Postoperative spinal infection mimicking systemic vasculitis with titanium-spinal implants

<p>Abstract</p> <p>Background</p> <p>Secondary systemic vasculitis after posterior spinal fusion surgery is rare. It is usually related to over-reaction of immune-system, to genetic factors, toxicity, infection or metal allergies.</p> <p>Case Description</p> <p>A 14 year-old girl with a history of extended posterior spinal fusion due to idiopathic scoliosis presented to our department with diffuse erythema and nephritis (macroscopic hemuresis and proteinuria) 5 months post surgery. The surgical trauma had no signs of inflammation or infection. The blood markers ESR and CRP were increased. Skin tests were positive for nickel allergy, which is a content of titanium alloy. The patient received corticosteroids systematically (hydrocortisone 10 mg) for 6 months, leading to total recess of skin and systemic reaction. However, a palpable mass close to the surgical wound raised the suspicion of a late infection. The patient had a second surgery consisting of surgical debridement and one stage revision of posterior spinal instrumentation. Intraoperative cultures were positive to Staphylococcus aureus. Intravenous antibiotics were administered. The patient is now free of symptoms 24 months post revision surgery without any signs of recurrence of either vasculitis or infection.</p> <p>Literature Review</p> <p>Systemic vasculitis after spinal surgery is exceptionally rare. Causative factors are broad and sometimes controversial. In general, it is associated with allergy to metal ions. This is usually addressed with metal on metal total hip bearings. In spinal surgery, titanium implants are considered to be inert and only few reports have presented cases with systemic vasculitides. Therefore, other etiologies of immune over-reaction should always be considered, such as drug toxicity, infection, or genetic predisposition.</p> <p>Purposes and Clinical Relevance</p> <p>Our purpose was to highlight the difficulties during the diagnostic work-up for systemic vasculitis and management in cases of posterior spinal surgery.</p

Can pulsed radiofrequency of the occipital nerves cause sedation? A new perspective of existing knowledge

Background: Pulsed radiofrequency stimulation (PRF) of the greater and lesser occipital nerves (GON and LON) has neuromodula-tive and analgesic properties. Objectives: The aim of this study was to investigate whether the PRF of the occipital nerves can cause sedation. Methods: This is an observational case series study in Pain Management Unit of Attikon University Hospital. Patients suffering from primary headaches were scheduled for PRF of occipital nerves following a standardized protocol. The Bispectral Index device was applied and recorded every minute throughout the procedure. Results: 22 patients were studied. BIS values were lowered in all but three patients during GON stimulation, and in all patients during LON stimulation. Values of decline compared to baseline ranged between 0-23 (median 8.5) for GON and 1-27 (median 14) for LON, with LON decline being significantly lower. Conclusions: PRF at the occipital nerves led to mild sedation in all patients. Further studies are required to investigate this effect and clarify the exact mode of action of pulsed radiofrequency. © 2020, Author(s)

Rocuronium antagonized by sugammadex for series of electroconvulsive therapy (ECT) in a patient with pseudocholinesterase deficiency

We report the anesthetic management of a patient with catatonic schizophrenia and pseudocholinesterase deficiency, using the nondepolarizing neuromuscular blocking drug, rocuronium, reversed by its specific reversal agent, sugammadex, for a series of electroconvulsive therapy sessions. Rocuronium and sugammadex were used every 48 hours for 8 consecutive times and proved to be an effective and safe combination in a situation where succinylcholine was contraindicated. © 2011 Lippincott Williams &amp; Wilkins, Inc

Comparison of the Efficacy between Intradiscal Gelified Ethanol (Discogel) Injection and Intradiscal Combination of Pulsed Radiofrequency and Gelified Ethanol (Discogel) Injection for Chronic Discogenic Low Back Pain Treatment. A Randomized Double-Blind Clinical Study

Objective. The aim of the present study was to compare two new techniques, intradiscal gelified ethanol injection (Discogel) and the combination of intradiscal pulsed radiofrequency and gelified ethanol injection (PRF+Discogel), regarding their efficacy in discogenic low back pain treatment. Design. Randomized, double-blind, clinical study. Methods. The final sample was randomized into group A (N = 18, D) and group B (N = 18, PRF+D). During the procedure, four patients from group B were excluded from the study. Groups A and B were assessed regarding the pain score (VAS 0–10), before the interventional procedures, and one, three, six, and 12 months after. Secondary objectives of the study were to compare the two groups regarding the results of the Roland Morris Disability Questionnaire, Lanss score, and quality of life score (EQ-5D). Results. There was no significant evidence for an overall difference in pain score between the two groups (analysis of variance, F = 3.24, df = 1, P = 0.084), except for the sixth and 12th months, when group B presented a statistically important difference compared with group A (Wilcoxon test). Group B appeared to be more effective, with a statistically significant difference, compared with group A regarding the secondary objectives of the study. Conclusions. After rigorous and comprehensive assessment by an independent observer, both Discogel alone and Discogel in combination with pulsed radiofrequency produced tangible improvements in pain, function, quality of life, and consumption of analgesics, which were sustained at 12 months. © The Author(s) 2020. Published by Oxford University Press on behalf of the American Academy of Pain Medicine

