Search

Throughout their training, anesthesiology residents are exposed to a variety of surgical subspecialties, many of which have specific anesthetic considerations. According to the Accreditation Council for Graduate Medical Education requirements, each anesthesiology resident must provide anesthesia for at least twenty intracerebral cases. There are several studies that demonstrate that checklists may reduce deficiencies in pre-induction room setup. We are introducing a novel checklist for neuroanesthesia, which we believe to be helpful for residents during their neuroanesthesiology rotations. Our checklist provides a quick and succinct review of neuroanesthetic challenges prior to case setup by junior residents, covering noteworthy aspects of equipment setup, airway management, induction period, intraoperative concerns, and postoperative considerations. We recommend displaying this checklist on the operating room wall for quick reference.

Background: Neurosurgeons and orthopedists, who have received specific training, should be the ones performing spinal surgery. Here, we present a case in which spinal surgeons secondarily (e.g., 6 months later) found that a patient’s first lumbar discectomy, performed by an interventional specialist, had been a “sham” procedure. Case Description: A 30-year-old male presented with sciatica attributed to a magnetic resonance imaging documented large, extruded disc at the L4-5 level. An interventional pain management specialist (IPMS) performed two epidural steroid injections; these resulted in an exacerbation of his pain. The IPMS then advised the patient that he was a surgeon and performed an “interventional” microdiscectomy. Secondarily, 6 months later, when the patient presented to a spinal neurosurgeon with a progressive cauda equina syndrome, the patient underwent a bilateral laminoforaminotomy and L4-L5 microdiscectomy. Of interest, at surgery, there was no evidence of scarring from the IPMS’ prior “microdiscectomy;” it had been a “sham” operation. Following the second surgery, the patient’s cauda equina syndrome resolved. Conclusion: IMPS, who are not trained as spinal surgeons should not be performing spinal surgery/ microdiscectomy.

Background: In the context of the current coronavirus pandemic, we propose an inexpensive, innovative overhead transparent plastic barrier with powered suction (OTPBPS) technique using materials that are ubiquitous in the hospital, easy to set up in minutes and well tolerated by the patients. As presented in this case report, it is an effective method to reduce viral spread from patients with positive or suspected yet unconfirmed coronavirus disease 2019 status. Case Description: A 49-year-old male was admitted to the hospital with a diagnosis of cervical stenosis and a C6-C7 disc herniation with spinal cord compression. The OTPBPS technique was set up to create a negative pressure environment around the patient’s head, using a Mayo stand, a transparent plastic bag, and powered wall canister suction. The neurosurgeon successfully performed an anterior cervical discectomy and instrumented fusion under OTPBPS. The patient was satisfied with the intubation and anesthetic management and reported excellent feedback. Conclusion: The OTPBPS technique helps control the spread of an aerosolized viral load from the patient’s mouth or airway during awake fiber-optic intubation. This technique will help anesthesiologists and other front-line health-care providers manage copious endotracheal secretions and droplet particles, which have an immense infectious potential.

Background:Suicide cases are the end product of a combination of biological, clinical, psychological, social, and cultural risk/protective factors, and attempts to remain unpredictable.Case Description:A 43-year-old male presented to the hospital with jaundiced skin/eyes of 7 days’ duration. He had a history of a major depressive disorder and chronic alcohol consumption (e.g., 3–5 alcoholic drinks/day for the past 15 years). Studies documented acute hepatic disease (e.g., biopsy-documented hepatocellular alcoholic hepatitis), accompanied by a cholestatic disease. The patient was discharged on clonidine, iron multivitamin, folic acid, gabapentin, and prednisone. Eight days postdischarge from the hospital, he committed suicide (e.g., self- inflicted gunshot wound to the head).Conclusion:Concomitant administration of gabapentin, prednisone, and clonidine, especially if used for the first time, may play a synergistic effect in increasing a patient’s suicide risk.

