UNASSIGNED: The goal of this study is to assess the clinical effectiveness and prognostic potential of simultaneous bilateral lumbar transforaminal epidural steroid injections (TFESIs) in patients with bilateral radicular back pain with previous history of lumbar laminectomy and/or fusion surgery.
UNASSIGNED: Retrospective case series.
UNASSIGNED: Single physiatrist in an academic setting.
UNASSIGNED: 23 patients with previous lumbar surgery who received bilateral TFESIs.
UNASSIGNED: Cumulative bilateral radicular back pain was assessed with a pain numerical rating scale (NRS, 0-10) prior to receiving bilateral TFESI and at minimum 2 weeks follow-up. Responders included patients who experienced any NRS pain reduction post-procedure and non-responders were patients who reported no change in pain. A minimal clinically important difference (MCID) was defined as NRS change ≥2.0 to identify the proportion of responders who experienced a clinically significant reduction in pain. Other outcome measures included subsequent repeat bilateral TFESI, operations at the level of injections, and operative outcomes of these patients.
UNASSIGNED: There was a statistically significant (P ​< ​0.0001) reduction of 2.2 in mean NRS at average 3.7 weeks follow-up. With the MCID defined as NRS pain reduction ≥2, 13 of 16 responders (56%; CI 36.8-74.4%) achieved a clinically significant reduction in pain. Nine patients (39.1%) went on to receive repeat bilateral TFESIs and 9 patients (39.1%) underwent surgical interventions involving the same spinal level as the injections. Eight of the 9 patients who underwent repeat bilateral TFESIs met follow-up criteria and each responded to repeat injections with an average NRS pain reduction of 2.2. Of the 9 surgical patients, 5 responded to the previous injections and each reported improvements in pain and function after their operations (PPV ​= ​100%). Of the 4 surgical patients who were non-responders to the injections, 2 reported improvements in pain and function post-operatively and the remaining 2 reported no change or worsening outcomes (NPV ​= ​50%).
UNASSIGNED: This study suggests bilateral TFESIs are clinically effective in short-term management of bilateral radicular back pain in patients with previous lumbar surgery, and they reveal potential prognostic information for subsequent surgical intervention.

Spinal epidural arteriovenous fistulas with sacral arteriovenous malformation (AVM) are a rare type of spinal arteriovenous fistulas. There are two varieties of spinal epidural arteriovenous fistulas (SEDAVFs), with type 1 involving intradural venous drainage and type 2 not involving intradural venous drainage. We present a case of transarterial embolization for type 1 SEDAVFs with sacral AVM. Within 8 months, a 14-year-old boy presented with progressively weaker lower extremities and bladder-bowel dysfunction. Magnetic resonance imaging (MRI) of the whole spine revealed thoracic spinal cord congestion, a single dilated flow void running from the lumbosacral area to the conus medullaris, and continuing cranial draining up to the C5 level via the perimedullary vein. Filling of the venous sac through a preferential feeder after embolizing the AVM nidus was performed. After 3 months, the clinical follow-up showed improvement of motoric function, although mild. Endovascular treatment for SEDAVF type 1 might have achieved total obliteration without any procedural complications. Nevertheless, it can be very challenging due to multiple feeders and the presence of an AVM nidus like in this case. However, the most difficult thing in fistula cases is establishing the diagnosis and finding the fistula point. Early treatment is required, due to the fact that longstanding lesions could cause irreversible damage.

UNASSIGNED: Radiculopathy can be a debilitating condition. Amniotic membrane/umbilical cord (AM/UC) particulate is a relatively new injectable treatment modality. Herein we report the outcomes of epidural injection of AM/UC particulate in managing lumbar radiculopathy.
UNASSIGNED: Consecutive patients with lumbar radiculopathy who received epidural injection of AM/UC particulate for lumbar radiculopathy were included. Primary outcome was change in pain as measured by the 11-point numerical rating scale. Safety was assessed by AM/UC- and procedure-related complications. Paired t-tests were used to determine statistical significance.
UNASSIGNED: A total of 12 patients with a mean age of 56.7 ± 21.0 years were included in the analysis. The patients were previously treated with physical therapy (91.7%), chiropractic corrective measures (16.7%), epidural steroid injection (83.3%), and radiofrequency ablation (8.3%). Two patients (16.7%) were taking opioids for chronic pain syndrome. After AM/UC injection, the average pain score decreased from 6.6 ± 1.5 to 5.2 ± 1.9 at 1-3 months, 2.0 ± 1.4 at 6 months, and 2.9 ± 1.4 at last mean follow-up of 21.3 ± 11.1 months (p < 0.001). No patients required subsequent treatment or surgery. There were also no complications.
UNASSIGNED: This case series supports the preliminary safety and shows potential benefit of epidural AM/UC particulate injection in this cohort of patients with lumbar radiculopathy pain.

