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Journal of Neurosurgery. Pediatrics Dec 2018OBJECTIVE Carotid body tumors (CBTs), extraadrenal paragangliomas, are extremely rare neoplasms in children that often require multimodal surgical treatment, including...
OBJECTIVE Carotid body tumors (CBTs), extraadrenal paragangliomas, are extremely rare neoplasms in children that often require multimodal surgical treatment, including preoperative anesthesia workup, embolization, and resection. With only a few cases reported in the pediatric literature, treatment paradigms and surgical morbidity are loosely defined, especially when carotid artery infiltration is noted. Here, the authors report two cases of pediatric CBT and provide the results of a systematic review of the literature. METHODS The study was divided into two sections. First, the authors conducted a retrospective review of our series of pediatric CBT patients and screened for patients with evidence of a CBT over the last 10 years (2007–2017) at a single tertiary referral pediatric hospital. Second, they conducted a systematic review, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, of all reported cases of pediatric CBTs to determine the characteristics (tumor size, vascularity, symptomatology), treatment paradigms, and complications. RESULTS In the systematic review (n = 21 patients [includes 19 cases found in the literature and 2 from the authors’ series]), the mean age at diagnosis was 11.8 years. The most common presenting symptoms were palpable neck mass (62%), cranial nerve palsies (33%), cough or dysphagia (14%), and neck pain (19%). Metastasis occurred only in 5% of patients, and 19% of cases were recurrent lesions. Only 10% of patients presented with elevated catecholamines and associated sympathetic involvement. Preoperative embolization was utilized in 24% of patients (external carotid artery in 4 and external carotid artery and vertebral artery in 1). Cranial nerve palsies (cranial nerve VII [n = 1], IX [n = 1], X [n = 4], XI [n = 1], and XII [n = 3]) were the most common cause of surgical morbidity (33% of cases). The patients in the authors’ illustrative cases underwent preoperative embolization and balloon test occlusion followed by resection, and both patients suffered from transient Horner’s syndrome after embolization. CONCLUSIONS Surgical management of CBTs requires an extensive preoperative workup, anesthesia, and multimodal surgical management. Due to a potentially high rate of surgical morbidity and vascularity, balloon test occlusion with embolization may be necessary in select patients prior to resection. Careful thorough preoperative counseling is vital to preparing families for the intensive management of these children. ABBREVIATIONS BTO = balloon test occlusion; CBT = carotid body tumor; CN = cranial nerve; ECA = external carotid artery; ICA = internal carotid artery; MIBG = iodine-123-meta-iodobenzylguanidine; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Topics: Adolescent; Anesthesia; Carotid Body Tumor; Child; Child, Preschool; Combined Modality Therapy; Cranial Nerve Diseases; Deglutition Disorders; Embolization, Therapeutic; Female; Humans; Male; Neck Pain; Postoperative Complications; Preoperative Care; Rare Diseases; Retrospective Studies
PubMed: 30544333
DOI: 10.3171/2018.8.PEDS18393 -
International Journal of Obstetric... Aug 2018Horner's syndrome is a rarely reported complication of neuraxial blockade. In obstetric practice, the neurological signs of Horner's syndrome may cause anxiety amongst... (Review)
Review
Horner's syndrome is a rarely reported complication of neuraxial blockade. In obstetric practice, the neurological signs of Horner's syndrome may cause anxiety amongst patients and healthcare staff, but more importantly may herald the onset of maternal hypotension. Medline, CINAHL, and EMBASE databases were searched to identify cases of Horner's syndrome following obstetric neuraxial blockade. Anaesthetic technique, clinical features, anaesthetic management of the Horner's syndrome and time to resolution were assessed. Seventy-eight case reports of Horner's syndrome following obstetric neuraxial blockade were identified. Nine cases also had trigeminal nerve palsy and one case had hypoglossal nerve palsy. Amongst the 78 cases, 74% developed Horner's syndrome within one hour of a local anaesthetic bolus. The median time for resolution of Horner's syndrome was two hours, though one case was permanent. One case of Horner's syndrome was found to be due to an internal carotid artery dissection. Some cases of Horner's syndrome resolved spontaneously despite ongoing administration of epidural local anaesthetic. Hypotension was reported in 13%. Horner's syndrome is usually a benign phenomenon, the consequence of high cephalad spread of local anaesthetic, that resolves spontaneously within a few hours. Patients with a persistent Horner's syndrome, or one associated with atypical features such as neck pain, should undergo a diagnostic workup including magnetic resonance angiography of the neck. The dermatomal level of neuraxial blockade, maternal and fetal well-being should be taken into account when making decisions regarding neuraxial blockade. The presence of Horner's syndrome alone should not lead to discontinuation of neuraxial blockade.
