Long-term results of cervical epidural steroid injection with and without morphine in chronic cervical radicular pain.

To evaluate the long-term effectiveness of a single cervical epidural steroid injection (CESI) performed with or without morphine, 24 patients, without need of surgery, but suffering for more than 12 months from cervical radicular pain, were included in a prospective and randomised study. The cervical epidural space was injected (C7-D1; 18-ga needle) with an increasing volume (10 ml maximum) of isotonic saline solution to exacerbate the patient's radicular pain. The patients were then randomly allocated to 2 groups: the steroid group (group S, n = 14) received an equivalent volume of 0.5% lidocaine plus triamcinolone acetonide (10 mg/ml) and the steroid plus morphine group (group S + M, n = 10) received the same combination plus 2.5 mg of morphine sulphate. Pain relief was assessed as the percentage of pain decrease on a visual analogue scale on day 1 and at months 1, 3, 6, 8 and 12 after CESI, up to 48 months. Anthropometric data between the 2 groups were similar. The mean volume injected in the epidural space was: 6.6 +/- 2.1 and 6.3 +/- 1.9 ml in groups S and S + M, respectively, and this volume exacerbated pain in 21 of 24 patients. Despite observing a better transient improvement the day after CESI in the S + M group, long-term results did not differ. The success rate was 78.5% in group S and 80% in group S + M providing pain relief of 86.8 +/- 14.7% and 86.9 +/- 17.9%, respectively. Pain relief remained stable with time (mean follow-up: 43 +/- 18.1 months).(ABSTRACT TRUNCATED AT 250 WORDS)

Study of correlation between intradiscal pressure and magnetic resonance imaging data in evaluation of disc degeneration. Therapeutic issue with percutaneous nucleotomy.

Intradiscal pressure and volume measurements using discomanometry were correlated to features of degeneration noted with magnetic resonance (MR) imaging in 36 discs in patients scheduled for percutaneous nucleotomy. Discomanometric data (intradiscal pressure and degree of pressure loss at 0 and 60 seconds after intradiscal infusion, area under the pressure curve, and discal volume) were not correlated with the MR data (degree of disc height loss and degree of signal intensity loss on T2-weighted images). Results of nucleotomy were strongly correlated with discomanometric data but not with the studied MR factors. Discomanometry by evaluating the physical status of discs, may predict results of percutaneous nucleotomy and consequently play a major role in patients selection.

[Comparative repercussions of general and spinal anesthesia on the psychological functions of the aged subject]. / Répercussions comparées de l'anesthésie générale et de la rachianesthésie sur les fonctions psychiques du sujet âgé.

Although worsening cerebral function in the elderly is often said to be due to anaesthesia, it still remains to be proved that anesthesia acts on an elderly patient's psychological make-up. This study aimed to compare the psychological effects of general or spinal anaesthesia on 35 patients more than 70-yr old under repair of a subcapital femoral fracture, after having excluded 63 patients. They were randomly divided into two groups, the first receiving a spinal anaesthetic with 1.5 mg.kg-1 prilocaine (RA; n = 19), and the others a general anaesthetic with 5 mg.kg-1 thiopentone, dextromoramide, nitrous oxide and enflurane (GA; n = 16). None of the patients wer given a premedication. They underwent a battery of six psychological tests before and 36 h after surgery, all carried out by the same physician. Six patients in GA group and three in RA group developed a transient fall in mean blood pressure just after anaesthetic induction (not significant). There were no significant differences between the two groups in age, sex distribution, ASA class and performance in the tests, both before and after surgery. Individual psychological scores did not differ either. In the RA group, the postoperative tests were even better carried out than before surgery (p less than 0.05). It could therefore be concluded that anaesthesia alone has little impact on the psychological status of elderly patients.

[Chronic cervico-brachial neuralgia treated by cervical epidural injection of corticosteroids. Long-term results]. / Névralgie cervico-brachiale chronique traitée par injection péridurale cervicale de corticoïdes. Résultats à long terme.

OBJECTIVE: To assess long-term results of a single cervical epidural corticosteroid injection (CECI) in patients suffering from chronic cervicobrachial neuralgia (CCBN). STUDY DESIGN: Open prospective study. PATIENTS: A CECI was performed in 29 patients suffering for more than 12 months from a non-compressive and non-surgical CCBN with permanent pain for at least three months non relieved by an adequately conducted medical treatment. METHODS: The cervical epidural space was injected (C7-T1, 18 G needle) with an increasing volume (maximum 10 mL) of isotonic saline solution to exacerbate patient's cervicobrachial pain. The patients then received an equivalent volume of 0.5% lidocaine plus triamcinolone acetonide (10 mg.mL-1). The pain decrease was estimated on a visual analogic scale (VAS), in comparison to intensity of pain rated at 100 mm before CECI. RESULTS: The mean volume injected into the epidural space was 6 +/- 2 mL. It increased pain in 26 out of 29 patients. After 3 months, a success rate of 83% was obtained, with a pain rate of 12 mm on VAS. Concerning mid- and long-term results, pain relief remained stable for at least 24 months (mean follow-up: 48 +/- 18 months). Simultaneously, the need for analgesics decreased significantly. CONCLUSION: A single CECI in patients suffering from non-compressive and non-surgical CCBN results in long-lasting pain relief.

[Propofol versus methohexital in the surgery of the spinal canal]. / Propofol versus méthohexital dans la chirurgie du canal rachidien.

