1/92. Clinical letter: epidural analgesia in a newborn with Hirschsprung's disease, associated with congenital central hypoventilation syndrome.A case is presented of a neonate with Hirschsprung's disease, associated with congenital central hypoventilation syndrome. After an ileostomy (at 2 days) and a stoma revision (at 10 days), postoperative pain management was established by continuous intravenous infusion of morphine, which caused severe postoperative respiratory depression. At 6 weeks a re-exploration and stoma revision was performed using postoperative epidural analgesia with bupivacaine. This caused no respiratory depression. A colectomy under epidural analgesia at 8 months was also uneventful. Respiratory difficulties in children with congenital central hypoventilation syndrome associated with Hirschsprung's disease are discussed in relation to the technique of choice for postoperative pain management.- - - - - - - - - - ranking = 1keywords = disc (Clic here for more details about this article) |
2/92. An unexpected benefit of pre-emptive rectal analgesic administration: the "key" to postoperative analgesia.Analgesic and anti-inflammatory drugs are frequently administered intraoperatively by the rectal route to provide pre-emptive postoperative analgesia. We report the case of an inmate of a federal penitentiary who underwent orthopedic surgery in a public hospital. After induction of general anesthesia, indomethacin and acetaminophen were administered rectally. This led to the incidental discovery of a handcuff key hidden in the rectum and, thereby, the prevention of a planned escape. A review of data regarding escapes by prisoners from public hospitals is provided, as well as a description of cases of patients presenting with foreign rectal objects. A number of benefits have been described for the use of pre-emptive analgesia. This is the first reported description of an incidental benefit: the prevention of a planned escape by a prison inmate.- - - - - - - - - - ranking = 1keywords = disc (Clic here for more details about this article) |
3/92. An unusual post-operative wound infection with salmonella typhi: case report.A 25 year old male student presented with a discharging sinus and swelling over right forearm, which on culture yielded S. typhi, sensitive to ciprofloxacin. Predisposing factors were absent but there was a history of surgery for chronic osteomyelitis of right ulna and injury with cricket ball at same site. Pus obtained during surgery was sterile. Patient responded to oral ciprofloxacin. soft tissue infections are uncommon manifestation of salmonellosis. This case is an unusual presentation of post-operative salmonella typhi wound infection.- - - - - - - - - - ranking = 1keywords = disc (Clic here for more details about this article) |
4/92. Late operative site pain with isola posterior instrumentation requiring implant removal: infection or metal reaction?OBJECTIVES: To elucidate the cause of late operative site pain in six cases of scoliosis managed with Isola posterior instrumentation that required removal of the implants. METHOD: Microbiologic examination of wound swabs and enriched culture of operative tissue specimens was undertaken in all cases. Histologic study of the peri-implant membranes also was conducted. RESULTS: The presentation in all cases was similar: back pain appearing between 12-20 months after surgery, followed by a local wound swelling leading to a wound sinus. In only one of these cases was the discharge positive for bacterial growth. Implant removal was curative. Histologic examination of tissue specimens revealed a neutrophil-rich granulation tissue reaction suggestive of an infective etiology despite the failure to isolate organisms. Within the granulation tissue was metallic debris that varied from very sparse to abundant from fretting at the distal cross-connector junctions. A review of recent literature describing similar problems suggests that late onset spinal pain is a real entity and a major cause of implant removal. CONCLUSIONS: On reviewing the evidence for an infective etiology versus a metallurgic reaction etiology for these cases of late onset spinal pain, it was concluded that a subacute low-grade implant infection was the main cause. Histologic findings would seem to confirm low-grade infection. There may be more than one causative factor for late operative site pain, as it is possible that fretting at cross connection junctions may provide the environment for the incubation of dormant or inactive microbes.- - - - - - - - - - ranking = 1keywords = disc (Clic here for more details about this article) |
5/92. The role of laparoscopic biopsies in lumbar spondylodiscitis.The infection of an intervertebral disk is a serious condition. The diagnosis often is elusive and difficult to make. It is imperative to have appropriate microbiologic specimens before the initiation of treatment. We report the case of a 51-year-old woman with lumbar spondylodiscitis caused by infection after the placement of an epidural catheter for postoperative analgesia. A spinal magnetic resonance imaging (MRI) scan confirmed the diagnosis, but computed tomography (CT)-guided fine-needle biopsy did not yield adequate material for a microbiologic diagnosis. Laparoscopic biopsies of the involved disk provided good specimens and a diagnosis of propionibacterium acnes infection. We believe that this minimally invasive procedure should be performed when CT-guided fine-needle biopsy fails to yield a microbiologic diagnosis in spondylodiscitis.- - - - - - - - - - ranking = 408.76772252193keywords = intervertebral, disc (Clic here for more details about this article) |
6/92. Intramedullary neurenteric cysts of the spine. Case report and review of the literature.This case of a 68-year-old woman with a low-thoracic intramedullary neurenteric cyst is notable for clinical presentation, cyst location, intraoperative findings, and imaging characteristics. The patient's postoperative course was complicated by neurological deterioration and a neuropathic pain syndrome. Potential causes of these complications are discussed, as are possible ways to reduce the risk of their occurrence.- - - - - - - - - - ranking = 1keywords = disc (Clic here for more details about this article) |
