Commenced in January 2007
Frequency: Monthly
Edition: International
Paper Count: 11

Search results for: intrathecal

11 The Effect of Intrathecal Adenosine in Control of Neuropathic Pain after Lumbar Discectomy in One Level

Authors: Dawood Aghamohammadi, Mahmoud Eidi, Alireza Pishgahi, Azam Esmaeilnejad


Adenosine has an analgesic and anti-inflammatory role and its injections are used for peri-operative pain management. We want to study efficacy of intrathecal injection of adenosine for post operative radicular pain after lumbar discectomy. 40 patients with unilevel lumbar discectomy who had radicular lower limb pain were treated by 1000 micrograms of intrathecal injection of adenosine. Pain severity, pain killer consumption per day and sleep quality were assessed during a 3 months follow up period. Radicular pain severity was significantly reduced in 3 month follow-up period in comparison to the baseline (F=19760, DF=2.53, p-value<0.001). Further painkiller medication consumption rate in average during 3 month follow-up period after injection was significantly lower in comparison to baseline (F= 19.244, df= 1.98, p-value<0.001). This study suggests that intrathecal injection of adenosine is a safe method in order to reduce postoperative pain after lumbar discectomy.

Keywords: adenosine, intrathecal injection, discectomy, neuropathic pain

Procedia PDF Downloads 179
10 Audit of Post-Caesarean Section Analgesia

Authors: Rachel Ashwell, Sally Millett


Introduction: Adequate post-operative pain relief is a key priority in the delivery of caesarean sections. This improves patient experience, reduces morbidity and enables optimal mother-infant interaction. Recommendations outlined in the NICE guidelines for caesarean section (CS) include offering peri-operative intrathecal/epidural diamorphine and post-operative opioid analgesics; offering non-steroidal anti-inflammatory drugs (NSAIDs) unless contraindicated and taking hourly observations for 12 hours following intrathecal diamorphine. Method: This audit assessed the provision of post-CS analgesia in 29 women over a two-week period. Indicators used were the use of intrathecal/epidural opioids, use of post-operative opioids and NSAIDs, frequency of observations and patient satisfaction with pain management on post-operative days 1 and 2. Results: All women received intrathecal/epidural diamorphine, 97% were prescribed post-operative opioids and all were prescribed NSAIDs unless contraindicated. Hourly observations were not maintained for 12 hours following intrathecal diamorphine. 97% of women were satisfied with their pain management on post-operative day 1 whereas only 75% were satisfied on day 2. Discussion: This service meets the proposed standards for the provision of post-operative analgesia, achieving high levels of patient satisfaction 1 day after CS. However, patient satisfaction levels are significantly lower on post-operative day 2, which may be due to reduced frequency of observations. The lack of an official audit standard for patient satisfaction on postoperative day 2 may result in reduced incentive to prioritise pain management at this stage.

Keywords: Caesarean section, analgesia, postoperative care, patient satisfaction

Procedia PDF Downloads 303
9 Intrathecal Fentanyl with 0.5% Bupivacaine Heavy in Chronic Opium Abusers

Authors: Suneet Kathuria, Shikha Gupta, Kapil Dev, Sunil Katyal


Chronic use of opioids in opium abusers can cause poor pain control and increased analgaesic requirement. We compared the duration of spinal anaesthesia in chronic opium abusers and non-abusers. This prospective randomised study included 60 American Society of Anesthesiologists (ASA) Grade I or II adults undergoing surgery under spinal anaesthesia with 10 mg bupivacaine, and 25 μg fentanyl in non-opium abusers (Group A); and chronic opium abusers (Group B), and 40 μg fentanyl in chronic opium abusers (Group C). Patients were assessed for onset and duration of sensory and motor blockade and duration of effective analgesia. Mean time to onset of adequate analgesia in opium abusers was significantly longer in chronic opium abusers than in opium-naive patients. The duration of sensory block and motor block was significantly less in chronic opium abusers than in non-opium abusers. Duration of effective analgesia in groups A, B and C was 255.55 ± 26.84, 217.85 ± 15.15, and 268.20 ± 18.25 minutes, respectively; this difference was statistically significant. In chronic opium abusers, the duration of spinal anaesthesia is significantly shorter than that in opium nonabusers. The duration of spinal anaesthesia with bupivacaine and fentanyl in chronic opium abusers can be improved by increasing the intrathecal fentanyl dose from 25 μg to 40 μg.

