Better timing of ultrasound-guided transversus abdominis plane block for early recovery after open inguinal herniorrhaphy: A prospective randomised controlled study

BackgroundThis study investigated the optimal timing of analgesic transversus abdominis plane (TAP) block in the operating room for better recovery quality using the Korean version of the Quality of Recovery-40 (QoR-40K) questionnaire in patients who had undergone open inguinal herniorrhaphy.MethodsThis single-centre, prospective randomised controlled study included adult male patients who had an ASA physical status of I–II. A total of 80 patients were analysed. The patients were randomly assigned and classified into pre-incisional TAP (pre-TAP) block (n = 40) and post-incisional TAP (post-TAP) block (n = 40) groups. The quality of postoperative functional recovery and complications were compared between the two groups during 24 h postoperatively.ResultsPreoperative findings of the two groups were comparable. The global QoR-40K score was higher in the pre-TAP group than in the post-TAP group. Among sub-dimensions, scores of physical comfort and pain were higher in the pre-TAP group than in the post-TAP group. In the post-anaesthesia care unit, the pre-TAP group showed lower pain scores than the post-TAP block group. There was no severe pain in the pre-TAP group, but two patients (5.0%) in the post-TAP block group suffered severe pain. The pre-TAP group required lower doses of IV rescue opioid in the PACU than the post-TAP group. All patients were discharged from hospital on postoperative day 1 without surgical complications.ConclusionsThe timing of analgesic TAP block may be of clinical importance to prevent postoperative pain and to improve the quality of early patient recovery following open inguinal herniorrhaphy.     

Vascular anatomy and surgical approach in oblique lateral interbody fusion at lumbosacral transitional vertebrae

BackgroundOblique lateral interbody fusion (OLIF) at lumbosacral junction is typically performed on the central window between the bifurcations of iliac vessels. However, the central window of lumbosacral transitional vertebrae (LSTVs) is usually obstructed by the iliocaval venous structures. We aimed to describe the vascular anatomy and surgical approach in OLIF at LSTVs compared with those in OLIF at typical L5-S1 junction.MethodsSixty-eight consecutive patients who underwent OLIF at lumbosacral junction were included. Of these, 31 patients had LSTVs and 37 patients had typical L5-S1 junction. The position of the iliocaval junction and the configuration of the left common iliac vein were compared using the preoperative CT and MR images of the lumbar spine. The surgical approach and intraoperative vascular findings were analyzed.ResultsAlmost 70% of LSTVs had the iliocaval junction at low or very low position. Mobilization of left common iliac vein for central window was potentially difficult in almost 74% of OLIF at LSTVs while it was not required or was potentially easy in almost 80% of OLIF at typical L5-S1. Vascular injury was identified in 2 (6.5%) patients with OLIF at LSTVs and in 3 (8.1%) patients with OLIF at typical L5-S1 junction (P = 0.904).ConclusionsIn our series, OLIF at LSTVs was performed through lateral window in 93.5% of the cases. Preoperative evaluation of the iliocaval junction using CT/MR of lumbar spine was reliable and valid in the determination of OLIF approach at lumbosacral junction.     

Inversion Recovery Ultrashort TE MR Imaging of Myelin is Significantly Correlated with Disability in Patients with Multiple Sclerosis

BACKGROUND AND PURPOSE:MR imaging has been widely used for the noninvasive evaluation of MS. Although clinical MR imaging sequences are highly effective in showing focal macroscopic tissue abnormalities in the brains of patients with MS, they are not specific to myelin and correlate poorly with disability. We investigated direct imaging of myelin using a 2D adiabatic inversion recovery ultrashort TE sequence to determine its value in assessing disability in MS.MATERIALS AND METHODS:The 2D inversion recovery ultrashort TE sequence was evaluated in 14 healthy volunteers and 31 patients with MS. MPRAGE and T2-FLAIR images were acquired for comparison. Advanced Normalization Tools were used to correlate inversion recovery ultrashort TE, MPRAGE, and T2-FLAIR images with disability assessed by the Expanded Disability Status Scale.RESULTS:Weak correlations were observed between normal-appearing white matter volume (R = –0.03, P = .88), lesion load (R = 0.22, P = .24), and age (R = 0.14, P = .44), and disability. The MPRAGE signal in normal-appearing white matter showed a weak correlation with age (R = –0.10, P = .49) and disability (R = –0.19, P = .31). The T2-FLAIR signal in normal-appearing white matter showed a weak correlation with age (R = 0.01, P = .93) and disability (R = 0.13, P = .49). The inversion recovery ultrashort TE signal was significantly negatively correlated with age (R = –0.38, P = .009) and disability (R = –0.44; P = .01).CONCLUSIONS:Direct imaging of myelin correlates with disability in patients with MS better than indirect imaging of long-T2 water in WM using conventional clinical sequences.

