Single Entry Posterior Parasagittal Approach Radiofrequency Neurotomy of Cervical Medial Branch: A Feasible Alternative to Conventional Approaches in the Treatment of Cervical Facet Pain.

BACKGROUND: Cervical facet joint pain is an important cause of chronic neck pain. The recommended treatment for this condition is radiofrequency (RF) neurotomy of the medial branch of dorsal rami. There have been attempts to find safe and effective ways to perform this procedure. The objective of this study is to describe the single entry posterior parasagittal approach and to evaluate the efficacy and safety of this approach compared to the conventional posterolateral approach of RF neurotomy of cervical medial branch. METHODS: The record of all patients with cervical facet pain who were treated with RF neurotomy medial branch of dorsal rami between January 2016 and December 2019 were reviewed retrospectively. Comparisons were made between patients who underwent RF neurotomy with multiple skin entry posterolateral approach and those who underwent RF neurotomy with single entry posterior parasagittal approach. The primary outcome was measured as the mean changes in numerical rating scale (NRS), and the secondary outcomes were duration and complications related to both approaches. RESULTS: Thirty-one patients who underwent RF neurotomy via posterolateral approach were compared with 40 patients who underwent the procedure via posterior parasagittal approach. Both approaches showed a significant decrease in the NRS from baseline values. However, the differences in the NRS lowering effect at 3 and 12 months between these 2 approaches were not statistically significant. The duration of the procedure was significantly shorter with posterior parasagittal approach (44.13 ± 4.72 minutes vs 54.68 ± 7.39 minutes; P < 0.001). There were no serious complications encountered in both approaches. CONCLUSIONS: With comparable efficacy and safety profile between the posterior parasagittal and the conventional posterolateral approaches, the former single skin entry approach offers the added advantage of being less time-consuming. Further randomized prospective studies are necessary to validate these findings.

Acute chest pain and breathlessness in a haemodialysis patient.

Acute chest pain and breathlessness in a haemodialysis patient is a common but challenging clinical scenario, can you diagnose and manage it? http://bit.ly/2Qf1mXr.

Causes and predictors of mortality in biopsy-proven lupus nephritis: the Sarawak experience.

BACKGROUND: Lupus nephritis (LN) is a serious manifestation of systemic lupus erythematosus that can be fatal if left untreated. The causes and prognostic predictors of mortality in LN have been well studied in developed countries but evidence is lacking for developing countries. The objective of this study was to investigate the causes and predictors of mortality in a cohort of Malaysian patients with biopsy-proven LN. METHODS: We retrospectively studied all patients with biopsy-proven LN treated in Sarawak General Hospital during the period of 2000-15. Demographic data, clinical features and outcomes were collected. Cox regression analysis was carried out to determine the independent predictors of mortality. RESULTS: There was a total of 250 patients with 259 renal biopsies available for our analysis. Our patients were of multi-ethnic origins with a female predominance (90%). Their mean ± standard deviation age was 37.7 ± 12.8 years. The patients had a mean disease duration of 135.6 ± 81.9 months. Nephrotic syndrome was the most common presentation (29.6%) and acute renal failure was evident at initial presentation in 16% of patients. Class IV LN was the predominant biopsy class within the cohort (66.8%). The majority of patients achieved remission (81.2%) and had normal renal function (83.9%) at the last follow-up. The 5-, 10-, 15- and 20-year survival rates for our cohort were 93%, 88%, 82% and 77%, respectively. There were 37 deaths (14.8%), of which the main causes were: infection and flare (52.7%), infection alone (25.0%) and other causes (22.3%). Independent predictors of mortality in our cohort of LN patients were: the presence of acute kidney injury at presentation [hazard ratio (HR) 3.41; confidence interval (CI) 1.50-7.76], failure to achieve remission at 1-year post-induction therapy (HR 2.99; CI 1.35-6.65) and non-compliance with treatment (HR 1.89; CI 1.22-2.96). Age, ethnicity, class of LN and type of immunosuppressant used were not predictive of mortality. CONCLUSIONS: Survival and renal outcomes in our LN cohort were comparable to most LN studies reported worldwide. Both flare and infection remained the main causes of death. The presence of acute renal failure at presentation, failure to achieve remission at 1 year post-treatment and non-compliance with treatment were independent prognostic predictors of mortality in LN.

Levobupivacaine vs racemic bupivacaine in spinal anesthesia for sequential bilateral total knee arthroplasty: a retrospective cohort study.

STUDY OBJECTIVES: To compare the anesthetic potency and safety of spinal anesthesia with higher dosages of levobupivacaine and bupivacaine in patients for bilateral sequential for total knee arthroplasty (TKA). DESIGN: Retrospective cohort study. SETTING: Operation theater with postoperative inpatient follow-up. PATIENTS: The medical records of 315 patients who underwent sequential bilateral TKA were reviewed. INTERVENTIONS: Patients who received intrathecal levobupicavaine 0.5% were compared with patients who received hyperbaric bupivacaine 0.5% with fentanyl 25 µg for spinal anesthesia. MEASUREMENTS: The primary outcome was the use of rescue analgesia (systemic opioids, conversion to general anesthesia) during surgery for both groups. Secondary outcomes included adverse effects of local anesthetics (hypotension and bradycardia) during surgery and morbidity related to spinal anesthesia (postoperative nausea, vomiting, and bleeding) during hospital stay. MAIN RESULTS: One hundred fifty patients who received intrathecal levobupivacaine 0.5% (group L) were compared with 90 patients given hyperbaric bupivacaine 0.5% with fentanyl 25 µg (group B). The mean volume of levobupivacaine administered was 5.8 mL (range, 5.0-6.0 mL), and that of bupivacaine was 3.8 mL (range, 3.5-4.0 mL). Both groups achieved similar maximal sensory level of block (T6). The time to maximal height of sensory block was significantly shorter in group B than group L, 18.2 ± 4.5 vs 23.9 ± 3.8 minutes (P< .001). The time to motor block of Bromage 3 was also shorter in group B (8.7 ± 4.1 minutes) than group L (16.0 ± 4.5 minutes) (P< .001). Patients in group B required more anesthetic supplement than group L (P< .001). Hypotension and postoperative bleeding were significantly less common in group L than group B. CONCLUSION: Levobupivacaine at a higher dosage provided longer duration of spinal anesthesia with better safety profile in sequential bilateral TKA.

