Periarticular multimodal drug injection does not improves early postoperative analgesia compared with continuous interscalene brachial plexus block after arthroscopic rotator cuff repair: A retrospective single-center comparative study.

BACKGROUND: Although continuous interscalene brachial plexus block (CISBPB) is common method in pain management following arthroscopic rotator cuff repair (ARCR), little is known about the analgesic effects of periarticular multimodal drug injection (PMDI) for ARCR. This retrospective study sought to clarify which technique could provide the best analgesic effect after ARCR. METHODS: We retrospectively reviewed consecutive patients who underwent ARCR performed by the same surgeon at our institution between June 2016 and November 2017. Patients who underwent surgery before January 2017 received CISBPB and those who underwent surgery after February 2017 received PMDI for postoperative pain control. Both treatment groups also received fentanyl by intravenous patient-controlled analgesia (IV-PCA). Postoperative pain was evaluated by visual analog scale (VAS) pain scores at 3, 6, 12, 24, and 48 h and need for IV-PCA at 8, 16, and 24 h. RESULTS: Twenty-eight patients received CISBPB and 21 received PMDI. According to the VAS scores, the postoperative analgesic effect was significantly better in the CISBPB group during the first 6 h (p < 0.05). Total fentanyl consumption by IV-PCA during the first 8 postoperative h was significantly greater in the PMDI group than in the CISBPB group. CONCLUSIONS: PMDI does not improve early postoperative analgesia after ARCR compared with CISBPB. CISBPB had a significantly better analgesic effect in the first 8 h postoperatively. LEVEL OF EVIDENCE: Level III.

[Retrospective Risk Factor Analysis of Spinal Cord Ischemia after Thoracic Endovascular Aneurysm Repair].

BACKGROUND: Thoracic endovascular aneurysm repair carries a risk of spinal cord ischemia(SCI), similar to open repair. We conducted a retrospective study of the incidence and outcome of SCI after thoracic endovascular aneurysm repair (TEVAR). METHODS: From March 2007 to September 2012, 96 patients underwent TEVAR at Saitama Cardiovascular and Respiratory Center. A loss of lower extremity motor evoked potentials (MEP) or lower extremity strength was treated emergently to maintain a mean arterial blood pressure ≥ 70-80 mmHg. For the protection of spinal cord, combined use of naloxone and cerebrospinal fluid drainage (≤ 13 mmHg) was employed. RESULTS: 4 (4.2%) of the 96 patients had paraplegia. One had lower extremity strength loss after extubation and 3 developed delayed-onset paraparesis/paraplegia. Afterward 2 (50%) of them were dead. SCI patients were more likely to be elderly (78 ± 5.5 vs 70 ± 7.1 years; P = 0.0476). A trend toward an increase in SCI was noted in women (25.0% vs 2.2%; P = 0.0338), and in length of aortic coverage (25.9 ± 2.6 cm vs 16.2 ± 5.6 cm; P = 0.008). CONCLUSIONS: Early detection and intervention to improve spinal cord perfusion may benefit patients at risk for SCI.

One-year follow-up for the therapeutic efficacy of pregabalin in patients with leg symptoms caused by lumbar spinal stenosis.

BACKGROUND: Pregabalin is a well-accepted treatment option for patients with neuropathic pain. However, the therapeutic efficacy of pregabalin for reducing the incidence of spinal surgery to treat leg symptoms in patients with lumbar spinal stenosis remains unknown. The purpose of this study was to analyze the therapeutic efficacy of pregabalin for reducing the incidence of spinal surgery for leg symptoms in patients with lumbar spinal stenosis during the first year of treatment. METHODS: Consecutive patients diagnosed with lumbar spinal stenosis at our hospital from January to June 2009 were treated with nonsteroidal anti-inflammatory drug monotherapy and formed the control group (n = 47; 22 males, 25 females). Patients diagnosed with lumbar spinal stenosis at our hospital between August 2010 and October 2011 were treated with a nonsteroidal anti-inflammatory drug and pregabalin combination therapy and formed the pregabalin group (n = 49; 27 males, 22 females). The proportions of patients who underwent spinal surgery during the first year of treatment were assessed and compared between the two groups using the Mann-Whitney U test. In addition, the periods in which patients decided to undergo spinal surgery were compared using the Kaplan-Meier method. RESULTS: Six patients (12.2%) in the pregabalin group and 22 patients (46.8%) in the control group underwent spinal surgery during the first year of treatment (P = 0.0035). The period in which patients decided to undergo spinal surgery was significantly delayed in the pregabalin group compared with the control group in those for whom spinal surgery was necessary (P = 0.0128). CONCLUSIONS: Nonsteroidal anti-inflammatory drug and pregabalin combination therapy may result in a lower incidence of spinal surgery during the first year of treatment or a delayed period before undergoing spinal surgery if necessary compared with nonsteroidal anti-inflammatory drug monotherapy in patients with leg symptoms caused by lumbar spinal stenosis.

