Analgesic Effect of Combined Spinal-Epidural Anesthesia and its Effect on TNF-α and CRP Levels in Elderly Patients with Hip Fracture During Surgical Treatment

Objective:To observe the analgesic effect of combined spinal and epidural anesthesia on older patients undergoing hip fracture surgery.Method:One hundred and twenty elderly hip fracture surgery patients treated in our hospital from January 2021 to December 2022 were selected and randomly divided into two groups,with 60 cases in the experimental group and 60 in the control group.The experimental group was given combined spinal-epidural anesthesia intervention measures,while the control group was given epidural anesthesia intervention measures.The analgesic effect,tumor necrosis factor-alpha(TNF-α),C-reactive protein(CRP)levels,and other observation indicators were analyzed after anesthesia intervention.Result:After the intervention,the analgesic effect and the evaluation results of the subjects in the experimental group were better than those in the control group(P<0.05);the obtained values of TNF-αand CRP levels in the experimental group were higher than those of the control group(P<0.05).Conclusion:The combined spinal-epidural anesthesia intervention demonstrated positive outcomes.The analgesic effect of patients during surgery and their inflammatory factor levels improved,which makes this intervention worthy of clinical application and promotion.

Safety and effectiveness of electromyography-induced rehabilitation treatment after epidural electrical stimulation for spinal cord injury:study protocol for a prospective,randomized,controlled trial

Epidural electrical stimulation is a new treatment method for spinal cord injury(SCI).Its efficacy and safety have previously been reported.Rehabilitation treatment after epidural electrical stimulation is important to ensure and improve the postoperative efficacy of epidural electrical stimulation in patients with SCI.Considering that electromyography(EMG)-induced rehabilitation treatment can accurately match the muscle contraction of patients with SCI,we designed a study protocol for a prospective,randomized controlled trial.In this trial,on the premise of adjusting the spinal cord electrical stimulator to obtain the maximum EMG signal of the target muscle,patients with SCI receiving epidural electrical stimulation will undergo EMG-induced rehabilitation treatment.Recovery of muscle strength of key muscles,quality of life,safety and therapeutic effects will be monitored.Twenty patients with SCI who are scheduled to undergo epidural electrical stimulation in Shanghai Ruijin Rehabilitation Hospital will be randomly divided into two groups with 10 patients per group.The control group will receive conventional rehabilitation treatment.The EMG-induced rehabilitation group will receive EMG-induced rehabilitation treatment of the target muscles of the upper and lower limbs based on conventional rehabilitation treatment.After rehabilitation treatment,follow up for all patients will occur at 2 weeks and 1,3 and 6 months.The primary outcome measure of this trial will be evaluation of target muscle recovery using the Manual Muscle Testing grading scale.Secondary outcome measures will include modified Barthel Index scores,integrated EMG values,the visual analogue scale,Spinal Cord Independence Measure scores,and modified Ashworth scale scores.The safety indicator will be the incidence of adverse events.This trial will collect data regarding the therapeutic effects of EMG-induced rehabilitation in patients with SCI receiving epidural electrical stimulation for 6 months after rehabilitation treatment.Findings from this trial will help develop rehabilitation methods in patients with SCI after epidural electrical stimulation.This study protocol was approved by Ethics Committee of Shanghai Ruijin Rehabilitation Hospital(Approval No.RKIRB2022-12)on February 15,2022 and was registered with Chinese Clinical Trial Registry(registration number:ChiCTR2200061674;date:June 30,2022).Study protocol version:1.0.

Successful remimazolam sedation-epidural block in an older patient with severe chronic obstructive pulmonary disease:A case report

