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Refractory cancer pain affects 10–20% of patients with advanced malignancies and is not adequately controlled by opioids. The intrathecal therapy is an effective interventional procedure for referral, but the implanted infusion pumps are costly and the refilling requires technical expertise. Hypophysectomy, in its three stages—surgical, chemical, and radiosurgical—has emerged as an alternative for managing this pain. However, the underlying mechanism remains elusive, with existing hypotheses unable to comprehensively account for both the initial and long-term analgesic effects. This literature review explores the historical evolution, clinical outcomes, and hypothesized mechanisms of hypophysectomy for pain relief. Surgical hypophysectomy initially demonstrated an 85.5% success rate but carried significant risks like diabetes insipidus and hypopituitarism. Chemical hypophysectomy reduced invasiveness, achieving 75.1% pain relief with fewer complications. Modern pituitary radiosurgery has improved safety while maintaining high efficacy (initial relief: 95.9%, long-term: 73.5%). The mechanisms underlying pain relief remain unclear but include tumor regression, increased β -endorphins, neuroendocrine modulation, and hypothalamic involvement. A new hypothesis suggests that radiosurgery induces hormone redistribution (e.g., oxytocin, vasopressin) through hypothalamic–pituitary modulation, contributing to both immediate and long-term analgesia. Despite its potential, unresolved issues such as optimal radiation dose, pain assessment standardization, and precise mechanisms limit widespread adoption. This review underscores the need for larger, homogenous studies to validate the safety and efficacy of hypophysectomy in treating refractory cancer pain. These findings offer a promising avenue for improving palliative care in oncology. [ABSTRACT FROM AUTHOR]

Acute lymphoblastic leukemia (ALL) is a malignant condition of lymphoid progenitor cells that primarily affects the pediatric population, but also adults. The 5-year survival rate is 90% in children and approximately 40% in adults, with survival increasing through the use of peripheral stem cell allotransplantation (SCT). The relapse rate after stem cell transplantation (SCT) in adult acute lymphoblastic leukemia (ALL) patients ranges from 35% to 45%, making relapse a major cause of death in this population. Background: We present an atypical case of late testicular involvement in ALL in a 50-year-old man diagnosed with ALL pro-T in remission post-chemotherapy (GMALL 2003 protocol) and allogeneic stem cell transplantation (alloSCT) from a related donor. Methods: This case describes a 50-year-old male with ALL pro-T who experienced three rare extramedullary relapses post-chemotherapy and alloSCT. Five years after remission, he had a unilateral testicular relapse confirmed by immunophenotyping of spermatic fluid. Results: Despite no bone marrow involvement, he was treated with chemotherapy, intrathecal therapy, and bilateral testicular radiotherapy. He later relapsed in the orbit, controlled by radiotherapy, followed by a third relapse in the heart and colon. Conclusions: This case highlights the unusual sites and consecutive nature of extramedullary relapses in adult ALL. [ABSTRACT FROM AUTHOR]

Recently, an increase in cases of multidrug-resistant Gram-negative bacteria post-neurosurgical ventriculitis and meningitis is reported. Treating these infections has become challenging due to the limited availability of antibiotics and the need to select those with optimal pharmacodynamic and pharmacokinetic profiles. There is limited evidence regarding the use of meropenem-vaborbactam in treating carbapenem-resistant Enterobacterales infections of the central nervous system. We report two new cases of shunt-related ventriculitis due to carbapenem-resistant K.pneumoniae with a favorable microbiological evolution after IV only combination therapy with meropenem-vaborbactam. [ABSTRACT FROM AUTHOR]

Intrathecal therapy with implanted devices is often reported in some recommendations.for the management of difficult cancer pain However, data is often biased by optimistic view and poor assessment. We report a case of patient in which a comprehensive and complex palliative care treatment was effective in managing a patient who was implanted a subcutaneous port for intrathecal analgesia This patient had many characteristics of a difficult pain, really defined as refractory due to various negative prognostic pain factors, such as neuropathic pain and psychological distress.. A comprehensive pain management with a balanced approach including both interventional therapy and palliative care simultaneously, allowed to achieve optimal pain control. Terms such as intractable or refractory pain, have been ambiguously used in literature to select patients as candidates for implated pumps. A meaningful evaluation and a comprehensive treatment should be mandatory when using intrathecal anlgesia in patients with very difficult pain conditions. [ABSTRACT FROM AUTHOR]

Leptomeningeal metastases (LM) occurs in approximately 5% of individuals diagnosed with metastatic breast cancer (BC). Both systemic and intrathecal (IT) agents can be used for treatment. However, data to support the effectiveness of IT therapy are insufficient. The primary aim of this study was to assess the efficacy and safety of IT therapy in BC patients with LM. This was a retrospective observational study. SPSS version 27 was used for statistical analysis. Kaplan--Meier and Cox regression analyses were used for survival analysis. The study included 14 patients (median age, 52 years). The predominant histopathological t ypes were invasive ductal carcinoma (57%) and invasive lobular carcinoma (36%). In IT treatment, methotrexate was used in 64% of the patients and trastuzumab was used in 36%. Notably, 36% of patients had a partial response, 14% had a stable response, and 5 0% had disease progression. It was found that approximately 50% of patients with positive cerebrospinal fluid (CSF) cytology became negative after treatment. Furthermore, toxicity of grade 2 or higher was observed in 49% of patients. The median progression-free survival duration among patients who received methotrexate was 1.46 months (95% CI, 0.29-2.0) and among those who received trastuzumab was 5.1 months (95% CI, 0-13.1). The median overall survival duration among all patients was 3.8 months. LM is an indicator of poor prognosis among patients with breast cancer. However, IT therapy is one of the few treatment options. IT trastuzumab should be considered as a treatment if leptomeningeal metastases develop in HER2-positive breast cancer. [ABSTRACT FROM AUTHOR]

Objectives: Carbapenem-resistant A. baumannii is a common cause of nosocomial meningitis, and it presents a challenge in terms of treatment because of limited therapeutic options. Intravenous tigecycline has been considered a potential salvage therapy against multi-drug–resistant Acinetobacter baumannii. However, its effectiveness is limited by its poor ability to cross the blood–brain barrier. As an alternative treatment option, intrathecal tigecycline has shown promise with its minimal side effects and high concentration in cerebrospinal fluid. Methods: In this report, we present a series of four cases infected with multi-drug–resistant A. baumannii following neurosurgery and treated with intrathecal tigecycline, including antimicrobial therapy. Results: The rate of successful microbiological response was 2 out of 3 cases (66%) in whom microbiological response could be tested anytime during the intrathecal therapy, whereas the 30-day survival rate after treatment completion was ¼ (25%). Conclusion: Although intrathecal tigecycline treatment has shown relative efficacy in achieving microbiological response, its impact on overall survival is still uncertain. Further studies involving larger groups of patients are necessary to evaluate the outcomes of intrathecal tigecycline therapy. [ABSTRACT FROM AUTHOR]

