Spinal epidural abscess with myelitis and meningitis caused by Streptococcus pneumoniae in a young child

Background

Spinal epidural abscess (SEA) in children is a rare infectious emergency warranting prompt intervention. Predisposing factors include immunosuppression, spinal procedures, and local site infections such as vertebral osteomyelitis and paraspinal abscess. Staphylococcus aureus is the most common isolate.

Design

Case report and literature review.

Findings

A 2.5-year-old boy with tetraparesis was found to have an SEA in the posterior lumbar epidural space with evidence of meningitis and myelitis on MRI spine in the absence of any local or systemic predisposing factors or spinal procedures. Streptococcus pneumoniae was isolated from the evacuated pus.

Conclusions

Definitive treatment of SEA is a combination of surgical decompression and iv antibiotics. Timely management limits the extent of neurological deficit.     

Acute epidural lipedema: a novel entity and potential complication of bone morphogenetic protein use in lumbar spine fusion

Background context

Bone morphogenetic proteins (BMPs) induce osteogenesis, making them useful for decreasing time to union and increasing union rates. Although the advantages of BMP-2 as a substitute for iliac crest graft have been elucidated, less is known about the safety profile and adverse events linked to their use in spinal fusion. An accumulation of reactive edema in the epidural fat may lead to neural compression and significant morbidity after lumbar spinal fusion. Bone morphogenetic protein has never been implicated as a cause of spinal epidural lipedema.

Purpose

We report on a case of rapid accumulation of edematous adipose tissue in the epidural space after lumbar spine decompression and fusion with bone morphogenic protein.

Study design

Case report.

Methods

The patient was a 45-year-old woman with chronic back pain, worsening bilateral L5 radiculopathy, and degenerative disc disease. Surgery consisting of a one-level transpedicular decompression, transforaminal lumbar interbody fusion, and posterolateral fusion was performed using BMP-2 as an adjunct for arthrodesis.

Results

Two days postoperatively, the patient developed progressive cauda equina syndrome. Lumbar magnetic resonance imaging revealed edematous epidural fat extending above the initial laminectomy, compromising the spinal canal, and compressing the thecal sac. Emergent laminectomies at L3, L4, and L5 were performed, and intraoperative pathology revealed edematous epidural adipose tissue. The patient's cauda equina syndrome resolved after spinal decompression and the removal of epidural fat. Final cultures were negative for infection, and histology report yielded an accumulation of edematous fibroadipose tissue.

Conclusions

We present a case of rapid accumulation of edematous adipose tissue causing cauda equina syndrome after a lumbar decompression and fusion surgery. The acute nature and extensive development of the lipedema presented in this case indicate an intense inflammatory reaction. We hypothesize that there may be a link between the use of BMP-2 and the accumulation of this edematous tissue. A thorough understanding of the mechanisms of BMP-2 and specific guidelines for their role in spinal surgery may improve functional outcomes and reduce the number of preventable complications. To the best of our knowledge and after a thorough literature search, this is the only reported case of epidural lipedema causing cauda equina syndrome.     

Whole cerebrospinal axis infection after lumbar epidural injection: a case report

Purpose

Lumbar epidural injection is a popular treatment for degenerative lumbar disease. Although post-procedural epidural infection is rare, meningitis and epidural abscess are life-threatening conditions, and need additional medical and surgical intervention. The purpose of this article is to report a patient with fatal whole cerebrospinal axis infection after lumbar epidural injections.

Methods

A 64-year-old female patient presented with septic shock and quadriparesis. In the past, this patient had received lumbar epidural injections several times for degenerative spondylolisthesis at L4-5 in another hospital. The magnetic resonance imaging showed epidural abscess, a compressed dura and spinal cord from C1 to S2, and cerebral meningitis. We performed laminectomies and removal of the abscesses. Her mental status was diminished to a deep, drowsy state after three postoperative weeks. Brain computed tomography scans revealed hydrocephalus. Therefore, ventriculoperitoneal shunting was performed.

Results

Methicillin resistant Staphylococcus epidermidis was cultured from blood samples. The patient’s infection was completely controlled and her mental status improved to alert; however, her quadriparesis remained.

