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Anaesthesia Nov 2017Epidural volume extension, a modification of combined spinal-epidural anaesthesia, involves the epidural injection of saline in order to increase the spread of drugs... (Meta-Analysis)
Meta-Analysis
Effects of epidural volume extension by saline injection on the efficacy and safety of intrathecal local anaesthetics: systematic review with meta-analysis, meta-regression and trial sequential analysis.
Epidural volume extension, a modification of combined spinal-epidural anaesthesia, involves the epidural injection of saline in order to increase the spread of drugs given intrathecally. Results from individual studies have so far been contradictory and we aimed to gather the available evidence for this technique. We performed a systematic literature search for randomised, controlled trials comparing epidural volume extension after spinal injection with a control group without epidural injection in patients undergoing surgery. Conventional meta-analyses, trial sequential analyses and meta-regression were performed, with the Grading of Recommendations on Assessment, Development and Evaluation (GRADE) approach used to express reliability of outcome estimates. We included 15 studies with 1177 participants. Meta-analyses for the primary outcomes, such as maximum sensory height (6 studies, 274 participants, mean difference (MD) (95%CI) -0.59 (-1.24 to 0.07) dermatomes, low-quality evidence) and hypotension (10 studies, 683 participants, risk ratio (95%CI) 0.84 (0.66-1.07), low-quality evidence), did not differ significantly between the two treatment arms, but trial sequential analysis suggested insufficient evidence to be certain of these findings. Meta-regression suggested a volume-dependent effect, with higher volumes causing a higher spread of intrathecal drugs and a higher incidence of hypotension. A sub-group analysis indicated a pronounced effect on motor block recovery time when a lower anaesthetic dose plus epidural volume extension was compared with a higher anaesthetic dose without epidural volume extension, the MD (95%CI) being -66.75 (-76.0 to -57.5) min, with trial sequential analysis suggesting the evidence was sufficient to draw this conclusion. In trials using the same anaesthetic mixture in the epidural volume extension and the control groups, motor block recovery time did not differ between groups, with a MD (95%CI) of -1.06 (-5.48 to 3.36) min, although trial sequential analysis suggested insufficient evidence. In summary, there is not enough evidence to draw definite conclusions on the effect of epidural volume extension. The quality of the current evidence is low for both efficacy (maximum sensory height) and safety (hypotension). However, there may be a significantly shorter motor block recovery time when different anaesthetic mixtures are used in epidural volume extension and control groups; this warrants further investigation.
Topics: Anesthesia, Epidural; Anesthesia, Spinal; Anesthetics, Local; Epidural Space; Humans; Injections, Spinal; Saline Solution
PubMed: 28891203
DOI: 10.1111/anae.14033 -
The Journal of Spinal Cord Medicine Mar 2021Considerable controversy exists over surgical procedures for ossification of the posterior longitudinal ligament (OPLL). The purpose of the meta-analysis was to compare... (Meta-Analysis)
Meta-Analysis
Is anterior decompression and fusion superior to laminoplasty for cervical myelopathy due to ossification of posterior longitudinal ligament? A systematic review and meta-analysis.
Considerable controversy exists over surgical procedures for ossification of the posterior longitudinal ligament (OPLL). The purpose of the meta-analysis was to compare the clinical outcome of anterior decompression and fusion (ADF) with laminoplasty (LAMP) in treatment of cervical myelopathy due to OPLL. PubMed, EMBASE and the Cochrane Register of Controlled Trials database were searched to identify potential clinical studies compared ADF with LAMP for cervical myelopathy owing to OPLL. We also manually searched the reference lists of articles and reviews for possible relevant studies. Thirteen studies with 1120 patients were included in our analysis. Subgroup analyses were performed by the canal occupying ratio of OPLL. Overall, the mean preoperative Japanese Orthopaedic Association (JOA) score was similar between two groups. Compared with LAMP group, ADF group was higher at the mean postoperative JOA scores and mean recovery rate, reoperation rate, and longer at mean operation time. There was not significantly different in mean blood loss and complication rate between two groups. In subgroup analysis, ADF had a higher mean postoperative JOA score and recovery rate than LAMP in cases of OPLL with occupying ratios ≥ 50%, while those difference were not found in cases of OPLL with occupying ratios < 50%. ADF achieves better neurological improvement compared with LAMP in treatment of cervical myelopathy due to OPLL, especially in cases of OPLL with occupying ratios ≥ 50%. Complication rate is similar between two groups, but ADF can increase the risk of reoperation.
Topics: Cervical Vertebrae; Decompression, Surgical; Humans; Laminoplasty; Longitudinal Ligaments; Ossification of Posterior Longitudinal Ligament; Osteogenesis; Retrospective Studies; Spinal Cord Diseases; Spinal Cord Injuries; Spinal Fusion; Treatment Outcome
PubMed: 30888255
DOI: 10.1080/10790268.2019.1579987 -
Global Spine Journal Sep 2017Systematic review.
