Changes of tissue images visualised by ultrasonography in the process of pressure ulcer occurrence.

OBJECTIVE: Ultrasonography is suitable for assessing pressure ulcers, and several features of ultrasonographic images that indicate abnormalities have been reported. However, no study has compared ultrasonographic images between normal and pressure-loaded skin and subcutaneous tissue from the same patients. This study aimed to assess lateral thoracic tissue using ultrasonography for both pre- and postoperative conditions and investigate changes in the tissue caused by loading. Surgeries were performed with patients in the park-bench position. METHOD: A nursing researcher obtained ultrasonographic images of the skin and subcutaneous tissue of the lower thoracic region in areas in contact with the surgical table one or two days before and after surgery. This study focused on three groups of two patients who had a category I pressure ulcer (PU), blanchable erythema, or normal skin on their lateral thoracic region. RESULTS: A total of six patients participated. Postoperatively, muscle layers became thinner and less clear compared with pre-operative conditions in patients with the Category I pressure ulcers. These patients complained of significant pain in the areas of their pressure ulcers. CONCLUSION: Thickness of muscle layers could be an early sign of deep tissue injury.

Meralgia Paresthetica Caused by Surgery in the Park-Bench Position.

OBJECTIVE: Meralgia paresthetica (MP) is an entrapment neuropathy of the lateral femoral cutaneous nerve (LFCN). We report a rare case of MP after microvascular decompression (MVD) surgery in the park-bench position in a patient with hemifacial spasm. CASE: The patient was a nondiabetic 46-year-old woman (height: 155 cm, weight: 42 kg) who consumed alcohol infrequently. After a first MVD for right hemifacial spasm, the symptom recurred and she underwent a second MVD procedure in the park-bench position, after which hemifacial spasm resolved. However, she reported right anterolateral thigh pain and dysesthesia without motor weakness. The pain was limited to the LFCN area, and a pelvic compression test elicited a positive Tinel-like sign. Our preliminary diagnosis was MP. Because conservative therapy was ineffective, she underwent LFCN block 9 months after the second MVD procedure. Her pain improved dramatically and we made a definitive diagnosis of MP. There has been no recurrence after 30 months of observation, although she reported persistent mild dysesthesia in the LFCN area. CONCLUSION: MP is a rare complication after MVD surgery in the park-bench position. LFCN block can resolve symptoms and hasten diagnosis.

Modified 30-Degree Head-Up Tilt Park Bench Position in Semielective Posterior Fossa Surgery in a Patient with Pheochromocytoma / Posição de banco de apoio de inclinação de cabeça para cima de 30 graus modificada em cirurgia de fossa posterior semieletiva em paciente com feocromocitoma

Von Hippel­Lindau (VHL) disease is a rare genetic disorder associated with the central nervous system and visceral organs. Pheochromocytomas occur in 10% of VHL patients, while cerebellar tumors are common tumors in VHL syndrome, with an incidence of 60%. The most common position for posterior fossa operations is the park bench or lateral decubitus position. These positions have primarily replaced the sitting position. However, the advantages of the supine position cannot be overlooked. The coexistence of pheochromocytoma and the cerebellar tumor may require modification in surgical position and anesthesia management in line with possible pathophysiological changes. We present the anesthesia management in posterior fossa surgery in patients with postponed pheochromocytoma surgery. The present case highlights the importance of a multidisciplinary team approach and anesthetic management.

A doença de Von Hippel-Lindau (VHL) é uma doença genética rara associada ao sistema nervoso central e órgãos viscerais. Feocromocitomas ocorrem em 10% dos pacientes com VHL, enquanto os tumores cerebelares são tumores comuns na síndrome de VHL, com incidência de 60%. A posição mais comum para operações da fossa posterior é o banco do parque ou posição de decúbito lateral. Essas posições substituíram principalmente a posição sentada. No entanto, as vantagens da posição supina não podem ser negligenciadas. A coexistência de feocromocitoma e tumor cerebelar pode exigir modificação da posição cirúrgica e manejo da anestesia de acordo com possíveis alterações fisiopatológicas. Apresentamos o manejo da anestesia na cirurgia da fossa posterior em pacientes com cirurgia de feocromocitoma adiada. O presente caso destaca a importância de uma abordagem de equipe multidisciplinar e do manejo anestésico.

Suboccipital osteoblastoma: Microsurgical resection of a rare entity.

