Fetal spinal-cord allograft as a substitute for peripheral-nerve reconstruction: a preliminary experimental and histologic study

The aim of this preliminary experimental study consisted of an exploration of the suitability of fetal spinal-cord allograft as an alternative guiding conduit for bridging peripheral-nerve defects, since fetal tissue is considered to be less immunogenic than tissue from adults or maturely born individuals. The experiment was carried out with 10 Long Evans inbred rats. Within the control group, autologous sural-nerve grafts served to bridge an artificially created defect of 1.5 cm along the course of the sciatic nerve in the thigh of adult male rats. On the contralateral thigh, a defect of the same size was bridged by spinal cord, taken from 17- to 20-day old fetuses. Ten weeks thereafter, the reconstructed nerves were examined histologically. Compared to the autologous nerve grafts with optimal regeneration, the spinal-cord grafts showed less ingrowth of axons. But, surprisingly, an exceptionally long survival time of astrocytes and other nerve cells resulted while, at the graft margin, bundles of astrocytes apparently served as a conduit for ingrowing axons. Using fetal spinal-cord allograft to reconstruct peripheral-nerve defects may present a future alternative for coexisting methods, but further studies with longer follow-ups, a greater number of larger animals, and with the additional evaluation of immunologic interactions, should be attempted, to draw clear conclusions.     

Regional anaesthesia for labor adn delivery in a parturient with neuropathy with liability to pressure palsy (tomaculous neuropathy)

Tomaculous neuropathy (or hereditary neuropathy with liability to pressure palsy [HNLPP]) is a rare and hereditary disease which incidence has probably been underestimated. It is characterised by demyelination resulting in numbness and weakness after nerve pressure, injury or stretch. Despite a well-documented genetic pathophysiologic mechanism, implications for anaesthesia in patients with HNLPP are only speculative and the use of regional anaesthesia is debatable. We report here the case of a patient with HNLPP who was followed during two consecutive pregnancies in the same hospital and for whom an expert of the SOS-RA hotline service was consulted before each delivery. For the first delivery, epidural analgesia was performed for labour pain control but a caesarean section was necessary because of failure to progress (0.0625% bupivacaine with 0.2 microg/ml sufentanil for labour then 2% lidocaine with adrenaline for surgery). Two years later, the patient was again seen for a preanaesthetic visit because elective Caesarean section was planned. Spinal anaesthesia using hyperbaric bupivacaine and sufentanil was used. Both deliveries were uneventful and there were no neurologic complaints in the postpartum periods.     

Anesthetic management of a patient with progressive supranuclear palsy

A 74-year-old woman with progressive supranuclear palsy (PSP) was scheduled for laryngotracheal separation surgery. Her neck showed severe backward tilt as a symptom of PSP. Magnetic resonance imaging (MRI) showed a significant airway stenosis due to the neck deformity. In the operating room, awake orotracheal intubation failed because of the neck deformity and airway stenosis. Therefore, tracheotomy was performed for airway management. General anesthesia was induced and maintained with sevoflurane (1.0%–2.5%) and fentanyl (total, 200 μg). Vecuronium (total, 5 mg) was used as a muscle relaxant. Monitoring of the train-of—four ratio in the ulnar nerve was impossible because of contracture of the fingers. Patients with PSP may have some serious associated deformities, and specific management, especially for the airway, may be necessary for general anesthesia.     

Radial neck fractures in children: a management algorithm

Fractures of the radial neck in children are relatively rare. The outcome is dependent not only on the injury but also on the method of treatment and the presence of any associated injury. During the past 20 years, two new minimally invasive reduction techniques have been described in an attempt to improve the prognosis, and their results have been reported. A meta-analysis of the recent literature with the focus on outcome, and a management algorithm for this rare fracture are presented.     

Mycobacterium ulcerans ulcers: a proposed surgical management algorithm

Mycobacterium ulcerans (MU) is the third common mycobacterial infection after tuberculosis and leprosy. In endemic areas, MU ulcers should be considered in the differential diagnosis of any unusual or nonhealing lesion or ulcer. Diagnosis and treatment should be instigated promptly. Delay may lead to disfiguring or disabling scars. Surgical management, therefore, should aim towards early excision, with clear margins of the ulcer.We present 4 consecutive patients treated by our department within a 6-month period for MU ulcers. The presentation, diagnosis and surgical management are described. Based on our experience and after reviewing the literature, we have developed a surgical algorithm for the management of MU ulcers.     

