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Eizaga Rebollar R, Carnota Martín AI, Borreiros Rodríguez E, Rojo Díez R. Tethered Spinal Cord Syndrome Discovered during Ultrasound-guided Caudal Block. Anesthesiology 2024; 140:1203-1204. [PMID: 38498665 DOI: 10.1097/aln.0000000000004899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Affiliation(s)
- Ramón Eizaga Rebollar
- Department of Anesthesiology and Reanimation, Puerta de Mar University Hospital, Cádiz, Spain
| | | | | | - Raquel Rojo Díez
- Department of Pediatric Surgery, Puerta del mar University Hospital, Cádiz, Spain
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Toms AS, Rai E, John NC, Panwar J. Use of ultrasound to estimate the prevalence of occult spinal dysraphism in children undergoing urogenital and anorectal surgeries: A cross-sectional study. J Anaesthesiol Clin Pharmacol 2024; 40:90-94. [PMID: 38666156 PMCID: PMC11042110 DOI: 10.4103/joacp.joacp_254_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 04/28/2024] Open
Abstract
Background and Aim The use of ultrasound has immensely increased the safety toward regional blocks and central venous access and has been considered as the standard of care for securing central access. The aim of this study is to estimate the prevalence of occult spinal dysraphism using ultrasound in children less than 2 years of age undergoing elective urogenital or anorectal surgery. Material and Methods The lumbosacral region of 159 American Society of Anesthesiologists (ASA) category I/II patients, posted for elective urogenital and anorectal surgery was scanned with ultrasound, prior to giving caudal block. Results The prevalence of occult spina bifida was 3% in our study. There was no statistically significant association of cutaneous marker with abnormal scan. Conclusion Prevalence of occult spina bifida was ten-times higher in our study than in the general population. Perioperative ultrasound screening of the lower spinal anatomy by anesthesiologist done prior to performing neuraxial block is worthwhile in ruling out occult spinal anomalies in high-risk children of occult spinal dysraphism.
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Affiliation(s)
- Ann Sumin Toms
- Asst. Professor, Department of Anaesthesiology, CMC Vellore, Tamil Nadu, India
| | - Ekta Rai
- Professor and Head, Department of Anaesthesiology, CMC Vellore, Tamil Nadu, India
| | - Novin Chacko John
- Senior Registrar, Department of Anaesthesiology, CMC Vellore, Tamil Nadu, India
| | - Jyoti Panwar
- Professor, Department of Radiology, CMC Vellore, Tamil Nadu, India
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Baskin P, Berde C, Saravanan A, Alrayashi W. Ultrasound-guided spinal anesthesia in infants: a narrative review. Reg Anesth Pain Med 2023; 48:608-614. [PMID: 36517202 DOI: 10.1136/rapm-2022-104025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 12/01/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND/IMPORTANCE Infant spinal anesthesia has many potential benefits. However, the delivery of infant spinal anesthesia is technically challenging. The landmark-based technique has not changed for over a century. Advancements in ultrasound technology may provide an opportunity to improve infant spinal procedures. OBJECTIVE Our primary objective is to conduct a comprehensive review of the current literature on ultrasonography for spinal anesthesia in infants. Given the narrow scope of this topic, our secondary objective is to review the current literature on ultrasonography for lumbar puncture in infants. EVIDENCE REVIEW We reviewed all papers related to the use of ultrasound for infant spinal anesthesia. Two large databases were searched with key terms. Eligibility criteria were full-text articles in English. For our secondary objective, we searched one large database for key terms relating to ultrasonography and infant lumbar puncture. Eligibility criteria were the same. FINDINGS Our primary search retrieved six articles. These consisted of four review articles, one case report, and one retrospective observational study. Our secondary search retrieved fourteen articles. These consisted of five randomized control trials, four prospective studies, three retrospective studies, and two review papers. CONCLUSIONS Ultrasound yields high-quality images of the infant spine. Most literature regarding ultrasound for infant spinal procedures arises from emergency medicine or interventional radiology specialties. The literature on ultrasound for infant spinal anesthesia is extremely limited, but shows promise. Future studies are needed in order to determine whether ultrasound can improve the success rate for delivery of infant spinal anesthesia.
