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At least 955 records · Page 53Linked to original sources
PubMed1983

Continuous opioid infusion for scoliosis fusion surgery.

Paraplegia is the major risk involved in reconstructive surgery for scoliosis with fusion. To detect spinal cord dysfunction intraoperatively, somatosensory cortical-evoked potential (SCEP) monitoring and a wake-up test or a combination of the two is generally used. Our pilot studies indicated that a balanced anesthesia technique consisting of nitrous oxide, narcotics, and a muscle relaxant is well-suited both for SCEP monitoring as well as for wake-up tests. However, at times the intermittent administration of narcotics adversely affected SCEP interpretation and wake-up tests. To facilitate both SCEP interpretation and wake-up tests, we employed N2O/O2 with continuous infusion of narcotics and compared it with intermittent bolus administration of narcotics in 35 patients. For our purposes fentanyl (FE) was assumed to be 100 times more potent than morphine (MS). Our first 13 patients were studied using bolus increments of either MS (5-10 mg) every 30-40 minutes or FE (50-100 micrograms) every 20-30 minutes. The remaining 22 patients were studied during continuous infusions of either MS at a rate ranging from 150-250 micrograms X kg-1 X hr-1 or FE at a rate ranging from 1.5 to 2.5 micrograms X kg-1 X hr-1. Continuous infusions reduced total narcotic requirements (P less than 0.005). In addition, the technique produced stable suppression of SCEPs and made it easier to interpret surgically induced SCEP changes. Wake-up tests were smooth and repeatable. Patients who received fentanyl infusions fared better than those receiving MS in that they did not require postoperative respiratory support. Continuous infusions of fentanyl are useful in reconstructive spinal surgery for scoliosis with monitoring.

Adolescent↗
PubMed2001

Biphasic urethral sphincter responses to acetic acid infusion into the lower urinary tract in anesthetized cats.

PURPOSE: Varying the concentration of infused acetic acid produced bladder irritation and dose dependent increases in external urethral sphincter electromyography activity in cats. We further characterized acetic acid induced external urethral sphincter electromyography activity in intact and acute spinal cord injured animals. MATERIALS AND METHODS: Bladder cystometrography and external urethral sphincter electromyography were continuously recorded in chloralose anesthetized cats. Dilute 0.05% to 0.8% acetic acid was infused into the lower urinary tract through the bladder dome. Intravesical or intraurethral infusion was performed separately in bladder neck ligated preparations. In some animals the spinal cord was transected at L1 to L2 2 to 8 hours before the study. RESULTS: Acetic acid infusion into the lower urinary tract elicited dose dependent increases in tonic external urethral sphincter activity. However, a prolonged infusion of 0.7% to 0.8% acetic acid usually inhibited external urethral sphincter activity. The excitatory external urethral sphincter response was elicited by intraurethral but not by intravesical infusion. This response remained in acute spinal cord injured animals. The inhibition of tonic external urethral sphincter activity during 0.7% to 0.8% acetic acid infusion was observed when there was extreme bladder irritation characterized by continual contractions. Induced tonic external urethral sphincter activity was attenuated by intrathecal administration of prazosin or scopolamine and abolished by hexamethonium. CONCLUSIONS: Acetic acid infusion into the lower urinary tract elicits biphasic external urethral sphincter responses. The early excitatory response is a spinal urethrourethral reflex and the late inhibitory phase results from negative vesicourethral feedback control. Spinal muscarinic cholinergic and alpha-adrenergic receptors are involved in acetic acid induced excitatory external urethral sphincter responses.

Acetic Acid↗
PubMed2003

Chronic opioid antagonist treatment dose-dependently regulates mu-opioid receptors and trafficking proteins in vivo.

Chronic opioid antagonist treatment increases the density of mu-opioid receptors (muOR) in many model systems. In previous studies, naltrexone treatment produced an increase in muOR density accompanied by decreases in GRK-2 and DYN-2 protein abundance. To examine the relationship between changes in receptor density and proteins involved in receptor trafficking, the dose-dependent effect of chronic naloxone infusion was determined. Dose-dependent antagonism of morphine analgesia was also examined. Mice were infused with naloxone (0.1, 1.0, 5.0 mg/kg/day sc) for 7 days via osmotic pump. Controls were treated with placebo pellets. On the 7th day, morphine dose-response studies were determined using the tail flick. Other mice were sacrificed at the end of the treatment and spinal cords were collected for determination of muOR density and GRK-2 and DYN-2 protein abundance. Naloxone infusion dose-dependently increased spinal muOR density with no change in affinity. The increases in mu-receptor density were proportional to dose-dependent decreases in GRK-2 and DYN-2 protein levels. Furthermore, naloxone dose-dependently antagonized morphine. These data suggest that opioid antagonist-induced muOR up-regulation in mouse spinal cord is associated with regulation of proteins involved in receptor trafficking and support suggestions that opioid antagonist-induced receptor up-regulation is due to reduced constitutive internalization of opioid receptors.