STUDY DESIGN
Systematic review.
OBJECTIVES
To determine the preoperative computed tomography (CT) myelogram imaging parameters in patients diagnosed with degenerative cervical myelopathy (DCM) that correlate with severity of DCM and predict postoperative patients' functional outcome.
METHODS
An electronic database search was performed using Ovid Medline and Embase. CT myelogram studies investigating the correlation between imaging characteristics and DCM severity or postoperative outcomes were included. Two independent reviewers performed citation screening, selection, qualitative assessment, and data extraction using an objective and blinded protocol.
RESULTS
A total of 5 studies (402 patients) were included in this review and investigated the role of preoperative CT myelogram parameters in predicting the functional outcome after surgical treatment of DCM. All studies were retrospective cohort studies. CT myelogram characteristics included the transverse area of the spinal cord at maximum level of compression, spinal canal narrowing, number of blocks, spinal canal diameter, and flattening ratio. There is low evidence suggesting that patients with a preoperative transverse area of the spinal cord >30 mm at the level of maximum compression have better postoperative recovery and outcome. We found no studies investigating the correlation between preoperative CT myelogram parameters and DCM severity.
CONCLUSIONS
Patients with greater transverse area of spinal cord at the level of maximum compression on the preoperative CT myelogram are more likely to have better neurological outcome after surgery. There is insufficient evidence to suggest that any of the other CT myelogram parameters investigated are predictors of postoperative outcomes in patients with DCM.
PubMed: 28894681
DOI: 10.1177/2192568217701101 -
Journal of Clinical Anesthesia Sep 2021The novel infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) has been described to relieve posterior knee pain after knee surgery.... (Meta-Analysis)
Meta-Analysis
STUDY OBJECTIVE
The novel infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) has been described to relieve posterior knee pain after knee surgery. The study objective is to determine whether iPACK provides analgesia after knee surgery when compared with a control group.
DESIGN
Systematic review, meta-analysis and trial sequential analysis.
SETTING
Operating room, postoperative recovery area and ward, up to 24 postoperative hours.
PATIENTS
Patients scheduled for knee surgery under general or spinal anaesthesia.
INTERVENTIONS
We searched five electronic databases for randomized controlled trials comparing iPACK with a control group.
MEASUREMENTS
The primary outcome was rest pain score scores on a visual analogue scale (VAS) of 0-10 at 12 h postoperatively, analysed according to the nature of surgery (total knee arthroplasty vs. anterior cruciate ligament reconstruction) and the use of multimodal analgesia. Secondary outcomes included rest and dynamic pain scores, intravenous morphine-equivalent consumption at 2 h and 24 h, and functional outcomes including ambulation distance and range of motion at discharge.
MAIN RESULTS
Six trials involving 687 patients were included, all of which received total knee arthroplasty only. When compared with a control group, iPACK significantly reduced rest pain scores at 12 h, with a mean difference (95% CI) of -1.0 (-1.5 to -0.5), I = 93%, p = 0.0003, without subgroup differences for postoperative multimodal analgesia (p = 0.15). Secondary pain outcomes were inconsistently improved with iPACK. Functional outcomes were either similar between groups or had clinically unimportant differences. The overall quality of evidence was moderate.
CONCLUSIONS
There is moderate level evidence that iPACK might provide analgesia for posterior pain after total knee arthroplasty when compared with a control group at 12 h, but was not associated with any other meaningful benefits. Based on these results, there is currently limited evidence supporting the use of iPACK as a complement to adductor canal block for analgesia after total knee arthroplasty.
Topics: Analgesia; Analgesics; Analgesics, Opioid; Arthroplasty, Replacement, Knee; Humans; Nerve Block; Pain, Postoperative
PubMed: 33930796
DOI: 10.1016/j.jclinane.2021.110305 -
The Neuroradiology Journal Jun 2023Spinal filum terminale pial arteriovenous fistulas (FT PAVFs) are uncommon. Most FT PAVFs are located in the lumbar region; far fewer are located in the sacral region....
Spinal filum terminale pial arteriovenous fistulas (FT PAVFs) are uncommon. Most FT PAVFs are located in the lumbar region; far fewer are located in the sacral region. Due to the rarity of sacral FT PAVFs, the precise surgical dissection and removal of these lesions are challenging. Here, we report an FT PAVF in the sacral region. The patient was a 45-year-old male who suffered from progressive weakness and numbness of the bilateral lower limbs; his symptoms gradually worsened. Digital subtraction angiography (DSA) showed an AVF at the sacral canal at the S3-4 level. Microsurgical treatment with intraoperative DSA was performed, and the FT PAVF was resected. After the operation, the patient gradually recovered. Follow-up magnetic resonance imaging revealed a recession in the dilation of the spinal cord venous plexuses. A literature review was also performed, and a total of 14 FT PAVFs of the sacral region were identified. The patients identified in the literature review had an average age of 58.9 ± 12.9 years, and 92.9% of the patients were male. Spinal cord edema was present in 85.7% of the FT PAVF patients. Regarding treatment, 64.3% of the FT PAVF patients underwent microsurgical resection, 28.6% patients underwent endovascular treatment, and 7.1% patients underwent a hybrid operation; good outcomes were achieved with all three methods. Therefore, FT PAVF of the sacral region is a unique lesion whose angioarchitecture needs to be identified carefully; prompt treatment is necessary, and microsurgery can yield good outcomes.
