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PubMed1990

Intrathecal morphine's effect on somatosensory impulses transmission-studied with posterior tibial nerve SSEP.

In order to investigate neurotoxic potential of spinally injected morphine solution, somatosensory evoked potential (SSEP) was utilized to detect the change of electrophysiologic activity of spinal neurons after long term application of intrathecal morphine. Eight patients received intrathecal morphine injection regularly after CHEMO-PORT implantation were studied with posterior tibial nerve SSEP. Patients received SSEP examination just before and right after first episode of morphine injection and were followed up at 30 minutes, 60 minutes, 2 hours, 8 hours, and the 7th day and the third month of regularly injection. The results showed that there were no definite change of latencies and amplitudes of impulses generated by lumbar spinal cord (N22) and cortex (P40). We therefore suggest that electrophysiologic activities of spinal cord and cortex are not affected by chronic intrathecal morphine injection. Possible mechanism and proposed pathway of morphine's action were also discussed.

Evoked Potentials, Somatosensory↗
PubMed1997

The effect of spinal GABA receptor agonists on tactile allodynia in a surgically-induced neuropathic pain model in the rat.

This study evaluated the effects of spinal gamma-aminobutyric acid (GABA) receptor agonists on the tactile allodynia observed in rats with ligation of the L5/L6 nerve roots (Chung model) and chronic lumbar intrathecal catheters. In these rats, the spinal injection of the GABAB agonist baclofen (BAC; 0.03-03 micrograms) and GABAA agonist muscimol (MUS; 0.1-1.0 micrograms) resulted in a dose-dependent antagonism of the allodynia at doses which had no detectable effect upon motor function. Intrathecal injection of the GABAB antagonist CGP 35348 (CGP; 30 micrograms) or the GABAA antagonist bicuculline (BIC; 0.3 micrograms) prior to injection of each GABA receptor agonist had little effect upon normal or tactile allodynic thresholds, but significantly reversed the anti-allodynic effects produced by the respective receptor agonists. The antagonistic effects were limited to the agonist of the respective receptor. These observations indicate that spinal GABAA and GABAB receptors modulate spinal systems activated by low threshold mechanoreceptors which mediate the allodynia observed following peripheral nerve injury.

Animals↗
PubMed2002

Comparison of intrathecal fentanyl and diamorphine in addition to bupivacaine for caesarean section under spinal anaesthesia.

BACKGROUND: Co-administration of small doses of opioids and bupivacaine for spinal anaesthesia reduces intraoperative discomfort and may reduce postoperative analgesic requirements in patients undergoing Caesarean section. Fentanyl and diamorphine are the two most frequently used agents in UK obstetric anaesthetic practice. METHODS: Seventy-five healthy parturients scheduled for elective Caesarean section under spinal anaesthesia using hyperbaric 0.5% bupivacaine, were randomly allocated to additionally receive intrathecal fentanyl 20 micrograms, diamorphine 300 micrograms or 0.9% saline. Patients also received i.v. cyclizine and rectal diclofenac. RESULTS: Less supplementary intraoperative analgesia was required by patients in either opioid group (4%) compared with the control (32%) (P < 0.05). Twenty four hours after spinal injection, total mean (SD) postoperative morphine requirement was significantly lower if diamorphine was administered (31 (21) mg), in comparison with the other two groups (control 68 (26) mg; fentanyl 62 (26) mg) (P < 0.05). Reduced visual analogue pain scores were evident 12 h following diamorphine, but observed only for 1 h after fentanyl when compared with the control (P < 0.05). Mild pruritus was more common for 2 h after either spinal opioid (P < 0.05), but no inter-group differences were observed for the remainder of the first 24 h. Patients displayed deeper levels of sedation both acutely and 12 h after administration of intrathecal fentanyl (P < 0.05). CONCLUSIONS: Both intrathecal opioids reduce intraoperative discomfort, but only diamorphine reduced postoperative analgesic requirement beyond the immediate postoperative period.

Adult↗
PubMedDate not supplied

Low-dose bupivacaine-fentanyl spinal anesthesia for cesarean delivery.

