A novel checklist for anesthesia in neurosurgical cases.

Throughout their training, anesthesiology residents are exposed to a variety of surgical subspecialties, many of which have specific anesthetic considerations. According to the Accreditation Council for Graduate Medical Education requirements, each anesthesiology resident must provide anesthesia for at least twenty intracerebral cases. There are several studies that demonstrate that checklists may reduce deficiencies in pre-induction room setup. We are introducing a novel checklist for neuroanesthesia, which we believe to be helpful for residents during their neuroanesthesiology rotations. Our checklist provides a quick and succinct review of neuroanesthetic challenges prior to case setup by junior residents, covering noteworthy aspects of equipment setup, airway management, induction period, intraoperative concerns, and postoperative considerations. We recommend displaying this checklist on the operating room wall for quick reference.

Recent decline in the use of invasive neurocritical care monitoring for traumatic brain injury: A case report.

BACKGROUND: In this article, we discuss the dramatic decline in the utilization of invasive cranial monitoring of patients with traumatic brain injury (TBI). CASE DESCRIPTION: A 52-year-old male presented with a severe TBI following a motor vehicle accident. The initial computed tomography scan showed a subdural hematoma, and the patient underwent a craniotomy. However, preoperatively, intraoperatively, and postoperatively, the critical care team never utilized invasive cranial monitoring. Therefore, when the patient expired several weeks later due to multiorgan failure, his death was in part attributed to the neurocritical care specialists' failure to employ invasive cranial monitoring techniques. CONCLUSION: Evidence-based and defensive medicine, cost containment, and a lack of leadership have contributed to neurocritical care specialists' increased failure to utilize invasive hemodynamic and neurological monitoring for TBI.

SNI case of the week: Initial concomitant use of gabapentin, clonidine, and prednisone may enhance suicidal ideation: A case report.

BACKGROUND: Suicide cases are the end product of a combination of biological, clinical, psychological, social, and cultural risk/protective factors, and attempts to remain unpredictable. CASE DESCRIPTION: A 43-year-old male presented to the hospital with jaundiced skin/eyes of 7 days' duration. He had a history of a major depressive disorder and chronic alcohol consumption (e.g., 3-5 alcoholic drinks/day for the past 15 years). Studies documented acute hepatic disease (e.g., biopsy-documented hepatocellular alcoholic hepatitis), accompanied by a cholestatic disease. The patient was discharged on clonidine, iron multivitamin, folic acid, gabapentin, and prednisone. Eight days postdischarge from the hospital, he committed suicide (e.g., self- inflicted gunshot wound to the head). CONCLUSION: Concomitant administration of gabapentin, prednisone, and clonidine, especially if used for the first time, may play a synergistic effect in increasing a patient's suicide risk.

Interventionist performs a "sham" lumbar microdiscectomy: Should interventionalists be performing spinal surgery?

BACKGROUND: Neurosurgeons and orthopedists, who have received specific training, should be the ones performing spinal surgery. Here, we present a case in which spinal surgeons secondarily (e.g., 6 months later) found that a patient's first lumbar discectomy, performed by an interventional specialist, had been a "sham" procedure. CASE DESCRIPTION: A 30-year-old male presented with sciatica attributed to a magnetic resonance imaging documented large, extruded disc at the L4-5 level. An interventional pain management specialist (IPMS) performed two epidural steroid injections; these resulted in an exacerbation of his pain. The IPMS then advised the patient that he was a surgeon and performed an "interventional" microdiscectomy. Secondarily, 6 months later, when the patient presented to a spinal neurosurgeon with a progressive cauda equina syndrome, the patient underwent a bilateral laminoforaminotomy and L4-L5 microdiscectomy. Of interest, at surgery, there was no evidence of scarring from the IPMS' prior "microdiscectomy;" it had been a "sham" operation. Following the second surgery, the patient's cauda equina syndrome resolved. CONCLUSION: IMPS, who are not trained as spinal surgeons should not be performing spinal surgery/ microdiscectomy.

