Anesthetic management of mini sternotomy and excision of mediastinal neurogenic tumor: Brain-Heart crosstalk.

Brachial plexus tumors are rare and pose challenges for neurosurgeons due to their anatomical complexity. Retrosternal extension of a tumor makes it more difficult for the surgeons as well as for the anesthesiologists to secure a definitive airway. A cardiopulmonary bypass would be lifesaving in the event of acute cardiorespiratory decompensation. Multidisciplinary collaboration and cooperation between the neurosurgeon, oncosurgeon, cardiothoracic surgeon, and anesthesiologist are imperative to ensure good patient outcomes. Meticulous preoperative evaluation and operative planning are essentially the key factors in anesthetic management. Here we report a successful management of a 49-year-old male patient presented with a large painless mass arising from his right supraclavicular region and compressing the roots of the brachial plexus, trachea, and esophagus and extending up to the apex of the lungs, posted for mini sternotomy and excision of the mass.

Anesthetic management of deep brain stimulation in Hallervorden-Spatz syndrome: Surviving the "eye of the tiger".

Anesthetic management of dystonic patients with uncontrolled involuntary movements refractory to medical management is a challenge to neuroanaesthetists. According to some studies, the prevalence of Panthothenate Kinase Associated Neurodegeneration is 1 to 9/1,000,000. Report of Deep Brain Stimulation for Hallervorden-Spatz is extremely rare in literature. "Awake" bilateral electrode placement, with microelectrode recording (MER) and stimulation with a scalp nerve block, titrated conscious sedation with Monitored Anesthesia Care (MAC) is preferable. However, in those patients needing general anesthesia, a balanced anesthesia technique with careful selection and monitored titration of anesthetic drugs ensuring MERs for precise placement and stimulation of target nuclei along with adequate plane and depth of anesthesia and prevention of awareness are essentially the key factors in the anesthetic management. Surgery is the mainstay of the disease due to poor response to medical management. Multidisciplinary collaboration and cooperation among neurologists, neurosurgeons, neuroradiologists, and neuroanaesthesiologists are imperative to ensure good patient outcomes.

A prospective observational single center study evaluating emergence agitation in the early postoperative period in adult patients undergoing elective craniotomies under general anesthesia.

Background and Aims: Emergence agitation is a significant clinical issue during recovery from general anesthesia. Patients after intracranial operations are even more vulnerable to the stress resulting from emergence agitation. Due to the limited data available in neurosurgical patients, we evaluated the incidence, risk factors, and complications of emergence agitation. Material and Methods: 317 consenting eligible patients undergoing elective craniotomies were recruited. The preoperative Glasgow Coma Scale (GCS)) and pain score were recorded. Bispectral Index (BIS) guided balanced general anesthesia was administered and reversed. Immediate postoperatively, the GCS and the pain score were noted. The patients were observed for 24 hours following extubation. The levels of agitation and sedation were evaluated by the Riker's Agitation-Sedation Scale. Emergence Agitation was defined as Riker's Agitation score of 5 to 7. Results: In our subset of the patient population, the incidence was 5.4%, mildly agitated in the first 24 hours and none required sedative medication as therapy. The sole risk factor identified was prolonged surgery beyond 4 hours. None of the patients in the agitated group had any complications. Conclusion: Early objective assessment of risk factors in the preoperative period with objective validated tests and shorter duration of surgery maybe the way forward in patients at high risk for emergence agitation, to reduce the incidence and mitigate the undesirable consequences.

Age - Does it really count? A study of the Perioperative Morbidity and Long-Term Outcome in Patients Above 70 Years of Age Undergoing Spine surgery for Lumbar Degenerative Disorders.

