[Scapular fractures]. / Scapulafrakturen.

Scapular fractures are rare injuries that require different treatment strategies. Nondisplaced fractures and the majority of scapular body fractures can be treated conservatively, while surgical treatment should be considered for displaced fractures involving the glenoid. Displaced glenoid fractures of appropriate size and intra-articular step formation should be treated surgically. Different classification systems for scapular fractures can support the treatment decision. Postoperative and posttraumatic management should include early mobilization to achieve a good functional outcome. Clear recommendations and treatment algorithms at the evidence level are not available and long-term outcomes of scapular fractures are the subject of further investigation. The results published so far show good to excellent results for surgical and conservative treatment, depending on the type of fracture. Individual patient factors should be considered when planning treatment.

[Fracture sequelae type 2 of the proximal humerus-clinical results after arthroplasty]. / Frakturfolge Typ 2 des proximalen Humerus ­ klinische Ergebnisse nach endoprothetischer Therapie.

Locked dislocations of the glenohumeral joint are rare but often painful and are associated with limited range of motion in the shoulder. In patients of advanced age, arthroplasty is increasingly indicated as a surgical treatment option. Preoperatively, the direction of dislocation, the presence and extent of a glenoid defect, and the soft tissue situation (rotator cuff status, joint capsule) should be analyzed in a differentiated manner. Based on the above factors, we recommend the subclassification of type 2 according to Boileau: posterior locked dislocation (2a), anterior locked dislocation without glenoid defect (2b), and anterior locked dislocation with glenoid defect (2c). In the case of dorsally locked dislocation, a good clinical result can be achieved by using an anatomical endoprosthesis. For ventrally locked dislocations, we recommend using an inverse total endoprosthesis with, if necessary, bony glenoid reconstruction and transfer of the pectoralis major muscle.Level of evidence: IV.

[Fracture analysis, indication for endoprosthesis and implant selection in proximal humeral fractures]. / Frakturanalyse, Indikation zur Endoprothese und Implantatwahl bei proximaler Humerusfraktur.

Proximal humeral fractures (PHF) are the third most common fracture in humans and the incidence is increasing. There are basically three treatment strategies: conservative, joint-preserving reconstructive or joint-replacing procedures. In addition to fracture morphology, patient-specific and surgeon-specific factors are particularly important when deciding on treatment. The experience and training of the surgeon also play a decisive role. In the case of joint-preserving treatment, the risk of osteosynthesis failure and of sequelae of the fracture must always be assessed. If conservative or reconstructive treatment methods are not promising, the joint-replacing procedure is the treatment of choice. The anatomical fracture prosthesis is only indicated, if at all, for young patients with a destroyed humeral head with a preserved rotator cuff and large fragments of the tuberosities. In advanced age, the implantation of a reverse endoprosthesis is increasingly used for dislocated, multifragmentary PHF. In both procedures, the anatomical healing of the tuberosities has a significant impact on the functional outcome.

[Latissimus dorsi transfer with a modified single-incision Herzberg technique and description of its arthroscopic advancement]. / Latissimus-dorsi-Transfer in modifizierter Single-incision-Technik nach Herzberg und Beschreibung einer arthroskopischen Erweiterung.

