Retroperitoneoscopic drainage of complicated psoas abscesses in patients with tuberculous lumbar spondylitis.

PURPOSE: Nowadays, endoscopic techniques are widely used in surgical procedures. Retroperitoneoscopy has been an extremely valuable tool for a wide variety of urologic disorders, whereas, it has limited use in orthopedic procedures. METHODS: We performed retroperitoneoscopic drainage (in combination with medical treatment) of complicated psoas abscess on 12 patients with tuberculous spondylitis. All the procedures were done under general anesthesia and in the lateral decubitus position. Psoas abscess was evacuated during procedure, and postoperatively, drainage was continued through a large silastic tube. The definitive diagnosis and the treatment were made based on the results of culture-antibiogram and PCR testing. RESULTS: Complete clinical and radiologic remission was observed in all patients in 3-6 months. The complication was not observed in any case postoperatively. CONCLUSIONS: Retroperitoneoscopic drainage of psoas abscesses gains advantages in terms of rapid recovery, minimal invasiveness, absence of radiation, and shorter hospital stay. This procedure can be used not only for cold abscesses but also for other pathologies of lumbar vertebral area.

Tramadol use for axillary brachial plexus blockade.

BACKGROUND: We investigated the effects of tramadol added to the mixture of local anesthetic for axillary brachial plexus blockade (ABB) in patients to have undergone hand and forearm surgery. MATERIALS AND METHODS: Forty patients from the ASA classification I and II, between 18 and 60 y of age, were included in this randomized double-blind study. Group C: levobupivacaine (150 mg) + lidocaine (200 mg) (n = 20), Group T: levobupivacaine (150 mg), + lidocaine (200 mg) + tramadol (100 mg) (n = 20). Intravenous midazolam of 0.02 mg/kg was given for premedication. ABB was performed with 42 mL mixture of local anesthetic, using peripheral nerve stimulator. The duration of onset of motor and sensory blockades was recorded. The postoperative first analgesic need, sedation, and satisfaction score and side effects were recorded. RESULTS: There was no significant difference between the groups regarding intraoperative visual analog scale (VAS), hemodynamics, adverse effects, sedative and analgesic requirement, and the patient satisfaction. The development of motor block at the median nerve on the 5th min (P = 0.03) and at the ulnar nerve on 10th and 15th min in Group T were (P = 0.01, P = 0.03, respectively) considerably longer than that in Group C. CONCLUSIONS: Adding 100 mg of tramadol to the combination of levobupivacaine and lidocaine during ABB could not provide an important clinical effect in patients undergoing hand and forearm surgery.

Dexmedetomidine premedication of outpatients under IVRA.

PURPOSE: Dexmedetomidine is approximately 8 times more selective toward the alpha-2-adrenoceptors than clonidine. It induces analgesia in patients and decreases anesthetic requirements by up to 90%. The current study aimed to evaluate the effects of dexmedetomidine premedication on tourniquet pain, intraoperative - postoperative analgesic requirements, sedation levels, quality of anesthesia, and the hemodynamic parameters when used as a single dose before intravenous regional anesthesia (IVRA). MATERIAL AND METHODS: Fifty-four patients undergoing hand surgery (carpal tunnel and tendon release) were randomly divided into 2 groups for IVRA. IVRA was performed with 40 mL of 0.5 % lidocaine in both groups. A single dose of dexmedetomidine 0.5 microg/kg in 20 mL saline was administered to group D (n = 27) and placebo solution 20 mL to group C (n = 27) through the non-IVRA catheter 15 minutes before IVRA. Sensory and motor block onset and recovery time, hemodynamic variables, tourniquet pain, analgesic requirements according to verbal rating scale (VRS) and visual analog scale(VAS), sedation score, and anesthesia quality were recorded in the intraoperative and postoperative period. RESULTS: Improved quality of anesthesia, reduced postoperative pain scores, and total analgesic requirements were found in group D during postoperative period. Additionally, the patients experienced a higher degree of sedation during intraoperative and postoperative period. CONCLUSION: The premedication of 0.5 microg/kg low dose dexmedetomidine before IVRA improves the quality of anesthesia and decreases the postoperative analgesic requirement of outpatients undergoing hand surgery without any serious side effects.

