Incidental detection of bowel herniation with ultrasonography and fluoroscopy during a caudal block. Can J Anaesth. 2011;58:551-554. [PMID: 21432004 DOI: 10.1007/s12630-011-9489-3]

Establishment of Difficult Caudal Epidural Blockade Prediction Model

Background

We aimed to develop a predictive difficult caudal epidural blockade (pDCEB) model when ultrasound was not available and verified the role of ultrasound in difficult caudal epidural blockade (CEB).

Methods

From October 2018 to March 2019, this study consisted of three phases. First, we prospectively enrolled 202 patients scheduled to undergo caudal epidural anesthesia and assessed risk factors by binary logistic regression to develop the predictive scoring system. Second, we enrolled 87 patients to validate it. The receiver operating characteristic (ROC) curve was used to evaluate the performance of the prediction model. Youden-index was used to determine the cut-off value. Third, we enrolled 68 patients with a high risk of difficult CEB (pDCEB score ≥3) and randomized them into ultrasound and landmark groups to verify the role of ultrasound.

Result

The rate of difficult CEB was 14.98% overall 289 patients. We found a correlation between unclear palpation of the sacral hiatus (OR 9.688) and cornua (OR 4.725), the number of the sacral hiatus by palpation ≥1 (OR 4.451), and history of difficult CEB (OR 39.282) with a higher possibility of difficult CEB. The area under the receiver operating characteristic curve of the pDCEB model involving the aforementioned factors was 0.889 (95% CI, 0.827-0.952) in the development cohort and 0.862 (95% CI, 0.747-0.977) in the validation cohort. For patients with a pDCEB score ≥3, a preprocedure ultrasound scan could reduce the incidence of difficult CEB (55.56% in the Landmark group vs. 9.38% in the ultrasound group, p < 0.001).

Conclusion

This novel pDCEB score, which takes into account palpation of the sacral hiatus/cornua, number of the sacral hiatus by palpation ≥1, and history of difficult CEB, showed a good predictive ability of difficult CEB. The findings suggested that performing an ultrasound scan is essential for patients with a pDCEB score ≥3. Trial registration: No: ChiCTR1800018871, Site URL: https://www.chictr.org.cn/edit.aspx?pid=31875&htm=4; Principal investigator: Jialian Zhao, Date of registration: 2018.10.14.

Mesh repair of sacrococcygeal hernia via a combined laparoscopic and sacrococcygeal approach: A case report

BACKGROUND

Sacrococcygeal hernia is a very rare condition that is usually secondary to sacrococcygectomy, and its ideal treatment regimen is unclear. Herein, we report a case of sacrococcygeal hernia occurring in a patient who had no history of sacrococcygeal operation, present the operative procedures of mesh repair via a combined laparoscopic and sacrococcygeal approach that has not been described, and discuss our experience in diagnosis and treatment with a review of the literature.

CASE SUMMARY

A 54-year-old woman who chiefly complained of a 10-year history of a reversible bulge in her right sacrococcygeal region was admitted to our hospital. The physical examination revealed a bulge in the right sacrococcygeal region upon standing, which disappeared in the prone position but relapsed when performing the Valsalva manoeuvre. Computed tomography displayed an abnormality in the structure of the tissues between the midline of the sacrococcygeal region and the right gluteus muscle. The patient was diagnosed with sacrococcygeal hernia and received hernia repair with mesh through a combined laparoscopic and sacrococcygeal approach. On laparoscopy, the rectum was dissected posterolaterally, and a defect was identified in the right anterior sacrococcygeal region through which part of the rectum protruded. This was followed by the placement of a self-gripping polyester mesh via a sacrococcygeal approach. There were no postoperative complications. The patient was discharged on postoperative day 7 and was followed for more than 6 mo with no recurrence.

CONCLUSION

Laparoscopic mesh repair is recommended as a priority of surgical options for sacrococcygeal hernias, while choosing a self-gripping mesh can help avoid the risk of presacral vessel injury by reducing suture fixation.

The Treatment of Chronic Coccydynia and Postcoccygectomy Pain With Pelvic Floor Physical Therapy

BACKGROUND

Coccydynia is a challenging disorder that often is refractory to treatments such as medications and injections. Physical therapy for coccydynia rarely has been studied.

OBJECTIVE

To evaluate the efficacy of pelvic floor physical therapy for reducing pain levels in patients with coccydynia.

DESIGN

Retrospective chart review.

SETTING

The pelvic floor rehabilitation clinic of a major university hospital.

PATIENTS

A total of 124 consecutive patients over age 18 with a chief complaint of coccydynia between 2009 and 2012. A subgroup of 17 of the 124 patients had previously undergone coccygectomy with continued pain postoperatively.

METHODS OR INTERVENTIONS

The primary treatment intervention was pelvic floor physical therapy aimed at pelvic floor muscle relaxation. Secondary treatment interventions included the prescription of baclofen for muscle relaxation (19% of patients), ganglion impar blocks (8%), or coccygeus trigger point injections (17%).

MAIN OUTCOME MEASURES

Primary outcome measures included final minimum, average, and maximum pain numeric rating scales. A secondary outcome measure was the patient's subjective percent global improvement assessment. Baseline demographics were used to determine which pretreatment characteristics were correlated with treatment outcomes.

RESULTS

Of the 124 patients, 93 participated in pelvic floor physical therapy and were included in statistical analysis. For the 79 patients who completed treatment (with a mean of 9 physical therapy sessions), the mean average pain ratings decreased from 5.08 to 1.91 (P < .001) and mean highest pain ratings decreased from 8.81 to 4.75 (P < .001). The mean percent global improvement was 71.9%. Mean average pain ratings in postcoccygectomy patients improved from 6.64 to 3.27 (P < .001). Greater initial pain scores and a history of previous injections were correlated with P < .001 pain scores on completion of physical therapy. Pain duration and history of trauma did not affect treatment outcomes.

CONCLUSIONS

Pelvic floor physical therapy is a safe and effective method of treating coccydynia.

LEVEL OF EVIDENCE

III.

Repair of a coccygeal hernia with a biological mesh

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We present a case of coccygeal hernation after coccygectomy.

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Hernia repair was performed with a biological mesh via an direct approach.

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Only 8 other cases could be identified in literature.

Coccygeal herniation after coccygectomy is rare. Little is known about the management of this complication. We present a case of a 44 year old women with a coccygeal herniation 7 years after coccygectomy. She was treated two times for an infected pilonidal sinus with incision and drainage. After the last incision and drainage she had complaints of a painful swelling in the sacral area and difficulty with evacuation of her stools. A defaecography showed a coccygeal herniation. An additional MRI of the pelvic region showed a defect with a diameter of approximately 38 mm. We performed a hernia repair with a biological mesh (Strattice™ surgical mesh, LifeCell Corporation USA) via a sacral approach. Her recovery was complicated by a small wound dehiscence without clinical signs of infection. The sacral wound healed per secundam. Her complaints had completely disappeared. A defaecography 2 months after surgery showed no residual herniation. To our knowledge, it is the first reported case of a coccygeal hernia repair with a biological Strattice™ surgical mesh.

Regional anesthesia in children: the future

Pediatric regional anesthesia continues to evolve. Education and attention to anatomical detail remain key elements to successful outcomes. New techniques, some adapted from adult practice, provide analgesia for pediatric surgical procedures such cleft palate or congenital hip dysplasia. Despite technological advances a number of controversial issues remain unresolved.