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PubMed2004

[Idiopathic medullary decompression sickness: myth or reality?].

Severe decompression sickness occurs unfrequently, with, generally an identifying cause (error in decompression protocols, promoting factors.). We report a case of severe spinal cord damage; onset after a common dive, neither deep nor long, without any promoting factor, absence of responsiveness to recompression, three hours post-dive, importance of MRI signal abnormalities, make us to point out the confounding variability of onset and evolution of such illness.

Adult↗
PubMed2000

Effect on migraine of closure of cardiac right-to-left shunts to prevent recurrence of decompression illness or stroke or for haemodynamic reasons.

BACKGROUND: A relation between migraine with aura and cardiac right-to-left shunts has been reported. Right-to-left shunts are also associated with stroke and certain forms of decompression illness. We investigated the effect of closure of right-to-left shunts on migraine symptoms. METHODS: A consultant neurologist, who was unaware of information about residual shunt, undertook a structured interview with individuals who had had transcatheter closure of an atrial septal defect or patent foramen ovale to assess how the procedure affected migraine symptoms. FINDINGS: 37 of 40 consecutive patients who had had a closure procedure (to permit resumption of diving after decompression illness in 29, after stroke when paradoxical thromboembolism was suspected in four, or to close a large atrial septal defect in four) could be contacted. 21 (57%) had a history of migraine before the procedure (with aura in 16, without aura in five). 11 individuals had fortification spectra in the period immediately after closure. During long-term follow-up, no migraine symptoms were reported by seven individuals who had previously had migraine with aura and three who had previously had migraine without aura. Eight others who had had migraine with aura before closure reported improvement in frequency and severity of migraines. Three (one migraine with aura, two migraine without aura) reported no alteration in migraine episodes. INTERPRETATION: These observations suggest a causal association between right-to-left shunts and migraine with aura. There may be a subgroup of patients who have severe migraine associated with a large right-to-left shunt in whom closure of the atrial defect may improve or abolish migraine.

Cardiac Catheterization↗
PubMedDate not supplied

Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial.

BACKGROUND: The standard treatment for spinal cord compression caused by metastatic cancer is corticosteroids and radiotherapy. The role of surgery has not been established. We assessed the efficacy of direct decompressive surgery. METHODS: In this randomised, multi-institutional, non-blinded trial, we randomly assigned patients with spinal cord compression caused by metastatic cancer to either surgery followed by radiotherapy (n=50) or radiotherapy alone (n=51). Radiotherapy for both treatment groups was given in ten 3 Gy fractions. The primary endpoint was the ability to walk. Secondary endpoints were urinary continence, muscle strength and functional status, the need for corticosteroids and opioid analgesics, and survival time. All analyses were by intention to treat. FINDINGS: After an interim analysis the study was stopped because the criterion of a predetermined early stopping rule was met. Thus, 123 patients were assessed for eligibility before the study closed and 101 were randomised. Significantly more patients in the surgery group (42/50, 84%) than in the radiotherapy group (29/51, 57%) were able to walk after treatment (odds ratio 6.2 [95% CI 2.0-19.8] p=0.001). Patients treated with surgery also retained the ability to walk significantly longer than did those with radiotherapy alone (median 122 days vs 13 days, p=0.003). 32 patients entered the study unable to walk; significantly more patients in the surgery group regained the ability to walk than patients in the radiation group (10/16 [62%] vs 3/16 [19%], p=0.01). The need for corticosteroids and opioid analgesics was significantly reduced in the surgical group. INTERPRETATION: Direct decompressive surgery plus postoperative radiotherapy is superior to treatment with radiotherapy alone for patients with spinal cord compression caused by metastatic cancer.

Combined Modality Therapy↗
PubMed1989

Patent foramen ovale and decompression sickness in divers.

30 patients with a history of decompression sickness were examined for the presence of patent foramen ovale by bubble contrast, two-dimensional echocardiography and colour flow doppler imaging. With bubble contrast, 11 (37%) of the patients had right-to-left shunting through a patent foramen ovale during spontaneous breathing. 61% of a subset of 18 patients with serious signs and symptoms had shunting. This number was significantly higher than the 5% prevalence seen with the same diagnostic technique in 176 healthy volunteers. The presence of patent foramen ovale seems to be a risk factor for the development of decompression sickness in divers.

