One Versus 3-Week Immobilization Period for Nonoperatively Treated Proximal Humeral Fractures: A Prospective Randomized Trial.

BACKGROUND: There is no consensus on the duration of immobilization for nonoperatively treated proximal humeral fractures (PHFs). The main objective of the study was to determine the differences in pain between PHFs that were treated nonoperatively with 3-week immobilization and those treated with 1-week immobilization. METHODS: A prospective randomized trial was designed to evaluate whether the immobilization time frame (1-week immobilization [group I] versus 3-week immobilization [group II]) for nonoperatively treated PHFs had any influence on pain and functional outcomes. Pain was assessed using a 10-cm visual analog scale (VAS) that was administrated 1 week after the fracture, at 3 weeks, and then at the 3, 6, 12, and 24-month follow-up. The functional outcome was evaluated using the Constant score. To assess the functional disability of the shoulder, a self-reported shoulder-specific questionnaire, the Simple Shoulder Test (SST), was used. The Constant score and the SST were recorded at the 3, 6, 12, and 24-month follow-up. Complications and secondary displacement were also recorded. RESULTS: One hundred and forty-three patients were randomized, and 111 (88 females and 23 males) who had been allocated to group I (55 patients) or group II (56 patients) were included in the final analysis. The mean age of the patients was 70.4 years (range, 42 to 94 years). No significant differences were found between the 2 groups in terms of pain as measured with the VAS at any time point (1 week [5.9 versus 5.6; p = 0.648], 3 weeks [4.8 versus 4.1; p = 0.059], 3 months [1.9 versus 2.4; p = 0.372], 6 months [1.0 versus 1.2; p = 0.605], 1 year [0.65 versus 0.66; p = 0.718], and 2 years [0.63 versus 0.31; p = 0.381]). No significant differences were found in the Constant score or SST score at any time point. No significant differences were noted in the complication rate. CONCLUSIONS: Short and long periods of immobilization yield similar results for nonoperatively treated PHFs, independent of the fracture pattern. These fractures can be successfully managed with a short immobilization period of 1 week in order to not compromise patients' independence for an overly extended period. LEVEL OF EVIDENCE: Randomized controlled trial Level II. See Instructions for Authors for a complete description of levels of evidence.

Influence of curve morphology and location on the efficacy of rigid conservative treatment in patients with adolescent idiopathic scoliosis.

AIMS: The aim of the present study was to answer the question whether curve morphology and location have an influence on rigid conservative treatment in patients with adolescent idiopathic scoliosis (AIS). METHODS: We retrospectively analyzed AIS in 127 patients with single and double curves who had been treated with a Chêneau brace and physiotherapeutic specific exercises (B-PSE). The inclusion criteria were the presence of structural major curves ≥ 20° and < 50° (Risser stage 0 to 2) at the time when B-PSE was initiated. The patients were divided into two groups according to the outcome of treatment: failure (curve progression to ≥ 45° or surgery) and success (curve progression < 45° and no surgery). The main curve type (MCT), curve magnitude, and length (overall, above and below the apex), apical rotation, initial curve correction, flexibility, and derotation by the brace were compared between the two groups. RESULTS: In univariate analysis treatment failure depended significantly on: 1) MCT (p = 0.008); 2) the apical rotation of the major curve before (p = 0.007) and during brace treatment (p < 0.001); 3) the initial and in-brace Cobb angles of the major (p = 0.001 and p < 0.001, respectively) and minor curves (p = 0.015 and p = 0.002); 4) major curve flexibility (p = 0.005) and the in-brace curve correction rates (major p = 0.008, minor p = 0.034); and 5) the length of the major curve (LoC) above (p < 0.001) and below (p = 0.002) the apex. Furthermore, MCT (p = 0.043, p = 0.129, and p = 0.017 in MCT comparisons), LoC (upper length p = 0.003, lower length p = 0.005), and in-brace Cobb angles (major p = 0.002, minor p = 0.027) were significant in binary logistic regression analysis. CONCLUSION: Curve size, location, and morphology were found to influence the outcome of rigid conservative treatment of AIS. These findings may improve future brace design and patient selection for conservative treatment. Cite this article: Bone Joint J 2021;103-B(2):373-381.

