CSF Lumbar Drainage: A Safe Surgical Option in Refractory Intracranial Hypertension Associated with Acute Posttraumatic External Hydrocephalus.

INTRODUCTION: External lumbar drainage (ELD) of cerebrospinal fluid (CSF) in posttraumatic refractory intracranial hypertension (ICHT) is controversial. We report our experience of ELD in ICHT associated with acute disturbance of CSF flow within subarachnoid spaces (SASs). MATERIALS AND METHODS: Four adult patients admitted to the neurointensive care unit for severe TBI who presented with secondary ICHT are retrospectively reported. When refractory to second-tier therapy, if external ventricular drainage were not possible or failed, and in the absence of an indication for craniotomy to treat a mass lesion or decompressive craniectomy, we assessed the evolution of CSF volume within cranial SAS and checked the presence of basal cisterns and the absence of tonsillar herniation to evaluate interest in and the safety of ELD. RESULTS: As second-tier therapy failed to lower intracranial pressure (ICP; mean ICP 37 ± 5 mmHg), and computed tomography (CT) showed abnormally enlarged cranial SAS following traumatic subarachnoid hemorrhage, patients received ELD. ICP decreased, with immediate and long-term effect (mean ICP 5 mmHg ± 2 mmHg). There were no complications to report. DISCUSSION: Acute traumatic external hydrocephalus may explain some of the specific situations of secondary increased ICP, with a "normal" CT scan, that is refractory to medical treatment. In these situations, lumbar drainage should be considered to be a safe, minimally invasive, and effective surgical option.

Effect of mandibular nerve block on postoperative analgesia in patients undergoing oropharyngeal carcinoma surgery under general anaesthesia.

BACKGROUND: Postoperative analgesia after oropharyngeal carcinoma surgery remains poorly studied. This study investigates the effects of mandibular nerve block (MNB) with ropivacaine 10 mg ml(-1) in conjunction with general anaesthesia (GA) on postoperative analgesia after partial glossectomy or transmandibular lateral pharyngectomy. METHODS: In a randomized double-blind study, 42 patients (21 in each group) received an MNB by the lateral extra-oral approach (MNB group) or a deep s.c. injection of normal saline (control group). Both groups received a standardized general anaesthetic. Postoperative analgesia included fixed dose of i.v. acetaminophen and morphine via a patient-controlled analgesia device. Consumption of morphine and supplemental analgesics and pain scores at rest were measured. RESULTS: The mean cumulative morphine consumption was reduced by 56 and 45% at 12 and 24 h after operation in the MNB group. The administration of analgesic rescue medications was delayed in the MNB group. The visual analogue scale (VAS) pain scores were comparable in the two groups during the first 24 h. Adequate analgesia (mean VAS < or = 3) was observed throughout the study period in the MNB group, but only from 4 h after operation onwards in the control group. The number of patients who experienced severe pain (VAS > 7) during the first postoperative day was lower in the MNB group than in the control group (3 vs 10. respectively, P < 0.05). CONCLUSIONS: In this study, MNB performed before GA for oropharyngeal carcinoma surgery improved postoperative analgesia, resulting in reduced morphine consumption at 24 h and severe pain in fewer patients.