Occurrence of Trochlear Nerve Palsy after Epiduroscopic Laser Discectomy and Neural Decompression

Epiduroscopic laser discectomy and neural decompression (ELND) is known as an effective treatment for intractable lumbar pain and radiating pain which develop after lumbar surgery, as well as for herniation of the intervertebral disk and spinal stenosis. However, various complications occur due to the invasiveness of this procedure and epidural adhesion, and rarely, cranial nerve damage can occur due to increased intracranial pressure. Here, the authors report case in which double vision occurred after epiduroscopic laser discectomy and neural decompression in a patient with failed back surgery syndrome (FBSS).

Disseminated Herpes Zoster in an Immunocompetent Elderly Patient

Herpes zoster is a cutaneous infection that is characterized by an acute vesicobullous rash with ipsilateral one or two dermatomal distribution and painful allodynia, while predominantly being found in the elderly. Extensive cutaneous dissemination has been reported in immune-compromised patients, such as those who suffer from HIV infections, cancer, chemotherapy, and corticosteroid therapy patients. However, we report a case of disseminated herpes zoster infection in an immuno-competent elderly individual.

Antinociceptive effect of phenyl N-tert-butylnitrone, a free radical scavenger, on the rat formalin test / 대한마취과학회지

BACKGROUND: Reactive oxygen species (ROS) such as superoxide radicals, hydrogen peroxide, nitric oxide, and nitroperoxide, cause oxidative stress which interferes with normal cell functioning, resulting in cell damage. It is reported to be associated with chronic pain, especially neuropathic pain, and inflammatory pain. ROS is also closely related to central sensitization. Therefore, this study was designed to explore the effects of Phenyl N-tert-butylnitrone (PBN), an ROS scavenger, in acute, continuous, and increasing pain caused by central sensitization. METHODS: Male Sprague-Dawley rats were divided into 2 groups, an intraperitoneal group (IP) and an intrathecal group (IT), and once again divided into an experimental group and a control group. The experimental group was injected with Phenyl N-tert-butylnitrone (PBN), a free radical scavenger, either intraperitoneally or intrathecally. After inducing pain by injecting formalin into the hind paw, pain behaviors were measured. Lumbar enlargement immmunohistochemistry was performed to assess nitrotyrosine, an oxidative stress marker, to identify the degree of protein nitration. RESULTS: Both experimental groups of IP and IT showed statistically significant decreases in the number of flinches compared to the control group in phase 1 and 2. Immunohistochemical evaluation in the control group revealed an increase in nitrated proteins in the gray matter of the lumbar spinal cord, but a significant decrease in nitrated proteins in the gray matter of lumbar spinal cord of the experimental group. CONCLUSIONS: Intraperitoneal and intrathecal administration of PBN decreases analgesic behaviors, allowing us to believe that ROS is mainly responsible for acute pain and central sensitization.

Antinociceptive effect of phenyl N-tert-butylnitrone, a free radical scavenger, on the rat formalin test / 대한마취과학회지

BACKGROUND: Reactive oxygen species (ROS) such as superoxide radicals, hydrogen peroxide, nitric oxide, and nitroperoxide, cause oxidative stress which interferes with normal cell functioning, resulting in cell damage. It is reported to be associated with chronic pain, especially neuropathic pain, and inflammatory pain. ROS is also closely related to central sensitization. Therefore, this study was designed to explore the effects of Phenyl N-tert-butylnitrone (PBN), an ROS scavenger, in acute, continuous, and increasing pain caused by central sensitization. METHODS: Male Sprague-Dawley rats were divided into 2 groups, an intraperitoneal group (IP) and an intrathecal group (IT), and once again divided into an experimental group and a control group. The experimental group was injected with Phenyl N-tert-butylnitrone (PBN), a free radical scavenger, either intraperitoneally or intrathecally. After inducing pain by injecting formalin into the hind paw, pain behaviors were measured. Lumbar enlargement immmunohistochemistry was performed to assess nitrotyrosine, an oxidative stress marker, to identify the degree of protein nitration. RESULTS: Both experimental groups of IP and IT showed statistically significant decreases in the number of flinches compared to the control group in phase 1 and 2. Immunohistochemical evaluation in the control group revealed an increase in nitrated proteins in the gray matter of the lumbar spinal cord, but a significant decrease in nitrated proteins in the gray matter of lumbar spinal cord of the experimental group. CONCLUSIONS: Intraperitoneal and intrathecal administration of PBN decreases analgesic behaviors, allowing us to believe that ROS is mainly responsible for acute pain and central sensitization.

