Joon-Hee Park

Prediction of postoperative pain intensity after lumbar spinal surgery using pain sensitivity and preoperative back pain severity.

OBJECTIVES To investigate the role of preoperative pain sensitivity and preoperative symptom severity for prediction of postoperative pain intensity after lumbar spine surgery. METHODS This study consisted of two groups who underwent decompression surgery alone (62 patients) or decompression with fusion surgery (37 patients) for lumbar spinal stenosis (LSS). Pain Sensitivity Questionnaire (PSQ) and visual analog pain scale (VAS) for back pain and leg pain were collected preoperatively with detailed medical history. The assessment was performed immediately after surgery when the patients had completely recovered and regained their complete consciousness from general anesthesia (H0) and subsequently 4, 8, 18, 30, 48, and 72 hours (H4, H8, H18, H30, H48, and H72) thereafter as they recovered. RESULTS Both groups showed a decrease in back pain and leg pain with the time postoperatively. In fusion group, preoperative VAS for back pain was significantly correlated with postoperative VAS for back pain at H0, H4, H8, and H18, and PSQ minor/total PSQ also showed a significant correlation with postoperative back pain at H48 and H72. In contrast, only total PSQ and PSQ minors were significantly correlated with postoperative back pain at H18 and H30 in decompression group. Hierarchical regression analysis finally showed that each preoperative back pain and PSQ minor was predictive of immediate postoperative back pain (from H0 to H18) in fusion group and delayed postoperative back pain (H18, H30) in decompression group. CONCLUSIONS The study highlights that each preoperative back pain and individual pain sensitivity could predict the different aspects of postoperative pain after lumbar surgery.

Three-dimensional C-arm computed tomography-guided sacroplasty for the treatment of sacral body fracture.

Study Design. Case report. Objective. To report our results of a sacroplasty technique, using 3-dimensional C-arm CT for the treatment of sacral body fracture. Summary of Background Data. Sacroplasty may provide symptomatic relief and hasten recovery in the treatment of sacral insufficiency fractures. To our knowledge, there is no case report in the literature describing the application of sacroplasty for the treatment of sacral body fracture. We present a case of patient who had percutaneous sacroplasty for sacral body fracture and sacral alar fracture under 3-dimensional C-arm CT guidance and discuss the clinical results and technical considerations. Methods. The procedure included a standard prone positioning of the patient and the area to be treated was prepared in a strictly sterile manner, and a local anesthesia was used. After a small skin incision, an 11-gauge vertebroplasty needle was positioned at the entry point in the sacrum. Then, the needle was inclined, directed, and advanced from the posterior aspect to the anterior aspect of the sacral vertebral body. PMMA cement was incrementally introduced in 0.5 mL aliquots and the volume of PMMA cement injected was total 4 mL. Precise needle placement and PMMA cement injection was performed under the 3-dimensional C-arm CT system and the right sacral alar region was performed in a similar manner. Results. There were no peri-procedural complications occurred and the patient experienced an immediate and substantial pain relief that was persistent during a 12-month follow-up. Conclusions. 3-dimensional C-arm CT-guided sacroplasty is a safe, practical, and effective solution to treatment of sacral body fracture.

Influence of arm position on catheter placement during real-time ultrasound-guided right infraclavicular proximal axillary venous catheterization

BACKGROUND Real-time ultrasound-guided infraclavicular proximal axillary venous catheterization is used in many clinical situations and provides the advantages of catheter stabilization, a reduced risk of catheter-related infection, and comfort for the patient without limitation of movement. However, unintended catheter tip dislocation and accidental arterial puncture occur occasionally. This study was designed to investigate the influence of arm position on catheter placement and complications. METHODS Patients were randomized to either the neutral group (n=240) or the abduction group (n=241). In the neutral group, patients were positioned with the head and shoulders placed in an anatomically neutral position and the arms kept by the side during catheterization. In the abduction group, the right upper arm was abducted at 90° from the trunk during catheterization. After real-time ultrasound-guided catheterization was carried out in the right infraclavicular proximal axillary vein, misplacement of the catheter and all complications were evaluated with ultrasound and chest radiography. RESULTS The success rate of complete catheterization before evaluating the placement of the catheter was high in both groups (97.1 vs 98.8%, P=not significant). The incidence of accidental arterial puncture was not different (1.7 vs 0%, P=not significant). The incidence of misplacement of the catheter was higher in the neutral group than in the abduction group (3.9 vs 0.4%, P=0.01). There were no complications, such as haemothorax, pneumothorax, or injury to the brachial plexus and phrenic nerve, in either group. CONCLUSIONS Upper arm abduction may minimize the risk of misplacement of the catheter during real-time ultrasound-guided infraclavicular proximal axillary venous catheterization. CLINICAL TRIAL REGISTRATION The trial was registered with the Clinical Trial Registry of Korea: https://cris.nih.go.kr/cris/index.jsp. Identifier: KCT0001417.