BACKGROUND Chronic obstructive pulmonary disease(COPD)is associated with high morbidity and mortality rates worldwide.Older patients have a degenerative cardiopulmonary function,weak compensatory capacity,and poor surgical tolerance.Therefore,the mode of anesthesia must be optimized.Remimazolam is a new ultrashort-acting benzodiazepine with a rapid onset of action,rapid metabolism,and mild effects on pulmonary circulation.Remimazolam sedation combined with an epidural block has not been reported in hypertensive older adults with severe COPD and inguinal mass resection.CASE SUMMARY We report the case of a 73-year-old man with hypertension and severe COPD,who underwent resection of an enlarged inguinal mass that he had noticed more than 7 mo before presentation.The patient presented with a“right inguinal mass”and was recommended to undergo an enlarged inguinal mass resection.Surgery was relatively challenging,due to the large mass(13 cm×8 cm×7 cm),hard texture,and poor mobility.Considering the advanced age of the patient,gradeⅢhypertension,and severe COPD,we administered remimazolam combined with an epidural block for anesthesia to ensure perioperative safety and careful consideration.The anesthetic effect was precise;the procedure was performed smoothly without any complications,and the patient was successfully anesthetized.However,anesthetic management in such cases has not yet been reported by previous studies.CONCLUSION Remimazolam sedation combined with an epidural block is safe and effective in older patients with hypertension and severe COPD.

Extensive Spinal Epidural Abscess: Cord Compression with Permanent Neurological Defects

Spinal epidural abscesses (SEA) are considerably rare and tend to present over two to five vertebral segments. Occasionally, there will be two or more noncontiguous areas of pyogenic collections [1]. Minimal cases have been reported to span the entire vertebral column;a meta-analysis estimates that 1% of all SEA are holospinal [2]. The triad of presenting symptoms includes fever, back pain (often midline), and neurologic defects [1] [2] [3]. Early detection is identified as a critical aspect of improved outcomes. Cases that do not present in this manner or with other masking symptoms can lead to delayed diagnosis, thus delaying treatment. In the event of cord compression, the occurrence of neurologic defects increases. Time from the onset of clinical manifestations to the operating room is crucial in reversing symptoms [2]. This article seeks to review a case of a 65-year-old male that presented to the emergency department (ED) due to a falling second to weakness and thigh pain. On presentation, he was also noted to have rhabdomyolysis causing acute kidney injury (AKI) with tubular necrosis. The patient was admitted to the hospital with a complex history of progressive leg weakness, pain in the lower back, incontinence, and elevated white blood cell count. Days into the admission, a magnetic resonance imaging (MRI) study was performed, which revealed a continuous posterior SEA from C4 to S2 with anterior mass effect causing spinal cord compression. Emergency neurosurgery was scheduled for laminectomies in the cervical, thoracic and lumbar spine to drain the abscess. Evaluation of this complex medical course, surgical approach to drainage of an incessant spinal column abscess, and sustained neurologic defects will be discussed.

Is It Safe to Perform an Autologous Epidural Blood Patch on Patients with Underlying Spinal Stenosis or Lumbar Disc Disease? Case Report and Literature Review

The most common spinal pathology seen in the obstetric population is lumbar disc herniation. There is currently no literature documenting the safety of performing an epidural blood patch on obstetric patients with underlying spinal pathology. We present a case of a patient with known severe lumbar spinal stenosis with compressive radiculopathy who received a successful epidural blood patch without worsening her underlying neurologic symptoms. Epidural blood patches can be safely performed in this patient population. However, the anesthesiologist should be aware of the risk of potentially worsening preexisting neurological deficits. Thus, we advise caution prior to placing an epidural blood patch on these patients. The risks and benefits of the procedure should be carefully weighed and considered. It is important to have a thorough discussion with the patient regarding the risks of an epidural blood patch prior to performing the procedure.

The Effect of Different Regional Blocks: Combined Femoral-Sciatic, Spinal and Epidural Blocks on the Different Side Effects of Arterial Tourniquet in Patients Undergoing Lower Limb Orthopedic Surgeries —A Randomized Controlled Trail