Cauda equina syndrome after spinal anesthesia in a patient with severe spinal stenosis: A case report / 대한마취과학회지

Cauda equina syndrome is a well-known but rare complication of spinal anesthesia. An 80-year-old man was scheduled for both herniorrhaphy. Spinal anesthesia was performed at the L3-4 interspinous space with 0.5% hyperbaric bupivacaine 12 mg. Eight hours after anesthesia, the patient complained bilateral sensorimotor deficits of the lower extremities and peroneal region. Urinary and fecal incontinence were also observed. MRI and myelography showed severe central spinal stenosis at L3-4 and L4-5. EMG showed cauda equina syndrome. Seven weeks after the procedure, left decompressive subtotal laminectomy L2-L5 was done. The patient still complains the neuropathic pain in the both lower extremities and ambulates using a walker. The local anesthetic was injected into thecal sac between maximum stenoses, and it is likely that there was poor upward spread leading to maldistribution of local anesthetic and resultant local anesthetic toxicity.

Herpes Zoster in Healthy Child: A case report / 대한통증학회지

Herpes zoster in childhood is uncommon, but it is more common in association with immunosuppression. Maternal varicella infection during pregnancy and varicella occurring in the newborn represent risk for childhood herpes zoster. However, some controversies persist on risk factors, diagnosis, and the natural history of childhood disease. We report a 10-year-old healthy boy with shingles and review the risk factors, prognosis, and treatment of pediatric zoster.

Motor Paresis Caused by Herpes Zoster in Patients with Rotator Cuff Tear: A report cases / 대한통증학회지

Segmental zoster paresis is characterized by focal, asymmetric motor weakness in the myotome corresponding to the dermatome of the rash. A 73-year-old man, who presented with severe right shoulder pain and shoulder girdle muscle weakness, was diagnosed with segmental zoster paresis involvement of the C5 C6 motor roots as a complication of herpes zoster. Girdle muscles (supraspinatus, deltoid and infraspinatus) atrophy had developed in his right shoulder. An MRI showed rotator cuff tearing in his right shoulder; therefore, an arthroscopic rotator cuff repair was performed. Herein, this case is presented to emphasize the importance of considering post-herpetic segmental motor paresis in the differential diagnosis of acute painful motor weakness of the upper extremities.

The Influence of Lidocaine on the Onset of Rocuronium-induced Neuromuscular Block in Rapid-sequence Tracheal Intubation / 대한마취과학회지

BACKGROUND: Most local anesthetics decrease neuromuscular transmission and potentiate the neuromuscular blocks of muscle relaxants. The purpose of this study was to examine the influence of lidocaine on it effects rocuronium onset and intubation conditions in rapid-sequence intubation and to compare with those of succinylcholine. METHODS: Seventy five ASA physical status 1 and 2 patients were randomly allocated to three groups. Group S received succinylcholine (1.0 mg/kg), Group R received rocuronium (0.6 mg/kg) and additional lidocaine (1.5 mg/kg) was given intravenously prior to the administration of rocuronium 0.6 mg/kg in Group RL. Anesthesia was induced with midazolam 0.03 mg/kg, fentanyl 2microgram/kg, and thiopental 5 mg/kg. Intubation was performed 60 seconds after the administration of muscle relaxants and intubation conditions were evaluated. Neuromuscular blockades were assessed by single twitch responses of the adductor pollicis after ulnar nerve stimulation by accelerography (0.1 Hz, 0.2 ms supramaximal stimuli). RESULTS: The onset time of Group S (47.8+/-11.3) was shorter than those of Group R (87.8+/-30.2) and Group RL (75.4+/-21.5), but no differences was observed between the onset times of Group R and Group RL. Intubation conditions were good or excellent in all groups. CONCLUSIONS: Additional lidocaine to rocuronium neither influences intubation condition nor accelerate the rocuronium onset, and it is cannot be viewed as an alternative for succinylcholine in rapid-sequence tracheal intubation.

Epidural Abscess after Percutaneous Vertebroplasty: A case report / 대한통증학회지

Although the incidence of epidural abscess is rare, once it occurs, its high morbidity rate and high mortality rate create a great deal of serious sequalae for these patient, if this condition is not diagnosed in time. We experienced a case of epidural abscess after performing percutaneous vertebroplasty in a patient who had a lumbar spinal compression fracture. This case will remind the pain clinician of the possibility of epidural abscess after such a procedure.