OBJECTIVE: Latissimus dorsi transfer aims to reduce pain and improve function for irreparable tears of the posterosuperior rotator cuff by restoring the transversal force couple to improve external rotation and delaying superior migration of the humeral head. INDICATIONS: Surgery is advocated in patients with unbearable shoulder pain and limited external rotation caused by an irreparable posterosuperior rotator cuff tear. Usually, a latissimus transfer is recommended in the presence of superior migration of the humeral head, higher grade fatty infiltration of the rotator cuff and a restriction of range of motion and strength for abduction and external rotation. Advantages of the arthroscopically assisted technique are the missing need of detaching the deltoid from its origin, smaller incisions and therapy of concomitant intraarticular lesions. CONTRAINDICATIONS: Little pain and sufficient shoulder function in massive posterosuperior rotator cuff tears do not necessitate latissimus transfer. In the presence of subscapularis tears, osteoarthritis and deltoid dysfunction as well as shoulder stiffness tendon transfer are associated with inferior clinical outcomes. SURGICAL TECHNIQUE: Surgery is performed in prone position. The incision is made about 5 cm caudal of the posterolateral corner of the acromion and extends over 6 cm at the inferior border of the deltoid muscle. After exploration and protection of the axillary and radial nerve the latissimus tendon is peeled off of the humerus. The medial part of the latissimus is then mobilized to gain length for the later transfer. Afterwards the footprint of the infraspinatus is visualized and debrided. Two or three suture anchors are placed into the posterosuperior aspect of the greater tuberosity. The sutures are stitched through the tendon in a horizontal mattress stitch configuration and the tendon tied onto the bone. In arthroscopic advancement, the patient is placed in an upright beach-chair position with the arm attached to an arm holder. After debridement of the supraspinatus and infraspinatus footprint, arthroscopic preparation at the anterior border of the subscapularis tendon is performed. The latissimus tendon is visualized and detached with electrocautery. Afterwards the interval between posterior rotator cuff and deltoid muscle is prepared to allow the transfer of the latissimus tendon to the posterosuperior footprint. This marks the transition to the open approach, in which the arm is placed in a flexed and internally rotated position. POSTOPERATIVE MANAGEMENT: Immobilization in a shoulder sling for 3 weeks. Early passive range of motion (ROM: flexion 30°, internal rotation 60°, abduction 0°, external rotation 0°) was immediately allowed. After 3 weeks, passive ROM was increased to 90° of flexion, 60° of abduction, whereas external rotation was still restricted. After 7 weeks, free passive ROM and after 8 weeks active ROM (assisted) were allowed. RESULTS: In all, 67 patients (mean age 63 years) were examined 54 months (±â€¯28) after open transfer of the latissimus dorsi tendon. Constant score improved from 24 (±â€¯6) points to 68 (±â€¯17) points. Active flexion increased from 83° (±â€¯47°) to 144° (±â€¯35°), abduction from 69° (±â€¯33°) to 134° (±â€¯42°) and external rotation from 24° (±â€¯18°) to 35° (±â€¯21°). The VAS score decreased from 6.3 (±â€¯1.1) to 1.8 (±â€¯2). However, osteoarthritis worsened over time and the Hamada-Fukuda stage increased from 1.4 to 2.1 and the acromihumeral distance decreased from 7.9 (±â€¯2.6) to 5.1 (±â€¯2.2) at final follow-up.

Relative effectiveness of insects versus hummingbirds as pollinators of Rubiaceae plants across elevation in Dominica, Caribbean.

Most angiosperms rely on animal pollination for reproduction, but the dependence on specific pollinator groups varies greatly between species and localities. Notably, such dependence may be influenced by both floral traits and environmental conditions. Despite its importance, their joint contribution has rarely been studied at the assemblage level. At two elevations on the Caribbean island of Dominica, we measured the floral traits and the relative contributions of insects versus hummingbirds as pollinators of plants in the Rubiaceae family. Pollinator importance was measured as visitation rate (VR) and single visit pollen deposition (SVD), which were combined to assess overall pollinator effectiveness (PE). In the wet and cool Dominican highland, we found that hummingbirds were relatively more frequent and effective pollinators than insects, whereas insects and hummingbirds were equally frequent and effective pollinators at the warmer and less rainy midelevation. Furthermore, floral traits correlated independently of environment with the relative importance of pollinators, hummingbirds being more important in plant species having flowers with long and wide corollas producing higher volumes of dilute nectar. Our findings show that both environmental conditions and floral traits influence whether insects or hummingbirds are the most important pollinators of plants in the Rubiaceae family, highlighting the complexity of plant-pollinator systems.

[Arthroscopic fracture treatment of the shoulder joint]. / Arthroskopische Frakturversorgung des Schultergelenks.

In recent years, the understanding of shoulder fractures has changed due to the progress of arthroscopy. In addition to the cosmetic result, the access morbidity, particularly the integrity of the subscapularis muscle in glenoid and scapular fractures, must be mentioned as an advantage of a minimally invasive approach. Furthermore, necessary secondary interventions, e. g. hook plate removal, can be prevented or minimized by modern implants and arthroscopic techniques.However, the available data and publications are almost exclusively limited to technical notes or small case series, so statements about faster recreation or potential reduction of infection risk cannot be made. Whether addressing concomitant injuries has an effect on the clinical and functional outcome is also unclear at the present time.

Are there any prognostic prediction parameters (PPPs) in the treatment of the massive rotator cuff tear with latissimus dorsi transfer? Latissimus dorsi transfer in massive rotator cuff tears.