Animals↗
PubMedDate not supplied

Effects of preemptive analgesia using continuous subcutaneous morphine for postoperative pain in scoliosis surgery: a randomized study.

The authors evaluated prospectively the efficacy and safety of continuous subcutaneous morphine administration for postoperative analgesia after posterior spinal fusion and instrumentation for idiopathic scoliosis. Thirty patients were given the subcutaneous morphine infusion (20 mg/day), and 20 patients were not given morphine (control group). Postoperative pain control was assessed using a verbal response score (VRS) and a visual analog pain scale (VAS). The number of times the patient requested supplemental analgesics was also evaluated. VRS and VAS measurements were significantly lower in the continuous subcutaneous morphine group compared with the control group. Also, analgesic consumption in the continuous subcutaneous morphine group was lower than that of the control group. There was no respiratory depression or constipation. Preemptive analgesia using continuous subcutaneous infusion of morphine is a simple, safe, and effective method to control postoperative pain after posterior instrumentation and spinal fusion for idiopathic scoliosis.

Adolescent↗
PubMed1994

Persistent sacral sensory deficit induced by intrathecal local anesthetic infusion in the rat.

BACKGROUND: Several cases of cauda equina syndrome after continuous spinal anesthesia have been recently reported. One possible etiology is toxic exposure of the sacral roots resulting from intrathecal maldistribution of a relatively large dose of local anesthetic. The current experiments sought to determine whether a local anesthetic solution, injected intrathecally to produce a restricted distribution of anesthesia, could result in a sacral deficit. In addition, we sought to test the hypothesis that, when equal volumes are administered intrathecally, significant differences exist in the potential to three commonly used anesthetic solutions to induce sensory impairment. METHODS: Thirty-two rats were implanted with intrathecal catheters to permit repetitive infusion of local anesthetic. Animals were randomly assigned to four groups of eight to receive either 5% lidocaine with 7.5% dextrose; 0.75% bupivacaine with 8.25% dextrose; 0.5% tetracaine with 5% dextrose; or normal saline. Each rat received, in sequence, a 1-h (60 microliters), a 2-h (120 microliters), and a 4-h (240 microliters) infusion; the infusions were separated by a 4-day rest period. Sensory function was assessed using the tail-flick test, which was performed immediately before each infusion and 6 days after the last infusion by an investigator blinded to the solution infused. RESULTS: There was no significant difference in baseline tail-flick latencies for the four groups. Tail-flick latency for the lidocaine group was significantly prolonged when compared with the bupivacaine, tetracaine, and saline groups. This difference was apparent after the first infusion and persisted throughout the study. CONCLUSIONS: In the rat, restricted anesthetic distribution can be achieved, and sensory impairment may result. These findings further support an etiology of local anesthetic neurotoxicity for recent clinical injuries after continuous spinal anesthesia. The functional model described appears to be suitable for in vivo study of local anesthetic neurotoxicity.

Anesthesia, Local↗
PubMed1984

Effect of intravenous lidocaine on experimental spinal cord injury.

A series of experiments was conducted to study the effect of systemic intravenous administration of lidocaine on neurological recovery after acute experimental spinal cord injury in cats. The spinal cord was injured by the rapid inflation of an epidural balloon at T-6. The physiological integrity of the spinal cord ceased within 2 seconds in all animals, as demonstrated by acute disappearance of the somatosensory evoked response (SER). There was essentially no return of the SER in the five untreated animals when monitored for 4 hours post-injury. All of the pathological specimens from these animals revealed severe central cord hemorrhage. Intravenous lidocaine was begun 15 minutes after the injury in five animals. Three of these animals had significant return of the SER. The pathological specimens from the lidocaine-treated animals revealed either mild or moderate central cord hemorrhage. The results of this experiment suggest that systemic lidocaine administration has a significant beneficial effect in the treatment of acute spinal cord injury.

Animals↗
PubMed1992

[Effects of continuous administration of nimodipine during the acute phase of spinal cord injury in baboons].

