[Pulmonary hypertension and femoral neck fracture: interest of continuous spinal anaesthesia]. / Hypertension pulmonaire et fracture du col fémoral : intérêt de la rachianesthésie continue.

Anaesthetic management of patients with pulmonary hypertension is challenging and alternatives to general anaesthesia are encouraged. We report anaesthetic management of two patients with pulmonary hypertension admitted for femoral neck fracture. In order to reduce the risk of right-sided heart failure and systemic hypotension, it was decided to operate the patients under continuous spinal anaesthesia. Anaesthesia was induced with excellent hemodynamic tolerance. Quality and extension of the block was correct and allowed surgery. No postoperative complication was observed. These cases suggest that continuous spinal anaesthesia may be considered for the management of patients with pulmonary hypertension undergoing femoral neck fracture surgery.

Neuropathic complications after 157 procedures of continuous popliteal nerve block for hallux valgus surgery. A retrospective study.

BACKGROUND: Continuous peripheral nerve block (CPNB), in particular at the popliteal fossa, is widely used in orthopedic surgery, allowing good postoperative analgesia. Possible neuropathic complications, however, remain poorly known. OBJECTIVE: To review the characteristics of peripheral neuropathy (PN) after sciatic CPNB at the popliteal fossa, estimating prevalence, severity, evolution and possible risk factors, especially those relating to the procedure. METHODS: Retrospective study of PN associated with popliteal fossa CPNB for hallux valgus surgery, between November 1st, 2005 and November 1st, 2009. All procedures were analyzed (type of anesthesia, approach, nerve location technique, number of procedures by operator) with, for each case of PN, analysis of clinical and electromyographic data. RESULTS: One hundred and fifty seven sciatic CPNBs were performed (92% women; mean age, 55 years). The approach was lateral (n=62), posterior (n=74) or unknown (n=21). Ultrasound guidance was combined to neurostimulation for 69 patients (44%). Three women (prevalence=1.91%), aged 19, 24 and 65 years respectively, developed associated common superficial peroneal and sural nerve injury (2), axonal on electromyography, with motor (n=1) and/or sensory (n=3) residual dysfunction. DISCUSSION: The higher prevalence found in the present study than in the literature (0 to 0.5%) raises questions of methodological bias or technical problems. The common peroneal and sural nerves seem to be exposed, unlike the tibial. Several mechanisms can be suggested: anesthetic neurotoxicity, direct mechanical lesion, or tourniquet-related ischemia and conduction block. Further studies are necessary to determine the ideal anesthetic procedure. CONCLUSION: Patients should be informed of the potential risk, however rare, even during mild surgery. The best possible technique should be implemented, with reinforced surveillance.

Gunshot injury without direct injury to the cord may lead to complete paraplegia.

Paraplegia following gunshot injury without direct injury to the cord is extremely rare. We describe the case of a 31-year-old woman who was admitted to our trauma resuscitation unit for a penetrating gunshot wound to the abdomen with hemorrhagic shock and paraplegia. Computed tomography (CT) scan of the abdomen showed severe hepatic and pulmonary injuries, with the trajectory of the missile away from the spinal canal. Magnetic resonance imaging (MRI) confirmed a spine contusion from T8 to T10. After 24 months, no significant neurologic improvement occurred. Physicians managing severe trauma should be aware of the possibility to observe severe neurologic deficit following gunshot wounds even without violation of the spinal canal. These injuries might be in relation to the kinetic energy emission to the surrounding tissue by the missile.