Background: Intrathecal drug delivery (IDD) is part of the fourth analgesic step. Evidence on the quality of life of patients with refractory chronic non-cancer pain (CNCP) using these devices and their long-term outcomes is scarce. This study aims to evaluate patients with IDD to assess their HRQoL. Additionally, the study seeks to understand the patients' satisfaction with the treatment and changes in pain magnitude over time. Methods: Adult patients with CNCP and intrathecal drug delivery systems (IDDS) were included. The study population was divided into two groups: less than and more than 15 years of treatment. HRQoL was analyzed using validated questionnaires. Pain reduction was assessed using the visual analog scale (VAS), and treatment satisfaction was evaluated using the Patient Global Impression of Improvement scale. Results: The results indicate a poor HRQoL in IDD patients, with better scores in the group with ≥15 years of treatment. Pain reduction was similar in both groups, and patients reported a positive satisfaction level with the treatment. Conclusions: HRQoL in CNCP patients is severely affected. Long-term IDD patients have a similar or even better HRQoL in some respects compared to those with shorter follow-ups. IDD patients experienced pain reduction, with most feeling better or much better. [ABSTRACT FROM AUTHOR]

Background: Sonic Hedgehog (Shh), extensively researched for its role in early neurogenesis and brain development, has recently been recognized for its neuroprotective potential following neuronal injuries. This study examines the immediate impact of early administered Shh on the local inflammatory response post-acute spinal cord injury in rats. Methods: Thirty-four female Wistar rats underwent either sham surgery (laminectomy; n = 10) or clip compression/contusion spinal cord injury (SCI) at the T9 level. This was followed by implantation of an osmotic pump and a subdural catheter for continuous intrathecal delivery of Shh (n = 12) or placebo (NaCl; n = 12). Locomotor function was assessed at 3- and 7-days post-injury (dpi) using the Basso, Beattie, and Bresnahan (BBB) score and the Gridwalk test. Animals were euthanized after 3 or 7 days for immunohistochemical analysis of the local inflammatory reaction and immune cell migration. Results: Shh-treated rats demonstrated significant hindlimb movement and coordination improvements at 7 days post-injury, compared to controls. This enhancement was accompanied by a significant reduction in both immune cell presence and blood plasma products within spinal cord lesions, suggesting Shh's dual role in modulating immune cell migration and maintaining the integrity of the blood-spinal cord barrier. Separately, these Shh-treated rats also showed an increase in M(IL-4) polarization of macrophages, further underlining the potential therapeutic impact of Shh in post-injury recovery. Notably, these effects were not evident at three days post-injury. Conclusion: Shh application at 7 days post-injury showed immunomodulatory effects, possibly via enhanced blood-spinal cord barrier integrity, reduced immune cell migration, and increased anti-inflammatory immune cell differentiation. These mechanisms collectively contribute to enhanced locomotor recovery. [ABSTRACT FROM AUTHOR]

Background: Nalbuphine, a synthetic k-agonist and µ-antagonist, provides efficient pain relief while reducing opioid-related adverse effects. This study aims to compare the efficacy of intrathecal nalbuphine (ITN) with intrathecal morphine (ITM) for post-TKA pain. Methods: A retrospective cohort analysis of 131 patients who underwent TKA with spinal anesthesia (SA), a single shot of adductor canal block, and periarticular injections was conducted. The patients were divided into 2 groups, Group N received 0.8 mg nalbuphine, and Group M received 0.2 mg morphine as an adjuvant to SA. Propensity-score matching was employed to compare the visual analog scales (VAS) of postoperative pain intensity, cumulative morphine use (CMU), maximum knee flexion angle, straight leg raise (SLR) ability, incidence of postoperative nausea and vomiting (PONV), and length of hospital stay (LHS). Results: The mean VAS of group M were significantly lower than group N at 6, 12, 18, and 24 h (P < 0.01). Group M had lower CMU than group N at 24 h (P < 0.01) and 48 h (P < 0.01), while there was no significant difference between groups in terms of knee flexion angle and SLR at any time point. Additionally, 29.3 and 57.9% of patients in group N and M experienced PONV, respectively (p = 0.04), and group N had significantly shorter LHS compared to group M (P < 0.001). Conclusion: Although, intrathecal morphine (ITM) still provides better pain control particularly in the first 24 h, patients who received intrathecal nalbuphine (ITN) had significantly fewer incidence of PONV, and shorter LHS. [ABSTRACT FROM AUTHOR]

Background Melanoma leptomeningeal disease (LMD) has a poor prognosis. However, the management of patients with advanced melanoma has evolved with time, including those with LMD. We reviewed a large cohort of melanoma LMD patients to assess factors associated with survival. Methods Retrospective clinical data was collected on patients diagnosed with LMD at MD Anderson Cancer Center from 2015 to 2020. Overall survival (OS) was determined from LMD diagnosis to date of death or last follow-up. The Kaplan–Meier method and log-rank test were used to estimate OS and to assess univariate group differences, respectively. Multivariable associations of survival with variables of interest were determined using Cox proportional hazards regression models. Results A total of 172 patients were identified. The median age at LMD diagnosis was 53 (range 20–79) years, and all patients had radiographic evidence of LMD on magnetic resonance imaging of either brain or spine. In total 143 patients previously received systemic therapy (83%), with a median of 2 prior treatments (range 0–5). 81 patients (47%) had concurrent uncontrolled systemic disease and 80 patients (53%) had elevated serum LDH at the time of diagnosis. With a median follow-up of 4.0 months (range 0.1–65.3 months), median OS for all patients from LMD diagnosis was 4.9 months. Patients (n  = 45) who received intrathecal therapy or systemic immunotherapy for LMD had a median OS of 8.0 months and 10.2 months, respectively. On multivariable analysis, decreased performance status, positive CSF cytology, elevated LDH, and whole brain radiation were associated with worse OS. Conclusions Despite many advances in therapeutic options, the outcomes of melanoma patients with LMD remains poor. However, a subset of patients appears to derive benefit from LMD-directed treatment. [ABSTRACT FROM AUTHOR]

