Application of percutaneous foraminotomy with a specially designed drill tip for foraminal stenosis patient: A case report

This case report describes a new method of pain management intervention: percutaneous foraminotomy using the Claudicare system (Seawon Meditech, Korea). In this case, a 77-year-old Asian man visited the hospital with motor weakness in his left foot. He was diagnosed with L4–5 grade three foraminal stenosis using Magnetic Resonance Imaging on both sides. A left L4–5 foraminal decompression was performed using percutaneous foraminotomy. The patient revisited the hospital after 17 months because the same symptoms recurred in his right foot. We observed that the symptoms on the left foot had disappeared completely. We confirmed the lesion on the right side and the postoperative change on the left side on the magnetic resonance imaging (MRI) image. Both the pre- and postoperative MRI images were compared by measuring the dimensions of the foraminal area (28.12 mm² vs. 38.58 mm², repectively). T1W images showed signs of increased epidural soft tissue after percutaneous foraminotomy.

Cervical nucleoplasty as an effective treatment method of cervical degenerative disc disease / 대한마취과학회지

No abstract available.

Comparison of cardioprotection between sevoflurane-remifentanil and midazolam-sufentanil total intravenous anesthesia during off-pump coronary artery bypass surgery

BACKGROUND: Volatile agents have been reported to protect myocardium against ischemia. But, there were a few clinical reports about the myocardial protection of inhalation agents. So we investigated the cardiac protection of sevoflurane in comparison with total intravenous anesthesia (TIVA). The study is a retrospective unrandomized study via the medical record review. METHODS: The records of 102 patients who received off-pump CABG were reviewed. One patient group received TIVA by midazolam and sufentanil continuous infusion (TIVA group, n = 68), and the other patient group received an inhalational anesthesia by sevoflurane (sevoflurane group, n = 34). Except maintenance of anesthesia, two groups of patients received an identical surgical, anesthetical, and postoperative care. At arrival in the intensive care unit, and after 1, 2, 3 and 5 days, serum cardiac enzyme levels were measured. RESULTS: All the median values of cardiac enzyme concentrations were lower in the sevoflurane group than TIVA group. Moreover, there were the significant differences between groups at the immediate postoperative CK-MB (median 4.7 ng/ml versus 5.9 ng/ml (P = 0.049)), 1-5 days postoperative LD (1 day 271.5 U/L versus 292 U/L (P = 0.045), 2 day 227.5 U/L versus 270 U/L (P = 0.009), 3 day 215 U/L versus 250 U/L (P = 0.030), 5 day 218 U/L versus 231 U/L (P = 0.005)), and 1, 3 postoperative troponin I level (0.485 ng/ml versus 1.12 ng/ml [P = 0.029], 0.090 ng/ml versus 0.235 ng/ml [P = 0.047] respectively). CONCLUSIONS: Sevoflurane lowered cardiac enzyme levels in comparison with TIVA after off-pump CABG anesthesia. These data suggest a cardioprotective effect of sevoflurane during CABG.

The Results of Cervical Nucleoplasty in Patients with Cervical Disc Disorder: A Retrospective Clinical Study of 22 Patients

BACKGROUND: Nucleoplasty is a minimally invasive spinal surgery using a Coblation(R) technique that creates small voids within the disc. The purpose of this study was to evaluate the efficacy of cervical nucleoplasty in patients with cervical disc disorder. METHODS: Between March 2008 and December 2009, 22 patients with cervical disc disorders were treated with cervical nucleoplasty after failed conservative treatment. All procedures were performed under local anesthesia, and fluoroscopic guidance and voids were created in the disc with the Perc(TM) DC Spine Wand(TM). Clinical outcomes were evaluated by the Modified Macnab criteria and VAS score at preprocedure, postprocedure 1 month, and 6 months. RESULTS: Six patients had one, eight patients had two and eight patients had three discs treated; a total of 46 procedures was performed. Mean VAS reduced from 9.3 at preprocedure to 3.7 at postprocedure 1 month and to 3.4 at postprocedure 6 months. There was no significant complication related to the procedure within the first month. Outcomes were good or excellent in 17/22 (77.3%) cases. Postprocedure magnetic resonance imaging was acquired in two patients after two months showing morphologic evidence of volume reduction of protruded disc material in one patient but not in the other. CONCLUSIONS: Percutaneous decompression with a nucleoplasty using a Coblation(R) technique in the treatment of cervical disc disorder is a safe, minimally-invasive and less uncomfortable procedure, with an excellent short-term clinical outcome.

