Superselective methohexital challenge prior to intracranial endovascular embolization.

Pharmacologic provocative testing (PT) and intraoperative neurophysiologic monitoring (IONM) both mitigate and predict risks associated with endovascular embolization procedures. We present a series of patients undergoing endovascular intracranial embolization predominantly for AVMs both under general anesthesia and awake with the use of IONM. We reviewed our database to identify all patients undergoing endovascular procedures between January 1, 2014 and January 1, 2016. Awake patients were tested with SSEP, EEG and real time neurologic examination while TcMEPs were performed in all anesthetized patients. BAEPs were performed in anesthetized patients if indicated. Methohexital was administered as an injection at a dose of 5 mg or 10 mg and repeat testing was performed if needed.Sixty-three endovascular procedures that met criteria were performed in 32 patients. 54 procedures in 28 patients were performed under general anesthesia, 9 procedures in 4 patients were performed in wakefulness. PT was negative in 61 procedures and subsequently completed embolizations without neurological sequelae. In two cases, the testing was positive and the procedure was terminated without embolization in one patient. The other patient underwent embolization at an alternative site without repeat PT. There were no new postoperative neurologic deficits after any of these procedures. Specificity of PT was 100% as none of the patients with a negative provocative test developed a new postoperative neurologic deficit after embolization. To our knowledge, this is the first review of PT with the use of neurophysiologic IONM techniques under general anesthesia. These data suggest a high specificity comparable to awake testing.

Positive pharmacologic provocative testing with methohexital during cerebral arteriovenous malformation embolization.

A middle-aged patient underwent staged endovascular embolization of a Spetzler-Martin grade V right parietal arteriovenous malformation(AVM).In the fifth endovascular embolization, after methohexital 10 mg injection into a right posterior choroidal artery feeding the AVM nidus, there was an immediate change in the electroencephalogram (EEG) with simultaneous loss of motor evoked potentials (MEPs) in the bilateral upper and lower extremities and a delayed change in somatosensory evoked potential responses (SSEPs). No embolization was made and procedure was terminated. This case demonstrates the utility of intraoperative neurophysiologic monitoring (IONM) with pharmacologic provocative testing in predicting and mitigating the risks prior to the proposed embolization.

The spinal cord: a review of functional neuroanatomy.

The spinal cord controls the voluntary muscles of the trunk and limbs and receives sensory input from these areas. It extends from the medulla oblongata to the lower border of the first lumbar vertebra. A basic knowledge of spinal cord anatomy is essential for interpretation of clinical signs and symptoms and for understanding of pathologic processes involving the spinal cord. In this article, anatomic structures are correlated with relevant clinical signs and symptoms and a step-wise approach to spinal cord diagnosis is outlined.

HIV, rods, and the muscles--a discussion about HIV-associated nemaline rod myopathy.

This case reports a 21-year-old, homosexual African-American male who presented to our facility with a two-week history of progressive proximal muscle weakness. Quadriceps muscle biopsy showed a diagnosis of Nemaline Rod Myopathy, the presenting disease of his HIV infection. A review of the literature shows 13 prior case reports of similar disease process, often as the presenting symptom of the HIV disease. Anecdotal reports of effective treatment regimens include steroids and intravenous immune globulin; our patient had a profound response to high-dose steroids. This case report discusses this rare presentation of HIV in hopes to increase awareness amongst clinicians as the incidence and prevalence of HIV increases.

Total hip arthroplasty after prior surgical treatment of hip fracture is it always challenging?

Salvage total hip arthroplasty (THA) presents a viable solution for failed open reduction internal fixation. This study compares salvage THA in patients with prior femoral neck fractures vs patients with prior intertrochanteric fractures. One hundred fifty-four hips in 152 patients underwent conversion from open reduction internal fixation to THA. Eighty-three patients had previous femoral neck fractures, and 69 patients (71 hips) had prior intertrochanteric fractures. Salvage THA in patients with prior intertrochanteric fractures presented a more technically demanding procedure with longer operative times and larger amounts of blood loss. Although conversion THA presents a technically challenging procedure, it is safe and yields relatively few orthopedic complications.

Total knee arthroplasty in patients with fibromyalgia.

Fibromyalgia has recently emerged as a diagnosis of exclusion for patients with chronic, widespread pain. We investigated the influence of this comorbidity on outcomes of total knee arthroplasty (TKA). We matched 59 patients (90 knees) who underwent primary TKA with a diagnosis of fibromyalgia to control patients who underwent the same surgery. Postoperative satisfaction and functional outcomes were assessed using a Likert scale and the SF-36 survey, respectively. At 3.4 years' follow-up, fibromyalgia patients were less satisfied with TKA than control patients, and had lower preoperative and postoperative SF-36 scores. They demonstrated improvement comparable to that of controls following TKA, however. Fibromyalgia patients appear to show improvement comparable to that of controls following surgery. This syndrome should not be considered a contraindication for surgery.

Total Joint Arthroplasty in Patients with Obstructive Sleep Apnea: Strategies for Reduction of Perioperative Complications.