Aim:Aim of this study was to compare the characteristics of spinal block, hemodynamic changes, and postoperative analgesia, following administration of intravenous dexmedetomidine (0.25 mcg/kg and 0.5 mcg/kg) in patients undergoing TURP under spinal anaesthesia. Methods:90 patients of ASA grade I and II posted for elective transurethral resection of prostate surgeries were included in the study and randomly allocated into three groups. All three groups received 3ml of intrathecal 0.5% bupivacaine heavy, followed by infusion of study drug.Group D5 received intravenous dexmedetomidine 0.5mcg/kg over 10 min,Group D2 intravenous dexmedetomidine 0.25mcg/kg over 10 min and Group NS received infusion of same volume of normal saline as placebo.Duration of analgesia,time to 1st analgesia request,VAS score,hemodynamics and side effects were recorded and analyzed. Results:The prolongation in duration of analgesia in D5 group was statistically significant in comparison to other groups. Time to 1st analgesia request was delayed in group D5 compared to other groups which was statistically significant. Hemodynamic stability was well maintained in both dexmedetomidine group. Conclusion:Intravenous dexmedetomidine not only increased the duration of spinal analgesia but also maintained hemodynamic stability. IV Dexmedetomidine in a dose of 0.5 mcg/kg was more effective than 0.25 mcg/kg without increasing the risk of adverse effect. [ABSTRACT FROM AUTHOR]

Background: Robot-assisted laparoscopic partial nephrectomy (RAPN) for renal tumor treatment provides ergonomic advantages to surgeons and improves surgical outcomes. However, moderate-to-severe pain is unavoidable even after minimally invasive surgery. Despite the growing interest in multimodal analgesia, few studies have directly compared its efficacy with intrathecal morphine, a traditional opioid-based analgesic. Methods: We retrospectively investigated the efficacy of multimodal analgesia compared with that of intrathecal analgesia and intravenous patient-controlled analgesia (IV-PCA) in patients who underwent transperitoneal RAPN at our institute between 2020 and 2022. Among the 334 patients who met the inclusion criteria, intrathecal analgesia using morphine 200 µg was performed in 131 patients, and multimodal analgesia, including transversus abdominis plane block and intraoperative infusion of paracetamol 1 g and nefopam 20 mg, was administered to 105 patients. The remaining 98 patients received postoperative IV-PCA alone. Results: As the primary outcome, the area under the curve of pain scores over 24 h was significantly lower in the intrathecal analgesia and multimodal analgesia groups than in the IV-PCA group (89 [62–108] vs. 86 [65–115] vs. 108 [87–126] h, p < 0.001). Cumulative opioid requirements were also significantly lower in the intrathecal analgesia and multimodal analgesia groups at 24 h after surgery (p < 0.001). However, postoperative nausea and vomiting were significantly increased in the intrathecal analgesia group (27.5% vs. 13.3% vs. 13.3%, p = 0.005). Conclusions: Multimodal analgesia with a transversus abdominis plane block is an efficient analgesic method with fewer adverse effects compared to other analgesic methods. Our findings suggest the efficacy and safety of a multimodal approach for opioid-sparing analgesia after RAPN in the current opioid epidemic. [ABSTRACT FROM AUTHOR]

Spasticity is a potentially debilitating symptom of various acquired and congenital neurologic pathologies that, without adequate treatment, may lead to long-term disability, compromise functional independence, and negatively impact mental health. Several conservative as well as non-nerve targeted surgical strategies have been developed for the treatment of spasticity, but these may be associated with significant drawbacks, such as adverse side effects to medication, device dependence on intrathecal baclofen pumps, and inadequate relief with tendon-based procedures. In these circumstances, patients may benefit from nerve-targeted surgical interventions such as (i) selective dorsal rhizotomy, (ii) hyperselective neurectomy, and (iii) nerve transfer. When selecting the appropriate surgical approach, preoperative patient characteristics, as well as the risks and benefits of nerve-targeted surgical intervention, must be carefully evaluated. Here, we review the current evidence on the efficacy of these nerve-targeted surgical approaches for treating spasticity across various congenital and acquired neurologic pathologies. [ABSTRACT FROM AUTHOR]

Leptomeningeal metastasis (LM) is a serious late complication in patients with solid tumors, which is common in patients with lung cancer, breast cancer and melanoma. In recent years, due to the progress of diagnosis, the diagnosis rate of LM has gradually increased. The main goal of the therapy is to maintain neurological function, improve the quality of life and the overall survival rate, and prolong the progression-free survival time of patients. Intrathecal therapy is one of the main treatments for LM, which can deliver drugs directly to the subarachnoid space. The traditional intrathecal drugs are methotrexate, cytarabine and thiotepa. With the development of new research, a variety of chemotherapeutic drugs, targeted drugs and immune checkpoint inhibitors have also been used in intrathecal therapy. In addition, different ways of intrathecal administration also bring new hope to patients. This article reviewed the clinical research progress of intrathecal therapy in the treatment of LM. [ABSTRACT FROM AUTHOR]

39-year-old male patient with solitary fibrous tumor of the right hip with advanced disease presenting severe mixed pain, with frequent episodes of breakthrough pain, refractory to analgesic treatment. Disabling pain, with significant deterioration of quality of life and with adverse effects due to high systemic opioid requirements. The patient was considered tributary to intrathecal therapy with implantation of variable internal flow pump with MyPTM™ system (Personal Therapy Manager), which allows continuous perfusion of medication and administration by the patient himself of intrathecal rescue bolus, thus reducing the need for systemic medication and the adverse effects derived from it. The implementation of the MyPTM™ system, with the possibility of autonomous rescue administration, achieved optimal pain control, eliminating the need for systemic opioid rescue, reducing adverse effects and improving the patient’s quality of life and functionality. [ABSTRACT FROM AUTHOR]