Postoperative Bronchopleural Fistula: A Conservative Way of Treatment in Selected Cases.

BACKGROUND: Postoperative bronchopleural fistula represents a challenging issue for thoracic surgeons. The treatment options reported include bronchoscopic or surgical procedures but the method yielding the best results remains unclear. METHODS: In our thoracic surgery department, between January 2011 and June 2020, 11 patients treated conservatively for early bronchopleural fistula after lobectomy or bilobectomy were reviewed. The fistula size ranged between 2 and 3 mm and complete suture dehiscence. RESULTS: In all 11 patients favorable conditions such as clinical stability, complete expansion of the remaining lung, and resolution of the pleural infection allowed a successful conservative treatment with chest tube drainage. CONCLUSION: In selected cases, conservative management of early bronchopleural fistula after lobectomy or bilobectomy may be an alternative therapeutic option to bronchoscopic or surgical procedures, regardless of the fistula size.

Management of Fecal Incontinence.

Nine percent of adult women experience episodes of fecal incontinence at least monthly. Fecal incontinence is more common in older women and those with chronic bowel disturbance, diabetes, obesity, prior anal sphincter injury, or urinary incontinence. Fecal incontinence negatively affects quality of life and mental health and is associated with increased risk of nursing home placement. Fewer than 30% of women with fecal incontinence seek care, and lack of information about effective solutions is an important barrier for both patients and health care professionals. Even among women with both urinary and fecal incontinence presenting for urogynecologic care, the rate of verbal disclosure of fecal incontinence symptoms remains low. This article provides an overview of the evaluation and management of fecal incontinence for the busy obstetrician-gynecologist, incorporating existing guidance from the American College of Obstetricians and Gynecologists, the American College of Gastroenterology, and the American Society of Colon and Rectal Surgeons. The initial clinical evaluation of fecal incontinence requires a focused history and physical examination. Recording patient symptoms using a standard diary or questionnaire can help document symptoms and response to treatment. Invasive diagnostic testing and imaging generally are not needed to initiate treatment but may be considered in complex cases. Most women have mild symptoms that will improve with optimized stool consistency and medications. Additional treatment options include pelvic floor muscle strengthening with or without biofeedback, devices placed anally or vaginally, and surgery, including sacral neurostimulation, anal sphincteroplasty, and, for severely affected individuals for whom other interventions fail, colonic diversion.

The Wrist and Radius Injury Surgical Trial: 12-Month Outcomes from a Multicenter International Randomized Clinical Trial.

BACKGROUND: Optimal treatment for distal radius fractures in older adults remains uncertain. No randomized trials comparing the most frequently used treatments in this population have been conducted. Surgical treatment rates vary widely, and the sustained benefits of surgery are uncertain. METHODS: The Wrist and Radius Injury Surgical Trial, a randomized, multicenter trial, enrolled 304 adults aged 60 years and older with isolated, unstable distal radius fractures at 24 institutions. Patients who wanted surgery (n = 187) were randomized to internal fixation, external fixation, or percutaneous pinning; patients who preferred conservative management (n = 117) received casting. The primary outcome was the 12-month Michigan Hand Outcomes Questionnaire (MHQ) summary score. RESULTS: At 12 months, there were no differences by treatment in primary outcome. Twelve-month MHQ summary scores differed between internal fixation and external fixation by 3 points (97.5 percent CI, 6.0 to 11.5) and between internal fixation and pinning by -0.14 (97.5 percent CI, -9.2 to 8.9). However, at 6 weeks, the mean MHQ summary score for internal fixation was greater than for external fixation by 19 (p < 0.001), pinning by 11 (p < 0.001), and casting by 7 (p = 0.03). Internal fixation participants demonstrated significantly better radiologic alignment throughout the follow-up period. Malunion was experienced by 48 percent of casting participants. CONCLUSIONS: Recovery was fastest for internal fixation and slowest for external fixation according to most measures, but by 12 months there were no meaningful differences in outcomes. Casting participants experienced satisfactory results despite loss of radiologic alignment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Implications of the Ankle Injury Management (AIM) trial: close contact casting or surgery for older adults with an unstable ankle fracture?