Obstructive sleep apnea (OSA) has been associated with increased risk for medical complications following total joint arthroplasty. Our institution employs postoperative precautions for OSA patients in an effort to minimize the impact of postoperative complications in this group. We performed this study to assess the effect of careful monitoring on postoperative complication rates in OSA patients. We identified patients with a clinically suspected or objective diagnosis of OSA who received total joint arthroplasty between January 1998 and January 2008. 1016 cases in 792 OSA patients were matched to 1016 cases in 993 control patients to compare complication rates. There were no differences between OSA and control patients in cardiovascular and respiratory complications following TJA. Patients with OSA experienced increased rates of postoperative acute renal failure when compared with controls (p = 0.02) and experienced mild desaturations (Hb O2 < 92%) (p = 0.002), but not severe desaturations (Hb O2 < 88%) (p = 0.2). We conclude that our postoperative monitoring protocols are successful in reducing postoperative complications most commonly associated with OSA. We were interested to note the increased risk for OSA patients to develop postoperative acute renal failure and believe that future study is warranted to explore the link between OSA and renal failure.

Perioperative stroke after total joint arthroplasty: prevalence, predictors, and outcome.

BACKGROUND: The risk of perioperative stroke following cardiac and carotid artery surgery is well documented. There is an apparent lack of recognition and appreciation of this complication after total joint arthroplasty. The present study was designed to determine the prevalence of, and outcome after, perioperative stroke following total joint arthroplasty. In addition, risk factors for the development of this complication were evaluated in an attempt to identify a strategy that could minimize the prevalence of this complication. METHODS: We performed an observational study of 18,745 consecutive patients undergoing primary or revision total hip or total knee arthroplasty from 2000 to 2007 at our institution. The institutional perioperative stroke rate was 0.2% (thirty-six of 18,745). The thirty-six patients who had a stroke included seventeen men and nineteen women with a mean age of 68.2 years (range, forty-five to eighty-seven years). The average duration of follow-up for all patients and controls in the present study was sixty-two months (range, zero to 124.9 months). In a predictive model, different patient-related and surgery-related factors that could predispose patients to this complication and/or affect outcome were evaluated. RESULTS: The first-year mortality among stroke patients was 25% (nine of thirty-six), and four of these nine patients died in the hospital following total joint arthroplasty. Of three patients who received emergency intra-arterial thrombolysis, two had complete neurologic recovery and one died in the hospital. The final regression model showed that a history of noncoronary heart disease, urgent (versus elective) surgery, general (versus regional) anesthesia, and an intraoperative arrhythmia or other alterations in the heart rate during surgery are significant predictors of perioperative stroke. CONCLUSIONS: Perioperative stroke is a rare but potentially devastating complication of total joint arthroplasty, with a high rate of morbidity and mortality. Vigilant attention to prevent, detect, and treat this complication in a timely manner may alter the course of the disease.

Is deep vein thrombosis a good proxy for pulmonary embolus?

It is assumed that prevention of deep venous thrombosis (DVT) is likely to lead to a reduction in the incidence of pulmonary embolus (PE). This study examines the association between symptomatic DVT and PE in patients undergoing orthopedic procedures. We reviewed medical records of 1495 patients who underwent evaluation for DVT or PE within 90 days of an index orthopedic procedure at our institution between 2004 and 2008. Only 27 cases were positive for both DVT and PE (1.7% of the total cohort, 10.8% of cases scanned for both DVT and PE). Tests of association, performed across the entire cohort and within specific subsets of patients, did not demonstrate that patients were more likely to have both DVT and PE than to have either DVT or PE. The high association between DVT and PE that is assumed to exist does not seem to hold true for orthopedic surgery patients.

Arthroscopy for labral tears in patients with developmental dysplasia of the hip: a cautionary note.

Patients with developmental dysplasia of the hip may present with acetabular rim overloading, labral hypertrophy, and tear. Our hypothesis was that isolated arthroscopic treatment of labral tear is likely to fail in most patients. We investigated 34 patients who underwent at least one arthroscopy of the hip for labral tear. Developmental hip dysplasia or other morphologic abnormalities of the hip were confirmed in all patients. Arthroscopy failed to relieve pain in 24 patients. We observed accelerated arthritis in 14 patients and migration of the femoral head in 13 patients. Sixteen patients underwent further surgery (further surgeries included periacetabular osteotomy [6 patients], femoroacetabular osteoplasty [7 patients], and total hip arthroplasty [3 patients]). At the latest follow-up, all patients but one were pain-free. Patients with evidence of abnormal hip morphologies may not benefit from hip arthroscopy and isolated treatment of the labrum; in fact, the latter may accelerate the process of arthritis in some patients.

Benign splenic epithelial cyst accompanied by elevated Ca 19-9 level: a case report.

We report the case of a 30-year-old woman with a benign epidermoid splenic cyst and a high CA 19-9 serum level (268 U/mL). The patient underwent resection of the cyst and splenectomy. After removal of the cyst, the serum CA 19-9 level decreased to a normal level within 6 weeks. True non-parasitic splenic cysts are rare. Approximately 30 cases of benign true splenic cysts with a high CA 19-9 serum level have been published.