Background: Spinal anesthesia is the most popular regional anesthesia technique for lower limb and lower abdominal surgery. Bupivacaine 0.5% heavy is commonly used for intrathecal use. New long-acting local anesthetic agents such as ropivacaine have claimed benefits of reduced cardiac toxicity on overdose and more specific effects on sensory rather than motor nerve fibers. The use of intrathecal hyperbaric ropivacaine is not much studied. With this background, we studied intrathecal ropivacaine hyperbaric 0.75% against intrathecal bupivacaine hyperbaric 0.5% for lower abdominal and lower limb surgery. Aims and Objectives: To note the effectiveness of intrathecal ropivacaine and bupivacaine on characteristics of subarachnoid block such as sensory block, motor block, hemodynamic parameters, and complications if any. Materials and Methods: We randomized patients undergoing lower abdominal surgeries and lower limb orthopedic surgeries under spinal anesthesia into two groups so as to receive intrathecal either ropivacaine 0.75% hyperbaric (3 mL) or bupivacaine 0.5% hyperbaric (3mL) and noted study parameters. Results: Time of sensory block onset (P=0.0005), peak sensory level (P=0.0029), and onset of L1 bromage-3 motor block (P=1.27E--08) was significantly delayed in the ropivacaine group as compared to bupivacaine group. However, maximum sensory level achieved (T6), time required for two-segment sensory regressions (P=0.1162), and time of onset of pain (P=0.1162) were comparable in both groups. Conclusion: Intrathecal ropivacaine 0.75% hyperbaric produced slow onset sensory and motor block than 0.5% hyperbaric bupivacaine with comparable cephalic spread and duration of sensory block. [ABSTRACT FROM AUTHOR]

The use of intrathecal (IT) dexamethasone during subarachnoid block (SAB) has not been evaluated. There are no pooled data available to decide on the optimal regimen of IT dexamethasone during SAB, irrespective of the type of surgery. There is uncertainty about its dosage, effectiveness, and safety, and a need to establish clear guidelines on its use. Our objective was to evaluate the effectiveness and safety of use of IT dexamethasone during SAB. We performed a meta-analysis (PROSPERO, CRD42022304944) of trials that included patients who underwent a variety of surgical procedures under SAB. Patients received concomitant IT dexamethasone as an adjuvant to spinal local anesthetics. The analyzed outcomes included sensory and motor effects as well as adverse and/or beneficial side effects. Subgroup analysis was planned based on different doses used. Trial sequential analysis (TSA) was used to estimate the required sample size information (RIS) for each outcome. Eighteen studies (2531 participants) were included in this analysis. Addition of IT dexamethasone (4-8 mg) to heavy bupivacaine effectively prolonged the duration of sensory blockade (mean difference, MD = 63.8 minutes; [95% confidence interval, CI, 33.1-94.5], P < 0.0001), two-segment regression time (MD = 20.1[95% CI, 0.96-39.2], P = 0.04) and first rescue analgesic time (MD = 143.3 [95% CI, 90.3-196.0], P = 0.001). Subgroup analyses revealed superior effects of 8 mg dose over 4 mg for sensory and analgesic effects. The effect of dexamethasone on duration of motor blockade was inconclusive. Additionally, lower risk ratios (RRs) were recorded for spinal anesthesia-related hypotension (RR = 0.74 [95% CI, 0.6-0.9], P = 0.0003) and nausea/vomiting (RR = 0.62 [95% CI, 0.41-0.93], P = 0.02) in the dexamethasone group. For outcomes such as sensory blockade, analgesia, and hypotension, the required information size was reached during TSA. In conclusion, IT dexamethasone, used as an adjuvant to spinal local anesthetic, especially at the dose of 8 mg, increases sensory blockade duration and the time for request of the first rescue analgesic. SAB-induced side effects such as hypotension, nausea, and vomiting are lesser with the use of IT dexamethasone. However, further studies are necessary to draw meaningful conclusions on its safety profile. [ABSTRACT FROM AUTHOR]

Background: Postoperative pain management can be achieved by adjuvant medications during the analgesia procedure. The study investigated the effect of intrathecal dexamethasone-bupivacaine combination with bupivacaine alone in spinal anesthesia for cesarean delivery. Methods: This randomized, double-blind clinical examination included 50 females who had previously experienced a cesarean section. The participants were assigned randomly into two categories: the intervention group, received intrathecal bupivacainedexamethasone, and the control group, received intrathecal bupivacaine-normal saline. Levels of pain were evaluated using a 10 cm visual analog scale (VAS) at intervals of 30 minutes, 1 hour, 2 hours after the operation. The span of the sensory block and postoperative analgesia were assessed. Results: The inclusion of intrathecal dexamethasone with bupivacaine resulted in a significant enhancement in the duration of pain relief during the intervention, lasting for an average of 473.4 ± 39.95 minutes (p<0.001). The duration of sensory and motor block analgesia in the intervention group was more than the control group (128.32 ± 7.30 vs. 92.84 ± 7.84) and (155.6±12.34 vs. 126.16±11.89), respectively (p<0.001). Pain score on the VAS scale at 30, 60, and 120 minutes was significantly lower in the intervention group (p<0.001). There was no difference in side effects and onset time between the study groups. Conclusion: The inclusion of intrathecal dexamethasone alongside bupivacaine has demonstrated enhancement in the duration of sensory block during spinal anesthesia. This improvement was observed without any alterations in the time it takes for the anesthesia to take effect and without any adverse effects during the postoperative period. [ABSTRACT FROM AUTHOR]

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Background: Hyperornithinemia-hyperammonemia-homocitrullinuria (HHH) syndrome is a rare autosomal recessive urea cycle disorder associated with a high risk of exacerbation of hyperammonemia during the perioperative period. Here, we describe an adult patient with HHH syndrome who developed hyperammonemic encephalopathy secondary to postoperative constipation. Case presentation: A 52-year-old patient with HHH syndrome underwent intrathecal baclofen pump insertion for lower limb spasticity under general anesthesia. The surgery was uneventful, without any increase in serum ammonia levels. However, after surgery, he was constipated, and on postoperative day (POD) 3, he fell into a coma with an exacerbation of hyperammonemia (894 µg/dL). After administering a glycerin enema, he defecated, leading to a rapid decrease in serum ammonia levels to 165 µg/dL. He regained consciousness, and serum ammonia levels remained stable as long as he defecated. Conclusions: We suggest strict management of defecation during the perioperative period to prevent hyperammonemia in patients with HHH syndrome. [ABSTRACT FROM AUTHOR]