The Ankle Injury Management (AIM) trial was a pragmatic equivalence randomized controlled trial conducted at 24 hospitals in the United Kingdom that recruited 620 patients aged more than 60 years with an unstable ankle fracture. The trial compared the usual care pathway of early management with open reduction and internal fixation with initially attempting non-surgical management using close contact casting (CCC). CCC is a minimally padded cast applied by an orthopaedic surgeon after closed reduction in the operating theatre. The intervention groups had equivalent functional outcomes at six months and longer-term follow-up. However, potential barriers to using CCC as an initial form of treatment for these patients have been identified. In this report, the results of the AIM trial are summarized and the key issues are discussed in order to further the debate about the role of CCC. Evidence from the AIM trial supports surgeons considering conservative management by CCC as a treatment option for these patients. The longer-term follow-up emphasized that patients treated with CCC need careful monitoring in the weeks after its application to monitor maintenance of reduction. Cite this article: Bone Joint J 2019;101-B:1472-1475.

Providence nighttime bracing is effective in treatment for adolescent idiopathic scoliosis even in curves larger than 35°.

Since 2006, the Providence nighttime brace has been used for a conservative treatment for scoliosis. Previous studies comparing the outcomes after full-time bracing and nighttime bracing have reported a comparable outcome with curves < 35°. The aim of this study was to report the outcome after treatment in a cohort of adolescent idiopathic scoliosis patients, with curves between 20° and 45°. METHODS: One hundred and twenty-four patients with adolescent idiopathic scoliosis were included in this study with Cobb > 20°, remaining growth potential and no previous scoliosis treatment. Providence nighttime treatment, 8 h nightly, was initiated. Treatment was continued until 2 years post-menarcheal for females and until 6-month growth arrest for males. The patients were evaluated using standing radiographs during treatment and 6 and 12 months after termination of bracing. RESULTS: One hundred and twenty-four patients were included; 80 patients terminated brace treatment and were available for follow-up. Mean in-brace correction was 82%, and curve progression was observed in 9 patients. Brace treatment was success full in 89% of the patients, 88% of the patients braced with curves 20°-29°, 93% of the patients braced with 30°-39° and 77% of the patients braced with curves 40°-45°. Five of the 80 AIS patients were referred to surgery: 4 due to progression and 1 due to cosmetic concerns. CONCLUSIONS: Providence nighttime braces are an effective treatment for adolescent idiopathic scoliosis patients. This study reports a success rate of 89%, and the results are comparable to full-time treatment with the Boston brace. In-brace correction is crucial in part-time bracing, and we recommend at least 70% curve correction, if part-time bracing should be considered. These slides can be retrieved under Electronic Supplementary Material.

Non-operative treatment of unicompartmental osteoarthritis of the knee: a prospective randomized trial with two different braces-ankle-foot orthosis versus knee unloader brace.

BACKGROUND: The use of an unloader brace is a non-surgical treatment option for patients with medial osteoarthritis (OA). However, many patients do not adhere to brace treatment, because of skin irritation due to the pads at the level of the joint space and bad fit. A new concept to unload the medial compartment of the knee is a foot ankle brace with a lever arm pressing the thigh in valgus. The aim of this prospective randomized trial was to examine the outcomes of patients with medial OA after treatment with a conventional knee unloader brace (Unloader One®) and the new foot ankle orthosis (Agilium FreeStep®). METHODS: For this multicenter trial, 160 patients (> 35 years) with medial OA were randomly allocated to treatment with a conventional knee unloader brace (Unloader One®) or treatment with the new knee OA ankle brace (Agilium FreeStep®). The primary outcome measure was pain (numerical analog scale) at baseline (T0), 8 weeks (T1), and 6 months (T2). Secondary outcome measures were knee function (Knee Injury and Osteoarthritis Outcome Score, KOOS), side effects, additional interventions, and compliance. RESULTS: In both groups, walking pain improved between T0 and T1 and also between T0 and T2 without a significant group difference. For pain at sports, both groups showed a significant improvement between T0 and T2 without a significant group difference. The KOOS subscales symptoms, pain, activity, sport, and quality of life increased significantly in both treatment groups without any significant group differences at T 0, T1, and T2. There was also no significant group difference in additional interventions and weekly or daily brace use. In the Agilium FreeStep® group (23.5%), significantly less patients reported bruises in contrast to the Unloader One® group (66.7%). DISCUSSION: The results of this clinical trial show that the foot ankle brace is as effective as a conventional knee unloader brace for the treatment of medial knee OA with regard to clinical outcome. The rate of side effects such as bruises was significantly lower in the Agilium FreeStep® group. TRIAL REGISTRATION: DRKS00009215, 13.8.2015.

