Severe pain confounds neuropsychological test performance.
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There is little information on the effect of pain on neuropsychological test performance. We have undertaken this study to explore which tests are affected by pain, the magnitude of these changes, and other confounders of neuropsychological performance in a population of patients having spine surgery. Twenty-four elderly English speaking Caucasian patients (age > 60 years) were enrolled pre-operatively in this Institutional Review Board approved study. Pain scores using an 11-point Numeric Pain Intensity scale and performance on a neuropsychological battery (Controlled Oral Word Association, Rey Complex Figure, Trails A and B) were assessed at two times, before and one day after surgery. Scores were calculated using the standard algorithms and change scores were calculated by subtracting the baseline from follow-up scores. After surgery, performance on the Rey Complex Figure ( r = -0.577, p = 0.004) and Trails Part A (r = 0.527, p = 0.01) declined with increasing post-operative pain scores. Women reported higher pain scores post-operatively than men (p = 0.046), and performed worse than men for change in performance on Trails Part A (p = 0.027). These data suggest that pain can influence performance on certain cognitive tests, and that some gender differences in these effects may occur. Interpretation of performance measures should take into account possible effects of pain, although our understanding of pain effects and ability to predict them in individual people, currently are quite limited. (+info)
Neuroblastoma with symptomatic spinal cord compression at diagnosis: treatment and results with 76 cases.
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PURPOSE: To report on the treatment of patients with newly diagnosed neuroblastoma presenting with spinal cord compression (SCC). PATIENTS AND METHODS: Of 1,462 children with neuroblastoma registered between 1979 and 1998, 76 (5.2%) presented with signs/symptoms of SCC, including motor deficit in 75 patients (mild in 43, moderate in 22, severe [ie, paraplegia] in 10), pain in 47, sphincteric deficit in 30, and sensory loss in 11. Treatment of SCC consisted of radiotherapy in 11 patients, laminectomy in 32, and chemotherapy in 33. Laminectomy was more frequently performed in cases with favorable disease stages and in those with severe motor deficit, whereas chemotherapy was preferred in patients with advanced disease. RESULTS: Thirty-three patients achieved full neurologic recovery, 14 improved, 22 remained stable, and eight worsened, including three who become paraplegic. None of the 10 patients with grade 3 motor deficit, eight of whom were treated by laminectomy, recovered or improved. In the other 66 patients, the neurologic response to treatment was comparable for the three therapeutic modalities. All 11 patients treated by radiotherapy and 26 of 32 patients treated by laminectomy, but only two of 33 treated by chemotherapy, received additional therapy for SCC. Fifty-four of 76 patients are alive at time of the analysis, with follow-up of 4 to 209 months (median, 139 months). Twenty-six (44%) of 54 survivors have late sequelae, mainly scoliosis and sphincteric deficit. CONCLUSION: Radiotherapy, laminectomy, and chemotherapy showed comparable ability to relieve or improve SCC. However, patients treated with chemotherapy usually did not require additional therapy, whereas patients treated either with radiotherapy or laminectomy commonly did. No patient presenting with (or developing) severe motor deficit recovered or improved. Sequelae were documented in 44% of surviving patients. (+info)
Comparison of efficacy and side effects of epidural tramadol and morphine in patients undergoing laminectomy: a repeated dose study.
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Tramadol acts through multiple mechanisms and has a low risk of post operative respiratory depression. We compared the efficacy of epidural tramadol with that of morphine for postoperative analgesia in these patients. The demographic data and the summed pain intensity difference scores (SPID) were similar in both the groups. The time to first supplementary dose was significantly shorter in the tramadol group compared to the morphine group (p<0.05). No patient in either group suffered respiratory depression. (+info)
Coordination of the bladder detrusor and the external urethral sphincter in a rat model of spinal cord injury: effect of injury severity.
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Recovery of urinary tract function after spinal cord injury (SCI) is important in its own right and may also serve as a model for studying mechanisms of functional recovery after injury in the CNS. Normal micturition requires coordinated activation of smooth muscle of the bladder (detrusor) and striated muscle of the external urethral sphincter (EUS) that is controlled by spinal and supraspinal circuitry. We used a clinically relevant rat model of thoracic spinal cord contusion injury to examine the effect of varying the degree of residual supraspinal connections on chronic detrusor-EUS coordination. Urodynamic evaluation at 8 weeks after SCI showed that detrusor contractions of the bladder recovered similarly in groups of rats injured with a 10 gm weight dropped 12.5, 25, or 50 mm onto the spinal cord. In contrast, the degree of coordinated activation of the EUS varied with the severity of initial injury and the degree of preservation of white matter at the injury site. The 12.5 mm SCI resulted in the sparing of 20% of the white matter at the injury site and complete recovery of detrusor-EUS coordination. In more severely injured rats, the chronic recovery of detrusor-EUS coordination was very incomplete and correlated to decreased innervation of lower motoneurons by descending control pathways and their increased levels of mRNA for glutamate receptor subunits NR2A and GluR2. These results show that the extent of recovery of detrusor-EUS coordination depends on injury severity and the degree of residual connections with brainstem control centers. (+info)
Candida osteomyelitis and diskitis after spinal surgery: an outbreak that implicates artificial nail use.
