Our results do not support the use of EA in this population of painful neuropathy patients. Further studies in larger groups of patients are warranted to confirm our observation.
Primary brain tumours and pregnancy rarely occur together; meningioma and pregnancy is rarer still. We describe a 30-yr-old woman in the 25th week of pregnancy who underwent surgery in the sitting position for a large cerebellopontine angle meningioma that was compressing and displacing the pons and medulla. The surgical procedure and postoperative period were uneventful. This case demonstrates that when absolutely necessary, anaesthesia and neurosurgery for posterior fossa lesions can be successful during the second trimester of pregnancy. Furthermore, if indicated and if the operating team is experienced, the operation can be performed safely with the patient in the classical sitting position. It is emphasized that continuous and attentive monitoring of the mother and fetus are essential.
SummarySensitivity to the action of nondepolarising relaxants was compared in muscles of upper and lower limbs in four syringomyelic patients undergoing elective neurosurgical procedures. It was observed that muscles with signs of lower motor neurone dysfunction are supersensitive to the action of nondepolarising relaxants. Terminal sprouting of motor axons and the occurrence of newly formed neuromuscular junctions may be responsible for a low synaptic eficacy and may explain the high sensitivity to factors that reduce the safety margin of neuromuscular transmission. Key wordsNeuromuscular relaxants; syringomyelia.Syringomyelia is a pathological condition in which motor deficit of the upper limbs may be frequently caused by lower motor neurone dysfunction and lower limb deficit by a pyramidal lesion. Resistance of centrally denervated muscles to the action of nondepolarising relaxants is well d~curnented.'-~ However, little is known about the sensitivity of denervated muscles in patients with lower motor neurone dysfunction. ' Experimental evidence demonstrates that extrajunctional acetylcholine receptors appearing after denervation may have a poor affinity for tubocurarine,'Oxl' which, it has also been shown, may exert an agonist type of action on denervated muscles in some animals.I2 Clinical experience, on the other hand, indicates that sensitivity to curare might be greater than normal in patients with lower motor neurone dysfunction. Decremental responses and increased jitter, in fact, are common in electromyographic examinations of these We report clinical observations which indicate that denervated muscles of syringomyelic patients have an increased sensitivity to the action of nondepolarising relaxants. MethodsPatients were scheduled for elective neurosurgery. They were premedicated with diazepam and atropine. Anaesthesia was induced with fentanyl and thiopentone and maintained with either halothane or isoflurane, nitrous oxide and oxygen. Ventilation of the lungs was adjusted to produce a normal end-tidal carbon dioxide concentration, and the heart rate was recorded with an ECG monitor.Neuromuscular block produced by the intubating dose of nondepolarising relaxants was assessed by the use of a Datex Relaxograph and at various intervals, a Medelec 'MS 92a' unit was used to compare the extent of neuromuscular blockade in different muscles. Motor nerves were stimulated at 2 Hz with supramaximal stimuli given in trains-of-four or in trains-of-nine. The extent of block was assessed by the evaluation of fade. Fade was given by (1 -T4/T1) x 100; where T4 is the amplitude of the fourth response in a train and T1 is the amplitude of the first response.To increase the reliability of the procedure, studies that had been initiated with the Datex unit were completed with the Medelec and vice versa. The same surface electrodes were used in both examinations. Case historiesPatient 1, a 74 kg, 45-year-old woman was admitted to hospital with a history of many years of cervical pain and progressive weakness of the left...
We describe 3 patients, who exhibited neurological symptoms after single dose epidural anaesthesia. In patient 1 an unrecognized spinal arteriovenous fistula (AVF) caused paraparesis following epidural block. The dilated veins draining an AVF are space-occupying structures and the injection of the anaesthetic solution may have precipitated latent ischaemic hypoxia of the spinal cord due to raised venous pressure. In patient 2, epidural block was followed by postoperative permanent saddle pain and hypoaesthesia. The injection of the anaesthetic in a narrow spinal canal with multiple discal protrusions and restriction of interlaminar foramina may have acutely produced mechanical compression of the spinal cord or roots. Patient 3 exhibited post-epidural block spinal arachnoiditis. Although the few reported cases of this syndrome exhibit severe neurological damage, our patient presented with scarse symptoms. Our cases point out the importance of accurate neurological history and examination of candidates for epidural anaesthesia and of accurate anaesthetic history for neurological patients.
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