Analgesic efficacy of transversus abdominis plane block in neonates and early infants for colostomy and reversal of colostomy.

The application of ultrasound-guided transversus abdominis plane (TAP) block in paediatric population is gaining popularity among anaesthetists. We present a case series of ultrasound-guided TAP block in ten neonate and infants undergoing colostomy and reversal of stoma. Classical TAP as described by Hebbard was carried out and a maximum dosage of 1ml/kg of 0.25% levobupivacaine was injected. Pain score was assessed using Neonatal Infant Pain Scale for 24 hours. In all patients, the block was successful with minimal hemodynamic changes intraoperatively and no additional systemic analgesia was needed intraoperative and immediate postoperatively. Ultrasound-guided TAP block has an important role in providing safe and effective analgesia for colostomy creation and reversal of stoma surgeries in paediatric population.

Percutaneous t2 and t3 radiofrequency sympathectomy for complex regional pain syndrome secondary to brachial plexus injury: a case series.

Complex regional pain syndrome secondary to brachial plexus injury is often severe, debilitating and difficult to manage. Percuteneous radiofrequency sympathectomy is a relatively new technique, which has shown promising results in various chronic pain disorders. We present four consecutive patients with complex regional pain syndrome secondary to brachial plexus injury for more than 6 months duration, who had undergone percutaneous T2 and T3 radiofrequency sympathectomy after a diagnostic block. All four patients experienced minimal pain relief with conservative treatment and stellate ganglion blockade. An acceptable 6 month pain relief was achieved in all 4 patients where pain score remained less than 50% than that of initial score and all oral analgesics were able to be tapered down. There were no complications attributed to this procedure were reported. From this case series, percutaneous T2 and T3 radiofrequency sympathectomy might play a significant role in multi-modal approach of CRPS management.

A comparison of analgesic efficacy between oblique subcostal transversus abdominis plane block and intravenous morphine for laparascopic cholecystectomy. A prospective randomized controlled trial.

BACKGROUND: The ultrasound-guided oblique subcostal transversus abdominis plane (OSTAP) block provides a wider area of sensory block to the anterior abdominal wall than the classical posterior approach. We compared the intra-operative analgesic efficacy of OSTAP block with conventional intravenous (IV) morphine during laparoscopic cholecystectomy. METHODS: Forty adult patients undergoing laparoscopic cholecystectomy under standard general anesthesia, were randomly assigned for either bilateral OSTAP block using 1.5 mg/kg ropivacaine on each side (n = 20) or IV morphine 0.1 mg/kg (n = 20). The intra-operative pulse rate, systolic and diastolic blood pressure and mean arterial blood pressure were monitored every five minutes. Repetitive boluses of IV fentanyl 0.5 µg/kg were given as rescue analgesia when any of the above-mentioned parameters rose more than 15% from the baseline values. Time to extubation was documented. Additional boluses of IV morphine 0.05 mg/kg were administered in the recovery room if the recorded visual analogue score (VAS) was more than 4. Nausea and vomiting score, as well as sedation score were recorded. RESULTS: The morphine group required more rescue fentanyl as compared to the OSTAP block group but the difference was not significant statistically. Time to extubation was significantly shorter in the OSTAP block group (mean [SD] 10.4 [2.60] vs 12.4 [2.54] min; P = 0.021). Both methods provided excellent analgesia and did not differ in postoperative morphine requirements. No between-group differences in sedation score and incidence of nausea and vomiting were demonstrated. CONCLUSIONS: Ultrasound-guided OSTAP block has an important role as part of balanced anesthesia. It is as efficacious as IV morphine in providing effective analgesia during laparoscopic cholecystectomy.

Alcohol neurolysis of lateral femoral cutaneous nerve for recurrent meralgia paresthetica.

Meralgia paresthetica is an entrapment mononeuropathy of lateral femoral cutaneous nerve, which results in localized area of paresthesia and numbness on the anterolateral aspect of the thigh. We describe the use of alcohol neurolysis of lateral femoral cutaneous nerve in a 74-year-old female who presented with paresthesia over antero-lateral aspect of her left thigh, which was consistent with meralgia paresthetica. Diagnostic block with local anaesthetic confirmed the diagnosis but only archieved temporary pain relief. Alcohol neurolysis was then offered and patient responded well with no complication. The patient experienced prolonged pain relief at 6-month follow-up, with return of ability to ambulate and perform daily activity. Alcohol neurolysis of lateral femoral cutaneous nerve is safe, effective and able to provide sustained pain relief for recurrent meralgia paresthetica.