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Postoperative wound infection after laminectomy is uncommon. In February 1997, 3 patients were confirmed to have postlaminectomy deep wound infections due to Candida albicans. No similar case had been seen during the previous 10 years. The infections were indolent, with a mean time from initial operation to diagnosis of 54 days (range, 26-83 days). All patients were successfully treated. Pulsed-field gel electrophoresis revealed the Candida isolates to be identical. A case-controlled study and medical record review revealed that a single operating room technician scrubbed on all 3 infected case patients but on only 32% of the uninfected controls. The technician had worn artificial nails for a 3-month period that included the dates of laminectomy site infections, and C. albicans was isolated from her throat. She was treated with fluconazole and removed from duty. No subsequent cases have occurred during the ensuing 3 years. Artificial nails are known to promote subungual growth of gram-negative bacilli and yeast. This may be clinically relevant, and hospitals should enforce policies to prevent operating room personnel from wearing artificial nails. (+info)
Anterior decompression and fixation versus posterior reposition and semirigid fixation in the treatment of unstable burst thoracolumbar fracture: prospective clinical trial.
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AIM: To compare the anterior and posterior surgical approach in the emergency treatment of unstable burst thoracolumbar fracture. METHODS: Twenty-five patients with unstable thoracolumbar fracture underwent either anterior neurodecompression and fixation (n=13) or posterior reposition and semirigid fixation by hook-rod with pedicle screw fixation (n=12), depending on the type of implants available at the time of operation. Neurologically injured patients were operated on within the first 8 hours and neurologically intact patients within the first 2 days after the fracture. Neurological improvement was assessed according to the American Spinal Injury Association grading scale and the Prolo economic/function outcome scale. We also recorded operation time, blood loss, cosmetic outcome, hospital stay and cost, complications, and donor site pain. RESULTS: There were no significant differences between the two groups in either neurological improvement (p=0.86) or favorable economic or function outcome (p=0.54 and p=0.53, respectively). The operation time was shorter in the posterior approach group than in the anterior approach group (median 174 min, range 130-215 vs median 250 min, range 200-295, respectively, p<0.001). The blood loss was smaller in the posterior approach group (median 750 mL, range 500-1,10, vs median 1,362 mL, range 1,150-1,50, in the anterior approach group; p<0.001). The posterior approach group also had better esthetic outcome, lower hospital cost, lower complication rate, and no donor site pain. CONCLUSION: Both surgical techniques were equally effective in neurological improvement and functional outcome. Posterior surgery can be recommended in emergency neurodecompression and fixation of unstable thoracolumbar fractures because of the shorter operation time and smaller blood loss. (+info)
Treatment and outcome of 83 children with intraspinal neuroblastoma: the Pediatric Oncology Group experience.
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PURPOSE: To investigate whether the rate of neurologic recovery or the incidence of long-term sequelae differed for children with neuroblastoma (NB) initially treated with chemotherapy versus surgical decompression with laminectomy, we reviewed the Pediatric Oncology Group (POG) experience. PATIENTS AND METHODS: A retrospective review of children diagnosed with intraspinal NB registered on POG NB Biology Protocol 9047 was performed. Survival, neurologic outcome, and orthopedic sequelae were evaluated according to age of the patient at diagnosis, stage of disease, duration and severity of neurologic symptoms, and therapeutic intervention. RESULTS: Between May 1990 and January 1998, 83 children with intraspinal NB were entered onto the study. Five-year survival for this cohort of patients was 71% +/- 9%. Forty-three (52%) of the patients had neurologic symptoms at diagnosis. After treatment, six of 15 severely affected patients, who presented with paralysis, completely recovered neurologic function. Two of five patients with moderate deficits, consisting of paresis and bowel/bladder dysfunction, completely recovered neurologic function. Seventeen of 22 assessable children, who had mild symptoms comprised of paresis alone, fully recovered. Seven of 24 assessable patients who had undergone laminectomy developed scoliosis, whereas spinal deformities were only detected in one of 49 assessable patients managed without laminectomy (P =.001). CONCLUSION: The frequency of complete neurologic recovery in children with intraspinal NB inversely correlated with the severity of the presenting neurologic deficits. The rate of neurologic recovery was similar for patients treated with chemotherapy compared to those managed with laminectomy. Fewer orthopedic sequelae were observed in the children managed with chemotherapy than were seen in children managed with laminectomy. (+info)
Serum immunoglobulins after surgical operation.
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We measured immunoglobulins in the sera of 33 patients on days 1, 3, 6, 10, and 17 and three to four weeks after surgical operations (mostly hysterectomy or appendectomy) or (six patients) after spinal injury. In the absence of infection or blood transfusion, IgG usually decreased slightly and transiently after hysterectomy or appendectomy, as did IgA or IgM after hysterectomy. IgD concentrations showed no consistent changes, but in one patient after hysterectomy and with minimal infection IgD concentration decreased sharply, which contrasted with significant and early increases in IgG, IgA, and IgM. IgD concentration was not correlated with type of operation, presence of infection, or changes in the other immunoglobulins. IgE concentrations either die not change or, in some patients, increased or decreased initially, after operation. We conclude that immunoglobulin concentrations in serum are subject to multiple, unpredictable influences after trauma. (+info)