Endoscopic Resection of Pseudoarticulation as a Treatment for Bertolotti's Syndrome.

Bertolotti's syndrome is described as lower back pain with the presence of lumbosacral transitional vertebrae (LSTV) associated with an articulation, pseudoarticulation, or full fusion of the transverse process to the sacrum and ilium. We present a unique case of the management of a 57-year-old woman with treatment-resistant lower back pain who underwent endoscopic resection of a pseudoarticulation related to LSTV. The patient underwent multiple treatment regimens without achieving satisfactory relief. These included physical therapy, sacroiliac (SI) joint injections, radiofrequency lesioning at multiple levels, and spinal cord stimulator placement. Relief with injection at the patient's pseudoarticulation confirmed this as a contributor to the patient's back pain. Interventional management of Bertolotti's syndrome can include different modalities, most recently including minimally invasive surgical techniques. This patient experienced partial relief of lower back pain after undergoing minimally invasive resection of the pseudoarticulation. This case demonstrates the benefit of a minimally invasive resection of this anatomic abnormality in a patient who has undergone previous treatments. Isolating this anomaly as a source of pain is necessary to ensure a favorable response and prevent needless surgery.

Delayed Onset of Subclavian Artery Pseudoaneurysm With Brachial Plexus Compression Following Gunshot Wound Injury.

Early diagnosis of brachial plexus injuries is crucial to prevent long-term morbidity and improve outcomes. We present a unique case of delayed onset of brachial plexus compression two months following a traumatic gunshot injury causing multiple injuries including a T1 vertebral body comminuted fracture and pneumothorax. The patient experienced significant pain and progressive neurological examination changes during follow-up visits, and thus duplex ultrasound and computed tomography (CT) angiography were performed, which demonstrated a left subclavian artery pseudoaneurysm. This was managed operatively by evacuation and interposition bypass. Injuries to the cervical and upper thoracic spine are complex, and when patients present with new-onset neurological findings, axillary swelling, or significant uncontrolled postoperative pain, secondary complications should be suspected. Patients at a high risk of vascular reinjury should be routinely monitored at follow-up to prevent the development of progressive neurological damage to the brachial plexus.

Endoscopic Spinal Decompression: A Retrospective Review of Pain Outcomes at an Academic Medical Center.

INTRODUCTION:  Spinal stenosis is a chronic, debilitating condition that is expected to affect an increasing number of people as the population ages. Symptomatic spinal stenosis, like other spine pathologies, including disc herniation and degenerative disc disease, traditionally required an open decompressive surgical approach if more conservative approaches failed. An emerging alternative has been developed to address the needs of this population of patients in the form of endoscopic spine surgery (ESS). Advantages of ESS include minimal tissue trauma, decreased risk of damage to the neurovascular structures, minimal epidural fibrosis/scarring, reduced hospital stay, early functional recovery, and improved cosmetic outcomes. The purpose of this study was to review the outcomes of patients undergoing transforaminal endoscopic spinal decompression at an academic pain program. METHODS: We conducted a retrospective review of electronic medical records with approval from the University of Florida Institutional Review Board (IRB #202001529). Twenty patients underwent successful transforaminal endoscopic lumbar spinal decompression surgery at UF Health Pain Medicine from July 1, 2019, to June 1, 2020. The majority of cases were performed at L4-5 (n = 14), followed by an equal number (n = 3) of cases at L3-4 and L5-S1. Preoperative and postoperative visual analog scale (VAS) pain scores from patients' pain clinic appointments were obtained from the electronic health records system to assess the intervention as a pain relief strategy. RESULTS:  Patients had an average pain reduction of 82% (SD = 31%), resulting in an average postoperative pain score of 1.8 (SD = 2.8) on a 10-point VAS. CONCLUSION:  This study highlights the benefits of endoscopic spine surgery for patients, including pain reduction and reduced scarring.

Anesthetic Management of Resection of Metastatic Occipital Malignancy in a Patient With Fontan Physiology.

Significant advances in surgical management have allowed patients with congenital heart disease to survive to adulthood. Often, these patients present for non-cardiac surgeries, including patients who have undergone the three-staged Fontan repair for congenital single ventricle. The primary aim in the anesthetic management of adult patients with Fontan physiology is to maintain adequate venous pressure, low pulmonary vascular resistance (PVR) and normal contractility to maintain the cardiac output. We present the case of a 26-year-old female with Fontan physiology following a three-staged Fontan repair for tricuspid atresia who underwent a stealth-guided left occipital craniotomy for the palliative resection of a metastatic brain tumor. This case highlights the importance of understanding Fontan physiology and its implications in the anesthetic management of a patient undergoing an open craniotomy. These patients require a high central venous pressure and low PVR to maintain optimum venous return to the left atrium. A rise in PVR can result in the shunting of the deoxygenated blood from the Fontan shunt to the systemic circulation. Hence, alpha agonists and high airway pressure are to be avoided. To minimize the risk of perioperative mortality, there is an increased need to optimize systemic to pulmonary blood flow ratios and maintain normal arterial saturation and euvolemic fluid status.

Anesthetic Management of Resection of a Large Anterior Mediastinal Carcinoid Tumor.

This case report presents a 66-year-old man with chest pain and shortness of breath who had a 16 cm × 9 cm × 12-cm anterior mediastinal atypical carcinoid tumor with compression causing severe right ventricular outflow tract obstruction. We were consulted for anesthetic management of surgical resection of this tumor. Thoracic epidural, femoral, and radial arterial catheterizations, and femoral central venous access were performed with sedation. Upon ensuring adequate surgical site analgesia under thoracic epidural, chest incision was performed. Thereafter, induction and intubation were performed without complication. During intubation, fiberoptic bronchoscopy highlighted external compression of the left mainstem bronchus. The procedure was completed, and the patient was extubated in the operating room and transported to the intensive care unit in stable condition without complications.

Deformation of the Zurich cementless acetabular cup caused by implantation in a canine cadaver model.

OBJECTIVE: To evaluate the change in geometry of the Zurich total hip arthroplasty (THA) acetabular component after implantation. ANIMALS: Hemipelves from adult mix-breed dogs weighing between 20 and 25 kg. METHODS: Digital image correlation imaging was performed prior to, immediately after, and 24 hours after impaction of Zurich THA acetabular component, and after removal of the cup from the specimen. Patterns of deformation were qualitatively described, and maximal deformations were compared between time points. RESULTS: All cups deformed after implantation into the hemipelves by "pinching" in a cranial-caudal direction and dorsoventral expansion, resulting in an ellipsoid configuration to the peripheral rim. The mean ± SD maximum deformation at the rim immediately post-impaction was 0.202 ± 0.052 mm, or approximately 0.4 mm of diametrical deformation. Deformation did not change after the 24-hour saline bath. Impaction and subsequent extraction had a marginal effect on the original cup geometry, as maximum deformation at the rim after cup extraction was 0.074 ± 0.032 mm, relative to prior to impaction. CONCLUSIONS: The original Zurich cup geometry is distorted as a consequence of the press-fit mechanism. Further studies are required to determine whether deformation induced by impaction has any association with polyethylene wear rates or other prosthesis-related complications.