Athletic pubalgia misdiagnosed as lumbar radiculopathy - A case report.

BACKGROUND: Athletic pubalgia is a painful complex syndrome encountered by many athletes involved in sports. Multiple pathologies often coexist, and many systems can refer pain to the groin. The current case reflects the failure to distinguish pubalgia from lumbar radiculopathy. CASE DESCRIPTION: Originally, a 47-year-old male with left-sided inner thigh pain was diagnosed as having a L3-4-disc herniation and spinal stenosis; he underwent a L3-4 and L4-5 laminectomy/discectomy. For 2 years postoperatively, the pain persisted. Ultimately, he underwent surgical reinsertion of the adductor muscle and experienced immediate and sustained pain relief. CONCLUSION: This case report highlights how pubalgia may be misdiagnosed as a lumbar disc herniation and may inadvertently lead to unnecessary lumbar surgery.

Gabapentin-related suicide: Myth or fact?

BACKGROUND: The opioid epidemic in America is real and is estimated to be the number one cause of death in adults under 50 years of age. Finding alternative analgesic medications is part of the effort to decrease the prescription of narcotics, with gabapentin being at the top of the list. CASE DESCRIPTION: In the present case, we discuss the side-effects of gabapentin, used as part of the multimodal treatment approach of painful spinal degenerative disease. The patient stated that he had noticed personality changes after gabapentin was initiated, and that he had become more depressed, frustrated, and aggressive. His uncontrolled pain and acute mood changes led him to attempt suicide by hanging himself. Gabapentin was discontinued and the patient's suicidal ideation completely subsided. CONCLUSION: It is imperative to screen, identify, and appropriately manage patients with underlying psychiatric disorders prior to initiating pain management with gabapentin. Therefore, it is crucial to raise awareness of gabapentin as a potential cause of depression, aggressive behavior, and suicidal ideation.

Lumbar epidural analgesia for labor in a parturient with a history of surgery for lumbar intradural ependymoma: Literature review and case presentation.

BACKGROUND: Ependymomas represent 50-60% of all brain and central nervous system tumors. Previous lumbar spine surgery for resection of an ependymoma should not be considered a relative contraindication for the administration of epidural/subarachnoid anesthesia to patients in labor. CASE DESCRIPTION: A 34-year-old G1P0, who underwent resection of an L1-L3 intramedullary ependymoma 8 years previously, presented in active labor with residual left leg numbness and tingling. The lumbar magnetic resonance imaging showed scar tissue and the L1-L3 laminectomy defect. With the acute onset of labor pain, the patient underwent continuous lumbar epidural analgesia; the epidural catheter was placed at the L5-S1 level. The patient underwent an emergency cesarean section with surgical anesthesia being attained up to a T4 dermatomal sensory level. CONCLUSIONS: Neuraxial anesthesia can be performed safely in patients who have previously undergone lumbar resections of intradural ependymomas. However, the anesthesiologist should place the epidural needle/catheter at a nonoperative level (e.g. above/below). Furthermore, epidural local anesthetics and opioids, as in this case, placed at the L5-S1 level below an L1-L3 prior surgical scar, may diffuse intradurally, bypassing the obliterated surgical epidural space and/or attendant scar tissue.

Transforaminal epidural steroid injection can result in further neurological injury in a patient with severe foraminal stenosis and nerve impingement.