Acute Disease↗
PubMed1999

Role of microvascular decompression in trigeminal neuralgia and multiple sclerosis.

An excellent outcome after microvascular decompression for medically intractable trigeminal neuralgia in patients with multiple sclerosis is reported in seven of 15 cases. A dual cause could be hypothesised in some patients with multiple sclerosis and trigeminal neuralgia, and that microvascular decompression can be a therapeutic option.

Adult↗
PubMed2004

[Orbital fat decompression techniques].

Fat removal orbital decompression (FROD) was first described by Olivari in 1988. Through a blepharoplasty approach, fat pads from the five palpebral pockets, as well as intraconal fat, are carefully removed. The main complications are retrobulbar hemorrhage and postoperative diplopia. The best indications are patients with wide orbits without compressive optic neuropathy. FROD is an inescapable procedure in a balanced approach to surgical orbital decompression.

Blepharoplasty↗
PubMedDate not supplied

Differential diagnostic problems of decompression sickness--examples from specialist physicians' practices in diving medicine.

It can be expected that the differential diagnosis problem of decompression sickness will increase in the future due to the increasing number of divers. During the last 30 years, 232 divers were treated for decompression sickness (DCS) at the Naval Medical Institute (NMI) in Split, Croatia. In 66 cases (28%), physicians at various diving sites reached diagnosis with difficulty, and 86 divers (37%) came directly to the NMI without seeing a physician first. Physicians at remote diving locations frequently have only basic knowledge of diving medicine and are often inexperienced. The language barrier was a major obstacle in obtaining a medical history and examination of foreign divers. Consultations at the NMI proved a major contribution to correct diagnosis and treatment. We present six illustrative cases from NMI Archives that demonstrate how prejudices, panic, and inexperience could create problems in establishing DCS diagnosis.

Adult↗
PubMed1985

Delayed treatment of serious decompression sickness.

We report the cases of three patients with residual symptoms from diving decompression sickness, each of whom presented to a recompression chamber three to seven days following original exposure. All three had complete resolution of symptomatology despite the delayed treatment. The late resolution of symptoms is evidence both of residual bubble effect and of distal tissue hypoxia responding to oxygen therapy with the recompression. We recommend that decompression sickness symptoms be treated whenever they are seen, even ten to 14 days postinjury.

Adult↗
PubMed1986

Progressive ulnar palsy as a late complication of decompression sickness.

We report an unusual case of decompression sickness in which a progressive ulnar palsy developed 22 days after the onset of neurological decompression sickness. The initial symptoms of numbness and paresthesias of the hand were treated with recompression therapy, resulting in only partial relief. The patient subsequently developed weakness of the left hand, which increased in severity until the institution of repeated daily hyperbaric oxygen treatments. A total of seven treatments resulted in partial resolution of the patient's signs and symptoms. Recovery was complete within four months.

Adult↗
PubMed1997

Intravenous lidocaine as adjunctive therapy in the treatment of decompression illness.

Two cases of severe decompression illness for which IV lidocaine was used as adjunctive therapy to recompression and hyperbaric oxygen therapy are described. The first patient demonstrated improvement only after lidocaine was added to her treatment; the second had essentially complete recovery after only a single treatment despite severe symptoms and a significant delay in presentation. These cases support the need for a controlled clinical trial of lidocaine as an adjunct to hyperbaric therapy in decompress on illness.

Adult↗
PubMed2003

Surgical quality assurance in the Ischemic Optic Neuropathy Decompression Trial (IONDT).