The effect of low fresh gas flow rate on sevoflurane consumption / 대한마취과학회지

BACKGROUND: In an era of medical cost containment, cost-effectiveness has become a major focus in healthcare. The effect of a new policy on the use of low fresh gas flow during maintenance of general anesthesia with volatile anesthetics was evaluated. METHODS: The numbers and duration of general anesthesia cases using sevoflurane 5 weeks prior to and 15 weeks after policy implementation were retrieved from the electronic medical records database. The number of sevoflurane bottles consumed was also assessed. The anesthesia hours per bottle of sevoflurane were compared before and after policy implementation. RESULTS: The number of anesthesia hours performed per bottle of sevoflurane increased by 38.3%. The effect varied over time and tended to fade with time. CONCLUSIONS: The implementation of a low fresh gas flow rate policy effectively reduces the amount of sevoflurane consumed for the same duration of anesthesia.

Axillary approach versus the infraclavicular approach in ultrasound-guided brachial plexus block: comparison of anesthetic time / 대한마취과학회지

BACKGROUND: With ultrasound guidance, the success rate of brachial plexus block (BPB) is 95-100% and the anesthetic time has become a more important factor than before. Many investigators have compared ultrasound guidance with the nerve stimulation technique, but there are few studies comparing different approaches via the same ultrasound guidance. We compared the axillary BPB with the infraclavicular BPB under ultrasound guidance. METHODS: Twenty-two ASA physical status I-II patients presenting with elective forearm surgery were prospectively randomized to receive an axillary BPB (group AX) or an infraclavicular BPB (group IC) with ultrasound guidance. Both groups received a total of 20 ml of 1.5% lidocaine with 5 microg/ml epinephrine and 0.1 mEq/ml sodium bicarbonate. Patients were then evaluated for block onset and block performance time was also recorded. RESULTS: Group IC demonstrated a reduction in performance time vs. group AX (622 +/- 139 sec vs. 789 +/- 131 sec, P < 0.05). But, the onset time was longer in group IC than in group AX (7.7 +/- 8.8 min vs. 1.4 +/- 2.3 min, P < 0.05). All blocks were successful in both groups. CONCLUSIONS: Under ultrasound guidance, infraclavicular BPB was faster to perform than the axillary approach. But the block onset was slower with the infraclavicular approach.

The Results of Cervical Nucleoplasty in Patients with Cervical Disc Disorder: A Retrospective Clinical Study of 22 Patients / 대한통증학회지

BACKGROUND: Nucleoplasty is a minimally invasive spinal surgery using a Coblation(R) technique that creates small voids within the disc. The purpose of this study was to evaluate the efficacy of cervical nucleoplasty in patients with cervical disc disorder. METHODS: Between March 2008 and December 2009, 22 patients with cervical disc disorders were treated with cervical nucleoplasty after failed conservative treatment. All procedures were performed under local anesthesia, and fluoroscopic guidance and voids were created in the disc with the Perc(TM) DC Spine Wand(TM). Clinical outcomes were evaluated by the Modified Macnab criteria and VAS score at preprocedure, postprocedure 1 month, and 6 months. RESULTS: Six patients had one, eight patients had two and eight patients had three discs treated; a total of 46 procedures was performed. Mean VAS reduced from 9.3 at preprocedure to 3.7 at postprocedure 1 month and to 3.4 at postprocedure 6 months. There was no significant complication related to the procedure within the first month. Outcomes were good or excellent in 17/22 (77.3%) cases. Postprocedure magnetic resonance imaging was acquired in two patients after two months showing morphologic evidence of volume reduction of protruded disc material in one patient but not in the other. CONCLUSIONS: Percutaneous decompression with a nucleoplasty using a Coblation(R) technique in the treatment of cervical disc disorder is a safe, minimally-invasive and less uncomfortable procedure, with an excellent short-term clinical outcome.

Manipulation of frozen shoulder under monitored anesthesia care with propofol and remifentanil / 대한마취과학회지

BACKGROUND: Manual manipulation under anesthesia in primary frozen shoulder is recommended for restoring range of motion and improving function. Usually, manipulation is performed briefly under general anesthesia, which accompanies some anesthesia- related risks for outpatients. METHODS: 12 patients suffered from primary frozen shoulder were received manipulation under monitored anesthesia care (MAC) with propofol (1 mg/kg) and remifentanil (25microgram) as an initial dose. And then we injected additional bolus dose (propofol 20 mg, remifentanil 10microgram) in case of inadequate sedation. After manipulation, sodium hyaluronate 20 mg, 0.75% ropivacaine 22.5 mg and ketorolac 30 mg were injected into the glenohumeral joint. Clinical data were gathered at baseline and at 4 weeks after manipulation. RESULTS: The procedure was carried out successfully under MAC. Clinical results including improvements of visual analogue scale of pain and range of motion were comparable to previous studies. 2 patients who received relatively large doses of anesthetics have required triple airway maneuver and manual mask ventilation for 1 to 2 minutes respectively because of desaturation below 90%. There are not any serious adverse effects. CONCLUSIONS: MAC with propofol and remifentanil makes it possible to get adequate level of sedation for shoulder manipulation and to reduce recovery time from anesthesia at the same time. MAC, therefore, is the adequate outpatient anesthetic method for shoulder manipulation.

