Accuracy of Live Fluoroscopy to Detect Intravascular Injection During Lumbar Transforaminal Epidural Injections

BACKGROUND: Complications following lumbar transforaminal epidural injection are frequently related to inadvertent vascular injection of corticosteroids. Several methods have been proposed to reduce the risk of vascular injection. The generally accepted technique during epidural steroid injection is intermittent fluoroscopy. In fact, this technique may miss vascular uptake due to rapid washout. Because of the fleeting appearance of vascular contrast patterns, live fluoroscopy is recommended during contrast injection. However, when vascular contrast patterns are overlapped by expected epidural patterns, it is hard to distinguish them even on live fluoroscopy. METHODS: During 87 lumbar transforaminal epidural injections, dynamic contrast flows were observed under live fluoroscopy with using digital subtraction enhancement. Two dynamic fluoroscopy fluoroscopic images were saved from each injection. These injections were performed by five physicians with experience independently. Accuracy of live fluoroscopy was determined by comparing the interpretation of the digital subtraction fluoroscopic images. RESULTS: Using digital subtraction guidance with contrast confirmation, the twenty cases of intravascular injection were found (the rate of incidence was 23%). There was no significant difference in incidence of intravascular injections based either on gender or diagnosis. Only five cases of intravascular injections were predicted with either flash or aspiration of blood (sensitivity = 25%). Under live fluoroscopic guidance with contrast confirmation to predict intravascular injection, twelve cases were predicted (sensitivity = 60%). CONCLUSION: This finding demonstrate that digital subtraction fluoroscopic imaging is superior to blood aspiration or live fluoroscopy in detecting intravascular injections with lumbar transforaminal epidural injection.

Sacral Nerve Stimulation for Treatment of Chronic Intractable Anorectal Pain: A Case Report

Despite recent methodological advancement of the practical pain medicine, many cases of the chronic anorectal pain have been intractable. A 54-year-old female patient who had a month history of a constant severe anorectal pain was referred to our clinic for further management. No organic or functional pathology was found. In spite of several modalities of management, such as medications and nerve blocks had been applied, the efficacy of such treatments was not long-lasting. Eventually, she underwent temporary then subsequent permanent sacral nerve stimulation. Her sequential numerical rating scale for pain and pain disability index were markedly improved. We report a successful management of the chronic intractable anorectal pain via permanent sacral nerve stimulation. But further controlled studies may be needed.

The Usefulness of Preoperative Airway Characteristics as Predictors of Dental Trauma during Laryngoscopy / 대한마취과학회지

BACKGROUND: Damage to teeth has long been associated with endotracheal intubation. But, no rules designed to predict dental injuries have been formulated. In this prospective study, we undertook to identify relationships between anatomic airway measurements used customarily in bedside practice, and blade-tooth distance during laryngoscopy, to assess the usefulness of these anatomic measurements as predictors of dental injury. METHODS: Four hundred and eighty-three patients scheduled for elective surgery requiring general anesthesia with endotracheal tube placement were included. During a preoperative visit, a number of measurements and assessments of features that might predict difficult intubation were performed. When optimum visibility of the glottis was obtained during laryngoscopy, the distance between the flange of the blade and the upper incisor was measured. We determined which of the individual airway characteristics correlated with the blade-tooth distance and best predicted the potential of dental injury. RESULTS: The blade-tooth distance was found to correlate with the individual scales of the Mallampati classification (Spearman's correlation coefficient, r = - 0.356, P < 0.01), mandibular protrusion (r = - 0.390, P < 0.01), head and neck movement (r = - 0.276, P < 0.01), interincisor gap (r = - 0.648, P < 0.01), and the condition of the upper teeth (r = - 0.313, P < 0.01). The frequency of direct blade-tooth contact significantly increased as the scales of these five anatomic measurements increased (P < 0.01). CONCLUSIONS: This study shows for the first time that some airway measurements are correlated with blade-tooth distance, and that they can be considered as useful predictors of dental injury during laryngoscopy.

Severe Hypercarbia by Subcutaneous Emphysema Occurring during Hand Assisted Laparoscopic Donor Nephrectomy: A case report / 대한마취과학회지

Hand assisted laparoscopic donor nephrectomy (HALDN) has recently emerged as a very attractive modality in standard donor nephrectomy because of its many advantages. However, it also has disadvantages, which include gas emboli, subcutaneous emphysema, hypercarbia, pneumothorax and pneumomediastinum. This case involves a male patient who had suffered from temporary hypercarbia due to increased carbon dioxide absorption due to massive subcutaneous emphysema about 1 hour after pneumoperitoneum during HALDN. Following multiple skin punctures with an 18 G disposable needle, chest compliance and blood gas findings improved. Three hours later the operation ended successfully and he was transferred to the recovery room, and show no further problems. We report upon this clinical experience and include a brief review of the literature.