BACKGROUND AND OBJECTIVES: The hypotension following spinal anesthesia remains commonplace in cesarean delivery. Intrathecal opioids are synergistic with local anesthetics and intensify sensory block without increasing sympathetic block. The combination makes it possible to achieve spinal anesthesia with otherwise inadequate doses of local anesthetic. We hypothesized that this phenomenon could be used to provide spinal anesthesia for cesarean delivery while incurring less frequent hypotension. METHODS: Thirty-two women scheduled for cesarean delivery were divided into 2 groups of patients who received a spinal injection of either 10 mg of isobaric (plain) bupivacaine 0.5% or 5 mg of isobaric bupivacaine with 25 microg fentanyl added. Each measurement of a systolic blood pressure less than 95 mm Hg or a decrease in systolic pressure of greater than 25% from baseline was considered as hypotension and treated with a bolus of 5 to 10 mg of intravenous ephedrine. RESULTS: Spinal block provided surgical anesthesia in all patients. Peak sensory level was higher (T3 v T4. 5) and motor block more intense in the plain bupivacaine group. The plain bupivacaine patients were more likely to require treatment for hypotension (94% v 31%) and had more persistent hypotension (4.8 v 0.6 hypotensive measurements per patient) than patients in the minidose bupivacaine-fentanyl group. Mean ephedrine requirements were 23.8 mg and 2.8 mg, respectively, for the 2 groups. Patients in the plain bupivacaine group also complained of nausea more frequently than patients in the minidose bupivacaine-fentanyl group (69% v 31%). CONCLUSIONS: Bupivacaine 5 mg + fentanyl 25 microg provided spinal anesthesia for cesarean delivery with less hypotension, vasopressor requirements, and nausea than spinal anesthesia with 10 mg bupivacaine.

Adjuvants, Anesthesia↗
PubMed1995

Prolongation of spinal anesthesia with bupivacaine-loaded (DL-lactide) microspheres.

There is considerable interest in developing a sustained-release local anesthetic formulation to provide long-lasting anesthesia and to decrease systemic toxicity. Bupivacaine (B), 10 mg, loaded in two different types of polylactide microspheres (PLA1 and PLA2) was evaluated after spinal injection and compared with plain bupivacaine (pB), 2 mg. Experiments were performed in six New Zealand rabbits. Duration of motor block was significantly prolonged for PLA1 compared to pB (177.5 +/- 79.5 min vs 44.6 +/- 18.0 min; P < 0.05), as well as for the recovery time (545.0 +/- 299.6 min vs 44.2 +/- 21.5 min; P < 0.05). The duration and recovery were not prolonged for PLA2. Systemic release of B after intrathecal injection was measured from blood samples by using high-performance liquid chromatography. There was no significant difference in maximum B plasma concentration between pB and PLA1 (326 +/- 81 mg/mL vs 321 +/- 57 ng/mL). The time taken to reach the maximum plasma concentration (6.6 +/- 2.6 min vs 41.7 +/- 20.4 min; P < 0.05) was significantly different. This study demonstrated that the use of bupivacaine-loaded (DL-lactide) microspheres can prolong spinal motor block.

Anesthesia Recovery Period↗
PubMed1998

The advantages of the lateral decubitus position after spinal anesthesia with hyperbaric tetracaine.

UNLABELLED: We investigated the effects of lateral decubitus positioning after spinal anesthesia with hyperbaric tetracaine on the spread of sensory blockade and hemodynamic variables. One hundred ASA physical status I or II patients scheduled for elective surgery to the lower limb received spinal anesthesia at a rate of approximately 0.1 mL/s using 0.5% tetracaine in 7.5% glucose with 0.125% phenylephrine in the lateral decubitus position with the operated side dependent. They were randomly divided into three groups: patients in Group I were placed supine immediately after spinal injection; those in Group II remained in the lateral position for 10 min before being turned supine; those in Group III were kept in the lateral position for 20 min then turned supine. Neural block was assessed by cold, pinprick, and touch sensation, and a modified Bromage scale. Hemodynamic variables included blood pressure, heart rate, and the use of ephedrine for the treatment of hypotension. The median (10th, 90th percentiles) peak dermatomal level to pinprick on the dependent side in Group III was T8 (T11, T5), which was significantly lower than that in Groups I and II, which extended to T4 (T9, T3) and T5 (T10, T2), respectively (P < 0.05). The difference in the maximal cephalad spread of sensory blockade between both sides in Group III was only one dermatome but was statistically significant (P < 0.05); in contrast, there was no significant difference in the maximal sensory level between both sides in Groups I and II. The use of ephedrine for the treatment of hypotension was significantly less frequent in Group III than the other groups. We conclude that keeping a patient in the lateral decubitus position for 20 min after hyperbaric tetracaine spinal anesthesia maintains preferential anesthetic distribution to the dependent side. Despite small differences between the two sides, the restricted spread of blockade and less hemodynamic variability may be clinically advantageous. IMPLICATIONS: The effects of posture on the spread of hyperbaric spinal anesthesia have not been adequately investigated. The results of the present study suggest an advantage of prolonged lateral decubitus positioning after intrathecal hyperbaric tetracaine.