Anaesthesia and pain management in cerebral palsy

Cerebral palsy is the result of an injury to the developing brain during the antenatal, perinatal or postnatal period. Clinical manifestations relate to the area affected. Some of the conditions associated with cerebral palsy require surgical intervention. Problems during the peri-operative period may include hypothermia, nausea and vomiting and muscle spasm. Peri-operative seizure control, respiratory function and gastro-oesophageal reflux also require consideration. Intellectual disability is common and, in those affected, may range from mild to severe. These children should be handled with sensitivity as communication disorders and sensory deficits may mask mild or normal intellect. They should be accompanied by their carers at induction and in the recovery room as they usually know how best to communicate with them. Postoperative pain management and the prevention of muscle spasm is important and some of the drugs used in the management of spasm such as baclofen and botulinum toxin are discussed. Epidural analgesia is particularly valuable when major orthopaedic procedures are performed.     

Progressive systemic sclerosis: Intrathecal pain management

Background and Objectives. At present, there is no reliable method for long-term treatment of severe pain from progressive systemic sclerosis (PSS) associated with Raynaud's phenomena leading to ischemia and ulcerations of the extremities. Long-term continuous intrathecal (IT) buprenorphine/bupivacaine analgesia was used in such a case. Methods. The patient was a 71-year-old woman in whom conservative treatment, including opioids, dorsal column stimulation, and epidural bupivacaine, had failed to provide satisfactory, long-term relief for her severe lower extremity pain. An 18-gauge Portex intrathecal catheter was inserted via the L4–L5 interspace. An infusion of 4.75 mg/mL bupivacaine and 0.015 mg/mL buprenorphine was started from a portable Pharmacia-Deltec (St. Paul, MN) pump at a rate of 0.1 mL/h with optional bolus doses of 0.1 mL, 2–4 times/h by patient controlled intrathecal analgesia. The rate was adjusted to give the patient satisfactory (80–100%) pain relief. Results. The IT treatment was continued with 0.1 mL (≈0.5 mg/h bupivacaine) for most of the time (mean dose = 18.6 mg/d). This treatment gave the patient 90–100% pain relief, which subsequently improved the quality of her life. Nocturnal sleep duration increased from 2 hours before to 7–8 hours during the IT treatment. The treatment was complicated by transient postdural puncture headache and further by meningitis, successfully treated with parenteral and intrathecal antibiotics. Every attempt to increase the IT bupivacaine to > 20 mg/d led to transient urinary retention, paresthesia, and reduced motor strength in the lower extremities accompanied by gait disturbances. The IT treatment lasted for 861 days (of which 580 days were spent at home), until the patient's death, not related to the treatment. Conclusion. Intrathecal infusion of buprenorphine/bupivacaine provided satisfactory long-term pain relief in a patient with PSS-associated Raynaud's phenomena, skin ulcerations, and intractable ischemic pain.     

Issues and challenges in diabetic neuropathy management: A narrative review

Diabetic neuropathy (DN) is a devastating disorder with an increasing prevalence globally. This epidemic can pose a critical burden on individuals and com-munities, subsequently affecting the productivity and economic output of a country. With more people living a sedentary lifestyle, the incidence of DN is escalating worldwide. Many researchers have relentlessly worked on ways to combat this devastating disease. Their efforts have given rise to a number of commercially available therapies that can alleviate the symptoms of DN. Unfortunately, most of these therapies are only partially effective. Worse still, some are associated with unfavorable side effects. This narrative review aims to highlight current issues and challenges in the management of DN, especially from the perspective of molecular mechanisms that lead to its progression, with the hope of providing future direction in the management of DN. To improve the approaches to diabetic management, the suggested resolutions in the literature are also discussed in this review. This review will provide an in-depth understanding of the causative mechanisms of DN, apart from the insights to improve the quality and strategic approaches to DN management.     

Epidural analgesia in labour for a patient with hereditary neuropathy with liability to pressure palsy

Hereditary neuropathy with liability to pressure palsy (HNPP) is a rare but probably under-diagnosed disorder of peripheral nerves in which individuals suffer from repeated motor and sensory neuropathies (pressure palsies) following brief nerve compression or mild trauma. A seemingly trivial insult such as sitting or kneeling may result in a focal neurological deficit lasting for hours to months. Despite the growing recognition of this problem, information regarding the anaesthetic management of labour is sparse. We present a woman with HNPP who was provided with a modified epidural regimen (low concentration bupivacaine and fentanyl) for analgesia in labour and delivery. Labour progressed uneventfully and there were no neurological sequelae following delivery.     

Femoral neuropathy following total hip arthroplasty: review and management guidelines

Femoral neuropathy following primary or revision total hip arthroplasty (THA) is a rare but acknowledged complication. Treatment of femoral neuropathy has long been debated and there is a paucity of accepted principles on which to base management. Currently, no definitive management protocol exists in the literature. A literature search was performed by a review of PubMed, Google Scholar and OVID articles published from 1972-2011. The literature reports an incidence rate of femoral neuropathy following THA ranging from 0.1 to 2.4 percent. Determining the precise aetiology, establishing a diagnosis and subsequent treatment of femoral nerve injury remains a difficult task, with conservative management remaining the treatment benchmark. In this review, we aim to summarise the aetiologies and risk factors associated with femoral neuropathy following THA and provide management guidelines.     