Objective To assess the long-term outcome and perioperative morbidity in spine surgeries for lumbar degenerative disorders and, thereby, to evaluate the safety of surgery in the aging population. Methods Retrospective study of patients aged > 70 years, operated for degenerative lumbar disorders between 2011 and 2015. We evaluated patient demographic, clinical and surgical data; comorbidities, perioperative complications, pre & postoperative pain scores and Oswestry disability index (ODI) scores, patient satisfaction and overall mortality. Results A total of 103 patients (Males: Females55:48) with mean age 74.6 years (70-85yrs) were studied. 60 patients (58.2%) had decompression alone, while 43 (41.8%) had decompression & fusion. Mean hospital stay was 5.7days. Mean follow-up was 47.6months (24-73mnths). Patients reported significant improvement in backpain (Numerical pain score 7.7 vs 1.6; p < 0.001), leg pain (Numerical pain score 7.4 vs 1.7; p < 0.001), disability (ODI 82.3 vs 19.1; p < 0.001) and walking distance ( p < 0.001). 76% patients were satisfied with the results at the time of final follow-up. 26 patients (25.24%) had perioperative complications which were all minor, without mortality. Most common intraoperative & postoperative complications were dural tear (6.79%) & urinary tract infection (6.79%) respectively. Conclusions With meticulous perioperative care lumbar spine surgery is safe and effective in elderly population. Patients had longer mean hospital stay in view of the gradual and comprehensive rehabilitation program. Presence of comorbidities or minor perioperative complications did not increase the overall morbidity or affect the clinical outcomes of surgery in our study.

Age - Does it really count? A study of the Perioperative Morbidity and Long-Term Outcome in Patients Above 70 Years of Age Undergoing Spine surgery for Lumbar Degenerative Disorders / Idade - Deve ser levada em conta? Estudo da morbidade perioperatória e a evolução no longo prazo dos pacientes acima de 70 anos submetidos à cirurgia da coluna vertebral, devido a doenças degenerativas lombares

Abstract Objective To assess the long-term outcome and perioperative morbidity in spine surgeries for lumbar degenerative disorders and, thereby, to evaluate the safety of surgery in the aging population. Methods Retrospective study of patients aged > 70 years, operated for degenerative lumbar disorders between 2011 and 2015. We evaluated patient demographic, clinical and surgical data; comorbidities, perioperative complications, pre & postoperative pain scores and Oswestry disability index (ODI) scores, patient satisfaction and overall mortality. Results A total of 103 patients (Males: Females55:48) with mean age 74.6 years (70-85yrs) were studied. 60 patients (58.2%) had decompression alone, while 43 (41.8%) had decompression & fusion. Mean hospital stay was 5.7days. Mean follow-up was 47.6months (24-73mnths). Patients reported significant improvement in backpain (Numerical pain score 7.7 vs 1.6; p < 0.001), leg pain (Numerical pain score 7.4 vs 1.7; p < 0.001), disability (ODI 82.3 vs 19.1; p < 0.001) and walking distance (p < 0.001). 76% patients were satisfied with the results at the time of final follow-up. 26 patients (25.24%) had perioperative complications which were all minor, without mortality. Most common intraoperative & postoperative complications were dural tear (6.79%) & urinary tract infection (6.79%) respectively. Conclusions With meticulous perioperative care lumbar spine surgery is safe and effective in elderly population. Patients had longer mean hospital stay in view of the gradual and comprehensive rehabilitation program. Presence of comorbidities or minor perioperative complications did not increase the overall morbidity or affect the clinical outcomes of surgery in our study.