Impact of sex, age and BMI on depth and diameter of the infraclavicular axillary vein when measured by ultrasonography.

Background and objective The axillary vein is another option for central venous catheterisation, with less chance of accidental arterial puncture as there is a greater distance between artery and vein, and from vein to rib cage, compared with other sites. Better success, lower complication rates and faster access can be achieved with ultrasound guidance which is becoming the established technique for central venous catheterisation. We measured two key factors for successful infraclavicular axillary venous catheterisation: depth and diameter of the infraclavicular axillary vein in its medial part using ultrasound. Methods We recruited 98 patients, classified according to sex, age and BMI. Groups were divided according to BMI as follows: group 1 (≤20 kg m−2), group 2 (20.01–25.00 kg m−2) and group 3 (>25 kg m−2); and these were further subdivided according to age: 20–39 years, 40–59 years and 60–80 years. The depth and diameter of the infraclavicular axillary vein was measured at a point between the medial third and midpoint of the clavicle. Results Vein diameter was significantly different between men and women (P = 0.005), whereas depth showed no significant difference. In the BMI subgroups, there was a significant difference in depth (P < 0.001), and a trend to significant difference in diameter (P = 0.056). However, age-specific differences in depth and diameter were not observed. Conclusion During catheterisation of infraclavicular axillary vein, real-time visualisation of the needle tip when using ultrasound to gauge vein depth and diameter may diminish major complications such as pneumothorax and artery puncture.

Incidence and Risk Factors of Postoperative Hematoma Requiring Reoperation in Single-level Lumbar Fusion Surgery.

Study Design. Retrospective cohort. Objective. The purpose of the present study was to examine the incidence and risk factors for postoperative hematoma requiring reoperation in patients undergoing single-level lumbar fusion surgery. Summary of Background Data. Postoperative hematoma can cause devastating neurological consequences after spine surgery. Risk factors for hematoma in specific spine procedures have not been well established. Methods. A cohort of patients undergoing single-level lumbar fusion surgery was constructed from the 2012 to 2013 American College of Surgeons National Surgical Quality Improvement Program dataset using Current Procedural Terminology codes (22533, 22558, 22612, 22630, and 22633). In cases requiring reoperation within 30 days after initial surgery, postoperative hematoma was identified using the ICD-9 code 998.1. Risk factors for postoperative hematoma were assessed with logistic regression modeling. Results. Of 5280 patients undergoing single-level lumbar fusion surgery, 27 patients (0.5%) developed a postoperative hematoma requiring reoperation for hematoma evacuation. A heightened incidence of postoperative hematoma was found in patients who were smokers (1.0% vs. 0.4% for nonsmokers, P = 0.016) or who had a diagnosis of bleeding disorder (3.8% vs. 0.5% for those without bleeding disorder, P = 0.007). Multivariate logistic regression analysis indicated that the adjusted odds ratios for postoperative hematoma associated with smoking and bleeding disorder were 3.34 (95% confidence interval, 1.15–9.71) and 10.2 (95% confidence interval, 1.9–54.8), respectively. Conclusion. Smoking and bleeding disorder appear to be major risk factors for postoperative hematoma requiring reoperation after single-level lumbar fusion surgery. Intervention programs targeting patients with these risk factors are needed to reduce their excess risk of postoperative hematoma. Level of Evidence: 3

Short-term changes of intraocular pressure after cervical interlaminar epidural injection: a pilot study

BACKGROUND Cervical epidural injection (CEI) is widely performed on patients with intervertebral disc herniation. The aim of the present study was to investigate the short-term effects of CEI on non-invasive intraocular pressure (IOP) measurements in subjects with normal eyes. METHODS This prospective study enrolled 15 patients who were undergoing CEI at the C5/6 level with an interlaminar approach in the left lateral decubitus position. IOP was measured in both eyes by a rebound tonometer (Icare-PRO, Icare Finland Oy, Helsinki, Finland). A total volume of 14 ml (4 ml non-ionic contrast, a mixture of 0.2% lidocaine 1 ml and normal saline 4 ml for irrigation and a mixture of normal saline 4.5 ml with non-particulate betamethasone 2 mg) was injected with 1.0 ml s(-1). IOP was measured 5 min after the lateral decubitus position (T0, baseline), immediately after CEI (T1), and 1 min intervals for 5 min (T2-T6). RESULTS The values of left and right baseline IOP (T0) were 18.9 (2.0) and 15.6 (2.6) mm Hg, respectively. IOP of left and right eyes at T1 [26.6 (4.2) and 21.2 (2.5) mm Hg, respectively] and T2 [26.2 (4.5) and 21.0 (2.8) mm Hg, respectively] were significantly higher compared with T0. These values immediately decreased at T3 and returned to baseline levels within 5 min after CEI. CONCLUSIONS CEI resulted in an elevation of IOP of both eyes. However, the effects were transient only lasting a few minutes.