UNASSIGNED: Percutaneous transforaminal endoscopic discectomy (PTED) has become popular over the years due to its safety and low invasiveness. This surgery can be performed with different anesthesia techniques; however, the extent to which the surgeon and patient are satisfied with the analgesia is debatable.
UNASSIGNED: This study investigated the efficiency of the S1 transforaminal epidural block.
UNASSIGNED: This retrospective study was conducted on 60 patients with L4 - L5 lumbar disc herniation who underwent PTED under the S1 transforaminal epidural block. All patients had clinical symptoms associated with unilateral radiculopathy and were candidates for surgery. Percutaneous transforaminal endoscopy and S1 epidural block were performed by a surgeon for all patients.
UNASSIGNED: Of the 60 evaluated cases, 61.7% and 38.3% were female and male, respectively, with a mean age of 42.98 ± 10.79 years. The mean pain score before surgery was 7.83 ± 0.69, which decreased to 2.58 ± 0.65 during surgery and 0.50 ± 0.50 48 hours after surgery (P < 0.001). The mean duration of operation in these patients was 58.58 ± 16.95 minutes, and the mean onset time was 10.08 ± 3.12 minutes. Moreover, the mean bleeding was 124.17 ± 25.20 cc.
UNASSIGNED: The PTED with S1 epidural anesthesia is a simple, safe, and effective method that causes good analgesia during the operation and cooperates well with the surgeon in neurological monitoring due to patient consciousness.

暂无摘要。

A broken epidural catheter with a retained fragment in the spinal canal is a rare complication of an otherwise low-risk procedure. We present a case of a 37-year-old post-partum female with a fractured epidural catheter with a retained fragment in the epidural space, after epidural anaesthesia using a midline L3/L4 approach. The patient was completely asymptomatic, and the management decision lay between surgical exploration with removal and conservative management with no intervention. CT scan findings were unhelpful, and MRI imaging showed a probable retained fragment penetrating the midline ligamentum flavum, with the catheter tip lying within the spinal canal. The fragment was removed under general anaesthesia 3 days post-delivery. In our proposed treatment algorithm, if the residual catheter fragment is proved radiologically to lie outside the spinal canal and there is no residual catheter breaching the skin to provide a portal for infection, conservative management is reasonable. Early removal is advised when the retained fragment is within the spinal canal-preferably within days to prevent the formation of dural adhesions. This is easier under direct vision, allowing rapid discharge and avoiding much more difficult and higher risk surgery later on.

BACKGROUND: Pneumocephalus is rare in vaginal deliveries. Pneumocephalus may be asymptomatic or present with signs of increased intracranial pressure. However, parturients who received epidural anesthesia with air in their brains may experience low intracranial pressure headaches after giving birth, causing the diagnosis of pneumocephalus to be delayed. We report a case of a parturient who developed post-dural puncture headache combined with pneumocephalus secondary to vaginal delivery following epidural anesthesia.
METHODS: A 24-year-old G1P0 Chinese woman at 38 weeks gestation was in labor and received epidural anesthesia using the loss of resistance to air technique and had a negative prior medical history. She presented with postural headache, neck stiffness and auditory changes 2 h after vaginal delivery. The head non-contrast computed tomography revealed distributed gas density shadows in the brain, indicating pneumocephalus. Her headache was relieved by bed rest, rehydration, analgesia, and oxygen therapy and completely disappeared after 2 weeks of postpartum bed rest.
CONCLUSIONS: This is the first report that positional headaches after epidural anesthesia may not indicate low intracranial pressure alone; it may combine with pneumocephalus, particularly when using the loss of resistance to air technique. At this moment, head computed tomography is essential to discover other conditions like pneumocephalus.