PURPOSE OF THE STUDY: Especially in such complex salvage procedures as latissimus dorsi transfer for irreparable rotator cuff tears there is a need for valid prognostic prediction parameters. Parameters such as osteoarthritis, acromiohumeral distance, subscapularis, or teres minor insufficiency are controversial. The aim of this study is to present our data and to evaluate the literature regarding such parameters. METHODS: Fifty-seven patients with a follow-up of 3 years (range, 18-72 months, n = 57) were selected for this study. Average age of patients at the time of surgery was 64.9 years. Patients were evaluated using the age and gender adjusted scoring system according to Constant and Murley score (CS). Standard radiography was attempted containing a true-ap, outlet, and axillary view. The acromio-humeral distance was measured in the true ap view. The grade of glenohumeral osteoarthritis and cuff tear arthropathy was detected using the classification of Hamada et al. Differences in CS were compared for each of the PPP. RESULTS: Mean Constant score increased significantly (p < 0.0001) 3 years postoperatively from initially 22.7 points to 66.0 points (adjusted CS 80.3%). We found a major difference in the Constant score in patients with or without previous surgery (80.4% vs, 65.2%). CONCLUSION: Latissimus dorsi transfer is an excellent option in the treatment of irreparable postero-superior tears of the rotator cuff in well-selected patients. The literature remains ambiguous with regard to valid prognostic predictive parameters for complex salvage procedures, owing to the consistent use of small study samples. Thus, there is an overwhelming need for a multicenter study.

[Sport injuries and overuse damage of the elbow]. / Sportverletzungen und Überlastungsschäden des Ellenbogengelenks.

Sports injuries of the elbow joint can be acute or can arise due to chronic overuse. Such overstress syndromes are common in overhead, throwing and racket sports activities. The present article introduces diagnostic algorithms developed from knowledge gained through motion analysis, clinical examination and further imaging. The diagnosis of the overtaxing syndromes mainly depends on these findings. Basically most of the disorders in the elbow joint can be treated conservatively. If this is not the case or if the conservative treatment does not succeed, arthroscopic techniques, ligament reconstruction or nerve decompression are the major alternatives. The prognosis for regaining elbow function and returning to the previous level of performance is generally good. The resulting therapy recommendations are summarised on the basis of the current highest grades of evidence.

[Is the patient age a negative predictive factor in the reconstruction of SLAP lesions?]. / Ist das Patientenalter ein negativer Vorhersageparameter bei der Rekonstruktion der SLAP-Läsion?

BACKGROUND: The treatment strategy of SLAP (superior labrum anterior posterior) lesions is generally a matter of controversy, particularly in patients over 40 years of age. Various factors, such as the increasing number of associated injuries in older age, play a role in the decision-making process. There currently is no empirical evidence for the greater efficacy of treatment planning for SLAP repair as compared to tenodesis/tenotomy. The aim of this study was to analyse, as part of a cohort comparison, the results after SLAP repair in patients under and over 40 years of age. METHODS: We followed 45 patients after surgical treatment of a SLAP lesion, with a mean follow-up of 60 months (5 years), clinically using the Constant score (CS), the Rowe score, and the "subjective shoulder value" (SSV). Of these, 18 patients in group 1 (age at surgery<40 years, mean age at surgery 29 years, range: 21-39 years) and 27 patients in group 2 (age≥40 years at surgery, mean age at surgery 50 years, range: 40-60 years). RESULTS: A mean CS of 89% (min 16%-max 105%) resulted. The Rowe score averaged 90 points (min. 35 points-max 100 points), while the SSV averaged 90% (min 20%-max 100%). In comparing the two groups, neither displayed a significant difference in the CS (p=0.198) (group 1: min 58%-max 105%, median 92%, group 2: min 16%-max 105%, median 89%) nor in the Rowe score (p=0.5) (group 1: min 55-max 100 points, median 85 points, group 2: min 35-max 100 points, median 92.5 points). The SSV also showed no significant difference in level (p=0.068) between the two groups (group 1: min 60%-max 100%, median 95%, group 2: min 20%-max 100%, median 90%), although the SSV in group 1 had a better correlation with the CS than in group 2. DISCUSSION: The patient's age seems to have less influence on the outcome after reconstruction of SLAP than previously thought. Even at age≥40 years results show that the reconstruction results of the complex SLAP are comparable with the known literature data, and that it is good clinical practice. Impact on the long-term outcome seems to be particularly dependent on the number and severity of associated injuries, not the patient's age.

Scintigraphic evaluation of rhBMP-2-biocoated implants reveals no ectopic bone formation.