Transient neurologic syndrome after spinal anesthesia with epidural steroid treatment.

BACKGROUND: Transient neurologic syndrome (TNS) is a rare complication of spinal and epidural anesthesia. It is defined as paradoxic postoperative back pain radiating to the lower extremities with no neurologic deficits. Because it is a self-limited disease, the treatment is usually symptomatic and consists of NSAIDs and injections of a neuromuscular-blocking drug at the trigger points. The syndrome may be resistant to this treatment regimen and may last for several months, resulting in a long convalescence. CASE SUMMARY: A 63-year-old Turkish woman (height, 165 cm; weight, 71 kg) underwent hemorrhoidectomy in the jackknife position using spinal anesthesia. No adverse events occurred during puncture or surgery or in the immediate postoperative recovery period. Recovery from the sensory and motor block was normal. Twenty-four hours after surgery, lower limb and plantar pain developed with no sensory or motor deficit. Neurologic examination revealed normal motor and sensory function. Electroneuromyography showed partial denervation potential of muscles innervated by the left sciatic nerve. The symptoms were suggestive of TNS. Combination oral NSAID treatment with amitriptyline (25 mg/d) and gabapentin (1200 mg/d) was initiated. Because the pain still persisted 6 weeks after surgery, epidural steroid injection with triamcinolone acetate (80 mg) with isotonic saline was administered, resulting in definite pain relief (visual analog scale score = 0). CONCLUSIONS: Epidural steroid treatment was effective in this patient with TNS resistant to treatment with NSAIDs, amitriptyline, and gabapentin. Future studies are needed to evaluate this treatment.

Glomus tumour of the deltoid muscle. A case report.

Glomus tumours around the shoulder are very rare. To the best of our knowledge, seven cases have been reported to date. We present a case with special emphasis on its localization and time of appearance. Contrary to the related reports in the literature, the lesion was of short duration and it became symptomatic just 6 months before referral. Complete pain relief was achieved with surgical treatment.

Tuberculous spondylitis: abscess drainage after failure of anti-tuberculous therapy.

Spinal tuberculous abscesses usually respond to anti-tuberculous drugs. The purpose of this study was to evaluate the results of surgical drainage after failure of first-line anti-tuberculous drugs. Patients with spinal instability or vertebral collapse were excluded from the study. The authors retrospectively reviewed 11 patients. The operation was successful in all patients. Anterior/posterior spinal fusion or curettage was not performed. Drains were removed after two to three days. None of the patients required a second operation. Complications, such as spinal instability, vertebral collapse, or death did not occur.

Neurotologic manifestations of the fibromyalgia syndrome.

The purpose was to assess otologic symptoms, and audiologic and vestibular findings in fibromyalgia (FM) syndrome. Twenty-four female patients with FM syndrome (FMS) were included in the study. The assessments were based on history, physical examination, audiometry, bithermal caloric testing and auditory brainstem response (ABR) testing. Dizziness was the most common complaint of the patients, and was followed by tinnitus, hearing loss and vertigo. Almost 50% of the patients had some sort of otologic symptoms.Dix-Halpike maneuver proved positional rotary vertigo in 5 (20.8%) patients. The audiometry results of 23 patients were normal. None of the patients had abnormal bithermal caloric testing. Although there were a variety of ABR abnormalities, the ABR results of the patients with and without cochleovestibular symptoms were not significantly different (p<0.05). In conclusion, FM patients can complain otologic symptoms even though they do not have any clinically or audiologically detectable ear disease. A neural disintegration or some other events related to neural mediators may be the mechanisms involved in the pathogenesis of otoneurologic as well as systemic manifestations of the disease that possibly leads to abnormal perception of the stimuli coming from internal or external environment.

Primitive neuroectodermal tumour of the mandible.

