Current Issue : October - December Volume : 2013 Issue Number : 4 Articles : 9 Articles
Sciatica is a symptom rather than a specific diagnosis. It usually consists in a radiating leg pain from the buttock\r\ntoward the knee, ankle, foot and toes. Pain could be associated with neurological deficit, such as muscle weakness\r\nand reflex deficit.\r\nThe prevalence of sciatica in spine pathology is highly variable with values ranging from 1.6% to 43%. Between\r\n70%-90% of the cases of herniated disc with nerve-root compression caused sciatica. Other causes are lumbar\r\ncanal or foraminal stenosis, tumours or cysts.\r\nWe present a case evaluated in our Pain Unit with left-sided sciatic pain after an intense voluntary movement two\r\nmonths ago. He was previously pharmacologically treated for a non-specific low back pain with pseudo-sciatica. One\r\nweek later buttock soft tissues sarcoma was diagnosed. He deceased two weeks after the diagnosis....
Intravenous mannitol may lead to electrolyte disturbances involving sodium and potassium and resulting in\r\ncardiac dysfunction. This report demonstrates that when mannitol is given during intracranial surgery it can cause\r\nlarge increase potassium ion concentration and decrease in sodium ion concentration in the absence of any other\r\npossible causes. Intraoperative checks of serum electrolyte levels, arterial blood gas analysis and electrocardiogram\r\nmonitoring could be recommended to be done routinely when using mannitol....
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Purpose: We investigated the relationship between plasma glucose and serum 1,5-anhydroglucitol (1,5-AG)\r\nconcentrations in surgical patients to determine the role of 1,5-AG concentrations in perioperative glycemic control.\r\nMethods: We enrolled 57 patients (19 with and 38 without diabetes) in the study, who underwent hepatectomy\r\nunder general anesthesia with sevoflurane and remifentanil. Plasma glucose and serum 1,5-AG concentrations were\r\nmeasured and their correlations were evaluated.\r\nResults: In all patients, plasma glucose concentrations increased significantly during hepatectomy, but serum\r\n1,5-AG concentrations declined after surgery. Linear regression analysis revealed a weak but significant correlation\r\nbetween the decrease rate of 1,5-AG concentrations and the increase rate of plasma glucose concentrations.\r\nRegression analyses revealed this correlation to be more intense in patients without diabetes than in all\r\npatients, whereas no correlation was observed in patients with diabetes. These results suggest that serum 1,5-\r\nAG concentrations decrease significantly in proportion to increase in plasma glucose concentrations in patients\r\nwithout diabetes, but are less sensitive to such changes in patients with diabetes. Consequently, this indicates\r\nthat preoperative serum 1,5-AG concentrations in patients with diabetes are too low to be influenced by glycemic\r\nfluctuations. In both patient groups, decreased 1,5-AG concentrations did not normalize until 72 h after initiation of\r\nsurgery.\r\nConclusion: Measurement of 1,5-AG concentrations may be a useful for evaluating glycemic control during\r\nanesthesia in patients with normal glycemic metabolism; however, this approach may not be as useful in patients\r\nwith diabetes as in those without diabetes....
Background: Poor characterization of propofol pharmacokinetics and pharmacodynamics in the morbidly obese\r\n(MO) pediatric population poses dosing challenges. This study was conducted to evaluate propofol total\r\nintravenous anesthesia (TIVA) in this population.\r\nMethods: After IRB approval, a prospective study was conducted in 20 MO children and adolescents undergoing\r\nlaparoscopic surgery under clinically titrated propofol TIVA. Propofol doses/infusion rates, hemodynamic variables,\r\ntimes to induction and emergence, and postoperative occurrence of respiratory adverse events (RAE) were\r\nrecorded, along with intraoperative blinded Bispectral Index/BIS and postoperative Ramsay sedation scores (RSS).\r\nStudy subjects completed awareness questionnaires on postoperative days 1 and 3. Propofol concentrations were\r\nobtained at predetermined intra- and post-operative time points.\r\nResults: Study subjects ranged 9 ââ?¬â?? 18 years (age) and 97 - 99.9% (BMI for age percentiles). Average percentage\r\nvariability of hemodynamic parameters from baseline was Ã?Å? 20%. Patients had consistently below target BIS values\r\n(BIS < 40 for >90% of maintenance phase), delayed emergence (25.8 Ã?± 22 minutes), increased somnolence (RSS = 4)\r\nin the first 30 minutes of recovery from anesthesia and 30% incidence of postoperative RAE, the odds for which\r\nincreased by 14% per unit increase in BMI (p = 0.05). Mean propofol concentration was 6.2 mg/L during\r\nmaintenance and 1.8 mg/L during emergence from anesthesia.\r\nConclusions: Our findings indicate clinical overestimation of propofol requirements and highlight the challenges of\r\nclinically titrated propofol TIVA in MO adolescents. In this setting, it may be advantageous to titrate propofol to\r\ntargeted BIS levels until more accurate weight-appropriate dosing regimens are developed, to minimize relative\r\noverdosing and its consequences....
