Non-traumatic complete cervical spine dislocation with severe fixed kyphosis: successful multidisciplinary approach to a challenging case.

BACKGROUND: To our knowledge, there is no previous report in the literature of non-traumatic neglected complete cervical spine dislocation characterized by anterior spondyloptosis of C4, extreme head drop, and irreducible cervicothoracic kyphosis. CASE PRESENTATION: We report the case of a 33-year-old Caucasian man with a 17-year history of severe immune polymyositis and regular physiotherapy who presented with severe non-reducible kyphosis of the cervicothoracic junction and progressive tetraparesia for several weeks after a physiotherapy session. Radiographs, computed tomography, and magnetic resonance imaging revealed a complete dislocation at the C4-C5 level, with C4 spondyloptosis, kyphotic angulation, spinal cord compression, and severe myelopathy. Due to recent worsening of neurological symptoms, an invasive treatment strategy was indicated. The patient's neurological status and spinal deformity greatly complicated the anesthetic and surgical management, which was planned after extensive multidisciplinary discussion and relied on close collaboration between the orthopedic surgeon and the anesthetist. Regarding anesthesia, difficult airway access was expected due to severe cervical angulation, limited mouth opening, and thyromental distance, with high risk of difficult ventilation and intubation. Patient management was further complicated by a theoretical risk of neurogenic shock, motor and sensory deterioration, instability due to position changes during surgery, and postoperative respiratory failure. Regarding surgery, a multistage approach was carefully planned. After a failed attempt at closed reduction, a three-stage surgical procedure was performed to reduce displacement and stabilize the spine, resulting in correct spinal realignment and fixation. Progressive complete neurological recovery was observed. CONCLUSION: This case illustrates the successful management of a critical situation based on a multidisciplinary collaboration involving radiologists, anesthesiologists, and spine surgeons.

Effect of Intravenous Dexamethasone Dose on the Occurrence of Rebound Pain after Axillary Plexus Block in Ambulatory Surgery.

Rebound pain (RP) remains a challenge in ambulatory surgery, characterized by severe pain upon resolution of a peripheral nerve block (PNB). Intravenous (IV) administration of Dexamethasone (DEXA) potentiates PNB analgesic effect and reduces RP incidence although preventive effective dose remains undetermined. This retrospective analysis evaluates the preventive effect of IV DEXA on RP in outpatients undergoing upper limb surgery under axillary block. DEXA was divided into high (HD > 0.1 mg/kg) or low (LD < 0.1 mg/kg) doses. RP was defined as severe pain (NRS ≥ 7/10) within 24 h of PNB resolution. DEXA HD and LD patients were matched with control patients without DEXA (n = 55) from a previous randomized controlled study. Records of 118 DEXA patients were analyzed (DEXA dose ranged from 0.05 to 0.12 mg/kg). Intraoperative IV DEXA was associated with a significant reduction of the pain felt when PNB wore off as well as to a significant reduction of RP incidence (n = 27/118, 23% vs. 47% in controls, p = 0.002) with no effect related to the dose administered (p = 0.053). Our results support the administration of intraoperative DEXA as a preventive measure to reduce the occurrence of RP.

Use of regional analgesia to prevent the conversion from acute to chronic pain.

PURPOSE OF REVIEW: Chronic post-surgical pain (CPSP) prevalence has not changed over the past decades what questions the efficacy of preventive strategies. Regional analgesia is used to control acute pain, but preventive effect on CPSP remains debated. Failures and future application of regional analgesia to prevent transition from acute to chronic pain will be discussed. RECENT FINDINGS: After thoracotomy, perioperative regional analgesia does not seem to prevent CPSP. After breast cancer surgery, paravertebral block might prevent CPSP intensity and impact on daily life up to 12 months, particularly in high catastrophizing patients. In knee arthroplasty, perioperative regional analgesia or preoperative genicular nerve neuroablation do not prevent CPSP, although current studies present several bias. The protective role of effective regional analgesia and early pain relief in trauma patients deserves further studies. SUMMARY: Regional analgesia failure to prevent CPSP development should prompt us to reconsider its perioperative utilization. Patients' stratification, for example high-pain responders, might help to target those who will most benefit of regional analgesia. The impact of regional analgesia on secondary pain-related outcomes such as intensity and neuropathic character despite no difference on CPSP incidence requires more studies. Finally, the preventive effect of regional analgesia targeted interventions on CPSP in patients suffering from severe subacute pain deserves to be assessed.