Conclusions

Although lumbar epidural injection is an effective procedure to treat lumbar radicular pain, this procedure can induce fatal complications such as sepsis and epidural abscess.

Level of evidence

5.

     

Cervicothoracic intraspinal pseudomeningocele with cord compression after a traumatic brachial plexus injury

Background context

Pseudomeningoceles are noted within the neural foramen after avulsion plexus injuries. We present the case of a cervicothoracic epidural pseudomeningocele with spinal cord compression 18 years after a brachial plexus injury.

Purpose

To present a case report of a patient and literature review on cases with epidural pseudomeningoceles.

Study design

Case report and review of the literature.

Methods

Retrospective review of the medical records of a patient presenting with an epidural pseudomeningocele after a plexus injury.

Results

A 37-year-old male presented with neurological decline 18 years after sustaining a brachial plexus injury. Magnetic resonance tomography revealed an epidural fluid collection from C5 to T7 with significant spinal cord compression. Surgical intervention initially involved fenestration of the cyst and then rhizotomies of the C7 and C8 roots resulting in resolution of his new symptoms.

Conclusions

Pseudomeningoceles are common after brachial plexus avulsion injury and are usually stable, causing no symptoms, other than plexus neuropathies. We are unaware of previous reports of a patient with a traumatic brachial plexus avulsion who developed a large cervicothoracic, symptomatic, spinal, epidural, intracanalicular pseudomeningocele with cord compression 18 years after the initial injury. Patients with prior trauma and known plexus injuries with development of new neurological symptoms should be evaluated for the rare case of intradural pseudomeningoceles. Preoperative imaging with computed tomography myelography is important to isolate and definitively treat the fistulous connection.     

The difficult hepaticojejunostomy after pancreatic head resection: reconstruction with a T tube

Background

After pancreatic head resection, bile leaks from a difficult hepaticojejunostomy secondary to a small or fragile common hepatic duct may be reduced by a T tube at the side of the anastomosis.

Methods

A retrospective analysis of patients who underwent a difficult hepaticojejunostomy without or with a T tube was performed.

Results

In 48% (55/114) of patients, a T tube was placed at the side of the hepaticojejunostomy; 52% (59/114) did not have a T tube. Bile leaks occurred in 12% (14/114) (9% [5/55] in patients with a T tube vs 15% [9/59] without a T tube, P = .316). Bile leaks were associated with mortality, abscess formation, hemorrhage, and sepsis. Seven percent (8/114) of patients required revisional laparotomy (2% [1/55] with a T tube vs 12% [7/59] without a T tube, P = .036). Mortality was not different between the groups. Minor T-tube–associated complications occurred in 15% (8/55) without major complications.

Conclusions

Augmentation of anastomosis with a T tube cannot prevent biliary leakage but does reduce the severity of bile leaks, resulting in less reoperations.     

Life after colectomy for fulminant Clostridium difficile colitis: a 7-year follow up study

Background

The long-term prognosis of patients undergoing colectomy for fulminant Clostridium difficile colitis has not been well studied. The authors present 7-year survival trends in such patients.

Methods

Patients were identified through a pathologic database. Medical records were reviewed and follow-up phone calls made to determine relevant patient history, longevity, and quality of life.

Results

The 61 patients identified had mean and median survival of 18.1 and 3.2 months, respectively, and 1-year, 2-year, 5-year, and 7-year mortality of 68.5%, 79.6%, 88.9%, and 90.7%, respectively. Previous C difficile infection, hypotension, requirement of vasopressors, mental status changes, elevated arterial lactate, decreased platelet counts, intubation, and longer duration on nonoperative therapy were associated with in-hospital mortality. There were no factors correlated with long-term survival.

Conclusions

Patients who require colectomy for fulminant C difficile colitis have a poor prognosis with poor long-term survival and significant morbidity. Although there are several factors associated with in-hospital mortality, there were no factors correlated with long-term survival.     

