A Double Blind Comparative Study between Intrathecal Bupivacaine and Intrathecal Fentanyl as the Initial Dose of Combined Spinal Epidural Technique for Labour Analgesia

Introduction: Labour analgesia techniques is the mostwidely practised procedures of pain management performedby an anaesthesiologist and are requested by the obstetriciancolleagues as well as the parturient mothers. Presently,Combined Spinal Epidural (CSE) is the most popular andeffective technique of Labour Analgesia to render the motherpain free. This technique has two parts. Our study is primarilyconcerned with the first part of CSE for the comparison ofdrugs. The aim of the study was to compare the efficacybetween a small and fixed doses Fentanyl (25μgm) andHyperbaric 0.5% Bupivacaine (2.5mg) as the initial step ofCSE technique for labour analgesia.Material and methods: This double blind study aims tocompare the efficacy between a intrathecal fixed dose oflipophilic opioid i.e, Fentanyl (25μgm) and a fixed dose oflocal anaesthetic hyperbaric 0.5% Bupivacaine ( 2.5mg) as theinitial step to establish labour analgesia . 60 parturient willbe divided into two group. Group I will receive intrathecalFentanyl and Group II will receive intrathecal Bupivacaine.Onset, quality and quantity of pain relief achieved followingintrathecal injection of drugs will be taken into account whereasincidence of side-effects like motor paralysis, hypotension,pruritus, foetal bradycardia & respiratory depression willbe noted and compared. This will indicate which drug willbe more preferable as a sole drug for the initial intrathecalcomponent of CSE technique for labour analgesia.Results: The shortest time of onset of analgesia in group Iwas 60sec and in group II was 40sec which was statisticallysignificant (p<0.05). The average duration to reach maximumanalgesia in Group I was 5.93 ± 1.68 min and in Group IIwas 5.30 ± 1.31 min.Whereas the duration of analgesia wasfound varying widely. It was 54±15.16 minutes in Group Iwhereas 73.5±14.74 minutes in Group II. The duration rangedfrom 25 minutes to 80 minutes in Group I and 35 minutesto 100 minutes in Group II. This difference was statisticallysignificant (p=0.000005).The significant side effect noted waspruritus (56.67%) in Group I and motor paralysis (80%) andhypotension (6.67%) in Group II.Conclusion: A small dose of Fentanyl is preferable to asimilar small dose of Bupivacaine for the initial intrathecaladministration as a part of Combined Spinal Epidurallabour analgesia technique as muscle weakness prevents themother from taking active part in second stage of labour andhypotension is non desirable.

Delayed-Onset Leg Weakness Caused by Posterior Migration of a Herniated Disc to the Thecal Sac Mimicking Epidural Hematoma in a Flexion-Distraction Injury of the Lumbar Spine: A Case Report

STUDY DESIGN: Case report. OBJECTIVES: To document the first known case of posterior migration of a herniated disc in a lumbar flexion-distraction injury. SUMMARY OF LITERATURE REVIEW: Lumbar disc herniation is sometimes confused with epidural hematoma, especially when the disc migrates posterior to the thecal sac. There has been no report of posterior migration of a herniated disc after a lumbar flexion-distraction injury. MATERIALS AND METHODS: A 47-year-old woman with no pertinent medical history was diagnosed with a flexion-distraction injury of the L2–L3 vertebrae after a motor vehicle accident. The patient had no neurological deficit initially. Magnetic resonance imaging (MRI) showed a space-occupying lesion with T2 hyperintensity and T1 isointensity on the dorsal side of the thecal sac at L2–L3. After posterior lumbar fixation and fusion, progressive leg weakness occurred 1 week postoperatively. RESULTS: A second operation revealed no evidence of epidural hematoma, but a sequestrated disc. Decompression and sequestrectomy were performed, and the patient's neurological status had recovered fully at 4 months postoperatively. CONCLUSIONS: This case highlights the potential for posterior migration of a herniated disc with flexion-distraction injuries of the thoracolumbar spine. Discontinuity of the posterior annulus fibrosus on MRI may aid the distinction of posterior migration of a herniated disc from epidural hematoma. Because posterior migration of a herniated disc is associated with progressive neurological deficits, surgeons must consider decompression surgery when such herniation is suspected, even in the absence of neurological symptoms.