This study was carried out to assess the putative improvement of spinal cord blood flow obtained with a calcium channel blocker after acute spinal cord injury in ten baboons. The injury was generated by compressing the cord at L1 level for 5 seconds with a balloon catheter inflated to 2 bars with Ringer's solution. Subsequently, five monkeys received a saline infusion, and five others a nimodipine infusion (0.04 mg.kg-1 x h-1), for seven days. Spinal cord blood flow (SCBF) was measured using a scanographic technique with stable xenon. Somatosensory evoked potentials (SEP), magnetic resonance imaging (MRI) and a histological study of the spine were carried out a different times of the study. SCBF and SEP were recorded before injury. Thereafter SCBF was measured every thirty minutes during the four hours following the injury, as well as on day 7. SEP and MRI were recorded on days 1 and 7. The histological study was carried out on the eighth day. Three spinal cord and vertebral segments were collected, fixed, sliced and stained. SCBF before injury was not significantly different in either group (39.8 +/- 15.9 ml x 100 g-1 x min-1 for the treatment group 40.9 +/- 16.3 ml x 100 g-1 x min-1 for the control group). During the injury, there were major variations between animals. The results were expressed as percentages of each animal's control SCBF (before injury). Immediately after injury, SCBF increased in both groups. However, in the control group, SCBF decreased more than in the treatment group on the seventh day after injury (80 to 90% vs 25 to 50%, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1988

A study of the interaction between clonidine and morphine on analgesia and blood pressure during continuous intrathecal infusion in the rat.

In the rat, the continuous intrathecal (i.t.) infusion of clonidine (0.4 microgram/hr) significantly increased the tail-flick latency (TF) and the threshold for paw pressure (PP) withdrawal for 5 days and decreased the systolic blood pressure (up to 24 mm Hg) for 7 days. The antinociceptive effect of continuous intrathecal infusion of clonidine (0.4 microgram/hr) in the tail flick and paw pressure tests was not attenuated in rats that were tolerant to morphine. The acute intrathecal administration of clonidine (2.7 micrograms) and morphine (1.0 microgram) resulted in a synergistic interaction in the tail-flick and paw pressure tests. A synergistic interaction was also observed during the continuous intrathecal infusion of morphine (1.25 micrograms/hr) and clonidine (0.2 microgram/hr) in the tail-flick and paw pressure tests. Individually, these doses of morphine and clonidine had no antinociceptive effect. However, intrathecal infusion together yielded peak tail-flick and paw pressure responses comparable to that of 0.4 microgram/hr clonidine alone, without affecting systolic blood pressure. No delay in the onset of tolerance to the analgesic effect was observed with the combination as compared with clonidine (0.4 microgram/hr) alone. The data indicate that clonidine-induced spinal analgesia is independent of endogenous opioid systems linked to mu-receptors in the spinal cord, and that optimization of spinal analgesia (e.g. synergism) can be achieved during continuous intrathecal infusion without affecting cardiovascular activity.

Analgesics↗
PubMed1989

Methylprednisolone in spinal cord compression.

In acute nonsurvival studies, eight anesthetized lambs were subjected to cord compression at T13 by means of an epidural balloon distended to a pressure of 200 mm Hg for 40 minutes. Subsequent to withdrawal of the balloon, each animal received 30 mg/kg of methylprednisolone succinate in an intravenous bolus followed by a continuous infusion of 10 mg/kg/hr for the duration of the experiment. Spinal cord blood flow (SCBF) and spinal evoked potential (SEP) determinations were obtained sequentially prior to, during, and at 1/2, 1 1/2, and 2 1/2 hours following compression. In spite of the absence of ischemia following compression, SEPs failed to recover. Methylprednisolone had no apparent effect on blood flow or on the recovery of SEPs when compared with results in ten control animals that received saline alone.

Animals↗
PubMed2000

Intrathecal baclofen for dystonia: benefits and complications during six years of experience.

Fourteen patients with primary or secondary dystonia received intrathecal baclofen (ITB) through an implanted pump following a trial dose. Patients were selected for ITB trial if they had clinically unsatisfactory responses to oral antidystonic medications, including oral baclofen. Patients were rated using the Burke-Fahn-Marsden rating scale by a blinded rater after the dose of ITB was optimized. Five patients experienced improvement in symptoms as determined by a change in rating scale scores, although only two had a clear clinical benefit. Etiology of dystonia did not determine the efficacy of ITB therapy, as benefit or failure was seen in both primary and secondary dystonia.

Adult↗
PubMed2005

Use of an implantable drug delivery system for refractory chronic sickle cell pain.