Resumo Objetivos Avaliar o resultado no longo prazo e a morbidade perioperatória em cirurgias da coluna vertebral, devido a doenças lombares degenerativas e, assim, avaliar a segurança da cirurgia na população idosa. Métodos Estudo retrospectivo de pacientes com idade superior a 70 anos, submetidos à cirurgia em virtude de distúrbios lombares degenerativos, entre 2011 e 2015. Foram avaliados os dados demográficos, clínicos e cirúrgicos dos pacientes; comorbidades; complicações perioperatórias; escores de dor no pré e no pós-operatório; índice de incapacidade de Oswestry (ODI, na sigla em inglês); satisfação do paciente e a mortalidade geral. Resultados Foram estudados 103 pacientes (homens:mulheres, 55:48) com idade média de 74,6 anos (70 a 85 anos). 60 pacientes (58,2%) apresentaram somente descompressão, enquanto 43 (41,8%) apresentaram descompressão e fusão. O tempo médio de internação foi de 5,7 dias. O tempo médio de acompanhamento foi de 47,6 meses (24-73 meses). Os pacientes relataram melhora significativa da dor nas costas (pontuação numérica da dor 7,7 versus 1,6; p < 0,001), dor nas pernas (pontuação numérica da dor 7,4 versus 1,7; p < 0,001), incapacidade (ODI 82,3 versus 19,1; p < 0,001) e distância percorrida a pé (p < 0,001). Um total de 76% dos pacientes estavam satisfeitos com os resultados no momento do acompanhamento final. 26 pacientes (25,24%) apresentaram complicações perioperatórias, todas sem relevância e sem mortalidade. As complicações intra e pós-operatórias mais comuns foram ruptura dural (6,79%) e infecção do trato urinário (6,79%), respectivamente. Conclusões Com meticulosos cuidados perioperatórios, a cirurgia da coluna lombar é segura e eficaz na população idosa. Os pacientes tiveram um maior tempo médio de internação hospitalar, em virtude do programa de reabilitação gradual e abrangente. A presença de comorbidades ou complicações perioperatórias sem relevância, não aumentou a morbidade geral, nem afetou os resultados clínicos da cirurgia em nosso estudo.

A prospective randomized double-blind study to compare the early recovery profiles of desflurane and sevoflurane in patients undergoing laparoscopic cholecystectomy.

BACKGROUND AND AIMS: General anesthesia using agents like Desflurane or Sevoflurane are beneficial for early recovery especially for ambulatory procedures. The aim of this randomised controlled double-blind study was to compare the early recovery profiles of sevoflurane and desflurane in patients undergoing laparoscopic cholecystectomy. MATERIAL AND METHODS: ASA I, II patients, undergoing laparoscopic cholecystectomy were randomly assigned to receive desflurane (n = 30) or sevoflurane (n = 30), using Bispectral Index System (BIS) to determine the depth of anaesthesia. An independent adjudicator, who was blinded to the agent used, recorded the events during the recovery phase. The time required for extubation, eye opening, verbal response and achievement of a modified Aldrete score of 9 were recorded. RESULTS: The time required for extubation and for eye opening was significantly shorter in the Desflurane group as compared to the Sevoflurane group [9.1 min ± 5.0 versus 12.5 min ± 7.1, P = 0.049 and 10.1 min ± 5.2 versus 6.3 min ± 4.0, P = 0.008]. Verbal Response also occurred significantly faster in the Desflurane group [12.7 min ± 5.4 versus 8.7 min ± 4.7, P = 0.002]. A significantly higher mean modified Aldrete score was seen at extubation [7.1 ± 0.6 vs 6.0 ± 0.8, P < 0.001] in the Desflurane group, which also achieved a modified Aldrete score of ≥9 significantly sooner [11.1 min ± 4.6 versus 17.8 min ± 6.9, P < 0.001] than the Sevoflurane group. The frequency of adverse effects was not significantly different in either of the groups. CONCLUSION: The time required for early recovery from anaesthesia, was significantly shorter in the Desflurane group compared to the Sevoflurane group.

CT-guided percutaneous sacroiliac stabilization in unstable pelvic fractures: a safe and accurate technique.