Topics: Adult; Anesthesia, Obstetrical; Eye; Face; Female; Horner Syndrome; Humans; Nerve Block; Pregnancy
PubMed: 29657082
DOI: 10.1016/j.ijoa.2018.03.005 -
Heart, Lung & Circulation Mar 2019Multiple case studies have suggested that video-assisted thoracoscopic sympathectomy (VATS) reduces the occurrence and frequency of symptoms in long QT syndrome (LQTS)...
BACKGROUND
Multiple case studies have suggested that video-assisted thoracoscopic sympathectomy (VATS) reduces the occurrence and frequency of symptoms in long QT syndrome (LQTS) [1,2,3]. To date there has not been a literature review to report on the short-term and long-term outcomes of this procedure. Our primary aims are to review the literature findings on the clinical outcomes of VATS sympathectomy for long QT and present a local centre case report on the outcomes of T2-T5 sympathectomy.
METHODS
Relevant articles were identified by a systematic search of PubMed, Cochrane and Scopus databases, from November 1985 to October 2015. A total of 520 patients from 21 publications were included for analysis and discussion in three main areas: presenting symptoms and indication for surgery, perioperative complications, and patient quality of life following surgery. Our case study reviews a 49-year-old female with recently diagnosed long QT syndrome and intolerance to beta blocker therapy successfully managed with T2-T5 thoracic sympathectomy.
RESULTS
The most common presenting indication for operative management of long QT syndrome was syncope (208/520 patients) and tachyarrhythmia (207/520 patients). T1-T5 left sympathectomy was performed in 15/21 published reports (332/520 patients) with partial stellate removal or in its entirety. Follow-up of patients ranged from 1 month to 11 years. Four patients died in the postoperative period, from fatal arrhythmias. The most common postoperative findings were no symptoms (64/520 patients); tachyarrhythmia (55/520 patients), syncope (45/520 patients), and Horner's syndrome (13/520 patients with 27 patients reporting associated symptoms). Thirteen cases reported on the QTc changes post sympathectomy and 9/13 cases involving 220/520 patients showed marked QTc reduction following surgery. Mean preoperative QTc was 558ms and median 559ms. Mean postoperative QTc was 476ms and median 466ms. Our patient showed a marked reduction in QTc following surgery, with no evidence of arrhythmias and reduced beta blocker dependence.
CONCLUSIONS
Surgical management of LQTS has historically involved a left cervicothoracic stellectomy removing stellate ganglia and typically part of the left thoracic sympathetic chain resulting in reduction in symptoms but increasing the risk of Horner's syndrome and intermittent temperature changes [4,5]. Surgical resection of the thoracic ganglia alone for management of LQTS is scarce in the literature. Short-term follow-up in our case study following a T2-T5 sympathectomy revealed reduction in symptoms, no requirement for beta blocker therapy and reduced QTc interval. Further follow-up using greater patient numbers will further support T2-T5 sympathectomy as an option for surgical management of LQTS.