Background: Opioids are considered an effective method for acute and chronic pain management, but they are not suitable for all cases and should be used in carefully selected patients. In the past several decades, their use has come under intense scrutiny due to significant deviations from the classically described applicability of opioids in cancer-related pain. Case Description: A 34-year-old female with a 6-year history of worsening neck pain and suboccipital headaches was managed medically including the use of oral muscle relaxants, steroids, gabapentin, and opioid-based medications as well as interventional pain procedures that provided only temporary pain relief. She made repeated ER visits and had multiple hospital admissions for pain control, during which times she was placed on patient-controlled analgesia with IV hydromorphone administration. During the most recent admission for an acute exacerbation of chronic pain, she was found by her mother to be unresponsive and not breathing. A code blue was called and cardiopulmonary resuscitation per an advanced cardiac life support algorithm was conducted. The patient was successfully resuscitated and was discharged from the hospital in satisfactory condition. This incident was reported as an “allergic reaction” to hydromorphone. After consultation with a neurosurgeon, the patient underwent a definitive surgical intervention consisting of a C5–6 anterior cervical discectomy and fusion using an interbody spacer and anterior instrumentation. Within 6 weeks, she reported significant decreases in her pain, stopped using the pain medication, and was able to return to her normal lifestyle. Conclusions: The present case report is an example of long-term pain management with multiple medications, including opioid use and performing interventional pain procedures, while avoiding early surgical correction of cervical disc herniation. This resulted in years of suffering with pain and serious morbidity from opioid overdosing. Surgical intervention was definitive in terms of ultimately improving her pain and reducing her reliance on opioid analgesics.

Background: Bone morphogenic protein (BMP) for instrumented lumbar fusion was approved in 2002, and since then has led to an increasing incidence of BMP-related neuropathic pain. These patients are usually resistant to conventional medical therapy and frequently undergo multiple surgical revisions without any pain relief. Case Description: A 58-year-old male was referred to the author's outpatient clinic after four lumbar surgeries did not provide satisfactory pain relief. During his 10 years of suffering from low back pain after an injury, the patient was resistant to conventional and interventional treatment options. He was experiencing severe back pain rated 10/10, as well as right lower extremity pain, numbness, tingling, and motor deficits. Outside spine specialists had performed revision surgeries for BMP-related exuberant bone formation at L5–S1, which included the removal of the ipsilateral hardware and debridement of intradiscal and intraforamina heterotrophic exuberant bony formation. The author implanted the patient with a permanent continuous spinal cord stimulator, after which he achieved complete pain relief (0/10) and restoration of motor, sensory, autonomic, and sphincter functions. Conclusion: This is the first reported case of restorative function with neuromodulation therapy in a BMP-induced postoperative complication, which is considered as a primarily inflammatory process, rather than nerve root compression due to exuberant bony formation. We hypothesize that neuromodulation may enhance blood flow and interfere with inflammatory processes, in addition to functioning by the accepted gate control theory mechanism. The neuromodulation therapy should be strongly considered as a therapeutic approach, even with confirmed BMP-induced postoperative radiculitis, rather than proposing multiple surgical revisions.

Background:Cervical nerve root avulsion is a well-documented result of high-velocity motor vehicle accidents (MVAs). In up to 21% of cases, preganglionic cervical root avulsion can result in a complex regional pain syndrome (CRPS) impacting the quality of life for patients already impaired by motor, sensory, and autonomic dysfunction. The optimal treatment strategies include repeated stellate ganglion blocks (SBGs).Case Description:A 43-year-old male sustained a high-velocity MVA resulting in the left C8 nerve root avulsion. This resulted in weakness in the C8 distribution, tactile allodynia, and dysesthesias. The magnetic resonance imaging demonstrated an abnormal signal ventral to the C8–T1 level. As the patient was not considered a candidate for surgical intervention secondary to the attendant brachial plexus injury, a C7–C8 epidural steroid injection was performed; this did not provide improvement. Before placing a spinal cord stimulator, the patient underwent a series of six ultrasound-guided SBGs performed 2 weeks apart; there was 75% improvement in pain and strength. Six years later, the patient continues to do well while receiving SBGs 4 times a year.Conclusion:A preganglionic cervical nerve root avulsion should not be a contraindication for a stellate ganglion block in a patient with established CRPS.

