Neurologic evaluation of erectile dysfunction

Most patients with neurogenic impotence present with a pre-existing neurologic disease. The neurologic assessment in these patients is generally performed to confirm that the underlying neuropathology plays a role in the erectile dysfunction. There are patients, however, with no obvious pre-existing neuropathology who are identified as having a vibratory impairment of the dorsal nerve on penile biothesiometry. Subsequent neurophysiologic testing in several of these patients has confirmed unsuspected neuropathology. An objective evaluation of autonomic cavernosal neurointegrity is still awaited. Such a test may enable the detection of efferent denervation resulting in neurogenic erectile dysfunction that is not clinically obvious.     

Neurologic evaluation in thoracolumbar vertebral fractures

A standardized and universal neurologic evaluation is of essential importance in defining the prognosis, treatment, and long-term results in patients with spinal cord injury. The American Spinal Injury Association was the first to publish a neurologic classification in 1992. This classification, which was subsequently submitted to numerous revisions, was also adopted by the International Medical Society of Paraplegia and by the national scientific associations of many other countries. In Italy, too, the ASIA/IMSOP form has been accepted as a standard for neurologic evaluation, but with the exception of specialized centers, it is still not well-known. The authors critically analyze the international terminology and its translation, they define the technical aspects of the neurologic examination in relation to priorities, and to the specific goals. Finally, they report several thoughts deriving from clinical practice in the Spinal Unit of Florence.     

Neurologic sequelae after caesarean section

BACKGROUND: Because pregnancy increases the sensitivity of nervous tissue to local anaesthetics, pregnant patients may be at higher risk of developing neurologic deficits after spinal block than non-pregnant patients. Therefore, we evaluated prospectively the incidence and type of neurologic symptoms after spinal anaesthesia with hyperbaric bupivacaine for caesarean section. METHODS: In this prospective follow-up study we recorded neurologic complications during anaesthesia and postoperatively until discharge from the hospital of 219 patients, who underwent caesarean section under spinal anaesthesia with hyperbaric bupivacaine (5 mg/ml, mean 13 mg). The patients filled in a questionnaire on the first and fifth postoperative days. In the case of complaints typical of neurologic symptoms they were checked first by the anaesthesiologist and, in the case of persistent symptoms, afterwards additionally by a neurologist. RESULTS: Twenty-six of 219 patients were not included in the further evaluation because of incomplete return of their questionnaires. Seventeen mothers (8.8%) complained of transient neurologic symptoms (TNSs), lasting mostly 1-2 days, in the buttocks and/or legs during the first three postoperative days. Eleven patients (5.7%) complained of postdural puncture headache. Two patients (emergency caesarean section because of protracted labour in one and elective caesarean section because of previous caesarean section in the other) complained of persisting pain or sensory abnormalities. Neither of them felt paraesthesia during lumbar puncture. CONCLUSION: Women after caesarean section under a spinal block seem to suffer more often from TNSs than non-pregnant women. The conclusions are, however, uncertain since we had no control group operated on under other than spinal anaesthesia. The persisting neurologic symptoms in two patients might also be due to the obstetric procedure itself. To find out about the validity and possible underlying causes of our results, we need randomised studies with control groups receiving epidural or general anaesthesia.     

Neurologic evaluation and treatment of the diabetic foot

Neuropathy is a frequent complication of diabetes and is most commonly manifest as a sensory neuropathy involving the feet. Although biochemical and experimental animal studies suggest a direct link between the hyperglycemia of diabetes and the development of neuropathy, this link is unproven in humans. Evaluation for neuropathy can usually be accomplished clinically, but in selected cases electromyography is helpful. Other testing methods have a well-defined research note, but their clinical utility is less well established. Treatment of diabetic neuropathy is empirical. Better blood glucose control is attempted and a variety of medications are used to treat the symptoms. Promising treatment methods are being investigated, but none is of proven benefit.     