Topics: Electrocardiography; Heart Conduction System; Humans; Long QT Syndrome; Stellate Ganglion; Sympathectomy; Thoracic Surgery, Video-Assisted
PubMed: 29525134
DOI: 10.1016/j.hlc.2018.02.005 -
Pain Physician Jan 2018Understanding the characteristics of the middle cervical sympathetic ganglion (MCSG) may minimize procedure-related complications and maximize efficacy during surgery or... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Understanding the characteristics of the middle cervical sympathetic ganglion (MCSG) may minimize procedure-related complications and maximize efficacy during surgery or ultrasound (US)-guided procedures. The location and detection rate of the MCSG were variable in small population studies. Therefore, a large population study or meta-analysis could give more information about the MCSG.
OBJECTIVES
We aim to review the published literature and evaluate the anatomical features of the MCSG, including the detection rate, location, size, and a normal variation, and to review the clinical relevance of MCSG for procedures including, US-guided ganglion block, ethanol ablation (EA), or radiofrequency ablation (RFA).
STUDY DESIGN
A systematic review and meta-analysis. The Ovid-MEDLINE and EMBASE databases were searched to find the detection rate, location, and other characteristics of the MCSG.
SETTING
The pooled proportions for the detection rate of the MCSG were assessed using the DerSimonian-Laird random-effects model.
METHODS
Heterogeneity among the studies was determined using a chi-square analysis for the pooled estimates and inconsistency index (I²). In order to reduce the heterogeneity, sensitivity analyses were performed.
RESULTS
A review of 542 studies identified 8 eligible studies, with 273 MCSGs included in the meta-analysis. The pooled proportion for the detection rate of the MCSG was 50.4% (95% confidence interval [CI], 34.5 - 66.4%). Considerable heterogeneity among the studies was observed (I² = 94.9%). In the sensitivity analysis, when excluding one study, heterogeneity was reduced with a recalculated pooled proportion of 44.2% (95% CI, 32.1 - 56.2%; I² = 86.0%). The location of the MCSG is usually posterior to the carotid sheath and anterior to the longus colli muscle at the level of the C3 - C7 vertebrae. There was a variant where the cervical sympathetic trunk was located at the posterior wall of the carotid sheath and was adherent to the sheath. The size of the MCSG is as follows: the width, length, and height ranges were 3.8 - 6.3 mm, 6.3 - 10.5 mm, and 1.7 - 2.1 mm, respectively. A specific type of MCSG, referred to as the "double middle cervical ganglion", consisting of 2 ganglia, was demonstrated in 3 studies with a detection rate of 2.9 - 10%.
LIMITATIONS
This meta-analysis included a relatively small number of studies. Significant heterogeneity was also present in the detection rate of MCSG in these studies. There was a lack of concentrated information about the MCSG, because the majority of the included studies focused on the entire cervical sympathetic chain, not only MCSG primarily. Improving complication rates might be limited due to the approximate 50% detection rate.
CONCLUSION
Understanding the characteristics and variations of the MCSG could minimize complications and maximize efficacy during surgery and US-guided procedures.
KEY WORDS
Middle cervical sympathetic ganglion, cervical sympathetic trunk, cervical sympathetic chain, ultrasound, nerve block, ethanol ablation, radiofrequency ablation, thyroid, Horner syndrome, meta-analysis.
Topics: Cervical Vertebrae; Ganglia, Sympathetic; Humans
PubMed: 29357327
DOI: No ID Found -
Chinese Medical Journal Jun 2017This systematic review examined whether radiofrequency ablation (RFA) is a safe treatment modality for benign thyroid nodules (BTNs). (Review)
Review
OBJECTIVE
This systematic review examined whether radiofrequency ablation (RFA) is a safe treatment modality for benign thyroid nodules (BTNs).
DATA SOURCES
PubMed, Embase, and the Cochrane Library database were searched for articles that (a) targeted human beings and (b) had a study population with BTNs that were confirmed by fine-needle aspiration cytology and/or core needle biopsy.
STUDY SELECTION
Thirty-two studies relating to 3409 patients were included in this systematic review.
