Limited Laminectomy and Restorative Spinoplasty in Spinal Canal Stenosis

STUDY DESIGN: Prospective cohort study. PURPOSE: Evaluation of the clinico-radiological outcome and complications of limited laminectomy and restorative spinoplasty in spinal canal stenosis. OVERVIEW OF LITERATURE: It is critical to achieve adequate spinal decompression, while maintaining spinal stability. METHODS: Forty-four patients with degenerative lumbar canal stenosis underwent limited laminectomy and restorative spinoplasty at our centre from July 2008 to December 2010. Four patients were lost to follow-up leaving a total of 40 patients at an average final follow-up of 32 months (range, 24-41 months). There were 26 females and 14 males. The mean+/-standard deviation (SD) of the age was 64.7+/-7.6 years (range, 55-88 years). The final outcome was assessed using the Japanese Orthopaedic Association (JOA) score. RESULTS: At the time of the final follow-up, all patients recorded marked improvement in their symptoms, with only 2 patients complaining of occasional mild back pain and 1 patient complaining of occasional mild leg pain. The mean+/-SD for the preoperative claudication distance was 95.2+/-62.5 m, which improved to 582+/-147.7 m after the operation, and the preoperative anterio-posterior canal diameter as measured on the computed tomography scan was 8.3+/-2.1 mm, which improved to 13.2+/-1.8 mm postoperatively. The JOA score improved from a mean+/-SD of 13.3+/-4.1 to 22.9+/-4.1 at the time of the final follow-up. As for complications, dural tears occurred in 2 patients, for which repair was performed with no additional treatment needed. CONCLUSIONS: Limited laminectomy and restorative spinoplasty is an efficient surgical procedure which relieves neurogenic claudication by achieving sufficient decompression of the cord with maintenance of spinal stability.

Infraclavicular brachial plexus block: comparison of posterior cord stimulation with lateral or medial cord stimulation, a prospective double blinded study

Infraclavicular approach to the brachial plexus sheath provides anesthesia for surgery on the distal arm, elbow, forearm, wrist, and hand. It has been found that evoked distal motor response or radial nerve-type motor response has influenced the success rate of single-injection infraclavicular brachial plexus block. We conducted this study to compare the extent and effectiveness of infraclavicular brachial plexus block achieved by injecting a local anesthetic drug after finding specific muscle action due to neural stimulator guided posterior cord stimulation and lateral cord/medial cord stimulation. After ethical committee approval, patients were randomly assigned to one of the two study groups of 30 patients each. In group 1, posterior cord stimulation was used and in group 2 lateral/medial cord stimulation was used for infraclavicular brachial plexus block. The extent of motor block and effectiveness of sensory block were assessed. All four motor nerves that were selected for the extent of block were blocked in 23 cases [76.7%] in group 1 and in 15 cases [50.0%] in group 2 [P:0.032]. The two groups did not differ significantly in the number of cases in which 0, 1, 2, and 3 nerves were blocked [P>0.05]. In group 1, significantly lesser number of patients had pain on surgical manipulation compared with patients of group 2 [P:0.037]. Stimulating the posterior cord guided by a nerve stimulator before local anesthetic injection is associated with greater extent of block [in the number of motor nerves blocked] and effectiveness of block [in reporting no pain during the surgery] than stimulation of either the lateral or medial cord

patient of terson's syndrome for ocular surgery: Perianesthetic concerns

Terson's syndrome may be challenging for the anesthesiologist in view of its multisystem involvement including neurological, cardiovascular, and ophthalmological involvement. We describe anesthetic management of a 55-year-old male having Terson's syndrome for pars plana viterctomy

Simultaneous anterior and posterior dislocation of hips: a case report and review of literature / 中华创伤杂志(英文版)

The presence of anterior hip dislocation along with contralateral posterior hip dislocation in the absence of other major traumas is a distinctly rare injury pattern. We report such a case, along with a review of previous cases. A 40-year-old male patient after motorcycle skidding had posterior dislocation of the left hip and anterior dislocation of the right one without other associated injuries. The patient underwent successful closed reduction of both hips. The clinical course and follow-up assessment of the patient was uneventful.

Perioperative concerns in patients with tumor-induced osteomalacia for surgical excision of tumor.