Primitive neuroectodermal tumors (PNETs) are relatively rare tumors. Tumors that once would have been diagnosed as Ewing's sarcoma are now often designated as peripheral neuroepithelioma or synonymously PNET. Herein we report the first case of PNET of the mandible in a 6-year-old female who was admitted to the hospital with a two-months history of painless, progressively enlarging lower jaw mass.

Biopsy of vertebral tumour metastasis for diagnosing unknown primaries.

PURPOSE: To examine patients with vertebral tumour metastasis using transpedicular biopsy for diagnosing unknown primary tumours. METHODS: 13 men and 8 women aged 41 to 80 (mean, 61) years with vertebral tumour metastasis of unknown primary origin underwent transpedicular biopsy of the affected vertebra. RESULTS: The origins of the primary tumours were lung cancer (n = 6), prostate cancer (n = 5), colorectal cancer (n = 5), kidney cancer (n = 4) and lymphoma (n = 1). All the specimens matched pathological characteristics of their corresponding primary tumours, except in one patient. This 42-year-old man had stage-4 colon cancer, in whom the pathologic findings could not enable differentiation between colon and prostate cancer. CONCLUSION: Transpedicular biopsy of the vertebra is a cost-effective diagnostic tool for evaluating unknown primary tumours.

Percutaneous release of the trigger thumb: is it safe, cheap and effective?

Percutaneous release of the trigger finger and trigger thumb has recently gained popularity. The aim of this study was to determine the clinical results and safety of percutaneous release in trigger thumbs. Twenty-five thumbs of 21 patients were released percutaneously in the polyclinic under local anaesthesia. Steroid injection was performed following the release procedure using the same needle. The thumb function was evaluated by a patient questionnaire, and functional thumb scores (VAS) were calculated in the preoperative and postoperative periods. At the 1 week follow-up, four patients had signs of discomfort and triggering because of incomplete release. These patients underwent open A1 pulley release. Three superficial tendon lacerations were seen during these open procedures. There were no wound complications or signs of digital nerve or artery injury in any of the patients. The preoperative mean VAS was 26.62 (18-36). This decreased to 2.57 (0-5) at the first postoperative month (P<0.001) and to 2.19 (0-3; P<0.001) at the sixth month. When the VAS scores at the first and sixth months were compared, the difference was statistically significant. We concluded that percutaneous release of trigger thumbs is a cheap, safe and effective procedure with a low rate of complications.

Tuberculous osteomyelitis of the lumbosacral region: a spinal epidural abscess with presacral extension.

INTRODUCTION: Tuberculous osteomyelitis in the lumbosacral region is an uncommon occurrence, and its treatment is not well-defined in the literature, particularly when it is associated with abscess formation. We present the outcome of a patient who had an epidural abscess with presacral extension. MATERIALS AND METHODS: A 30-year-old man had microbiologically confirmed tuberculous infection of the lumbosacral vertebrae complicated by extensive abscess formation. After a trial of chemotherapy, the infection proved refractory, and the treatment proceeded with abscess drainage through the anterior route. RESULTS: Approximately 1 year after surgery, the patient was symptom-free and did not show any significant radiologic changes. CONCLUSION: Antituberculous chemotherapy combined with anterior surgery seems to be beneficial in the setting of lumbosacral osteomyelitis complicated by epidural abscess formation with presacral extension.

Seprafilm interposition for preventing adhesion formation after tenolysis. An experimental study on the chicken flexor tendons.

BACKGROUND: Hyaluronic acid and its derivatives have become increasingly popular for preventing adhesions in primary tendon repair. Their use in tenolysis, however, has not been established yet. The purpose of the current study was to evaluate the efficacy of Seprafilm, a combination of carboxymethylcellulose membrane and hyaluronate, in prevention of adhesion formation after tenolysis. MATERIALS AND METHODS: Thirty chickens were initially operated on their right central toes in order to constitute an experimental setting of postoperative flexor tendon adhesion. They were then randomly assigned to 3 groups at 6 weeks. Group 1 received no further procedure, group 2 underwent simple tenolysis with physiologic saline injection, and group 3 had tenolysis with Seprafilm interposition. RESULTS: Group 3 scored a significantly higher average gliding excursion value than the other groups. Histologic examination corroborated the biomechanical data. CONCLUSION: Seprafilm was effective in preventing adhesions after tenolysis.