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Affiliation(s)
- Paola Baskin
- Department of Anesthesiology Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Charles Berde
- Department of Anesthesiology Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Arjun Saravanan
- Department of Anesthesiology Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Walid Alrayashi
- Department of Anesthesiology Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
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Sacral Spina Bifida Occulta: A Frequency Analysis of Secular Change. ANTHROPOLOGICAL REVIEW 2022. [DOI: 10.18778/1898-6773.85.2.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Substantial relaxation of natural selection beginning around 1900 changed the mutation/selection balance of modern genetic material, producing an increase in variable anatomical structures. While multiple structures have been affected, the temporal increase in variations of the sacrum, specifically, ‘Sacral Spina Bifida Occulta,’ have been reliably demonstrated on a localised scale. Calculation of largescale frequency has been hindered by the localised nature of these publications, the morphological variability of this variation, and potential pathological associations, which have produced divergent classifications, and conflicting reported rates of occurrence. A systematic review of the reported literature was conducted to provide an objective analysis of Sacral Spina Bifida Occulta frequency from 2500 BCE to the present. This review was designed to compensate for observed inconsistencies in reporting and to ascertain, for the first time, the temporal trajectory of this secular trend. A systematic review of Sacral Spina Bifida Occulta literature was conducted through the strict use of clinical meta-analysis criteria. Publications were retrieved from four databases: PubMed, Embase, the Adelaide University Library database, and Google Scholar. Data were separated into three historical groups, (1 = <1900, 2 = 1900 to 1980 and 3 = >1980), and frequency outcomes compared, to determine temporal rates of occurrence.
A total of 39/409 publications were included in the final analysis, representing data for 16,167 sacra, spanning a period of 4,500 years. Statistically significant results were obtained, with total open S1 frequency increasing from 2.34%, (79 to 1900CE), to 4.80%, (1900 to 1980CE) and to 5.43% (>1980CE). These increases were significant at p<0.0001, with Chi-squared analysis. A clear secular increase in the global frequency of Sacral Spina Bifida Occulta has been demonstrated from 1900 to the present. This research provides a novel and adaptable framework for the future assessment of variation distribution, with important implications for the fields of biological anthropology and bioarchaeology.
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Jain D, Hussain SY, Ayub A. Comparative evaluation of landmark technique and ultrasound-guided caudal epidural injection in pediatric population: A systematic review and meta-analysis. Paediatr Anaesth 2022; 32:35-42. [PMID: 34752689 DOI: 10.1111/pan.14332] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 08/17/2021] [Accepted: 11/04/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Caudal block is a common regional anesthesia technique in pediatrics with landmark method predominantly being practiced. Ultrasound-guided technique provides real-time visualization of the structures and injection while performing caudal block. We performed this meta-analysis to determine the utility of ultrasound in caudal blocks in children over the landmark-based technique. METHODS Randomized controlled trials comparing ultrasound-guided caudal blocks and landmark technique in pediatrics were searched from databases-PubMed, Embase, Scopus, and CENTRAL from inception until August 2020. The primary objective was success rate between the two techniques and secondary objectives included time to perform the block, first puncture success, and complications. RESULTS Five trials with 904 participants were included for this meta-analysis. There was no difference in success rate between the two techniques (Risk ratio-1.07; 95% CI [0.97, 1.18]; p = .15). Time to perform the block was similar (Mean difference-8.88 s; 95% CI [-21.64, 39.40; p = .57) while first puncture success was higher with ultrasound-guided technique (Risk ratio-1.31; 95% CI [1.15, 1.49]; p = .0001). Complications like vascular puncture and needle misplacement were lower in the ultrasound group, and no serious complications were seen in any patient. Needle visualization and sacral canal distension were seen in 82% and 97.5% of the cases, respectively, in ultrasound group. CONCLUSION Ultrasound-guided caudal injection does not improve the success rate or time to perform the block but results in higher first puncture success and lower incidence of complications compared to landmark technique.