Adolescent↗
PubMed2005

Chronic changes in cerebrospinal fluid pathways produced by subarachnoid kaolin injection and experimental spinal cord trauma in the rabbit: their relationship with the development of spinal deformity. An electron microscopic study and magnetic resonance imaging evaluation.

Post-traumatic cystic changes in cerebrospinal fluid (CSF) pathways such as ventriculomegaly and/or hydrosyringomyelia are not uncommon, but their characteristics have not yet been fully clarified. This study was designed to investigate the alterations affecting the CSF pathways in rabbits at a late stage, and to clarify the relationship between these changes and the development of spinal deformity. In this study, a total of 60 New Zealand white rabbits were used and they were segregated into four different groups of 15 animals each: sham-operation group, kaolin group, and kaolin plus mild trauma group and kaolin plus severe trauma group. The animals were subjected to radiological investigation using direct X-ray study and magnetic resonance imaging (MRI) after 4 months. The thoracic spinal cords of the animals were dissected after intracardiac perfusion-fixation with 10% formalin for light microscopy and 2.5% glutaraldehyde for transmission electron microscopic study. Following the sectioning and staining procedures, the histological characteristics of the spinal cords were evaluated with light microscopy and transmission electron microscopy. A spinal deformity developed in 90% in rabbits in both kaolin injection group and spinal trauma groups. MRI revealed generalized dilatation of the ventricular system and the central canal of the spinal cord after the kaolin injection with/without trauma in this study. Gross morphologic examination showed some enlargement of entire CSF pathways in these groups. All animals with central canal dilatation had mild or severe scoliotic and kyphotic deformities. In a light microscopic study, a denuded ependymal line and multicyst formations in periependymal areas were found in both kaolin injection and spinal trauma groups. Ultrastructurally, an apical flattening of the ependyma, microcysts in the ependymal cells, axonal degeneration, demyelination, and loss of ependymal cells adjacent mild spongy were found in the spinal cords of animals in these groups. To the best of our knowledge, this is the first study to investigate the chronic effects of spinal cord injury (SCI) on the CSF pathways and their relationship with the development of spinal deformity in an experimental model of kaolin injection and trauma, using MRI as well as light and transmission electron microscopy. In the light of this study, the severity of spinal cord injury on the development of some degenerative findings in the spinal cord was clear, but further clinical and experimental studies using dynamic imaging techniques will be valuable.

Animals↗
PubMedDate not supplied

Postoperative analgesia and antiemetic efficacy after intrathecal neostigmine in patients undergoing abdominal hysterectomy during spinal anesthesia.

