Spontaneous Spinal Epidural Hematoma After Normal Spontaneous Delivery with Epidural Analgesia: Case Report and Literature Review.

BACKGROUND: Pregnancy is a known risk factor for spontaneous spinal epidural hematoma. During cesarean section or vaginal delivery, the unstable hemodynamic status that may occur owing to fluctuation of intra-abdominal pressure increases the possibility of spontaneous spinal epidural hematoma. During labor and the postpartum period, neurologic symptoms may be masked by labor pain or anesthesia block, which makes early diagnosis difficult, especially in the obstetric clinic without a neurologist or neurosurgeon. CASE DESCRIPTION: A 28-year-old woman who had a normal spontaneous delivery under epidural anesthesia developed bilateral lower limb flaccid paralysis and loss of sensation 12.5 hours after delivery. Magnetic resonance imaging showed a 5.2 × 0.9 × 2 cm spinal epidural hematoma with severe spinal cord stenosis at the T2-T5 level with no evidence of a vascular anomaly. After emergent evacuation of the spinal epidural hematoma, lower limb muscle power improved from 0/5 to 1/5, and sensation gradually returned to bilateral lower limbs 22 days postoperatively. Deep vein thrombosis developed at 35 days postoperatively, and an inferior vena cava filter was implanted with urokinase infusion for thrombolytic therapy. She was discharged on day 52 after admission, and lower limb muscle power returned to normal after 3 months. CONCLUSIONS: Clinicians should observe postpartum women for signs of myelopathy or back tenderness and closely monitor neurologic function until anesthesia has run its course. A prompt diagnosis can enable prompt intervention.

Hyperbaric Oxygen Effects on Depression-Like Behavior and Neuroinflammation in Traumatic Brain Injury Rats.

OBJECTIVE: The aim of this study was to determine whether hyperbaric oxygen (HBO) therapy causes attenuation of traumatic brain injury (TBI)-induced depression-like behavior and its associated anti-neuroinflammatory effects after fluid percussion injury. METHODS: Anesthetized male Sprague-Dawley rats were divided into 3 groups: sham operation plus normobaric air (NBA) (21% oxygen at 1 absolute atmosphere [ATA]), TBI plus NBA, and TBI plus HBO (100% oxygen at 2.0 ATA). HBO was applied immediately for 60 min/d after TBI for 3 days. Depression-like behavior was tested by a forced swimming test, motor function was tested by an inclined plane test, and infarction volume was tested by triphenyltetrazolium chloride (TTC) staining on days 4, 8, and 15. Neuronal apoptosis (terminal deoxynucleotidyl transferase dUTP nick-end labeling assay), microglial (marker OX42) activation, and tumor necrosis factor (TNF)-α expression in microglia in the hippocampus CA3 were measured by immunofluorescence methods. RESULTS: Compared with the TBI controls, without significant changes in TTC staining or in the motor function test, TBI-induced depression-like behavior was significantly attenuated by HBO therapy by day 15 after TBI. Simultaneously, TBI-induced neuronal apoptosis, microglial (marker OX42) activation, and TNF-α expression in the microglia in the hippocampus CA3 were significantly reduced by HBO. CONCLUSIONS: Our results suggest that HBO treatment may ameliorate TBI-induced depression-like behavior in rats by attenuating neuroinflammation, representing one possible mechanism by which depression-like behavior recovery might occur. We also recommend HBO as a potential treatment for TBI-induced depression-like behavior if early intervention is possible.

Rhabdomyolysis after cerebral perfusion pressure-guided management in severe head injury.

Intravenous infusion of norepinephrine is usually effective and safe to maintain adequate cerebral perfusion pressure for the management of posttraumatic intracranial hypertension. We report the case of a 17-year-old woman who suffered from traumatic intracranial bleeding and hypotension; she developed rhabdomyolysis, myoglobinuria and acute renal failure after receiving high dose norepinephrine postoperatively. Hemodialysis was begun 3 days after the onset of myoglobinuria when acute renal failure was noted, despite aggressive fluid supplementation and alkaline diuresis. After aggressive treatment and dialysis, the patient's myoglobinuria and rhabdomyolysis gradually declined. Her kidneys eventually regained normal function. We consider that systemic hypotension may have been the leading cause for development of rhabdomyolysis, and vasoconstrictors such as norepinephrine aggravated this. We emphasise the potentially devastating consequences of rhabdomyolysis when a large dose of norepinephrine is given for the treatment of hypotension during cerebral perfusion pressure-guided management.

Intraoperative applications of intracranial pressure monitoring in patients with severe head injury.

From December 2002 to January 2004, 30 patients (20 men and 10 women; mean age 36.8 years [+/- 14.9 years]) with preoperative Glasgow Coma Scale scores of 8 or less underwent emergency haematoma evacuation surgery and continuous intracranial pressure (ICP), cerebral perfusion pressure (CPP) and mean arterial blood pressure monitoring to determine ICP and CPP thresholds to predict patient outcomes. Receiver-operating characteristic (ROC) curves were plotted. Using the ROC curve, the diagnostic accuracy is given by the area under the curve and at the point on the curve farthest from the diagonal, which indicates the threshold value. The results showed that the initial ICP for unfavourable outcomes was 47.4 +/- 21.4 mmHg, resulting in a CPP of 22.8 +/- 12.83 mmHg. The initial ICP for favourable outcomes was 26.4 +/- 10.1 mmHg, resulting in a CPP of 48.8 +/- 13.4 mmHg. The CPP had the largest area under the ROC curve in all stages of the operation, corresponding to intraoperative CPP thresholds of 37 mmHg (initial), 51.8 mmHg (intraoperative) and 52 mmHg (after scalp closure). The ROC curve analysis showed that CPP was a better predictor of outcome than ICP.