Airway emergency during general anesthesia in a child with plastic bronchitis following Fontan surgery: a case report.

BACKGROUND: Plastic bronchitis (PB) is a complication of Fontan surgery, results in the formation of mucus plug in the tracheobronchial tree, causing potentially fatal airway obstruction. We report critical airway emergency during general anesthesia in a child with plastic bronchitis. CASE PRESENTATION: A 5-year-old boy was scheduled for intrapulmonary lymphatic embolization through percutaneous catheterization under general anesthesia. He underwent Fontan surgery at the age of 2 and frequently developed respiratory failure due to plastic bronchitis. After induction of general anesthesia and tracheal intubation, mechanical ventilation became difficult even with an inspiratory pressure ≥ 50 mmHg due to airway obstruction. He expectorated a large mucus plug through the tracheal tube after administration of sugammadex, naloxone, and flumazenil, and respiratory condition was stabilized thereafter. CONCLUSION: General anesthesia for a patient with plastic bronchitis should be planned with extracorporeal membrane oxygenation or cardiopulmonary bypass stand by.

High-intensity transient signals during transcatheter aortic valve implantation assessed by ultrasonic carotid artery blood-flow monitoring: A single center prospective observational study.

BACKGROUND: No reports to date have assessed the procedural patterns of high-intensity transient signals (HITS) by monitoring blood flow in cervical arteries. The aim of this study was to examine the sequential distribution of HITS in each procedural phase and predictive factors for HITS during transcatheter aortic valve implantation (TAVI) by monitoring blood flow in the common carotid artery. METHODS: This prospective observational study included 73 patients who underwent TAVI via the transfemoral artery approach. We continuously evaluated and analyzed HITS from administration of heparin to valve implantation. RESULTS: HITS peaked during balloon valvuloplasty (BAV), amounting to almost 30% of the total HITS count, followed by valve implantation [BAV 141 (73-186) and valve implantation 86 (64-126), respectively]. In univariate and multivariate analysis, the Agatston score of the aortic valve and low-density lipoprotein were confirmed as independent predictors of HITS frequency with logarithmically converted coefficients of 0.00015 (p < 0.001) and 0.0032 (p = 0.027), respectively. CONCLUSIONS: These results provide the first evidence that micro-emboli deriving from calcified burden were scattered primally during BAV, followed by valve implantation. The Agatston score may be a predictor for the amount of HITS.

Medium and long-term prognosis of transcatheter aortic valve implantation from the perspective of left ventricular diastolic function.

BACKGROUND: The effects of left ventricular (LV) diastolic function are well known in cardiac surgery, but unclear in transcatheter aortic valve implantation (TAVI). The objective of this study was to exam- ine the association of preoperative LV diastolic function with medium to long-term outcomes of TAVI. METHODS: Eighty patients who underwent TAVI were classified into grades I, II and III based on pre- operative LV diastolic function. Findings related to cardiovascular outcomes after TAVI were extracted retrospectively from clinical and echocardiographic data and relationships with diastolic function were examined. RESULTS: The average follow-up was 529 days (interquartile range {IQR] 358-741 days). Cardiovascu- lar events occurred in 17 cases, including 6 deaths, and were significantly associated with Euro II score (p = 0.043), albumin level (p = 0.026), coronary artery disease (CAD) (p = 0.017), and diastolic func- tion (p < 0.001). The 360-day event-free rates were 89.5%, 89.5% and 37.5% for grades I, II and III (p = 0.00013). Median event-free survival (EFS) in grade III cases was 180 days. In a Cox propor- tional hazard model, LV diastolic dysfunction (hazard ratio [HR] 3.99, 95% confidence interval [CI] 1.35-11.80, p = 0.012) and low albumin (HR 4.73, 95% CI 1.42-15.80, p = 0.012) were significant independent predictors of reduced EFS. CONCLUSIONS: Medium to long-term outcomes of TAVI were poorer in patients with deteriorated LV diastolic function, and outcomes in grade III cases were significantly worse than those in grade I and II cases. Preoperative LV diastolic function may be useful in prediction of outcomes after TAVI.

Successful use of regional anesthesia in non-intubated video-assisted thoracic surgery in patients with cardiopulmonary failure: two case reports.