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Affiliation(s)
- Dhruv Jain
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Sana Yasmin Hussain
- Department of Anaesthesiology, Hamdard Institute of Medical Sciences and Research, New Delhi, India
| | - Arshad Ayub
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Dunlap JD, Allison JE, Green MC, Ackerman LL, Whittam BM. Intrasacral Meningocele Complicating Caudal Analgesia in a 6-Year-Old Child After 3 Previous Uneventful Caudals: A Case Report. A A Pract 2021; 15:e01457. [PMID: 33973901 DOI: 10.1213/xaa.0000000000001457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 6-year-old male undergoing bilateral hydrocelectomy was to receive caudal analgesia after induction of general anesthesia. After insertion of the caudal needle, cerebrospinal fluid was unexpectedly aspirated and the caudal was abandoned. The surgeon performed bilateral ilioinguinal nerve blocks just before incision. Surgery was uneventful. The patient had difficulty ambulating postoperatively, and a detailed neurologic examination revealed quadriceps weakness. A lumbosacral magnetic resonance imaging (MRI) revealed a sacral meningocele. By the next morning, quadriceps function had returned, and he was ambulating normally. The ilioinguinal block was most likely deep to the internal oblique muscle and produced femoral nerve dysfunction.
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Affiliation(s)
| | | | | | | | - Benjamin M Whittam
- Urology, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
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Amelot A, Cretolle C, de Saint Denis T, Sarnacki S, Catala M, Zerah M. Spinal dysraphism as a new entity in V.A.C.TE.R.L syndrome, resulting in a novel acronym V.A.C.TE.R.L.S. Eur J Pediatr 2020; 179:1121-1129. [PMID: 32055959 DOI: 10.1007/s00431-020-03609-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/09/2020] [Accepted: 02/06/2020] [Indexed: 10/25/2022]
Abstract
Anorectal malformation (ARM) is the most common symptom in VACTERL syndrome (vertebral, anal, cardiac, tracheo-esophageal fistula, renal, and limb anomalies). The association of ARM and spinal dysraphisms (DYS) is well documented. We aim to better evaluate children with VACTERL association and ARM, considering the presence or not of DYS. Between 2000 and 2015, 279 children with VACTERL associations were identified in Necker Children's Hospital, Paris. We identified 61 VACTERL children (22%) with ARM. A total of 52 VACTERL children with ARM were included. DYS were identified in 36/52 of cases (69.2%). A total of 33 (63.5%) VACTERL children presented with sphincterial dysfunction. We constated that 28/33 (84.8%) of them had DYS + (p < 0.0001). More children in ARM (DYS +) subgroup are presenting with initial urinary sphincter dysfunction (58 vs 19%, p < 0.009) than ARM (DYS -). We identified 29 lipoma filum in our series, which were not statistically associated with urinary disorders (p = 0.143).Conclusion: We propose to refine the definition of VACTERL association, by adding S as Spinal defect to include it as an integral part of this syndrome, resulting in a novel acronym V.A.C.TE.R.L.S.What is Known:• The VACTERL association: congenital anomalies of the bony vertebral column (V), anorectal malformation (A), congenital cardiopathy (C), tracheo-esophageal defects (TE), renal and urinary tract anomalies (R), and limb malformations (L).• VACTERL children needs a complete appraisal, as early as possible, to adopt the most appropriate therapeutic management.What is New:• Include spine dysraphism (DYS) as a part of this syndrome, resulting in a novel acronym V.A.C.TE.R.L.S.• The significant correlation between VACTERL/DYS and urinary dysfunction requires to investigate the spine cord prenatally.