The pathogenic mechanisms of motor weakness following aneurysmal subarachnoid hemorrhage: A review

Motor weakness is one of the neurological complication that can occur after aneurysmal subarachnoid hemorrhage (SAH); incidence of motor weakness of 14~29% has been reported. Detailed information on the pathogenic mechanism of motor weakness is essential for brain rehabilitation because it enables estimation of the severity of injury, establishment of scientific rehabilitative strategies, and prediction of motor outcomes by clinicians. However, the exact pathogenic mechanisms of motor weakness following aneurysmal SAH have not been clearly elucidated. In this article, 14 previous studies on pathogenic mechanisms in patients with aneurysmal SAH were reviewed according to the location of the lesion (cerebral cortex, brainstem, spinal cord, and peripheral nerve). The following pathogenic mechanisms have been suggested: vasospasm, cerebral ischemia, hydrocephalus, compression of cerebral cortex, neural injury, spinal cord infarction, and radiculo-neuropathy. Considering the high incidence of aneurysmal SAH and motor weakness following aneurysmal SAH, we believe that the pathogenic mechanisms of motor weakness have been relatively understudied. More effort should be taken to investigate this important topic.

Psoas compartment block for treatment of motor weakness and pain following herpes zoster

Reactivation of the latent varicella zoster virus in the sensory ganglion causes herpes zoster (HZ). Its characteristic symptom is a painful rash in the involved dermatome. HZ-induced motor weakness is rare and is usually resolved within one year of the onset, but some patients permanently experience motor dysfunction. Epidural steroid administration, with antiviral therapy, can be effective in treating pain from HZ and preventing postherpetic neuralgia. But an epidural block is contraindicated in patients receiving thromboprophylaxis. A psoas compartment block (PCB) provides equivalent analgesic efficacy with significantly low incidence of complication, compared to an epidural block. A 68 year old male patient recieving thromboprophylaxis presented with motor weakness following painful rash in his left L4 dermatome. Ten days before presentation, herpetic rash occurred on his left leg. We performed PCB with a steroid and local anesthetic, which successfully and safely alleviated the pain and motor weakness from HZ.

The Applicability of Intraoperative Neuromonitoring in Patients with Preoperative Motor Weakness during Spine Surgery

OBJECTIVE: The purpose of our study is to evaluate the success rate and feasibility of intraoperative neuromonitoring (IONM) focusing on transcranial motor evoked potential (TcMEP) monitoring for patients with preoperative motor weakness in spine surgery. METHODS: Between November 2011 and December 2013, TcMEP and somatosensory evoked potential (SSEP) monitoring were attempted in 130 consecutive patients undergoing spine surgeries for cervical or thoracic cord lesions. Patients ranged in age from 14 to 81 years (mean±standard deviation, 56.7±14.8 years), and 84 patients were male. The success rates of both SSEP and MEPs monitoring were assessed according to the preoperative Medical Research Council (MRC) and Nurick grades. RESULTS: TcMEP was recorded successfully in 0%, 28.6%, 72.3%, and 100% of patients with MRC grades 1, 2, 3, 4, and 5, respectively. SSEP was obtained from 0%, 37.5%, 21.5%, 61.4%, and 85.4% of patients with MRC grades 1, 2, 3, 4, and 5, respectively. TcMEP was recorded successfully in 84% of patients with Nurick grades 1-3 and 26% of patients with Nurick grades 4-5. SSEPs were recorded successfully in 76.3% of patients with Nurick grades 1-3 and 24% of patients with grades 4-5. CONCLUSION: IONM during spine surgery may be useless in patients with MRC grades 1-2, applicable MRC grade 3, and useful MRC grades 4-5. MRC grade 3 is a critical point of indication for application of MEPs. In unmonitorable cases with MRC grade 3, increasing stimulus intensity or facilitation techniques may be considered to improve the usefulness of TcMEP.

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

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.