Comparative effect of intra-articular administration of hyaluronan and/or cortisone with evaluation of malondialdehyde on degenerative osteoarthritis of the rabbit's knee.

Hyaluronan and cortisone have controversial and an important role in the healing of degenerative osteoarthritis. The purpose of the research was to compare individual and combined effects of hyaluronan and cortisone on the healing of degenerative osteoarthritis and to determine the serum malondialdehyde level as a lipid peroxidation marker. A rabbit model was used in which a degenerative osteoarthritis was created in the articular cartilage by resection of anterior cruciate ligament. The rabbits divided into three groups namely were injected with hyaluronan (group A) and cortisone (group B) at days 31, 38 and 45. Cortisone at day 31 and hyaluronan at days 38 and 45 were injected to the third group (group C). We obtained blood samples from each rabbit to determine the malondialdehyde levels at days 1, 30, and 52. At day 52, 21 rabbits were sacrificed. In biopsies obtained from treated and untreated knees articular cartilage degeneration was examined by light microscopy. Histopathologically the healing rate was significantly higher in group C than the other groups. Degeneration decreased 72% in group A, 52% in group B and 88% in group C at day 22. Malondialdehyde levels were 2.056 +/- 0.37 in the control group, 1.94 +/- 0.54 in group A, 1.98 +/- 0.37 in group B and 1.55 +/- 0.41 in goup C. The malondialdehyde levels of group A and B were less than the control group (statistically insignificant, p > 0.05). But, there were statistically significant values between control group and group C (p < 0.05). The results showed that the combination of cortisone and hyaluronan is the most effective in the treatment of cartilage degeneration in the course of the ostearthritis and the malondialdehyde levels are correlated with the severity of degeneration.

Multidisciplinary evaluation of occult spinal dysraphism in 47 children.

OBJECTIVE: To present the clinical (urologic, orthopedic and neurologic) and urodynamic findings of 47 children suffering from occult spinal dysraphism, together with the long-term follow-up results obtained with various treatment modalities. MATERIAL AND METHODS: Between 1997 and 2000 a total of 47 children (27 girls, 20 boys; male:female ratio 1.3) referred to the Urology and/or Pediatrics Departments with symptoms and signs of closed spina bifida were enrolled in the study program. All patients underwent routine assessment of the urinary tract, including detailed anamnesis, physical examination and radiologic evaluation (X-ray, renal bladder ultrasonography and sacral MRI). In addition to video-urodynamic evaluation of the lower urinary tract, all patients were also evaluated by the Orthopedic Department with respect to possible lower extremity deformities. RESULTS: The age range of the children was 2 months to 16 years (mean 6.9 years). At first referral, 23 children were found to have normal urinary and fecal continence after toilet training; among the other presenting symptoms and signs, 34% of patients demonstrated recurrent urinary tract infections and 38.2% had abnormal findings on urinary tract investigations. Evaluation of urodynamic parameters before and after conservative treatment demonstrated an increase in age-related bladder capacity in 34 patients and detrussor instability had been cured in 23/30 patients (p < 0.05). Overall, bladder capacity was found to be normal in 40 children following conservative management (p < 0.05). The conservative approach proved to be effective in 40 children (85.1%), and intravesical instillation therapy with oxybutynine hydrochloride was successful in one of the remaining seven children (14.2%). Bladder augmentation was performed in six children (12.7%) in whom conservative measures were ineffective. CONCLUSIONS: In the light of our findings and the literature data it is obvious that a multidisciplinary approach together with early urologic evaluation to determine the extent of neurologic involvement of the lower urinary tract is essential to ensure a successful treatment outcome and to prevent the occurrence of serious functional and structural complications. Clinical, radiologic and video-urodynamic assessments should be performed to define the neuro-urologic pathophysiology and to provide management guidelines and a baseline for future comparison.