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Affiliation(s)
- Aymeric Amelot
- Department of Pediatric Neurosurgery, Necker-EM Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Descartes, Paris, France.
| | - Célia Cretolle
- Department of Visceral Pediatric surgery, Necker-EM Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Descartes, Paris, France.,Reference center for AnoRectal and rare Pelvic anomalies MAREP, Necker-EM Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Descartes, Paris, France
| | - Timothée de Saint Denis
- Department of Pediatric Neurosurgery, Necker-EM Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Descartes, Paris, France
| | - Sabine Sarnacki
- Department of Visceral Pediatric surgery, Necker-EM Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Descartes, Paris, France.,Reference center for AnoRectal and rare Pelvic anomalies MAREP, Necker-EM Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Descartes, Paris, France
| | - Martin Catala
- cUMR7622 UPMC et CNRS, Paris cedex 05, France; dFédération de Neurologie, Groupe Hospitalier Pitié-Salpêtrière 47-83 boulevard de l'Hôpital, Paris Cedex 13, France
| | - Michel Zerah
- Department of Pediatric Neurosurgery, Necker-EM Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Descartes, Paris, France.,Reference center for Chiari and Malformations of the Spine and the Spinal Cord C-MAVEM and Institute for Genetic Diseases IMAGINE , Necker-EM Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Descartes, Paris, France
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Sato M. Ultrasound-guided quadratus lumborum block compared to caudal ropivacaine/morphine in children undergoing surgery for vesicoureteric reflex. Paediatr Anaesth 2019; 29:738-743. [PMID: 31034730 DOI: 10.1111/pan.13650] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 04/15/2019] [Accepted: 04/19/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Ultrasound-guided quadratus lumborum block is a regional anesthetic technique which can provide perioperative analgesia for all age groups, including pediatric patients undergoing abdominal surgery. We hypothesized that the quadratus lumborum block would be as efficacious as a caudal block, the gold standard of pediatric lower abdominal regional anesthesia, in providing pain control after ureteral reimplantation but also have a longer duration. METHODS Forty-seven pediatric patients between the ages of 1 and 17 years undergoing bilateral ureteral reimplantation surgery via a low transverse incision were enrolled and randomized into the quadratus lumborum block and caudal block groups. All blocks were performed preoperatively under general anesthesia. We analyzed the following outcomes: the requirement for narcotic analgesics, pain score, episodes of emesis, and complications at 0, 4, 24, and 48 hours postoperatively. RESULTS The study included 44 patients after excluding three who were ineligible. The fentanyl requirement for postoperative rescue analgesia during the first 24 hours was significantly lower in the quadratus lumborum block group than in the caudal block group (median [interquartile range]: 0 [0-1] vs 3 [0-5], P = 0.016, 95% confidence intervals: -4 to 0) but not at 30 minutes, 4, or 48 hours. No significant difference was observed in the pain scores or the incidence of interventions to treat nausea and vomiting during the entire period. No postoperative complication was observed. CONCLUSION The quadratus lumborum block was more effective in reducing the postoperative opioid requirement for rescue analgesia during the initial 24 hours than caudal ropivacaine/morphine.
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Affiliation(s)
- Makoto Sato
- Department of Anesthesiology, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
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Kil HK. Caudal and epidural blocks in infants and small children: historical perspective and ultrasound-guided approaches. Korean J Anesthesiol 2018; 71:430-439. [PMID: 30086609 PMCID: PMC6283718 DOI: 10.4097/kja.d.18.00109] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 08/01/2018] [Indexed: 12/20/2022] Open
Abstract
In infants and small children, ultrasound (US) guidance provides ample anatomical information to perform neuraxial blocks. We can measure the distance from the skin to the epidural space in the US image and can refer to it during needle insertion. We may also visualize the needle or a catheter during real-time US-guided epidural catheterization. In cases where direct needle or catheter visualization is difficult, US allows predicting successful puncture and catheterization using surrogate markers, such as dura mater displacement, epidural space widening due to drug injection, or mass movement of the drug within the caudal space. Although many experienced anesthesiologists still prefer to use conventional techniques, prospective randomized controlled trials using US guidance are providing increasing evidence of its advantages. The use of US-guided regional block will gradually become widespread in infants and children.