Background: Pneumatic arterial tourniquet is a very commonly used technique in limb surgeries to provide bloodless field to facilitate dissection and decrease blood loss. However, arterial tourniquet has many deleterious effects including hemodynamic changes, serum lactate and potassium level changes and tourniquet-induced pain which sometimes can be severe and intolerable. Aim of the study: To evaluate the effect of different regional blocks: femoral-sciatic, spinal and epidural blocks on serum lactate and potassium levels and the degree of arterial tourniquet-induced pain in patients undergoing lower limb orthopedic surgeries. Methods: 60 patients underwent lower limb orthopedic surgery with application of tourniquet for duration not more than 90 minutes. Patients were assigned randomly to one of three groups (20 each) Group I had sciatic-femoral block, Group II: patients had spinal anesthesia and Group III: patients had epidural anesthesia. Intraoperative hemodynamics, changes in serum potassium and lactate levels and tourniquet pain after tourniquet inflation & deflation, were recorded. Results: There was no statistically significant difference among the three groups regarding tourniquet pain after tourniquet inflation (p = 0.872) and deflation (p = 0.902), and regarding serum levels changes of potassium (p = 0.067) and lactate (p = 0.051). However, each group showed statistically significant increase in post deflation tourniquet pain (p = 0.003, 0.002, 0.003, in groups F, S, E respectively) and serum potassium (p = 0.004, 0.006, 0.000, in groups F, S, E respectively) and lactate levels (p = 0.004, 0.000, 0.000, in groups F, S, E respectively) when compared to the pre-deflation values, and the increase was directly proportional to the duration of tourniquet. Conclusion: the three different types of anesthesia (femoral-sciatic, spinal and epidural block) have the same effect on serum lactate and potassium levels and the degree of tourniquet pain, which were related to the duration of tourniquet inflation.

Survival and clinical outcomes in patients with metastatic epidural spinal cord compression after spinal surgery:a prospective,multicenter,observational cohort study

Background:High quality studies have been challenging to undertake in patients with metastatic epidural spinal cord compression.Nonetheless,in the article "Survival and Clinical Outcomes in Surgically Treated Patients With Metastatic Epidural Spinal Cord Compression:Results of the Prospective Multicenter AOSpine Study" recently published in the Journal of Clinical Oncology,our team provided convincing evidence that spinal surgery improves overall quality of life in patients with this potentially devastating complication of cancer.Considering that metastatic spinal lesions treated with surgery have the highest mean cost among all oncological musculo-skeletal issues,it is essential to provide high quality data to optimize the therapeutic approaches and cost-effective use of health care resources.Main body:Although the AOSpine Study provided high quality prospective data,it was primarily limited by the lack of non-operative controls and the relatively small sample size.Given the dearth of medical equipoise and the fundamental difference between patients deemed to be adequate surgical candidates and those who are not amenable to operative intervention,conducting a randomized controlled trial in this patient population was not felt to be ethically or medically feasible.Consequently,the optimal option to overcome limitations of both the lack of controls and the relatively small sample size is through collection of large prospective datasets through rigorously developed and maintained registries.Conclusions:With the alarming increase in the incidence of cancer in China and China's parallel growing cancer control efforts,China would offer a fantastic platform to set up a national metastatic spinal lesion registry.Such registry would not only enhance metastatic epidural spinal cord compression translational research but also optimize patient care.

Epidural electrical stimulation for spinal cord injury

A long-standing goal of spinal cord injury research is to develop effective repair strategies,which can restore motor and sensory functions to near-normal levels.Recent advances in clinical management of spinal cord injury have significantly improved the prognosis,survival rate and quality of life in patients with spinal cord injury.In addition,a significant progress in basic science research has unraveled the underlying cellular and molecular events of spinal cord injury.Such efforts enabled the development of pharmacologic agents,biomaterials and stem-cell based therapy.Despite these efforts,there is still no standard care to regenerate axons or restore function of silent axons in the injured spinal cord.These challenges led to an increased focus on another therapeutic approach,namely neuromodulation.In multiple animal models of spinal cord injury,epidural electrical stimulation of the spinal cord has demonstrated a recovery of motor function.Emerging evidence regarding the efficacy of epidural electrical stimulation has further expanded the potential of epidural electrical stimulation for treating patients with spinal cord injury.However,most clinical studies were conducted on a very small number of patients with a wide range of spinal cord injury.Thus,subsequent studies are essential to evaluate the therapeutic potential of epidural electrical stimulation for spinal cord injury and to optimize stimulation parameters.Here,we discuss cellular and molecular events that continue to damage the injured spinal cord and impede neurological recovery following spinal cord injury.We also discuss and summarize the animal and human studies that evaluated epidural electrical stimulation in spinal cord injury.