Tumor-induced osteomalacia [TIO] or oncogenic osteomalacia is a paraneoplastic syndrome, usually associated with mesenchymal tumors. TIO is probably an underreported entity owing to diagnostic and localizing limitations. With improvement in such modalities, patients with TIO are likely to be encountered more frequently in future anesthetic practice. It does not respond to conservative medical management; thus surgical resection of the lesion is the treatment of choice. Anesthetic management of such cases has not been reported in published studies and thus we report two such cases of hypophosphatemia, induced by frontoethmoidal tumors and the anesthetic implications and challenges of such a rare entity. Surgical excision of the causative lesion results in dramatic resolution of symptoms. Vigilant adherence to the pertinent perioperative concerns related to severe hypophosphatemia is crucial to a favorable surgical outcome in these patients.

randomized, placebo-controlled, doubleblind study of the analgesic efficacy of extraperitoneal wound instillation of bupivacaine and morphine in abdominal surgeries

The use of opioid for blockage of peripheral receptors has been used previously in many surgical settings but with a variable response. However, the use of morphine for extraperitoneal instillation after abdominal surgery has not been studied. We designed this study to evaluate the analgesic efficacy of extraperitoneal wound instillation of bupivacaine and morphine in abdominal surgeries. We also evaluated whether using this combination could lead to improvement of the respiratory functions. After ethical committee clearance, this prospective, randomized, placebo-controlled, double blind study was carried out in sixty patients of age group 18-65 years, undergoing abdominal surgery and specifically requiring midline incision. In the operating room, a standardized technique of general anesthesia was followed. At the end of the surgery a multiport Romovac[registered sign] suction catheter [Romsons Group of Companies India] was placed along the length of the wound between the peritoneal layer and muscle layers and led out through a separate stab wound. The patients were then randomized into three groups: Group C [n-20]: Wound perfused with normal saline; Group B [n-20]: Wound perfused with 0.5% bupivacaine; Group BM [n-20]: Wound perfused with 0.5% bupivacaine along plus morphine [0.05 mg/kg]. 15 ml of solution was given as slow bolus over 2-3 minutes via the catheter. Rescue analgesia was provided with intravenous tramadol [50 mg] if VAS score>30 mm. The VAS score at rest and on coughing was noted at 1, 3, 6, 9, 12, 24 hours. Time to demand the first rescue analgesia was recorded. Vital signs, peak expiratory flow rate and inspiratory flow rate were also recorded at 1, 3, 6, 9, 12 and 24 hour after operation. The demographic profile, type of surgery, duration of surgery were comparable among the three groups [p>0.05]. The peak expiratory flow rate was maximum at any point of time in Group BM as compared to Group C and B [p value <0.05]. But inspiratory flow rate with respect to time was almost same in the three groups [p value >0.05]. The VAS scores [on rest and cough] were significantly lower at all time intervals in Group BM as compared to Group B and C [p value [0.001]. The first rescue analgesia was demanded at 1.25 +/- 0.3 hours in Group C as compared to 3.68 +/- 0.71 hours in Group B and 10.7 +/- 4.1 hours in Group BM [p value 0.001]. We observed from our study that wound perfusion with 0.5% bupivacaine and morphine combination reduces pain and thus the need of rescue analgesia. The combination was also associated with significant improvement in lung functions postoperatively without any additional side effects

clinical prospective, randomized study to compare intrathecal isobaric bupivacaine - fentanyl and isobaric ropivacaine - fentanyl for lower abdominal and lower limb surgeries