Background: Altered mental status describes impaired mental functioning ranging from confusion to coma and indicates an illness, either metabolic or structural in nature. Metabolic causes include hypothyroidism, hyperuremia, hypo/hyperglycemia, hypo/hypernatremia, and encephalopathy. The structural causes include tumors, brain hemorrhage, infection, and stroke. To our knowledge, this is the first case in which a patient presented with altered mental status from both metabolic (myxedema coma) and structural diseases (frontal meningioma) with vasogenic edema and midline shift. Case Description: A 55-year-old female presented with progressive coma. The clinical features included bradycardia and hypothermia. The imaging demonstrated a large frontal meningioma with a significant midline shift with laboratory findings suggestive of severe hypothyroidism and myxedema coma. Hypothyroidism was treated aggressively with intravenous T3 and T4 with close neurosurgical observation. Osmodiuretics and steroids were administered as temporizing agents prior to craniotomy. Craniotomy was successfully undertaken after using these appropriate pre-emptive measures. Conclusions: Management of concomitant metabolic encephalopathy and meningioma with vasogenic edema and impending herniation can be challenging. Correction of the encephalopathy is crucial to minimize perioperative morbidity and mortality. Awareness of metabolic causes of acute decompensation is critical for perioperative management, so a high index of clinical suspicion can make an important timely diagnosis for treatment initiation. Severely hypothyroid patients are sensitive to anesthetic agents and are at a high risk for perioperative complications. Prompt treatment prior to surgical intervention can help minimize perioperative complications.

Background: Athletic pubalgia is a painful complex syndrome encountered by many athletes involved in sports. Multiple pathologies often coexist, and many systems can refer pain to the groin. The current case reflects the failure to distinguish pubalgia from lumbar radiculopathy. Case Description: Originally, a 47-year-old male with left-sided inner thigh pain was diagnosed as having a L3-4-disc herniation and spinal stenosis; he underwent a L3-4 and L4-5 laminectomy/discectomy. For 2 years postoperatively, the pain persisted. Ultimately, he underwent surgical reinsertion of the adductor muscle and experienced immediate and sustained pain relief. Conclusion: This case report highlights how pubalgia may be misdiagnosed as a lumbar disc herniation and may inadvertently lead to unnecessary lumbar surgery.

Background: Occipitocervical instability may be attributed to congenital, bony/ligamentous abnormalities, trauma, neoplasm, degenerative bone disease, and failed atlantoaxial fixation. Indications for occipitocervical fixation include the prevention of disabling pain, cranial nerve dysfunction, paralysis, or even sudden death. Methods: The screw trajectory for the modified transcondylar screw (mTCS) is optimally planned utilizing a three-dimensional skull reconstructed image. Results: The modified mTCS technique is helpful where there is a loss of bone, such as after prior suboccipital craniotomy and/or an inadequate occipital condyle. The new proposed technique is similar to the classical transcondylar screw placement but follows a deeper course along the bony lip of foramen magnum toward clivus from a dorsolateral approach. Conclusion: The modified mTCS technique allows for direct visualization and, therefore, helps to avoid damage to the hypoglossal nerve and lateral aspect of brain stem.