Epidural abscess and cauda equina syndrome after percutaneous intradiscal therapy in degenerative lumbar disc disease

Background context

Percutaneous intradiscal therapies are gaining popularity as a regenerative treatment option for spinal disc degeneration. The risks, benefits, and possible complications associated with such procedures have been poorly defined. As these procedures are performed with increasing frequency, the likelihood that clinicians will be faced with significant complications also increases.

Purpose

The purpose of this study is to describe a significant complication of a percutaneous intradiscal bone marrow and adipose tissue transplantation for symptomatic lumbar disc degeneration.

Study design

The study design is a case report.

Methods

Two weeks after an injection of adipose cells, bone marrow aspirate and plasma into his L3–L4 and L5–S1 lumbar discs, a 64-year-old patient presented to the emergency room with cauda equina syndrome, fever, and back pain. Magnetic resonance imaging diagnosed L3–L4 disc extrusion, discitis with osteomyelitis, and epidural abscess, resulting in emergency decompressive surgery. An epidural abscess was drained, extruded disc material was removed, and cultures obtained. Five days later, once afebrile on antibiotics, he underwent a definitive interbody arthrodesis and stabilization.

Results

Cauda equina syndrome resolved, osteomyelitis (methicillin-resistant Staphylococcus epidermidis) was treated, and instrumented arthrodesis stabilized the involved segment.

Conclusions

Complications associated with the intradiscal injection of agents, such as stem cells, fibrin glue, adipose tissue, or bone marrow, have been poorly defined. Given the nature of the degenerating disc, serious adverse events, including discitis, osteomyelitis, and extrusion of disc contents, may occur.     

Analgésie péridurale pour le traitement chirurgical des carcinoses péritonéales : une pratique à risque ?

Background

To study the risks of haemodynamic instability, and the possible occurrence of spinal haematoma, meningitis and epidural abscess when epidural analgesia is performed for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).

Methods

We retrospectively analyzed the data of 35 patients treated by HIPEC with oxaliplatin or cisplatin. An epidural catheter was inserted before induction of general anaesthesia. Postoperatively, a continuous epidural infusion of ropivacain, then a patient-controlled epidural analgesia were started.

Results

The epidural catheter was used peroperatively before HIPEC in 12 subjects (34%), and after HIPEC in 23 subjects (66%). The median dose of ropivacain given peroperatively in the epidural catheter was 40 mg (30–75). Norepinephrin was used in two subjects (6%) peroperatively (median infusion rate 0.325 μg/kg per minute [0.32–0.33]), and in four subjects (11%) in the postoperative 24 hours. No spinal haematoma, meningitis or epidural abscess were noted. Five subjects (14%) had a thrombopenia or a prothrombin time less than 60% before catheter removal. Two subjects (6%) had a leukopenia before catheter removal. No thrombopenia or blood coagulation disorders were recorded the day of catheter removal.

Conclusion

In this series of 35 patients, the use of epidural analgesia for HIPEC does not seem to be associated with a worse risk of haemodynamic instability, spinal haematoma, meningitis or epidural abscess. HIPEC with platinum salt is not incompatible with the safety of epidural analgesia, with an optimized fluid management peroperatively and the following of perimedullary anesthesia practice guidelines.     

The incidence of epidural abscess following epidural analgesia in open abdominal aortic aneurysm repair

INTRODUCTION

Complications of epidural catheterisation can cause significant morbidity. Epidural abscess following epidural catheterisation is rare and the reported incidence is variable. The purpose of this study was to review the incidence of epidural abscess in patients undergoing open abdominal aortic aneurysm (AAA) repair.

PATIENTS AND METHODS

A retrospective case note review of all patients having open AAA repair over a 5-year period.

RESULTS

A total of 415 patients underwent open AAA repair between January 2003 and March 2008. Of these, 290 were elective procedures and 125 were for ruptured aneurysms. Six patients underwent postoperative magnetic resonance imaging of the spine for clinical suspicion of an epidural abscess. Two of these (0.48%) had confirmed epidural abscess and two superficial infection at the epidural site.

CONCLUSIONS

The incidence of epidural abscess following epidural analgesia in patients undergoing open AAA repair within our department was 0.48%. Although a rare complication, epidural abscess can cause significant morbidity. Epidural abscesses rarely develop before the third postoperative day.     

