Thalamic Pain Misdiagnosed as Cervical Disc Herniation

Thalamic pain is a primary cause of central post-stroke pain (CPSP). Clinical symptoms vary depending on the location of the infarction and frequently accompany several pain symptoms. Therefore, correct diagnosis and proper examination are not easy. We report a case of CPSP due to a left acute thalamic infarction with central disc protrusion at C5-6. A 45-year-old-male patient experiencing a tingling sensation in his right arm was referred to our pain clinic under the diagnosis of cervical disc herniation. This patient also complained of right cramp-like abdominal pain. After further evaluations, he was diagnosed with an acute thalamic infarction. Therefore detailed history taking should be performed and examiners should always be aware of other symptoms that could suggest a more dangerous disease.

The relationship between postoperative cognitive dysfunction and the depth of sedation with propofol during spinal anesthesia in elderly patients

BACKGROUND: Postoperative cognitive dysfunction (POCD) is a common perioperative complication. The definitive causes of POCD have not been identified, but depth of anesthesia or sedation has been reported to influence POCD. The purpose of the present study was to assess the possible effect of the level of sedation on POCD at 1 week after surgery under spinal anesthesia in elderly patients. METHODS: We included 48 patients aged over 60 years, who were scheduled for elective knee and hip joint surgery under spinal anesthesia. Those patients were randomly allocated to one of the 2 groups: deep sedation group and light sedation group. The depth of sedation was monitored by entropy and observer's assessment of alertness/sedation (OAA/S) score. Cognitive function was assessed by 5 neurocognitive tests before and at 1 week after surgery. A postoperative deficit was defined as a postoperative decrement to preoperative score greater than 1 standard deviation on any test. A patient whose postoperative performance deteriorated by 1 or more standard deviations on 2 or more tests was classified as having experienced POCD. RESULTS: POCD occurred in 7 patients (28%) in the deep sedation group and in 4 patients (17.4%) in the light sedation group. The incidence of the POCD was not significantly different between the 2 groups. CONCLUSIONS: We were unable to detect a significant association between the depth of sedation and the presence of POCD at 1 week after surgery under spinal anesthesia.

A case of postpartum cerebral angiopathy with intracranial hemorrhage in Cesarean delivery: A case report

The occurrence of stroke during pregnancy and the postpartum period is uncommon but is a leading cause of maternal death. Postpartum cerebral angiopathy is one of the causes of the occurrence of stroke during peripartum. A 39-year-old woman with a gestational age of 38 weeks and with uncomplicated pregnancy was admitted to these authors' hospital and was made to undergo emergency Cesarean section under spinal anesthesia due to fetal distress. After the Cesarean delivery, it was found that her state of mind had changed into drowsiness to stupor in the post-anesthetic care unit. The brain computed tomography showed intracranial and subarachnoid hemorrhage. On the cerebral angiography, no aneurysm or arteriovenous malformation was found, except for the focal stenosis of the callosomarginal artery. Emergency decompressive craniectomy was done. After the craniectomy, the patient showed an alert mental status, mild Rt hemiplegia, and slight dysarthria three months after the surgery.

Comparison of the Effects of Intrathecal Fentanyl and Meperidine on Shivering after Cesarean Delivery under Spinal Anesthesia / 대한마취과학회지

BACKGROUND: Meperidine has proved a far more effective treatment for shivering after spinal anesthesia than equianalgesic doses of opioid agonist. We performed this prospective, double-blinded, randomized study to compare the antishivering effect of fentanyl and meperidine when added to intrathecal hyperbaric bupivacaine during Cesarean delivery under spinal anesthesia. METHODS: Sixty ASA I or II patients undergoing Cesarean delivery under spinal anesthesia were randomly assigned into three groups. Fentanyl 12.5 ug (group F) or meperidine 12.5 mg (group M) or normal saline 2.5 ml (group C) were added to 0.5% hyperbaric bupivacaine 8.5 mg for spinal anesthesia. Data including mean arterial pressure, heart rate, sensory block level, core temperature, shivering incidence and intensity were collected every 2 min for 10 min and then every 5 min until the end of surgery. RESULTS: There were no significant statistical differences in patient characteristics, the mean arterial pressure, heart rate and core temperature among the groups. The incidences of shivering in fentanyl and meperidine group were significantly lower than in the control group, but there were no significant differences between fentanyl and meperidine group. Shivering intensity was significantly lower in fentanyl and meperidine group than in the control group. CONCLUSIONS: Intrathecal fentanyl and meperidine added to 0.5% hyperbaric bupivacaine are effective in reducing the incidence and intensity of shivering associated with spinal anesthesia.