Keywords: bupivacaine, chronic opium abusers, fentanyl, intrathecal

Procedia PDF Downloads 202
8 The 10,000 Fold Effect Retrograde Neurotransmission: A Newer Concept for Paraplegia’s Physiological Revival by the Use of Intrathecal Sodium Nitroprusside

Authors: V. K. Tewari, M. Hussain, H. K. D. Gupta


B-Methylprednisolone-level-1-benefit (20%) usually given in paraplegia (but within 8hrs). Patients wait-long-duration for physiological-recovery. Intrathecal-Sodium-Nitroprusside(ITSNP) has been used-in vasospasm-due-to-subarachnoid-hemorrhage. ITSNP-has been studied-here for wide-window-period-range for-treatment, fast-recovery/affordability. 2- for acute-cases-and 1-mechanism-for chronic-cases, which-are-interrelated, are being-proposed-for-physiological-recovery. retrograde-neurotransmission, vasospasm and long-term-potentiation-(ltp) mechanisms are proposed here for recovery. It’s a case-control-prospective-study. 82paraplegia-patients(10patients taken as control-no superfusion or dextrose5% superfusion and 72patients as ITSNP-group). The mean time for superfusion was 14.11 days. ITSNP administered at a dosage of 0.2 mg/kg bo wt. Pre/post ITSNP monitored by SSEP/MEP. After-2-Hours in ITSNP-group Mean-Change-From-Baseline-Asia Motor/Sensory-Score 13.84%/13.10%, after-24-hours MOTOR-1.27-points decrease(3.77%) and SENSORY 10.5points-increase(6.22%)as compared to Control-group no-change noted upto 24-hours, At-7days ITSNP motor/sensory;11.56%/6.22% as compared to Control-group 7.60/4.48%, At-2-months in ITSNP 27.69%/6.22% as compared to Control-group 16.02/4.5%. SSEP/MEP-documented-improvements-noted. ITSNP, a-swift-acting-drug in treatment-of-paraplegia, is effective within-two-hours(mean-change-MOTOR-13.84% and SENSORY-13.10%) on-mean14.11th postparaplegia-day with a small-detrimental-response after-24-hours which-recovers-fast.

Keywords: paraplegias, intrathecal sodium nitroprusside, retrograde transmission, the 10, 000 fold effect, perforators, vasodilatations, long term potenciations

Procedia PDF Downloads 338
7 Neuron Point-of-Care Stem Cell Therapy: Intrathecal Transplant of Autologous Bone Marrow-Derived Stem Cells in Patients with Cerebral Palsy

Authors: F. Ruiz-Navarro, M. Matzner, G. Kobinia


Background: Cerebral palsy (CP) encompasses the largest group of childhood movement disorders, the patterns and severity varies widely. Today, the management focuses only on a rehabilitation therapy that tries to secure the functions remained and prevents complications. However the treatments are not aimed to cure the disease. Stem cells (SCs) transplant via intrathecal is a new approach to the disease. Method: Our aim was to performed a pilot study under the condition of unproven treatment on clinical practice to assessed the safety and efficacy of Neuron Point-of-care Stem cell Therapy (N-POCST), an ambulatory procedure of autologous bone marrow derived SCs (BM-SCs) harvested from the posterior superior iliac crest undergo an on-site cell separation for intrathecal infusion via lumbar puncture. Results: 82 patients were treated in a period of 28 months, with a follow-up after 6 months. They had a mean age of 6,2 years old and male predominance (65,9%). Our preliminary results show that: A. No patient had any major side effects, B. Only 20% presented mild headache due to LP, C. 53% of the patients had an improvement in spasticity, D. 61% improved the coordination abilities, 23% improved the motor function, 15% improved the speech, 23% reduced the number of convulsive events with the same doses or less doses of anti-convulsive medication and 94% of the patients report a subjective general improvement. Conclusions: These results support previous worldwide publications that described the safety and effectiveness of autologous BM-SCs transplant for patients wit CP.