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Affiliation(s)
- Hae Keum Kil
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University Health System, Seoul, Korea
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Rai E. Ultrasonography can unfold many Mysteries! J Anaesthesiol Clin Pharmacol 2018; 34:282-283. [PMID: 30104860 PMCID: PMC6066902 DOI: 10.4103/joacp.joacp_355_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Lane VA, Skerritt C, Wood RJ, Reck C, Hewitt GD, McCracken KA, Jayanthi VR, DaJusta D, Ching C, Deans KJ, Minneci PC, Levitt MA. A standardized approach for the assessment and treatment of internationally adopted children with a previously repaired anorectal malformation (ARM). J Pediatr Surg 2016; 51:1864-1870. [PMID: 27554917 DOI: 10.1016/j.jpedsurg.2016.07.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 07/25/2016] [Accepted: 07/26/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION A significant number of internationally adopted children have congenital birth defects. As a specialist center for colorectal diagnoses, we evaluate such children with an anorectal malformation (ARM) and have found that a significant number need a reoperation. Knowledge of the common complications following ARM surgery has led us to develop treatment algorithms for patients with unknown past medical and surgical history, a situation typically encountered in the adopted population. METHODS The results of investigations, indications, and rate of reoperation were assessed for adopted children with an ARM evaluated between 2014 and 2016. RESULTS 56 patients (28 males) were identified. 76.8% required reoperative surgery. Mislocation of the anus outside the sphincter complex was seen in 50% of males and 39.3% of females. Anal stricture, rectal prolapse, retained vaginal septum, and a strictured vaginal introitus were also common. CONCLUSION The reoperative surgery rate in the internationally adopted child with an ARM is high. Complete, systematic evaluation of these children is required to identify complications following initial repair. Development of mechanisms to improve the primary surgical care these children receive is needed.
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Affiliation(s)
- Victoria A Lane
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Clare Skerritt
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Richard J Wood
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Carlos Reck
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Geri D Hewitt
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA; Section of Gynecology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Kate A McCracken
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA; Section of Gynecology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Venkata R Jayanthi
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA; Section of Urology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Daniel DaJusta
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA; Section of Urology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Christina Ching
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA; Section of Urology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Katherine J Deans
- Center for Outcomes Research (CSOR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Peter C Minneci
- Center for Outcomes Research (CSOR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Marc A Levitt
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA.
