Back pain after labour under epidural analgesia.

In this case report we have discussed a parturient patient who had epidural analgesia during childbirth and then presented with back pain 50 days postpartum as well as the causes of postpartum back pain.

Prevention of brisk hyperactive response during selective dorsal rhizotomy in children with spasticity: isoflurane versus sevoflurane maintenance anesthesia.

In children with spasticity, deep tendon reflexes are hyperactive and even stimulation of normal dorsal rootlets can produce exaggerated full-strength, single-twitch responses in the muscles they innervate. This phenomenon is called the brisk hyperactive response (BHR). The aim of this study was to compare the efficacy of 2 volatile anesthetics, isoflurane and sevoflurane, for suppressing the confounding effect of BHR during selective dorsal rhizotomy (SDR) in children with spasticity. The subjects were 54 consecutive children of American Society of Anesthesiology physical status III who were scheduled for SDR. After tracheal intubation, each child was randomly assigned to Group I (isoflurane; n=27) or Group S (sevoflurane; n=27). There was no significant difference between the mean operation times in Groups I and S (200+/-40 vs. 220+/-35 minutes, respectively; p=0.0559). Thirteen patients in Group I (48.1%) and 5 in Group S (18.5%) exhibited BHR during stimulation of the dorsal rootlets (odds ratio 4.086; p=0.0418). Three of these 18 patients (2 in Group I and 1 in Group S) experienced hypertension and tachycardia simultaneously with BHR (odds ratio 4.086; p=1.0). The results suggest that sevoflurane is more effective at preventing BHR and might be a better choice for anesthetic management of children with spasticity undergoing SDR.

Intraoperative Neuromonitoring of Motor-Evoked Potentials in Infants Undergoing Surgery of the Spine and Spinal Cord.

PURPOSE: The aim of this single-center prospective cohort study is to record reliable transcranial motor-evoked potentials (TcMEPs) and to determine their thresholds under inhalational anesthesia in infants undergoing spine and spinal cord surgery. METHODS: A total of 15 infants (age <12 months) with mean (SD) months: 5.82 ± 3.45 were included. The entry criteria were that the child should be no older than 1 year of age and undergoing a surgical procedure at the conus-cauda region. The patients were monitored with motor-evoked potentials (TcMEPs) and bulbocavernosus reflex. RESULTS: Transcranial motor-evoked potentials were recorded in all the patients in both upper and lower extremities in one muscle at least. All patients were monitored with a mean TcMEP threshold of 488.46 ± 99.76 V (range 310-740 V). The lowest threshold of TcMEPs was used to record the musculus abductor pollicis brevis mean of 315.15 ± 126.95 V (range 140-690 V) and the highest for musculus sphincter ani mean of 444.17 ± 138.54 V (range 206-700 V). CONCLUSIONS: Intraoperative neuromonitoring for spine and spinal cord procedures of the infant population requires higher TcMEP thresholds and train count. Most patients aged older than 6 months require significantly lower TcMEPs.

Ten years of experience with pediatric neuroendoscopic third ventriculostomy: features and perioperative complications of 210 cases.

Obstructive hydrocephalus remains a problem, and improvements in fiberoptic technology have promoted interest in neuroendoscopic ventriculostomy (NTV) as an alternative to standard cerebrospinal fluid shunts. The present study assessed 210 pediatric NTVs performed between 1994 and 2004 in patients aged 2 months to 10 years. Five children needed same-session ventriculoperitoneal shunting due to insufficient bypass of the obstruction. The other 205 procedures were technically successful, but 7 patients needed early-postoperative shunting and 10 required late shunting. During NTV, 86 (40.1%) of the patients developed arrhythmia. One patient arrested during balloon dilatation, but normal rhythm returned after deflation and epinephrine/atropine therapy, with no resultant morbidity. Twenty-six (10.2%) patients developed tachycardia (without hypertension) followed by bradycardia, and 6 children (2.8%) developed hypertension. In 1 case (0.5%), a branch of the basilar artery ruptured during fenestration and the hemorrhage was controlled after craniotomy. In 5 cases, mild venous bleeding was controlled by irrigation. The early complications included transient ocular divergence (n = 1), anisocoria (n = 2), and hyponatremia (n = 5). Five children were diagnosed with temporary diabetes insipidus in the late-postoperative period. The neuroendoscopic approach is considered safe for treating hydrocephalus in children, but complications can be severe or lethal and the anesthesiologist must respond accordingly.

Assessment of sedated pediatric brain with 3D-FLAIR sequence at 3T MRI.

BACKGROUND AND PURPOSE: In sedated pediatric brains, 2D-FLAIR causes increased signal intensity of the cerebrospinal fluid (CSF) leading to false-positive diagnoses. Our aim is to determine whether increased CSF signal intensity is observed on 3D-FLAIR images. METHODS: In this institutional review board-approved study, a 2-year retrospective analysis of our MRI database was conducted which revealed 48 sedated pediatric patients with normal cranial MRI findings and 3D-FLAIR sequence. One adult volunteer was imaged before and after O2 inhalation with 2D and 3D-FLAIR sequences. The hyperintensity in the subarachnoid spaces and basal cisterns were quantified as follows: 0: artifact free; 1: homogeneous minimal CSF signal; 2: abnormal CSF signal. Inter-observer agreement was assessed with kappa agreement analysis. RESULTS: Grade 0 and grade 1 signals were observed at inferior to Liliequist membrane (LLQ) in 48/48 and 0/48 cases; prepontine cistern 47/48 and 1/48; superior to LLQ 26/48 and 22/48; 4th ventricle 16/48 and 32/48; 3rd ventricle 34/48 and 14/48; lateral ventricle 3/48 and 45/48; subarachnoid space 36/48 and 12/48, respectively. No patients showed grade 2 signal. Inter-observer agreement was 0.81-1. In the volunteer, after O2 inhalation, grade 2 signal intensity was evident on 2D-FLAIR however; 3D-FLAIR did not show any signal increase. CONCLUSIONS: In sedated pediatric brains, 3D-FLAIR suppresses CSF signal, and enables reliable assessment free from CSF artifacts.

Cauda equina syndrome after induction of spinal anesthesia.

In this report the authors present a case of cauda equina syndrome that developed following induction of spinal anesthesia in a patient who had no apparent preexisting bleeding abnormality. An acute subdural hematoma caused the syndrome and was believed to have resulted from direct vascular trauma during administration of spinal anesthesia or from vascular trauma combined with thrombocytopenia in the postoperative period.

Moyamoya disease and anesthesia.

Moyamoya disease is a condition that results from bilateral stenosis or obstruction of the intracranial arteries at the base of the brain. Patients exhibit ischemic symptoms, and vascular reconstruction is the therapy of choice. Surgical treatment for Moyamoya disease is often complicated by cerebral ischemia, so the goal in perioperative management is to maintain the balance between oxygen supply and demand in the brain. This report presents three cases of Moyamoya disease in patients under 3 years of age, and discusses anesthesia management issues for pediatric patients with this condition.