Opioid sparing effect of epidural levobupivacaine on postoperative pain treatment in major spinal surgery

BACKGROUND AND OBJECTIVE

Continuous epidural administration of a local anesthetic drug for postoperative pain treatment of patients, who undergo a fusion operation of lumbar vertebrae is limited by the suction of wound drainage. The effect of the single epidural administration of levobupivacaine 0.25% 10 mL 20 minutes before finishing of skin closure was examined on the postoperative demand for piritramide.

METHODS

The study was conducted in a prospective, single blind and randomized manner. Forty patients scheduled for posterior intervertebral body fusion of two or three vertebrae were divided into two groups. Group A received levobupivacaine 0.25% 10 mL epidurally, Group B received piritramide 0.08 mg kg(-1) i.v. Time of administration was 20 minutes before predicted finish of skin closure in both groups. Piritramide was administered intravenously to achieve a VAS of 3 or less during the phase of awakening. After regaining of co-operativity, piritramide was self administered via PCA pump. VAS and the demand of piritramide within 12 hours postoperative were recorded.

RESULTS

VAS at the time of being approachable (P = 0.23), VAS at the time of regaining co-operativity (P = 0.53) and VAS 12 hours postoperative (P = 0.27) did not differ significantly. The postoperative demand of piritramide was significantly lower in Group A (0.36 +/- 0.25 mg kg(-1) vs. 0.52 +/- 0.19 mg kg(-1) in Group B) (P = 0.026).

CONCLUSION

The epidural administration of levobupivacaine 0.25% 10 mL 20 minutes before finishing of skin closure effects opioid sparing in the pain treatment of patients undergoing posterior interbody fusion of two or three vertebrae.

Malignant glioma as a secondary malignant neoplasm after radiation therapy for craniopharyngioma: report of a case and review of reported cases

BACKGROUND

The development of a secondary neoplasm in childhood cancer survivors attains growing importance due to the reported excellent survival and therefore the long exposure to potentially carcinogenic effects of treatment.

CASE REPORT

We report a 14-year-old girl in whom a large craniopharyngioma (CP) was diagnosed. After surgery, radiation therapy (RT) was given for residual tumour. Discrete progression necessitated further surgery, resulting in permanent tumour control. Soon after the second surgery hypothalamic-pituitary dysfunction developed together with obesity. Supportive hormone therapy was initiated. Growth hormone (GH) therapy was also given for 15 months. Four years after the diagnosis, a cerebropontine anaplastic astrocytoma WHO grade III was detected, with the main lesion being at the dorsal edge of the irradiated area. The girl died 1 month later from this secondary presumably radiation-induced tumour. Only recently a second child with RT for a CP was diagnosed with malignant glioma in our hospital. CASE REPORTS IN THE LITERATURE: 12 other cases of malignant glioma have been reported after RT for CP. Including our present cases, the mean latency period was 10.7 years (median 9.6 years). However, the shortest latency periods were found in patients who had received GH therapy. In numerous cases, the secondary tumour was seen at the edge of the irradiated volume, and not in the region with the highest absorbed dose.

CONCLUSIONS

Therapy-induced secondary gliomas after treatment of CP or other intracranial tumours are rare but dramatic late events with a very poor prognosis. Including our own 2 patients, we reviewed 14 cases of CP with occurrence of a secondary, probably radiation-induced malignant glioma. The short latency periods for patients treated with GH is remarkable. We therefore suspect that GH therapy may accelerate the development of a secondary brain tumour. We are reluctant to recommend GH therapy in conventionally irradiated CP patients. In order to seriously answer the questions about therapy-induced secondary neoplasms, a life-long follow-up is mandatory for all patients who are survivors of childhood cancer.

The use of polyglactin 910-polydioxanon in the treatment of defects of the orbital roof

PURPOSE

This study evaluated the use of polyglactin 910-polydioxanon (PPP) for repair of orbital roof defects.

PATIENTS AND METHODS

Between 1988 and 1996, 144 patients treated in the Department of Neurosurgery, Christian-Doppler-Medical-Center Salzburg, were operated on transcranially for fractures of the orbital roof or intraorbital tumors. In 85 of these 144 patients, PPP was used for reconstruction of the orbital roof or closure of the periorbita. The postoperative results in patients in whom the PPP patch was used for reconstruction of the orbital roof were compared with the results of a group treated without PPP.

RESULTS

Even in severely injured patients, the reconstruction was judged to be very good in 71 patients (83.5%).

CONCLUSION

PPP is a useful material for the reconstruction of the orbital roof.

[Surgical outcome in chronic subdural hematoma]

In a retrospective study the operative results of 200 patients with chronic subdural hematoma were investigated. In the majority of patients a burr hole and a closed drainage was performed. The operative result was very good (resumption of normal life) in 67.5% of the patients. Operative mortality was 4.5%, in these patients an obvious connection was appearant between the result and the poor preoperative condition. The recurrence of hematomas required a second operation in 8% and a third in 1%.

Operative results in hypertensive intracerebral hematomas in patients over 60

In a retrospective study, we analyzed the operative results of 300 patients over 60 years with hypertensive intracerebral hemorrhages treated from September 1981 to June 1995 at the Department of Neurosurgery, Landesnervenklinik Salzburg. The patients underwent surgery for hypertensive hemorrhages measuring 30 mm or more on CT scan. The postoperative results were assessed by the Glasgow Outcome Score, which showed that the postoperative mortality was 31.3%; 22% of the patients made a good or very good recovery. The mode of selecting the intracerebral hematomas by size and location to achieve good results with surgical treatment is discussed. The authors consider surgery beneficial for selected cases.

