Cervical Interlaminar Epidural Injections at High Doses Do Not Increase Optic Nerve Sheath Diameter on a Long-Term Basis.

BACKGROUND: Cervical epidural injection (CEI) is widely performed on patients with pain originating from the cervical spine. Studies have shown a good relationship between the optic nerve sheath diameter (ONSD) and the intracranial pressure (ICP). OBJECTIVE: The aim of this study was to evaluate the changes in the ONSD as a non-invasive surrogate marker of ICP after CEI. STUDY DESIGN: Prospective observational study. SETTING: Hospital and ambulatory pain clinic. METHODS: Twenty patients undergoing CEI at the C5-6 level were enrolled in this observational study. The CEIs were performed using a total of 14 mL of mixture volume via the interlaminar approach in the right lateral decubitus position. The ONSD through ultrasonography was measured in the initial supine position (T0, baseline), 30 seconds after the completion of CEI (T0.5), at 30-second intervals for 5 minutes (T0.5~T5), and at one-minute intervals for 5 minutes (T6~T10). RESULTS: The values of the baseline ONSD (T0) in both eyes were 4.1 ± 0.4 mm. The ONSD significantly increased from T1 to T10 (P < 0.05) compared with T0. The maximum value of the ONSD was measured as 5.1 ± 0.4 mm at T4, and the mean difference between the baseline ONSD and its maximum value was 1.0 mm, which represented about 27%. There was no increase in ICP-related complications such as dizziness, headache, visual acuity, or retinal hemorrhage. LIMITATIONS: This was an observational study without a control group. All patients were presumed to have no intracranial pathology. CONCLUSION: The 14 mL CEI resulted in an increase in the ONSD by ultrasonography over time. The most critical increase in ONSD was observed 4 minutes after CEI, but this increase was not sustained. Further work is needed to confirm the effects of the speed and volume of the injection and of the position. REGISTRATION: Registered in the Clinical Research Information Service of the Korea National Institute of Health, registration number: KCT0001487. Key words: Analgesic techniques, epidural block, intracranial pressure, optic nerve sheath diameter, ultrasonography Analgesic techniques, epidural block, intracranial pressure, optic nerve sheath diameter, ultrasonography.

Resorption of Massive Lumbar Disc Herniation on MRI Treated with Epidural Steroid Injection: A Retrospective Study of 28 Cases.

BACKGROUND: Although herniated disc fragments may resolve spontaneously, the optimal treatment option for massive lumbar disc herniation (LDH) has not been determined. OBJECTIVE: To evaluate the extent of reduction in the size of massive LDH on magnetic resonance imaging (MRI) and the pain relief effect of transforaminal epidural steroid injection (TFESI) during the study period. STUDY DESIGN: Retrospective evaluation. SETTING: Hospital and ambulatory pain clinic, Korea. METHODS: After Institutional Review Board approval, we conducted a retrospective review of 28 patients who underwent at least 2 MRIs during the period from January 2012 to December 2014. The size of the herniated mass was determined from the ratio of the anterior-posterior diameter of the spinal canal (C-value) to the maximum anterior-posterior diameter of the herniated disc (H-value) on axial MRI (C-H ratio). We also analyzed visual analogue scale (VAS) scores at baseline (T0), 2 weeks after the first and second TFESI (T1, T2), and at the second follow-up MRI (T3). RESULTS: The mean C-value was 18.3 ± 2.9 mm. The mean H-value changed from 10.4 ± 1.9 mm to 4.5 ± 2.7 mm, and the mean C-H ratio changed from 58 ± 1.0% to 24 ± 1.4% (P < 0.001). Twenty-four of 28 patients demonstrated a reduction in the size of the herniation, and the mean reduction rate of the C-H ratio was 59%. In 4 patients, the LDH had not resolved on MRI, but the symptoms had diminished to such an extent that surgery was not required. The mean VAS score had significantly decreased at T1 and showed a continued decrease at the time of the last follow-up (P < 0.001). LIMITATIONS: This is a retrospective study and only offers data for patients who chose not to undergo surgery. In addition, the timing of repeat MRI was not standardized. CONCLUSION: The majority of cases of massive LDH demonstrated resolution at variable points between 3 and 21 months. TFESI could provide effective pain relief for patients with massive LDH in the interval without severe neurologic deterioration.IRB approval: Kangdong Sacred Heart Hospital: IRB Number # 14-1-10.