Background Spinal cord stimulation is currently approved to treat chronic intractable pain of the trunk and limbs. However, such implantable electronic devices are vulnerable to external electrical currents and magnetic fields. Within the hospitals and modern operating rooms (ORs), there is an abundance of electrical devices and other types of equipment that could interfere with such devices. Despite the increasing number of patients with neuromodulation implantable devices, there are no written guidelines available or consensus of cautions for such patients undergoing unrelated surgery. Case descriptions A 60-year-old female with a permanent St. Jude's spinal cord stimulator (SCS) presented for open total abdominal hysterectomy. Both the anesthesia and gynecology staffs were aware of the device presence, but were unaware of any precautions regarding intraoperative management. The device was found to be nonmagnetic resonance imaging compatible, and bipolar cautery was used instead of monopolar cautery. A 59-year-old female with a 9-year-old permanent Medtronic SCS, presented for right total hip arthroplasty. The device was switched off prior to entering the OR, bipolar cautery was used, and grounding pads were placed away from her battery site. In each case, the manufacturer's representative was contacted preoperative. Both surgeries proceeded uneventfully. Conclusions The Food and Drug Administration safety information manual warns about the use of diathermy, concomitant implanted stimulation devices, lithotripsy, external defibrillation, radiation therapy, ultrasonic scanning, and high-output ultrasound, all of which can lead to permanent implant damage if not turned off prior to undertaking procedures. Lack of uniform guidelines makes intraoperative management, as well as remote anesthesia care of patients with previously implanted SCSs unsafe.

Background The opioid epidemic in America is real and is estimated to be the number one cause of death in adults under 50 years of age. Finding alternative analgesic medications is part of the effort to decrease the prescription of narcotics, with gabapentin being at the top of the list. Case description In the present case, we discuss the side-effects of gabapentin, used as part of the multimodal treatment approach of painful spinal degenerative disease. The patient stated that he had noticed personality changes after gabapentin was initiated, and that he had become more depressed, frustrated, and aggressive. His uncontrolled pain and acute mood changes led him to attempt suicide by hanging himself. Gabapentin was discontinued and the patient's suicidal ideation completely subsided. Conclusion It is imperative to screen, identify, and appropriately manage patients with underlying psychiatric disorders prior to initiating pain management with gabapentin. Therefore, it is crucial to raise awareness of gabapentin as a potential cause of depression, aggressive behavior, and suicidal ideation.

Background Ependymomas represent 50-60% of all brain and central nervous system tumors. Previous lumbar spine surgery for resection of an ependymoma should not be considered a relative contraindication for the administration of epidural/subarachnoid anesthesia to patients in labor. Case description A 34-year-old G1P0, who underwent resection of an L1-L3 intramedullary ependymoma 8 years previously, presented in active labor with residual left leg numbness and tingling. The lumbar magnetic resonance imaging showed scar tissue and the L1-L3 laminectomy defect. With the acute onset of labor pain, the patient underwent continuous lumbar epidural analgesia; the epidural catheter was placed at the L5-S1 level. The patient underwent an emergency cesarean section with surgical anesthesia being attained up to a T4 dermatomal sensory level. Conclusions Neuraxial anesthesia can be performed safely in patients who have previously undergone lumbar resections of intradural ependymomas. However, the anesthesiologist should place the epidural needle/catheter at a nonoperative level (e.g. above/below). Furthermore, epidural local anesthetics and opioids, as in this case, placed at the L5-S1 level below an L1-L3 prior surgical scar, may diffuse intradurally, bypassing the obliterated surgical epidural space and/or attendant scar tissue.

Background: The elderly represent a unique challenge for the effects of regional anesthesia, and very few cases of block onset delay have been described. Their delayed response is attributed to a number of factors that include: Physiologic deterioration, musculoskeletal contractures, degenerative joint disease, autonomic regulatory dysfunction, cognitive dysfunction, altered pharmacokinetics, and pharmacodynamics of local anesthetics and adjuvants. Case Description: In this report we present the rare case of 45-min delay between the administration and onset of action of a subarachnoid blockade in a 103-year-old female, who was scheduled for left hip pinning, for repair of a femoral neck fracture. Patient received an injection of hyperbaric bupivacaine, 1.5 ml of 0.75% (11.25 mg), with 15 mcg of fentanyl into the subarachnoidal space and underwent the surgical procedure without complications. Conclusions: Delayed responses to subarachnoid anesthesia can be expected in extremely elderly patients. Anesthetic procedures should be monitored and managed on a case-by-case basis.