BACKGROUND: Osteoblastomas are rare lesions comprising 1% of all bone tumors. The occipital bone is one of the rarest affected bone, with only 11 cases reported during the last 40 years. CASE DESCRIPTION: Here, we describe the clinical presentation and the radiological features of a suboccipital osteoblastoma that was successfully resected in a 30-year-old man. A short video shows the microsurgical removal of the lesion. There was no recurrence during a 12-month follow-up. CONCLUSIONS: Even if osteoblastomas are benign tumors, a complete removal has to be achieved to reduce the risk of recurrences. This makes necessary an appropriate monitoring of the patient.

Unanticipated Disturbance in Somatosensory Evoked Potentials in a Patient in Park-Bench Position.

Perioperative neuropathy is a known complication of malpositioning during anaesthesia. Somatosensory evoked potentials are used for detecting such a complication in selected surgeries. Most reports of intraoperative nerve injuries due to malpositioning are limited to injuries to the peripheral nervous system, and there have been no previously reported cases of somatosensory evoked potential monitoring disturbance attributable to position-related cerebral ischemia in the park-bench position. We present the case of a patient with glioblastoma in the park-bench position whose somatosensory evoked potential waveforms disappeared after head and neck repositioning. A prompt diagnosis of this complication and elimination of the underlying cause led to the return of somatosensory evoked potential waveforms, and there was no relevant neurologic deficit at the end of the surgery.

The supracerebellar-transtentorial approach to posteromedial temporal lesions in children with refractory epilepsy.

OBJECT: Operations on tumors of the posteromedial temporal (PMT) region, that is, on those arising from the posterior parahippocampal, fusiform, and lingual gyri, are challenging to perform because of the deep-seated location of these tumors between critical cisternal neurovascular structures and the adjacent temporal and occipital cortexes. Traditional surgical approaches require temporal or occipital transgression, retraction, or venous sacrifice. These approaches may result in unintended complications that should be avoided. To avoid these complications, the supracerebellar-transtentorial (SCTT) approach to this region has been used as an effective alternative treatment in adult patients. The SCTT approach uses a sitting position that offers a direct route to the posterior fusiform and lingual gyri of the temporal lobe. The authors report the feasibility, safety, and efficacy of this approach, using a modified lateral park-bench position in a small cohort of pediatric patients. METHODS: The authors carried out a retrospective case review of 5 consecutive patients undergoing a paramedian SCTT approach between 2009 and 2014 at the authors' institution. RESULTS: The SCTT approach in the park-bench position was used in 3 boys and 2 girls with a mean age of 7.8 years (range 13 months to 16 years). All patients presented with a seizure disorder related to a tumor in a PMT region involving the parahippocampal and fusiform gyri of the left (n = 3) or right (n = 2) temporal lobe. No procedure-related complications were observed. Gross-total resection and control of seizures were achieved in all cases. Tumor classes and types included 1 Grade II astrocytoma, 1 pleomorphic xanthoastrocytoma, 1 ganglioglioma, and 2 glioneural tumors. None of the tumors had recurred by the mean follow-up of 22 months (range 1-48 months). Outcomes of epileptic seizures were excellent, with seizure symptoms in all 5 patients scoring in Engel Class IA. CONCLUSIONS: The SCTT approach represents a viable option when resecting tumors in this region, providing a reasonable working corridor and low morbidity. The authors' experience in a cohort of pediatric patients demonstrates that complete resection of the lesions in this location is feasible and is safe when involving an approach that involves using a park-bench lateral positioning.

The park-bench position in cervico-facial reconstructive surgery: a technical note.

Resection and simultaneous reconstruction with free flaps of wide tumours of the scalp and posterior neck region are difficult to perform through a single surgical approach. In such cases, the park-bench position - a lateral oblique position - could allow simultaneous resection and reconstruction of tumours of the scalp and occipital region without changing the patient's position. In the case described here, this position was used to treat microcystic adnexal carcinoma in a patient who presented with three scalp lesions and a lesion of the right scapular region. This arrangement allowed both resection and reconstruction with a microvascular flap without changing the patient's position, as a result of being able to find neck vessels suitable for microanastomosis. Reconstruction was carried out using a right latissimus dorsi myogenous and subcutaneous flap, and anastomoses were created between the thoracodorsal artery and vein, and the transverse cervical artery and vein. In this position, transverse cervical vessels are well placed, with good exposure, and are in an optimal location for use in microvascular surgery. At 8 months post-reconstruction, the patient was in good condition without local recurrence or distant metastases, and the flap showed a good lining and contour. In conclusion, the park-bench position facilitates surgical excision, flap harvesting and microsurgery in the same patient position.