Clinical Implications of Opioid Therapy.

Although opioids are potent central acting broad-spectrum analgesics, their effectiveness is diminished by various factors pertaining to their metabolism, drug interactions, genetic issues, adverse/side effects, and potential for abuse. All these factors present potential barriers to effective analgesia requiring specific considerations in clinical practice, which include monitoring and case-based intervention.

Management of CRPS secondary to preganglionic C8 nerve root avulsion: A case report and literature review.

BACKGROUND: Cervical nerve root avulsion is a well-documented result of high-velocity motor vehicle accidents (MVAs). In up to 21% of cases, preganglionic cervical root avulsion can result in a complex regional pain syndrome (CRPS) impacting the quality of life for patients already impaired by motor, sensory, and autonomic dysfunction. The optimal treatment strategies include repeated stellate ganglion blocks (SBGs). CASE DESCRIPTION: A 43-year-old male sustained a high-velocity MVA resulting in the left C8 nerve root avulsion. This resulted in weakness in the C8 distribution, tactile allodynia, and dysesthesias. The magnetic resonance imaging demonstrated an abnormal signal ventral to the C8-T1 level. As the patient was not considered a candidate for surgical intervention secondary to the attendant brachial plexus injury, a C7-C8 epidural steroid injection was performed; this did not provide improvement. Before placing a spinal cord stimulator, the patient underwent a series of six ultrasound-guided SBGs performed 2 weeks apart; there was 75% improvement in pain and strength. Six years later, the patient continues to do well while receiving SBGs 4 times a year. CONCLUSION: A preganglionic cervical nerve root avulsion should not be a contraindication for a stellate ganglion block in a patient with established CRPS.

Management of concomitant metabolic encephalopathy and meningioma with vasogenic edema and impending herniation.

BACKGROUND: Altered mental status describes impaired mental functioning ranging from confusion to coma and indicates an illness, either metabolic or structural in nature. Metabolic causes include hypothyroidism, hyperuremia, hypo/hyperglycemia, hypo/hypernatremia, and encephalopathy. The structural causes include tumors, brain hemorrhage, infection, and stroke. To our knowledge, this is the first case in which a patient presented with altered mental status from both metabolic (myxedema coma) and structural diseases (frontal meningioma) with vasogenic edema and midline shift. CASE DESCRIPTION: A 55-year-old female presented with progressive coma. The clinical features included bradycardia and hypothermia. The imaging demonstrated a large frontal meningioma with a significant midline shift with laboratory findings suggestive of severe hypothyroidism and myxedema coma. Hypothyroidism was treated aggressively with intravenous T3 and T4 with close neurosurgical observation. Osmodiuretics and steroids were administered as temporizing agents prior to craniotomy. Craniotomy was successfully undertaken after using these appropriate pre-emptive measures. CONCLUSIONS: Management of concomitant metabolic encephalopathy and meningioma with vasogenic edema and impending herniation can be challenging. Correction of the encephalopathy is crucial to minimize perioperative morbidity and mortality. Awareness of metabolic causes of acute decompensation is critical for perioperative management, so a high index of clinical suspicion can make an important timely diagnosis for treatment initiation. Severely hypothyroid patients are sensitive to anesthetic agents and are at a high risk for perioperative complications. Prompt treatment prior to surgical intervention can help minimize perioperative complications.