BACKGROUND: Chronic low back pain (LBP) is highly prevalent and costly in our society. The use of epidural steroid injections (ESIs) for the treatment of radicular LBP is very widespread and continues to rise. The most popular injection is the lumbar/sacral transforaminal epidural steroid injection (TFESI). Here, we present a serious neurological complication resulting from such a TFESI that was only reversed by timely neurosurgical intervention. CASE DESCRIPTION: A 49-year-old male presented with a 5-year history of progressive neurogenic claudication and right lower extremity pain/radiculopathy. He had previously received multiple lumbar ESIs and other conservative therapy. Due to a recent exacerbation of his radiculopathy associated with MRI-documented lumbosacral spondylosis, he underwent a right L5/S1 TFESI under fluoroscopic guidance. This resulted in acute right lower extremity weakness accompanied by a right-sided foot drop and sphincter dysfunction. Although the follow-up MRI was noncontributory, the EMG showed L5/S1 denervation, and the patient underwent an L4-5, L5-S1 laminectomy with discectomies at the L4-5 and L5-S1 levels. Immediately after the surgery, the patient's weakness and sensory deficits improved. Two years later, the patient continued to do well without evidence of recurrence of signs or symptoms of lumbosacral radiculopathy. CONCLUSION: Patients should be counseled about the risk and benefits of TFESI. Surgical treatment may be warranted in patients who develop acutely progressive worsening following these non-FDA (Food/Drug Administration) approved injections.

Transcutaneous Electrical Nerve Stimulation in Treatment of Occipital Neuralgia: A Case Report.

Occipital neuralgia is the third most common headache syndrome after migraine and tension type headaches. There is no well-established treatment regimen for a reliable cure. The current case presents a 39-year-old woman, diagnosed with occipital neuralgia of idiopathic cause. The condition was difficult to control by conservative or interventional approaches. The patient was started on conventional transcutaneous electrical nerve stimulation, 3 sessions per week. After the procedure, the patient achieved significant pain relief: 1-2/10 on the numeric rating scale, pain initially being 10/10. With maintenance therapy consisting of physical therapy, deep tissue massage, and muscle relaxants, 12 months after starting transcutaneous electrical nerve stimulation therapy, she is pain free.

Management of concomitant metabolic encephalopathy and meningioma with vasogenic edema and impending herniation.

BACKGROUND: Altered mental status describes impaired mental functioning ranging from confusion to coma and indicates an illness, either metabolic or structural in nature. Metabolic causes include hypothyroidism, hyperuremia, hypo/hyperglycemia, hypo/hypernatremia, and encephalopathy. The structural causes include tumors, brain hemorrhage, infection, and stroke. To our knowledge, this is the first case in which a patient presented with altered mental status from both metabolic (myxedema coma) and structural diseases (frontal meningioma) with vasogenic edema and midline shift. CASE DESCRIPTION: A 55-year-old female presented with progressive coma. The clinical features included bradycardia and hypothermia. The imaging demonstrated a large frontal meningioma with a significant midline shift with laboratory findings suggestive of severe hypothyroidism and myxedema coma. Hypothyroidism was treated aggressively with intravenous T3 and T4 with close neurosurgical observation. Osmodiuretics and steroids were administered as temporizing agents prior to craniotomy. Craniotomy was successfully undertaken after using these appropriate pre-emptive measures. CONCLUSIONS: Management of concomitant metabolic encephalopathy and meningioma with vasogenic edema and impending herniation can be challenging. Correction of the encephalopathy is crucial to minimize perioperative morbidity and mortality. Awareness of metabolic causes of acute decompensation is critical for perioperative management, so a high index of clinical suspicion can make an important timely diagnosis for treatment initiation. Severely hypothyroid patients are sensitive to anesthetic agents and are at a high risk for perioperative complications. Prompt treatment prior to surgical intervention can help minimize perioperative complications.

Management of parturients in active labor with Arnold Chiari malformation, tonsillar herniation, and syringomyelia.

