Surgically Relevant Morphological Parameters of the L5-S1 Interlaminar Window: A Statistical Analysis Based on 3D Reconstruction of CT Data

Study design: Retrospective study. Objectives: The interlaminar window is the most important anatomical corridor for posterior approach of lumbar procedures. Three-dimensional (3D) reconstruction of the L5-S1 interlaminar window may benefit the accurate measurement and assessment of surgical considerations. The aim of this study was to measure surgical relevant parameters of the L5-S1 interlaminar window based on 3D reconstruction of lumbar CTs. Methods: 50 thin-layer CT data were retrospectively collected, segmented, and reconstructed. Surgical relevant parameters included the width, left height, right height, interpedicular distance, area, and operable area of the L5-S1 interlaminar window. Morphological measurements were performed independently by two experienced experts. Patients with radiologic abnormalities at L5-S1 level were regarded as group A (n=28), while those without L5-S1 disc herniation were regarded as group B (n=22). Results: The average left height, right height, width, and area of the L5-S1 interlaminar window were 9.14±2.45mm, 9.55±2.56mm, 23.55±4.91mm, and 144.57±57.05mm2. The average interpedicular distance (IPD) at superior, middle, and inferior pedicle level were 29.29±3.39mm, 27.96±3.38mm and 37.46±4.23mm, with significant differences among these three parameters (P<0.05). The average operable areas of the L5-S1 interlaminar window were: left-axilla 24.52±15.91mm2, left-shoulder 27.14±15.48mm2, right-axilla 29.95±17.17mm2, and right-shoulder 31.12±16.40mm2 (P>0.05). There were no significant differences between group A and B in these parameters (P>0.05), except the inferior IPD (36.69±3.73mm vs 39.23±3.01mm, P=0.017<0.05). Conclusion: The morphological measurement of the L5-S1 interlaminar window based on 3D reconstruction provided accurate and reliable reference data for epidural puncture approach and posterior approach of lumbar surgery. Moreover, it could also assist the placement of endoscopic working channel in percutaneous endoscopic interlaminar discectomy (PEID) and might be useful for further studies of anatomical and surgical consideration of unilateral biportal endoscopic spinal surgery (UBE) procedures. Key words: Interlaminar window; percutaneous endoscopic interlaminar discectomy (PEID); unilateral biportal endoscopy spinal surgery (UBE); 3D reconstruction.

Soft System Based on Fiber Bragg Grating Sensor for Loss of Resistance Detection during Epidural Procedures: In Silico and In Vivo Assessment

Epidural analgesia represents a clinical common practice aiming at pain mitigation. This loco-regional technique is widely used in several applications such as labor, surgery and lower back pain. It involves the injections of anesthetics or analgesics into the epidural space (ES). The ES detection is still demanding and is usually performed by the techniques named loss of resistance (LOR). In this study, we propose a novel soft system (SS) based on one fiber Bragg grating sensor (FBG) embedded in a soft polymeric matrix for LOR detection during the epidural puncture. The SS was designed to allow instrumenting the syringe’s plunger without relevant modifications of the anesthetist’s sensations during the procedure. After the metrological characterization of the SS, we assessed the capability of this solution in detecting LOR by carrying it out in silico and in clinical settings. For both trials, results revealed the capability of the proposed solutions in detecting the LOR and then in recording the force exerted on the plunger.

Can I have epidural analgesia if I have tinea versicolor?

Labor and delivery, while perceived as gratifying and joyful, are nonetheless among the most painful events women can experience in life. Treating pain is nowadays one of the essential elements in assisting women during labor. Epidural analgesia is the best option to ensure the optimal control of pain for the mother without compromising the wellbeing of the fetus. The main contraindications to neuraxial analgesia techniques include patient refusal, known bleeding diathesis or abnormal coagulation tests, elevated intracranial pressure (particularly in the presence of an intracranial space occupying lesion), severe aortic or mitralic valve stenosis and infections at the puncture site [1]. There are many pathogens responsible for cutaneous infections at the dorsal-lumbar level, yeasts of the Malassetia genus being the most commonly implicated. Malassetia Globulosa is the predominant species in the Tinea Versicolor infection [2,3]. Also implicated are M. Sympodialis, M. Furfur and others as well [4]. These fungi are normal components of the cutaneous flora but the transformation from yeasts to micelia can lead to the pathology. The cause for this occurrence is still unknown, yet there are a few contributing factors leading to this infection that affects mostly adolescents and young adults; these are genetic predisposition [5], heat and humidity, immunosuppression, contraceptives, pregnancy and malnutrition. It manifests with characteristic hypo- or hyper-pigmented spots alongside the trunk, the neck, and the face. The majority of the times infection is entirely superficial but cases of meningitis and Central Nervous System (CNS) infections from hematogenous spread have been reported [6,7]. The literature supports with data that adequate antiseptic preparation of the skin effectively prevents meningitis occurrence after epidural puncture [8]; other cases are reported where a small incision of the skin allows for a safer passage of the needle directly in the subcutis without going thnrough the corneal layer.