The aim of this study was to compare the quality of postanaesthetic recovery after anaesthesia with methohexitone (M) or with propofol (P). Thirty patients undergoing spinal surgery were randomly assigned to either group. The induction dose was 2 mg . kg-1 for both M and P. Anaesthesia was maintained by continuous infusion. The rate was 0.15 mg . kg-1 . min-1 for P and 0.07 mg . kg-1 . min-1 for M. Analgesia was obtained with fentanyl with the same doses in both groups. The maintenance doses were subsequently decreased by 50 and 75% of the initial values. This work compared the quality induction and the criteria of recovery (Aldrete score, Newman test). In two patients in each group, sensory evoked potentials (SEP) were recorded to monitor neurological integrity. The quality of induction was similar in both groups. Awakening was significantly more rapid in group P. The SEP were much decreased in group P, whilst there were few changes in group M. Monitoring of medullar integrity is mandatory in spinal surgery, requiring a rapid recovery. This objective was obtained with shorter delays in patients anaesthetized with propofol than in those who had received methohexitone. However, the former, at the doses used, seemed to depress the SEP.

[A prospective study of ENT complication following surgery of the cervical spine by the anterior approach (preliminary results)]. / Etude prospective des complications ORL de la chirurgie du rachis cervical par voie antérieure (résultats préliminaires).

In order to evaluate complications due to cervical spine surgery using the anterior cervical approach a prospective study was conducted on 125 patients. ENT examination with the fibroscope was employed for all the patients before the procedure. The patients were operated on under general anesthesia and were intubated with an armoured tube, and then were placed in an intensive care unit for 24 hours. Assessment of deglutition and an ENT examination were performed the day after surgery. Before surgery, two cases of vocal cord paralysis were noted. 111 patients (88.8%) presented with subjective disorders: problems such as sore throat, odynophagia, dysphagia, dysphagia with overspill and hoarseness were respectively noted in 55 (44%), 34 (27.2%), 32 (25.6%), 11 (8.8%) and 13 (10.4%) cases. Dyspnoea was found in 2 cases (1.6%). 117 patients (93.6%) presented postoperative anomalies which were found on the posterolateral pharyngeal wall, on the arytenoids and on posterior third of the vocal cords. Inflammatory and/or swollen lesions were slight, moderate, significant or very significant in respectively 22.4%, 22.4%, 15.2% and 1.6% of cases. Very significant circumferential swelling of the pharyngeal wall and of the arytenoids was responsible for two cases of respiratory distress, and the patients required reintubation and return to theatre. Severe pharyngeal lesion correlated with duration of surgery (r = 0.20; p < 0.05), with the number levels of fusion (r = 0.02; p < 0.02) and with the age of the patient (p < 0.02). Six patients presented problems of mobility of the vocal cords: 3 had a right vocal cord paresis which was temporary and 3 had paralysis, also on the right but which persisted. There were no other complications. It is concluded that (i) ENT complications are frequently found in postoperative cervical spine surgery using the anterior cervical approach, some of them being severe. An ENT examination must be performed before the procedure for legal reasons. It is also recommended in the postoperative period in the case of discomfort; (ii) patients need to be placed in an intensive care unit during for the first 24 hours (iii). This study needs to be attended over more patients (iv) comparison with a control group of patients having non cervical surgery and intubated in the same way is needed to differentiate lesions related to surgery or intubation.

Propofol anaesthesia alters somatosensory evoked cortical potentials.

This study evaluated the effects of propofol on somatosensory evoked cortical potentials in 20 ASA grade 1 or 2 patients who underwent spinal surgery. Anaesthesia consisted of propofol, dextromoramide, 50% nitrous oxide and oxygen mixture. The induction dose of propofol was 2 mg/kg and was followed by an infusion of 6 mg/kg for the first hour and 3 mg/kg subsequently. Somatosensory evoked cortical potentials were recorded on the scalp and compared to pre-operative values using Student's paired t-test. We observed a significant depression of evoked potential 10 minutes after induction, which continued until the early phase of recovery. Because of its short and quickly reversible action, propofol is an acceptable agent when clinical monitoring of the spinal cord is indicated but is not satisfactory when monitoring has to be based on somatosensory cortical evoked potentials.

Pharyngolaryngeal lesions in patients undergoing cervical spine surgery through the anterior approach: contribution of methylprednisolone.

Cervical spinal surgery through anterior approaches can lead to ear, nose and throat (ENT) complications, some of which, such as obstruction of upper airways by edema, are potentially life threatening. The purpose of this study was to evaluate the incidence of various categories of ENT lesions and to determine whether preventive treatment with methylprednisolone (Mp) is useful in this indication. In a prospective trial, 236 patients who were undergoing anterior cervical spine surgery were separated into two groups, a control group (group I: 158 patients) and a group receiving 1 mg/kg of Mp intravenously at the end of the operation and 12 and 24 h later (group II: 78 patients). All 236 patients underwent nasofibroscopic examination by an ENT specialist the day before the operation and 24 and 36 h after the operation. The lesions observed during these examinations and reported symptoms such as uncomfortable sensation, odynophagia, or dysphagia were compared between the two groups (chi(2) or Mann-Whitney test) in terms of relative risk, with a confidence interval of 95%. Quantitative findings were compared using Student's t-test ( P<0.05). Demographic characteristics and duration of endotracheal intubation were comparable in the two groups. The ENT examination was considered abnormal in 30 patients of group I and 15 patients of group II preoperatively (NS). It was abnormal in 146 patients of group I (92%) and 46 patients of group II (59%) postoperatively. Altered vocal cord motility was noted in six patients of group I and two patients of group II. The relative risk was 1.6 (CI: 1.3-1.9). Postoperatively, 130 patients in group I and 56 of group II (NS) reported unwanted symptoms. The observed lesions were significantly more severe in group I ( P<0.001), involving primarily the pharyngeal wall, the arytenoids, and the vocal cords. The results of this study indicate that ENT complications of anterior cervical spinal surgery are diminished by administration of Mp. Systematic ENT examination is warranted before this type of operation.