OBJECTIVE: To investigate dosage changes in intrathecal baclofen during long-term treatment of patients with severe leg spasticity. METHODS: We performed a retrospective chart review of 49 patients treated with an intrathecal baclofen pump (ITB) because of severe leg spasticity, for a minimum of 7 years. Eight patients were excluded due to catheter/pump failure or factors aggravating spasticity. Of the remaining 41 patients, 19 had spinal cord injury (SCI) and 22 were diagnosed with multiple sclerosis (MS). Among the SCI patients, 15 had cervical and 4 thoracic SCI, with 7 patients showing the American Spinal Injury Association impairment scale (AIS) A and 12 patients with AIS B–D. The dose was regulated by discussion among the patients and their physicians, usually 4–10 times annually, to reduce leg spasticity and also avoid leg/trunk weakness. RESULTS: After 1 year patients on ITB needed a median dose of 168 mg/24 hr (range, 30–725 mg) for an optimal effect. After 7 to 10 years the dosage needed to reduce leg spasticity in the MS patients was significantly increased compared with the initial dose (mean 157%, n=22 and mean 194%, n=18). In contrast, the SCI patients needed only a modest increase (mean 113% and 121%). The difference between MS and SCI patients was significant (t-test p=0.006 and p=0.004). CONCLUSION: The increased dosage in MS patients compared with patients diagnosed with SCI probably reflects the progressive disease course. The need for a large dosage increase in patients with SCI suggests possible pump failure, triggering factors for spasticity or progressive spinal disease.
Baclofen ; Humans ; Infusions, Spinal ; Leg ; Multiple Sclerosis ; Muscle Spasticity ; Retrospective Studies ; Spinal Cord Injuries ; Spinal Cord ; Spinal Diseases ; Spinal Injuries

The clinical syndrome of posttraumatic syringomyelia can complicate major spinal trauma and develops many months after spinal injury. The 50-90% of patients experienced the pain and especially the component of central pain. In patients with central pain following spinal cord injury, ketamine has been shown to be an effective analgesic. We report a case of posttraumatic syringomyelia in a 30-year-old woman who complained of central pain, weakness of both legs and dysesthesia. She had not responded to pulsed radiofrequency, or lidocaine infusion therapy, but a continuous intravenous infusion of ketamine, an N-methyl-D-asparate receptor antagonist, reduced her severe central pain. In conclusion, a ketamine infusion therapy resulted in a significant reduction of central pain without decreasing of motor power and function.
Adult ; Female ; Humans ; Infusions, Intravenous ; Ketamine ; Leg ; Lidocaine ; Paresthesia ; Spinal Cord Injuries ; Spinal Injuries ; Syringomyelia

Anesthesiology ; methods ; Catheterization ; Equipment Failure ; Humans ; Infusions, Intravenous ; instrumentation ; Injections, Spinal ; instrumentation ; Needles ; Plastics

Midazolam and propofol by continuous intravenous infusion produce excellent and easily controllable sedation as an adjunct to spinal anesthesia. The purpose of the present study is to compare the cardiovascular and respiratory effect, degree of sedation and recovery of midazolam and propofol, and then determines the mean infusion rate of both groups. Forty patients of ASA class 1 or 2 scheduled to lower extremities surgery under spinal anesthesia were classified randomly into 2 groups. Group 1 were infused with midazolam 0.1-0.2mg/kg/h and group 2 propofol 2-3mg/kg/h. The results were as follows: 1) The mean induction dose of midazolam was 0.29+/-0.03mg/kg/h and propofol was 5.56+/-0.78mg/kg/h and the mean infusion rate of midazolam was 0.09+/-0.02mg/kg/h and propofol was 2.13+/-0.41mg/kg/h, which resulted in easily controllable sedation during operation. 2) The quality of sedation was assessed as good in 19 patients but 1 patient showed excitatory movements after midazolam infusion. Good sedation was provided in 16 patients but 2 patients showed excitatory movements and 2 patients complained pain on injection after propofol infusion. 3) The mean arterial pressure was more significantly decreased in propofol than midazolam group. 4) The heart rate was more decreased than control in both groups. 5) Airway maintenance was excellent and side effects were rare. 6) Recovery, judged by ability to open the eyes and recall date of birth, was significantly more rapid after propofol than after midazolam infusion.
Anesthesia, Spinal* ; Arterial Pressure ; Heart Rate ; Humans ; Infusions, Intravenous* ; Lower Extremity ; Midazolam* ; Parturition ; Propofol*