Background: We describe three patients who received lumbar epidural steroid injections (LESI) for lumbosacral radicular pain that resulted in worsening of their symptoms. The procedures were performed following a review of remote diagnostic imaging studies. These cases demonstrate the lack of consensus in pain management domains for how to approach the workup and treatment of persistent/chronic low back pain, with a noted fragmentation in pain management strategies and applied therapies. Case Description: We present three patients; two female patients (37 and 38 years old) undergoing LESI for remotely diagnosed disc herniations, and one 61-year-old male receiving an LESI for a presumed, unverified lumbar intervertebral disc disorder. Following a worsening of symptoms after LESI, neurosurgical consultations ultimately determined the presence of, respectively, an epidural hematoma, a neurilemoma, and a lung cancer metastasis to the sacrum as the source of symptoms, instead of being due to the intervertebral disc pathology. Conclusions: We would like to emphasize several principles in the diagnosis and use of imaging of the lumbosacral region prior to undertaking invasive neuraxial procedures.

Background Arnold-Chiari malformation Type 1 (ACM-1) in parturients is a topic of ongoing discussion between obstetricians and anesthesiologists. The primary unanswered question remains; How should the anesthesia provider proceed with labor analgesia and anesthesia for cesarean section when confronted with an advanced, asymptomatic, or minimally symptomatic case of ACM-1 during labor? Case description A 24-year-old, ASA II, G1P0 full-term parturient presented to Labor and Delivery for vaginal delivery. A diagnosis of ACM-1 was made 12 years ago when a brain magnetic resonance imaging (MRI) was performed for right-sided numbness following a rear-end motor vehicle collision. The patient had been asymptomatic since then and had been seen by an outside neurologist frequently for the past 10 years. During the anesthesia evaluation, it was noted that she had an exaggerated patellar reflex, and a questionable left-sided Babinski; subsequently, an MRI study was requested. Review of a brain MRI demonstrated an advanced form of ACM with a 1.7 cm transtonsillar herniation and a large syrinx extending from C1 down to C5. Following a discussion with the patient, family, and primary OB team, a plan for elective cesarean section was made per neurosurgical recommendations. This was conducted uneventfully under general anesthesia. The patient had no complaints in the post-anesthesia care unit. Conclusion Unfamiliarity of health care providers with regards to ACM-1 parturients can be countered by increasing awareness of this condition throughout medical specialties involved in their care. The Ghaly Obstetric Guide to Arnold-Chiari malformation Type 1, along with proper training of anesthesia care providers regarding the specificities of ACM-1 parturients aids in better management and understanding of this complex condition.

Background Spinal cord stimulators (SCSs) are gaining increasing indications and utility in an expanding variety of clinical conditions. Complications and initial expenses have historically prevented the early use of SCS therapy despite ongoing efforts to educate and promote its utilization. At present, there exists no literature evidence of SCS implantation in a chronically anticoagulated patient, and neuromodulation manufacturers are conspicuously silent in providing warnings or recommendations in the face of anticoagulant use chronically. It would appear as through these issues demand scrutiny and industry as well as neuromodulation society advocacy and support in terms of the provision of coherent guidelines on how to proceed. Case description A 79-year-old male returned to the neurosurgical clinic with persistent low back pain and leg heaviness due to adjacent level degenerative spondylosis and severe thoracic spinal stenosis. The patient had a notable history of multiple comorbidities along with atrial fibrillation requiring chronic anticoagulation. On initial presentation, he was educated with three choice of conservative medical therapy, intrathecal drug delivery system implantation, or additional lumbar decompression laminectomy with instrumented fusion of T10-L3 and a palliative surgical lead SCS implantation. Description A 79-year-old male returned to the neurosurgical clinic with persistent low back pain and leg heaviness due to adjacent level degenerative spondylosis and severe thoracic spinal stenosis. The patient had a notable history of multiple comorbidities along with atrial fibrillation requiring chronic anticoagulation. On initial presentation, he was educated with three choice of conservative medical therapy, intrathecal drug delivery system implantation, or additional lumbar decompression laminectomy with instrumented fusion of T10-L3 and a palliative surgical lead SCS implantation. Conclusion Our literature search did not reveal any evidence of SCS therapy among patients with chronic anticoagulation. This case illustrated a complicated clinical case scenario wherein a percutaneous SCS implantation would normally be contraindicated due to severe thoracic spinal stenosis and chronic anticoagulation which could lead to possible paralysis or even a lethal consequences associated with the possible formation of a thoracic epidural hematoma.