Population pharmacokinetic analysis of propofol in underweight patients under general anaesthesia

Background: The modified Marsh and Schnider pharmacokinetic models for propofol consistently produce negatively and positively biased predictions in underweight patients, respectively. We aimed to develop a new pharmacokinetic model of propofol in underweight patients. Methods: Twenty underweight (BMI<18.5 kg m−2) patients aged 20–68 yr were given an i.v. bolus of propofol (2 mg kg−1) for induction of anaesthesia. Anaesthesia was maintained with a zero‐order infusion (8 mg kg−1 h−1) of propofol and target‐controlled infusion of remifentanil. Arterial blood was sampled at preset intervals. A population pharmacokinetic analysis was performed using non‐linear mixed effects modelling. The time to peak effect (tpeak, maximally reduced bispectral index) was measured in 28 additional underweight patients receiving propofol 2 mg kg−1. Results: In total, 455 plasma concentration measurements from the 20 patients were used to characterise the pharmacokinetics of propofol. A three‐compartment mammillary model well described the propofol concentration time course. BMI and lean body mass (LBM) calculated using the Janmahasatian formula were significant covariates for the rapid peripheral volume of distribution and for the clearance of the final pharmacokinetic model of propofol, respectively. The parameter estimates were as follows: V1(L)=2.02, V2(L)=12.9(BMI/18.5), V3(L)=139, Cl (L·min−1)=1.66(LBM/40), Q1 (L·min−1)=1.44, Q2 (L·min−1)=0.87+0.0189×(LBM−40). The median tpeak of propofol was 1.32 min (n=48). Conclusions: A three‐compartment mammillary model can be used to administer propofol via target effect‐site concentration‐controlled infusion of propofol in underweight patients. Clinical trial registration: KCT0001760.

Rescue of hemodynamic compromise in superior vena cava syndrome with transesophageal echocardiography

The anesthetic management of patients with an anterior mediastinal mass is very challenging due to the potential risk of hemodynamic and respiratory compromise. A specialized anesthetic plan should be developed for in patients with an anterior mediastinal mass based on the preoperative clinical symptoms as well as, radiographic, computed tomographic, spirometric, and echocardiographic data [1,2]. A 31-year-old man (height 173.5 cm, weight 70.4 kg) came to our emergency department with right-sided chest discom fort, dry cough, progressive dyspnea, and orthopnea for the previous 4 weeks. The initial chest X-ray evaluation revealed a large amount of right side pleural effusion and a bulky mediastinal mass. Multi directional computed tomography revealed a 12.3 cm homogenous soft tissue mass in the anterior mediastinum compressing the superior vena cava and dis placing the ascending aorta. The trachea and both main bronchi were patent, but a cross-sectional area of the right upper lobe bronchus (7.21 mm) was reduced 44% relative to the left upper lobe bronchus (12.97 mm). Right loculated pleural effusion, totally collapsed right lower lobe and subsegmental atelectasis in the right middle lobe were noted. A therapeutic and diagnostic thoracentesis was done under local anesthesia, and 1,600 ml of pleural fluid was removed. Cytology of pleural fluid revealed many lymphocytes and mesothelial cells, but these were negative for malignancy. However, because dyspnea persisted and pleural effusion was increased after admission, a mediastinoscopic biopsy and pleural decortication were performed under general anesthesia. In the operating room, the CAPIOX emergency bypass system (CAPIOX Ⓡ EBS TM , Terumo Corporation, Tokyo, Japan) was prepared in the event of cardiopulmonary collapse. Before the induction of general anesthesia, a 20-guage catheter was placed in the right radial artery for continuous blood pressure monitoring. The patient was placed in the Semi-Fowler’s position with the head elevated 30 degrees to relieve the discomfort of the supine position. Initial vital signs were blood pressure 105/65 mmHg, heart rate 100 beats/min, respiration 25 breaths/min, and O2 saturation 96%. Preoxygenation with 100% O2 was administered using a face mask, and anesthesia was induced with a continuous infusion of propofol (effect-site concentration 4.0-5.0 μg/ml and remifentanil (effect- site concentration 3.0 5.0 ng/ml using a target-controlled infusion pump (Orchestra Ⓡ Base Primea, Fresenius Vial, Brezins, France) and a bolus dose of rocuronium 50 mg via a preexisting 16-guage IV catheter in the vein on the medial surface of the right leg. Intubation was successfully achieved using the left-sided Robert-Shaw double lumen bronchial tube in the supine position. Breath sounds were heard on both sides of the chest. Mechanical ventilation was maintained with a tidal volume, respiratory rate and partial pressure of end-tidal carbon dioxide of 500 ml, 15 breaths/min, and 28-32 mmHg, respectively. After induction, the arterial blood pressure began to drop to 60/35 mmHg and the heart rate increased to 110 beats/min. Ephedrine 10 mg were administered intravenously, but the vital signs were not improved. A transesophageal echocardiography (TEE) was performed for evaluation of hemodynamic instability. It showed that a large mass compressed the right atrium