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PubMed1993

Implantable transvenous cardioverter-defibrillators.

BACKGROUND: Implantable transvenous cardioverter-defibrillators offer a significant opportunity to decrease procedural morbidity and medical costs in the care of patients with life-threatening ventricular arrhythmias who otherwise would have required a sternotomy or thoracotomy for device insertion. The purpose of this study was to examine prospectively the safety, efficacy, and limitations associated with the use of a transvenously implanted, tiered-therapy cardioverter-defibrillator with antitachycardia pacing function in a consecutive population of 84 ventricular fibrillation (VF) and sustained ventricular tachycardia (VT) survivors. METHODS AND RESULTS: The index arrhythmia promoting transvenous cardioverter-defibrillator implantation was VF in 41 patients, VT in 27, and both VF and VT in 16. In each patient, transvenous defibrillation via a coronary sinus, a right ventricular, a superior vena caval, and/or a subcutaneous chest patch lead system was attempted. The pulsing methods used include two-electrode single-pathway pulsing or three-electrode dual-pathway simultaneous or sequential pulsing. A transvenous cardioverter-defibrillator was inserted if the defibrillation threshold (DFT) was < or = 20 J. Successful implantation of a transvenous cardioverter-defibrillator was possible in 80 of 84 (95%) patients. The mean implant DFT was 10.9 +/- 4.8 J. After cardioverter-defibrillator implantation, all patients were extubated in the operating room and sent to a standard telemetry ward for monitoring. No patient suffered a postoperative pulmonary complication or perioperative flurry of cardiac arrhythmias. Postoperative complications included lead dislodgments in eight, transient long thoracic nerve injury in one, asymptomatic left subclavian vein occlusion in two, asymptomatic small pericardial effusion in one, subcutaneous patch pocket hematomas in four, pulse generator pocket infection in one, and lead fracture in one. As experience was gained with the procedure, it was routine to discharge patients 3 days after surgery. The mean hospital stay was 6.0 +/- 2.4 days. Upon discharge, all patients returned to their prehospital activities including those with complications except for the patient with a pocket infection, who required intravenous antibiotic therapy. Patient survival using an intention-to-treat analysis was 98% over an 11 +/- 7-month follow-up period. During this time period, 31 of the 80 patients (39%) with transvenous lead systems were successfully treated by their device for sustained VT or VF. Antitachycardia pacing was used in 424 episodes of monomorphic VT and was successful in 371 (88%). All episodes of VF were aborted by the device. Antiarrhythmic drugs were used after device implantation in only eight of 80 patients (10%). CONCLUSIONS: Transvenous cardioverter-defibrillator implantation is practical in most candidates. Implant DFTs are usually low, surgical morbidity and postoperative complications are modest, therapy of VT and VF is efficient, and survival is excellent.

Algorithms↗
PubMed1998

Expiratory muscle function in amyotrophic lateral sclerosis.

Few data exist concerning expiratory muscle function in amyotrophic lateral sclerosis (ALS). We studied 26 patients with ALS (16 with respiratory symptoms and 10 without) and measured the maximal static expiratory mouth pressure (MEP), the gastric pressure during a maximal cough (Cough Pga), and the gastric pressure after magnetic stimulation of the lower thoracic nerve roots (Tw Pga). These measurements were related to the ability to generate transient supramaximal flow during a cough (cough spikes), to arterialized capillary blood gases, and to inspiratory muscle strength. Vocal cord motion was examined endoscopically in 11 of the 16 symptomatic patients. Expiratory muscle weakness was related to inability to generate cough spikes with a threshold effect such that spikes were absent for Cough Pga < 50 cm H2O (p = 0.009) or Tw Pga < 7 cm H2O (p = 0.006) and was usually associated with inspiratory muscle weakness. However, in multivariate analysis, PaCO2 was only significantly associated with the maximal sniff esophageal pressure (p = 0.02). Symptomatic patients had significantly lower inspiratory muscle strength, whereas, of the expiratory muscle tests, only Tw Pga was significantly lower (p = 0.0009) in symptomatic patients. Abnormal vocal cord motion was observed in two of the 11 patients examined. We conclude that abdominal muscle weakness in ALS, when substantial, results in an inability to generate transient supramaximal flow during a cough. However, the primary determinant of both ventilatory failure and respiratory symptoms seems to be inspiratory muscle weakness.

Adult↗
PubMed2000

Abdominal muscle strength in patients with tetraplegia.