A Comparison of the Effects of Propofol and Sevoflurane Anesthesias on Intraocular Pressure during Laparoscopic Hysterectomy / 대한마취과학회지

BACKGROUND: Laparoscopic surgery in the Trendelenburg position affects the cardiopulmonary system and may also influence intraocular pressure (IOP). The purpose of this study was to compare the effects of propofol and sevoflurane anesthesias on IOP change during laparoscopic hysterectomy. METHODS: Thirty-one women were randomly allocated to either a propofol (P-group, n = 15) intravenous anesthesia group or a sevoflurane (S-group, n = 16) inhaled anesthesia group with fentanyl-N2O/O2-vecuronium. Heart rate, mean arterial pressure, plateau airway pressure, ETCO2, and IOP were measured before induction (T1), 10 min after induction (T2), 10 min after pneumoperitoneum in the Trendelenburg position (T3), and 5 min after pneumoperitoneum deflation in the horizontal position (T4). RESULTS: IOP was significantly decreased in both groups after induction. IOP was increased in both groups after pneumoperitoneum in the Trendelenburg position, but IOP in the sevoflurane group was significantly higher than that in the propofol group. CONCLUSIONS: Propofol intravenenous anesthesia may be a better choice for IOP control during laparoscopic surgery.

Pulmonary Thromboembolism during Femur Surgery under General Anesthesia -A case report- / 대한마취과학회지

Although perioperative pulmonary thromboembolisms (PTEs) are not rare, most anesthetists are unfamilar with the condition. We experience a case, which showed a sudden capnographic score drop, increased pumonary arterial pressure, and a D-shaped right ventricle by echocardiography in a femur surgery patient under general anesthesia. The case described provides an example of PTE and should remind anesthetists of the clinical course and treatment of this condition.

Bronchospasm during the Maintenance of General Anesthesia: A case report / 대한마취과학회지

Although a bronchospastic attack is common during the induction and emergence of general anesthesia, it is quite rare during maintenance of it. We experienced a severe case of a bronchospasm in a male patient during the maintenance of general anesthesia. His past medical history indicated no risk factors for the bronchospasm except for heavy smoking. He suffered from poor ventilation, hypercarbia and a pneumothorax that occurred abruptly, 2 hours after inducing general anesthesia. Ten hours later, he recovered his normal respiratory function without any respiratory complication. This case highlights the possibility of a bronchospasm during the maintenance of general anesthesia.

The Effects of Esmolol on BIS, Patient Movement, and Hemodynamic Changes during General Anesthesia with Propofol / 대한마취과학회지

BACKGROUND: Lidocaine, alpha, beta-adrenergic blocker, angiotensin converting enzyme inhibitor, and various other analgesics have been used for blocking awakening, movements, and hemodynamic instability during general anesthesia. The purpose of this study was to evaluate the ability of esmolol to attenuate the cardiovascular, motor, and central nervous system responses to nociceptive stimulation, such as intubation, during general anesthesia. METHODS: Forty randomly selected patients participated in this study either as a control (n = 20) or as a study (n = 20) group, respectively. As soon as patients lost consciousness, at a propofol effect-site concentration of 4 microgram /ml, a touniquet was applied to one arm and inflated to 150 mmHg higher than the systolic pressure, and then vecuronium (1 mg/kg) was injected. Simultaneously esmolol (1 mg/kg + 250 microgram /kg/min) or normal saline were injected in the study and control groups respectively. Four minutes after starting esmolol, orotracheal intubation was administered. We monitered the BP, HR, BIS and gross movement during the study. RESULTS: Statistically significant differences were observed in mean BP, HR, and BIS between the two groups during esmolol injection. CONCLUSIONS: Esmolol can reduce anesthetic requirements during general anesthesia with propofol.