UNASSIGNED: Esophagectomy traditionally has high levels of perioperative morbidity and mortality due to surgical techniques and case complexity. While thoracic epidural analgesia (TEA) is considered first-line for postoperative analgesia after esophagectomy, complications can arise related to its sympathectomy and mobility impairment. Additionally, it has been shown that postoperative outcomes are improved with early extubation following esophagectomy. Our aim is to describe the impact of transversus abdominis plane (TAP) blocks on extubation rates following esophagectomy when uncoupled from TEA.
UNASSIGNED: This is a case series of 42 patients who underwent trans-hiatal esophagectomy between 2019 and 2022 who received a TAP block without TEA. The primary outcomes of interest were the rates of extubation within the operating room (OR) and reintubation. Secondary outcomes included: intensive care unit (ICU) and hospital length of stay (LOS), opioid pain medication use, post-operative hypotension, fluid administration, postoperative pain scores, development of anastomotic leak, and 30-day readmission.
UNASSIGNED: The mean age at operation was 63 years and 97.6% of patients were represented by American Society of Anesthesia (ASA) physical status class III or IV. Thirty-four (81%) patients immediately extubated postoperatively. Nine patients (21.4%) underwent reintubation during their hospital course. Only seven patients (16.7%) required vasopressors postoperatively. The median LOS was five days in the ICU and 10 days in the hospital. TAP block alone was found to be equivalent to TAP with additional regional blocks (TAP+) on the basis of immediate extubation, reintubation, ICU and hospital LOS, and reported postoperative pain.
UNASSIGNED: The results of this study demonstrated immediate extubation is possible using TAP blocks while limiting post-operative hypotension and fluid administration. This was shown despite the elevated comorbidity burden of this study\'s population. Overall, this study supports the use of TAP blocks as a possible alternative for primary analgesia in patients undergoing trans-hiatal esophagectomy.
UNASSIGNED: This study includes participants who were retrospectively registered. IRB# 037.HPB.2018.R.

Thoracic epidural placement is considered the gold standard for pain management for abdominal or thoracic surgery. It provides analgesia superior to that provided by opioids with a decreased risk of pulmonary complications. Insertion of a thoracic epidural catheter requires the knowledge and expertise of an anesthetist; epidural catheter insertion may be challenging especially when sited in the higher thoracic region, in patients with unusual neuraxial anatomy, patients unable to position adequately for insertion or morbidly obese patients. Postoperatively the anesthetic team is required to look after the patient and assess for any complications such as hypotension. Even though the incidence of complications may be low; however, some of these could have detrimental consequences for the patients such as epidural abscess, hematoma formation, and temporary or permanent neurological damage. In this case report, we will discuss a patient who underwent a three-stage esophagectomy for esophageal squamous cell carcinoma under general anesthesia with epidural analgesia. The epidural catheter (Portex® Epidural Minipack System with NRFit® connector, ICUmedical, USA) was found in the intrapleural space during video-assisted thoracoscopy for the thoracic part of esophagectomy. To facilitate surgical access, the catheter was removed immediately, and the patient was given patient-controlled analgesia with morphine for postoperative pain control.

UNASSIGNED: Commonly spinal cavernous hemangioma (CH) is found in vertebral body at thoracic level. Purely extraosseous epidural CH contributes only 4% of all CH. In addition, these patients usually present in their 3rd-6th decade of life. Here, we report emergently treated rare case of hemorrhagic extraosseous epidural thoracic CH in a 26-year-old male.
UNASSIGNED: A 26-year-old male presented with inability to walk without support with acute onset paraparesis and hypoesthesia below D7 with positive myelopathy signs. Magnetic resonance imaging showed posterior epidural well-defined homogenous mass from D6-8 region. PET scan ruled out other primary lesions in body. Intraoperative after D6-8 laminectomy extradural vascular mass was found which was bleeding on touch. With adequate hemostasis complete mass was excised and sent for sampling which revealed CH. The patient showed gradual clinical recovery with complete neurological recovery after 3 months with no signs of clinical and radiological recurrence on 2 years of follow-up.
UNASSIGNED: Extraosseous epidural CH is very rare presentation; hence, the differentials of schwannoma, lymphoma, tubercular/pyogenic epidural abscess, metastasis, and others must always be ruled out. They can present a decade earlier in a case of hemorrhagic CH with rapid progressive neurological deficit which warrants early surgical decompression like in our case and the foraminal or paravertebral extension needs foraminotomy or thoracotomy for complete excision.