The efficacy of pre-warming on reducing intraprocedural hypothermia in endovascular coiling of cerebral aneurysms.

BACKGROUND: The anesthetic management of patients undergoing endovascular treatment of cerebral aneurysms in the interventional neuroradiology suite can be challenged by hypothermia because of low ambient temperature for operating and maintaining its equipments. We evaluated the efficacy of skin surface warming prior to induction of anesthesia to prevent the decrease in core temperature and reduce the incidence of hypothermia. METHODS: Seventy-two patients were randomized to pre-warmed and control group. The patients in pre-warmed group were warmed 30 minutes before induction with a forced-air warming blanket set at 38°C. Pre-induction tympanic temperature (Tpre) was measured using an infrared tympanic thermometer and core temperature was measured at the esophagus immediately after intubation (T0) and recorded at 20 minutes intervals (T20, T40, T60, T80, T100, and T120). The number of patients who became hypothermic at each time was recorded. RESULTS: Tpre in the control and pre-warmed group were 36.4 ± 0.4°C and 36.6 ± 0.3°C, whereas T0 were 36.5 ± 0.4°C and 36.6 ± 0.2°C. Core temperatures in the pre-warmed group were significantly higher than the control group at T20, T40, T60, T80, T100, and T120 (P < 0.001). Compared to T0, core temperatures at each time were significantly lower in both two groups (P = 0.007 at T20 in pre-warmed group, P < 0.001 at the other times in both groups). The incidence of hypothermia was significantly lower in the pre-warmed group than the control group from T20 to T120 (P = 0.002 at T20, P < 0.001 at the other times). CONCLUSION: Pre-warming for 30 minutes at 38°C did not modify the trends of the temperature decrease seen in the INR suite. It just slightly elevated the beginning post intubation base temperature. The rate of decrease was similar from T20 to T120. However, pre-warming considerably reduced the risk of intraprocedural hypothermia. TRIAL REGISTRATION: Clinical Research Information Service (CRiS) Identifier: KCT0001320. Registered December 19th, 2014.

Percutaneous bipolar radiofrequency T3 sympathicotomy in Raynaud's disease -A case report-.

A 54-year-old female was suffering from cold-induced Raynaud's attacks in her both hands with symptoms most severe in her left hand. As the patient did not respond to previous medical treatments and endoscopic thoracic sympathectomy, we performed percutaneous bipolar radiofrequency thoracic sympathicotomy at the left T3 vertebral level. After the procedure, the patient obtained a long duration of symptom relief over 3 years. Percutaneous bipolar radiofrequency T3 sympathicotomy is minimally invasive and effective technique by creating large continuous strip lesion.

Cardiac arrest associated with carbon dioxide gas embolism during laparoscopic surgery for colorectal cancer and liver metastasis -A case report-.

Clinically apparent carbon dioxide (CO(2)) gas embolism is uncommon, but it may be a potentially lethal complication if it occurs. We describe a 40-year-old woman who suffered a CO(2) gas embolism with cardiac arrest during laparoscopic surgery for colorectal cancer and liver metastasis. Intra-abdominal pressure was controlled to less than 15 mmHg during CO(2) gas pneumoperitoneum. The right hepatic vein was accidentally disrupted during liver dissection, and an emergent laparotomy was performed. A few minutes later, the end-tidal CO(2) decreased, followed by bradycardia and pulseless electrical activity. External cardiac massage, epinephrine, and atropine were given promptly. Ventilation with 100% oxygen was started and the patient was moved to the Trendelenburg position. Two minutes after resuscitation was begun, a cardiac rhythm reappeared and a pulsatile arterial waveform was displayed. A transesophageal echocardiogram showed air bubbles in the right pulmonary artery. The patient recovered completely, with no cardiopulmonary or neurological sequelae.

Morphologic Analysis of Water-Cooled Bipolar Radiofrequency lesions on Egg White in Vitro.