Therapy with anti-flagellin A monoclonal antibody limits Pseudomonas aeruginosa invasiveness in a mouse burn wound sepsis model

Background

The aim of this study was to evaluate the effect of an anti-flagellin sub-type monoclonal antibody (anti-fla-a) on Pseudomonas aeruginosa infection in a mouse burn model and to assay bacterial dissemination and invasiveness.

Methods

After immediate post-burn infection with P. aeruginosa, mortality and morbidity (daily weight changes) were monitored in mice treated with anti-fla-a as compared to untreated mice. Bacterial dissemination and invasiveness were monitored by bacterial counts at the burn site and spleen. Three different timing regimens for anti-fla-a treatment were studied: (a) prophylaxis (pre-infection), (b) therapeutic (post-infection), and (c) combined mode.

Results

Combined regimen of anti-fla-a markedly improved survival of mice infected with P. aeruginosa from 6% to 96% (p < 0.0001), similar to treatment with Imipenem. Furthermore, a significant improvement in survival was obtained when anti-fla-a was given prior to (75% survival) or post-infection (50% survival). It reduced bacterial load in the spleen (p = 0.01), preventing bacterial sepsis.

Conclusion

Anti-fla-a is effective in reducing mortality and morbidity in murine P. aeruginosa-infected burn model.     

Acute spinal subdural hematoma with hemiplegia after acupuncture: a case report and review of the literature

Background context

Subdural spinal hematoma (SDH) is a very rare entity; however, it can lead to serious complications resulting from injuries to the spinal cord and roots. Although acupuncture has been a popular method for the management of pain control, we encountered the first case of SDH after acupuncture.

Purpose

The purpose of this case report was to present the first case of subdural hematoma after acupuncture and the reasons for the risks of blind cervical acupuncture.

Study design

A case report and review of the previous literature are presented.

Methods

A 69-year-old man complained of progressive weakness in the right upper and lower extremities 2 hours after acupuncture on the cervical spine and back. The diagnosis was delayed because of unilateral weakness, and the symptom was initially misinterpreted as a transient ischemic attack because of no sensory change and pain and normal findings of two brain magnetic resonance imaging (MRI).

Results

Cervical MRI 36 hours after onset revealed acute hematoma from the C3–C5 level; hematoma showed an isointensity on T1-weighted image (WI) with the preservation of epidural fat and a hypointensity on T2WI. A decompressive surgery was scheduled to perform within 2 days after the cervical MRI scan because of a previous anticoagulation therapy, but the patient refused it. Finally, 9 days after the onset, surgical decompression and removal of hematoma were performed. Three months postoperatively, the patient had fully recovered demonstrating fine hand movement and good ability to walk up and down the stairs.

Conclusions

Our study indicates that it is essential to perform cervical MRI when a patient does not show an improvement in the neurologic deficit and has a negative brain MRI after acupuncture. In addition, blind acupuncture if not correctly practiced may be harmful to the cervical structures.     

Excrescence of neurotransmitter glutamate from disc material has nociceptive qualities: evidence from a rat model

Background context

The authors have previously demonstrated that herniated human lumbar disc is rich in free glutamate from degradation of aggrecan. Prior data have suggested that free glutamate could contribute to a nociceptive state.

Purpose

Previous behavioral experiments suggested glutamate-related nociception by comparing pre- and postglutamate infusion responses only. This indirectly suggested nociceptive effects of epidural glutamate but was not a definitive evidence. Now, by using larger numbers of subjects, we have demonstrated that lumbar epidural glutamate infusion causes significant left-to-right differences in hind paw response during treatment, demonstrating more directly the focal nociceptive effects of glutamate.

Study design

Behavioral studies and immunohistochemistry were used to assess for evidence of a nociceptive state. All researchers were blinded to infusion solution.

Methods

Via an implanted mini osmotic pump, the epidural space of rats was infused with 0.02 mM glutamate or normal saline for 72 hours. Signs of nociception were assessed by von Frey and plantar thermal stimulation testing and by glutamate receptor expression in the corresponding dorsal horn of the spinal cord and dorsal root ganglion.

