[Paraganglioma of the cauda equina region: Report of six cases and review of the literature]. / Paragangliomes de la queue de cheval : à propos de six cas et revue de la littérature.

BACKGROUND AND PURPOSE: Paragangliomas of the cauda equina are rare tumors. The standard treatment is surgical resection. Our study aims to compare our clinical, radiological, prognostic data to the literature and to offer management and follow-up recommendations. METHODS: In this retrospective study, six patients with paraganglioma of the cauda equina region were treated. Symptoms included radicular nerve pain and low back pain with occasional sphincter dysfunction and motor deficit. MRI showed well-circumscribed lesions with homogeneous enhancement following gadolinium injection. Treatment involved complete surgical resection of the tumor under electrophysiological control. In addition to the characteristics of the tumor, we assessed operating results as well as postoperative morbidity and follow-up. RESULTS: All patients had complete removal of the tumor, which required in most cases the resection of the carrying root. The intervention allowed a regression of the initial symptoms, with possible postoperative regressive sphincter disorders. Clinical and radiological follow-up (19 months on average), showed no tumor recurrence. CONCLUSIONS: The reference treatment of these tumors is complete surgical resection, usually requiring the sacrifice of the carrying nerve root. Intra-operative nerve roots stimulation is recommended to reduce the risk of motor deficit linked to this radical treatment. A long-term clinical and radiological follow-up is recommended.

Adjunctive analgesia with intravenous propacetamol does not reduce morphine-related adverse effects.

BACKGROUND: Propacetamol is widely used in the management of postoperative pain. It decreases morphine requirements but its effect on the incidence of morphine-related adverse effects remains unknown. METHODS: Patients (550) were randomly assigned to receive propacetamol or a placebo over the first 24 h after operation in a blinded study. Intravenous morphine titration was performed, after which morphine was administered s.c. every 4 h according to their pain score. Pain was assessed using a visual analogue scale (VAS). The primary end-point was the incidence of morphine-related adverse effects. The main secondary end-points were morphine requirements and VAS score. RESULTS: After morphine titration, the VAS score and the number of patients with pain relief did not differ between groups. Morphine requirements were decreased in the propacetamol group (21 vs 14.5 mg, P<0.001) but the incidence of morphine-related adverse effects did not differ between groups (42 vs 46%, not significant). In patients with moderate pain (n=395), morphine requirements decreased by 37% (P<0.001) and the percentage of patients requiring no morphine was greater (21 vs 8%, P=0.002) in the propacetamol group. In patients with severe pain (n=155), morphine requirements decreased by 18% (P=0.04) in the propacetamol group and the number of patients who did not require morphine (3 vs 8%) did not differ significantly. CONCLUSIONS: Although propacetamol induced a small morphine-sparing effect, it did not change the incidence of morphine-related adverse effects in the postoperative period. Moreover, no benefit could be demonstrated in patients with severe postoperative pain.

[Transfusional strategy in neurosurgery: preoperative hemodilution by erythrocytapheresis]. / Une stratégie transfusionnelle en neurochirurgie: hémodilution préopératoire par érythrocytaphérèse.

Autologous blood transfusion techniques have been devised in order to decrease the risk of homologous transfusion-related complications. In neurosurgery, preoperative autologous blood collection is difficult because of the rather short time interval before surgery, as well as the risk of increasing cerebral oedema or intracranial hypertension. Therefore erythrocytapheresis has been performed the day before surgery as a preoperative haemodilution in 33 patients, using a discontinuous flow cell separator (PCS + Heamonetics). Patients with anaemia, unstable cardiovascular condition, infections, malignant tumor with a bad prognosis, or a poor peripheral venous status were not included. The mean volume of collected red cells was 526 +/- 176 mL, allowing a minimal colloid perfusion adjusted on this volume, with a simultaneous restitution of plasma and platelets. For a mean peroperative estimated blood loss of 1,040 +/- 52 mL, a homologous blood transfusion was avoided in 29 patients (88%). Four patients who underwent meningioma surgery received homologous red cells units in addition to their autologous blood. Two patients did not require any transfusion. Finally, 88% of autologous red cells units were readministered and 8 units were not retransfused. Preoperative erythrocytapheresis has proven to be a very simple and well tolerated technique. It can be considered for elective neurosurgery, when the time delay before surgery is short and when the blood loss is anticipated as to be moderate. It may also be associated with iterative autologous blood donation programme or the peroperative use of a cell saver.

