Search

An 82 year-old woman with Parkinson's disease complained of a tendency to fall. She has had an extensive kyphosis since she was 66 years old. Over the last 6 months, she has repeatedly fallen. Even though she took anti-parkisonian drugs, she had also developed camptocormia. Her plasma levodopa concentration was analyzed for 4 hrs after administrating an oral dose of levodopa (200 mg) plus carbidopa (20 mg) at the time of fasting. The change in the plasma levodopa concentration showed bimodal peaks. The physical symptoms depended on the plasma concentration and improved twice. Esophageal tortuosity and esophageal hiatal hernia were detected by esophagography and upper gastric endoscopy. Such physical symptoms were speculated to have been caused by the transit disturbance of the drug in the gastrointestinal duct. During a second analysis of the plasma levodopa concentration, the patient was instructed to keep extending her back after consuming the same dose of drugs but with a greater amount of water than in the first analysis. A single and a higher peak were observed for the plasma levodopa concentration, and the physical symptoms, including camptocormia and parkinsonism, were improved. Hunched posture could influence the absorption of antiparkinsonian drugs.

There is little report describing the effect of remifentanil on cardiac conduction system. We present a successful anesthetic management with remifentanil in a patient with sick sinus syndrome. A 66-year-old woman (31-kg, 121-cm) having sinoatrial (SA) block was diagnosed as having hepatic cell carcinoma, and radiofrequency ablation (RFA) was scheduled. She was also suffering from kyphosis due to the past history of tuberculous spondylitis. Preoperative examination of her respiratory function indicated a severe constrictive pulmonary disorder. Anesthesia was induced with propofol (30 mg), and maintained with sevoflurane (1-2%) and oxygen/air in combination with remifentanil (0.5 microg x kg(-1) x min(-1)). Temporary pacemaker was prepared during anesthesia. Neither remifentanil nor sevoflurane deteriorated SA block and her heart rate was well controlled. Respiratory dysfunction was not seen in the postoperative course. Our case suggests that remifentanil may be a suitable analgesic for patients with cardiac conduction abnormalities.

Recent reports indicate an increased prevalence of reflux esophagitis (RE) in Japan. There are many factors causing RE, and many kinds of changes associating aging are important in the cause of RE in elderly patients. We reported that the osteoporosis and the orthopedics degenerative disease in elderly people had relation in development of symptoms of RE of our country. The elderly are complicated with posture change (kyphosis) due to osteoporosis caused by menopause; some pharmaceutical agents such as bisphosphonates (BPs) or NSAIDs. Furthermore, it is necessary to provide elderly RE treatment with the all-inclusive treatment not only the conventional medical treatment which made the PPI maintenance therapy but a living environment, complications, an oral medicine including BPs and NSAIDs.

This 75-year-old male who fell from a 1-m hight road shoulder subsequently suffered persistent neck pain. On admission to our institute he exhibited no neurological abnormalities. CT scan revealed an odontoid Anderson type III fracture. We selected conservative treatment with external fixation using a hard collar. No cervical deformity was recognized over the course of a month and he was transferred to another hospital for rehabilitation. As a cervical X-ray performed a month later disclosed a progressive kyphotic deformity, he was readmitted to our institute for surgery. He underwent internal fixation with a Ransford loop between the occipital bone and the C3 lamina. During the operation we noted that his bone was very fragile. His postoperative course was uneventful and he exhibited no neurological deficits; his cervical alignmen stabilized completely. At his 2nd admission, his bone mineral density was 0.767 g/cm2, 64% of the young adult mean and thus indicative of severe osteoporosis. We conclude that careful observation and appropriate internal fixation are necessary in osteoporotic patients who manifest deformity following an odontoid fracture.

We herein report a technique which facilitates a retroperitoneal approach to the kidney in cases of highly deformed thorax due to kyphoscoliosis. The operation consists of a lumbar oblique incision with removal of the 11th rib, combined with the additional removal of the 12th and 10th ribs. Resection of the upper two ribs was performed subperiosteally, leaving the periosteum of the deep side untouched. However, the deep side periosteum of the 12th rib was incised caudal from the pleural margin in order to facilitate exposure of the diaphragm. The retroperitoneal space was entered through the tip of the 11th rib bed. The diaphragm was incised dorso-medially at a level 1 cm caudal from the lower margin of the pleura, to an extent necessary to enable the pleura together with the cranial diaphragm to be manoeuvred in an upward direction. Two cases with renal tuberculosis associated with high-grade kyphosis and one case with staghorn calculi accompanied with lordosis were operated on utilizing this technique. In the former two cases, the thoracic cage was in direct contact with the iliac bone and there was practically no space between the rib border and the iliac crest. This was also true of the third case, but the grade of deformity was not as extensive as in the former two cases. Removal of the 10th, 11th and 12th ribs could be achieved without injuring the pleura and a satisfactorily large operating field could thus be developed which enabled a simple nephrectomy to be performed without difficulty. The characteristic feature of the described approach is that resection of the 10th and 11th ribs is simply to facilitate manoevrability of the wound margin, without going through the rib bed. The technique could be advantageous in selected cases where there is a highly deformed thorax.

We reported a case in which cervical myelopathy exacerbated 20 years after the stabilization of juvenile muscular atrophy of unilateral distal upper extremity. The patient presented progressive weakness in the right proximal upper extremity and spastic paraparesis in addition to the long-lasting muscular atrophy of right distal upper extremity. Plain x-ray showed severe cervical spondylosis with kyphosis of the cervical spine. Dynamic study on MRI disclosed cervical spinal cord atrophy and compression enhanced in both flexion and extension position of the neck. Malalignment (kyphosis) and severe spondylotic change of the cervical spine seemed to affect the spinal cord with little functional reservoir, manifesting the delayed exacerbation of myelopathy. We conclude that malalignment and subsequent spondylotic change of the cervical spine would be significant factors to determine the long term prognosis of patients with juvenile muscular atrophy of unilateral distal upper extremity.