Nonsurgical Treatment of Chest Wall Deformities: Contradiction or Complement?

For decades, open surgical repair was the only available method to treat congenital and acquired chest wall deformities (CWDs). In 1998, D. Nuss described a minimally invasive procedure for surgical repair of pectus excavatum (PE), and a few years later H. Abramson reported on his experience with the "reversed Nuss technique" for surgical repair of pectus carinatum (PC). Both procedures are performed with increasing frequency worldwide.However, nonsurgical measures such as vacuum bell (VB) therapy for conservative treatment of PE and more differentiated bracing systems for conservative treatment of PC were established 15 to 20 years ago. Nowadays, information on new therapeutic modalities circulates not only among surgeons and pediatricians, but also rapidly among patients. In particular, patients who refused operative treatment by previously available procedures now appear at the outpatient clinic and request to be considered for the new methods.Analyzing the increasing number of studies reporting on conservative treatment of CWDs as well as our own group of patients who visited a busy outpatient clinic in a small country within the last 15 to 20 years, we have to realize that the majority of patients asked for nonsurgical treatment of their CWD. Based on these experiences and results, we have to realize that nonsurgical treatment of CWD is no contradiction but a helpful complement to treat congenital and acquired CWDs and may be applied for the majority of patients suffering from a CWD.

The Use of Oral Appliances in the Management of Temporomandibular Disorders.

Oral appliances (OAs) are widely used for treating various types of temporomandibular disorders (TMDs); however, many controversies persist about how they should be designed, how they should be used, and even what their ultimate purpose might be. This article discusses 6 of the current controversies, with a focus on the evidence available to support reasonable practice guidelines for the clinical use of OAs in treating certain TMDs.

Conservative treatment of distal fractures after the age of 65: a review of literature.

The goal of this study was to evaluate the role of conservative treatment of distal radius fractures in the elderly since 2000. Our series included 22 articles, of which 3 reviews, 2 meta-analyses, 6 descriptive series of conservative treatment, 10 series comparing surgical and conservative treatments and 1 series comparing different types of conservative treatments. The reduction was performed by closed reduction in 7 cases and by traction in 3 cases. A short-arm cast was used in 8 cases and a long-arm cast in 4 cases for an average length of 6 weeks. The indications of conservative treatment were varied: AO type A fractures in 2 cases, type C fractures in 1 case, types A and C in 8 cases and types A, B and C in 3 cases. No article reported any significant difference between surgical and conservative treatments in terms of DASH or PRWE, whereas strength was sometimes improved when surgical treatment was used. Radiological results were always better after surgical treatment. The rate of complications varied greatly, greater, equally or lower compared to conservative treatment depending on the series. All in all, there is no consensus to assert that a conservative treatment is more justified than a surgical treatment to treat distal radius fractures after the age of 65. Most authors consider that the long-term clinical outcome is identical and that the radiological result is better after surgical treatment. The fact that the fixation of a distal radius fracture by a volar locking plate after 65 years speeds up the recovery remains to be proven.

Burden between Undersupply and Overtreatment in the Care of Primary Spontaneous Pneumothorax.