While Enhanced Recovery After Surgery (ERAS) protocols are becoming more common in pediatric surgery, there is still little published about protocol compliance and sustainability. This is a prospective observational study to evaluate the compliance of an ERAS protocol for pectus repair at a large academic children's hospital. Our primary outcome was overall protocol compliance at 1-y postimplementation of the ERAS protocol. Our comparison group included all pectus repairs for 2 y before protocol implementation. Overall protocol compliance at 12 mo was 89%. Of the 16 pectus repairs included in the ERAS protocol group, 94% (n = 15) and 94% (n = 15) received preoperative acetaminophen and gabapentin, respectively, which was significantly greater than the historical control group (P < 0.001). For the intraoperative components analyzed, only the intrathecal morphine was significantly different than historical controls (100% versus 49%, P < 0.001). Postoperatively, the time from operating room to return to normal diet was shorter for the ERAS group (0.53 d versus 1.16 d, P < 0.001). There was no significant difference in readmission rates between the two groups. ERAS protocol compliance varies based on phase of care. Solutions to sustain protocols depend on the institution and the patient population. However, the utilization of implementation science fundamentals was invaluable in this study to identify and address areas for improvement in protocol compliance. Other institutions may adapt these strategies to improve protocol compliance at their centers. • Implementation of ERAS protocols has been shown to improve clinical outcomes. • ERAS protocol compliance and sustainability can be improved using fundamentals of implementation science. Methods that can be broadly applied in pediatric surgery are highlighted in this article. [ABSTRACT FROM AUTHOR]

Justin Weppner, DO, Andrea Conti, DO, Tonja M. Locklear, PhD, and Robert Samuel Mayer, MD Objective: This study compared the effectiveness of traditional lectures and microvideos in teaching baclofen pump programming and refilling to physicians who have completed less than 10 refills for the previous 2 yrs. Design: A mixed-method approach was used with 60 participating physicians specializing in physical medicine and rehabilitation or pain management. Preintervention and postintervention assessments were conducted using a rubric, and the participants' perceptions and preferences were gathered through focus group sessions. Results: Two thirds of the participants specialized in physical medicine and rehabilitation. No significant differences in the preintervention, postintervention, or knowledge retention scores were found between the traditional lecture and microvideo groups. Both methods demonstrated comparable effectiveness in improving the baclofen pump refilling and programming skills. Qualitatively, participants perceived both approaches as equally helpful, but those in the microvideo group raised concerns because of instructors' unavailability and online platform navigation. Nevertheless, they preferred the convenience, accessibility, and time efficiency of the microvideos. Conclusions: The study concluded that microvideos are an effective alternative to traditional lectures for acquiring knowledge on baclofen pump programming and refilling. Further research should consider learners' characteristics and investigate the benefits of blended learning in medical education. [ABSTRACT FROM AUTHOR]

Background: Gastrodin (GAS), a main bioactive component of the herbal plant, Gastrodia elata Blume, has shown to have beneficial effects on neuroinflammatory diseases such as Alzheimer's disease in animal studies and migraine in clinical studies. Inflammasome is a multimeric protein complex having a core of pattern recognition receptor and has been implicated in the development of neuroinflammatory diseases. Gastrodin has shown to modulate the activation of nucleotide-binding oligomerization domain (NOD)-like receptor protein 3 (NLRP3) inflammasome. This study investigated the effects of GAS on the intensity of mechanical allodynia and associated changes in NLRP3 inflammasome expression at the spinal level using L5/6 spinal nerve ligation model (SNL) in rats. Methods: Intrathecal (IT) catheter implantation and SNL were used for drug administration and pain model in male Sprague-Dawley rats. The effect of gastrodin or MCC950 (NLRP3 inflammasome inhibitor) on mechanical allodynia was measured by von Frey test. Changes in NLRP3 inflammasome components and interleukin-1β (IL-1β) and cellular expression were examined in the spinal cord and dorsal root ganglion. Results: The expression of NLRP3 inflammasome components was found mostly in the neurons in the spinal cord and dorsal root ganglion. The protein and mRNA levels of NLRP3, apoptosis-associated speck-like protein containing a caspase recruitment domain (ASC), caspase-1, and IL-1β were upregulated in SNL animals compared to Sham animals. IT administration of GAS significantly attenuated the expression of NLRP3 inflammasome and the intensity of SNL-induced mechanical allodynia. NLRP3 inflammasome inhibitor, MCC950, also attenuated the intensity of allodynia, but the effect is less strong and shorter than that of GAS. Conclusions: Expression of NLRP3 inflammasome and IL-1β is greatly increased and mostly found in the neurons at the spinal level in SNL model, and IT gastrodin exerts a significant anti-allodynic effect in SNL model partly through suppressing the expression of NLRP3 inflammasome. [ABSTRACT FROM AUTHOR]

Background and Objectives: This study aimed to investigate the relationship between neuropathic pain and CREB-binding protein (CBP) and methyl-CpG-binding protein 2 (MeCP2) expression levels in a rat model with spared nerve injury (SNI). Materials and Methods: Rat (male Sprague-Dawley white rats) models with surgical SNI (n = 6) were prepared, and naive rats (n = 5) were used as controls. The expression levels of CBP and MeCP2 in the spinal cord and dorsal root ganglion (DRG) were compared through immunohistochemistry at 7 and 14 days after surgery. The relationship between neuropathic pain and CBP/MeCP2 was also analyzed through intrathecal siRNA administration. Results: SNI induced a significant increase in the number of CBPs in L4 compared with contralateral DRG as well as with naive rats. The number of MeCP2 cells in the dorsal horn on the ipsilateral side decreased significantly compared with the contralateral dorsal horn and the control group. SNI induced a significant decrease in the number of MeCP2 neurons in the L4 ipsilateral DRG compared with the contralateral DRG and naive rats. The intrathecal injection of CBP siRNA significantly inhibited mechanical allodynia induced by SNI compared with non-targeting siRNA treatment. MeCP2 siRNA injection showed no significant effect on mechanical allodynia. Conclusions: The results suggest that CBP and MeCP2 may play an important role in the generation of neuropathic pain following peripheral nerve injury. [ABSTRACT FROM AUTHOR]