7/92. Subdural air collection: a likely source of radicular pain after lumbar epidural.This case conference reports two cases of epidural anesthesia in which air was used to identify the epidural space during a loss-of-resistance placement technique. Both patients subsequently complained of severe pain and subdural air was demonstrated in case 1 by computed tomography and in case 2 by magnetic resonance imaging. The possible causes of the pain syndrome experienced by both patients are discussed.- - - - - - - - - - ranking = 1keywords = disc (Clic here for more details about this article) |
8/92. A portable mechanical pump providing over four days of patient-controlled analgesia by perineural infusion at home.BACKGROUND AND OBJECTIVES: Local anesthetics infused via perineural catheters postoperatively decrease opioid use and side effects while improving analgesia. However, the infusion pumps described for outpatients have been limited by several factors, including the following: limited local anesthetic reservoir volume, fixed infusion rate, and inability to provide patient-controlled doses of local anesthetic in combination with a continuous infusion. We describe a patient undergoing open rotator cuff repair who was discharged home with an interscalene perineural catheter and a mechanical infusion pump that allowed a variable rate of continuous infusion, as well as patient-controlled boluses of local anesthetic for over 4 days. CASE REPORT: A 77-year-old woman, who had previously required a 3-day hospital admission for acute postoperative pain following an open repair of her left rotator cuff, presented for an open repair of her contralateral rotator cuff. Preoperatively she received an interscalene block and perineural catheter. After the procedure she was discharged home with a portable pump that infused ropivacaine continuously at a rate of 6 mL/h and allowed a 2-mL patient-controlled bolus every 20 minutes (550-mL reservoir). The basal infusion was decreased, as tolerated, by having the patient reprogram the pump with instructions given over the telephone. Without the use of any oral opioids, the patient scored her surgical pain 0 to 1 (on a scale of 0 to 10) while at rest and 2 to 3 for 2 physical therapy sessions during which she used the bolus function to reinforce her analgesia. After 98 hours of infusion, the patient's husband removed the catheter with instructions given over the telephone, and her subsequent surgical pain was treated with oral opioids. CONCLUSION: Continuous, perineural local anesthetic infusions are possible on an ambulatory basis for multiple days using a portable, programmable pump that provides a variable basal infusion rate, patient-controlled boluses, and a large anesthetic reservoir.- - - - - - - - - - ranking = 2keywords = disc (Clic here for more details about this article) |
9/92. Acellular dermal matrix allograft in the treatment of mucogingival defects in children: illustrative case report.Mucogingival defects can occur in children and are of particular concern when orthodontic treatment is indicated. The rationale for surgical intervention is predicated on the need to repair the mucogingival defect and to establish adequate thickness of attached gingiva. The free gingival graft, usually obtained from the hard palate, is often used to increase the amount of attached gingiva. The prospect of a second surgical site, and its inherent risks and complications, which may include pain, discomfort, and bleeding, is especially undesirable in children. Important to consider is the possibility that a child may not have adequate tissue thickness at the donor site. A case report is presented utilizing the alternative soft tissue graft, Alloderm, to correct a mucogingival defect prior to orthodontic treatment. Adhering to the free gingival autograft technique, an acellular dermal matrix allograft was utilized at the graft site. The patient revealed good post-operative healing, tissue vascularization, and a healthy zone of attached gingiva at the six month follow up visit. Comparable results to the conventional autograft were obtained with less surgical time, surgical sites, and discomfort to the patient.- - - - - - - - - - ranking = 2keywords = disc (Clic here for more details about this article) |
10/92. Repeated failure of epidural analgesia: an association with epidural fat?BACKGROUND AND OBJECTIVES: To report the case of a patient who experienced repeated failed epidural analgesia associated with an unusual amount of fat in the epidural space (epidural lipomatosis). CASE REPORT: A 44-year-old female presented for an elective small bowel resection. An L(1-2) epidural catheter was placed for postoperative analgesia. The patient gave no indication of having pain at the time of emergence from general anesthesia or in the first 2 hours in the recovery room. Assessment of the level of hypoesthesia to ice while the patient was comfortable in the recovery room suggested a functional epidural catheter (cephalad level of T(10)). Two hours after admission to the recovery room the patient began to complain of increasing pain. Another 6 mL 0.25% bupivacaine was administered via the catheter. The patient's pain decreased, but remained substantial, and there was minimal evidence of sensory block above the T(10) level. Subsequently, a T(10) epidural catheter was placed. Testing confirmed proper placement of the catheter in the epidural space at the T(10) level. A test dose of 5 mL 0.25% bupivacaine resulted in prompt and complete relief of the patient's pain. However, the level of hypoesthesia to ice did not exceed the T(10) level. Approximately 1 hour later the patient complained of increasing discomfort again. There was no evidence of any sensory block, and there was no response to a bolus of 8 mL 1% lidocaine. A thorough examination of the patient did not suggest any cause for the pain other than a malfunctioning epidural catheter. A third epidural catheter was placed at the T(8-9) level. This catheter was again confirmed to be in the epidural space with a test dose of 10 mL 0.5% bupivacaine. The level of hypoesthesia to ice was restricted to a narrow bilateral band from T(7)-T(9). analgesia failed 2 hours later. The epidural catheter was removed and the patient's pain was subsequently managed with intravenous patient-controlled analgesia (PCA) morphine. A magnetic resonance imaging (MRI) scan revealed extensive epidural fat dorsal to the spinal cord from C(5)-C(7) and from T(3)-T(9). An imaging diagnosis of asymptomatic epidural lipomatosis was established. CONCLUSION: We have described a case of repeated failure of epidural analgesia in a patient with epidural lipomatosis.- - - - - - - - - - ranking = 1keywords = disc (Clic here for more details about this article) |
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