Keywords: autologous transplant, cerebral palsy, point of care, childhood movement disorders

Procedia PDF Downloads 356
6 Microglia Activity and Induction of Mechanical Allodynia after Mincle Receptor Ligand Injection in Rat Spinal Cord

Authors: Jihoon Yang, Jeong II Choi


Mincle is expressed in macrophages and is members of immunoreceptors induced after exposure to various stimuli and stresses. Mincle receptor activation promotes the production of these substances by increasing the transcription of inflammatory cytokines and chemokines. Cytokines, which play an important role in the initiation and maintenance of such inflammatory pain diseases, have a significant effect on sensory neurons in addition to their enhancement and inhibitory effects on immune and inflammatory cells as mediators of cell interaction. Glial cells in the central nervous system play a critical role in development and maintenance of chronic pain states. Microglia are tissue-resident macrophages in the central nervous system, and belong to a group of mononuclear phagocytes. In the central nervous system, mincle receptor is present in neurons and glial cells of the brain.This study was performed to identify the Mincle receptor in the spinal cord and to investigate the effect of Mincle receptor activation on nociception and the changes of microglia. Materials and Methods: C-type lectins(Mincle) was identified in spinal cord of Male Sprague–Dawley rats. Then, mincle receptor ligand (TDB), via an intrathecal catheter. Mechanical allodynia was measured using von Frey test to evaluate the effect of intrathecal injection of TDB. Result: The present investigation shows that the intrathecal administration of TDB in the rat produces a reliable and quantifiable mechanical hyperalgesia. In addition, The mechanical hyperalgesia after TDB injection gradually developed over time and remained until 10 days. Mincle receptor is identified in the spinal cord, mainly expressed in neuronal cells, but not in microglia or astrocyte. These results suggest that activation of mincle receptor pathway in neurons plays an important role in inducing activation of microglia and inducing mechanical allodynia.

Keywords: mincle, spinal cord, pain, microglia

Procedia PDF Downloads 92
5 Clinical Comparative Study Comparing Efficacy of Intrathecal Fentanyl and Magnesium as an Adjuvant to Hyperbaric Bupivacaine in Mild Pre-Eclamptic Patients Undergoing Caesarean Section

Authors: Sanchita B. Sarma, M. P. Nath


Adequate analgesia following caesarean section decreases morbidity, hastens ambulation, improves patient outcome and facilitates care of the newborn. Intrathecal magnesium, an NMDA antagonist, has been shown to prolong analgesia without significant side effects in healthy parturients. The aim of this study was to evaluate the onset and duration of sensory and motor block, hemodynamic effect, postoperative analgesia, and adverse effects of magnesium or fentanyl given intrathecally with hyperbaric 0.5% bupivacaine in patients with mild preeclampsia undergoing caesarean section. Sixty women with mild preeclampsia undergoing elective caesarean section were included in a prospective, double blind, controlled trial. Patients were randomly assigned to receive spinal anesthesia with 2 mL 0.5% hyperbaric bupivacaine with 12.5 µg fentanyl (group F) or 0.1 ml of 50% magnesium sulphate (50 mg) (group M) with 0.15ml preservative free distilled water. Onset, duration and recovery of sensory and motor block, time to maximum sensory block, duration of spinal anaesthesia and postoperative analgesic requirements were studied. Statistical comparison was carried out using the Chi-square or Fisher’s exact tests and Independent Student’s t-test where appropriate. The onset of both sensory and motor block was slower in the magnesium group. The duration of spinal anaesthesia (246 vs. 284) and motor block (186.3 vs. 210) were significantly longer in the magnesium group. Total analgesic top up requirement was less in group M. Hemodynamic parameters were similar in both the groups. Intrathecal magnesium caused minimal side effects. Since Fentanyl and other opioid congeners are not available throughout the country easily, magnesium with its easy availability and less side effect profile can be a cost effective alternative to fentanyl in managing pregnancy induced hypertension (PIH) patients given along with Bupivacaine intrathecally in caesarean section.