Chronic low back pain is a major cause of disability and health care costs. Current treatments are inadequate for\r\nmany patients. A number of preclinical models have been developed that attempt to mimic aspects of clinical\r\nconditions that contribute to low back pain. These involve application of nucleus pulposus material near the\r\nlumbar dorsal root ganglia (DRG), chronic compression of the DRG, or localized inflammation of the DRG. These\r\nmodels, which are primarily implemented in rats, have many common features including behavioral hypersensitivity\r\nof the hindpaw, enhanced excitability and spontaneous activity of sensory neurons, and locally elevated levels of\r\ninflammatory mediators including cytokines. Clinically, epidural injection of steroids (glucocorticoids) is commonly\r\nused when more conservative treatments fail, but clinical trials evaluating these treatments have yielded mixed\r\nresults. There are relatively few preclinical studies of steroid effects in low back pain models. One preclinical study\r\nsuggests that the mineralocorticoid receptor, also present in the DRG, may have pro-inflammatory effects that\r\noppose the activation of the glucocorticoid receptor. Although the glucocorticoid receptor is the target of\r\nanti-inflammatory steroids, many clinically used steroids activate both receptors. This could be one explanation\r\nfor the limited effects of epidural steroids in some patients. Additional preclinical research is needed to address\r\nother possible reasons for limited efficacy of steroids, such as central sensitization or presence of an ongoing\r\ninflammatory stimulus in some forms of low back pain....
Background: Local anesthetics can cause vasoconstriction and disrupt neuronal impulses, reducing regional\r\nblood flow and increasing tissue oxygen consumption. This could alter regional oxygen supply and demand. Because\r\nmicrocirculation modifies during development and oxygen consumption kinetics differ between children and adults,\r\nwe aimed to assess effects of ropivacaine Peripheral Nerve Block (PNB) on regional tissue saturation in children and\r\nyoung adults using Near-Infrared Spectroscopy (NIRS).\r\nMethods: Following Institutional Review Board approval and informed consent, 20 patients undergoing PNB\r\nfor various orthopedic surgeries were studied. NIRS sensors were placed on the operative limb, contralateral limb,\r\nand forehead. Tissue saturations (rSO2) were recorded at baseline and every 5 minutes for 60 minutes following\r\nropivacaine PNB. Mean rSO2 was assessed with repeated measures ANOVA. Correlation of tissue rSO2 with cerebral\r\noximetry was calculated and significance determined with student�s t-test.\r\nResults: In all patients, blocked limb rSO2 decreased significantly compared to control limb 20 minutes after\r\ninjection and remained lower. Control limb rSO2 and cerebral oximetry did not change over time. Non-blocked limb\r\nrSO2 demonstrated weak but significant correlation with cerebral oximetry while blocked limb rSO2 showed no\r\ncorrelation. Mean change in blocked limb rSO2 from baseline was significantly negative compared to a net positive\r\nmean change in the non-blocked limb.\r\nConclusions: Decreased rSO2 following PNB suggests reduced local blood flow due to vasoconstriction,\r\nincreased tissue oxygen consumption, or both. Changes in rSO2 provide an opportunity to develop NIRS as a\r\nnon-invasive tool to identify successful PNB. Local anesthetic-induced decline in rSO2 could have implications in\r\noperative settings with ischemia or low-flow....