The main objectives of the study described below were of two-fold nature: (1) to examine if rhBMP-2-biocoated implants in a pig model could lead to ectopic bone formation and (2) if quantitative and/or qualitative differences could be found between adhesively and covalently bonded BMP II using the scintigraphic method. In order to examine these central questions, 26 Göttingen minipigs were allocated to three groups with a control group (n=7) and two study groups (n=9 each) receiving one of three implant types: (a) chromosulfuric acid treated titanium surface as control, (b) non-covalently bonded BMP-2, and (c) covalently bonded and immobilized rhBMP-2. Each animal received four barbell-shaped implants, one in the proximal and distal metaphysis of each femur. The scintigraphic analyses were conducted after four, eight, and 12 weeks postoperatively. The visual (qualitative) analysis failed to show ectopic bone formation in any of the three groups. The statistical analysis of the relative values for bone formation yielded no significant differences between the groups, although the limitation in the applied methods do not enable one to draw conclusions regarding the histomophometric results.

[Biochemical analysis of the synovial fluid of the shoulder joint in patients with and without rotator cuff tears]. / Biochemische Analyse der Synovialflüssigkeit bei Patienten mit und ohne Rotatorenmanschettendefekt.

AIM: The biochemical changes associated with rotator cuff tearing are still unclear. The aim of this study is to assess whether concentrations of matrix metalloproteinase in the synovial fluid are specifically altered in shoulders with torn rotator cuff tendons. PATIENTS AND METHOD: Synovial fluid was extracted via arthroscopy in 21 patients with complete rotator cuff tears (RCTs). The control group was composed of 21 patients without complete tears. The catabolic cartilage metabolism markers MMP-1 (collagenase), MMP-3 (stromelysin1) and MMP-13 (collagenase3) were quantified by an ELISA test and these results were then statistically analysed using SAS. RESULTS: The mean concentration of the 21 samples with rotator cuff tears shows a higher concentration of MMP 3 (2601.73 ng/mL vs. 1775.67 ng/mL) and MMP 13 (2.69 ng/mL vs. 2.35 ng/mL) as well as a significantly higher concentration of MMP 1 (p=0.0047) in the control group. CONCLUSIONS: A significant variation in the concentration of catabolic cartilage enzymes in the synovial fluid in patients with and without rotator cuff tears could not be found. Nonetheless, there is a bias for the MMP-3 and MMP-13 values, which makes a conductive influence in the aetiology of osteoarthritis probable.

[Osteoathritis after SLAP Lesion? Clinical and arthro-MRI evaluation after arthroscopic SLAP refixation]. / Die SLAP-Läsion als Präarthrose? Klinische und MR-Arthrografie-Ergebnisse nach arthroskopischer Refixation einer SLAP-II-Läsion.

INTRODUCTION: The development of glenohumeral osteoarthritis is sufficiently described after instability and rotator cuff pathologies. The purpose of this work was to evaluate a coherency between glenohumeral osteoarthritis and SLAP lesions by means of MR arthrography which has not been described up to now in the literature. MATERIAL AND METHODS: 20 patients with a SLAP lesion type II were treated with arthroscopic SLAP repair. MR arthrography was performed after intra-articular administration of diluted gadolinium (after positive vote of the ethics committee) after a mean FU of 36 months (26 to 54 months). The MR arthrography data were analysed by 3 investigators (two radiologists, one orthopaedic surgeon) in consensus. Osteoarthritis was graded according to the modified Outerbridge classification for MRI. Besides image quality and artifacts, adhesions from the tendon to the bone and the rotator cuff were evaluated. Intraoperative documented findings were used for comparison. The clinical investigation encompassed Roweand Constant score, clinical investigation of instability and SLAP lesion (O'Brian test, SLAP apprehension test) as well as the subjective contentment. The statistical evaluation was performed with SAS reverse. RESULTS: In 12 of 20 cases an increase of glenohumeral osteoarthritis was seen, in 4 cases a circumscribed entire cartilage defect appeared in the MRI. Osteoarthritis did not correlate with the subjective and objectively collected clinical results or the aetiology of the SLAP lesion at the time of the re-examination. Results of the MR arthrography revealed that, in six cases, the biceps anchor did not show proper bony ingrowth. Nonetheless, these cases do not correlate with a poorer clinical result. CONCLUSION: Due to the small case number a correlation between SLAP lesion and osteoarthritis cannot be postulated statistically, however, the results still indicate a trend which should be pursued in the long-term course.