Opioids have been used intrathecally as adjuvant to bupivacaine and ropivacaine for improvement in quality and extending the duration of spinal blockade. We hypothesized that intrathecal ropivacaine provides similar anaesthesia with lesser motor blockade as compared to bupivacaine. So, we conducted this prospective, randomized, double blind study with an aim of comparing the effect of isobaric bupivacaine with fentanyl to isobaric ropivacaine with fentanyl with regards to sensory blockade, motor blockade and quality of analgesia in postoperative period. After ethical committee approval and consent, 100 patients, aged 18 to 60 years, undergoing lower abdomen and lower limb surgery were included in the study. The patients were randomly divided into two groups: Group I received 3 ml 0.5% isobaric bupivacaine plus 20 micro g fentanyl. Group II received 3 ml 0.5% isobaric ropivacaine plus 20 micro g fentanyl. The subarachnoid block was administered in sitting position in L3-L4 inter vertebral space and the study drugs were given at a rate of 0.2 ml/second. The patient was placed in supine position till maximum effect was achieved. The parameters observed included time of onset of sensory blockade, extent of sensory blockade, degree of motor blockade and duration of analgesia. The heart rate, blood pressure, oxygen saturation and respiratory rate were recorded. All the parameters were recorded just after giving spinal anaesthesia, at 5 minute intervals till 15 minutes, then at 15 minute intervals till 180 minutes. Bradycardia and hypotension was treated with inj. atropine, crystalloid solutions and inj. ephedrine IV. Inj. tramadol 1mg/kg was administered as a rescuer analgesic if the patient's VAS score was >3. Any side effects were recorded. The demographic parameters, duration of surgery and the types of surgery were comparable in the two groups. The time taken to achieve T10, T8 and T6 level of sensory block was significantly more [p<0.05] in Group II as compared to Group I, but time to sensory block level was comparable [p=0.981]. Mean time taken to achieve maximum grade of motor blockade was lesser in Group I as compared to Group II [p<0.001]. The sensory block regression to S2 was faster in Group II as compared to Group I [p=0.025]. The motor recovery was comparable in the two groups [p=0.264]. The duration of analgesia was prolonged in Group I as compared to Group II [p=0.027]. The mean pulse rate was comparable in the two groups [p >0.05]. The mean arterial blood pressure [MAP] was comparable [p>0.05] except between 10 min to 30 min intervals where MAP was relatively lower in group I [p<0.05]. The episodes of hypotension was higher in Group I [p=0.001]. We conclude that intrathecal administration of ropivacaine-fentanyl has faster onset and regression of sensory block, delayed onset but comparable regression of motor block and shorter duration of analgesia as compared to intrathecal bupivacaine-fentanyl

Hemodynamic changes during robotic radical prostatectomy

Effect on hemodynamic changes and experience of robot-assisted laparoscopic radical prostatectomy [RALRP] in steep Trendelenburg position [45] with high-pressure CO[2] pneumoperitoneum is very limited. Therefore, we planned this prospective clinical trial to study the effect of steep Tredelenburg position with high-pressure CO[2] pneumoperitoneum on hemodynamic parameters in a patient undergoing RALRP using FloTrac/Vigileo[TM]1.10. After ethical approval and informed consent, 15 patients scheduled for RALRP were included in the study. In the operation room, after attaching standard monitors, the radial artery was cannulated. Anesthesia was induced with fentanyl [2 microg/kg] and thiopentone [4-7 mg/kg], and tracheal intubation was facilitated by vecuronium bromide [0.1 mg/kg]. The patient's right internal jugular vein was cannulated and the Pre Sep[TM] central venous oximetry catheter was connected to it. Anesthesia was maintained with isoflurane in oxygen and nitrous oxide and intermittent boluses of vecuronium. Intermittent positive-pressure ventilation was provided to maintain normocapnea. After CO[2] pneumoperitoneum, position of the patient was gradually changed to 45 Trendelenburg over 5 min. The robot was then docked and the robot-assisted surgery started. Intraoperative monitoring included central venous pressure [CVP], stroke volume [SV], stroke volume variation [SVV], cardiac output [CO], cardiac index [CI] and central venous oxygen saturation [ScvO[2]]. After induction of anesthesia, heart rate [HR], SV, CO and CI were decreased significantly from the baseline value [P > 0.05]. SV, CO and CI further decreased significantly after creating pneumoperitoneum [P > 0.05]. At the 45 Trendelenburg position, HR, SV, CO and CI were significantly decreased compared with baseline. Thereafter, CO and CI were persistently low throughout the 45 Trendelenburg position [P=0.001]. HR at 20 min and 1 h, SV and mean arterial blood pressure after 2 h decreased significantly from the baseline value [P > 0.05] during the 45° Trendelenburg position. CVP increased significantly after creating pneumoperitoneum and at the 45 Trendelenburg position [after 5 and 20 min] compared with the baseline postinduction value [P > 0.05]. All these parameters returned to baseline after deflation of CO[2] pneumoperitoneum in the supine position. There were no significant changes in SVV and ScvO[2] throughout the study period. The steep Trendelenburg position and CO[2] pneumoperitoneum, during RALRP, leads to significant decrease in stroke volume and cardiac output

