The Optimal Angle of Needle Insertion for Caudal Block in Adults / 대한마취과학회지

BACKGROUND: This study was conducted to investigate the optimal angle of needle insertion during caudal epidural injection in chronic low back pain patients using ultrasound imaging. METHODS: One hundred eight patients (40 male and 68 female patients) with low back pain and sciatica were studied.Soft tissue ultrasonography was performed to identify the sacral hiatus. The optimal angle of the needle to the skin was measured with an imaginary line drawn parallel to the sacral base using a protractor on a longitudinal plane. A 22-gauge caudal epidural needle was inserted and was guided by ultrasound to the sacral hiatus and into the caudal epidural space. RESULTS: The mean +/- SD for the intercornual distance, depth of the caudal space and the thickness of the sacrococcygeal membrane were 19.0 +/- 3.2 mm, 3.6 +/- 0.9 mm and 1.8 +/- 0.8 mm, respectively. The optimal angle showed a significant correlation with the depth of the caudal space and the thickness of the sacrococcygeal membrane. The mean +/- SD for the optimal angle of the needle insertion was 23.5 +/- 6.9 degrees. CONCLUSIONS: We conclude that the needle should be inserted at an angle of approximately 23.5 degrees to the skin in order to avoid injury to the periosteum and an inadvertent intra-osseous injection.

Treatment Experiences of Abdominal Cutaneous Nerve Entrapment Syndrome: A report of 3 cases / 대한통증학회지

The diagnosis of chronic abdominal pain due to abdominal cutaneous nerve entrapment can be elusive. Tenderness in patients with abdominal pain is naturally assumed to be of either peritoneal or visceral origin. Studies have shown that some patients suffer from prolonged pain in the abdominal wall and are often misdiagnosed, even after unnecessary and expensive diagnostic tests, including potentially dangerous invasive procedures, and treated as having a visceral source for their complaints, even in the presence of negative X-ray findings and atypical symptoms. Abdominal cutaneous nerve entrapment syndrome is rarely diagnosed, which is possibly due to failure to recognize the condition rather than the lack of occurrence. The accepted treatment for abdominal cutaneous nerve entrapment syndrome is a local injection, with infiltration of anesthetic agents coupled with steroids. Careful history taking and physical examination, in conjunction with the use of trigger zone injections, can advocate the diagnosis of abdominal cutaneous nerve entrapment and preclude any unnecessary workup of these patients. Herein, 3 cases of abdominal cutaneous nerve entrapment syndrome, which were successfully treated with local anesthetics and steroid, are reported.

The Treatment of a Droopy Shoulder Syndrome Patient: A case report / 대한통증학회지

Droopy shoulder syndrome (DSS) is a rare disease, characterized by drooping shoulders, which stretches the brachial plexus, and causes pain, but without any signs of neurological impairment. These patients suffer from pain in the neck, shoulders, arms and hands, which result in long, graceful, swan necks, low-set shoulders, and horizontal or down sloping clavicles. No abnormalities in the vascular, neurological or electrical findings have also been known. The T1 and/or T2 bodies can be seen in the lateral view in a radiological study of the cervical spine. In the majority of cases, conservative treatments, such as postural correction and shoulder girdle strengthening exercise, are commonly recommended. However, DSS may be misdiagnosed as severe thoracic outlet syndrome or herniated cervical disc disease, leading to unnecessary and hazardous invasive treatments. The presented case was consistent with DSS, and was treated with stellate ganglion block, trigger point injection, and shoulder girdle strengthening exercise.

Cardiac Output Estimations by Esophageal Doppler Cannot Replace Estimations by the Thermodilution Method in Off-pump Coronary Artery Bypass Surgery Patients / 대한마취과학회지

BACKGROUND: Esophageal doppler is discribed as a non-invasive alternative to cardiac output (CO) estimation by thermodilution, the current bedside "gold standard". This study was designed to evaluate the accuracy of CO estimations performed by esophageal doppler (EDCO), compared to those obtained using a continuous CO pulmonary flotation catheter (TDCO). METHODS: In 16 patients undergoing off-pump coronary artery bypass surgery, CO was measured simultaneously by the esophageal doppler and the thermodilution method, after induction (A), after sternotomy (B), after coronary revascularization (C), and after sternal closure (D). Agreement between the TDCO and EDCO estimations was assessed by analyzing their mean differences and the distribution of these differences. Relative CO changes (percentages of the previous value) was analyzed by the same method. RESULTS: Both absolute CO values and relative CO changes by esophageal doppler showed a considerable scatter compared to those obtained using the thermodilution method. The bias (EDCO-TDCO) between the two mehtods was -0.8 +/- 2.7 L/min for A, -0.9 +/- 2.5 L/min for B, -0.9 +/- 3.6 L/min for C, and -0.6 +/- 2.7 (mean +/- 2 SD) L/min for D. On analyzing changes in CO, no significant method bias was found but 2 SD of the bias were +/- 74% for A to B, +/- 100% for B to C, and +/- 83% for C to D. CONCLUSIONS: These results suggest that CO estimations by esophageal doppler cannot replace estimations by the thermodilution method in patients undergoing off-pump coronary artery bypass graft surgery.

Radial Nerve Paralysis due to Kent Retractor during Upper Abdominal Operation

After general anesthesia, peripheral nerve paralysis is a rare complication. The frequently damaged nerves including: branches of the brachial plexus, the ulnar, radial and common peroneal nerves, and sometimes the facial nerve. The radial nerve is the most infrequently damaged one, accounting for only 3% of nerve damage. We report a case of radial nerve paralysis due to self retractor during abdominal operation, its clinical findings, and review of the literature on peripheral nerve paralysis.

Radial Nerve Paralysis due to Kent Retractor during Upper Abdominal Operation

After general anesthesia, peripheral nerve paralysis is a rare complication. The frequently damaged nerves including: branches of the brachial plexus, the ulnar, radial and common peroneal nerves, and sometimes the facial nerve. The radial nerve is the most infrequently damaged one, accounting for only 3% of nerve damage. We report a case of radial nerve paralysis due to self retractor during abdominal operation, its clinical findings, and review of the literature on peripheral nerve paralysis.