Carpal tunnel syndrome caused by thrombosed persistent median artery - A case report.

BACKGROUND: A rare case of carpal tunnel syndrome caused by a thrombosed persistent median artery is presented here. CASE: The diagnosis was delayed due to the overlapping cervical radiculopathy. Acute severe pain and nocturnal paresthesia were chief complaints. Ultrasonography, magnetic resonance imaging, and computed tomography angiography revealed that the median nerve was compressed by the occluded median artery. Instead of surgery, conservative therapy was tried. It worked well for six months. CONCLUSIONS: The importance of using modalities for decision making of diagnosis and treatment is emphasized in this report.

The timing of administration of intravenous dexmedetomidine during lower limb surgery: a randomized controlled trial.

BACKGROUND: Dexmedetomidine, a selective alpha-2 agonist, has sedative, analgesic, and anxiolytic effects without respiratory depression. Dexmedetomidine can cause a biphasic cardiovascular response, and induce transient hypertension. Hypotension is a common complication of spinal anesthesia. Decreasing anxiety of patients before procedure is important for high quality of procedure. This study aimed to compare the incidence of hypotension and patients' anxiety and comfort levels when dexmedetomidine was intravenously administered before and after spinal anesthesia. METHODS: Seventy-four patients with American Society of Anesthesiologists physical status classification I or II were randomly allocated into two groups. Spinal anesthesia was performed using 12 mg of 0.5% heavy bupivacaine. In Group A, 1 µg/kg of dexmedetomidine was intravenously administered for 10 min, followed by the maintenance infusion of dexmedetomidine 0.2 µg/kg/hr after 5 min of intrathecal bupivacaine injection. Patients in Group B received same dose of dexmedetomidine by intravenous administration before 5 min of intrathecal bupivacaine injection. Perioperative vital signs, anxiety (using the Spielberger's State-Trait Anxiety Inventory) and comfort (using the numerical rating scale) were evaluated. RESULTS: The incidence of hypotension was significantly lower in Group A (16.1%) than in Group B (48.4%) during infusion of dexmedetomidine (p = 0.01). The need for treatment of hypotension is higher in Group B than Group A (p = 0.02). The incidence of bradycardia and desaturation did not significantly differ between the two groups. There were no statistically significant differences regarding the patients' anxiety and comfort. CONCLUSIONS: Hypotension is more frequently occurred, and the treatment of hypotension is more needed in Group B. The intravenously administration of dexmedetomidine before spinal anesthesia has no advantages in hemodynamic status and patients' comfort compared to that after spinal anesthesia during lower limb surgery. TRIAL REGISTRATION: ClinicalTrials.gov number, NCT02155010 . Retrospectively registered on May 22, 2014.

Influence of Ketamine on Early Postoperative Cognitive Function After Orthopedic Surgery in Elderly Patients.

BACKGROUND: Postoperative cognitive dysfunction (POCD) is a serious and frequent complication after surgery, especially in elderly patients. Ketamine is an N-methyl D-aspartic acid receptor antagonist with demonstrated neuroprotective effects. An intravenous bolus of a sub-anesthetic dose (0.5 mg/kg) of ketamine can reduce postoperative delirium (POD) and POCD after cardiac surgery. But, the influence of ketamine on early POCD after non-cardiac surgery is unclear. OBJECTIVES: The current study aimed to evaluate the influence of ketamine on early postoperative cognitive function after orthopedic surgery in elderly patients. PATIENTS AND METHODS: Fifty six elderly patients (> 60-years-old), scheduled for elective orthopedic surgery during general anesthesia (duration of anesthesia > two hours) were enrolled. Patients received intravenous bolus, a total of 3 mL mixed with 0.9% normal saline and 0.5 mg/kg ketamine (K group) or 3 mL of 0.9% normal saline (N group). Three neurocognitive function tests (mini-mental status examination, trail-making test, digit substitution test), and c-reactive protein (CRP) concentration were determined before surgery and on postoperative day one (POD 1) and postoperative day six (POD 6). RESULTS: The two groups had similar demographic characteristics except for the gender. Surgical and anesthetic data were not significantly different. A statistically significant difference was observed in comparison of trail-making test score. Trail-making test score increased more in the N group (52.5 points) than the K group (13 points) at POD 1 (P = 0.047) compared with baseline scores. There were no significant differences in the mini-mental status examination, digit substitution test and CRP concentration at POD 1 and POD 6 between the two groups. POCD (the two Z-scores in more than two tests or the combined Z-score was 1.96 or more) was present in one patient (4%) in the K group at POD 6 (P = 0.98). CONCLUSIONS: The incidence of POCD was not significantly influenced by a bolus dose of ketamine (0.5 mg/kg) after orthopedic surgery in elderly patients. There were no negative effects of ketamine on early POCD.

Percutaneous adjustment method for transversely migrated spinal cord stimulation leads: a technical report.

Lead migration is the most common complication of spinal cord stimulation (SCS). However, the only corrective method for lead migration is revision surgery, which may cause additional complications. Here, we describe a new technique for adjusting a transversely migrated SCS lead. The medical records of four patients diagnosed with complex regional pain syndrome (n = 3) or failed back surgery syndrome (n = 1) who underwent implantation of percutaneous leads for SCS were retrospectively reviewed. Transverse lead migration was diagnosed radiographically after patients reported recurrence of pain or numbness in treated sites. The guide wire from the SCS implant kit was bent and inserted into the target epidural space using a 14-gauge Tuohy needle. When the guide wire contacted the migrated SCS lead, they were advanced to the correct location under C-arm guidance. After re-adjustment of the SCS lead, good coverage of the electrical stimulation was confirmed. Patients were followed for 9-19 months and they reported satisfactory pain relief and good electrical coverage after adjusting the SCS lead. Here, we describe a new technique for adjusting a transversely migrated SCS lead using a percutaneous epidural approach as a simple, safe, and cost-effective alternative to revision surgery.