Combination of epidural electrical stimulation with ex vivo triple gene therapy for spinal cord injury:a proof of principle study

Despite emerging contemporary biotechnological methods such as gene-and stem cell-based therapy,there are no clinically established therapeutic strategies for neural regeneration after spinal cord injury.Our previous studies have demonstrated that transplantation of genetically engineered human umbilical cord blood mononuclear cells producing three recombinant therapeutic molecules,including vascular endothelial growth factor(VEGF),glial cell-line derived neurotrophic factor(GDNF),and neural cell adhesion molecule(NCAM)can improve morpho-functional recovery of injured spinal cord in rats and mini-pigs.To investigate the efficacy of human umbilical cord blood mononuclear cells-mediated triple-gene therapy combined with epidural electrical stimulation in the treatment of spinal cord injury,in this study,rats with moderate spinal cord contusion injury were intrathecally infused with human umbilical cord blood mononuclear cells expressing recombinant genes VEGF165,GDNF,NCAM1 at 4 hours after spinal cord injury.Three days after injury,epidural stimulations were given simultaneously above the lesion site at C5(to stimulate the cervical network related to forelimb functions)and below the lesion site at L2(to activate the central pattern generators)every other day for 4 weeks.Rats subjected to the combined treatment showed a limited functional improvement of the knee joint,high preservation of muscle fiber area in tibialis anterior muscle and increased H/M ratio in gastrocnemius muscle 30 days after spinal cord injury.However,beneficial cellular outcomes such as reduced apoptosis and increased sparing of the gray and white matters,and enhanced expression of heat shock and synaptic proteins were found in rats with spinal cord injury subjected to the combined epidural electrical stimulation with gene therapy.This study presents the first proof of principle study of combination of the multisite epidural electrical stimulation with ex vivo triple gene therapy(VEGF,GDNF and NCAM)for treatment of spinal cord injury in rat models.The animal protocols were approved by the Kazan State Medical University Animal Care and Use Committee(approval No.2.20.02.18)on February 20,2018.

Resolution of herpes zoster-induced small bowel pseudo-obstruction by epidural nerve block:A case report

BACKGROUND When herpes zoster is complicated with paralytic ileus,this mostly involves acute intestinal pseudo-obstruction of Ogilvie’s syndrome manifesting as obvious dilatation of the cecum and right colon;small intestinal obstruction is rare.Here,we present a patient with a very rare case of small bowel pseudo-obstruction.CASE SUMMARY A 76-year-old female patient complained of right upper quadrant pain.Two days later,a blistering,right-sided rash of the thoracoabdominal dermatome(T5-T10) emerged in conjunction with small intestinal dilatation and the inability to defecate.Computed tomography of the abdomen confirmed small bowel pseudoobstruction.Antiviral therapy,gastrointestinal decompression,and enemas proved unproductive.After 4 d of stagnation,an epidural block was performed for pain relief and prompted the passage of gas and stool,resolving the obstructive problem.Three days later,the rash appeared dry and crusted,and the pain diminished.After 5 d,no abnormality was visible by gastroenteroscopy,and the patient was discharged on day 7.CONCLUSION This case shows that herpes zoster may induce small bowel pseudo-obstruction in addition to colonic pseudo-obstruction.Epidural block can not only treat intercostal neuralgia but also resolve small bowel pseudo-obstruction caused by herpes zoster.

Spinal epidural hematoma after spinal manipulation therapy:Report of three cases and a literature review

BACKGROUND Spinal manipulation therapy(SMT)has been widely used worldwide to treat musculoskeletal diseases,but it can cause serious adverse events.Spinal epidural hematoma(SEH)caused by SMT is a rare emergency that can cause neurological dysfunction.We herein report three cases of SEH after SMT.CASE SUMMARY The first case was a 30-year-old woman who experienced neck pain and numbness in both upper limbs immediately after SMT.Her symptoms persisted after 3 d of conservative treatment,and she was admitted to our hospital.Magnetic resonance imaging(MRI)demonstrated an SEH,extending from C6 to C7.The second case was a 55-year-old man with sudden back pain 1 d after SMT,numbness in both lower limbs,an inability to stand or walk,and difficulty urinating.MRI revealed an SEH,extending from T1 to T3.The third case was a 28-year-old man who suddenly developed symptoms of numbness in both lower limbs 4 h after SMT.He was unable to stand or walk and experienced mild back pain.MRI revealed an SEH,extending from T1 to T2.All three patients underwent surgery after failed conservative treatment.The three cases recovered to ASIA grade E on day 5,1 wk,and day 10 after surgery,respectively.All patients returned to normal after 3 mo of follow-up.CONCLUSION SEH caused by SMT is very rare,and the condition of each patient should be evaluated in full detail before operation.SEH should be diagnosed immediately and actively treated by surgery.