[Use of fiberoptic bronchoscope for difficult intubation in maxillofacial surgery]. / Utilisation du fibroscope bronchique pour l'intubation difficile en chirurgie maxillofaciale.

This retrospective study analyzed the cases of difficult intubations carried out with a fiberoptic bronchoscope between March 1984 and May 1989. During this period, 222 such procedures were attempted in 131 male and 68 female patients. All cases were diagnosed at the preoperative visit. A fiberoptic bronchoscope was used as a guide under topical nasal and laryngeal anaesthesia, together with appropriate benzodiazanalgesia, in order to maintain spontaneous breathing. The nasotracheal route was used in 218 cases. Successful intubation was achieved in 219 cases (98.6%), 209 of them (95.4%) within fifteen minutes. Of the three failures, only one was unpredictable (inability to withdraw the fiberoptic bronchoscope from the endotracheal tube). In the two others, the technique was subsequently found to have been wrongly indicated: major nasopharyngeal secretions occluded the fiberoptic device in the first one, and an anatomically compromised airway led to apnoea under sedation in the other. A narrow nasotracheal passage, spreading oedema, bloody secretions or coughing gave rise to technical difficulties in 39 cases (17.5%). There was one case of regurgitation without any drawback. Benzodiazanalgesia was responsible for two cases of respiratory depression. This technique was otherwise very satisfactory, patients being cooperative and frequently having amnesia of intubation. The indications for the use of a fiberoptic bronchoscope were: insufficient oral opening, orofacial obstacles to laryngoscopy, and cases where laryngoscopy had to be avoided. The main drawbacks of this technique were the cost and fragility of fiberoptic device as well as operator efficiency. The anaesthesiologists involved in the present series performed ten easy intubations each with the fiberoptic bronchoscope, and routinely used the teaching eye-piece.(ABSTRACT TRUNCATED AT 250 WORDS)

[Randomized study of amoxicillin-clavulanic acid versus amoxicillin-metronidazole combinations in pyogenic infections of dental origin]. / Etude randomisée de l'association amoxicilline-acide clavulanique versus amoxicilline + métronidazole dans les cellulites de la face d'origine dentaire.

Thirty patients, without any valve defect, cardiac malformation or previous antibiotic administration and presenting dental infections, have been treated either with amoxycillin-clavulanic acid or amoxycillin and metronidazole. Aerobic and anaerobic bacteria have been isolated. These infections were due to mixed flora. Nearly one half of anaerobes were Peptostreptococcus, S. milleri and S. sanguis being predominant among aerobes. The species identified were those found in the mouth in the absence of infection becoming as opportunistic flora. The percentage of cures was equivalent in the two groups. the association amoxycillin-clavulanic acid seems to be as active as amoxycillin + metronidazole on the microflora isolated from dentogenous pyogenic infections.

[The amnesic effects of midazolam in premedication of children]. / Effets amnésiants du midazolam en prémédication chez l'enfant.

The aim of this study was to check local and general tolerance as well as anxiolytic and amnesic effects of midazolam intramuscular administration as a premedication in 4 to 10 years old children. A double blind, comparative study with a placebo was achieved, after drawing lots, in 40 children divided into two equal groups. Premedication consisted of either midazolam or injectable water administrated with a posology of 0.3 to 0.5 mg.kg-1 combined, in both cases, with atropine sulfate (0.015 mg.kg-1). Results confirmed good local and general tolerance. Also anterograde amnesia was found to be excellent: 17 children in the midazolam group did not remember a photograph shown after premedication, instead of only one in the placebo group. Anxiolytic effects, similar in both groups, cannot be considered owing to the too short interval of time from premedication to induction.

Effects of hypotension on cutaneous and subcutaneous blood flow in anaesthetized humans.