Keywords: analgesia, magnesium, pre eclampsia, spinal anaesthesia

Procedia PDF Downloads 249
4 Intrathecal Sufentanil or Fentanyl as Adjuvants to Low Dose Bupivacaine in Endoscopic Urological Procedures

Authors: Shikha Gupta, Suneet Kathuria, Supriya Sampley, Sunil Katyal


Opioids are being increasingly used these days as adjuvants to local anesthetics in spinal anesthesia. The aim of this prospective, randomized, double‑blind study is to compare the effects of adding sufentanil or fentanyl to low dose bupivacaine in spinal anesthesia for endoscopic urological procedures. A total of 90 elective endoscopic urological surgery patients, 40‑80 years old, received spinal anesthesia with 7.5 mg hyperbaric bupivacaine 0.5% (Group A) or by adding sufentanil 10 μg (Group B) or fentanyl 25 μg (Group C) to 5 mg hyperbaric bupivacaine 0.5%. These groups were compared in terms of the quality of spinal anesthesia as well as analgesia. Analysis of variance and Chi‑square test were used for Statistical analysis. The onset of sensory and motor blockade was significantly rapid in Group A as compared with Groups B and C. The maximum upper level of sensory block was higher in Group A patients than Groups B and C patients. Quality of analgesia was significantly better and prolonged in sufentanil group as compared with other two groups. Motor block was more intense and prolonged in Group A as compared with Groups B and C patients. Request for post‑operative analgesic was significantly delayed in Group B patients. Hence in conclusions, spinal anesthesia for endoscopic urological procedures in elderly patients using low dose bupivacaine (5 mg) combined with 10 μg sufentanil is associated with a lower incidence of hemodynamic instability, better quality and prolonged duration as compared to that by adding 25 μg fentanyl.

Keywords: adjuvants, bupivacaine, fentanyl, intrathecal, low dose spinal, sufentanil

Procedia PDF Downloads 293
3 Is Brain Death Reversal Possible in Near Future: Intrathecal Sodium Nitroprusside (SNP) Superfusion in Brain Death Patients=The 10,000 Fold Effect