BACKGROUND AND OBJECTIVES: Postoperative analgesia and antiemetic efficacy after intrathecal neostigmine were investigated in a randomized, double-blind, placebo-controlled trial of 100 patients undergoing abdominal hysterectomy. METHODS: The patients were assigned to one of five groups (n = 20), and received intravenous prior to the spinal block the antiemetic test drug (except propofol) and 0.05 mg/kg midazolam. The control group (group C), the neostigmine group (group N), and the propofol group (group P) received saline as the test drug. The droperidol group (group D) received 0.5 mg intravenous droperidol, and the metoclopramide group (group M) 10 mg intravenous metoclopramide. Group P was single-blinded and had an intravenous continuous propofol infusion (2-4 mg/kg/h) turned on 10 minutes after the spinal injection. The intrathecal drugs administered were 20 mg hyperbaric bupivacaine (0.5%) associated with either 100 microg neostigmine or saline (for group C). Nausea, emetic episodes, and the need for rescue medication were recorded for the first 24 hours postoperative and scored by the Visual Analog Scale (VAS). RESULTS: Time-to-first-rescue medication and rescue medications in 24 hours were similar among the groups (P = .2917 and P = .8780, respectively). Intrathecal 100 microg neostigmine was associated with a high incidence of nausea and vomiting perioperative, leading to a high consumption of antiemetics (P < .002). None of the antiemetic test drugs were effective in preventing nausea and vomiting after 100 microg neostigmine. CONCLUSIONS: Intrathecal neostigmine (100 microg) was ineffective for postoperative analgesia after abdominal hysterectomy due to side effects of nausea and vomiting.

Anesthesia, Spinal↗
PubMed1997

Effects of ginsenosides injected intrathecally or intracerebroventricularly on antinociception induced by morphine administrated intracerebroventricularly in the mouse.

1. Total saponin fraction at doses of 0.1 to 1.0 microgram, which administered IT alone did not affect the latencies of the tail-flick threshold, dose dependently attenuated inhibition of the tail-flick response induced by ICV-administered morphine (2 micrograms). 2. Total saponin fraction at doses of 1 to 20 micrograms, which administered ICV alone did not affect the latencies of the tail-flick response, did not affect ICV-administered morphine-induced antinociception. 3. The duration of antagonistic action of the total saponin fraction against morphine-induced antinociception lasted for at least 6 hrs. 4. Various doses of ginsenosides Rb2, Rc, Rd and Rg1, but not Rb1 and Re, injected IT dose dependently attenuated antinociception induced by morphine administered ICV. 5. In summary, ginsenosides Rb2, Rc, Rd and Rg1 injected spinally appear to have antagonistic action against the antinociception induced by supraspinally applied morphine. On the other hand, the total ginseng fraction, at supraspinal sites, may not have an antagonistic action against the antinociception induced by morphine administered supraspinally.

Analgesics, Opioid↗
PubMed1999

Effects of ginsenosides injected intrathecally or intracerebroventricularly on antinociception induced by beta -endorphin administered intracerebroventricularly in the mouse.

The effect of total saponin fraction of ginseng injected intrathecally (i.t.) or intracerebroventricularly (i.c.v.) on the antinociception induced by beta-endorphin administered i.c.v. was studied in ICR mice in the present study. The antinociception was assessed by the tail-flick test. Total saponin fraction at doses 0.1 to 1.0 microgram, which administered i.t. alone did not affect the latencies of tail-flick threshold, attenuated dose-dependently the inhibition of the tail-flick response induced by i.c.v. administered beta-endorphin (1 microgram). However, total saponin fraction at doses 1 to 20 microgram, which administered i.c.v. alone did not affect the latencies of the tail-flick response, did not affect i.c.v. administered beta-endorphiun (1 microgram)-induced antinociception. The duration of antagonistic action of total saponin fraction against beta-endorphin-induced antinociception lasted at least for 6 h. Various doses (from 0.1 to 1 microgram) of ginsenoside R(c), but not R(b2), R(d), Rg(1), R(b1)and R(e)injected i.t. dose-dependently attenuated antinociception induced by beta-endorphin administered i.c.v. Our results indicate that total saponin fraction injected spinally appears to have antagonistic action against the antinociception induced by supraspinally applied beta-endorphin. Ginsenoside R(c)appears to be responsible for blocking i.c.v. administered beta-endorphin-induced antinociception. On the other hand, total ginseng fraction, at supraspinal sites, may not exert an antagonistic action against the antinociception induced by supraspinally administered beta-endorphin.

Analgesics↗
PubMed2003

Single-shot intrathecal sufentanil with bupivacaine in late labour--analgesic quality and obstetric outcome.

