A case of neural injury by defective epidural needle]

A 70-year-old man who had undergone an elective transverse colectomy developed neural injury caused by defective epidural needle. The stylet of the 17-gauge disposable Tuohy needle used consisted of two components. The tip of the stylet was made of teflon and the material of the body was steel. The needle was inserted at Th 11-12, Th 10-11 and Th 9-10 interspaces utilizing the loss of resistance method with saline, but all the trials resulted in failure to identify needle entry into the epidural space. The patient complained of fatigue in his right lower extremity and the blood pressure was elevated to 235/125 mmHg during the series of the needle placement. The cause of the failure was finally found to be complete obstruction of the needle with a small piece torn from the stylet tip. Right femoral pain, right instep hypesthesia and muscle weakness in the right leg remained after the operation. These symptoms gradually improved and he left the hospital with slight hypesthesia remaining in his right instep 42 days after the operation.     

Hepatic foreign body - a sewing needle - in a child

We report a case of a 1-year-old boy with a needle-like foreign body embedded in the liver. The foreign body was incidentally found in the right hypochondrium on routine chest X-ray during a periodic medical examination. He was asymptomatic and there was neither a history of swallowing a needle nor a puncture wound on his body. The results of blood tests and physical examination were entirely within normal limits. Computed tomography scan showed that the needle was completely buried in the liver. At laparotomy, some fibrous tissue and a scar were recognized between the surface of the left lobe of the liver and the parietal peritoneum of the upper abdominal wall. The end of the sewing needle was manually squeezed out and extracted from the liver. From this operative finding, it was assumed that the needle had penetrated the liver through his skin. His postoperative course was uneventful and he was discharged on postoperative day 8.     

Anatomic bifurcated reconstruction of chronic bilateral innominate-superior vena cava occlusion using the Y-stenting technique

This article presents the case of a 42-year-old man who presented with superior vena cava (SVC) syndrome due to fibrosing mediastinitis with multiple failed attempts at recanalization. We initially treated him with unilateral sharp needle recanalization of the right innominate vein into the SVC stump followed by stenting. Although his symptoms improved immediately, they did not completely resolve. Six months later, he returned with worsening symptoms, and venography revealed in-stent restenosis. The patient requested simultaneous treatment on the left side. The right stent was dilated, and a 3-cm-long occlusion of the left innominate vein was recanalized, again using sharp needle technique, homing into the struts of the right-sided stent. Following fenestration of the stent, a second stent was deployed from the left side into the SVC, and the two Y limbs were sequentially dilated to allow a true bifurcation anatomy (figure). The patient had complete resolution of his symptoms and continues to do well 6 months later.     

Treatment of multiple primary hydatid cysts

Hydatid disease, which is caused by the parasite Echinococcus granulosis, is endemic in certain parts of the world in which humans and sheep live in proximity. Hydatid cysts occur most often in the liver, and affliction with multiple cysts is rare. We present the case of a 48-year-old woman with 55 hydatid cysts (47 in the liver, 5 in the right lung, and 3 in the left lung). The cysts in the right lung were intact, and those in the left lung had ruptured. A partial cystectomy was performed to excise 34 cysts through a right thoracoabdominal incision. The remaining deeply seated cysts were treated by needle aspiration and the ultrasonographically guided injection of hypertonic saline. This case report indicates that open surgery accompanied by ultrasonographically guided aspiration can effectively treat multiple hydatid cysts in a single laparotomy session.     

Intracranially Retained Sewing Needle in a Child: Does the Rust on the Needle Have any Implication?

Abstract A penetrating injury with a sewing needle is a rare phenomenon. The pathophysiological mechanism of late epilepsy after penetrating injuries is not clear. A 10-year-old female child had a seizure. An X-ray study of the skull and the cranial computed tomography scans showed a foreign object retained in the skull cavity. She was intact on neurological examination. Electroencephalogram (EEG) showed that there was bioelectrical disorganization in both hemispheres, being more prominent on the left side. A right posterior frontal median craniotomy was performed in order not to retract the left hemisphere within the interhemispheric fissure and the sewing needle was removed successfully. The sewing needle was rusted. The reason for the patient's seizure, 10 years after the injury, may be the corrosion of the sewing needle and rust formation in this case.     

