Repair of cervical esophageal perforation using longus colli muscle flap: a case report of a patient with cervical spinal cord injury

BACKGROUND CONTEXT: Perforation of the esophagus after anterior cervical spine surgery is a rare, but well-recognized complication. The management of esophageal perforation is controversial, and either nonoperative or operative treatment can be selected. PURPOSE: Several reports have described the use of a sternocleidomastoid muscle flap for esophageal repair. In this case report, we describe a longus colli muscle flap as a substitute for a sternocleidomastoid flap in a patient with an esophageal perforation. STUDY DESIGN: Case report. PATIENT SAMPLE: A 20-year-old man sustained cervical spinal cord injury, on diving and hitting his head against the bottom of a pool. A C6 burst fracture was observed with posterior displacement of a bone fragment into the spinal canal. The patient exhibited complete paralysis below the C8 spinal segment level. METHODS: The patient underwent subtotal corpectomy of the sixth cervical vertebra with the iliac bone graft and augmented posterior spinal fixation (C5-7) with pedicle screws. After the primary operation, the patient showed signs of infection such as throat pain, a high fever, and osteolytic change of the grafted bone by cervical radiograph. A second operation was performed to replace the graft bone using fibula. On the day after the operation, food residue was confirmed in the suction drainage tube, suggesting esophagus perforation. A third operation was immediately performed to confirm and treat esophagus perforation, although apparent esophageal perforation could not be detected at the second operation. Because the erosion around the perforation of the esophageal posterior wall was extensive, a longus colli muscle flap transposition was accordingly performed into the interspace between the esophageal posterior wall and the grafted bone in addition to simple suturing of the perforation. RESULTS: Neither high fever nor pharyngeal pain has recurred at latest follow-up, 5 years after surgery. CONCLUSIONS: To the best of our knowledge, this is the first report concerning the use of a longus colli muscle flap for esophageal perforation after anterior cervical spine surgery.     

Two cases of "steal VBI" with stenosis of the internal carotid artery

Although previous reports have suggested "steal VBI" due to occlusive carotid artery diseases, there have been no reports that clearly define "steal VBI" from the viewpoint of cerebral hemodynamics. The authors presented two cases with "steal VBI" due to severe stenosis of the internal carotid artery. Both patients had well-developed collateral circulation through the ipsilateral posterior communicating artery. Although no occlusive lesion was found in the vertebrobasilar system, blood flow studies revealed impaired hemodynamics in the contralateral occipital lobe, which fact correlated with their neurological deficit, visual field disturbance. Carotid stenting markedly corrected the stenotic lesions, leading to neurological improvement. Follow-up blood studies showed normalization of hemodynamics in the contralateral occipital lobe. The findings strongly suggest that carotid surgery or stenting can improve cerebral hemodynamics in the carotid systems, resolving "steal VBI" due to developed collaterals from the posterior to the anterior circulation.     

The effect of lidocaine on the bispectral index during anesthesia induction with propofol]

We investigated the effect of premixing lidocaine with propofol on a bispectral index (BIS) during propofol infusion. We studied 40 adult patients given mixture of 1% propofol 20 ml with 2 ml of normal saline (control group) or 2% lidocaine (lidocaine group) infused at 2 ml.kg-1.hr-1 for 10 minutes. Heart rate, mean arterial pressure, and BIS were measured every minute. The addition of lidocaine to propofol reduced the incidence of injection pain from 85% to 10% but did not change the induction time. Propofol significantly decreased mean arterial pressure and BIS but there was no difference between the groups. In conclusion, premixing lidocaine with propofol reduces injection pain without affecting the hypnotic effect.     

A case of emergency surgery for acute mitral regurgitation due to complete papillary muscle rupture as a severe form of reperfusion injury: report of a case

Complete rupture of a papillary muscle following acute myocardial infarction is a severe complication associate with acute left ventricular failure and pulmonary edema. Since the introduction of acute percutaneous transluminal coronary angioplasty (PTCA) in the management of acute myocardial infarction, the frequency of this complication has further decreased. We described a patient who had acute mitral regurgitation due to complete rupture of papillary muscle rupture after successful coronary intervention. Transesophageal echocardiography demonstrated severe mitral regurgitation and the ruptured papillary muscle. At operation, posteriol papillary muscle was found to be totally ruptured. Mitral valve replacement was performed. Postoperative course was uneventful, with 2 days of IABP and 5 days of ventilator support.     