A Comparison of the Incidence of Hypotension During Unilateral vs Conventional Spinal Anesthesia with Hyperbaric Bupivacaine / 대한마취과학회지

BACKGROUND: Hypotension is the most frequent side effect of spinal anesthesia. Unilateral spinal anesthesia may be advantageous because it reduce the extent of spinal block. The aim of this study was to compare the incidence of hypotension and the difference of heart rate between unilateral and conventional bilateral spinal anesthesia. METHODS: Seventy patients were randomly allocated into two groups, which both received 2.0 ml (10 mg) of 0.5% hyperbaric bupivacaine. In group 1, local anesthetic was injected for two minutes with the needle orifice turned toward the dependent side; the lateral position was maintained for 20 minutes (unilateral, n = 35). In group 2, local anesthetic was injected through a cranially directed needle orifice, then patients were immediately turned supine (conventional, n = 35). Observers recorded noninvasive hemodynamic variables, as well as loss of cold and touch sensation and motor block on both side. RESULTS: In the unilateral group, 16 patients (45.7%) showed a unilateral loss of cold sensation and 23 patients (65.7%) had no motor block on the nondependent side for the duration of the study, whereas all conventional patients had bilateral distribution of spinal block (P < 0.001). The incidence of hypotension was higher in the conventional (22.9%) than unilateral group (5.7%) (P < 0.01). Considering the mean changes from baseline values of arterial blood pressure, patients of the conventional group showed greater decreases in systolic arterial blood pressure at 40, 50, 60, and 70 min (P < 0.05). Maximum percentage changes from baseline values of systolic arterial blood pressure and heart rate were greater in the conventional group (-17.8 +/- 9.8% and -19.7 +/- 10.4%) than in unilateral group (-14.6 +/- 5.5% and -16.9 +/- 11.2%). CONCLUSIONS: Unilateral spinal anesthesia reduces the incidence of hypotension during spinal anesthesia.

Conscious Sedation by Propofol TCi for Corrective Surgery of a Mandibular Fracture / 대한마취과학회지

BACKGORUND: infusion of propofol by a target-controlled infusion (TCi) system is effective in achieving conscious sedation for anxious patients presenting for dental surgery. However, there is no report of conscious sedation for mandibular fracture patients using propofol TCi. The objective of this study was to evaluate the appropriation of a conscious sedation using propofol for mandibular fracture patients. METHODS: Twenty patients with a mandibular fracture undergoing an open reduction and miniplate insertion operation were analyzed. We anesthetized patients using a propofol infusion by a TCi system (Diprifusor :Master TCi:Pilot Anesthesia is, France) with local anesthesia using lidocaine. The BiS score was evaluated continually during surgery using a microcomputer (A-2000 BiS monitor , Aspect Medical System, USA). We set the infusion machine at a target concentration 2mug/ml, and adjusted the propofol concentration for a BiS score range of 80-85. infusion rate, total dosage, duration of induction, recall of operative procedure and cooperation scores were checked. BiS, heart rate, noninvasive arterial blood pressure, and SpO2 were recorded during the operation. RESULTS: The mean BiS score was 82.95, the mean target concentration of propofol was 2.645mug/ml, the mean infusion rate was 136.3mug/kg/min, and the mean cooperation score was 2.5, the patients were cooperative. The score of amnesia was 0.2, almost patients did not recall the intraoperative event. The mean duration of stay in the recovery room was 22.2 minutes, and the most frequent side effect was pain on injecion of propofol. CONCLUSiONS: Conscious sedation with propofol TCi is an effective anesthesia method substitute for general anesthesia with quick emergence, few side effects, and safety for mandibular fracture patients.

Accidental Subdural Block during Epidural Anesthesia: A case report / 대한마취과학회지

Despite the high incidence of subdural block (SDB) during epidural anesthesia, the condition is unfamiliar to anesthesiologist. We experienced a case of SDB: severe hypotension, transient hemiplegia, wide extent of block and late onset and recovery from block. The case described is an examples of SDB and should remind anesthesiologist of the clinical course and treatment.

A Cervical Epidural Block Combined with Light General Anesthesia in Takayasu's Arteritis: A case report / 대한마취과학회지

Takayasu's arteritis is a chronic and occlusive inflammatory disease of uncertain etiology affecting medium to large sized arteries. We anesthetized a patient who had Takayasu's arteritis affecting both common carotid arteries, the left anterior descending coronary artery, and the left subclavian artery. During beating heart coronary artery bypass graft and aorto-carotid bypass graft we chose a cervical epidural block combined with light general anesthesia as an anesthetic technique. We managed the patient successfully with consistant hemodynamic stability. The operation was done without cardiopulmonary bypass and the patient was returned to consciousness immediately after the end of the operation. We extubated the endotracheal tube in the operating room without pain. The patient maintained hemodynamic stability in the intensive care unit and we controlled the pain via a cervical epidural catheter with morphine and 0.1% bupivacaine.

