Unilateral Sixth Cranial Nerve Palsy Following C/S as a Complication of Spinal Anaesthesia.

Cranial nerve palsy (CNP) is a rare complication following lumbar puncture, which is a common procedure used most often for diagnostic and anaesthetic purposes. The sixth cranial (abducens) nerve is the most commonly affected cranial nerve. We report a case of unilateral sixth nerve palsy after spinal anaesthesia that improved immediately after an epidural blood patch (EBP).

Ultrasound anatomy of the brachial plexus nerves in the neurovascular bundle at the axilla in patients undergoing upper-extremity block anesthesia.

PURPOSE: Familiarity with the localization of the nerves in the neurovascular bundle that constitutes the axillary segment of the brachial plexus (BP) is important when applying ultrasound (US)-guided block anesthesia. Therefore in this study we aimed to delineate the anatomy of the median, radial, and ulnar nerves of the BP at the axilla with US and electrical stimulation. MATERIALS AND METHODS: The study included 60 patients who were scheduled to undergo upper-arm surgery with axillary block anesthesia. Prior to anesthesia, ulnar, radial, and median nerves were localized with US using a 12-h quadrant identification system that placed the axillary artery (AA) in the middle. The nerves were then functionally tested using a neurostimulator. RESULTS: The radial nerve was mainly located in the 4-6 o'clock arc (posterior and posteromedial to AA) in 50 (83 %) of patients. Ulnar nerve was mainly at the 12-3 o'clock arc (anteromedial to AA) in 51 (85 %) of patients. Ulnar nerve showed a second peak at 9-10 o'clock quadrant (anterolateral to AA) in 11 % (7) of patients. Median nerve location was most common in the 12 and 9 o'clock arc (anterior and anterolateral to AA) in 53 (88 %) of the patients. CONCLUSIONS: Ultrasound is a useful tool for depicting BP anatomy in the axillary fossa prior to block anesthesia. Median, ulnar, and radial nerves form a highly consistent triangular pattern around the axillary artery that is easily recognizable with US.

Stem cell therapy in spinal cord injury: in vivo and postmortem tracking of bone marrow mononuclear or mesenchymal stem cells.

OBJECTIVE: The aim of this study was to address the question of whether bone marrow-originated mononuclear cells (MNC) or mesenchymal stem cells (MSC) induce neural regeneration when implanted intraspinally. MATERIALS AND METHODS: The study design included 4 groups of mice: Group 1, non-traumatized control group; Groups 2, 3 and 4 spinal cord traumatized mice with 1 g force Tator clips, which received intralesionally either no cellular implants (Group 2), luciferase (Luc) (+) MNC (Group 3) or MSC (Group 4) obtained from CMV-Luc or beta-actin Luc donor transgenic mice. Following the surgery until decapitation, periodical radioluminescence imaging (RLI) and Basso Mouse Scale (BMS) evaluations was performed to monitor neural activity. Postmortem immunohistochemical techniques were used to analyze the fate of donor type implanted cells. RESULTS: All mice of Groups 3 and 4 showed various degrees of improvement in the BMS scores, whereas there was no change in Groups 1 and 2. The functional improvement was significantly better in Group 4 compared to Group 3 (18 vs 8, p=0.002). The immunohistochemical staining demonstrated GFP(+)Luc(+) neuronal/glial cells that were also positive with one or more of these markers: nestin, myelin associated glycoprotein, microtubule associated protein or myelin oligodendrocyte specific protein, which is considered as indicator of donor type neuronal regeneration. Frequency of donor type neuronal cells; Luc + signals and median BMS scores were observed 48-64% and 68-72%; 44-80%; 8 and 18 within Groups III and IV respectively. DISCUSSION: MSCs were more effective than MNC in obtaining neuronal recovery. Substantial but incomplete functional improvement was associated with donor type in vivo imaging signals more frequently than the number of neuronal cells expressing donor markers in spinal cord sections in vitro. Our results are in favor of functional recovery arising from both donor MSC and MNCs, contributing to direct neuronal regeneration and additional indirect mechanisms.

An attempt to treat patients who have injured spinal cords with intralesional implantation of concentrated autologous bone marrow cells.

BACKGROUND AIMS: Spinal cord injury is common among young subjects involved in motor vehicle accidents. Mechanisms and attempts to reverse post-traumatic pathophysiologic consequences are still being investigated. Unfortunately no effective and well-established treatment modality has been developed so far. The regeneration capability of the human nervous system following an injury is highly limited. METHODS: The study involved four patients (two male, two female) who had suffered spinal cord injury as a result of various types of trauma. On neurologic examination, all the patients were determined to be in American Spinal Injury Association (ASIA) grade A. All patients were treated with decompression, stabilization and fusion for vertebral trauma anteriorly, as well as intralesional implantation of cellular bone marrow concentrates using a posterior approach 1 month after the first operation. The patients were then treated and followed-up in the physical rehabilitation clinic. RESULTS: At the end of the post-operative 1-year follow-up, two of the patients were classified as ASIA C while one was classified as ASIA B. One patient showed no neurologic change; none of the patients suffered from any complications or adverse effects as a result of intralesional application of bone marrow cells. CONCLUSIONS: The results of this experimental study show the potential contribution of intralesional implantation of bone marrow to neuronal regeneration in the injured spinal cord, with neuronal changes. In light of the results of this experimental study, the potential for regenerative treatment in injuries of the human spinal cord is no longer a speculation but an observation.