[Shoulder injuries in overhead athletes: utility of MR arthrography]. / Schulterverletzungen des Uberkopfsportlers: Wertigkeit der MR-Arthrografie.

INTRODUCTION: The goal of this work was to assess the accuracy of the MR-Arthrografie in the evaluation of over head athletes injuries in comparison with athroscopy. MATERIAL AND METHODS: In 29 patients (middle age: 30 years, 21 male, 8 female, age 16 - 53 years) with persistent pain after conservative therapy an Arthro-MRI with intraarticular application of gadolinum was performed prior to arthroscopic surgery. The MRI was retrospectivly analysed of three examiners independently from one another. The result were compared to the results of the Arthroscopy. Interrater Reliability was calculated by using of Cohens Kappa. RESULTS: The MR-Arthrography could demonstrate 8 of 9 (88.9 %) partial tears of he rotator cuff. All SLAP (Superiores Labrum from Anterior to Posterior) Lesions as well as all bankart type Lesions were recognized through the MR-Arthrography. However, dependent upon the experience of the examiner in a span between 33.3 % (fellow radiologist) and 93.3 % (consultant radiologist). We found a high agreement between consultant radiologist and shoulder surgeon with Kappa of 0.79 for rotator cuff tear-, 0.86 for Bankart- and 0.82 for SLAP-Läsionen.

[Delayed repair of traumatic shoulder girdle muscle tears]. / Die verzögerte Rekonstruktion traumatischer Rupturen grosser Schultergürtelmuskeln.

Muscle ruptures effecting the shoulder girdle represent a comparatively rare event. Especially after delayed diagnostics, the operative result is only heavily predictable. Due to few case reports, there are no experiences to guide us. This case report describes the delayed surgical treatment of two cases of traumatic shoulder girdle muscle tears. These results encourage, that also after a long time period operative treatment can lead to a good result.

[Isolated traumatic rupture of the subscapular muscle tendon as an adolescent injury]. / Die isolierte traumatische Ruptur der Sehne des M. subscapularis als Verletzungsform des Jugendlichen.

INTRODUCTION: Until now no case of a traumatic tear of the subascapularis muscle in children was described in the German speaking literature. Using the example of 2 cases of a 12 and 14 year boys youth history, clinic, diagnostics and therapy will be presented. METHODS: The accident happened in extension and external rotation of the arm without dislocation. Beside the complete tear of the SCP-tendon in one case an accompanying expanded humeral flake fracture at the minor tuberosity was found. Under protection of the epiphysis line the refixation was performed using suture anchors. RESULTS: The post-operative control after 12 months showed a complete tendon healing, no arthritis or delayed bony ingrowth with return to full activity. CONCLUSION: Isolated traumatic SCP-tears can be occur also in young patients. As major consequence, it is necessary to perform a thorough clinical examination with additional apparative diagnostics (Sonography, MRI). This way, this rare but important lesion can be detected early and lead to adequate surgery without any delay.

Transdermal fentanyl in postoperative pain.

BACKGROUND AND OBJECTIVES: The aim of this study was to determine the safety and effectiveness of a transdermal fentanyl delivery system for the relief of pain following abdominal surgery. METHODS: In a nonblinded, noncrossover, placebo-controlled study, 40 ASA I and II patients of both sexes, 18-69 years of age, who were scheduled for abdominal surgery under general anesthesia, were randomly divided into two groups of 20 patients each. Patients in group I received a transdermal patch containing 0.16 mg/cm2 of fentanyl, which was applied to the skin over the subclavian area 60 minutes before the induction of anesthesia. For body weight less than 60 kg, a 30 cm2 patch was applied, and for weight greater than 60 kg, a 40 cm2 patch was used. A second group of 20 patients received placebo patches of identical size. Approximately 20 to 30 minutes before the expected end of surgery, 60 mg ketorolac was administered intramuscularly. Patients were observed for 36 hours after placement of the patch. If patients reported their pain at rest as 5 or greater at rest on a 0-10 visual analog scale, they were given 30-mg increments of ketorolac 5 to 7 hours apart. If this regimen did not relieve their pain, they received 1,300 mg acetaminophen between two ketorolac doses. If despite this, they still had pain 30 minutes afterward, intravenous morphine was given, and the patients were excluded from further study. The patch was removed in four patients in the fentanyl group and seven in the placebo group for various reasons, which included, inadequate pain relief requiring additional analgesia postoperatively and more than 1 microgram/kg of sufentanil given intraoperatively or immediately prior to the end of surgery. During the 36-hour observation period, 30 doses of 30 mg ketorolac and 14 doses of 1.3 g acetaminophen were given to 13 patients in the placebo group and 18 doses of ketorolac and 8 doses of acetaminophen were administered to 16 in the fentanyl group. RESULTS: The differences in postoperative analgesic requirements were significant. Plasma fentanyl concentrations at 12 and 24 hours after the application of the fentanyl patch were 0.98 +/- 0.14 ng/mL and 1.22 +/- 0.17 ng/mL, respectively. At 8, 16, 24, and 36 hours after application of the patch, the pain relief, assessed by a VAS at rest and with movement, was similar in the two groups. In the fentanyl and control groups, 12 and 5 patients, respectively, experienced nausea, and 2 and 3 patients, respectively, vomited. CONCLUSIONS: Similar postoperative analgesia was achieved with less parenteral analgesics in patients who received transdermal fentanyl preoperatively than in control patients. Fentanyl, 50-75 micrograms/h, administered in a transdermal delivery system, did not depress respiratory rate or hemoglobin oxygen saturation. Although the exact role of continuously administered opioids in managing acute postoperative pain has yet to be clearly defined, it is concluded that if properly used, this new transdermal device can be effective in providing a background of analgesia, which may assist in the management of acute postoperative pain as well as some chronic pain states.

