore, a bone fragment from a communicated fracture displaced toward the inside. The patient was treated conservatively for EDH because of his good general condition. The hematoma gradually resolved, and his tremor did not recur. We suggest the following mechanism of posterior fossa EDH development in our patient: (1) external force was applied to the occiput inside the birth canal during delivery, resulting in diastasis; (2) a communicated fracture occurred, and a bone fragment displaced toward the inside (linear fracture was caused indirectly by the force); (3) a transverse sinus was injured by the fragment; and (4) EDH developed in both the posterior fossa and supratentorial region. Copper deficiency can also cause fragility of connective tissues, vessels, and bones.

  7. Postoperative patient-controlled epidural analgesia in patients with spondylodiscitis and posterior spinal fusion surgery.

    PubMed

    Gessler, Florian; Mutlak, Haitham; Tizi, Karima; Senft, Christian; Setzer, Matthias; Seifert, Volker; Weise, Lutz

    2016-06-01

    OBJECTIVE The value of postoperative epidural analgesia after major spinal surgery is well established. Thus far, the use of patient-controlled epidural analgesia (PCEA) has been denied to patients undergoing debridement and instrumentation in spondylodiscitis, with the risk of increased postoperative pain resulting in prolonged recovery. The value of PCEA with special regard to infectious complications remains to be clarified. The present study examined the value of postoperative PCEA in comparison with intravenous analgesia in patients with spondylodiscitis undergoing posterior spinal surgery. METHODS Thirty-two patients treated surgically for spondylodiscitis of the thoracic and lumbar spine were prospectively included in a database and retrospectively reviewed for this study. Postoperative antibiotic treatment, functional capacity, pain levels, side effects, and complications were documented. Sixteen patients were given patient-demanded intravenous analgesia (PIA) followed by 16 patients assigned to PCEA. If PCEA was applied, the insertion of an epidural catheter was performed under the direct visual guidance of the surgeon at the end of the surgery. RESULTS Three patients intended for PCEA treatment were excluded due to predefined exclusion criteria. Postoperative pain was significantly lower in the PCEA group during the first 48 hours after surgery (p = 0.03). As determined by the trunk control test conducted at 8 (p < 0.001), 24 (p = 0.004), 48 (p = 0.015), 72 (p = 0.0031), and 96 hours (p < 0.001), patients in the PCEA treatment group displayed significantly increased mobilization capacity compared with those of the PIA group. Time until normal accomplishment of all mobilization maneuvers was reduced in the PCEA group compared with that in the PIA group (p = 0.04). No differences in complication rates were observed between the 2 groups (p = 0.52). CONCLUSIONS PCEA may reduce postoperative pain and lead to earlier achievement of functional capacity at a low

  8. Spinal Epidural Hematoma after Thoracolumbar Posterior Fusion Surgery without Decompression for Thoracic Vertebral Fracture

    PubMed Central

    Minato, Tsuyoki; Miyagi, Masayuki; Saito, Wataru; Shoji, Shintaro; Nakazawa, Toshiyuki; Inoue, Gen; Imura, Takayuki; Minehara, Hiroaki; Matsuura, Terumasa; Kawamura, Tadashi; Namba, Takanori; Takahira, Naonobu; Takaso, Masashi

    2016-01-01

    We present a rare case of spinal epidural hematoma (SEH) after thoracolumbar posterior fusion without decompression surgery for a thoracic vertebral fracture. A 42-year-old man was hospitalized for a thoracic vertebral fracture caused by being sandwiched against his back on broken concrete block. Computed tomography revealed a T12 dislocation fracture of AO type B2, multiple bilateral rib fractures, and a right hemopneumothorax. Four days after the injury, in order to promote early orthostasis and to improve respiratory status, we performed thoracolumbar posterior fusion surgery without decompression; the patient had back pain but no neurological deficits. Three hours after surgery, he complained of acute pain and severe weakness of his bilateral lower extremities; with allodynia below the level of his umbilicus, postoperative SEH was diagnosed. We performed immediate revision surgery. After removal of the hematoma, his symptoms improved gradually, and he was discharged ambulatory one month after revision surgery. Through experience of this case, we should strongly consider the possibility of preexisting SEH before surgery, even in patients with no neurological deficits. We should also consider perioperative coagulopathy in patients with multiple trauma, as in this case. PMID:26989542

  9. Parascapular mass revealing primary tuberculosis of the posterior arch

    PubMed Central

    Arbault, Anais; Ornetti, Paul; Chevallier, Olivier; Avril, Julien; Pottecher, Pierre

    2016-01-01

    We report the case of a parascapular abscess revealing primary tuberculosis of the posterior arch in a 31-year-old man. Sectional imaging is essential in order to detect the different lesions of this atypical spinal tuberculosis as osteolysis of the posterior arch extendible to vertebral body, osteocondensation, epidural extension which is common in this location, and high specificity of a zygapophysial, costo-vertebral or transverse arthritis. PMID:27709081

  10. A Comparison of the Effect of Epidural Patient-Controlled Analgesia with Intravenous Patient-Controlled Analgesia on Pain Control after Posterior Lumbar Instrumented Fusion

    PubMed Central

    Lee, Sang Hoon; Kim, Kyung Hyun; Cheong, Seong-Mee; Kim, Sumi; Kooh, Mirang

    2011-01-01

    Objective Retrospective analysis to compare the effect and complication of epidural patient-controlled analgesia (epidural PCA) with intravenous patient-controlled analgesia (IV PCA) for the treatment of the post-operative pain after posterior lumbar instrumented fusion. Methods Sixty patients who underwent posterior lumbar instrumented fusion for degenerative lumbar disease at our institution from September 2007 to January 2008 were enrolled in this study. Out of sixty patients, thirty patients received IV PCA group and thirty patients received epidural PCA group. The pain scale was measured by the visual analogue scale (VAS) score. Results There were no significant difference between IV PCA group and epidural PCA group on the PCA related complications (p=0.7168). Ten patients in IV PCA group and six patients in epidural PCA group showed PCA related complications. Also, there were no significant differences in reduction of VAS score between two groups on postoperative 2 hours (p=0.9618) and 6 hours (p=0.0744). However, postoperative 12 hours, 24 hours and 48 hours showed the significant differences as mean of reduction of VAS score (p=0.0069, 0.0165, 0.0058 respectively). Conclusion The epidural PCA is more effective method to control the post-operative pain than IV PCA after 12 hours of spinal fusion operation. However, during the first twelve hours after operation, there were no differences between IV PCA and epidural PCA. PMID:22102950

  11. Efficacy of post-operative analgesia after posterior lumbar instrumented fusion for degenerative disc disease: a prospective randomized comparison of epidural catheter and intravenous administration of analgesics

    PubMed Central

    Kluba, Torsten; Hofmann, Fabian; Bredanger, Sabine; Blumenstock, Gunnar; Niemeyer, Thomas

    2010-01-01

    This prospective study aimed to compare the efficacy of epidural (EDA) versus intravenous (PCA) application of analgesics after lumbar fusion. Fifty-two patients scheduled for elective posterior instrumented lumbar fusion were randomized into two groups. EDA patients received an epidural catheter intraoperatively, and administration of ropivacain and sulfentanil was started after a normal postoperative wake-up test in the recovery room area. PCA patients received intravenous opioids in the post-operative period. Differences between EDA and PCA groups in terms of patient satisfaction with respect to pain relief were not significant. Nevertheless, EDA patients reported less pain on the third day after surgery. There were significantly more side effects in the EDA group, including complete reversible loss of sensory function and motor weakness. There were no major side effects, such as infection or persisting neurological deficits, in either group. The routine use of epidural anesthesia for lumbar spine surgery has too many risks and offers very little advantage over PCA. PMID:21808704

  12. Multiple epidural steroid injections and body mass index linked with occurrence of epidural lipomatosis: a case series

    PubMed Central

    2014-01-01

    Background Epidural lipomatosis (EL) is an increase of adipose tissue, normally occurring in the epidural space, sufficient to distort the thecal sac and compress neural elements. There is a lack of knowledge of risk factors, impact on patient’s symptoms, and its possible association with epidural steroid injections. Methods History, physical examination, patient chart, and MRI were analyzed from 856 outpatients referred for epidural steroid injections. Seventy patients with signs of EL on MRI comprised the study group. Thirty-four randomly selected patients comprised the control group. The severity of EL was determined by the MRI assessment. The impact of EL was determined by the patient’s history and physical examination. Logistic regression was used to correlate the probability of developing EL with BMI and epidural steroid injections. Results EL was centered at L5 and S1 segments. The average BMI for patients with EL was significantly greater than that of control group (36.0 ± 0.9 vs. 29.2 ± 0.9, p <0.01). The probability of developing EL with increasing BMI was linear up to the BMI of 35 after which it plateaued. Triglycerides were significantly higher for the EL group as compared to controls (250 ± 30 vs. 186 ± 21 mg/dL p < 0.01). The odds of having EL were 60% after two epidural steroid injections, 90% after three epidural steroid injections and approached 100% with further injections, independent of BMI. Other risk factors considered included alcohol abuse, use of protease inhibitors, levels of stress, hypothyroidism and genetic predisposition. However there were insufficient quantities to determine statistical significance with a degree of confidence. The impact of EL on patient’s symptoms correlated with EL severity with Spearman correlation coefficient of 0.73 at p < 0.01 significance level. Conclusions The BMI and triglycerides levels were found to be significantly elevated for the EL group, pointing to an increased

  13. Posterior left atrial wall hematoma mimicking cystic intracavitary atrial mass.

    PubMed

    Bahnacy, Yasser; Suresh, Cheriyil; Dawoud, Hamed; Zubaid, Mohammad

    2010-10-01

    Atrial myxoma is the most common benign primary tumor of the heart most commonly in the left atrium (LA). Cystic or cavitated intracardiac masses are rare. We report the case of a 43-year-old male patient admitted with chest infection, hemoptysis, and severe respiratory distress, who had to be ventilated. Chest computed tomography showed bilateral lung consolidation with large mass occupying the region of the LA. Transthoracic echocardiography and transesophageal echocardiography showed a large intracavitary left atrial cystic mobile mass. Open-heart surgical exploration did not show any mass inside the LA. A posterior left atrial wall hematoma was found and evacuated. Biopsies confirmed the presence of blood clots. Posterior left atrial wall hematoma may appear as left atrial intracavitary cystic mass and should be included in the differential diagnosis of cystic left atrial mass.

  14. Thoracic epidural catheter in the management of a child with an anterior mediastinal mass: a case report and literature review.

    PubMed

    Soliman, Loran M; Mossad, Emad B

    2006-02-01

    We describe a case of an anterior mediastinal mass compressing the right main bronchus that required a biopsy through a thoracotomy incision. The anesthetic management of these patients is associated with several risks and challenges, including potential airway compression and cardiovascular collapse. Inhalation induction and maintenance of spontaneous respiration is recommended to preserve normal transpulmonary pressure gradient and improve flow through conducting airways. We placed a thoracic epidural catheter under general anesthesia as the main analgesic technique in order to maintain spontaneous breathing. The use of regional anesthesia, especially continuous epidurals in pediatric cardiothoracic anesthesia have many theoretical advantages including attenuation of the neuroendocrine response, facilitation of rapid extubation and improved ventilatory mechanics secondary to decreased narcotic requirements. The absolute risk of nerve injury and epidural hematoma for this procedure is unknown and hard to define in this patient population. We reviewed multiple studies and case reports addressing its safety and reported side effects. Finally, we emphasize that a thoracic epidural anesthesia is a reasonable choice that can be applied carefully in special situations even for children under general anesthesia.

  15. Epidural abscess

    MedlinePlus

    ... this page: //medlineplus.gov/ency/article/001416.htm Epidural abscess To use the sharing features on this page, please enable JavaScript. An epidural abscess is a collection of pus (infected material) between ...

  16. Use of intraoperative sodium tetradecyl sulfate for the treatment of a spinal epidural hemangioma. Technical note.

    PubMed

    Baig, Mirza N; Saquib, Syed; Christoforidis, Greg; Caragine, Louis P

    2007-08-01

    Spinal hemangiomas can be categorized into three different groups based on location. Vertebral body (VB) hemangiomas are frequent incidental findings on magnetic resonance (MR) imaging. There is a subdivision of these with spinal epidural extension that have been reported in the literature. Spinal hemangiomas can also be epidural without VB involvement; these are extremely rare with few reported cases in the thoracic epidural spinal column. The diagnosis and imaging characteristics as well as the surgical tools used in gross-total resection of spinal epidural hemangioma are not well understood. The authors present a detailed characterization of a spinal epidural hemangioma in a 30-year-old woman who presented with complaints of gradual onset of low-back pain that worsened over 1 year. The MR imaging findings indicated a large L2-S1 epidural spinal mass causing thecal sac compression. The patient underwent an L2-S1 laminectomy, and a vascular extradural mass was noted on the posterior aspect of the dura mater. Preoperative spinal angiography as well as intraoperative angiography was performed. Total resection of the tumor was achieved using intraoperative embolization with sodium tetradecyl sulfate and microscopic dissection. The postoperative MR imaging findings and clinical outcome were excellent. The findings and use of sodium tetradecyl sulfate in gross-total resection are discussed. The authors also review treatment modalities and demonstrate the utility and effectiveness of intraoperative sodium tetradecyl sulfate in grosstotal resection of large difficult spinal epidural hemangiomas.

  17. Bilateral en-masse distalization of maxillary posterior teeth with skeletal anchorage: a case report

    PubMed Central

    Noorollahian, Saeed; Alavi, Shiva; Shirban, Farinaz

    2016-01-01

    ABSTRACT Objective: The aim of this study was to introduce a new method for bilateral distal movement of the entire maxillary posterior segment. Case report: A 17-year-old girl with Class I skeletal malocclusion (end-to-end molar relationships, deviated midline and space deficiency for left maxillary canine) was referred for orthodontic treatment. She did not accept maxillary first premolars extraction. A modified Hyrax appliance (Dentaurum Ispringen, Germany) was used for bilateral distalization of maxillary posterior teeth simultaneously. Expansion vector was set anteroposteriorly. Posterior legs of Hyrax were welded to first maxillary molar bands. All posterior teeth on each side consolidated with a segment of 0.017 × 0.025-in stainless steel wire from the buccal side. Anterior legs of Hyrax were bent into eyelet form and attached to the anterior palate with two mini-screws (2 × 10 mm) (Jeil Medical Corporation Seoul, South Korea). Hyrax opening rate was 0.8 mm per month. Lateral cephalometric radiographs were used to evaluate the extent of distal movement. 3.5-mm distalization of posterior maxillary teeth was achieved in five months. Results: A nearly bodily distal movement without anchorage loss was obtained. Conclusion: The mini-screw-supported modified Hyrax appliance was found to be helpful for achieving en-masse distal movement of maxillary posterior teeth. PMID:27409657

  18. Stridor due to an innominate artery compression and posterior mediastinal mass in a pediatric patient.

    PubMed

    Abraham, Edwin; Parray, Tariq; Poteet-Schwartz, Kim

    2012-06-01

    There are many causes for stridor in a pediatric patient. We present an interesting case of a pediatric patient who had stridor due to an innominate artery compression and posterior mediastinal mass. We discuss the anesthetic complication and management of patients with stridor.

  19. Biomechanical evaluation of DTRAX® posterior cervical cage stabilization with and without lateral mass fixation

    PubMed Central

    Voronov, Leonard I; Siemionow, Krzysztof B; Havey, Robert M; Carandang, Gerard; Patwardhan, Avinash G

    2016-01-01

    Introduction Lateral mass screw (LMS) fixation with plates or rods is the current standard procedure for posterior cervical fusion. Recently, implants placed between the facet joints have become available as an alternative to LMS or transfacet screws for patients with cervical spondylotic radiculopathy. The purpose of this study was to evaluate the biomechanical stability of the DTRAX® cervical cage for single- and two-level fusion and compare this to the stability achieved with LMS fixation with rods in a two-level construct. Methods Six cadaveric cervical spine (C3–C7) specimens were tested in flexion–extension, lateral bending, and axial rotation to ±1.5 Nm moment without preload (0 N) in the following conditions: 1) intact (C3–C7), 2) LMS and rods at C4–C5 and C5–C6, 3) removal of all rods (LMS retained) and placement of bilateral posterior cages at C5–C6, 4) bilateral posterior cages at C4–C5 and C5–C6 (without LMS and rods), and 5) C4–C5 and C5–C6 bilateral posterior cages at C4–C5 and C5–C6 with rods reinserted. Results Bilateral posterior cervical cages significantly reduced range of motion in all tested directions in both single- and multilevel constructs (P<0.05). Similar stability was achieved with bilateral posterior cages and LMS in a two-level construct: 0.6°±0.3° vs 1.2°±0.4° in flexion–extension (P=0.001), (5.0°±2.6° vs 3.1°±1.3°) in lateral bending (P=0.053), (1.3°±1.0° vs 2.2°±0.9°) in axial rotation (P=0.091) for posterior cages and LMS, respectively. Posterior cages, when placed as an adjunct to LMS, further reduced range of motion in a multilevel construct (P<0.05). Conclusion Bilateral posterior cages provide similar cervical segmental stability compared with a LMS and rod construct and may be an alternative surgical option for select patients. Furthermore, supplementation of a lateral mass construct with posterior cages increases cervical spine stability in single- and multilevel conditions. PMID

  20. Epidural Injections for Spinal Pain

    MedlinePlus

    ... Physician Resources Professions Site Index A-Z Epidural Injections An epidural injection provides temporary or prolonged relief ... limitations of Epidural Injection? What is an Epidural Injection? An epidural injection is an injection of medication ...

  1. [Characteristics and distribution of normal human epidural fat].

    PubMed

    Reina, M A; Pulido, P; Castedo, J; Villanueva, M C; López, A; Sola, R G

    2006-01-01

    Epidural fat provides sufficient cushion for the pulsatile movements of the dural sac, protects nerve structures, facilitates the movement of the dural sac over the periosteum of the spinal column during flexion and extension, and forms a pharmacologic reservoir of lipophilic substances. We review epidural fat and related structures, including their development during the fetal period when the epidural space is filled by undifferentiated loose, areolar mesenchymal tissue that surrounds the dural sac. In the adult, epidural fat has a continuous distribution and follows a certain metameric pattern. It is located mainly on the dorsal side of the epidural space, where it is organized in triangular capsules joined to the midline of the ligamentum flavum by a vascular pedicle. We consider the distribution of epidural fat in the axial and sagittal planes; its presence in the anterior, lateral and posterior epidural space; its presence in the cervical, thoracic and lumbar portions of the spinal column; and its characteristics and variations according to differing body habits and sex. Finally, we speculate on the possible anesthetic implications of epidural fat in terms of the pharmacokinetics of drugs injected into the epidural space and the tasks of locating the epidural space and inserting an epidural catheter during anesthetic procedures.

  2. Association Between Lateral Posterior Tibial Slope, Body Mass Index, and ACL Injury Risk

    PubMed Central

    Bojicic, Katherine M.; Beaulieu, Mélanie L.; Imaizumi Krieger, Daniel Y.; Ashton-Miller, James A.; Wojtys, Edward M.

    2017-01-01

    Background: While body mass index (BMI), a modifiable parameter, and knee morphology, a nonmodifiable parameter, have been identified as risk factors for anterior cruciate ligament (ACL) rupture, the interaction between them remains unknown. An understanding of this interaction is important because greater compressive axial force (perhaps due to greater BMI) applied to a knee that is already at an increased risk because of its geometry, such as a steep lateral posterior tibial slope, could further increase the probability of ACL injury. Purpose: To quantify the relationship between BMI and select knee morphological parameters as potential risk factors for ACL injury. Study Design: Case-control study; Level of evidence, 3. Methods: Sagittal knee magnetic resonance imaging (MRI) files from 76 ACL-injured and 42 uninjured subjects were gathered from the University of Michigan Health System’s archive. The posterior tibial slope (PTS), middle cartilage slope (MCS), posterior meniscus height (PMH), and posterior meniscus bone angle (MBA) in the lateral compartment were measured using MRI. BMI was calculated from demographic data. The association between the knee structural factors, BMI, and ACL injury risk was explored using univariate and multivariate logistic regression. Results: PTS (P = .043) and MCS (P = .037) significantly predicted ACL injury risk. As PTS and MCS increased by 1°, odds of sustaining an ACL injury increased by 12% and 13%, respectively. The multivariate logistic regression analysis, which included PTS, BMI centered around the mean (cBMI), and their interaction, showed that this interaction predicted the odds of ACL rupture (P = .050; odds ratio, 1.03). For every 1-unit increase in BMI from the average that is combined with a 1° increase in PTS, the odds of an ACL tear increased by 15%. Conclusion: An increase in BMI was associated with increased risk of ACL tear in the presence of increased lateral posterior tibial slope. Larger values of PTS or

  3. Epidural Steroid Injections

    MedlinePlus

    ... slipped vertebrae’, also known as spondylolisthesis). The epidural space is a fat filled ‘sleeve’ that surrounds the ... spinal cord. Steroids (‘cortisone’) placed into the epidural space have a very potent anti-inflammatory action that ...

  4. Extramedullary plasmacytoma presenting as a solitary mass in the intracranial posterior fossa.

    PubMed

    Daghighi, Mohammad Hossein; Poureisa, Masoud; Shimia, Mohammad; Mazaheri-Khamene, Ramin; Daghighi, Shadi

    2012-11-01

    A patient with a 3-month history of headache refractory to pain medication was admitted. The CT scan and MRI showed evidence of a posterior fossa mass. This was pathologically confirmed as an extra medullary plasmacytoma (EMP). He had a pathologic fracture of the left humerus 7 years ago while the radiologist was unaware at the time of diagnosis. A solitary bone plasmacytoma (SBP) was the cause of the pathologic fracture. This report includes the first description of MRI findings in a patient with a rare-incidence intracranial solitary extra medullary plasmacytoma (SEP) in Iran. There is a striking similarity between the features of intracranial SEP and meningiomas. Intracranial SEP, although rare, should be included in the differential diagnosis of brain tumors in areas where meningiomas commonly arise. The MRI findings and differential diagnosis of plasmacytoma are reviewed. Before this case report, only few cases have been reported in the literature. Nonetheless, this is the first report of posterior fossa EMP from Iran.

  5. Extramedullary Plasmacytoma Presenting as a Solitary Mass in the Intracranial Posterior Fossa

    PubMed Central

    Daghighi, Mohammad Hossein; Poureisa, Masoud; Shimia, Mohammad; Mazaheri-Khamene, Ramin; Daghighi, Shadi

    2012-01-01

    A patient with a 3-month history of headache refractory to pain medication was admitted. The CT scan and MRI showed evidence of a posterior fossa mass. This was pathologically confirmed as an extra medullary plasmacytoma (EMP). He had a pathologic fracture of the left humerus 7 years ago while the radiologist was unaware at the time of diagnosis. A solitary bone plasmacytoma (SBP) was the cause of the pathologic fracture. This report includes the first description of MRI findings in a patient with a rare-incidence intracranial solitary extra medullary plasmacytoma (SEP) in Iran. There is a striking similarity between the features of intracranial SEP and meningiomas. Intracranial SEP, although rare, should be included in the differential diagnosis of brain tumors in areas where meningiomas commonly arise. The MRI findings and differential diagnosis of plasmacytoma are reviewed. Before this case report, only few cases have been reported in the literature. Nonetheless, this is the first report of posterior fossa EMP from Iran. PMID:23408237

  6. Lateral mass screw stimulation thresholds in posterior cervical instrumentation surgery: a predictor of medial deviation.

    PubMed

    Wilson, Bayard; Curtis, Erik; Hirshman, Brian; Oygar, Ahmet; Chen, Karen; Gabel, Brandon C; Vaida, Florin; Allison, David W; Ciacci, Joseph D

    2017-03-01

    OBJECTIVE Normative data exists for stimulus-evoked pedicle screw electromyography (EMG) current thresholds in the lumbar spine, and is routinely referenced during spine surgeries to detect a screw breach, prevent injury of neural elements, and ensure the most biomechanically sound instrumentation construct. To date, similar normative data for cervical lateral mass screws is limited, thus the utility of lateral mass screw testing remains unclear. To address this disparity, in this study the authors describe cumulative lateral mass screw stimulation threshold data in patients undergoing posterior cervical instrumentation with lateral mass screws. These data are correlated with screw placement on postoperative imaging, and a novel correlation is discovered with direct clinical implications. METHODS Using a ball-tip probe, 154 lateral mass screws in 21 patients were electrically tested intraoperatively. In each case, for each screw, the lowest (or threshold) current at which the first polyphasic stimulus-evoked EMG response was reproducibly observed by a neurophysiologist was recorded. All patients underwent postoperative CT. Screw position within the lateral mass was first measured in the axial and sagittal planes for each lateral mass screw using the CT images. Screw placement was also evaluated by 2 independent physicians, blinded to current threshold data, on a binary scale of acceptability. The predictive capacity of screw EMG threshold data was evaluated via multivariable regression analyses and receiver operating characteristic (ROC) analyses. Predictive capacity was examined with respect to screw position within the lateral mass, as well as screw acceptability. RESULTS Lateral mass screw EMG thresholds did not appear to differ significantly for screws considered "acceptable" versus "unacceptable" according to the radiographic criteria. Accordingly, ROC analysis confirmed that EMG current threshold data were of minimal utility in predicting screw radiographic

  7. CHRONIC SPONTANEOUS LUMBAR EPIDURAL HEMATOMA SIMULATING EXTRADURAL SPINAL TUMOR : A CASE REPORT

    PubMed Central

    MATSUI, HIROKI; IMAGAMA, SHIRO; ITO, ZENYA; ANDO, KEI; HIRANO, KENICHI; TAUCHI, RYOJI; MURAMOTO, AKIO; MATSUMOTO, TOMOHIRO; ISHIGURO, NAOKI

    2014-01-01

    ABSTRACT Spinal epidural hematoma (SEH) is an uncommon disorder, and chronic SEHs are rarer than acute SEHs. However, there is few reported involving the bone change of the vertebral body in chronic SEHs. We present a case report of lumbar epidural hematoma that required differentiation from extramedullary spinal tumors by a long process because the CT scan revealed scalloping of the vertebral body and review the relevant literature. A 78-year-old man had experienced a gradual onset of low back pain and excruciating pain in both legs. Lumbar MRI on T1-weighted images revealed a space-occupying lesion with a hyperintense signal relative to the spinal cord with no enhancement on gadolinium adminisration. Meanwhile, T2-weighted images revealed a heterogeneous intensity change, accompanying a central area of hyperintense signals with a hypointense peripheral border at the L4 vertebra. Moreover, the CT scan demonstrated scalloping of the posterior wall of the L4 vertebral body which is generally suspected as the CT finding of spainal tumor. During the epidural space exploration, we found a dark red-colored mass surrounded by a capsular layer, which was fibrous and adhered to the flavum and dura mater. Microscopic histological examination of the resected mass revealed a mixture of the relatively new hematoma and the hematoma that was moving into the connective tissue. Accordingly, the hematoma was diagnosed as chronic SEH. The particular MRI findings of chronic SEHs are helpful for making accurate preoperative diagnoses of this pathology. PMID:25130006

  8. Intramuscular myxoma presenting as a rare posterior neck mass in a young child: case report and literature review.

    PubMed

    Ishoo, Edwin

    2007-04-01

    Intramuscular myxoma (IMM) is an uncommon benign tumor that presents as a slow-growing, deep-seated mass confined to the skeletal muscle. Histologically, these lesions most resemble umbilical cord tissue. They are generally found in the proximal thigh, gluteal region, or shoulder girdle and are exceedingly rare neck masses in the pediatric population. These tumors most often present as painless, deep-seated intramuscular masses that may exhibit symptoms of compression of surrounding structures.(1) I report a case of a 22-month-old girl with an IMM in the posterior cervical triangle.

  9. Prediction by computerised tomography of distance from skin to epidural space during thoracic epidural insertion.

    PubMed

    Carnie, J; Boden, J; Gao Smith, F

    2002-07-01

    In this single group observational study on 29 patients, we describe a technique that predicts the depth of the epidural space, calculated from the routine pre-operative chest computerised tomography (CT) scan using Pythagorean triangle trigonometry. We also compared the CT-derived depth of the epidural space with the actual depth of needle insertion. The CT-derived and the actual depths of the epidural space were highly correlated (r = 0.88, R2 = 0.78, p < 0.0001). The mean (95% CI) difference between CT-derived and actual depths was 0.26 (0.03-0.49) cm. Thus, the CT-derived depth tends to be greater than the actual depth by between 0.03 and 0.49 cm. There were no associations between either the CT-derived or the actual depth of the epidural space and age, weight, height or body mass index.

  10. Spontaneous spinal epidural abscess.

    PubMed

    Ellanti, P; Morris, S

    2011-10-01

    Spinal epidural abscess is an uncommon entity, the frequency of which is increasing. They occur spontaneously or as a complication of intervention. The classical triad of fever, back pain and neurological symptoms are not always present. High index of suspicion is key to diagnosis. Any delay in diagnosis and treatment can have significant neurological consequences. We present the case of a previously well man with a one month history of back pain resulting from an epidural abscess.

  11. Salmonella Typhi Vertebral Osteomyelitis and Epidural Abscess

    PubMed Central

    Chua, Ying Ying; Chen, John L. T.

    2016-01-01

    Salmonella vertebral osteomyelitis is an uncommon complication of Salmonella infection. We report a case of a 57-year-old transgender male who presented with lower back pain for a period of one month following a fall. Physical examination only revealed tenderness over the lower back with no neurological deficits. MRI of the thoracic and lumbar spine revealed a spondylodiscitis at T10-T11 and T12-L1 and right posterior epidural collection at the T9-T10 level. He underwent decompression laminectomy with segmental instrumentation and fusion of T8 to L3 vertebrae. Intraoperatively, he was found to have acute-on-chronic osteomyelitis in T10 and T11, epidural abscess, and discitis in T12-L1. Tissue and wound culture grew Salmonella Typhi and with antibiotics susceptibility guidance he was treated with intravenous ceftriaxone for a period of six weeks. He recovered well with no neurological deficits. PMID:27034871

  12. Acute lymphocytic leukemia recurring in the spinal epidural space.

    PubMed

    Higashida, Tetsuhiro; Kawasaki, Takashi; Sakata, Katsumi; Tanabe, Yutaka; Kanno, Hiroshi; Yamamoto, Isao

    2007-08-01

    A 27-year-old man presented with a very rare spinal epidural mass associated with recurrence of acute lymphocytic leukemia (ALL) manifesting as acute progressive neurological deficits. The patient presented with shoulder pain and ambulatory difficulties 3 years after remission of ALL treated by bone marrow transplantation. Magnetic resonance imaging revealed an epidural mass extending from C-7 to T-3, which compressed the cord and extended to the intervertebral foramen along the roots. After decompression surgery, the symptoms dramatically improved. Histological examination showed clusters of immature lymphocytes consistent with recurrence of leukemia, so chemotherapy and radiation therapy were carried out. At 1 year after the operation, no local mass expansion or systemic progression of leukemia had occurred. Leukemic mass must be considered in the differential diagnosis of spinal epidural mass, even in patients with ALL.

  13. Spinal epidural abscess.

    PubMed

    Miftode, E; Luca, V; Mihalache, D; Leca, D; Stefanidis, E; Anuţa, C; Sabadis, L

    2001-01-01

    In a retrospective study, 68 patients with Spinal Epidural Abscess (SEA) were reviewed. Of these, 66% had different predisposing factors such as staphylococcal skin infections, surgical procedures, rachicentesis, trauma, spondilodiscitis. Abscess had a lumbar region location in 53% of cases. Staphylococcus aureus was the most frequent etiological agent (81%). The overall rate of mortality in SEA patients was 13.2%.

  14. Severe Scapular Pain Following Unintentional Cervical Epidural Air Injection.

    PubMed

    Henthorn, Randall W; Murray, Kerra

    2016-03-01

    This a unique case of severe scapular pain following unintentional epidural space air injection during epidural steroid injection.A 70-year-old woman presented for a fluoroscopically guided C7-T1 interlaminar epidural steroid injection. Three injection attempts were made using the loss of resistance with air technique. On the first attempt the epidural space was entered, but contrast injection showed that the needle was intravenous. On the second attempt an equivocal loss of resistance with air was perceived and 5 mL of air was lost from the syringe. The needle was withdrawn and redirected, and upon the third needle passage the contrast injection showed appropriate epidural space filling up to the C4-5 level. Injection of betamethasone mixed in lidocaine was initially uneventful.However, 20 minutes post-injection the patient experienced sudden sharp and continuous pain along the medial edge of the scapula. After failing to respond to multiple intravascular analgesics, the patient was transferred to the emergency room. Her pain subsided completely following an intravenous diazepam injection. Cervical spine computerized tomography showed obvious air in the posterior epidural space from C4-5 to C6-7 as well as outside the spinal canal from (C4-T2). Having recovered fully, she was discharged the following morning. In reviewing the procedure, the equivocal loss of resistance on the second passage was actually a true loss of resistance to epidural space and air was unintentionally injected. Surprisingly, severe scapular pain resulted in a delayed manner after the steroid solution was injected. The authors theorize that unintentional prefilling of the epidural space with air prior to the injection of the subsequent steroid mixture added sufficient pressure to the epidural space to cause right-sided C4 nerve root stretching/entrapment and ensuing radicular pain to the right scapular border. The subsequent intravenous diazepam provided cervical muscle relaxation and

  15. [Vertebral osteomyelitis associated with epidural block].

    PubMed

    Carrillo Esper, R; Cruz-Bautista, I

    2001-01-01

    Infectious complications after epidural anesthesia are infrequent and the most common are epidural and subdural abscess. We report one rare case of vertebral osteomyelitus associated with an epidural catheter and review the literature.

  16. Aspergillus spinal epidural abscess

    SciTech Connect

    Byrd, B.F. III; Weiner, M.H.; McGee, Z.A.

    1982-12-17

    A spinal epidural abscess developed in a renal transplant recipient; results of a serum radioimmunoassay for Aspergillus antigen were positive. Laminectomy disclosed an abscess of the L4-5 interspace and L-5 vertebral body that contained hyphal forms and from which Aspergillus species was cultured. Serum Aspergillus antigen radioimmunoassay may be a valuable, specific early diagnostic test when systemic aspergillosis is a consideration in an immunosuppressed host.

  17. Medicolegal cases for spinal epidural hematoma and spinal epidural abscess.

    PubMed

    French, Keisha L; Daniels, Eldra W; Ahn, Uri M; Ahn, Nicholas U

    2013-01-01

    Spinal epidural hematoma and spinal epidural abscess are rare surgical emergencies resulting in significant neurologic deficits. Making the diagnosis for spinal epidural hematoma and spinal epidural abscess can be challenging; however, a delay in recognition and treatment can be devastating. The objective of this retrospective analysis study was to identify risk factors for an adverse outcome for the provider. The LexisNexis Academic legal search database was used to identify a total of 19 cases of spinal epidural hematoma and spinal epidural abscess filed against medical providers. Outcome data on trial verdicts, age, sex, initial site of injury, time to consultation, time to appropriate imaging studies, time to surgery, and whether a rectal examination was performed or not were recorded. The results demonstrated a significant association between time to surgery more than 48 hours and an unfavorable verdict for the provider. The degree of permanent neurologic impairment did not appear to affect the verdicts. Fifty-eight percent of the cases did not present with an initial deficit, including loss of bowel or bladder control. All medical professionals must maintain a high level of suspicion and act quickly. Physicians who are able to identify early clinical features, appropriately image, and treat within a 48 hour time frame have demonstrated a more favorable medicolegal outcome compared with their counterparts in filed lawsuits for spinal epidural hematoma and spinal epidural abscess cases.

  18. Spinal epidural abscess.

    PubMed

    Johnson, Katherine G

    2013-09-01

    Spinal epidural abscess is a rare bacterial infection located within the spinal canal. Early diagnosis and rapid treatment are important because of its potential to cause rapidly progressive spinal cord compression and irreversible paralysis. A staphylococcus bacterial infection is the cause in most cases. Treatment includes antibiotics and possible surgical drainage of the abscess. A favorable neurologic outcome correlates with the severity and duration of neurologic deficits before surgery and the timeliness of the chosen intervention. It is important for the critical care nurse to monitor the patient's neurologic status and provide appropriate interventions.

  19. Spinal epidural abscess in a patient with piriformis pyomyositis

    PubMed Central

    Oh, Gerald S.; Abou-Al-Shaar, Hussam; Arnone, Gregory D.; Barks, Ashley L.; Hage, Ziad A.; Neckrysh, Sergey

    2016-01-01

    Background: Spinal epidural abscess resulting from piriformis pyomyositis is extremely rare. Such condition can result in serious morbidity and mortality if not addressed in a timely manner. Case Description: The authors describe the case of a 19-year-old male presenting with a 2-week history of fever, low back pain, and nuchal rigidity. When found to have radiographic evidence of a right piriformis pyomyositis, he was transferred to our institution for further evaluation. Because he demonstrated rapid deterioration, cervical, thoracic, and lumbar magnetic resonance imaging scans were emergently performed. They revealed an extensive posterior spinal epidural abscess causing symptomatic spinal cord compression extending from C2 to the sacrum. He underwent emergent decompression and abscess evacuation through a dorsal midline approach. Postoperatively, he markedly improved. Upon discharge, the patient regained 5/5 strength in both upper and lower extremities. Cultures from the epidural abscess grew methicillin-sensitive Staphylococcus aureus warranting a 6-week course of intravenous nafcillin. Conclusion: A 19-year-old male presented with a holospinal epidural abscess (C2 to sacrum) originating from piriformis pyomyositis. The multilevel cord abscess was emergently decompressed, leading to a marked restoration of neurological function. PMID:28028447

  20. Upper Cervical Epidural Abscess in a Patient With Parkinson Disease

    PubMed Central

    Al-Hourani, Khalid; Frost, Chelsea

    2015-01-01

    To our knowledge, there are no reports in the literature of patients with Parkinson disease (PD) developing upper cervical spine infections. Our objective is to present a case of upper cervical epidural abscess in a patient with PD and to review upper cervical spine infection. We present the patient’s presentation, physical examination, imaging findings, and management as well a review of the literature. A 66-year-old male with PD presented to the emergency department (ED) following referral by a neurologist for a presumed C2 fracture. The preceding history was 1 week of severe neck pain requiring a magnetic resonance imaging (MRI), which was initially interpreted as a C2 fracture. On admission from the ED, further review of the MRI appeared to show anterior prevertebral abscess and an epidural abscess. The patient’s neurological examination was at baseline. In the span of 2 days, the patient developed significant motor weakness. A repeat MRI demonstrated expansion of the epidural collection and spinal cord compression. Surgical management consisting of C1 and C2 laminectomy, irrigation, and debridement from anterior and posterior approaches was performed. Postoperatively, the patient did not recover any motor strength and elected to withdraw care and died. Spinal epidural abscess requires a high index of suspicion and needs prompt recognition to prevent neurological impairment. Upper cervical spine infections are rare but can lead to lethal consequences. PMID:26623170

  1. Spinal epidural angiolipomas: Clinical characteristics, management and outcomes

    PubMed Central

    Bouali, Sofiene; Maatar, Nidhal; Bouhoula, Asma; Abderrahmen, Khansa; Said, Imed Ben; Boubaker, Adnen; Kallel, Jalel; Jemel, Hafedh

    2016-01-01

    Purpose: The spinal epidural angiolipomas are rare expansive processes made of mature lipomatous and angiomatous elements. They often have a benign character. Their etiology, pathogenesis remains uncertain, and it is a cause of spinal cord compression. The magnetic resonance imaging is the most important neuroradiological examination. Histological examination is the only examination to confirm the diagnosis. Surgery is the treatment of choice. Methods: A retrospective study of all patients operated on for a spinal epidural angiolipoma at the Department of Neurosurgery at the National Institute of Neurology of Tunis between January 2000 and December 2014 (15 years) was performed. The aim of this study is to describe the clinical, radiological, histological characteristics and the treatment of this tumor. Results: A total of nine patients were operated from January 01, 2000 to November 30, 2014. The average age of our patients was 51 years with ages that ranged from 29 to 65 with a male predominance. The period between onset of symptoms and diagnosis ranged from 24 months with an average 12 months. Posterior localization of the tumor was seen in all patients. Surgical resection was performed for all cases. The postoperative course has been satisfactory, with a complete recovery of neurological functions in all patients. Conclusions: The spinal epidural angiolipomas is rare expansive process causing spinal cord compression. Treatment is exclusively surgical resection. The functional outcome of spinal epidural angiolipomas is particularly favorable with a complete neurological recovery is if the patient was quickly operated. PMID:27695535

  2. EPIDURAL ANALGESIA IN LABOR - CONTROVERSIES.

    PubMed

    Bilić, Nada; Djaković, Ivka; Kličan-Jaić, Katarina; Rudman, Senka Sabolović; Ivanec, Željko

    2015-09-01

    Labor pain is one of the most severe pains. Labor is a complex and individual process with varying maternal requesting analgesia. Labor analgesia must be safe and accompanied by minimal amount of unwanted consequences for both the mother and the child, as well as for the delivery procedure. Epidural analgesia is the treatment that best meets these demands. According to the American Congress of Obstetrics and Gynecology and American Society of Anesthesiologists, mother's demand is a reason enough for the introduction of epidural analgesia in labor, providing that no contraindications exist. The application of analgesics should not cease at the end of the second stage of labor, but it is recommended that lower concentration analgesics be then applied. Based on the latest studies, it can be claimed that epidural analgesia can be applied during the major part of the first and second stage of labor. According to previous investigations, there is no definitive conclusion about the incidence of instrumental delivery, duration of second stage of labor, time of epidural analgesia initiation, and long term outcomes for the newborn. Cooperation of obstetric and anesthesiology personnel, as well as appropriate technical equipment significantly decrease the need of instrumental completion of a delivery, as well as other complications encountered in the application of epidural analgesia. Our hospital offers 24/7 epidural analgesia service. The majority of pregnant women in our hospital were aware of the advantages of epidural analgesia for labor, however, only a small proportion of them used it, mainly because of inadequate level of information.

  3. [Epidural emphysema complicating bronchial asthma].

    PubMed

    Rouetbi, N; Ben Saad, A; Joobeur, S; Skhiri, N; Cheikh Mhamed, S; Mribah, H; El Kamel, A

    2012-12-01

    Epidural emphysema is an exceptional complication of bronchial asthma, revealed by an incidental finding in chest tomography. We report a case of a 21-year-old man admitted with asthma attack complicated by subcutaneous and mediastinal emphysema. Chest tomography confirmed the mediastinal emphysema and also revealed the epidural emphysema within the vertebral canal. Neurological examination was negative. The patient showed complete recovery 10days after the onset of symptoms. The epidural emphysema is a rare complication during asthma attacks. The benignity of this complication should not require a systematic chest tomography.

  4. [Inadvertent epidural infusion of paracetamol].

    PubMed

    Charco Roca, L M; Ortiz Sánchez, V E; del Pino Moreno, A L

    2014-10-01

    A 45-year-old woman was accidentally administered an epidural infusion of paracetamol instead of levobupivacaine for postoperative pain therapy during the postoperative period of abdominal hysterectomy under general anesthesia combined with epidural analgesia. The patient had no neurological symptoms at any time, although a slight tendency to arterial hypotension that did not require treatment was observed. No rescue analgesia was necessary until 8h after the start of epidural infusion. The incidence of these types of errors is probably underestimated, although there are several cases reported with various drugs.

  5. Immunoglobulin G4-related epidural inflammatory pseudotumor presenting with pulmonary complications and spinal cord compression: case report.

    PubMed

    Rumalla, Kavelin; Smith, Kyle A; Arnold, Paul M

    2017-03-17

    Immunoglobulin G4-related disease (IgG4-RD) is a recently defined condition characterized by inflammatory tumefactive lesions in various organ systems. IgG4-RD is a clinical and radiological diagnosis of exclusion and requires the presence of specific histopathological criteria for diagnosis. A 50-year-old man presented to an outside hospital with a 3-month history of progressively worsening back pain and symptoms of pleurisy, nasal crusting, and hematochezia. Radiological workup revealed an epidural-paraspinal mass with displacement of the spinal cord, destruction of the T5-6 vertebrae, and extension into the right lung. Biopsy sampling and subsequent histopathological analysis revealed dense lymphoplasmacytic infiltrate with an increased number of IgG4-positive plasma cells and a storiform pattern of fibrosis. With strong histopathological evidence of IgG4-RD, the patient was started on a regimen of prednisone. Further testing ruled out malignant neoplasm, infectious etiologies, and other autoimmune diseases. Two weeks later, the patient presented with acute-onset paraplegia due to spinal cord compression. The patient underwent decompression laminectomy of T5-6, posterior instrumented fusion of T2-8, and debulking of the epidural-paraspinal mass. After the continued administration of glucocorticosteroids, the patient improved remarkably to near-normal strength in the lower extremities and sensory function 6 months after surgery. To the authors' knowledge, this is the first case of IgG4-related epidural inflammatory pseudotumor and spinal cord compression in the United States. This case highlights the importance of early administration of glucocorticosteroids, which were essential to preventing further progression and preventing relapse. IgG4-RD evaluation is important after other diseases in the differential diagnosis are ruled out.

  6. Epidural injections for back pain

    MedlinePlus

    ESI; Spinal injection for back pain; Back pain injection; Steroid injection - epidural; Steroid injection - back ... pillow under your stomach. If this position causes pain, you either sit up or lie on your ...

  7. [Chronic epidural haematoma mimicking meningioma].

    PubMed

    Beculić, Hakija; Skomorac, Rasim; Jusić, Aldin; Mekić-Abazović, Alma; Bajtarević, Alma

    2011-02-01

    The study presents a rare case of organised chronic epidural haematoma that imitated a meningioma. A patient was admitted to the Department of Neurology of the Cantonal Hospital Zenica due to loss of consciousness and right hemiparesis. Non-contrast Computed Tomography (CT) scan had shown an expansive intracranial process in the left parietal region which was radiologically diagnosed as a meningioma. During the operation a linear skull fracture and organised chronic epidural haematoma were found.

  8. Antibacterial activity of epidural infusions.

    PubMed

    Coghlan, M W; Davies, M J; Hoyt, C; Joyce, L; Kilner, R; Waters, M J

    2009-01-01

    The incidence of epidural abscess following epidural catheterisation appears to be increasing, being recently reported as one in 1000 among surgical patients. This study was designed to investigate the antibacterial activity of various local anaesthetics and additives, used in epidural infusions, against a range of micro-organisms associated with epidural abscess. The aim was to determine which, if any, epidural infusion solution has the greatest antibacterial activity. Bupivacaine, ropivacaine and levobupivacaine crystals were dissolved and added to Mueller-Hinton Agar in concentrations of 0.06%, 0.125%, 0.2%, 0.25%, 0.5% and 1%. Fentanyl, adrenaline and clonidine were also mixed with agar in isolation and in combination with the local anaesthetics. Using a reference agar dilution method, the minimum inhibitory concentrations were determined for a range of bacteria. Bupivacaine showed antibacterial activity against Staphylococcus aureus, Enterococcus faecalis and Escherichia coli with minimum inhibitory concentrations between 0.125% and 0.25%. It did not inhibit the growth of Pseudomonas aeruginosa at any of the concentrations tested. Levobupivacaine and ropivacaine showed no activity against Staphylococcus aureus, Enterococcus faecalis and Pseudomonas aeruginosa, even at the highest concentrations tested, and minimal activity against Escherichia coli (minimum inhibitory concentrations 0.5% and 1% respectively). The presence of fentanyl, adrenaline and clonidine had no additional effect on the antibacterial activity of any of the local anaesthetic agents. The low concentrations of local anaesthetic usually used in epidural infusions have minimal antibacterial activity. While the clinical implications of this in vitro study are not known, consideration should be given to increasing the concentration of bupivacaine in an epidural infusion or to administering a daily bolus of 0.25% bupivacaine to reduce the risk of epidural bacterial growth.

  9. Spinal epidural abscess.

    PubMed

    Krishnamohan, Prashanth; Berger, Joseph R

    2014-11-01

    Spinal epidural abscess (SEA) remains a relatively infrequent diagnosis. Staphylococcus aureus is the most common organism identified, and the infectious source in SEA emanates from skin and soft tissue infections in about 20 % of instances. The thoracic spine is most often involved followed by the lumbar spine. The classic triad of fever, spinal pain, and neurological deficit is present in but a minority of patients. The appearance of neurological deficits with SEA has a significant impact on the prognosis; therefore, early diagnosis is imperative. Magnetic resonance imaging has permitted earlier diagnosis, although significant delays in diagnosis are common due to the nonspecific symptoms that frequently attend the disorder. Due to the rarity of this condition, there have been few randomized controlled trials to evaluate new treatment strategies, and most recommendations regarding treatment are based on case series studies often derived from the experiences at a single center.

  10. Adult Primary Spinal Epidural Extraosseous Ewing's Sarcoma: A Case Report and Review of the Literature

    PubMed Central

    Thomas, Cheddhi; Modrek, Aram S.; Bayin, N. Sumru; Snuderl, Matija; Schiff, Peter B.

    2016-01-01

    Background. Extraosseous Ewing's sarcoma in the spinal epidural space is a rare malignancy, especially in adults. Case Presentation. A 40-year-old male presented with back pain and urinary hesitancy. MRI revealed a thoracic extradural mass with no osseous involvement. He underwent surgery for gross total resection of the mass, which was diagnosed as Ewing's sarcoma. He was subsequently treated with chemoradiotherapy. He remains disease-free 1 year after surgery. Review of the literature indicated only 45 previously reported cases of spinal epidural extraosseous Ewing's sarcoma in adults. Conclusions. Extraosseous Ewing's sarcoma in the spinal epidural space is a rare clinical entity that should be included in the differential for spinal epidural masses. Its treatment is multidisciplinary but frequently requires surgical intervention due to compressive neurologic symptoms. Gross total resection appears to correlate with improved outcomes. PMID:27610254

  11. Primary spinal epidural B-lymphoblastic lymphoma

    PubMed Central

    Nambiar, Rakul K.; Prabhakaran, Pranab K.; Mathew, Sherin P.

    2017-01-01

    Extranodal lymphomas constitute 20% to 30% of all non-Hodgkin's lymphomas. The common sites involved are skin, stomach, brain, and small intestine. Epidural localization is a rare site for lymphomas, accounting for 10% of spinal epidural tumors. Lymphomas occurring primarily in the epidural space without other previously detected lymphomatous foci (i.e., primary spinal epidural lymphomas) represent an even rarer entity. We report a case of primary spinal epidural B-lymphoblastic lymphoma. The patient presented with paraparesis, and a spinal epidural lesion was diagnosed. Considering the rapidity of symptom onset, the possibility of epidural abscess was considered, and he underwent partial laminectomy with decompression of the lesion. Histopathology and immunohistochemistry were diagnostic of B-lymphoblastic lymphoma. The present case is the first report in the literature of B-lymphoblastic lymphoma presenting as a spinal epidural lesion. PMID:28127138

  12. Holospinal epidural abscess of the spinal axis: two illustrative cases with review of treatment strategies and surgical techniques.

    PubMed

    Smith, Gabriel A; Kochar, Arshneel S; Manjila, Sunil; Onwuzulike, Kaine; Geertman, Robert T; Anderson, James S; Steinmetz, Michael P

    2014-08-01

    Despite the increasing prevalence of spinal infections, the subcategory of holospinal epidural abscesses (HEAs) is extremely infrequent and requires unique management. Panspinal imaging (preferably MRI), modern aggressive antibiotic therapy, and prompt surgical intervention remain the standard of care for all spinal axis infections including HEAs; however, the surgical decision making on timing and extent of the procedure still remain ill defined for HEAs. Decompression including skip laminectomies or laminoplasties is described, with varied clinical outcomes. In this review the authors present the illustrative cases of 2 patients with HEAs who were treated using skip laminectomies and epidural catheter irrigation techniques. The discussion highlights different management strategies including the role of conservative (nonsurgical) management in these lesions, especially with an already identified pathogen and the absence of mass effect on MRI or significant neurological defects. Among fewer than 25 case reports of HEA published in the past 25 years, the most important aspect in deciding a role for surgery is the neurological examination. Nearly 20% were treated successfully with medical therapy alone if neurologically intact. None of the reported cases had an associated cranial infection with HEA, because the dural adhesion around the foramen magnum prevented rostral spread of infection. Traditionally a posterior approach to the epidural space with irrigation is performed, unless an extensive focal ventral collection is causing cord compression. Surgical intervention for HEA should be an adjuvant treatment strategy for all acutely deteriorating patients, whereas aspiration of other infected sites like a psoas abscess can determine an infective pathogen, and appropriate antibiotic treatment may avoid surgical intervention in the neurologically intact patient.

  13. Fluoroscopically guided extraforaminal cervical nerve root blocks: analysis of epidural flow of the injectate with respect to needle tip position.

    PubMed

    Shipley, Kyle; Riew, K Daniel; Gilula, Louis A

    2014-02-01

    Study Design Retrospective evaluation of consecutively performed fluoroscopically guided cervical nerve root blocks. Objective To describe the incidence of injectate central epidural flow with respect to needle tip position during fluoroscopically guided extraforaminal cervical nerve root blocks (ECNRBs). Methods Between February 19, 2003 and June 11, 2003, 132 consecutive fluoroscopically guided ECNRBs performed with contrast media in the final injected material (injectate) were reviewed on 95 patients with average of 1.3 injections per patient. Fluoroscopic spot images documenting the procedure were obtained as part of standard quality assurance. An independent observer not directly involved in the procedures retrospectively reviewed the images, and the data were placed into a database. Image review was performed to determine optimal needle tip positioning for injectate epidural flow. Results Central epidural injectate flow was obtained in only 28.9% of injections with the needle tip lateral to midline of the lateral mass (zone 2). 83.8% of injectate went into epidural space when the needle tip was medial to midline of the lateral mass (zone 3). 100% of injectate flowed epidurally when the needle tip was medial to or at the medial cortex of the lateral mass (zone 4). There was no statistically significant difference with regards to central epidural flow and the needle tip position on lateral view. Conclusion To ensure central epidural flow with ECNRBs one must be prepared to pass the needle tip medial to midplane of the lateral mass or to medial cortex of the lateral mass. Approximately 16% of ECNRBs with needle tip medial to midline of the lateral mass did not flow into epidural space. One cannot claim a nerve block is an epidural block unless epidural flow of injectate is observed.

  14. The Epidural Ligaments (of Hofmann): A Comprehensive Review of the Literature

    PubMed Central

    Tardieu, Gabrielle G; Loukas, Marios; Moisi, Marc; Chapman, Jens; Oskouian, Rod J; Tubbs, R. Shane

    2016-01-01

    The epidural space contains the internal vertebral venous plexus, adipose, and other connective tissues. In the anatomical literature, there are nonspecific descriptions of varying fibrous connective tissue bands in the epidural space, mainly mentioned in the lumbar region, that tether the dural sac to the posterior longitudinal ligament, the vertebral canal, and the ligamentum flavum. These ligaments have been termed as Hofmann’s ligaments. This review expands on the anatomy and function of Hofmann’s ligaments, increasing the awareness of their presence and serves as an impetus for further study of their histology, innervation, and function.  PMID:27752405

  15. Recent Advances in Epidural Analgesia

    PubMed Central

    Bauer, Maria; George, John E.; Seif, John; Farag, Ehab

    2012-01-01

    Neuraxial anesthesia is a term that denotes all forms of central blocks, involving the spinal, epidural, and caudal spaces. Epidural anesthesia is a versatile technique widely used in anesthetic practice. Its potential to decrease postoperative morbidity and mortality has been demonstrated by numerous studies. To maximize its perioperative benefits while minimizing potential adverse outcomes, the knowledge of factors affecting successful block placement is essential. This paper will provide an overview of the pertinent anatomical, pharmacological, immunological, and technical aspects of epidural anesthesia in both adult and pediatric populations and will discuss the recent advances, the related rare but potentially devastating complications, and the current recommendations for the use of anticoagulants in the setting of neuraxial block placement. PMID:22174708

  16. [Case of spinal epidural abscess after continuous epidural block to manage the pain of herpes zoster].

    PubMed

    Miyamoto, Tatsuhito; Nakatani, Toshihiko; Narai, Yasuhiro; Sakakibara, Manabu; Hashimoto, Tatsuya; Saito, Youji

    2014-03-01

    A woman in her 90's received continuous epidural block for the pain of herpes zoster. Four days after epidural catheterization, she was found with cellutitis. Fourteen days after epidural catheterization, spinal epidural abscess was pointed out on MRI. Since there were no neurological symptoms, we performed conservative medical management with antibiotics. She recovered without sequela When the symptoms of cellutitis appeared after epidural block (even if there are neither neurological symptoms nor infectious signs), there is a possibility of progressing into spinal epidural abscess.

  17. Reversal of tetraplegia in a patient with haematogenous cervical epidural abscess.

    PubMed

    Katonis, Pavlos; Souvatzis, Xenia; Tsavalas, Nikolaos; Alpantaki, Kalliopi

    2011-08-01

    Pyogenic haematogenous cervical epidural abscess complicated by tetraplegia is an uncommon entity, but its clinical importance overshadows its rarity. Predisposing risk factors for spinal epidural abscess include diabetes, intravenous drug abuse, liver disease, renal failure, malignancy, HIV, infection elsewhere, rheumatoid conditions, trauma and a number of spinal interventions. Lack of recovery and death are much more frequent when complete paralysis exists since more than 24 to 48 hours. Most authors combine decompressive laminectomy and antibiotics. Anterior decompression and needle aspiration are rarely used, the former more specifically in case of anterior abscess formation. A high index of suspicion along with reliance on gadolinium-enhanced MRI is essential to diagnose the pathology and institute appropriate treatment on an individual basis. The authors report on a diabetic male patient who developed a cervical epidural abscess with tetraplegia after dental extraction. He was treated within six hours by one stage anterior/posterior decompression and fusion, with complete recovery.

  18. Emergency surgery for epidural abcess secondary to sacral fistula after laparoscopic proctectomy

    PubMed Central

    Zeitoun, Jeremie; Menahem, Benjamin; Fohlen, Audrey; Lebreton, Gil; Lubrano, Jean; Alves, Arnaud

    2016-01-01

    A 61-year-old man presented via the emergency department with a few days history of abdominal and colic occlusion symptoms. He presented signs of sepsis, midline lumbar spine tenderness and reduced hip flexion. Computer tomography of the abdomen and pelvis showed a presacral collection contiguous with the posterior part of the colo-rectal anastomosis, and MRI lumbar spine revealed abscess invation into the epidural space. He underwent a laparotomy with washout of the presacral abscess and a colostomy with a prolonged course of intravenous antibiotic therapy. At 3 weeks after initial presentation he had made a full clinical recovery with progressive radiological resolution of the epidural abscess. The objective of the case report is to highlight a unique and clinically significant complication of a rare post-operative complication after rectal surgery and to briefly discuss other intra-abdominal sources of epidural abscess. PMID:27421299

  19. Spontaneous spinal epidural hematoma after abrupt sneezing with prompt recovery of severe paraparesis.

    PubMed

    Štětkářová, Ivana; Jelínková, Lenka; Janík, Vaclav; Peisker, Tomas

    2014-12-01

    Spontaneous spinal epidural hematoma (SSEH) is a rare neurologic condition with threatening consequences when spinal cord compression is present. The diagnosis must be performed quickly using magnetic resonance imaging (MRI), which shows collection of blood in the epidural space. With spinal cord compression, there is an indication for urgent surgical decompression. Here, we present a 64-year-old woman who developed sudden thoracic and lower back pain accompanied by severe paraparesis and urinary retention after sneezing abruptly. An MRI revealed a posterior thoracic epidural hematoma extending from the T6 to T11 vertebral level with spinal cord compression. Decompression was recommended, but the patient refused surgery, while neurologically improving with time. Complete neurologic recovery was observed within 24 hours after SSEH onset. A conservative therapeutic approach with careful observation may therefore be considered as a treatment of choice in some cases where surgery is refused, (due to high risk or other reasons) and neurologic recovery is early and sustained.

  20. [Hyperthermia after obstetrical epidural anesthesia].

    PubMed

    Mercier, F J; Benhamou, D

    1994-01-01

    Unlike epidural anaesthesia for general surgery or caesarean section, épidural analgesia for labour leads to maternal hyperthermia. Its recent demonstration is probably related to the multiple influencing factors: site of measurement, ambient temperature, previous labour duration and dilatation at the time of epidural puncture, and occurrence of shivering. During the first 2 to 5 hours of epidural analgesia, there is a weak--if any--thermic increase. Then, when labour is prolonged (mostly primiparae) a linear increase occurs with time, at a mean rate of 1 degree C per 7 hours. The pathophysiology remains hypothetical: heat loss (sweating and hyperventilation) would be reduced during epidural analgesia and therefore surpassed by the important labour-induced heat production. This hyperthermia has been correlated with foetal tachycardia but never with any infectious process. A potential deleterious effect is still debated and may lead to propose an active cooling for the mother. This hyperthermia must also be recognized to avoid an inadequate obstetrical attitude (antibiotics, extractions).

  1. The Use of a Dehydrated Amnion/Chorion Membrane Allograft in Patients Who Subsequently Undergo Reexploration after Posterior Lumbar Instrumentation

    PubMed Central

    Subach, Brian R.; Copay, Anne G.

    2015-01-01

    Background Context. Products that can reduce development of epidural fibrosis may reduce risk for ongoing pain associated with development of scar tissue and make subsequent epidural reexploration easier. Purpose. To evaluate the use of dehydrated human amnion/chorion membrane (dHACM) on the formation of soft tissue scarring in the epidural space. Study Design. Case series. Patient Sample. Five patients having transforaminal lumbar interbody lumbar fusion (TLIF) with posterior instrumentation and implantation of dHACM in the epidural space and subsequent epidural reexploration. Outcome Measures. Degree of scar tissue adjacent to the epidural space at reexploration. Intraoperative and postoperative complications related to dHACM and patient reported outcomes. Methods. The degree of scar tissue adjacent to the epidural space was assessed during the reexploration surgery. Patients' outcomes were collected using standard validated questionnaires. Results. Four of 5 cases had easily detachable tissue during epidural reexploration. Angiolipoma of 10% was noted in 1 case and 5% in 2 cases. Significant improvements in patient reported outcomes were observed. No intraoperative or postoperative complications occurred. Conclusions. Our findings suggest that dHACM implant during TLIF may have favorable effects on epidural fibrosis and is well tolerated. Further studies with larger cohorts are required to prove our results. PMID:25653880

  2. [Spinal epidural lymphoma. A study using computed tomography].

    PubMed

    Ibarra, B; Romero, F J; Torrents, C; Rovira, M

    1990-02-01

    We have gone through the computerized tomographies (CT) of four cases of spinal epidural lymphomas (SEL) studied in our department. Paraparesis with a sensitive level was the beginning of the disease three times; sciatic pain with recurrent fever once. A myelography followed by CT was done in the three cases of paraparesis while a non-contrast CT and a contrast-enhanced study was done in the case of sciatic pain. An homogeneous intraspinal mass stretching at least along one vertebral segment was the most usual finding. This mass spread into paraspinal tissue effacing fat lines. The mass was hyperdense in relation to dural sack and was limited to intraspinal space in one occasion. We have revised bibliography about osseous lesions in SEL and have found out disagreement on it. We have found them only once in our study. Intrathecal contrast was useless in determining tumour nature but useful in delimiting intraspinal extent. We have searched for tomographic features in order to establish differential diagnosis with other spinal epidural diseases. We did not find any SEL-exclusive features but we found that an homogeneous intra-extraspinal mass, extended at least along one vertebral segment and either producing or not producing osseous lesions can make us think of the presence of spinal epidural lymphoma.

  3. Paraplegia After Thoracic Epidural Steroid Injection.

    PubMed

    Loomba, Vivek; Kaveeshvar, Hirsh; Dwivedi, Samvid

    2016-09-01

    Epidural steroid injections are a common procedure performed by pain physicians. The American Society of Regional Anesthesia along with several other groups recently provided guidelines for performing epidural injections in the setting of anticoagulants. We present a case of a patient who developed an epidural hematoma and subsequent paraplegia despite strict adherence to these guidelines. Although new guidelines serve to direct practice, risks of devastating neurologic complications remain as evidenced by our case.

  4. [Maintaining epidural anesthesia by the midwife].

    PubMed

    Dörfling, C; Nolte, A G

    1990-12-01

    Epidural anaesthesia as a method of pain relief during labour has lately become very popular. Statistics show that in some labour units up to 70 per cent of all patients undergo epidural anaesthesia. The popularity of this method can be attributed to its effectiveness in relieving pain during labour. The anaesthetist commences an epidural block by introducing an epidural catheter into the epidural space. The anaesthetist administers the test dose and the first therapeutic dose. Within a short duration of time (10 to 20 minutes) the patient can already experience the numbing effect of the anaesthetic. This anaesthetic loses its numbing effect within two to three hours and effective pain relief can only be achieved by administering a further dose of local anaesthetic via the epidural catheter. This procedure can be repeated between three to six times during the average duration of labour. Alternatively, a continuous epidural infusion procedure can be used. The last method, however, sometimes requires the administration of additional epidural "top-ups". There are some risks in administering additional "top-up" dosages. The possibility exists of the anaesthetic causing a spinal block as a result of being administered into the spinal fluid. The "top-up" can also cause convulsions if administered intravenously. In some units it is expected of the midwife to maintain epidural anaesthesia on prescription by the doctor. These side-effects can, however, also occur when the patient is being treated by medical personnel with ample experience and knowledge. It is expected of some midwives to maintain an epidural block on prescription by the anaesthetist. If the midwife lacks the necessary knowledge of epidural anaesthetic and its maintenance, she might unintentionally administer the local anaesthetic into the spinal fluid or intravascularly. This might cause a threat to the mother's and baby's lives. This research covers the maintenance of epidural anaesthesia as carried out by

  5. The Effect of Epidural Analgesia on the Delivery Outcome of Induced Labour: A Retrospective Case Series

    PubMed Central

    2016-01-01

    Objective. To investigate whether the use of epidural analgesia during induced labour was a risk factor for instrumental vaginal delivery and caesarean section (CS) delivery. Study Design. This was a retrospective case series of primigravidae women being induced at term for all indications with a normal body mass index (BMI) at booking and under the age of 40 years. Results. We identified 1,046 women who fulfilled the inclusion criteria of which 31.2% had an epidural analgesia. Those with an epidural analgesia had significantly greater maternal age, higher BMI, greater percentage of oxytocin usage, and a longer first and second stage of labour. Women with an epidural analgesia had a higher instrumental delivery (37.9% versus 16.4%; p < 0.001) and CS delivery rate (26% versus 10.1%; p < 0.001). Multivariable analysis indicated that the use of an epidural was not a risk factor for a CS delivery but was a risk factor for an instrument-assisted delivery (adjusted OR = 3.63; 95% CI: 2.51–5.24; p < 0.001). Conclusion. Our study supports the literature evidence that the use of an epidural increases the instrumental delivery rates. It has also added that there is no effect on CS delivery and the observed increase is due to the presence of confounding factors. PMID:27990163

  6. Epidural optogenetics for controlled analgesia

    PubMed Central

    Bonin, Robert P; Wang, Feng; Desrochers-Couture, Mireille; Ga¸secka, Alicja; Boulanger, Marie-Eve; Côté, Daniel C

    2016-01-01

    Background Optogenetic tools enable cell selective and temporally precise control of neuronal activity; yet, difficulties in delivering sufficient light to the spinal cord of freely behaving animals have hampered the use of spinal optogenetic approaches to produce analgesia. We describe an epidural optic fiber designed for chronic spinal optogenetics that enables the precise delivery of light at multiple wavelengths to the spinal cord dorsal horn and sensory afferents. Results The epidural delivery of light enabled the optogenetic modulation of nociceptive processes at the spinal level. The acute and repeated activation of channelrhodopsin-2 expressing nociceptive afferents produced robust nocifensive behavior and mechanical sensitization in freely behaving mice, respectively. The optogenetic inhibition of GABAergic interneurons in the spinal cord dorsal horn through the activation of archaerhodopsin also produced a transient, but selective induction of mechanical hypersensitivity. Finally, we demonstrate the capacity of optogenetics to produce analgesia in freely behaving mice through the inhibition of nociceptive afferents via archaerhodopsin. Conclusion Epidural optogenetics provides a robust and powerful solution for activation of both excitatory and inhibitory opsins in sensory processing pathways. Our results demonstrate the potential of spinal optogenetics to modulate sensory behavior and produce analgesia in freely behaving animals. PMID:27030718

  7. Thoracic spinal epidural abscess caused by Salmonella typhi.

    PubMed

    Abdullah, Saad Hamdan; Ata, Osama Abu; El-Adwan, Nael

    2008-03-01

    A 56-year-old man presented with a rare spinal epidural abscess manifesting as attacks of back pain associated with fever, weight loss, generalized weakness and fatigability, and constipation. He had multiple skin pustules in the last 4 months treated with oral amoxicillin. He had suffered diabetes mellitus for the last 5 years and was insulin dependent. Physical examination found slight paraparesis with sensory loss around the nipple and sphincteric urgency, and diabetic retinopathy. Magnetic resonance imaging showed edematous T2, T3, and T4 vertebral bodies, and narrow enhanced T3-4 disk space with a soft tissue enhanced mass mostly anterior to the spinal cord and indenting the cord. T3-4 costotransversectomy was performed to remove the extradural mass and evacuate the intradiscal material. Histological examination of the bone found osteomyelitis, and culture of the soft tissue showed Salmonella typhi sensitive to ceftriaxone and ciprofloxacin. Intravenous ceftriaxone administration was started, and the patient was discharged after 6 days in good condition. The outcome of spinal epidural abscess is devastating unless recognized and treated early. The present case of spinal epidural abscess in the thoracic spine caused by Salmonella typhi infection illustrates the importance of cultures to assess the drug sensitivity of the specific strain detected and adjusting the treatment accordingly.

  8. Digging up the recent Spanish memory: genetic identification of human remains from mass graves of the Spanish Civil War and posterior dictatorship.

