It is concluded that the perioperative use of bupivacaine and corticosteroids during lumbar discectomy maintains effective postoperative analgesia and decreases opioid usage without complications.
Occurrence of hematoma in the epidural space is common after lumbar disc surgery even if meticulous hemostasis has been achieved. Insertion of a drain decreases both the incidence and the size of hematoma on the first postoperative day as detected by MRI. This may have practical implications for the prevention of significant postoperative fibrosis and obtaining better surgical outcome.
Depressed skull fractures (DSFs) account for 7-10% of children admitted to hospital with a head injury and 15-25% of children with skull fractures. We reviewed the records of 530 patients operated on for DSF from January 1, 1973, to December 31, 1993. This group was made up of 357 boys (67%) and 173 girls (33%) whose ages ranged from 1 day to 16 years (mean age 6.1 years). Fall was the most common cause of injury. Of the 530 patients with DSF, 66% had compound fractures. The incidence of compound fractures increased with age. Compound fractures caused more brain lacerations (29%) than simple fractures (15.5%) did. We also classified DSFs radiologically as true, flat, or ping-pong ball fractures. Associated intracranial lesions were found to be a bad prognostic factor. There were 13 deaths (2.5%) in this series. Satisfactory results were achieved in over 95% of the patients. Compound fractures are associated with a worse outcome and a higher incidence of intracranial lesions and cortical laceration. Unilateral pupillary dilatation and an admission GCS score of 8 or less are ominous signs in regard to mortality. We also found that the deeper the depressed bone, the higher the risk of both dural tear and cortical laceration and the worse the prognosis. A conservative approach should be followed in cases of simple DSF without associated intracranial hematoma and in cases in which the bone depression is not deeper than 1 cm.
The medical records of 190 patients with meningomyelocele operated on between 1979 and 1993 were reviewed. In 65 patients, psychometric tests were performed. The Denver Developmental Screening Test and the Wechsler Intelligence Scale for Children, Revised (WISC-R) were used in children under and over 6 years old, respectively. There were 82 boys (43.2%) and 108 girls (56.8%). The lumbar region was the site of the meningomyelocele in 113 patients (59.5%). Patients with cervical and sacral meningomyelocele had a higher rate of almost normal motor function than those with meningomyelocele at other levels (P=0.000). Only 36 (21.7%) of 166 patients followed up by us did not have hydrocephalus. We also noted that the higher the location of the meningomyelocele, the greater the control of both sphincters (P=0.014). Fifty-four percent of the hydrocephalic patients had a normal development or IQ. Psychometric tests were normal in 76% of those without hydrocephalus. Twenty-four patients were lost to follow-up. The follow-up of the remaining 166 patients ranged from 1 month to 180 months (mean 60.2 months). Fifty-three patients (32%) died, central nervous system infection being the most common cause of death (44%). The management of children with meningomyelocele needs a team approach.
A previously healthy, HIV-negative, 40-year-old man presented with a 2-month history of progressive weakness of his left arm. Magnetic resonance imaging revealed an intradural, extramedullary plaque-shaped lesion at C6-T1 levels with high contrast enhancement. Based on the patient's clinical and radiologic findings, it was believed that the patient had an en plaque meningioma, and he was operated on. Histologic examination of the mass revealed granulomas with multinucleated and Langhans-type giant cells, typical of a tuberculoma. Intradural extramedullary tuberculomas should be considered in the differential diagnosis of en plaque meningioma as a rare entity.
This study was designed to evaluate the effects of propofol alone and propofol-clonidine combination on human middle cerebral artery blood flow velocity (Vmca) and cerebrovascular carbon dioxide (CO2) response by using transcranial Doppler ultrasonography. Mean Vmca in response to changes in arterial partial pressure of CO2 (Paco2) was determined under the following conditions: awake (group 1), propofol anesthesia (group 2), and combined propofol-clonidine anesthesia (group 3). Normocapnic, hypercapnic, and hypocapnic values of heart rate, mean arterial pressure, partial end-tidal CO2 pressure, Paco2, and Vmca were obtained. The mean Vmca in groups 2 and 3 was significantly lower than that in group 1 at each level of Paco2. The calculated Vmca at each level of Paco2 was not different between groups 2 and 3. There was a correlation between Paco2 and Vmca in all groups, but in the anesthetized groups the effect of Paco2 on Vmca was attenuated. The present data demonstrated that clonidine-propofol does not change CO2 reactivity compared with propofol alone, but both anesthetics attenuate cerebral blood flow compared with awake controls.
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