BACKGROUND: The optimal treatment of primary spontaneous pneumothorax (PSP) is still controversial. The purpose of this study was to analyze the incidence of recurrence, the recurrence-free time, and to identify risk factors for recurrence after PSP. METHODS: We performed a retrospective analysis of 135 patients with PSP who were treated either conservatively with a chest tube (n = 87) or surgically with video-assisted thoracoscopic surgery (VATS; n = 48) from January 2008 through December 2012. RESULTS: In this study, 101 (74.8%) male and 34 (25.2%) female patients were included with a mean age of 35.7 years. The indications for surgery included blebs/bullae in the radiological images (n = 20), persistent air leaks (n = 15), or the occupations/wishes of the patients (n = 13). A first ipsilateral recurrent pneumothorax (true recurrence) was observed in 31.1% of all patients (VATS: 6.25%, conservative: 44.8%). Including contralateral recurrence, the overall first recurrence rate was 41.3% (VATS: 14.6%, conservative: 57.5%). The recurrence-free time did not differ significantly between the treatment groups (p = 0.51), and most recurrences were observed within the first 6 months after PSP. Independent risk factors identified for the first recurrence were conservative therapy (p = 0.0001), the size of the PSP (conservative; p = 0.016), and a body mass index <17 (VATS; 0.022). The risk for second and third recurrences of PSP was 17.5 and 70%, respectively, for both treatment groups, but it was 100% after conservative therapy. CONCLUSION: Surgery for PSP should be selected based on the risk factors and the patient's wishes to prevent first recurrences but also to avoid overtreatment. The treatment of first and subsequent PSP recurrences should be with surgery since conservative treatment is associated with a 100% recurrence rate.

Early Protected Weightbearing for Acute Ruptures of the Achilles Tendon: Do Commonly Used Orthoses Produce the Required Equinus?

Conservative "functional" management of acute Achilles tendon ruptures has become increasingly popular. Critical to this is the use of the walking orthosis, which positions the ankle in equinus to allow for early weightbearing. Our aim was to test whether 2 common orthoses achieved a satisfactory equinus position. A total of 11 sequentially treated Achilles tendon ruptures were assigned to either a fixed angle walking boot with wedges (FAWW) or an adjustable external equinus-corrected brace (EEB). The lateral radiographs of the cast immobilized tendons showed a mean tibiotalar angle (TTA) of 56° (range 54° to 57°) and a mean tibio-first metatarsal angle (1MTA) of 74° (range 62° to 85°). The FAWW resulted in a mean TTA of 28° (range 15° to 35°) and 1MTA of 37° (range 30° to 45°). The EEB resulted in a TTA of 48° (range 43° to 45°) and 1MTA of 54° (range 47° to 57°). Ankle equinus was significantly greater with the EEB than with the FAWW (p < .05) and similar to that with an equinus cast. The use of wedges produced an equinus appearance through the midfoot but not at the ankle. We express caution in the use of the FAWW because it is unlikely to achieve sufficient ankle equinus to shorten the Achilles tendon.

A Non-surgical Intervention for Triangular Fibrocartilage Complex Tears.

BACKGROUND AND PURPOSE: The current literature contains no reports of treatment options other than surgery following failed conservative management of a triangular fibrocartilage complex (TFCC) tear. The purpose of this study is to describe the use of a novel brace as a non-surgical intervention for TFCC tears. METHODS: This paper is a case study of a subject with a magnetic resonance imaging-confirmed TFCC tear. As an alternative to surgery, he consented to wear a novel brace for 12 weeks after conservative management of his injury had failed. His recovery from injury was monitored with a weight-bearing tolerance test and the disabilities of the arm, shoulder and hand (DASH) outcome measure. RESULTS: An increase in weight-bearing tolerance and upper extremity use was evident immediately after donning the brace. After 12 weeks, the subject demonstrated a return to normal weight-bearing tolerance and normal DASH outcome measure scores. These improvements were still evident at a 1-year follow-up appointment. DISCUSSION: Utilizing this novel brace resulted in functional status improvement in a subject with a TFCC tear as demonstrated by significant changes in his DASH outcome measure scores. This case study demonstrates the first non-surgical alternative treatment for a TFCC tear after conservative management has failed. Copyright © 2016 John Wiley & Sons, Ltd.

The effectiveness of the SpineCor brace for the conservative treatment of adolescent idiopathic scoliosis. Comparison with the Boston brace.