BACKGROUND: Arnold-Chiari malformation Type 1 (ACM-1) in parturients is a topic of ongoing discussion between obstetricians and anesthesiologists. The primary unanswered question remains; How should the anesthesia provider proceed with labor analgesia and anesthesia for cesarean section when confronted with an advanced, asymptomatic, or minimally symptomatic case of ACM-1 during labor? CASE DESCRIPTION: A 24-year-old, ASA II, G1P0 full-term parturient presented to Labor and Delivery for vaginal delivery. A diagnosis of ACM-1 was made 12 years ago when a brain magnetic resonance imaging (MRI) was performed for right-sided numbness following a rear-end motor vehicle collision. The patient had been asymptomatic since then and had been seen by an outside neurologist frequently for the past 10 years. During the anesthesia evaluation, it was noted that she had an exaggerated patellar reflex, and a questionable left-sided Babinski; subsequently, an MRI study was requested. Review of a brain MRI demonstrated an advanced form of ACM with a 1.7 cm transtonsillar herniation and a large syrinx extending from C1 down to C5. Following a discussion with the patient, family, and primary OB team, a plan for elective cesarean section was made per neurosurgical recommendations. This was conducted uneventfully under general anesthesia. The patient had no complaints in the post-anesthesia care unit. CONCLUSION: Unfamiliarity of health care providers with regards to ACM-1 parturients can be countered by increasing awareness of this condition throughout medical specialties involved in their care. The Ghaly Obstetric Guide to Arnold-Chiari malformation Type 1, along with proper training of anesthesia care providers regarding the specificities of ACM-1 parturients aids in better management and understanding of this complex condition.

Spinal neuromodulation as a novel surgical option for failed back surgery syndrome following rhBMP exuberant bony growth in instrumented lumbar fusion: A case report and literature review.

BACKGROUND: Bone morphogenic protein (BMP) for instrumented lumbar fusion was approved in 2002, and since then has led to an increasing incidence of BMP-related neuropathic pain. These patients are usually resistant to conventional medical therapy and frequently undergo multiple surgical revisions without any pain relief. CASE DESCRIPTION: A 58-year-old male was referred to the author's outpatient clinic after four lumbar surgeries did not provide satisfactory pain relief. During his 10 years of suffering from low back pain after an injury, the patient was resistant to conventional and interventional treatment options. He was experiencing severe back pain rated 10/10, as well as right lower extremity pain, numbness, tingling, and motor deficits. Outside spine specialists had performed revision surgeries for BMP-related exuberant bone formation at L5-S1, which included the removal of the ipsilateral hardware and debridement of intradiscal and intraforamina heterotrophic exuberant bony formation. The author implanted the patient with a permanent continuous spinal cord stimulator, after which he achieved complete pain relief (0/10) and restoration of motor, sensory, autonomic, and sphincter functions. CONCLUSION: This is the first reported case of restorative function with neuromodulation therapy in a BMP-induced postoperative complication, which is considered as a primarily inflammatory process, rather than nerve root compression due to exuberant bony formation. We hypothesize that neuromodulation may enhance blood flow and interfere with inflammatory processes, in addition to functioning by the accepted gate control theory mechanism. The neuromodulation therapy should be strongly considered as a therapeutic approach, even with confirmed BMP-induced postoperative radiculitis, rather than proposing multiple surgical revisions.

Are there a guidelines for implantable spinal cord stimulator therapy in patients using chronic anticoagulation therapy? - A review of decision-making in the high-risk patient.