Background: Repetitive transcranial magnetic stimulation (rTMS) has shown promise in the alleviation of acute and\r\nchronic pain by altering the activity of cortical areas involved in pain sensation. However, current single-coil rTMS\r\ntechnology only allows for effects in surface cortical structures. The ability to affect activity in certain deep brain\r\nstructures may however, allow for a better efficacy, safety, and tolerability. This study used PET imaging to\r\ndetermine whether a novel multi-coil rTMS would allow for preferential targeting of the dorsal anterior cingulate\r\ncortex (dACC), an area always activated with pain, and to provide preliminary evidence as to whether this targeted\r\napproach would allow for efficacious, safe, and tolerable analgesia both in a volunteer/acute pain model as well as\r\nin fibromyalgia chronic pain patients.\r\nMethods: Part 1: Different coil configurations were tested in a placebo-controlled crossover design in volunteers\r\n(N = 16). Tonic pain was induced using a capsaicin/thermal pain model and functional brain imaging was performed\r\nby means of H2\r\n15O positron emission tomography ââ?¬â?? computed tomography (PET/CT) scans. Differences in NRS pain\r\nratings between TMS and sham treatment (NRSTMS-NRSplacebo) which were recorded each minute during the\r\n10 minute PET scans. Part 2: 16 fibromyalgia patients were subjected to 20 multi-coil rTMS treatments over 4 weeks\r\nand effects on standard pain scales (Brief Pain Inventory, item 5, i.e. average pain NRS over the last 24 hours) were\r\nrecorded.\r\nResults: A single 30 minute session using one of 3 tested rTMS coil configurations operated at 1 Hz consistently\r\nproduced robust reduction (mean 70% on NRS scale) in evoked pain in volunteers. In fibromyalgia patients, the 20\r\nrTMS sessions also produced a significant pain inhibition (43% reduction in NRS pain over last 24 hours), but only when\r\noperated at 10 Hz. This degree of pain control was maintained for at least 4 weeks after the final session.\r\nConclusion: Multi-coil rTMS may be a safe and effective treatment option for acute as well as for chronic pain, such as\r\nthat accompanying fibromyalgia. Further studies are necessary to optimize configurations and settings as well as to\r\nelucidate the mechanisms that lead to the long-lasting pain control produced by these treatments....
Objectives: this study aims at assessment of acute inflammatory response; measured by high sensitivity\r\nC-reactive protein (hs-CRP), and myocardial injury; measured by serum cardiac troponin-T (Tn-T) in patients\r\nundergoing elective major abdominal cancer surgery with general anaesthesia or combined general and lumbar\r\nepidural anesthesia.\r\nMethods: The study included 60 ischemic patients undergoing elective major abdominal cancer surgery with risk\r\nfactor(s) like(history of myocardial infraction, diabetes, hypertension, obesity or heavy smoking)randomly assigned\r\ninto 2 groups; 30 patients each to receive general anesthesia (G1) or combined general and epidural anesthesia\r\n(G2). Pain severity, time to first request of rescue analgesic, analgesic consumption, hemodynamics and side effects\r\nwere recorded in first 72 hrs postoperative. Serum Tn-T and hs-CRP, ECG were assessed peroperatively and 1,2,3\r\ndays postoperativly also 12-lead ECGs were recorded before and 1,2,3 days after surgery.\r\nResults: The mean VAS scores were significantly reduced in G2 allover time in comparison to G1 (p<0.05)\r\nexcept at 32hrs postoperatively. Mean time to first request for rescue analgesic was significantly prolonged in G2\r\ncompared to G1 (p=0.001). Mean morphine consumption was significantly reduced in G2 (p<0.001). Mean serum\r\nlevel of CPR increased in both groups. Mean level of serum troponin-T was significantly increased only in G1\r\ncompared to baseline value (p<0.05) with no significant difference between G1 and G2. There were 5 patients\r\n(16.6%) in G1 and 2 patients (6.6%) in G2 showed serum troponin-T level > 0.03ng/ml. Regarding ECGs changes\r\nthere were 2 patients (6.6%) in G1 and one patient (3.3%) in G2 showed new ischemic changes postoperatively in\r\nthe form of depressed ST segment >1mm.\r\nConclusion: The use of LEA with general anesthesia in high risk patients with ischemic heart disease undergoing\r\nmajor non-cardiac surgery is associated with less perioperative acute inflammatory response, less post-operative\r\npain and can reduce the perioperative myocardial damage....
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