Tumor location affects the results of simple excision for multiple osteochondromas in the forearm

BACKGROUND: The effectiveness of excision of osteochondromas in controlling the progression of forearm and wrist deformity remains an issue of controversy. The purpose of this study was to analyze the effectiveness of tumor excision in the correction of forearm and wrist deformity due to multiple osteochondromas in children, with an interpretation of the results based on different patterns of deformity. METHODS: Fourteen forearms in thirteen children with a follow-up of more than twenty-four months (average, fifty-three months) were included in the study. The forearms were divided into two groups on the basis of the location of the tumor and the pattern of deformity. In Group 1 (six forearms), the osteochondroma was only in the distal aspect of the ulna and caused compression of the radius. In Group 2 (eight forearms), tumors were in both the distal aspect of the ulna and the ulnar side of the distal part of the radius and were in contact with each other. Radial length, ulnar shortening, radial bowing, the radial articular angle, and carpal slip were measured as radiographic parameters. Ulnar shortening and radial bowing were expressed as a percentage of the radial length to make it possible to compare data between the individuals. Each parameter was evaluated before surgery and at the time of final follow-up. RESULTS: In Group 1, the percentage of ulnar shortening and the percentage of radial bowing had improved at the time of final follow-up; however, in Group 2, both the radial articular angle and the percentage of radial bowing had deteriorated significantly after the tumor excision (p = 0.049 and p = 0.017, respectively), even though the percentage of ulnar shortening showed no change. CONCLUSIONS: The effectiveness of simple excision of osteochondromas of the distal aspect of the forearm is influenced by the tumor location and is related to the pattern of the deformity. Simple tumor excision can correct the forearm deformity in patients with an isolated tumor of the distal part of the ulna. Conversely, in patients with tumors involving the distal part of the ulna and the ulnar side of the distal end of the radius, tumor excision alone is a less promising procedure for the correction of the deformity. LEVEL OF EVIDENCE: Prognostic Level IV.     

Complicated anesthetic management for esophageal atresia repair in a baby with total anomalous pulmonary venous connection diagnosed after esophageal surgery

A male newborn infant born at 38 weeks of gestation and weighing 2,660 g, was diagnosed as esophageal atresia. Although there was mild cyanosis at birth, his initial ultrasonographic examination performed by neonatologist showed normal anatomy of the heart. He underwent a surgical repair of esophageal atresia under general anesthesia. Anesthesia was induced with fentanyl and pancuronium, and maintained with sevoflurane and 60% oxygen. Frequent desaturation occurred during the procedure, requiring manual hyperventilation with 100% oxygen. Since blood pressure during the operation was unstable, volume loading with albumin was attempted. Further echocardiography was performed by pediatric cardiologist after going back to NICU. This revealed total anomalous pulmonary venous connection (TAPVC). He underwent cardiac surgery for repair of TAPVC on the next day. Although TAPVC was not preoperatively diagnosed regardless of results of echocardiogram, cyanosis and unstable blood pressure should be considered as signs of potential cardiac disease. Fluid restriction, higher hemoglobin, lower inspired oxygen and slightly higher carbon dioxide rather than albumin administration and hyperventilation should have been attempted during the esophageal repair.     

Persistent local pain after posterior spine surgery for thoracic lesions

Many surgeons have investigated local pain associated with posterior spine surgery for cervical or lumbar lesions. However, little information is available concerning local pain after posterior thoracic spine surgery. This prospective study was, thus, performed to investigate the frequency and clinical features of local pain after posterior spine surgery for thoracic lesions. In 29 consecutive patients undergoing posterior spine surgery for various thoracic spinal disorders, local pain was investigated before and after surgery. In all 19 patients with preoperative back pain presumably due to thoracic lesions, pain was well alleviated after surgery. In contrast, 6 patients (21%) newly developed persistent shoulder angle pain after surgery, which resembled axial pain after cervical laminoplasty. In 5 of these 6 patients surgical exposure was extended to the cervicothoracic junction, whereas persistent shoulder angle pain was independent of disease etiologies and surgical procedure, and all of the 5 patients had no other etiologies of local pain such as surgical site infections, hardware failures, pseudoarthrosis, other metastasis, and vertebral fractures. These results suggest that dissection of muscle attachments to the cervicothoracic junction would play some part in the development of persistent local pain after posterior spine surgery for thoracic lesions, although surgical exposure of the zygapophysial joints at the cervicothoracic junction might be a possible source of postoperative shoulder pain. Therefore, to minimize such surgical complications, muscle insertions into the cervicothoracic junction should be preserved as far as possible.     