    PubMed

    Baeta, Miriam; Núñez, Carolina; Cardoso, Sergio; Palencia-Madrid, Leire; Herrasti, Lourdes; Etxeberria, Francisco; de Pancorbo, Marian M

    2015-11-01

    The Spanish Civil War (1936-1939) and posterior dictatorship (until 1970s) stands as one of the major conflicts in the recent history of Spain. It led to nearly two hundred thousand men and women executed or murdered extra-judicially or after dubious legal procedures. Nowadays, most of them remain unidentified or even buried in irretraceable mass graves across Spain. Here, we present the genetic identification of human remains found in 26 mass graves located in Northern Spain. A total of 252 post-mortem remains were analyzed and compared to 186 relatives, allowing the identification of 87 victims. Overall, a significant success of DNA profiling was reached, since informative profiles (≥ 12 STRs and/or mitochondrial DNA profile) were obtained in 85.71% of the remains. This high performance in DNA profiling from challenging samples demonstrated the efficacy of DNA extraction and amplification methods used herein, given that only around 14.29% of the samples did not provide an informative genetic profile for the analysis performed, probably due to the presence of degraded and/or limited DNA in these remains. However, this study shows a partial identification success rate, which is clearly a consequence of the lack of both appropriate family members for genetic comparisons and accurate information about the victims' location. Hence, further perseverance in the exhumation of other intact graves as well as in the search of more alleged relatives is crucial in order to facilitate and increase the number of genetic identifications.

  9. Facial nerve paralysis and partial brachial plexopathy after epidural blood patch: a case report and review of the literature

    PubMed Central

    Shahien, Radi; Bowirrat, Abdalla

    2011-01-01

    We report a complication related to epidural analgesia for delivery in a 24- year-old woman who was admitted with mild pre-eclampsia and for induction of labor. At the first postpartum day she developed a postdural puncture headache, which was unresponsive to conservative measures. On the fifth day an epidural blood patch was done, and her headache subsided. Sixteen hours later she developed paralysis of the right facial nerve, which was treated with prednisone. Seven days later she complained of pain in the left arm and the posterior region of the shoulder. She was later admitted and diagnosed with partial brachial plexopathy. PMID:21386953

  10. Cervical epidural hematoma after chiropractic spinal manipulation.

    PubMed

    Heiner, Jason D

    2009-10-01

    Spinal epidural hematoma is a rare but potentially devastating complication of spinal manipulation therapy. This is a case report of a healthy pregnant female who presented to the emergency department with a cervical epidural hematoma resulting from chiropractic spinal manipulation therapy that responded to conservative treatment rather than the more common route of surgical management.

  11. Postlumbar puncture arachnoiditis mimicking epidural abscess

    PubMed Central

    Gürbüz, Mehmet Sabri; Erdoğan, Barıs; Yüksel, Mehmet Onur; Somay, Hakan

    2013-01-01

    Lumbar spinal arachnoiditis occurring after diagnostic lumbar puncture is a very rare condition. Arachnoiditis may also present with fever and elevated infection markers and may mimic epidural abscess, which is one of the well known infectious complications of lumbar puncture. We report the case of a 56-year-old man with lumbar spinal arachnoiditis occurring after diagnostic lumbar puncture who was operated on under a misdiagnosis of epidural abscess. In the intraoperative and postoperative microbiological and histopathological examination, no epidural abscess was detected. To our knowledge, this is the first case of a patient with postlumbar puncture arachnoiditis operated on under a misdiagnosis of epidural abscess reported in the literature. The authors suggest that arachnoiditis may mimic epidural abscess due to its clinical and radiological features and should be considered in the differential diagnosis of complications of lumbar puncture. PMID:24197809

  12. Symptomatic posterior mediastinal angioleiomyoma.

    PubMed

    I, Hoseok; Jeong, Yeon Joo; Choi, Kyung Un; Kim, Yeong-Dae

    2008-08-30

    We report a case of a symptomatic angioleiomyoma in the left posterior mediastinum. A 66-year-old woman presented with left back and flank pain for 6 months. Chest computed tomography (CT) and magnetic resonance imaging (MRI) revealed a well-circumscribed 4.3 cm round mass. The mass was initially diagnosed as nerve sheath tumor, because of her symptoms and its close location to the sympathetic trunk and intercostal nerve. It was uneventfully removed through video-assisted thoracoscopic surgery. The pathology revealed an angioleiomyoma.

  13. Management of acute spontaneous thoracic spinal epidural hematoma causing paraplegia.

    PubMed

    Alić, Fahrudin; Bečulić, Hakija; Jusić, Aldin; Skomorac, Rasim; Moranjkić, Mirza; Hrvat, Lejla; Tandir, Lejla

    2017-02-01

    Aim To emphasize the importance of early recognition, diagnostic processing and emergent surgical treatment of spontaneous spinal epidural hematoma (SSEH). Methods A 39-year-old female presented with sudden onset of severe pain between the shoulder blades followed by paraparesis and alerted sensibility in the lower extremities. An hour later she developed paraplegia with sensory deficits below ThIV level, absence of patellar reflex, ankle jerk reflex and sphincter dysfunction. Results Magnetic resonance imaging (MRI) demonstrated acute extensive epidural mass of thoracic spinal segments (ThI-ThIII). The patient underwent emergent decompressive laminectomy ThI-ThIII with epidural hematoma evacuation within 24 hours of symptoms onset. After the surgical treatment, because of suspicion on spinal arteriovenous malformation, complete diagnostic evaluation with spinal angiography was done and no form of vascular malformation was found. Idiopathic SSEH was diagnosed. Two months later the patient reached complete neurological improvement. Conclusion The SSEH is a rare condition that should be kept in mind in patients presenting with neurological deficit and a sudden onset of back pain like it was in our case. For early diagnosis, immediate MRI is essential. Prompt surgical decompression such as laminectomy is an absolute surgical indication widely accepted for patients with progressive neurological deficit. The SSEH should be considered as one of the important differential diagnoses in patients who have developed acute myelopathy.

  14. Cervical epidural steroid injection for cervicobrachialgia.

    PubMed

    Stav, A; Ovadia, L; Sternberg, A; Kaadan, M; Weksler, N

    1993-08-01

    Fifty patients with chronic resistant cervicobrachialgia were randomly divided into two groups. Twenty-five patients (group A) were treated with cervical epidural steroid/lidocaine injections and 17 patients (group B) were treated with steroid/lidocaine injections into the posterior neck muscles. Another eight patients from group B were excluded from the study because they had started the process of litigation of insurance claims and their subjective analysis of pain relief might therefore not be trustworthy. One to three injections were administered at 2-week intervals according to the clinical response. All patients continued their various pre-study treatments: non-steroidal anti-inflammatory drugs, non-opioid analgesics and physiotherapy. Pain relief was evaluated by the visual analogue scale 1 week after the last injection and then 1 year later. One week after the last injection we rated pain relief as very good and good in 76% of the patients in group A, as compared to 35.5% of the patients in group B. One year after the treatment 68% of the group A patients still had very good and good pain relief, whereas only 11.8% of group B patients reported this degree of pain relief. These differences were statistically significant. We failed to achieve significant improvement of tendon reflexes or of sensory loss in both groups, but the increase in the range of motion, the fraction of patients who were able to decrease their daily dose of analgesics, and recovery of the capacity for work were significantly better in group A. We encountered no complications in either group of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

  15. Spinal epidural abscess in a young girl without risk factors.

    PubMed

    Mantadakis, Elpis; Birbilis, Theodosios; Michailidis, Lambros; Souftas, Vasileios; Chatzimichael, Athanassios

    2011-07-01

    Spinal epidural abscess (SEA) is a rare infection associated with well-established risk factors mainly in adults. We describe an 11-year-old girl without any known risk factors who presented with fever and localized spinal tenderness in the lumbar area and was diagnosed with spinal MRI as suffering from a posterior SEA extending between T11 and L4. She was successfully managed with sequential intravenous and oral antibiotics along with minimally invasive surgery without laminectomy. Methicillin-sensitive Staphylococcus aureus was the responsible pathogen isolated at surgery. Immediate institution of antibiotics, spinal MRI, and well-timed neurosurgical consultation are mandatory for a favorable outcome in cases of SEA in children.

  16. Epidural blood patch and acute varicella.

    PubMed

    Martin, David P; Bergman, Bradley D; Berger, Ines H

    2004-12-01

    We present the case of a 38-yr-old woman who required an epidural blood patch in the context of acute varicella (chickenpox). The unique risks in this case include the possible triggering of central nervous system complications after the introduction of viremic blood into the epidural or intrathecal space. However, the risk was believed to be acceptable because the patient was receiving antiviral coverage. She enjoyed complete relief of her headache but experienced transient back and leg pain. Leptomeningeal irritation caused by acute varicella infection may put patients at increased risk for pain after epidural blood patch.

  17. Effect of epidural analgesia on labor and delivery: a retrospective study.

    PubMed

    Gerli, Sandro; Favilli, Alessandro; Acanfora, Marta M; Bini, Vittorio; Giorgini, Carla; Di Renzo, Gian Carlo

    2011-03-01

    Two groups of women have been retrospectively compared: 155 women who received analgesia and 1355 women who delivered without analgesia. The duration of the first stage, second stage, and total duration of labor was longer in epidural group, however epidural analgesia was not demonstrated as an independent risk factor for a prolonged labor. The variable most influencing the total duration of labor and the duration of the first stage was nulliparity; the variables most influencing the duration of the second stage were the older age, a reduced body mass index, a high newborn weight and nulliparity.

  18. Successful medical treatment of spinal epidural abscess.

    PubMed

    Xiao, Bo-Ren; Wang, Chih-Wei; Lin, Jung-Chung; Chang, Feng-Yee

    2008-04-01

    Spinal epidural abscess is a rare but potentially fatal disease. A 67-year-old female suffered fever and painful swelling of the right knee and lower leg for one week. Both synovial fluid and blood cultures yielded methicillin-sensitive Staphylococcus aureus. Low back pain developed and fever was sustained despite the administration of intravenous oxacillin. Magnetic resonance imaging (MRI) of the thoracolumbar spine revealed spinal epidural abscess from T12 to S1. Because of severe hypoalbuminemia and general anasarca and followed by exploratory laparotomy for massive duodenal bleeding, she did not receive surgical intervention for the spinal epidural abscess. After intravenous administration of oxacillin 2 g 4-hourly for 12 weeks, she recovered and follow-up MRI confirmed the efficacy of the medical treatment. She remained well at 1-year follow-up. In a patient with minimal neurological deficit or surgical contraindication, spinal epidural abscess can be successfully treated with a medical regimen.

  19. Cervical Meningomyelitis After Lumbar Epidural Steroid Injection

    PubMed Central

    Kim, Joon-Sung; Kim, Ji Yeon

    2015-01-01

    Epidural steroid injections (ESI) are a common treatment for back pain management. ESI-related complications have increased with the growing number of procedures. We report a case of cervical meningomyelitis followed by multiple lumbar ESI. A 60-year-old male with diabetes mellitus presented to our hospital with severe neck pain. He had a history of multiple lumbar injections from a local pain clinic. After admission, high fever and elevated inflammatory values were detected. L-spine magnetic resonance imaging (MRI) revealed hematoma in the S1 epidural space. Antibiotic treatment began under the diagnosis of a lumbar epidural abscess. Despite the treatment, he started to complain of weakness in both lower extremities. Three days later, the weakness progressed to both upper extremities. C-spine MRI revealed cervical leptomeningeal enhancement in the medulla oblongata and cervical spinal cord. Removal of the epidural abscess was performed, but there was no neurological improvement. PMID:26161360

  20. Epidural Analgesia in the Postoperative Period

    DTIC Science & Technology

    2001-10-01

    an unwanted side effect of surgery, and is associated with many postoperative complications. This descriptive study was conducted to determine which...surgical patients experienced the most analgesia with the fewest side effects when receiving epidural analgesia in the postoperative period. A...hospital. A description of the patients age, gender, type of surgery, type of epidural medication, side effects , incidence of breakthrough pain, and

  1. Epidural hematoma associated with spinal fracture in diffuse idiopathic skeletal hyperostosis.

    PubMed

    Tauchi, Ryoji; Imagama, Shiro; Satake, Kotaro; Iwase, Toshiki; Ishiguro, Naoki

    2014-01-01

    The authors describe the clinical findings, radiographic appearance and surgical treatment of a spinal epidural hematoma (SEH) associated with spinal fracture in diffuse idiopathic skeletal hyperostosis (DISH). An 81-year-old male patient injured after falling from a 2.5 m tree presented with severe back pain. On plain radiographs and CT images, DISH with anterolateral osteophytes and fused thoracolumbar vertebrae was found along with a T12 fracture. Patient was initially treated with bed rest followed by placement into a body cast. Three weeks later, he presented with incomplete paraplegia of his lower limbs. CT images did not reveal any fracture displacement, but MRI images showed an epidural hematoma compressing the dura mater. The patient was successfully treated by posterior fixation surgery using pedicle screws and rod with vertebroplasty. We aimed to report a unique case of a SEH complicating a spinal fracture in DISH.

  2. Spinal epidural abscess in brucellosis.

    PubMed

    Boyaci, Ahmet; Boyaci, Nurefsan; Tutoglu, Ahmet; Dokumaci, Dilek Sen

    2013-09-26

    Involvement of the skeletal system is a common complication of brucellosis. However, muscle involvement or paraspinal abscess formation are rare complications. Paraspinal abscess usually develops secondary to spondylitis. A case is reported here of a 33-year-old woman with symptoms of night sweats, fever and low back pain. Rose-Bengal test for brucellosis was positive and Brucella standard tube agglutination test was positive at a titre of 1/160. The diagnosis was made on MRI. The patient was treated with doxycycline and rifampin daily for 16 weeks. On day 14 of treatment, decline was observed in the patient's symptoms. In the presence of inflammatory lower back pain and fever, brucellosis should be considered particularly in the endemic areas. Furthermore, tuberculosis should be remembered in the differential diagnosis when a spinal epidural abscess is determined.

  3. [Low back pain secondary to lumbar epidural venous plexus dilatation due to compression of the inferior vena cava].

    PubMed

    Juan, L Jiménez; Argüelles, C Ferreiro; Gallardo, J M Fernández

    2008-01-01

    We present the case of a patient presenting at the emergency department with subacute low back pain radiating to both lower limbs in whom ultrasonography and abdominal computed tomography diagnosed a retroperitoneal adenopathic mass compressing the inferior vena cava. Magnetid resonance imagin of the lumbar spine showed the retroperitoneal mass and also showed dilatation and tortuosity of the vessels of the lumbar epidural venous plexus, which was considered responsible for the radiating low back pain. Histological study defined the retroperitoneal mass as follicular non-Hodgkin's lymphoma. The dilatation of the lumbar epidural venous plexus can cause lumbar and radicular pain.

  4. Symptomatic Spinal Epidural Lipomatosis After a Single Local Epidural Steroid Injection

    SciTech Connect

    Tok, Chung Hong Kaur, Shaleen; Gangi, Afshin

    2011-02-15

    Spinal epidural lipomatosis is a rare disorder that can manifest with progressive neurological deficits. It is characterized by abnormal accumulation of unencapsulated epidural fat commonly associated with the administration of exogenous steroids associated with a variety of systemic diseases, endocrinopathies, and Cushing syndrome (Fogel et al. Spine J 5:202-211, 2005). Occasionally, spinal epidural lipomatosis may occur in patients not exposed to steroids or in patients with endocrinopathies, primarily in obese individuals (Fogel et al. Spine J 5:202-211, 2005). However, spinal lumbar epidural lipomatosis resulting from local steroid injection has rarely been reported. We report the case of a 45-year-old diabetic man with claudication that was probably due to symptomatic lumbar spinal lipomatosis resulting from a single local epidural steroid injection.

  5. Posterior peritoneal recesses: assessment using CT

    SciTech Connect

    Rubenstein, W.A.; Auh, Y.H.; Zirinsky, K.; Kneeland, J.B.; Whalen, J.P.; Kazam, E.

    1985-08-01

    Intraperitoneal compartments may extend posteriorly to the level of known retroperitoneal structures at several locations within the abdomen. These locations include the posterior subhepatic or hepatorenal space, the splenorenal space, the retropancreatic recess, the paracolic gutters, and the pararectal fossae. Because of their posterior location, fluid collections within these compartments may be mistaken radiologically for retroperitoneal masses. The sectional anatomy of these spaces and particularly their appearance on computed tomographic scans, are illustrated in this paper.

  6. Difficulty in the removal of epidural catheter for labor analgesia

    PubMed Central

    Hajnour, Mohamed S.; Khokhar, Rashid Saeed; Ejaz, Abdul Aziz Ahmed; Al Zahrani, Tariq; Kanchi, Naveed Uddin

    2017-01-01

    For labor pain management epidural analgesia is a popular and an effective method. Difficult removal of epidural catheters occasionally occurs, and several maneuvers have been recommended. The purpose of this article is to raise awareness of the problem of retained epidural catheter fragments and identify the potential impact of complications. PMID:28217071

  7. Pneumococcal Vertebral Osteomyelitis after Epidural Injection: A Rare Event

    PubMed Central

    Johnson, Tamara M; Chitturi, Chandrika; Lange, Michael; Suh, Jin S; Slim, Jihad

    2016-01-01

    Streptococcus pneumoniae vertebral infections have rarely been reported. Herein, we report a case of pneumococcal vertebral osteomyelitis with paraspinal and epidural abscesses as well as concomitant bacteremia following epidural injection. This will be the second case in the literature reporting pneumococcal vertebral osteomyelitis related to epidural manipulation. PMID:27621563

  8. Unusual Spinal Epidural Lipomatosis and Lumbosacral Instability

    PubMed Central

    Ruiz Picazo, David; Ramírez Villaescusa, José

    2016-01-01

    Introduction. Epidural lipomatosis is most frequently observed in patients on chronic steroid treatment. Only a few idiopathic epidural lipomatosis cases have been described. Material and Methods. 64-year-old male patient presented with low back pain and left leg pain. Later, the patient experienced neurogenic claudication and radicular pain in the left leg without urinary dysfunction. Plain radiography and magnetic resonance imaging demonstrated an abnormal fat tissue overgrowth in the epidural space with compression of the dural sac, degenerative disc disease at L4-L5 level, and instability at L5-S1. Endocrinopathic diseases and chronic steroid therapy were excluded. If conservative treatment failed, surgical treatment can be indicated. Results. After surgery, there was a gradual improvement in symptoms and signs, and six months later the patient returned to daily activities and was neurologically normal. Conclusion. In the absence of common causes of neurogenic claudication, epidural lipomatosis should be considered. The standard test for the diagnosis of epidural lipomatosis is magnetic resonance (MR). At first, conservative treatment must be considered; weight loss and the suspension of prior corticosteroid therapy are indicated. In the presence of neurological impairment, the operative treatment of wide surgical decompression must be performed soon after diagnosis. PMID:27069704

  9. Idiopathic Spinal Epidural Lipomatosis in the Lumbar Spine.

    PubMed

    Al-Omari, Ali A; Phukan, Rishabh D; Leonard, Dana A; Herzog, Tyler L; Wood, Kirkham B; Bono, Christopher M

    2016-05-01

    Overgrowth of epidural fat, known as spinal epidural lipomatosis (SEL), can cause symptomatic compression of the spinal cord, conus medullaris, or cauda equina. Suggested predisposing factors such as obesity, steroid use, and diabetes mellitus have been based on a few reported cases, many of which were not surgically confirmed. There is a paucity of epidemiological data in surgically confirmed cases for this disorder. The purpose of this independently reviewed, retrospective, matched cohort analysis was to compare the demographics and incidence of comorbidities of patients who underwent lumbar decompression for SEL vs degenerative stenosis without SEL. Two surgeons' databases were reviewed to identify patients older than 18 years who underwent decompression surgery for magnetic resonance imaging-verified, symptomatic lumbar SEL. A matched control group comprised an equal number of patients with degenerative stenosis (n=14). Demographic data, body mass index, symptom type/duration, comorbidities, complications, treatment history, and associated pathology were collected from medical records. Previously suggested risk factors, such as obesity, endocrinopathy, and epidural steroid injections, were not significantly different between the SEL and control groups. Furthermore, there were no differences in operative times, complications, or blood loss. The only noted difference between the 2 groups was the preoperative duration of symptoms, on average double in patients with SEL. This series represents the largest of its kind reported to date. Because symptom duration was the only difference noted, it is postulated to be the result of lack of awareness of SEL. Future prospective study in a larger group of patients is warranted. [Orthopedics. 2016; 39(3):163-168.].

  10. Spontaneous epidural hematoma due to cervico-thoracic angiolipoma.

    PubMed

    Eap, C; Bannwarth, M; Jazeron, J-F; Kleber, J-C; Theret, É; Duntze, J; Litre, C-F

    2015-12-01

    Epidural angiolipomas are uncommon benign tumors of the spine. Their clinical presentation is usually a progressive spinal cord compression. We report the case of a 22-year-old patient who presented with an acute paraparesis and a spontaneous epidural hematoma, which revealed a epidural angiolipoma which extended from C7 to T3. The patient underwent a C7-T3 laminectomy, in emergency, with evacuation of the hematoma and extradural complete resection of a fibrous epidural tumor bleeding. The postoperative course was favorable with regression of neurological symptoms. Epidural angiolipomas can be revealed by spontaneous intratumoral hemorrhage without traumatism. The standard treatment is total removal by surgery.

  11. Experience with symptomatic spinal epidural cysts.

    PubMed

    Freidberg, S R; Fellows, T; Thomas, C B; Mancall, A C

    1994-06-01

    Epidural cysts, either synovial or ganglion, are an unusual cause of epidural compressive syndromes. We report a series of 26 patients with cysts, including 1 cervical, 2 thoracic, and 23 lumbar. Complaints at the time of admission and findings were similar to those associated with other epidural lesions at the same locations. The surgical technique is similar to that for other spinal lesions, with a wide exposure to enable a clear view of the cyst and surrounding structures, and is governed by imaging studies. Patients with cervical and thoracic lumbar cysts were free of symptoms and signs postoperatively. Of the 23 patients with lumbar cysts, 15 were free of symptoms after an operation, 7 had symptomatic improvement but had some pain and neurological findings, and 1 patient had no improvement. Computed tomography and magnetic resonance imaging permit accurate preoperative evaluation.

  12. Lumbar Epidural Varix Mimicking Disc Herniation

    PubMed Central

    Bursalı, Adem; Guvenal, Ahmet Burak; Yaman, Onur

    2016-01-01

    Lumbar radiculopathy is generally caused by such well-recognized entity as lumbar disc herniation in neurosurgical practice; however rare pathologies such as thrombosed epidural varix may mimic them by causing radicular symptoms. In this case report, we present a 26-year-old man with the complaint of back and right leg pain who was operated for right L4–5 disc herniation. The lesion interpreted as an extruded disc herniation preoperatively was found to be a thrombosed epidural varix compressing the nerve root preoperatively. The nerve root was decompressed by shrinking the lesion with bipolar thermocoagulation and excision. The patient's complaints disappeared in the postoperative period. Thrombosed lumbar epidural varices may mimic lumbar disc herniations both radiologically and clinically. Therefore, must be kept in mind in the differential diagnosis of lumbar disc herniations. Microsurgical techniques are mandatory for the treatment of these pathologies and decompression with thermocoagulation and excision is an efficient method. PMID:27446525

  13. Obstetric epidurals and chronic adhesive arachnoiditis.

    PubMed

    Rice, I; Wee, M Y K; Thomson, K

    2004-01-01

    It has been suggested that obstetric epidurals lead to chronic adhesive arachnoiditis (CAA). CAA is a nebulous disease entity with much confusion over its symptomatology. This review outlines the pathological, clinical, and radiological features of the disease. The proposed diagnostic criteria for CAA are: back pain that increases on exertion, with or without leg pain; neurological abnormality on examination; and characteristic MRI findings. Using these criteria, there is evidence to show that epidural or subarachnoid placement of some contrast media, preservatives and possibly vasoconstrictors, may lead to CAA. No evidence was found that the preservative-free, low concentration bupivacaine with opioid mixtures or plain bupivacaine currently used in labour lead to CAA.

  14. Rapidly Progressive Spontaneous Spinal Epidural Abscess.

    PubMed

    Aycan, Abdurrahman; Aktas, Ozgür Yusuf; Guzey, Feyza Karagoz; Tufan, Azmi; Isler, Cihan; Aycan, Nur; Gulsen, İsmail; Arslan, Harun

    2016-01-01

    Spinal epidural abscess (SEA) is a rare disease which is often rapidly progressive. Delayed diagnosis of SEA may lead to serious complications and the clinical findings of SEA are generally nonspecific. Paraspinal abscess should be considered in the presence of local low back tenderness, redness, and pain with fever, particularly in children. In case of delayed diagnosis and treatment, SEA may spread to the epidural space and may cause neurological deficits. Magnetic resonance imaging (MRI) remains the method of choice in the diagnosis of SEA. Treatment of SEA often consists of both medical and surgical therapy including drainage with percutaneous entry, corpectomy, and instrumentation.

  15. Rapidly Progressive Spontaneous Spinal Epidural Abscess

    PubMed Central

    Aktas, Ozgür Yusuf; Guzey, Feyza Karagoz; Tufan, Azmi; Isler, Cihan; Aycan, Nur; Gulsen, İsmail

    2016-01-01

    Spinal epidural abscess (SEA) is a rare disease which is often rapidly progressive. Delayed diagnosis of SEA may lead to serious complications and the clinical findings of SEA are generally nonspecific. Paraspinal abscess should be considered in the presence of local low back tenderness, redness, and pain with fever, particularly in children. In case of delayed diagnosis and treatment, SEA may spread to the epidural space and may cause neurological deficits. Magnetic resonance imaging (MRI) remains the method of choice in the diagnosis of SEA. Treatment of SEA often consists of both medical and surgical therapy including drainage with percutaneous entry, corpectomy, and instrumentation. PMID:27688918

  16. Percutaneous Posterior Calcaneal Osteotomy.

    PubMed

    Lui, Tun Hing

    2015-01-01

    Different types of posterior calcaneal osteotomy are used for calcaneal realignment in the management of hindfoot deformity. We describe a percutaneous technique of posterior calcaneal osteotomy that can be either a Dwyer-type closing wedge osteotomy or displacement osteotomy.

  17. Spinal epidural abscess and meningitis following short-term epidural catheterisation for postoperative analgaesia.

    PubMed

    van Rappard, Juliaan R M; Tolenaar, Jip L; Smits, Anke B; Go, Peter M N Y H

    2015-08-20

    We present a case of a patient with a spinal epidural abscess (SEA) and meningitis following short-term epidural catheterisation for postoperative pain relief after a laparoscopic sigmoid resection. On the fifth postoperative day, 2 days after removal of the epidural catheter, the patient developed high fever, leucocytosis and elevated C reactive protein. Blood cultures showed a methicillin-sensitive Staphylococcus aureus infection. A photon emission tomography scan revealed increased activity of the spinal canal, suggesting S. aureus meningitis. A gadolinium-enhanced MRI showed a SEA that was localised at the epidural catheter insertion site. Conservative management with intravenous flucloxacillin was initiated, as no neurological deficits were seen. At last follow-up, 8 weeks postoperatively, the patient showed complete recovery.

  18. Epidural Analgesia in the Postoperative Period

    DTIC Science & Technology

    2001-10-01

    violations. VI ABSTRACT Postoperative pain is an unwanted side effect of surgery, and is associated with many postoperative complications...This descriptive study was conducted to determine which surgical patients experienced the most analgesia with the fewest side effects when...epidural medication, side effects , incidence of breakthrough pain, and treatments were recorded and cross-tabulated. The following surgical categories

  19. Which should be appropriate surgical treatment for subtentorial epidural empyema? Burr-hole evacuation versus decompressive craniectomy: Review of the literature with a case report

    PubMed Central

    Köksal, Vaner; Özgür, Abdulkadir; Terzi, Suat

    2016-01-01

    Subtentorial empyema is a rare intracranial complication of chronic otitis media. Moreover, if not correctly treated, it is a life-threatening infection. Epidural and subdural empyemas on subtentorial space have different effects. This difference is not mentioned in literature. If the distinction can be made, surgical treatment method will be different, and the desired surgical treatment may be less minimal invasive. A 26-year-old male patient was found to have developed epidural empyema in the subtentorial space. We performed a burr-hole evacuation in this case because there was low cerebellar edema, Also, the general condition of the patient was good, the empyema was a convex image on the lower surface of tentorium on magnetic resonance images, and when the dura mater base is reached during mastoidectomy for chronic otitis media, we were observed to drain a purulent material through the epidural space. After 10 days from surgery increased posterior fossa edema caused hydrocephalus. Therefore, ventriculoperitoneal shunt insertion was performed. The patient fully recovered and was discharged after 6 weeks. Complete correction in the posterior fossa was observed by postoperative magnetic resonance imaging. Burr-hole evacuation from inside of the mastoidectomy cavity for subtentorial epidural empyema is an effective and minimal invasive surgical treatment. PMID:27057210

  20. Chronic adhesive arachnoiditis after repeat epidural blood patch.

    PubMed

    Carlswärd, C; Darvish, B; Tunelli, J; Irestedt, L

    2015-08-01

    Epidural blood patching is an effective treatment for postdural puncture headache but has potential risks. Arachnoiditis is a very rare disabling condition and few cases have been described following an epidural blood patch. We present a case of chronic adhesive arachnoiditis in a parturient treated with a repeat epidural blood patch. A healthy 29-year-old woman had an accidental dural puncture following epidural insertion during labour. Initial treatment of postdural puncture headache with an epidural blood patch was ineffective and was therefore repeated. She gradually developed severe neurological symptoms consistent with arachnoiditis confirmed with magnetic resonance imaging. Despite intensive multimodal treatment with analgesics and physiotherapy, her neurological condition remains unresolved two years later. This serious but rare complication should encourage caution when treating parturients with postdural puncture headache with a repeat epidural blood patch.

  1. Management and visualization of a kinked epidural catheter

    PubMed Central

    Aslanidis, T; Fileli, A; Pyrgos, P

    2010-01-01

    A lumbar epidural catheter inserted in a 29-year-old woman for labor analgesia. The catheter failed to provide adequate analgesia. Moreover, after labor, it proved difficult to be removed. After computer tomography (CT) and magnetic resonance impedance (MRI) examination the course of the catheter was visible, the entrapped catheter was dislodged intact, revealing a kinking near its distal tip. Kinking of an epidural catheter leading to entrapment is an unusual complication of epidural catheterization. PMID:21311644

  2. Lab in a needle for epidural space identification

    NASA Astrophysics Data System (ADS)

    Carotenuto, B.; Micco, A.; Ricciardi, A.; Amorizzo, E.; Mercieri, M.; Cutolo, A.; Cusano, A.

    2016-05-01

    This work relies on the development of a sensorized medical needle with an all-optical guidance (Lab in a Needle) system for epidural space identification. The device is based on the judicious integration of a Fiber Bragg grating sensor inside the lumen of an epidural needle to discriminate between different types of tissue and thus providing continuous and real time measurements of the pressure experienced by the needle tip during its advancement. Experiments carried out on an epidural training phantom demonstrate the validity of our approach for the correct and effective identification of the epidural space.

  3. Serratia marcescens spinal epidural abscess formation following acupuncture.

    PubMed

    Yang, Chih-Wei; Hsu, Shun-Neng; Liu, Jhih-Syuan; Hueng, Dueng-Yuan

    2014-01-01

    The formation of spinal epidural abscess following acupuncture is very rare. We herein report the case of a 54-year-old woman who presented with progressive low back pain and fever with a root sign. She underwent surgical decompression, with an immediate improvement of the low back pain. A culture of the epidural abscess grew Serratia marcescens. One year postoperatively, magnetic resonance imaging revealed the almost complete eradication of the abscess. This case is the first case of Serratia marcescens-associated spinal epidural abscess formation secondary to acupuncture. The characteristics of spinal epidural abscess that develop after acupuncture and how to prevent such complications are also discussed.

  4. Myelopathy with syringomyelia following thoracic epidural anaesthesia.

    PubMed

    Aldrete, J A; Ferrari, H

    2004-02-01

    Under general anaesthesia and muscle relaxation, a thoracic epidural catheter was inserted at the T8-T9 level in a 7-year-old boy scheduled to have a Nissen fundoplication to provide postoperative analgesia. After 4 ml of lignocaine 1.5% was injected through the catheter, hypotension resulted. Fifty-five minutes later 5 ml of bupivacaine 0.25% produced the same effect. In the recovery room a similar injection resulted in lower blood pressure and temporary apnoea. Sensory and motor deficits were noted the next day and four days later magnetic resonance imaging demonstrated spinal cord syringomyelia extending from T5 to T10. Four years later, dysaesthesia from T6 to T10 weakness of the left lower extremity and bladder and bowel dysfunction persist. The risks of inserting thoracic epidural catheters in patients under general anaesthesia and muscle relaxation are discussed, emphasising the possibility of spinal cord injury with disastrous consequences.

  5. Epidural Abscess Masquerading as Lateral Sinus Thrombosis

    PubMed Central

    Brodner, David C.; Cutler, Jeff; Gianoli, Gerard J.; Amedee, Ronald G.

    2000-01-01

    Controversy regarding the use of anticoagulants, the evacuation of the sinus, or the use of medical treatment alone surrounds the treatment of lateral sinus thrombosis. Treatment of an epidural abscess associated with coalescent mastoiditis is much less controversial-drainage is usually recommended. The differing treatments of these complications mandate accurate diagnosis. The advent of more sophisticated radiological studies has facilitated diagnosis of these complications; however, tests are not infallible. We present three cases in which preoperative imaging demonstrates an epidural abscess mimicking lateral sinus thrombosis by compression of the vessel. A false-positive computed tomography (CT) or magnetic resonance imaging (MRI) study may lead to the wrong diagnosis and, consequently, improper treatment. In light of this possibility, we recommend surgical exploration in all such cases. ImagesFigure 1Figure 2Figure 3Figure 4 PMID:17171148

  6. Hepatocellular carcinoma metastases to the epidural space.

    PubMed

    Somerset, Hilary; Witt, J Peter; Kleinschmidt-Demasters, Bette K

    2009-12-01

    Hepatocellular carcinoma (HCC) is relatively uncommon in the United States, although hepatitis C, one of the known risk factors for disease, is currently showing burgeoning growth in the country. Hence, it is possible that the incidence of HCC also will increase. Clinicians and pathologists in the United States are relatively unfamiliar with the patterns of metastatic spread for HCC. We report 2 US-native patients with cirrhosis and HCC who developed epidural space metastasis, a pattern of disease spread seen infrequently, even in endemic areas. Diagnostic testing was delayed in both patients because of the lowered suspicion for metastasis and the fact that neither patient had recognized metastatic spread to more common sites, such as lung or lymph nodes. New-onset neck or back pain-especially with symptoms of paresthesia, radiculopathy, or cord compression-in the setting of HCC warrants prompt investigation for metastases to the spine and epidural space.

  7. Epidural analgesia in cattle, buffalo, and camels

    PubMed Central

    Ismail, Zuhair Bani

    2016-01-01

    Epidural analgesia is commonly used in large animals. It is an easy, cheap, and effective technique used to prevent or control pain during surgeries involving the tail, anus, vulva, perineum, caudal udder, scrotum, and upper hind limbs. The objectives of this article were to comprehensively review and summarize all scientific data available in the literature on new techniques and drugs or drug combinations used for epidural anesthesia in cattle, camel, and buffalo. Only articles published between 2006 and 2016 were included in the review. The most common sites for epidural administration in cattle, camels, and buffalos were the sacrococcygeal intervertebral space (S5-Co1) and first intercoccygeal intervertebral space (Co1-Co2). The most frequently used drugs and dosages were lidocaine (0.22-0.5 mg/kg), bupivacaine (0.125 mg/kg), ropivacaine (0.11 mg/kg), xylazine (0.05 mg/kg), medetomidine (15 µg/kg), romifidine (30-50 µg/kg), ketamine (0.3-2.5 mg/kg), tramadol (1 mg/kg), and neostigmine (10 µg/kg), and the clinical applications, clinical effects, recommendations, and side effects were discussed. PMID:28096620

  8. Epidural analgesia in cattle, buffalo, and camels.

    PubMed

    Ismail, Zuhair Bani

    2016-12-01

    Epidural analgesia is commonly used in large animals. It is an easy, cheap, and effective technique used to prevent or control pain during surgeries involving the tail, anus, vulva, perineum, caudal udder, scrotum, and upper hind limbs. The objectives of this article were to comprehensively review and summarize all scientific data available in the literature on new techniques and drugs or drug combinations used for epidural anesthesia in cattle, camel, and buffalo. Only articles published between 2006 and 2016 were included in the review. The most common sites for epidural administration in cattle, camels, and buffalos were the sacrococcygeal intervertebral space (S5-Co1) and first intercoccygeal intervertebral space (Co1-Co2). The most frequently used drugs and dosages were lidocaine (0.22-0.5 mg/kg), bupivacaine (0.125 mg/kg), ropivacaine (0.11 mg/kg), xylazine (0.05 mg/kg), medetomidine (15 µg/kg), romifidine (30-50 µg/kg), ketamine (0.3-2.5 mg/kg), tramadol (1 mg/kg), and neostigmine (10 µg/kg), and the clinical applications, clinical effects, recommendations, and side effects were discussed.

  9. Epidural labour analgesia using Bupivacaine and Clonidine

    PubMed Central

    Syal, K; Dogra, RK; Ohri, A; Chauhan, G; Goel, A

    2011-01-01

    Background: To compare the effects of addition of Clonidine (60 μg) to Epidural Bupivacaine (0.125%) for labour analgesia, with regard to duration of analgesia, duration of labour, ambulation, incidence of instrumentation and caesarean section, foetal outcome, patient satisfaction and side effects. Patients & Methods: On demand, epidural labour analgesia was given to 50 nulliparous healthy term parturients (cephalic presentation), divided in two groups randomly. Group I received bupivacaine (0.125%) alone, whereas Group II received bupivacaine (0.125%) along with Clonidine (60 μg). 10 ml of 0.125% bupivacaine was injected as first dose and further doses titrated with patient relief (Numerical Rating Scale <3). Top ups were given whenever Numerical Rating Scale went above 5. Results: There was statistically significant prolongation of duration of analgesia in Group II, with no difference in duration of labour, ambulation, incidence of instrumentation and caesarean section or foetal outcome. Also clonidine gave dose sparing effect to bupivacaine and there was better patient satisfaction without any significant side effects in Group II. Conclusion: Clonidine is a useful adjunct to bupivacaine for epidural labour analgesia and can be considered as alternative to opioids. PMID:21804714

  10. Can the human lumbar posterior columns be stimulated by transcutaneous spinal cord stimulation? A modeling study.

    PubMed

    Danner, Simon M; Hofstoetter, Ursula S; Ladenbauer, Josef; Rattay, Frank; Minassian, Karen

    2011-03-01

    Stimulation of different spinal cord segments in humans is a widely developed clinical practice for modification of pain, altered sensation, and movement. The human lumbar cord has become a target for modification of motor control by epidural and, more recently, by transcutaneous spinal cord stimulation. Posterior columns of the lumbar spinal cord represent a vertical system of axons and when activated can add other inputs to the motor control of the spinal cord than stimulated posterior roots. We used a detailed three-dimensional volume conductor model of the torso and the McIntyre-Richard-Grill axon model to calculate the thresholds of axons within the posterior columns in response to transcutaneous lumbar spinal cord stimulation. Superficially located large-diameter posterior column fibers with multiple collaterals have a threshold of 45.4 V, three times higher than posterior root fibers (14.1 V). With the stimulation strength needed to activate posterior column axons, posterior root fibers of large and small diameters as well as anterior root fibers are coactivated. The reported results inform on these threshold differences, when stimulation is applied to the posterior structures of the lumbar cord at intensities above the threshold of large-diameter posterior root fibers.

  11. Caudal Epidural Block: An Updated Review of Anatomy and Techniques

    PubMed Central

    2017-01-01

    Caudal epidural block is a commonly used technique for surgical anesthesia in children and chronic pain management in adults. It is performed by inserting a needle through the sacral hiatus to gain entrance into the sacral epidural space. Using conventional blind technique, the failure rate of caudal epidural block in adults is high even in experienced hands. This high failure rate could be attributed to anatomic variations that make locating sacral hiatus difficult. With the advent of fluoroscopy and ultrasound in guiding needle placement, the success rate of caudal epidural block has been markedly improved. Although fluoroscopy is still considered the gold standard when performing caudal epidural injection, ultrasonography has been demonstrated to be highly effective in accurately guiding the needle entering the caudal epidural space and produce comparative treatment outcome as fluoroscopy. Except intravascular and intrathecal injection, ultrasonography could be as effective as fluoroscopy in preventing complications during caudal epidural injection. The relevant anatomy and techniques in performing the caudal epidural block will be briefly reviewed in this article. PMID:28337460

  12. Minimally invasive treatment of multilevel spinal epidural abscess.

    PubMed

    Safavi-Abbasi, Sam; Maurer, Adrian J; Rabb, Craig H

    2013-01-01

    The use of minimally invasive tubular retractor microsurgery for treatment of multilevel spinal epidural abscess is described. This technique was used in 3 cases, and excellent results were achieved. The authors conclude that multilevel spinal epidural abscesses can be safely and effectively managed using microsurgery via a minimally invasive tubular retractor system.

  13. Extensive spinal epidural abscess as a complication of Crohn's disease.

    PubMed

    Smith, Chez; Kavar, Bhadrakant

    2010-01-01

    A spinal epidural abscess is a neurosurgical emergency. Successful treatment frequently requires decompression of the spinal canal in combination with intravenous antibiotics. We report a patient with Crohn's disease who developed an extensive spinal epidural abscess communicating with an intra-abdominal collection.

  14. [Spontaneous epidural hematoma after open heart surgery: case report].

    PubMed

    Anegawa, S; Hayashi, T; Furukawa, Y; Nagashima, T; Kumate, M

    1999-11-01

    Acute epidural hematoma not associated with head injury is rarely encountered and is known as spontaneous epidural hematoma. To our knowledge, only five cases with epidural hematoma after open-heart surgery have been published. Pathogenesis and preventive measures have not yet been determined. We report a case of such spontaneous epidural hematoma and consider the possible pathogenesis. A 12-year-old female received a radical operation for severe subaortic stenosis. The intraoperative course was uneventful except for massive hemorrhage which was adequately controlled. Postoperatively, she was moved to the CCU still not having aroused from anesthesia. Eleven hours later, it was found that her pupils were fixed and dilated. CT scan demonstrated a huge bifrontal epidural hematoma with disappearance of the basal cistern. Even though immediate emergency evacuation was performed, the patient died of acute brain swelling four days after the operation.

  15. Citrobocter kasori spinal epidural abscess: a rare occurrence.

    PubMed

    Kumar, Ashok; Jain, Pramod; Singh, Pritish; Divthane, Rupam; Badole, C M

    2013-01-01

    Pyogenic spinal epidural abscess Is an uncommon Infectious occurrence. Clinical prospects of pyogenic spinal epidural abscess are graver if not promptly diagnosed and treated appropriately. A case of spinal epidural abscess has been presented with sinus tract formation at L4-L5 level, of pyogenic aetiology that progressed to paraplegia over the course of the disease. MRI pointed towards an epidural abscess extending from T12 vertebral level to S1 vertebral level. Surgical decompression in the form of laminectomy and evacuation of pus was done and antibiotics were given according to culture and sensitivity. Histopathological analysis revealed the acute suppurative nature of the abscess. Citrobacter kasori was isolated on pus culture. Pyogenic epidural abscess with causative organism being Citrobacter kasori has least been documented.

  16. Spinal epidural abscess presenting as intra-abdominal pathology: a case report and literature review.

    PubMed

    Bremer, Andrew A; Darouiche, Rabih O

    2004-01-01

    Spinal epidural abscess is a rare infectious disease. However, if left unrecognized and untreated, the clinical outcome of spinal epidural abscess can be devastating. Correctly diagnosing a spinal epidural abscess in a timely fashion is often difficult, particularly if the clinician does not actively consider the diagnosis. The most common presenting symptoms of spinal epidural abscess include backache, radicular pain, weakness, and sensory deficits. However, early in its course, spinal epidural abscess can also present with vague and nondescript manifestations. In this report, we describe a case of spinal epidural abscess presenting as abdominal pain, and review the literature describing other cases of spinal epidural abscess presenting as intra-abdominal pathology.

  17. Epidural analgesia during labor vs no analgesia: A comparative study

    PubMed Central

    Mousa, Wesam Farid; Al-Metwalli, Roshdi; Mostafa, Manal

    2012-01-01

    Background: Epidural analgesia is claimed to result in prolonged labor. Previous studies have assessed epidural analgesia vs systemic opioids rather than to parturients receiving no analgesia. This study aimed to evaluate the effect of epidural analgesia on labor duration compared with parturients devoid of analgesia. Methods: One hundred sixty nulliparous women in spontaneous labor at full term with a singleton vertex presentation were assigned to the study. Parturients who request epidural analgesia were allocated in the epidural group, whereas those not enthusiastic to labor analgesia were allocated in the control group. Epidural analgesia was provided with 20 mL bolus 0.5% epidural lidocaine plus fentanyl and maintained at 10 mL for 1 h. Duration of the first and second stages of labor, number of parturients receiving oxytocin, maximal oxytocin dose required for each parturient, numbers of instrumental vaginal, vacuum-assisted, and cesarean deliveries and neonatal Apgar score were recorded. Results: There was no statistical difference in the duration of the active-first and the second stages of labor, instrumental delivery, vacuum-assisted or cesarean delivery rates, the number of newborns with 1-min and 5-min Apgar scores less than 7 between both groups and number of parturients receiving oxytocin, however, the maximal oxytocin dose was significantly higher in the epidural group. Conclusion: Epidural analgesia by lidocaine (0.5%) and fentanyl does not prolong labor compared with parturients without analgesia; however, significant oxytocin augmentation is required during the epidural analgesia to keep up the aforementioned average labor duration. PMID:22412775

  18. Posterior Cruciate Ligament Injury

    MedlinePlus

    ... ACL connect your thighbone (femur) to your shinbone (tibia). If either ligament is torn, it might cause ... ligaments connect the thighbone (femur) to the shinbone (tibia). The anterior and posterior cruciate ligaments form an " ...

  19. Posterior ankle impingement syndrome.

    PubMed

    Maquirriain, Javier

    2005-10-01

    Posterior ankle impingement syndrome is a clinical disorder characterized by posterior ankle pain that occurs in forced plantar flexion. The pain may be acute as a result of trauma or chronic from repetitive stress. Pathology of the os trigonum-talar process is the most common cause of this syndrome, but it also may result from flexor hallucis longus tenosynovitis, ankle osteochondritis, subtalar joint disease, and fracture. Patients usually report chronic or recurrent posterior ankle pain caused or exacerbated by forced plantar flexion or push-off maneuvers, such as may occur during dancing, kicking, or downhill running. Diagnosis of posterior ankle impingement syndrome is based primarily on clinical history and physical examination. Radiography, scintigraphy, computed tomography, and magnetic resonance imaging depict associated bone and soft-tissue abnormalities. Symptoms typically improve with nonsurgical management, but surgery may be required in refractory cases.

  20. Differential Effects of Epidural Analgesia on Modes of Delivery and Perinatal Outcomes between Nulliparous and Multiparous Women: A Retrospective Cohort Study

    PubMed Central

    Hung, Tai-Ho; Hsieh, T’sang-T’ang; Liu, Hung-Pin

    2015-01-01

    Background Epidural analgesia is considered one of the most effective methods for pain relief during labor. However, it is not clear whether similar effects of epidural analgesia on the progression of labor, modes of delivery, and perinatal outcomes exist between nulliparous and multiparous women. Methodology/Principal Findings A retrospective cohort study was conducted to analyze all deliveries after 37 weeks of gestation, with the exclusion of pregnancies complicated by multiple gestations and fetal anomalies and deliveries without trials of labor; these criteria produced a study population of n=16,852. A multivariable logistic regression model was constructed to control for confounders. In total, 7260 of 10,175 (71.4%) nulliparous and 2987 of 6677 (44.7%) multiparous parturients were administered epidural analgesia. The independent factors for intrapartum epidural analgesia included a low prepregnancy body mass index, genetic amniocentesis, group B streptococcal colonization of the genito-rectal tract, and augmentation and induction of labor. In the nulliparous women, epidural analgesia was a significant risk factor for operative vaginal delivery (adjusted odds ratio [OR] 2.14, 95% confidence interval [CI] 1.80-2.54); however, it was a protective factor against Caesarean delivery (adjusted OR 0.62, 95% CI 0.55-0.69). Epidural analgesia remained a significant risk factor for operative vaginal delivery (adjusted OR 2.17, 95% CI 1.58-2.97) but not for Caesarean delivery (adjusted OR 1.09, 95% CI 0.77-1.55) in the multiparous women. Furthermore, the women who were administered epidural analgesia during the trials of labor had similar rates of adverse perinatal outcomes compared with the women who were not administered epidural analgesia, except that a higher rate of 1-minute Apgar scores less than 7 was noted in the nulliparous women who were administered epidural analgesia. Conclusions/Significance Intrapartum epidural analgesia has differential effects on the

  1. Novel use of epidural catheter: Air injection for neuroprotection during radiofrequency ablation of spinal osteoid osteoma

    PubMed Central

    Doctor, JR; Solanki, SL; Patil, VP; Divatia, JV

    2016-01-01

    Osteoid osteoma (OO) is a benign bone tumor, with a male-female ratio of approximately 2:1 and mainly affecting long bones. Ten percent of the lesions occur in the spine, mostly within the posterior elements. Treatment options for OO include surgical excision and percutaneous imaging-guided radiofrequency ablation (RFA). Lesions within the spine have an inherent risk of thermal damage to the vital structure because of proximity to the neural elements. We report a novel use of the epidural catheter for air injection for the neuroprotection of nerves close to the OO of the spine. A 12-year-old and 30 kg male child with an OO of the L3 vertebra was taken up for RFA. His preoperative examinations were within normal limits. The OO was very close to the L3 nerve root. Under general anesthesia, lumbar epidural catheter was placed in the L3-L4 space under imaging guidance. Ten ml of aliquots of air was injected under imaging guidance to avoid injury to the neural structures due to RFA. The air created a gap between neural elements and the tumor and served as an insulating material thereby protecting the neural elements from damage due to the RFA. Postoperatively, the patient did not develop any neurological deficit. PMID:27375396

  2. Talar Osteochondroma Fracture Presenting as Posterior Ankle Impingement.

    PubMed

    Ercin, Ersin; Bilgili, Mustafa Gokhan; Gamsizkan, Mehmet; Avsar, Serdar

    2016-05-01

    Osteochondromas are the most common benign bone tumors. They are usually asymptomatic and found incidentally. When symptomatic, the symptoms are usually due to its location and size. Fracture of an osteochondroma presenting as posterior ankle impingement is a rare condition. We describe a 22-year-old man with solitary exostosis who presented with a posterior ankle mass and posterior ankle impingement with 2 years of follow-up. Surgical intervention was the treatment of choice in this patient, and histologic examination revealed a benign osteochondroma. Osteochondromas found in the posterior aspect of the talus can be complicated by fracture due to persistent motion of the ankle. Talar osteochondroma should be included in the differential diagnosis of posterior ankle impingement causes. Posterior talar osteochondromas, especially when a stalk is present, should be treated surgically before it is more complicated by a fracture and posterior ankle impingement.

  3. The tibialis posterior tendon.

    PubMed

    Lhoste-Trouilloud, A

    2012-02-01

    The tibialis posterior tendon is the largest and anteriormost tendon in the medial ankle. It produces plantar flexion and supination of the ankle and stabilizes the plantar vault. Sonographic assessment of this tendon is done with high-frequency, linear-array transducers; an optimal examination requires transverse retromalleolar, longitudinal retromalleolar, and distal longitudinal scans, as well as dynamic studies. Disorders of the posterior tibial tendon include chronic tendinopathy with progressive rupture, tenosynovitis, acute rupture, dislocation and instability, enthesopathies. The most common lesion is a progressive "chewing gum" lesion that develops in a setting of chronic tendinopathy; it is usually seen in overweight women over 50 years of age with valgus flat feet. Medial ankle pain must also be carefully investigated, and the presence of instability assessed with dynamic maneuvers (forced inversion, or dorsiflexion) of the foot. Sonography plays an important role in the investigation of disorders involving the posterior tibial tendon.

  4. Posterior Fossa Tumors.

    PubMed

    Brandão, Lara A; Young Poussaint, Tina

    2017-02-01

    Pediatric brain tumors are the leading cause of death from solid tumors in childhood. The most common posterior fossa tumors in children are medulloblastoma, atypical teratoid/rhabdoid tumor, cerebellar pilocytic astrocytoma, ependymoma, and brainstem glioma. Location, and imaging findings on computed tomography (CT) and conventional MR (cMR) imaging may provide important clues to the most likely diagnosis. Moreover, information obtained from advanced MR imaging techniques increase diagnostic confidence and help distinguish between different histologic tumor types. Here we discuss the most common posterior fossa tumors in children, including typical imaging findings on CT, cMR imaging, and advanced MR imaging studies.

  5. Posterior crossbites in children.

    PubMed

    Zhu, J F; Crevoisier, R; King, D L; Henry, R; Mills, C M

    1996-11-01

    Posterior crossbite, the most common malocclusion in young children, can be caused by a variety of skeletal, muscular, or dental factors. This condition produces insufficient maxillary arch width and is frequently associated with various oral sucking and postural habits. If left untreated, this problem can result in adverse skeletal growth changes. Various mechanical treatment modalities designed to expand the posterior maxillary arch width are available to correct this problem. The appropriate treatment method depends on the patient's age and level of cooperation as well as the determined etiology of the constriction.

  6. Tibialis Posterior Tendon Entrapment Within Posterior Malleolar Fracture Fragment.

    PubMed

    Fantry, Amanda; Lareau, Craig; Vopat, Bryan; Blankenhorn, Brad

    2016-01-01

    Management of posterior malleolus fractures continues to be controversial, with respect to both need for fixation and fixation methods. Fixation methods include an open posterior approach to the ankle as well as percutaneous reduction and fixation with or without arthroscopy for visualization of the articular surface. Plain radiographs are unreliable in identifying fracture pattern and intraoperative reduction, making arthroscopy a valuable adjunct to posterior malleolus fracture management. In this article, we report a case of tibialis posterior tendon entrapment within a posterior malleolus fracture, as identified by arthroscopy and managed with open reduction. Tibialis posterior tendon entrapment within a posterior malleolus has not been previously reported. Ankle arthroscopy for posterior malleolus fractures provides an opportunity to identify soft-tissue or tendinous entrapment, articular surface reduction, and articular cartilage injuries unlikely to be identified with fluoroscopy alone and should be considered in reduction and fixation of posterior malleolus fractures.

  7. The impact of preoperative epidural injections on postoperative infection in lumbar fusion surgery.

    PubMed

    Singla, Anuj; Yang, Scott; Werner, Brian C; Cancienne, Jourdan M; Nourbakhsh, Ali; Shimer, Adam L; Hassanzadeh, Hamid; Shen, Francis H

    2017-03-14

    OBJECTIVE Lumbar epidural steroid injections (LESIs) are performed for both diagnostic and therapeutic purposes for a variety of indications, including low-back pain, the leading cause of disability and expense due to work-related conditions in the US. The steroid agent used in epidural injections is reported to relieve nerve root inflammation, local ischemia, and resultant pain, but the injection may also have an adverse impact on spinal surgery performed thereafter. In particular, the possibility that preoperative epidural injections may increase the risk of surgical site infection after lumbar spinal fusion has been reported but has not been studied in detail. The goal of the present study was to use a large national insurance database to analyze the association of preoperative LESIs with surgical site infection after lumbar spinal fusion. METHODS A nationwide insurance database of patient records was used for this retrospective analysis. Current Procedural Terminology codes were used to query the database for patients who had undergone LESI and 1- or 2-level lumbar posterior spinal fusion procedures. The rate of postoperative infection after 1- or 2-level posterior spinal fusion was analyzed. These study patients were then divided into 3 separate cohorts: 1) lumbar spinal fusion performed within 1 month after LESI, 2) fusion performed between 1 and 3 months after LESI, and 3) fusion performed between 3 and 6 months after LESI. The study patients were compared with a control cohort of patients who underwent lumbar fusion without previous LESI. RESULTS The overall 3-month infection rate after lumbar spinal fusion procedure was 1.6% (1411 of 88,540 patients). The infection risk increased in patients who received LESI within 1 month (OR 2.6, p < 0.0001) or 1-3 months (OR 1.4, p = 0.0002) prior to surgery compared with controls. The infection risk was not significantly different from controls in patients who underwent lumbar fusion more than 3 months after LESI

  8. Lower Back Tattoo: OK to Have an Epidural?

    MedlinePlus

    ... and delivery, postpartum care Could a lower back tattoo keep me from having an epidural during labor? ... Yvonne Butler Tobah, M.D. A lower back tattoo won't necessarily prevent you from having an ...

  9. Considering symptomatic spinal epidural lipomatosis in the differential diagnosis.

    PubMed

    Alvarez, Adriana; Induru, Raghava; Lagman, Ruth

    2013-09-01

    Spinal epidural lipomatosis (SEL) is the abnormal accumulation of normal fat within the spinal canal. It is more frequent in those patients receiving chronic glucocorticoid therapy or in cases of endogenous hypercortisolism states. We report a case of SEL in a patient with metastatic prostate cancer with history of steroid treatment as part of his chemotherapy regimen, presenting with clinical manifestations of partial cord compression. Magnetic resonance imaging images of the lumbar spine revealed the presence of epidural tumor suspicious for metastatic disease. Operative findings were consistent with epidural lipomatosis. Spinal epidural lipomatosis is a rare condition that needs to be included in the differential diagnosis of patients with risk factors, presenting with symptomatic cord compression.

  10. Epidural analgesia for labour: maternal knowledge, preferences and informed consent.

    PubMed

    Fröhlich, S; Tan, T; Walsh, A; Carey, M

    2011-01-01

    Epidural analgesia has become increasingly popular as a form of labour analgesia in Ireland. However obtaining true inform consent has always been difficult. Our study recruited 100 parturients who had undergone epidural analgesia for labour, aimed to determine the information they received prior to regional analgesia, and to ascertain their preferences regarding informed consent. Only 65 (65%) of patients planned to have an epidural. Knowledge of potential complications was variable and inaccurate, with less than 30 (30%) of women aware of the most common complications. Most women 79 (79%) believed that discomfort during labour affected their ability to provide informed consent, and believe consent should be taken prior to onset of labour (96, 96%). The results of this study helps define the standards of consent Irish patients expect for epidural analgesia during labour.

  11. Epidural analgesia during labour - maternal understanding and experience - informed consent.

    PubMed

    Mahomed, K; Chin, D; Drew, A

    2015-01-01

    Women obtain information on epidural analgesia from various sources. For epidural for pain relief in labour this is provided by the anaesthetist as part of the consenting process. There is much discussion about the inadequacy of this consenting process; we report on women's knowledge, experience and recall of this process at a regional hospital with a 24-h epidural service. Fifty-four women were interviewed within 72 h of a vaginal birth. 91% of the women had acquired information from friends, relatives and antenatal classes. Lack of recall of benefits of epidural analgesia accounted for 26 (38%) and 25 (26%) of the responses, respectively. Similarly in terms of amount of pain relief they could expect, 13 (21%) could not remember and 13 (21%) thought that it may not work. We suggest use of varying methods of disseminating information and wider utilisation of anaesthetists in the antenatal educational programmes.

  12. [MRI appearance of lumbar epidural abscesses: report of three cases].

    PubMed

    Semlali, S; Fikri, M; Nassar, I; El Quessar, A; El Hassani, Mr; Chakir, N; Jiddane, M

    2004-03-01

    The authors report three cases of non-tuberculous epidural abscess. Presenting symptoms included lumbar back pain, muscle spasms, soft tIssue swelling, and neurological deficits in all three cases. MR imaging was helpful for diagnosis and showed involvement of perivertebral soft tissues and an epidural abscess of variable size. There was no significant involvement of intervertebral disks or vertebrae. Diagnosis was confirmed by bacteriologic exam. Clinical outcome was favourable with antibiotic treatment.

  13. Epidural Anesthesia Complicated by Subdural Hygromas and a Subdural Hematoma

    PubMed Central

    Marovic, Paul; Ingram, Brendan

    2016-01-01

    Inadvertent dural puncture during epidural anesthesia leads to intracranial hypotension, which if left unnoticed can cause life-threatening subdural hematomas or cerebellar tonsillar herniation. The highly variable presentation of intracranial hypotension hinders timely diagnosis and treatment. We present the case of a young laboring adult female, who developed subdural hygromas and a subdural hematoma following unintentional dural puncture during initiation of epidural anesthesia. PMID:27651956

  14. [Combined epidural and spinal anesthesia for cesarean section].

    PubMed

    Hody, J L

    1994-01-01

    Combined spinal epidural block has proven its efficacy in skilled hands. This technique allies advantages of spinal anaesthesia, regarding its speed of action and intensity of motor blockade and advantages of postoperative epidural analgesia. This block must be performed with great care and method to reach a success rate of almost 100%. Local anaesthetics and additives are reviewed and commented. The two main complications, hypotension and post dural puncture headache can be contained in very low limits.

  15. Unilateral anhidrosis: A rare complication of thoracic epidural analgesia.

    PubMed

    Gulbahar, Gultekin; Gundogdu, Ahmet Gokhan; Alkan, Güzide; Baysalman, Hatice Baran; Kaplan, Tevfik

    2016-02-01

    Management of pain following thoracotomy is an important issue for the control of early morbidity. We herein present the case of a patient who was referred to our hospital after a fall from a height. Right-sided multiple rib fractures, hemopneumothorax, and diaphragmatic rupture were detected. Thoracic epidural catheterization was performed for pain management just before thoracotomy. The patient developed unilateral anhidrosis postoperatively. We discuss this rare complication of thoracic epidural analgesia with a review of relevant literature.

  16. Spinal epidural arteriovenous hemangioma mimicking lumbar disc herniation.

    PubMed

    Kim, Kyung Hyun; Song, Sang Woo; Lee, Soo Eon; Lee, Sang Hyung

    2012-10-01

    A spinal epidural hemangioma is rare. In this case, a 51 year-old female patient had low back pain and right thigh numbness. She was initially misdiagnosed as having a ruptured disc with possible sequestration of granulation tissue formation due to the limited number of spinal epidural hemangiomas and little-known radiological findings. Because there are no effective diagnostic tools to verify the hemangioma, more effort should be put into preoperative imaging tests to avoid misdiagnosis and poor decisions).

  17. Is epidural steroid injection effective for degenerative lumbar spinal stenosis?

    PubMed

    Flores, Sebastián; Molina, Marcelo

    2015-11-16

    There are several nonsurgical alternatives to treat radicular pain in degenerative lumbar spinal stenosis. Epidural steroid injections have been used for several decades, but the different studies have shown variable effects. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified nine systematic reviews including seven pertinent randomized controlled trials. We concluded epidural steroid injection probably leads to little or no effect on reducing radicular pain of spinal stenosis.

  18. Epidural Anesthesia for Caesarean Section in a Pregnant Patient with Pituitary Macroadenoma

    PubMed Central

    Babu, D. Dinesh; Sureshkumar, K; Patil, Shubhada A.

    2014-01-01

    Anaesthesia for patient with pituitary adenoma posted for non-neurosurgical surgeries is a challenge to the anaesthesiologist with the risk of sudden change in intracranial dynamics during administration of spinal anaesthesia or during stress response of general anaesthesia. There is a chance of increase in tumour size during antenatal period. A careful assessment of pituitary function and a screening of visual field and fundus examination are essential to rule out any mass effect. We are presenting the anaesthetic management of patient with pituitary macroadenoma posted for elective caesarean section done under epidural anaesthesia due to its rarity. PMID:25177577

  19. Thoracic epidural anesthesia decreases endotoxin-induced endothelial injury

    PubMed Central

    2014-01-01

    Background The sympathetic nervous system is considered to modulate the endotoxin-induced activation of immune cells. Here we investigate whether thoracic epidural anesthesia with its regional symapathetic blocking effect alters endotoxin-induced leukocyte-endothelium activation and interaction with subsequent endothelial injury. Methods Sprague Dawley rats were anesthetized, cannulated and hemodynamically monitored. E. coli lipopolysaccharide (Serotype 0127:B8, 1.5 mg x kg-1 x h-1) or isotonic saline (controls) was infused for 300 minutes. An epidural catheter was inserted for continuous application of lidocaine or normal saline in endotoxemic animals and saline in controls. After 300 minutes we measured catecholamine and cytokine plasma concentrations, adhesion molecule expression, leukocyte adhesion, and intestinal tissue edema. Results In endotoxemic animals with epidural saline, LPS significantly increased the interleukin-1β plasma concentration (48%), the expression of endothelial adhesion molecules E-selectin (34%) and ICAM-1 (42%), and the number of adherent leukocytes (40%) with an increase in intestinal myeloperoxidase activity (26%) and tissue edema (75%) when compared to healthy controls. In endotoxemic animals with epidural infusion of lidocaine the values were similar to those in control animals, while epinephrine plasma concentration was 32% lower compared to endotoxemic animals with epidural saline. Conclusions Thoracic epidural anesthesia attenuated the endotoxin-induced increase of IL-1β concentration, adhesion molecule expression and leukocyte-adhesion with subsequent endothelial injury. A potential mechanism is the reduction in the plasma concentration of epinephrine. PMID:24708631

  20. Epidural fibrosis after permanent catheter insertion and infusion.

    PubMed

    Aldrete, J A

    1995-11-01

    Forty-six permanent epidural catheters and life-port units were implanted in 43 patients with severe, recurrent low back pain who had been considered not to be candidates for surgical intervention and in whom other therapeutic modalities had failed. Eight cases developed epidural fibrosis (EF). For analgesia, patients received either infusions with preservative-free solutions of fentanyl and bupivacaine or daily boluses of morphine and bupivacaine. Catheters remained from 75 days to 433 days. Signs of EF appeared from 21 days to 320 days after implantation. Pain at injection or resistance to injection were initial manifestations of EF, followed by poor, and eventually, nil analgesic effect. The epidural catheters were made of either polyamide, silicone, or polyurethane. Epidurograms revealed encapsulation, narrowing, and loculation of epidural space with gradually reduced spread of the contrast material. The occurrence of EF limits the permanency of implanted epidural catheters. The infusate does not cause this complication, which appears to be a foreign body reaction due to the presence of the catheter in the epidural space.

  1. [Combined subarachnoid-epidural technique for obstetric analgesia].

    PubMed

    Fernández-Guisasola, J; García del Valle, S; Gómez-Arnau, J I

    2000-05-01

    Combined spinal-epidural blockade for labor pain has enjoyed increasing popularity in obstetric anesthesia. The usual procedure is to use a single space and a single needle for dural puncture, inserting a spinal needle through an epidural needle followed by insertion of a catheter. A small dose of one or several substances (usually a lipophilic opioid and a local anesthetic) is first injected in the intrathecal space to provide rapid, effective analgesia with minimal muscle blockade. The epidural catheter is used if labor lasts longer than the spinal block, if the spinal block is insufficient, or in case of cesarean section. Combined spinal-epidural blockade is a safe, valid alternative to conventional epidural analgesia and has become the main technique for providing obstetric analgesia in many hospitals. The most widely-recognized advantage of the technique is high maternal satisfaction with rapid and effective analgesia. Mobility of the lower extremities is preserved and the mother is often able to walk. Because opioids are injected into the intrathecal space and because the technique is more invasive than standard epidural analgesia, the potential risk to mother and fetus increases.

  2. Pneumocephalus during cervical transforaminal epidural steroid injections: a case report.

    PubMed

    Kim, Won-Joong; Park, Hae-Gyun; Park, Yong-Hee; Shin, Mee-Ran; Koo, Gill-Hoi; Shin, Hwa-Yong

    2015-01-01

    A cervical transforaminal epidural injection of anesthetic and corticosteroids (CTFESI) is a frequently used procedure for cervical radiculopathy. Most cases of pneumocephalus after an epidural block occur when using an interlaminar approach with the loss-of-resistance technique. The authors present the first case of pneumocephalus after cervical transforaminal epidural injection of anesthetic and corticosteroids. A 64-yr-old woman with left C7 radiculopathy was undergoing C6-7 transforaminal epidural injection of anesthetic and corticosteroids. The epidural spread of contrast was checked by fluoroscope, and 5 mg of dexamethasone in 4 ml of 0.1875% ropivacaine was injected. She lost consciousness 5 mins after the procedure and regained awareness after manual ventilation. She subsequently complained of nausea and headache, and a computed tomography brain scan revealed pneumocephalus. After carefully assessing the fluoroscopic images, the authors believe that the needle may have punctured the dura mater of the nerve root sleeve, allowing air to enter the subdural space. Thus, fluoroscopic images should be carefully examined to reduce dural puncture when performing cervical transforaminal epidural injection of anesthetic and corticosteroids, and air should be completely removed from the needle, extension tube, and syringe.

  3. Spinal epidural abscess treated with antibiotics alone.

    PubMed

    Pathak, Ashish; Singh, Poonam; Gehlot, Prateek; Dhaneria, Mamta

    2013-04-30

    Spinal epidural abscess (SEA) is a rare clinical condition among children. Most patients do not present with classical signs. A 13-year-old boy without any predisposing factors presented with paraparesis, bladder and bowel involvement. MRI spine demonstrated an SEA at the C7 and D1 levels on both sides of the midline with cord oedema at the C2-3 to C6 level with minimal marrow oedema in the C6 vertebral body. We treated the patient with antibiotics (ceftriaxone and vancomycin) alone. The patient showed excellent response with only minimal residual gait disturbance at the end of 6 weeks of antibiotic therapy. This is the first paediatric report of complete recovery of a patient at clinical stage 4 following antibiotic treatment alone from India. However, caution should be exercised to closely monitor the patient's recovery as any progression in the neurological state warrants surgery.

  4. Controlled release ibuprofen-poloxamer gel for epidural use - A pharmacokinetic study using microdialysis in pigs.

    PubMed

    Paavola, Anne; Bernards, Christopher M; Rosenberg, Per H

    2016-11-01

    In order to avoid the risks of sideeffects of epidural local anesthetics and opioids, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) epidurally would be an interesting option of analgesic therapy. The fairly short duration of action of spinally administered NSAIDs, e.g., ibuprofen, may be prolonged by using controlled release poloxamer gel formulation. Using a microdialysis technique we studied the epidural and intrathecal pharmacokinetics of ibuprofen after its epidural administration as a poloxamer 407 formulation or a solution formulation. In addition, plasma ibuprofen concentrations were analyzed from central venous blood samples. Ibuprofen concentrations in the epidural space were significantly higher and longer lasting after the epidural gel injection compared with the epidural solution injection. The epidural AUC of ibuprofen was over threefold greater after epidural ibuprofen gel injection compared with the ibuprofen solution injection (p<0.001). The systemic absorption of ibuprofen from 25% poloxamer 407 gel was very low. The in situ forming poloxamer gel acted as a reservoir allowing targeted ibuprofen release at the epidural injection site and restricted ibuprofen molecules to a smaller spinal area. Ibuprofen diffusion from the epidural space to the intrathecal space was steady and prolonged. These results demonstrate that the use of epidurally injectable poloxamer gel can increase and prolong ibuprofen delivery from epidural space to the CSF enhancing thus ibuprofen entry into the central neuroaxis for spinal analgesia. Further toxicological and dose-finding studies are justified.