Associations between chronic diseases and choking deaths among older adults in the USA: a cross-sectional study using multiple cause mortality data from 2009 to 2013.

OBJECTIVES: To examine whether the strengths of the associations between chronic diseases and overall choking differ from those of the associations between chronic diseases and only food-related choking. DESIGN: This cross-sectional study used nationwide multiple cause mortality files. SETTING: The USA. PARTICIPANTS: Older adults aged 65 years or more died between 2009 and 2013. MAIN OUTCOME MEASURES: Mortality ratio (observed/expected) of number of deaths from both causes (chronic diseases and choking) and 95% CIs. RESULTS: We identified 76543 deaths for which the death certificates report choking (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes W78, W79 and W80 combined) as a cause of death and only 4974 (6.5%) deaths were classified as food-related choking (ICD-10 code W79). Schizophrenia, Parkinson's disease, Alzheimer's disease and oral cancer are four chronic diseases that had significant associations with both overall and food-related choking. Stroke, larynx cancer and mood (affective) disorders had significant associations with overall choking, but not with food-related choking. CONCLUSIONS: We suggest using overall choking instead of only food-related choking to better describe the associations between chronic diseases and choking.

Trends in Unintentional Fall-Related Traumatic Brain Injury Death Rates in Older Adults in the United States, 1980-2010: A Joinpoint Analysis.

Unintentional fall-related traumatic brain injury (TBI) death rate is high in older adults in the United States, but little is known regarding trends of these death rates. We sought to examine unintentional fall-related TBI death rates by age and sex in older adults from 1980 through 2010 in the United States. We used multiple-cause mortality data from 1980 through 2010 (31 years of data) to identify fall-related TBI deaths. Using a joinpoint regression program, we determined the joinpoints (years at which trends change significantly) and annual percentage changes (APCs) in mortality trends. The fall-related TBI death rates (deaths per 100,000 population) in older adults ages 65-74, 75-84, and 85 years and above were 2.7, 9.2, and 21.5 for females and 8.5, 18.2, and 40.8 for males, respectively, in 1980. The rate was about the same in 1992, yet increased markedly to 5.9, 23.4, and 68.9 for females and 11.6, 41.2, and 112.4 for males, respectively, in 2010. For males all 65 years years of age and above, we found the first joinpoint in 1992, when the APC for 1980 through 1992, -0.8%, changed to 6.2% for 1992-2005. The second joinpoint occurred in 2005, when the APC decreased to 3.7% for 2005-2010. For all females 65 years of age and above, the first joinpoint was in 1993 when the APC for 1980 through 1993, -0.2%, changed to 7.6% from 1993 to 2005. The second joinpoint occurred in 2005 when the APC decreased to 3.8% for 2005-2010. This descriptive epidemiological study suggests increasing fall-related TBI death rates from 1992 to 2005 and then a slowdown of increasing trends between 2005 and 2010. Continued monitoring of fall-related TBI death rate trends is needed to determine the burden of this public health problem among older adults in the United States.

Chronic Indwelling Urinary Catheter Increase the Risk of Bladder Cancer, Even in Patients Without Spinal Cord Injury.

Chronic indwelling urinary catheters (CIDCs) are known as a risk factor for bladder cancer in patients with spinal cord injury (SCI). This study examined the potential risk of bladder cancer from CIDCs in patients without SCI.The National Health Insurance Research Database in Taiwan was used to identify SCI patients (N = 1816). This group was compared against a control CIDC cohort without SCI (N = 1816) and a reference cohort with normal individuals without SCI and a record of CIDC (N = 7264). Comparisons were made based on age and gender matching over a maximum of 11 follow-up years. The incidence risk and hazard ratio (HR) of bladder cancer were estimated in all 3 groups.During the follow-up period, the bladder cancer incidence rates were 68.90 and 102.53 per 100,000 person-years in the SCI and CIDC-non-SCI groups, respectively. These values were both higher than that of the reference cohort (12.00 per 100,000 person-years). Patients who had history of SCI (HR: 6.51; 95% CI, 2.56-16.52) or CIDC without SCI (HR: 9.11; 95% CI, 3.9-21.29) had a higher risk of bladder cancer compared with the reference cohort.Patients with CIDCs may have an increased risk of bladder cancer development, especially in older aged and male patients compared with general population.

Right iliac aortic aneurysmal hemorrhage as a complication of lumbar discectomy.

BACKGROUND: Vascular injury is rarely reported but can be a life-threatening complication after lumbar disc surgery. CASE DESCRIPTION: We report a case of the rupture of a pseudoaneurysm of the right common iliac artery after spinal surgery for herniation of an intervertebral disc. It was successfully treated by prompt surgical repair. CONCLUSION: This case reminds us of this rare but possible complication, and emphasizes the importance of early diagnosis and urgent intervention.