RESULTS
Based on literatures, no deaths were associated with the procedure, serious complications were rare, and RFA appears to be a safe and well-tolerated treatment modality. However, a broad spectrum of complications offers insights into some undesirable complications, such as track needle seeding and Horner syndrome.
CONCLUSIONS
RFA appears to be a safe and well-tolerated treatment modality for BTNs. More research is needed to characterize the complications of RFA for thyroid nodules.
Topics: Catheter Ablation; Female; Humans; Male; Thyroid Nodule; Treatment Outcome
PubMed: 28524837
DOI: 10.4103/0366-6999.206347 -
Surgical Endoscopy Nov 2017Palmar hyperhidrosis involves excessive sweating of the palms, with no known etiology. Endoscopic thoracic sympathectomy (ETS) is a safe and effective treatment for... (Review)
Review
BACKGROUND
Palmar hyperhidrosis involves excessive sweating of the palms, with no known etiology. Endoscopic thoracic sympathectomy (ETS) is a safe and effective treatment for palmar hyperhidrosis, but compensatory hyperhidrosis is a common complication after ETS, leading to reduced patient satisfaction and postoperative quality of life. However, the appropriate level of the sympathetic chain to target with ETS to achieve maximum efficacy and reduce the risk of compensatory hyperhidrosis (CH) is controversial. In this systemic review, we investigated the appropriate level of sympathectomy for palmar hyperhidrosis.
METHODS
PRISMA guidelines were implemented to complete a systematic review. We performed a computerized systematic literature search using PubMed and EMBASE from January 1990 to July 2016. We chose the Cochrane Collaboration's tool and the methodological index for non-randomized studies tool for examining study bias.
RESULTS
A total of 4075 citations were identified, of which 91 were eligible for inclusion, including 68 observational studies and 23 comparative trials. In observational studies, sympathectomies showed similar efficacies for curing PH at different levels. However, T2-free groups (i.e., at levels T3, T4, or T3-T4 combined) could render a lower risk of Horner's syndrome (0 vs. 1.21 ± 0.49%, p = 0.036) and CH (28.75 ± 7.25 vs. 57.46 ± 3.86, p = 0.002) compared with T2 involved. In comparative trials, there were 12 studies describing the comparison between T2-free ETS and T2 involved, and 9 of 12 (75%) showed T2-free ETS could reduce the incidence of CH. Overall, lowering the level and limiting the extent of sympathectomy could reduce the incidence of complications.
CONCLUSIONS
Cumulative data from more than 13,000 patients suggest that ETS is a safe, effective, and reproducible procedure with a high degree of patient satisfaction. Currently available evidence suggests that T2-free ETS may reduce the incidence of compensatory hyperhidrosis without compromising success rates and safety.
Topics: Adult; Endoscopy; Female; Hand; Humans; Hyperhidrosis; Male; Middle Aged; Sympathectomy; Treatment Outcome
PubMed: 28389800
DOI: 10.1007/s00464-017-5508-y -
Anesthesia and Analgesia Feb 2017Supraclavicular (SC) and infraclavicular (IC) brachial plexus block (BPB) are commonly used for upper extremity surgery. Recent clinical studies have compared the effect... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Supraclavicular (SC) and infraclavicular (IC) brachial plexus block (BPB) are commonly used for upper extremity surgery. Recent clinical studies have compared the effect of SC- and IC-BPB, but there have been controversies over spread of sensory blockade in each of the 4 peripheral nerve branches of brachial plexus.
METHODS
This study included a systemic review, using the Medline and EMBASE database from their inceptions through March 2016. Randomized controlled trials (RCTs) comparing SC- and IC-BPB were included. The prespecified primary outcome was the incidences of incomplete sensory blockade in each of the 4 terminal nerve branches of brachial plexus. Secondary outcome included the incidence of successful blockade, performance time, onset of sensory block, duration of analgesia, and complication rates.