  5. Comparison of epidural oxycodone and epidural morphine for post-caesarean section analgesia: A randomised controlled trial

    PubMed Central

    Sng, Ban Leong; Kwok, Sarah Carol; Mathur, Deepak; Ithnin, Farida; Newton-Dunn, Clare; Assam, Pryseley Nkouibert; Sultana, Rehena; Sia, Alex Tiong Heng

    2016-01-01

    Background and Aims: Epidural morphine after caesarean section may cause moderate to severe pruritus in women. Epidural oxycodone has been shown in non-obstetric trials to reduce pruritus when compared to morphine. We hypothesised that epidural oxycodone may reduce pruritus after caesarean section. Methods: A randomised controlled trial was conducted in pregnant women at term who underwent caesarean section with combined spinal-epidural technique initiated with intrathecal fentanyl 15 μg. Women received either epidural morphine 3 mg or epidural oxycodone 3 mg via the epidural catheter after delivery. The primary outcome was the incidence of pruritus at 24 h after caesarean section. The secondary outcomes were the pruritus scores, treatment for post-operative nausea and vomiting (PONV), pain scores and maternal satisfaction. Results: One hundred women were randomised (group oxycodone O = 50, morphine M = 50). There was no difference between Group O and M in the incidence of pruritus (n [%] 28 [56%] vs. 31 [62%], P = 0.68) and the worst pruritus scores (mean [standard deviation] 2.6 (2.8) vs. 3.3 [3.1], P = 0.23), respectively. Both groups had similar pain scores at rest (2.7 [2.3] vs. 2.0 [2.7], P = 0.16) and sitting up (5.0 [2.3] vs. 4.6 [2.4], P = 0.38) at 24 h. Pruritus scores were lower at 4–8, 8–12 and 12–24 h with oxycodone, but pain scores were higher. Both groups had a similar need for treatment of PONV and maternal satisfaction with analgesia. Conclusion: There was no difference in the incidence of pruritus at 24 h between epidural oxycodone and morphine. However, pruritus scores were lower with oxycodone between 4 and 24 h after surgery with higher pain scores in the same period. PMID:27053782

  6. Microscopic epidural lesions in goats given repeated epidural injections of morphine: use of a modified autopsy procedure.

    PubMed

    Larsen, J J; Svendsen, O; Andersen, H B

    1986-01-01

    Epidural catheterization was performed in six goats. Five days later either saline or 20 mg (5 mg/ml) preservative free morphine was injected epidurally once daily for 8 days. The goats were sacrificed 4, 24 or 48 hours after the last injection. The lumbar part of columna was removed in toto for microscopic examination of the spinal cord and the entire epidural space after decalcification and transverse sectioning. After saline, minimal changes including a fibrous membrane surrounding the catheter, scattered fat cell necrosis, scattered small focal cell infiltrations and occasionally focal haemorrhages were seen. After morphine the changes were considerably more severe including diffuse cellular inflammatory reaction in the epidural space, fat cell necrosis, occasionally focal exudative inflammation and chronic inflammatory reaction in the vicinity of the fibrous membrane demarcating position of the catheter. It is concluded that the present modified autopsy procedure permits microscopic examination of the epidural space. It has been shown that repeated administration of morphine caused tissue damage in the epidural space of goats. The human predictability of the results obtained is unknown. However, the results are encouraging for investigations with similar procedure in humans.

  7. Estimating the Incidence of Suspected Epidural Hematoma and the Hidden Imaging Cost of Epidural Catheterization: A Retrospective Review of 43,200 Cases

    PubMed Central

    Henneman, Justin P.; Sandberg, Warren S.

    2013-01-01

    Introduction Hematoma associated with epidural catheterization is rare, but the diagnosis might be suspected relatively frequently. We sought to estimate the incidence of suspected epidural hematoma after epidural catheterization, and to determine the associated cost of excluding or diagnosing an epidural hematoma through radiologic imaging. Methods We conducted an electronic retrospective chart review of 43,200 patient charts using 4 distinct search strategies and cost analysis, all from a single academic institution from 2001 through 2009. Charts were reviewed for use of radiological imaging studies to identify patients with suspected and confirmed epidural hematomas. Costs for imaging to exclude or confirm the diagnosis were related to the entire cohort. Results In our analysis, over a 9-year period that included 43,200 epidural catheterizations, 102 patients (1:430) underwent further imaging studies to exclude or confirm the presence of an epidural hematoma—revealing 6 confirmed cases and an overall incidence (per 10,000 epidural blocks) of epidural hematoma of 1.38 (95% CI 0, 0.002). Among our patients, 207 imaging studies, primarily lumbar spine MRI, were performed. Integrating Medicare cost expenditure data, the estimated additional cost over a 9-year period for imaging and hospital charges related to identifying epidural hematomas nets to approximately $232,000 or an additional $5.37 per epidural. Discussion About 1 in 430 epidural catheterization patients will be suspected to have an epidural hematoma. The cost of excluding the diagnosis, when suspected, is relatively low when allocated across all epidural catheterization patients. PMID:23924685

  8. Posterior Circulation Ischemic Stroke.

    PubMed

    Go, Steven

    2015-01-01

    Approximately 20-25% of all acute strokes occur in the posterior circulation. These strokes can be rather difficult to diagnose because they present in such diverse ways, and can easily be mistaken for more benign entities. A fastidious history, physical exam, high clinical suspicion, and appropriate use of imaging are essential for the emergency physician to properly diagnose and treat these patients. Expert stroke neurologist consultation should be utilized liberally.

  9. Mass

    SciTech Connect

    Quigg, Chris

    2007-12-05

    In the classical physics we inherited from Isaac Newton, mass does not arise, it simply is. The mass of a classical object is the sum of the masses of its parts. Albert Einstein showed that the mass of a body is a measure of its energy content, inviting us to consider the origins of mass. The protons we accelerate at Fermilab are prime examples of Einsteinian matter: nearly all of their mass arises from stored energy. Missing mass led to the discovery of the noble gases, and a new form of missing mass leads us to the notion of dark matter. Starting with a brief guided tour of the meanings of mass, the colloquium will explore the multiple origins of mass. We will see how far we have come toward understanding mass, and survey the issues that guide our research today.

  10. Synovial Cyst Mimicking an Intraspinal Sacral Mass

    PubMed Central

    2014-01-01

    A 68-year-old female had a three-week history of severe low back pain radiating down the posterior left buttocks and left leg exacerbated by standing and walking. Lumbar spine MRI revealed cystic mass with similar intensity to cerebrospinal fluid located on dorsolateral left side of the sacral spinal canal inferior to the S1 pedicle. There was compression of left exiting S1 and traversing S2 nerve roots. Neurosurgery consult was requested to evaluate the cystic mass in the sacral spinal canal. After clinical evaluation, an unusually located synovial cyst was thought possible. Cyst contents were heterogeneous, suggestive of small hemorrhage and acute clinical history seemed reasonable. Left S1 and partial left S2 hemilaminectomy was performed and an epidural, partially hemorrhagic cyst was removed. There was no obvious connection to the ipsilateral L5-S1 facet joint. Pathology revealed synovial cyst, and the patient's leg pain was improved postoperatively. This synovial cyst was unusual as it had no connection with the facet joint intraoperatively and its location in the sacral canal was uncommon. PMID:24716025

  11. Labor epidural anesthesia, obstetric factors and breastfeeding cessation.

    PubMed

    Dozier, Ann M; Howard, Cynthia R; Brownell, Elizabeth A; Wissler, Richard N; Glantz, J Christopher; Ternullo, Sharon R; Thevenet-Morrison, Kelly N; Childs, Cynthia K; Lawrence, Ruth A

    2013-05-01

    Breastfeeding benefits both infant and maternal health. Use of epidural anesthesia during labor is increasingly common and may interfere with breastfeeding. Studies analyzing epidural anesthesia's association with breastfeeding outcomes show mixed results; many have methodological flaws. We analyzed potential associations between epidural anesthesia and overall breast-feeding cessation within 30 days postpartum while adjusting for standard and novel covariates and uniquely accounting for labor induction. A pooled analysis using Kaplan-Meier curves and modified Cox Proportional Hazard models included 772 breastfeeding mothers from upstate New York who had vaginal term births of healthy singleton infants. Subjects were drawn from two cohort studies (recruited postpartum between 2005 and 2008) and included maternal self-report and maternal and infant medical record data. Analyses of potential associations between epidural anesthesia and overall breastfeeding cessation within 1 month included additional covariates and uniquely accounted for labor induction. After adjusting for standard demographics and intrapartum factors, epidural anesthesia significantly predicted breastfeeding cessation (hazard ratio 1.26 [95% confidence interval 1.10, 1.44], p < 0.01) as did hospital type, maternal age, income, education, planned breastfeeding goal, and breastfeeding confidence. In post hoc analyses stratified by Baby Friendly Hospital (BFH) status, epidural anesthesia significantly predicted breastfeeding cessation (BFH: 1.19 [1.01, 1.41], p < 0.04; non-BFH: 1.65 [1.31, 2.08], p < 0.01). A relationship between epidural anesthesia and breastfeeding was found but is complex and involves institutional, clinical, maternal and infant factors. These findings have implications for clinical care and hospital policies and point to the need for prospective studies.

  12. Labor Epidural Analgesia and Breastfeeding: A Systematic Review.

    PubMed

    French, Cynthia A; Cong, Xiaomei; Chung, Keun Sam

    2016-08-01

    Despite widespread use of epidural analgesia during labor, no consensus has been reached among obstetric and anesthesia providers regarding its effects on breastfeeding. The purpose of this review was to examine the relationship between labor epidural analgesia and breastfeeding in the immediate postpartum period. PubMed, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature were searched for articles published in 1990 or thereafter, using the search term breastfeeding combined with epidural, labor epidural analgesia, labor analgesia, or epidural analgesia Of 117 articles, 23 described empirical studies specific to labor epidural analgesia and measured a breastfeeding outcome. Results were conflicting: 12 studies showed negative associations between epidural analgesia and breastfeeding success, 10 studies showed no effect, and 1 study showed a positive association. Most studies were observational. Of 3 randomized controlled studies, randomization methods were inadequate in 2 and not evaluable in 1. Other limitations were related to small sample size or inadequate study power; variation and lack of information regarding type and dosage of analgesia or use of other intrapartum interventions; differences in timing, definition, and method of assessing breastfeeding success; or failure to consider factors such as mothers' intention to breastfeed, social support, siblings, or the mother's need to return to work or school. It is also unclear to what extent results are mediated through effects on infant neurobehavior, maternal fever, oxytocin release, duration of labor, and need for instrumental delivery. Clinician awareness of factors affecting breastfeeding can help identify women at risk for breastfeeding difficulties in order to target support and resources effectively.

  13. Visible Evidence of Lumbar Epidural Catheter Misplacement–A Critical Incident Case Report

    PubMed Central

    Butala, Beena; Parikh, Geeta; Pargi, Rajesh

    2017-01-01

    One of the causes of failed epidurals is catheter misplacement. Though various techniques of epidural space identification have been developed, none of them is 100% successful. Here, we present a case of lumbar epidural catheter misplacement in a patient scheduled to undergo right sided open nephrectomy. Catheter was found in the surgical field coming out of psoas major muscle. PMID:28274024

  14. Acute epidural-like appearance of an encapsulated solid non-organized chronic subdural hematoma.

    PubMed

    Prieto, Ruth; Pascual, José M; Subhi-Issa, Issa; Yus, Miguel

    2010-01-01

    We report the exceptional case of an encapsulated solid non-organized chronic subdural hematoma (SDH) in a 67-year-old woman that was admitted with acute hemiplegia followed by rapid deterioration in consciousness 5 months after a minor head trauma. Computed tomography (CT) showed an extracerebral biconvex shaped hyperdense mass that led to the misdiagnosis of an acute epidural hematoma. Urgent craniotomy revealed an encapsulated mass filled with solid fresh clot in the subdural space. Complete evacuation of this SDH, including both its inner and outer membranes, was achieved, and the patient recovered successfully. Histological analysis confirmed that the content of the hematoma corresponded to a newly formed clot that was enclosed between an inner membrane, composed of two collagen layers, and an outer membrane with a three layered structure. Chronic SDH may seldom present as an encapsulated solid non-organized lesion that consists of a fibrous capsule enclosing a fresh clot and lacking the thick fibrous septations that typically connect the inner and outer membranes of organized chronic SDH. This entity mimics the clinical course and radiological appearance of acute epidural hematomas and should be considered in the differential diagnosis of extracerebral hyperdense biconvex shaped lesions.

  15. Posterior interosseous neuropathy

    PubMed Central

    Kele, Henrich; Xia, Annie; Weiler, Markus; Schwarz, Daniel; Bendszus, Martin; Pham, Mirko

    2016-01-01

    Objective: To investigate the spatial pattern of lesion dispersion in posterior interosseous neuropathy syndrome (PINS) by high-resolution magnetic resonance neurography. Methods: This prospective study was approved by the local ethics committee and written informed consent was obtained from all patients. In 19 patients with PINS and 20 healthy controls, a standardized magnetic resonance neurography protocol at 3-tesla was performed with coverage of the upper arm and elbow (T2-weighted fat-saturated: echo time/repetition time 52/7,020 milliseconds, in-plane resolution 0.27 × 0.27 mm2). Lesion classification of the radial nerve trunk and its deep branch (which becomes the posterior interosseous nerve) was performed by visual rating and additional quantitative analysis of normalized T2 signal of radial nerve voxels. Results: Of 19 patients with PINS, only 3 (16%) had a focal neuropathy at the entry of the radial nerve deep branch into the supinator muscle at elbow/forearm level. The other 16 (84%) had proximal radial nerve lesions at the upper arm level with a predominant lesion focus 8.3 ± 4.6 cm proximal to the humeroradial joint. Most of these lesions (75%) followed a specific somatotopic pattern, involving only those fascicles that would form the posterior interosseous nerve more distally. Conclusions: PINS is not necessarily caused by focal compression at the supinator muscle but is instead frequently a consequence of partial fascicular lesions of the radial nerve trunk at the upper arm level. Neuroimaging should be considered as a complementary diagnostic method in PINS. PMID:27683851

  16. Posterior Urethral Strictures

    PubMed Central

    Gelman, Joel; Wisenbaugh, Eric S.

    2015-01-01

    Pelvic fracture urethral injuries are typically partial and more often complete disruptions of the most proximal bulbar and distal membranous urethra. Emergency management includes suprapubic tube placement. Subsequent primary realignment to place a urethral catheter remains a controversial topic, but what is not controversial is that when there is the development of a stricture (which is usually obliterative with a distraction defect) after suprapubic tube placement or urethral catheter removal, the standard of care is delayed urethral reconstruction with excision and primary anastomosis. This paper reviews the management of patients who suffer pelvic fracture urethral injuries and the techniques of preoperative urethral imaging and subsequent posterior urethroplasty. PMID:26691883

  17. Pentoxifylline Inhibits Epidural Fibrosis in Post-Laminectomy Rats

    PubMed Central

    Kelten, Bilal; Erdogan, Hakan; Antar, Veysel; Sanel, Selim; Tuncdemir, Matem; Kutnu, Muge; Karaoglan, Alper; Orki, Tulay

    2016-01-01

    Background The aim of this experimental study was to investigate the effectiveness of intramuscular pentoxifylline in the prevention of postoperative fibrosis. Material/Methods We divided 16 adult Wistar albino rats into 2 equal groups: treatment and control. Both groups underwent L1 vertebral total laminectomy to expose the dura. The intramuscular treatment group received pentoxifylline. Four weeks later, epidural fibrosis was studied in both groups using electron microscopy, light microscopy, histology, biochemistry, and macroscopy. Results The evaluation of epidural fibrosis in the 2 groups according to macroscopic (p<0.01) assessment and light microscopy revealed that epidural scar tissue formation was lower in the treatment group compared to the control group (p<0.001) and the number of fibroblasts was also decreased significantly in the pentoxifylline-treated group (p<0.05). More immature fibers were demonstrated in the treatment group by electron microscopy in comparison with the control group. In biochemical analysis, a statistically significant decrease was detected in hydroxyproline, which indicates fibrosis and myeloperoxidase activity, and shows an inflammatory response (P<0.001). Conclusions Systemic pentoxifylline application prevents postoperative epidural fibrosis and adhesions with various mechanisms. Our study is the first to present evidence of experimental epidural fibrosis prevention with pentoxifylline. PMID:26974057

  18. Morphine and hydromorphone epidural analgesia. A prospective, randomized comparison.

    PubMed

    Chaplan, S R; Duncan, S R; Brodsky, J B; Brose, W G

    1992-12-01

    Because evidence from uncontrolled, unblinded studies suggested fewer side effects from epidural hydromorphone than from epidural morphine, we employed a randomized, blinded study design to compare the side effects of lumbar epidural morphine and hydromorphone in 55 adult, non-obstetric patients undergoing major surgical procedures. A bolus dose of epidural study drug was given at least 1 h prior to the conclusion of surgery, followed by a continuous infusion of the same drug for two postoperative days. Infusions were titrated to patient comfort. Visual analog scale (VAS) pain scores, VAS sedation scores, and subjective ratings of nausea and pruritus were assessed twice daily. The two treatments provided equivalent analgesia. Sedation scores and prevalence of nausea did not differ significantly between groups. Prevalence of pruritus, however, differed significantly on postoperative day 1, with moderate to severe pruritus reported by 44.4% of patients in the morphine group versus 11.5% in the hydromorphone group (P < .01). On post-operative day 2, reports of pruritus by patients receiving morphine remained higher than those among the hydromorphone-treated subjects, although this difference was no longer statistically significant (32% vs. 16.7%, P = .18). We conclude that lumbar epidural morphine and hydromorphone afford comparable analgesia, but the occurrence of moderate to severe pruritus on the first postoperative day is reduced by the use of hydromorphone.

  19. Posterior Cortical Atrophy

    PubMed Central

    Crutch, Sebastian J; Lehmann, Manja; Schott, Jonathan M; Rabinovici, Gil D; Rossor, Martin N; Fox, Nick C

    2013-01-01

    Posterior cortical atrophy (PCA) is a neurodegenerative syndrome that is characterized by a progressive decline in visuospatial, visuoperceptual, literacy and praxic skills. The progressive neurodegeneration affecting parietal, occipital and occipito-temporal cortices which underlies PCA is attributable to Alzheimer's disease (AD) in the majority of patients. However, alternative underlying aetiologies including Dementia with Lewy Bodies (DLB), corticobasal degeneration (CBD) and prion disease have also been identified, and not all PCA patients have atrophy on clinical imaging. This heterogeneity has led to diagnostic and terminological inconsistencies, caused difficulty comparing studies from different centres, and limited the generalizability of clinical trials and investigations of factors driving phenotypic variability. Significant challenges remain in identifying the factors associated with both the selective vulnerability of posterior cortical regions and the young age of onset seen in PCA. Greater awareness of the syndrome and agreement over the correspondence between syndrome-and disease-level classifications are required in order to improve diagnostic accuracy, research study design and clinical management. PMID:22265212

  20. Posterior Fossa Meningioma

    PubMed Central

    Saleh, Essam A.; Taibah, Abdel Kader; Achilli, Vittorio; Aristegui, Miguel; Mazzoni, Antonio; Sanna, Mario

    1994-01-01

    Posterior fossa meningioma is the second most common tumor in the cerebellopontine angle. It has a higher rate of postoperative morbidity and mortality compared to acoustic neuroma. Forty posterior fossa meningioma patients managed in our centers were reviewed. Thirty-nine patients were managed surgically with 42 surgical procedures. The approaches used were the translabyrinthine approach in 18 patients (43%), the modified transcochlear in 11 cases (26%), the petro-occipital transsigmoid in 5 cases (12%), the suboccipital in 4 cases (10%), the petro-occipital trassigmoid transcervical in 2 cases (5%), the petro-occipital transsigmoid transtentorial in 1 case (2%), and a subtemporal transtentorial for another case (2%). Facial nerve anatomical integrity was preserved in 87% of procedures but was interrupted in 5 cases, with 4 of the latter subsequently repaired. Total tumor removal was accomplished in 38 cases. A second-stage total tumor removal is planned for the remaining case. There was only one case of perioperative death and no cases of radiological recurrence so far. ImagesFigure 1Figure 2Figure 3Figure 4p206-bFigure 5p207-bFigure 5 PMID:17171173

  1. Knotting of a Cervical Epidural Catheter in the Patient with Post-Herpetic Neuralgia: A Rare Complication

    PubMed Central

    Park, Jong Taek; Cho, Dong Woo; Lee, Young Bok

    2017-01-01

    Epidural block is achieved either by single injection of local anesthetic through an epidural needle or as a continuous block by infusion pump through an epidural catheter. Complications associated with epidural catheters include breakage, entrapment, and knotting. Knotting of epidural catheters is very rare, but knotting in lumbar epidural catheters has been reported in a number of studies, and most of these cases involved removal difficulty. We report a case in which we inserted a cervical epidural catheter in a patient who was experiencing severe post-herpetic neuralgia and then removed the knotted catheter without complications. PMID:28261560

  2. Epidural infection: Is it really an abscess?

    PubMed Central

    Avilucea, Frank R.; Patel, Alpesh A.

    2012-01-01

    Background: We reviewed the literature regarding the pathogenesis, clinical presentation, diagnosis, and management of spinal epidural abscess (SEA). Methods: Utilizing PubMed, we performed a comprehensive review of the literature on SEAs. Results: SEA remains a difficult infectious process to diagnose. This is particularly true in the early stages, when patients remain neurologically intact, and before the classic triad of fever, back pain, and neurologic deficit develop. However, knowledge of risk factors, obtaining serologic markers, and employing magnetic resonance scans facilitate obtaining a prompt and accurate diagnosis. In patients without neurologic deficits, lone medical therapy may prove effective. Conclusions: More prevalent over the previous three decades, SEA remains a rare but deleterious infectious process requiring prompt identification and treatment. Historically, identification of SEA is often elusive, diagnosis is delayed, and clinicians contend that surgical debridement is the cornerstone of treatment. Early surgery leads to more favorable outcomes and preserves neurologic function, particularly in the early stages of disease when minimal or no neurologic deficits are present. The advent of improved imaging modalities, diagnostic techniques, and multidrug antimicrobial agents has enabled medical/spinal surgical consultants to more rapidly diagnose SEA and institute more effective early medical treatment (e.g., data suggest that lone medical therapy may prove effective in the early management of SEA). PMID:23248757

  3. Pathophysiology of intracranial epidural haematoma following birth.

    PubMed

    Hamlat, Abderrahmane; Heckly, Anne; Adn, Mahmoudreza; Poulain, Patrice

    2006-01-01

    Epidural haematoma in newborn infants is rare, and few specific obstetrical data related to its formation are available in the literature. The aim of this study is to discuss the pathophysiology of this condition. EDH is always a post traumatic lesion and it is only possible if the insult has produced a cleavage of the dura mater from bone. Therefore, EDH results from the mechanical forces exerted on the foetal head during birth, with or with no instrumental interference. Although it is still unclear whether the injury (and dura mater cleavage) was directly caused by the forceps or had already been inflicted by natural forces, or a combination of both however, in some patients (with neither dystocia nor skull fracture), there is no basis for explaining EDH formation, apart from propulsion of the fore coming head through the birth canal. Excessive moulding, whether or not associated with iatrogenic trauma, has been incriminated in most cases of EDH. As dystocia cannot always be anticipated, EDH will remain an ever-present cause of morbidity in the neonatal population, albeit a rare occurrence.

  4. Evaluation and management of spinal epidural abscess.

    PubMed

    DeFroda, Steven F; DePasse, J Mason; Eltorai, Adam E M; Daniels, Alan H; Palumbo, Mark A

    2016-02-01

    Spinal epidural abscess (SEA) is an uncommon and potentially catastrophic condition. SEA often presents a diagnostic challenge, as the "classic triad" of fever, spinal pain, and neurological deficit is evident in only a minority of patients. When diagnosis is delayed, irreversible neurological damage may ensue. To minimize morbidity, an appropriate level of suspicion and an understanding of the diagnostic evaluation are essential. Infection should be suspected in patients presenting with axial pain, fever, or elevated inflammatory markers. Although patients with no known risk factors can develop SEA, clinical concern should be heightened in the presence of diabetes, intravenous drug use, chronic renal failure, immunosuppressant therapy, or a recent invasive spine procedure. When the clinical profile is consistent with the diagnosis of SEA, gadolinium-enhanced magnetic resonance imaging of the spinal column should be obtained on an emergent basis to delineate the location and neural compressive effect of the abscess. Rapid diagnosis allows for efficient treatment, which optimizes the potential for a positive outcome.

  5. Computational modeling of epidural cortical stimulation

    NASA Astrophysics Data System (ADS)

    Wongsarnpigoon, Amorn; Grill, Warren M.

    2008-12-01

    Epidural cortical stimulation (ECS) is a developing therapy to treat neurological disorders. However, it is not clear how the cortical anatomy or the polarity and position of the electrode affects current flow and neural activation in the cortex. We developed a 3D computational model simulating ECS over the precentral gyrus. With the electrode placed directly above the gyrus, about half of the stimulus current flowed through the crown of the gyrus while current density was low along the banks deep in the sulci. Beneath the electrode, neurons oriented perpendicular to the cortical surface were depolarized by anodic stimulation, and neurons oriented parallel to the boundary were depolarized by cathodic stimulation. Activation was localized to the crown of the gyrus, and neurons on the banks deep in the sulci were not polarized. During regulated voltage stimulation, the magnitude of the activating function was inversely proportional to the thickness of the CSF and dura. During regulated current stimulation, the activating function was not sensitive to the thickness of the dura but was slightly more sensitive than during regulated voltage stimulation to the thickness of the CSF. Varying the width of the gyrus and the position of the electrode altered the distribution of the activating function due to changes in the orientation of the neurons beneath the electrode. Bipolar stimulation, although often used in clinical practice, reduced spatial selectivity as well as selectivity for neuron orientation.

  6. Comparison of lidocaine and saline for epidural top-up during combined spinal-epidural anesthesia in volunteers.

    PubMed

    Trautman, W J; Liu, S S; Kopacz, D J

    1997-03-01

    This study was designed to determine the efficacy of saline as an epidural top-up to prolong spinal anesthesia during combined spinal-epidural anesthesia (CSEA). Eight volunteers received three separate CSEAs with intrathecal lidocaine (50 mg). After two-segment regression, each subject received either a saline (10 mL), lidocaine 1.5% (10 mL), or control sham (0.5 mL saline) epidural injection in a randomized, double-blind, triple cross-over fashion. Sensory block was assessed by pinprick and tolerance to transcutaneous electrical stimulation (TES) equivalent to surgical stimulation at the knee and ankle. Motor strength was assessed with iso-metric force dynamometry. Data were analyzed with a repeated measures analysis of variance and a paired t-test. Sensory block to pinprick was prolonged in the thoracolumbar dermatomes only by lidocaine (P < 0.05). Neither lidocaine nor saline prolonged the duration of tolerance to TES at the tested sites. Instead, saline decreased the duration of tolerance to TES by 20 and 24 min at the knee and ankle (P < 0.05). Recovery from motor block at the quadriceps was prolonged by an epidural injection of lidocaine (P < 0.05). We conclude that when 10 mL of epidural saline is administered after two-segment regression, it is an ineffective top-up and may decrease the duration of spinal anesthesia during CSEA.

  7. Continuous Cervical Epidural Analgesia in Metastatic Spinal Cord Compression

    PubMed Central

    Menon, Mahesh; Taha, Nafisa; Purohit, Navita; Kothari, Vatsal; Singh, Shweta

    2016-01-01

    Metastatic spinal cord compression is a devastating complication of cancer. Patients may often require high doses of opioids that may cause side effects, myoclonus being one such. A 63-year-old male suffering from malignant spinal cord compression was admitted to our institution. The primary team managed him conservatively with pharmacotherapy with no relief of pain, and he experienced myoclonus and sedation as adverse effects. A continuous cervical epidural catheter with local anesthetic infusion was inserted for 5 days to control his pain. This relieved his pain, which was sustained even after we removed the epidural catheter on day 5, for up to 64 days until the time of his death. Continuous cervical epidural local anesthetic infusions may help with refractory pain by deafferentation of noxious stimuli. Central neuraxial blocks may be a valuable rescue in selected patients. PMID:27803576

  8. Reversal of Progressive Conscious Disturbance with Epidural Blood Patch for Cerebrospinal Fluid Leakage at C2 Level.

    PubMed

    Lai, Yi-Chen; Chia, Yuan-Yi; Lien, Wei-Hung

    2017-03-01

    Intracranial hypotension syndrome (IHS) is generally caused by cerebrospinal fluid (CSF) leakage. Complications include bilateral subdural hygroma or haematoma and herniation of the cerebellar tonsils. Epidural blood patch (EBP) therapy is indicated if conservative treatment is ineffective. We reported the case of a 46-year-old man with a history of postural headache and dizziness. The patient was treated with bed rest and daily hydration with 2000 mL of fluid for 2 weeks. However, dizziness and headache did not resolve, and he became drowsy and disoriented with incomprehensible speech. Magnetic resonance imaging demonstrated diffuse dural enhancement on the postcontrast study, sagging of the midbrain, and CSF leakage over right lateral posterior thecal sac at C2 level. We performed EBP at the level of T10-T11. We injected 14 mL of autologous blood slowly in the Trendelenburg position. Within 30 minutes, he became alert and oriented to people, place, and time. We chose thoracic EBP as first line treatment in consideration of the risk of cervical EBP such as spinal cord and nerve root compression or puncture, chemical meningitis. Also we put our patient in Trendelenburg position to make blood travel towards the site of the leak. Untreated IHS may delay the course of resolution and affect the patient's consciousness. Delivery of EBP via an epidural catheter inserted from the thoracic spine is familiar with most of anesthesiologists. It can be a safe and effective treatment for patients with IHS caused by CSF leak even at C2.Key words: Anaesthetic techniques, regional, thoracic; cerebrospinal fluid leakage; epidural blood patch; heavily T2-weighted magnetic resonance myelography; intracranial hypotension syndrome; Trendelenburg position.

  9. Immunoglobulin G4-related disease mimicking an epidural spinal cord tumor: case report.

    PubMed

    Williams, Michelle M; Mashaly, Hazem; Puduvalli, Vinay K; Jin, Ming; Mendel, Ehud

    2017-01-01

    The authors report a case of immunoglobulin G4-related disease (IgG4-RD) presenting as a paraspinal, epidural mass. This disease encompasses a host of autoimmune conditions that were previously thought to be separate entities. It is characterized by fibrosis, mediated by the aberrant proliferation and tissue invasion of IgG4-positive plasma cells, which can occur in any organ. As with other autoimmune conditions, it tends to be responsive to steroids and other immunosuppressants. It can rarely present as a tumefactive lesion of the central nervous system, creating the potential for misdiagnosis (given its similar radiological appearance to malignancy) and mistreatment. In 2015, a panel of experts convened to set forth guidelines for the diagnosis and treatment of IgG4-RD. In the case presented here, the patient initially presented with pain and weakness in the left upper extremity. Initial neuroimages revealed a contrast-enhancing mass extending from C-4 to T-1, invading the epidural spinal canal, encasing the exiting nerve roots, infiltrating the paraspinal musculature, and surrounding the left vertebral artery. A PET scan confirmed the mass was hypermetabolic, but results of fine-needle aspiration and CT-guided biopsy were inconclusive. Open biopsy yielded fibrotic tissue that met the pathological criteria for IgG4-RD: lymphoplasmacytic infiltrate, fibrosis in a storiform pattern, and obliterative phlebitis. The patient was treated with 2 doses of 4 mg of dexamethasone (Decadron) and then 50 mg of prednisone per day. Within 2 weeks, the mass was radiologically shown to have drastically decreased in size. The prednisone dose was decreased to 40 mg per day, and 100 mg of azathioprine per day was added. The patient continued to improve and the mass continued to decrease over the next 6 months. Currently, she has been weaned from all steroids and will be maintained on a daily dose of 100 mg of azathioprine.

  10. [Posterior reversible encephalopathy syndrome and cerebrovascular constriction syndrome in the differential diagnosis of post-partum headaches].

    PubMed

    Ruiz López, N; Cano Hernández, B; Balbás Álvarez, S

    2016-02-01

    Postpartum headache can be due to many causes. In a patient with previous epidural analgesia, the headache can be attributed to post-dural puncture headache, even if the symptoms are not typical of this clinical entity. We report a case of a post-partum with accidental dural tap during the insertion of an epidural catheter for labour analgesia, and who referred to headaches in the third post-partum day. Initially, a post-dural puncture headache was suspected, but the subsequent onset of seizures and visual impairment meant that the diagnosis had to be reconsidered. In this case report, the clinical and pathophysiological features of posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome, as well as the differential diagnosis of post-partum headaches are described.

  11. Epidural analgesia complicated by dural ectasia in the Marfan syndrome

    PubMed Central

    Gray, Chelsea; Hofkamp, Michael P.; Noonan, Patrick T.; McAllister, Russell K.; Pilkinton, Kimberly A.; Diao, Zhiying

    2016-01-01

    Patients with the Marfan syndrome are considered to be high risk during pregnancy and warrant a complete multidisciplinary evaluation. One goal is to minimize hemodynamic fluctuations during labor since hypertensive episodes may result in aortic dissection or rupture. Although they may prevent these complications, neuraxial techniques may be complicated by dural ectasia. The case of a parturient with the Marfan syndrome and mild dural ectasia is presented. During attempted labor epidural placement, unintentional dural puncture occurred. A spinal catheter was used for adequate labor analgesia, and a resultant postdural puncture headache was alleviated by an epidural blood patch under fluoroscopic guidance. PMID:27695168

  12. Rapidly Progressive Gas-containing Lumbar Spinal Epidural Abscess

    PubMed Central

    Bang, Jin Hyuk

    2015-01-01

    Gas-containing (emphysematous) infections of the abdomen, pelvis, and extremities are well-known disease entities, which can potentially be life-threatening. They require aggressive medical and often surgical treatment. In the neurosurgical field, some cases of gas-containing brain abscess and subdural empyema have been reported. Sometimes they progress rapidly and even can cause fatal outcome. However, gas-containing spinal epidural abscess has been rarely reported and clinical course is unknown. We report on a case of rapidly progressive gas-containing lumbar spinal epidural abscess due to Enterococcus faecalis in a 72-year-old male patient with diabetes mellitus. PMID:26512268

  13. Rapidly Progressive Gas-containing Lumbar Spinal Epidural Abscess.

    PubMed

    Bang, Jin Hyuk; Cho, Keun-Tae

    2015-09-01

    Gas-containing (emphysematous) infections of the abdomen, pelvis, and extremities are well-known disease entities, which can potentially be life-threatening. They require aggressive medical and often surgical treatment. In the neurosurgical field, some cases of gas-containing brain abscess and subdural empyema have been reported. Sometimes they progress rapidly and even can cause fatal outcome. However, gas-containing spinal epidural abscess has been rarely reported and clinical course is unknown. We report on a case of rapidly progressive gas-containing lumbar spinal epidural abscess due to Enterococcus faecalis in a 72-year-old male patient with diabetes mellitus.

  14. Epidural catheter design: history, innovations, and clinical implications.

    PubMed

    Toledano, Roulhac D; Tsen, Lawrence C

    2014-07-01

    Epidural catheters have evolved during the past several decades, as clinicians and manufacturers have sought to influence the quality of analgesia and anesthesia and reduce the incidence of catheter-related complications. This evolution has allowed a transformation from single-shot to continuous-infusion techniques and resulted in easier passage into the epidural space, more extensive medication distribution, and ultimately, improved patient satisfaction. Particular catheter features, including the materials used, tip design, and orifice number and arrangement, have been associated with specific outcomes and provide direction for future development.

  15. Novel posterior fixation keratoprosthesis

    NASA Astrophysics Data System (ADS)

    Lacombe, Emmanuel

    1992-08-01

    The keratoprosthesis is the last solution for corneally blind patients that cannot benefit from corneal transplants. Keratoprostheses that have been designed to be affixed anteriorly usually necessitate multi-step surgical procedures and are continuously subjected to the extrusion forces generated by the positive intraocular pressure; therefore, clinical results in patients prove inconsistent. We proposed a novel keratoprosthesis concept that utilizes posterior corneal fixation which `a priori' minimizes the risk of aqueous leakage and expulsion. This prosthesis is implanted in a single procedure thereby reducing the number of surgical complications normally associated with anterior fixation devices. In addition, its novel design makes this keratoprosthesis implantable in phakic eyes. With an average follow-up of 13 months (range 3 to 25 months), our results on 21 cases are encouraging. Half of the keratoprostheses were implanted in severe burn cases, with the remainder in cases of pseudo- pemphigus. Good visual results and cosmetic appearance were obtained in 14 of 21 eyes.

  16. Posterior pole tumor update.

    PubMed

    Ou, Judy I; Wheeler, Sharon M; O'Brien, Joan M

    2002-12-01

    This chapter focuses on the diagnosis and management of choroidal melanoma in light of recent findings from the COMS. Retinoblastoma is emphasized to describe recent trends in primary treatment away from EBRT and toward chemoreduction with local therapy. In addition, vascular and glial tumors of the retina and tumors of the retinal pigment epithelium are described because of the association between these lesions and systemic disease. Recent advances in treatment and genetic testing for these diseases are discussed. Finally, ocular metastasis, intraocular lymphoid tumors, and intraocular leukemia are included because of their importance in determining systemic treatment and prognosis. The chapter gives an overview of important posterior pole tumors and highlights recent developments in the management of each intraocular disease process.

  17. Primary spinal epidural extraosseous Ewing's sarcoma: report of five cases and literature review.

    PubMed

    Mukhopadhyay, P; Gairola, M; Sharma, M; Thulkar, S; Julka, P; Rath, G

    2001-08-01

    Ewing's sarcoma is the most common malignant bone tumour occurring in children and adolescents and exists in two different clinicopathological entities: osseous Ewing's sarcoma (OES) and extraosseous Ewing's sarcoma (EES). Five cases of primary epidural EES are described, which presented with non-specific symptoms leading to a long diagnostic delay. The median age at diagnosis was 22 years (range 13-36 years). The median diagnostic delay was 3 months. All patients had one or more neurological deficits. All underwent surgical exploration with a laminectomy and partial resection followed by adjuvant radiotherapy to a dose of 46-50 Gy and chemotherapy with VAC (vincristine, adriamycin and cyclophosphamide) alternating with ICE (ifosphamide, cisplatin and etoposide) for at least six cycles. The mean follow-up period is 21.2 months (range 11-32 months). Four of the five patients achieved a complete remission and are disease free at the time of writing this report. Two patients have a residual neurological deficit--both having presented with long history of neurological deficit. Primary spinal epidural EES should be suspected whenever young patients present with back pain and/or radicular pain, have abnormal neurology and an extradural mass is demonstrated on MRI. Surgical excision followed by adjuvant radiotherapy (50 Gy) and combination chemotherapy (VAC alternating with ICE) achieved local and systemic control in these patients. A greater number of patients and longer follow up are required to evolve a generally accepted treatment policy for this aggressive but potentially curable malignancy.

  18. Update on epidural analgesia during labor and delivery.

    PubMed

    Lurie, S; Priscu, V

    1993-05-01

    Properly administered epidural analgesia provides adequate pain relief during labor and delivery, shortens the first stage of labor, avoids adverse effects of narcotics, hypnotics, or inhalation drugs and it could be used as anesthesia in case a cesarean section is required. Epidural analgesia should be provided to all patients who need and ask for it with an exception of contraindications such as coagulation disorders, suspected infection or gross anatomic abnormality. The technique must be carried out with care if serious life-threatening complications, such as intravenous or intrathecal injection of local anesthetic, are to be avoided. The aim of many recent investigations has been to reduce the total dose of local anesthetic used. Supplementation of an opioid (mainly fentanyl) and introduction of the patient controlled epidural pump may not only serve this goal, but also reduce the demands on the time of obstetric anesthetists. We conclude that properly and skillfully administered epidural is the best form of pain relief during labor and delivery and we hope that more mothers could enjoy its benefits.

  19. Upper Cervical Epidural Abscess in Clinical Practice: Diagnosis and Management

    PubMed Central

    Al-Hourani, Khalid; Al-Aref, Rami; Mesfin, Addisu

    2015-01-01

    Study Design Narrative review. Objective Upper cervical epidural abscess (UCEA) is a rare surgical emergency. Despite increasing incidence, uncertainty remains as to how it should initially be managed. Risk factors for UCEA include immunocompromised hosts, diabetes mellitus, and intravenous drug use. Our objective is to provide a comprehensive overview of the literature including the history, clinical manifestations, diagnosis, and management of UCEA. Methods Using PubMed, studies published prior to 2015 were analyzed. We used the keywords “Upper cervical epidural abscess,” “C1 osteomyelitis,” “C2 osteomyelitis,” “C1 epidural abscess,” “C2 epidural abscess.” We excluded cases with tuberculosis. Results The review addresses epidemiology, etiology, imaging, microbiology, and diagnosis of this condition. We also address the nonoperative and operative management options and the relative indications for each as reviewed in the literature. Conclusion A high index of suspicion is required to diagnose this rare condition with magnetic resonance imaging being the imaging modality of choice. There has been a shift toward surgical management of this condition in recent times, with favorable outcomes. PMID:27190742

  20. Vertical Small-Needle Caudal Epidural Injection Technique

    PubMed Central

    Maniquis Smigel, Liza; Dean Reeves, Kenneth; Jeffrey Rosen, Howard; Patrick Rabago, David

    2016-01-01

    Background Anecdotal evidence suggests that a vertical small-needle injection method enters the caudal epidural space with comparable efficacy to cephalad-directed methods, with less intravascular injection. Objectives Assess the success rate of vertical caudal epidural injection using epidurography and the frequency of intravascular injection using a vertical small-needle approach. Patients and Methods Participants had chronic generalized non-surgical low back pain and either gluteal and/or leg pain and were enrolled in a simultaneous clinical trial assessing the analgesic effect of 5% dextrose epidural injection. A 25 gauge 3.7 cm hypodermic needle was placed at the sacral hiatus using a fingertip-guided vertical technique without imaging assistance, followed by fluoroscopic epidurography. Minimal needle redirection was allowed up to 10 degrees from the vertical plane if the initial epidurogram showed an extradural pattern, followed by repeat epidurography. Results First needle placement without imaging resulted in blood return in 1/199 participants and positive epidurography in 179/199 (90%). Minimal needle repositioning resulted in a positive epidurogram in the remaining 19 attempts. No intravascular injection patterns were observed. Conclusions This compares favorably to published success rates of fluoroscopically-guided technique and was well tolerated. Vertical caudal epidural injection may be suitable for combination with ultrasound-guided methods with Doppler flow monitoring. PMID:27826539

  1. Disseminated blastomycosis presenting as mastoiditis and epidural abscess.

    PubMed

    Makary, Chadia A; Roberts, Thomas D; Wetmore, Stephen J

    2014-01-01

    Blastomycosis is a systemic fungal infection that affects primarily the lungs. Head and neck involvement has been reported most commonly in the larynx as well as oral and nasal mucosa. Temporal bone involvement is extremely rare. We report a case of disseminated blastomycosis presenting as mastoiditis and epidural abscess. We discuss the importance of early diagnosis and prompt initiation of treatment for optimal outcome.

  2. Epidural morphine analgesia in Guillain Barré syndrome.

    PubMed Central

    Genis, D; Busquets, C; Manubens, E; Dávalos, A; Baró, J; Oterino, A

    1989-01-01

    Severe pain is a frequent symptom in the Guillain Barré syndrome and can be intense, long lasting and with no response to the usual analgesics, including parenteral opiates. Epidural analgesia using morphine chloride in low doses has satisfactorily relieved pain in this disease in nine patients. PMID:2795070

  3. [Iliopsoas abscess accompanied by epidural abscess--a case report].

    PubMed

    Fukushige, Tetsushi; Sano, Tomomi; Yamada, Sinichi; Ueda, Sawako; Kano, Tatsuhiko

    2003-09-01

    A 55-year-old man was admitted to a hospital with pain of the low back as well as the left leg, and fever. He was suspected of suffering from the lumbar disc herniation because of the presence of Lasegue's sign on the first physical examination. Abdominal computed tomography, however, revealed the swelling of the left iliopsoas muscle. Iliopsoas abscess accompanied epidural abscess was confirmed by subsequent magnetic resonance imaging (MRI). Antibiotic therapy was started for the successive 8 days. The fever resolved, but the pain persisted. The abscess extending from the iliopsoas muscle to the epidural space was still seen on the MRI 20 days after the completion of the antibiotic therapy, and he still complained of the pain of his low back and left leg. Therefore, we conducted epidural puncture under fluoroscopic guidance. Approximately 3 ml of pus was aspirated from the epidural space. Then, his complains decreased remarkably. Iliopsoas abscess should be taken into account in case of a patient with pain on the low back and leg and also inflammatory signs such as fever and leucocytosis.

  4. Posterior Reversible Encephalopathy Syndrome

    PubMed Central

    Algahtani, Abdulhadi; Aldarmahi, Ahmad; Hmoud, Mohammed; Marzuk, Yousef; Shirah, Bader

    2016-01-01

    Objectives: Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by headache, altered mental status, seizures, or loss of vision. In this study, we report the largest series of PRES coming from Saudi Arabia and explore the etiology, clinical presentation, and outcome. We also report new imaging findings associated with this condition. Methods: We performed a retrospective study of all cases of PRES admitted to King Abdulaziz Medical City, Jeddah, Saudi Arabia, between the years 2005 and 2015. A neurologist reviewed all charts and analyzed the clinical presentations, etiological factors, and outcomes, and a neuroradiologist reviewed the imaging studies. Only patients with clinical and imaging features consistent with PRES were included in the study. Results: We collected 31 patients who had clinical and radiological features consistent with PRES. Females were more affected than males (18 females and 13 males), and patients’ age ranged from 6 to 95 years, with a mean of 38.3 years. Patients were treated by removing the precipitating causes and treating the underlying conditions. Resolution of neurologic signs occurred within 2 to 3 weeks in all patients. Conclusion: In our opinion, PRES itself is usually a benign condition with complete recovery if the condition is recognized early and managed appropriately. Although clinical signs are nonspecific, the constellation of symptoms including headache, visual problems, seizures, and altered level of consciousness should suggest the possibility of PRES, especially in high-risk group. Abnormalities on magnetic resonance imaging are often characteristic and may be the first clue to the diagnosis. PMID:28042366

  5. Limitations of the Use of Pressure Waves to Verify Correct Epidural Needle Position in Dogs

    PubMed Central

    Bergadano, Alessandra; Spadavecchia, Claudia

    2013-01-01

    The use of pressure waves to confirm the correct position of the epidural needle has been described in several domestic species and proposed as a valid alternative to standard methods, namely, control radiographic exam and fluoroscopy. The object of this retrospective clinical study was to evaluate the sensitivity of the epidural pressure waves as a test to verify the correct needle placement in the epidural space in dogs, in order to determine whether this technique could be useful not only in the clinical setting but also when certain knowledge of needle's tip position is required, for instance when performing clinical research focusing on epidural anaesthesia. Of the 54 client-owned dogs undergoing elective surgeries and enrolled in this retrospective study, only 45% showed epidural pressure waves before and after epidural injection. Twenty-six percent of the animals showed epidural pressure waves only after the injection, whereas 29% of the dogs showed epidural pressure waves neither before nor after injection and were defined as false negatives. Our results show that the epidural pressure wave technique to verify epidural needle position lacks sensitivity, resulting in many false negatives. As a consequence, the applicability of this technique is limited to situations in which precise, exact knowledge of the needle's tip position is not mandatory. PMID:23853736

  6. Patient-controlled epidural analgesia: interactions between nalbuphine and hydromorphone.

    PubMed

    Parker, R K; Holtmann, B; White, P F

    1997-04-01

    Epidural opioid analgesia can offer advantages over intravenous administration, however, opioid-related side effects are common after epidural administration. We studied the effect of adding nalbuphine (NB), an opioid agonist-antagonist, to hydromorphone (HM) for patient-controlled epidural analgesia (PCEA) in 78 healthy women after elective cesarean delivery. Patients were randomly assigned to one of four treatment groups. The control group received preservative-free HM (Dilaudid) alone, 0.075 mg/mL, while the three study groups received HM, 0.075 mg/mL, containing preservative-free NB (Nubain) 0.02, 0.04, or 0.08 mg/mL. Intraoperatively, all patients received epidural bupivacaine 0.5%. Postoperatively, a patient-controlled anesthesia (PCA) device was connected to the epidural catheter and programmed to deliver a 3-mL loading dose of the analgesic solution. Subsequently, patients could self-administer 2 mL bolus doses on demand with a 30-min lockout interval. Patients were encouraged to ambulate approximately 8 h after surgery, and PCEA therapy was discontinued when a clear liquid diet was tolerated. Visual analog scale scores were used to assess pain at 8-h intervals while using PCEA therapy. Although the overall incidences of nausea (19%-35%) and pruritus (32%-62%) were similar in all four groups, the addition of NB decreased the need for bladder catheterization. The highest NB concentration resulted in increased PCA demands during the 32-h study period. In conclusion, the combination of HM 0.075 mg/mL and NB 0.04 mg/mL resulted in lower nausea scores and a decreased incidence of urinary retention compared with HM alone, without increasing the opioid analgesic requirement.

  7. Efficacy of single dose epidural morphine versus intermittent low-dose epidural morphine along with bupivacaine for postcaesarean section analgesia

    PubMed Central

    Agarwal, Kiran; Agarwal, Navneet; Agrawal, V. K.; Agarwal, Ashok; Sharma, Mahender

    2012-01-01

    Background: Obstetric anesthesia presents a challenge to the anesthesiologist. The effective pain management allows the partu-rient adequate degree of comfort and promotes physical reco-very and a sense of well being. Materials and Methods: This randomized controlled study was designed to assess the analgesic efficacy and side effects of 1.20 mg single-dose epidural morphine (Group 1) versus intermittent 12 hourly epidural morphine (0.5 mg) with bupivacaine (Group2) for postoperative analgesia in lower segment caesarean section cases. Results: Each group consisted of 36 patients. Demographic characteristics of two groups were comparable and differences among them were not statistically significant. Mean duration of analgesia was significantly longer in group one patients (16.5±2.5h) in comparison to group two patients (11.5±1.5h). Mean highest visual analog scales (VAS scale) was significantly lower (3.2±0.9) in group one patients in comparison of group two (6.7±0.8) patients. Only 43% patient in group one required supplementary perenteral analgesic (Paracetamole/Diclofenac) and 71% required epidural morphine/bupivacaine in group two. Mean number of supplementary perenteral analgesic required in group one was 0.7 and it was 1.8 in group two. There was no significant difference in nausea, vomiting, itching, and pruritis in two groups of patients. Conclusion: Our study showed that the use of single dose epidural morphine is associated with lower pain scores at rest and movement when compared to intermittent epidural morphine with bupivacaine in postcaesarean section analgesia. PMID:25885497

  8. Posterior sampling with improved efficiency

    SciTech Connect

    Hanson, K.M.; Cunningham, G.S.

    1998-12-01

    The Markov Chain Monte Carlo (MCMC) technique provides a means to generate a random sequence of model realizations that sample the posterior probability distribution of a Bayesian analysis. That sequence may be used to make inferences about the model uncertainties that derive from measurement uncertainties. This paper presents an approach to improving the efficiency of the Metropolis approach to MCMC by incorporating an approximation to the covariance matrix of the posterior distribution. The covariance matrix is approximated using the update formula from the BFGS quasi-Newton optimization algorithm. Examples are given for uncorrelated and correlated multidimensional Gaussian posterior distributions.

  9. Modern approach to an old technique: Narrative revision of techniques used to locate the epidural space.

    PubMed

    Brogly, N; Guasch Arévalo, E; Kollmann Camaiora, A; Alsina Marcos, E; García García, C; Gilsanz Rodríguez, F

    2017-03-16

    Since the first description of the epidural technique during the 1920s, the continuous progress of knowledge of the anatomy and physiology of the epidural space has allowed the development of different techniques to locate this space while increasing both the safety and efficacy of the procedure. The most common techniques used today are based on the two main characteristics of the epidural space: the difference in distensibility between the ligamentum flavum and the epidural space, and the existence of negative pressure within the epidural space. However, over recent years, technological advances have allowed the development of new techniques to locate the epidural space based on other physical properties of tissues. Some are still in the experimental phase, but others, like ultrasound-location have reached a clinical phase and are being used increasingly in daily practice.

  10. Spontaneous Spinal Epidural Hematoma on the Ventral Portion of Whole Spinal Canal: A Case Report

    PubMed Central

    Lee, Hyun-Ho; Kim, Young; Ha, Young-Soo

    2015-01-01

    Spontaneous spinal epidural hematoma is an uncommon but disabling disease. This paper reports a case of spontaneous spinal epidural hematoma and treatment by surgical management. A 32-year-old male presented with a 30-minute history of sudden headache, back pain, chest pain, and progressive quadriplegia. Whole-spinal sagittal magnetic resonance imaging (MRI) revealed spinal epidural hematoma on the ventral portion of the spinal canal. Total laminectomy from T5 to T7 was performed, and hematoma located at the ventral portion of the spinal cord was evacuated. Epidural drainages were inserted in the upper and lower epidural spaces. The patient improved sufficiently to ambulate, and paresthesia was fully recovered. Spontaneous spinal epidural hematoma should be considered when patients present symptoms of spinal cord compression after sudden back pain or chest pain. To prevent permanent neurologic deficits, early and correct diagnosis with timely surgical management is necessary. PMID:26512277

  11. Treatment of Spinal Epidural Abscess and Predisposing Factors of Motor Weakness: Experience with 48 Patients

    PubMed Central

    Ju, Min-Wook; Kwon, Hyon-Jo; Kim, Seon-Hwan; Koh, Hyeon-Song; Youm, Jin-Young; Song, Shi-Hun

    2015-01-01

    Objective Spinal epidural abscess (SEA) can be fatal if untreated, so early diagnosis and treatment are essential. We conducted a retrospective study to define its clinical features and evaluate the risk factors of motor weakness. Methods We retrospectively analyzed the medical records and images of patients with SEA who had been hospitalized in our institute from January 2005 to June 2012. Pyogenic SEA patients were categorized as patients without motor weakness (Group A) and with motor weakness (Group B). Abscess volume was measured using the Gamma-Plan program. Intervertebral foramen height and posterior disc height were measured to evaluate degree of spinal stenosis. Results Of 48 patients with pyogenic SEA, 33 (68%) were treated surgically, and 15 (32%) were treated with antibiotics. Eleven patients had weakness and abscess volume was unrelated to motor weakness. Old age, 'spare room' (abscess volume subtracted from spinal volume) and intervertebral foramen height and posterior disc height were statistically significant. Among the 48 patients, 43 (85%) had good outcome and erythrocyte sedimentation rate (ESR) was the only meaningful prognostic factor (p=0.014). The cut-off value of ESR was 112mm/h with 80% sensitivity and 79% specificity and had borderline significance (p=0.062). Conclusion SEA needs emergent diagnosis and treatment. Motor weakness is the most important factor in treatment decision. By careful image reading, early surgical treatment can be an option for selected patients with severe spinal stenosis for prevent motor weakness. Inflammatory markers, especially ESR, are valuable to identify worsening of SEA. PMID:26512265

  12. Methicillin-Resistant Staphylococcus aureus Vertebral Osteomyelitis Following Epidural Catheterization: A Case Report and Literature Review

    PubMed Central

    Krishnakumar, R.; Renjitkumar, J.

    2012-01-01

    Indwelling epidural catheters are frequently used to manage postoperative pain. This report describes a patient who developed methicillin-resistant Staphylococcus aureus (MRSA) vertebral osteomyelitis of the lumbar spine following epidural catheterization. To the best of our knowledge, this is the first reported case of MRSA vertebral osteomyelitis secondary to epidural catheter use in the English orthopedic literature. The patient and his family consented to publishing the data. PMID:24353973

  13. Safety of different acupuncture manipulations for posterior circulation ischemia with vertigo

    PubMed Central

    Wen, Yan; Zhang, Chao; Zhao, Xiao-feng; Deng, Shi-zhe; He, Si; Huang, Ling-hui; Tian, Guang; Meng, Zhi-hong

    2016-01-01

    Acupuncture at Fengchi (GB20) in the posterior neck improves vertigo. However, subarachnoid hemorrhage and spinal epidural hematoma have been reported to occur after acupuncture in the posterior neck. Therefore, in the present study, we assessed the safety of acupuncture at Fengchi. Laboratory tests and adverse event reports were used to evaluate the safety of different acupuncture manipulations for the treatment of posterior circulation ischemia with vertigo. A total of 136 patients were randomly assigned to four groups. Verum acupuncture was conducted with different needle insertion directions (contralateral paropia or prominentia laryngea) and different needle twisting frequencies (60 or 120 times/minute) at Fengchi and matching acupoints (for example, Zhongwan [CV12], Qihai [CV6], Zusanli [ST36], and Fenglong [ST40]). The patients received 14 treatments over 3–4 weeks. Routine blood analysis, hepatic and renal function tests, urine and feces tests and electrocardiography were performed before the first treatment session and after the final session. Adverse events were recorded after every session. Of the 136 patients, 120 completed the study. There were no significant differences between pretreatment and posttreatment test results in any of the groups. Only five patients suffered from minor adverse events (needling pain, slight hematoma and transient chest tightness). No serious adverse events were found. Our results indicate that a 14-session course of needling at Fengchi is relatively safe for treating posterior circulation ischemia with vertigo. PMID:27651774

  14. Safety of different acupuncture manipulations for posterior circulation ischemia with vertigo.

    PubMed

    Wen, Yan; Zhang, Chao; Zhao, Xiao-Feng; Deng, Shi-Zhe; He, Si; Huang, Ling-Hui; Tian, Guang; Meng, Zhi-Hong

    2016-08-01

    Acupuncture at Fengchi (GB20) in the posterior neck improves vertigo. However, subarachnoid hemorrhage and spinal epidural hematoma have been reported to occur after acupuncture in the posterior neck. Therefore, in the present study, we assessed the safety of acupuncture at Fengchi. Laboratory tests and adverse event reports were used to evaluate the safety of different acupuncture manipulations for the treatment of posterior circulation ischemia with vertigo. A total of 136 patients were randomly assigned to four groups. Verum acupuncture was conducted with different needle insertion directions (contralateral paropia or prominentia laryngea) and different needle twisting frequencies (60 or 120 times/minute) at Fengchi and matching acupoints (for example, Zhongwan [CV12], Qihai [CV6], Zusanli [ST36], and Fenglong [ST40]). The patients received 14 treatments over 3-4 weeks. Routine blood analysis, hepatic and renal function tests, urine and feces tests and electrocardiography were performed before the first treatment session and after the final session. Adverse events were recorded after every session. Of the 136 patients, 120 completed the study. There were no significant differences between pretreatment and posttreatment test results in any of the groups. Only five patients suffered from minor adverse events (needling pain, slight hematoma and transient chest tightness). No serious adverse events were found. Our results indicate that a 14-session course of needling at Fengchi is relatively safe for treating posterior circulation ischemia with vertigo.

  15. Histopathological Alterations after Single Epidural Injection of Ropivacaine, Methylprednizolone Acetate, or Contrast Material in Swine

    SciTech Connect

    Kitsou, Maria-Chrysanthi; Kostopanagiotou, Georgia; Kalimeris, Konstantinos; Vlachodimitropoulos, Demetrios; Soultanis, Konstantinos; Batistaki, Chrysanthi; Kelekis, Alexis

    2011-12-15

    Purpose: The consequences from the injection of different types of drugs in the epidural space remains unknown. Increasing evidence suggests that localized inflammation, fibrosis, and arachnoiditis can complicate sequential epidural blockades, or even epidural contrast injection. We investigate the in vivo effect of epidural injections in the epidural space in an animal model. Materials and Methods: A group of ten male adult pigs, five punctures to each at distinct vertebral interspaces under general anesthesia, were examined, testing different drugs, used regularly in the epidural space (iopamidol, methylprednisolone acetate, ropivacaine). Each site was marked with a percutaneous hook wire marker. Histological analysis of the epidural space, the meninges, and the underlying spinal cord of the punctured sites along with staining for caspase-3 followed 20 days later. Results: The epidural space did not manifest adhesions or any other pathology, and the outer surface of the dura was not impaired in any specimen. The group that had the contrast media injection showed a higher inflammation response compared to the other groups (P = 0.001). Positive staining for caspase-3 was limited to <5% of neurons with all substances used. Conclusion: No proof of arachnoiditis and/or fibrosis was noted in the epidural space with the use of the above-described drugs. A higher inflammation rate was noted with the use of contrast media.

  16. Incidence of intradiscal injection during lumbar fluoroscopically guided transforaminal and interlaminar epidural steroid injections.

    PubMed

    Candido, Kenneth D; Katz, Jeffrey A; Chinthagada, Mariadas; McCarthy, Robert A; Knezevic, Nebojsa Nick

    2010-05-01

    Intradiscal injections during transforaminal epidural steroid injections and interlaminar lumbar epidural steroid injections have been reported rarely. In that regard, this retrospective observational report is the first attempt to quantify the overall rate of this complication. A retrospective analysis of 3 years of accrued data (2004-2007) showed that 2412 transforaminal epidural steroid injections were performed at the 2 training institutions (Loyola University Medical Center and Northwestern University/Feinberg School of Medicine). There were 6 intradiscal (annular) injections of contrast, for a rate of 1:402. Over the same interval, 4723 lumbar epidural steroid injections were performed, with 1 intradiscal injection, for a rate of 1:4723.

  17. Epidural analgesia during labor: continuous infusion or patient-controlled administration?

    PubMed

    Benhamou, D

    1995-05-01

    Patient-controlled epidural analgesia (PCEA) has several advantages over continuous epidural infusion of bupivacaine during labor: it produces a good analgesia with a limited sensory spread; generally, less bupivacaine is administered and maternal satisfaction with pain control is increased. However, the quality of analgesia is similar to that obtained with other forms of epidural administration. Moreover, PCEA is only a particular form of epidural and, as such, has the same safety requirements. PCEA does not appear to reduce the workload of the anesthetic team. The cost of the PCA pump will need to be included in future evaluation of the cost/benefit ratio.

  18. Epidural catheter misplaced into the thoracic cavity: Utilized to provide interpleural analgesia

    PubMed Central

    Sundary, M. Thiriloga

    2015-01-01

    Thoracic epidural analgesia is one of the most effective and time-tested modalities of providing postthoracotomy pain relief. It improves postoperative pulmonary outcome. Nevertheless, being a blind procedure several complications have been associated with the technique. Pleural puncture is one rare complication that might occur following thoracic epidural catheterization. We have discussed a patient who underwent a right thoracotomy for excision of emphysematous bulla of lung under general anesthesia with thoracic epidural. The epidural catheter was misplaced in the pleural cavity and was detected intraoperatively after thoracotomy. The catheter was left in situ and was successfully utilized to provide postoperative analgesia via the interpleural route. PMID:25886437

  19. Spinal epidural abscess: a rare complication of olecranon bursitis

    PubMed Central

    Evans, Rhys D.R.; Thaya, Moe; Chew, Ne Siang; Gibbons, Charles E.R.

    2009-01-01

    Spinal epidural abscess is a rare but potentially fatal condition if left untreated. We report the case of a 67-year old man who presented to the Accident and Emergency department complaining of acute onset of inter-scapular back pain, left leg weakness and loss of sensation in the left foot. On examination he was found to be pyrexial with long tract signs in the left lower leg. In addition he had a left sided olecranon bursitis of three weeks duration. Blood tests revealed raised inflammatory markers and a staphylococcal bacteremia. Magnetic resonance imaging (MRI) confirmed the diagnosis of spinal epidural abscess and he subsequently underwent a three level laminectomy with good resolution of his back pain and neurological symptoms. He has made a complete recovery with a prolonged course of intravenous antibiotics. PMID:21808663

  20. Lumbar spine osteomyelitis and epidural abscess formation secondary to acupuncture

    PubMed Central

    Godhania, Vinesh

    2016-01-01

    A 39-year-old male with no previous medical history presented with abdominal and low back pain. Based on clinical and radiological findings he was diagnosed with L1/L2 osteomyelitis and epidural abscess. Further history taking revealed recent use of acupuncture for treatment of mechanical back pain. The patient was treated conservatively with an extended course of antibiotics, monitored with repeat MRI scans and had a full recovery with no neurological deficit. This is the first reported case of epidural abscess formation and osteomyelitis after acupuncture in the UK. As acupuncture becomes more commonly used in western countries, it is important to be aware of this rare but serious complication. PMID:26976275

  1. Rosai-Dorfman Disease Isolated to the Thoracic Epidural Spine

    PubMed Central

    Kozak, Benjamin; Talbott, Jason; Uzelac, Alina; Rehani, Bhavya

    2015-01-01

    Rosai-Dorfman disease is a rare benign histiocytic disease that infrequently presents in the spine. We report a case of Rosai-Dorfman disease isolated to the epidural thoracic spine in a 26-year-old male. To our knowledge, this is the 15th reported case of isolated spinal disease and only the fourth case of isolated thoracic epidural disease. Given its rarity as well as non-specific symptoms and imaging findings, Rosai-Dorfman disease is often not considered and misdiagnosed on imaging studies. To help improve awareness of Rosai-Dorfman spinal disease, we review the literature and discuss the epidemiology, clinical presentation, imaging features, and treatment considerations for this condition. PMID:27252790

  2. Spinal epidural abscess: a rare complication of olecranon bursitis.

    PubMed

    Evans, Rhys D R; Thaya, Moe; Chew, Ne Siang; Gibbons, Charles E R

    2009-06-30

    Spinal epidural abscess is a rare but potentially fatal condition if left untreated. We report the case of a 67-year old man who presented to the Accident and Emergency department complaining of acute onset of inter-scapular back pain, left leg weakness and loss of sensation in the left foot. On examination he was found to be pyrexial with long tract signs in the left lower leg. In addition he had a left sided olecranon bursitis of three weeks duration. Blood tests revealed raised inflammatory markers and a staphylococcal bacteremia. Magnetic resonance imaging (MRI) confirmed the diagnosis of spinal epidural abscess and he subsequently underwent a three level laminectomy with good resolution of his back pain and neurological symptoms. He has made a complete recovery with a prolonged course of intravenous antibiotics.

  3. Epidural injections of indomethacin for postlaminectomy syndrome: a preliminary report.

    PubMed

    Aldrete, J Antonio

    2003-02-01

    Since there have been side effects reported with the administration of corticosteroids epidurally, their application has been limited. Because some nonsteroidal antiinflammatory drugs have central and spinal antinociceptive actions, we have compared the effects of indomethacin (INM) given by the epidural route to methylprednisolone (MTP). This was a prospective, comparative study in an ambulatory pain care center. Two hundred six patients with recurrent low back pain (Visual Analog Scale >7) and radiculopathy after they had had 2 or more lumbar laminectomies with the diagnosis of "postlaminectomy syndrome" were randomly assigned to 1 of 3 groups. Group I (64 patients) was given 2 epidural injections of lyophilized INM 1 mg. Group II (60 patients) received 2 injections of 2 mg of INM at the same intervals. Group III (82 patients) was treated by 2 epidural injections of MTP 80 mg. In every case, the medication was diluted in 3 mL of 0.5% bupivacaine. Reductions of pain were assessed by changes in the Visual Analog Scale; physical activities, attitude, and medication intake were graded by the Pain Progress Score recorded before each treatment and 2 wk after the last. After each injection, all patients had pain relief to Visual Analog Scale <3. Increased analgesia (P < 0.05) was noted when a double dose of INM was used (Group II) or when 80 mg of MTP was given. The total average scores of the Pain Progress Score showed significant differences at the second injection in Groups II and III only. Physical activity, emotional attitudes, and medication intake were also improved but the changes were not statistically significant. In conclusion, in this group of patients, INM produced adequate analgesia in Groups I and II, with evidence suggesting that 2 mg of INM may produce a similar degree of pain relief as 80 mg of MTP after the second injection. Other nonsteroidal antiinflammatory drugs may be explored in the future for the same purpose.

  4. Hands-and-knees positioning during labor with epidural analgesia.

    PubMed

    Stremler, Robyn; Halpern, Stephen; Weston, Julie; Yee, Jennifer; Hodnett, Ellen

    2009-01-01

    Hands-and-knees position has shown promise as an intervention to improve labor and birth outcomes, but no reports exist that examine its use with women laboring with epidural analgesia. Concerns of safety, effects on analgesia, and acceptability of use may limit use of active positioning during labor with regional analgesia. This article presents a case study series of 13 women who used hands-and-knees position in the first stage of labor.

  5. Disseminated cat scratch disease with vertebral osteomyelitis and epidural abscess.

    PubMed

    Abdel-Haq, Nahed; Abuhammour, Walid; Al-Tatari, Hossam; Asmar, Basim

    2005-11-01

    A 5-year-old boy with cat scratch disease presented with fever of unknown origin and osteomyelitis of the thoracic spine and epidural abscess. He did not have localizing signs or symptoms. Computed tomography of the abdomen, which was initially negative, showed hepatosplenic disease. Cat scratch disease has variable systemic presentations and should be included in the differential diagnosis of fever of unknown origin if an epidemiologic risk factor is present.