Guyon Canal Syndrome: lack of management in a case of unresolved handlebar palsy

Objective:

To present the clinical diagnostic features including management of Guyon canal syndrome in a case with unresolved sensory deficits in a young female cyclist.

Clinical Presentation:

After 14 days of cycling across Canada, a 23-year old female experienced sensory loss, followed by atrophy and a “claw” hand appearance of her left hand.

Intervention and Outcome:

Treatment included cervical chiropractic manipulation, soft tissue therapy and the use of cycling gloves. Seven years after the initial injury a lack of sensation in the ulnar nerve distribution of her left hand has persisted.

Discussion:

This case demonstrates that a lack of proper management can lead to permanent sensory loss and is worth highlighting. Various therapists evaluated the patient’s symptoms and provided minimal care. No diagnosis was given, nor were appropriate measures taken for her to understand the risks of continuing to ride.

Summary:

Although treatment for Guyon Canal Syndrome can be as easy as cessation from cycling until symptoms subside, other treatment options could be utilized to help manage ulnar nerve compression injuries in cyclists.     

Foreign body ingestion and management: "I swallowed a crack pipe"

There is a wide variety of objects that find their way into the human gastrointestinal tract, either accidentally or deliberately. In this case a crack pipe was ingested in its entirety. Despite the seemingly rare and random nature that this scenario presents, this patient's care serves to reinforce what should be done to successfully manage a patient with an ingested foreign body, as well as the important issues related to crack cocaine abuse.     

Nonoperative management of acute epidural hematomas: a "no-brainer"

BACKGROUND: Acute epidural hematomas are generally considered to require urgent operation for clot evacuation and bleeding control. It has become increasingly apparent, however, that many epidural hematomas will resolve with nonoperative management. The purpose of the current study was to review our experience with nonoperative management of acute epidural hematomas. METHODS: Patients admitted to our busy urban level I trauma center with an epidural hematoma were identified using our trauma registry. Patients were excluded if they suffered other significant intracranial injury mandating operative intervention. Patient records were reviewed and relevant data collected. Patients who required subsequent craniotomy were compared to those who did not in order to identify risk factors for failure of nonoperative treatment. RESULTS: Between January 1995 and June 2004, 84 patients were identified. The mean age was 27 +/- 1.6 years and 68 (81%) were male. Mean Glasgow Coma Scale in the emergency department was 13.7 +/- 0.3. The most common mechanism of injury was a fall. Fifty-four (64%) patients were initially managed nonoperatively and 30 (36%) were taken directly to the operating room for craniotomy. Nonoperative management was successful in 47/54 (87%) patients. Failure of initial nonoperative management was not associated with adverse outcome. There were no deaths in patients managed operatively or nonoperatively. Seventy-two (86%) patients were discharged to home with excellent neurologic outcome. CONCLUSIONS: Epidural hematomas can be successfully managed nonoperatively in an appropriately selected group of patients. Moreover, failure of initial nonoperative management has no adverse effect on outcome.     

Evaluation of the acute cervical spine: a management algorithm

BACKGROUND: Safe, efficient, and cost-effective evaluation of the spine is the goal in the trauma setting. At our Level I trauma facility, the trauma service, emergency medicine, radiology, anesthesia, and the spine service combined individual concerns into one agreed-upon clearance protocol. Here, we present the effectiveness of a new cervical spine clearance protocol. METHODS: A retrospective review was initiated of all trauma patients evaluated in a Level I trauma center the year before and after implementation of a new cervical spine protocol to determine the incidence of missed cervical injuries. An additional 6 months were reviewed to detect any missed injuries late in the study period. RESULTS: During the 2-year study period, 4,460 patients presented to the emergency room with some form of cervical spine precautions. Blunt trauma comprised 90% of the study population. According to the protocol, approximately 45% required further cervical radiographs after presentation. In the preprotocol year, 77 of 2,217 (3.4%) patients were diagnosed with cervical spine injuries, 16 of 77 (21%) with multiple level of injuries, and 25 of 77 (32%) with neurologic compromise. Three of 2,217 patients had missed cervical spine injuries on their initial evaluations. In the postprotocol year, 84 of 2,243 (3.4%) patients had cervical injuries, 25 of 84 (30%) with multiple levels of injuries and 28 of 84 (28%) with neurologic compromise. No patient evaluated during the protocol year was missed. All statistics between the two groups were not significant. CONCLUSION: The current protocol by risk stratifying patients on presentation is effective in assessing patients for cervical spine injuries.