An increasing number of chronic sickle cell patients are being treated with sustained-release opioids in the same manner as cancer patients. In a randomized clinical trial of patients with refractory cancer pain, implantable intrathecal drug delivery systems (IDDS) improved clinical success compared to comprehensive medical management alone. We implanted IDDS pumps in two sickle cell patients with refractory bone pain. Both patients achieved rapid and sustained relief of pain, with dramatic reduction in the use of as-needed opioids, crises, and admissions. IDDS may offer relief for sickle cell patients with refractory pain. A prospective trial with more participants is planned.

Adult↗
PubMed1997

Severe tardive dystonia: treatment with continuous intrathecal baclofen administration.

Treatment of tardive dystonia with oral baclofen produces ambivalent and overall disappointing results. However, because only a small proportion of the baclofen penetrates into the central nervous system when administered orally, we tested whether it is possible to increase the efficacy of treatment by continuous intrathecal infusion of baclofen (CITB) in a patient with severe tardive axial dystonia unresponsive to conventional therapy. A dose of 100 micrograms/day improved muscle tone, head control, posture, and walking distance; electromyography showed a marked decrease of dystonic muscle activity with fully preserved voluntary muscle activity, and the patient reported substantial reduction of pain. Apart from some minor discomfort at the site of operation, no side effects were noted. Further studies should be encouraged to evaluate the usefulness of CITB for other patients with severe and otherwise untreatable tardive dystonia.

Antipsychotic Agents↗
PubMed2003

Early use of intrathecal baclofen in brain injury in pediatric patients.

BACKGROUND: The Food and Drug Administration (FDA) approved the use of intrathecal Baclofen for spasticity from traumatic brain injury in June of 1996 based on a Phase III clinical trial that documented efficacy in patients one year post injury. The FDA approval is only for patients who are one year post injury based on the Phase III study. We have found use of ITB in the first few months after injury very effective in a subgroup of severe traumatic brain injury (TBI) pediatric patients with spasticity, dystonia and autonomic storming following brain injury. METHOD: The author's database of over 250 patients receiving intrathecal baclofen was reviewed. Retrospective chart review was undertaken of the 6 patients identified with brain injuries over a three year period that were given ITB less than one year post injury. The patients' diagnosis included asphyxia, traumatic brain injury and stroke. The ages were one year to fourteen years of age. ITB was offered after all conventional therapy had been exhausted and the patient's spasticity remained intractable. These patients also all experienced autonomic dysfunction with severe autonomic storms. FINDINGS: All of the patients had a decrease in their spasticity of at least 2 points on the Ashworth score. The autonomic storms ceased in all 6 patients when adequate dosages of ITB were reached. The patients could be weaned from all oral and intravenous medications for tone, storming and fever. Many of the patients became much more alert and interactive when the medications were stopped. Five of the six are still using their pump for their tone one to five years post implant, the sixth had the pump stopped at the parents' request for religious reasons. INTERPRETATION: Early use of ITB can play a significant role in the rehabilitation of brain injury in children.

Adolescent↗
PubMed2003

Intrathecal drug delivery 2002.

BACKGROUND: Intrathecal drug delivery has been used clinically since the 1970's. Significant clinical advances have been made combining new technology with pharmacology and surgery. Continuous infusion of medication for both analgesia and spasticity has become a part of the armamentarium for specialists in these areas. Significant recent advances in technology promise further enhancements and improvements for intrathecal therapy. METHODS: A review of the literature combined with 20 years personal experience with intrathecal drug delivery. FINDINGS/DISCUSSION: Intrathecal therapy has established a role in the treatment of malignant pain, benign pain and severe spasticity. Significant literature and the current state of practice in the United States are reviewed. Recent therapeutic enhancements are discussed, and a wish list of future technological enhancements presented.

Baclofen↗
PubMed2002

The important role of pain in neurorehabilitation. The neurosurgeon's approach or (neurorehabilitation: the neurosurgeon's role with special emphasis on pain and spasticity).

Pain syndromes due to peripheral or central nervous system damage, or both, may hinder neurorehabilitation. Control of pain may be obtained by ablative or augmentative procedures. Of the ablative modes only DREZ and Cordectomy are still being employed in cases of pain due to Brachial Plexus Avulsion and conus and cauda damage at T9-L1: in both pain is not simply due to "deafferentiation". The augmentative procedures include spinal cord, deep brain and cortical stimulation. Subarachnoid infusion of drugs (midazolam, clonidine, baclofen, etc.) is a new avenue open to control pain. Indications, results and mechanisms of action of those procedures in neuropathic pain are discussed on the basis of literature and personal experience.

Electric Stimulation Therapy↗