  6. Does pregnancy increase the efficacy of lumbar epidural anesthesia?

    PubMed

    Arakawa, M

    2004-04-01

    Pregnancy has been reported to enhance the sensitivity of nerves to local anesthetics and to decrease anesthetic requirements during regional anesthesia. In this study, whether pregnancy increased the efficacy of lumbar epidural anesthesia was evaluated. Two populations (14 pregnant and 14 non-pregnant women) undergoing lumbar epidural anesthesia were studied and received 17 mL of 2% lidocaine-epinephrine (1: 200,000). The pain threshold response after repeated electrical stimulation was used to assess sensory blockade at the L2, S1 and S3 dermatomes. Motor blockade was evaluated using the Bromage score. Demographic data except for weight were comparable between the two groups. There was a significant difference in cephalad spread of anesthesia between the groups. No significant differences in pain threshold or onset of sensory blockade at the L2, S1 or S3 segments were found between the groups. The pain thresholds at the S1 and S3 dermatomes were significantly lower than that at L2 within each group. The mean onset times at the S1 and S3 dermatomes were significantly longer than that at L2 within each group. No differences in Bromage score were found between the groups. In pregnant women, cephalad spread of epidural anesthesia was facilitated but latency of blockade, density and motor blockade were not. It takes over 25 min to achieve satisfactory blockade at sacral segments. Those who perform lumbar epidural anesthesia alone for cesarean section should consider the use of additives (e.g. fentanyl, bicarbonate) to enhance the block, or a greater volume of local anesthetic.

  7. Diabetes mellitus and spinal epidural abscess: clinical or surgical treatment?

    PubMed

    Felício, João S; Martins, Carlliane Lins P; Liberman, Bernardo

    2011-12-01

    Spinal epidural abscess (SEA) is an uncommon condition and its most important predisposing factor is diabetes mellitus. Although the treatment of choice is prompt surgical abscess evacuation, followed by antibiotic therapy, successful conservative treatment of SEA has been reported in some cases. We describe a SEA case in a 23-year old white woman with diabetes for 14 years, who was successfully treated only with antibiotics, and achieved full recovery at the fourth month of follow-up.

  8. Epidural Catheter Migration in a Patient with Severe Spinal Stenosis

    PubMed Central

    Anderson, Ryan

    2016-01-01

    Establishment of appropriate neuraxial catheter positioning is typically a straightforward procedural undertaking. It can, however, lead to deception of even the most experienced clinician and occur despite the most meticulous attention to detail. Written and verbal consent were obtained from the patient to prepare, discuss, and publish this case report; we describe the occurrence of what we believe was the intraoperative migration of an epidural catheter in the setting of significant tissue changes resulting from a previous spinal fusion. PMID:28097025

  9. Care and management of intrathecal and epidural catheters.

    PubMed

    Du Pen, Anna

    2005-01-01

    Epidural and intrathecal catheters have increasingly become a part of acute and chronic pain management over the past 25 years. Externalized systems include temporary, permanent exteriorized, and permanent port systems for use over weeks to months of expected therapy. Implanted, completely internalized systems are available for conditions expected to require many months or years of therapy. Expert care includes routine management as well as advanced troubleshooting. Prevention of infection is a key priority for nurses managing these devices.

  10. The Neurological Safety of Epidural Pamidronate in Rats

    PubMed Central

    Lee, Pyung Bok; Kim, Yong Chul; Lee, Chul Joong; Shin, Hye Young; Lee, Seung Yun; Park, Jong Cook; Choi, Yun Suk; Kim, Chong Soo

    2010-01-01

    Background Pamidronate is a potent inhibitor of osteoclast-mediated bone resorption. Recently, the drug has been known to relieve bone pain. We hypothesized that direct epidural administration of pamidronate could have various advantages over oral administration with respect to dosage, side effects, and efficacy. Therefore, we evaluated the neuronal safety of epidurally-administered pamidronate. Methods Twenty-seven rats weighing 250-350 g were equally divided into 3 groups. Each group received an epidural administration with either 0.3 ml (3.75 mg) of pamidronate (group P), 0.3 ml of 40% alcohol (group A), or 0.3 ml of normal saline (group N). A Pinch-toe test, motor function evaluation, and histopathologic examination of the spinal cord to detect conditions such as chromatolysis, meningeal inflammation, and neuritis, were performed on the 2nd, 7th, and 21st day following administration of each drug. Results All rats in group A showed an abnormal response to the pinch-toe test and decreased motor function during the entire evaluation period. Abnormal histopathologic findings, including neuritis and meningeal inflammation were observed only in group A rats. Rats in group P, with the exception of 1, and group N showed no significant sensory/motor dysfunction over a 3-week observation period. No histopathologic changes were observed in groups P and N. Conclusions Direct epidural injection of pamidronate (about 12.5 mg/kg) showed no neurotoxic evidence in terms of sensory/motor function evaluation and histopathologic examination. PMID:20556213

  11. Cerebrospinal fluid cutaneous fistula following obstetric epidural analgaesia. Case report.

    PubMed

    Fedriani de Matos, J J; Quintero Salvago, A V; Gómez Cortés, M D

    2017-03-28

    Cutaneous fistula of cerebrospinal fluid is a rare complication of neuroaxial blockade. We report the case of a parturient in whom an epidural catheter was placed for labour analgesia and 12h after the catheter was removed, presented an abundant asymptomatic fluid leak from the puncture site, compatible in the cyto-chemical analysis with cerebrospinal fluid. She was treated with acetazolamide, compression of skin orifice of the fluid leakage, antibiotic prophylaxis, hydration and rest, and progressed satisfactorily without requiring blood patch.

  12. Bupivacaine crystal deposits after long-term epidural infusion.

    PubMed

    Balga, I; Gerber, H; Schorno, X H; Aebersold Keller, F; Oehen, H-P

    2013-07-01

    The case of a 45-year-old male patient (body weight 52 kg, height 1.61 m) with a locally invasive gastric carcinoma infiltrating into the retroperitoneal space is reported. Because of severe cancer pain a tunnelled thoracic epidural catheter (EC) was placed at thoracic spinal level 7/8 and a local anesthetic (LA) mixture of bupivacaine 0.25 % and morphine 0.005 % was infused continuously at 6 ml h(-1). To optimize pain therapy the concentration was doubled (bupivacaine 0.5 %, morphine 0.01 %) 3 months later but the infusion rate was reduced to 3 ml h(-1) thus the total daily dose did not change. The patient died 6 months after initiation of the epidural analgesia from the underlying disease. The total amount of bupivacaine infused was 69 g and of morphine 1.37 g. The patient never reported any neurological complications. The autopsy revealed large white crystalline deposits in the thoracic epidural space which were identified as bupivacaine base by infrared spectrometry. Morphine could not be detected. A histological examination showed unreactive fatty tissue necrosis within the crystalline deposits but nerve tissue could not be identified. It is concluded that the bupivacaine crystalline deposits arose due to precipitation but the clinical significance with regard to sensory level and neuraxial tissue toxicity is unknown.

  13. Delayed Presentation of a Cervical Spinal Epidural Abscess of Dental Origin after a Fall in an Elderly Patient.

    PubMed

    Bodman, Alexa; Riordan, Margaret; Chin, Lawrence S

    2016-05-23

    Spinal epidural abscesses are an uncommon cause of spinal cord injury but, depending on the size and presence of neurological deficits, urgent neurosurgical intervention may be required. We present a unique case of a patient presenting with a spinal epidural collection several days after a fall. While a spinal epidural hematoma was suspected based on the patient's history and MRI findings, a spinal epidural abscess was found during surgery. The patient underwent laminectomy and instrumented fusion with successful treatment of her infection.

  14. The use of combined spinal-epidural technique to compare intrathecal ziconotide and epidural opioids for trialing intrathecal drug delivery.

    PubMed

    Gulati, Amitabh; Loh, Jeffrey; Puttanniah, Vinay; Malhotra, Vivek

    2013-03-01

    SUMMARY Choosing the initial medications for intrathecal delivery is often confusing and not standardized. We describe a novel way for using a combined spinal-epidural technique to compare two first-line medications for intrathecal delivery; ziconotide and morphine (or hydromorphone). Five patients with intractable chronic or cancer pain were elected to have an intrathecal drug delivery system implanted for pain management. Each patient was given a 3-day inpatient trial with the combined spinal-epidural technique. The Visual Analog Scale, Numerical Rating Scale, short-term McGill questionnaire and opioid consumption were monitored daily. The results were used to develop a paradigm to describe how ziconotide can be used in practice.

  15. Large, spontaneous spinal subdural–epidural hematoma after epidural anesthesia for caesarean section: Conservative management with excellent outcome

    PubMed Central

    Siasios, Ioannis D.; Vakharia, Kunal; Gibbons, Kevin J.; Dimopoulos, Vassilios G.

    2016-01-01

    Background: Iatrogenic or spontaneous spinal hematomas are rarely seen and present with multiple symptoms that can be difficult to localize. Most spontaneous spinal hematomas are multifactorial, and the pathophysiology is varied. Here, we present a case of a scattered, multicomponent, combined subdural and epidural spinal hematoma that was managed conservatively. Case Description: A 38-year-old woman came to the emergency department (ED) complaining of severe neck and back pain. She had undergone a caesarean section under epidural anesthesia 4 days prior to her arrival in the ED. She was placed on heparin and then warfarin to treat a pulmonary embolism that was diagnosed immediately postpartum. Her neurological examination at presentation demonstrated solely the existence of clonus in the lower extremities and localized cervical and low thoracic pain. In the ED, the patient's international normalized ratio was only mildly elevated. Spinal magnetic resonance imaging revealed a large thoracolumbar subdural hematoma with some epidural components in the upper thoracic spine levels. Spinal cord edema was also noted at the T6-T7 vertebral level. The patient was admitted to the neurosurgical intensive care unit for close surveillance and reversal of her coagulopathy. She was treated conservatively with pain medication, fresh frozen plasma, and vitamin K. She was discharged off of warfarin without any neurological deficit. Conclusions: Conservative management of spinal hematomas secondary to induced coagulopathies can be effective. This case suggests that, in the face of neuroimaging findings of significant edema and epidural blood, the clinical examination should dictate the management, especially in such complicated patients. PMID:27843682

  16. Complete transthoracic resection of giant posterior mediastinal goiter: case report and review of surgical strategies

    PubMed Central

    Zhao, Honglin; Ren, Dian; Liu, Yi; Li, Xin; Wu, Yi; Chen, Gang; Chen, Jun

    2016-01-01

    Intrathoracic goiters generally occupy anterior mediastinum, rarely involving the posterior mediastinal space. Reported herein is a 54-year-old female with a giant posterior mediastinal mass that was successfully resected via right posterolateral thoracotomy. The final pathologic diagnosis was giant posterior mediastinal goiter. This patient has done well postoperatively, with no evidence of local recurrence at 12-month follow-up. Related surgical strategies in past publications are summarized. PMID:27217766

  17. Rethinking "posterior" tongue-tie.

    PubMed

    Douglas, Pamela Sylvia

    2013-12-01

    Currently, many clinicians who help with breastfeeding problems are diagnosing "posterior" tongue-tie in infants and performing or referring for frenotomy. In this "Speaking Out" article, I argue that the diagnosis of "posterior" tongue-tie has successfully raised awareness of the importance of impaired tongue function in breastfeeding difficulty. However, the diagnosis of "posterior" tongue-tie also applies a reductionist, medicalized theoretical frame to the complex problem of impaired tongue function, risking unintended outcomes. Impaired tongue function arises out of multiple interacting and co-evolving factors, including the interplay between social behaviors concerning breastfeeding and mother-infant biology. Consideration of theoretical frames is vital if we are to build an evidence base through efficient use of the scarce resources available for clinical breastfeeding research and minimize unintended outcomes.

  18. A Case of Extensive Sacral Decubitus Ulcer Complicated by an Epidural Abscess

    PubMed Central

    Murata, Mai; Hiratsuka, Munehisa; Suzuki, Shigehiko

    2016-01-01

    Summary: We herein report a 62-year-old man with an extensive sacral decubitus ulcer complicated by an epidural abscess. An epidural abscess is a rare disease, but it should be considered in the differential diagnosis of a deep infection with decubitus. Moreover, the diagnosis may be late in such instances and should be carefully considered when a patient has paralysis. PMID:27536469

  19. [Epidural anesthesia and analgesia in the perioperative treatment of a patient with Kartagener syndrome].

    PubMed

    Errando, C L; Sifre, C; López-Alarcón, D

    1998-12-01

    Kartagener's syndrome is an inherited disease characterized by a triad of symptoms--bronchiectasis, situs inversus and sinusitis--and is classified as an immotile cilia syndrome. Patients may experience specific airway problems when undergoing anesthesia for surgical procedures. We report the case of a woman with Kartagener's syndrome who underwent surgery under epidural anesthesia with postoperative epidural analgesia, both techniques proving successful.

  20. [Comparative study of detection methods in epidural anesthesia: Episensor and loss of resistance].

    PubMed

    de Andrés, J A; Gomar, C; Calatrava, P; Nalda, M A

    1990-01-01

    The aim of the present study is to evaluate an electronic detector of negative pressure (Episensor, Palex, Spain) designed for the identification of epidural space. Ninety patients were randomly assigned to two groups: group 1 (n = 47) received epidural anesthesia as perioperative analgesic technique with Episensor method and group 2 (n = 43) received epidural anesthesia with the classic method of loss of resistance with gas mandrin. The following parameters were studied: a) demographic features, b) characteristics of epidural anesthesia, and c) complications occurring during space detection. There were no statistical differences in the analysis of demographic variables neither in the quality of the epidural anesthesia achieved in both groups. With respect to complications, group I presented the highest number of complications although only the lack of detection of epidural space achieved statistical significance (8.5%, p less than 0.05); the incidence was lower than that reported in the literature as physiologically possible in the lumbar epidural segment. We conclude that progressive knowledge of Episensor may decrease the initial incidence of complications with a success rate similar to that of classic techniques of identification of epidural space.

  1. Paraplegia following cervical epidural catheterization using loss of resistance technique with air: a case report.

    PubMed

    Chae, Yun Jeong; Han, Kyung Ream; Park, Hyung Bae; Kim, Chan; Nam, Si Gweon

    2016-02-01

    We report a case of paraplegia without neurologic deficit of upper extremities following cervical epidural catheterization using air during the loss of resistance technique. A 41-year-old woman diagnosed with complex regional pain syndrome had upper and lower extremity pain. A thoracic epidural lead was inserted for a trial spinal cord stimulation for treating lower extremity pain and cervical epidural catheterization was performed for treating upper extremity pain. Rapidly progressive paraplegia developed six hours after cervical epidural catheterization. Spine CT revealed air entrapment in multiple thoracic intervertebral foraminal spaces and surrounding epidural space without obvious spinal cord compression before the decompressive operation, which disappeared one day after the decompressive operation. Her paraplegia symptoms were normalized immediately after the operation. The presumed cause of paraplegia was transient interruption of blood supply to the spinal cord through the segmental radiculomedullary arteries feeding the spinal cord at the thoracic level of the intervertebral foramen caused by the air.

  2. Asymptomatic pneumomediastinum resulting from air in the epidural space -a case report-.

    PubMed

    Lim, Hyun Kyoung; Cha, Young Deog; Song, Jang Ho; Park, Ji Woong; Lee, Mi Hyeon

    2013-09-01

    There are no reports regarding pneumomediastinum caused by thoracic epidural block complications. We believe that it is possible to experience an occurrence of pneumomediastinum caused by air in the epidural space after performing a thoracic epidural block using the loss of resistance (LOR) technique with air. We report a witnessed case where pneumomediastinum appeared after a thoracic epidural block. Pneumorrrhachis, paravertebral muscle emphysema, and pneumomediastinum were diagnosed by Positron Emission Tomography-Computed Tomography. Although extremely rare, pneumomediastinum can be caused by an epidural block using LOR technique with air. In order to avoid the above danger, the use of saline or very minimal amount of air is required during a careful LOR technique.

  3. [Clinical Manifestations of Spinal Epidural Hematoma-Stroke Mimic and Pitfalls in Diagnosis].

    PubMed

    Kuriyama, Masaru

    2017-02-01

    Clinical manifestations of spinal epidural hematoma are presented, and the cases mimicking acute ischemic stroke have been reviewed from the literature. Many reports described the cases of spinal epidural hematoma with acute hemiparesis mimicking ischemic stroke in which intravenous thrombolytic treatment with recombinant tissue plasminogen activator was considered. A correct diagnosis of acute ischemic stroke must be made within 4.5 hours from the onset of symptoms, a relatively short window period. A spinal epidural hematoma is a potentially important stroke mimic in a wide variety of conditions that mimic a stroke. The literature review and discussion will emphasize allowing the distinction between these hemiparetic presentation of spinal epidural hematoma and acute ischemic stroke. A spinal epidural hematoma should be considered in the differential diagnosis of patients with acute onset of hemiparesis when associated with neck pain and signs of Horner's syndrome and Brown-Sēquard syndrome.

  4. Bilateral epidural extension of thoracic capillary vertebral (intraosseous) hemangioma mimicking spinal meningioma.

    PubMed

    Kan, C H; Saw, C B; Rozaini, R; Fauziah, K; Ng, C M; Saffari, M H

    2008-06-01

    We describe a rare case of vertebra (intraosseous) hemangioma with bilateral and symmetrical epidural extension causing cord compression in a 24-year-old woman. The epidural component was isointense to cord on both T1 and T2 sequences, and enhanced markedly and homogenously following gadolinium administration. The gradual in onset and progressive nature with the typical enhancing pattern lead the neurosurgeon to the more common diagnosis of spinal meningioma. Epidural extension of vertebral hemangiomas causing cord compression is rarely reported. Review of literatures reveal that cases that have been reported are of unilateral extension into epidural space and of cavernous type. This is the first case report of capillary vertebral (intraossous) hemangioma with bilateral extension through both intervetebral foramen into the epidural space causing myelopathy.

  5. Children's Understanding of Posterior Probability

    ERIC Educational Resources Information Center

    Girotto, Vittorio; Gonzalez, Michael

    2008-01-01

    Do young children have a basic intuition of posterior probability? Do they update their decisions and judgments in the light of new evidence? We hypothesized that they can do so extensionally, by considering and counting the various ways in which an event may or may not occur. The results reported in this paper showed that from the age of five,…

  6. Stereolithography for Posterior Fossa Cranioplasty

    PubMed Central

    Agner, Celso; Dujovny, Manuel; Evenhouse, Raymond; Charbel, Fady T.; Sadler, Lewis

    1998-01-01

    Posterior fossa cranioplasty has been suggested for improvement of neurological symptoms following craniectomy. However, there is no particular recommendation in the literature about techniques for prosthesis manufacture and implantation. We report our experience using rapid prototyping technology and stereolithography for pre-surgical implant design and production of cranioplasties. ImagesFigure 1Figure 2Figure 3Figure 4Figure 5 PMID:17171056

  7. Surgical management of posterior fossa metastases.

    PubMed

    Sunderland, Geraint J; Jenkinson, Michael D; Zakaria, Rasheed

    2016-12-01

    The diagnosis of brain metastases is associated with a poor prognosis reflecting uncontrolled primary disease that has spread to the relative sanctuary of the central nervous system. 20 % of brain metastases occur in the posterior fossa and are associated with significant morbidity. The risk of acute hydrocephalus and potential for sudden death means these metastases are often dealt with as emergency cases. This approach means a full pre-operative assessment and staging of underlying disease may be neglected and a proportion of patients undergo comparatively high risk surgery with little or no survival benefit. This study aimed to assess outcomes in patients to identify factors that may assist in case selection. We report a retrospective case series of 92 consecutive patients operated for posterior fossa metastases between 2007 and 2012. Routine demographic data was collected plus data on performance status, primary cancer site, details of surgery, adjuvant treatment and survival. The only independent positive prognostic factors identified on multivariate analysis were good performance status (if Karnofsky performance score >70, hazard ratio (HR) for death 0.36, 95 % confidence interval (CI) 0.18-0.69), adjuvant whole brain radiotherapy (HR 0.37, 95 % CI 0.21-0.65) and adjuvant chemotherapy where there was extracranial disease and non-synchronous presentation (HR 0.51, 95 % CI 0.31-0.82). Patients presenting with posterior fossa metastases may not be investigated as thoroughly as those with supratentorial tumours. Staging and assessment is essential however, and in the meantime emergencies related to tumour mass effect should be managed with steroids and cerebrospinal fluid diversion as required.

  8. Posterior-Only Circumferential Decompression and Reconstruction in the Surgical Management of Lumbar Vertebral Osteomyelitis

    PubMed Central

    Skovrlj, Branko; Guzman, Javier Z.; Caridi, John; Cho, Samuel K.

    2015-01-01

    Study Design Case report. Objective The purpose of this report is to discuss the surgical management of lumbar vertebral osteomyelitis with a spinal epidural abscess (SEA) and present a single-stage, posterior-only circumferential decompression and reconstruction with instrumentation using an expandable titanium cage and without segmental nerve root sacrifice as an option in the treatment of this disease process. Methods We report a 42-year-old man who presented with 3 days of low back pain and chills who rapidly decompensated with severe sepsis following admission. Magnetic resonance imaging of his lumbosacral spine revealed intramuscular abscesses of the left paraspinal musculature and iliopsoas with SEA and L4 vertebral body involvement. The patient failed maximal medical treatment, which necessitated surgical treatment as a last resort for infectious source control. He underwent a previously undescribed procedure in the setting of SEA: a single-stage, posterior-only approach for circumferential decompression and reconstruction of the L4 vertebral body with posterior segmental instrumented fixation. Results After the surgery, the patient's condition gradually improved; however, he suffered a wound dehiscence necessitating a surgical exploration and deep wound debridement. Six months after the surgery, the patient underwent a revision surgery for adjacent-level pseudarthrosis. At 1-year follow-up, the patient was pain-free and off narcotic pain medication and had returned to full activity. Conclusion This patient is the first reported case of lumbar osteomyelitis with SEA treated surgically with a single-stage, posterior-only circumferential decompression and reconstruction with posterior instrumentation. Although this approach is more technically challenging, it presents another viable option for the treatment of lumbar vertebral osteomyelitis that may reduce the morbidity associated with an anterior approach. PMID:26835214

  9. Posterior-Only Circumferential Decompression and Reconstruction in the Surgical Management of Lumbar Vertebral Osteomyelitis.

    PubMed

    Skovrlj, Branko; Guzman, Javier Z; Caridi, John; Cho, Samuel K

    2016-02-01

    Study Design Case report. Objective The purpose of this report is to discuss the surgical management of lumbar vertebral osteomyelitis with a spinal epidural abscess (SEA) and present a single-stage, posterior-only circumferential decompression and reconstruction with instrumentation using an expandable titanium cage and without segmental nerve root sacrifice as an option in the treatment of this disease process. Methods We report a 42-year-old man who presented with 3 days of low back pain and chills who rapidly decompensated with severe sepsis following admission. Magnetic resonance imaging of his lumbosacral spine revealed intramuscular abscesses of the left paraspinal musculature and iliopsoas with SEA and L4 vertebral body involvement. The patient failed maximal medical treatment, which necessitated surgical treatment as a last resort for infectious source control. He underwent a previously undescribed procedure in the setting of SEA: a single-stage, posterior-only approach for circumferential decompression and reconstruction of the L4 vertebral body with posterior segmental instrumented fixation. Results After the surgery, the patient's condition gradually improved; however, he suffered a wound dehiscence necessitating a surgical exploration and deep wound debridement. Six months after the surgery, the patient underwent a revision surgery for adjacent-level pseudarthrosis. At 1-year follow-up, the patient was pain-free and off narcotic pain medication and had returned to full activity. Conclusion This patient is the first reported case of lumbar osteomyelitis with SEA treated surgically with a single-stage, posterior-only circumferential decompression and reconstruction with posterior instrumentation. Although this approach is more technically challenging, it presents another viable option for the treatment of lumbar vertebral osteomyelitis that may reduce the morbidity associated with an anterior approach.

  10. Prediction of life expectancy in patients with spinal epidural metastasis

    PubMed Central

    Bartels, Ronald H.M.A.; de Ruiter, Godard; Feuth, Ton; Arts, Mark P.

    2016-01-01

    Background The treatment of spinal epidural metastasis is multidisciplinary and usually involves a team of medical oncologists, radiologists, radiotherapists, and spinal surgeons. Life expectancy is one of the factors considered when deciding whether surgery is warranted. Because expert estimates of life expectancy are generally not reliable, a prediction model is needed. Here, we temporally validated a model that was previously validated geographically. Methods The records of 110 consecutive patients who were referred with a spinal epidural metastasis were collected prospectively from 2009 to 2013 in order to validate the model, which was published in 2011. The actual and estimated life expectancies were represented graphically, and calibration and discrimination were determined. The calibration slope, Harrell's c-index, D, and RD2 were calculated. Hazard ratios in the derivation set of 2011 were compared with the validation set. Misspecification was determined using the joint test for β*. Results The calibration slope was 0.64 ± 0.15 (95% CI: 0.34–0.94), Harrell's c-index was 0.72, D was 1.08, and RD2 was 0.22, indicating slightly worse discrimination in the derivation set. The joint test for β* = 0 was statistically significant and indicated misspecification; however, this misspecification was attributed entirely to the surgical group. Conclusions We validated a prediction model for surgical decision making, showing that the model's overall performance is good. Based on these results, this model will help clinicians to decide whether to offer surgery to patients with spinal epidural metastasis. PMID:26254478

  11. Epidural application of ionomeric cement implants. Experimental and clinical results.

    PubMed

    Geyer, G; Baier, G; Helms, J

    1998-04-01

    During setting and hardening, the hybrid bone substitute ionomeric cement (Ionocem) achieves a stable and durable bond with the apatite of the adjacent bone without interpository soft tissue. Fluid contact during setting results in the release of aluminium ions which may reach critical levels as high as 3000 micrograms/l. On epidural application it is, therefore, essential to prevent cement constituents from gaining access to the intradural space. After the cement has hardened, the presence of aluminium is demonstrable in the adjacent bone to a maximum depth of 20 microns (EDX microanalysis). In rabbits, epidural placement of freshly mixed cement causes slight thickening of the dura. There is reason to believe that human dura, with a thickness 10 times greater, is impermeable to components of the cement. After epidural application of the freshly mixed cement in the frontobasal and laterobasal regions and at the skull cap and petrous apex, 76 patients in all have been followed for up to 6.5 years. During this period no complications have arisen and functional (and cosmetic) results are promising. The availability of preformed implants (Ionoroc, Ionocast) permitted the peridural placement of minimal quantities of freshly mixed cement. These implants were fixed to localized sites on the adjacent calvarial bone by use of Ionocem. Notwithstanding the stringent manufacturer guidelines, there have been reports in the literature that during the vulnerable stage of setting neurotoxic aluminium ions were released into the dural space with a fatal outcome in two cases. In view of potential intradural complications, such as may occur in case of dural leaks, it was considered that further application of the material adjacent to the dura was no longer warranted. The production of Ionocem was discontinued in May 1995.

  12. Effect of magnesium infusion on thoracic epidural analgesia

    PubMed Central

    Gupta, Sampa Dutta; Mitra, Koel; Mukherjee, Maitreyee; Roy, Suddhadeb; Sarkar, Aniruddha; Kundu, Sudeshna; Goswami, Anupam; Sarkar, Uday Narayan; Sanki, Prakash; Mitra, Ritabrata

    2011-01-01

    Introduction: Patients of lung volume reduction surgery (LVRS) having an ASA status III or more are likely to be further downgraded by surgery to critical levels of pulmonary function. Aim: To compare the efficacy of thoracic epidural block with (0.125%) bupivacaine, fentanyl combination and (0.125%) bupivacaine, fentanyl combination with adjunctive intravenous magnesium infusion for the relief of postoperative pain in patients undergoing LVRS. Methods: Patients were operated under general anesthesia. Thirty minutes before the anticipated completion of skin closure in both groups, (Group A and Group B) 7 ml of (0.125%) bupivacaine calculated as 1.5 ml/thoracic segment space for achieving analgesia in dermatomes of T4, T5, T6, T7, and T8 segments, along with fentanyl 50 μg (0.5 ml), was administered through the catheter, activating the epidural block, and the time was noted. Thereafter, in patients of Group A, magnesium sulfate injection 30 mg/kg i.v. bolus was followed by infusion of magnesium sulfate at 10 mg/kg/hr and continued up to 24 hours. Group B was treated as control. Results and Analysis: A significant increase in the mean and maximum duration of analgesia in Group A in comparison with Group B (P<0.05) was observed. Total epidural dose of fentanyl and bupivacaine required in Group A was significantly lower in comparison with Group B in 24 hours. Discussion: Requirement of total doses of local anesthetics along with opioids could be minimized by magnesium infusion; therefore, the further downgradation of patients of LVRS may be prevented. Conclusion: Intravenous magnesium can prolong opioid-induced analgesia while minimizing nausea, pruritus, and somnolence. PMID:21655018

  13. [medullar adhesive arachnoiditis: a late complication after obstetrical epidural analgesia].

    PubMed

    Ploteau, S; de Kersaint-Gilly, A; Boog, G

    2004-11-01

    A 30-year-old woman, G3P3, was progressively affected by spastic paraparesis with loss of sensitivity and urinary incontinence due to medullar adhesive arachnoiditis occurring five months after an epidural analgesia for repeat cesarean section. Magnetic resonance imaging showed a voluminous subarachnoid cyst and a septated syringomyelic cavitation attributed to metabisulfite, the preservative of epinephrine and to multiple lidocaine injections through the catheter in the postoperative period. Despite two decompressive neurosurgical operations, the neurological state of the patient continues to worsen.

  14. Lumbar adhesive arachnoiditis following attempted epidural anesthesia--case report.

    PubMed

    Haisa, T; Todo, T; Mitsui, I; Kondo, T

    1995-02-01

    A 30-year-old female experienced a sudden sharp pain radiating down to the left leg from the lower back at epidural intubation for anesthesia at childbirth. She continued to complain of pain in the left leg afterwards. Magnetic resonance images demonstrated a conglomeration of adherent nerve roots due to lumbar adhesive arachnoiditis. Microsurgical dissection of adherent nerve roots was performed. Her symptoms disappeared after surgery, but soon recurred, being less severe and responsive to anti-inflammatory agents. Lumbar adhesive arachnoiditis should be considered for differential diagnosis in patients presenting with back and leg pain syndrome.

  15. Inflammation and Epidural-Related Maternal Fever: Proposed Mechanisms.

    PubMed

    Sultan, Pervez; David, Anna L; Fernando, Roshan; Ackland, Gareth L

    2016-05-01

    Intrapartum fever is associated with excessive maternal interventions as well as higher neonatal morbidity. Epidural-related maternal fever (ERMF) contributes to the development of intrapartum fever. The mechanism(s) for ERMF has remained elusive. Here, we consider how inflammatory mechanisms may be modulated by local anesthetic agents and their relevance to ERMF. We also critically reappraise the clinical data with regard to emerging concepts that explain how anesthetic drug-induced metabolic dysfunction, with or without activation of the inflammasome, might trigger the release of nonpathogenic, inflammatory molecules (danger-associated molecular patterns) likely to underlie ERMF.

  16. Remote Postoperative Epidural Hematoma after Brain Tumor Surgery

    PubMed Central

    Chung, Ho-Jung; Park, Jae-Sung; Jeun, Sin-Soo

    2015-01-01

    A postoperative epidural hematoma (EDH) is a serious and embarrassing complication, which usually occurs at the site of operation after intracranial surgery. However, remote EDH is relatively rare. We report three cases of remote EDH after brain tumor surgery. All three cases seemed to have different causes of remote postoperative EDH; however, all patients were managed promptly and showed excellent outcomes. Although the exact mechanism of remote postoperative EDH is unknown, surgeons should be cautious of the speed of lowering intracranial pressure and implement basic procedures to prevent this hazardous complication of brain tumor surgery. PMID:26605271

  17. Epidural Tube: A Useful Device in Sialendoscopy Operations.

    PubMed

    Li, Jin; Fang, Wei; Chen, Ju-feng; Long, Xing

    2016-03-01

    Salivary endoscopy, which was first described in 1991, is a safe technique with few complications. The sialendoscopy operation has been developed and successfully offered as a minimally invasive and gland-preserving approach for the treatment of chronic obstructive sialadenitis. For many surgeons, entering the duct lumen of the salivary gland is the most difficult and time-consuming step of the sialendoscopy operation. This report introduces a timesaving and straightforward method for entering the duct lumen using an epidural tube, which is a plastic tube with a blunt tip.

  18. Posterior Fixation Techniques in the Subaxial Cervical Spine

    PubMed Central

    Ghori, Ahmer; Makanji, Heeren; Cha, Thomas

    2015-01-01

    This article reviews the historical context, indications, techniques, and complications of four posterior fixation techniques to stabilize the subaxial cervical spine. Specifically, posterior wiring, laminar screw fixation, lateral mass fixation, and pedicle screw fixation are among the common methods of operative fixation of the subaxial cervical spine. While wiring and laminar screw fixation are now rarely used, both lateral mass and pedicle screw fixation are technically challenging and present the risk of significant complications if performed incorrectly. With a sound understanding of anatomy and rigorous preoperative evaluation of bony structures, both lateral mass and pedicle screw fixation provide a safe and reliable method for subaxial cervical spine fixation. PMID:26594602

  19. Persistent post-dural-puncture headache treated with epidural infusion of dextran.

    PubMed

    Aldrete, J A

    1994-05-01

    A retrospective review was done on medical records of 13 patients with persistent post-dural-puncture headaches after one or more epidural blood patches. Headache occurred in nine patients with post-laminectomy syndrome after "wet taps" while performing epidural blocks. In two patients post-dural-puncture headache appeared after long term implanted intrathecal catheters were removed. In two other cases headache developed after spinal anesthesia. Treatment included bed rest, intravenous hydration and at least one epidural blood patch; three patients were given 60 milliliters of epidural saline, without success. Eight epidural catheters were inserted through the lumbar access and five through the caudal approach. Initially, a bolus of 20 milliliters of dextran-40 was given followed by an infusion of 3 mL/hr, until 12 hours after the head pain and any other related symptoms subsided. In all patients the headache disappeared within 20 hours after initiating therapy (9.55 mean hours, SD +/- 0.79). In five patients headache ceased in less than five hours. Nausea and photo-phobia subsided earlier. Patients with post-dural-puncture headache resistant to other treatments, including at least one epidural blood patch, were successfully treated by a bolus followed by continuous epidural infusion of dextran-40.

  20. Spinal epidural abscess following glossectomy and neck dissection: A case report

    PubMed Central

    Cheng, Esther; Thorpe, Eric; Borrowdale, Richard

    2016-01-01

    Introduction Spinal epidural abscess is an uncommon but potentially life threatening entity that rarely occurs after otolaryngology procedures. Presentation of case We report a case of a diabetic patient who presented with a lumbar spinal epidural abscess eight days after head and neck oncologic surgery. Magnetic resonance imaging revealed an L4 spinal epidural abscess. Cultures from the spinal epidural abscess, blood, urine, and the previous neck incision grew Klebsiella pneumoniae. The patient recovered neurologic function after surgical decompression and drainage, long-term intravenous antibiotics, and physical therapy. Discussion The development of postoperative spinal epidural abscess is rare after otolaryngology procedures but has been reported in the cervical epidural space. To our knowledge, lumbar spinal epidural abscess has not yet been reported after head and neck oncologic surgery. Even more unique is the presence of the pathogen K. pneumoniae. Conclusion A high index of suspicion of this potential outcome is paramount as early recognition and intervention are keys to recovery of neurologic function. PMID:26799413

  1. Informed consent for epidural analgesia in labour: a survey of Irish practice.

    PubMed

    Hegarty, A; Omer, W; Harmon, D

    2014-06-01

    Currently, we do not have a national standard regarding epidural consent in Ireland. The aim of this survey was to assess practice in obstetric units in Ireland with regard to obtaining informed consent prior to epidural insertion, and whether the risks discussed with women are being documented. A postal survey of anaesthetists in Irish obstetric units was performed in January 2012 to assess practice regarding obtaining informed consent prior to epidural insertion, and documentation of the risks discussed. The response rate was 16/18 (88%). There was major variation both in which risks are discussed with women in labour and what risks are quoted. The most frequently quoted risks were headache--15/16 (93.8% of the respondents), partially/not working epidural--15/16 (93.8%), drop in blood pressure--14/16 (87.5%) and temporary backache/local tenderness--12/16 (75%). The more serious risks were not discussed as frequently: permanent nerve damage--8/16 (50%), paralysis--8/16 (50%), epidural abscess/haematoma--6/16 (37.5%), meningitis--3/16 (18.7%). The vast majority of respondents supported introduction of a national standardised information leaflet, detailing all the benefits and risks of epidural analgesia, to be shown to all women before consenting to epidural insertion.

  2. Distortions of posterior visual space.

    PubMed

    Phillips, Flip; Voshell, Martin G

    2009-01-01

    The study of spatial vision is a long and well traveled road (which, of course, converges to a vanishing point at the horizon). Its various distortions have been widely investigated empirically, and most concentrate, pragmatically, on the space anterior to the observer. The visual world behind the observer has received relatively less attention and it is this perspective the current experiments address. Our results show systematic perceptual distortions in the posterior visual world when viewed statically. Under static viewing conditions, observer's perceptual representation was consistently 'spread' in a hyperbolic fashion. Directions to distant, peripheral locations were consistently overestimated by about 11 degrees from the ground truth and this variability increased as the target was moved toward the center of the observer's back. The perceptual representation of posterior visual space is, no doubt, secondary to the more immediate needs of the anterior visual world. Still, it is important in some domains including certain sports, such as rowing, and in vehicular navigation.

  3. Extensive spinal epidural abscess treated with "apical laminectomies" and irrigation of the epidural space: report of 2 cases.

    PubMed

    Abd-El-Barr, Muhammad M; Bi, Wenya Linda; Bahluyen, Biji; Rodriguez, Samuel T; Groff, Michael W; Chi, John H

    2015-03-01

    Spinal epidural abscess (SEA) is a rare but often devastating infection of the epidural space around the spinal cord. When an SEA is widespread, extensive decompression with laminectomy is often impossible, as it may subject the patient to very long operative times, extensive blood loss, and mechanical instability. A technique called "skip laminectomy" has been described in the literature, in which laminectomies are performed at the rostral and caudal ends of an abscess that spans 3-5 levels and a Fogarty catheter is used to mechanically drain the abscess, much like in an embolectomy. In this report of 2 patients, the authors present a modification of this technique, which they call "apical laminectomies" to allow for irrigation and drainage of an extensive SEA spanning the entire length of the vertebral column (C1-2 to L5-S1). Two patients presented with cervico-thoraco-lumbar SEA. Laminectomies were performed at the natural apices of the spine, namely, at the midcervical, midthoracic, and midlumbar spine levels. Next, a pediatric feeding tube was inserted in the epidural space from the thoracic laminectomies up toward the cervical laminectomy site and down toward the lumbar laminectomy site, and saline antibiotics were used to irrigate the SEA. Both patients underwent this procedure with no adverse effects. Their SEAs resolved both clinically and radiologically. Neither patient suffered from mechanical instability at 1 year after treatment. For patients who present with extensive SEAs, apical laminectomies seem to allow for surgical cure of the infectious burden and do not subject the patient to extended operating room time, an increased risk of blood loss, and the risk of mechanical instability.

  4. Efficacy of Epidural Injections in the Treatment of Lumbar Central Spinal Stenosis: A Systematic Review

    PubMed Central

    Manchikanti, Laxmaiah; Kaye, Alan David; Manchikanti, Kavita; Boswell, Mark; Pampati, Vidyasagar; Hirsch, Joshua

    2015-01-01

    Context: Lumbar central spinal stenosis is common and often results in chronic persistent pain and disability, which can lead to multiple interventions. After the failure of conservative treatment, either surgical or nonsurgical modalities such as epidural injections are contemplated in the management of lumbar spinal stenosis. Evidence Acquisition: Recent randomized trials, systematic reviews and guidelines have reached varying conclusions about the efficacy of epidural injections in the management of central lumbar spinal stenosis. The aim of this systematic review was to determine the efficacy of all three anatomical epidural injection approaches (caudal, interlaminar, and transforaminal) in the treatment of lumbar central spinal stenosis. A systematic review was performed on randomized trials published from 1966 to July 2014 of all types of epidural injections used in the management of lumbar central spinal stenosis. Methodological quality assessment and grading of the evidence was performed. Results: The evidence in managing lumbar spinal stenosis is Level II for long-term improvement for caudal and lumbar interlaminar epidural injections. For transforaminal epidural injections, the evidence is Level III for short-term improvement only. The interlaminar approach appears to be superior to the caudal approach and the caudal approach appears to be superior to the transforaminal one. Conclusions: The available evidence suggests that epidural injections with local anesthetic alone or with local anesthetic with steroids offer short- and long-term relief of low back and lower extremity pain for patients with lumbar central spinal stenosis. However, the evidence is Level II for the long-term efficacy of caudal and interlaminar epidural injections, whereas it is Level III for short-term improvement only with transforaminal epidural injections. PMID:25789241

  5. Epidural hematomas after the implantation of thoracic paddle spinal cord stimulators.

    PubMed

    Moufarrij, Nazih A

    2016-10-01

    OBJECTIVE There is little information on the frequency of symptomatic epidural hematomas after the implantation of paddle spinal cord stimulators (SCSs) in the thoracic spine. The purpose of this paper is to provide this metric and compare it to the frequency of symptomatic epidural hematomas for all other thoracic laminectomies combined. METHODS This study involved retrospectively analyzing the experience of a single surgeon in a consecutive series of patients who underwent the implantation of a thoracic paddle SCS with respect to the occurrence of a symptomatic epidural hematoma. For comparison, the occurrence of a symptomatic epidural hematoma in non-SCS thoracic laminectomies done during the same period of time was determined. RESULTS One hundred fifty-four thoracic paddle SCSs were implanted between May 2002 and February 2015. Despite perfect hemostasis and no preoperative risk factors, 4 of 154 patients (2.60%) developed postoperative lower-extremity weakness caused by an epidural hematoma. There were no other causes of a neurological deficit. In 3 of the 4 patients, the symptoms were delayed. Over the same time period, only 1 of 119 patients (0.84%) developed a postoperative motor deficit from a symptomatic epidural hematoma after a non-SCS laminectomy. CONCLUSIONS The occurrence of epidural hematomas after thoracic paddle SCS implantation may be underreported. Suggestions are given to decrease its incidence. It seems paradoxical that an epidural hematoma occurred 3 times more often after small SCS thoracic laminectomies than after larger non-SCS thoracic laminectomies. If confirmed by future studies, this finding may suggest that the intrusion of instruments into a confined epidural sublaminar space or the presence of a paddle and a hematoma in this restricted space may account for this differential.

  6. Tachyphylaxis associated with repeated epidural injections of lidocaine is not related to changes in distribution or the rate of elimination from the epidural space

    SciTech Connect

    Mogensen, T.; Simonsen, L.; Scott, N.B.; Henriksen, J.H.; Kehlet, H. )

    1989-08-01

    The relationship between tachyphylaxis (measured as a decrease in the rate of regression of sensory levels of analgesia) during repeated epidural injections of lidocaine and both the distribution of lidocaine within the epidural space (as measured by spread of simultaneous injection of the tracer technetium-99m diethylenetriaminepentaacetate (99mTc-DTPA)) and elimination of lidocaine from the epidural space (as measured by serum concentrations of lidocaine) was investigated in 18 patients undergoing minor surgery during lumbar epidural analgesia. Twelve patients received four injections of 20 mL of 2% lidocaine at 2-hr intervals. Epidural distribution was assessed by injection of 99mTc-DTPA diluted in saline on the preoperative day and diluted in an equal volume of 2% lidocaine on the morning before surgery and again after the fourth injection of lidocaine 6 hr later. The distribution of 99mTc-DTPA in the epidural space was unchanged during the three measurements despite significant tachyphylaxis in both sensory analgesia and motor blockade (11 of 12 patients had sensory analgesia 2 hr after the first injection in contrast to only 3 of 12 patients during the third injection). In another six patients 20 mL of 2% lidocaine were injected three times at 2-hr intervals before surgery, with measurements of serum concentrations of lidocaine after the first and last injections. Despite tachyphylaxis (no patient had sensory analgesia 2 hr after the third injection), there was no difference in the rate of disappearance of lidocaine from the epidural space as assessed by plasma lidocaine concentration curves during the first and third injection (0.5 +/- 0.1 and 0.3 +/- 0.04 microgram.mL-1.min-1, respectively).

  7. Hypothalamic-Pituitary-Adrenal Suppression and Iatrogenic Cushing's Syndrome as a Complication of Epidural Steroid Injections

    PubMed Central

    2013-01-01

    Epidural steroid injections are well accepted as a treatment for radicular back pain in appropriate candidates. While overall incidence of systemic side effects has not been well established, at least five biochemically proven cases of iatrogenic Cushing's Syndrome have been reported as complications of epidural steroid treatment. We present an additional case of iatrogenic Cushing's Syndrome and adrenal suppression in a middle-aged woman who received three epidural steroid injections over a four-month period. We review this case in the context of previous cases and discuss diagnostic and management issues. PMID:23991341

  8. Spontaneous spinal epidural abscess in a 21-month-old child.

    PubMed

    Harris, Tyler J; Seamon, Jason P

    2014-12-01

    Spontaneous epidural abscess formation is a rare finding in all populations and even more so in the pediatric population. Its rarity and varied presentations often lead to misdiagnosis. We present a pediatric case in which the diagnosis of spontaneous spinal epidural abscess was missed upon initial presentation and subsequently identified at a later visit to the emergency department. Literature suggests utilizing three simple physical exam findings that may improve the first visit diagnosis of spontaneous epidural abscesses in children. Findings of any two of the following signs should guide the clinician to consider SEA as a possibility prior to discharge: fever, back or neck pain, extremity weakness or inability to walk.

  9. Cervical spontaneous epidural hematoma as a complication of non-Hodgkin's lymphoma.

    PubMed

    Mastronardi, L; Carletti, S; Frondizi, D; Spera, C; Maira, G

    1996-01-01

    Epidural hematoma is a rare cause of spinal cord compression, which usually provokes severe neurological deficits. It is presumed to originate from venous or, more probably, arterial bleeding. Thrombocytopenia and other disorders of coagulation may precipitate the onset of epidural hematoma and facilitate the evolution of the disease. We report the case of a patient suffering from a non-Hodgkin's lymphoma with severe thrombocytopenia during a MACOP-B schedule, who presented with a spontaneous cervical epidural hematoma. We discuss the etiopathological aspects, diagnosis, and treatment of this rare cause of acute cervical spinal cord compression.

  10. Fracture of epidural catheter: A case report and review of literature

    PubMed Central

    Reena; Vikram, A

    2017-01-01

    Epidural blocks are a very important part of the anesthetic armamentarium. Among some of the known complications, fracture of epidural catheter, though is extremely rare, is a well-established entity. When it happens, it leaves the anesthesiologist puzzled and worried. We describe the occurrence of such an event where epidural catheter broke during insertion since it will also add to such an under-reported complication of a very commonly performed procedure. A brief review is also done which will delineate the recommendations for the prevention and management of such an event. PMID:28217068

  11. Spinal Myoclonus Developed during Cervical Epidural Drug Infusion in Postherpetic Neuralgia Patient

    PubMed Central

    Jeon, Younghoon; Baek, Sung Uk

    2011-01-01

    Postherpetic neuralgia is the most frequent complication of herpes zoster. Treatment of this neuropathic pain syndrome is difficult and often disappointing. Although postherpetic neuralgia is generally a self-limited condition, it can last indefinitely. Continuous epidural blockade for patients with acute zoster can shorten the duration of treatment. However, continuous epidural block has some complications such as infection, dural puncture, and total spinal and nerve damages. We report a case of myoclonus during continuous epidural block with ropivacaine, morphine, and ketamine in an acute zoster patient. PMID:21935497

  12. Spinal Myoclonus Developed during Cervical Epidural Drug Infusion in Postherpetic Neuralgia Patient.

    PubMed

    Jeon, Younghoon; Baek, Sung Uk; Yeo, Jin Seok

    2011-09-01

    Postherpetic neuralgia is the most frequent complication of herpes zoster. Treatment of this neuropathic pain syndrome is difficult and often disappointing. Although postherpetic neuralgia is generally a self-limited condition, it can last indefinitely. Continuous epidural blockade for patients with acute zoster can shorten the duration of treatment. However, continuous epidural block has some complications such as infection, dural puncture, and total spinal and nerve damages. We report a case of myoclonus during continuous epidural block with ropivacaine, morphine, and ketamine in an acute zoster patient.

  13. Paraplegia caused by aortic coarctation complicated with spinal epidural hemorrhage.

    PubMed

    Tsai, Yi-Da; Hsu, Chin-Wang; Hsu, Chia-Ching; Liao, Wen-I; Chen, Sy-Jou

    2016-03-01

    Aortic coarctation complicated with spinal artery aneurysm rupture is exceptionally rare and can be source of intraspinal hemorrhage with markedly poor prognosis. A 21-year-old man visited the emergency department because of chest and back pain along with immobility of bilateral lower limbs immediately after he woke up in the morning. Complete flaccid paraplegia and hypoesthesia in dermatome below bilateral T3 level and pain over axial region from neck to lumbar region were noted. A computed tomography excluded aortic dissection. Magnetic resonance imaging revealed a fusiform lesion involving the anterior epidural space from C7 to T2 level suspected of epidural hemorrhage, causing compression of spinal cord. He started intravenous corticosteroid but refused operation concerning the surgical benefits. Severe chest pain occurred with newly onset right bundle branch block that developed the other day. Coronary artery angiography revealed myocardial bridge of left anterior descending coronary artery at middle third and coarctation of aorta. He underwent thoracic endovascular aortic repair uneventfully. The patient was hemodynamically stable but with slow improvement in neurologic recovery of lower limbs. Aortic coarcation can cause paralysis by ruptured vascular aneurysms with spinal hemorrhage and chest pain that mimics acute aortic dissection. A history of hypertension at young age and aortic regurgitated murmurs may serve as clues for further diagnostic studies. Cautious and prudent evaluation and cross disciplines cares are essential for diagnosis and successful management of the disease.

  14. An Active Learning Algorithm for Control of Epidural Electrostimulation.

    PubMed

    Desautels, Thomas A; Choe, Jaehoon; Gad, Parag; Nandra, Mandheerej S; Roy, Roland R; Zhong, Hui; Tai, Yu-Chong; Edgerton, V Reggie; Burdick, Joel W

    2015-10-01

    Epidural electrostimulation has shown promise for spinal cord injury therapy. However, finding effective stimuli on the multi-electrode stimulating arrays employed requires a laborious manual search of a vast space for each patient. Widespread clinical application of these techniques would be greatly facilitated by an autonomous, algorithmic system which choses stimuli to simultaneously deliver effective therapy and explore this space. We propose a method based on GP-BUCB, a Gaussian process bandit algorithm. In n = 4 spinally transected rats, we implant epidural electrode arrays and examine the algorithm's performance in selecting bipolar stimuli to elicit specified muscle responses. These responses are compared with temporally interleaved intra-animal stimulus selections by a human expert. GP-BUCB successfully controlled the spinal electrostimulation preparation in 37 testing sessions, selecting 670 stimuli. These sessions included sustained autonomous operations (ten-session duration). Delivered performance with respect to the specified metric was as good as or better than that of the human expert. Despite receiving no information as to anatomically likely locations of effective stimuli, GP-BUCB also consistently discovered such a pattern. Further, GP-BUCB was able to extrapolate from previous sessions' results to make predictions about performance in new testing sessions, while remaining sufficiently flexible to capture temporal variability. These results provide validation for applying automated stimulus selection methods to the problem of spinal cord injury therapy.

  15. An Active Learning Algorithm for Control of Epidural Electrostimulation

    PubMed Central

    Desautels, Thomas A.; Nandra, Mandheerej S.; Roy, Roland R.; Zhong, Hui; Tai, Yu-Chong; Edgerton, V. Reggie; Burdick, Joel W.

    2015-01-01

    Epidural electrostimulation has shown promise for spinal cord injury therapy. However, finding effective stimuli on the multi-electrode stimulating arrays employed requires a laborious manual search of a vast space for each patient. Widespread clinical application of these techniques would be greatly facilitated by an autonomous, algorithmic system which choses stimuli to simultaneously deliver effective therapy and explore this space. We propose a method based on GP-BUCB, a Gaussian process bandit algorithm. In n = 4 spinally transected rats, we implant epidural electrode arrays and examine the algorithm's performance in selecting bipolar stimuli to elicit specified muscle responses. These responses are compared with temporally interleaved, intra-animal stimulus selections by a human expert. GP-BUCB successfully controlled the spinal electrostimulation preparation in 37 testing sessions, selecting 670 stimuli. These sessions included sustained, autonomous operations (10 session duration). Delivered performance with respect to the specified metric was as good as or better than that of the human expert. Despite receiving no information as to anatomically likely locations of effective stimuli, GP-BUCB also consistently discovered such a pattern. Further, GP-BUCB was able to extrapolate from previous sessions’ results to make predictions about performance in new testing sessions, while remaining sufficiently flexible to capture temporal variability. These results provide validation for applying automated stimulus selection methods to the problem of spinal cord injury therapy. PMID:25974925

  16. Posterior arch C-1 screw technique: a cadaveric comparison study.

    PubMed

    Moisi, Marc; Fisahn, Christian; Tkachenko, Lara; Jeyamohan, Shiveindra; Reintjes, Stephen; Grunert, Peter; Norvell, Daniel C; Tubbs, R Shane; Page, Jeni; Newell, David W; Nora, Peter; Oskouian, Rod J; Chapman, Jens

    2017-03-17

    OBJECTIVE Posterior atlantoaxial stabilization and fusion using C-1 lateral mass screw fixation has become commonly used in the treatment of instability and for reconstructive indications since its introduction by Goel and Laheri in 1994 and modification by Harms in 2001. Placement of such lateral mass screws can be challenging because of the proximity to the spinal cord, vertebral artery, an extensive venous plexus, and the C-2 nerve root, which overlies the designated starting point on the posterior center of the lateral mass. An alternative posterior access point starting on the posterior arch of C-1 could provide a C-2 nerve root-sparing starting point for screw placement, with the potential benefit of greater directional control and simpler trajectory. The authors present a cadaveric study comparing an alternative strategy (i.e., a C-1 screw with a posterior arch starting point) to the conventional strategy (i.e., using the lower lateral mass entry site), specifically assessing the safety of screw placement to preserve the C-2 nerve root. METHODS Five US-trained spine fellows instrumented 17 fresh human cadaveric heads using the Goel/Harms C-1 lateral mass (GHLM) technique on the left and the posterior arch lateral mass (PALM) technique on the right, under fluoroscopic guidance. After screw placement, a CT scan was obtained on each specimen to assess for radiographic screw placement accuracy. Four faculty spine surgeons, blinded to the surgeon who instrumented the cadaver, independently graded the quality of screw placement using a modified Upendra classification. RESULTS Of the 17 specimens, the C-2 nerve root was anatomically impinged in 13 (76.5%) of the specimens. The GHLM technique was graded Type 1 or 2, which is considered "acceptable," in 12 specimens (70.6%), and graded Type 3 or 4 ("unacceptable") in 5 specimens (29.4%). In contrast, the PALM technique had 17 (100%) of 17 graded Type 1 or 2 (p = 0.015). There were no vertebral artery injuries found

  17. Comparison of loss of resistance technique between Epidrum® and conventional method for identifying the epidural space

    PubMed Central

    Kim, Seon Wook; Kim, Young Mi; Kim, Soo Hwan; Chung, Mi Hwa; Choi, Young Ryong

    2012-01-01

    Background Epidrum® is a recently developed, air operated, loss of resistance (LOR) device for identifying the epidural space. We investigated the usefulness of Epidrum® by comparing it with the conventional LOR technique for identifying the epidural space. Methods One hundred eight American Society of Anesthesiologists (ASA) physical status I or II patients between the ages of 17 and 68 years old and who were scheduled for elective surgery under combined spinal-epidural anesthesia were enrolled in this study. The patients were randomized into two groups: one group received epidural anesthesia by the conventional LOR technique (C group) and the second group received epidural anesthesia using Epidrum® (ED group). While performing epidural anesthesia, the values of variables were recorded, including the number of failures, more than 2 attempts, the incidence of dural puncture, the time needed to locate the epidural space, the distance from the skin to the epidural space and ease of performance, and the satisfaction scores. Results The ED group showed a lower failure rate, fewer cases of more than 2 attempts, a lesser time to identify the epidural space, and better ease and satisfaction scores of procedure than the C group, with statistical significance. Conclusions Using Epidrum® compared to the conventional LOR technique is an easy, rapid, and reliable method for identifying the epidural space. PMID:22558497

  18. Posterior commissure of the human larynx revisited.

    PubMed

    Tucker, John A; Tucker, Sean T

    2010-05-01

    The existence of the posterior commissure (PC) of the human larynx has been disputed (Hirano M, Sato K, et al. The posterior glottis. Trans Am Laryngol Assoc. 1986;107:70-75). "The term posterior commissure has no relevance to anatomical structure. The term commissure means a joining together. The bilateral vocal folds never join at their posterior ends. The posterior aspect of the glottis is a wall. The posterior lateral aspect of the posterior glottis is also the lateral wall of the posterior glottis" (Hirano M, Sato K, et al. The posterior glottis. Trans Am Laryngol Assoc. 1986;107:70-75). This study is intended to clarify the development of anatomical and morphological aspects of the PC in conjunction with a clinical classification of the larynx in sagittal view. This study uses human embryo and fetal laryngeal sections from the Carnegie Collection of Human Embryos (the world standard) and whole organ laryngeal sections from the Tucker Laryngeal Fetal Collection. Correlation of histologic and gross anatomical structure is made with the Hirano et al atlas, the Vidić Photographic Atlas of the Human Body, and the O'Rahilly Embryonic Atlas. Embryologic data clearly describe and illustrate the posterior union of the cricoid cartilage with formation of the PC. The anatomical functional aspects of the posterior lateral cricoid lamina as the supporting buttress of the articulating arytenoid cartilages are illustrated.

  19. Isolated posterior cruciate ligament calcification

    PubMed Central

    Koukoulias, Nikolaos E; Papastergiou, Stergios G

    2011-01-01

    The authors present a case of calcified posterior cruciate ligament (PCL). A 61-year-old female presented in our department reporting 12 months history of knee pain that was getting worse during the night. The patient was under medication for epileptic seizure, osteoporosis and hyperthyroidism. X-rays demonstrated calcification of the PCL. CT and MRI excluded any other intra-articular and extra-articular pathology. Arthroscopic debridement of the calcium deposits was performed and the symptoms resolved immediately, while the postoperative x-rays were normal. Histological examination confirmed the calcium nature of the lesion. Two years postoperatively the patient remains asymptomatic. PMID:22669889

  20. [Continuous epidural administration of droperidol to prevent postoperative nausea and vomiting].

    PubMed

    Hayashi, Kenji; Higuchi, Jun; Sakio, Hideaki; Tanaka, Yoshikazu; Onoda, Noboru

    2002-02-01

    This randomized double-blind trial was designed to evaluate the antiemetic effect of continuous epidural analgesia with droperidol mixed with bupivacaine and buprenorphine. We studied 78 patients for abdominal gynecological surgery under general-epidural anesthesia. After recovery from anesthesia, they received epidural administration of 0.25% bupivacaine 40 ml and buprenorphine 0.4 mg with or without droperidol 2.5-5.0 mg at a rate of 2 ml.h-1 for 24 hours. The addition of droperidol 5.0 mg led to serious undesirable effects. Droperidol 2.5 mg, however, showed not only significant antiemetic effect without any adverse action, but also the reduction of rescue analgesics. We conclude that the addition of a small dose of droperidol to epidural analgesics reduces the incidence of postoperative emesis and the requirement of rescue analgesics.

  1. Delayed neurological deficits induced by an epidural hematoma associated with a thoracic osteoporotic compression fracture.

    PubMed

    Kang, Min-Soo; Shin, Yong-Hwan; Lee, Choon-Dae; Lee, Sang-Ho

    2012-01-01

    A 79-year-old woman developed neurological deficits 6 weeks after the onset of a thoracic osteoporotic compression fracture. Magnetic resonance (MR) imaging of the thoracic spine revealed an epidural hematoma at the T10-L2 levels. Acute decompressive laminectomy and percutaneous vertebroplasty were performed. Following the surgery, the patient's neurologic deficits improved and follow-up MR imaging showed complete resolution of the hematoma. Spinal epidural hematomas are rare and associated delayed neurological deficits are extremely rare. Conservative treatment may be effective for epidural hematomas in neurologically intact patients, but epidural hematomas can be a cause of neural compression and symptomatic deterioration resulting in delayed neurological deficits during the follow-up period.

  2. Giving Birth With Epidural Analgesia: The Experience of First-Time Mothers

    PubMed Central

    Hidaka, Ryoko; Callister, Lynn Clark

    2012-01-01

    The purpose of our qualitative descriptive study was to describe the birth experiences of women using epidural analgesia for pain management. We interviewed nine primiparas who experienced vaginal births. Five themes emerged: (a) coping with pain, (b) finding epidural administration uneventful, (c) feeling relief having an epidural, (d) experiencing joy, and (e) having unsettled feelings of ambivalence. Although epidural analgesia was found to be effective for pain relief and may contribute to some women’s satisfaction with the birth experience, it does not guarantee a quality birth experience. In order to support and promote childbearing women’s decision making, we recommend improved education on the variety of available pain management options, including their risks and benefits. Fostering a sense of caring, connection, and control in women is a key factor to ensure positive birth experiences, regardless of pain management method. PMID:23277728

  3. Combined Spinal Epidural Anaesthesia for Caesarean Section and Hysterectomy in a Parturient with Placenta Accreta

    PubMed Central

    Seyhan, Tülay Özkan; Sungur, Mukadder Orhan; Edipoğlu, İpek; Baştu, Ercan

    2014-01-01

    Placenta accreta complicates the anaesthetic and surgical approach in caesarean section. In this report, a parturient with placenta accreta and multiple drug allergies who was managed using combined spinal epidural anaesthesia for caesarean hysterectomy is discussed. PMID:27366410

  4. Does epidural analgesia affect the rate of spontaneous obstetric lacerations in normal births?

    PubMed

    Albers, Leah L; Migliaccio, Laura; Bedrick, Edward J; Teaf, Dusty; Peralta, Patricia

    2007-01-01

    The precise relationship between epidural use and genital tract lacerations in normal childbirth is unclear. Data from a clinical trial on measures to lower genital tract trauma in vaginal birth were used for a secondary analysis. The goal was to assess whether epidurals affect the rate of spontaneous obstetric lacerations in normal vaginal births. Maternal characteristics and intrapartum variables were compared in women who did and did not use an epidural in labor, and also in those with and without any sutured lacerations following vaginal birth. Variables that were statistically different in both cases were entered into regression equations for simultaneous adjustment. Epidural use was not an independent predictor of sutured lacerations. Predictors of sutured lacerations included nulliparity, a prolonged second stage, being non-Hispanic white, and an infant birthweight greater than 4000 grams. Elements of midwifery management need further research.

  5. Early removal of urinary catheters in patients with thoracic epidural catheters.

    PubMed

    Tripepi-Bova, Kathleen A; Sun, Zhiyuan; Mason, David; Albert, Nancy M

    2013-01-01

    The purpose of this study was to determine whether early removal of urinary catheters in patients with thoracic epidurals resulted in urinary retention (>500 mL by bladder scanner). Patients were given up to 8 hours to void before further intervention. Of 61 patients, only 4 (6.6%) required urinary catheter reinsertion due to urinary retention. Early removal of urinary catheters after thoracic surgery in patients with thoracic epidurals was safe, with minimal urinary retention.

  6. “Dry tap” during spinal anaesthesia turns out to be epidural abscess

    PubMed Central

    Sahu, Dinesh Kumar; Kaul, Vinca; Parampill, Reena

    2012-01-01

    We report a case of “dry tap” during spinal anaesthesia in a patient posted for incision and drainage of lower limb with cellulitis. When the patient was being given sub-arachnoid block (SAB) for regional anaesthesia, it turned out to be a case of pyogenic ilio-psoas abscess extended up to the paravertebral and epidural spaces. The causative organism was Staphylococcus aureus. This is probably the first case reported when epidural abscess is diagnosed during SAB. PMID:22923830

  7. [Continuous epidural blockade for frostbite of the lower extremities (author's transl)].

    PubMed

    Schlarb, K

    1980-06-01

    We describe the case of a patient suffering from freezing of the lower extremities, for which continuous epidural-blockade, over a period of four days, was conducted. By this means it was possible to relieve the vessel-spasm caused by the freezing and the patient was spared bilateral upper-thigh amputation. As the lower extremities are concerned in many cases of freezing, a continuous epidural-blockade as described here, seems to be the therapy to choose.

  8. Huge interparietal posterior fontanel meningohydroencephalocele

    PubMed Central

    Dos Santos, Manuel Filipe Dias; de Santa Barbara, Rita de Cassia

    2015-01-01

    Congenital encephalocele is a neural tube defect characterized by a sac-like protrusion of the brain, meninges, and other intracranial structures through the skull, which is caused by an embryonic development abnormality. The most common location is at the occipital bone, and its incidence varies according to different world regions. We report a case of an 1-month and 7-day-old male child with a huge interparietal-posterior fontanel meningohydroencephalocele, a rare occurrence. Physical examination and volumetric computed tomography were diagnostic. The encephalocele was surgically resected. Intradural and extradural approaches were performed; the bone defect was not primarily closed. Two days after surgery, the patient developed hydrocephaly requiring ventriculoperitoneal shunting. The surgical treatment of the meningohydroencephalocele of the interparietal-posterior fontanel may be accompanied by technical challenges and followed by complications due to the presence of large blood vessels under the overlying skin. In these cases, huge sacs herniate through large bone defects including meninges, brain, and blood vessels. The latter present communication with the superior sagittal sinus and ventricular system. A favorable surgical outcome generally follows an accurate strategy taking into account individual features of the lesion. PMID:26484324

  9. Longevity of Posterior Composite Restorations

    PubMed Central

    Opdam, N.J.M.; van de Sande, F.H.; Bronkhorst, E.; Cenci, M.S.; Bottenberg, P.; Pallesen, U.; Gaengler, P.; Lindberg, A.; Huysmans, M.C.D.N.J.M.; van Dijken, J.W.

    2014-01-01

    The aim of this meta-analysis, based on individual participant data from several studies, was to investigate the influence of patient-, materials-, and tooth-related variables on the survival of posterior resin composite restorations. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a search resulting in 12 longitudinal studies of direct posterior resin composite restorations with at least 5 years’ follow-up. Original datasets were still available, including placement/failure/censoring of restorations, restored surfaces, materials used, reasons for clinical failure, and caries-risk status. A database including all restorations was constructed, and a multivariate Cox regression method was used to analyze variables of interest [patient (age; gender; caries-risk status), jaw (upper; lower), number of restored surfaces, resin composite and adhesive materials, and use of glass-ionomer cement as base/liner (present or absent)]. The hazard ratios with respective 95% confidence intervals were determined, and annual failure rates were calculated for subgroups. Of all restorations, 2,816 (2,585 Class II and 231 Class I) were included in the analysis, of which 569 failed during the observation period. Main reasons for failure were caries and fracture. The regression analyses showed a significantly higher risk of failure for restorations in high-caries-risk individuals and those with a higher number of restored surfaces. PMID:25048250

  10. Hemorrhagic lumbar synovial facet cyst secondary to transforaminal epidural injection: A case report and review of the literature

    PubMed Central

    Elgafy, Hossein; Peters, Nicholas; Lea, Justin E; Wetzel, Robert M

    2016-01-01

    A 64-year-old-female presented with progressive left foot weakness, low back and radicular pain after a left sided S1 transforaminal epidural steroid injection (ESI). Magnetic resonance imaging revealed left side L5-S1 large extradural heterogeneous mass with layering areas suggesting different stages of hematoma formation. Past medical history was significant for peripheral vascular disease and transient ischemic attacks, for which she took aspirin and clopidogrel (antiplatelet agent). These medications were discontinued one week prior to ESI. Although synovial cysts associated with facet arthropathy are common, hemorrhagic cyst is not. To the best of the authors’ knowledge, this is the first reported case of symptomatic hemorrhagic lumbar facet synovial cyst following ESI on a patient taking anti-platelet medications. PMID:27458557

  11. Primary Spinal Epidural Lymphoma As a Cause of Spontaneous Spinal Anterior Syndrome: A Case Report and Literature Review.

    PubMed

    Córdoba-Mosqueda, M E; Guerra-Mora, J R; Sánchez-Silva, M C; Vicuña-González, R M; Torre, A Ibarra-de la

    2017-01-01

    Background Primary spinal epidural lymphoma (PSEL) is one of the rarest categories of tumors. Spinal cord compression is an uncommon primary manifestation and requires to be treated with surgery for the purpose of diagnosis and decompression. Case Presentation A 45-year-old man presented with a new onset thoracic pain and progress to an anterior spinal syndrome with hypoesthesia and loss of thermalgesia. Magnetic resonance image showed a paravertebral mass that produces medullary compression at T3. The patient was taken up to surgery, where the pathology examination showed a diffuse large B-cell lymphoma. Conclusions PSEL is a pathological entity, which must be considered on a middle-aged man who began with radicular compression, and the treatment of choice is decompression and biopsy. The specific management has not been established yet, but the literature suggests chemotherapy and radiotherapy; however, the outcome is unclear.

  12. Caudal epidural analgesia using lidocaine alone or in combination with ketamine in dromedary camels Camelus dromedarius.

    PubMed

    Azari, Omid; Molaei, Mohammad M; Ehsani, Amir H

    2014-02-27

    This study was performed to investigate the analgesic effect of lidocaine and a combination of lidocaine and ketamine following epidural administration in dromedary camels. Ten 12-18-month-old camels were randomly divided into two equal groups. In group L, the animals received 2% lidocaine (0.22 mg/kg) and in group LK the animals received a mixture of 10% ketamine (1 mg/kg) and 2% lidocaine (0.22 mg/kg) administered into the first intercoccygeal (Co1-Co2) epidural space while standing. Onset time and duration of caudal analgesia, sedation level and ataxia were recorded after drug administration. Data were analysed by U Mann-Whitney tests and significance was taken as p < 0.05. The results showed that epidural lidocaine and co-administration of lidocaine and ketamine produced complete analgesia in the tail, anus and perineum. Epidural administration of the lidocaine-ketamine mixture resulted in mild to moderate sedation, whilst the animals that received epidural lidocaine alone were alert and nervous during the study. Ataxia was observed in all test subjects and was slightly more severe in camels that received the lidocaine-ketamine mixture. It was concluded that epidural administration of lidocaine plus ketamine resulted in longer caudal analgesia in standing conscious dromedary camels compared with the effect of administering lidocaine alone.