Low Extremity Weakness after Cervical Epidural Steroid Injection in Previous Spinal Surgery Patient: A case report / 대한마취과학회지

A 46-year-old woman received one cervical epidural injection for the management of her neck and shoulder pain. The patient was placed in the prone position without sedation. By using the "loss of resistance to injection of air" technique, the epidural space was identified at the level of C7-T1 inter-laminar space. After needle placement was confirmed by biplanar fluoroscopy and contrast dye, mixture composed of 20 mg of triamcinolone acetonide and 0.125% chirocaine (6.5 ml total volume) was injected. The patient reported no reaction or signs of spinal cord irritation during needle placement attempt. She was developed both low extremity motor weakness and the repeated MRI of the cervical spine indicated right focal cervical myelopathy. It is unknown whether the neurologic injury sustained by patient was the result of spinal cord penetration by the needle, adverse effects from neural tissue exposure to the injected drug, or a combination of both factors.

The Mechanical Antiallodynic Effect of Intrathecal Lamotrigine in Rats with Spinal Nerve Ligation / 대한통증학회지

BACKGROUND: A nerve ligation injury may produce a tactile allodynia. The effects of intrathecally delivered lamotrigine on allodynia induced due to fifth and sixth lumbar spinal nerves ligation in rats, using lumbar intrathecal catheters were examined. METHODS: Sprague-Dawley rats (body weight 160-180 g) were prepared by tightly ligating the fifth and sixth left lumbar spinal nerves, with the implantation of a chronic intrathecal catheter for drug administration. Mechanical allodynia and allodynic threshold were measured using von Frey filaments and the updown method, respectively. After the baseline hind paw withdrawal thresholds had been obtained, lamotrigine (10, 30, 100 and 300microgram) was administered intrathecally. Thereafter, the dose-response curves and 50% effective dose (ED50) were obtained. Motor dysfunction was assessed by observing the righting/stepping reflex responses and abnormal weight bearing. RESULTS: Intrathecal administration of lamotrigine produced a dose-dependent antiallodynic action (ED50 = 61.7microgram). Mild motor weakness was observed with 300microgram lamotrigine, but no severe motor impairment was found. CONCLUSIONS: It is suggested that intrathecal lamotrigine could produce moderate antagonism of mechanical allodynia at the spinal level in a rat neuropathic pain model with minimal motor weakness.

A Case of Abdominal Protrusion Caused by Herpes Zoster / 대한피부과학회지

Segmentally distributed cutaneous eruptions along with sensory change and pain are frequently seen in herpes zoster. Occasionally it affects motor nerves in the segments corresponding to the involved sensory dermatomes, causing a flaccid paralysis. Motor weakness following herpes zoster infection has been well documented, with about half of the cases involving the cranial nerves and the other half involving the extremities. Interestingly, myotomal paresis involving the thoracic segment is unusual. We report a case of segmental herpes zoster paralysis presenting as an abdominal protrusion.

Motor Weakness on Lower Extremities after the Combined Spinal-epidural Anesthesia and Analgesia: A case report / 대한마취과학회지

The spinal-epidural nerve block is widely used for anesthesia or postoperative pain control. The incidence of neurological complications after spinal and epidural anesthesia is increased although it is usually transient. Such complications may be caused by various mechanical, chemical, and ischemic factors. We experienced a case of motor weakness following combined spinal-epidural anesthesia and analgesia. The motor weakness and hypoesthesia were reversible on right leg, but persistent on left leg.