Results

Both von Frey mechanical and plantar thermal stimulations showed differences in hind paw reactivity depending on whether it was on the ipsilateral or contralateral side of glutamate infusion. Saline infusion had no significant behavioral effects. Dorsal horn expression of 2-amino-3-(5-methyl-3-oxo-1,2-oxazol-4-yl) propanoic acid and N-methyl-d-aspartic acid receptors was significantly increased in glutamate-infused animals, further indicative of a nociceptive state related to glutamate infusion.

Conclusions

Elevated epidural glutamate concentrations caused a focal hyperesthetic state. Increased epidural glutamate concentration could be a driving force or “chemical” component of disc-related radiculopathy.     

Reoperation rate after surgery for lumbar spinal stenosis without spondylolisthesis: a nationwide cohort study

Background context

Lumbar spinal stenosis is one of the most common degenerative spine diseases. Surgical options are largely divided into decompression only and decompression with arthrodesis. Recent randomized trials showed that surgery was more effective than nonoperative treatment for carefully selected patients with lumbar stenosis. However, some patients require reoperation because of complications, failure of bony fusion, persistent pain, or progressive degenerative changes, such as adjacent segment disease. In a previous population-based study, the 10-year reoperation rate was 17%, and fusion surgery was performed in 10% of patients. Recently, the lumbar fusion surgery rate has doubled, and a substantial portion of the reoperations are associated with a fusion procedure. With the change in surgical trends, the longitudinal surgical outcomes of these trends need to be reevaluated.

Purpose

To provide the longitudinal reoperation rate after surgery for spinal stenosis and to compare the reoperation rates between decompression and fusion surgeries.

Study design/setting

Retrospective cohort study using national health insurance data.

Patient sample

A cohort of patients who underwent initial surgery for lumbar stenosis without spondylolisthesis in 2003.

Outcome measures

The primary end point was any type of second lumbar surgery. Cox proportional hazards regression modeling was used to compare the adjusted reoperation rates between decompression and fusion surgeries.

Methods

A national health insurance database was used to identify a cohort of patients who underwent an initial surgery for lumbar stenosis without spondylolisthesis in 2003; a total of 11,027 patients were selected. Individual patients were followed for at least 5 years through their encrypted unique resident registration number. After adjusting for confounding factors, the reoperation rates for decompression and fusion surgery were compared.

Results

Fusion surgery was performed in 20% of patients. The cumulative reoperation rate was 4.7% at 3 months, 7.2% at 1 year, 9.4% at 2 years, 11.2% at 3 years, 12.5% at 4 years, and 14.2% at 5 years. The adjusted reoperation rate was not different between decompression and fusion surgeries (p=.82). The calculated reoperation rate was expected to be 22.9% at 10 years.

Conclusions

The reoperation rate was not different between decompression and fusion surgeries. With current surgical trends, the reoperation rate appeared to be higher than in the past, and consideration of this problem is required.     

Outcomes of primary fascial closure after open abdomen for nontrauma emergency general surgery patients

Background

Emergency general surgery patients are increasingly being managed with an open abdomen (OA). Factors associated with complications after primary fascial closure (PFC) are unknown.

Methods

Demographic and operative variables for all emergency general surgery patients managed with OA at an academic medical center were prospectively examined from June to December 2013. Primary outcome was complication requiring reoperation.

Results

Of 58 patients, 37 managed with OA achieved PFC. Of these, 14 needed re-exploration for dehiscence, compartment syndrome, infection, or other. Complications after PFC were not associated with age, type of operative intervention, time to closure, re-explorations, comorbidities, or mortality. Complications correlated with higher body mass index (P = .02), skin closure (P = .04), plasma infusion (P = .01), and less intraoperative bleeding (P = .05). Deep surgical site infection correlated with fascial dehiscence (P = .02).

Conclusions

Reoperation after PFC was more likely in obese and nonhemorrhagic patients. Recognition of these factors and strategies to reduce surgical site infection may improve outcomes.     