Advantages of intrathecal nalbuphine, compared with intrathecal morphine, after cesarean delivery: an evaluation of postoperative analgesia and adverse effects

We performed a prospective, randomized, double-blinded, multicenter study to compare the analgesic efficacy and adverse effects of intrathecal nalbuphine, at three different doses, and intrathecal morphine for postoperative pain relief after cesarean deliveries. Ninety healthy patients at full term who were scheduled for elective cesarean delivery with spinal anesthesia were enrolled in the study. They received 10 mg of hyperbaric bupivacaine 0.5% with either morphine 0.2 mg (Group 1), nalbuphine 0.2 mg (Group 2), nalbuphine 0. 8 mg (Group 3), or nalbuphine 1.6 mg (Group 4). Only patients in Groups 1 and 2 reported pain during surgery. Postoperative analgesia lasted significantly longer in the morphine group, compared with the nalbuphine groups (P: < 0.0001). In the nalbuphine groups, postoperative analgesia lasted longest with the 0.8-mg dose. The additional increase to 1.6 mg did not increase efficacy. The incidence of pruritus was significantly higher in Group 1 (11 of 22), compared with Group 2 (0 of 22, P: < 0.0002), Group 3 (0 of 23, P: < 0.0001), and Group 4 (3 of 20, P: < 0.02). Postoperative nausea and vomiting were more frequent in Group 1 (5 of 22), compared with Group 2 (0 of 22, P: < 0.05), Group 3 (0 of 23, P: < 0.05), and Group 4 (3 of 23, not significant). There was no maternal or newborn respiratory depression. Neonatal conditions (Apgar scores and umbilical vein and artery blood gas values) were similar for all groups. This study suggests that intrathecal nalbuphine 0.8 mg provides good intraoperative and early postoperative analgesia without side effects. However, only morphine provides long-lasting analgesia. IMPLICATIONS: Small doses of intrathecal nalbuphine produce fewer adverse effects, such as pruritus and postoperative nausea and vomiting, compared with intrathecal morphine. This may allow earlier discharge of patients from the recovery room.     

Preoperative radiographic and histopathologic evaluation of central chondrosarcoma

Background

Distinguishing grade 1 chondrosarcoma from grade 2 chondrosarcoma is critical both for planning the surgical procedure and for predicting the outcome. We aimed to review the preoperative radiographic and histologic findings, and to evaluate the reliability of preoperative grading.

Methods

We retrospectively reviewed the medical records of 17 patients diagnosed with central chondrosarcoma at our institution between 1996 and 2011. In these cases, we compared the preoperative and postoperative histologic grades, and evaluated the reliability of the preoperative histologic grading. We also assessed the preoperative radiographic findings obtained using plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI).

Results

Preoperative histologic grade was 1 in 12 patients, 2 in 4 patients, and 3 in 1 patient. However, 6 of the 12 cases classified as grade 1 before surgery were re-classified as grade 2 postoperatively. In the radiographic evaluation, grade 1 was suspected by the presence of a ring-and-arc pattern of calcification on plain radiography and CT and entrapped fat and ring-and-arc enhancement on MRI. Grades 2 and 3 were suspected by the absence of calcification and the presence of cortical penetration and endosteal scalloping on plain radiography and CT, as well as soft-tissue mass formation on MRI.

Conclusion

Although the combination of radiographic interpretation and histologic findings may improve the accuracy of preoperative grading in chondrosarcoma, the establishment of a standard evaluation system with the histologic and radiographic findings and/or the development of new biologic markers are necessary for preoperative discrimination of low-grade chondrosarcoma from high-grade chondrosarcoma.     

Pain after spinal intrathecal clonidine

A case is reported in which spinal intrathecal administration of clonidine produced pain. The interaction between clonidine and tricyclic antidepressants is discussed, and is suggested as the basis for this observation.     

Respiratory depression after intrathecal opioids

Morphine 20 mg and pethidine 50 mg were accidentally injected intrathecally in a patient who had received large doses of opioids epidurally for cancer pain and who had shown tolerance to their effects. The well established tolerance to spinal opioids did not protect the patient against a moderate degree of respiratory depression. Morphine concentrations 6.5 hours after the morphine injection were 103,500 ng/ml and 52 ng/ml in cerebrospinal fluid and serum, respectively.     

Respiratory depression after intrathecal narcotics

Three out of six patients who had received 1 mg of morphine and 0.22 ml plain bupivacaine 0.5%/segment as a subarachnoid spinal anaesthetic developed serious and delayed respiratory depression on several occasions. This was reversed by intravenous naloxone. It is postulated that the morphine had diffused to the level of the cisterna magnum and thence through brain tissue around the fourth ventricle. Naloxone did not reverse the analgesia.     

Neurologic complications after lumbar spine surgery

With the increasing complexity and number of lumbar spine operations being performed, the potential number of patients who will sustain perioperative complications, including those that involve neural structures, has also increased. Neurologic complications after lumbar spine surgery can be categorized by the perioperative time period during which they occur and by their mechanism of injury. Although the overall incidence of neurologic complications after lumbar surgery is low, the severity of these injuries mandates careful preoperative planning, awareness of risk, and meticulous attention to perioperative details.     