Subarachnoid bupivacaine 0.5% for caesarean section

A series of 52 patients in whom 0.5% bupivacaine was used to produce spinal analgesia for awake Caesarean section is described. Analgesia tended to be asymmetrical and of limited extent until the patients were turned from the left lateral to the right lateral position immediately after injecting the spinal solution. This movement produced a more symmetrical block with better cephalic spread. Initially 26-gauge spinal needles were passed through a Sise introducer, but this was modified to a needle through needle technique whereby a long-shafted 26-gauge needle was passed through a Tuohy needle which was subsequently used to insert an extradural catheter. The optimal volume of bupivacaine was 2.25-2.75 ml. The mean +/- SEM time to achieve maximal spread of analgesia was 17.5 +/- 0.6 min. The mean- +/- SEM time to the administration of the first postoperative analgesic was 163.5 +/- 7.0 min. The disadvantages of the technique were hypotension and the unpredictable spread of analgesia.     

The effect of preoperative needle abrasion of the recipient site on survival of autologous free fat grafts in rats.

Pads of fat ranging from 670-1758 mg in weight were taken from the right groins of 20 rats and implanted subcutaneously over their right pectoral muscles. One week previously the recipient site on the thorax had been abraded with a needle in 10 of the rats. After three months the transplanted fat was taken out, weighed, and examined histologically by light microscopy. Regional tissue blood flow in the transplanted fat and in the fat from the left groin was measured by the microsphere technique. The amount of surviving fat and blood flow in the fat transplanted to an abraded recipient site was significantly higher than in the control group after three months. We conclude that preoperative needle abrasion of the recipient site may increase the chance of revascularisation and survival of the transplanted fat in rats.     

A simple technique for placement of a portacaval shunt tube in rats

We devised a new technique for the placement of portacaval shunts in rats. Using a Teflon tube with a commercially available puncture needle, we placed the tube between the infrarenal inferior vena cava (IVC) and the main portal branch. An upper laparotomy was performed, after which the tube attached to the needle was used to puncture the IVC from the right dorsal wall through toward the left side. Subsequently, the needle was advanced further to puncture the main portal vein. After each end of the tube had been successfully placed in the lumina of the IVC and portal vein, the needle was gently pulled out. Bleeding was controlled by compressing the puncture site gently for approximately 30s. Seven shunts out of ten were found to be patent at second laparotomies carried out 1 week after the primary tubing operation. The remaining three were occluded with white and red thrombi. No dislodging of the tube was noted, and radiography confirmed the patency of the shunt. This method is fast and simple, and yields a high patency rate, even in the hands of relatively inexperienced surgeons. It can be recommended as an experimental model for additional studies.     

“Kneedle pain”: slipped upper femoral epiphysis in disguise

A 14-year-old boy presented to the outpatient fracture clinic with a foreign body in his left knee. He was complaining of chronic knee pain. An X-ray revealed a foreign body—a sewing needle. On closer examination, he was noted to be obese and pre-pubertal. He had decreased range of motion in his right hip. X-ray of hip revealed a Grade 2 Slipped upper femoral epiphysis. He proceeded to OT for pinning in situ right hip and removal of foreign body in the left knee. Clinical case, and case photos are discussed.     

New needle for catheter introduction in left atrium.

We describe a new needle for left atrial catheter introduction. It allows catheter introduction through the right superior pulmonary vein or through the interatrial septum. Used in 32 patients (adults and children), the device proved to be highly efficient, simple, and safe.     

Real-time ultrasound-guided spinal anesthesia using the SonixGPS® needle tracking system: a case report

Purpose

The SonixGPS® is an electromagnetic needle tracking system for ultrasound-guided needle intervention. Both current and predicted needle tip position are displayed on the ultrasound screen in real-time, facilitating needle-beam alignment and guidance to the target. This case report illustrates the use of the SonixGPS system for successful performance of real-time ultrasound-guided spinal anesthesia in a patient with difficult spinal anatomy.

Clinical features

A 67-yr-old male was admitted to our hospital to undergo revision of total right hip arthroplasty. His four previous arthroplasties for hip revision were performed under general anesthesia because he had undergone L3-L5 instrumentation for spinal stenosis. The L4-L5 interspace was viewed with the patient in the left lateral decubitus position. A 19G 80-mm proprietary needle (Ultrasonix Medical Corp, Richmond, BC, Canada) was inserted and directed through the paraspinal muscles to the ligamentum flavum in plane to the ultrasound beam. A 120-mm 25G Whitacre spinal needle was then inserted through the introducer needle in a conventional fashion. Successful dural puncture was achieved on the second attempt, as indicated by a flow of clear cerebrospinal fluid. The patient tolerated the procedure well, and the spinal anesthetic was adequate for the duration of the surgery.

