Reversible tactile hypoesthesia associated with myofascial trigger points: a pilot study on prevalence and clinical implications.

INTRODUCTION: Tactile hypoesthesia observed in patients with myofascial pain syndrome (MPS) is sometimes reversible when pain is relieved by trigger point injections (TPIs). We aimed to investigate the prevalence of such reversible hypoesthesia during TPI therapy and topographical relations between areas of tactile hypoesthesia and myofascial trigger points (MTrP) in patients with MPS. METHODS: Forty-six consecutive patients with MTrP were enrolled in this study. We closely observed changes in areas of tactile hypoesthesia in patients who had tactile hypoesthesia at the first visit, and throughout TPI therapy. Tactile stimulation was given using cotton swabs, and the areas of tactile hypoesthesia were delineated with an aqueous marker and recorded in photographs. RESULTS: A reduction in the size of hypoesthetic area with TPI was observed in 27 (58.7%) patients. All the 27 patients experienced a reduction in pain intensity by more than 50% in a numerical rating scale score through TPI therapy. In 9 patients, the reduction in the sizes of hypoesthetic areas occurred 10 minutes after TPI. Complete disappearance of tactile hypoesthesia after TPI therapy was observed in 6 of the 27 patients. Myofascial trigger points were located in the muscles in the vicinity of ipsilateral cutaneous dermatomes to which the hypoesthetic areas belonged. CONCLUSION: Our results indicate a relatively high prevalence of reversible tactile hypoesthesia in patients with MPS. Mapping of tactile hypoesthetic areas seems clinically useful for detecting MTrP. In addition, treating MTrP with TPI may be important for distinguishing tactile hypoesthesia associated with MPS from that with neuropathic pain.

Rocuronium-sugammadex use for electroconvulsive therapy in a hemodialysis patient: a case report.

BACKGROUND: Recently, rocuronium with subsequent use of sugammadex was proposed for electroconvulsive therapy (ECT) as an alternative to succinylcholine. Because sugammadex is cleared via the kidney with no metabolism, it is unknown that rocuronium-sugammadex use is safe in hemodialysis patients who received ECT. CASE PRESENTATION: In this case report, we used rocuronium with subsequent administration of sugammadex in a 69-year-old female, hemodialysis patient, scheduled for ten ECT sessions for severe major depression. In the initial eight sessions, we tested the feasibility of rocuronium-sugammadex use for ECT. During the series of four ECT sessions, we measured plasma concentrations for the sum of sugammadex and sugammadex-rocuronium complex and observed whether possible residual sugammadex affected muscle relaxation during subsequent sessions of ECT. The results showed the feasibility of rocuronium-sugammadex use as muscle relaxants for ECT in patients undergoing hemodialysis. However, an accumulation of sugammadex did occur even after two sessions of hemodialysis, and residual sugammadex decreased the effect of the rocuronium given in the subsequent ECT sessions. Rocuronium-sugammadex was successfully utilized as muscle relaxants for ECT in this patient. CONCLUSIONS: Our experience in this case may indicate that if succinylcholine is contraindicated, rocuronium-sugammadex can be an alternative method for muscle relaxation during ECT in patients undergoing hemodialysis. When this rocuronium-sugammadex procedure is used, the effect of residual sugammadex after hemodialysis on the subsequently administered rocuronium should be considered.

Urinary retention occurring one week after spinal anesthesia: a case of Elsberg syndrome.

PURPOSE: We describe a case of urinary retention caused by viral sacral myeloradiculitis (Elsberg syndrome) that occurred one week after spinal anesthesia. The differential diagnosis of urinary retention after spinal anesthesia is discussed. CLINICAL FEATURES: A 76-yr-old male patient presented for operative removal of a right testicular hydrocele under spinal anesthesia. Anesthesia and surgery were uneventful, and he was discharged on the fifth postoperative day. Two days after discharge, he developed intermittent anal pain and voiding difficulty and was readmitted to hospital on the tenth postoperative day. He subsequently developed urinary retention, incontinence of feces, and difficulty in defecation. Magnetic resonance imaging showed no epidural hematoma, abscess, or other lesions in the spinal column, cauda equina, or spinal cord. Neurological examination showed dysesthesia in the perineal region and loss of the anal reflex and bulbocavernosus response, which indicated sacral (S4-5) radiculopathy or a lesion of the conus of the spinal cord. A cerebrospinal analysis showed slight elevation of protein without pleocytosis. After neurologic consultation, herpetic sacral myeloradiculitis was suspected and intravenous acyclovir was administered along with large doses of methylprednisolone and immunoglobulin. The symptoms gradually resolved, and the difficulty in voiding resolved 19 days after initiation of the treatment. The patient was discharged 23 days after the start of the treatment without any other complications. CONCLUSION: This case suggests that Elsberg syndrome is important in the differential diagnosis of urinary retention after spinal anesthesia and should be discriminated from other anesthesia-related complications.

[Loss of anesthesia records during network failure of anesthesia management information system: a case of malfunction of backup system].

We report a case of an accidental loss of anesthesia records through network failure of an anesthesia information management system (AIMS). The backup data were not kept in the anesthesia workstations or the server during the failure. Accordingly, anesthesia records of five patients were lost for one hour. Our AIMS has a network redundancy where the server keeps anesthesia monitoring data via two pathways: one via the monitoring server to the AIMS server and the other via anesthesia workstation to the server. Despite the redundant pathways, transient power failures of network switches caused interruptions in both pathways. Our case indicates that, to improve the robustness of the AIMS as electronic medical records, every network apparatus of AIMS, should be supplied with an uninterrupted power supply. Furthermore, each anesthesia workstation should function independently as an anesthesia record keeping client when network failure occurs.

Distance from the skin to the epidural space at the first lumbar interspace in a Japanese obstetric population.

We prospectively examined the distance from the skin to the epidural space (SE distance) in 95 Japanese parturient women who underwent epidural anesthesia at the L1-2 interspace, and studied the correlation between various physical factors and SE distance. The same anesthesiologist inserted the epidural tubing with the patient in the right lateral decubitus position. An epidural needle was introduced into the skin vertically via the midline approach. The epidural space was located using the loss-of-resistance technique. SE distance was measured to the nearest 0.5 cm using centimeter markings on the shaft of the epidural needle. The median value of SE distance was 3.5 cm, with a range of 2.5 to 6.5 cm, and in 80% of cases SE distances were 3 to 4 cm. The correlation of body weight with SE distance was the highest of the physical factors (r2 = 0.800, p = 0.0001), and a simple regression equation was formulated to aid in predicting SE distance: "SE distance (cm) = 0.05 x body weight (kg) + 0.36". This formula will be a useful clinical guide for administering epidural anesthesia in Japanese parturient women. In conclusion, the SE distance in most Japanese parturient women is between 3 and 4 cm at the L1-2 interspace and this value is most closely correlated with their body weight.