Neurologic injuries after total hip arthroplasty

Neurologic injuries are a potentially devastating complication of total hip arthroplasty (THA). Review of the literature reveals that these injuries are uncommon. The reported incidence ranges from 0.08% to 7.6%. The incidence in primary THA ranges from 0.09% to 3.7% and in revision THA from 0% to 7.6%. Reported etiologies include intraoperative direct nerve injury, significant leg lengthening, improper retractor placement, cement extravasation, cement-related thermal damage, patient positioning, manipulation, and postoperative hematoma. Risk factors include developmental dysplasia of the hip, the female sex, posttraumatic arthritis, and revision surgery. However, no single risk factor has been consistently reported to be significant, and many patients with no known risk factors incur neurologic injuries.     

Neurologic complications after solid organ transplantation

Neurologic complications are common after solid organ transplantation and are associated with significant morbidity. Approximately one-third of transplant recipients experiences neurologic alterations with incidence ranging from 10% to 59%. The complications can be divided into such of those common to all types of transplant and others of those specific to transplanted organ. The most common complication seen with all types of transplanted organ is neurotoxicity attributable to immunosuppressive drugs, followed by seizures, opportunistic central nervous system (CNS) infections, cardiovascular events, encephalopathy and de novo CNS neoplasms. Amongst immunosuppressants, calcineurin inhibitors are the main drugs involved in neurotoxicity, leading to complications which ranges from mild symptoms, such as tremors and paresthesia to severe symptoms, such as disabling pain syndrome and leukoencephalopathy. Neurologic complications of liver transplantation are more common than that of other solid organ transplants (13–47%); encephalopathy is the most common CNS complication, followed by seizures; however, central pontine myelinolysis can appear in 1–8% of the patients leading to permanent disabilities or death. In kidney transplanted patients, stroke is the most common neurologic complication, whereas cerebral infarction and bleeding are more typical after heart transplantation. Metabolic, electrolyte and infectious anomalies represent common risk factors; however, identification of specific causes and early diagnosis are still difficult, because of patient's poor clinical status and concomitant systemic and metabolic disorders, which may obscure symptoms.     

Behavioral and histopathologic effects following intrathecal administration of butorphanol, sufentanil, and nalbuphine in sheep.

A large number of opioids and nonopioids have been administered epidurally and intrathecally in the hope of providing segmental analgesia without serious adverse effects. However, neurotoxicity data are generally unavailable for many of these drugs. The present study evaluated the behavioral, motor, electroencephalographic, and histopathologic changes following intrathecal injection of large and small doses of butorphanol, sufentanil, and nalbuphine in sheep. Thirty-two sheep (20-32 kg) were anesthetized and catheters placed intrathecally after hemilaminectomy. The large doses of butorphanol, sufentanil and nalbuphine were 0.375 mg/kg (4.4-5.2 ml), 7.5 micrograms/kg (3.6-4.8 ml) and 0.75 mg/kg (1.5-2.4 ml), and the small doses were 0.075 mg/kg (0.9-1.1 ml), 1.5 micrograms/kg (0.7-0.9 ml) and 0.15 mg/kg (0.38-0.5 ml), respectively. The opioids were administered intrathecally every 6 h for 3 days and the above-mentioned parameters studied. Five sheep received intrathecal saline (1.1 or 5.2 ml) and served as controls. Histopathologic changes were evaluated by a neuropathologist blinded to the study protocol. Irrespective of dose, intrathecal injection of butorphanol was associated with severe behavioral responses such as agitation, rigidity, vocalization, and restlessness, as well as prolonged or irreversible hindlimb paralysis. Electroencephalography showed increased cortical activity or seizure activity. One sheep died because of severe respiratory depression that did not respond to naloxone. Spinal cord histologic changes consisted of suppurative meningitis and myelitis as well as neuronal changes such as spongiosis and chromatolysis. Large doses of intrathecal sufentanil were associated with similar though somewhat less severe responses. The behavioral and motor changes following the small dose of intrathecal sufentanil were of mild to moderate nature. Following intrathecal nalbuphine, the above-mentioned changes were similar to those seen in control animals. We conclude that butorphanol in doses of 0.075 and 0.375 mg/kg intrathecally and sufentanil 7.5 micrograms/kg intrathecally are neurotoxic in sheep.