Postoperative Pain Control with Epidural Meperidine Infusion / 대한통증학회지

BACKGROUND: Epidural opioids are commonly used for postoperative analgesia. However, the side effects of epidural opioids include respiratory depression, sedation, pruritus, nausea, vomiting and urinary retention. Meperidine, due to its intermediate lipid solubility and local anesthetic properties, permits postoperative analgesia. The aim of this study was to compare meperidine alone to meperidine coupled with bupivacaine, and to determine the effects of epidural meperidine without bupivacaine, when used for epidural analgesia following hepatectomy abdominal surgery. METHODS: Patients received thoracic epidural analgesia with meperidine alone (3.5 mg/ml in saline) or with additional bupivacaine (0.15%) for 2 days after surgery. Postoperative pain was assessed using a visual analog scale (VAS) pain score 2 days after the operation, with the incidence and dose supplementation also evaluated. Postoperative side effects were assessed using a 3 grade system. RESULTS: No significant difference was found between the two groups in terms of age and weight, or in the pain scores, side effects, incidence and dose supplementation. CONCLUSIONS: 3.5 mg/ml epidural meperidine at a dose of 2 ml/hr provides effective postoperative analgesia.

Delayed Recovery after Continuous Infusion of Midazolam in Hepatic Dysfunction: A case report / 대한마취과학회지

Benzodiazepines are frequently administered for sedation to surgical intensive care unit patients who require postoperative intubation and mechanical ventilation. Midazolam is the most commonly used drug, which is water soluble, short-acting benzodiazepine and rapidly metabolized by the liver. Continuous intravenous infusion of midazolam was administered to the man who was 40 years old for mechanical ventilation in the intensive care unit for 58 hours. After discontinued midazolam, patient who had acute hepatic dysfunction had been sedated with endotracheal intubation for 5 days. Even flumazenil was tried twice to reverse the effect of midazolam, the response was limited by the time. Finally he awaked as recovery of his hepatic function.

Anaphylactic Reaction to Cefotetan during Spinal Anesthesia: A case report / 대한마취과학회지

A 37-year-old male was admitted for a hemorrhoidectomy. He received uneventfully spinal anesthesia for a hemorrhoidectomy. He had no previous history of any allergic tendency. By the request of the general surgeon, a cefotetan was intravenously administered slowly to reduce the incidence of infection. A few minutes later, anaphylactic reaction developed with hypotension, tachycardia, consciousness change and urticaria. After appropriate management, he recovered without any complication.

Anaphylactic Reaction to Cefotetan during Spinal Anesthesia: A case report / 대한마취과학회지

A 37-year-old male was admitted for a hemorrhoidectomy. He received uneventfully spinal anesthesia for a hemorrhoidectomy. He had no previous history of any allergic tendency. By the request of the general surgeon, a cefotetan was intravenously administered slowly to reduce the incidence of infection. A few minutes later, anaphylactic reaction developed with hypotension, tachycardia, consciousness change and urticaria. After appropriate management, he recovered without any complication.

Effects of Mivacurium in the Patients with Myasthenia Gravis / 대한마취과학회지

BACKGROUND: Myasthenia gravis is an autoimmune neuromuscular disorder that shows increased sensitivity to nondepolarizing muscle relaxants. Mivacurium chloride is a short acting nondepolarizing neuromuscular blocker and a benzylisoquinolin diester that is hydrolized rapidly to inactive metabolites by plasma pseudocholinesterase. The onset and duration of mivacurium in patients undergoing a thymectomy with myasthenia gravis was studied. METHODS: Fifteen patients undergoing a thymectomy for myasthenia gravis and fifteen patients of ASA class I, II without liver, kidney or neuromuscular disease undergoing orthopedic surgical procedures were included in this study. Anesthesia was induced with thiopental 4 5 mg/kg and maintained with inhalation of N2O:O2 (1:1) and enflurane 1.0 2.0 vol%. Mivacurium 0.2 mg/kg was given as a muscle relaxant and then intubation performed after the twitch response was depressed more than 90%. Neuromuscular relaxation was assessed by TOF (T1) at the adductor pollicis with supramaximal stimulation of the ulnar nerve at 2 Hz every 12 seconds. The onset and duration of 5%, 25%, 50%, 75%, and 95% recovery time of T1 and recovery index were recorded. RESULTS: Onset of block was shortened but recovery time of 5%, 25%, 50%, 75%, 95% and recovery index were prolonged in patients with myasthenia gravis. CONCLUSIONS: In patients with myasthenia gravis, mivacurium induced rapid onset time and prolonged recovery time of 5%, 25%, 50%, 75%, 95% and recovery index.