BACKGROUND: Spinal cord stimulators (SCSs) are gaining increasing indications and utility in an expanding variety of clinical conditions. Complications and initial expenses have historically prevented the early use of SCS therapy despite ongoing efforts to educate and promote its utilization. At present, there exists no literature evidence of SCS implantation in a chronically anticoagulated patient, and neuromodulation manufacturers are conspicuously silent in providing warnings or recommendations in the face of anticoagulant use chronically. It would appear as through these issues demand scrutiny and industry as well as neuromodulation society advocacy and support in terms of the provision of coherent guidelines on how to proceed. CASE DESCRIPTION: A 79-year-old male returned to the neurosurgical clinic with persistent low back pain and leg heaviness due to adjacent level degenerative spondylosis and severe thoracic spinal stenosis. The patient had a notable history of multiple comorbidities along with atrial fibrillation requiring chronic anticoagulation. On initial presentation, he was educated with three choice of conservative medical therapy, intrathecal drug delivery system implantation, or additional lumbar decompression laminectomy with instrumented fusion of T10-L3 and a palliative surgical lead SCS implantation. DESCRIPTION: A 79-year-old male returned to the neurosurgical clinic with persistent low back pain and leg heaviness due to adjacent level degenerative spondylosis and severe thoracic spinal stenosis. The patient had a notable history of multiple comorbidities along with atrial fibrillation requiring chronic anticoagulation. On initial presentation, he was educated with three choice of conservative medical therapy, intrathecal drug delivery system implantation, or additional lumbar decompression laminectomy with instrumented fusion of T10-L3 and a palliative surgical lead SCS implantation. CONCLUSION: Our literature search did not reveal any evidence of SCS therapy among patients with chronic anticoagulation. This case illustrated a complicated clinical case scenario wherein a percutaneous SCS implantation would normally be contraindicated due to severe thoracic spinal stenosis and chronic anticoagulation which could lead to possible paralysis or even a lethal consequences associated with the possible formation of a thoracic epidural hematoma.

Do we need to establish guidelines for patients with neuromodulation implantable devices, including spinal cord stimulators undergoing nonspinal surgeries?

BACKGROUND: Spinal cord stimulation is currently approved to treat chronic intractable pain of the trunk and limbs. However, such implantable electronic devices are vulnerable to external electrical currents and magnetic fields. Within the hospitals and modern operating rooms (ORs), there is an abundance of electrical devices and other types of equipment that could interfere with such devices. Despite the increasing number of patients with neuromodulation implantable devices, there are no written guidelines available or consensus of cautions for such patients undergoing unrelated surgery. CASE DESCRIPTIONS: A 60-year-old female with a permanent St. Jude's spinal cord stimulator (SCS) presented for open total abdominal hysterectomy. Both the anesthesia and gynecology staffs were aware of the device presence, but were unaware of any precautions regarding intraoperative management. The device was found to be nonmagnetic resonance imaging compatible, and bipolar cautery was used instead of monopolar cautery. A 59-year-old female with a 9-year-old permanent Medtronic SCS, presented for right total hip arthroplasty. The device was switched off prior to entering the OR, bipolar cautery was used, and grounding pads were placed away from her battery site. In each case, the manufacturer's representative was contacted preoperative. Both surgeries proceeded uneventfully. CONCLUSIONS: The Food and Drug Administration safety information manual warns about the use of diathermy, concomitant implanted stimulation devices, lithotripsy, external defibrillation, radiation therapy, ultrasonic scanning, and high-output ultrasound, all of which can lead to permanent implant damage if not turned off prior to undertaking procedures. Lack of uniform guidelines makes intraoperative management, as well as remote anesthesia care of patients with previously implanted SCSs unsafe.

A rare case of delayed subarachnoid anesthetic blockade effects in a 103-year-old female patient.

BACKGROUND: The elderly represent a unique challenge for the effects of regional anesthesia, and very few cases of block onset delay have been described. Their delayed response is attributed to a number of factors that include: Physiologic deterioration, musculoskeletal contractures, degenerative joint disease, autonomic regulatory dysfunction, cognitive dysfunction, altered pharmacokinetics, and pharmacodynamics of local anesthetics and adjuvants. CASE DESCRIPTION: In this report we present the rare case of 45-min delay between the administration and onset of action of a subarachnoid blockade in a 103-year-old female, who was scheduled for left hip pinning, for repair of a femoral neck fracture. Patient received an injection of hyperbaric bupivacaine, 1.5 ml of 0.75% (11.25 mg), with 15 mcg of fentanyl into the subarachnoidal space and underwent the surgical procedure without complications. CONCLUSIONS: Delayed responses to subarachnoid anesthesia can be expected in extremely elderly patients. Anesthetic procedures should be monitored and managed on a case-by-case basis.