Evaluation of the longus colli muscle in relation to stellate ganglion block.

BACKGROUND AND OBJECTIVES: The longus colli (LC) muscle is an important structure of the anterior cervical spine and has a critical role in stellate ganglion block. This technique involves withdrawing the needle to locate its port for injection above the anterior surface of the LC muscle; however, its exact thickness at the C5, C6, and C7 levels has not been measured. The aim of this anatomic and magnetic resonance-supported study was to evaluate the thickness of the LC muscle at these levels from the anterior tubercle of each vertebra toward the vertebral body at 5-, 10-, and 15-mm distances to provide precise anatomic data for stellate ganglion block. METHODS: Ten cadavers, 60 vertebral body specimens, and cervical magnetic resonance imaging (MRI) scans of 40 adult patients were used for measurements. RESULTS: The main findings of this study are that the thickness of the LC muscle varies between 5.0 and 10.0 mm at C6 and C7 in cadavers and between 8.0 and 10.0 mm in MRI scans. Sex has an important role; MRI scans revealed that male patients have a considerably thicker LC muscle at each vertebral level. CONCLUSION: We found a highly variable thickness of the LC muscle in anatomic and imaging studies, which may lead to negative block results.

Use of intrapleural streptokinase in experimental minimal clotted hemothorax.

OBJECTIVE: In clotted hemothorax, both thoracocentesis and closed tube thoracostomy will not be able to evacuate the pleural cavity especially if it is minimal. The aim of this study was to assess the effectiveness of intrapleural administered streptokinase on minimal clotted hemothorax without drainage, in order to accelerate the spontaneous resolution and absorption in blunt thoracic trauma. METHODS: Thirteen adult ewes were used for this experiment. The animals were divided into two groups. First group served as the control group (Group C) (n=5) and did not receive any intrapleural fibrinolytic treatment. In both groups, 200 ml of blood was taken from the left jugular vein and injected into the pleural cavity with a serum line through the scope after pleural abrasion. Streptokinase (150.000 U) was diluted in 100 ml of saline and applied to the second group (Group S) (n=5) in second postoperative day. One ewe in each group was sacrificed with a lethal dose of sodium thiopental in postoperative 2nd, 4th, 6th, 8th, and 10th weeks, respectively. When a left posterolateral thoracotomy was performed, pleural thickening and adhesion were evaluated. The lung and pleural tissue samples were taken for histopathologic examination. The slides were examined in a blinded manner. RESULTS: Thoracentesis was performed in all ewes in the second postoperative day and no fluid was detected. There was no allergic reaction in group S after the injection of streptokinase into the pleural cavity. During postmortem macroscopic evaluation, we observed clot in one of the ewes in group C in second postoperative week. A statistically significant difference was found between Group C and S regarding pleural thickening and adhesion (P=0.05). The ewes of Group S had less pleural thickening and adhesion compared to those of Group C. These results were confirmed with histopathological examination. CONCLUSION: We conclude that intrapleural streptokinase increases resolution of clot in the pleural space and decreases pleural thickening and adhesion in experimental minimal clotted hemothorax in ewes. This study has also demonstrated that intrapleural streptokinase can be used without drainage. Use of intrapleural streptokinase without drainage can be a novel therapeutic option for trauma patients with minimal clotted hemothorax after haemorrhage of other organs was excluded.

The optimum doses of and injection locations for periprostatic nerve blockade for transrectal ultrasound guided biopsy of the prostate: a prospective, randomized, placebo controlled study.

PURPOSE: We evaluated the efficiency of various amounts of local anesthesia and various numbers of injection sites to determine the most effective pain control with the least number of injections and the amount of injected medium in patients who underwent transrectal ultrasound guided prostate biopsy. MATERIALS AND METHODS: Transrectal ultrasound guided 8 core biopsy of the prostate was performed in 175 consecutive men. Patients were randomized into 7 groups with 25 per group. Group 1 received 5 cc saline and groups 2 to 7 received 2.5, 5 or 10 cc 1% lidocaine injected as local anesthesia at basal or basal plus apical locations. The patients were then evaluated for pain and other complications to determine whether there was a difference regarding groups. RESULTS: Mean pain scores were significantly lower than in saline group for all anesthesia injected groups except group 2 with a 2.5 cc bilateral basal injection. The most effective pain control was achieved by 10 cc anesthetic injections. Basal plus apical injections were not superior than only basal injections for pain control. There was no significant difference in the hematuria, hematospermia, rectal bleeding or infection rate among the groups. Increasing the number of injections and amount of lidocaine had no effect on complication rates. CONCLUSION: Our placebo controlled, prospective, randomized study indicated that 10 cc local anesthetic injections supply significantly better pain control than lower doses for periprostatic nerve blockade during prostate biopsy. Although bilateral basal plus apical 10 cc lidocaine injections resulted in the lowest mean pain score, there was no statistically significant difference from 10 cc bilateral basal injections.