The purpose of this article is to report the methods and results of the surgical quality assurance program associated with the Ischemic Optic Neuropathy Decompression Trial (IONDT). A surgical quality assurance committee developed and implemented a quality assurance program for a randomized clinical trial requiring surgical intervention. A surgical technique questionnaire was administered at two times during the study course, and maintenance of surgeon certification required submission and approval of a masked videotape of an optic nerve sheath decompression surgery by each study surgeon. Surgical quality was assessed through completion of surgical report forms and standardized, masked review of operative notes. Rates of compliance and intra- and interreviewer agreement were assessed for each aspect of the program. Twenty-five of 32 surgeons (81%) successfully completed and maintained certification. Item agreement varied from 21-92% among reviewers of satisfactory videotapes and 22-89% on unsatisfactory videotapes. Intrarater agreement for videotape acceptability was 11 of 13 (85%), and for specific surgical steps, 147 of 182 (81%). Operative notes were submitted for 123 of 125 (98%) patients receiving surgery. Interrater agreement on individual items ranged from 73-100%. Classification of individual items was identical on first and second review for 1285 of 1344 (95.6%) items. Overall agreement for individual reviewers was 93.8-97.8%. We conclude that use of a small peer review committee, which developed and oversaw a quality assurance program, allowed for consistent certification and monitoring of surgical performance. This in turn increased the credibility of the IONDT results, which demonstrated no difference in outcome between operated and unoperated groups of patients.

Certification↗
PubMed1997

Touch allodynia following endoscopic (single portal) or open decompression for carpal tunnel syndrome.

We investigated if single-portal endoscopic carpal tunnel decompression equipment (Agee, 3M, USA) would cause increased carpal tunnel pressure during the release and if endoscopic release would reduce postoperative touch allodynia. Measurements on cadavers of the pressure produced during endoscopic release showed similar pressures to those produced during maximal range of motion. One hundred patients underwent either open or endoscopic decompressions. Twenty normal individuals served as controls. At 1 month after surgery both groups had significant allodynia compared with the controls, but at 3 months the endoscopic group had returned to normal though the open group was still significantly abnormal. The reported endoscopic release may therefore be of particular advantage to patients who would seriously be disadvantaged if postoperative touch allodynia should develop. The Agee endoscope is unlikely to cause disturbance of the nerve function due to increased carpal pressure during the release.

Carpal Tunnel Syndrome↗
PubMed2000

Posterior fossa decompression in syringomyelia associated with a Chiari malformation: a retrospective analysis of 22 patients.

BACKGROUND: The technique of posterior fossa decompression, nowadays preferred by most neurosurgeons as the first surgical option in the treatment of hindbrain associated syringomyelia, was reintroduced in our center in 1989. We present a retrospective analysis of 22 patients with this pathology who underwent the procedure since then. METHODS: In all patients diagnosis was made by MRI of the craniospinal junction. The operation consisted of a suboccipital craniectomy, removal of the posterior arc of C1, laminectomy of C2 or C3 when necessary and a wide duraplasty at the end. The intradural manipulations (opening of the arachnoid membrane, coagulation or resection of the tonsils) were not uniform. Postoperatively short- and long-term clinical outcome and MRI findings were assessed. RESULTS: Sixteen out of 21 patients (76%) experienced an improvement in the early follow-up period. In the late follow-up period 13 out of 19 patients (68%) were improved, whereas five patients (26%) experienced a marked deterioration. There was no unequivocal effect on all symptoms and signs. Postoperative MR images showed a favorable result in 16 out of 20 patients (80%), consisting of syrinx collapse or reduction of the syrinx diameter. CONCLUSIONS: We conclude that decompression of the posterior fossa is a safe procedure with a considerable chance of clinical improvement. Although total syrinx collapse is not as frequently seen as in syrinx shunting procedures, the clinical outcome may be better. Moreover, there seemed to be no unequivocal correlation between clinical outcome and postoperative syrinx size in the present study.

Adolescent↗
PubMed2003

Degassed liquids to prevent/treat decompression sickness.