The Role of Peripheral N-Methyl-D-Aspartate (NMDA) Receptors in Freund's Complete Adjuvant Induced Mechanical Hyperalgesia in Rats / 대한마취과학회지

BACKGROUND: While the effects of excitatory amino acids have been characterized in the central nervous system, relatively little is known about their possible modulation of elements responsible for hyperalgesia within peripheral tissue. The purpose of this study was to investigate the role of excitatory amino acid receptors in mechanical hyperalgesia induced by a subcutaneous injection of Freund's complete adjuvant (FCA) into the rat hind paw. METHODS: Inflammations were induced by injecting FCA on the dorsal surface of the right hind paw of rats. Effects of excitatory aminoacid agonists or antagonists on mechanical hyperalgesia were investigated by a subcutaneous injection of a drug to the inflamed paw. Mechanical hyperalgesia was expressed as percent change in paw withdrawal threshold compared to baseline value that was measured before drug injection after inflammation was induced with FCA. RESULTS: In normal rats, an intraplantar (i.pl.) injection of L-glutamate, but not of D-glutamate (3 pmol/0.1 ml each) produced a mechanical hyperalgesia in the hind paw with a lowered paw paw-withdrawal threshold to pressure. In rats that developed the mechanical hyperalgesia associated with inflammation in the hind paw following an i.pl. injection of FCA (0.15 ml), the injection of a N-methyl-D-aspartate (NMDA) receptor antagonist, MK-801 (1 pmol/0.1 ml) into the inflamed paw increased the paw pressure threshold (24.24.6% increase from baseline, P < 0.05). On the other hand, the injection of a non-NMDA receptor antagonist, 6-cyano-7-nitroqiunoxaline-2,3-dione (CNQX, 10 pmol/0.1 ml) into the inflamed paw had no effect on the FCA-induced lowering of the paw pressure threshold. CONCLUSIONS: The results suggest that NMDA, but not non-NMDA receptors play a substantial role in mediating the development of mechanical hyperalgesia induced in the inflamed paw following an i.pl. FCA injection.

Response to Capsaicin and Changes in Sodium Currents in Dorsal Root Ganglion Neurons of Neuropathic Rats / 대한마취과학회지

BACKGROUND: Allodynia, one of the most debilitating symptoms of neuropathic pain syndromes, can be defined as `pain due to a stimulus that does not normally provoke pain'. Subsets of dorsal root ganglion (DRG) neurons involved in nociception are characteristically expressed capsaicin sensitivity and high proportion of tetrodotoxin resistant sodium current (TTX-R INa). We performed an experiment to elucidate whether nerve injury induced mechanical allodynia could be resulted from elctrophysiological modulation of large, nonnociceptive afferent neurons to nociceptors. METHODS: Whole cell patch clamp recordings were made from acutely dissociated dorsal root ganglion (DRG) neurons of normal and experimental neuropathic rats. We compared the proportion of capsaicin sensitive neurons which responded to capsaicin (1micrometer) with an inward current > or = 100 pA in amplitude and the proportion of sodium channel subtypes measured in the absence and presence of tetrodotoxin (1micrometer), in small and large DRG neurons. RESULTS: The proportion of capsaicin sensitive cells to total number of cells tested was not changed by nerve injury in both small and large cell populations. In large cell population of nerve injured rats, the proportion of TTX-R INa was significantly increased as compared with normal group (p <0.05), and in small cell population of nerve injured rats, TTX-S INa was increased, but there was no statistical significance. CONCLUSIONS: These data indicate that expression of the sensitivity to capsaicin in DRG neurons would not be altered by nerve injury and increased TTX-R INa in large cell population of nerve injured DRG may underlie increased excitability.

Hemodynamic Effects of General Anesthesia during Thoracic Epidural Block / 대한마취과학회지

BACKGROUND: It has been a standard practice in many institutions to combine light general anesthesia with epidural block for abdominal and pelvic surgery. We attempted to prove the effectiveness of prehydration and to find an suitable epidural local anesthetic dose in terms of hemodynamic stability for upper abdominal surgery. METHODS: For preliminary studies, 11 patients scheduled for elective upper abdominal surgery had received general anesthesia immediately after epidural anesthesia. After epidural injection of 10~16 mL of 2% plain lidocaine into the T9~10 intervertebral space, the changes in blood pressure were observed. Thirty-two patients scheduled for elective upper abdominal surgery were divided into two groups. In group A (study group), after prehydration with Hartmann solution (10 mL/kg), 5~7 mL of 2% plain lidocaine was injected into T8~9 or T9~10 intervertebral space and general anesthesia was then induced. Group B (control group) received general anesthesia only. RESULTS: There were no significant differences in hemodynamics between the epidural with general anesthesia and the control group except SVR (systemic vascular resistance). SVR in group A increased in contrast to the group B in which it remained unchanged. CONCLUSIONS: The combined epidural and general anesthesia, using prehydration and 0.5~1 mL/segment of 2% plain lidocaine at the T8~9 or T9~10 intervertebral space was safe without significant hemodynamic changes.