Epidural oscillating field stimulation increases axonal regenerative capacity and myelination after spinal cord trauma

Oscillating field stimulation(OFS)with regular alterations in the polarity of electric current is a unique,experimental approach to stimulate,support,and potentially guide the outgrowth of both sensory and motor nerve fibers after spinal cord injury(SCI).In previous experiments,we demonstrated the beneficial effects of OFS in a 4-week survival period after SCI.In this study,we observed the major behavioral,morphological,and protein changes in rats after 15 minutes of T9 spinal compression with a 40 g force,followed by long-lasting OFS(50μA),over a 8-week survival period.Three groups of rats were analyzed:rats after T9 spinal compression(SCI group);SCI rats subjected to implantation of active oscillating field stimulator(OFS+SCI group);and SCI rats subjected to nonfunctional OFS(nOFS+SCI group).Histopathological analysis of spinal tissue indicated a strong impact of epidural OFS on the reduction of tissue and myelin loss after SCI in the segments adjacent to the lesion site.Quantitative fluorescent analysis of the most affected areas of spinal cord tissue revealed a higher number of spared axons and oligodendrocytes of rats in the OFS+SCI group,compared with rats in the SCI and nOFS+SCI groups.The protein levels of neurofilaments(NF-l),growth-associated protein-43(marker for newly sprouted axons),and myelin basic protein in rats were signifiantly increased in the OFS+SCI group than in the nOFS+SCI and SCI groups.This suggests a supporting role of the OFS in axonal and myelin regeneration after SCI.Moreover,rats in the OFS+SCI group showed great improvements in sensory and motor functions than did rats in the nOFS+SCI and SCI groups.All these findings suggest that long-lasting OFS applied immediately after SCI can provide a good microenviroment for recovery of damaged spinal tissue by triggering regenreative processes in the acute phase of injury.

Comparative Study between Ultrasound-Guided Serratus Anterior Plane Block versus Thoracic Epidural Analgesia for Post-Thoracotomy Pain: A Prospective, Randomized, Clinical Trial

Objectives and Aim: Thoracotomies are widely recognized to cause acute pain which is associated with many complications. The target study aimed to assess the safety and efficacy of SAPB compared to TEA for relieving severe thoracotomy pain. Patients and Methods: Forty patients scheduled for thoracotomy randomly allocated either to receive SAPB or thoracic epidural (TEA). Visual analogue pain score (VAS) at rest and coughing every 6 hrs. Postoperative, hemodynamic parameters (heart rate and MAP), pain rescue analgesic consumption in the first 24 hrs., complications, and duration of hospital stay recorded. Results: In our study, we found that the recently described SAPB, while maintaining stable blood pressure, provided excellent analgesia comparable to that offered by TEA for acute post-thoracotomy pain. Hypotension was more noteworthy in those who had epidurals than those with serratus anterior plane (SAP) catheters. Morphine rescue analgesia, as well as Visual Analogue Scale (VAS) pain scores during normal tidal breathing, were like in both groups. Conclusion: We recommend that the Serratus anterior plane block appears to be a safe and effective alternative for postoperative analgesia after thoracotomy.