The aim of this study was to determine the effect of controlled hypotension on subcutaneous and cutaneous haemodynamics in humans. Moderate hypotension was achieved with nitroglycerin (NTG) and sodium nitroprusside (SNP) infusion during narconeuroleptanalgesia in seven patients. Subcutaneous and cutaneous blood flow were measured by a superficial and deep heat clearance (HC) technique. The mean arterial pressure (BPa) decreased by 23%-30% and heart rate (fc) increased but only during NTG infusion (+22%; P less than 0.02). Subcutaneous and cutaneous blood flows remained unchanged despite a significant decrease in calculated cutaneous resistance (NTG: -26%, P less than 0.01; SNP: -34%, P less than 0.02] and subcutaneous vascular resistance changed only with SNP (-31%, P less than 0.02). After hypotension was discontinued the subcutaneous blood flow decreased (-13%, P = 0.05), whereas subcutaneous vascular resistance returned to its control values. An inverse relationship was found between fc and BPa (NTG: r = -0.525, P less than 0.01; SNP: r = -0.622, P less than 0.01) as well as with subcutaneous blood flow (NTG: r = -0.653, P less than 0.001; SNP: r = -0.573, P less than 0.01). In addition, we found oscillatory changes in deep HC values which differed in magnitudes (NTG 0.22 (SEM 0.09) W.m-1.degree C-1 vs SNP 0.42 (SEM 0.1) W.m-1.degrees C-1, P less than 0.01) and frequencies (NTG 0.02 (SEM 0.006) Hz vs SNP 0.01 (SEM 0.002) Hz, P less than 0.01). Despite unchanged blood flow, the effects of controlled hypotension on cutaneous and subcutaneous haemodynamics were different depending on the type of drug. These differences may have been related to counterregulatory responses and/or to direct vascular effects.

Cutaneous and subcutaneous blood flow during general anaesthesia.

The vasodilator effect of anaesthetic agents on cutaneous vessels has often been investigated. In contrast, although subcutaneous tissue is concerned with metabolism and thermoregulation, the effects of anaesthesia on subcutaneous blood flow have not been well documented. The purpose of this study was to determine the magnitude of changes in cutaneous and subcutaneous blood flow during general anaesthesia in Man. Anaesthesia was induced with flunitrazepam in 15 patients before facial plastic surgery. Blood flow was estimated using heat thermal clearance (HC). Two HC sensors in different areas allowed the measurement of superficial and deep HC. Systolic (SABP), diastolic (DABP) and mean arterial blood pressure (MABP), heart rate (HR), and rectal and mean skin temperature were also recorded. After induction of anaesthesia, HR increased significantly (p less than 0.05) whereas SABP, DABP and MABP remained unchanged. The rectal-toe temperature gradient fell from 6.3 +/- 4.1 degrees C to 3.4 +/- 1.1 degrees C (p less than 0.01) suggesting a reduction in vasomotor tone. Superficial HC increased from 0.37 +/- 0.06 to 0.42 +/- 0.08 W.m-1.degrees C-1 (p less than 0.05) whereas deep HC decreased from 0.33 +/- 0.07 to 0.31 +/- 0.09 W.m-1.degrees C-1 (NS) and returned to the control value thereafter. Rectal temperature and mean skin temperature were unchanged. The changes in deep HC are similar to those previously observed in muscle during induction of anaesthesia. Our results show that anaesthesia mainly affects cutaneous blood flow, without any significant change in subcutaneous blood flow during the early phase of anaesthesia in human beings.

[Hemodynamic parameters and blood-free surgical field with nitroglycerin in maxillofacial surgery]. / Paramètres hémodynamiques et exsanguinité du champ opératoire sous nitroglycérine en chirurgie maxillo-faciale.

73 oral facial surgery have been performed using controlled-hypotension induced with nitroglycerin (NTG) to reduce surgical bleeding. Surgical bleeding has been reduced in more than 45% of cases. But frequent lack of correlation between blood pressure, heart beat and bleeding might imply vascular reflex mechanisms induced by controlled-hypotension using NTG. Hemodynamic parameters such as blood pressure and heart rate seem to be insufficient to monitor controlled hypotension efficiency on surgical bleeding. The use of peroperative tissues blood flow monitoring may help for the better understanding of surgical bleeding during controlled-hypotension using NTG.