RESULTS
Ten RCTs involving 676 patients were included. Pooled analyses showed the incidence of incomplete block at 30 minutes in radial nerve territory was significantly higher in IC-BPB, favoring SC-BPB (risk ratio 0.39; 95% confidence interval [0.17-0.88], P = .02, I = 0%). However, subgroup analysis according to the number of injections of IC-BPB showed that double or triple injections IC-BPB yielded no difference in the incomplete radial block. Furthermore, the incidence of incomplete ulnar block at 30 minutes was significantly lower in IC-BPB when using double or triple injection IC-BPB. There was no difference in the secondary outcomes between SC- and IC-BPB groups, with the exception of complication rates. The incidence of paresthesia/pain on local anesthetic injection, phrenic nerve palsy, and Horner syndrome was significantly higher in the SC group, favoring IC-BPB.
CONCLUSIONS
This meta-analysis demonstrated that IC-BPB showed a significantly high incidence of incomplete radial nerve sensory block at 30 minutes, which may be avoided by double or triple injection. Furthermore, IC-BPB with multiple injection technique showed significantly lower incidence of incomplete ulnar block than SC-BPB. There were no differences in the incidence of successful blockade, block onset, and duration of analgesia between SC- and IC-BPB. Procedure-related paresthesia/pain and adjacent nerve-related complications were more frequent in SC-BPB. However, because of the small sample size, publication bias remains a concern when interpreting our results. Further studies with sufficient sample size and reporting large number of outcomes are required.
Topics: Humans; Brachial Plexus; Clavicle; Nerve Block; Randomized Controlled Trials as Topic; Treatment Failure; Ultrasonography, Interventional
PubMed: 27828793
DOI: 10.1213/ANE.0000000000001713 -
Preoperative diagnosis of vagal and sympathetic cervical schwannomas based on radiographic findings.Journal of Neurosurgery Mar 2017OBJECTIVE Vagus nerve and sympathetic chain cervical schwannomas (VNCSs and SCCSs) are benign nerve sheath tumors that arise in the head and neck. Despite similar...
OBJECTIVE Vagus nerve and sympathetic chain cervical schwannomas (VNCSs and SCCSs) are benign nerve sheath tumors that arise in the head and neck. Despite similar presentations that make accurate preoperative diagnosis more difficult, the potential for morbidity following resection is significantly higher for patients with VNCS. Therefore, the authors analyzed a retrospective case series and performed a comparative analysis of the literature to establish diagnostic criteria to facilitate more accurate preoperative diagnoses. METHODS The authors conducted a blinded review of imaging studies from retrospectively collected, operatively confirmed cases of VNCS and SCCS. They also performed a systematic review of published series that reported patient-specific preoperative imaging findings in VNCS or SCCS. RESULTS Nine patients with VNCS and 11 with SCCS were identified. In the study cohort, splaying of the internal carotid artery (ICA) and internal jugular vein (IJV) did not significantly predict the nerve of origin (p = 0.06); however, medial and lateral ICA displacement were significantly associated with VNCS and SCCS, respectively (p = 0.01 and p = 0.003, respectively). Multivariate analysis demonstrated that ICA and IJV splaying with medial ICA displacement carried an 86% probability of VNCS (p = 0.001), while the absence of splaying with lateral ICA displacement carried a 91% probability of SCCS (p = 0.006). The presence of vocal cord symptoms or peripheral enhancement significantly augmented the predictive probability of VNCS, as did Horner's syndrome or homogeneous enhancement for SCCS. A review of the literature produced 25 publications that incorporated a total of 106 patients, including the present series. Splaying of the ICA and IJV was significantly, but not uniquely, associated with VNCS (p < 0.0001); multivariate analysis demonstrated that ICA and IJV splaying with medial ICA displacement carries a 75% probability of VNCS (p < 0.0001), while the absence of such splaying with lateral ICA displacement carries an 87% probability of SCCS (p = 0.0003). CONCLUSIONS ICA and IJV splaying frequently predicts VNCS; however, this finding is also commonly observed in SCCS and, among the 9 cases in the present study, was observed more often than previously reported. When congruent with splaying, medial or lateral ICA displacement significantly enhances the reliability of preoperative predictions, empowering more accurate prognostication.