Authors: Vinod Kumar Tewari, Mazhar Husain, Hari Kishan Das Gupta


Background: Primary or secondary brain death is also accompanied with vasospasm of the perforators other than tissue disruption & further exaggerates the anoxic damage, in the form of neuropraxia. In normal conditions the excitatory impulse propagates as anterograde neurotransmission (ANT) and at the level of synapse, glutamate activates NMDA receptors on postsynaptic membrane. Nitric oxide (NO) is produced by Nitric oxide Synthetase (NOS) in postsynaptic dendride or cell body and travels backwards across a chemical synapse to bind to the axon terminal of a presynaptic neuron for regulation of ANT this process is called as the retrograde neurotransmission (RNT). Thus the primary function of NO is RNT and the purpose of RNT is regulation of chemical neurotransmission at synapse. For this reason, RNT allows neural circuits to create feedback loops. The haem is the ligand binding site of NO receptor (sGC) at presynaptic membrane. The affinity of haem exhibits > 10,000-fold excess for NO than Oxygen (THE 10,000 FOLD EFFECT). In pathological conditions ANT, normal synaptic activity including RNT is absent. NO donors like sodium nitroprusside (SNP) releases NO by activating NOS at the level of postsynaptic area. NO now travels backwards across a chemical synapse to bind to the haem of NO receptor at axon terminal of a presynaptic neuron as in normal condition. NO now acts as impulse generator (at presynaptic membrane) thus bypasses the normal ANT. Also the arteriolar perforators are having Nitric Oxide Synthetase (NOS) at the adventitial side (outer border) on which sodium nitroprusside (SNP) acts; causing release of Nitric Oxide (NO) which vasodilates the perforators causing gush of blood in brain’s tissue and reversal of brain death. Objective: In brain death cases we only think for various transplantations but this study being a pilot study reverses some criteria of brain death by vasodilating the arteriolar perforators. To study the effect of intrathecal sodium nitroprusside (IT SNP) in cases of brain death in which: 1. Retrograde transmission = assessed by the hyperacute timings of reversal 2. The arteriolar perforator vasodilatation caused by NO and the maintenance of reversal of brain death reversal. Methods: 35 year old male, who became brain death after head injury and has not shown any signs of improvement after every maneuver for 6 hours, a single superfusion done by SNP via transoptic canal route for quadrigeminal cistern and cisternal puncture for IV ventricular with SNP done. Results: He showed spontaneous respiration (7 bouts) with TCD studies showing start of pulsations of various branches of common carotid arteries. Conclusions: In future we can give this SNP via transoptic canal route and in IV ventricle before declaring the body to be utilized for transplantations or dead or in broader way we can say that in near future it is possible to revert back from brain death or we have to modify our criterion.

Keywords: brain death, intrathecal sodium nitroprusside, TCD studies, perforators, vasodilatations, retrograde transmission, 10, 000 fold effect

Procedia PDF Downloads 320
2 The 10,000 Fold Effect of Retrograde Neurotransmission: A New Concept for Cerebral Palsy Revival by the Use of Nitric Oxide Donars

Authors: V. K. Tewari, M. Hussain, H. K. D. Gupta


Background: Nitric Oxide Donars (NODs) (intrathecal sodium nitroprusside (ITSNP) and oral tadalafil 20mg post ITSNP) has been studied in this context in cerebral palsy patients for fast recovery. This work proposes two mechanisms for acute cases and one mechanism for chronic cases, which are interrelated, for physiological recovery. a) Retrograde Neurotransmission (acute cases): 1) Normal excitatory impulse: at the synaptic level, glutamate activates NMDA receptors, with nitric oxide synthetase (NOS) on the postsynaptic membrane, for further propagation by the calcium-calmodulin complex. Nitric oxide (NO, produced by NOS) travels backward across the chemical synapse and binds the axon-terminal NO receptor/sGC of a presynaptic neuron, regulating anterograde neurotransmission (ANT) via retrograde neurotransmission (RNT). Heme is the ligand-binding site of the NO receptor/sGC. Heme exhibits > 10,000-fold higher affinity for NO than for oxygen (the 10,000-fold effect) and is completed in 20 msec. 2) Pathological conditions: normal synaptic activity, including both ANT and RNT, is absent. A NO donor (SNP) releases NO from NOS in the postsynaptic region. NO travels backward across a chemical synapse to bind to the heme of a NO receptor in the axon terminal of a presynaptic neuron, generating an impulse, as under normal conditions. b) Vasopasm: (acute cases) Perforators show vasospastic activity. NO vasodilates the perforators via the NO-cAMP pathway. c) Long-Term Potentiation (LTP): (chronic cases) The NO–cGMP-pathway plays a role in LTP at many synapses throughout the CNS and at the neuromuscular junction. LTP has been reviewed both generally and with respect to brain regions specific for memory/learning. Aims/Study Design: The principles of “generation of impulses from the presynaptic region to the postsynaptic region by very potent RNT (10,000-fold effect)” and “vasodilation of arteriolar perforators” are the basis of the authors’ hypothesis to treat cerebral palsy cases. Case-control prospective study. Materials and Methods: The experimental population included 82 cerebral palsy patients (10 patients were given control treatments without NOD or with 5% dextrose superfusion, and 72 patients comprised the NOD group). The mean time for superfusion was 5 months post-cerebral palsy. Pre- and post-NOD status was monitored by Gross Motor Function Classification System for Cerebral Palsy (GMFCS), MRI, and TCD studies. Results: After 7 days in the NOD group, the mean change in the GMFCS score was an increase of 1.2 points mean; after 3 months, there was an increase of 3.4 points mean, compared to the control-group increase of 0.1 points at 3 months. MRI and TCD documented the improvements. Conclusions: NOD (ITSNP boosts up the recovery and oral tadalafil maintains the recovery to a well-desired level) acts swiftly in the treatment of CP, acting within 7 days on 5 months post-cerebral palsy either of the three mechanisms.

