The effect of neuromuscular blockade on mask ventilation.

We wished to test the hypothesis that neuromuscular blockade facilitates mask ventilation. In order reliably and reproducibly to assess the efficiency of mask ventilation, we developed a novel grading scale (Warters scale), based on attempts to generate a standardised tidal volume. Following induction of general anaesthesia, a blinded anaesthesia provider assessed mask ventilation in 90 patients using our novel grading scale. The non-blinded anaesthesiologist then randomly administered rocuronium or normal saline. After 2 min, mask ventilation was reassessed by the blinded practitioner. Rocuronium significantly improved ventilation scores on the Warters scale (mean (SD) 2.3 (1.6) vs 1.2 (0.9), p<0.001). In a subgroup of patients with a baseline Warters scale value of >3 (i.e. difficult to mask ventilate; n=14), the ventilation scores also showed significant improvement (4.2 (1.2) vs 1.9 (1.0), p=0.0002). Saline administration had no effect on ventilation scores. Our data indicate that neuromuscular blockade facilitates mask ventilation. We discuss the implications of this finding for unexpected difficult airway management and for the practice of confirming adequate mask ventilation before the administration of neuromuscular blockade.

Treatment of lumbar spinal stenosis by extensive unilateral decompression and contralateral autologous bone fusion: operative technique and results.

A new surgical technique for the treatment of lumbar spinal stenosis features extensive unilateral decompression with undercutting of the spinous process and, to preserve stability, uses contralateral autologous bone fusion of the spinous processes, laminae, and facets. The operation was performed in 29 patients over a 19-month period ending in December of 1991. All individuals had been unresponsive to conservative treatment and presented with low-back pain in addition to signs and symptoms consistent with neurogenic claudication or radiculopathy. Nine had undergone previous lumbar decompressive surgery. The minimum and mean postoperative follow-up times were 2 and 2 1/2 years, respectively. The mean patient age was 64 years; only two patients were younger than 50 years of age. Of the patients with neurogenic claudication, 69% reported complete pain relief at follow-up review. Of those with radicular symptoms, 41% had complete relief and 23% had mild residual pain that was rated 3 or less on a pain-functionality scale of 0 to 10. For the entire sample, this surgery decreased pain from 9.2 to 3.3 (p < 0.0001) on the scale. Sixty-nine percent of patients were satisfied with surgery. Low-back pain was significantly relieved in 62% of all patients (p < 0.0001). Low-back pain relief correlated negatively with number of levels decompressed (p < 0.05). To assess fusion, follow-up flexion/extension radiographs were obtained, and no motion was detected at the surgically treated levels in any patient. The results suggest that this decompression procedure safely and successfully treats not only the radicular symptoms caused by lateral stenosis but also the neurogenic claudication symptoms associated with central stenosis. In addition, the procedure, by using contralateral autologous bone fusion along the laminae and spinous processes, can preserve stability without instrumentation.

Surgical approaches for the correction of unstable thoracolumbar burst fractures: a retrospective analysis of treatment outcomes.

The authors retrospectively studied 49 nonparaplegic patients who sustained acute unstable thoracolumbar burst fractures. All patients underwent surgical treatment and were followed for an average of 27 months. All but one patient achieved solid radiographic fusion. Three treatment groups were studied: the first group of 16 patients underwent anterior decompression and fusion with instrumentation; the second group of 27 patients underwent posterior decompression and fusion; and the third group of six patients had combined anterior-posterior surgery. Prior to surgical intervention, these groups were compared and found to be similar in age, gender, level of injury, percentage of canal compromise, neurological function, and kyphosis. Patients treated with posterior surgery had a statistically significant diminution in operative time and blood loss and number of units transfused. There were no significant intergroup differences when considering postoperative kyphotic correction, neurological function, pain assessment, or the ability to return to work. Posterior surgery was found to be as effective as anterior or anterior-posterior surgery when treating unstable thoracolumbar burst fractures. Posterior surgery, however, takes the least time, causes the least blood loss, and is the least expensive of the three procedures.

Intraoperative chemonucleolysis as an adjunct to lumbar discectomy.

STUDY DESIGN: This is a report of a series of 104 patients who underwent lumbar discectomy and chemonucleolysis at the University of Virginia between 1985 and 1989. OBJECTIVE: The primary objective was to determine the safety of this procedure. A secondary objective was to begin studying its efficacy. SUMMARY OF BACKGROUND DATA: This is the first report on the use of chymopapain during open surgery. METHODS: Patients with low back pain and radicular symptoms not cured with conservative therapy were selected for participation in the study. Intraoperatively, disc spaces were injected with 2 ml of chymopapain. Patients were followed-up for an average of 5 years. Patients were surveyed regarding pain relief, and failures of the procedure were analyzed. RESULTS: Seventy percent of patients reported good or excellent pain relief. Operative failures, characterized by reoperation at the same level, totaled 9.6%. Recurrent disc herniation at the time of reoperation occurred in 4.8%. CONCLUSION: The procedure is safe and the relief of pain was similar to that in other published series. The suggestion is that the rate of recurrent disc herniation is reduced.

Fusion with occipital bone for atlantoaxial instability: technical note.

A technique is described of using autologous occipital bone for posterior atlantoaxial fusions. The advantages include the ease of harvest, the lack of postoperative discomfort, and the suitability of occipital bone for the fusion.

[On the beginnings of sixteen-century science in Hungary]. / Adalékok a XVI. századi magyar természettudomány születeséhez.

Among the 222 letters by Gáspár Fraxinus to Count Nádasdy that have been recently published by T. Vida and T. Grynaeus (Budapest 1988), some 88 are concerned with or at least mention medical therapies and pharmaceutical practice. The authors examined the scientific terms and usage of the correspondence, and corroborate and detail the findings of Botta about the emergence of pharmaco-botanical education in the Nádsdys chateau at Sárvár during the first half of the XVIth century. The first scientific writer of this school interested in botany and medicine was the Hungarian humanist and teacher, the translator of the New Testament, Johannes Sylvester (Erdosi Sylvester János). In his book, the Grammatica Hungaro-Latina (1539) and in his translation of the New Testament (1541) he was the first to publish texts in Hungarian that referred to plants and maladies. The leading figure of the school, however, was Caspar Fraxinus (Szegedi Korös Gáspár), the humanist physician and friend of the Italian A. Fracantianus and P. Matthiolus. According to his letters, the authors suppose that he might have been the tutor of Peter Melius (Somogyi Juhász Péter), and Georg Lenczius (Váradi Lencsés György), whom both became respected scholars later on. Melius made name for himself as the writer of the first pharmaco-botanical monograph in Hungarian (Herbarium, Kolozsvár, 1578). Lenczius, on the other hand, wrote exhaustively in his six-volume Ars medica (Gyulafehévár, 1570-90) about theoretical and practical medicine. Though inventively arguing in favour of the connections between Fraxinus, Melius and Lencsés, the main contribution of the article is rather the collection of pharmaceutical and botanical terms that appeared in letters of these persons who visited Sárvár, or even stayed there. The authors give a set of thoroughly elaborated indices, about medical plants and herbs, (either in Latin or Hungarian), about medicaments and drugs, names of illnesses and anatomical terms; about the suggested or used therapies, the names of famous physicians and scientists, etc. By the use of these lists the detailed scientific knowledge and medical education of these late Renaissance characters are perfectly raised.