Opinion of different professional categories about the intensity of procedural pain in adult intensive care units

Objectives

To assess the procedures considered as the most painful by health personnel of two adult critical care units.

Methods

Individual written survey with a questionnaire about 46 potentially painful procedures. Each individual has to estimate the pain intensity as well as the frequency of performance for each painful procedures.

Results

One hundred questionnaires were provided (15 physicians, 71 nurses and 14 auxiliaries). The rate of answer was 53 % and 2110 scores were recorded and analyzed. The insertion of a pleural drain was associated with the higher pain score (7.5 [6.5–9]). Discrepancies were observed between the professional categories in ranking painful procedures. However, the mobilization of a severe trauma patient, the removal of an otorhinolaryngological or a pleural drain were classified in the 10 most painful procedures by physicians, nurses as well as auxiliaries. Whatever the procedure was, the median global scores estimated by the auxiliaries (n = 385; 6 [4–7]) were higher than those corresponding to the nurses (n = 1267; 5 [3–7]) (p < 0.01). Nurses attributed a higher score than the physicians for 39 of 46 procedures. No relation was found between the estimated pain intensity and the estimated frequency of the procedures.

Conclusion

As in paediatrics, adult intensivist physicians underestimate pain during procedure comparing with nurses and auxiliaries. Consequently, health care professionals should elaborate protocols to accurately assess, prevent, or treat painful procedures in intensive care units.     

Traitements antifongiques en réanimation au cours des infections fongiques invasives documentées ou suspectées

Objective

Describe systemic antifungal therapy in non-neutropenic adult patients in intensive care unit (ICU).

Patients and method

A prospective, observational study was conducted during the first half of 2010 in the 7 ICU in a hospital with medical consultant on antimicrobial therapy. All non-neutropenic consecutive adult patients receiving systemic antifungal therapy for documented or suspected invasive fungal infection (IFI) apart from aspergillosis were included.

Results

Out of 1502 patients admitted in ICU, 104 (7 %) underwent systemic antifungal therapy, including 30 (29 %) for a documented IFI and 74 (71 %) for a suspected IFI. Candida albicans was identified in 23 (77 %) of the IFI and 45/52 (86 %) of the broncho-pulmonary and/or urinary colonizations in suspected IFI. Echinocandin was significantly more prescribed in patients with a documented infection (19/30 patients) and fluconazole in patients with a suspected infection (48/74 patients). The first line therapy was primarily stopped after recovery (11/30 patients) or de-escalation (9/30 patients) in documented infections, and for lack of indication (34/74 patients) or due to recovery (21/74 patients) in suspected infections after on average of 7 days of treatment.

Conclusion

For ICU non-neutropenic adult patients in our center, antifungal therapy is prescribed two times out of three for suspected, unproved infections, in most cases with fluconazole. Documented infections were more often treated by echinocandin with secondary de-escalation. An interventional prospective study to assess the role of antifungal pre-emptive or empirical therapy is necessary.     

Incision and drainage of subcutaneous abscesses without the use of packing

Purpose

The classic intervention for subcutaneous abscesses is incision and drainage followed by wound packing. This is thought to aid hemostasis, and prevent reorganization of the abscess. Removal of packing material may be painful and anxiety provoking. We sought to determine whether packing could be omitted with equal efficacy.

Methods

One hundred pediatric patients with subcutaneous abscesses were enrolled between May, 2008 and December, 2010. All underwent incision and drainage, then seven days of oral antibiotics and warm soaks. Patients were randomized to the packing group (PG) or non-packing group (NPG). Packing was removed 24 h after the procedure. Patients were excluded if: 1) diabetic/immunosuppressed, 2) the abscess was perianal or pilonidal, or 3) the abscess was secondary to a previous operation. Patients were evaluated in clinic if recurrence was suspected during follow-up calls on postoperative days seven and 30.

Results

Eighty-five patients completed the study (43 PG/42 NPG). The two groups were not statistically different with respect to initial parameters, recurrent abscesses (one in each group), or MRSA incidence (81.4% PG/85.7% NPG).