OBJECTIVE: To determine whether cystometry performed by bladder filling stimulation using furosemide (DCMG) reveals different findings compared to conventional cystometry (CCMG) in the neurogenic bladder. METHOD: The maximum intravesical pressure (MPves) and compliance of the bladder in CCMG and DCMG were compared in 24 patients with neurogenic bladder after spinal cord injury. The MPves was estimated by urethral leak pressure or intravesical pressure at 600 ml filling. Compliance was calculated from the cystometric bladder capacity and the MPves. For CCMG, the bladder was filled with 32oC normal saline via 10 F urethral catheter at 50 ml/min until the patient leaked or filled 600 ml. Three hours later, 20 mg of furosemide was injected intravenously after intravenous infusion of 300 ml normal saline for DCMG. Ultrasound measuring of filled urine volume was made at least every 5 minutes until defined MPves. RESULTS: Significant differences were found between DCMG and CCMG in hyperreflexic neurogenic bladders with respect to: decrease in MPves (p<0.05) and increase in compliance (p<0.05) in DCMG. There was no significant differences in MPves and compliance in hyporeflexic or areflexic neurogenic bladders between the two techniques (p>0.05). CONCLUSION: We have found DCMG provides a more effective and near physiological diagnostic method of detrusor characteristics than CCMG in evaluating both genuine MPves and compliance in patients with hyperreflexic neurogenic bladder.
Compliance ; Diuretics* ; Furosemide ; Humans ; Infusions, Intravenous ; Spinal Cord Injuries* ; Spinal Cord* ; Ultrasonography ; Urinary Bladder ; Urinary Bladder, Neurogenic* ; Urinary Catheters

BACKGREOUND: Despite many advantages of spinal anesthesia, hypotension after spinal anesthesia is a common complication. The practice of routine preemptive infusion of crystalloid before spinal anesthesia has been widespread acceptance. But the value of this practice has recently been questioned. This study was designed to determine whether preoperative administration of crystalloid decrease the incidence of hypotension after spinal anesthesia. METHODS: Thirty ASA I and II patients for elective lower extremities operations under spinal anesthesia were randomized to receive either 500 ml Ringer's lactate solution prior to induction of spinal anesthesia (group I) or no prehydration (group II). Hypotension was defined as a 30% decrease from baseline systolic blood pressure or systolic <90 mmHg, and was treated with ephedrine 5 mg IV boluses. RESULTS: The incidence of hypotension was not significantly different between the two groups. Baseline systolic blood pressure significantly decreased after 5 min in the group I, 1 min in the group II, after induction of spinal anesthesia. The ephedrine dose requirement to maintain systolic pressure >70% of baseline, systolic blood pressure and heart rate were not significantly different between both groups. CONCLUSIONS: We conclude that, in normovolemic adult patients undergoing elective lower extremities surgery, an intravenous infusion of 500 ml of Ringer's lactate solution is ineffective in preventing hypotension during spinal anesthesia.
Adult ; Anesthesia, Spinal ; Blood Pressure ; Ephedrine ; Heart Rate ; Humans ; Hypotension* ; Incidence ; Infusions, Intravenous ; Lactic Acid ; Lower Extremity

OBJECTIVE: The vestibular system contributes control of blood pressure during postural changes through the vestibulosympathetic reflex. In the vestibulosympathetic reflex, afferent signals from the peripheral vestibular receptors are transmitted to the vestibular nuclei, rostral ventrolateral medullary nuclei, and then to the intermediolateral cell column of the thoracolumbar spinal cord. Physiological characteristics of the vestibulosympathetic reflex in terms of neurogenic and humoral control of blood pressure were investigated in this study. METHODS: Conscious rats with sinoaortic denervation were used for removal of baroreceptors in reflex control of blood pressure, and hypotension was induced by intravenous infusion of sodium nitroprusside (SNP). Expression of c-Fos protein was measured in the medial vestibular nuclei (MVN), rostral vestrolateral medullary nuclei(RVLM), and intermediolateral cell column (IMC) in T4-7, and levels of blood epinephrine were measured following SNP-induced hypotension. RESULTS: SNP-induced hypotension significantly increased expression of c-Fos protein in the MVN, RVLM, and IMC, also significantly increased level of blood epinephrine compared to normotensive control animals. CONCLUSION: These results suggest that the vestibulosympathetic reflex regulates blood pressure through neurogenic control including MVN, RVLM, and IMC, also through humoral control including epinephrine secretion by the adrenal medulla following SNP-induced hypotension. The physiological characteristics of the reflex may contribute to basic treatment of impairment of blood pressure control during postural changes.
Adrenal Medulla ; Animals ; Blood Pressure ; Denervation ; Epinephrine ; Hypotension ; Infusions, Intravenous ; Nitroprusside ; Pressoreceptors ; Rats ; Reflex ; Spinal Cord ; Vestibular Nuclei