Recompression and oxygen breathing constitute the primary treatments for decompression sickness (DCS). Increasing the volume of distribution of dissolved gas with high-volume liquid therapy represents an alternative strategy to prevent or treat DCS. Furthermore, degassing of ingested and infused liquids would increase their potential to keep supersaturated tissue gases in solution after decompression. We hypothesize that administration of degassed liquids will prevent or reverse mild-moderate DCS by increasing the volume of distribution of dissolved gas in DCS victims. Degassed perfluorocarbon ingestion offers particularly attractive potential: one liter theoretically dissolves approximately 300ml of N(2) in vivo at 1atm. One could speculate that degassed liquids may adequately treat mild DCS in lieu of recompression, particularly DCS expressed in 'fast compartment' (well-perfused) tissues. Furthermore, degassed liquid administration should prove to be even more effective adjunct therapy for severe DCS than present gas-saturated liquids.

Decompression Sickness↗
PubMed1978

Acute decompression sickness: 50 cases.

In a review of the most recent 50 consecutive cases of acute decompression sickness in US Navy divers undergoing training at the Naval School, Diving and Salvage, in no instance was recompression following the initial treatment necessary, nor was there any permanent morbidity post-treatment. Factors common to this series are 1) strict physical screening and conditioning; 2) physician and diver awareness of the signs and symptoms of decompression sickness; 3) short surface interval between symptom onset and recompression; 4) aggressive diagnostic and therapeutic use of hyperbaric oxygenation, and 5) judicious use of adjunctive measures such as intravenous fluid and dexamethasone (Decadron). In the ideal management, the physician sees the patient shortly after symptom appears. As soon as central nervous system involvement appears, 100% oxygen by mask is administered and the patient is recompressed supine to 60 feet of sea water.

Decompression Sickness↗
PubMed1997

Radial tunnel syndrome: long-term results of surgical decompression.

Between 1980 and 1990, 31 patients (33 extremities) underwent decompression of the radial tunnel. All procedures were performed at the same institution by the senior author using a brachioradialis muscle-splitting approach. Twenty-three patients (24 extremities) were available for follow-up evaluation at an average of 8 years after surgery. The outcome was determined using the original criteria of Roles and Maudsley and Ritts et al. By the criteria of Roles and Maudsley, outcomes for 15 patients (16 extremities; 67%) were rated as excellent/good and for 8 patients (8 extremities; 33%), as fair/poor. By the criteria of Ritts et al., 16 patients (17 extremities; 71%) had good results and 7 patients (7 extremities; 29%), a fair/poor result. Overall, the majority of patients were satisfied and felt helped by the surgery. Five patients changed their occupation because of continued discomfort. Significant differences in outcome were not found for workers' compensation patients. Similarly, no differences in outcome were found for site of compression, patient sex, history of trauma, or associated neuropathies. The results of this study suggest that complete pain relief and return to activities following radial tunnel surgery is not as predictable as previous studies have indicated. Nineteen patients (20 extremities), however, felt satisfied and helped and believed they gained improved function because of surgical decompression of the radial tunnel.

Adolescent↗
PubMed1998

The use of arthroscopy to document accurate position of core decompression of the hip.

The use of hip arthroscopy is documented as a means of determining accurate placement for core decompression of the femoral head. The authors describe the technique whereby the patient is placed on the fracture table in the supine position and the guide wire for the core decompression is inserted into the middle of the infarct. The surgeon is assured of accurate placement within the center of the infarct.

Adult↗
PubMed2000

Core decompression in atraumatic osteonecrosis of the hip.

Core decompression for osteonecrosis of the femoral head continues to be a controversial procedure. We report the results of core decompression in the treatment of hip osteonecrosis. Forty-two patients (67 hips) were evaluated. Minimum follow-up was 2 years. Preoperative outcome instruments were assessed. Volume of involvement (%) from magnetic resonance imaging was assessed. Failure was described as a total hip arthroplasty (THA). Mean patient age was 40.26 years. The average clinical and radiologic follow-up was 40.7 months and 33.1 months. The average Harris Hip Scores preoperatively and postoperatively were 49 and 58. None of the hips classified as Ficat I progressed to THA, whereas 17% of Ficat II hips and 66% of Ficat III hips progressed to THA. Our results demonstrate no relationship between the volume of involvement of the femoral head or the location of the lesion in progression to collapse. Staging with the Ficat classification demonstrated the most statistically significant correlation with progression to THA. The SF-36 scores at last follow-up on our patients were significantly worse than patients undergoing THA.

Adult↗