  13. Antinociceptive effects of low dose lumbosacral epidural ropivacaine in healthy ponies.

    PubMed

    van Loon, Johannes P A M; Menke, Eveline S; Doornenbal, Arie; Back, Willem; Hellebrekers, Ludo J

    2012-07-01

    The objective of this study was to evaluate the safety and efficacy of low dose lumbosacral epidural ropivacaine in ponies. Antinociceptive effects of epidural ropivacaine were evaluated by means of mechanical nociceptive thresholds (MNTs) at several spinal levels in conscious ponies. The effects of ropivacaine on nociceptive afferent transmission to the spinal cord were also assessed by measuring spinal cord somatosensory evoked potentials (SSEPs) in anaesthetised ponies. Ataxia scores were determined in conscious ponies to assess the effects on motor function. A randomised, placebo controlled, double blind cross-over design was used. Low dose lumbosacral epidural ropivacaine led to increases in MNTs at various anatomical locations with a maximum effect at the lumbosacral and sacrococcygeal regions, both with respect to increase in threshold and duration of effect. Analysis of SSEPs showed that epidural ropivacaine influenced both Aβ- and Aδ-mediated afferent transmission to the spinal cord at the level of the lumbosacral junction. Ponies showed mild ataxia after low dose lumbosacral epidural ropivacaine, but all ponies remained standing. Application of low dose lumbosacral epidural ropivacaine provided safe and efficacious antinociceptive effects in conscious and anaesthetised ponies, and could therefore be a valuable addition to multimodal analgesic protocols in Equidae.

  14. Bacterial Infection in Deep Paraspinal Muscles in a Parturient Following Epidural Analgesia

    PubMed Central

    Xue, Xuhong; Song, Jiefu; Liang, Qingyuan; Qin, Jibin

    2015-01-01

    Abstract Bacterial infection related to epidural catheterizations could occur. In general, the incidence of postoperative infection at the insertion site is very low. Paucity literatures are reported for paraspinal muscle infection after epidural analgesia in parturient. We report a case of paraspinal muscle infection shortly after epidural analgesia in a parturient, who was subjected to because of threatened preterm labor. Epidural morphine was administered for 2 days for childbirth pain control. She began to have constant low-back pain and fever on postpartum Day 2. Magnetic resonance image revealed a broad area of subcutaneous edema with a continuum along the catheter trajectory deep to the paraspinal muscles. A catheter-related bacterial infection was suspected. The surgical debridement and drainage was required combined with intravenous antibiotics on postpartum Day 3. She was soon cured uncomplicatedly. Epidural analgesia is effective to control labor pain and, in general, it is safe. However, the sequelae of complicated infection may be underestimated. A literature search yielded 7 other cases of catheter-related epidural abscess or soft tissue infection. Vigilance for these infections, especially in postpartum patients with backache, is needed. Moreover, early detection and proper treatment of infectious signs at postanesthetic visit are very important. PMID:26683923

  15. Pure spinal epidural cavernous hemangioma with intralesional hemorrhage: a rare cause of thoracic myelopathy.

    PubMed

    Jang, Donghwan; Kim, Choonghyo; Lee, Seung Jin; Ryu, Young-Joon; Kim, Jiha

    2014-06-01

    Although cavernous hemangiomas occur frequently in the intracranial structures, they are rare in the spine. Most of spinal hemangiomas are vertebral origin and "pure" epidural hemangiomas not originating from the vertebral bone are very rare. Our spinal hemangioma case is extremely rare because of its "pure" epidural involvement and intralesional hemorrhage. A 64-year-old man presented with progressive paraparesis from two months ago. His motor weakness was rated as grade 4/5 in bilateral lower extremities. He also complained of decreased sensation below the T4 sensory dermatome, which continuously progressed to the higher dermatome level. Magnetic resonance imaging demonstrated thoracic spinal tumor at T3-T4 level. The tumor was located epidural space compressing thoracic spinal cord ventrally. The tumor was not involved with the thoracic vertebral bone. We performed T3-5 laminectomy and removed the tumor completely. The tumor was not infiltrating into intradural space or vertebral bone. The histopathologic study confirmed the epidural tumor as cavernous hemangioma. Postoperatively, his weakness improved gradually. Four months later, his paraparesis recovered completely. Here, we present a case of pure spinal epidural cavernous hemangioma, which has intralesional hemorrhage. We believe cavernous hemangioma should be included in the differential diagnosis of the spinal epidural tumors.

  16. Anaesthetists' experiences with the early labour epidural recommendation for obese parturients: a qualitative study.

    PubMed

    Eley, V A; Callaway, L K; van Zundert, A A J; Lipman, J; Gallois, C

    2016-09-01

    Caring for obese pregnant women presents challenges for all medical professionals. Despite a lack of supporting evidence, expert opinion and international guidelines suggest early labour epidural insertion for obese women. Anecdotally this is not supported by all anaesthetists. This qualitative study explored the experiences of anaesthetists regarding early epidural analgesia in obese parturients, to answer the research question: Are anaesthetists consistent in how they apply early epidural analgesia in obese parturients? Personal in-depth interviews with 42 specialist anaesthetists working in south-east Queensland, Australia, were completed between February and April, 2015. Leximancer™ text analysis software applied a validated algorithm to the data to identify themes and concepts. The major themes were explored by the first author to answer the research question. Three major themes were identified: the demands associated with caring for obese women; concern regarding the anaesthetic technique used in obese women; and the importance of communication with obstetric staff. Disagreement regarding interpretation and application of early epidural analgesia was identified within this group of anaesthetists. These anaesthetists were inconsistent in how they interpreted and applied early epidural analgesia for obese parturients, with some questioning the validity of the practice. The combination of uncertainty, urgency and technical difficulty presented by obese parturients provoked anxiety in these clinicians, particularly the anticipation of unplanned general anaesthesia. Consistent anaesthetic practice could improve the implementation of early epidural analgesia in obese parturients.

  17. In vivo images of the epidural space with two- and three-dimensional optical coherence tomography in a porcine model

    PubMed Central

    Tsou, Mei-Yung

    2017-01-01

    Background No reports exist concerning in vivo optical coherence tomography visualization of the epidural space and the blood patch process in the epidural space. In this study, we produced real-time two-dimensional and reconstructed three-dimensional images of the epidural space by using optical coherence tomography in a porcine model. We also aimed to produce three-dimensional optical coherence tomography images of the dura puncture and blood patch process. Methods Two-dimensional and three-dimensional optical coherence tomography images were obtained using a swept source optical coherence tomography (SSOCT) system. Four laboratory pigs were intubated and ventilated after the induction of general anesthesia. An 18-gauge Tuohy needle was used as a tunnel for the optical coherence tomography probe to the epidural space. Two-dimensional and three-dimensional reconstruction optical coherence tomography images of the epidural space were acquired in four stages. Results In stage 1, real-time two-dimensional and reconstructed three-dimensional optical coherence tomography of the lumbar and thoracic epidural space were successfully acquired. In stage 2, the epidural catheter in the epidural space was successfully traced in the 3D optical coherence tomography images. In stage 3, water injection and lumbar puncture were successfully monitored in all study animals. In stage 4, 10 mL of fresh blood was injected into the epidural space and two-dimensional and three-dimensional optical coherence tomography images were successfully acquired. Conclusions These animal experiments suggest the potential capability of using an optical coherence tomography-based imaging needle in the directed two-dimensional and three-dimensional visualization of the epidural space. More investigations involving humans are required before optical coherence tomography can be recommended for routine use. However, three-dimensional optical coherence tomography may provide a novel, minimally invasive

  18. Encapsulated Unresolved Subdural Hematoma Mimicking Acute Epidural Hematoma: A Case Report.

    PubMed

    Park, Sang-Soo; Shin, Woo-Ram; Kim, Hyo-Joon; Kwon, Chang-Young

    2014-10-01

    Encapsulated acute subdural hematoma (ASDH) has been uncommonly reported. To our knowledge, a few cases of lentiform ASDH have been reported. The mechanism of encapsulated ASDH has been studied but not completely clarified. Encapsulated lentiform ASDH on a computed tomography (CT) scan mimics acute epidural hematoma (AEDH). Misinterpretation of biconvex-shaped ASDH on CT scan as AEDH often occurs and is usually identified by neurosurgical intervention. We report a case of an 85-year-old man presenting with a 2-day history of mental deterioration and right-sided weakness. CT scan revealed a biconvex-shaped hyperdense mass mixed with various densities of blood along the left temporoparietal cerebral convexity, which was misinterpreted as AEDH preoperatively. Emergency craniectomy was performed, but no AEDH was found beneath the skull. In the subdural space, encapsulated ASDH was located. En block resection of encapsulated ASDH was done. Emergency craniectomy confirmed that the preoperatively diagnosed AEDH was an encapsulated ASDH postoperatively. Radiologic studies of AEDH-like SDH allow us to establish an easy differential diagnosis between AEDH and ASDH by distinct features. More histological studies will provide us information on the mechanism underlying encapsulated ASDH.

  19. [A Case of Spinal Epidural Hematoma Presenting with Transient Hemiplegia].

    PubMed

    Komai, Takanori; Nakashima, Kazuya; Tominaga, Takashi; Nogaki, Hidekazu

    2016-04-01

    We report a rare case of a patient with spinal epidural hematoma who presented with transient hemiplegia. A 90-year-old man awakened from sleep due to sudden neck pain. Fifteen minutes later, the man experienced progressively worsening weakness in his left hand, and was transported in an ambulance to our hospital. At the hospital, he presented with hemiplegia, and we suspected intracranial disease. Therefore, we performed magnetic resonance imaging (MRI), which revealed no intracranial lesions. Shortly after the MRI, the patient showed no signs of hemiplegia. However, since the severe neck pain persisted, we performed cervical MRI, which showed a high-intensity area at the C2-C5 level, predominantly on the left side. Despite recovery from hemiplegia, we performed a laminectomy of C3-C5 with evacuation of a hematoma at the C2-C6 level. After the surgery, the patient had no neck pain.

  20. Cat scratch disease with epidural extension while on antimicrobial treatment.

    PubMed

    Hussain, Sabiha; Rathore, Mobeen H

    2007-01-01

    We report the first case of a child with an epidural abscess caused by Bartonella henselae. This case is unique in that the diagnosis was confirmed by polymerase chain reaction (PCR) of the abscess fluid. A 3-year-old male was admitted with a 1-week history of fever and lower back pain. Magnetic resonance imaging (MRI) of the lumbar spine revealed a paraspinal soft tissue abnormality extending from the T(12) to the L(4) level, and a computed tomography (CT) scan of the lumbar spine showed osteomyelitis at the T(12) level with soft tissue changes. B. henselae serology showed an IgG titer of 1:256 and IgM of <1:16.

  1. Spontaneous spinal epidural hematoma presenting as paraplegia after cardiac surgery.

    PubMed

    Kin, Hajime; Mukaida, Masayuki; Koizumi, Junichi; Kamada, Takeshi; Mitsunaga, Yoshino; Iwase, Tomoyuki; Ikai, Akio; Okabayashi, Hitoshi

    2016-03-01

    An 86-year-old woman was scheduled to undergo aortic valve replacement and coronary artery bypass graft. On postoperative day 3, she developed sudden-onset neck pain followed by weakness in the right arm. Her symptoms worsened with time, and she developed paraplegia. At 60 h after the first complaint, spontaneous spinal epidural hematoma (SSEH) from C2 to C6 with spinal cord compression was diagnosed from a magnetic resonance image of the cervical region. We decided on conservative therapy because operative recovery was impossible. Delayed diagnosis led to grievous results in the present case. When neurological abnormalities follow neck or back pain after open heart surgery, SSEH must be considered in the differential diagnosis. Further, if it is suspected, early cervical computed tomography/magnetic resonance imaging and surgery should be considered.

  2. Holocord spinal epidural abscess: Case report and literature review.

    PubMed

    Xiang, H; Ma, X; Shen, N; Yue, B; Zhang, G; Chen, B

    2016-10-01

    Holocord spinal epidural abscess (SEA) is a rare condition. To our knowledge, five cases of SEA have been reported so far, and no consensus has been made on the treatment yet. In this article, we report a case of holocord SEA and review literature to further understanding of SEA. The advent of antibiotic treatment and the recognition of surgical debridement have been important in searching for alternatives to recovery, so the patient was treated surgically together with systemic antibiotics. The patient remained neurologically stable and continued to be clinically in good condition without any low back pain after 1 year. Surgical drainage, together with systemic antibiotics, is the main treatment choice for extensive SEAs. Although treatment should be considered that highlights the importance of examining the factors related to the health and condition of the patients and the anatomy and extent of the abscess, early surgical treatment associated with prolonged antibiotic treatment is necessary.

  3. [Observations on epidural anesthesia in cats from the anatomical viewpoint].

    PubMed

    Maierl, J; Reindl, S; Knospe, C

    1997-05-01

    The topographic-anatomical situation of the conus medullaris and the cauda equina in cats is shown: in about two thirds of the cases the conus medullaris at least reaches the level of the first sacral vertebra. As far as the site of the epidural injection is concerned the sacrococcygeal space or the first intercoccygeal space are proposed in order to avoid damage to the spinal cord. When seeking the site of injection it is advantageous to orientate oneself by following the sacral processus spinosi in caudal direction beginning with the lumbosacral space. In case of adipose animals the first intercoccygeal space can be palpated by moving the tail up and down. Both sites are equivalent. The volume to be injected varies between 0.3 and 0.9 ml solution per cat depending on the needs.

  4. Fluoroscopy guided transforaminal epidural anesthesia in ankylosing spondylitis.

    PubMed

    Channabasappa, S M; Dharmappa, S; Pandurangi, R

    2016-01-01

    A 48-year-old male patient with a long-standing history of ankylosing spondylitis (AS) presented for ureteroscopic stone removal. On preoperative assessment, tracheal intubation was likely to be difficult due to decreased cervical spine mobility. Traditional neuraxial block was impossible due to the fusion of vertebral bodies. AS patients present the most serious array of intubation, which is secondary to decrease in cervical spine mobility and possible temporomandibular joint disease. Management of a case of AS can be very challenging when the airway and the central neuraxial blockade, both are difficult. Fluoroscopic assisted central neuraxial blockade may lead to predictable success in AS. We present a case report with severe AS where conventional techniques failed and C-arm assisted helped in successful epidural anesthesia for ureteroscopic stone removal.

  5. Inserting epidural patient controlled analgesia into a peripheral venous line.

    PubMed

    2016-01-01

    A case is reported from the Safety Reporting System in Anaesthesia and Resuscitation database. The event occurred in a patient undergoing abdominal surgery in whom an epidural catheter was inserted for analgesia. After the intervention, the patient was transferred to the recovery unit where the patient controlled analgesia (PCA) is programmed. Due to an error, the PCA was connected to a peripheral venous line, which was detected early without harm to the patient. Communication and analysis of this incident served to introduce a new drug delivery protocol through PCA pumps, including the obligation to prescribe the PCA in the electronic system, a dual computerised check immediately before connecting PCA, labelling the medication bag as well as the proximal and distal lines, standardisation of daily visits to patients, and monthly monitoring of results.

  6. The potential contributing effect of ketorolac and fluoxetine to a spinal epidural hematoma following a cervical interlaminar epidural steroid injection: a case report and narrative review.

    PubMed

    Chien, George C Chang; McCormick, Zack; Araujo, Marco; Candido, Kenneth D

    2014-01-01

    Cervical interlaminar epidural steroid injections (ESIs) are commonly performed as one part of a multi-modal analgesic regimen in the management of upper extremity radicular pain. Spinal epidural hematoma (SEH) is a rare complication with a reported incidence ranging from 1.38 in 10,000 to 1 in 190,000 epidurals. Current American Society of Regional Anesthesia (ASRA), American Society of Interventional Pain Physicians (ASIPP), and the International Spine Intervention Society (ISIS) recommendations are that non-steroidal anti-inflammatory drugs (NSAIDs) do not need to be withheld prior to epidural anesthesia. We report a case wherein intramuscular ketorolac and oral fluoxetine contributed to a SEH and tetraplegia following a cervical interlaminar (ESI). A 66 year-old woman with chronic renal insufficiency and neck pain radiating into her right upper extremity presented for evaluation and was deemed an appropriate CESI candidate. Cervical magnetic resonance imaging (MRI) revealed multi-level neuroforaminal stenosis and degenerative intervertebral discs. Utilizing a loss of resistance to saline technique, an 18-gauge Tuohy-type needle entered the epidural space at C6-7. After negative aspiration, 4 mL of saline with 80 mg of methyl-prednisolone was injected. Immediately thereafter, the patient reported significant spasmodic-type localized neck pain with no neurologic status changes. A decision was made to administer 30 mg intramuscular ketorolac as treatment for the spasmodic-type pain. En route home, she developed a sudden onset of acute tetraplegia. She was brought to the emergency department for evaluation including platelet and coagulation studies which were normal. MRI demonstrated an epidural hematoma extending from C5 to T7. She underwent a bilateral C5-T6 laminectomy with epidural hematoma evacuation and was discharged to an acute inpatient rehabilitation hospital. Chronic renal insufficiency, spinal stenosis, female gender, and increasing age have been

  7. Delayed Presentation of a Cervical Spinal Epidural Abscess of Dental Origin after a Fall in an Elderly Patient

    PubMed Central

    Riordan, Margaret; Chin, Lawrence S.

    2016-01-01

    Spinal epidural abscesses are an uncommon cause of spinal cord injury but, depending on the size and presence of neurological deficits, urgent neurosurgical intervention may be required. We present a unique case of a patient presenting with a spinal epidural collection several days after a fall. While a spinal epidural hematoma was suspected based on the patient’s history and MRI findings, a spinal epidural abscess was found during surgery. The patient underwent laminectomy and instrumented fusion with successful treatment of her infection. PMID:27382529

  8. Imaging of the Posterior Skull Base.

    PubMed

    Job, Joici; Branstetter, Barton F

    2017-01-01

    The posterior skull base can be involved by a variety of pathologic processes. They can be broadly classified as: traumatic, neoplastic, vascular, and inflammatory. Pathology in the posterior skull base usually involves the lower cranial nerves, either as a source of pathology or a secondary source of symptoms. This review will categorize pathology arising in the posterior skull base and describe how it affects the skull base itself and surrounding structures.

  9. Posterior ankle impingement in the dancer.

    PubMed

    Moser, Brad R

    2011-01-01

    Dancers spend a lot of time in the relevé position in demi-pointe and en pointe in their training and their careers. Pain from both osseous and soft tissue causes may start to occur in the posterior aspect of their ankle. This article reviews the potential causes of posterior ankle impingement in dancers. It will discuss the clinical evaluation of a dancer and the appropriate workup and radiographic studies needed to further evaluate a dancer with suspected posterior ankle impingement.

  10. [Localization of lumbar epidural space by loss of resistance and using the Episensor: a comparative study].

    PubMed

    de Andrés, J; Gomar, C; Calatrava, P; Gutiérrez, M H; Rojas, R; Nalda, M A

    1990-01-01

    Since the existence of negative pressure in the epidural space was reported, its technique of localization has undergone changes directed to improve objectivity, reliability and safety. The aim of the present study was to evaluate a new electronic divide to localize the epidural space, i.e. the Episensor (Palex, Spain). To this end, 71 patients, both males and females, undergoing elective urological surgery and in whom catheterization of the lumbar epidural space had been planned, were prospectively evaluated and randomly assigned to two homogeneous groups. In group I (n = 35) the epidural space was localized by the classical technique of loss of resistance, while in group II the Episensor was used. In both groups several technical parameters, the qualification of the operator and the complications of the procedure were evaluated. There were no significant differences between both groups regarding the quality of epidural blockade or the subjective technical difficulty of the operator. The incidence of complications of the technique of puncture was significantly higher in group II (p less than 0.05); the most common were dura mater puncture in 13 group II patients and in one group I patient (p less than 0.001). There was no correlation between the qualification of the operator and the development of complications. It was concluded that the use of Episensor to localize lumbar epidural space did not improve the effectiveness of blockade but increased the iatrogenic effects of the puncture. Our lack of experience with this new technique and the low negative pressure of lumbar epidural space might have been the causes of the poor results, that we consider as initial in the evaluation of this new method.

  11. Maternal and foetal outcome after epidural labour analgesia in high-risk pregnancies

    PubMed Central

    Samanta, Sukhen; Jain, Kajal; Bhardwaj, Neerja; Jain, Vanita; Samanta, Sujay; Saha, Rini

    2016-01-01

    Background and Aims: Low concentration local anaesthetic improves uteroplacental blood flow in antenatal period and during labour in preeclampsia. We compared neonatal outcome after epidural ropivacaine plus fentanyl with intramuscular tramadol analgesia during labour in high-risk parturients with intrauterine growth restriction of mixed aetiology. Methods: Forty-eight parturients with sonographic evidence of foetal weight <1.5 kg were enrolled in this non-randomized, double-blinded prospective study. The epidural (E) group received 0.15% ropivacaine 10 ml with 30 μg fentanyl incremental bolus followed by 7–15 ml 0.1% ropivacaine with 2 μg/ml fentanyl in continuous infusion titrated until visual analogue scale was three. Tramadol (T) group received intramuscular tramadol 1 mg/kg as bolus as well as maintenance 4–6 hourly. Neonatal outcomes were measured with cord blood base deficit, pH, ionised calcium, sugar and Apgar score after delivery. Maternal satisfaction was also assessed by four point subjective score. Results: Baseline maternal demographics and neonatal birth weight were comparable. Neonatal cord blood pH, base deficit, sugar, and ionised calcium levels were significantly improved in the epidural group in comparison to the tramadol group. Maternal satisfaction (P = 0.0001) regarding labour analgesia in epidural group was expressed as excellent by 48%, good by 52% whereas it was fair in 75% and poor in 25% in the tramadol group. Better haemodynamic and pain scores were reported in the epidural group. Conclusion: Epidural labour analgesia with low concentration local anaesthetic is associated with less neonatal cord blood acidaemia, better sugar and ionised calcium levels. The analgesic efficacy and maternal satisfaction are also better with epidural labour analgesia. PMID:27013750

  12. The Effects of Rifampin, Povidone-Iodine and Hydrogen Peroxide on the Formation of Epidural Fibrosis in the Experimental Epidural Fibrosis Model.

    PubMed

    Kizilay, Zahir; Cetin, Nesibe Kahraman; İsmailoglu, Özgur; Yılmaz, Ali; Omurlu, İmran Kurt; Coskun, Mehmet Erdal; Aktaş, Serdar

    2016-08-01

    The aim of the study was to determine the effect of direct application of rifampin, povidone-iodine, and hydrogen peroxide on the formation of epidural fibrosis in rats. Forty-eight adult male Wistar albino rats were equally and randomly divided into four groups (laminectomy, topical rifampin, topical povidone-iodine, and topical hydrogen peroxide). Laminectomy was performed at the T12 level in all rats. Four weeks later, the extent of epidural fibrosis was assessed both macroscopically and histopathologically. ANOVA test was used for the evaluation of dural thickness. Kruskal-Wallis test was used for the pathology and macroscopic evaluation. Chi-square test was used for evaluation of the arachnoid involvement. p value <0.05 was accepted as statistically significant. Our data revealed that topical application of both povidone-iodine and hydrogen peroxide were effective in reducing epidural fibrosis formation. The results of our study provide the experimental evidence of the preventive effects of topical application of povidone-iodine and hydrogen peroxide over epidural fibrosis.

  13. Dynamic properties of the posterior cricoarytenoid muscle.

    PubMed

    Cooper, D S; Shindo, M; Sinha, U; Hast, M H; Rice, D H

    1994-12-01

    The aim of this research was to investigate the contractile properties of the posterior cricoarytenoid (PCA) muscle. Simultaneous measurements were made of the isometric force, temperature, and electromyographic activity of the dorsal cricoarytenoid muscle of anesthetized dogs during supramaximal stimulation of the recurrent laryngeal nerve for twitch and tetanic contraction. The conduction delay between stimulation of the recurrent nerve at the level of the larynx and the onset of the muscle action potential averaged 2.0 +/- 0.2 milliseconds (ms), and the latent period between the onset of electrical activity of the muscle and the onset of contraction had a mean duration of 3.3 +/- 0.8 ms. The mean of isometric contraction times found was 33.3 +/- 2.0 ms, shorter than most previous studies of canine PCA muscle. Tetanic frequency defined as smooth contraction was higher than previous estimates. Considerations of scaling of physiological time based on animal mass were applied to analysis of the experimental findings to make possible systematic comparison of previous findings across species and animal size.

  14. [Cysts in the posterior triangle of the neck in adults].

    PubMed

    Brea-Álvarez, Beatriz; Roldán-Hidalgo, Amaya

    2015-01-01

    Cystic lesions of the posterior triangle are a pathologic entity whose diagnosis is made in the first two years of life. Its presentation in adulthood is an incidental finding and the differential diagnosis includes cystic lymphangioma, lymphatic metastasis of thyroid cancer and branchial cyst. Often with the finding of a cervical lump, FNA is made before diagnostic imaging is performed, however, this procedure is not always advisable. We reviewed the cases of patients who came last year to our department with a cystic mass in this location and correlating the imaging findings with pathologic specimen. We show characteristic findings of these lesions in order to make an early diagnosis and thus to get the approach and treatment appropriate of adult patients with a cystic lesion in the posterior cervical triangle.

  15. Long-Term Evaluation of Continuous Epidural Anesthesia in an Improved Canine Model

    PubMed Central

    Sasauchi, Kyoko; Sunada, Katsuhisa; Nakamura, Tatsuo

    2016-01-01

    Background Continuous epidural analgesia with catheterization is a useful technique, because it has a wide adaptation range and provides prolonged analgesia. Problems that may arise from long-term epidural analgesia are changes in the analgesic area, duration of analgesia and catheter-related problems. Few articles have evaluated gradual changes of long-term epidural analgesia. In the animal models used in those studies, the catheter was inserted by an invasive surgical procedure. In the present study, we evaluated changes in a canine model in which the catheter was inserted by a minimally invasive procedure. Objectives To evaluate long-term changes in the efficacy of epidural analgesia in an improved canine model in which the epidural catheter was inserted and fixed for 5 weeks using a minimally invasive procedure. Materials and Methods Six beagles underwent epidural catheterization under general anaesthesia. The catheter tip was located in the sixth lumbar region; the catheter peripheral end was passed subcutaneously through the neck. Physiological saline was continuously infused (1.0 mL/h) via the catheter throughout the study. The efficacy of epidural analgesia was assessed weekly with 2% lidocaine once a week in 5 weeks. Peripheral blood analysis including interleukin-6 (IL-6) level in the cerebrospinal fluid (CSF), histological evaluations and epidurography were performed to evaluate the mechanisms underlying the changes. Results No dog died and the catheters were kept in place. The efficacy of analgesia was well maintained until 4 weeks; at 5th week, the efficacy decreased by half. The spread of injected medium was not observed in the cranial direction at 5th week and the tip of catheter was capped with granulation tissue. Throughout the study period, white blood cell counts and C-reactive protein levels were slightly high for catheterization and the IL-6 level in CSF was below detectable limits. Conclusions This was the longest study period with continuous

  16. Posterior repair and sexual function

    PubMed Central

    Komesu, Yuko M.; Rogers, Rebecca G.; Kammerer-Doak, Dorothy N.; Barber, Matthew D.; Olsen, Ambre L.

    2011-01-01

    OBJECTIVE The purpose of this study was to determine the effect of posterior repair (PR) on sexual function in patients who have undergone incontinence and/or pelvic reconstructive surgery. STUDY DESIGN A cohort study of women who underwent incontinence and/or prolapse surgery was performed. Participants completed the pelvic organ prolapse urinary incontinence sexual questionnaire (PISQ) before and after the operation. PISQ scores were compared between women who underwent PR and women who did not. RESULTS Of 73 study participants, 30 women underwent PR; 43 women did not (no PR). Although there was no difference in dyspareunia between groups pre-op, dyspareunia prevalence post-op was significantly lower in the no PR group. Preoperative PISQ scores were similar between groups. After the operation, both groups significantly improved their PISQ scores, without a difference between groups. CONCLUSION Although the incidence of dyspareunia differed between PR and no PR groups, overall improvement in sexual function was reflected in improved total PISQ scores that occurred irrespective of PR performance. PMID:17618777

  17. Severe hypotension related to high negative pressure suction drainage on a thoracic epidural drain during multilevel spinal fixation.

    PubMed

    Brahmbhatt, Anjalee; Hall, Nicholas D P; Bradley, William Pierre Litherland

    2013-11-15

    Hypotension or bradycardia or both related to intracranial hypotension after craniotomy has been reported in the literature. However, such reports are uncommon with thoracic epidural drains. We describe a case in which application of high negative pressure suction to a thoracic epidural drain caused a sudden decrease in arterial blood pressure.

  18. Saline as the Sole Contrast Agent for Successful MRI-guided Epidural Injections

    SciTech Connect

    Deli, Martin; Mateiescu, Serban Busch, Martin; Becker, Jan Garmer, Marietta Groenemeyer, Dietrich

    2013-06-15

    Purpose. To assess the performance of sterile saline solution as the sole contrast agent for percutaneous magnetic resonance imaging (MRI)-guided epidural injections at 1.5 T. Methods. A retrospective analysis of two different techniques of MRI-guided epidural injections was performed with either gadolinium-enhanced saline solution or sterile saline solution for documentation of the epidural location of the needle tip. T1-weighted spoiled gradient echo (FLASH) images or T2-weighted single-shot turbo spin echo (HASTE) images visualized the test injectants. Methods were compared by technical success rate, image quality, table time, and rate of complications. Results. 105 MRI-guided epidural injections (12 of 105 with gadolinium-enhanced saline solution and 93 of 105 with sterile saline solution) were performed successfully and without complications. Visualization of sterile saline solution and gadolinium-enhanced saline solution was sufficient, good, or excellent in all 105 interventions. For either test injectant, quantitative image analysis demonstrated comparable high contrast-to-noise ratios of test injectants to adjacent body substances with reliable statistical significance levels (p < 0.001). The mean table time was 22 {+-} 9 min in the gadolinium-enhanced saline solution group and 22 {+-} 8 min in the saline solution group (p = 0.75). Conclusion. Sterile saline is suitable as the sole contrast agent for successful and safe percutaneous MRI-guided epidural drug delivery at 1.5 T.

  19. Portable Optical Epidural Needle-A CMOS-Based System Solution and Its Circuit Design

    PubMed Central

    Gong, Cihun-Siyong Alex; Lin, Shih-Pin; Mandell, M. Susan; Tsou, Mei-Yung; Chang, Yin; Ting, Chien-Kun

    2014-01-01

    Epidural anesthesia is a common anesthesia method yet up to 10% of procedures fail to provide adequate analgesia. This is usually due to misinterpreting the tactile information derived from the advancing needle through the complex tissue planes. Incorrect placement also can cause dural puncture and neural injury. We developed an optic system capable of reliably identifying tissue planes surrounding the epidural space. However the new technology was too large and cumbersome for practical clinical use. We present a miniaturized version of our optic system using chip technology (first generation CMOS-based system) for logic functions. The new system was connected to an alarm that was triggered once the optic properties of the epidural were identified. The aims of this study were to test our miniaturized system in a porcine model and describe the technology to build this new clinical tool. Our system was tested in a porcine model and identified the epidural space in the lumbar, low and high thoracic regions of the spine. The new technology identified the epidural space in all but 1 of 46 attempts. Experimental results from our fabricated integrated circuit and animal study show the new tool has future clinical potential. PMID:25162150

  20. Efficacy of epidural local anesthetic and dexamethasone in providing postoperative analgesia: A meta-analysis

    PubMed Central

    Jebaraj, B; Khanna, P; Baidya, DK; Maitra, S

    2016-01-01

    Background: Dexamethasone is a potent anti-inflammatory, analgesic, and antiemetic drug. Individual randomized controlled trials found a possible benefit of epidural dexamethasone. The purpose of this meta-analysis is to estimate the benefit of epidural dexamethasone on postoperative pain and opioid consumption and to formulate a recommendation for evidence-based practice. Materials and Methods: Prospective, randomized controlled trials comparing the analgesic efficacy of epidural local anesthetic and dexamethasone combination, with local anesthetic alone for postoperative pain management after abdominal surgery, were planned to be included in this meta-analysis. PubMed, PubMed Central, Scopus, and Central Register of Clinical Trials of the Cochrane Collaboration (CENTRAL) databases were searched for eligible controlled trials using the following search words: “Epidural”, “dexamethasone”, and “postoperative pain”, until February 20, 2015. Results: Data from five randomized control trials have been included in this meta-analysis. Epidural dexamethasone significantly decreased postoperative morphine consumption (mean difference −7.89 mg; 95% confidence interval [CI]: −11.66 to −3.71) and number of patients required postoperative rescue analgesic boluses (risk ratio: 0.51; 95% CI: 0.41-0.63). Conclusion: The present data shows that the addition of dexamethasone to local anesthetic in epidural is beneficial for postoperative pain management. PMID:27375389

  1. A pure epidural spinal cavernous hemangioma - with an innocuous face but a perilous behaviour!!

    PubMed

    A L, Hemalatha; T, Ravikumar; Chamarthy, Neelima P; Puri, Kunal

    2013-07-01

    Cavernous hemangiomas occur frequently in the intracranial structures but they are rare in the spine, with an incidence of 0.22 cases/million/year, which account for 5 - 12% of the spinal vascular lesions, 51% of which are extradural. Most of the epidural hemangiomas are secondary extensions from the vertebral lesions. The spinal cavernous hemangiomas which do not involve the vertebrae are referred to as "pure" types. The pure epidural hemangiomas are rare, which account for only 4% of all the epidural lesions. A case of a Pure spinal epidural cavernous hemangioma in a 50 year old male, with the clinical picture of a slowly progressive compressive myelopathy, has been presented here. The imaging studies showed a well-defined, enhancing epidural lesion at the T7 - T8 level, with dorsal cordedema and myelomalacic changes. A radiological diagnosis of a meningioma was considered. Histopathologically, the lesion was diagnosed as a hemangioma. The patient improved dramatically after the excision of the lesion.

  2. Thoracic epidural anesthesia: Effects on splanchnic circulation and implications in Anesthesia and Intensive care

    PubMed Central

    Siniscalchi, Antonio; Gamberini, Lorenzo; Laici, Cristiana; Bardi, Tommaso; Faenza, Stefano

    2015-01-01

    AIM: To evaluate the currently available evidence on thoracic epidural anesthesia effects on splanchnic macro and microcirculation, in physiologic and pathologic conditions. METHODS: A PubMed search was conducted using the MeSH database. Anesthesia, Epidural was always the first MeSH heading and was combined by boolean operator AND with the following headings: Circulation, Splanchnic; Intestines; Pancreas and Pancreatitis; Liver Function Tests. EMBASE, Cochrane library, ClinicalTrials.gov and clinicaltrialsregister.eu were also searched using the same terms. RESULTS: Twenty-seven relevant studies and four ongoing trials were found. The data regarding the effects of epidural anesthesia on splanchnic perfusion are conflicting. The studies focusing on regional macro-hemodynamics in healthy animals and humans undergoing elective surgery, demonstrated no influence or worsening of regional perfusion in patients receiving thoracic epidural anesthesia (TEA). On the other hand most of the studies focusing on micro-hemodynamics, especially in pathologic low flow conditions, suggested that TEA could foster microcirculation. CONCLUSION: The available studies in this field are heterogeneous and the results conflicting, thus it is difficult to draw decisive conclusions. However there is increasing evidence deriving from animal studies, that thoracic epidural blockade could have an important role in modifying tissue microperfusion and protecting microcirculatory weak units from ischemic damage, regardless of the effects on macro-hemodynamics. PMID:25685727

  3. Factors for Predicting Favorable Outcome of Percutaneous Epidural Adhesiolysis for Lumbar Disc Herniation

    PubMed Central

    Moon, Sang Ho; Lee, Jae Il; Cho, Hyun Seok; Shin, Jin Woo

    2017-01-01

    Background. Lower back pain is a common reason for disability and the most common cause is lumbar disc herniation. Percutaneous epidural adhesiolysis has been applied to relieve pain and increase the functional capacity of patients who present this condition. Objectives. In this study, we retrospectively evaluated the factors which predict the outcome of percutaneous epidural adhesiolysis in patients who were diagnosed with lumbar disc herniation. Methods. Electronic medical records of patients diagnosed with lumbar disc herniation who have received percutaneous epidural adhesiolysis treatment were reviewed. The primary outcome was the factors that were associated with substantial response of ≥4 points or ≥50% of pain relief in the numerical rating scale pain score 12 months after the treatment. Results. Multivariate logistic regression analysis demonstrated that the presence of high-intensity zone (HIZ) at magnetic resonance imaging was a predictor of substantial response to percutaneous epidural adhesiolysis for 12 months (P = 0.007). The presence of a condition involving the vertebral foramen was a predictor for unsuccessful response after 12 months (P = 0.02). Discussion and Conclusion. The presence of HIZ was a predictor of favorable long-term outcome after percutaneous epidural adhesiolysis for the treatment of lower back pain with radicular pain caused by lumbar disc herniation. PMID:28246488

  4. Epidural needle with embedded optical fibers for spectroscopic differentiation of tissue: ex vivo feasibility study

    PubMed Central

    Desjardins, Adrien E.; Hendriks, Benno H.W.; van der Voort, Marjolein; Nachabé, Rami; Bierhoff, Walter; Braun, Guus; Babic, Drazenko; Rathmell, James P.; Holmin, Staffan; Söderman, Michael; Holmström, Björn

    2011-01-01

    Epidural injection is commonly used to provide intraoperative anesthesia, postoperative and obstetric analgesia, and to treat acute radicular pain. Identification of the epidural space is typically carried out using the loss of resistance (LOR) technique, but the usefulness of this technique is limited by false LOR and the inability to reliably detect intravascular or subarachnoid needle placement. In this study, we present a novel epidural needle that allows for the acquisition of optical reflectance spectra from tissue close to the beveled surface. This needle has optical fibers embedded in the cannula that deliver and receive light. With two spectrometers, light received from tissue is resolved across the wavelength range of 500 to 1600 nm. To determine the feasibility of optical tissue differentiation, spectra were acquired from porcine tissues during a post mortem laminectomy. The spectra were processed with an algorithm that derives estimates of the hemoglobin and lipid concentrations. The results of this study suggest that the optical epidural needle has the potential to improve the accuracy of epidural space identification. PMID:21698009

  5. Chemosensitive epidural spinal cord disease in non-Hodgkins lymphoma.

    PubMed

    Wong, E T; Portlock, C S; O'Brien, J P; DeAngelis, L M

    1996-06-01

    Epidural spinal cord disease (ESCD), an infrequent complication of systemic non-Hodgkins lymphoma (NHL), can occur at diagnosis or at relapse, and is usually treated with radiotherapy, or infrequently surgical decompression. We retrospectively analyzed 140 patients with intermediate-grade NHL (IG-NHL) who were treated on a dose-intense protocol using doxorubicin, vincristine, and high-dose cyclophosphamide (NHL-15). There were seven episodes of ESCD in six (4.3%) patients. Five episodes were asymptomatic at presentation; one patient had back pain, leg numbness, and tingling; and one had radicular pain and mild leg weakness. None had malignant cells in the CSF. One patient received high-dose dexamethasone after laminectomy for diagnostic biopsy; otherwise, dexamethasone was used only as an anti-emetic prior to chemotherapy. Patients who developed ESCD at diagnosis received the planned course of NHL-15 chemotherapy as treatment for ESCD, and those treated with NHL-15 who developed ESCD at relapse were given a regimen containing ifosfamide, carboplatin, and etoposide (ICE). After chemotherapy alone, five of seven episodes showed radiographic resolution of ESCD and improvement of neurologic deficits. One patient received consolidation radiotherapy (2,700 cGy) to the spine after ICE for relapsed ESCD and had a complete response. One patient had progression of systemic lymphoma and ESCD despite chemotherapy. These data suggest that chemotherapy may be effective as initial treatment of ESCD in IG-NHL and may reduce the potential complications of spinal surgery and radiotherapy.

  6. Principles of therapeutic use of transcranial and epidural cortical stimulation.

    PubMed

    Lefaucheur, Jean-Pascal

    2008-10-01

    Among the alternatives to drugs in the treatment of neurological and psychiatric disorders, neuromodulation techniques, including brain stimulation, have been used increasingly this past decade. Cortical targets are especially appealing, because they are easily accessible by noninvasive or invasive methods. Applicable techniques include repetitive transcranial magnetic stimulation (rTMS), transcranial electrical stimulation using pulsed or direct current, and epidural cortical stimulation (ECS) with surgically implanted electrodes. In contrast to deep brain stimulation in movement disorders or electroconvulsive therapy in depression, the efficacy of cortical stimulation to treat neurological or psychiatric disorders has not been yet clearly demonstrated. However, encouraging results have been reported in neuropathic pain (for ECS) and depression (for rTMS). In this review, we will consider some principles and mechanisms of action of these methods. First, it must be noted that fibers of intracortical or cortico-subcortical networks are more prone to be activated by the stimulation than cell bodies of local cortical neurons. Hence, the site(s) of action may be distant from the site of stimulation. In addition, various parameters of stimulation (such as stimulation frequency, intensity, or electrode polarity) and the configuration of the induced electrical field greatly influence the nature of the recruited circuits, and therefore, the overall efficacy. Finally, clinical changes may be delayed and prolonged beyond the time of stimulation, complicating programming algorithms in the case of implanted stimulation device. All these features need to be taken into account when considering cortical stimulation as a method of treatment.

  7. Decrease in serum potassium concentration during epidural anaesthesia.

    PubMed

    Hahn, R G

    1987-11-01

    A mean decrease in the arterial serum potassium concentration (S-K) of 0.40 mmol/l (range 0-1.0) was found in 45 elderly men who were studied before and after induction of epidural anaesthesia (using mepivacaine 2% with adrenaline). The decrease was similar in patients who received acetated Ringer solution or dextran 40 in normal saline as intravenous fluid supplementation. No difference in S-K change was found between patients with a normal (less than 115 mumol/l) or elevated serum creatinine concentration. The decrease in S-K prevailed at the end of surgery except in patients with an elevated serum creatinine. Corrections of S-K for changes in arterial blood pH and rectal temperature during induction of anaesthesia did not explain the decrease in S-K. Correlations of clinical parameters such as the extension of anaesthesia, amount of intravenous fluid given and blood pressure changes gave conflicting results. A smaller decrease or no change in S-K was usually seen in arterial (n = 7) and venous (n = 7) samples when no intravenous fluid was given, as well as in venous samples when acetated Ringer solution was given (n = 6).

  8. Thoracic spinal epidural abscess caused by fishbone perforation

    PubMed Central

    Chen, Jian-Min; Wang, Zhi-Yong; Ni, Guo-Xin

    2016-01-01

    Abstract Rationale: Ingestion of a fishbone is a common cause of esophageal injury, but spinal epidural abscess (SEA) is a rare condition due to the esophageal penetration by a swallowed fishbone. Prompt diagnosis can be seldom made owing to incomplete patient history taking and difficulties in imaging evidence identification. Patient concerns: We describe the case of a 62-year-old woman who was stuck in her throat by a fishbone, and complained of back pain, paresis of the lower limbs and fever, successively. To our knowledge, this is the first case report that we know of thoracic SEA caused by fishbone perforation. Diagnoses: About 20 days after the onset of severe back pain, she was diagnosed with SEA based on the clinical presentation and imaging findings. Interventions: Antibiotic therapy and rehabilitation therapy were carried out afterwards. However, due to exacerbation of her condition, surgical intervention had to be taken eventually. Outcomes: It is quite unfortunate for this patient to have a poor prognosis due to a delayed diagnosis and an improper management. Lessons: A number of lessons can be learnt from this case. PMID:27930507

  9. Transient Glaucoma after an Epidural Steroid Injection: A Case Report

    PubMed Central

    Manjiani, Deepak; Said, Salam; Kaye, Alan David

    2015-01-01

    Background Steroids are recognized as a beneficial treatment for various medical conditions, yet clinically relevant side effects of steroids are common and problematic, ranging from a minor case of acne to a potentially life-threatening Addisonian crisis. In anesthetic medicine, the use of epidural steroid injections (ESIs) for chronic low back pain and other radicular pain-related conditions has become standard practice in interventional pain management. Case Report We report the case of a patient who experienced sudden bilateral blurred vision after receiving an ESI and required urgent ophthalmic interventions and follow-up care. The main clinical findings from this case showed that the patient had high intraocular pressure (IOP) that caused unexpected short-term vision loss. The symptom resolved after 3½ months without ophthalmic treatment. Conclusion Clinicians should inform patients about the possibility of visual complications associated with pain procedures involving steroids. Among the high-risk groups with predisposing factors, such as uncontrolled hypertension and diabetes mellitus, routine eye tests that include measuring IOP prior to ESI should be recommended as a preventive measure. Alternative pain management therapies should be considered if possible. Comprehensive planning of patient care will also ensure safety and prevent unwanted outcomes, particularly with high-risk patients receiving steroids for pain procedures. PMID:25829885

  10. Stereotactic Body Radiotherapy Reirradiation for Recurrent Epidural Spinal Metastases

    SciTech Connect

    Mahadevan, Anand; Floyd, Scott; Wong, Eric; Jeyapalan, Suriya; Groff, Michael; Kasper, Ekkehard

    2011-12-01

    Purpose: When patients show progression after conventional fractionated radiation for spine metastasis, further radiation and surgery may not be options. Stereotactic body radiotherapy (SBRT) has been successfully used in treatment of the spine and may be applicable in these cases. We report the use of SBRT for 60 consecutive patients (81 lesions) who had radiological progressive spine metastasis with epidural involvement after previous radiation for spine metastasis. Methods and Materials: SBRT was used with fiducial and vertebral anatomy-based targeting. The radiation dose was prescribed based on the extent of spinal canal involvement; the dose was 8 Gy Multiplication-Sign 3 = 24 Gy when the tumor did not touch the spinal cord and 5 to 6 Gy x 5 = 25 to 30 Gy when the tumor abutted the cord. The cord surface received up to the prescription dose with no hot spots in the cord. Results: The median overall survival was 11 months, and the median progression-free survival was 9 months. Overall, 93% of patients had stable or improved disease while 7% of patients showed disease progression; 65% of patients had pain relief. There was no significant toxicity other than fatigue. Conclusions: SBRT is feasible and appears to be an effective treatment modality for reirradiation after conventional palliative radiation fails for spine metastasis patients.

  11. Treatment implications of posterior fossa ependymoma subgroups.

    PubMed

    Ramaswamy, Vijay; Taylor, Michael D

    2016-11-15

    Posterior fossa ependymoma comprises two distinct molecular entities, ependymoma_posterior fossa A (EPN_PFA) and ependymoma_posterior fossa B (EPN_PFB), with differentiable gene expression profiles. As yet, the response of the two entities to treatment is unclear. To determine the relationship between the two molecular subgroups of posterior fossa ependymoma and treatment, we studied a cohort of 820 patients with molecularly profiled, clinically annotated posterior fossa ependymomas. We found that the strongest predictor of poor outcome in patients with posterior fossa ependymoma across the entire age spectrum was molecular subgroup EPN_PFA, which was recently reported in the paper entitled "Therapeutic impact of cytoreductive surgery and irradiation of posterior fossa ependymoma in the molecular era: a retrospective multicohort analysis" in the Journal of Clinical Oncology. Patients with incompletely resected EPN_PFA tumors had a very poor outcome despite receiving adjuvant radiation therapy, whereas a substantial proportion of patients with EPN_PFB tumors can be cured with surgery alone.

  12. Congenital basis of posterior fossa anomalies

    PubMed Central

    Cotes, Claudia; Bonfante, Eliana; Lazor, Jillian; Jadhav, Siddharth; Caldas, Maria; Swischuk, Leonard

    2015-01-01

    The classification of posterior fossa congenital anomalies has been a controversial topic. Advances in genetics and imaging have allowed a better understanding of the embryologic development of these abnormalities. A new classification schema correlates the embryologic, morphologic, and genetic bases of these anomalies in order to better distinguish and describe them. Although they provide a better understanding of the clinical aspects and genetics of these disorders, it is crucial for the radiologist to be able to diagnose the congenital posterior fossa anomalies based on their morphology, since neuroimaging is usually the initial step when these disorders are suspected. We divide the most common posterior fossa congenital anomalies into two groups: 1) hindbrain malformations, including diseases with cerebellar or vermian agenesis, aplasia or hypoplasia and cystic posterior fossa anomalies; and 2) cranial vault malformations. In addition, we will review the embryologic development of the posterior fossa and, from the perspective of embryonic development, will describe the imaging appearance of congenital posterior fossa anomalies. Knowledge of the developmental bases of these malformations facilitates detection of the morphological changes identified on imaging, allowing accurate differentiation and diagnosis of congenital posterior fossa anomalies. PMID:26246090

  13. Recurrent posterior shoulder instability. Diagnosis and treatment.

    PubMed

    Pollock, R G; Bigliani, L U

    1993-06-01

    Recurrent posterior glenohumeral instability is regarded as a difficult problem to diagnose and treat. A careful history and physical examination are the most helpful tools in making this diagnosis. A positive posterior stress test, demonstrable posterior subluxation, and a sulcus sign are frequently present on examination. Special roentgenographic studies, such as the computerized arthrotomography (arthro-CT) scan, may be used in cases in which plain roentgenographs suggest bony glenoid abnormalities. When conservative therapy fails, there is no consensus on the operative treatment. Procedures that address the soft tissues, such as capsulorrhaphy and posterior labral repair, as well as those that alter the bony geometry of the joint, such as posterior bone blocks and glenoid or humeral osteotomies, have been described. Capsular laxity is the most common pathologic finding in the authors' experience, and they favor the use of a posterior-inferior capsular shift procedure to correct this problem. Augmentation of the repair with a posterior bone block is reserved for unusual cases, such as when glenoid hypoplasia is present or in certain revision situations.

  14. Posterior labral injury in contact athletes.

    PubMed

    Mair, S D; Zarzour, R H; Speer, K P

    1998-01-01

    Nine athletes (seven football offensive linemen, one defensive lineman, and one lacrosse player) were found at arthroscopy to have posterior labral detachment from the glenoid. In our series, this lesion is specific to contact athletes who engage their opponents with arms in front of the body. All patients had pain with bench pressing and while participating in their sport, diminishing their ability to play effectively. Conservative measures were ineffective in relieving their symptoms. Examination under anesthesia revealed symmetric glenohumeral translation bilaterally, without evidence of posterior instability. Treatment consisted of glenoid rim abradement and posterior labral repair with a bioabsorbable tack. All patients returned to complete at least one full season of contact sports and weightlifting without pain (minimum follow-up, > or = 2 years). Although many injuries leading to subluxation of the glenohumeral joint occur when an unanticipated force is applied, contact athletes ready their shoulder muscles in anticipation of impact with opponents. This leads to a compressive force at the glenohumeral joint. We hypothesize that, in combination with a posteriorly directed force at impact, the resultant vector is a shearing force to the posterior labrum and articular surface. Repeated exposure leads to posterior labral detachment without capsular injury. Posterior labral reattachment provides consistently good results, allowing the athlete to return to competition.

  15. Combined Spinal-Epidural for Vaginal Delivery in a Parturient With Takayasu’s Arteritis

    PubMed Central

    Clifford, Sean Patrick; Mick, Paul Brian; Derhake, Brian Matthew

    2016-01-01

    Takayasu’s arteritis is a rare, progressive panendarteritis involving all layers of the arterial wall. This disease includes variable involvement of the aorta and its major branches. The most common complication with this condition is severe, uncontrolled hypertension, often leading to end organ dysfunction. We describe the management of a 27-year-old woman diagnosed with Takayasu’s arteritis that presented in labor with intense pain and underwent a combined spinal-epidural for anesthetic management. Per literature review, a combined spinal-epidural technique for planned vaginal delivery has not been described for a laboring Takayasu patient. Our technique, utilizing intrathecal opioids and a low-dose local anesthetic-opioid epidural infusion, provided adequate analgesia while maintaining hemodynamic stability throughout labor augmentation and successful vaginal delivery. PMID:28210635

  16. Ryszard Rodzinski-A Forgotten Polish Inventor and Pioneer of Combined Spinal-Epidural Anesthesia.

    PubMed

    Daszkiewicz, Andrzej R; Copik, Maja M; Misiolek, Hanna D; Reiss, Wojciech Z

    2016-10-01

    Dr. Ryszard Rodzinski was a Polish surgeon who, in spite of his short life, had a productive career. His most important discovery was a safer method of performing regional anesthesia for abdominal surgery. The first description of combined spinal epidural anesthesia is generally attributed to Soresi in 1937. In the early 20th century, Rodzinski invented a novel technique, "combined lumbosacral anesthesia," which combined lumbar spinal anesthesia and sacral epidural anesthesia. During the 19th Meeting of Polish Surgeons in July 1922 in Warsaw, Rodzinski presented an article entitled "On Combined Lumbosacral Anaesthesia," in which he described this technique used in surgical clinic in Lwów since October 1921. Given this presentation, Rodzinski could be considered to have made the first known presentation of the combined spinal and epidural anesthesia.

  17. Cervical Spondylitis and Epidural Abscess Caused by Brucellosis: a Case Report and Literature Review.

    PubMed

    Reşorlu, Hatice; Saçar, Suzan; Inceer, Beşir Şahin; Akbal, Ayla; Gökmen, Ferhat; Zateri, Coskun; Savaş, Yilmaz

    2016-12-01

    Brucellosis is a zoonotic disease widely seen in endemic regions and that can lead to systemic involvement. The musculoskeletal system is frequently affected, and the disease can exhibit clinical involvements such as arthritis, spondylitis, spondylodiscitis, osteomyelitis, tenosynovitis and bursitis. Spondylitis and spondylodiscitis, common complications of brucellosis, predominantly affect the lumbar and thoracic vertebrae. Epidural abscess may occur as a rare complication of spondylitis. Spinal brucellosis and development of epidural abscess in the cervical region are rare. Development of epidural abscess affects the duration and success of treatment. Spinal brucellosis should be considered in patients presenting with fever and lower back-neck pain in endemic regions, and treatment must be initiated with early diagnosis in order to prevent potential complications.

  18. Treatment of holocord spinal epidural abscess via alternating side unilateral approach for bilateral laminectomy.

    PubMed

    Hwang, Roy; Yung, Brian H; Sedney, Cara; Miele, Vincent J

    2015-01-01

    To date, this is the first reported case of the surgical management of a holocord epidural abscess done through level-skipping laminectomies. It is also the first reported case of these laminectomies being performed via an alternating side unilateral approach for this condition. A 51-year-old patient presenting with progressive lower extremity weakness secondary to a spinal epidural abscess extending from C4 to S1. A minimally disruptive method of relieving the spinal cord compression via evacuation of the abscess was employed successfully. This report demonstrates the efficacy of level skipping laminectomies via a unilateral approach for holocord epidural abscesses (extending 20 vertebral levels). Performing the laminectomies via a unilateral approach as well as alternating the side of the approach minimized iatrogenic instability risk. Both strategies were designed to minimize incision size, tissue disruption, and the amount of muscular weakness/imbalance postoperatively.

  19. [Prolonged epidural analgesia induced by clopheline in combination with lidocaine in obstetric analgesia].

    PubMed

    Semenikhin, A A; En Din Kim; Kurbanov, S D

    1998-01-01

    The study was carried out in 178 women without grave obstetrical or extragenital diseases. In group 1 labor pain was relieved by prolonged epidural anesthesia with 2% lidocaine solution (2-2.5 mg/kg), in group 2 prolonged epidural anesthesia with 1% lidocaine solution (1 mg/kg) and 0.01% clofelin (1 microgram/kg) was administered. Central hemodynamics, heart rhythm, external respiration function, uterine contractility, and fetal intrauterine status were assessed. The findings indicate that none of the methods had a negative impact on the vital parameters of women and newborns at any stage of anesthesia. However, a combination of epidural clofelin (1 microgram/kg) with lidocaine permits an appreciable decrease in the doses of both drugs without decreasing the efficacy of anesthesia. This method has a favorable effect on the course of labor: the mouth of the womb opens sooner at a lower uterine activity and there are no negative effects on the fetus and newborn.

  20. Cervical Epidural Abscess in Haemodialysis Patients by Catheter Related Infection: Report of Two Cases

    PubMed Central

    Gezici, Ali Riza

    2010-01-01

    Despite advances in neuroimaging and neurosurgical treatment modalities, spinal epidural abscess remains a challenging problem. Early diagnosis is often difficult and treatment is always delayed. Spinal epidural abscess usually develops in patients with predisposing factors such as IV drug abuse, senillity, diabetes mellitus, spinal attempts, alcoholism, immunosuppression, liver diseases and catheterizations. It is rarely seen in cervical region. A successful treatment is only possible with early diagnosis and accurate surgical and medical treatment. Optimal management is unclear and morbidity and mortality are significant. We present two adult haemodialysis patients with end-stage renal insufficiency who developed cervical epidural abscess following central venous catheter placement. Early surgical intervention is mandatory in cases those have progressive neurological deficit and spinal deformity, and this is also increases the success rate of medical therapy. PMID:20052368

  1. Informed consent for epidural analgesia in labour: a survey of UK practice.

    PubMed

    Middle, J V; Wee, M Y K

    2009-02-01

    Anaesthetists are legally obliged to obtain informed consent before performing regional analgesia in labour. A postal survey of consultant-led UK anaesthetic units was performed in September 2007 to assess practice regarding obtaining informed consent before inserting an epidural, and documentation of the risks discussed. The response rate was 72% (161/223). There was great variation between units regarding which risks women were informed about and the likely incidence of that risk. One hundred and twenty-three respondents out of 157 providing an epidural service (78%) supported a national standardised information card endorsed by the Obstetric Anaesthetists' Association, with all the benefits and risks stated, to be shown to all women before consenting to an epidural in labour.

  2. Conservative management of recurrent lumbar disk herniation with epidural fibrosis: a case report

    PubMed Central

    Welk, Aaron B.; Werdehausen, Destiny N.; Kettner, Norman W.

    2012-01-01

    Objective A retrospective case report of a 24-year-old man with recurrent lumbar disk herniation and epidural fibrosis is presented. Recurrent lumbar disk herniation and epidural fibrosis are common complications following lumbar diskectomy. Clinical Features A 24-year-old patient had a history of lumbar diskectomy and new onset of low back pain and radiculopathy. Magnetic resonance imaging revealed recurrent herniation at L5/S1, left nerve root displacement, and epidural fibrosis. Intervention and Outcomes The patient received a course of chiropractic care including lumbar spinal manipulation and rehabilitation exercises with documented subjective and objective functional and symptomatic improvement. Conclusion This case report describes chiropractic management including spinal manipulative therapy and rehabilitation exercises and subsequent objective and subjective functional and symptomatic improvement. PMID:23843756

  3. [Epidural anesthesia and local administration of high-dose prostaglandin in obstetrics. A dangerous combination].

    PubMed

    Veeckman, L; Müller, E; Van Aken, H

    1989-07-01

    The use of high epidural anesthesia for cesarean section has generally been accepted as a safe and comfortable means of intra- and post-operative pain relief in recent years. However, the accompanying vasomotor blockade of the lower body and the sometimes impaired cardiac reflex activity restrict the use of concomitant--even local--medication. Described are the deleterious side effects on hemodynamic stability and patient comfort of an intramyometrically administered synthetic prostaglandin E (PGE2)-compound (dinoprostone) given to three female patients under high epidural anesthesia during cesarean section. Differentiation of the various symptoms is made in relation to their epidural or PGE origin or to a combination of the two. A striking therapeutic resistance of the hypotension of a sufficiently volume-expanded patient to even large doses of ephedrine is discussed as representing possible PGE-mediated suppression of peripheral norepinephrine release.

  4. Technique of fiber optics used to localize epidural space in piglets.

    PubMed

    Ting, Chien-Kun; Chang, Yin

    2010-05-24

    Technique of loss-of-resistance in epidural block is commonly used for epidural anesthesia in humans with approximately 90% successful rate. However, it may be one of the most difficult procedures to learn for anesthesia residents in hospital. A two-wavelength (650 nm and 532 nm) fiber-optical method has been developed according to the characteristic reflectance spectra of ex-vivo porcine tissues, which are associated with the needle insertion to localize the epidural space (ES). In an in-vivo study in piglets showed that the reflected lights from ES and its surrounding tissue ligamentum flavum (LF) are highly distinguishable. This indicates that this technique has potential to localize the ES on the spot without the help of additional guiding assistance.

  5. An unusual and spectacular case of spindle cell lipoma of the posterior neck invading the spinal cervical canal and posterior cranial fossa.

    PubMed

    Petit, Damien; Menei, Philippe; Fournier, Henri-Dominique

    2011-11-01

    The authors describe the first case of spindle cell lipoma of the posterior neck invading the upper cervical spinal canal and the posterior cranial fossa. Spindle cell lipoma is an extremely rare variant of benign lipoma. It usually occurs as a solitary subcutaneous well-circumscribed lesion in the posterior neck or shoulders of adult men. Local aggressiveness is unusual. This 61-year-old man presented with an increased left cerebellar syndrome and headaches. He also had a posterior neck tumefaction, which had been known about for a long time. Computed tomography and MR imaging studies revealed a voluminous mass extending to the upper cervical canal and posterior cranial fossa and eroding the neighboring bones. The lesion was well delimited, and contrast enhancement was intense and heterogeneous. The tumor, which had initially developed under the muscles of the posterior neck, was totally resected. Histological assessment revealed numerous fat cells with spindle cells secreting collagen. The large size of the tumor and the submuscular location, bone erosion, and compression of the CNS were unusual in this rare subtype of benign adipose tumor. Its presentation could simulate a sarcoma.

  6. Negligible Effect of Perioperative Epidural Analgesia Among Patients Undergoing Elective Gastric and Pancreatic Resections

    PubMed Central

    Shah, Dhruvil R.; Brown, Erin; Russo, Jack E.; Li, Chin-Shang; Martinez, Steve R.; Coates, Jodi M.; Bold, Richard J.; Canter, Robert J.

    2014-01-01

    Background There are conflicting data regarding improvements in postoperative outcomes with perioperative epidural analgesia. We sought to examine the effect of perioperative epidural analgesia versus intravenous narcotic analgesia on perioperative outcomes including pain control, morbidity, and mortality in patients undergoing gastric and pancreatic resections. Methods We evaluated 169 patients from 2007 to 2011 who underwent open gastric and pancreatic resections for malignancy at a university medical center. Emergency, traumatic, pediatric, enucleations, and disseminated cancer cases were excluded. Clinicopathologic data were reviewed among epidural (E) and non-epidural (NE) patients for their association with perioperative endpoints. Results 120 patients (71%) received an epidural, and 49 (29%) did not. There were no significant differences (P > 0.05) in mean pain scores at each of the four days (days 0-3) among E ( 3.2 ± 2.7, 3.2 ± 2.3, 2.3 ± 1.9, and 2.1 ± 1.9, respectively) and NE patients ( 3.7 ± 2.7, 3.4 ± 1.9, 2.9 ± 2.1, and 2.4 ± 1.9, respectively). Within each of the E and NE patient groups, there were significant differences (P < 0.0001) in mean pain scores from day 0 to day 3 (P < 0.0001). 69% of E patients also received intravenous patient-controlled analgesia (PCA). Ileus (13% E vs. 8% NE), pneumonia (12% E vs. 8% NE), venous thromboembolism (6% E vs. 4% NE), length of stay [ 11.0±12.1(8,4-107) E vs. 12.2±10.7(7,3-54) NE], overall morbidity (36% E vs. 39% NE), and mortality (4% E vs. 2% NE) were not significantly different. Conclusions Routine use of epidurals in this group of patients does not appear to be superior to PCA. PMID:23345053

  7. Effects of Systemic and Local Interferon Beta-1a on Epidural Fibrosis

    PubMed Central

    Işık, Semra; Doğan, Şeref; Özgün, Gonca; Ocakoğlu, Gökhan; Uğraş, Nesrin

    2016-01-01

    Study Design Level 1 randomized controlled study. Purpose To investigate the effects of systemic and local interferon-beta-1a (IFN-β-1a) on prevention of epidural fibrosis using histopathological parameters. Overview of Literature Epidural fibrosis involves fibroblastic invasion of nerve roots into the epidural space. Formation of dense fibrous tissue causes lumbar and radicular pain. Many surgical techniques and several materials have been proposed in the literature, but no study has assessed the effect of IFN-β-1a on prevention of epidural fibrosis. Methods Forty-eight adult female Sprague-Dawley rats were divided into six groups of eight: sham group, control group, systemic 44 μg IFN-β-1a group and 22 μg IFN-β-1a group (after laminectomy and discectomy, 0.28 mL and 0.14 mL IFN-β-1a applied subcutaneously three times for a week, respectively), local 44 μg IFN-β-1a group (laminectomy and discectomy, followed by 0.28 mL IFN-β-1a on the surgical area), and local 22 μg IFN-β-1a group (laminectomy and discectomy, followed by 0.14 mL IFN-β-1a on the surgical area). All rats were sacrificed after 4 weeks and groups were evaluated histopathologically. Results Compared with sham and control groups, significantly less epidural fibrosis, dural adhesion, and fibroblast cell density were observed in the local and systemic 44 μg IFN-β-1a groups. No other differences were evident between the local and systemic groups. Conclusions IFN-β-1a is effective in preventing epidural fibrosis with systemic and local application. PMID:27340517

  8. Preprocedural ultrasound examination versus manual palpation for thoracic epidural catheter insertion

    PubMed Central

    Hasanin, Ahmed M.; Mokhtar, Ali M.; Amin, Shereen M.; Sayed, Ahmed A.

    2017-01-01

    Background and Aims: Ultrasound imaging before neuraxial blocks was reported to improve the ease of insertion and minimize the traumatic trials. However, the data about the use of ultrasound in thoracic epidural block are scanty. In this study, pre-insertion ultrasound scanning was compared to traditional manual palpation technique for insertion of the thoracic epidural catheter in abdominal operations. Subjects and Methods: Forty-eight patients scheduled to midline laparotomy under combined general anesthesia with thoracic epidural analgesia were included in the study. Patients were divided into two groups with regard to technique of epidural catheter insertion; ultrasound group (done ultrasound screening to determine the needle insertion point, angle of insertion, and depth of epidural space) and manual palpation group (used the traditional manual palpation technique). Number of puncture attempts, number of puncture levels, and number of needle redirection attempts were reported. Time of catheter insertion and complications were also reported in both groups. Results: Ultrasound group showed lower number of puncture attempts (1 [1, 1.25] vs. 1.5 [1, 2.75], P = 0.008), puncture levels (1 (1, 1) vs. 1 [1, 2], P = 0.002), and needle redirection attempts (0 [0, 2.25] vs. 3.5 [2, 5], P = 0.00). Ultrasound-guided group showed shorter time for catheter insertion compared to manual palpation group (140 ± 24 s vs. 213 ± 71 s P = 0.00). Conclusion: Preprocedural ultrasound imaging increased the incidence of first pass success in thoracic epidural catheter insertion and reduced the catheter insertion time compared to manual palpation method. PMID:28217056

  9. Spinal Epidural Varices, a great Mimic of Intervertebral Disc Prolapse - A Case Series

    PubMed Central

    V, Raghavendra; Haridas, Papanaik; Kumar, Anand; K, Ajith

    2014-01-01

    Introduction: Epidural venous plexus enlargement, presenting with low back pain and radiculopathy, is an uncommon cause of nerve roots impingement. This condition commonly mimics a herniated nucleus pulposus radiologically. The radiological diagnosis is often missed and the diagnosis is made during the surgery. We are hereby presenting 2 such cases of epidural varices mimicking intervertebral disc prolapse with lumbar radiculopathy. Case Report: Case 1: 43 yr old female presented with acute exacerbation of low back ache and significant right L5–S1 radiculopathy without neurological deficit. MRI reported as L5-S1 disc prolapse. Intra-operatively engorged dilated epidural vein seen compressing S1 nerve root. Associated Disc bulge removed and Coagulative ablation of the dilated epidural vein was performed Case 2: 45 year old male manual labourer presented with backache with left sided sciatica since 8 months, increased in severity since past 1month associated with sensory blunting in L5 and S1 dermatomes. Neurologic examination revealed normal muscle power in his lower extremities. Sensations was blunted in L5 and S1 dermatomes. MRI was reported as L5-S1 disc prolapsed compressing left S1 nerve root. Decompression of the L5–S1 intervertebral space was performed through a left –sidelaminotomy. Large, engorged serpentine epidural veins was found in the axilla of S1 nerve root, compressing it. Coagulative ablation of the dilated epidural vein was performed. Retrospectively, features of epidural varices were noted in the preoperative magnetic resonance imaging scans. Both patients had significant improvement in radiculopathy immediate postoperatively, and sensory symptoms resolved over the next 6 weeks in second case. At recent follow up, both patients had significant relief of symptoms and no recurrent radicular symptoms. Conclusion: An abnormal dilated epidural venous plexus that mimics a herniated lumbar disc is a rare entity. This pathology should be always kept

  10. Effect of maternal ambulation on labour with low-dose combined spinal-epidural analgesia.

    PubMed

    Collis, R E; Harding, S A; Morgan, B M

    1999-06-01

    Two hundred and twenty-nine nulliparous women who requested regional analgesia during labour were given a combined spinal-epidural block. They were randomly allocated to stay in bed or spend at least 20 min of every hour out of bed. There was no significant difference in duration of labour, analgesia requirements, mode of delivery or condition of the baby between the groups. Ambulation appeared to be safe for the mother and baby. Maternal satisfaction with the low-dose combined spinal-epidural was high in both groups.

  11. Doxorubicin-induced dilated cardiomyopathy for modified radical mastectomy: A case managed under cervical epidural anaesthesia

    PubMed Central

    Jain, Anuj; Kishore, Kamal

    2013-01-01

    Doxorubicin (Dox) is an antineoplastic agent used in a wide variety of malignancies. Its use is limited because of a cumulative, dose-dependent irreversible cardiomyopathy. We report a case of Dox induced cardiomyopathy, posted for modified radical mastectomy. The patient had poor LV function along with moderate pulmonary hypertension. Regional anaesthesia was planned as the risk associated with general anaesthesia was more. A cervical epidural was placed and a block adequate for surgery could be achived. The haemodynamic parameters as measured by esophageal doppler showed a stable trend. The surgery could be managed well under cervical epidural and also provided a good postoperative pain relief. PMID:23825820

  12. Epidural analgesia, fetal monitoring and the condition of the baby at birth with breech presentation.

    PubMed

    Donnai, P; Nicholas, A D

    1975-05-01

    Between December 1970 and March 1973, 138 patients with a singleton fetus presenting by the breech after 36 weeks of pregnancy were deemed suitable for vaginal delivery under epidural analgesia; 130 were delivered vaginally, 10 of them by breech extraction. There was one stillbirth and no neonatal deaths. Epidural analgesia for vaginal breech delivery seemed beneficial. In 65 cases it was possible to compare the umbilical vein pH with the Apgar score at one minute. In 35 patients a continuous recording of the fetal heart rate was used to predict the Apgar score at one minute and the results are discussed.