Conclusion

The SonixGPS is a novel technology that can reduce the technical difficulty of real-time ultrasound-guided neuraxial blockade. It may also have applications in other advanced ultrasound-guided regional anesthesia techniques where needle-beam alignment is critical.     

Appropriate puncture site for CT monitored celiac plexus block determined from CT films]

We investigated appropriate puncture site, angle of needle entry, and the distance of the insertion for CT monitored celiac plexus block using CT photograms on prone position in sixteen patients with gastrointestinal diseases. In retrocrural approach during CT monitored celiac plexus block, the average distances of puncture sites to midline were 3.84 cm on the right and 4.06 cm on the left, and the average needle angles were 74.1 degrees on the right and 76.9 degrees on the left. The average depths from the puncture site to marked position in retrocrural space were 7.88 cm on the right and 7.85 cm on the left. The rates of predicted organ puncture when needle is inserted 7 cm lateral to the midline of the spinal process were 43.8 percent in the right lung, 12.5 percent in the left lung, 56.2 percent in the right kidney and 68.8 percent in the left kidney. From these results, we found high possibilities of organ injuries using the conventional technique for celiac plexus block. We conclude that we could perform celiac plexus block more safely and surely using the retrocrural approach by CT monitoring, as serious complications are avoidable by viewing ideal puncture course on CT photographs.     

Serious spinal cord injury due to haematomyelia caused by spinal anaesthesia in a patient treated with low-dose heparin

Failed spinal anaesthesia for left total hip arthroplasty was followed postoperatively by dense motor paralysis and sensory deficit in the right leg. The patient had received a dose of subcutaneous heparin 1 h before the spinal anaesthetic was attempted. She died of pulmonary embolism on the ninth postoperative day. At autopsy extensive haematomyelia was found in relation to the needle track.     

Anatomic considerations in relation to the maxillary nerve block

BACKGROUND AND OBJECTIVES: To determine the length of the needle that should be used to reach the maxillary nerve after the lateral pterygoid plate has been contacted. METHODS: The study was conducted on patients and skulls. Patient study: The distances from skin at the midpoint of lower border of zygomatic arch to lateral pterygoid plate and to the point where a paresthesia in the distribution of maxillary nerve was obtained were measured in 75 patients. Osteologic study: The distance from the midpoint of lower border of zygomatic arch to lateral pterygoid plate and to a probe inserted from the orbital aspect through the inferior orbital fissure and pterygopalatine fossa into the foramen rotundum (representing maxillary nerve) was measured in 120 skulls. RESULTS: Patient study: The distance to the point where paraesthesia occurred was more than that to the lateral pterygoid plate by 0.21 cm on the right side and 0.22 cm on the left side. Osteologic study: The distance to the probe in the pterygopalatine fossa was more than the distance to lateral pterygoid plate by 0.13 cm on the right side and 0.14 cm on the left side. CONCLUSIONS: The needle should not be advanced by more than approximately 0.25 cm beyond the distance to the pterygoid plate while performing maxillary nerve block by the lateral extraoral approach.     

Evaluation of Monaldi’s approach with regard to needle decompression of the tension pneumothorax—A cadaver study

BackgroundAlthough needle decompression of tension pneumothorax through the second intercostal space in the midclavicular line (Monaldi’s approach) is a life-saving procedure, severe complications have been reported after its implementation. We evaluated the procedure by comparing how it was performed on cadavers by study participants with different training levels.MethodsSix participants including one thoracic surgeon performed bilateral thoracic drainage after Monaldi on 82 torsos. After the thoraces were opened, the distances from the internal thoracic artery (A), the site of the puncture (B) and the midclavicular line (C) were measured bilaterally with reference to the median of the sternum. Further, it was determined whether the participants had correctly identified the second intercostal space. The differences between B-A and C-B were analysed.ResultsThe needle was placed in the second intercostal space in 136 hemithoraces (83%). The thoracic surgeon showed a hit rate of 0% laceration of adjacent vessels. All the other participants had hit rates between 10% and 15%. The interval B-A ranged from 2.88 to 5.06 cm in right and from 3.00 to 5.00 cm in left hemithoraces. The distance C-B lay between 1.03 cm and 1.87 cm (right side), and 0.84 cm and 2.02 cm (left side).ConclusionIn our collective, the main problem was failure to assess correctly the lateral extension of the clavicle. If this fact is emphasized during training, Monaldi’s approach is a safe method for needle decompression of pneumothorax.     