Comparison of the Two Impairment Classes Publicized by the American Medical Association in Complex Regional Pain Syndrome Patients / 대한통증학회지

BACKGROUND: Complex regional pain syndrome (CRPS) is not regarded as an impairment in Korea. Guidelines for rating this impairment are under development by the Korean Academy of Medical Science based on that of the American Medical Association (AMA). However, no studies have been done on the validity of these guidelines in Korea. We therefore evaluated the validity of these guidelines using the criteria from the chapter on the central and peripheral nervous system (CNS-PNS class) and the worksheet for calculating total pain-related impairment score (TPRIS class). METHODS: TPRIS and CNS-PNS classes were calculated through interviews of 28 CRPS patients. The correlation between the two classes was calculated. RESULTS: TPRIS class and CNS-PNS class were well correlated (r = 0.593, P < 0.05). CONCLUSIONS: Both TPRIS or CNS-PNS classes were well correlated and could be used for evaluation of impairment. However, the CNS-PNS class is simpler and quicker to complete.

Experience of the Pediatric Patients Consulted to Pain Center

BACKGROUND: The aim of this study was to investigate the management of pediatric patients who were referred to the pain center. METHODS: The data was collected based on 32 pediatric patients referred to the pain center from March 2002 to August 2006. The number of patients each year, gender distribution, age, requested departments, clinical causes of consultation, and the pain management before and after the consultation were analyzed retrospectively. RESULTS: 32 pediatric patients (19 males and 13 females), aged 3- 17 years, were enrolled in this study. Fifty-six percent of patients were in adolescence. The major need for the consultation was cancer pain (50.0%), myofascial pain syndrome (10.0%) and central pain (10.0%). Before the consultation, 62.1% of the patients were managed by opioid-based medications of which 26.1% were managed by only partial agonists and 29.6% were managed by only PRN. At the pain center, opioid-based medication was also the main treatment. CONCLUSIONS: The number of pediatric patients referred to the pain center has increased. Under this condition, the pain physician should be concerned about pediatric pain patients and their management.

A Case of Balloon Kyphoplasty in High Risk under Cement Leakage: A case report / 대한통증학회지

A vertebral compression fracture can cause chronic back pain, and may also result in progressive kyphosis. The traditional treatments of a vertebral compression fracture include bed rest, analgesics and bracing. Balloon kyphoplasty can restore the vertebral height and allow safe bone cement injection into the cavity made by the balloon, which significantly reduces the risk of cement leakage compared to vertebroplasty. An 82-year-old female patient suffered from severe low back pain. Due to the intractable pain and immobility, which could not be relieved by conventional care, as well as the empty vertebral body associated with communicated fractures of the vertebral surfaces, balloon kyphoplasty, with a thicker bone cement injection than usual with balloon kyphoplasty, was chosen. The preoperative intractable pain and immobility were dramatically relieved soon after the procedure, without any complications.

Clinical Outcomes of Percutaneous Lumbar Discectomy Using Dekompressor(R) / 대한통증학회지

BACKGROUND: Discogenic leg pain is a major cause of health problems, often due to herniation of the intervertebral disc, and has traditionally been treated conservatively or with an open surgical discectomy. Conventional open surgery has many complications, such as nerve root injury, discitis and a relatively high mortality rate; failure of conservative treatments is also common. Recently, the Dekompressor(R) Percutaneous Lumbar Discectomy probe was developed. Herein, we present the early results for a percutaneous lumbar discectomy in herniated lumbar disc disease. METHODS: Eleven patients, including 8 men and 3 women, with ages ranging from 22 to 78 years, were enrolled in this study. Those patients with a previous history of back surgery were not excluded from the study. All patients were postoperatively evaluated for their clinical outcomes, such as visual analogue scale (VAS) for pain after 1 and 3 months, reduction in analgesics, functional improvement and overall satisfaction. RESULTS: The percutaneous lumbar discectomy was completed in 11 patients (17 levels), with average reductions in pre-VAS of 61.3 and 60.2% at 1 and 3 months, respectively. Also, 72.7% of patients reported functional improvement, with 81.1% expressing overall satisfaction. There were no procedural related complications. CONCLUSIONS: We concluded that a percutaneous lumbar discectomy is a safe and effective treatment modality for a herniated lumbar disc.