Topics: Diagnosis, Differential; Female; Head and Neck Neoplasms; Humans; Male; Middle Aged; Neurilemmoma; Preoperative Care; Retrospective Studies; Vagus Nerve
PubMed: 27104848
DOI: 10.3171/2016.1.JNS151763 -
Pain Physician 2015While most trials of thoracic paravertebral nerve blocks (TPVB) for breast surgery show benefit, their effect on postoperative pain intensity, opioid consumption, and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
While most trials of thoracic paravertebral nerve blocks (TPVB) for breast surgery show benefit, their effect on postoperative pain intensity, opioid consumption, and prevention of chronic postsurgical pain varies substantially across studies. Variability may result from use of different drugs and techniques.
OBJECTIVES
To examine the use of TPVB in breast surgery, and to determine which method(s) provide optimal efficacy and safety.
STUDY DESIGN
Mixed-Effects Meta-Analysis.
METHODS
We conducted a systematic review of randomized trials comparing TPVB to no intervention using random-effects models. To evaluate the contributions of various techniques, clinical approaches were included as moderators in mixed-effects models.
RESULTS
A total of 24 randomized controlled trials (RCTs) with 1,822 patients were included. Use of TPVB decreased postoperative pain scores at rest and movement at the first 2, 24, 48, and 72 hours. TPVB modestly decreased intraoperative and postoperative opioid consumption, reduced nausea and vomiting, and shortened hospitalization, but to a probably clinically irrelevant degree. Blocks also appeared to reduce the incidence of chronic postsurgical pain at 6 months. Adding fentanyl to the TPVB improved pain at rest (at 24, 48, and 72 hours) and movement (at 24 and 72 hours). Multilevel blocks provided better postoperative pain control, but only during movement (at 2, 48, and 72 hours). Fewer procedural complications (especially hypotension, epidural spread, and Horner's syndrome) occurred when anatomical landmarks were supplemented with ultrasound guidance.
LIMITATIONS
The number of studies available was limited in the meta-analytic model of incidence of chronic post-surgical pain.
CONCLUSION
TPVB reduces postoperative pain and opioid consumption, and has a limited beneficial effect on the quality of recovery. From all the techniques that were evaluated, only the addition of fentanyl, and performing multilevel blocks were associated with improved acute analgesia. TPVB may reduce chronic postsurgical pain at 6 months.
Topics: Analgesics; Breast; Humans; Mastectomy; Nerve Block; Pain, Postoperative; Randomized Controlled Trials as Topic
PubMed: 26431130
DOI: No ID Found -
Acta Ophthalmologica Scandinavica Oct 2005Upper spinal manipulation (USM) is frequently used by chiropractors and other health care professionals to treat minor complaints. This systematic review aimed to... (Review)
Review
OBJECTIVE
Upper spinal manipulation (USM) is frequently used by chiropractors and other health care professionals to treat minor complaints. This systematic review aimed to summarize ophthalmological adverse effects of USM recently reported in the medical literature.
METHODS
Five electronic databases were searched for all case reports of ophthalmological adverse effects after USM published between January 1995 and April 2003. No language restrictions were applied. Key data from the primary publications thus located were extracted and critically evaluated.
RESULTS
Fourteen case reports were found. Clinical symptoms and signs were diverse and included loss of vision, ophthalmoplegia, diplopia and Horner's syndrome. The underlying mechanism was arterial wall dissection in most cases. The eventual outcome varied and often included permanent deficits. Causality was frequently deemed likely or certain.
CONCLUSION
Upper spinal manipulation is associated with ophthalmological adverse effects of unknown frequency. Ophthalmologists should be aware of its risks. Rigorous investigations must be conducted to establish reliable incidence figures.
Topics: Complementary Therapies; Databases, Factual; Eye Diseases; Humans; Manipulation, Chiropractic
PubMed: 16187996
DOI: 10.1111/j.1600-0420.2005.00488.x