Background: Primary brain tumors are usually treated by surgical removal with the goal of complete resection within the constraints of preservation of neurological function. However, gross total resection may not mean complete tumor removal, and ongoing compression from a mass effect can lead to serious sequelae. Spinal subarachnoid blockade is contraindicated in patients with brain tumors or space occupying lesions. Case Description: A 32-year-old full term parturient presented to Labor and Delivery for semi-urgent repeat cesarean section. Three months ago, she underwent resection of a benign brain tumor and recovered with no new neurological deficits. The neurosurgeon was consulted by the anesthesia team and stated that the tumor was completely extirpated. Since there was no postoperative magnetic resonance imaging (MRI) and the patient still had some neurological deficits, the anesthesia team decided to proceed with a general anesthetic using a rapid sequence induction and intubation. Mild hyperventilation to maintain an end-tidal CO2 of 30 mmHg was selected and conservative fluid management was maintained. Postcesarean MRI revealed residual tumor compressing the brain stem and a loculated cyst. If a spinal subarachnoid blockade technique had been selected, the risk of uncal herniation, based on the postoperative MRI findings, may have been realized. Conclusions: The present case demonstrates the necessity of a comprehensive and thorough review prior to selecting the anesthetic approach to mange the patients with a history of brain tumor resection. Postoperative MR imaging should be performed to evaluate the extent of tumor resection and possible existence of residual tumor.

Background: Intracerebral hemorrhage is an infrequent but severe complication in pregnant women with hypertension. Case Description: We describe an atypical case of a patient with no risk factors who developed sudden eclampsia and spontaneous intracerebral hemorrhage during the 34th week of pregnancy. She underwent successful emergent Cesarean section followed by craniotomy. Both intraoperative surveillance and postoperative magnetic resonance angiographic examination of the cerebral vessels failed to identify an aneurysm, arteriovenous malformation, tumor, or leptomeningeal disease. Conclusion: We discuss the management of this case and review the literature regarding the threshold for which initiation of antihypertensive treatment is indicated in pregnant patients.

Background: There is little written about the management of perioperative cerebrovascular accident (CVA). To the best of our knowledge, the present case report represents the first case in the literature of a well-documented intraoperative embolic CVA and perioperative mortality in a relatively healthy, young patient with no contributing comorbidity and no noteworthy intraoperative event. Case Description: A 53-year-old man presented for radical prostatectomy under general anesthesia. The anesthetic course and procedure were uneventful. In the postanesthesia care unit (PACU), the patient was moving all extremities but was still sedated. One hour later, he developed left hemiplegia, facial dropping, slurred speech and his head was turned to the right. The next day his mental status deteriorated, and on an emergency basis he was intubated. A CT scan of the head showed a malignant hemispheric right cerebrovascular accident with leftward midline shift. Even aggressive treatment, including a right decompressive hemicraniectomy, could not lower the high intracranial pressure, and the patient expired on the third postoperative day. Conclusion: Guidelines for identifying and treating perioperative hemispheric CVA are urgently needed, with modification of the antiquated and useless criterion of “patient seen neurologically normal at induction time” to more useful objective criteria including “intraoperative neurophysiological recording change, gross extremity movements, facial dropping, follows simple commands” while excluding a drug-induced, sedative-influenced globally-impaired cognitive state that may last for hours.