To evaluate the efficacy of intrathecal magnesium sulphate for hysterectomy under subarachnoid block with bupivacaine and fentanyl: a prospective randomized double blind clinical trial

Intrathecal magnesium has been found to prolong the duration of analgesia in various surgical procedures like lower limb surgeries and as adjuncts to general anesthesia for pain management. The present study was designed to examine whether addition of intrathecal magnesium sulfate would enhance the analgesic efficacy of intrathecal bupivacaine and fentanyl in patients undergoing total abdominal hysterectomy. After taking informed consent, 60 patients were randomised into two groups with 30 patients. Group "S" received 2.5 mL [12.5 mg] of hyperbaric bupivacaine + 0.5 mL [25 mcg] of fentanyl + 0.5 mL of normal saline and Group "M" received 2.5 mL [12.5 mg] of hyperbaric bupivacaine + 0.5 mL [25 mcg] of fentanyl + 0.5 mL [100 mg] of magnesium sulfate. Onset of sensory, motor block and duration of analgesia was noted. Demographic profile and duration of surgery were comparable [P > 0.5]. Time of onset of sensory and motor blockade was delayed in Group M compared with Group S, and this was statistically significant. A statistically significant longer duration of analgesia was observed in Group M compared with the control Group S. However, the recovery of motor blockade was found to be statistically insignificant in both the groups. The hemodynamic parameters were comparable in the perioperative period [P > 0.05]. The incidence of side-effects in both the groups were also comparable [P > 0.05]. The addition of 100 mg intrathecal magnesium led to prolonged duration of analgesia significantly without increasing the incidence of side-effects. Also, there was a significant delay in the onset of both sensory and motor blockade

Evaluation of single epidural bolus dose of magnesium as an adjuvant to epidural fentanyl for postoperative analgesia: a prospective, randomized, double-blind study

Magnesium has been used as an adjuvant by various routes, including intravenous, intrathecal, and epidural in different dosage regimens. The effect of single bolus dose of magnesium as an adjuvant to fentanyl for postoperative analgesia has not been studied. This prospective randomized controlled trial was done to evaluate the efficacy of single bolus administration of magnesium epidurally as an adjuvant to epidural fentanyl for postoperative analgesia in patients undergoing total hip replacement under combined spinal epidural anesthesia. Sixty patients received combined spinal-epidural anesthesia with 2 mL of 0.5% hyperbaric bupivacaine intrathecally. After the surgery, patients were randomized into Group F [epidural fentanyl [1 microg/kg] in 10 mL saline] and Group FM [epidural magnesium [75 mg] along with fentanyl [1 microg/kg] in 10 mL saline]. Supplementary analgesia was provided by 50 mg intravenous tramadol if Verbal Rating Score [VRS] > 4. Patient's first analgesic requirement and duration of analgesia were recorded. The duration of analgesia was significantly longer for Group FM, 340 +/- 28.8 min, compared with Group F, 164 +/- 17.1 min [P=0.001]. The frequency of rescue analgesics required in 24-h postoperative period in Group FM [2.3 +/- 0.5] was significantly less than that in Group F [4.3 +/- 0.5] [P=0.001]. VRS was significantly lower in Group FM up to 4 h in the postoperative period [P=0.001]. Bromage scale was statistically insignificant at all points of time. The administration of magnesium [75 mg] as an adjuvant to epidural fentanyl [1 microg/ kg] for postoperative analgesia results in significantly lower VRS with prolonged duration of analgesia as compared with epidural fentanyl [1 microg/kg] alone. Concomitant administration of magnesium also reduces the requirement of breakthrough analgesics with no increased incidence of side effects

Periosteal nociceptors induced hypotension and bradycardia under spinal anesthesia: A report of two cases / 대한마취과학회지

The sudden hemodynamic disturbance in the perioperative period can occur because of various surgical and anesthetic reasons but hemodynamic collapse due to noxious stimulus of periosteum stripping has not been described. We report two cases of severe hypotension and bradycardia during periosteum stripping in orthopedic surgery under subarachnoid block even though the block level was adequate. In our patients, hemodynamic collapse occurred specifically at a moment when surgeons manipulated periosteum and fall in blood pressure and heart rate was sudden in onset. The hemodynamic disturbance did not appear to be related to vagally mediated or due to blockade of sympathetic fibers but appeared to be related to periosteal nociceptors.