Effect of epidural block combined intravenous general anesthesia stress on the stress response and T lymphocyte subsets in patients with breast cancer undergoing radical mastectomy

Objective: To investigate the effect of epidural block combined with intravenous anesthesia on stress response and T lymphocyte subsets in patients with breast cancer undergoing radical mastectomy. Methods: In our hospital from July 2016 to June 2017 undergoing radical mastectomy for breast cancer of 88 patients were randomly divided into observation group and control group of 44 cases, 2 patients underwent routine preoperative preparation, and routine blood pressure, heart rate, pulse, oxygen saturation, ECG monitoring, control group with intravenous anesthesia. The observation group was treated with epidural block combined with intravenous anesthesia. 2 groups of patients before anesthesia, 30 MIM (T0), 1 h after skin incision (T1), 4 h after operation (T2), 24 h after operation (T3), 48 h after operation (T4) from peripheral venous blood were measured by interleukin-8 (IL-8) and interferon gamma (IFN-γ), cortisol (Cor), prolactin (PRL), growth hormone (GH) and T lymphocyte subsets (CD3+, CD4+, CD8+), the calculation of CD4+/CD8+ value. Results: the serum IL-8 level of T1, T2, T3and T4 decreased gradually, were lower than at T0, and the control group at each time point had no significant difference, T1, T2, T3group, T4IL-8 levels lower than the control group;the 2 groups of serum IFN-γ levels T1 and T2had no significant change, T3and T4increased gradually, was higher than that of T0, but no significant difference between the 2 groups of IFN-γ levels. 2 serum Cor levels peaked at T1, decreased at T2, was higher than that of T0, T3, T4returned to T0, the observation group T1, T2Cor level lower than the control group;the serum PRL levels of 2 groups reached a peak at T1, T2, T3at the time of T4decreased gradually, was higher than that of T0, T1, T2, T3of the observation group at the PRL level is lower than the control group;the serum level of GH 2 in group T1increased gradually, reached a peak at T2, T3and T4 decreased gradually, was higher than that of T0, the observation group T1, T2, T3, T4, GH levels lower than the control group. 2 groups of CD3+ decreased gradually in T1, T2, were lower than T0, T3, T4returned to T0, the observation group T1, T2CD3+ was higher than the control group;group CD4+ decreased gradually in T1, T2, T3and T4were lower than control, T0when, and the observation group CD4+ in T1, T2, T3, T4, no significant changes were observed in group T1, T2, T3, T4and CD4+ higher than that of the control group;the 2 group CD8+ had no obvious changes in T1, T2, T3, T4;observation group CD4+/CD8+ decreased gradually in T1, T2, were lower than T0, T3, T4returned to T0, the observation group T1, T2CD4+/CD8+ was higher than the control group. Conclusion: epidural block combined with intravenous anesthesia for breast cancer radical mastectomy can effectively relieve the stress and inflammatory reaction, alleviate the immunosuppression, and help to restore the postoperative immune function.

A flexible electrode array for determining regions of motor function activated by epidural spinal cord stimulation in rats with spinal cord injury

Epidural stimulation of the spinal cord is a promising technique for the recovery of motor function after spinal cord injury.The key challenges within the reconstruction of motor function for paralyzed limbs are the precise control of sites and parameters of stimulation.To activate lower-limb muscles precisely by epidural spinal cord stimulation,we proposed a high-density,flexible electrode array.We determined the regions of motor function that were activated upon epidural stimulation of the spinal cord in a rat model with complete spinal cord,which was established by a transection method.For evaluating the effect of stimulation,the evoked potentials were recorded from bilateral lowerlimb muscles,including the vastus lateralis,semitendinosus,tibialis anterior,and medial gastrocnemius.To determine the appropriate stimulation sites and parameters of the lower muscles,the stimulation characteristics were studied within the regions in which motor function was activated upon spinal cord stimulation.In the vastus lateralis and medial gastrocnemius,these regions were symmetrically located at the lateral site of L1 and the medial site of L2 vertebrae segment,respectively.The tibialis anterior and semitendinosus only responded to stimulation simultaneously with other muscles.The minimum and maximum stimulation threshold currents of the vastus lateralis were higher than those of the medial gastrocnemius.Our results demonstrate the ability to identify specific stimulation sites of lower muscles using a high-density and flexible array.They also provide a reference for selecting the appropriate conditions for implantable stimulation for animal models of spinal cord injury.This study was approved by the Animal Research Committee of Southeast University,China(approval No.20190720001) on July 20,2019.