Orbital emphysema post laparoscopic Nissen fundoplication in an adult with ventriculoperitoneal shunt. Case report.

INTRODUCTION: Currently there is controversy with regard to safety of laparoscopic surgery performed in patients with a ventriculoperitoneal shunt (VPS). An increased intra-abdominal pressure and eventually impaired shunt function may possibly increase intracranial pressure. Although no report of pneumocephalus due to retrograde valve failure has been published, other complications may not be neglected. PRESENTATION OF CASE: A 72-year-old woman was scheduled for a laparoscopic Nissen fundoplication due to a large intrathoracic gastric hernia. Her medical history revealed a gait disorder, requiring a VPS for normotensive hydrocephalus, set up in the right lateral ventricle 11 years earlier. No neurological symptoms were revealed preoperatively. Surgery was uneventful. Postoperatively, important right palpebral emphysema was noticed. Her Glasgow score was 15. She presented no headache, no impairment of the visual acuity, with normal sensitivity and motricity. After multidisciplinary discussion, a chest and neck x-ray were performed. No other complications were noticed. The palpebral emphysema completely disappeared 3 days later. The patient was discharged uneventfully at day 5. DISCUSSION: Orbital emphysema is an uncommon clinical occurrence of subcutaneous emphysema. It may lead to compressive orbital emphysema when air enters the orbit but cannot leave it freely. The increase of intra-orbital pressure followed by intrabulbar hypertension may cause an occlusion of central retinal artery and optic nerve ischaemia. Tension pneumocephalus must concomitantly be excluded. CONCLUSION: Although orbital emphysema is often a benign finding, it may result in serious and life threatening complications that must be excluded in patients with a VPS.

Influence of Sternotomy on Delta Pulse Pressure and Delta Down During Open Chest Cardiac Surgery: A Preliminary Study.

OBJECTIVE: Delta pulse pressure and delta down are used as dynamic preload indicators of fluid responsiveness during closed chest surgery. There are few data regarding their accuracy in open chest surgery. The present study aimed to evaluate the influence of sternotomy on the accuracy of both delta pulse pressure and delta down. DESIGN: Prospective study. SETTING: Single institution, nonacademic hospital. PARTICIPANTS: The study comprised 127 adult patients scheduled for elective open chest cardiac surgery. INTERVENTIONS: Delta pulse pressure and delta down were calculated for all patients before and 10 minutes after sternotomy. MEASUREMENTS AND MAIN RESULTS: Statistical analyses were performed to assess the influence of sternotomy on the accuracy of delta down and delta pulse pressure. Mann-Whitney and Bland-Altman analyses demonstrated a significant influence of sternotomy on delta pulse pressure values but not on delta down values. Among patients who had a positive delta down and/or delta pulse pressure before sternotomy, sternotomy significantly modified the delta pulse pressure value (p = 0.02), but not the delta down value (p = 0.22). The kappa coefficient indicated a very good agreement between delta down before and after sternotomy (0.83) and a fair agreement between delta pulse pressure before and after sternotomy (0.4). The difference between kappa coefficients was highly significant (p < 0.001). CONCLUSIONS: Within the study population, sternotomy significantly influenced delta pulse pressure but not delta down. In this preliminary study, delta down appeared to be more accurate to evaluate fluid responsiveness during open chest surgery than did delta pulse pressure. Before promoting delta down in current practice, confirmation is needed on a larger scale.