A cross-sectional study of bone turnover markers in healthy premenopausal women

BACKGROUND: Biochemical markers of bone turnover (BTMs) provide useful information in the diagnosis and management of metabolic bone diseases. Currently, there exist few published reference ranges for bone markers in healthy premenopausal women using the newer, automated assays of bone turnover. This cross-sectional study of healthy premenopausal women was performed to determine reference ranges for four different markers of bone turnover and to compare reference ranges in users and non-users of oral contraceptives (OCs). METHODS: Urinary N-telopeptide of type 1 collagen (NTX) was determined from fasting second morning-void urine of healthy premenopausal women. In addition, fasting serum was collected for determination of C-telopeptide of type I collagen (CTX), bone-specific alkaline phosphatase (bone ALP), and N-terminal propeptide of type 1 procollagen (PINP). Subjects underwent central dual energy X-ray absorptiometry and completed a questionnaire regarding medical history and activities known to affect bone health. RESULTS: Serum and urine samples were collected from 237 healthy premenopausal women (119 OC users and 118 non-users) between the ages of 28 and 45 years. The mean age of subjects was 37 years, with a mean bone mineral density T-score of -0.1 at the lumbar spine and 0.0 at the total hip. Logarithmic transformation produced normal distributions for all markers but NTX. Mid-95% ranges for each marker were generally consistent with those reported by manufacturers. For each BTM examined, values were skewed toward the lower end of the range. Median NTX levels for OC users and non-users were 16.0 and 29.0 nmol/mmol creatinine, respectively. The mid-95% ranges for NTX in OC users and non-users were 3-60 and 4-64 nmol/mmol creatinine, respectively. Median levels of CTX, bone ALP, and PINP were also lower in OC users than non-users. The mean level of each BTM was significantly lower in OC users than non-users (P<0.01), whereas reference ranges (geometric mean+/-2 SD) were somewhat similar for the two groups. CONCLUSION: Values obtained from this well-characterized population provide reference ranges for BTMs in healthy premenopausal women. Median and mean BTM levels for OC users were consistently lower compared with non-users; thus, separate reference ranges are required for these two groups of premenopausal women. The relevance of premenopausal reference ranges for postmenopausal women remains uncertain.     

Kinematics of the thoracic spine in trunk lateral bending: in vivo three-dimensional analysis

Background contextIn vivo three-dimensional kinematics of the thoracic spine in trunk lateral bending with an intact rib cage and soft tissues has not been well documented. There is no quantitative data in the literature for lateral bending in consecutive thoracic spinal segments, and there has not been consensus on the patterns of coupled motion with lateral bending.PurposeTo demonstrate segmental ranges of motion (ROMs) in lateral bending and coupled motions of the thoracic spine.Study designIn vivo three-dimensional biomechanics study of the thoracic spine.Patient sampleFifteen healthy male volunteers.Outcome measuresComputed analysis by using voxel-based registration.MethodsParticipants underwent computed tomography of the thoracic spine in three supine positions: neutral, right maximum lateral bending, and left maximum lateral bending. The relative motions of vertebrae were calculated by automatically superimposing an image of vertebrae in a neutral position over images in bending positions, using voxel-based registration. Mean values of lateral bending were compared among the upper (T1–T2 to T3–T4), the middle-upper (T4–T5 to T6–T7), the middle-lower (T7–T8 to T9–T10), and the lower (T10–T11 to T12–L1) parts of the spine.ResultsAt lateral bending, the mean ROM (±standard deviation) of T1 with respect to L1 was 15.6°±6.3° for lateral bending and 6.2°±4.8° for coupled axial rotation in the same direction as lateral bending. The mean lateral bending of each spinal segment with respect to the inferior adjacent vertebra was 1.4°±1.3° at T1–T2, 1.3°±1.2° at T2–T3, 1.4°±1.3° at T3–T4, 0.9°±0.9° at T4–T5, 0.8°±1.0° at T5–T6, 1.1°±1.1° at T6–T7, 1.7°±1.2° at T7–T8, 1.3°±1.2° at T8–T9, 1.6°±0.7° at T9–T10, 1.8°±0.8° at T10–T11, 2.3°±1.0° at T11–T12, and 2.2°±0.8° at T12–L1. The smallest and the largest amounts of lateral bending were observed in the middle-upper and the lower parts, respectively. There was no significant difference in lateral bending between the upper and the middle-lower parts. Coupled axial rotation of each segment was generally observed in the same direction as lateral bending. However, high variability was found at the T2–T3 to T5–T6 segments. Coupled flexion was observed at the upper and middle parts, and coupled extension was observed at the lower part.ConclusionsThis study revealed in vivo three-dimensional motions of consecutive thoracic spinal segments in trunk lateral bending. The thoracolumbar segments significantly contributed to lateral bending. Coupled axial rotation generally occurred in the same direction with lateral bending. However, more variability was observed in the direction of coupled axial rotation at T2–T3 to T5–T6 segments in the supine position. These results are useful for understanding normal kinematics of the thoracic spine.