[Results of surgery in acute subdural hematoma]

In a retrospective study the prognosis of acute subdural hematoma was considered with reference to the data of 255 patients who underwent surgery because of acute subdural hematoma during a period of 10 years in the Department of Neurosurgery of the Landesnervenklinik in Salzburg. The mortality rate was 43.5%, and 21.6% had a full functional recovery. The findings of the study confirm that the preoperative neurological condition, the age, the kind of accident sustained and the extent of concomitant brain injury influence on the prognosis decisively.

Surgical techniques in orbital roof fractures: early treatment and results

Repositioning of fractured fragments, stabilization with miniplates and reconstruction using autologous bone are commonly used techniques in the treatment of fractures of the orbital roof. Between 1988 and 1993, 101 patients were operated upon transcranially in the Department of Neurosurgery of the Landesnervenklinik Salzburg, for fractures of the orbital roof. The method, the timing and the results of treatments are presented. It can be demonstrated that even in severely injured patients the results were good in 79.2% (80 patients).

[Clinical aspects and therapy of carpal tunnel syndrome]

In a retrospective study the clinical symptomatology and the clinical results of carpal tunnel syndrome is evaluated by means of 1000 patients. The results of 1047 operated hands assessed by the patients were rated as very good 72%, good 21.2% and satisfactory 5.6%.

Postoperative fungal arteritis mimicking vasospasm--case report

Intracranial arteritis due to fungal infection is an uncommon complication of neurosurgical operations. A 36-year-old female developed arteritis caused by Aspergillus fumigatus at the site of the temporary clip following the clipping of an initially uncomplicated intracranial aneurysm. The inflammatory, slowly progressing vascular occlusion mimicked the vasospasm common in subarachnoid hemorrhage.

Spondylodiscitis after lumbar disk surgery

The value of perioperative prophylactic use of antibiotics in lumbar disc surgery is investigated, based on a retrospective study of the operative results of 5041 patients. The rate of occurrence of postoperative spondylodiscitis was significantly higher during the period in which no perioperative prophylaxis was carried out, than it was during the period, in which perioperative prophylaxis was routine. Thus the perioperative prophylactic use of antibiotics seems highly recommendable.

The primary treatment of frontobasal and midfacial fractures in patients with head injuries

The timing of operation can be especially difficult when frontobasal fractures are combined with other head injuries and midfacial injuries. In these cases, the head injury represents a considerable hazard to the patient and therefore it is mandatory to avoid any additional strain that might be caused by treating the midfacial injury first. On the other hand, because of poorer results with the secondary treatment, the surgical therapy for midfacial injuries should be achieved as early as possible. This report describes the results obtained in 68 patients managed over a period of 5 years and discusses their definite primary treatment. It emphasizes the need for close cooperation between the various surgical specialties involved.

[Clinical criteria of acute epidural hematoma]

In a retrospective study 368 epidural hematomas are presented, treated from 1970 until August 1991. The clinical course and manifestation of acute epidural hematomas is commented on by means of own cases. Assessing the success of treatment, it could be demonstrated that the prompter diagnosis reduced the lethal outcome of epidural hematoma to 6.6%.

[Results of treatment of brain gunshot injuries]

Craniocerebral missile injuries are a relatively rare type of head injury during peacetime. In the Department of Neurosurgery of the Landesnervenklinik Salzburg 72 patients were operated on for gunshot wounds of the brain in the period 1970-1990, and 31 survived. In the same period 6763 patients were treated for other head injuries. As shown by the clinical courses and the operative results, the velocity and thus the extent of the primary brain damage determine the prospects of success in the treatment of cerebral missile injuries.

Subarachnoid hemorrhage caused by a fungal aneurysm of the vertebral artery as a complication of intracranial aneurysm clipping. Case report

Intracranial aneurysms are an uncommon manifestation of fungal infection. A case is described in which the formation of an aneurysm followed an intracranial intraoperative Aspergillus infection attributable to a long period of preoperative antibiotic medication and immunosuppressive therapy with steroids.

Scanning electron microscopic findings on the rabbit meninges after local lavage with Polyvinylpyrrolidon-Jod-Komplex

The microbicide Polyvinylpyrrolidon-Jod-Komplex (P.J.K.) was experimentally evaluated for its use in local lavage of the epidural space. In 20 rabbits a lumbar laminectomy was performed followed either by local lavage with P.J.K. or with NaCl. After one month the meningeal covering of the operated spinal cords revealed no signs of fibrosis or arachnoid adhesions when studied macroscopically or by scanning electron microscopy (SEM).

The intra-operative application of povidone-iodine in neurosurgery

Over a period of 6 months 250 patients were operated on for lumbar disc prolapse, 125 patients each receiving prophylactic antibiotic therapy or only local, intra-operative administration of povidone-iodine. The analysis of variance showed a significant difference between the patient group treated with the antiseptic and the prophylactic antibiotic group. More abscesses and signs of infection occurred in the antibiotic treated group. Animal studies are also described.

[Epidural tumor (calcified fibroma) as a cause for the "cervical syndrome"]

A calcified fibroma caused a so called cervical syndrome not responding to medical treatment. In the computerized tomography a compression of the cervical spinal cord could be demonstrated. From this the indication for the operation was given.