Penetration forces in cannulation of the dorsal veins of the hand: I. A comparison between polyurethane (Insyte®) and polytetrafluoroethylene (Venflon®) cannulae

The functional tip tapering design of peripheral venous cannulae (introducer steel needle + catheter) made of polyurethane (PUR-Instye) and polytetrafluoroethylene (PTFE-Venflon) was studied with 3 techniques: A) Scanning electron microscopy (SEM). B) Measurement of penetration forces in vitro through latex membranes and lamb skins with a tensile-compression apparatus (Instron-1122) at 1) the introducer steel-needle point, 2) the needle heel (the spot marking the passage from the point of the needle to its shaft). 3) the catheter top (i.e. the beginning of the plastic sheath), 4) the catheter tip, i.e. the beginning of the largest diameter of the plastic sheath, and 5) between the catheter tip and its hub (catheter friction). C) Two cannulae (one of each type for every subject were inserted at random into the dorsal veins of the left and right hand in 37 volunteers, and the penetration forces were measured with a force transducer. Results: A) The PUR-cannulae had a lancet-like appearance and a smoother transition at the catheter top, whilst the PTFE cannulae were arrow-like, cut back and had a less accentuated conical design. B) Penetration forces in vitro through latex membranes were 9-41 times lower (P less than 0.0001) than those through the large skins. The highest forces (mean +/- s.d.) registered in vitro (lamb skins) were 4.1 +/- 0.2 Newtons (N) with PUR-cannulae at the catheter tip, and 3.4 +/- 0.6 with the PTFE-cannulae at the catheter top (P less than 0.05). C).(ABSTRACT TRUNCATED AT 250 WORDS)     

Easier hepatic resections with a straight needle

BACKGROUND: A stainless-sheathed, straight needle with a hook near the top of the inner needle was designed to facilitate hepatic resections. METHODS:First, using this needle, two rows of interlocking mattress sutures were made along the division line; then, hepatic transection was performed between these rows by electrocautery or forceps. RESULTS: Since 1997, we have performed this kind of hepatic resections in 43 cases, including 9 right lobectomies, 5 bisegmentectomies, 7 segmentectomies, 4 subsegmentectomies, 2 partial hepatectomies, 15 left lateral segmentectomies, and 1 hepatorrhaphy. In most cases, intraoperative hemorrhage was minimal. Neither specified inflow nor backflow control procedures were needed. CONCLUSION: Use of this needle may reduce the difficulty of the technique and blood loss for right hepatic lobectomy, left lateral segmentectomy, and some segmental or partial hepatectomy procedures.     

Two cases of renal angiomyolipoma

Two cases of renal angiomyolipoma without tuberous sclerosis are reported. The first case was of a 35-year-old man with complaints of right upper abdominal and right flank pain. Preoperative diagnosis was right renal angiomyolipoma. Thoracoabdominal radical nephrectomy and lymphadenectomy were performed. The pathological diagnosis was renal angiomyolipoma with lymph node involvement. The second case was of a 46-year-old woman whose left renal mass had been accidentally found by ultrasound study. Preoperative diagnosis was left renal angiomyolipoma. This tumor was enucleated from the left kidney through flank incision.     

Percutaneous electrode placement for spinal cord stimulation in a patient with spinal fusion: a technical report

A spinal cord stimulation (SCS) trial was attempted to alleviate left knee pain in a patient with spinal fusion from T12 to L4. Good paresthesia coverage for the knee pain was attained with SCS. However, while removing the needle used for electrode placement, the needle became fixed in the bony supplementary tissue. Moreover, while attempting to remove the needle using Kelly forceps, the hub of the needle became blocked. Without the hub, we had no choice but to use a pneumatic drill for removing the needle. Accordingly, the supplementary bone tissue was drilled under real-time imaging, using a pneumatic drill with a 3.2-mm drill bit, and another epidural needle was inserted through the hole. We consider that, in patients with spinal fusion, making a borehole with a pneumatic drill for introducing the epidural needle for percutaneous SCS electrode placement may be advisable in order to avoid the above-mentioned difficulties.     

Thoracoscopic lobectomy for an infected intrapulmonary bronchogenic cyst

A 19-year-old male who presented with cough and fever was found to have an 8-cm cyst in his left lung. Video-assisted thoracoscopic left lower lobectomy was performed. The cyst had to be decompressed by needle aspiration prior to retrieval through a 5-cm minithoracotomy. The patient was discharged on postoperative day 4 in good condition. The technical aspects form the basis of this report.