Autonomic hyperreflexia is a syndrome of massive reflex sympathetic discharge that occurs in patients with chronic spinal cord lesions above the major sympathetic splanchnic outflow (T 4 -T6). We experienced autonomic hyperreflexia that occured in a patient with spinal cord trans-section at T5 level during general anesthesia with O2-N2O-halothane. Hypertension was controlled with intravenous infusion of sodium nitroprusside (1-2 ug/kg/min) and ventricular arrhythmia was treated with intra- venous lidocaine. We recommend that direct acting vasodilators are useful drugs to control hypertension in autonomic hyperreflexia during anesthesia in patients with chronic spinal cord injury.
Anesthesia ; Anesthesia, General* ; Arrhythmias, Cardiac ; Autonomic Dysreflexia* ; Humans ; Hypertension* ; Infusions, Intravenous ; Lidocaine ; Nitroprusside* ; Reflex ; Sodium* ; Spinal Cord Injuries* ; Spinal Cord* ; Vasodilator Agents

BACKGROUND: An intravenous infusion of lidocaine has been used on numerous occasions to produce analgesia in neuropathic pain. In the cases of failed back surgery syndrom, the pain generated as result of abnormal impulse from the dorsal root ganglion and spinal cord, for instance as a result of nerve injury may be particularly sensitive to lidocaine. The aim of the present study was to identify the effects of IV lidocaine on neuropathic pain items of FBSS. METHODS: The study was a randomized, prospective, double-blinded, crossover study involving eighteen patients with failed back surgery syndrome. The treatments were: 0.9% normal saline, lidocaine 1 mg/kg in 500 ml normal saline, and lidocaine 5 mg/kg in 500 ml normal saline over 60 minutes. The patients underwent infusions on three different appointments, at least two weeks apart. Thus all patients received all 3 treatments. Pain measurement was taken by visual analogue scale (VAS), and neuropathic pain questionnaire. RESULTS: Both lidocaine (1 mg/kg, 5 mg/kg) and placebo significantly reduced the intense, sharp, hot, dull, cold, sensitivity, itchy, unpleasant, deep and superficial of pain. The amount of change was not significantly different among either of the lidocaine and placebo, or among the lidocaine treatments themselves, for any of the pain responses, except sharp, dull, cold, unpleasant, and deep pain. And VAS was decreased during infusion in all 3 group and there were no difference among groups. CONCLUSIONS: This study shows that 1 mg/kg, or 5 mg/kg of IV lidocaine, and palcebo was effective in patients with neuropathic pain attributable to FBSS, but effect of licoaine did not differ from placebo saline.
Analgesia ; Appointments and Schedules ; Cold Temperature ; Cross-Over Studies ; Failed Back Surgery Syndrome ; Ganglia, Spinal ; Humans ; Infusions, Intravenous ; Lidocaine ; Neuralgia ; Pain Measurement ; Prospective Studies ; Spinal Cord

PURPOSE: This study evaluated the use of adding morphine to bupivacaine in spinal anesthesia for pain control in patients who underwent an open hemorrhoidectomy. METHODS: Forty patients were prospectively selected for an open hemorrhoidectomy at the same institution and were randomized into two groups of 20 patients each: group 1 had a spinal with 7 mg of heavy bupivacaine associated with 80 microg of morphine (0.2 mg/mL). Group 2 had a spinal with 7 mg of heavy bupivacaine associated with distilled water, achieving the same volume of spinal infusion as that of group 1. Both groups were prescribed the same pain control medicine during the postoperative period. Pain scores were evaluated at the anesthetic recovery room and at 3, 6, 12, and 24 hours after surgery. Postoperative complications, including pruritus, nausea, headaches, and urinary retention, were also recorded. RESULTS: There were no anthropometric statistical differences between the two groups. Pain in the anesthetic recovery room and 3 hours after surgery was similar for both groups. However, pain was better controlled in group 1 at 6 and 12 hours after surgery. Although pain was better controlled for group 1 after 24 hours of surgery, the difference between the groups didn't achieved statistical significance. Complications were more common in group 1. Six patients (6/20) presented coetaneous pruritus and 3 with (3/20) urinary retention. CONCLUSION: A hemorrhoidectomy under a spinal with morphine provides better pain control between 6 and 12 hours after surgery. However, postoperative complications, including cutaneous pruritus (30%) and urinary retention (15%), should be considered as a negative side of this procedure.
Anesthesia* ; Anesthesia, Spinal ; Bupivacaine ; Headache ; Hemorrhoidectomy* ; Humans ; Infusions, Spinal ; Morphine* ; Nausea ; Pain, Postoperative ; Postoperative Complications* ; Postoperative Period ; Prospective Studies* ; Pruritus ; Recovery Room ; Urinary Retention ; Water