OBJECTIVES: To investigate the analgesic effect and obstetric outcome after single-shot intrathecal sufentanil with bupivacaine in late labour. STUDY DESIGN: Forty multiparous women in advanced labour were given a spinal injection of sufentanil 7.5 microg and bupivacaine 2 mg. Pain intensity was recorded by the parturient on a visual analogue scale. The quality of pain relief was also rated with a verbal score directly after delivery. Side effects, such as hypotension, pruritus, sedation, nausea and motor block were noted. Obstetric parameters were followed and recorded. Apgar score and umbilical artery pH were noted. RESULTS: Median visual analogue scores after 5, 15, 30, 60, 90, 120 and 150 min were 1.5, 0.5, 0, 1, 1.5, 2 and 3, respectively. Seventy-seven percent of the parturients scored the analgesic quality as excellent. Six parturients had hypotension. Motor block, sedation and nausea were rare. Pruritus was seen in 85% of the cases. No ceasarean section was performed. Vacuum extraction was done in six (15%) cases. Oxytocin augmentation was needed in 26 (65%) of the parturients. Fetal heart rate disturbances following the spinal block were seen in four cases. Apgar scores were high. No neonate had Apgar < 7. CONCLUSIONS: Intrathecal block with sufentanil 7.5 microg in combination with bupivacaine 2 mg is a very effective pain relief in late labour. Due to its limited duration it is important to select women in rapid progress of labour, and active obstetric management is necessary. It is also very important that the obstetrician is aware of the risk of non-reassuring fetal heart rate changes after intrathecal block.

Analgesia, Obstetrical↗
PubMed2003

Effect of ginsenosides administered intrathecally on the antinociception induced by cold water swimming stress in the mouse.

We examined the effects of ginseng total saponin (GTS) and several ginsenosides injected intrathecally (i.t.) or intracerebroventricularly (i.c.v.) on the antinociception induced by cold water swimming. The tail-flick response was used as an antinociceptive parameter. We found that i.t. injection of GTS time- and dose-dependently attenuated inhibition of the tail-flick response induced by cold water swimming, although GTS given i.c.v. had no significant effect on the latency of the tail-flick response induced by cold water swimming. To identify those responsible for antagonism of GTS against cold water swimming-induced antinociception, the effects of various kinds of ginsenosides (R(b1), R(b2), R(c), R(d), R(e), and R(g1)) on inhibition of the tail-flick response induced by cold water swimming were examined. R(b1), R(d), R(e), and R(g1) effectively attenuated the inhibition of the tail-flick response induced by cold water swimming stress. Our results suggest that GTS injected spinally, but not supraspinally, reduces the antinociception induced by this stress, and that the responsible ginsenosides against antinociception induced by cold water swimming may be R(b1), R(d), R(e), and R(g1). Moreover, the possible involvement of the opioid system in the regulation of cold water swimming stress-induced antinociception by these four ginsenosides is discussed.

Analgesics↗
PubMed2006

Side effects and adverse events related to intraligamentous injection of sclerosing solutions (prolotherapy) for back and neck pain: A survey of practitioners.

OBJECTIVE: To study the side effects and adverse events related to intraligamentous injection of sclerosing solutions (prolotherapy) for back and neck pain. DESIGN: Practitioner postal survey. SETTING: Postal survey of practitioners of prolotherapy for back and neck pain in the United States and Canada. PARTICIPANTS: A sample of prolotherapy practitioners from 2 professional organizations were surveyed about their training and experience, use of specific treatment procedures, estimated prevalence of side effects, and adverse events related to prolotherapy for back and neck pain. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Prevalence of side effects and adverse events. RESULTS: Surveys were completed by 171 practitioners (response rate, 50%). Ninety-eight percent held medical degrees, and 83% were board certified in various disciplines. Respondents had a median of 10 years of experience, during which they had treated a median of 500 patients and given a median of 2000 treatments. Side effects with the highest median estimated prevalence were pain (70%), stiffness (25%), and bruising (5%). There were 472 reports of adverse events, including 69 that required hospitalization and 5 that resulted in permanent injury secondary to nerve injury. The vast majority (80%) were related to needle injuries such as spinal headache (n = 164), pneumothorax (n=123), temporary systemic reactions (n = 73), nerve damage (n = 54), hemorrhage (n = 27), nonsevere spinal cord insult (ie, meningitis, paralysis, spinal cord injury) (n = 9), and disk injury (n = 2). CONCLUSIONS: Side effects related to prolotherapy for back and neck pain, such as temporary postinjection pain, stiffness, and bruising, are common and benign. Adverse events related to prolotherapy for back and neck pain are similar in nature to other widely used spinal injection procedures. Further study is needed to fully describe the adverse event profile of prolotherapy for back and neck pain.