Comparison of recovery profile in selective spinal anaesthesia using lignocaine and sufentanyl with propofol based general anaesthesia for gynaecological laparoscopy surgery: a randomized controlled study

To compare the recovery characteristics of selective spinal anaesthesia [SSA] with propofol based GA for short duration outpatient gynaecological laparoscopic surgeries. Prospective, randomized clinical trial. Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College, New Delhi, India. Conducted from August 2007 to March 2008. This trial was done in forty adult female patients who were randomized in two groups: Group GA: GA was induced with intravenous fentanyl [2microg/kg] and propofol [2mg/kg]. Airway was secured with proseal laryngeal mask airway. Anaesthesia was maintained with titrated propofol infusion [100-150microg/kg/min], nitrous oxide and oxygen [50:50]. Group SSA: Patients received subarachnoid block in sitting position with lignocaine 10mg and sufentanyl 10microg to a total volume of 2.5mL with sterile water. Patient remained sitting for 1minute and then in reverse Trendelenburg position for 6-8minutes. Recovery time from the end of surgery and any adverse effects were recorded. Patients demographic profile and duration of surgery were comparable. The time from the end of surgery to exit from operating room, time to straight leg raising and deep knee bend were significantly prolonged in group GA as compared to group SSA. The time to reach a modified Aldrete score>9 was significantly prolonged in group GA as compared to group SSA. The mean time to first analgesic requirement postoperatively was significantly longer for group SSA as compared with group GA. SSA could effectively be used for patients undergoing short duration outpatient gynecological laparoscopy as compared to propofol infusion based general anaesthesia

Comparison of respiratory quotient and resting energy expenditure in two regimens of enteral feeding - continuous vs. intermittent in head-injured critically ill patients

Measurement of respiratory quotient [RQ] and resting energy expenditure [REE] has been shown to be helpful in designing nutritional regimens. There is a paucity of the literature describing the impact of a feeding regimen on the energy expenditure patterns. Therefore, we studied the effect of continuous vs. intermittent feeding regimen in head-injured patients on mechanical ventilation on RQ and REE After institutional ethical approval, this randomized study was conducted in 40 adult male patients with head injury requiring controlled mode of ventilation. Patients were randomly allocated into two groups. Group C: Feeds [30 kcal/kg/day] were given for 18 h/day, with night rest for 6 h. Group I: Six bolus feeds [30 kcal/kg/day] were given three hourly for 18 h with night rest for 6 h. RQ and REE were recorded every 30 min for 24 h. Blood sugar was measured 4 hourly. Other adverse effects such as feed intolerance, aspiration were noted. Demographic profile and SOFA score were comparable in the two groups. Base line RQ [0.8 vs. 0.86] and REE [1527 vs. 1599 kcal/day] were comparable in both the groups [P>0.05]. RQ was comparable in both groups during the study period at any time of the day [P>0.05]. Base line RQ was compared with all other RQ values measured every half hour and fluctuation from the base line value was insignificant in both groups [P>0.05]. REE was comparable in both the groups throughout the study period [P>0.5]. Adequacy of feeding as assessed by EI/MREE was 105.7% and 105.3% in group C and group I, respectively. There was no significant difference in the blood sugar levels between the two groups [P>0.05]. We found from our study that RQ, REE, and blood sugar remain comparable with two regimens of enteral feeding - continuous vs. intermittent in neurosurgical patients on ventilator support in a ICU setup

Delayed recovery due to exaggerated acid, base and electrolyte imbalance in prolonged laparoscopic repair of diaphragmatic hernia