OBJECTIVE: The use of open reduction and internal fixation (ORIF) for unstable pelvic injuries is associated with extensive blood loss, iatrogenic neurovascular injury, and infection. Moreover, the placement of sacroiliac (SI) screws is a blinded procedure, guided primarily by palpation and two-dimensional radiological screening, which demands expertise. The complex three-dimensional anatomy of SI joint and its proximity to neurovascular structure require a safe and precise technique. Computed tomography (CT)-guided SI joint stabilization allows an accurate intra-operative assessment of screw placement. This study demonstrated a technique of CT-guided closed reduction and screw fixation of the SI joint in unstable pelvic fractures. METHODS: This was a retrospective non-randomized cohort study conducted at a tertiary care hospital. Six patients with unstable pelvic fractures were operated; the anterior rim was stabilized first by ORIF with plate on the superior and anterior aspects of the pubic symphysis. Subsequently, the posterior stabilization was made percutaneously under CT guidance with a 7-mm cannulated cancellous screw. RESULTS: The mean operative time was 48 min (35-90 min), the mean effective radiation dose was 9.32 (4.97-13.27), and the mean follow-up was 26 months (6-72 months). All patients had satisfactory healing, with near-anatomic reduction and no complications, except in one case where the plate broke at 61 months post surgery, but no intervention was required. The mean VAS score at the final follow-up was 1.8, and all patients returned to their original occupation without any limitations. CONCLUSION: CT-guided SI joint stabilization offers many advantages, including safe and accurate screw placement, reduced operating time, decreased blood loss, early definitive fixation, immediate mobilization, and fewer infections and wound complications.

OBJETIVO: O uso de redução aberta e fixação interna (RAFI) em lesões pélvicas instáveis está associado a hemorragia ampla, lesão neurovascular iatrogênica e infecção. Além disso, os parafusos sacroilíacos (SI) são colocados às cegas − o procedimento é guiado principalmente pela palpação e triagem radiológica bidimensional, o que exige especialização. A complexa anatomia tridimensional da articulação SI e sua proximidade à estrutura neurovascular requerem o uso de uma técnica segura e precisa. A estabilização da articulação SI guiada por tomografia computadorizada (TC) permite uma avaliação intra-operatória precisa do posicionamento do parafuso. Este estudo demonstrou uma técnica, guiada por TC, de redução fechada e fixação da articulação SI com parafusos em fraturas pélvicas instáveis. MÉTODOS: Trata-se de um estudo de coorte retrospectivo, não randomizado, realizado em um hospital terciário. Seis pacientes com fraturas pélvicas instáveis foram operados. A borda anterior foi estabilizada primeiro por RAFI com placa nos aspectos superior e anterior da sínfise púbica. Então, a estabilização posterior foi feita de forma percutânea, guiada por TC, com um parafuso esponjoso canulado de 7 mm. RESULTADOS: O tempo médio de cirurgia foi de 48 min (35-90 min); a dose média efetiva de radiação foi de 9,32 (4,97-13,27) e o seguimento médio foi de 26 meses (6-72 meses). Todos os pacientes apresentaram cura satisfatória, com redução quase anatômica e sem complicações, exceto em um caso em que a placa quebrou 61 meses após a cirurgia, sem a necessidade de intervenção. O escore EVA médio no seguimento final foi de 1,8 e todos os pacientes retornaram às suas ocupações originais sem quaisquer limitações. CONCLUSÃO: A estabilização da articulação SI guiada por TC apresenta muitas vantagens, incluindo um posicionamento seguro e preciso do parafuso, redução do tempo de cirurgia, diminuição da perda de sangue, fixação definitiva precoce, mobilização imediata e redução no número de infecções e complicações da ferida cirúrgica.

CT-guided percutaneous sacroiliac stabilization in unstable pelvic fractures: a safe and accurate technique / Estabilização sacroilíaca percutânea guiada por tomografia computadorizada nas fraturas pélvicas instáveis: uma técnica segura e precisa