The abdominal muscles are completely paralyzed after traumatic transection of the cervical cord. To assess the residual pressure-generating capacity of these muscles, we first measured the changes in gastric pressure (DeltaPga) during paired bilateral stimulation of the lower thoracic nerve roots in eight chronic patients with C5-C7 tetraplegia and eight matched unaffected subjects in the seated posture. Stimulations were applied with a 90-mm circular magnetic coil positioned at the level of T10 and connected to a Magstim 250 stimulator. During relaxation at FRC, DeltaPga during maximal stimulation averaged (mean +/- SE) 76.0 +/- 11.7 cm H(2)O in the control subjects, whereas in the patients it was only 29.9 +/- 3.7 cm H(2)O (p = 0.002). Stimulations were next applied during the course of a forced expiration. All patients consistently demonstrated an abrupt increase in esophageal pressure (22.7 +/- 4.5 cm H(2)O), and six of them also showed an increase in expiratory flow. The cumulative thickness of the four abdominal muscles, as measured with an ultrasound probe, was 34% smaller in the patients than in the control subjects and correlated positively with maximal DeltaPga. We conclude that in patients with tetraplegia, muscle atrophy causes a marked reduction in abdominal muscle strength. However, magnetic stimulation of the abdominal muscles elicits increases in intrathoracic pressure that are greater than those required to initiate dynamic airway compression; it might, therefore, improve the clearing of airway secretions.

Abdominal Muscles↗
PubMed2003

Anatomical characteristics of the upper serratus anterior: cadaver dissection.

STUDY DESIGN: A descriptive study of the anatomical characteristics of the upper serratus anterior. OBJECTIVES: To delineate the upper serratus anterior with comparison to classical descriptions of the anatomy of the muscle as a whole. BACKGROUND: Although the serratus anterior has a major role in scapulothoracic stability, description of the separate function and anatomy of the upper, middle, and lower portions of the muscle has been limited. METHODS AND MEASURES: Bilateral anatomical dissection of 8 cadavers (3 female and 5 male) exposed 13 serratus anterior and surrounding structures for review. The number of serrations, attachment sites, length, and girth of the upper serratus anterior were measured. RESULTS: The upper serratus anterior presented with dual serrations and single serrations in 7 (54%) and 6 (46%) of 13 observations, respectively. Attachments to both first and second ribs were noted in 6 (46%) of the 13 observations. The remaining proximal attachments were to the second rib only, the first rib only, and dual attachments to the second and third ribs. In all cases, cranial attachments were to the superior scapular angle blending with the levator scapulae attachment. Length ranged from 4.8 to 9.0 cm (mean +/- SD, 6.9 +/- 1.2 cm). The girth ranged from 3.0 to 8.5 cm (mean +/- SD, 6.1 +/- 1.5 cm). One or more branches of the long thoracic nerve were observed to consistently innervate the upper serratus anterior fibers. CONCLUSION: The upper serratus anterior demonstrated wide variation in anatomy and was noted to be distinct in appearance and peripheral innervation from the middle and lower serratus anterior.

Aged↗
PubMed1983

Successful treatment of a group of spinal cord arteriovenous malformations by interruption of dural fistula.

As demonstrated by selective spinal cord arteriography, over 80% of spinal cord arteriovenous malformations (AVM's) occupy a predominantly extramedullary position. Current therapy frequently requires surgical stripping of the long dorsal intradural vessel(s) from the underlying spinal cord over many cord segments. The authors report six patients with a dural arteriovenous fistula fed by a cluster of abnormal epidural arteries. These vessels, which surrounded and were embedded into the dural covering of a thoracic nerve root, drained into a long sinuous intrathecal paramedullary vein(s). The angiographic and surgical appearance of the intradural component of these lesions was identical to that of lesions previously classified as Type I AVM's of the spinal cord. All patients had symptoms and signs of myelopathy. In five patients, surgery was limited to coagulation and excision of the extradural vessels and division of the intradural arterialized vein. Progressive improvement began within days following surgery. No residual abnormality was demonstrated by postoperative selective spinal cord arteriography, which was performed in all five patients. The findings support those of Kendall and Logue, that surgery restricted to elimination of the arteriovenous fistula at the intervertebral foramen is curative, and that more extensive surgery is unnecessary for this subgroup of AVM's of the spinal cord. These lesions comprise a sizable percent of all spinal AVM's. Resolution of myelopathy in these patients supports the hypothesis that venous hypertension causes chronic progressive myelopathy.

Adult↗
PubMed1989

Thoracic dorsal ramus entrapment. Case report.

Entrapment of the dorsal ramus of a thoracic spinal nerve is described in a patient with chronic back pain and sensory disturbance in the cutaneous territory served by the T3-5 dorsal rami. The dorsal ramus of the T-4 nerve was found to be compressed by a bone spur involving the inferior T-4 apophyseal facet. The point of entrapment was a tunnel bounded by the transverse process, apophyseal joint, rib, and superior costotransverse ligament.

Adult↗
PubMed1977

Abdominal pain caused by diabetic radiculopathy.