  13. Adolescence spinal epidural abscess with neurological symptoms: case report, a lesson to be re-learnt.

    PubMed

    Sales, Jafar Ganjpour; Tabrizi, Ali; Elmi, Asghar; Soleimanpour, Jafar; Gavidel, Ehsan

    2013-02-01

    Epidural abscess of the spinal column is a rare condition that can be fatal if left untreated. It promptly progresses and can cause neurologic paralysis, urinary retention or cauda equina syndrome. Compromised immune system that occurs in patients with diabetes mellitus, AIDS, chronic renal failure, alcoholism, or cancer is a predisposing factor. It mostly occurs in adults. Here we would like to report a case of spontaneous pyogenic lumbar epidural abscess with neurological deficit diagnosed in a 15 year old boy. We treated this case successfully with surgical microscopic decompression and drainage.

  14. High-flow Paraspinal Osseous Epidural Arteriovenous Fistula. A Case Report.

    PubMed

    Iizuka, Yuo; Suzuki, Mitimasa; Suzuki, Kazuhiro; Shimoji, Keigo; Komura, Shinji

    2008-06-03

    We report the clinical and neuroradiological imaging findings of a 26-year-old man who presented with lumbago related to high flow paraspinal osseous epidural arteriovenous fistulas in the thoracic spine. This case was of particular interest because of his exclusive epidural and paraspinal venous drainage and the presence of a prominent dilated venous pouch in the spinal canal. Angiography demonstrated multiple high flow arteriovenous fistulas with an osseous nidus. Transarterial glue embolization was performed by multistage sessions. Clinical symptoms improved dramatically. The unusual features of this case have important implications for therapeutic management.

  15. Posterior Hip Pain in an Athletic Population

    PubMed Central

    Frank, Rachel M.; Slabaugh, Mark A.; Grumet, Robert C.; Virkus, Walter W.; Bush-Joseph, Charles A.; Nho, Shane J.

    2010-01-01

    Context: Posterior hip pain is a relatively uncommon but increasingly recognized complaint in the orthopaedic community. Patient complaints and presentations are often vague or nonspecific, making diagnosis and subsequent treatment decisions difficult. The purposes of this article are to review the anatomy and pathophysiology related to posterior hip pain in the athletic patient population. Evidence Acquisition: Data were collected through a thorough review of the literature via a MEDLINE search of all relevant articles between 1980 and 2010. Results: Many patients who complain of posterior hip pain actually have pain referred from another part of the body—notably, the lumbar spine or sacroiliac joint. Treatment options for posterior hip pain are typically nonoperative; however, surgery is warranted in some cases. Conclusions: Recent advancements in the understanding of hip anatomy, pathophysiology, and treatment options have enabled physicians to better diagnosis athletic hip injuries and select patients for appropriate treatment. PMID:23015944

  16. Posterior cruciate ligament (PCL) injury - aftercare

    MedlinePlus

    Adib F, Curtis C, Bienkowski P Micheli LJ. Posterior cruciate ligament sprain. In: Frontera WR, Silver JK, Rizzo TD Jr, eds. Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, ...

  17. Best approach for posterior mediastinal goiter removal: transcervical incision and lateral thoracotomy.

    PubMed

    Ojanguren Arranz, Amaya; Baena Fustegueras, Juan Antonio; Ros López, Susana; Santamaría Gómez, Maite; Ojanguren Arranz, Iñigo; Olsina Kissle, Jorge Juan

    2014-06-01

    Surgical removal of intrathoracic goiter can be performed by a cervical approach in the majority of patients. Review of literature shows that experienced surgeons need to perform an extracervical approach in 2-3% of cases. In spite of surgical management of substernal goiter is well defined, there is little available information about surgical approach of intrathoracic goiters extending beyond the aortic arch into the posterior mediastinum. We report two cases and propose combination of cervical incision and muscle-sparing lateral thoracotomy for posterior mediastinal goiter removal. In such cases, we do not favour sternotomy as posterior mediastinum is inaccessible due to the presence of heart and great vessels anterior to the thyroidal mass that would lead to perform a perilous blind dissection. Based in our experience, transcervical and thoracotomy approach is indicated for a complete and safe posterior mediastinal goiter removal.

  18. Differential effects of aging on transport properties of anterior and posterior human sclera.

    PubMed

    Boubriak, O A; Urban, J P G; Bron, A J

    2003-06-01

    The transport properties and composition of 44 pairs of human sclera, 37-91 years were compared. Solute transport, diffusion and partition coefficients of posterior sclera for solutes ranging in mass from 0.023-70kDa were higher than those of anterior sclera; the posterior region was also more hydrated. The differences in partition coefficient between anterior and posterior sclera became more pronounced as solute molecular weight increased. Partition coefficients and hydration of both regions decreased with increasing age. Chondroitinase ABC digestion, which removed the majority of glycosaminoglycans, increased partition coefficients of both regions significantly. These results suggest that for regions of equal scleral thickness, neglecting the influence of vascular factors, drug delivery will be more readily achieved across the posterior sclera than the anterior sclera in the age group studied and that, for both regions, ease of delivery will decrease with decreasing age.

  19. Thoracic duct cyst of posterior mediastinum: a "challenging" differential diagnosis.

    PubMed

    Electra, Michalopoulou-Manoloutsiou; Evangelia, Athanasiou; Mattheos, Bobos; Dimitris, Hatzibougias I; Zarogoulidis, Paul; Tsavlis, Drosos; Kougioumtzi, Ioanna; Machairiotis, Nikolaos; Charalampidis, Chralampos; Fassiadis, Nikolaos; Mparmpetakis, Nikolaos; Pavlidis, Pavlos; Andreas, Mpakas; Stamatis, Arikas; Alexandros, Kolettas; Kosmas, Tsakiridis

    2016-05-01

    Thoracic duct cysts of the mediastinum are extremely rare entities and their pathogenesis still remains unknown. Imaging methods are not specific and show a cystic mass, however the real nature of the lesion is confirmed only with the help of histopathological examination after surgical excision. Here, we present a case of thoracic cyst in a 28-year-old female, lining in posterior lower mediastinum. The cyst was removed by video-assisted thoracic surgery (VATS) and the histopathological findings were that of thoracic duct cyst. Through this case, we propose an ideal surgical approach and diagnostic procedure.

  20. Gibbs Sampling for Marginal Posterior Expectations

    DTIC Science & Technology

    1991-11-19

    Achcar and Smith (1989) shows that performance of the Laplace method is often very sensitive to parametrization. Morris (1988) offers expansions based on...Berkeley Symp. 1, 453-468. Lindley, D.V. (1980). "Approximate Bayesian Methods" in Bayesian Statistics, J.M. Bernardo, M.H. DeGroot , D.V. Lindley...A.F.M. Smith, University Press, Valencia, Spain. Morris , C. "Approximating Posterior Distributions and Posterior Moments" In: Bayesian Statistics 3, J.M

  1. [Posterior cortical atrophy (Benson-syndrome)].

    PubMed

    Rózsa, Anikó; Szilvássy, Ildikó; Kovács, Krisztina; Boór, Krisztina; Gács, Gyula

    2010-01-30

    We present the characteristics of posterior cortical atrophy--a very rare cortical dementia--in a 69 year old woman's case. Our patient's symptoms began with a visual problem which was initially explained by ophthalmological disorder. After neurological exam visual agnosia was diagnosed apart from other cognitive disorder (alexia without agraphia, acalculia, prosopagnosia, constructional disorder, clock-time recognition disorder, dressing apraxia, visuospatial disorientation). The brain MRI showed bilateral asymmetric parieto-occipital atrophy which is characteristic of posterior cortical atrophy.

  2. Posterior Wnts Have Distinct Roles in Specification and Patterning of the Planarian Posterior Region.

    PubMed

    Sureda-Gómez, Miquel; Pascual-Carreras, Eudald; Adell, Teresa

    2015-11-05

    The wnt signaling pathway is an intercellular communication mechanism essential in cell-fate specification, tissue patterning and regional-identity specification. A βcatenin-dependent signal specifies the AP (Anteroposterior) axis of planarians, both during regeneration of new tissues and during normal homeostasis. Accordingly, four wnts (posterior wnts) are expressed in a nested manner in central and posterior regions of planarians. We have analyzed the specific role of each posterior wnt and the possible cooperation between them in specifying and patterning planarian central and posterior regions. We show that each posterior wnt exerts a distinct role during re-specification and maintenance of the central and posterior planarian regions, and that the integration of the different wnt signals (βcatenin dependent and independent) underlies the patterning of the AP axis from the central region to the tip of the tail. Based on these findings and data from the literature, we propose a model for patterning the planarian AP axis.

  3. Vertigo due to posterior circulation stroke.

    PubMed

    Kim, Ji Soo; Lee, Hyung

    2013-07-01

    Stroke in the distribution of the posterior circulation may present as acute onset spontaneous vertigo and imbalance. Although vertigo due to posterior circulation stroke is usually associated with other neurologic symptoms or signs, small infarcts in the cerebellum or brainstem can present with vertigo without other localizing symptoms. Approximately 17% of patients with isolated posterior inferior cerebellar artery territory infarction presented with isolated vertigo, nystagmus, and postural unsteadiness. A head impulse test can differentiate acute isolated vertigo associated with cerebellar stroke from more benign disorders involving the inner ear. Sometimes acute isolated audiovestibular loss can be the initial symptom of impending posterior circulation ischemic stroke (particularly within the territory of the anterior inferior cerebellar artery). In this case, evaluation of isolated audiovestibular loss may prevent the progression of acute vertigo and hearing loss into more widespread areas of infarction in the posterior circulation. In this article, the clinical syndromes and signs of acute vestibular syndrome due to posterior circulation stroke involving the brainstem and cerebellum are summarized.

  4. The lucid interval associated with epidural bleeding: evolving understanding.

    PubMed

    Ganz, Jeremy C

    2013-04-01

    The aim of this paper was to elucidate the evolution of our understanding of the term "lucid interval." A number of texts were reviewed to assess their suitability for analysis. The primary requirement was that the text contain detailed descriptions of a series of patients. Details of the clinical course, the findings and timing of surgery, and, when relevant, the time of death and postmortem findings were required. Books written by Henri-François Le Dran, Percival Pott, and James Hill fulfilled these criteria. Surgical findings included the presence and type of fractures, changes in the bone, separation of periosteum, malodorous or purulent material, tense brain, and hematoma. Postmortem findings supplemented and/or complemented the surgical findings. The courses of the patients were then tabulated, and the correlation between different clinical and operative findings was thereby determined. Our understanding of a lucid interval began in the early 18th century with the work of Henri-François Le Dran and Percival Pott in London. They did not, however, demonstrate an interval without symptoms between trauma and deterioration in patients with epidural hematomas (EDHs). The interval they described was longer than usually expected with EDHs and occurred exclusively in patients who had a posttraumatic infection. In 1751, James Hill, from Dumfries, Scotland, described the first hematoma-related lucid interval in a patient with a subdural hematoma. The first case of a lucid interval associated with an EDH was described by John Abernethy. In the 19th century, Jonathan Hutchinson and Walter Jacobson described the interval as it is known today, in cases of EDH. The most recent work on the topic came from studies in Cincinnati and Oslo, where it was demonstrated that bleeding can separate dura mater and that hemorrhage into the epidural space can be shunted out via the veins. This shunting could delay the accumulation of a hematoma and thus the rise in intracranial pressure

  5. Ethnic differences in the use of intrapartum epidural analgesia

    PubMed Central

    2012-01-01

    Background Obstetric epidural analgesia (EA) is widely applied, but studies have reported that its use may be less extensive among immigrant women or those from minority ethnic groups. Our aim was to examine whether this was the case in our geographic area, which contains an important immigrant population, and if so, to describe the different components of this phenomenon. Methods Cross-sectional observational study. Setting: general acute care hospital, located in Marbella, southern Spain. Analysis of computer records of deliveries performed from 2004 to 2010. Comparison of characteristics of deliveries according to the mothers’ geographic origins and of vaginal deliveries noting whether EA was received, using univariate and bivariate statistical analysis and multiple logistic regression (MLR). Results A total of 21,034 deliveries were recorded, and 37.4% of these corresponded to immigrant women. EA was provided to 61.1% of the Spanish women and to 51.5% of the immigrants, with important variations according to geographic origin: over 52% of women from other European countries and South America received EA, compared with around 45% of the African women and 37% of the Asian women. These differences persisted in the MLR model after adjusting for the mother's age, type of labor initiation, the weight of the neonate and for single or multiple gestation. With the Spanish patients as the reference category, all the other countries of origin presented lower probabilities of EA use. This was particularly apparent for the patients from Asia (OR 0.38; 95%CI 0.31-0.46), Morocco (OR 0.49; 95%CI 0.43-0.54) and other Africa (OR 0.55; 95%CI 0.37-0.81). Conclusions We observed a different use of EA in vaginal deliveries, according to the geographic origin of the women. The explanation for this involves a complex set of factors, depending both on the patient and on the healthcare staff. PMID:22818255

  6. Diabetic foot complicated by vertebral osteomyelitis and epidural abscess

    PubMed Central

    Trombetta, Maddalena; Imbriaco, Chiara; Rigolon, Riccardo; Mingolla, Lucia; Zamboni, Federica; Dal Molin, Francesca; Cioccoloni, Dario; Sanga, Viola; Bruti, Massimiliano; Brocco, Enrico; Conti, Michela; Ravenna, Giorgio; Perrone, Fabrizia; Stoico, Vincenzo; Bonora, Enzo

    2016-01-01

    Summary Vertebral osteomyelitis (or spondylodiscitis) is steadily increasing in Western countries and often results from hematogenous seeding, direct inoculation during spinal surgery, or contiguous spread from an infection in the adjacent soft tissue. We present the case of a 67-year-old white patient with type 2 diabetes who went to Hospital for high fever, back pain, and worsening of known infected ulcers in the left foot. Despite intravenous antibiotic treatment and surgical debridement of the foot infection, high fever and lower back pain continued. Bone biopsy and two consecutive blood cultures were positive for Staphylococcus aureus. A spinal magnetic resonance imaging (MRI) was performed, revealing serious osteomyelitis in L4 and L5 complicated by an epidural abscess. Contiguous or other distant focuses of infection were not identified. In this case, diabetic foot could be considered as a primary distant focus for vertebral osteomyelitis. Clinicians should consider vertebral osteomyelitis as a ‘possible’ diagnosis in patients with type 2 diabetes complicated by foot infection that is associated with fever and lower back pain. Learning points Vertebral osteomyelitis is increasing in Western countries, especially in patients with type 2 diabetes. The primary focus of infection is the genitourinary tract followed by skin, soft tissue, endocarditis, bursitis, septic arthritis, and intravascular access. Diabetic foot could be a rare primary focus of infection for vertebral osteomyelitis, and, however, vertebral osteomyelitis could be a serious, albeit rare, complication of diabetic foot. Clinicians should keep in mind the many potential complications of diabetic foot ulcerations and consider vertebral osteomyelitis as a “possible” diagnosis in patients with type 2 diabetes and foot ulcers associated with nonspecific symptoms such as lower back pain. Early diagnosis and correct management of vertebral osteomyelitis are crucial to improve clinical outcomes

  7. Posterior urethral polyp with type I posterior urethral valves: a rare association in a neonate.

    PubMed

    Kesan, Krushnakumar V; Gupta, Rahul Kumar; Kothari, Paras; Gupta, Abhaya; Mudkhedkar, Kedar; Kamble, Ravikiran; Dikshit, K Vishesh

    2014-06-01

    Urethral polyp is a rare cause of bladder outlet obstruction, voiding dysfunction, and hematuria in the pediatric age group. Urethral polyps are rarely associated with other congenital urinary tract anomalies. In this study, we report a case of solitary posterior urethral polyp with type I posterior urethral valve in a 7-day-old neonate presented with urinary retention and deranged renal function. The polyp was diagnosed on cystoscopy. Transurethral resection of the polyp with posterior urethral valve fulguration was performed. Pathologic assessment revealed a fibroepithelial lesion, which was consistent with congenital posterior urethral polyp.

  8. Epidural tramadol via intraoperatively placed catheter as a standalone analgesic after spinal fusion procedure: An analysis of efficacy and cost

    PubMed Central

    Ilangovan, Vijaysundar; Vivakaran, Thanga Tirupathi Rajan; Gunasekaran, D.; Devikala, D.

    2017-01-01

    Objective: This was a prospective analysis of epidural tramadol as a single analgesic agent delivered through intraoperatively placed epidural catheter for postoperative pain relief after spinal fusion procedures in terms of efficacy and cost. Materials and Methods: Twenty patients who underwent spinal fusion procedures were included in the study. After completion of the procedure, an epidural catheter was placed at the highest level of exposed dura and brought out through a separate tract. Postoperatively, tramadol was infused into the epidural space via the catheter at a dose of 1 mg/kg diluted in 10 ml of saline. The dosage frequency was arbitrarily fixed at every 6 h during the first 2 days and thereafter reduced to every 8 h after the first 2 days till day 5. Conventional intravenous analgesics were used only if additional analgesia was required as assessed by visual analog scale (VAS). Results: Patients’ VAS score was assessed every 4 h from the day of surgery. Patients with a VAS score of 6 or more were given additional analgesia in the form of intravenous paracetamol. Of the twenty patients, eight patients needed additional analgesia during the first 24 h and none required additional analgesia after the first 24 h. The median VAS score was 7 within the first 24 h and progressively declined thereafter. Epidural tramadol was noted to be many times cheaper than conventional parenteral analgesics. Conclusion: Epidural tramadol infusion is safe and effective as a standalone analgesic after open spinal fusion surgery, especially after the 1st postoperative day. Intraoperative placement of the epidural catheter is a simple way of delivering tramadol to the epidural space. The cost of analgesia after spinal fusion surgery can be reduced significantly using epidural tramadol alone. PMID:28149082

  9. Role of epidural anesthesia in a fast track liver resection protocol for cirrhotic patients - results after three years of practice

    PubMed Central

    Siniscalchi, Antonio; Gamberini, Lorenzo; Bardi, Tommaso; Laici, Cristiana; Gamberini, Elisa; Francorsi, Letizia; Faenza, Stefano

    2016-01-01

    AIM To evaluate the potential benefits and risks of the use of epidural anaesthesia within an enhanced recovery protocol in this specific subpopulation. METHODS A retrospective review was conducted, including all cirrhotic patients who underwent open liver resection between January 2013 and December 2015 at Bologna University Hospital. Patients with an abnormal coagulation profile contraindicating the placement of an epidural catheter were excluded from the analysis. The control group was composed by patients refusing epidural anaesthesia. RESULTS Of the 183 cirrhotic patients undergoing open liver resections, 57 had contraindications to the placement of an epidural catheter; of the remaining 126, 86 patients received general anaesthesia and 40 combined anaesthesia. The two groups presented homogeneous characteristics. Intraoperatively the metabolic data did not differ between the two groups, whilst the epidural group had a lower mean arterial pressure (P = 0.041) and received more colloid infusions (P = 0.007). Postoperative liver and kidney function did not differ significantly. Length of mechanical ventilation (P = 0.003) and hospital stay (P = 0.032) were significantly lower in the epidural group. No complications related to the epidural catheter placement or removal was recorded. CONCLUSION The use of Epidural Anaesthesia within a fast track protocol for cirrhotic patients undergoing liver resections had a positive impact on the patient’s outcomes and comfort as demonstrated by a significantly lower length of mechanical ventilation and hospital stay in the epidural group. The technique appears to be safely manageable in this fragile population even though these results need confirmation in larger studies. PMID:27660677

  10. Cephalad distribution of three differing volumes of new methylene blue injected into the epidural space in adult goats.

    PubMed

    Johnson, R A; Lopez, M J; Hendrickson, D A; Kruse-Elliott, K T

    1996-01-01

    Epidural anesthesia and analgesia are popular regional anesthetic techniques in many animal species. However, we have not found any reports of studies in animals that have investigated the extent of cephalad migration and level of sensory blockade achieved based only on the volume of drug injected into the epidural space. The purpose of this study was to determine if there is a relationship between the volume (mL/kg) of an injectate injected epidurally and the extent of its cephalad migration within the epidural space. Twelve adult goats were randomly assigned to three treatment groups based on the volume of 0.12% New Methylene Blue (NMB), 0.1, 0.2, or 0.3 mL/kg, injected into the epidural space. The site and speed of injection, animal position, and direction of needle bevel were held constant. All injections were performed at the lumbo-sacral space immediately following euthanasia. At necropsy, the vertebral columns were transected longitudinally. The extent of cephalad migration of dye within the epidural space was easily determined by staining of the dura. Measurements were rounded to the nearest intervertebral space to which the dye had migrated. The individual making assessments was blinded to all treatments. In goats treated with 0.1, 0.2, or 0.3 mL/kg NMB, the number of stained spinal segments was 3.5 +/- 0.6, 6.5 +/- 0.9, and 8.8 +/- 0.6, (mean +/- SEM), respectively. Linear regression performed on the data was significant (P < .05) with R2 = 0.86. There was a strong linear relationship between volume (mL/kg) of epidurally injected NMB and cranial migration, with the larger volumes producing more cephalad spread within the epidural space. These results provide evidence for the volume of epidural injectate needed to produce a desired level of sensory blockade in adult goats.

  11. Arachnoiditis Following Caudal Epidural Injections for the Lumbo-Sacral Radicular Pain

    PubMed Central

    Nanjayan, Shashi Kumar; Yallappa, Sachin; Bommireddy, Rajendra

    2013-01-01

    Caudal epidural steroid injection is a very common intervention in treatment of low back pain and sciatica symptoms. Although extensively used, it is not devoid of complications. A few reports of chemical and infective arachnoiditis exist following lumbar epidural anaesthesia, but none following a caudal epidural steroid injection.We report a case of arachnoiditis following caudal epidural steroid injections for lumbar radiculopathy. The patient presented with contralateral sciatica, worsening low back pain and urinary retention few days following the injection, followed by worsening motor functions in L4/L5/S1 myotomes with resultant dense foot drop. Gadolinium-enhanced magnetic resonance imaging suggested infective arachnoiditis with diffuse enhancement and clumping of the nerve roots within the lumbar and sacral thecal sac. As the number of injections in the management of back pain and lumbo-sacral radicular pain is increasing annually, it is imperative to have a thorough understanding of this potentially dangerous complication and educate the patients appropriately. PMID:24353855

  12. The comparative study of epidural levobupivacaine and bupivacaine in major abdominal surgeries

    PubMed Central

    Uzuner, Ali; Saracoglu, Kemal Tolga; Saracoglu, Ayten; Erdemli, Ozcan

    2011-01-01

    BACKGROUND: Opioid and local anesthetic infusion by an epidural catheter is widely used as a postoperative pain management method after major abdominal surgeries. There are several agents nowadays to provide sufficient analgesia. The agents which cause less side effects but better quality of analgesia are more valuable. We aimed to postoperatively compare the analgesic, hemodynamic and arrhythmogenic effects of epidural levobupivacaine-fentanyl and bupivacaine-fentanyl solutions. METHODS: Fifty patients were scheduled to undergo major abdominal surgery in this clinical trial. The parameters were recorded pre- and post-operatively. In Group I (n=25), bupivacaine with fentanyl solution and in Group II (n=25), levobupivacaine with fentanyl solution was infused via epidural patient-controlled analgesia (PCA). According to the preoperative and postoperative holter recording reports, the arrhythmogenic effects were examined in four catagories: ventricular arrhythmia (VA), supraventricular arrhythmia (SVA), atrioventricular conduction abnormalities and pauses longer than two seconds. RESULTS: Mean visual analog scale (VAS) values of groups did not differ at all time. They were 6 at the end of the surgery (0. Min, p = 0.622). The scores were 5 in Group I and 4 in Group II in 30. min (p = 0.301). The frequency of SVA was higher in bupivacaine group. CONCLUSIONS: The results of our study suggest that same concentration of epidural levobupivacaine and bupivacaine with fentanyl provide stable postoperative analgesia and both were found safe for the patients undergoing major abdominal surgery. PMID:22973384

  13. Thoracic osteomyelitis and epidural abscess formation due to cat scratch disease: case report.

    PubMed

    Dornbos, David; Morin, Jocelyn; Watson, Joshua R; Pindrik, Jonathan

    2016-12-01

    Osteomyelitis of the spine with associated spinal epidural abscess represents an uncommon entity in the pediatric population, requiring prompt evaluation and diagnosis to prevent neurological compromise. Cat scratch disease, caused by the pathogen Bartonella henselae, encompasses a wide spectrum of clinical presentations; however, an association with osteomyelitis and epidural abscess has been reported in only 4 other instances in the literature. The authors report a rare case of multifocal thoracic osteomyelitis with an epidural abscess in a patient with a biopsy-proven pathogen of cat scratch disease. A 5-year-old girl, who initially presented with vague constitutional symptoms, was diagnosed with cat scratch disease following biopsy of an inguinal lymph node. Despite appropriate antibiotics, she presented several weeks later with recurrent symptoms and back pain. Magnetic resonance imaging revealed 2 foci of osteomyelitis at T-8 and T-11 with an associated anterior epidural abscess from T-9 to T-12. Percutaneous image-guided vertebral biopsy revealed B. henselae by polymerase chain reaction analysis, and she was treated conservatively with doxycycline and rifampin with favorable clinical outcome.

  14. Evidence for using air or fluid when identifying the epidural space.

    PubMed

    Sanford, Curtis L; Rodriguez, Ricardo E; Schmidt, James; Austin, Paul N

    2013-02-01

    Lumbar epidural analgesia is frequently employed to provide pain relief for women during labor. Anesthesia providers use various methods to identify the epidural space. Some providers use air, some use fluid, and others use a combination of air and fluid during the loss of resistance technique. Loss of resistance to air has been speculated to result in a lesser quality of analgesia compared with loss of resistance to only fluid. A search strategy focusing on preappraised sources was used to locate evidence from interventional and observational studies. Four evidence sources were located, including a systematic review with meta-analysis of 4 older studies. The evidence reviewed was inconclusive in determining whether a difference in analgesia quality results from the use of air or fluid during the loss of resistance technique. Future studies should include an adequate number of subjects and address other problems such as operator experience, observer blinding, equivalence of subject characteristics, outcomes definition and measurement, and composition of epidural solution. Providers should consider other factors when selecting loss of resistance medium, such as the reported complications of large amounts of air injected into the epidural space and surrounding structures.

  15. Spontaneous spinal epidural abscess presenting in a previously healthy young adult man.

    PubMed

    McDonald, Andrew M; Rollins, Jason L

    2013-01-01

    We report a case of spontaneous spinal epidural abscess (SEA) with initial chief complaint of shoulder pain and no appreciable neurologic symptoms. Since outcomes of SEA appear to be related to the degree of neurologic deficit at the time of intervention, we explore opportunities for earlier diagnosis.

  16. Spinal epidural abscess as a result of dissemination from gluteal abscess secondary to intramuscular analgesic injection.

    PubMed

    Sasani, Mehdi; Aydin, Ozlem; Aydin, Ahmet Levent; Oktenoglu, Tunc; Ozer, Ali Fahir; Ercelen, Omur

    2009-01-01

    Spinal epidural abscess is a collection of suppurative material that forms between the dura mater and the ligamentum flavum. If not recognized early and treated correctly, it can lead to life-threatening sepsis. Here we report the case of a female patient, 51 years of age, with difficulty walking and bilateral leg pain after having had degenerative discogenic pain for many years. The patient had occasionally received intramuscular non-steroidal anti-inflammatory drug injections. The current report is that of an unusual case of epidural abscess that formed following multiple dose of intramuscular non-steroidal anti-inflammatory drug over a 1-year period. Hematogenous or direct dissemination is the suspected cause. To prevent serious morbidity and mortality, early diagnosis is essential. Patients with localized back pain who are at risk for developing such epidural spinal abscesses should receive a magnetic resonance imaging scan with contrast enhancement without delay. The existence of predisposing factors such as intramuscular injections should be considered in the assessment of suspected spinal epidural abscess.

  17. Nonoperative Management of a Multi-Regional Epidural Abscess with Neurological Dysfunction

    PubMed Central

    Hernandez, Miguel; Berg, Andrew; Bhatia, Chandra

    2015-01-01

    Spinal epidural abscesses are uncommon, but their incidence is increasing. They represent a collection of purulent material in the epidural space and most commonly occur in the lumbar spine, where they remain localised. Abscesses that affect all three spinal levels (holospinal or multiregional abscesses) are extremely rare, with only a few cases published in the literature. Epidural abscesses are particularly high risk infections as progressive neurological dysfunction can occur rapidly; early diagnosis and treatment is therefore essential to avoid long term neurological complications and reduce potential mortality. Given the uncommon nature of this condition, the treatment remains controversial with no definitive guidance on conservative versus surgical management. The literature mostly recommends surgical decompression along with intravenous antibiotics in patients with neurological abnormalities. We describe a case of a 77-year-old patient presenting with a delayed diagnosis of a multi-regional epidural abscess with associated upper motor neurone signs. The patient was successfully treated nonoperatively with a course of antibiotics resulting in complete radiological resolution of the abscess and full neurological recovery. PMID:26512341

  18. Percutaneous tapping for the treatment of sinusitis-related intracranial epidural abscess in children

    PubMed Central

    Miyabe, Rumi; Niida, Mami; Obonai, Toshio; Aoki, Nobuhiko; Okada, Takaharu

    2014-01-01

    A 13-year-old boy with medically intractable sinusitis-related intracranial epidural abscess in the frontal region was treated using percutaneous tapping. Drainage of pus measuring 7 ml yielded excellent postoperative course without cosmetic disadvantage on the forehead. Percutaneous tapping is considered to be the ideal treatment because of minimal invasiveness and cosmetic aspects of the wound. PMID:25624941

  19. [Combined spinal epidural anesthesia during endoprosthetic surgeries for bone tumors in old-age children].

    PubMed

    Matinian, N V; Saltanov, A I

    2005-01-01

    Thirty-five patients (ASA II-III) aged 12 to 17 years, diagnosed as having osteogenic sarcoma and Ewing's sarcoma localizing in the femur and tibia, were examined. Surgery was performed as sectoral resection of the affected bone along with knee joint endoprosthesis. Surgical intervention was made under combined spinal and epidural anesthesia (CSEA) with sedation, by using the methods for exact dosing of propofol (6-4 mg/kg x h). During intervention, a child's respiration remains is kept spontaneous with oxygen insufflation through a nasal catheter. CSEA was performed in two-segmental fashion. The epidural space was first catheterized. After administration of a test dose, 0.5% marcaine spinal was injected into dermatomas below the subarachnoidal space, depending on body weight (3.0-4.0 ml). Sensory blockade developed following 3-5 min and lasted 90-120 min, thereafter a local anesthetic (bupivacaine) or its mixture plus promedole was epidurally administered. ??Anesthesia was effective in all cases, motor blockade. During surgery, there was a moderate arterial hypotension that did not require the use of vasopressors. The acid-alkali balance suggested the adequacy of spontaneous respiration. The only significant complication we observed was atony of the bladder that requires its catheterization till the following day. An epidural catheter makes it possible to effect adequate postoperative analgesia.

  20. Side effects of spiramycin masquerading as local anesthetic toxicity during labor epidural analgesia.

    PubMed

    Julliac, B; Théophile, H; Begorre, M; Richez, B; Haramburu, F

    2010-07-01

    Significant fetal bradycardia occurred when a parturient receiving labor epidural analgesia experienced generalized numbness and tingling, a metallic taste and hot flushes. An emergent cesarean delivery under general anesthesia was performed with favorable outcomes for the mother and baby. The most likely source of the maternal symptoms was spiramycin, which was being administered for treatment of toxoplasmosis.

  1. Eisenmenger's syndrome in pregnancy: Use of epidural anesthesia and analgesia for elective cesarean section

    PubMed Central

    Mishra, Lipi; Pani, Nibedita; Samantaray, Ramesh; Nayak, Kalyani

    2014-01-01

    We describe a case of a pregnant patient with a large ventricular septal defect (VSD) and pulmonary artery hypertension, presented to the hospital and underwent elective cesarean section under epidural anesthesia and postoperative analgesia. The procedure was uneventful till the patient was discharged on 10th day. PMID:25190960

  2. A Highly Rare Cause of Lumbar Spondylodiscitis with Epidural Abscess: Actinomyces israelii

    PubMed Central

    Kapmaz, Mahir; Gülşen, İsmail; Kış, Naciye; Başaran, Seniha; Öksüz, Lütfiye; Gürler, Nezahat

    2014-01-01

    Actinomyces species may lead to slowly progressive infection of almost any site once mucosal breakdown exists; hence, it has the name “great pretender.” Its diagnosis may be unthinkable unless proper cultures/histologies are taken. We describe a patient with lumbar spondylodiscitis and epidural abscess. This is an exceptional another disease by actinomycosis. PMID:25024855

  3. Intrathecal morphine overdose during combined spinal-epidural block for Caesarean delivery.

    PubMed

    Cannesson, M; Nargues, N; Bryssine, B; Debon, R; Boselli, E; Chassard, D

    2002-12-01

    We describe a 25 mg intrathecal morphine overdose during a combined spinal-epidural block for a Caesarean delivery. Naloxone infusion (5.24 mg over 24 h) was started prior to the patient becoming symptomatic and almost immediately after the overdose. Invasive therapeutics such as mechanical ventilation were avoided.

  4. [Suspicious case of epidural hematoma due to coagulopathy caused by vitamin K deficiency associated with antibiotics].

    PubMed

    Hirata, Naoyuki; Kanaya, Noriaki; Shimizu, Hitoshi; Watanabe, Masanori; Namiki, Akiyoshi

    2007-02-01

    We experienced a case of epidural hematoma caused by coagulopathy 3 days after surgery. A 72-year-old man, who had undergone a total gastrectomy, suffered from nausea and vomiting by ileus. He underwent repair of ileus under general anesthesia with thoracic epidural anesthesia. Three days after surgery, abnormal bleeding followed by disorder of prothrombin activity (PT) and activated partial thromboplastin time (aPTT) and paralysis due to thoracic epidural hematoma developed. It was suspected that these coagulopathies were the results of vitamin K deficiency. Vitamin K deficiency in this patient was considered to have been caused by cephem antibiotics containing N-methyl-thiotetrazole (NMTT) side chain and no oral intake of food for a few days preoperatively. The patient was treated with fresh frozen plasma and intravenous menatetrenon, which improved abnormal bleeding and disorder of PT and aPTT within 24hr. After a discussion with orthopedic consultants, we selected a conservative therapy rather than surgical removal of the hematoma. Thoracic epidural hematoma disappeared two months after surgery, but motor paralysis requiring rehabilitation remained. In conclusion, when patients have not eaten anything for a few days and antibiotics with an NMTT sidechain has been administered, care must be taken to prevent vitamin K deficiency and coagulopathy.

  5. Therapeutic effect of epidural hyaluronic acid in a rat model of foraminal stenosis

    PubMed Central

    Nahm, Francis Sahngun; Lee, Pyung Bok; Choe, Ghee Young; Lim, Young Jin; Kim, Yong Chul

    2017-01-01

    Purpose Since receiving a warning from the US Food and Drug Administration (FDA) about injection of corticosteroids into the epidural space having serious adverse events, we have sought alternative medications for injection at this site. Hyaluronic acid (HA) has anti-adhesive, anti-inflammatory, and lubricating properties, so could potentially be useful for spinal pain. The exact mechanism by which spinal stenosis develops is not fully understood, but is likely to involve inflammation. Therefore, we hypothesized that HA could have a therapeutic effect in spinal stenosis. This study evaluated the effects of epidural administration of HA on alleviation of pain in a rat model of foraminal stenosis. Materials and methods After creating the animal model, HA (HA group) or saline solution (S group) was administered via an epidural catheter. The paw-withdrawal threshold to mechanical stimulation and motor dysfunction were monitored for up to 21 days. Tissue was collected to evaluate the degree of adhesion, inflammation in the perineural area, and chromatolysis in the dorsal root ganglion (DRG). Results The mechanical withdrawal threshold was restored in the HA group but not in the S group (P < 0.001). The HA group also showed less fibrosis (P = 0.026) and less chromatolysis (P = 0.002) than the S group. Conclusion HA administered epidurally had a therapeutic effect on the allodynia and hyperalgesia induced by chronic compression of the DRG. PMID:28182130

  6. Spinal Epidural Hematoma Following Cupping Glass Treatment in an Infant With Hemophilia A.

    PubMed

    Fruchtman, Yariv; Dardik, Rima; Barg, Assaf Arie; Livnat, Tami; Feldman, Zeev; Rubinstein, Marina; Grinberg, Gahl; Rosenberg, Nurit; Kenet, Gili

    2016-06-01

    A 6 months old infant, diagnosed with a rare mutation causing severe hemophilia A, presented with spinal epidural hematoma. Parents later admitted the infant had glass cupping therapy performed within 2 weeks of the onset of symptoms. The rare mutation, rare bleeding complication, and the eventual course of therapy applied in this case will be discussed in our case report.

  7. Comparison of epidural morphine, hydromorphone and fentanyl for postoperative pain control in children undergoing orthopaedic surgery.

    PubMed

    Goodarzi, M

    1999-01-01

    The safety and side-effects profile of epidural administration of a hydrophilic (morphine), highly lipophilic (fentanyl) and a drug with intermediate hydrophilic and lipophilic activity (hydromorphone) were compared in 90 children undergoing orthopaedic procedures. Ninety patients were randomly assigned (30 in each group) to receive epidural morphine, hydromorphone, or fentanyl for postoperative analgesia. Respiratory effects, nausea, somnolence, urinary retention, pruritus and visual pain scales were evaluated and compared during a 30-h period following surgery. In the morphine group, 25% showed respiratory depression with oxygen saturation below 90% but there was no incidence of respiratory depression in the fentanyl or hydromorphone groups. Somnolence was prominent in some of the patients in all the groups, but was more prolonged in the morphine group. Statistically, there was no significant difference in nausea between the groups, but pruritus was more severe and frequent in the morphine group. The incidence of urinary retention in the morphine group was higher compared with the fentanyl and hydromorphone groups. In conclusion, epidural hydromorphone, demonstrating less side-effects, is preferable to morphine and fentanyl for epidural analgesia in children.

  8. Epidural hydromorphone with and without epinephrine for post-operative analgesia after cesarean delivery.

    PubMed

    Dougherty, T B; Baysinger, C L; Henenberger, J C; Gooding, D J

    1989-03-01

    The efficacy of epidural hydromorphone alone or in combination with epinephrine for postoperative analgesia was evaluated in 30 healthy women who underwent cesarean delivery with epidural anesthesia. They were assigned randomly to receive either 1.5 mg hydromorphone alone (N = 15) or 1.5 mg hydromorphone with 1/200,000 epinephrine (N = 15). Duration of analgesia (mean +/- SD) was 24.3 +/- 9.4 hours after the epidural injection of hydromorphone plus epinephrine. This was significantly greater (p less than 0.01) than the duration of 18.2 +/- 5.9 hours after the same dose of plain hydromorphone. Analgesia was more rapid in onset and significantly better at the 0.5, 1, 3, and 12 hours postoperatively in the hydromorphone-epinephrine group. Side effects including pruritus (73%), nausea (20%), and vomiting (15%) were of similar frequency with and without epinephrine. Although mean venous PCO2 (PvCO2) levels three and six hours after the hydromorphone-epinephrine dose were elevated significantly over the pre-drug PvCO2 levels, no respiratory depression was detected by an apnea monitor to which all patients were connected. The addition of epinephrine to epidural hydromorphone hastened onset and prolonged the duration of analgesia after cesarean section.

  9. [Spontaneous spinal epidural hematoma after stillbirth in hepatosis of pregnancy (author's transl)].

    PubMed

    Panitz, K; Neundörfer, B; Taglieber, U; Susemihl, D

    1975-02-28

    The case history of a 26-year-old woman with spinal epidural hematoma after the expulsion of a fetus dead in utero and with a slight hepatosis of pregnancy. The case is discussed in the light of the previously known literature.

  10. A comparative study of magnesium sulfate vs dexmedetomidine as an adjunct to epidural bupivacaine

    PubMed Central

    Shahi, Vaibhav; Verma, Anil Kumar; Agarwal, Apurva; Singh, Chandra Shekhar

    2014-01-01

    Background and Aims: This prospective, randomized, double-blind study was undertaken to establish the effect of addition of magnesium or dexmedetomidine, as an adjuvant, to epidural bupivacaine in lower limb surgeries. Materials and Methods: One hundred and twenty ASA (American Society of Anesthesiologists) class I and II patients undergoing lower limb surgeries were enrolled to receive either magnesium sulfate (Group M) or dexmedetomidine (Group D) along with epidural bupivacaine for surgical anesthesia. All the study subjects received an epidural anesthesia with 14 ml of 0.5% bupivacaine along with either MgSO4 50 mg (Group M) or dexmedetomidine 0.5 μg/kg (Group D) or saline (Group C). The onset of motor and sensory block, duration of block, hemodynamic parameters, and any adverse events were monitored. Results: Analgesia in the postoperative period was better in Group D, duration of sensory and motor blockade was significantly prolonged in Group D and incidence of sedation was more in Group D. Conclusion: Hence, addition of dexemedetomidine to epidural bupivacaine can be advantageous with respect to increased duration of motor and sensory blockade and arousable sedation. PMID:25425781

  11. Potentiation of epidural lidocaine by co-administering tramadol by either intramuscular or epidural route in cats.

    PubMed

    Hermeto, Larissa C; DeRossi, Rafael; Marques, Beatriz C; Jardim, Paulo H A

    2015-07-01

    This study investigated the analgesic and systemic effects of intramuscular (IM) versus epidural (EP) administration of tramadol as an adjunct to EP injection of lidocaine in cats. Six healthy, domestic, shorthair female cats underwent general anesthesia. A prospective, randomized, crossover trial was then conducted with each cat receiving the following 3 treatments: EP injection of 2% lidocaine [LEP; 3.0 mg/kg body weight (BW)]; EP injection of a combination of lidocaine and 5% tramadol (LTEP; 3.0 and 2.0 mg/kg BW, respectively); or EP injection of lidocaine and IM injection of tramadol (LEPTIM; 3.0 and 2.0 mg/kg BW, respectively). Systemic effects, spread and duration of analgesia, behavior, and motor blockade were determined before treatment and at predetermined intervals afterwards. The duration of analgesia was 120 ± 31 min for LTEP, 71 ± 17 min for LEPTIM, and 53 ± 6 min for LEP (P < 0.05; mean ± SD). The cranial spread of analgesia obtained with LTEP was similar to that with LEP or LEPTIM, extending to dermatomic region T13-L1. Complete motor blockade was similar for the 3 treatments. It was concluded that tramadol produces similar side effects in cats after either EP or IM administration. Our findings indicate that EP and IM tramadol (2 mg/kg BW) with EP lidocaine produce satisfactory analgesia in cats. As an adjunct to lidocaine, EP tramadol provides a longer duration of analgesia than IM administration. The adverse effects produced by EP and IM administration of tramadol were not different. Further studies are needed to determine whether EP administration of tramadol could play a role in managing postoperative pain in cats when co-administered with lidocaine after painful surgical procedures.

  12. Potentiation of epidural lidocaine by co-administering tramadol by either intramuscular or epidural route in cats

    PubMed Central

    Hermeto, Larissa C.; DeRossi, Rafael; Marques, Beatriz C.; Jardim, Paulo H.A.

    2015-01-01

    This study investigated the analgesic and systemic effects of intramuscular (IM) versus epidural (EP) administration of tramadol as an adjunct to EP injection of lidocaine in cats. Six healthy, domestic, shorthair female cats underwent general anesthesia. A prospective, randomized, crossover trial was then conducted with each cat receiving the following 3 treatments: EP injection of 2% lidocaine [LEP; 3.0 mg/kg body weight (BW)]; EP injection of a combination of lidocaine and 5% tramadol (LTEP; 3.0 and 2.0 mg/kg BW, respectively); or EP injection of lidocaine and IM injection of tramadol (LEPTIM; 3.0 and 2.0 mg/kg BW, respectively). Systemic effects, spread and duration of analgesia, behavior, and motor blockade were determined before treatment and at predetermined intervals afterwards. The duration of analgesia was 120 ± 31 min for LTEP, 71 ± 17 min for LEPTIM, and 53 ± 6 min for LEP (P < 0.05; mean ± SD). The cranial spread of analgesia obtained with LTEP was similar to that with LEP or LEPTIM, extending to dermatomic region T13–L1. Complete motor blockade was similar for the 3 treatments. It was concluded that tramadol produces similar side effects in cats after either EP or IM administration. Our findings indicate that EP and IM tramadol (2 mg/kg BW) with EP lidocaine produce satisfactory analgesia in cats. As an adjunct to lidocaine, EP tramadol provides a longer duration of analgesia than IM administration. The adverse effects produced by EP and IM administration of tramadol were not different. Further studies are needed to determine whether EP administration of tramadol could play a role in managing postoperative pain in cats when co-administered with lidocaine after painful surgical procedures. PMID:26130854

  13. Combination of epidural anesthesia and general anesthesia attenuates stress response to renal transplantation surgery.

    PubMed

    Hadimioglu, N; Ulugol, H; Akbas, H; Coskunfirat, N; Ertug, Z; Dinckan, A

    2012-12-01

    Choice of the anesthestic technique can reduce or even eliminate stress responses to surgery and decrease the incidence of complications. Our aim was to compare a combination of epidural anesthesia+general anesthesia with general anesthesia alone as regards perioperative insulin resistance and inflammatory activation among renal transplant recipients. Forty-six nondiabetic patients undergoing renal transplantation were prospectively randomized to the epidural anesthesia + general anesthesia group (n = 21), or general anesthesia alone group (n = 25). Plasma levels of glucose, insulin, interleukin (IL)-6, tumour necrosis factor (TNF)-α, resistin, and adiponectin were measured at baseline (T1), end of surgery (T2), postoperative first hour (T3), postoperative second hour (T4) and postoperative 24th hour (T5). Homeostasis model assessment-estimated insulin resistance (HOMA-IR) scores were calculated at every time point that the blood samples were collected. Glucose levels (P < .001) and insulin levels at the end of surgery (P = .048) and at postoperative first hour (P = .005) and HOMA-IR levels at the end of surgery (P = .012) and at postoperative first hour (P = .010) showed significantly higher values among the general anesthesia alone group when compared with the epidural+general anesthesia group. TNF-α levels at postoperative 2nd and at 24th hour (P = .005 and P = .004, respectively) and IL-6 levels at postoperative 1st and 2nd hours (P = .002 and P = .045, respectively) were significantly higher in the general anesthesia alone group when compared with the epidural+general anesthesia group. The TNF-α levels were significantly less at all time points when compared with baseline only in the epidural+general anesthesia group (T1, 33.36 vs 37.25; T2, 18.45 vs 76.52; T3, 15.18 vs 78.27; T4, 10.75 vs 66.64; T5, 2.98 vs 36.32) Hospital stays were significantly shorter among the epidural+general anesthesia group (P = .022). We showed partly attenuated surgical stress

  14. Remifentanil patient controlled analgesia versus epidural analgesia in labour. A multicentre randomized controlled trial

    PubMed Central

    2012-01-01

    Background Pain relief during labour is a topic of major interest in the Netherlands. Epidural analgesia is considered to be the most effective method of pain relief and recommended as first choice. However its uptake by pregnant women is limited compared to other western countries, partly as a result of non-availability due to logistic problems. Remifentanil, a synthetic opioid, is very suitable for patient controlled analgesia. Recent studies show that epidural analgesia is superior to remifentanil patient controlled analgesia in terms of pain intensity score; however there was no difference in satisfaction with pain relief between both treatments. Methods/design The proposed study is a multicentre randomized controlled study that assesses the cost-effectiveness of remifentanil patient controlled analgesia compared to epidural analgesia. We hypothesize that remifentanil patient controlled analgesia is as effective in improving pain appreciation scores as epidural analgesia, with lower costs and easier achievement of 24 hours availability of pain relief for women in labour and efficient pain relief for those with a contraindication for epidural analgesia. Eligible women will be informed about the study and randomized before active labour has started. Women will be randomly allocated to a strategy based on epidural analgesia or on remifentanil patient controlled analgesia when they request pain relief during labour. Primary outcome is the pain appreciation score, i.e. satisfaction with pain relief. Secondary outcome parameters are costs, patient satisfaction, pain scores (pain-intensity), mode of delivery and maternal and neonatal side effects. The economic analysis will be performed from a short-term healthcare perspective. For both strategies the cost of perinatal care for mother and child, starting at the onset of labour and ending ten days after delivery, will be registered and compared. Discussion This study, considering cost effectiveness of remifentanil as

  15. Decoding continuous limb movements from high-density epidural electrode arrays using custom spatial filters

    PubMed Central

    Marathe, A R.; Taylor, D M

    2013-01-01

    Objective Our goal was to identify spatial filtering methods that would improve decoding of continuous arm movements from epidural field potentials as well as demonstrate the use of the epidural signals in a closed-loop brain-machine interface (BMI) system in monkeys. Approach Eleven spatial filtering options were compared offline using field potentials collected from 64-channel high-density epidural arrays in monkeys. Arrays were placed over arm/hand motor cortex in which intracortical microelectrodes had previously been implanted and removed leaving focal cortical damage but no lasting motor deficits. Spatial filters tested included: no filtering, common average referencing (CAR), principle component analysis (PCA), and eight novel modifications of the common spatial pattern (CSP) algorithm. The spatial filtering method and decoder combination that performed the best offline was then used online where monkeys controlled cursor velocity using continuous wrist position decoded from epidural field potentials in real time. Main results Optimized CSP methods improved continuous wrist position decoding accuracy by 69% over CAR and by 80% compared to no filtering. Kalman decoders performed better than linear regression decoders and benefitted from including more spatially-filtered signals but not from pre-smoothing the calculated power spectra. Conversely, linear regression decoders required fewer spatially-filtered signals and were improved by pre-smoothing the power values. The ‘position-to-velocity’ transformation used during online control enabled the animals to generate smooth closed-loop movement trajectories using the somewhat limited position information available in the epidural signals. The monkeys’ online performance significantly improved across days of closed-loop training. Significance Most published BMI studies that use electrocortographic signals to decode continuous limb movements either use no spatial filtering or CAR. This study suggests a

  16. The Impact of Epidural Steroid Injections on the Outcomes of Patients Treated for Lumbar Disc Herniation

    PubMed Central

    Radcliff, Kristen; Hilibrand, Alan; Lurie, Jon D.; Tosteson, Tor D.; Delasotta, Lawrence; Rihn, Jeffrey; Zhao, Wenyan; Vaccaro, Alexander; Albert, Todd J.; Weinstein, James N.

    2012-01-01

    Background: The Spine Patient Outcomes Research Trial (SPORT) is a prospective, multicenter study of operative versus nonoperative treatment of lumbar intervertebral disc herniation. It has been suggested that epidural steroid injections may help improve patient outcomes and lower the rate of crossover to surgical treatment. Methods: One hundred and fifty-four patients included in the intervertebral disc herniation arm of the SPORT who had received an epidural steroid injection during the first three months of the study and no injection prior to the study (the ESI group) were compared with 453 patients who had not received an injection during the first three months of the study or prior to the study (the No-ESI group). Results: There was a significant difference in the preference for surgery between groups (19% in the ESI group compared with 56% in the No-ESI group, p < 0.001). There was no difference in primary or secondary outcome measures at four years between the groups. A higher percentage of patients changed from surgical to nonsurgical treatment in the ESI group (41% versus 12% in the No-ESI, p < 0.001). Conclusions: Patients with lumbar disc herniation treated with epidural steroid injection had no improvement in short or long-term outcomes compared with patients who were not treated with epidural steroid injection. There was a higher prevalence of crossover to nonsurgical treatment among surgically assigned ESI-group patients, although this was confounded by the increased baseline desire to avoid surgery among patients in the ESI group. Given these data, we concluded that more studies are necessary to establish the value of epidural steroid injection for symptomatic lumbar intervertebral disc herniation. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence. PMID:22739998

  17. Facilitation of Stepping with Epidural Stimulation in Spinal Rats: Role of Sensory Input

    PubMed Central

    Lavrov, Igor; Courtine, Grégoire; Dy, Christine J.; van den Brand, Rubia; Fong, Andy J.; Gerasimenko, Yuri; Zhong, Hui; Roy, Roland R.; Edgerton, V. Reggie

    2010-01-01

    We investigated the role of afferent information during recovery of coordinated rhythmic activity of the hindlimbs in rats with a complete spinal cord section (~T8) and unilateral deafferentation (T12-S2) to answer the following questions: 1) Can bilateral stepping be generated with only afferent projections intact on one side? 2) Can the sensory input from the non-deafferented side compensate for the loss of the afferent input from the deafferented side through the crossed connections within the lumbosacral spinal cord? 3) Which afferent projections to the spinal cord from the non-deafferented side predominantly mediate the effect of epidural stimulation to facilitate stepping? Recovery of stepping ability was tested under the facilitating influence of epidural stimulation at the S1 spinal segment or epidural stimulation plus quipazine, a 5-HT agonist. All chronic spinal rats were able to generate stepping-like patterns on a moving treadmill on the non-deafferented, but not deafferented, side 3–7 weeks after surgery when facilitated by epidural stimulation. Adaptation to the loss of unilateral afferent input was evident at 7 weeks after surgery, when some movements occurred on the deafferented side. Spinal cord evoked potentials were observed on both sides, although middle (monosynaptic) and late (long-latency) responses were more prominent on the non-deafferented side. The afferent information arising from the non-deafferented side, however, eventually could mediate limited restoration of hindlimb movements on the deafferented side. These data suggest that facilitation of stepping with epidural stimulation is mediated primarily through ipsilateral afferents that project to the locomotor networks. PMID:18667609

  18. Postoperative analgesic efficacy of epidural tramadol as adjutant to ropivacaine in adult upper abdominal surgeries

    PubMed Central

    Singh, Anil P.; Singh, Dharmraj; Singh, Yashpal; Jain, Gaurav

    2015-01-01

    Background: Postoperative pain control after major abdominal surgery is the prime concern of anesthesiologist. Among various methodologies, epidural analgesia is the most preferred technique because of the excellent quality of analgesia with minimum side-effects. Aim: The present study was designated to compare postoperative analgesic efficacy and safety of epidural tramadol as adjuvant to ropivacaine (0.2%) in adult upper abdominal surgery. Settings and Design: Prospective, randomized-controlled, double-blinded trial. Materials and Methods: Ninety patients planned for upper abdominal surgery under general anesthesia were randomized into three equal groups to receive epidural drug via epidural catheter at start of incisional wound closure: Group R to receive ropivacaine (0.2%); Group RT1 to receive tramadol 1 mg/kg with ropivacaine (0.2%); and RT2 to receive tramadol 2 mg/kg with ropivacaine (0.2%). Duration and quality of analgesia (visual analog scale [VAS] score), hemodynamic parameters, and adverse event were recorded and statistically analyzed. Statistical Analysis: One-way analysis of variance test, Fisher's exact test/Chi-square test, whichever appropriate. A P < 0.05 was considered significant. Results: Mean duration of analgesia after epidural bolus drug was significantly higher in Group RT2 (584 ± 58 min) when compared with RT1 (394 ± 46 min) or R Group (283 ± 35 min). VAS score was always lower in RT2 Group in comparison to other group during the study. Hemodynamic parameter remained stable in all three groups. Conclusion: We conclude that tramadol 2 mg/kg with ropivacaine (0.2%) provides more effective and longer-duration analgesia than tramadol 1 mg/kg with ropivacaine (0.2%). PMID:26712976

  19. Epidural analgesia with morphine or buprenorphine in ponies with lipopolysaccharide (LPS)-induced carpal synovitis.

    PubMed

    Freitas, Gabrielle C; Carregaro, Adriano B; Gehrcke, Martielo I; De La Côrte, Flávio D; Lara, Valéria M; Pozzobon, Ricardo; Brass, Karin E

    2011-04-01

    This study evaluated the analgesia effects of the epidural administration of 0.1 mg/kg bodyweight (BW) of morphine or 5 μg/kg BW of buprenorphine in ponies with radiocarpal joint synovitis. Six ponies were submitted to 3 epidural treatments: the control group (C) received 0.15 mL/kg BW of a 0.9% sodium chloride (NaCl) solution; group M was administered 0.1 mg/kg BW of morphine; and group B was administered 5 μg/kg BW of buprenorphine, both diluted in 0.9% NaCl to a total volume of 0.15 mL/kg BW administered epidurally at 10 s/mL. The synovitis model was induced by injecting 0.5 ng of lipopolysaccharide (LPS) in the left or right radiocarpal joint. An epidural catheter was later introduced in the lumbosacral space and advanced up to the thoracolumbar level. The treatment started 6 h after synovitis induction. Lameness, maximum angle of carpal flexion, heart rate, systolic arterial pressure, respiratory rate, temperature, and intestinal motility were evaluated before LPS injection (baseline), 6 h after LPS injection (time 0), and 0.5, 1, 2, 4, 6, 8, 10, 12, 16, 20, and 24 h after treatments. Although the model of synovitis produced clear clinical signs of inflammation, the lameness scores in group C were different from the baseline for only up to 12 h. Both morphine and buprenorphine showed a reduction in the degree of lameness starting at 0.5 and 6 h, respectively. Reduced intestinal motility was observed at 0.5 h in group M and at 0.5 to 1 h in group B. Epidural morphine was a more effective analgesic that lasted for more than 12 h and without side effects. It was concluded that morphine would be a valuable analgesic option to alleviate joint pain in the thoracic limbs in ponies.

  20. Estimation of the depth of the thoracic epidural space in children using magnetic resonance imaging

    PubMed Central

    Wani, Tariq M; Rafiq, Mahmood; Nazir, Arif; Azzam, Hatem A; Al Zuraigi, Usama; Tobias, Joseph D

    2017-01-01

    Background The estimation of the distance from the skin to the thoracic epidural space or skin to epidural depth (SED) may increase the success rate and decrease the incidence of complications during placement of a thoracic epidural catheter. Magnetic resonance imaging (MRI) is the most comprehensive imaging modality of the spine, allowing for the accurate determination of tissue spaces and distances. The present study uses MRI-derived measurements to measure the SED and define the ratio between the straight and inclined SEDs at two thoracic levels (T6–7 and T9–10) in children. Methods The T2-weighed sagittal MRI images of 109 children, ranging in age from 1 month to 8 years, undergoing radiological evaluation unrelated to spine pathology were assessed. The SEDs (inclined and straight) were determined, and a comparison between the SEDs at two thoracic levels (T6–7 and T9–10) was made. Univariate and multivariate linear regression models were used to assess the relationship of the inclined thoracic T6–7 and T9–10 SED measurements with age, height, and weight. Results Body weight demonstrated a stronger association with the SED than did the age or height with R2 values of 0.6 for T6–7 and 0.5 for T9–10. The formulae describing the relationship between the weight and the inclined SED were T6–7 inclined (mm) = 7 + 0.9 × kg and T9–10 inclined (mm) = 7 + 0.8 × kg. Conclusion The depth of the pediatric thoracic epidural space shows a stronger correlation with weight than with age or height. Based on the MRI data, the predictive weight-based formulas can serve as guide to clinicians for placement of thoracic epidural catheters.

  1. Efficacy of the methoxyflurane as bridging analgesia during epidural placement in laboring parturient

    PubMed Central

    Anwari, Jamil S.; Khalil, Laith; Terkawi, Abdullah S.

    2015-01-01

    Background: Establishing an epidural in an agitated laboring woman can be challenging. The ideal pain control technique in such a situation should be effective, fast acting, and short lived. We assessed the efficacy of inhalational methoxyflurane (Penthrox™) analgesia as bridging analgesia for epidural placement. Materials and Methods: Sixty-four laboring women who requested epidural analgesia with pain score of ≥7 enrolled in an observational study, 56 of which completed the study. The parturients were instructed to use the device prior to the onset of uterine contraction pain and to stop at the peak of uterine contraction, repeatedly until epidural has been successfully placed. After each (methoxyflurane inhalation-uterine contraction) cycle, pain, Richmond Agitation Sedation Scale (RASS), nausea and vomiting were evaluated. Maternal and fetal hemodynamics and parturient satisfaction were recorded. Results: The mean baseline pain score was 8.2 ± 1.5 which was reduced to 6.2 ± 2.0 after the first inhalation with a mean difference of 2.0 ± 1.1 (95% confidence interval 1.7-2.3, P < 0.0001), and continued to decrease significantly over the study period (P < 0.0001). The RASS scores continuously improved after each cycle (P < 0.0001). Only 1 parturient from the cohort became lightly sedated (RASS = −1). Two parturients vomited, and no significant changes in maternal hemodynamics or fetal heart rate changes were identified during treatment. 67% of the parturients reported very good or excellent satisfaction with treatment. Conclusion: Penthrox™ provides rapid, robust, and satisfactory therapy to control pain and restlessness during epidural placement in laboring parturient. PMID:26543451

  2. Comparative study of epidural application of morphine versus gelfoam soaked in morphine for lumbar laminectomy

    PubMed Central

    Kundra, Sandeep; Gupta, Vishnu; Bansal, Hanish; Grewal, Anju; Katyal, Sunil; Choudhary, Ashwini Kumar

    2014-01-01

    Background: Epidural application of morphine has been used for postoperative analgesia following spine surgery but short duration of action of single application limits its widespread use. Materials and Methods: One hundred and fifty patients undergoing lumbar laminectomy were randomly allocated to two groups of 75 patients each. Anesthetic technique was standardized in both the groups. In Group I, at the completion of laminectomy, a 5 × 1-cm strip of gelfoam soaked in 5 mg morphine (1 mg/ml) was contoured to be placed in the epidural space whereas, in group II, gelfoam soaked in saline was placed in the epidural space and 5 mg morphine (1mg/ml) was instilled over the intact epidural space. Analgesic consumption for 48 hours, time-of first analgesic request, time of ambulation, time of discharge from post anesthesia care unit (PACU) and hospital and adverse effects were recorded. The data was analyzed using appropriate statistical tests. Results: Mean analgesic consumption in 48 hours was significantly less in group I (8.47 ± 3.674 mg) as compared to group II (24.80 ± 6.009 mg). Supplemental analgesia was requested at 30.03 ± 6.796 hours in Group I, vs 10.25 ± 2.243 in group II (P < 0.001). Group I patients were discharged earlier from PACU as compared to group II (P < 0.001) though time of discharge from hospital was similar in both the groups. There were no major adverse effects except pruritis, which was observed in 30.6% patients in group I and 37.3% in group II (statistically insignificant (P > 0.01)). Conclusion: Epidural application of morphine soaked in gelfoam is an effective method for prolonging the postoperative analgesia after spine surgery. PMID:24574593

  3. Epidural analgesia with morphine or buprenorphine in ponies with lipopolysaccharide (LPS)-induced carpal synovitis

    PubMed Central

    Freitas, Gabrielle C.; Carregaro, Adriano B.; Gehrcke, Martielo I.; De La Côrte, Flávio D.; Lara, Valéria M.; Pozzobon, Ricardo; Brass, Karin E.

    2011-01-01

    This study evaluated the analgesia effects of the epidural administration of 0.1 mg/kg bodyweight (BW) of morphine or 5 μg/kg BW of buprenorphine in ponies with radiocarpal joint synovitis. Six ponies were submitted to 3 epidural treatments: the control group (C) received 0.15 mL/kg BW of a 0.9% sodium chloride (NaCl) solution; group M was administered 0.1 mg/kg BW of morphine; and group B was administered 5 μg/kg BW of buprenorphine, both diluted in 0.9% NaCl to a total volume of 0.15 mL/kg BW administered epidurally at 10 s/mL. The synovitis model was induced by injecting 0.5 ng of lipopolysaccharide (LPS) in the left or right radiocarpal joint. An epidural catheter was later introduced in the lumbosacral space and advanced up to the thoracolumbar level. The treatment started 6 h after synovitis induction. Lameness, maximum angle of carpal flexion, heart rate, systolic arterial pressure, respiratory rate, temperature, and intestinal motility were evaluated before LPS injection (baseline), 6 h after LPS injection (time 0), and 0.5, 1, 2, 4, 6, 8, 10, 12, 16, 20, and 24 h after treatments. Although the model of synovitis produced clear clinical signs of inflammation, the lameness scores in group C were different from the baseline for only up to 12 h. Both morphine and buprenorphine showed a reduction in the degree of lameness starting at 0.5 and 6 h, respectively. Reduced intestinal motility was observed at 0.5 h in group M and at 0.5 to 1 h in group B. Epidural morphine was a more effective analgesic that lasted for more than 12 h and without side effects. It was concluded that morphine would be a valuable analgesic option to alleviate joint pain in the thoracic limbs in ponies. PMID:21731186

  4. Decoding continuous limb movements from high-density epidural electrode arrays using custom spatial filters

    NASA Astrophysics Data System (ADS)

    Marathe, A. R.; Taylor, D. M.

    2013-06-01

    Objective. Our goal was to identify spatial filtering methods that would improve decoding of continuous arm movements from epidural field potentials as well as demonstrate the use of the epidural signals in a closed-loop brain-machine interface (BMI) system in monkeys. Approach. Eleven spatial filtering options were compared offline using field potentials collected from 64-channel high-density epidural arrays in monkeys. Arrays were placed over arm/hand motor cortex in which intracortical microelectrodes had previously been implanted and removed leaving focal cortical damage but no lasting motor deficits. Spatial filters tested included: no filtering, common average referencing (CAR), principle component analysis, and eight novel modifications of the common spatial pattern (CSP) algorithm. The spatial filtering method and decoder combination that performed the best offline was then used online where monkeys controlled cursor velocity using continuous wrist position decoded from epidural field potentials in real time. Main results. Optimized CSP methods improved continuous wrist position decoding accuracy by 69% over CAR and by 80% compared to no filtering. Kalman decoders performed better than linear regression decoders and benefitted from including more spatially-filtered signals but not from pre-smoothing the calculated power spectra. Conversely, linear regression decoders required fewer spatially-filtered signals and were improved by pre-smoothing the power values. The ‘position-to-velocity’ transformation used during online control enabled the animals to generate smooth closed-loop movement trajectories using the somewhat limited position information available in the epidural signals. The monkeys’ online performance significantly improved across days of closed-loop training. Significance. Most published BMI studies that use electrocorticographic signals to decode continuous limb movements either use no spatial filtering or CAR. This study suggests a

  5. Posterior cruciate ligament removal contributes to abnormal knee motion during posterior stabilized total knee arthroplasty.

    PubMed

    Cromie, Melinda J; Siston, Robert A; Giori, Nicholas J; Delp, Scott L

    2008-11-01

    Abnormal anterior translation of the femur on the tibia has been observed in mid flexion (20-60 degrees ) following posterior stabilized total knee arthroplasty. The underlying biomechanical causes of this abnormal motion remain unknown. The purpose of this study was to isolate the effects of posterior cruciate ligament removal on knee motion after total knee arthroplasty. We posed two questions: Does removing the posterior cruciate ligament introduce abnormal anterior femoral translation? Does implanting a posterior stabilized prosthesis change the kinematics from the cruciate deficient case? Using a navigation system, we measured passive knee kinematics of ten male osteoarthritic patients during surgery after initial exposure, after removing the anterior cruciate ligament, after removing the posterior cruciate ligament, and after implanting the prosthesis. Passively flexing and extending the knee, we calculated anterior femoral translation and the flexion angle at which femoral rollback began. Removing the posterior cruciate ligament doubled anterior translation (from 5.1 +/- 4.3 mm to 10.4 +/- 5.1 mm) and increased the flexion angle at which femoral rollback began (from 31.2 +/- 9.6 degrees to 49.3 +/- 7.3 degrees). Implanting the prosthesis increased the amount of anterior translation (to 16.1 +/- 4.4 mm), and did not change the flexion angle at which femoral rollback began. Abnormal anterior translation was observed in low and mid flexion (0-60 degrees) after removing the posterior cruciate ligament, and normal motion was not restored by the posterior stabilized prosthesis.