Background: Yokukansan, a traditional Japanese medicine (Kampo), has been widely used to treat neurosis, dementia, and chronic pain. Previous in vitro studies have suggested that Yokukansan acts as a partial agonist of the 5-HT1A receptor, resulting in amelioration of chronic pain through inhibition of nociceptive neuronal activity. However, its effectiveness for treating postoperative pain remains unknown, although its analgesic mechanism of action has been suggested to involve serotonin and glutamatergic neurotransmission. This study aimed to investigate the effect of Yokukansan on postoperative pain in an animal model. Methods: A mouse model of postoperative pain was created by plantar incision, and Yokukansan was administered orally the day after paw incision. Pain thresholds for mechanical and heat stimuli were examined in a behavioral experiment. In addition, to clarify the involvement of the serotonergic nervous system, we examined the analgesic effects of Yokukansan in mice that were serotonin-depleted by para-chlorophenylalanine (PCPA) treatment and intrathecal administration of NAN-190, 5-HT1A receptor antagonist. Results: Orally administered Yokukansan increased the pain threshold dose-dependent in postoperative pain model mice. Pretreatment of para-chlorophenylalanine dramatically suppressed serotonin immunoreactivity in the spinal dorsal horn without changing the pain threshold after the paw incision. The analgesic effect of Yokukansan tended to be attenuated by para-chlorophenylalanine pretreatment and significantly attenuated by intrathecal administration of 2.5 µg of NAN-190 compared to that in postoperative pain model mice without para-chlorophenylalanine treatment and NAN-190 administration. Conclusion: This study demonstrated that oral administration of Yokukansan has acute analgesic effects in postoperative pain model mice. Behavioral experiments using serotonin-depleted mice and mice intrathecally administered with a 5-HT1A receptor antagonist suggested that Yokukansan acts as an agonist at the 5-HT1A receptor, one of the serotonin receptors, to produce analgesia. [ABSTRACT FROM AUTHOR]

BACKGROUND: A growing body of evidence has shown that activating spinal cord glial cells (typically astrocytes and microglial cells) is closely related to hyperpathia and persistent pain. OBJECTIVE: To investigate the expression of GFAP and CR3/CD11b in cornu dorsale medullae spinalis of rats with nonbacterial prostatitis, to explore the therapeutic efficacy and action mechanism of intrathecal injection of BNP alleviating chronic neuropathic pain. METHODS: Eighteen male SPF SD rats were randomly divided into sham operation control group, nonbacterial prostatitis group (NBP) and intrathecal injection BNP group, the NBP model was established by intraprostatic injection of CFA, and the spinal cord of L6-S1 segment was extracted seven days after intrathecal injection of BNP; The expression of GFAP and CR3/CD11b in dorsal horn of spinal cord were detected by immunofluorescence and Western blot. RESULTS: The cumulative optical density values of GFAP and CR3/CD11b immunofluorescence assay in the NBP group were higher than those in the sham operation group, with statistical significance (p ⁢ < ⁢ ¼ ⁢ 0.01); The expression of GFAP and CR3/CD11b in intrathecal injection BNP group were lower than those in NBP group, the differences were statistically significant (p ⁢ < ⁢ ¼ ⁢ 0.01). Western blot results showed that the expression of GFAP and CR3/CD11B in NBP group were higher than those in sham operation group, with statistical significance (p ⁢ < ⁢ ¼ ⁢ 0.05). The expression of GFAP and CR3/CD11B in intrathecal injection BNP group were lower than those in NBP group, the differences were statistically significant (p ⁢ < ⁢ ¼ ⁢ 0.05). CONCLUSION: Intrathecal injection of BNP can down-regulate the expressions of GFAP and CR3/CD11b in L6-S1 spinal cord of NBP rat model and to further inhibit chronic pain caused by NBP. [ABSTRACT FROM AUTHOR]

Serratus posterior intercostal plane block (SPSIPB) is a novel periparavertebral block. It provides anterolateral posterior chest wall analgesia. It is an interfascial plane block, performed under ultrasound guidance, and the visualization of landmarks is easy. It is performed deep into the serratus posterior superior muscle at the level of the third rib. Until now, there have been case reports about the usage of single-shot SPSIPB, but there are no reports about the usage of the block catheterization technique of SPSIPB. Continuous infusion from a catheter of interfascial plane blocks is important for postoperative analgesia management after painful surgeries such as thoracic and cardiac surgeries. Thus, we performed SPSIPB catheterization in a patient who underwent right atrial mass excision with minimally invasive thoracotomy surgery. Here, we present our successful analgesic experience with continuous SPSIPB in this case report. [ABSTRACT FROM AUTHOR]

Background: When it comes to orthopedic surgeries involving the lower limbs, spinal anesthesia offers the most predictable block due to the strong sensory as well as motor block that it provides, with the benefits of avoiding the risks of general anesthesia. This study aimed for comparing intrathecal dexamethasone versus intravenous dexamethasone on the quality of spinal anesthesia in lower limb orthopedic surgeries. Methods: We carried out this prospective randomized controlled study on 63 adult patients who undergoing orthopedic lower limb procedures under the influence of spinal anesthesia; they were randomized into three equal groups (each containing 21 patients): group C (control), group V (intravenous dexamethasone) and group S (intrathecal dexamethasone). The Visual Analogue Scale (VAS) was done at first admission to the PACU, then at 1, 3, 6,12, and 24 hours at rest and during movement with an assessment of complications postoperatively. Results: A significant longer duration of sensory block was revealed in group S compared to both group C and group V (191.43 ± 25.94, 109.52 ± 7.4, 110.67± 11.14, respectively). The visual analogue scale (VAS) was higher in the control group at 1, 3, and 6 hours postoperatively, especially at 3 hours. A statistically significant difference existed between the studied groups as regards intraoperative complications (P<0.001) in the control group; only six patients (28.6%) passed uncomplicated versus 76.2% of the patients who was given intravenous dexamethasone and 81% of the patients who was given intrathecal dexamethasone. Conclusion: Adding Intrathecal dexamethasone to bupivacaine in spinal anesthesia was associated with longer duration and level of sensory block, lower VAS and the total amount of rescue analgesia with decreasing complications of spinal anesthesia as hypotension, shivering, and vomiting compared to intravenous route administration. [ABSTRACT FROM AUTHOR]

Background: Intrathecal Drug Delivery Systems (IDDS) are underused in the management of cancer-related pain despite evidence of both efficacy and survival benefit. There is currently limited evidence to indicate which patients might benefit most from IDDS. Aim: The aim of the study was to describe the baseline characteristics and survival outcomes of patients who accepted IDDS, patients who declined IDDS and patients who wished to go ahead with IDDS but whose condition deteriorated before they could do so. Design/participants: The survival data for 75 consecutive patients who had been offered intrathecal drug delivery were examined as part of a retrospective cohort study. Survival data was compared between three groups: those who accepted intrathecal drug delivery and went on to receive it (n = 41), those who accepted it but whose condition deteriorated before it commenced (n = 17) and those who declined this treatment modality (n = 17). Results: Patients who received IDDS survived significantly longer after assessment compared to those who declined IDDS (hazard ratio (HR) for the IDDS group relative to the declined group 0.29 (95% CI 0.16 to 0.53), and 0.23 (95% CI 0.12 to 0.44) after adjustment for gender and baseline functional status. In patients who accepted IDDS but who were unable to commence treatment, survival after assessment was not significantly different from those who declined the IDDS (HR for the deteriorated group relative to the declined group 1.28 (95% CI 0.65 to 2.53), and 0.80 (95% CI 0.65 to 2.53) after adjustment for gender and baseline functional status). Conclusion: In this retrospective analysis, an improvement in survival may be associated with patients who accept ongoing pain management with an implanted intrathecal drug delivery system compared to those patients who either declined intrathecal drug delivery or deteriorated before it could be commenced. [ABSTRACT FROM AUTHOR]