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Lane VA, Ambeba E, Chisolm DJ, Lodwick D, Levitt MA, Wood RJ, Deans KJ, Minneci PC. Low vertebral ano-rectal cardiac tracheo-esophageal renal limb screening rates in children with anorectal malformations. J Surg Res 2016; 203:398-406. [DOI: 10.1016/j.jss.2016.03.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 03/03/2016] [Accepted: 03/24/2016] [Indexed: 10/22/2022]
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Bruce E, Spencer AO, Albayram MS. Failed caudal block due to physiologic changes associated with a cerebrospinal fluid leak: a case report. Can J Anaesth 2016; 63:603-7. [PMID: 26759160 DOI: 10.1007/s12630-016-0584-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/06/2015] [Accepted: 01/06/2016] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The sum of the volumes of brain tissue, cerebrospinal fluid (CSF), and intracranial blood remain constant. This tenet of the Monroe-Kellie hypothesis is most often considered in the setting of intracranial hypertension, but it can also be applied in the setting of CSF volume depletion. We used this hypothesis to explain a case of failed caudal block in a patient with an iatrogenic CSF leak. CLINICAL FEATURES A one-month-old baby (3 kg) born at 35 weeks' gestation presented for right inguinal hernia repair. His past medical history was significant for arthrogryposis (congenital joint contractures in two or more areas of the body) as well as ongoing apneic episodes that required continuous positive airway pressure therapy and neonatal intensive care. An ultrasound confirmed caudal block was completed and within five minutes of the procedure, the patient's heart rate increased, with an accompanying slight increase in T-wave amplitude. Pinch tests revealed anesthesia to the feet bilaterally but insufficient anesthesia to the abdomen. The surgery was delayed but successfully completed under general anesthesia the following week. Magnetic resonance imaging of the brain and spine following the surgery showed a significant CSF leak with engorgement of the epidural venous plexus along the entire spine. These findings were consistent with a CSF leak likely secondary to a prior lumbar puncture (at age 13 days) that was part of the investigation of his respiratory issues. CONCLUSIONS The possible mechanism of this failed caudal block was high systemic absorption of anesthetic given the epidural venous plexus engorgement thus leaving less anesthetic acting within the CSF and on the exiting spinal nerves. Decreased CSF flow in the thecal sac might also have contributed, as might dilution of the remaining local anesthetic caused by large amounts of leaking CSF within the epidural space.
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Affiliation(s)
- Erin Bruce
- Department of Anesthesia, University of Calgary, Calgary, AB, Canada
| | - Adam O Spencer
- Department of Pediatric Anesthesia, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada.
| | - Mehmet Sait Albayram
- Department of Radiology, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
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Ultrasound versus anatomical landmarks for caudal epidural anesthesia in pediatric patients. BMC Anesthesiol 2015; 15:102. [PMID: 26169595 PMCID: PMC4499894 DOI: 10.1186/s12871-015-0082-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 06/30/2015] [Indexed: 11/24/2022] Open
Abstract
Background Caudal block is easily performed because the landmarks are superficial. However, the sacral hiatus is small and shallow in pediatric patients. In the present study, we evaluated under general anesthesia whether the distance between the bilateral superolateral sacral crests increased with growth, whether an equilateral triangle was formed between the apex of the sacral hiatus and the bilateral superolateral sacral crests, and whether expansion of the epidural space could be confirmed by ultrasound. Methods This prospective observational study included 282 children who were ASA I–II. Under general anesthesia, each patient was placed in the lateral bent knees position, and the attending anesthesiologist drew an equilateral triangle and measured the distance between the bilateral superolateral sacral crests along a line forming the base of the triangle. Then the sacral hiatus was identified by ultrasound. Differences of the distance between the anatomical landmarks measured by the anesthetist and by ultrasound were evaluated. Results Two patients were excluded because the superolateral sacral crests and sacral hiatus could not be palpated. The base of the triangle increased in proportion to age up to 10 years old, with a significant correlation between age and the length of the base (Spearman’s r value = 0.97). The triangle was not an equilateral triangle under 7 years old. The sacral hiatus could be identified by ultrasound and we could confirm expansion of the epidural space in all patients. Conclusion We observed a correlation between age and the length of the triangle base in children under 10 years old. Although detection of the anatomical landmarks by palpation differed from identification by ultrasound in pediatric patients, performing ultrasound is important. Epinephrine should be added to the anesthetic to avoid complications. Trial registration Current Controlled Trials UMIN000017898. Registered 14 June 2015. Date of protocol fixation was 1st December, 2008 and Anticipated trial start date was 5th January, 2009.