Back Pain↗
PubMed1993

Posture and the spread of hyperbaric bupivacaine in parturients using the combined spinal epidural technique.

This study was undertaken to analyze the effect of posture on the spread of hyperbaric bupivacaine in pregnant women using a combined spinal extradural technique, and to assess the quality of analgesia provided by 10 mg bupivacaine when using this technique. Fifty parturients undergoing elective Caesarean section under regional anaesthesia were randomly allocated to receive 2.0 ml hyperbaric bupivacaine 0.5% in either the sitting or left lateral position. Spinal injection was performed with a 27 gauge, 120 mm long spinal needle using a single space combined spinal extradural technique. The onset time to analgesia at T4, and grade 3 motor block was on average 7.7 min and 6.9 min respectively in the lateral group, compared with 10.8 min (P < 0.05) and 9.4 min (P < 0.05) in the sitting group. Nine women in the sitting group and one woman (P < 0.05) in the lateral group required epidural supplementation. Hypotension occurred in 48% of the parturients in the lateral group and in 13% (P < 0.05) of the parturients in the sitting group. Nausea was noted in 61% of the parturients in the lateral group and in 22% (P < 0.05) of the parturients in the sitting group. There was no difference between the two groups in neonatal outcome. Overall, the position of the patient during induction of spinal anaesthesia does influence the rate of onset of analgesia and motor blockade. Injection of 10 mg hyperbaric bupivacaine in the sitting position would not provide adequate analgesia for Caesarean section when using a single space combined spinal extradural technique.

Adult↗
PubMed2004

Interspinous bursitis in an athlete.

We present a case of L2/3 interspinous bursitis treated with extraspinal injections. No previous investigations have used fluoroscopically guided spinal injections to confirm the clinical relevance of the MRI features of this type of bursae. Autopsy studies have revealed an increased incidence of interspinous lumbar bursal cavities with advancing age. Afflicted patients present with localised, midline lower lumbar pain exacerbated by extension. In young athletes these symptoms can mimic spondylolysis. MRI is useful in detecting soft-tissue injury of the posterior elements. Fluoroscopically guided diagnostic and therapeutic extraspinal injections can be used for confirmation and treatment of pain from such bursae.

Adolescent↗
PubMed2005

Anterior spinal column augmentation with injectable bone cements.

A vertebral fracture, whether originating from osteoporosis or trauma, can be the cause of pain, disability, deformation and neurological deficit. The treatment of vertebral compression fractures has, for many years until the advent of vertebroplasty, consisted of bedrest and analgesics. Vertebroplasty is a percutaneous technique during which bone cement is injected in a vertebral body to provide immediate pain relief by stabilization. Inflatable bone tamps can, prior to the injection of cement, be used to create a void in the vertebral body, in which case the technique is known as balloon vertebroplasty (or kyphoplasty). The chance of extracorporal cement leakage is smaller for balloon vertebroplasty than for vertebroplasty. Some authors also claim to have gained some correction in vertebral body height or angulation. Both interventions can be used for several indications, including osteoporotic compression fractures and osteolytic lesions of the vertebral body such as myeloma, hemangioma or metastasis, and also for traumatic burst fractures in combination with pedicle screw instrumentation. Polymethyl methacrylate cement is the bone void filler that is used most frequently, although the application of calcium phosphate cements has been studied widely in vitro, in vivo and also in small-scale clinical series. The clinical results of (balloon-) vertebroplasty are favorable with 85-95% of all patients experiencing immediate and long-lasting relief of pain. Serious complications are relatively rare but include neurological deficit and pulmonary embolism. In this paper, both vertebroplasty and balloon vertebroplasty and their respective indications, techniques and results are described in relation with the application and limitations of permanent and resorbable injectable bone cements.

Absorbable Implants↗