Conclusion

Incision and drainage of subcutaneous abscesses without the use of packing is a safe and effective technique. This approach omits a traditional, but painful and anxiety provoking, component of therapy.     

Postoperative fluid collections after colon resection: the utility of clinical assessment

Background

Computed tomography (CT) scans often identify postoperative fluid collections of uncertain clinical relevance.

Methods

Consecutive adult patients undergoing colorectal resection and postoperative CT scan from January 1, 2000 to December 31, 2008, at a university teaching hospital were identified from a prospective database. A host of clinical and CT findings were recorded. Fisher's exact test and logistic regression with univariate and multivariate analysis were used to assess the predictive value of clinical and radiologic variables.

Results

Nine hundred six patients had a colon resection during the study period. Fifty-four patients had a postoperative fluid collection, of which 36 were found to be abscesses. Only high clinical suspicion of an abscess predicted the presence of an abscess (P = .009); of the radiologic criteria, only proximity to the anastomosis was predictive (P = .05).

Conclusions

Clinical judgment is superior to radiologic and individual clinical parameters. This finding has the potential to prevent many unnecessary procedures.     

Perioperative epidural analgesia in children undergoing major abdominal tumor surgery — a single center experience

Purpose

The purpose of this study was to assess the use of continuous epidural analgesia in pediatric patients undergoing major abdominal tumor surgery.

Methods

Children undergoing major abdominal tumor surgery at our institution between 2008 and 2012 (n = 40) received continuous epidural analgesia via an epidural catheter. Surgical trauma scores, pain scores, and clinical data of the children were compared to a pair-matched historical control group operated on between 2002 and 2007 without epidural analgesia.

Results

Pain levels in the study group on day 1 and 3 after surgery were lower compared to the control group. The differences did, however, not reach statistical significance (p = 0.15 and 0.09). Children in the study group received significantly fewer additional doses of piritramide or morphine (45% versus 82%, p < 0.001). Despite significantly higher surgical trauma scores in the study group (p = 0.018), there were no statistical differences regarding clinical parameters, such as mechanical ventilation time, time on intensive care unit, and total hospital stay. There were no catheter-related complications.

Conclusions

Continuous epidural analgesia is beneficial for children undergoing complex abdominal tumor surgery with regard to pain levels, postoperative recovery, and general clinical course. Expertise of the managing team, a careful patient selection, and a continuous quality assessment are essential for success.     

Improvement in pain after lumbar surgery in cancer patients with mechanical radiculopathy

Background context

Lumbar metastases can result in spinal instability and mechanical radiculopathy, characterized by radicular pain produced by axial loading. This pain pattern represents a definitive symptom of neoplastic instability and may serve as a reliable indication for surgical stabilization.

Purpose

We examined the results of surgical decompression and fixation in the treatment of mechanical radiculopathy.

Study design/setting

A retrospective clinical study.

Patient sample

An internally maintained spine neurosurgery database was queried between February 2002 and April 2010. Patients were identified and deemed eligible for inclusion in this study based on the presence of all the following: metastatic tumor, lumbar surgery, and lumbar radiculopathy.

Outcome measures

Visual analog scale (VAS) of pain and Eastern Cooperative Oncology Group (ECOG) status.

Methods

The Memorial Sloan-Kettering Cancer Center Department of Neurosurgery operative database was queried over an 8-year period to identify all patients with spinal metastases who underwent lumbar surgery. Only patients whose operative indication included mechanical radiculopathy were included. Pre- and postoperative pain was assessed with the VAS of pain, whereas pre- and postoperative performance status was evaluated using the ECOG.

Results

Fifty-five patients were included in the cohort. L2 and L3 were the most common levels involved, and most patients underwent multilevel posterior decompression and instrumented fusion. After surgery, 98% of patients reported pain relief. A significant difference between average pre- and postoperative pain scores was found (p<.01). Overall, 41.5% of patients experienced improvement in their ECOG score postoperatively.

Conclusions

Mechanical radiculopathy in patients with spinal metastases represents a highly reliable surgical indication. Spinal decompression and fixation is an effective treatment for pain palliation in this patient population.