Anesthetic technique in a patient with multiple sclerosis scheduled for laparoscopic nephrectomy for a renal tumor: a case report

Early Recurrent Symptoms After Anterior Cervical Discectomy and Fusion Done for Myelopathy

We present a unique case with early recurrent myelopathic clinical manifestations following anterior cervical discectomy and fusion; however, he had an eventual diagnosis of multiple sclerosis rather than any residual cord compression on repeat imaging.

Anesthetic Management of a Patient With Multiple Sclerosis

A 54-year-old woman diagnosed with multiple sclerosis (MS) at the age of 19 years was scheduled to undergo temporomandibular joint mobilization. She was currently in a remission phase from her MS but with persistent sequelae, including impaired eyesight and muscle weakness of the limbs. In addition, the blood vessels in her upper limbs were compromised by the formation of internal shunts secondary to vascular prosthesis replacements for plasma exchange therapy in MS. After a previous joint mobilization surgery, her temporomandibular joint developed adhesions with resultant trismus. One of the adverse effects of general anesthesia can be exacerbations of MS symptoms. Minimizing mental and physical stress caused by surgical and anesthetic procedures and maintenance of stable body temperature are important considerations. Awake intubation was performed under sedation with midazolam and fentanyl. After intubation, anesthesia was induced with propofol, remifentanil, and rocuronium. Maintenance of anesthesia was achieved with oxygen-N2O-sevoflurane, remifentanil, fentanyl, and rocuronium. In this case, no adverse events occurred intraoperatively. However, the patient experienced lingering weakness of the limbs in the postoperative period, and activities of daily living of the patient were affected.

Anesthetic management of a patient with multiple sclerosis - case report

BACKGROUND AND OBJECTIVES

Multiple sclerosis is a demyelinating disease of the brain and spinal cord, characterized by muscle weakness, cognitive dysfunction, memory loss, and personality disorders. Factors that promote disease exacerbation are stress, physical trauma, infection, surgery, and hyperthermia. The objective is to describe the anesthetic management of a case referred to urological surgery.

CASE REPORT

A female patient, 44 years of age, with multiple sclerosis, diagnosed with nephrolithiasis, referred for endoscopic ureterolythotripsy. Balanced general anesthesia was chosen, with midazolam, propofol and remifentanil target-controlled infusion; sevoflurane via laryngeal mask airway; and spontaneous ventilation. Because the patient had respiratory difficulty presenting with chest wall rigidity, it was decided to discontinue the infusion of remifentanil. There was no other complication or exacerbation of disease postoperatively.

CONCLUSION

The use of neuromuscular blockers (depolarizing and non-depolarizing) is a problem in these patients. As there was no need for muscle relaxation in this case, muscle relaxants were omitted. We conclude that the combination of propofol and sevoflurane was satisfactory, not resulting in hemodynamic instability or disease exacerbation.

Development of a central nervous system axonal myelination assay for high throughput screening

Background

Regeneration of new myelin is impaired in persistent multiple sclerosis (MS) lesions, leaving neurons unable to function properly and subject to further degeneration. Current MS therapies attempt to ameliorate autoimmune-mediated demyelination, but none directly promote the regeneration of lost and damaged myelin of the central nervous system (CNS). Development of new drugs that stimulate remyelination has been hampered by the inability to evaluate axonal myelination in a rapid CNS culture system.

Results

We established a high throughput cell-based assay to identify compounds that promote myelination. Culture methods were developed for initiating myelination in vitro using primary embryonic rat cortical cells. We developed an immunofluorescent phenotypic image analysis method to quantify the morphological alignment of myelin characteristic of the initiation of myelination. Using γ-secretase inhibitors as promoters of myelination, the optimal growth, time course and compound treatment conditions were established in a 96 well plate format. We have characterized the cortical myelination assay by evaluating the cellular composition of the cultures and expression of markers of differentiation over the time course of the assay. We have validated the assay scalability and consistency by screening the NIH clinical collection library of 727 compounds and identified ten compounds that promote myelination. Half maximal effective concentration (EC₅₀) values for these compounds were determined to rank them according to potency.

Conclusions

We have designed the first high capacity in vitro assay that assesses myelination of live axons. This assay will be ideal for screening large compound libraries to identify new drugs that stimulate myelination. Identification of agents capable of promoting the myelination of axons will likely lead to the development of new therapeutics for MS patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12868-016-0250-2) contains supplementary material, which is available to authorized users.

[Anesthetic management of a patient with multiple sclerosis - case report]

BACKGROUND AND OBJECTIVES

Multiple sclerosis is a demyelinating disease of the brain and spinal cord, characterized by muscle weakness, cognitive dysfunction, memory loss, and personality disorders. Factors that promote disease exacerbation are stress, physical trauma, infection, surgery, hyperthermia. The objective is to describe the anesthetic management of a case referred to urological surgery.

CASE REPORT

A female patient, 44 years of age, with multiple sclerosis, diagnosed with nephrolithiasis, referred for endoscopic ureterolythotripsy. Balanced general anesthesia was chosen, with midazolam, propofol and remifentanil target-controlled infusion; sevoflurane via laryngeal mask airway; and spontaneous ventilation. Because the patient had respiratory difficulty presenting with chest wall rigidity, it was decided to discontinue the infusion of remifentanil. There was no other complication or exacerbation of disease postoperatively.

CONCLUSION

The use of neuromuscular blockers (depolarizing and non-depolarizing) is a problem in these patients. As there was no need for muscle relaxation in this case, muscle relaxants were omitted. We conclude that the combination of propofol and sevoflurane was satisfactory, not resulting in hemodynamic instability or disease exacerbation.