Epidural blockade in thoracic surgery: a case report

This report presents a clinical case of the treatment of pain syndrome in isolated chest trauma following an accident of a patient with liver cirrhosis and hypocoagulation syndrome who sustained bilateral fracture of the ribs (II, III, IV, V, and VI ribs on the right and II, III, IV, V, and VI ribs on the left), fracture of the sternum body in the middle third, bilateral hemopneumothorax, and contusion of both lungs. From the initial hours, fentanyl, which was administered intravenously in a complex of multimodal analgesia, was used for anesthesia. However, adequate pain control was not achieved. Against the background of pain syndrome, the patient developed impaired consciousness and respiratory failure. Epidural puncture and catheterization with an epidural injection of ropivacaine were performed, which relieved the pain syndrome and helped prevent pulmonary complications. The present case highlights the need for an individual assessment of the riskbenefit ratio of the use of epidural catheterization in patients with coagulopathy. Conclusion: The use of epidural analgesia for chest trauma in patients with moderate coagulopathy made it possible to initiate effective analgesia and reduce the risk of respiratory complications, which ultimately ensured a favorable outcome of severe trauma.

Study on the prevention of infection in terminal cancer patients applying epidural analgesia by adding cefazolin to anesthetics: a randomized controlled trial

Objective To observe the antibacterial effect of adding cefazolin into anesthetics in patients with terminal cancer undergoing long-term epidural analgesia. Methods Patients undergoing epidural analgesia with terminal cancer were randomly divided into two groups: the conventional drug group (group C) and the cefazolin group (group G). Both groups were given levobupivacaine and morphine, while cefazolin was added to group G. The mean arterial pressure (MAP), heart rate (HR), respiratory rates (R), visual analogue scale (VAS) scores, satisfaction and complications of patients in the two groups were observed. 3 ml of the used analgesic was taken for bacterial culture when replacing the new analgesic case. Results HR, MAP, R, VAS scores, dosages of morphine, satisfaction of the analgesic and the complications were not significantly different between the two groups (P &gt; 0.05). The overall satisfaction of patients in group G was significantly higher than that in group C (P &lt; 0.05). One patient’s anesthetics in group C were infected with colibacillus. Four patients in group C got infected in their epidural puncture sites. There was no infection in group G (P &lt; 0.05). Conclusion Adding cefazolin to local anesthetics could effectively prevent bacterial infection and ensured the safety of epidural analgesia for patients with terminal cancer.

Effects of Morphine on Interstitial Cells of Cajal in Rabbit Colon and Small Intestinal Transit: An Experimental Study

Objective: This study aims to investigate the effect of morphine with naloxone on intestinal peristalsis and the number of interstitial cells of Cajal (ICC) in colon tissues of rabbits. Methods: Thirty rabbits were randomly divided into five groups (n=6, each group): saline control group (NS group), low concentration of morphine group (L group), medium concentration of morphine group (M group), high concentration of morphine group (H group), medium concentration of morphine and naloxone mixed with antagonist group (NM group). Rabbits in these five groups were administered with an epidural puncture tube and dorsal epidural analgesia pump, and were continuously infused for seven days. Fecal characteristics were observed, and the ink propulsion rate was calculated. The expression level of ICC C-kit protein in colon tissues was tested by western blot. Results: The stool characteristics in the L, M and H groups were more severe than those in the NS and NM groups. Furthermore, the intestinal propulsion rate in the L, M and H groups was lower than that in the NS and NM groups. The C-kit mRNA and protein expression in the colon of rabbits were significantly lower in the L, M and H groups, when compared to the NS and NM groups. Conclusions: Naloxone blocked the mRNA and protein expression of C-kit, and improved intestinal motor function.

Effect of Cranial Flexion of Pelvic Limbs on Interlaminar Length of the Lumbosacral Space in Sternally and Laterally Recumbent Juvenile Duroc and Adult Yucatan Pigs

Epidural puncture in swine is technically challenging. Several combinations of limb and body positions have been suggested to increase lumbosacral interlaminar space (LSS) and lumbosacral angle (LSA). This study investigated whether cranial hyperflexion of pelvic limbs increased LSS and LSA in laterally and sternally recumbent juvenile Duroc and adult Yucatan pigs and assessed which position produced the largest LSS. Juvenile Duroc (n = 7) and adult Yucatan (n = 7) pigs were euthanized and randomly placed in 4 positions: sternal with neutral limbs, sternal with cranially hyperflexed limbs, lateral with neutral limbs, and lateral with hyperflexed limbs. LSS and LSA were measured on transverse axial CT images of the spine and compared by using multivariate ANOVA and the Student t test. In both age groups, LSS was greater in lateral flexed (juvenile, 7.0 ± 0.7 mm; adult, 15.9 ± 1.1 mm) and sternal flexed (juvenile, 7.5 ± 1 mm; adult, 17.1 ± 1.1 mm) positions than in lateral neutral (juvenile, 5.4 ± 0.9 mm; adult, 9.6 ± 1.6 mm) position. In addition, in both age groups, LSS and LSA in lateral neutral position were smaller than lateral flexed, sternal neutral, and sternal flexed positions. In adults, LSS was greater in lateral flexed and sternal flexed than in sternal neutral position. Hyperflexion of pelvic limbs increases LSS and LSA in sternally recumbent adult Yucatan pigs and laterally recumbent adult Yucatan and juvenile Duroc swine. Increased LSS from positioning pigs with pelvic limbs flexed in sternal or lateral recumbence may facilitate epidural puncture compared with neutral limb positioning.