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Mirjalili SA, Taghavi K, Frawley G, Craw S. Should we abandon landmark-based technique for caudal anesthesia in neonates and infants? Paediatr Anaesth 2015; 25:511-6. [PMID: 25597342 DOI: 10.1111/pan.12576] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Caudal anesthesia is a landmark-based technique with ultrasound guidance occasionally used in the absence of landmarks. The current surface landmark remains a popular approach due to its desirable success rate. However, incomplete ossification of the posterior vertebral elements can make this procedure for neonatal caudal anesthesia difficult. The aim of this study was to describe the anatomical relationship of the posterior superior iliac spines (PSISs) to the sacral cornua in infants using ultrasound. METHODS A total of 26 healthy infants (17 female; mean age 13 weeks) were scanned by an experienced radiologist in the prone position with hip and knee joints flexed. The PSISs and sacral cornua were identified clinically then using ultrasound to assess whether these markings corresponded with the clinical markings. The distance between the PSISs and the distance between the tip of the PSIS and tip of the sacral cornu were measured using ultrasound. RESULTS The PSISs were clinically identified in all babies, but the sacral cornua were not palpable in four babies (15%). The PSISs and sacral cornua were easily visualized using ultrasound in all participants. The mean distance between the two left and right PSISs was 3.4 ± 0.5 cm; the mean distance between the PSISs and cornu was 2.5 ± 0.5 cm on the left and right. CONCLUSION This study showed that the current landmark (equilateral triangle) for infant caudal anesthesia is unreliable. Importantly, the sacral hiatus is clinically identifiable only if the sacral cornua are palpable; otherwise, using ultrasound is essential.
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Affiliation(s)
- Seyed Ali Mirjalili
- Department of Anatomy with Radiology, University of Auckland, Auckland, New Zealand
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An approach to the identification of anomalies and etiologies in neonates with identified or suspected VACTERL (vertebral defects, anal atresia, tracheo-esophageal fistula with esophageal atresia, cardiac anomalies, renal anomalies, and limb anomalies) association. J Pediatr 2014; 164:451-7.e1. [PMID: 24332453 PMCID: PMC3943871 DOI: 10.1016/j.jpeds.2013.10.086] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 09/23/2013] [Accepted: 10/30/2013] [Indexed: 12/18/2022]
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Maitra S, Baidya DK, Pawar DK, Arora MK, Khanna P. Epidural anesthesia and analgesia in the neonate: a review of current evidences. J Anesth 2014; 28:768-79. [DOI: 10.1007/s00540-014-1796-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 01/19/2014] [Indexed: 01/16/2023]
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Amarante MA, Shrensel JA, Tomei KL, Carmel PW, Gandhi CD. Management of urological dysfunction in pediatric patients with spinal dysraphism: review of the literature. Neurosurg Focus 2013; 33:E4. [PMID: 23025445 DOI: 10.3171/2012.7.focus12232] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
An intact, fully functional spine is the result of a complex sequence of embryological events involving both nervous and musculoskeletal system precursors. Deviations from this highly ordered system can result in congenital abnormalities ranging from clinically insignificant cosmetic changes to CNS malformations that are incompatible with life. Closure of the neural tube, which is believed to be the embryological event gone awry in these cases, is complete by just 28 days' gestation, often before pregnancy is detected. Although progress has been made to help prevent neural tube defects in the children of those attempting to conceive, these congenital deformities unfortunately continue to affect a startling number of infants worldwide each year. Furthermore, the precise mechanisms governing closure of the neural tube and how they might be interrupted remain elusive. What is known is that there are a large number of individuals who must deal with congenital spine dysraphism and the clinical sequelae on a daily basis. Bladder and urinary dysfunction are frequently encountered, and urological care is a critical, often neglected, component in the lifelong multidisciplinary approach to treatment. Although many treatment strategies have been devised, a need remains for evidence-based interventions, analysis of quality of life, and preemptive education of both caregivers and patients as they grow older. Pediatric neurosurgeons in particular have the unique opportunity to address these issues, often in the first few days of life and throughout pre- and postoperative evaluation. With proper management instituted at birth, many patients could potentially delay or avoid the potential urological complications resulting from congenital neurogenic bladder.
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Affiliation(s)
- Matthew A Amarante
- Department of Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ 07101-1709, USA
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