Anterior cutaneous nerve entrapment syndrome: management challenges

Eleni Chrona,1,2 Georgia Kostopanagiotou,1 Dimitrios Damigos,3 Chrysanthi Batistaki1 1Second Department of Anesthesiology, School of Medicine, National and Kapodistrian University of Athens, &ldquo;Attikon&rdquo; Hospital, Athens,&nbsp;2Department of Anesthesiology, General Hospital of &ldquo;Ag. Panteleimon,&rdquo; Piraeus, 3Department of Medical Psychology, Medical School of Ioannina, University of Ioannina, Ioannina, Greece Abstract: Anterior cutaneous nerve entrapment syndrome (ACNES) is a commonly underdiagnosed and undertreated chronic state of pain. This syndrome is characterized by the entrapment of the cutaneous branches of the lower thoracoabdominal intercostal nerves at the lateral border of the rectus abdominis muscle, which causes severe, often refractory, chronic pain. This narrative review aims to identify the possible therapeutic strategies for the management of the syndrome. Seventeen studies about ACNES therapy were reviewed; of them, 15 were case&ndash;control studies, case series, or case reports, and two were randomized controlled trials. The presently available management strategies for ACNES include trigger point injections (diagnostic and therapeutic), ultrasound-guided blocks, chemical neurolysis, and surgical &shy;neurectomy, in combination with systemic medication, as well as some emerging techniques, such as radiofrequency ablation and neuromodulation. An increased awareness of the syndrome and the use of specific diagnostic criteria for its recognition are required to facilitate an early and successful management. This review compiles the proposed &shy;management strategies for ACNES. Keywords: anterior cutaneous nerve entrapment syndrome, intercostal, neuralgia, managemen

Anterior cutaneous nerve entrapment syndrome: Management challenges

Anterior cutaneous nerve entrapment syndrome (ACNES) is a commonly underdiagnosed and undertreated chronic state of pain. This syndrome is characterized by the entrapment of the cutaneous branches of the lower thoracoabdominal intercostal nerves at the lateral border of the rectus abdominis muscle, which causes severe, often refractory, chronic pain. This narrative review aims to identify the possible therapeutic strategies for the management of the syndrome. Seventeen studies about ACNES therapy were reviewed; of them, 15 were case–control studies, case series, or case reports, and two were randomized controlled trials. The presently available management strategies for ACNES include trigger point injections (diagnostic and therapeutic), ultrasound-guided blocks, chemical neurolysis, and surgical neurectomy, in combination with systemic medication, as well as some emerging techniques, such as radiofrequency ablation and neuromodulation. An increased awareness of the syndrome and the use of specific diagnostic criteria for its recognition are required to facilitate an early and successful management. This review compiles the proposed management strategies for ACNES. © 2017 Chrona et al

Patient-controlled epidural analgesia after caesarean section: Levobupivacaine 0.15% versus ropivacaine 0.15% alone or combined with fentanyl 2 μg/ml: a comparative study

Introduction: The aim of this study was to compare the postoperative analgesic efficacy of epidural ropivacaine 0.15%, levobupivacaine 0.15% and ropivacaine 0.15% plus fentanyl 2 μg/ml, used with a patient-controlled epidural analgesia (PCEA) device after Caesarean section. Material and methods: Sixty women undergoing elective Caesarean section under combined spinal-epidural anaesthesia were enrolled. Postoperatively, patients received PCEA with either ropivacaine or levobupivacaine 0.15% (basal rate 6 ml/h, bolus 5 ml/20 min), or ropivacaine 0.15% plus fentanyl 2 μg/ml (basal rate 6 ml/h, bolus 4 ml/20 min). Sympathetic and sensory level of analgesia, motor ability (Bromage 0-3), and pain scores at rest, movement and cough (VAS 0-10), haemodynamic parameters, oxygenation, side effects and total doses of local anaesthetic were documented every 6 h for 24 h. Patient satisfaction was assessed using a descriptive scale. Results: No significant difference was observed in pain scores at all time intervals. A significantly higher sympathetic and sensory blockade occurred with levobupivacaine and ropivacaine 0.15% compared to ropivacaine 0.15% plus fentanyl, with no significant difference in total local analgesic consumption at 24 h (p = 0.08). Rescue analgesic requirements did not differ between the groups (p = 0.8) while patients&apos; satisfaction was significantly higher in the ropivacaine 0.15% plus fentanyl group (p = 0.02). Haemodynamics, oxygenation, nausea, pruritus and numbness did not differ between the groups. Conclusions: Dilute local anaesthetic solutions provided satisfactory postoperative analgesia after Caesarean section when used with a PCEA device. The combination of ropivacaine 0.15% with fentanyl 2 μg/ml appeared superior, since it provided higher patient satisfaction with statistically equal pain scores and local anaesthetic consumption. Copyright © 2011 Termedia &amp; Banach

Ultrasound-guided saphenous nerve block for saphenous neuralgia after knee surgery: Two case reports and review of literature

Saphenous neuralgia is characterized by persistent neuropathic pain at the distribution of the saphenous nerve. Injury to the saphenous nerve, and specifically to its infrapatellar branch of the saphenous nerve has been implicated as a cause of medial knee pain after orthopedic knee surgery or trauma. We present two cases of saphenous neuralgia, one after total knee arthroplasty and the other after anterior cruciate ligament reconstruction, that were adequately treated with ultrasound-guided saphenous nerve blocks distal to the adductor canal. Early recognition and treatment of saphenous neuralgia is essential to prevent persistent disabling pain, which significantly affects patients&apos; quality of life. © 2019 Indian Journal of Orthopaedics