The International Association for the Study of Pain defines pain as «an unpleasant sensory and emotional experience associated with, or described in terms of, actual or potential tissue damage». The management of refractory chronic pain is complex. Intrathecal therapy is considered a safe and effective treatment. However, the psychological and social impact also needs to be considered. Ziconotide is an intrathecal drug and a first-line treatment for refractory chronic pain. We present the case of a patient with neuropathic pain after resection of an ependymoma and disc herniation. After failure of pharmacological therapy and spinal cord stimulation, it was decided to implant an intrathecal ziconotide infusion pump. Despite clinical improvement, the patient developed an anxious-depressive disorder and considered euthanizing. The patient was treated with acceptance and commitment therapy, showed improvement in the emotional scale and physical activity, and refused the request for euthanasia. [ABSTRACT FROM AUTHOR]

Background: Ziconotide is an intrathecal drug administered for the treatment of chronic pain. The current literature lacks an exhaustive benefit/risk assessment on this drug. We herein focus on Ziconotide's pharmacology and clinical applications. Methods: Literature research was conducted to identify studies on Ziconotide administration for the treatment of chronic pain, published between January 1990 and March 2023 and located via PubMed, Embase, Medline, Cinahl, and Web of Science, using the following keywords: Ziconotide, Omega conotoxin, Prialt, SNX-111, intrathecal therapy, and neuropathic pain. Only publications written in English were selected. Results: Among the 86 selected studies, we found 4 Randomized Controlled Trials (RCTs) and 3 prospective long-term studies concerning the intrathecal use of Ziconotide as a monotherapy in chronic pain. Other studies described the intrathecal infusion of Ziconotide combined with other drugs. Overall, Ziconotide has been proved to have strong efficacy for relieving chronic pain, although patients with co-morbid psychiatric disorders require a careful monitoring when treated with Ziconotide. Conclusions: Overall, the use of Ziconotide, as a monotherapy or in conjunction with other therapies for the treatment of chronic pain, was reported to be efficacious. Overall, its use in patients with chronic pain refractory to other pharmacologic agents outweighs the possible adverse consequences, thus resulting in a favorable benefit/risk assessment. [ABSTRACT FROM AUTHOR]

Purpose: Intrathecal vasoactive drugs have been proposed in patients with aneurysmal subarachnoid hemorrhage (aSAH) to manage cerebral vasospasm (CV). We analyzed the efficacy of intracisternal nicardipine compared to intraventricular administration to a control group (CG) to determine its impact on delayed cerebral ischemia (DCI) and functional outcomes. Secondary outcomes included the need for intra-arterial angioplasties and the safety profile. Methods: We performed a retrospective analysis of prospectively collected data of all adult patients admitted for a high modified Fisher grade aSAH between January 2015 and April 2022. All patients with significant radiological CV were included. Three groups of patients were defined based on the CV management: cisternal nicardipine (CN), ventricular nicardipine (VN), and no intrathecal nicardipine (control group). Results: Seventy patients met the inclusion criteria. Eleven patients received intracisternal nicardipine, 18 intraventricular nicardipine, and 41 belonged to the control group. No cases of DCI were observed in the CN group (p = 0.02). Patients with intracisternal nicardipine had a reduced number of intra-arterial angioplasties when compared to the control group (p = 0.03). The safety profile analysis showed no difference in complications across the three groups. Intrathecal (ventricular or cisternal) nicardipine therapy improved functional outcomes at 6 months (p = 0.04) when compared to the control group. Conclusion: Administration of intrathecal nicardipine for moderate to severe CV reduces the rate of DCI and improved long-term functional outcomes in patients with high modified Fisher grade aSAH. This study also showed a relative benefit of cisternal over intraventricular nicardipine, thereby reducing the number of angioplasties performed in the post-treatment phase. However, these preliminary results should be confirmed with future prospective studies. [ABSTRACT FROM AUTHOR]

PURPOSE: The use of intrathecal medications for the management of spasticity and various pain syndromes in the adult population has been previously reported. However, no evidence-based guidelines currently exist in the pediatric population. This case series presents patients (n = 8) with pediatric-onset disability who underwent placement of intrathecal baclofen pumps initially for management of severe spasticity. Despite titration of dose and use of oral analgesia, their uncontrolled pain persisted. Each patient was transitioned to a combination of baclofen and analgesic intrathecal therapy. The outcome in pain improvement and quality of life, as reported by patients and/or caregivers, were retrospectively reviewed. METHODS: Retrospective review of the background and decision-making process regarding transition to combination intrathecal therapy identified patient selection characteristics. Each patient and/or their caregivers completed a survey regarding improvements in pain, spasticity, function, and quality of life following initiation of combination intrathecal medications. RESULTS: Survey results revealed improvements in functional and pain assessments after initiation of combination baclofen and analgesic intrathecal medication. Patients and caregivers reported decreases in pain and oral spasticity medications. CONCLUSION: Use of pumps with antispasmodic and analgesic medication for combination intrathecal medication delivery should be considered in the management of patients with childhood-onset disabilities who have both severe spasticity and pain. [ABSTRACT FROM AUTHOR]

Patients suffering from refractory acute promyelocytic leukemia with central nervous system relapse often have a poor prognosis. Among these patients, those with PLZF::RARA rearrangement exhibit poor responses to all-trans retinoic acid and conventional chemotherapy. Venetoclax, a selective inhibitor of B-cell lymphoma-2, can cross the blood–brain barrier and has been widely applied to acute myeloid leukemia therapy recently. A case of central nervous system relapse in a patient with acute promyelocytic leukemia harboring PLZF::RARA rearrangement was successfully treated with anthracycline cytotoxic chemotherapy and cytarabine in combination with venetoclax, resulting in complete remission. Liquid chromatography-tandem mass spectrometry revealed that the concentration of venetoclax in the cerebrospinal fluid (CSF) was approximately 1/1,000 of that in plasma. Following the first treatment course, the patient's bone marrow sample tested negative for PLZF::RARA. After the third treatment course, abnormal promyelocytic leukemia cells in the CSF were not detected using flow cytometry, and the PLZF::RARA test in the CSF remained negative. This case report highlights a new approach for the treatment of central nervous system relapse in patients with PLZF::RARA-positive acute promyelocytic leukemia. [ABSTRACT FROM AUTHOR]