BACKGROUND: One-lung ventilation under general anesthesia is necessary for thoracic surgery, but this procedure is often difficult in surgery for patients with cardiopulmonary failure. Non-intubated video-assisted thoracic surgery (VATS) is performed under local anesthesia for patients with respiratory failure, but has not been performed for patients with circulatory failure. Here, we report management of two patients with cardiopulmonary failure who underwent non-intubated VATS with paravertebral block and infiltration anesthesia. CASE PRESENTATION: Case 1 was a 79-year-old male with dyspnea at rest due to left large pleural effusion and cardiac dysfunction who underwent thoracoscopic pleural biopsy with paravertebral block under spontaneous breathing. The patient was also receiving dialysis. Case 2 was a 53-year-old male who developed empyema due to large pleural effusion, resulting in a poor general condition and cardiac dysfunction, and underwent video-assisted empyema curettage only with infiltration anesthesia under spontaneous breathing. In both patients, intraoperative respiration and circulation remained stable with values similar to those present preoperatively, and there were no problems after surgery. CONCLUSIONS: We safely anesthetized two patients with difficulty to general anesthesia by ensuring sufficient regional anesthesia during VATS under spontaneous breathing. These cases suggest that regional anesthesia for non-intubated VATS can contribute to maintain intra- and postoperative respiration and circulation in patients with cardiopulmonary failure.

Four-year follow-up of pregnancy-associated osteoporosis: a case report.

A 22-year-old woman presented with complaints of severe pain in a wide region of the thoracolumbar spine. She developed severe pain in the thoracolumbar spine region 2 months after her first delivery and was referred 1 month later. A lateral thoracic X-ray showed depressed degenerative vertebrae (T7, T9). One month after the initial examination, thoracic sagittal magnetic resonance imaging showed low intensity areas on T1-weighted imaging and iso-high intensity areas on T2-weighted imaging at T5, 7, 8, 9 and 11. Bone mineral density measured by ultrasound was low (%YAM 76%). The bone metabolic markers were high, suggesting accelerated osteoclast activity. These findings prompted a diagnosis of pregnancy-associated osteoporosis. She was asked to stop breastfeeding and to wear a lumbar brace, and treatment with nutritional calcium, activated vitamin D3, and risedronate sodium was started. Her low back pain almost disappeared after treatment. Bone metabolic markers showed normalization 8 months after the initial examination. Risedronate sodium was stopped 2 years and 2 months after the initial examination. Teriparatide treatment was started because her bone mineral density remained low; however, the osteoblast marker P1NP was not increased 5 months after the start of teriparatide treatment.

Therapeutic efficacy of pregabalin in patients with leg symptoms due to lumbar spinal stenosis.

The purpose of this study was to evaluate the therapeutic efficacy of pregabalin in patients with leg symptoms due to lumbar spinal stenosis. Study subjects were classified into two groups according to their pharmacotherapy: the pregabalin group, treated with nonsteroidal anti-inflammatory drug and pregabalin combination therapy, and the control group, treated with nonsteroidal anti-inflammatory drug monotherapy. The two groups were compared in terms of the duration of pain after the onset of leg symptoms and the type of neurogenic intermittent claudication, whether radicular-, caudal-, or mixed-type. Numerical rating scale and Roland-Morris Disability Questionnaire scores were evaluated before and 3 months after treatment. After 3 months of treatment, there were significant differences in the numerical rating scale for radicular- and mixed-types, but not for caudal-type, between the two groups in the subjects with leg symptoms for greater than 3 months. There were significant differences between the two groups in Roland-Morris Disability Questionnaire scores for mixed-type, but not for radicular- and caudal-types, in the subjects with leg symptoms for less than 3 months and for radicular- and mixed-types, but not for caudal-type, in the subjects with leg symptoms for greater than 3 months. Nonsteroidal anti-inflammatory drug and pregabalin combination therapy may be more effective than nonsteroidal anti-inflammatory drug monotherapy for the relief of leg symptoms due to lumbar spinal stenosis, preventing aggravation of subjective symptoms and improving quality of life for patients with radicular- and mixed-types in subjects with leg symptoms for greater than 3 months, although it may be necessary to consider alternative therapy for patients with caudal-type.

Anatomic study of the axis for surgical planning of transarticular screw fixation.

Transarticular screw fixation has shown increased stability compared with other posterior stabilization techniques. However, there have been few reports on vertebral artery injury related to the screw insertion. The current study measured the parameters of the pedicle and vertebral artery groove of the axis and clarified the accuracy and safety of the transarticular screw fixation. Direct measurements were taken from 98 dry axis vertebrae. The width and height of the pedicle were measured. The mediolateral and anteroposterior dimensions of the vertebral artery groove also were measured. Forty-one percent had asymmetry. In 20% of the specimens, the pedicle was smaller than the diameter of the screw (3.5 mm). The pedicle of the axis has large anatomic variability and asymmetry. Some pedicles were not suitable for atlantoaxial transarticular screw fixation. The risks associated with screw fixation should be prevented by preoperative computed tomography with three-dimensional reconstruction. Screw trajectory reconstruction with coronal and sagittal reconstruction is useful to evaluate the pedicle width and height.