BACKGROUND CONTEXT: The Boston brace (Bb) is the most widely used brace design to treat adolescent idiopathic scoliosis (AIS). The dynamic SpineCor (SC) brace is prescribed in several scoliosis clinics worldwide, but its effectiveness remains controversial. PURPOSE: The study aimed to compare the treatment effectiveness of SC in patients with AIS treated by the developers of the brace with that of the Bb at a single institution. STUDY DESIGN/SETTING: This is a retrospective comparison between a cohort of AIS patients treated using the SC brace and a cohort treated using the Bb. PATIENT SAMPLE: We assessed 243 patients treated with either Bb or SC brace to prevent the progression of AIS. OUTCOME MEASURES: The primary outcome was the progression in main Cobb angle when reaching one of the following end point criteria: (1) progression in Cobb angle of ≥6°, (2) main Cobb angle of ≥45°, (3) surgery undertaken, or (4) reaching skeletal maturity (Risser sign of 5 or growth of <1 cm in the previous 6 months). METHODS: Patients were identified at a single institution between 2000 and 2012 following the Scoliosis Research Society criteria for brace treatment: (1) diagnosis of AIS, (2) Risser sign of ≤2, (3) curve magnitude between 25° and 40°, and (4) age ≥10 years. A total of 97 patients treated with SC by the developers of the brace and 146 patients treated with Bb were identified. Data collection and radiograph measurements were performed by a single experienced nurse not involved in the decision-making for brace treatment or in the data analysis. Age and Risser sign at onset of treatment, initialmain Cobb angle, curve type, and duration of follow-up were similar in both cohorts. Statistical analysis was done using chi-square and logistic regression models, with a level of significance of .05. RESULTS: The average progression was 14.7°±11.9° in the SC cohort compared with 9.6°±13.7° in the Bb cohort (p=.003). The average Cobb angle at the end point of the study reached 47°±13° in the SC cohort and 41.7°±14.2° in the Bb cohort (p=.005), whereas at the onset of bracing it was 32.2°±4.9° and 32.2°±4.4°, respectively, for the SC and Bb cohorts. The percentage of patients with a progression of ≥6° was 76% in the SC cohort and 55% in the Bb cohort (p=.001). The proportion of patients reaching 45° in the SC and Bb cohorts was, respectively, 51% and 37% (p=.03), whereas the proportion of patients referred to surgery was 39% and 30%, respectively, for the SC and Bb cohorts (p=.2). The odds of progressing ≥6° and of reaching ≥45° were 2.67 and 2.07 times greater, respectively, when using the SC brace. CONCLUSIONS: The SC brace did not prevent curve progression as effectively as the Bb. Although it has the potential benefit of increasing mobility during brace wear, the SC brace was associated with increased curve progression in comparison with the Bb. There is also a trend for increased risk of requiring surgery when the SC brace is worn.

Hematoma após anestesia peridural: tratamento conservador. Relato de caso / Hematoma after epidural anesthesia: conservative treatment. Case report

JUSTIFICATIVA E OBJETIVOS: O hematoma associado à compressão espinhal após anestesia peridural é uma complicação neurológica grave, apesar da pequena incidência relatada (1:150.000). É um episódio agudo, e o tratamento tradicionalmente aplicado é a descompressão cirúrgica de urgência. Mais recentemente, em casos específicos, o tratamento com corticosteróide tem sido aplicado como alternativa, com boa recuperação neurológica. O objetivo deste relato foi expor um caso de hematoma peridural com tratamento conservador e recuperação neurológica completa. RELATO DO CASO: Paciente do sexo feminino, 34 anos, estado físico ASA I, sem qualquer histórico de coagulopatia ou terapia anticoagulante, submetida à anestesia peridural com punção única, em L2-L3, para tratamento cirúrgico de varizes nos membros inferiores. Oito horas após a anestesia regional, ela ainda apresentava bloqueio motor completo (escala de Bromage), redução das sensibilidades térmica e dolorosa abaixo do nível L3, hiperalgesia na região plantar esquerda, preservação dos reflexos tendinosos e ausência de dor lombar. A tomografia computadorizada revelou hematoma peridural em L2 com compressão do saco dural. Dez horas após a punção peridural não havia progressão dos sinais e sintomas neurológicos. Optou-se, então, pelo tratamento com metilprednisolona em infusão venosa contínua (5,3 mg.kg-1 na primeira hora e 1,4 mg.kg-1.h-1 nas 23 horas subseqüentes). Oito horas após o início do tratamento, a paciente recuperou as sensibilidades térmica e dolorosa, e houve regressão total do bloqueio motor. Na 12ª hora, deambulava e referia dor na ferida operatória. O hematoma peridural não foi visualizado em nova tomografia computadorizada na 14ª hora após o início do tratamento. A paciente recebeu alta hospitalar 86 horas depois do início do tratamento conservador, sem comprometimento neurológico. Uma tomografia computadorizada de controle, após sete meses, mostrou o canal vertebral completamente...