Analgesia after Subacromial Arthroscopic Surgery: Prospective Double-blind Study of Continuous Mixed Intra-bursal Infusion with Bupivacaine, Bupivacaine/Morphine, Bupivacaine/Fentanyl / 대한마취과학회지

BACKGROUND: The purpose of this study was to compare the relative analgesic efficacies of the postoperative intra-bursal infusion of bupivacaine, bupivacaine/morphine, and bupivacaine/fentanyl after shoulder arthroscopy. METHODS: At the end of subacromial arthroscopy, a continuous intra-bursal infusion catheter was inserted. A bolus dose was injected via the catheter just after the operation and a maintenance dose was infused for 4 days (1 ml/h). The bupivacaine group (Group B, n = 25), received 10 ml of 0.5% bupivacaine and 96 ml of 0.25% bupivacaine. The bupivacaine/morphine group (Group BM, n = 25) received 2 mg of morphine in 10 ml of 0.5% bupivacaine and 8 microgram of morphine in 96 ml of 0.25% bupivacaine. And the bupivacaine/fentanyl group (Group BF, n = 25) received 100 microgram of fentanyl in 10 ml of 0.5% bupivacaine and 400 microgram of fentanyl in 96 ml of 0.25% bupivacaine. VAS at rest and exercise were evaluated preoperatively and postoperatively for 3 days. The frequency of IM rescue analgesic were recorded. RESULTS: We did not find any significant differences in VAS, or in need for rescue analgesic between the three groups. Resting pain score was significantly reduced at the 2 nd- and 3 rd postoperative day versus the preoperative value in Group B and BM, and at the 3 rd postoperative day in Group BF (P < 0.05). Pain score at exercise was reduced at the 3 rd postoperative day versus the preoperative value in all groups (P < 0.05). CONCLUSIONS: The combination of morphine or fentanyl with bupivacaine did not provide better postoperative analgesia than bupivacaine after shoulder arthroscopy.

An Analysis for Blood Transfusion in Revision Total Hip Arthroplasty / 대한마취과학회지

BACKGROUND: This study was performed to investigate the clinical usefulness of acute normovolemic hemodilution to reduce homologous transfusion in revision total hip arthroplasty. To avoid complications of homologous transfusion, many methods are being used in patients who undergo an operation, and autologous transfusion is the most popular modality. METHODS: Fifty-five patients operated on for revision THRA were reviewed. In the hemodilution group (n = 21), 2-4 units of autologous blood were procured immediately after anesthetic induction while Ringer's lactate and 6% Haes-steril were infused to maintain normovolemia. Differences in the amounts of transfusions and postoperative drainage were compared. Statistical analyses were performed by using the Student's t-test. RESULTS: No significant differences were observed between groups in terms of preoperative hematocrit and hematocrit at postoperative 7 days. However, in the homologous transfusion group, 10.1 +/- 3.2 units of RBC products were used in 34 patients. In the autologous transfusion group, 7.5 +/- 2.6 units of RBC products were transfused in 21 patients. And this difference in RBC produce usage was significantly different (P < 0.05). The amount of postoperative wound drainage in the two groups was comparable. CONCLUSIONS: ANH could reduce the reqirement for homologous transfusion in revision total hip arthroplasty.

Hemodynamic Changes during off Pump Coronary Artery Bypass Surgery / 대한마취과학회지

BACKGROUND: The number of coronary artery bypass graft surgery without cardiopulmonary bypass is increasing in Korea. This technique avoids a number of the adverse effects associated with cardiopulmonary bypass. But the cardiac exposure and stabilization during off pump coronary artery bypass graft surgery (OPCAB) are known to cause hemodynamic deterioration and it creates new challenges for the anesthesiologist. This study is designed to assess the hemodynamic changes during OPCAB. METHODS: Eighteen patients undergoing OPCAB were included in this study (male/female = 13/5, age = 63.5+/-5.2). An octopus(R), a local cardiac-wall restraining device was applied for stabilization of target coronary artery. Three different surgical settings of exposure and stabilization were used according to the site of anastomosis: left anterior descending artery (LAD), posterior descending artery (PDA) and circumflex branch of left coronary artery (LCx). Heart rate (HR), mean systemic arterial pressure (MAP), central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP) and cardiac output (CO) were measured. CO was measured with thermodilution technique. Stroke volume index (SVI) and cardiac index (CI) were calculated. On each of the surgical settings, hemodynamic parameters were measured at 5 minutes before exposure of target coronary artery, and 5 minutes after placement of the stabilizer and 5 minutes after the completion of anastomosis. RESULTS: During LAD anastomosis, SVI decreased slightly (7.8%), but MAP and CI remained unchanged. During PDA and LCx anatomosis, MAP decreased moderately (15.7% and 16.1%, respectively) and SVI decreased remarkably (24.9% and 32.9%). Also CI did decrease, but it was less remarkable compared to the decrease in SVI due to the increase of HR. CVP and PCWP increased during PDA and Cx anastomosis. When the heart was released, all of the hemodynamic parameters were restored to baseline values. CONCLUSIONS: Hemodynamic changes during OPCAB were remarkable, especially with PDA and LCx reconstruction. However, these changes were transient and they were well tolerated in most patients.