BACKGROUND: The aim of this study was to document the optimal spacing of two cannulae to form continuous strip lesions and maximal surface area by using water-cooled bipolar radiofrequency technology. METHODS: Two water-cooled needle probes (15 cm length, 18-gauge probe with 6 mm electrode tip) were placed in a parallel position 10, 20, 24, 26, and 28 mm apart and submerged in egg white. Temperatures of the probes were raised from 35℃ to 90℃ and the progress of lesion formation was photographed every 1 minute with the increase of the tip temperature. Approximately 30 photographs were taken. The resultant surface areas of the lesions were measured with the digital image program. RESULTS: Continuous strip lesions were formed when the cannulae were spaced 24 mm or less apart; monopolar lesions around each cannula resulted if they were spaced more than 26 mm apart. Maximal surface areas through the formation of continuous strip lesion were 221 mm(2), 375 mm(2), and 476 mm(2) in 10, 20, and 24 mm, respectively. Summations of maximal surface area of each monopolar lesions were 394 mm(2) and 103 mm(2) in 26 and 28 mm, respectively. CONCLUSIONS: Water-cooled bipolar Radiofrequency technology creates continuous "strip" lesions proportional in size to the distance between the probes till the distance between cannulae is 24 mm or less. Spacing the cannulae 24 mm apart and treating about 80℃ for 24 minutes maximizes the surface area of the lesion.

A New Anterior Approach for Fluoroscopy-guided Suprascapular Nerve Block - A Preliminary Report -.

BACKGROUND: The aim of the study was to investigate the feasibility of fluoroscopy-guided anterior approach for suprascapular nerve block (SSNB). METHODS: Twenty patients with chronic shoulder pain were included in the study. All of the nerve blocks were performed with patients in a supine position. Fluoroscopy was tilted medially to obtain the best view of the scapular notch (medial angle) and caudally to put the base of coracoid process and scapular spine on same line (caudal angle). SSNB was performed by introducing a 100-mm, 21-gauge needle to the scapular notch with tunnel view technique. Following negative aspiration, 1.0 ml of contrast was injected to confirm the scapular notch, and 1 % mepivacaine 2 ml was slowly injected. The success of SSNB was assessed by numerical rating scale (NRS) before and after the block. RESULTS: The average NRS was decreased from 4.8 ± 0.6 to 0.6 ± 0.5 after the procedure (P < 0.05). The best view of the scapular notch was obtained in a medial angle of 15.1 ± 2.2 (11-19°) and a caudal angle of 15.4 ± 1.7° (12-18°). The average distance from the skin to the scapular notch was 5.8 ± 0.6 cm. None of the complications such as pneumothorax, intravascular injection, and hematoma formation was found except one case of partial brachial plexus block. CONCLUSIONS: SSNB by fluoroscopy-guided anterior approach is a feasible technique. The advantage of using a fluoroscopy resulted in an effective block with a small dose of local anesthetics by an accurate placement of a tip of needle in the scapular notch while avoiding pneumothorax.

Percutaneous aspiration of lumbar zygapophyseal joint synovial cyst under fluoroscopic guidance -A case report-.

A 51-year-old man with a 1-month history of lower back pain and radiating pain visited to our pain clinic. A magnetic resonance imaging (MRI) scan demonstrated a cyst like mass at the level of the L4-5 interspace and compression of the thecal sac and the nerve root on the right side. We performed percutaneous needle aspiration of the lumbar zygapophyseal joint synovial cyst under fluoroscopic guidance. The patient felt an immediate relief of symptoms after the aspiration, and had no signs or symptoms of recurrence at the follow-up 6 months later. No demonstrable lesion was found in the 6 months follow-up MRI.

Symptomatic epidural gas cyst treated with epidural block and percutaneous needle aspiration -A case report-.

A 68-year-old woman suffered from lower back and radiating pain on her right buttock and posterior calf. Axial magnetic resonance imaging showed a 7 × 7 mm nodular lesion (T1 and, T2 low signal intensity) at the epidural space between the L5-S1 level and computed tomography revealed it was an epidural gas cyst. The authors performed an epidural block and percutaneous needle aspiration of the epidural gas cyst. The patient showed almost complete resolution of symptoms one year later. The authors suggest that an epidural nerve block with needle aspiration of a gas cyst could be an alternative treatment option for patients with a symptomatic epidural gas cyst before surgery.