MS is the most common demyelinating disease of the brain.¹ Demyelination affects many aspects of neurologic function, including speech, balance, and cognitive awareness. Across time, this frequently leads to severe and irreversible clinical disability. MR imaging has been widely used for accurate diagnosis of MS, with current techniques focused on imaging the long-T2 water components in WM and GM.^2-4 MS lesions often appear hypointense with T1-weighted gradient recalled-echo sequences² and hyperintense with T2-weighted FSE and T2-weighted FLAIR sequences.³ Active lesions can be highlighted with gadolinium-enhanced imaging.⁴ The magnetization transfer ratio has been used as an indirect marker of myelin disorder in regions of normal-appearing WM (NAWM).⁵ There are also several other advanced imaging techniques for indirect myelin imaging via assessment of myelin water, such as multicomponent T2 or T2* analysis^6,7 and direct visualization of components with short transverse relaxation times.^8,9While conventional MR imaging sequences are highly effective in detecting focal macroscopic brain tissue abnormalities, they are not specific for pathologic substrates of MS lesions such as demyelination and remyelination, and they may not correlate well with patients'' neurologic deficits. Current MR imaging techniques correlate only modestly with disability assessed by the Expanded Disability Status Scale (EDSS).^10-15 The total lesion load showed statistically significant-but-weak correlations with the EDSS score in several large-scale studies (R = 0.1–0.3).^10-12 Composite scores including relaxation times of different tissues and/or volumetric measures generally correlate more strongly with the EDSS score, with a maximum observed correlation of R = 0.34 (P < .001).¹³ Lesions seen with gadolinium-enhanced imaging are only moderately correlated with disability in the first 6 months and are not predictive of changes in the EDSS score in the subsequent 1 or 2 years.¹⁴ A large-scale multicenter study reported very limited correlation between the EDSS score and normalized brain volume (R = –0.18), cross-sectional area (R = –0.26), magnetization transfer ratio of whole-brain tissue (R = –0.16), and GM (R = –0.17).¹⁵The poor performance of conventional MR imaging sequences in assessing disability highlights the need for novel MR imaging techniques that can directly image myelin lipid and enable direct assessment of both myelin damage and repair. However, myelin has an extremely short transverse relaxation time and is not directly detectable with conventional MR images, which typically have TEs of several milliseconds or longer. Ultrashort TE (UTE) sequences can directly detect signal from myelin with ultrashort T2 (ie, excluding water with longer T2s).^16-21 In this study, we describe imaging of WM using a 2D adiabatic inversion recovery prepared UTE (IR-UTE) sequence in healthy volunteers and patients with MS and evaluate its performance in assessing disability in patients with MS compared with 2 conventional clinical sequences.     

Delayed pseudoaneurysm formation of the carotid artery following the oral cavity injury in a child: A case report

BACKGROUNDAn impalement injury of the oral cavity is a common traumatic injury in children. In most cases, it is not accompanied by sequelae, but if foreign body residues are not found due to a minor injury, they may result in inflammatory responses and delayed vascular injuries in the surrounding tissues. Without early diagnosis and appropriate initial management, residual foreign bodies can cause serious complications and even mortality in some cases. CASE SUMMARYA 9-year-old boy suffered an intra-oral injury by a wooden chopstick, and the patient was discharged from the hospital after receiving conservative treatment for the injury. However, the patient was readmitted to the hospital due to intra-oral bleeding, and since neck hematoma and right internal carotid artery pseudoaneurysm formation were detected on computed tomography, emergency surgery was performed. A remnant fragment of a wooden chopstick was found during the operation, and a delayed rupture of the internal carotid artery caused by the foreign body was also found.CONCLUSIONThe failure of early detection and diagnosis of a residual foreign body may result in delayed vascular rupture.     

Transient left bundle branch block after posture change to the prone position during general anesthesia: A case report

Rationale:The prone position is commonly used in spinal surgery. There have been many studies on hemodynamic changes in the prone position during general anesthesia. We report a rare case of transient left bundle branch block (LBBB) in a prone position.Patient concern:Electrocardiogram (ECG) of a 64-year-old man scheduled for spinal surgery showed normal sinus rhythm change to LBBB after posture change to the prone position.Diagnosis:Twelve lead ECG revealed LBBB. His coronary angio-computed tomography results showed right coronary artery with 30% to 40% stenosis and left circumflex artery with 40% to 50% stenosis. The patient was diagnosed with stable angina and second-degree atrioventricular block of Mobitz type II.Intervention:Nitroglycerin was administered intravenously during surgery. Adequate oxygen was supplied to the patient. After surgery, the patient was prescribed clopidogrel, statins, angiotensin II receptor blocker, and a permanent pacemaker was inserted.Outcome:Surgery was completed without complications. After surgery, the transient LBBB changed to a normal sinus rhythm. The patient did not complain of chest pain or dyspnea.Lesson:The prone position causes significant hemodynamic changes. A high risk of cardiovascular disease may cause ischemic heart disease and ECG changes. Therefore, careful management is necessary.