In diabetes mellitus, pain and weakness in a lower extremity can result from lumbosacral radiculopathy. However, abdominal pain caused by a similar type of thoracic nerve root disease is not generally recognized. Four diabetic patients with abdominal pain were studied. In none of the patients was the actual cause--radiculopathy--suspected until after extensive negative diagnostic investigation, which frequently included invasive procedures. Their clinical features were suggestive of malignant disease. Electromyographic examination revealed the correct diagnosis, and all four of the patients had a spontaneous and complete recovery.

Abdomen↗
PubMed2000

[Anesthetic management of a patient with chronic high spinal cord injury (second report)].

We administered anesthesia twice to a 43-year-old male patient with complete sensory and motor disturbance below the upper thoracic nerves due to chronic high spinal cord injury. The first operation was the gluteus maximus musculocutaneous flap for closure of a sacral decubitus ulcer under general anesthesia. The second was the transurethral lithotripsy for the bladder stone under spinal anesthesia. Severe hypertension occurred probably due to autonomic hyperreflexia (AH) during both operations. Therefore, we must be careful in anesthetic management of patients with chronic high spinal cord injury, because AH might occur in any anesthetic administration.

Adult↗
PubMed1975

Palmar hyperhidrosis. Long-term results following high thoracic sympathectomy.

Fourteen men and 22 wemon, with an average of 23 years (range 14-36 years) were operated on for hyperhidrosis of the upper extremity during the period from 1955 to 1970. Twenty-eight had had symptoms for more than 10 years. Resection of the 2nd and 3rd thoracic ganglia and the connecting sympathetic chain was carried out using a posterior approach; in 33 cases the operation was bilateral, and in three unilateral. Thirty-five patients were followed up after an average of 7.8 years (range 2-17 years). In one patient unilateral reoperation was carried out four months after the first operation. Since the first operation 34 patients had suffered from neither palmar nor axillary sweating. However 20 had permanent compensatory hyperhidrosis, and 15 suffered from gustatory facial sweating, which had usually started within six months of operation. Four, in whom two spinal thoracic nerves had also been resected, reported marked dysaesthesia over the front of the chest and in the axilla, lasting for several years.

Adolescent↗
PubMed2001

[Usefulness of epidural infusion of ketamine for relief of localized superficial pain].

Three patients with localized superficial pain had their pain alleviated by single epidural infusion with low dose ketamine. The patients are as follows: a 62-year-old female with herpetic neuralgia on her right sixth thoracic nerve area; a 52-year-old male whose left shoulder, anterior chest and abdomen had been burned by acetylene gas; and a 49-year-old male whose bilateral hands suffering from frostbite by propane gas. Epidural tube insertion to administer a single dose of 10 mg ketamine with lidocaine or bupibacaine was performed in all the three patients. They were administered single epidural infusion of 10 mg ketamine with lidocaine or bupibacaine everyday and they continued to receive epidural block with lidocaine or bupivacaine including buprenorphine or morphine. Therefore, we suspect that single epidural infusion of ketamine, an antagonist for N-methyl-D-aspartic acid receptor, could be an effective and useful alternative treatment in patients with various refractory localized superficial pain of either acute or chronic nature.

Analgesia, Epidural↗
PubMed2001

Nerve harvesting procedures.

Autogenous nerve grafts currently set the standard for reconstruction of motor and sensory nerve injuries that cannot be repaired by mobilization, advancement, and approximation, and suturing without tension. Donor nerves such as the GAN and SN are easily accessible and frequently used in maxillofacial microneurosurgery. Other nerves (MACN, LCNF, LTN) may serve well in special nerve reconstruction situations. In the future, availability of biodegradable nerve conduits with neurotrophic factors may render obsolete the reconstruction of the short-span nerve gap (< 3 cm) by autogenous nerve grafts.

Absorbable Implants↗
PubMed2003

Change of bone mechanical strength in rats after spinal cord injury over a short term.

This study investigated the time-course of changes in bone mechanical strength in rats with spinal cord injury (SCI). Sixty-four male Wistar rats underwent spinal cord transection at the thoracic nerve. Control rats underwent a sham procedure (SHAM). Animals were sacrificed at day 1, 4, 7 and 14 after operation. The mechanical strength of the left femur and tibia was measured by the three-point bending strength test. The bones were dried, weighed and burned to ash. A specimen of right tibia was prepared and examined under a microscope. Bone mechanical strength, dry bone weight, and ash content of the femur and tibia in SCI rats were significantly lower than those in SHAM animals. Dry bone weight and ash content began to decrease from the 4th day after SCI and reached their lowest at day 7 after operation. Bone mechanical strength had reduced significantly by the 14th day. Gaps and spaces were observed in the trabecular area at the same time. After SCI, calcified cartilage decreased and the reduction of bone mass occurred rapidly. Moreover, a decline of bone mechanical strength is caused within 2 weeks. Thus, SCI led to the atrophy of bone and caused the reduction of mechanical strength at an early stage. It is thus necessary to prevent bone loss after SCI immediately.

Animals↗