Spinal cord stimulation for intractable visceral pain due to sphincter of oddi dysfunction.

Sphincter of Oddi dysfunction (SOD) is a syndrome of chronic biliary pain or recurrent pancreatitis due to the functional obstruction of the pancreaticobiliary flow. We report a case of spinal cord stimulation (SCS) for chronic abdominal pain due to SOD. The patient had a history of cholecystectomy and had suffered from chronic right upper quadrant abdominal pain. The patient had been diagnosed as having SOD. The patient was treated with opioid analgesics and nerve blocks, including a splanchnic nerve block. However, two years later, the pain became intractable. We implanted percutaneous SCS at the T5-7 level for this patient. Visual analog scale (VAS) scores for pain and the amount of opioid intake decreased. The patient was tracked for more than six months without significant complications. From our clinical case, SCS is an effective and alternative treatment option for SOD. Further studies and long-term follow-up are necessary to understand the effectiveness and the limitations of SCS on SOD.

Change in pulmonary blood volume changes pulmonary artery systolic storage.

BACKGROUND: A fraction of right ventricular stroke volume (pulmonary artery systolic storage, [PASS]), which is stored in pulmonary arteries during systole and then discharged to the capillaries, determines the diastolic pulmonary capillary blood flow and hence the capillary blood volume participating in gas diffusion. Possibility that increases in pulmonary blood volume (PBV) increase PASS, leading to an improved distribution of ventilation-to-perfusion ratios (V/Q), was examined. METHODS AND RESULTS: Included were 34 obese patients undergoing bariatric surgery. We used a nitrous oxide-airway-pneumotachographic method to measure PASS. The measurements were repeated before and after increasing PBV. In 20 patients, PBV was increased with infusion of crystalloids, which was guided by pulmonary capillary wedge pressure (PCWP). There was a good correlation between change in PASS and change in PBV (r(2) = 0.741, P < 0.0001). However, when the baseline PASS was high, changes in PASS were much less. In patients with a pulmonary artery diastolic-pulmonary capillary wedge pressure gradient ≥ 6 mmHg, the baseline PASS was correlated with pulmonary venous resistance (r(2) = 0.644, P = 0.017). In 14 patients, in whom PBV was increased with both changes in position and infusion of crystalloids, the physiologic dead space-to-tidal volume ratio (VD/VT) was measured as an index of the distribution of V/Q. There was a good negative correlation between PASS and VD/VT (r(2) = 0.697, P < 0.0001). However, at a high baseline PASS, increases in PBV decreased PASS (P = 0.0006) and increased VD/VT (P = 0.0018). CONCLUSIONS: Changes in PBV change PASS and thereby the distribution of V/Q, depending on pulmonary venous resistance, which determines the baseline PASS.

Dexmedetomidine sedation for transesophageal echocardiography during percutaneous atrial septal defect closure in adult.

Atrial septal defect (ASD) is second common congenital heart disease that often leads to adult period. Intracardiac or transesophageal echocardiography (TEE) is essential for percutaneous closure of ASD using Amplatzer septal occluder. Dexmedetomidine (DEX), which is a highly selective α2-agonist, has sedative and analgesic properties without respiratory depression in the clinical dose range. We report percutaneous closure of ASD with TEE under DEX sedation.

Dexmedetomidine and remifentanil in the perioperative management of an adolescent undergoing resection of pheochromocytoma -A case report-.

A 15-year-old adolescent with unilateral multiple adrenal pheochromocytoma had an episode of subcortical intracerebral hemorrhage and seizure 6 weeks before the surgery. He was pretreated with terazosin, losartan, atenolol and levetiracetam for 2 weeks. Dexmedetomidine was started in the preoperative waiting area, and a combination of dexmedetomidine and remifentanil was continuously infused for most of anesthetic time. To control blood pressure, bolus injection of remifentanil and low-dose infusion of sodium nitroprusside, nicardipine, and esmolol were administered during three adrenergic crises. There was minimal post-resection hypotension, and his trachea was extubated safely 20 min after the surgery. He was discharged without noticeable complication. His catecholamine levels showed the steadily decreasing pattern during the operation in this case. Though a combination of dexmedetomidine and remifentanil may not prevent the hemodynamic instability impeccably during the tumor manipulation, this combination seems to be the way of interrupting release of catecholamines and minimizing hemodynamic fluctuations.

Lumbar plexopathy caused by metastatic tumor, which was mistaken for postoperative femoral neuropathy.

Surgical excision was performed on a 30-years old woman with a painful mass on her left thigh. The pathologic findings on the mass indicated fibromatosis. After the operation, she complained of allodynia and spontaneous pain at the operation site and ipsilateral lower leg. We treated her based on postoperative femoral neuropathy, but symptom was aggravated. We found a large liposarcoma in her left iliopsoas muscle which compressed the lumbar plexus. In conclusion, the cause of pain was lumbar plexopathy related to a mass in the left iliopsoas muscle. Prompt diagnosis of acute neuropathic pain after an operation is important and management must be based on exact causes.

Post-radiation Piriformis Syndrome in a Cervical Cancer Patient -A Case Report-.

The piriformis syndrome is a condition allegedly attributable to compression of the sciatic nerve by the piriformis muscle. Recently, magnetic resonance neurography and electrophysiologic study have helped to diagnose piriformis syndrome. High dose radiotherapy could induce acute and delayed muscle damage. We had experienced piriformis syndrome with fatty atrophy of piriformis muscle after radiotherapy for recurrent cervical cancer.