ABSTRACT Objective The use of open reduction and internal fixation (ORIF) for unstable pelvic injuries is associated with extensive blood loss, iatrogenic neurovascular injury, and infection. Moreover, the placement of sacroiliac (SI) screws is a blinded procedure, guided primarily by palpation and two-dimensional radiological screening, which demands expertise. The complex three-dimensional anatomy of SI joint and its proximity to neurovascular structure require a safe and precise technique. Computed tomography (CT)-guided SI joint stabilization allows an accurate intra-operative assessment of screw placement. This study demonstrated a technique of CT-guided closed reduction and screw fixation of the SI joint in unstable pelvic fractures. Methods This was a retrospective non-randomized cohort study conducted at a tertiary care hospital. Six patients with unstable pelvic fractures were operated; the anterior rim was stabilized first by ORIF with plate on the superior and anterior aspects of the pubic symphysis. Subsequently, the posterior stabilization was made percutaneously under CT guidance with a 7-mm cannulated cancellous screw. Results The mean operative time was 48 min (35-90 min), the mean effective radiation dose was 9.32 (4.97-13.27), and the mean follow-up was 26 months (6-72 months). All patients had satisfactory healing, with near-anatomic reduction and no complications, except in one case where the plate broke at 61 months post surgery, but no intervention was required. The mean VAS score at the final follow-up was 1.8, and all patients returned to their original occupation without any limitations. Conclusion CT-guided SI joint stabilization offers many advantages, including safe and accurate screw placement, reduced operating time, decreased blood loss, early definitive fixation, immediate mobilization, and fewer infections and wound complications.

RESUMO Objetivo O uso de redução aberta e fixação interna (RAFI) em lesões pélvicas instáveis está associado a hemorragia ampla, lesão neurovascular iatrogênica e infecção. Além disso, os parafusos sacroilíacos (SI) são colocados às cegas − o procedimento é guiado principalmente pela palpação e triagem radiológica bidimensional, o que exige especialização. A complexa anatomia tridimensional da articulação SI e sua proximidade com a estrutura neurovascular requerem o uso de uma técnica segura e precisa. A estabilização da articulação SI guiada por tomografia computadorizada (TC) permite uma avaliação intraoperatória precisa do posicionamento do parafuso. Este estudo demonstrou uma técnica, guiada por TC, de redução fechada e fixação da articulação SI com parafusos em fraturas pélvicas instáveis. Métodos Estudo de coorte retrospectivo, não randomizado, feito em um hospital terciário. Seis pacientes com fraturas pélvicas instáveis foram operados. A borda anterior foi estabilizada primeiro por RAFI com placa nos aspectos superior e anterior da sínfise púbica. Então, a estabilização posterior foi feita de forma percutânea, guiada por TC, com um parafuso esponjoso canulado de 7 mm. Resultados O tempo médio de cirurgia foi de 48 min (35-90 min); a dose média efetiva de radiação foi de 9,32 (4,97-13,27) e o seguimento médio foi de 26 meses (6-72 meses). Todos os pacientes apresentaram cura satisfatória, com redução quase anatômica e sem complicações, exceto em um caso em que a placa quebrou 61 meses após a cirurgia, sem a necessidade de intervenção. O escore EVA médio no seguimento final foi de 1,8 e todos os pacientes retornaram às suas ocupações originais sem quaisquer limitações. Conclusão A estabilização da articulação SI guiada por TC apresenta muitas vantagens, inclusive um posicionamento seguro e preciso do parafuso, redução do tempo de cirurgia, diminuição da perda de sangue, fixação definitiva precoce, mobilização imediata e redução no número de infecções e complicações da ferida cirúrgica.

Building the body: active learning laboratories that emphasize practical aspects of anatomy and integration with radiology.

Active learning exercises were developed to allow advanced medical students to revisit and review anatomy in a clinically meaningful context. In our curriculum, students learn anatomy two to three years before they participate in the radiology clerkship. These educational exercises are designed to review anatomy content while highlighting its relevance to the study of radiology. Laboratory exercises were developed using inexpensive materials in the form of hands-on stations designed for use by students working together in small groups. Station exercises include model building, exploring relevant radiological imaging, and practicing clinical techniques. Students are encouraged to move from abstract conceptualization of the anatomy using models to applying knowledge to living tissues by using a portable ultrasound to explore superficial anatomy on each other. Stations are designed to integrate knowledge and reemphasize concepts in different contexts, so that upon completion students have a reinforced understanding of the three-dimensional anatomy of the region in question, the appearance of the anatomy on radiological images, and an appreciation of the relevance of the anatomy to radiological procedures.