Successful use of epidural blood patch for postdural puncture headache following lumbar sympathetic block.

BACKGROUND AND OBJECTIVES: A 21-year-old man was scheduled for a diagnostic lumbar sympathetic block for reflex sympathetic dystrophy of the right lower extremity. METHODS: The patient experienced paresthesias with possible puncture of a dural sleeve during needle placement under fluoroscopy. After discharge, the patient developed a positional headache, which increased in intensity over 48 hours. An epidural blood patch was subsequently performed. RESULTS: The patient obtained complete relief from the headache. CONCLUSION: Postdural puncture headache resulting from leakage of cerebrospinal fluid through a punctured dural sleeve may be successfully treated with an epidural blood patch should more conservative treatments fail.

Migraine headache following stellate ganglion block for reflex sympathetic dystrophy.

The alteration of extracranial blood flow in conjunction with clinical signs of autonomic nervous system dysfunction have led to various explanations concerning the pathophysiology of migraine headache. Reflex sympathetic dystrophy, a painful disorder of the sympathetic nervous system, can be treated by blocking the sympathetic nerves located in the stellate ganglion, resulting in vasodilation, ptosis, miosis, and anhydrosis. In theory, these changes could trigger a migraine headache attack secondary to autonomic dysfunction reflecting an imbalance between sympathetic and parasympathetic nervous systems. This may be especially true in a patient with a previous history of meningitis that may have resulted in a disorder of cerebrovascular regulation. We report a 56-year-old man with no previous history of migraine who developed migraine with aura after a stellate ganglion block. These episodic headaches occurred with decreasing frequency and severity for over 6 months, with eventual complete resolution. This interesting phenomenon has not been reported in the English literature and may help to better understand the pathophysiology of migraine.

Cardiopulmonary complications during laparoscopy: two case reports.

Laparoscopic surgery is growing in popularity. As a result, laparoscopic procedures are being done on a broader and older patient population. These patients may have underlying cardiopulmonary disease that predisposes them to complications not seen in younger patients. Anesthesiologists should be aware of this possibility and of the problems inherent to the pneumoperitoneum necessary for laparoscopy. We present two cases involving elderly patients to illustrate cardiopulmonary complications that can occur during establishment or maintenance of the increased intra-abdominal pressures required for laparoscopic surgery. The first case describes a patient who developed bradycardia and asystole during insufflation for a laparoscopic hernia repair. The second case involves severe hypercarbia and a pneumothorax due to massive subcutaneous emphysema that developed during a laparoscopic colon resection.

Subdural injection of a local anesthetic with steroids: complication of epidural anesthesia.

We describe the unintentional injection of a small amount of local anesthetic with steroids into the subdural space during an attempted lumbar epidural injection for low back pain. When small volumes of local anesthetic are injected into the subdural space, a patchy and unilateral block of greater magnitude than expected will result. When larger volumes of local anesthetic are injected, a massive motor and sensory block can occur due to the small confines of this space. Accidental subdural injection must be recognized early and treated appropriately to avoid serious complications, especially in an outpatient setting.