The acid, base and electrolyte changes are usually observed in the perioperative settings. We report a case of prolonged laparoscopic repair of left-sided diaphragmatic hernia which involved a lot of tissue handling and fluid replacement leading to acid, base and electrolyte imbalance. A 42-year-old male underwent prolonged laparoscopic repair under general anesthesia. Intraoperatively, surgeon reported that contents of hernia includes bowel along with mesentery, spleen and lot of fatty tissue The blood loss was about 2 L which was replaced with 1 L of colloid and 7.5 L of lactated ringer. Near the end of surgery arterial blood gas analysis revealed metabolic acidosis, hyperkalemia, and hypocalcemia leading to delayed recovery. We conclude prolonged laparoscopic surgery involving lot of tissue handling including gut and fat should be monitored for acid, base, electrolyte imbalance and corrected timely to have uneventful rapid recovery

Awareness among resident doctors with regards to cardiac defibrillators

Electrical defibrillation is the most important therapy for patients in cardiac arrest. The audit was aimed to assess awareness among residents with respect to routine preuse checking of cardiac defibrillators. The audit was conducted at a multispeciality tertiary care referral and teaching center by means of a printed questionnaire from anaesthesiology residents. A database was prepared and responses were analyzed. Eighty resident doctors participated in the audit. Most [97.8%] of the residents were sure of the presence of a defibrillator in the operation room [OR]; 70% of postgraduates [PG]s were aware of the location of the defibrillator in the OR as compared to 83.7% of the senior resident [SRs]. Also, 32.1% residents routinely check the availability of a defibrillator. The working condition of the defibrillator was checked by 21.7% of the residents; 25.3% ensured delivery of the set charge. Further, 8.2% of residents ensured availability of both adult and paediatric paddles. About 27.8% of residents ensured the availability of appropriate conducting gel and 53.8% residents were of the opinion that the responsibility of checking the functioning and maintenance of the defibrillators lies with themselves. Some 22% thought that both doctors and technical staff should share the responsibility, while 19.5% opined that it should be the responsibility of the technical staff. All medical equipment is to be tested prior to initial use and periodically thereafter. An extensive, recurring training program, and continued attention to the training of clinical personnel is required to ensure that they are proficient in the operation and testing of specific defibrillator models in their work area. We conclude that apart from awareness of the use of the equipment we are using, its preuse testing is must. All resident doctors should be aware of the presence and adequate functioning of the defibrillator in their ORs and this audit reinforces the need for training of all resident doctors

Fentanyl pretreatment for alleviation of perineal symptoms following preoperative administration of intravenous dexamethasone sodium phosphate - a prospective, randomized, double blind, placebo controlled study

Corticosteroids have anti-inflammatory, analgesic and antiemetic effects but causes severe perineal symptoms when given intravenously. Simultaneous administration of dexamethasone and fentanyl have been known to decrease the duration of perineal pain but its role in alleviating perineal pain has not been studied. Therefore, we hypothesized that fentanyl pretreatment could prevent the perineal symptoms associated with the dexamethasone. Material and This prospective, randomized, double blind, placebo controlled study was done in 200 patients undergoing elective surgery requiring dexamethasone. The patients were randomized into two groups of 100 each. Group BD received 5 ml normal saline followed, 5 minutes later, by 8 mg dexamethasone bolus intravenously. Group FD received 1 micro g/kg fentanyl diluted in saline to a volume of 5 ml followed by 8 mg dexamethasone bolus 5 minutes later. The time of onset, intensity, site, duration and nature of the pain after the drug administration were recorded. The demographic profile was comparable in the two groups. The incidence and severity of pain was more in females as compared to males [p value = 0]. The pain was located especially in the perineal region and was expressed as itching [62%], burning [13%] or both [25%]. The incidence of pain, its duration and severity were significantly reduced after pretreatment with fentanyl [p value = 0]. Discussion: Our study showed that the intravenous administration of dexamethasone sodium phosphate leads to significant perineal symptoms. These symptoms are alleviated by pretreatment with fentanyl [1 micro g/kg] [incidence, severity and duration]. The pharmacological mechanism explaining perineal pain with intravenous administration of dexamethasone remains poorly understood, but could be related to the phosphate ester. We conclude, but intravenous administration of dexamethasone sodium sodium phosphate is associated with perineal pain an can be alleviated effectively by pretreatment with 1 micro g/ kg of fentanyl