Topics: Aged; Female; Humans; Male; Middle Aged; Arteriovenous Fistula; Cauda Equina; Magnetic Resonance Imaging; Sacrococcygeal Region; Spinal Cord Diseases
PubMed: 36086815
DOI: 10.1177/19714009221126017 -
Journal of Medical Case Reports Mar 2024Spinal cord tumors present a challenge in diagnosis and treatment due to their varied histopathological characteristics. While Ewing sarcoma is a rare malignant tumor...
BACKGROUND
Spinal cord tumors present a challenge in diagnosis and treatment due to their varied histopathological characteristics. While Ewing sarcoma is a rare malignant tumor typically originating from skeletal bone, cases of primary intradural extraskeletal Ewing sarcoma are exceptionally rare. The similarity of its presentation to other spinal tumors further complicates its identification and management.
CASE PRESENTATION
We report a case of a 58-year-old Palestinian male with intradural extraskeletal lumbar Ewing sarcoma. The patient initially presented with lower back pain and bilateral S1 radiculopathy, with more severe symptoms on the left side. Magnetic resonance imaging revealed a 7 cm oval-shaped mass with homogeneous contrast enhancement, obstructing the spinal canal from L3/L4 to L5/S1 levels. Initially, a myxopapillary ependymoma was suspected, but the patient's sensory and motor functions suddenly deteriorated during hospitalization. Repeat magnetic resonance imaging indicated heterogeneous contrast enhancement, indicating acute intratumoral hemorrhage. Consequently, the patient underwent emergent L3-L5 laminotomy, with successful gross total resection of the tumor. Histopathological and immunohistochemical analyses confirmed the diagnosis of intradural extraskeletal Ewing sarcoma. Adjuvant therapy was administered to minimize the risk of local recurrence or distant metastasis. A systematic review of relevant literature, along with retrospective analysis of medical records, operative reports, radiological studies, and histopathological findings of similar cases, was also conducted.
CONCLUSIONS
Intradural extraskeletal Ewing sarcoma is an infrequently encountered condition in adult patients, emphasizing the importance of considering it in the differential diagnosis of spinal tumors. Surgeons must possess a comprehensive understanding of this rare entity to ensure accurate staging and optimal management, particularly in the early stages when prompt intervention may improve prognosis.
Topics: Humans; Male; Middle Aged; Prognosis; Sarcoma, Ewing; Spinal Cord Neoplasms; Spinal Neoplasms
PubMed: 38459600
DOI: 10.1186/s13256-024-04384-8 -
Minerva Anestesiologica Apr 2019Epidural failure due to misidentification of the epidural space is not uncommon. Epidural wave form analysis has been suggested to identify the epidural space.
INTRODUCTION
Epidural failure due to misidentification of the epidural space is not uncommon. Epidural wave form analysis has been suggested to identify the epidural space.
EVIDENCE ACQUISITION
A systematic literature search (Medline, Epub, Embase.com (Embase plus Medline), Cochrane Central, Web of Science, and Google Scholar) was performed to identify studies comparing epidural wave form analysis (index test) to epidural analgesia (reference test).
EVIDENCE SYNTHESIS
Eight studies (3901 patients) were retrieved that provided data on diagnostic accuracy. These studies had a low risk of bias and of applicability concerns, as assessed by the quality assessment of diagnostic accuracy studies (QUADAS-2) tool. One study did not observe an epidural wave form in parturients, a finding that was not corroborated in another study. Because the reference test was different across the studies we decided not aggregate the data. The sensitivity values of the individual studies varied between 0.81 and 1.00, for the specificity values between 0.42 and 1.00 were found.
CONCLUSIONS
Our study suggests that epidural wave form analysis is a reliable method for identification of the epidural space that could become a useful adjunct especially in anticipated difficult catheter placements or in teaching situations. Further research is warranted to define the role of epidural wave form analysis in pregnant women.
Topics: Analgesia, Epidural; Analgesia, Obstetrical; Epidural Space; Female; Humans; Pregnancy; Reproducibility of Results; Surgical Procedures, Operative
PubMed: 30482001
DOI: 10.23736/S0375-9393.18.13089-6