Partial-thickness rotator cuff tears.

Although the incidence of partial-thickness rotator cuff tears (PTRCTs) was reported to be from 13% to 32% in cadaveric studies, the actual incidence is not yet known. The causes of PTRCTs can be explained by either extrinsic or intrinsic theories. Studies suggest that intrinsic degeneration within the rotator cuff is the principal factor in the pathogenesis of rotator cuff tears. Extrinsic causes include subacromial impingement, acute traumatic events, and repetitive microtrauma. However, acromially initiated rotator cuff pathology does not occur and extrinsic impingement does not cause pathology on the articular side of the tendon. An arthroscopic classification system has been developed based on the location and depth of the tear. These include the articular, bursal, and intratendinous areas. Both ultrasound and magnetic resonance image are reported with a high accuracy of 87%. Conservative treatment, such as subacromial or intra-articular injections and suprascapular nerve block with or without block of the articular branches of the circumflex nerve, should be considered prior to operative treatment for PTRCTs.

Impact of sex, age and BMI on depth and diameter of the infraclavicular axillary vein when measured by ultrasonography.

BACKGROUND AND OBJECTIVE: The axillary vein is another option for central venous catheterisation, with less chance of accidental arterial puncture as there is a greater distance between artery and vein, and from vein to rib cage, compared with other sites. Better success, lower complication rates and faster access can be achieved with ultrasound guidance which is becoming the established technique for central venous catheterisation. We measured two key factors for successful infraclavicular axillary venous catheterisation: depth and diameter of the infraclavicular axillary vein in its medial part using ultrasound. METHODS: We recruited 98 patients, classified according to sex, age and BMI. Groups were divided according to BMI as follows: group 1 (≤20 kg m⁻²), group 2 (20.01-25.00 kg m⁻²) and group 3 (>25 kg m⁻²); and these were further subdivided according to age: 20-39 years, 40-59 years and 60-80 years. The depth and diameter of the infraclavicular axillary vein was measured at a point between the medial third and midpoint of the clavicle. RESULTS: Vein diameter was significantly different between men and women (P = 0.005), whereas depth showed no significant difference. In the BMI subgroups, there was a significant difference in depth (P < 0.001), and a trend to significant difference in diameter (P = 0.056). However, age-specific differences in depth and diameter were not observed. CONCLUSION: During catheterisation of infraclavicular axillary vein, real-time visualisation of the needle tip when using ultrasound to gauge vein depth and diameter may diminish major complications such as pneumothorax and artery puncture.

Left atrial appendage thrombus detected by intraoperative transesophageal echocardiography in a patient with acute small bowel infarction -A case report-.

Acute mesenteric ischemia and infarction is an emergent situation associated with high mortality, commonly due to emboli or thrombosis of the mesenteric arteries. Embolism to the mesenteric arteries is most frequently due to a dislodged thrombus from the left atrium, left ventricle, or cardiac valves. We report a case of 70-year-old female patient with an acute small bowel infarction due to a mesenteric artery embolism dislodged from a left atrial appendage detected by intraoperative transesophageal echocardiography and followed by anticoagulation therapy.

Sequential bipolar radiofrequency lumbar sympathectomy in Raynaud's disease -A case report-.

A 39-year-old female was suffering from cold-induced Raynaud's attacks in both hands and feet, with symptoms being most severe in her left foot. The patient did not respond to medical treatments and was referred to our department of pain medicine. We performed sequential bipolar radiofrequency lumbar sympathectomy to the patient, which offered a long duration of symptom relief. Sequential bipolar radiofrequency lesions could create continuous strip lesion, and thus, could achieve better results, while the potential risk of liquid neurolytic agents could be avoided.

Spontaneous retropharyngeal hematoma - a case report -.

Spontaneous retropharyngeal hematoma is rare and difficult to diagnosis early. A 23-year-old male spontaneously developed acute onset of neck pain, limitation of neck motion, and mild dysphagia. Magnetic resonance imaging demonstrated blood products in prevertebral space from C2 to C4, suggesting a diagnosis of retropharyngeal hematoma. We report a rare case of spontaneous retropharyngeal hematoma causing neck pain.