Keywords: cerebral palsy, intrathecal sodium nitroprusside, oral tadalafil, perforators, vasodilations, retrograde transmission, the 10, 000-fold effect, long-term potantiation

Procedia PDF Downloads 304
1 Intracranial Hypotension: A Brief Review of the Pathophysiology and Diagnostic Algorithm

Authors: Ana Bermudez de Castro Muela, Xiomara Santos Salas, Silvia Cayon Somacarrera


The aim of this review is to explain what is the intracranial hypotension and its main causes, and also to approach to the diagnostic management in the different clinical situations, understanding radiological findings, and physiopathological substrate. An approach to the diagnostic management is presented: what are the guidelines to follow, the different tests available, and the typical findings. We review the myelo-CT and myelo-RM studies in patients with suspected CSF fistula or hypotension of unknown cause during the last 10 years in three centers. Signs of intracranial hypotension (subdural hygromas/hematomas, pachymeningeal enhancement, venous sinus engorgement, pituitary hyperemia, and lowering of the brain) that are evident in baseline CT and MRI are also sought. The intracranial hypotension is defined as a lower opening pressure of 6 cmH₂O. It is a relatively rare disorder with an annual incidence of 5 per 100.000, with a female to male ratio 2:1. The clinical features it’s an orthostatic headache, which is defined as development or aggravation of headache when patients move from a supine to an upright position and disappear or typically relieve after lay down. The etiology is a decrease in the amount of cerebrospinal fluid (CSF), usually by loss of it, either spontaneous or secondary (post-traumatic, post-surgical, systemic disease, post-lumbar puncture etc.) and rhinorrhea and/or otorrhea may exist. The pathophysiological mechanisms of hypotension and CSF hypertension are interrelated, as a situation of hypertension may lead to hypotension secondary to spontaneous CSF leakage. The diagnostic management of intracranial hypotension in our center includes, in the case of being spontaneous and without rhinorrhea and/or otorrhea and according to necessity, a range of available tests, which will be performed from less to more complex: cerebral CT, cerebral MRI and spine without contrast and CT/MRI with intrathecal contrast. If we are in a situation of intracranial hypotension with the presence of rhinorrhea/otorrhea, a sample can be obtained for the detection of b2-transferrin, which is found in the CSF physiologically, as well as sinus CT and cerebral MRI including constructive interference steady state (CISS) sequences. If necessary, cisternography studies are performed to locate the exact point of leakage. It is important to emphasize the significance of myelo-CT / MRI to establish the diagnosis and location of CSF leak, which is indispensable for therapeutic planning (whether surgical or not) in patients with more than one lesion or doubts in the baseline tests.

Keywords: cerebrospinal fluid, neuroradiology brain, magnetic resonance imaging, fistula

Procedia PDF Downloads 52