  6. Factors predicting surgical site infection after posterior lumbar surgery

    PubMed Central

    Wang, Tao; Wang, Hui; Yang, Da-Long; Jiang, Li-Qiang; Zhang, Li-Jun; Ding, Wen-Yuan

    2017-01-01

    Abstract This is a retrospective study. The purpose of this study is to explore incidence and risk factors for surgical site infection (SSI) after posterior lumbar surgery. SSI is a common complication after posterior lumbar surgery, bringing mental and physical pain and prolonging hospital stay. However, predisposing factors, as reported less, remain controversial. Patients who underwent posterior lumbar surgery at 3 centers between 2006 and 2016 were included. The possible factors include 3 aspects: demographic variables-age, sex, body mass index (BMI), waist-to-hip radio (WHR), hypertension, diabetes, heart disease, smoking, drinking, steroidal injection, surgical time between June and September, preoperative shower; blood test variables-white blood cell (WBC), neutrophil, red blood cell (RBC), hemoglobin (Hb), total protein (TP), albumin, albumin/globulin (A/G), C-reactive protein (CRP), procalcitonin (PCT), erythrocyte sedimentation rate (ESR) and surgical related variables-operation time, blood loss, operative level, instrumentation, incision length. Factors related with SSI were also performed by multivariate analysis. The prevalence of SSI was 3.00% (267 cases of 8879) had a postoperative wound infection. There were significant difference in WHR (0.92 vs 0.83), WBC (4.31 vs 6.69), TP (58.7 vs 65.2), albumin (36.9 vs 43.2), CRP (2.01 vs 0.57), PCT (0.097 vs 0.067), operation time (217.9 vs 195.7), blood loss (997.1 vs 915.3) and operative level (3.05 vs 2.45) and incision length (24.1 vs 20.0) between SSI group and non-SSI group. >60 years old, female, BMI <18.5 and >30.0, diabetes, male smoking, preoperative steroidal injection, surgical time between June and September, no preoperative shower, instrumentation surgery were risk factors for SSI after posterior lumbar surgery. Many factors, >60 years old, female, BMI, WHR, diabetes, male smoking, preoperative steroidal injection, surgical time between June and September, preoperative shower, WBC, TP, albumin

  7. Why Cannot Suction Drains Prevent Postoperative Spinal Epidural Hematoma?

    PubMed Central

    Ahn, Dong Ki; Kim, Jin Woo; Yi, Seong Min

    2016-01-01

    Background Postoperative spinal epidural hematoma (POSEH) is different from spontaneous or post-spinal procedure hematoma because of the application of suction drains. However, it appeared that suction drains were not effective for prevention of POSEH in previous studies. The purpose of this study was to test our hypothesis that POSEH can be caused by hypercoagulability. Methods This was an experimental study. One hundred fifty milliliters of blood was donated from each of the 12 consecutive patients who underwent spine surgery and infused into 3 saline bags of 50 mL each. One of the 3 bags in each set contained 5,000 units of thrombin. All of them were connected to 120 ± 30 mmHg vacuum suctions: drainage was started 8 minutes after connection to the vacuum system for 12 normal blood bags (BV8) and 12 thrombin-containing blood bags (TBV8) and 15 minutes after connection for the remaining 12 normal blood bags (BV15). The amount of initial and remaining hematoma at 20 minutes, 120 minutes, and 24 hours after vacuum application were measured by their weight (g). The primary endpoint was the difference between BV8 and TBV8. The secondary end point was the difference between BV8 and BV15. Results The remaining hematoma in TBV8 was significantly greater than that in BV8 at all measurement points: 46.3 ± 12.4 vs. 17.0 ± 1.3 (p = 0.000) at 20 minutes; 33.0 ± 8.2 vs. 16.3 ± 1.2 (p = 0.000) at 120 minutes; and 26.1 ± 4.0 vs. 15.8 ± 1.6 (p = 0.000) at 24 hours after vacuum application. The remaining hematoma of BV15 was significantly greater than that of BV8 at all measurement points: 30.0 ± 12.0 vs. 17.0 ± 1.3 (p = 0.002) at 20 minutes; 24.2 ± 7.6 vs. 16.3 ± 1.2 at 120 minutes (p = 0.002); and 22.2 ± 6.6 vs. 15.8 ± 1.6 (p = 0.004) at 24 hours after vacuum application. Conclusions With a suction drain in place, the amount of remaining hematoma could be affected by coagulability. Thrombin-containing local hemostatics and the length of time elapsed before the

  8. Fundus autofluorescence imaging in posterior uveitis.

    PubMed

    Durrani, Khayyam; Foster, C Stephen

    2012-01-01

    Although the phenomenon of fundus autofluorescence has been known for decades, it has only recently been recognized as a measure of retinal pigment epithelial function and health. Characteristic fundus autofluorescence patterns have been described in eyes affected by inflammation of the posterior segment, and these patterns have provided insights into the pathogenesis of posterior uveitis entities. In addition, preliminary data indicate that fundus autofluorescence characteristics may serve as markers of disease activity, allow prediction of visual prognosis, and may help determine the adequacy of therapy. We provide an overview of the current state of fundus autofluorescence imaging technology and review our current knowledge of fundus autoflourescence findings and their clinical use in the posterior uveitis entities.

  9. Lower extremities and iliopsoas pyomyositis with concurrent septic arthritis and spinal epidural abscess in a diabetic patient.

    PubMed

    Vallianou, N; Gounari, P; Skourtis, A; Kougias, M; Sioula, E

    2013-10-01

    Pyomyositis is a rarely encountered infection among diabetics, which usually affects lower extremities. Herein, we present a case of lower extremities and iliopsoas pyomyositis with concurrent septic arthritis and spinal epidural abscess in a patient with poorly controlled diabetes mellitus.

  10. Reversible cortical blindness: posterior reversible encephalopathy syndrome.

    PubMed

    Bandyopadhyay, Sabyasachi; Mondal, Kanchan Kumar; Das, Somnath; Gupta, Anindya; Biswas, Jaya; Bhattacharyya, Subir Kumar; Biswas, Gautam

    2010-11-01

    Cortical blindness is defined as visual failure with preserved pupillary reflexes in structurally intact eyes due to bilateral lesions affecting occipital cortex. Bilateral oedema and infarction of the posterior and middle cerebral arterial territory, trauma, glioma and meningioma of the occipital cortex are the main causes of cortical blindness. Posterior reversible encephalopathy syndrome (PRES) refers to the reversible subtype of cortical blindness and is usually associated with hypertension, diabetes, immunosuppression, puerperium with or without eclampsia. Here, 3 cases of PRES with complete or partial visual recovery following treatment in 6-month follow-up are reported.

  11. Posterior cortical atrophy: a brief review.

    PubMed

    Kirshner, Howard S; Lavin, Patrick J M

    2006-11-01

    Posterior cortical atrophy is a striking clinical syndrome in which a dementing illness begins with visual symptoms. Initially, the problem may seem to be loss of elementary vision, but over time the patient develops features of visual agnosia, topographical difficulty, optic ataxia, simultanagnosia, ocular apraxia (Balint's syndrome), alexia, acalculia, right-left confusion, and agraphia (Gerstmann's syndrome), and later a more generalized dementia. Occasional patients have visual hallucinations and signs of Parkinson's disease or Lewy body dementia. A number of different neuropathologic disorders are associated with posterior cortical atrophy.

  12. Isolated subacute tuberculous spinal epidural abscess of the cervical spine: a brief report of a special case.

    PubMed

    Alg, Varinder S; Demetriades, Andreas K; Naik, Sunil; Gunasekera, Lal

    2009-06-01

    A tuberculous spinal epidural abscess is seen rarely as a late complication of Pott's disease or in immunocompromised patients. Such abscesses in isolation are rare indeed and very uncommon in the developed and developing world. We report a patient with an isolated subacute tuberculous spinal epidural abscess without disc or vertebral involvement and no primary focus or risk factors associated with the development of spinal tuberculosis.

  13. A study of pethidine kinetics and analgesia in women in labour following intravenous, intramuscular and epidural administration.

    PubMed Central

    Husemeyer, R P; Cummings, A J; Rosankiewicz, J R; Davenport, H T

    1982-01-01

    1 Epidural administration of opiates for analgesia has recently generated widespread interest and would theoretically be advantageous as a method for relief of pain in labour. 2 Plasma pethidine concentrations were measured after intravenous, intramuscular and epidural administration of pethidine to women in labour and after epidural administration to non-pregnant female surgical patients. 3 Kinetic parameters were derived from the plasma concentration data in each group of subjects and the relationship between plasma kinetics and analgesia in labour were examined. 4 Absorption of pethidine from the epidural space in pregnant women in rapid and excepting the lower initial values, the average plasma concentration and area under the plasma concentration v time curve did not differ significantly (P less than 0.01) from those obtained with intravenous dosage, but were significantly higher (P less than 0.01) during the first 2 h after dosage than the results after intramuscular administration. The analgesia provided by the epidural route of administration was greater than with intravenous or intramuscular administration. 5 It is postulated that the analgesic efficacy of epidural pethidine in women in labour is due to a combination of systemic and local effects and that the local effect is attributable to the local anaesthetic properties of pethidine rather than a selective anti-nociceptive action on the spinal cord. PMID:7059414

  14. Identification of the epidural space: loss of resistance with air, lidocaine, or the combination of air and lidocaine.

    PubMed

    Evron, Samuel; Sessler, Daniel; Sadan, Oscar; Boaz, Mona; Glezerman, Marek; Ezri, Tiberiu

    2004-07-01

    The ideal technique for identifying the epidural space remains unclear. Five-hundred-forty-seven women in labor who requested epidural analgesia were randomly allocated to three groups according to the technique by which the epidural space was identified: 1) loss-of-resistance with air (air; n = 180), 2) loss-of-resistance with lidocaine (lidocaine; n = 185), and 3) loss-of-resistance with both air and lidocaine (air-plus-lidocaine; n = 182). We assessed ease of epidural catheter insertion, characteristics of the blockade, quality of analgesia, and complications. The inability to thread the epidural catheter occurred in 16% of the air, 4% of the lidocaine, and 3% of the air-plus-lidocaine patients (P < 0.001). More patients from the air group had unblocked segments (6.6% versus 3.2% and 2.2%, respectively; P < 0.02). The incidence of accidental dural puncture was greater in the air group (1.7% versus 0% in the other two groups; P < 0.02). Pain scores, time to onset of analgesia, upper sensory level, motor blockade, and the incidence of hypotension, transient neurological deficits, postpartum urinary retention, and postdural puncture headache were comparable. Identification of the epidural space with air was more difficult and caused more dural punctures than with lidocaine or air plus lidocaine. Additionally, sequential use of air and lidocaine had no advantage over lidocaine alone.

  15. Epidural administration of liposome-encapsulated hydromorphone provides extended analgesia in a rodent model of stifle arthritis.

    PubMed

    Schmidt, Jennifer R; Krugner-Higby, Lisa; Heath, Timothy D; Sullivan, Ruth; Smith, Lesley J

    2011-07-01

    Liposome encapsulation of opioids by using an ammonium-sulfate-gradient loading technique significantly slows the release time of the drug. This study evaluated the duration of analgesia in a rodent model of monoarthritis after epidural administration of liposome-encapsulated hydromorphone (LE-hydromorphone; prepared by ammonium-sulfate-gradient loading) compared with standard hydromorphone and a negative control of blank liposomes. Analgesia was assessed by changes in thermal withdrawal latency, relative weight-bearing, and subjective behavioral scoring. Analgesia in arthritic rats was short-lived after epidural hydromorphone; increases in pain threshold were observed only at 2 h after administration. In contrast, thermal pain thresholds after epidural LE-hydromorphone were increased for as long as 72 h, and subjective lameness scores were lower for as long as 96 h after epidural administration. Injection of LE-hydromorphone epidurally was associated with various mild changes in CNS behavior, and 2 rats succumbed to respiratory depression and death. In conclusion, LE-hydromorphone prolonged the duration of epidural analgesia compared with the standard formulation of hydromorphone, but CNS side effects warrant careful administration of this LE-hydromorphone in future studies.

  16. [Delayed Traumatic Intracerebral Hematoma during Antiplatelet Therapy after Operations for Ruptured Left ICPC Aneurysm and Right Traumatic Epidural Hematoma: A Case Report].

    PubMed

    Nomura, Shunsuke; Iwata, Yukiya; Baba, Motoki; Kawashima, Akitsugu; Sato, Hidetaka; Okada, Yoshikazu

    2015-07-01

    Delayed traumatic intracerebral hematoma (DTICH) is a rare complication of head injury that appears suddenly after an interval of several days or months. Here, we report a case of DTICH during antiplatelet therapy for vasospasm following surgeries for a ruptured left internal carotid-posterior communicating (ICPC) aneurysm and right acute epidural hematoma (EDH). A 77-year-old man with no medical history was diagnosed with a subarachnoid hemorrhage (SAH) due to rupturing of a left ICPC aneurysm and a right linear fracture of the right parietal bone due to a head injury following the rupture. On day 2, the patient underwent successful clipping of the left ICPC aneurysm. Computed tomography (CT) performed post-clipping revealed a right acute EDH below the linear fracture of the right parietal bone, which was removed immediately. A next-day CT revealed minor contusions in both temporal poles. Fasudil, ozagrel, and cilostazol were administered from Day 3 post-clipping and EDH evacuation to prevent vasospasm. The contusions did not enlarge until Day 10. On Day 11, the patient became comatose, and a huge hematoma was identified in the right temporal lobe to frontal lobe. Although the hematoma was removed immediately, the patient died on Day 13. The hematoma was considered to be a rare case of DTICH that developed from a minor contusion of the right temporal lobe during antiplatelet therapy for vasospasm. In cases of aneurysmal SAH with head injury and contusion, we must pay attention to DTICH and select more deliberate treatment for vasospasm.

  17. Treatment rationale of fractured posterior teeth.

    PubMed

    Silvestri, A R; Singh, I

    1978-11-01

    The four types of fractures most frequently encountered in posterior teeth--obliquely directed complete fractures, vertically directed complete fractures, obliquely directed incomplete fractures, and vertically directed incomplete fractures--have been described. A detailed treatment approach for each type has been presented.

  18. Posterior Predictive Model Checking in Bayesian Networks

    ERIC Educational Resources Information Center

    Crawford, Aaron

    2014-01-01

    This simulation study compared the utility of various discrepancy measures within a posterior predictive model checking (PPMC) framework for detecting different types of data-model misfit in multidimensional Bayesian network (BN) models. The investigated conditions were motivated by an applied research program utilizing an operational complex…

  19. Posterior Probabilities for a Consensus Ordering.

    ERIC Educational Resources Information Center

    Fligner, Michael A.; Verducci, Joseph S.

    1990-01-01

    The concept of consensus ordering is defined, and formulas for exact and approximate posterior probabilities for consensus ordering are developed under the assumption of a generalized Mallows' model with a diffuse conjugate prior. These methods are applied to a data set concerning 98 college students. (SLD)

  20. Complicated posterior capsulorhexis: aetiology, management, and outcome

    PubMed Central

    Van Cauwenberge, F.; Rakic, J.; Galand, A.

    1997-01-01

    BACKGROUND—A 1 year retrospective analysis of 650 patients, who underwent a posterior capsulorhexis on their intact capsules, was performed to examine the incidence of complications, their aetiologies, and the outcome.
METHODS—Data were analysed on 32 patients with complicated capsulorhexis for type of surgery, preoperative and postoperative factors, and relative risk factors for vitreous issue.
RESULTS—There were six patients with vitreous loss. The posterior capsulorhexis was uncontrolled in 14 cases and difficult to perform in 12 cases. Implantation into the capsular bag was possible in all cases. Systemic vascular hazard and old age (over 80 years) were found to be statistically significant risk factors for vitreous loss (p=0.002 and p=0.03 respectively). The mean follow up was 13.5 months (range 4-25 months). One patient developed a retinal detachment and two had a transient clinical cystoid macular oedema. Visual acuity of ≥ 20/40 was obtained in 93% of the patients.
CONCLUSION—Loss of control of the posterior capsulorhexis has a low incidence but can lead to serious problems during surgery. A good knowledge of the technique is necessary to complete the procedure with a posterior capsulorhexis of the optimum size without vitreous loss.

 PMID:9135382

  1. Subspecialization in the human posterior medial cortex

    PubMed Central

    Bzdok, Danilo; Heeger, Adrian; Langner, Robert; Laird, Angela R.; Fox, Peter T.; Palomero-Gallagher, Nicola; Vogt, Brent A.; Zilles, Karl; Eickhoff, Simon B.

    2014-01-01

    The posterior medial cortex (PMC) is particularly poorly understood. Its neural activity changes have been related to highly disparate mental processes. We therefore investigated PMC properties with a data-driven exploratory approach. First, we subdivided the PMC by whole-brain coactivation profiles. Second, functional connectivity of the ensuing PMC regions was compared by task-constrained meta-analytic coactivation mapping (MACM) and task-unconstrained resting-state correlations (RSFC). Third, PMC regions were functionally described by forward/reverse functional inference. A precuneal cluster was mostly connected to the intraparietal sulcus, frontal eye fields, and right temporo-parietal junction; associated with attention and motor tasks. A ventral posterior cingulate cortex (PCC) cluster was mostly connected to the ventromedial prefrontal cortex and middle left inferior parietal cortex (IPC); associated with facial appraisal and language tasks. A dorsal PCC cluster was mostly connected to the dorsomedial prefrontal cortex, anterior/posterior IPC, posterior midcingulate cortex, and left dorsolateral prefrontal cortex; associated with delay discounting. A cluster in the retrosplenial cortex was mostly connected to the anterior thalamus and hippocampus. Furthermore, all PMC clusters were congruently coupled with the default mode network according to task-constrained but not task-unconstrained connectivity. We thus identified distinct regions in the PMC and characterized their neural networks and functional implications. PMID:25462801

  2. Fuchs's heterochromic cyclitis and posterior capsulotomy.

    PubMed Central

    Roussel, T J; Coster, D J

    1985-01-01

    We report a case of intractable glaucoma following an uncomplicated secondary posterior capsulotomy in a 48-year-old male with Fuchs's heterochromic cyclitis. The patient had been free of inflammation and glaucoma since cataract extraction 27 years previously. We also report the results of phenotypic analysis of lymphocytes removed from the anterior chamber. Images PMID:3859323

  3. Posterior dislocation of the shoulder in athletes.

    PubMed

    Samilson, R L; Prieto, V

    1983-07-01

    Although posterior dislocation of the shoulder is a rare injury in athletes, failure to recognize and properly manage acute dislocation may have serious consequences. The article discusses the incidence, mechanism of injury, classification, pathologic findings, clinical and radiologic diagnosis, and management.

  4. BAER suppression during posterior fossa dural opening

    PubMed Central

    Shields, Christopher B.; Shields, Lisa B. E.; Jiang, Yi Dan; Yao, Tom; Zhang, Yi Ping; Sun, David A.

    2015-01-01

    Background: Intraoperative monitoring with brainstem auditory evoked responses (BAER) provides an early warning signal of potential neurological injury and may avert tissue damage to the auditory pathway or brainstem. Unexplained loss of the BAER signal in the operating room may present a dilemma to the neurosurgeon. Methods: This paper documents two patients who displayed a unique mechanism of suppression of the BAER apparent within minutes following dural opening for resection of a posterior fossa meningioma. Results: In two patients with anterior cerebellopontine angle and clival meningiomas, there was a significant deterioration of the BAER soon after durotomy but prior to cerebellar retraction and tumor removal. Intracranial structures in the posterior fossa lying between the tumor and dural opening were shifted posteriorly after durotomy. Conclusion: We hypothesized that the cochlear nerve and vessels entering the acoustic meatus were compressed or stretched when subjected to tissue shift. This movement caused cochlear nerve dysfunction that resulted in BAER suppression. BAER was partially restored after the tumor was decompressed, dura repaired, and bone replaced. BAER was not suppressed following durotomy for removal of a meningioma lying posterior to the cochlear complex. Insight into the mechanisms of durotomy-induced BAER inhibition would allay the neurosurgeon's anxiety during the operation. PMID:25883849

  5. Intravenous Remifentanil versus Epidural Ropivacaine with Sufentanil for Labour Analgesia: A Retrospective Study

    PubMed Central

    Xu, Zhendong; Su, Jing; Liu, Zhiqiang

    2014-01-01

    Remifentanil with appropriate pharmacological properties seems to be an ideal alternative to epidural analgesia during labour. A retrospective cohort study was undertaken to assess the efficacy and safety of remifentanil intravenous patient-controlled analgesia (IVPCA) compared with epidural analgesia. Medical records of 370 primiparas who received remifentanil IVPCA or epidural analgesia were reviewed. Pain and sedation scores, overall satisfaction, the extent of pain control, maternal side effects and neonatal outcome as primary observational indicators were collected. There was a significant decline of pain scores in both groups. Pain reduction was greater in the epidural group throughout the whole study period (0∼180 min) (P<0.0001), and pain scores in the remifentanil group showed an increasing trend one hour later. The remifentanil group had a lower SpO2 (P<0.0001) and a higher sedation score (P<0.0001) within 30 min after treatment. The epidural group had a higher overall satisfaction score (3.8±0.4 vs. 3.7±0.6, P = 0.007) and pain relief score (2.9±0.3 vs. 2.8±0.4, P<0.0001) compared with the remifentanil group. There was no significant difference on side effects between the two groups, except that a higher rate of dizziness (1% vs. 21.8%, P<0.0001) was observed during remifentanil analgesia. And logistic regression analysis demonstrated that nausea, vomiting were associated with oxytocin usage and instrumental delivery, and dizziness was associated to the type and duration of analgesia. Neonatal outcomes such as Apgar scores and umbilical-cord blood gas analysis were within the normal range, but umbilical pH and base excess of neonatus in the remifentanil group were significantly lower. Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia, with more sedation on parturients and a trend of newborn acidosis. Despite these adverse effects, remifentanil IVPCA can still be an alternative option for labor analgesia

  6. Evaluation of posterior clinoid process pneumatization by multidetector computed tomography.

    PubMed

    Burulday, Veysel; Akgül, Mehmet Hüseyin; Muluk, Nuray Bayar; Ozveren, Mehmet Faik; Kaya, Ahmet

    2016-10-21

    In the present study, we investigated the types and ratio of posterior clinoid process (PCP) pneumatization in paranasal sinus multidetector computed tomography (MDCT). Paranasal MDCT images of 541 subjects (227 males, 314 females), between 15 and 65 years old, were included into the study. Pneumatization of anterior clinoid process and pneumatization types (I, II, or III) were evaluated in the males and females. PCP pneumatization was detected in 20.7 % of the males and 11.5 % of the females. Right, left, and bilateral PCP pneumatizations were detected in 7.9, 5.7, and 7.0 % of the males and 2.9, 3.2, and 4.5 % of the females, respectively. PCP pneumatization of the males is significantly higher than the females. The most detected type of pneumatization was type I (61.2 %) for all groups. In right, left, and bilateral pneumatizations separately, type I pneumatization was the most detected pneumatization type with the ratio of the 70.4, 65.2, and 50.0 %, respectively. In males, type I (61.7 %), and similarly in females, type I (60.6 %) pneumatization were detected more. Type II and type III pneumatizations were detected in decreasing order in both groups. In younger subjects, pneumatization of posterior clinoid process was found as higher, and in older subjects, PCP pneumatization was found as lower. Sclerosis process related to the aging may be responsible for the lower pneumatization ratios in older subjects. Structure of the surrounding regions of PCP is important for surgical procedures related to cavernous sinus, basilar apex aneurysms, and mass lesions. Preoperative radiological examinations are useful for operative planning. Any anomalies to PCP can cause unnecessary injury to the neurovascular complex structure around the cavernous sinus or postclinoidectomy CSF fistulas. Posterior clinoidectomies should be avoided in patients with type III PCP pneumatization to prevent CSF fistulas.

  7. Comparison of Transversus Abdominis Plane Infiltration with Liposomal Bupivacaine versus Continuous Epidural Analgesia versus Intravenous Opioid Analgesia

    PubMed Central

    Ayad, Sabry; Babazade, Rovnat; Elsharkawy, Hesham; Nadar, Vinayak; Lokhande, Chetan; Makarova, Natalya; Khanna, Rashi; Sessler, Daniel I.; Turan, Alparslan

    2016-01-01

    Epidural analgesia is considered the standard of care but cannot be provided to all patients Liposomal bupivacaine has been approved for field blocks such as transversus abdominis plane (TAP) blocks but has not been clinically compared against other modalities. In this retrospective propensity matched cohort study we thus tested the primary hypothesis that TAP infiltration are noninferior (not worse) to continuous epidural analgesia and superior (better) to intravenous opioid analgesia in patients recovering from major lower abdominal surgery. 318 patients were propensity matched on 18 potential factors among three groups (106 per group): 1) TAP infiltration with bupivacaine liposome; 2) continuous Epidural analgesia with plain bupivacaine; and; 3) intravenous patient-controlled analgesia (IV PCA). We claimed TAP noninferior (not worse) over Epidural if TAP was noninferior (not worse) on total morphine-equivalent opioid and time-weighted average pain score (10-point scale) within first 72 hours after surgery with noninferiority deltas of 1 (10-point scale) for pain and an increase less of 20% in the mean morphine equivalent opioid consumption. We claimed TAP or Epidural groups superior (better) over IV PCA if TAP or Epidural was superior on opioid consumption and at least noninferior on pain outcome. Multivariable linear regressions within the propensity-matched cohorts were used to model total morphine-equivalent opioid dose and time-weighted average pain score within first 72 hours after surgery; joint hypothesis framework was used for formal testing. TAP infiltration were noninferior to Epidural on both primary outcomes (p<0.001). TAP infiltration were noninferior to IV PCA on pain scores (p = 0.001) but we did not find superiority on opioid consumption (p = 0.37). We did not find noninferiority of Epidural over IV PCA on pain scores (P = 0.13) and nor did we find superiority on opioid consumption (P = 0.98). TAP infiltration with liposomal bupivacaine and

  8. Long-term outcomes and prognostic analysis of modified open-door laminoplasty with lateral mass screw fusion in treatment of cervical spondylotic myelopathy

    PubMed Central

    Su, Nan; Fei, Qi; Wang, Bingqiang; Li, Dong; Li, Jinjun; Meng, Hai; Yang, Yong; Guo, Ai

    2016-01-01

    the postoperation JOA scores were significantly affected by age, preoperative JOA scores, and preoperative ISI. Except one case of epidural hematoma, there were no complications associated with the surgery. Conclusion Treatment of CSM with posterior open-door laminoplasty with lateral mass screw fusion is effective with few complications. In addition, the normal cervical lordosis was well maintained. Age, preoperative JOA scores, and preoperative ISI were the independent factors that significantly affect disease prognosis and surgical outcomes. PMID:27621642

  9. Spinal epidural abscess: common symptoms of an emergency condition. A case report.

    PubMed

    Rosc-Bereza, K; Arkuszewski, M; Ciach-Wysocka, E; Boczarska-Jedynak, M

    2013-08-01

    Spinal epidural abscess (SEA) is a severe pyogenic infection of the epidural space that leads to devastating neurological deficits and may be fatal. SEA is usually located in the thoracic and lumbar parts of the vertebral column and injures the spine by direct compression or local ischemia. Spinal injury may be prevented if surgical and medical interventions are implemented early. The diagnosis is difficult, because clinical symptoms are not specific and can mimic many benign conditions. The classical triad of symptoms includes back pain, fever and neurological deterioration. The gold standard in the diagnostic evaluation is magnetic resonance imaging with gadolinium enhancement, which determines the location and extent of the abscess. Increased awareness of the disease is essential for rapid recognition and immediate implementation of treatment. Here we describe the case of a 26-year-old woman with SEA with fever, back pain in the thoracic region and delayed symptoms of a transverse spinal cord injury.

  10. Paraspinal and Extensive Epidural Abscess: The Great Masqueraders of Abdominal Pain

    PubMed Central

    Chu, Andrew; Aung, Thu Thu; Shankar, Uday

    2015-01-01

    Paraspinal and epidural abscesses are rare conditions often diagnosed later in the disease process that can have significant morbidity and mortality. Predisposing risk factors include diabetes, human immunodeficiency virus, intravenous drug abuse, and previous history of spinal surgery or injection. They can threaten the spinal cord by compressive effect, leading to sensory motor deficits and ultimately paralysis and death. Diagnosis may be a challenge due to the delayed presentation of nonspecific back pain or radicular pain such as chest pain or abdominal pain. We present a rare case on a patient with periumbilical pain, constipation, and urinary retention who was ultimately diagnosed with a paraspinal abscess extending into the epidural space from T1 to S2. He underwent decompressive laminectomy with incision and drainage of the abscesses. The patient made an excellent recovery postoperatively, and repeat magnetic resonance imaging at six weeks showed resolution of the abscess. PMID:26770847

  11. Solitary spinal epidural cavernous haemangiomas as a rare cause of myelopathy.

    PubMed

    Meng, Ying; Shamji, Mohammed F

    2015-09-25

    Cavernous haemangiomas rarely occur in the spinal epidural space. We report the case of a 27-year-old man who presented with myelopathy secondary to spinal cord compression from a purely epidural lesion. The imaging characteristics of cavernous haemangiomas are unique, reflecting a highly vascular lesion. Key differentiating features from intracranial or intramedullary lesions include the lack of a surrounding hemosiderin ring and popcorn appearance. An urgent referral to a neurosurgeon is recommended given the possibility of acute neurological deterioration from intralesional haemorrhage, and good recovery from early surgical resection. Preoperative planning with thorough patient counselling and availability of matched blood is important, and an en bloc resection approach should be taken to minimise blood loss. In this case, the patient experienced complete recovery after surgical resection. No recurrence after complete resection has been reported in the literature. This suggests a good long-term outcome for the patient and that no early adjuvant therapy is necessary.

  12. Development of the force-feedback model for an epidural needle insertion simulator.

    PubMed

    Hiemenz, L; Stredney, D; Schmalbrock, P

    1998-01-01

    The Ohio Supercomputer Center and the Department of Anesthesiology at the OSU Medical Center have developed a computer-based simulation system for use in training anesthesiology residents in the technique of placing a needle for an epidural block. Although the simulator has been well regarded, the fidelity of the haptic feedback is limited because it is based on subjective expert-user evaluation and not on objective model-based or data-based empirical methods. Only a single degree of freedom for force-feedback is required. However, the simulation must be able to accurately portray the force required to puncture each layer of tissue in order to feel realistic. The purpose of the research described in this paper was to devise a methodology for creating empirically based realistic force-feedback models for the epidural needle insertion procedure using MRI data and biomechanical data from materials testing.

  13. Spinal Epidural Hematoma After Thrombolysis for Deep Vein Thrombosis with Subsequent Pulmonary Thromboembolism: A Case Report

    SciTech Connect

    Han, Young-Min Kwak, Ho-Sung; Jin, Gong-Young; Chung, Gyung-Ho; Song, Kyung-Jin

    2006-06-15

    A 38-year-old male was initially admitted for left leg swelling. He was diagnosed as having deep vein thrombosis (DVT) in the left leg and a pulmonary thromboembolism by contrast-enhanced chest computed tomography (CT) with delayed lower extremity CT. The DVT was treated by thrombolysis and a venous stent. Four hours later, he complained of severe back pain and a sensation of separation of his body and lower extremities; he experienced paraplegia early in the morning of the following day. Magnetic resonance imaging showed a spinal epidural hematoma between T11 and L2, which decompressed following surgery. We, therefore, report a case of a spinal epidural hematoma after thrombolysis in a case of DVT with a pulmonary thromboembolism.

  14. Thoracic epidural analgesia to control malignant pain until viability in a pregnant patient

    PubMed Central

    Mehta, Jaideep H; Gibson, Mary Elizabeth; Amaro-Driedger, David; Hussain, Mahammad N

    2016-01-01

    Management of nonobstetric pain in the pregnant patient presents unique challenges related to transplacental fetal exposure to opioids and the subsequent risk of neonatal withdrawal syndrome. We present the case of a pregnant patient suffering from the pain of a progressively enlarging thoracoabdominal sarcoma. Epidural analgesia (using local anesthetics with minimal opioid) was utilized over a span of weeks to manage oncologic pain, limiting fetal opioid exposure and culminating in the birth of a healthy infant. While nonobstetric abdominal pain during pregnancy is not that uncommon, neoplastic abdominal pain does appear to be rare. Combined local anesthetic and opioid continuous epidural infusion should be considered a viable option in the pain management approach to obstetric patients with nonobstetric pain associated with malignancy. PMID:27358573

  15. Posterior Wnts Have Distinct Roles in Specification and Patterning of the Planarian Posterior Region

    PubMed Central

    Sureda-Gómez, Miquel; Pascual-Carreras, Eudald; Adell, Teresa

    2015-01-01

    The wnt signaling pathway is an intercellular communication mechanism essential in cell-fate specification, tissue patterning and regional-identity specification. A βcatenin-dependent signal specifies the AP (Anteroposterior) axis of planarians, both during regeneration of new tissues and during normal homeostasis. Accordingly, four wnts (posterior wnts) are expressed in a nested manner in central and posterior regions of planarians. We have analyzed the specific role of each posterior wnt and the possible cooperation between them in specifying and patterning planarian central and posterior regions. We show that each posterior wnt exerts a distinct role during re-specification and maintenance of the central and posterior planarian regions, and that the integration of the different wnt signals (βcatenin dependent and independent) underlies the patterning of the AP axis from the central region to the tip of the tail. Based on these findings and data from the literature, we propose a model for patterning the planarian AP axis. PMID:26556349

  16. Epidural ketamine in post spinal cord injury-related chronic pain

    PubMed Central

    Amr, Yasser Mohamed

    2011-01-01

    Aim: This study was to identify the safety and efficacy of adding epidural N-methyl-D-aspartate receptor antagonists (ketamine) to oral gabapentin for the treatment of post spinal cord injury-related chronic pain. Materials and Methods: Forty patients in the age range of 18–50 years with a diagnosis of neuropathic pain secondary to spinal cord injury were randomized into two equal groups. Group I received 0.2 mg/Kg of preservative-free ketamine (2 ml) single bolus epidural injection and gabapentin 300 mg three times daily. Group II received isotonic saline 0.9% (2 ml) single bolus epidural injection and gabapentin 300 mg three times daily. Pain scores were evaluated pre-injection, 7, 15, 30,45 and 60 days post injection. Patients were asked about any side-effects occurred during follow-up period. Results: At all time points examined, pain scores were significantly lower in both groups than pre-injection values (P < 0.0001). Pain scores were significantly lower in Group I than in Group II at 7, 15, 30 days after injection (P 0.02, < 0.0001, =0.0001 respectively), but no statistically significant difference was detected between groups at 45, 60 days post injection (P = 0.54, =0.25), there was no statistically significant difference regarding incidence of side-effects in both groups. Conclusion: Epidurally administrated ketamine seems to be a safe adjunct to gabapentin in post spinal cord injury-related chronic pain. However, its analgesic efficacy was limited to 30 days after injection. PMID:25885306

  17. Safety of 1000 CT-guided steroid injections with air used to localize the epidural space.

    PubMed

    Chang, A; Pochert, S; Romano, C; Brook, A; Miller, T

    2011-10-01

    Historically, ESIs were performed without any imaging guidance, resulting in erroneous placement in up to 30% of injections. Fluoroscopic imaging is now used to guide most procedures. Recently, several reports have described the use of CT to guide ESIs instead of fluoroscopy. CT provides the ability to use air as contrast to localize the epidural space. This retrospective review will discuss findings in 1000 CT-guided ESIs with air localization.

  18. Combined spinal epidural (CSE) analgesia: technique, management, and outcome of 300 mothers.

    PubMed

    Collis, R E; Baxandall, M L; Srikantharajah, I D; Edge, G; Kadim, M Y; Morgan, B M

    1994-04-01

    Epidural analgesia in labour is commonly associated with some degree of lower limb weakness often severe enough to be described as paralysis by the mother. We aimed to produce rapid reliable analgesia with no motor block throughout labour. We report a pilot survey of 300 consecutive women requesting regional analgesia in labour who received a combined spinal epidural blockade (CSE). The initial dose was given into the subarachnoid space and analgesia maintained via an epidural catheter. A subarachnoid injection of 2.5 mg bupivacaine and 25 mug fentanyl was successfully given in 268 women (89.3%). Completely pain-free contractions within 3 min of this injection occurred in 195 women (65%) and in all 300 within 20 min and there was no associated motor block in 291 (97%). 141 women chose to stand, walk or sit in a rocking chair at some time during labour. Only 38 women (12.6%) were immobile during the first stage of labour. Analgesia was maintained via the epidural catheter with bolus doses of 10-15 ml of 0.1% bupivacaine and 0.0002% fentanyl. The mean bupivacaine requirement was 9.5 mg/h throughout the entire duration of analgesia. The incidence of post lumbar puncture headache was 2.3%. Transient hypotension occurred in 24 women (8%) and was treated with 6 mg intravenous boluses of ephedrine. Complete satisfaction with analgesia and mobility was reported 12-24 h post partum by 95% of mothers. The use of this analgesic technique caused no alteration in obstetric management or post partum care of the women.

  19. Epidural insertion simulator of higher insertion resistance & drop rate after puncture.

    PubMed

    Naemura, K; Sakai, A; Hayashi, T; Saito, H

    2008-01-01

    Accidents such as dural puncture remain one of the problems of epidural anesthesia, and unskilled doctors can repeat such accidents. The purpose of the current research was to provide a new simulator for epidural insertion training. No reference data regarding the resistance force used when inserting a needle into patients have been reported. A comparative study was conducted to aid in the development of a new simulator. Pork loin (n=5) were employed as a substitute for patients. Thickness was set at 2 cm so as to improve the reproducibility. The authors took the conventional simulator apart, and picked a block as an analogue of muscle and ligamentum flavum. A new simulator was made of a melamine foam resin block and a latex rubber sheet. An epidural needle fixed on a motorized stage was inserted at the speed of 2 mm per second. The reaction force was measured while the needle was inserted into each specimen. Waveform of the pork loin exhibited two slopes of different inclines up to peaks and then falls after puncture. The conventional simulator showed a simple increase up to peak and a slow fall after puncture. In contrast, the new simulator showed two slopes up to peak and then a sudden fall after puncture. The insertion resistances were 2.5 N/s for the porcine, 0.8 N/s for the conventional and 2.1 N/s for the new simulator. The drop rates were 5 N/s for the porcine, 0.6 N/s for the conventional and 24 N/s for the new simulator. The higher insertion resistance and drop rate for the new simulator than the conventional simulator will be suitable for epidural insertion training.

  20. Epidural Stimulation Induced Modulation of Spinal Locomotor Networks in Adult Spinal Rats

    PubMed Central

    Lavrov, Igor; Dy, Christine J.; Fong, Andy J.; Gerasimenko, Yury; Courtine, Grégoire; Zhong, Hui; Roy, Roland R.; Edgerton, V. Reggie

    2010-01-01

    The importance of the in vivo dynamic nature of the circuitries within the spinal cord that generate locomotion is becoming increasingly evident. We examined the characteristics of hindlimb EMG activity evoked in response to epidural stimulation at the S1 spinal cord segment in complete mid-thoracic spinal cord transected rats at different stages of post-lesion recovery. A progressive and phase-dependent modulation of monosynaptic (middle) and long latency (late) stimulation-evoked EMG responses was observed throughout the step cycle. During the first three weeks after injury the amplitude of the middle response was potentiated during the EMG bursts, whereas after 4 weeks both the middle and late responses were phase-dependently modulated. The middle and late response magnitudes were closely linked to the amplitude and duration of the EMG bursts during locomotion facilitated by epidural stimulation. The optimum stimulation frequency that maintained consistent activity of the long latency responses ranged from 40 to 60 Hz, whereas the short latency responses were consistent from 5 to 130 Hz. These data demonstrate that both middle and late evoked potentials within a motor pool are strictly gated during in vivo bipedal stepping as a function of the general excitability of the motor pool and, thus as a function of the phase of the step cycle. These data demonstrate that spinal cord epidural stimulation can facilitate locomotion in a time-dependent manner post-lesion. The long latency responses to epidural stimulation are correlated with the recovery of weight-bearing bipedal locomotion and may reflect activation of interneuronal central pattern-generating circuits. PMID:18524907

  1. Spinal epidural abscess associated with infliximab treatment for psoriatic arthritis. Case report.

    PubMed

    Smith, Adam P; Musacchio, Michael J; O'Toole, John E

    2008-09-01

    Tumor necrosis factor-alpha inhibitors are used to treat numerous chronic inflammatory and rheumatological diseases, such as Crohn disease, rheumatoid arthritis, and psoriatic arthritis. Because the mechanism of these inhibitors is to decrease the body's inflammatory response, the primary complication of treatment is infection. The authors present the first case of a spinal epidural abscess in a patient receiving long-term infliximab therapy for severe psoriatic arthritis. Infliximab and its side-effect profile are discussed, along with other associated complications.

  2. Epidural stimulation induced modulation of spinal locomotor networks in adult spinal rats.

    PubMed

    Lavrov, Igor; Dy, Christine J; Fong, Andy J; Gerasimenko, Yury; Courtine, Grégoire; Zhong, Hui; Roy, Roland R; Edgerton, V Reggie

    2008-06-04

    The importance of the in vivo dynamic nature of the circuitries within the spinal cord that generate locomotion is becoming increasingly evident. We examined the characteristics of hindlimb EMG activity evoked in response to epidural stimulation at the S1 spinal cord segment in complete midthoracic spinal cord-transected rats at different stages of postlesion recovery. A progressive and phase-dependent modulation of monosynaptic (middle) and long-latency (late) stimulation-evoked EMG responses was observed throughout the step cycle. During the first 3 weeks after injury, the amplitude of the middle response was potentiated during the EMG bursts, whereas after 4 weeks, both the middle and late responses were phase-dependently modulated. The middle- and late-response magnitudes were closely linked to the amplitude and duration of the EMG bursts during locomotion facilitated by epidural stimulation. The optimum stimulation frequency that maintained consistent activity of the long-latency responses ranged from 40 to 60 Hz, whereas the short-latency responses were consistent from 5 to 130 Hz. These data demonstrate that both middle and late evoked potentials within a motor pool are strictly gated during in vivo bipedal stepping as a function of the general excitability of the motor pool and, thus, as a function of the phase of the step cycle. These data demonstrate that spinal cord epidural stimulation can facilitate locomotion in a time-dependent manner after lesion. The long-latency responses to epidural stimulation are correlated with the recovery of weight-bearing bipedal locomotion and may reflect activation of interneuronal central pattern-generating circuits.

  3. Irreversible Electroporation in the Epidural Space of the Porcine Spine: Effects on Adjacent Structures.

    PubMed

    Tam, Alda L; Figueira, Tomas A; Gagea, Mihai; Ensor, Joe E; Dixon, Katherine; McWatters, Amanda; Gupta, Sanjay; Fuentes, David T

    2016-12-01

    Purpose To determine the effects of irreversible electroporation (IRE) on the neural tissues after ablation in the epidural space of the porcine spine. Materials and Methods The institutional animal care and use committee approved this study. With the IRE electrode positioned in the right lateral recess of the spinal epidural space, 20 IRE ablations were performed with computed tomographic (CT) guidance by using different applied voltages in four animals that were euthanized immediately after magnetic resonance (MR) imaging of the spine, performed 6 hours after IRE (terminal group). Histopathologic characteristics of the neural tissues were assessed and used to select a voltage for a survival study. Sixteen CT-guided IRE ablations in the epidural space were performed by using 667 V in four animals that were survived for 7 days (survival group). Clinical characteristics, MR imaging findings (obtained 6 hours after IRE and before euthanasia), histopathologic characteristics, and simulated electric field strengths were assessed. A one-way analysis of variance was used to compare the simulated electric field strength to histologic findings. Results The mean distance between the IRE electrode and the spinal cord and nerve root was 1.71 mm ± 0.90 and 8.47 mm + 3.44, respectively. There was no clinical evidence of paraplegia after IRE ablation. MR imaging and histopathologic examination showed no neural tissue lesions within the spinal cord; however, five of 16 nerve roots (31.2%) demonstrated moderate wallerian degeneration in the survival group. The severity of histopathologic injury in the survival group was not significantly related to either the simulated electric field strength or the distance between the IRE electrode and the neural structure (P > .05). Conclusion Although the spinal cord appears resistant to the toxic effects of IRE, injury to the nerve roots may be a limiting factor for the use of IRE ablation in the epidural space. (©) RSNA, 2016 Online

  4. Epidural Analgesia with Ropivacaine during Labour in a Patient with a SCN5A Gene Mutation

    PubMed Central

    Duvekot, J. J.; Roos-Hesselink, J. W.; Gonzalez Candel, A.; van der Marel, C. D.; Adriaens, V. F. R.

    2016-01-01

    SCN5A gene mutations can lead to ion channel defects which can cause cardiac conduction disturbances. In the presence of specific ECG characteristics, this mutation is called Brugada syndrome. Many drugs are associated with adverse events, making anesthesia in patients with SCN5A gene mutations or Brugada syndrome challenging. In this case report, we describe a pregnant patient with this mutation who received epidural analgesia using low dose ropivacaine and sufentanil during labour. PMID:27668095

  5. Experience of Laparoscopic Cholecystectomy Under Thoracic Epidural Anaesthesia: Retrospective Analysis of 96 Patients

    PubMed Central

    Bilgi, Murat; Alshair, Esin Erkan; Göksu, Hüseyin; Sevim, Osman

    2015-01-01

    Objective Although the traditional anaesthesia method for laparoscopic cholecystectomy has been general anaesthesia, regional anaesthesia techniques are also successfully used today. In this paper, we aimed to report our experiences with thoracic epidural anaesthesia, including complications, postoperative analgesia, technical difficulties and side effects. Methods Between December 2009 and November 2012, 90 patients undergoing laparoscopic cholecystectomy were retrospectively analysed. Demographic data, American Society of Anesthesiologists (ASA) scores, comorbidities, duration of operations, medications and doses used for sedation were reviewed. Results The gender distribution of patients were recorded as 15 males (15%) and 81 females (85%). The patients had an average age of 46.74±13.28, an average height of 162.50±5.57 cm and a mean weight of 73.57±12.48 kg. ASA classifications were distributed as follows: ASA I: 63 (65%) patients, ASA II 28 (29%) patients and ASA III: 5 patients. We recorded 3 patients with chronic obstructive pulmonary disease (COPD), 14 patients with diabetes mellitus (DM) and 22 patients with hypertension who got their diagnosis in the perioperative visit. During the operation, three patients had bradycardia (heart rate 50 min−1), and atropine was applied. Ephedrine and fluid resuscitation had been applied to 3 patients for the treatment of intraoperative hypotension. Midazolam, ketamine hydrochloride and propofol were administered to patients for sedation during the operations. Thoracic epidural anaesthesia was performed at the level of T7 -9 intervertebral space with the patients in the sitting position. Patients were given oxygen by a face mask at a rate of 3–4 L min−1. The pneumoperitoneum was created by giving carbon dioxide at the standard pressure of 12 mmHg into the abdominal cavity in all patients. If needed, postoperative analgesia was provided by epidural local anaesthetic administration. Conclusion Thoracic epidural

  6. Bilateral Heel Numbness due to External Compression during Obstetric Epidural Analgesia

    PubMed Central

    Kamphuis, Vivian P.; Zegers, Marie P.A.; Koppen, Hille

    2015-01-01

    We describe the case of a 32-year-old woman who developed bilateral heel numbness after obstetric epidural analgesia. We diagnosed her with bilateral neuropathy of the medial calcaneal nerve, most likely due to longstanding pressure on both heels. Risk factors for the development of this neuropathy were prolonged labour with spinal analgesia and a continuation of analgesia during episiotomy. Padded footrests decrease pressure and can possibly prevent this neuropathy. PMID:25802500

  7. Fentanyl versus tramadol with levobupivacaine for combined spinal-epidural analgesia in labor

    PubMed Central

    Chatrath, Veena; Khetarpal, Ranjana; Sharma, Sujata; Kumari, Pratibha; Sudha; Bali, Kusum

    2015-01-01

    Background: Neuraxial labor analgesia using new local anesthetics such as levobupivacaine has become very popular by virtue of the safety and lesser motor blockade caused by these agents. Combined spinal-epidural analgesia (CSEA) has become the preferred method for labor analgesia as it combines benefits of both spinal analgesia and flexibility of the epidural catheter. Adding opioids to local anesthetic drugs provide rapid onset and prolonged analgesia but may be associated with several maternal and fetal adverse effects. The purpose of this study is to compare fentanyl and tramadol used in CSEA in terms of duration of analgesia and frequency of the adverse fetomaternal outcome. Materials and Methods: A total of 60 primiparas with a singleton pregnancy in active labor were given CSEA after randomly allocating them in two groups of 30 each. Group I received intrathecal 2.5 mg levobupivacaine + 25 μg fentanyl followed by epidural top ups of 20 ml 0.125% solution of the same combination. Group II received 25 mg tramadol instead of fentanyl. Epidural top ups were given when parturient complained of two painful contractions (visual analogue scale ≥ 4). Data collected were demographic profile of the patients, analgesic qualities, side- effects and the fetomaternal outcome. Results: Patients in Group II had significantly prolonged analgesia (145 ± 9 minutes) than in Group I (95 ± 7 minutes). Patients receiving fentanyl showed rapid onset of analgesia, but there were more incidence of side-effects like shivering, pruritus, transient fetal bradycardia, hypotension, nausea and vomiting. Only side-effect in the tramadol group was nausea and vomiting. During labor, maternal satisfaction was excellent. Conclusions: Adding tramadol to local anesthetic provides prolonged analgesia with minimal side effects. Fentanyl, when used as adjuvant to local anesthetic, has a rapid onset of analgesia but has certain fetomaternal side-effects. PMID:26240543

  8. Radiofrequency Ablation of Lung Tumours with the Patient Under Thoracic Epidural Anaesthesia

    SciTech Connect

    Pouliquen, Cassiopee; Kabbani, Youssef Saignac, Pierre; Gekiere, Jean-Pierre; Palussiere, Jean

    2011-02-15

    Radiofrequency ablation of lung tumours is a curative technique that is newly considered being offered to nonsurgical patients. It is of major interest because it enables local destruction of the tumour without surgery and spares healthy parenchyma. However, some patients have previous serious respiratory failure, thus ruling out mechanical ventilation. To operate with the patient under thoracic epidural is an answer to this problem. Our experience shows that the procedure is able to be performed completely without converting to general anaesthesia.

  9. Management of Chronic Pain of Cervical Disc Herniation and Radiculitis with Fluoroscopic Cervical Interlaminar Epidural Injections

    PubMed Central

    Manchikanti, Laxmaiah; Cash, Kimberly A.; Pampati, Vidyasagar; Wargo, Bradley W.; Malla, Yogesh

    2012-01-01

    Study Design: A randomized, double-blind, active controlled trial. Objective: To evaluate the effectiveness of cervical interlaminar epidural injections of local anesthetic with or without steroids in the management of chronic neck pain and upper extremity pain in patients with disc herniation and radiculitis. Summary of Background Data: Epidural injections in managing chronic neck and upper extremity pain are commonly employed interventions. However, their long-term effectiveness, indications, and medical necessity, of their use and their role in various pathologies responsible for persistent neck and upper extremity pain continue to be debated, even though, neck and upper extremity pain secondary to disc herniation and radiculitis, is described as the common indication. There is also paucity of high quality literature. Methods: One-hundred twenty patients were randomly assigned to one of 2 groups: Group I patients received cervical interlaminar epidural injections of local anesthetic (lidocaine 0.5%, 5 mL); Group II patients received 0.5% lidocaine, 4 mL, mixed with 1 mL of nonparticulate betamethasone. Primary outcome measure was ≥ 50 improvement in pain and function. Outcome assessments included Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), opioid intake, employment, and changes in weight. Results: Significant pain relief and functional status improvement (≥ 50%) was demonstrated in 72% of patients who received local anesthetic only and 68% who received local anesthetic and steroids. In the successful group of participants, significant improvement was illustrated in 77% in local anesthetic group and 82% in local anesthetic with steroid group. Conclusions: Cervical interlaminar epidural injections with or without steroids may provide significant improvement in pain and function for patients with cervical disc herniation and radiculitis. PMID:22859902

  10. Neurological deficit following combined spinal-epidural anesthesia for knee arthroplasty.

    PubMed

    Tariq, Alzahrani

    2010-06-01

    A healthy man developed cauda equina syndrome after uneventful combined spinal and epidural anesthesia. No pre-existing neurologic disorder was recorded. There was no pain or paresthesia during needle placement, drug injection or catheter insertion. The sensory levels were improved within a few days following the deficit but little improvement on motor power but not on sphincter tone. Local anesthesia neurotoxicity was thought to be the leading cause of neurologic deficit in our case.

  11. An Unusual Presentation of a Posterior Mediastinal Schwannoma Associated with Traumatic Hemothorax

    PubMed Central

    Amin, Ruchi; Waibel, Brett H.

    2015-01-01

    Schwannomas of the thoracic cavity are typically an asymptomatic, benign neurogenic neoplasm of the posterior mediastinum. In this case, we present a traumatic hemothorax as the initial presentation for a previously undiscovered mediastinal mass. The patient presented with shortness of breath and right-sided chest pain after being struck in the chest with a soccer ball. An operative exploration was pursued due to persistent hemothorax with hemodynamic instability despite resuscitation and adequate thoracostomy tube placement. The intraoperative etiology of bleeding was discovered to be traumatic fracture of a large hypervascular posterior mediastinal schwannoma. Surgical resection is the treatment of choice for these tumors. Specific serological markers do not exist for this tumor, and radiographic findings can be variable, so tissue diagnosis is of importance in differentiating benign from malignant schwannomas, as well as other posterior mediastinal tumors. However, most patients have excellent survival following complete resection. PMID:26064757

  12. Choroid plexus papilloma of posterior third ventricle: A case report and review of literature

    PubMed Central

    Mishra, Arvind; Ojha, B. K.; Chandra, Anil; Singh, S. K.; Chandra, Nagesh; Srivastava, Chhitij

    2014-01-01

    Choroid plexus papillomas (CPPs) are rare intracranial neoplasms, especially in the third ventricle. The most common site of presentation of these lesions is in the fourth ventricle in adults and lateral ventricles in children. We report a male child with a posterior third ventricular CPP who presented with the symptoms of increased intracranial pressure. Magnetic resonance imaging revealed hydrocephalus related to a mass in the posterior third ventricle, occluding the aqueduct of Sylvius. After endoscopic third ventriculostomy, tumor was approached through the infratentorial-supracerebellar approach and completely excised. Pathological examination revealed a typical CPP. This entity should be considered an extremely rare cause of a lesion in the posterior third ventricle. PMID:25685228

  13. The direction dependence of thermoregulatory vasoconstriction during isoflurane/epidural anesthesia in humans.

    PubMed

    Ozaki, M; Sessler, D I; McGuire, J; Blanchard, D; Schroeder, M; Moayeri, A

    1993-10-01

    We tested the hypothesis that once thermoregulatory vasoconstriction is triggered at a given core temperature during isoflurane anesthesia, redilation starts at a substantially higher core temperature. To avoid direct perception of cutaneous cooling and warming, we used epidural anesthesia and limited our thermal manipulations to the blocked area. Seven volunteers were anesthetized with isoflurane/epidural anesthesia (approximately T9 dermatomal level). Core hypothermia was induced by surface cooling restricted to the legs. Cooling was continued until fingertip blood flow suddenly decreased (vasoconstriction threshold). The core was then rewarmed by heating the legs until fingertip flow suddenly increased toward initial values (redilation threshold). The difference between the two thresholds defined the direction-dependent hysteresis. Vasoconstriction occurred at 35.2 +/- 0.6 degrees C and vasodilation at 36.2 +/- 0.5 degrees C (P < 0.01, paired t-test); consequently, the hysteresis was 1.0 +/- 0.6 degrees C. The observed hysteresis suggests that thermoregulatory responses during combined isoflurane/epidural anesthesia are not determined simply by instantaneous thermal input to central controllers, but may also depend on the direction of core temperature change.

  14. Upper-limb muscle responses to epidural, subdural and intraspinal stimulation of the cervical spinal cord

    NASA Astrophysics Data System (ADS)

    Sharpe, Abigail N.; Jackson, Andrew

    2014-02-01

    Objective. Electrical stimulation of the spinal cord has potential applications following spinal cord injury for reanimating paralysed limbs and promoting neuroplastic changes that may facilitate motor rehabilitation. Here we systematically compare the efficacy, selectivity and frequency-dependence of different stimulation methods in the cervical enlargement of anaesthetized monkeys. Approach. Stimulating electrodes were positioned at multiple epidural and subdural sites on both dorsal and ventral surfaces, as well as at different depths within the spinal cord. Motor responses were recorded from arm, forearm and hand muscles. Main results. Stimulation efficacy increased from dorsal to ventral stimulation sites, with the exception of ventral epidural electrodes which had the highest recruitment thresholds. Compared to epidural and intraspinal methods, responses to subdural stimulation were more selective but also more similar between adjacent sites. Trains of stimuli delivered to ventral sites elicited consistent responses at all frequencies whereas from dorsal sites we observed a mixture of short-latency facilitation and long-latency suppression. Finally, paired stimuli delivered to dorsal surface and intraspinal sites exhibited symmetric facilitatory interactions at interstimulus intervals between 2-5 ms whereas on the ventral side interactions tended to be suppressive for near-simultaneous stimuli. Significance. We interpret these results in the context of differential activation of afferent and efferent roots and intraspinal circuit elements. In particular, we propose that distinct direct and indirect actions of spinal cord stimulation on motoneurons may be advantageous for different applications, and this should be taken into consideration when designing neuroprostheses for upper-limb function.

  15. Characterization of Motor and Somatosensory Evoked Potentials in the Yucatan Micropig Using Transcranial and Epidural Stimulation.

    PubMed

    Benavides, Francisco D; Santamaria, Andrea J; Bodoukhin, Nikita; Guada, Luis G; Solano, Juan P; Guest, James D

    2016-11-28

    Yucatan micropigs have brain and spinal cord dimensions similar to humans and are useful for certain spinal cord injury (SCI) translational studies. Micropigs are readily trained in behavioral tasks, allowing consistent testing of locomotor loss and recovery. However, there has been little description of their motor and sensory pathway neurophysiology. We established methods to assess motor and sensory cortical evoked potentials in the anesthetized, uninjured state. We also evaluated epidurally evoked motor and sensory stimuli from the T6 and T9 levels, spanning the intended contusion injury epicenter. Response detection frequency, mean latency and amplitude values, and variability of evoked potentials were determined. Somatosensory evoked potentials were reliable and best detected during stimulation of peripheral nerve and epidural stimulation by referencing the lateral cortex to midline Fz. The most reliable hindlimb motor evoked potential (MEP) occurred in tibialis anterior. We found MEPs in forelimb muscles in response to thoracic epidural stimulation likely generated from propriospinal pathways. Cranially stimulated MEPs were easier to evoke in the upper limbs than in the hindlimbs. Autopsy studies revealed substantial variations in cortical morphology between animals. This electrophysiological study establishes that neurophysiological measures can be reliably obtained in micropigs in a time frame compatible with other experimental procedures, such as SCI and transplantation. It underscores the need to better understand the motor control pathways, including the corticospinal tract, to determine which therapeutics are suitable for testing in the pig model.

  16. Evaluation of the use of continuous lumbar epidural anesthesia for hypertensive pregnant women in labor.

    PubMed

    Moore, T R; Key, T C; Reisner, L S; Resnik, R

    1985-06-15

    The use of continuous lumbar epidural anesthesia in women with pregnancy-induced hypertension remains controversial. We retrospectively reviewed the charts of 285 women with pregnancy-induced hypertension who were delivered in a 2-year period. Among 185 vaginally delivered patients who received continuous lumbar epidural or local anesthesia, there were no significant differences in the incidence of maternal hypotension, abnormal fetal heart rate tracings, low Apgar scores, or neonatal intensive care unit admissions. Of 100 patients delivered by cesarean section, the incidence of low Apgar scores, depressed umbilical cord pH values, and neonatal intensive care unit admission was increased among those who received general anesthesia (p less than 0.05). However, general anesthesia patients were more likely to have abnormal fetal heart rate tracings (27% versus 4%) requiring urgent delivery. Thus differences in outcome probably reflect poorer fetal condition prior to anesthesia induction rather than a specific anesthetic effect. These results demonstrate that continuous lumbar epidural anesthesia is safe and effective for both the fetus and the mother with pregnancy-induced hypertension.

  17. Decoding of motor intentions from epidural ECoG recordings in severely paralyzed chronic stroke patients

    NASA Astrophysics Data System (ADS)

    Spüler, M.; Walter, A.; Ramos-Murguialday, A.; Naros, G.; Birbaumer, N.; Gharabaghi, A.; Rosenstiel, W.; Bogdan, M.

    2014-12-01

    Objective. Recently, there have been several approaches to utilize a brain-computer interface (BCI) for rehabilitation with stroke patients or as an assistive device for the paralyzed. In this study we investigated whether up to seven different hand movement intentions can be decoded from epidural electrocorticography (ECoG) in chronic stroke patients. Approach. In a screening session we recorded epidural ECoG data over the ipsilesional motor cortex from four chronic stroke patients who had no residual hand movement. Data was analyzed offline using a support vector machine (SVM) to decode different movement intentions. Main results. We showed that up to seven hand movement intentions can be decoded with an average accuracy of 61% (chance level 15.6%). When reducing the number of classes, average accuracies up to 88% can be achieved for decoding three different movement intentions. Significance. The findings suggest that ipsilesional epidural ECoG can be used as a viable control signal for BCI-driven neuroprosthesis. Although patients showed no sign of residual hand movement, brain activity at the ipsilesional motor cortex still shows enough intention-related activity to decode different movement intentions with sufficient accuracy.

  18. Ibuprofen-conjugated hyaluronate/polygalacturonic acid hydrogel for the prevention of epidural fibrosis.

    PubMed

    Lin, Cheng-Yi; Peng, Hsiu-Hui; Chen, Mei-Hsiu; Sun, Jui-Sheng; Chang, Chih-Ju; Liu, Tse-Ying; Chen, Ming-Hong

    2016-05-01

    The formation of fibrous tissue is part of the natural healing response following a laminectomy. Severe scar tissue adhesion, known as epidural fibrosis, is a common cause of failed back surgery syndrome. In this study, by combining the advantages of drug treatment with a physical barrier, an ibuprofen-conjugated crosslinkable polygalacturonic acid and hyaluronic acid hydrogel was developed for epidural fibrosis prevention. Conjugation was confirmed and measured by 1D(1)H NMR spectroscopy.In vitroanalysis showed that the ibuprofen-conjugated polygalacturonic acid-hyaluronic acid hydrogel showed low cytotoxicity. In addition, the conjugated ibuprofen decreased prostaglandin E2production of the lipopolysaccharide-induced RAW264.7 cells. Histological data inin vivostudies indicated that the scar tissue adhesion of laminectomized male adult rats was reduced by the application of our ibuprofen-conjugated polygalacturonic acid-hyaluronic acid hydrogel. Its use also reduced the population of giant cells and collagen deposition of scar tissue without inducing extensive cell recruitment. The results of this study therefore suggest that the local delivery of ibuprofenviaa polygalacturonic acid-hyaluronic acid-based hydrogel reduces the possibility of epidural fibrosis.

  19. Accidental Epidural Injection of Rocuronium in a Pediatric Patient: A Case Report and Literature Review

    PubMed Central

    Wu, Ting-Ting

    2016-01-01

    Accidental administration of non-epidural drugs into the epidural or subarachnoid spaces may be associated with unexpected pain, morbidity, adverse effects, increased level of care, prolonged hospital stay, and mortality. We describe a 12-month-old admitted for secondary-stage hypospadias reconstruction. General anesthesia was induced with sevofiurane and a peripheral catheter was placed. Instead of ropivacaine, rocuronium (80 mg; 6.3 mg/kg) was injected into the epidural space by the caudal route. Surgery was uneventful and was completed 160 minutes after rocuronium was given. The patient exhibited paralysis with 1 of 4 twitches to the train-of-four with some posttetanic potentiation at the end of surgery. He was transferred to the pediatric intensive care unit for supportive ventilation and recovery. He did not experience oxygen desaturation or hypoventilation between the time of rocuronium administration and intubation. He was hemodynamically stable, without respiratory insufficiency, and his neurologic exam was normal, without motor or sensorial block. The patient was discharged home on the morning of the first postoperative day. Clinical examination 1 week after surgery revealed no lasting sequelae from the error. PMID:27877098

  20. Iatrogenic Cushing Syndrome Secondary to Ritonavir-Epidural Triamcinolone Interaction: An Illustrative Case and Review

    PubMed Central

    Berg, Melody L.

    2014-01-01

    HIV positive patients on ritonavir-containing antiretroviral therapy (ART) can develop iatrogenic Cushing syndrome (IACS) and adrenal insufficiency as a result of drug-drug interactions with inhaled or intranasal glucocorticoid therapy. Reports related to epidural triamcinolone injections are relatively uncommon but increasingly reported. We describe a 48-year-old woman with immunologically and virologically well-controlled HIV on ritonavir-based ART, who developed headache, dizziness, and candida and herpes simplex virus (HSV) ulcerative esophagitis 7 days after receiving an epidural triamcinolone injection for cervical radicular pain. Iatrogenic Cushing syndrome and relative adrenal insufficiency were suspected and proven. The patient's ART was changed to a non-HIV protease inhibitor- (PI-) containing program, her symptoms improved, and she did not require hydrocortisone replacement. In this paper, we review the literature on IACS and relative secondary adrenal insufficiency from epidural triamcinolone injections in HIV patients on ritonavir-containing ART regimens. A high index of clinical suspicion is needed for diagnosis. Prevention of drug-drug interactions by taking a thorough medication history for patients on ritonavir-containing ART regimens before prescribing any form of corticosteroid is crucial and effective and sustained interdisciplinary communication in the care of such patients. PMID:24895495

  1. Consent for labour epidural analgesia: an observational study in a single institution.

    PubMed

    Trumble, J; Lee, J; Slater, P M; Sellors, J; Cyna, A M

    2015-05-01

    There is a wide range of practice amongst obstetric anaesthetists when obtaining consent for women requesting labour epidural analgesia. This is the first prospective observational study recording the number and types of risks mentioned and whether the risk was quantified. Statements of benefits and alternatives to the procedure were also noted. Fourteen anaesthetists, each consulting a single patient, were recorded during the process of obtaining consent and inserting the epidural. The most commonly mentioned risks (median 7) were headache/dural puncture, failure/difficulty with insertion, nerve damage, bleeding/haematoma and infection/epidural abscess. There was no difference between consultants and trainees, although consultants showed greater variance. It was uncommon for anaesthetists to state a benefit (21%) or mention an alternative option (21%), but there was usually a quantitative statement of risk (71%). Data showed a deviation from the Australian and New Zealand College of Anaesthetists guidelines and these findings may encourage anaesthetists to reflect on their own practice and guide future research.

  2. Decoding the rat forelimb movement direction from epidural and intracortical field potentials

    NASA Astrophysics Data System (ADS)

    Slutzky, Marc W.; Jordan, Luke R.; Lindberg, Eric W.; Lindsay, Kevin E.; Miller, Lee E.

    2011-06-01

    Brain-machine interfaces (BMIs) use signals from the brain to control a device such as a computer cursor. Various types of signals have been used as BMI inputs, from single-unit action potentials to scalp potentials. Recently, intermediate-level signals such as subdural field potentials have also shown promise. These different signal types are likely to provide different amounts of information, but we do not yet know what signal types are necessary to enable a particular BMI function, such as identification of reach target location, control of a two-dimensional cursor or the dynamics of limb movement. Here we evaluated the performance of field potentials, measured either intracortically (local field potentials, LFPs) or epidurally (epidural field potential, EFPs), in terms of the ability to decode reach direction. We trained rats to move a joystick with their forepaw to control the motion of a sipper tube to one of the four targets in two dimensions. We decoded the forelimb reach direction from the field potentials using linear discriminant analysis. We achieved a mean accuracy of 69 ± 3% with EFPs and 57 ± 2% with LFPs, both much better than chance. Signal quality remained good up to 13 months after implantation. This suggests that using epidural signals could provide BMI inputs of high quality with less risk to the patient than using intracortical recordings.

  3. Neuroprotective effect of epidural hypothermia after spinal cord lesion in rats

    PubMed Central

    Barbosa, Marcello Oliveira; Cristante, Alexandre Fogaça; dos Santos, Gustavo Bispo; Ferreira, Ricardo; Marcon, Raphael Martus; de Barros Filho, Tarcisio Eloy Pessoa

    2014-01-01

    OBJECTIVES : To evaluate the neuroprotective effect of epidural hypothermia in rats subjected to experimental spinal cord lesion. METHODS: Wistar rats (n = 30) weighing 320-360 g were randomized to two groups (hypothermia and control) of 15 rats per group. A spinal cord lesion was induced by the standardized drop of a 10-g weight from a height of 2.5 cm, using the New York University Impactor, after laminectomy at the T9-10 level. Rats in the hypothermia group underwent epidural hypothermia for 20 minutes immediately after spinal cord injury. Motor function was assessed for six weeks using the Basso, Beattie and Bresnahan motor scores and the inclined plane test. At the end of the final week, the rats' neurological status was monitored by the motor evoked potential test and the results for the two groups were compared. RESULTS: Analysis of the Basso, Beattie and Bresnahan scores obtained during the six-week period indicated that there were no significant differences between the two groups. There was no significant difference between the groups in the inclined plane test scores during the six-week period. Furthermore, at the end of the study, the latency and amplitude values of the motor evoked potential test were not significantly different between the two groups. CONCLUSION: Hypothermia did not produce a neuroprotective effect when applied at the injury level and in the epidural space immediately after induction of a spinal cord contusion in Wistar rats. PMID:25141116

  4. [Posterior uveitis caused by highly malignant B cell lymphoma].

    PubMed

    Held, R; Eckardt, C; Brix, F; Feller, A C

    1989-01-01

    A diagnostic vitrectomy was performed on three patients with posterior uveitis of unknown origin and whose vitrous body was markedly affected. In all cases, cells of high-grade B-cell lymphoma (earlier referred to as reticulum cell sarcoma) were identified by cytological analysis of the specimen. In addition to the ocular findings, one of the three patients showed clinical and radiological evidence of a tumorous mass in the area of the right thalamus at the time of diagnosis. This was interpreted as a cerebral manifestation of the lymphoma. Initially, the other two patients did not show any cerebral involvement. One of them, however, developed clinical symptoms 9 months after diagnosis, which were radiologically verified as tumor infiltration of the cerebellum and the diencephalon. Under radiation therapy, the ocular findings disappeared within a few weeks.

  5. Comparison of the effects of epidural or intravenous methadone on the minimum alveolar concentration of isoflurane in dogs.

    PubMed

    Campagnol, Daniela; Teixeira-Neto, Francisco J; Peccinini, Rosangela G; Oliveira, Flávia A; Alvaides, Renata K; Medeiros, Luiza Q

    2012-06-01

    The effects of epidural and intravenous (IV) methadone (0.5mg/kg) on the minimum alveolar concentration of isoflurane (ISO(MAC)) were compared in dogs. Six dogs (16.5 ± 2.5 kg bodyweight) received three treatments in random order during isoflurane anaesthesia, with a 7 day washout interval between each study. Methadone was injected via a lumbosacral epidural catheter introduced 10 cm cranially into the epidural canal and the electrical stimulation for ISO(MAC) determination was applied either to the thoracic (EP(T) treatment) or to the pelvic limb (EP(P) treatment) during separate study days. In the IV treatment, ISO(MAC) was determined via electrical stimulation of the pelvic limb. Variables were recorded before (baseline), 2.5 and 5h after drug injection. The ISO(MAC) decreased significantly (P<0.05) from baseline at 2.5 and 5h after methadone in all treatments. At 2.5h, the magnitude of ISO(MAC) reduction did not differ between treatments (mean decreases from baseline: 30-33%). The ISO(MAC) reduction lasted longer following epidural methadone in the thoracic limb (decreases from baseline: 30% at 5h in the EP(T) treatment vs. 19% and 16% in the EP(P) and IV treatments, respectively). Although the isoflurane sparing effect provided by epidural methadone was not significantly greater than IV methadone during the initial stage (2.5h), it was more prolonged than the IV route in specific dermatomes (5h in the thoracic limb) with the epidural technique employed. Methadone may therefore provide a greater isoflurane sparing effect when administered epidurally, compared to IV, when noxious stimulation occurs in specific dermatomes.