Three-dimensional C-arm computed tomography-guided sacroplasty for the treatment of sacral body fracture.

STUDY DESIGN: Case report. OBJECTIVE: To report our results of a sacroplasty technique, using 3-dimensional C-arm CT for the treatment of sacral body fracture. SUMMARY OF BACKGROUND DATA: Sacroplasty may provide symptomatic relief and hasten recovery in the treatment of sacral insufficiency fractures. To our knowledge, there is no case report in the literature describing the application of sacroplasty for the treatment of sacral body fracture. We present a case of patient who had percutaneous sacroplasty for sacral body fracture and sacral alar fracture under 3-dimensional C-arm CT guidance and discuss the clinical results and technical considerations. METHODS: The procedure included a standard prone positioning of the patient and the area to be treated was prepared in a strictly sterile manner, and a local anesthesia was used. After a small skin incision, an 11-gauge vertebroplasty needle was positioned at the entry point in the sacrum. Then, the needle was inclined, directed, and advanced from the posterior aspect to the anterior aspect of the sacral vertebral body. PMMA cement was incrementally introduced in 0.5 mL aliquots and the volume of PMMA cement injected was total 4 mL. Precise needle placement and PMMA cement injection was performed under the 3-dimensional C-arm CT system and the right sacral alar region was performed in a similar manner. RESULTS: There were no peri-procedural complications occurred and the patient experienced an immediate and substantial pain relief that was persistent during a 12-month follow-up. CONCLUSIONS: 3-dimensional C-arm CT-guided sacroplasty is a safe, practical, and effective solution to treatment of sacral body fracture.

Unilateral phrenic nerve block guided by ultrasonography and nerve stimulator for the treatment of hiccup developed after tongue cancer operation: A case report.

Hiccups are common benign and usually transient phenomenon that occur in nearly everyone. However, persistent or intractable hiccups can cause multiple problems including malnutrition, weight loss, fatigue, dehydration, insomnia, and wound dehiscence. We have experienced a case of postoperative persistent hiccup. The patient was formerly diagnosed tongue cancer and developed persistent hiccup after partial glossectomy with modified radical neck dissection and a radial forearm free-flap operation. He was unsuccessfully managed using pharmacologic methods, and then we tried phrenic nerve block guided by ultrasonography and a nerve stimulator because the surface anatomy of neck was deformed by the previous operation. Thirty minutes after the block, the hiccups disappeared.

A comparative study on the analgesic effect of continuous intraarticular infusion with ropivacaine, ropivacaine/fentanyl and ropivacaine/fentanyl/ketorolac after arthroscopic shoulder surgery.

BACKGROUND: Arthroscopic shoulder surgery can result in severe postoperative pain. A variety of methods have been used to control pain in postoperative period and the results are variable. The purpose of this study was to compare the relative analgesic efficacies of the postoperative intraarticular infusion of ropivacaine, ropivacaine/fentanyl, and ropivacaine/fentanyl/ketorolac after arthroscopic shoulder surgery. METHODS: Thirty patients undergoing arthroscopic shoulder surgery under general anesthesia were randomly assigned to three groups. At the end of surgery, 0.5% ropivacaine 20 ml was infused into the articular space and a continuous infusion catheter was inserted into intraarticular operated site. After surgery, continuous infusion of 0.5% ropivacaine 100 ml (Group 1, n = 10), 0.5% ropivacaine 100 ml including fentanyl 10 microg/kg (Group 2, n = 10), or 0.5% ropivacaine 100 ml including fentanyl 10 microgram/kg and ketorolac 150 mg (Group 3, n = 10) was started through catheter at rate of 2 ml/hr with bolus dose of 0.5 ml with a lock out time of 15 minutes for 2 days. The level of pain was assessed using a visual analogue scale (VAS) postoperative 2, 6, 12, 24 and 48 hours and the amounts of supplemental analgesics were recorded. RESULTS: The VAS was significantly lower after 2, 6, 12 hours in Group 2 than in Group 1. In Group 3, the VAS was significantly lower all hours than in the other two groups. CONCLUSIONS: The combination of fentanyl and ketorolac with ropivacaine did provide better postoperative analgesia than the other groups after arthroscopic shoulder surgery.