BACKGROUND AND OBJECTIVES: Hematoma associated with spinal compression after epidural anesthesia is a severe neurological complication, despite the reduced incidence reported (1:150,000). It is an acute episode and the traditional treatment includes urgent surgical decompression. More recently, treatment with corticosteroids has been used as an alternative, in specific cases, with good neurological resolution. The objective of this report was to present the case of an epidural hematoma treated conservatively with complete neurological recovery. CASE REPORT: Female patient, 34 years old, ASA physical status I, with no prior history of bleeding disorders or anticlotting treatment, underwent epidural anesthesia at the L2-L3 level for the surgical treatment of lower limb varicose veins. Eight hours after the regional anesthesia, the patient still presented complete motor blockade (Bromage scale), reduction of thermal and pain sensitivity below L3, hyperalgesia in the left plantar region, preserved tendon reflexes, and absence of lumbar pain. A CT scan showed an epidural hematoma in L2, with compression of the dural sac. Ten hours after the epidural puncture, there was no regression of neurological signs and symptoms. It was decided, then, to treat the patient with a continuous infusion of methylprednisolone (5.3 mg.kg-1 in the first hour and 1.4 mg.kg-1.h-1 in the following 23 hours). Eight hours after the beginning of the treatment, the patient recovered thermal and pain sensitivity and presented total regression of the motor blockade. On the 12th hour, she was walking and complained of pain in the surgical wound. The epidural hematoma was not visualized in a CT scan done 14 hours after the beginning of the treatment. The patient was discharged 86 hours after the beginning of the treatment without neurological deficits. A CT scan done after 7 months showed a completely normal spinal canal. CONCLUSIONS: The efficacy of the conservative approach...

JUSTIFICATIVA Y OBJETIVOS: O hematoma asociado a la compresión espinal después de la anestesia peridural es una complicación neurológica grave, a pesar de la pequeña incidencia relatada (1:150.000). Es un episodio agudo y el tratamiento tradicionalmente aplicado es la descompresión quirúrgica de urgencia. Recientemente, en casos específicos, el tratamiento con corticosteroide ha sido aplicado como alternativa y con una buena recuperación neurológica. El objetivo de este relato fue exponer un caso de hematoma peridural con tratamiento conservador y recuperación neurológica completa. RELATO DEL CASO: Paciente del sexo femenino, 34 años, estado físico ASA I, sin ningún historial de coagulopatía o terapia anticoagulante, sometida a la anestesia peridural con punción única, en L2-L3, para tratamiento quirúrgico de várices en los miembros inferiores. Ocho horas después de la anestesia regional, todavía presentaba bloqueo motor completo (escala de Bromage), reducción de las sensibilidades térmica y dolorosa por debajo del nivel L3, hiperalgesia en la región plantar izquierda, preservación de los reflejos tendinosos y ausencia de dolor lumbar. La tomografía computadorizada reveló hematoma peridural en L2 con compresión del saco dural. Diez horas después de la punción peridural no había progresión de las señales y síntomas neurológicos. Se optó entonces por el tratamiento con metilprednisolona en infusión venosa continua (5,3 mg.kg-1 en la primera hora y 1,4 mg.kg-1.h-1 en las 23 horas siguientes). Ocho horas después del inicio del tratamiento, la paciente recuperó las sensibilidades térmica y dolorosa y la regresión total del bloqueo motor. En la 12ª hora, deambulaba y refería dolor en la herida operada. El hematoma peridural no se visualizó en una nueva tomografía computadorizada en la 14ª hora después del inicio del tratamiento. La paciente recibió alta hospitalaria 86 horas después del inicio del tratamiento conservador, sin comprometimiento neurológico. Una...