Combined Spinal Epidural Catheters for Epidural Cooling, Cerebrospinal Fluid Aspiration and Spinal Intralipid Infusion for Treatment of Spinal and Brain Injuries, Diseases and Protection

A new proposal for spinal cord and brain treatment and protection due to injuries and diseases is made herein. It is composed of two 20G nylon catheters with 6 lateral holes arranged circumferentially within 3 cm from the tip and a closed end. One catheter is inserted into the epidural space and the other catheter is inserted into the spinal space in two different lumbar interspaces using an 18G Tuohy needle 90 mm. The epidural catheter is used for cooled saline injection and infusion. The spinal catheter is used for Intralipid spinal injections and CSF aspiration. The proposal is based on the current studies on spinal cord cooling and CSF aspiration as well as on the Intralipid resuscitation properties and lipid brain protection. A study is needed to evaluate the clinical value of this combined approach.

Spontaneous Spinal Epidural Hematoma Causing Paraplegia: A Case Report

A spontaneous spinal epidural hematoma without any identified etiology is a very rare entity. We report here a 44 years old woman admitted within our department for 04 days of severe back pain complicated rapidly of bilateral lower-limbs weakness and urinary retention. Neurological examination found a complete paraplegia (0/5 stergh), with incomplete sensory deficit below the T-10 level, bowel and bladder dysfunction, decreased deep and superficial reflex. MRI with different sequences showed a large epidural mass lesion with slightly high signal intensity on T1-weighted images and heterogeneous low signal intensity on T2-weighted images from T11 to L1 suggesting an epidural hematoma. She underwent an urgent total laminectomy from T11 to L1 following by a complete removal of a large dark and compact epidural hematoma compressing the spinal cord. Operatively, there’s no sign suggesting an AVM. Postoperative course was uneventful and she was discharged ten days after surgery with complete recovery.

Epidural Blood Patch for Treatment of Postdural Puncture Headache in a Patient with Spinal Fusion and Recent Implantation of Intrathecal Pain Pump

We present an interesting case report of a 49-year-old female who presented with symptoms of post-dural puncture headache following implantation of an intrathecal pain pump. Her history was complicated by previous multi-level spinal fusion with hardware. The patient was evaluated and felt to be a candidate for epidural blood patch, which she elected to proceed with. Under fluoroscopic guidance epidural blood patch was successfully performed. Immediately following the procedure the patient noted significant improvement in the headache and six hours following the procedure was headache free and remained so at follow up three weeks later.

Early Diagnosis of Spontaneous Spinal Epidural Hematoma with Echo-Planar Gradient-Echo T2*-Weighted MR Imaging

Spontaneous spinal epidural hematoma (SSEH) is a rare idiopathic condition that leads to the acute onset of neurological deficits, which can have catastrophic consequences if not recognized early. It is important to make an early precise diagnosis. Spinal epidural hematoma has been increasingly recognized since the advent of magnetic resonance imaging (MRI). However, T1- and T2-weighted gradient-echo sequences are relatively less sensitive to the magnetic susceptibility effects of hemorrhage. Echo-planar gradient-echo T2*-weighted MR imaging (T2* MRI) is sensitive to these magnetic susceptibility effects and is commonly used for the detection of hemorrhage. We reported that the case of a 76-year-old man who presented with tetra paresis had an early diagnosis of spontaneous spinal epidural hematoma early diagnosed by T2* MRI.

Case Report: Rare Presentations of Accidental Subdural Block in Labor Epidural Anesthesia

The incidence of accidental injection or catheterization of the subdural space during performance of a neuroaxial block has recently increased. It can occur even when an experienced practitioner performs the neuraxial procedure. The presentation of numerous unexplainable clinical signs in the process of continuous epidural anesthesia, which do not fit the clinical picture of subarachnoid or intravascular injection, should envoke a high suspicion for unintentional subdural block. We report two cases of patients who achieved prolonged labor analgesia via epidural technique with only half the initial loading dose of local anesthetic. Both patients also had short episodes of hypotension. Additionally, one patient presented with severe hypoxemia and mild motor block of both upper and lower extremities. The other patient presented with transit unresponsiveness without motor block. Both patients rapidly responded to vasopressors. Desaturation in one patient, however, was persistent lasting for more than four hours. Her bedside chest X-ray was inconclusive “possible pulmonary edema” and the follow up Chest CT Scan on the second day revealed aspiration pneumonia. Based on the clinical findings, these two cases were suggestive of subdural block with cranial nerve involvement.