Clinical Analysis on 200 Cases of Kidney Transplantation in a Single Center / 대한이식학회지

PURPOSE: To determine the risk factors relating renal allograft and patient survival, we, Dae Jeon St. Mary's Hospital transplantaion team, Dae Jeon, Korea, reviewed 200 cases of kidney transplantation. METHODS: 200 medical records of kidney transplantation from February 1988 to June 2000 was reviewed retrospectively. The clinical follow up period was February 2001, and clinical analysis was done. RESULTS: 1) The original renal disease of the cases were 78 cases of chronic glomerulonephritis, 18 cases of diabetic nephropathy, 16 cases of hypertensive nephrosclerosis and 1 case of lupus nephritis, 2) The recipient-donor relationships were 14 cases of parent to offspring, 9 cases of offspring to parents, 26 cases of between siblings. There were 150 cases of non- related donor and 1 case of cadaveric donor, 3) At the end of Feb. 2001, 33 graft and 10 patients were lost (5 year graft survival was 88.3% and 5 year patient survival rate was 94.6%), 4) 7 cases of malignant tumors, 171 cases of hypertension, 141 cases of hyperlipdemia, 76 cases of Cushing's disease and 58 cases of hyperuricemia were developed, 5) There were 114 cases of infections (41 cases of bacterial infections, 40 cases of viral infections, 13 cases of tuberculosis and 20 cases of fungal infections), 6) The cases of surgical complications were 16 cases of lymphocele, 9 cases of urinary leakage, 5 cases of hematome and other 3 cases, 7) The factor analysis for graft survival showed that the donor and recipient age, number of acute rejection episodes had statistical significance. CONCLUSION: Episodes of acute rejection and old age group both in donor and recipient over 50 were the risk factors affecting renal allograft survival.

Analgesic Effects of Gabapentin on Post-hysterectomy Pain / 대한마취과학회지

BACKGROUND: The aim of the present study was to examine whether gabapentin, a new anti-epileptic agent with relatively low toxicities and side effects, could reduce postoperative pain. METHODS: Thirty-two patients scheduled for an elective total hysterectomy were investigated in this randomized, double blind, placebo-controlled study. The patients were randomized to receive either oral gabapentin 400 mg (gabapentin group, n = 16) or a matching placebo capsule (control group, n = 16) the night before and again 30 min before surgery as an adjunct to morphine patient-controlled analgesia (PCA). The visual analogue scale (VAS) for pain at rest and on movement, morphine consumption, overall satisfactions and postoperative side effects including sedation were recorded for 24 h after surgery. RESULTS: Total morphine consumption for 24 h after surgery was not significantly different between the two groups, but mean hourly morphine consumption during the period of 2 6 h after surgery was significantly greater in the control group. Movement VAS of gabapentin group measured at 6 h and 12 h after surgery was significantly lower than those of control group. There were no significant differences between the two groups with respect to the sedation score, patient's satisfaction and the frequencies of side effects. CONCLUSIONS: We observed that preoperatively administered oral gabapentin 800 mg reduced postoperative morphine consumption and incidental pain without increasing side effects. The addition of gabapentin to a morphine regimen may lower morphine consumption and provide better pain relief without increasing side effects.

The Parascalene Technique of Brachial Plexus Block for the Operation of the Upper Extremity and Shoulder / 대한마취과학회지

BACKGROUND: Brachial plexus is invested by a fascial envelope, which forms a perineural and perivascular space that extends all the way from the cervical intervertebral foramen to the distal axilla. Therefore a single injection of a local anesthetic into any sites of this space can provide anesthesia of the entire brachial plexus. Nowadays many methods of brachial plexus block have been developed but there are some severe complications and they can't prevent tourniquet pain completely. METHODS: We have performed parascalene technique for brachial plexus block in 206 cases from Jan., 1992 to Dec.,1994. We studied the cases retrospectively by reviewing patients' anesthesia records. The technique for parascalene block is the injection of local anesthetic solution into the lower part of the posterior triangle of the neck at the point 1.5~2.0 cm above the clavicle at the lateral border of the anterior scalene muscle. RESULTS: We could provide the proper anesthesia for the upper extremity and shoulder operation without any remarkable complications except Honor's syndrome of 3 cases. And there were no tourniquet pain in all 96 cases who had used tourniquet. CONCLUSIONS: The parascalene approach is the useful, safe and reliable method for brachial plexus block.