Parasagittal Meningiomas: Surgery & Postoperative Complications

OBJECTIVE: The authors report the evaluation of the surgical outcomes and postoperative complications for the 39 cases of parasagittal meningioma. METHODS: Thirty-nine patients have undergone operations for parasagittal meningioma between March 1994 and March 2002. The medical records and neuroimaging studies of thirty-nine patients were surveyed retrospectively to find out the perioperative clinical status, radiologic findings, operative methods, and postoperative complications. RESULTS: Preoperative symptoms were motor weakness(12), seizure(11), headache(11) and so on. The parasagittal meningioma was classified into lateral attachment(27), partial occlusion(4) or total occlusion(8) according to the degree of infiltration and into anterior one third(7), middle one third(28) or posterior one third(4) from the viewpoint of the origin site. The degree of tumor removal was classified into Simpson Grade: Grade I(13), Grade II(24), Grade III(2). Suture of the opened sinus was done in seven patients going through an operations. Four patients of them underwent sinus opening for mass removal and the others due to operative injury. Total removal of the sinus segment was carried out in six patients. The draining veins of six patients got injuried, those of four patients and the others respectively were coagulated and sutured. Postoperative complications were motor weakness(11), CSF leakage(9), seizure(1) and hemorrhage(1). CONCLUSION: However, most of the weakness is transient, the preservation of intracranial collateral circulation is important to minimize the motor weakness. The effort for complete tumor removal is required in parasagittal meningioma to take recurrence into account.

Transcranial Magnetic Stimulation for Neuropathic Pain with Motor Weakness Caused by Spine Orthodontic Fixation / The Japanese Journal of Rehabilitation Medicine

An 81-year-old woman sustained a fracture of the vertebra, resulting in grace deformation. After surgery for the spinal fixation, she suffered from left femoral neuropathic pain and motor weakness of both lower extremities. Daily repetitive transcranial magnetic stimulation (rTMS) of the lower extremity area in the right motor cortex was applied using a figure-8 coil connected to a magnetic stimulator (MagPro R30；Nagventure)．One thousand pulses per session were delivered (10 trains of 10Hz for 10 seconds with 25-seconds intertrain interval) in one day, and this treatment continued for 2 weeks except Sunday. The intensity of rTMS was set at the resting motor threshold for that day. rTMS together with physical therapy resulted in a remarkable amelioration of the femoral pain and motor weakness of both lower extremities. Pain on a Visual Analogue Scale dropped from 70％ to 22％, and walking speed and walking rate increased. Functional Independence Measure score increased from 58 to 79, and Euro QOL 5 score increased from 0.419 to 0.768. As previously reported in cases of post-stroke pain and motor weakness, rTMS together with physical therapy exerted measurable beneficial effects on intractable pain and motor weakness caused by spinal orthodontic fixation.

Paresthesia and Motor Weakness of Left Shoulder after Interscalene Nerve Block: A case report / 대한마취과학회지

Nerve injury can arise as a complication of peripheral nerve block. Three factors are of special etiologic interest: nerve lesion due to the needle injury or intraneural injection; toxic effects of drugs injected overall when epinephrine is used; ischemic trauma. The symptoms of such nerve lesions are dysesthesia, motor weakness or paralysis. We report a case of severe neurologic symptoms of left shoulder after interscalene nerve block in a 23-year-old ASA I male patient. Interscalene block utilizing nerve stimulator and elicitation of paresthesia was performed smoothly for incision and drainage of 2nd finger mass. Total 30 cc of 2% lidocaine with epinephrine was used. After the procedure, the patient developed a severe dysesthesia and motor weakness of left shoulder which gradually improved over the next 6 months through the extensive rehabilitation program. The block should be handled with care: rough paresthesia seeking techniques and intraneural injections should be avoided; short bevel needles and plain solutions should be used to avoid complications.

Paresthesia and Motor Weakness of Left Shoulder after Interscalene Nerve Block: A case report / 대한마취과학회지

Nerve injury can arise as a complication of peripheral nerve block. Three factors are of special etiologic interest: nerve lesion due to the needle injury or intraneural injection; toxic effects of drugs injected overall when epinephrine is used; ischemic trauma. The symptoms of such nerve lesions are dysesthesia, motor weakness or paralysis. We report a case of severe neurologic symptoms of left shoulder after interscalene nerve block in a 23-year-old ASA I male patient. Interscalene block utilizing nerve stimulator and elicitation of paresthesia was performed smoothly for incision and drainage of 2nd finger mass. Total 30 cc of 2% lidocaine with epinephrine was used. After the procedure, the patient developed a severe dysesthesia and motor weakness of left shoulder which gradually improved over the next 6 months through the extensive rehabilitation program. The block should be handled with care: rough paresthesia seeking techniques and intraneural injections should be avoided; short bevel needles and plain solutions should be used to avoid complications.