RESUMO
BACKGROUND: Sacral nerve stimulation is a therapeutic option with demonstrated efficacy for conditions presenting with perineal pain caused by different etiologies. We aimed to assess whether a sacral electrode (InterStim®, Medtronic, Minneapolis, MN, USA) inserted through the caudal pathway is able to offer an acceptable level of sacral stimulation and rate of catheter migration. METHODS: We present 12 patients with pelvic pain who received sacral neuromodulation via the sacral hiatus with the InterStim electrode. We evaluated patient satisfaction as well as migration and removal of the electrode, if necessary. RESULTS: Our experience included 12 patients, 10 women and two men, with a mean age of 60 years. In eight of the 12 patients, the initial therapy was effective, and the final system implantation was performed. During subsequent follow-up, patient satisfaction was good. To date, there have been no cases of electrode displacement or migration. CONCLUSIONS: The caudal insertion of the InterStim electrode, with its own fixation system, and initially designed for transsacral insertion, appears in our experience to be a satisfactory option which can minimize electrode displacements, achieving similar results in therapeutic efficacy and causing no difficulties in removal.
RESUMO
Abstract Amyotrophic lateral sclerosis is characterized by the progressive degeneration of motor neurons, causing a constellation of symptoms that include muscle weakness, atrophy, fasciculations, spasticity, and hyperreflexia. Currently, Rulizol is the only treatment that has been shown to delay its progression, though to a very small extent. Disease prognosis is grim, with death caused mainly by respiratory failure secondary to muscle weakness, making anesthetic management of these patients a true challenge. The use of muscle relaxants must be avoided as much as possible because of the high risk of ventilatory depression, considering that these patients have an abnormal unpredictable response as a result of heightened sensitivity related to the lower number of acetylcholine receptors. If muscle relaxants are required during the surgery, rocuronium, among nondepolarizing muscle relaxants, is the drug of choice because of its short half-life, while depolarizing relaxants such as succinylcholine are contraindicated because of the risk of lethal hyperkalemia. In terms of intraoperative hypnotics and analgesics, propofol and remifentanil are ideal because of their short half-life. Regarding neuroaxial anesthesia, despite widespread reluctancy to use it, its benefits and rather uncommon adverse effects lead many anesthetists to consider it as an important alternative when it comes to deciding between general or neuroaxial anesthesia, because it reduces airway manipulation significantly, thus reducing respiratory complications as described in this clinical case.
Resumen La esclerosis lateral amiotrófica se caracteriza por la degeneración progresiva de las neuronas motoras provocando una constelación de síntomas que incluyen debilidad muscular, atrofia, fasciculaciones, espasticidad e hiperreflexia. Actualmente, el unico tratamiento que ha demostrado retrasar mínimamente su progresión ha sido el Rulizol. Su pronóstico es infausto, falleciendo mayoritariamente por insuficiencia respiratoria secundaria a la debilidad de su musculatura, siendo el manejo anestésico de estos pacientes, un importante desafío. El uso de relajantes neuromusculares deberá evitarse en la medida de lo posible por el riesgo elevado de depresión ventilatoria, ya que estos pacientes tienen una respuesta anormal e impredecible a ellos al presentar una sensibilidad aumentada por el menor número de receptores de acetilcolina; Si la cirugía requiere de ellos, es de elección dentro de los relajantes neuromusculares no despolarizantes, el rocuronio por su vida media corta, contraindicándose el uso de los despolarizantes como la succinilcolina, por el riesgo de hiperkaliemia letal. En cuanto a los hipnóticos y analgésicos que deberemos de usar intraoperatoriamente, el propofol y remifentanilo serían los más ideales por su vida media corta. En cuanto a la anestesia neuroaxial, a pesar de la reticencia extendida a su uso, su beneficio y sus no tan frecuentes efectos adversos, hacen a muchos anestesistas, considerarla como una alternativa de peso a la hora de decidir entre anestesia general o neuroaxial, pues reduce considerablemente la manipulación de la vía aérea, disminuyendo por tanto complicaciones respiratorias posteriores, como referimos en el caso clínico que describiremos a continuación.