  6. [Manual rotation of occiput posterior presentation].

    PubMed

    Le Ray, C; Goffinet, F

    2011-10-01

    Delivery in occiput posterior position is associated with a higher risk of cesarean section, operative vaginal delivery and severe perineal tears. We report the technic of manual rotation described by Tarnier and Chantreuil and used daily in our maternity center. Only five studies were published on this topic; all of them demonstrate that manual rotation decreases the risk of cesarean section. Moreover, it could decrease the risk of prolonged second stage, chorioamnionitis and third and fourth degree tears in comparison with expectant management. However, manual rotation is associated with a two-fold higher risk of cervical and vaginal lacerations. Manual rotation performed with an adequate technic is an efficient and safe manœuvre to avoid complications associated with occiput posterior vaginal delivery.

  7. Acute traumatic posterior elbow dislocation in children.

    PubMed

    Lieber, Justus; Zundel, Sabine M; Luithle, Tobias; Fuchs, Jörg; Kirschner, Hans-Joachim

    2012-09-01

    Traumatic posterior dislocation of the elbow is often associated with significant morbidity and incomplete recovery. The aim of this study was to retrospectively analyse the outcome of 33 children (median age 10.8 years). Patients underwent reduction and assessment of stability under general anaesthesia. Pure dislocations (n=10) were immobilized, whereas unstable fractures (n=23) were stabilized. Refixation of ligaments was performed if stability was not achieved by fracture stabilization alone. Immobilization was continued for 26 (pure dislocations) or 35 days (associated injuries), respectively. Results were excellent (n=9) or good (n=1) after pure dislocation. Results were excellent (n=15), good (n=7) or poor (n=1) in children with associated injuries. Accurate diagnosis, concentric stable reduction of the elbow as well as stable osteosynthesis of displaced fractures are associated with good results in children with acute posterior elbow dislocations.

  8. Posterior tibial nerve lesions in ankle arthroscopy.

    PubMed

    Cugat, Ramon; Ares, Oscar; Cuscó, Xavier; Garcia, Montserrat; Samitier, Gonzalo; Seijas, Roberto

    2008-05-01

    Ankle arthroscopy provides a minimally invasive approach to the diagnosis and treatment of certain ankle disorders. Neurological complications resulting from ankle arthroscopy have been well documented in orthopaedic and podiatric literature. Owing to the superficial location of the ankle joint and the abundance of overlying periarticular neurovascular structures, complications reported in ankle arthroscopy are greater than those reported for other joints. In particular, all reported neurovascular injuries following ankle arthroscopy have been the direct result of distractor pin or portal placement. The standard posteromedial portal has recognized risks because of the proximity of the posterior neurovascular structures. There can be considerable variability in the course of these portals and their proximity to the neurovascular structures. We found one report of intra-articular damage to the posterior tibial nerve as a result of ankle arthroscopy in the English-language literature and we report this paper as a second case described in the literature.

  9. Minimally invasive posterior cervical decompression using tubular retractor: The technical note and early clinical outcome

    PubMed Central

    Hur, Jung-Woo; Kim, Jin-Sung; Shin, Myeong-Hoon; Ryu, Kyeong-Sik

    2014-01-01

    Background: The aim of this work is to present a novel decompression technique that approaches cervical spine posteriorly, but through minimal invasive method using tubular retractor avoiding detachment of posterior musculature. Methods: Six patients underwent minimally invasive posterior cervical decompression using the tubular retractor system and surgical microscope. Minimally invasive access to the posterior cervical spine was performed with exposure through a paramedian muscle-splitting approach. With the assistance of a specialized tubular retraction system and deep soft tissue expansion mechanism, multilevel posterior cervical decompression could be accomplished. This approach also allows safe docking of the retractor system on the lateral mass, thus avoiding the cervical spinal canal during exposure. A standard operating microscope was used with ×10 magnification and 400 mm focal length. The hospital charts, magnetic resonance imaging studies, and follow-up records of all the patients were reviewed. Outcome was assessed by neurological status and visual analog scale (VAS) for neck and arm pain. Results: There was no significant complication related to operation. The follow-up time was 4-12 months (mean, 9 months). Muscle weakness improved in all patients; sensory deficits resolved in four patients and improved in two patients. Analysis of the mean VAS for radicular pain and VAS for neck pain showed significant improvement. Conclusions: The preliminary experiences with good clinical outcome seem to promise that this minimally invasive technique is a valid alternative option for the treatment of cervical spondylotic myelopathy. PMID:24778922

  10. Progressive visual agnosia with posterior cortical atrophy.

    PubMed

    Mizuno, M; Sartori, G; Liccione, D; Battelli, L; Campo, R

    1996-05-01

    A patient of posterior cortical atrophy characterized by early signs of progressive visual agnosia documented by repeated neuropsychological tests, is reported. SPECT and MRI findings showed left unilateral parieto-occipital involvement in the earlier stage. A PET study executed eight months later showed bilateral parieto-occipital hypometabolism, but predominantly in the left hemisphere. This suggests that the degeneration may have developed asymmetrically, progressing from left unilateral to bilateral.

  11. Endoscopic posterior interhemispheric complete corpus callosotomy.

    PubMed

    Sood, Sandeep; Asano, Eishi; Altinok, Deniz; Luat, Aimee

    2016-12-01

    Traditionally corpus callosotomy is done through a craniotomy centered at the coronal suture, with the aid of a microscope. This involves dissecting through the interhemispheric fissure below the falx to reach the corpus callosum. The authors describe a posterior interhemispheric approach to complete corpus callosotomy with an endoscope, which bypasses the need to perform interhemispheric dissection because the falx is generally close to the corpus callosum in this region.

  12. Material Properties of the Posterior Human Sclera☆

    PubMed Central

    Grytz, Rafael; Fazio, Massimo A.; Girard, Michael J.A.; Libertiaux, Vincent; Bruno, Luigi; Gardiner, Stuart; Girkin, Christopher A.; Downs, J. Crawford

    2013-01-01

    To characterize the material properties of posterior and peripapillary sclera from human donors, and to investigate the macro- and micro-scale strains as potential control mechanisms governing mechanical homeostasis. Posterior scleral shells from 9 human donors aged 57–90 years were subjected to IOP elevations from 5 to 45 mmHg and the resulting full-field displacements were recorded using laser speckle interferometry. Eye-specific finite element models were generated based on experimentally measured scleral shell surface geometry and thickness. Inverse numerical analyses were performed to identify material parameters for each eye by matching experimental deformation measurements to model predictions using a microstructure-based constitutive formulation that incorporates the crimp response and anisotropic architecture of scleral collagen fibrils. The material property fitting produced models that fit both the overall and local deformation responses of posterior scleral shells very well. The nonlinear stiffening of the sclera with increasing IOP was well reproduced by the uncrimping of scleral collagen fibrils, and a circumferentially-aligned ring of collagen fibrils around the scleral canal was predicted in all eyes. Macroscopic in-plane strains were significantly higher in peripapillary region then in the mid-periphery. In contrast, the meso- and micro-scale strains at the collagen network and collagen fibril level were not significantly different between regions. The elastic response of the posterior human sclera can be characterized by the anisotropic architecture and crimp response of scleral collagen fibrils. The similar collagen fibril strains in the peripapillary and mid-peripheral regions support the notion that the scleral collagen architecture including the circumpapillary ring of collagen fibrils evolved to establish optimal load bearing conditions at the collagen fibril level. PMID:23684352

  13. Iris fixation of posterior chamber intraocular lenses.

    PubMed

    Yazdani-Abyaneh, Alireza; Djalilian, Ali R; Fard, Masoud Aghsaei

    2016-12-01

    We introduce a technique for iris fixation of a posterior chamber intraocular lens (IOL) in which most of the procedure is done outside the eye. This minimizes intraocular manipulation, maximizes corneal endothelial preservation, and avoids the risk for IOL drop into the vitreous cavity intraoperatively. The IOL is fixated to the most peripheral part of the iris, resulting in a rounder pupil. Sutures are placed at exact positions on the haptics, resulting in a well-centered IOL.

  14. Cervical disc hernia operations through posterior laminoforaminotomy

    PubMed Central

    Yolas, Coskun; Ozdemir, Nuriye Guzin; Okay, Hilmi Onder; Kanat, Ayhan; Senol, Mehmet; Atci, Ibrahim Burak; Yilmaz, Hakan; Coban, Mustafa Kemal; Yuksel, Mehmet Onur; Kahraman, Umit

    2016-01-01

    Objective: The most common used technique for posterolateral cervical disc herniations is anterior approach. However, posterior cervical laminotoforaminomy can provide excellent results in appropriately selected patients with foraminal stenosis in either soft disc prolapse or cervical spondylosis. The purpose of this study was to present the clinical outcomes following posterior laminoforaminotomy in patients with radiculopathy. Materials and Methods: We retrospectively evaluated 35 patients diagnosed with posterolateral cervical disc herniation and cervical spondylosis with foraminal stenosis causing radiculopathy operated by the posterior cervical keyhole laminoforaminotomy between the years 2010 and 2015. Results: The file records and the radiographic images of the 35 patients were assessed retrospectively. The mean age was 46.4 years (range: 34-66 years). Of the patients, 19 were males and 16 were females. In all of the patients, the neurologic deficit observed was radiculopathy. The posterolaterally localized disc herniations and the osteophytic structures were on the left side in 18 cases and on the right in 17 cases. In 10 of the patients, the disc level was at C5-6, in 18 at C6-7, in 2 at C3-4, in 2 at C4-5, in 1 at C7-T1, in 1 patient at both C5-6 and C6-7, and in 1 at both C4-5 and C5-6. In 14 of these 35 patients, both osteophytic structures and protruded disc herniation were present. Intervertebral foramen stenosis was present in all of the patients with osteophytes. Postoperatively, in 31 patients the complaints were relieved completely and four patients had complaints of neck pain and paresthesia radiating to the arm (the success of operation was 88.5%). On control examinations, there was no finding of instability or cervical kyphosis. Conclusion: Posterior cervical laminoforaminotomy is an alternative appropriate choice in both cervical soft disc herniations and cervical stenosis. PMID:27217655

  15. Posterior fossa syndrome—a narrative review

    PubMed Central

    Wahab, Salima S.; Hettige, Samantha; Mankad, Kshtij

    2016-01-01

    Posterior fossa syndrome (PFS), or cerebellar mutism syndrome (CMS), is a collection of neurological symptoms that occur following surgical resection of a posterior fossa tumour, and is characterised by either a reduction or an absence of speech. Some authors suggest that CM is only one symptom of the CMS complex that also includes ataxia, hypotonia and irritability as well as cranial nerve deficits, neurobehavioral changes and urinary retention or incontinence. It is seen almost exclusively in children. In 1985 Rekate et al. published the first work describing CM as a clinical entity, occurring as a consequence of bilateral cerebellar injury. Other associated symptoms include visual impairment, altered mood, impaired swallowing and significant gross and fine motor deficits. The effects of this can have a devastating impact on both the patient and their carers, posing a significant clinical challenge to neurorehabilitation services. The reported incidence was between 8% and 31% of children undergoing surgery for posterior fossa tumour. The underlying pathologies include vasospasm, oedema, and axonal/neuronal injury. Neuroimaging has contributed to a better understanding of the anatomical location of postoperative injury. There have been a number of suggestions for treatment interventions for PFS. However, apart from some individual reports, there have been no clinical trials indicating possible benefit. Occupational therapy, speech and language therapy, as well as neurocognitive support, contribute to the recovery of these patients. PMID:27942479

  16. Electrocardiographic diagnosis of remote posterior wall myocardial infarction using unipolar posterior lead V9

    SciTech Connect

    Rich, M.W.; Imburgia, M.; King, T.R.; Fischer, K.C.; Kovach, K.L. )

    1989-09-01

    The accuracy of four electrocardiographic criteria for diagnosing remote posterior myocardial infarction was assessed prospectively in 369 patients undergoing exercise treadmill testing with thallium scintigraphy. Criteria included the following: (1) R-wave width greater than or equal to 0.04 s and R-wave greater than or equal to S-wave in V1; (2) R-wave greater than or equal to S-wave in V2; (3) T-wave voltage in V2 minus V6 greater than or equal to 0.38 mV (T-wave index); (4) Q-wave greater than or equal to 0.04 s in left paraspinal lead V9. Twenty-seven patients (7.3 percent) met thallium criteria for posterior myocardial infarction, defined as a persistent perfusion defect in the posterobase of the left ventricle. Sensitivities for the four criteria ranged from 4 to 56 percent, and specificities ranged from 64 to 99 percent. Posterior paraspinal lead V9 provided the best overall predictive accuracy (94 percent), positive predictive value (58 percent), and ability to differentiate patients with and without posterior myocardial infarction of any single criterion (p less than .0001). Combining the T-wave index with lead V9 further enhanced the diagnostic yield: the sensitivity for detecting posterior infarction by at least one of these criteria was 78 percent, and when both criteria were positive, specificity was 98.5 percent. It is concluded that a single, unipolar posterior lead in the V9 position is superior to standard 12-lead electrocardiographic criteria in diagnosing remote posterior myocardial infarction, and that combining V9 with the T-wave index maximizes the diagnostic yield.

  17. Bilateral posterior cervical cages provide biomechanical stability: assessment of stand-alone and supplemental fixation for anterior cervical discectomy and fusion

    PubMed Central

    Voronov, Leonard I; Siemionow, Krzysztof B; Havey, Robert M; Carandang, Gerard; Phillips, Frank M; Patwardhan, Avinash G

    2016-01-01

    Introduction Supplemental posterior instrumentation has been widely used to enhance stability and improve fusion rates in higher risk patients undergoing anterior cervical discectomy and fusion (ACDF). These typically involve posterior lateral mass or pedicle screw fixation with significant inherent risks and morbidities. More recently, cervical cages placed bilaterally between the facet joints (posterior cervical cages) have been used as a less disruptive alternative for posterior fixation. The purpose of this study was to compare the stability achieved by both posterior cages and ACDF at a single motion segment and determine the stability achieved with posterior cervical cages used as an adjunct to single- and multilevel ACDF. Methods Seven cadaveric cervical spine (C2–T1) specimens were tested in the following sequence: intact, C5–C6 bilateral posterior cages, C6–C7 plated ACDF with and without posterior cages, and C3–C5 plated ACDF with and without posterior cages. Range of motion in flexion–extension, lateral bending, and axial rotation was measured for each condition under moment loading up to ±1.5 Nm. Results All fusion constructs significantly reduced the range of motion compared to intact in flexion–extension, lateral bending, and axial rotation (P<0.05). Similar stability was achieved with bilateral posterior cages and plated ACDF at a single level. Posterior cages, when placed as an adjunct to ACDF, further reduced range of motion in both single- and multilevel constructs (P<0.05). Conclusion The biomechanical effectiveness of bilateral posterior cages in limiting cervical segmental motion is comparable to single-level plated ACDF. Furthermore, supplementation of single- and multilevel ACDF with posterior cervical cages provided a significant increase in stability and therefore may be a potential, minimally disruptive option for supplemental fixation for improving ACDF fusion rates. PMID:27471414

  18. Comparison Between the Use of Ropivacaine Alone and Ropivacaine With Sufentanil in Epidural Labor Analgesia.

    PubMed

    Wang, Xian; Xu, Shiqin; Qin, Xiang; Li, Xiaohong; Feng, Shan-Wu; Liu, Yusheng; Wang, Wei; Guo, Xirong; Shen, Rong; Shen, Xiaofeng; Wang, Fuzhou

    2015-10-01

    To compare the analgesic efficacy and safety of the sole local anesthetic ropivacaine with the combination of both local anesthetic ropivacaine and opioidergic analgesic sufentanil given epidurally on the labor pain control.After institutional review board approval and patient consent, a total of 500 nulliparas requesting epidural labor analgesia were enrolled and 481 eventually were randomized into 2 groups: a sole local anesthetic group (ropivacaine 0.125%) and a combination of local anesthetic and opioidergic analgesic group (0.125% ropivacaine + 0.3 μg/mL sufentanil). After the test dose, a 10-mL epidural analgesic solution was given in a single bolus, followed by intermittent bolus injection of 10 to 15 mL of the solution. The primary outcome was the analgesic efficacy measured using Numerical Rating Scale (NRS) of pain. Other maternal and infant variables were evaluated as secondary outcomes.A total of 346 participants completed the study. The median NRS pain score during the 1st stage of labor was significantly lower in the combination group 2.2 (interquartile range [IQR]: 1.8-2.7) comparing to the sole local analgesic group 2.4 (IQR: 2.0-2.8) (P < 0.0001). No significant difference was observed in NRS pain score prior epidural analgesia and during the 2nd stage of labor. Patients in both groups rated same satisfaction of analgesia. Patients in the sole local analgesic group experienced fewer side effects than those in the combination group (37.7% vs 47.2%, P = 0.082). The individual analgesia-related cost in the sole local analgesic group was less ($5.7 ± 2.06) than that in the combination group ($9.76 ± 3.54) (P < 0.0001). The incidence of 1-minute Apgar ≤ 7 was lower in the sole local analgesic group 2 (1.2%) than the combination group 10 (5.5%) (P = 0.038). No difference was found between other secondary outcomes.The sole local anesthetic ropivacaine produces a comparable labor analgesic effect as the combination of

  19. Evaluation of Epidural and Peripheral Nerve Catheter Heating During Magnetic Resonance Imaging

    PubMed Central

    Owens, Sean; Erturk, M. Arcan; Ouanes, Jean-Pierre P.; Murphy, Jamie D.; Wu, Christopher L.; Bottomley, Paul A.

    2014-01-01

    Background Many epidural and peripheral nerve catheters contain conducting wire that could heat during magnetic resonance imaging (MRI), requiring removal for scanning. Methods We tested 2 each of 6 brands of regional analgesia catheters (from Arrow International, B. Braun Medical, and Smiths Medical/Portex) for exposure to clinical 1.5 and 3 Tesla (T) MRI. Catheters testing as non-magnetic were placed in an epidural configuration in a standard human torso-sized phantom, and an MRI pulse sequence applied at the maximum scanner-allowed radio frequency (RF) specific absorption rate (SAR) for 15 minutes Temperature and SAR exposure were sampled during MRI using multiple fiber-optic temperature sensors. Results Two catheters (the Arrow StimuCath Peripheral Nerve, and Braun Medical Perifix FX Epidural) were found to be magnetic and not tested further. At 3T, exposure of the remaining 3 epidural and 1 peripheral nerve catheter to the scanner’s maximum RF exposure, elicited anomalous heating of 4 to 7°C in 2 Arrow Epidural (MultiPort and Flex-Tip Plus) catheters at the entry points. Temperature increases for the other catheters at 3T and all catheters at 1.5T were ≤1.4°C. When normalized to the body-average FDA guideline SAR of 4W/kg, maximum projected temperature increases were 0.1 to 2.5°C at 1.5T and 0.7 to 2.7°C at 3T, except for the Arrow MultiPort Flex-Tip Plus catheter at 3T whose increase was 14°C. Conclusions Most but not all catheters can be left in place during 1.5T MRI scans. Heating of <3°C during MRI for most catheters is not expected to be injurious. While heating was lower at 1.5T vs 3T, performance differences between products underscore the need for safety testing before performing MRI. PMID:25275576

  20. [Caudal epidural injection in the management of lumbosacral nerve pain syndromes].

    PubMed

    Apáthy, A; Penczner, G; Licker, E; Eiben, A; Bálint, G; Genti, G; Paksy, A

    1999-05-09

    The effect of epidural steroid injections was assessed in 39 patients with lumbar nerve root compression syndromes in a double-blind controlled trial, the patients were allocated at random to 3 groups. In group A (n = 13) the patients received a caudal epidural injection of 1 ml (7 mg) bethametason (Diprophos) in 10 ml normal saline and 20 ml local anesthetic (Lignocaine 1%). The second group B (n = 13) received a caudal epidural injection of 20 ml local anaesthetic (Lignocaine 1%) and 10 ml normal saline. The third group C (n = 13) received a superficial injection of 1 ml (7 mg) bethametason around of the sacral hiatus. All injections were performed by the same experienced anaesthesiologist. An independent physician, who was not aware which type of injection had been given, carried out the clinical measurements and the evaluation. Taking of analgesic drug Tramadol was permitted. The symptoms were assessed by visual analogue scale (VAS 100 mm), lumbar flexion (Schober and finger-floor distance), the angle of raised leg sign (RLS degrees), and by complete neurological examination, the investigation was made 5 times (1 hour, 24 hours, 48 hours, 1 week, and 4 weeks after epidural injections). The results between 0-1 week and 0-4 week were statistically analysed by Student-, Wilcoxon-, and Mann-Whitney test and analysis of variance (ANOVA). The mean VAS values decreased in time in all patient groups. There was no difference between the three treatment groups either after one or after 4 weeks by ANOVA. The mobility of the lumbar spine improved in all patient groups, but there was no significant difference between the three treatment groups. The raised led sign--values improved in all patient groups. There was a significant difference between the three treatment groups by ANOVA after one week, due to the difference between group A and C. After four weeks there was no significant difference. No major complications or side effects were seen in our trial. The raised leg

  1. Comparison Between the Use of Ropivacaine Alone and Ropivacaine With Sufentanil in Epidural Labor Analgesia

    PubMed Central

    Wang, Xian; Xu, Shiqin; Qin, Xiang; Li, Xiaohong; Feng, Shan-Wu; Liu, Yusheng; Wang, Wei; Guo, Xirong; Shen, Rong; Shen, Xiaofeng; Wang, Fuzhou

    2015-01-01

    Abstract To compare the analgesic efficacy and safety of the sole local anesthetic ropivacaine with the combination of both local anesthetic ropivacaine and opioidergic analgesic sufentanil given epidurally on the labor pain control. After institutional review board approval and patient consent, a total of 500 nulliparas requesting epidural labor analgesia were enrolled and 481 eventually were randomized into 2 groups: a sole local anesthetic group (ropivacaine 0.125%) and a combination of local anesthetic and opioidergic analgesic group (0.125% ropivacaine + 0.3 μg/mL sufentanil). After the test dose, a 10-mL epidural analgesic solution was given in a single bolus, followed by intermittent bolus injection of 10 to 15 mL of the solution. The primary outcome was the analgesic efficacy measured using Numerical Rating Scale (NRS) of pain. Other maternal and infant variables were evaluated as secondary outcomes. A total of 346 participants completed the study. The median NRS pain score during the 1st stage of labor was significantly lower in the combination group 2.2 (interquartile range [IQR]: 1.8–2.7) comparing to the sole local analgesic group 2.4 (IQR: 2.0–2.8) (P < 0.0001). No significant difference was observed in NRS pain score prior epidural analgesia and during the 2nd stage of labor. Patients in both groups rated same satisfaction of analgesia. Patients in the sole local analgesic group experienced fewer side effects than those in the combination group (37.7% vs 47.2%, P = 0.082). The individual analgesia-related cost in the sole local analgesic group was less ($5.7 ± 2.06) than that in the combination group ($9.76 ± 3.54) (P < 0.0001). The incidence of 1-minute Apgar ≤ 7 was lower in the sole local analgesic group 2 (1.2%) than the combination group 10 (5.5%) (P = 0.038). No difference was found between other secondary outcomes. The sole local anesthetic ropivacaine produces a comparable labor analgesic effect as the

  2. Evaluation of anatomic landmarks and safe zones for screw placement in the atlas via the posterior arch.

    PubMed

    Gebauer, Matthias; Barvencik, Florian; Briem, Daniel; Kolb, Jan P; Seitz, Sebastian; Rueger, Johannes M; Püschel, Klaus; Amling, Michael

    2010-01-01

    Several studies have evaluated quantitative anatomic data for direct lateral mass screw fixation. To analyze anatomic landmarks and safe zones for optimal screw placement through the posterior arc of the human atlas, morphometric parameters of 41 adult native human atlas specimens were quantitatively measured. Internal dimensions of the atlas (lateral mass, maximum and minimum intraosseous screw length), minimum height and width of the posterior arc and optimal screw insertion angles were defined on pQCT scans. By this, an optimal posterior screw insertion point (OIP) and a preferable screw direction (PSD) through the posterior arch into the lateral mass of C1 were defined. External dimensions (transverse and sagittal diameter) as well as the width of the mid-portion of C1 lateral mass were significantly higher in male specimens. The mean height of the posterior arch at the vertebral artery groove was 4.1 +/- 0.8 mm in female and 4.6 +/- 0.9 mm in male specimens. The optimal screw insertion point was located 21.6 +/- 1.7 mm in female and 23.6 +/- 2.3 mm in male lateral from the posterior tubercle of C1 (P < 0.01). The preferable screw direction was a mean medial inclination of 7.9 +/- 1.9 degrees in female and 7.3 +/- 2.7 degrees in male specimens and a mean rostral direction of 2.4 +/- 1.8 degrees in female and 3.1 +/- 1.7 degrees in male specimens. In conclusion, the presented study provides information for the use and design of upper cervical spine instrumentation techniques, such as screw placement to C1 via the posterior arch. The characterization of working areas and safe zones (OIP, PSD) might contribute to a minimization of screw malposition in this highly demanding instrumentation technique.

  3. The Effect of Epidural Analgesia on Labour, Mode of Delivery and Neonatal Outcome in Nullipara of India, 2011-2014

    PubMed Central

    Makhija, Bela; Arora, Manjeet; Haritwal, Arpana; Gurha, Pavan

    2014-01-01

    Aims: This study aimed to evaluate the effect of ropivacaine epidural analgesia on duration and outcome of labour in nulliparous parturients of India with parturient not receiving any analgesia. Settings and Design: One hundred and twenty nulliparous parturient in established labour at full term with a singleton vertex presentation were assigned to the study. Parturients who request epidural analgesia were allocated in the epidural group (n=60), whereas those not enthusiastic to labour analgesia were allocated in the control group (n=60). Materials and Methods: Epidural analgesia was provided by a bolus injection of 10 ml of ropivacaine 0.2% and 50μg fentanyl and maintained by using a continuous infusion of ropivacaine 0.1% with fentanyl 2μl/ml at a 10ml/hour rate. The outcomes were duration of labour, incidence of cesarean sections and instrumental vaginal delivery and neonatal outcome. Statistical Analysis used: Statistical analysis was conducted using unpaired student t-test and chi-square test as required. All tests of significance were performed using two-tailed probability tests. Differences were considered significant when p-value was <0.05. Results: The two groups were comparable in terms of socio-demographic data. The mean duration of first stage of labour was shorter in epidural group (4.83 ± 1.59 h) compared with control group (5.48 ± 1.56 h) while the duration of second stage of labour was prolong in epidural group (33.13 ± 12.78 min) as compared to control (27.53 ± 11.73 min). Instrumental vaginal or caesarean delivery rate did not increase in the epidural group. The APGAR scores at 5 min were statistically similar in both groups. Conclusion: Epidural analgesia by ropivacaine in Indian nulliparous resulted in shorter duration of first stage and prolongs duration of second stage of labour compared with parturients without analgesia; however, instrumental vaginal or caesarean delivery rate does not increase in the epidural group. PMID:25478409

  4. Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia

    PubMed Central

    Estcourt, Lise J; Ingram, Callum; Doree, Carolyn; Trivella, Marialena; Stanworth, Simon J

    2016-01-01

    Background People with a low platelet count (thrombocytopenia) often require lumbar punctures or an epidural anaesthetic. Lumbar punctures can be diagnostic (haematological malignancies, epidural haematoma, meningitis) or therapeutic (spinal anaesthetic, administration of chemotherapy). Epidural catheters are placed for administration of epidural anaesthetic. Current practice in many countries is to correct thrombocytopenia with platelet transfusions prior to lumbar punctures and epidural anaesthesia, in order to mitigate the risk of serious procedure-related bleeding. However, the platelet count threshold recommended prior to these procedures varies significantly from country to country. This indicates significant uncertainty among clinicians of the correct management of these patients. The risk of bleeding appears to be low but if bleeding occurs it can be very serious (spinal haematoma). Therefore, people may be exposed to the risks of a platelet transfusion without any obvious clinical benefit. Objectives To assess the effects of different platelet transfusion thresholds prior to a lumbar puncture or epidural anaesthesia in people with thrombocytopenia (low platelet count). Search methods We searched for randomised controlled trials (RCTs) in CENTRAL (The Cochrane Library 2016, Issue 3), MEDLINE (from 1946), EMBASE (from 1974), the Transfusion Evidence Library (from 1950) and ongoing trial databases to 3 March 2016. Selection criteria We included RCTs involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given to prevent bleeding in people of any age with thrombocytopenia requiring insertion of a lumbar puncture needle or epidural catheter. We only included RCTs published in English. Data collection and analysis We used standard methodological procedures expected by Cochrane. Main results We identified no completed or ongoing RCTs in English. We did not exclude any completed or ongoing RCTs

  5. Postoperative epidural analgesia for patients undergoing pectus excavatum corrective surgery: a 10-year retrospective analysis

    PubMed Central

    Siddiqui, Asad; Tse, Andrew; Paul, James E; Fitzgerald, Peter; Teh, Bernice

    2016-01-01

    Introduction Managing postoperative pain in patients undergoing minimally invasive pectus excavatum repair (Nuss procedure) is challenging but essential in facilitating ambulation and minimizing the length of stay. Although multiple epidural regimens with varying opioids are presently used for pain management, there is currently no clinical consensus regarding which epidural regimen provides the best analgesia outcomes with the fewest side effects. This 10-year retrospective cohort study was performed to compare the quality of analgesia and the incidence of side effects associated with the three most common epidural regimens used at a tertiary care children’s hospital, in patients undergoing the Nuss procedure. Methods Seventy-two pediatric patients were identified as having been treated with one of three epidural regimens for postoperative pain management following the Nuss procedure: Group A (n=12) received 0.125% bupivacaine and 5 µg/mL fentanyl, Group B (n=21) received 0.125% bupivacaine and 10 µg/mL hydromorphone, and Group C (n=39) received 0.1% ropivacaine and 20 µg/mL hydromorphone. Our primary outcome was maximal daily pain scores (numerical rating scale 0–10), with an analytical focus on postoperative day 1 scores. The primary outcome was analyzed using linear regression. The secondary outcomes included the length of stay, side-effect profiles as reflected by the number of treatments for nausea and pruritus, pain scores according to epidural site insertion, occurrence of breakthrough pain, and presence of severe pain throughout their hospital stay. Secondary outcomes were analyzed using linear or logistic regression adjusted for pain scores at baseline. The criterion for statistical significance was set a priori at alpha =0.05. Results Group A had significantly higher day-1 pain scores (score 5.42/10) than Group B (4.52/10; P=0.030) and Group C (4.49/10; P=0.015) after adjusting for baseline pain and age. No significant difference in maximum daily

  6. Retrospective cohort study of usage patterns of epidural injections for spinal pain in the US fee-for-service Medicare population from 2000 to 2014

    PubMed Central

    Pampati, Vidyasagar; Hirsch, Joshua A

    2016-01-01

    Objective To assess the usage patterns of epidural injections for chronic spinal pain in the fee-for-service (FFS) Medicare population from 2000 to 2014 in the USA. Design A retrospective cohort. Methods The descriptive analysis of the administrative database from Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) master data from 2000 to 2014 was performed. The guidance from Strengthening the Reporting of Observational studies in Epidemiology (STROBE) was applied. Analysis included multiple variables based on the procedures, specialties and geography. Results Overall epidural injections increased 99% per 100 000 Medicare beneficiaries with an annual increase of 5% from 2000 to 2014. Lumbar interlaminar and caudal epidural injections constituted 36.2% of all epidural injections, with an overall decrease of 2% and an annual decrease of 0.2% per 100 000 Medicare beneficiaries. However, lumbosacral transforaminal epidural injections increased 609% with an annual increase of 15% from 2000 to 2014 per 100 000 Medicare population. Conclusions Usage of epidural injections increased from 2000 to 2014, with a decline thereafter. However, an escalating growth has been seen for lumbosacral transforaminal epidural injections despite numerous reports of complications and regulations to curb the usage of transforaminal epidural injections. PMID:27965254

  7. [Drainage of the Frontal Sinus to Cure Epidural and Brain Abscesses Developed after Surgery via Anterior Interhemispheric Approach].

    PubMed

    Bando, Kazuhiko; Ebisutani, Daizo

    2015-08-01

    We report a woman whose anterior communicating artery (AcomA) aneurysm was clipped via an anterior interhemispheric approach when she was 49 years old. At the age of 51, she presented with a subcutaneous abscess and osteomyelitis, so the cranioplastic bone was removed. Six months later, she underwent cranioplasty using hydroxyapatite. Her subcutaneous abscess recurred and the epidural abscess and hydroxyapatite were removed 11 years later after the first operation. The patient underwent observation therapy for the next 4 years, as the dura was ossified. She presented with frontal swelling 15 years after aneurysmal clipping, and neither abscess puncture nor the administration of antibacterial drugs was curative. The patient also complained of chill, thirst, and tremor, and developed disorientation 25 days later. Computed tomography (CT) and magnetic resonance imaging (MRI) showed extension of the epidural and subcutaneous abscesses to a frontal brain abscess. After consulting an otolaryngologist, we performed frontal drainage into the nasal cavity. After making a bicoronal skin incision, the subcutaneous, epidural, and intracapsular brain abscesses were removed while taking care not to damage the capsules. A silicone T-tube was placed in the bifrontal epidural cavity (previous frontal sinus), and its tip was inserted into the nasal cavity through the nasofrontal duct for abscess drainage. After 3 months, the tube was removed. A CT scan acquired 10 years later showed no brain abscess, perifocal edema, or epidural and subcutaneous abscesses.

  8. Foetal heart rate deceleration with combined spinal-epidural analgesia during labour: a maternal haemodynamic cardiac study.

    PubMed

    Valensise, Herbert; Lo Presti, Damiano; Tiralongo, Grazia Maria; Pisani, Ilaria; Gagliardi, Giulia; Vasapollo, Barbara; Frigo, Maria Grazia

    2016-01-01

    To understand the mechanisms those are involved in the appearance of foetal heart rate decelerations (FHR) after the combined epidural analgesia in labour. Observational study done at University Hospital for 86-term singleton pregnant women with spontaneous labour. Serial bedside measurement of the main cardiac maternal parameters with USCOM technique; stroke volume (SV), heart rate (HR), cardiac output (CO) and total vascular resistances (TVR) inputting systolic and diastolic blood pressure before combined epidural analgesia and after 5', 10', 15' and 20 min. FHR was continuously recorded though cardiotocography before and after the procedure. Correlation between the appearance of foetal heart rate decelerations and the modification of maternal haemodynamic parameters. Fourteen out of 86 foetuses showed decelerations after the combined spino epidural procedure. No decelerations occurred in the women with low TVR (<1000 dyne/s/cm(-5)) at the basal evaluation. FHR abnormalities were concentrated in 39 women who presented elevated TVR values at the basal evaluation (>1200 dyne/s/cm(-5)). Soon after the epidural procedure, the absence of increase in SV and CO was observed in these women. No variations in systolic and diastolic blood pressure values were found. The level of TVR before combined epidural analgesia in labour may indicate the risk of FHR abnormalities after the procedure. Low TVR (<1000 dyne/s/cm(-5)) showed a reduced risk of FHR abnormalities. FHR decelerations seem to occur in women without the ability to upregulate SV and CO in response to the initial effects of analgesia.

  9. Analgesic and anti-hyperalgesic effects of epidural morphine in an equine LPS-induced acute synovitis model.

    PubMed

    van Loon, Johannes P A M; Menke, Eveline S; L'ami, Jiske J; Jonckheer-Sheehy, Valerie S M; Back, Willem; René van Weeren, P

    2012-08-01

    Epidural morphine is widely used in veterinary medicine, but there is no information about the anti-hyperalgesic and anti-inflammatory effects in acute inflammatory joint disease in horses. The analgesic, anti-hyperalgesic and anti-inflammatory effects of epidural morphine (100mg/animal or 0.17 ± 0.02 mg/kg) were therefore investigated in horses with acute synovitis. In a cross-over study, synovitis was induced in the talocrural joint by intra-articular lipopolysaccharide (LPS). The effect of epidural morphine was evaluated using physiological, kinematic and behavioural variables. Ranges of motion (ROM) of the metatarsophalangeal and talocrural joints were measured, clinical lameness scores and mechanical nociceptive thresholds (MNTs) were assessed and synovial fluid inflammatory markers were measured. The injection of LPS induced transient synovitis, resulting in clinical lameness, decreased ranges of motion in the talocrural and metatarsophalangeal joints, decreased limb loading at rest and increased composite pain scores. Epidural morphine resulted in a significant improvement in clinical lameness, increased ROM and improved loading of the LPS-injected limb at rest, with no effects on synovial fluid inflammatory markers. Morphine prevented a decrease in MNT and, hence, inhibited the development of hyperalgesia close to the dorsal aspect of inflamed talocrural joints. This study showed that epidural morphine provides analgesic and anti-hyperalgesic effects in horses with acute synovitis, without exerting peripheral anti-inflammatory effects.

  10. A cost-effective, non-invasive system for pressure monitoring during epidural needle insertion: Design, development and bench tests.

    PubMed

    Tesei, M; Saccomandi, P; Massaroni, C; Quarta, R; Carassiti, M; Schena, E; Setola, R

    2016-08-01

    Epidural blockade procedures have gained large acceptance during last decades. However, the insertion of the needle during epidural blockade procedures is challenging, and there is an increasing alarming risk in accidental dural puncture. One of the most popular approaches to minimize the mentioned risk is to detect the epidural space on the base of the loss of resistance (LOR) during the epidural needle insertion. The aim of this paper is to illustrate an innovative and non-invasive system able to monitor the pressure exerted during the epidural blockade procedure in order to detect the LOR. The system is based on a Force Sensing Resistor (FSR) sensor arranged on the top of the syringe's plunger. Such a sensor is able to register the resistance opposed to the needle by the different tissues transducing the pressure exerted on the plunger into a change of an electrical resistance. Hence, on the base of a peculiar algorithm, the system automatically detects LOR providing visual and acoustic feedbacks to the operator improving the safety of the procedure. Experiments have been performed to characterize the measurement device and to validate the whole system. Notice that the proposed solution is able to perform an effective detection of the LOR.

  11. Efficacy of Platelet Rich Plasma via Lumbar Epidural Route in Chronic Prolapsed Intervertebral Disc Patients-A Pilot Study

    PubMed Central

    Chopra, Gaurav

    2016-01-01

    Introduction Lumbar radiculopathy is a major health problem often treated by surgery or guided lumbar epidural steroids for pain relief. We have used Platelet Rich Plasma (PRP) a novel therapeutic tool of autologous nature that has emerged strongly in recent years to treat patients of prolapsed intervertebral disc. Aim To evaluate the efficacy of PRP via interlaminar epidural route in treatment of pain in patients with prolapsed inter vertebral disc. Materials and Methods Ten patients were injected with five ml of autologous platelet rich plasma under fluoroscopic guidance via interlaminar lumbar epidural injection into area of affected nerve root. They were followed using VAS (Visual Analogue Scale), SLRT (Straight Leg Raising Test) and MODQ (Modified Oswestry Disability Questionnaire) for clinical improvement. Results Patients who had received epidural injections of autologous PRP showed improvements in their scores of evaluation tools. Improvement was sustained during the 3 month study period and was not associated with any complications. Conclusion Autologous PRP can be considered as a good alternative to epidural steroids and surgery in management of patients with chronic prolapsed intervertebral disc. PMID:27790553

  12. Posterior ventricular anchoring neochordal repair of degenerative mitral regurgitation efficiently remodels and repositions posterior leaflet prolapse†

    PubMed Central

    Woo, Y. Joseph; MacArthur, John W.

    2013-01-01

    OBJECTIVES Mitral valve repair techniques for degenerative disease typically entail leaflet resection or neochordal construction, which may require extensive resection, leaflet detachment/reattachment, reliance on diseased native chords or precise neochordal measuring. Occasionally, impaired leaflet mobility, reduced coaptation surface and systolic anterior motion (SAM) may result. We describe a novel technique for addressing posterior leaflet prolapse/flail, which both simplifies repair and addresses these issues. METHODS Fifty-four patients (age 62 ± 11 years) with degenerative MR underwent this new repair, 36 of whom minimally-invasively. A CV5 Gore-Tex suture was placed into the posterior left ventricular myocardium underneath the prolapsing segment as an anchor. This suture was then used to imbricate a portion of the prolapsed segment into the ventricle, creating a smooth, broad, non-prolapsed coapting surface on a leaflet with preserved mobility, additional neochordal support and posteriorly positioned enough to preclude SAM. RESULTS Repair was successful in all patients. The mean MR grade was reduced from +3.8 to +0.1 with 50 of 54 patients having zero MR and 4 of the 54 having trace or mild MR. All patients had proper antero-posterior location of the coaptation line of a mean length of 10.2 mm, and preserved posterior leaflet mobility. No patients had SAM or mitral stenosis. All patients were discharged and are currently doing well. CONCLUSION This new technique facilitated efficient single-suture repair of the prolapsed posterior leaflet mitral regurgitation without the need for resection or sliding annuloplasty. It precluded the need for precise neochordal measurement and preserved the leaflet coaptation surface. PMID:23449863

  13. [Posterior dislocation of the sternoclavicular joint].

    PubMed

    Mäkinen, Tatu; Madanat, Rami; Heinänen, Mikko; Brinck, Tuomas; Pajarinen, Jarkko

    2013-01-01

    Posterior dislocation of the sternoclavicular joint is a rare injury. It can be associated with life-threatening complications. Computed tomography is the imaging modality of choice with which possible associated injuries can be detected. Acute injuries are managed with closed reduction under general anaesthesia. A fracture-dislocation is inherently more unstable than an isolated dislocation. Surgical treatment is advocated in cases of delayed diagnosis or failed closed reduction. With early diagnosis and treatment, the long-term outcome of this injury is good.

  14. Relief of postural post dural puncture headache by an epidural blood patch 12 months after dural puncture.

    PubMed

    Klepstad, P

    1999-10-01

    A 20-year-old previously healthy male presented at the pain clinic with chronic headache of about one year duration. Clinical examination revealed no pathological manifestations. During the consultation the patient was drinking Coca-Cola. On direct questioning he told that drinking Coca-Cola gave partial relief from the headache, and that the headache started after he had received two spinal anaesthetics for treatment of a lower leg fracture. Postural post dural puncture headache was now suspected and an epidural blood patch performed. Despite an interval of nearly 12 months since the dural punctures, a single epidural blood patch completely relieved the headache. This case history demonstrates that an epidural blood patch should be tried if a chronic post dural puncture headache is suspected.

  15. Decompression of Posterior Ankle Impingement With Concomitant Anterior Ankle Pathology by Posterior Ankle Arthroscopy in the Supine Position.

    PubMed

    Lui, Tun Hing

    2016-10-01

    Posterior ankle endoscopy is a safe and effective approach for treatment of posterior ankle impingement. This is usually performed with the patient in prone position. The purpose of this technical note is to describe an arthroscopic approach of decompression of posterior ankle impingement with the patient in supine position. This is indicated if there is posterior ankle impingement together with other ankle pathology requiring anterior ankle arthroscopy. This approach allows treatment of both anterior ankle and posterior ankle pathology with the patient in the supine position. Concomitant anterior ankle arthroscopy can be performed with the usual orientation without the need of change of patient's position.

  16. Analgesic efficacy using loss of resistance to air vs. saline in combined spinal epidural technique for labour analgesia.

    PubMed

    Leo, S; Lim, Y; Sia, A T H

    2008-09-01

    Identification of the epidural space is often performed using the loss of resistance technique to either air or saline. We sought to investigate if the medium used affected the quality of analgesia obtained by parturients who received labour epidurals. We conducted a retrospective audit of labour epidurals performed on nulliparous parturients in our institution from May 2003 to March 2005. All epidural catheters were inserted by senior obstetric anaesthetists using a combined spinal epidural technique. The following information was recorded: parturients' demographic data, loss of resistance technique used, type and amount of local anaesthetic solution administered, complications encountered during procedure, pre-block and post-block pain scores, incidence of breakthrough pain requiring supplemental medication and post-block side-effects. Data from 2848 patients were collected and analysed; 56% of patients made up the saline group and 44% the air group. Patients in both groups had similar demographic profiles and similar incidences of complications and post-block side-effects. However patients in the air group had a higher incidence of recurrent breakthrough pain P = 0.023). We also identified three other factors that were associated with an increased incidence of recurrent breakthrough pain; administration of pre-block oxytocin, sitting position of the parturient during the procedure and the use of intrathecal bupivacaine for induction of analgesia. Our findings suggest that a loss of resistance to air is associated with a higher incidence of recurrent breakthrough pain among parturients who received combined spinal epidural analgesia for labour than a loss of resistance to saline.

  17. Venoconstrictor agents mobilize blood from different sources and increase intrathoracic filling during epidural anesthesia in supine humans

    SciTech Connect

    Stanton-Hicks, M.; Hoeck, A.S.; Stuehmeier, K.D.A.; Arndt, J.O.

    1987-03-01

    The authors studied the effects of dihydroergotamine (DHE) and etilefrine hydrochloride (E) on the regional distribution of /sup 99m/Tc-marked erythrocytes during epidural anesthesia in eight supine men to determine if vasoactive agents with venoconstrictor action would enhance cardiac filling during epidural anesthesia. Radioactivity was recorded with a gamma camera, and its distribution determined in the thorax, abdomen, and limbs. Arterial and central venous pressure, heart rate, and calf volume by plethysmography were measured. During epidural anesthesia with a sensory block up to T4/5, DHE (7.5 micrograms/kg) reduced the radioactivity, i.e., blood volume, in both the innervated (-5.9 +/- 3.5%) and denervated muscle/skin (-16.9 +/- 7%) regions, and increased it in both the intrathoracic (+7.0 +/- 2.3%), and splanchnic vasculature (+4.2 +/- 3.2). In contrast, E (6 micrograms X kg-1 X min-1) decreased the blood volume most markedly in the splanchnic region (-5.4 +/- 0.7%) and increased it in the thorax (+2 +/- 0.6%). All these changes were statistically significant. The combined effects were estimated to be equivalent to a transfusion of nearly 1.01 of blood. Both drugs reversed the hypotensive action of epidural anesthesia. During epidural anesthesia, DHE preferentially constricted the capacitance vessels in skeletal muscle and skin irrespective of the state of innervation, whereas E preferentially constricted the splanchnic vasculature. In the doses used, the two agents replenished in an additive fashion the central circulation during epidural anesthesia.

  18. Traumatic posterior dislocation of hip in children.

    PubMed

    Kutty, S; Thornes, B; Curtin, W A; Gilmore, M F

    2001-02-01

    Traumatic posterior dislocation of the hip joint in children is an uncommon injury. It constitutes a true orthopedic emergency. It makes up over 80% of pediatric hip dislocations. In children, it can occur as a result of minimal trauma, which is attributed to a soft pliable acetabulum and ligamentous laxity. In skeletally mature adolescents, a greater force is required to dislocate the hip joint. Delay in reduction is associated with long-term complications such as avascular necrosis and degenerative arthritis. Avascular necrosis is related to the duration of dislocation. A poorer prognosis is associated with delay in reduction beyond 6 hours, advanced skeletal maturity, or multiple traumas. Prompt reduction minimizes complications. We report two cases of traumatic posterior dislocation of hip in children aged 3 and 14 years. Both were reduced within 6 hours of dislocation, and review at 6 months revealed normal examination and no evidence of any post-traumatic changes. Post-reduction treatment remains without a consensus. This review highlights the clinical presentation, management, and time-sensitive complications of the injury.

  19. Management of an Uncomplicated Posterior Elbow Dislocation

    PubMed Central

    Blackard, Douglas; Sampson, Jo-Ann

    1997-01-01

    Objective: To present a case of an uncomplicated posterior elbow dislocation in a US World Cup athlete and discuss her rehabilitation. Background: Traditional protocol for management of this injury has been splint immobilization for several weeks, but research suggests a shortened duration of immobilization and early active motion. Differential Diagnosis: Elbow dislocation with possible fracture. Treatment: The dislocation was reduced and a compression bandage and sling were applied. The sports medicine staff and athlete determined that rehabilitation would involve limited immobilization with a posterior splint. Also, active range-of- motion exercises were to be incorporated early in the range-of- motion program to decrease pain at the articulation. Uniqueness: The athlete was not immobilized and her aggressive five-phase rehabilitation program progressed according to decrease in inflammation and increase in range of motion and strength. Conclusions: Shortened immobilization and return to World Championship competition 6 weeks postinjury had no longterm adverse effects on the athlete. ImagesFig 1.Fig 2.Fig 3.Fig 4.Fig. 5. PMID:16558436

  20. Posterior malleolar fractures of the ankle.

    PubMed

    Bartoníček, J; Rammelt, S; Tuček, M; Naňka, O

    2015-12-01

    Despite an increasing awareness of injuries to PM in ankle fracture-dislocations, there are still many open questions. The mere presence of a posterior fragment leads to significantly poorer outcomes. Adequate diagnosis, classification and treatment require preoperative CT examination, preferably with 3D reconstructions. The indication for surgical treatment is made individually on the basis of comprehensive assessment of the three-dimensional outline of the PM fracture and all associated injuries to the ankle including syndesmotic instability. Anatomic fixation of the avulsed posterior tibiofibular ligament will contribute to syndesmotic stability and restore the integrity of the incisura tibiae thus facilitating anatomic reduction of the distal fibula. A necessary prerequisite is mastering of posterolateral and posteromedial approaches and the technique of direct reduction and internal fixation. Further clinical studies with higher numbers of patients treated by similar methods and evaluation of pre- and postoperative CT scans will be necessary to determine reliable prognostic factors associated with certain types of PM fractures and associated injuries to the ankle.

  1. Microsurgical anatomy of the posterior fossa cisterns.

    PubMed

    Matsuno, H; Rhoton, A L; Peace, D

    1988-07-01

    The microsurgical anatomy of the posterior fossa cisterns was examined in 15 cadavers using 3X to 40X magnification. Liliequist's membrane was found to split into two arachnoidal sheets as it spreads upward from the dorsum sellae: an upper sheet, called the diencephalic membrane, which attaches to the diencephalon at the posterior edge of the mamillary bodies, and a lower sheet, called the mesencephalic membrane, which attaches along the junction of the midbrain and pons. Several other arachnoidal membranes that separate the cisterns were identified. These include the anterior pontine membrane, which separates the prepontine and cerebellopontine cisterns; the lateral pontomesencephalic membrane, which separates the ambient and cerebellopontine cisterns; the medial pontomedullary membrane, which separates the premedullary and prepontine cisterns; and the lateral pontomedullary membrane, which separates the cerebellopontine and cerebellomedullary cisterns. The three cisterns in which the arachnoid trabeculae and membranes are the most dense and present the greatest obstacle at operation are the interpeduncular and quadrigeminal cisterns and the cisterna magna. Numerous arachnoid membranes were found to intersect the oculomotor nerves. The neural and vascular structures in each cistern are reviewed.

  2. Pharmacokinetics of epidurally administered nicomorphine with its metabolites and glucuronide conjugates in patients undergoing pulmonary surgery during combined epidural local anaesthetic block and general anaesthesia.

    PubMed

    Koopman-Kimenai, P M; Vree, T B; Booij, L H; Hasenbos, M A

    1995-08-01

    After epidural administration of 15 mg 3, 6-dinicotinoylmorphine (nicomorphine) in 10 patients undergoing pulmonary surgery, the parent compound was quickly metabolized into the metabolites 6-mononicotinoylmorphine and morphine. The mean apparent half-lives (+/- SD) of elimination were 10 min (0.165 h +/- 0.053 h) for 3,6-dinicotinoylmorphine and 1.77 h +/- 1.23 h for 6-mononicotinoylmorphine. Morphine is subsequently metabolized into morphine-3-glucuronide and morphine-6-glucuronide. The apparent half-lives of morphine, morphine-3-glucuronide, and morphine-6-glucuronide are similar: 3.63 h +/- 1.63 h, 4.10 h +/- 0.57 h, and 4.20 h +/- 1.64 h respectively. The possible glucuronide conjugate of 6-mononicotinoylmorphine was not detected. The prodrug 3,6-dinicotinoylmorphine was biotransformed into three active compounds: 6-mononicotinoylmorphine, morphine, and morphine-6-glucuronide.

  3. Epidural anesthesia for laparoscopic cholecystectomy in a patient with sickle cell anemia, beta thalassemia, and Crohn's disease -A case report-

    PubMed Central

    Özlü, Onur

    2012-01-01

    A 37-year-old woman diagnosed with sickle cell anemia (SCA), beta (+) thalassemia, Crohn's disease, and liver dysfunction was scheduled for laparoscopic cholecystectomy (LC) due to acute cholecystitis with gall bladder. Regional anesthesia was performed. An epidural catheter was inserted into the 9-10 thoracal epidural space and then 15 ml of 0.5% bupivacaine was injected through the catheter. The level of sensorial analgesia tested with pinprick test reached up to T4. Here we describe the first case of the combination of sickle cell anemia (SCA), beta (+) thalassemia, and Crohn's disease successful anesthetic management with attention to hemodynamics, particularly with regards to liver dysfunction. PMID:23115690

  4. Disseminated Cunninghamella bertholletiae infection with spinal epidural abscess in a kidney transplant patient: case report and literature review.

    PubMed

    Navanukroh, O; Jitmuang, A; Chayakulkeeree, M; Ngamskulrungroj, P

    2014-08-01

    Cunninghamella bertholletiae is a rare cause of invasive mucormycosis. We report the case of a 42-year-old Thai woman who suffered from disseminated C. bertholletiae infection. The patient developed dry cough, sharp shooting pain in the left buttock referred to the left leg, and fever 1 month after undergoing deceased-donor kidney transplantation. Radiographic studies exhibited multiple pulmonary cavities, osteomyelitis of the sacral spine, epidural abscess along the lumbrosacral spine, and paravertebral soft tissue involvement. Surgical debridement of the epidural abscess concurrent with prolonged intravenous administration of amphotericin B resulted in a good outcome.

  5. Trajectory of platelets in pregnancy - do low-risk women need an intrapartum full blood count prior to epidural?

    PubMed

    Duong, Christine; Kidson-Gerber, Giselle; Peters, Nancy; Listijono, Dave R; Henry, Amanda

    2015-10-01

    This study aimed to investigate whether pregnant women with a normal 28-week gestation platelet count and no high-risk conditions for thrombocytopenia require a pre-epidural platelet count. All 1844 included women (platelet count > 150 × 10(9) /L at 28 weeks' gestation, term singleton birth, no thrombocytopenia risk conditions) had a platelet count > 100 × 10(9) /L prebirth, suggesting low-risk pregnant women do not require pre-epidural full blood count solely to check platelet count.

  6. Prehension Movements in a Patient (AC) with Posterior Parietal Cortex Damage and Posterior Callosal Section

    ERIC Educational Resources Information Center

    Frak, Victor; Paulignan, Yves; Jeannerod, Marc; Michel, Francois; Cohen, Henri

    2006-01-01

    Prehension movements of the right hand were recorded in a right-handed man (AC), with an injury to the left posterior parietal cortex (PPC) and with a section of the left half of the splenium. The kinematic analysis of AC's grasping movements in direct and perturbed conditions was compared to that of five control subjects. A novel effect in…

  7. GNSS integer ambiguity validation based on posterior probability

    NASA Astrophysics Data System (ADS)

    Wu, Zemin; Bian, Shaofeng

    2015-10-01

    GNSS integer ambiguity validation is considered to be a challenge task for decades. Several kinds of validation tests are developed and widely used in these years, but theoretical basis is their weakness. Ambiguity validation theoretically is an issue of hypothesis test. In the frame of Bayesian hypothesis testing, posterior probability is the canonical standard that statistical decision should be based on. In this contribution, (i) we derive the posterior probability of the fixed ambiguity based on the Bayesian principle and modify it for practice ambiguity validation. (ii) The optimal property of the posterior probability test is proved based on an extended Neyman-Pearson lemma. Since validation failure rate is the issue users most concerned about, (iii) we derive the failure rate upper bound of the posterior probability test, so the user can use the posterior probability test either in the fixed posterior probability or in the fixed failure rate way. Simulated as well as real observed data are used for experimental validations. The results show that (i) the posterior probability test is the most effective within the R-ratio test, difference test, ellipsoidal integer aperture test and posterior probability test, (ii) the posterior probability test is computational efficient and (iii) the failure rate estimation for posterior probability test is useful.

  8. Visual input to the mouse lateral posterior and posterior thalamic nuclei: photoreceptive origins and retinotopic order

    PubMed Central

    Allen, Annette E.; Procyk, Christopher A.; Howarth, Michael; Walmsley, Lauren

    2016-01-01

    Key points The lateral posterior and posterior thalamic nuclei have been implicated in aspects of visually guided behaviour and reflex responses to light, including those dependent on melanopsin photoreception.Here we investigated the extent and basic properties of visually evoked activity across the mouse lateral posterior and posterior thalamus.We show that a subset of retinal projections to these regions derive from melanopsin‐expressing retinal ganglion cells and find many cells that exhibit melanopsin‐dependent changes in firing.We also show that subsets of cells across these regions integrate signals from both eyes in various ways and that, within the lateral posterior thalamus, visual responses are retinotopically ordered. Abstract In addition to the primary thalamocortical visual relay in the lateral geniculate nuclei, a number of other thalamic regions contribute to aspects of visual processing. Thus, the lateral posterior thalamic nuclei (LP/pulvinar) appear important for various functions including determining visual saliency, visually guided behaviours and, alongside dorsal portions of the posterior thalamic nuclei (Po), multisensory processing of information related to aversive stimuli. However, despite the growing importance of mice as a model for understanding visual system organisation, at present we know very little about the basic visual response properties of cells in the mouse LP or Po. Prompted by earlier suggestions that melanopsin photoreception might be important for certain functions of these nuclei, we first employ specific viral tracing to show that a subset of retinal projections to the LP derive from melanopsin‐expressing retinal ganglion cells. We next use multielectrode electrophysiology to demonstrate that LP and dorsal Po cells exhibit a variety of responses to simple visual stimuli including two distinct classes that express melanopsin‐dependent changes in firing (together comprising ∼25% of neurons we recorded). We also

  9. Circulatory collapse following epidural bolus for Caesarean section a profound vasovagal reaction? A case report

    PubMed Central

    Oddby, Eva; Hein, Anette; Jakobsson, Jan G.

    2016-01-01

    Introduction Reduced blood pressure is commonly seen associated to spinal anaesthesia for Caesarean section and efforts to reduce its occurrence and its magnitude is common practice. Cardiovascular collapse requiring cardio-pulmonary resuscitation after putting the spinal/epidural block for Caesarean section is however a rare but most dramatic event. Presentation of case We describe a case with sudden short loss of circulation, circulatory collapse, short after start of emergency Caesarean section in top up epidural anaesthesia (3 + 12 ml ropivaciane 7.5 mg/ml), requiring CPR. The neonate was delivered during CPR with Apgar 1, 10, 10 at 1, 5 and 10 min. Circulation was restored following 60–90 s of CPR and administration of 0.5 mg adrenaline. No cardioversion was administered sinus rhythm was regained spontaneously. The mother and child had a further uncomplicated course. No signs of cardiac damage/anomaly, emboli, septicaemia, pereclampisa or local anaesthetic toxicity was found. The patient had prior to the decision about Caesarean section had fever and was subsequently relatively dehydrated. Discussion The patient had a fast return of sinus rhythm following birth of the child, without cardioversion. None of common causes for cardiac arrest was found and the patient an uncomplicated post Caesarean section course. The combination of epidural induced sympathetic block and reduced preload possibly triggered a Bezold-Jarisch reflex with a profound vasovagal reaction. Concluiosn A structured plan for the handling of cardiovascular crisis must be available wherever Caesarean section are performed. Adequate volume loading, left tilt and vigilant control of circulation following regional block performance is of outmost importance. PMID:27100952

  10. Continuous thoracic epidural anesthesia induces segmental sympathetic block in the awake rat.

    PubMed

    Freise, Hendrik; Anthonsen, Sören; Fischer, Lars G; Van Aken, Hugo K; Sielenkämper, Andreas W

    2005-01-01

    Thoracic epidural anesthesia (TEA) is used increasingly in critical care, especially for cardiac and intestinal sympathetic block. In this study we evaluated cardiorespiratory function and sympathetic activity in a new model of continuous TEA in awake rats. Thirteen rats received epidural saline control (CON) or bupivacaine 0.5% epidural infusion (EPI) at 15 microl/h for 2 h on day 1 and day 3. Mean arterial blood pressure, heart rate, respiration rate, arterial PCO2, and motor score were recorded at baseline and after 30, 60, 90, and 120 min. Skin temperature was measured at front paws, high-thoracic, mid-thoracic, and low-thoracic, hind paws, and the proximal and distal tail. Changes in sympathetic activity were assessed by skin temperature changes from baseline (DeltaT). In the EPI group, hemodynamics and respiration remained unchanged and only mild motor deficits occurred. DeltaT in thoracic segments was higher in the EPI than in the CON group (P <0.001 at all times at high-thoracic, mid-thoracic, and low-thoracic segments). Skin temperature decreased in the distal tail in the EPI group, e.g., after 90 min DeltaT=-0.86 +/- 0.25 degrees C (EPI) versus 0.4 +/- 0.12 degrees C (CON) (P <0.05 at 60, 90, and 120 min). DeltaT on day 3 was comparable to day 1. TEA induced stable segmental sympathetic block without cardiorespiratory and motor side effects in awake rats. This new technique may be applied in prolonged models of critical illness.

  11. Comparison of efficacy of bupivacaine and fentanyl with bupivacaine and sufentanil for epidural labor analgesia

    PubMed Central

    Kalra, Sumit; Saraswat, Namita; Agnihotri, G. S.

    2010-01-01

    Objectives: A study to compare the efficacy between fentanyl and sufentanil combined with low concentration (0.0625%) of bupivacaine for epidural labor analgesia in laboring women Materials and Methods: Fifty full term parturients received an initial bolus dose of a 10 ml solution containing 0.125% bupivacaine. The patients were randomly divided into two: group F received 0.0625% bupivacaine with 2.5 mcg/ml fentanyl and group S received 0.0625% bupivacaine with 0.25 mcg/ml sufentanil. Verbal analogue pain scores, need of supplementary/rescue boluses dose of bupivacaine consumed, mode of delivery, maternal satisfaction, and neonatal Apgar scores were recorded. No significant difference was observed between both groups. Results: Both the groups provided equivalent labor analgesia and maternal satisfaction. The chances of cesarean delivery were also not increased in any group. No difference in the cephalad extent of sensory analgesia, motor block or neonatal Apgar score were observed. Although mean pain scores throughout the labor and delivery were similar in both groups, more patients in fentanyl group required supplementary boluses though not statistically significant. Conclusion: We conclude that both 0.0625% bupivacaine-fentanyl (2.5 μg/ml) and 0.0625% bupivacaine-sufentanil (0.25 μg/ml) were equally effective by continuous epidural infusion in providing labor analgesia with hemodynamic stability achieving equivalent maternal satisfaction without serious maternal or fetal side effects. We found that sufentanil was 10 times more potent than fentanyl as an analgesic for continuous epidural labor analgesia. PMID:21189856

  12. Spinal subdural hematoma with cauda equina syndrome: A complication of combined spinal epidural anesthesia

    PubMed Central

    Singhal, Neha; Sethi, Priyanka; Jain, Jitesh Kumar; Agarwal, Saurabh

    2015-01-01

    Combined spinal-epidural anesthesia (CSE) is considered safe in lower limb surgeries. We report a case of sudden neurological deterioration in a stable postoperative patient who was given CSE for total knee replacement and low molecular weight heparin in postoperative period. On the 4th postoperative day, she developed sudden onset weakness in left lower limb along with bladder incontinence. Magnetic resonance imaging spine revealed a subdural hematoma at L2-L3 level. Immediate laminectomy along with cord decompression was done and patient recovered well except for a persistent foot drop on left side. PMID:25948911

  13. Salmonella Enterica Serotype Enteritidis Vertebral Osteomyelitis and Epidural Abscess Complicated with Meningitis.

    PubMed

    Oki, Masayuki; Ueda, Akihiro; Tsuda, Ayumi; Yanagi, Hidetaka; Ozawa, Hideki; Takagi, Atsushi

    2016-09-20

    Infection with non-typhoidal Salmonella often results in a self-limited acute gastroenteritis. Extra-intestinal Salmonella infection is relatively rare and occurs predominantly in infants and adults with significant underlying conditions. We describe a 54-year-old Japanese man with a history of heavy alcohol consumption and daily contact with a dog, who developed bacteremia complicated by vertebral osteomyelitis, spinal epidural abscess, and meningitis, due to Salmonella enterica serotype Enteritidis. This case suggests that Salmonella should be considered as an etiologic pathogen in adult patients with perivertebral infection or meningitis.

  14. Primary Epidural Varicosis as a Rare Cause of Sciatica: A Case Report

    PubMed Central

    Omidi-Kashani, Farzad; Hasankhani, Ebrahim Ghayem; Fathi, Mahdi

    2015-01-01

    Non-discogenic sciatica can be caused by any lesion along the course of the lumbosacral nerve roots and sciatic nerve. We aim to present a rare case of refractory sciatica in an otherwise healthy 25-year-old man. He complained of left leg pain without significant back pain. Extensor hallucis longus muscle was weak on the left side with limited straight leg rising. On magnetic resonance imaging, a space-occupying lesion resembling a sequestrated disc was noted that after surgical decompression, epidural varicosis was demonstrated. PMID:26538785

  15. Vertebral Osteomyelitis and Spinal Epidural Abscess: An Evidence-based Review.

    PubMed

    Boody, Barrett S; Jenkins, Tyler J; Maslak, Joseph; Hsu, Wellington K; Patel, Alpesh A

    2015-07-01

    Spinal infections have historically been associated with significant morbidity and mortality. Current treatment protocols have improved patient outcomes through prompt and accurate infection identification, medical treatment, and surgical interventions. Medical and surgical management, however, remains controversial because of a paucity of high-level evidence to guide decision making. Despite this, an awareness of presenting symptoms, pertinent risk factors, and common imaging findings are critical for treating spine infections. The purpose of this article is to review the recent literature and present the latest evidence-based recommendations for the most commonly encountered primary spinal infections: vertebral osteomyelitis and epidural abscess.

  16. Spinal epidural abscess caused by bacteroides fragilis group after dilation and curettage for incomplete abortion.

    PubMed

    Ohyagi, Masaki; Ohkubo, Takuya; Taniyama, Takashi; Tomizawa, Shoji; Okawa, Atsushi; Yokota, Takanori; Mizusawa, Hidehiro

    2012-04-01

    Spinal epidural abscess (SEA) is a rare infection complicated in patients who have some risk factors such as injection-drug use, diabetes mellitus, and several illnesses. However, no case of SEA associated with abortion has been reported. Here we report a case of SEA in a 30-year-old woman after dilation and curettage for incomplete abortion. The diagnosis of SEA was done by MRI and pus was drained after the cervical discectomy. Bacteroides fragilis group was cultured from the aspirated pus sample. The patient responded to surgical drainage and antibiotics.

  17. A Rare Case of Transverse Sinus Venous Thrombosis Simulating Postdural Puncture Headache After Cervical Epidural Injection.

    PubMed

    Guirguis, Maged; Jusino, Eduardo; Tolba, Reda; Samuel, Samuel

    2016-08-01

    Postdural puncture headache (PDPH) is a feared complication related to epidural steroid injections. We report a unique case in which all subjective and objective findings indicated the diagnosis of PDPH. However, the patient failed appropriate conservative and interventional management. Therapeutic failure prompted further investigation to establish the correct diagnosis of cerebral venous sinus thrombosis. Cerebral venous sinus thrombosis is a rare, difficult to diagnose, but potentially lethal disorder with nonspecific and variable clinical presentations, including headache and focal neurological deficits. Performing magnetic resonance imaging and magnetic resonance venogram should be considered early, especially in patients who fail to respond to standard interventions for PDPH.

  18. Spontaneous Spinal Epidural Hematoma Coexisting Guillan-Barré Syndrome in a Child: A Case Report.

    PubMed

    Lee, Chi Hyung; Song, Geun Sung; Kim, Young Ha; Son, Dong Wuk; Lee, Sang Weon

    2016-09-01

    Spontaneous spinal epidural hematoma (SSEH) has been reported as a rare cause of spinal cord compression, especially in children. Clinical features are usually nonspecific, although cervicothoracic location of hematoma could be presented with progressive paraplegia. Guillian-Barré syndrome (GBS) is clinically defined as an acute peripheral neuropathy causing progressive limb weakness. Because SSEH and GBS have very similar signs and symptoms, SSEH could be misdiagnosed as GBS. Nevertheless, they can be presented together. We describe a rare case of SSEH coexisting with GBS.

  19. Spontaneous Spinal Epidural Hematoma Coexisting Guillan-Barré Syndrome in a Child: A Case Report

    PubMed Central

    Lee, Chi Hyung; Kim, Young Ha; Son, Dong Wuk; Lee, Sang Weon

    2016-01-01

    Spontaneous spinal epidural hematoma (SSEH) has been reported as a rare cause of spinal cord compression, especially in children. Clinical features are usually nonspecific, although cervicothoracic location of hematoma could be presented with progressive paraplegia. Guillian-Barré syndrome (GBS) is clinically defined as an acute peripheral neuropathy causing progressive limb weakness. Because SSEH and GBS have very similar signs and symptoms, SSEH could be misdiagnosed as GBS. Nevertheless, they can be presented together. We describe a rare case of SSEH coexisting with GBS. PMID:27800000

  20. Epidural anesthesia for repeat cesarean delivery in a parturient with Klippel-Feil syndrome.

    PubMed

    Smith, Kathleen A; Ray, Adrienne P

    2011-07-01

    A patient with Klippel-Feil syndrome, morbid obesity, and scoliosis required cesarean delivery. Her previous cesarean deliveries were performed under general anesthesia. She desired a regional technique. Following aspiration prophylaxis and placement of standard monitors, ultrasound was used to identify midline and L(2-3) interspace. Unintentional dural puncture occurred at 10 cm, with an inability to advance the catheter. On second attempt, an epidural catheter was placed easily. After negative test dose, 18 ml of 2% lidocaine with epinephrine was administered to the patient. A T4 level was achieved. The patient tolerated surgery well. Complete block resolution occurred at 4 hours with no neurologic sequelae.