Purpose: To provide an overview of outcome and complications of selective dorsal rhizotomy (SDR) and intrathecal baclofen pump implantation (ITB) for spasticity treatment in children with hereditary spastic paraplegia (HSP). Methods: Retrospective study including children with HSP and SDR or ITB. Gross motor function measure (GMFM-66) scores and level of spasticity were assessed. Results: Ten patients were included (most had mutations in ATL1 (n = 4) or SPAST (n = 3) genes). Four walked without and two with walking aids, four were non-walking children. Six patients underwent SDR, three patients ITB, and one both. Mean age at surgery was 8.9 ± 4.5 years with a mean follow-up of 3.4 ± 2.2 years. Five of the SDR patients were walking. Postoperatively spasticity in the legs was reduced in all patients. The change in GMFM-66 score was + 8.0 (0–19.7 min–max). The three ITB patients treated (SPAST (n = 2) and PNPLA6 (n = 1) gene mutation) were children with a progressive disease course. No complications of surgery occurred. Conclusions: SDR is a feasible treatment option in carefully selected children with HSP, especially in walking patients. The majority of patients benefit with respect to gross motor function, complication risk is low. ITB was used in children with severe and progressive disease. [ABSTRACT FROM AUTHOR]

Background and Aims: Thoracic continuous spinal anaesthesia (TCSA) is emerging as the sole anaesthetic for major abdominal surgery due to its better perioperative outcomes. This study was designed to evaluate block characteristics and outcomes in 'opioid-free' and 'opioid-based' TCSA. Methods: After ethical approval, trial registration and written informed consent, 50 adult patients undergoing major abdominal surgery were randomised into 'opioid-free' (bupivacaine alone) and 'opioid-based' (bupivacaine with fentanyl) groups. After confirmation of T4-L1 dermatome level of spinal anaesthesia, sedation by intravenous (IV) midazolam (0.02–0.05 mg/kg), ketamine (0.25 mg/kg) and dexmedetomidine (bolus dose of 1 μg/kg IV over 10 min followed by 0.2–0.7 μg/kg/h infusion) were started. The primary outcome measured was postoperative pain scores for 72 h in both groups. The secondary objectives were rescue opioid requirement, and the dose of bupivacaine required to achieve T4 level. Data were compared using the two-sided Student t-test, Mann-Whitney and Fisher's exact tests. Results: The 'opioid-based' group performed significantly better compared with the 'opioid-free' group concerning pain scores at rest at 0 h (P = 0.023), 18 h (P = 0.023) and 24 h (P = 0.016) postoperatively, decreased intrathecal bupivacaine requirement [(induction (P = 0.012) and maintenance (P = 0.031)], postoperative rescue fentanyl requirement (P = 0.018) and patient satisfaction (P = 0.032) at the cost of increased postoperative nausea and vomiting (P = 0.049). Conclusion: The 'opioid-based' TCSA provided better postoperative analgesia with significantly lesser postoperative pain scores when compared to the 'opioid-free' group in patients undergoing major abdominal surgery. [ABSTRACT FROM AUTHOR]

Nowadays, obstetrical anesthesia-related mortality is a very rare complication in industrialized countries. The recommended choice of intrathecal opioid for spinal anesthesia in the context of a multimodal peripartum pain management concept is discussed in this narrative review. Nowadays, there is a consensus that a perioperative multimodal pain concept should be used for caesarean delivery. This pain concept should include neuraxial opioids for spinal anesthesia, acetaminophen, NSAIDs, intravenous dexamethasone, and postoperative local or regional anesthetic procedures. Long-acting lipophobic opioids (diamorphine and morphine) have a significant analgesic advantage over short-acting lipophilic opioids (sufentanil and fentanyl). The risk of clinically relevant respiratory depression after neuraxial long-acting opioids is nowadays considered negligible, even if the data situation is weak in this regard. The question remains as to whether a pain concept that is ideally adapted to a neuraxial short-acting opioid shows benefit to a pain concept that is optimally adapted to neuraxial morphine. If long-acting opioids are used, the timing of each additional component of the multimodal analgesia strategy could ideally be adjusted to this longer duration of action. [ABSTRACT FROM AUTHOR]

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Background: Extensive metastatic and refractory cancer pain is common, and exhibits a dissatisfactory response to the conventional intrathecal infusion of opioid analgesics. Case Presentation: The present study reports a case of an extensive metastatic esophageal cancer patient with severe intractable pain, who underwent translumbar subarachnoid puncture with intrathecal catheterization to the prepontine cistern. After continuous infusion of low-dose morphine, the pain was well-controlled with a decrease in the numeric rating scale (NRS) of pain score from 9 to 0, and the few adverse reactions to the treatment disappeared at a low dose of morphine. Conclusions: The patient achieved a good quality of life during the one-month follow-up period. [ABSTRACT FROM AUTHOR]

Neurological disorders are common, yet many neurological diseases don't have efficacious treatments. The protected nature of the brain both anatomically and physiologically through the blood brain barrier (BBB) make it exceptionally hard to access. Recent advancements in interventional approaches, like the Stentrode™, have opened the possibility of using the cerebral vasculature as a highway for minimally invasive therapeutic delivery to the brain. Despite the immense success that the Stentrode™ has faced recently, it is limited to major cerebral vasculature and exists outside the BBB, making drug eluting configurations largely ineffective. The present study seeks to identify a separate anatomical pathway for therapeutic delivery to the deep brain using the ventricular system. The intrathecal route, in which drug pumps and spinal cord stimulators are delivered through a lumbar puncture, is a well-established route for delivering therapies to the spinal cord as high as C1. The present study identifies an extension of this anatomical pathway through the foramen of Magendie and into the brains ventricular system. To test this pathway, a narrow self-expanding electrical recording device was manufactured and its potential to navigate the ventricular system was assessed on human anatomical brain samples. While the results of this paper are largely preliminary and a substantial amount of safety and efficacy data is needed, this paper identifies an important anatomical pathway for delivery of therapeutic and diagnostics tools to the brain that is minimally invasive, can access limbic structures, and is within the BBB. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective case-control study. Purpose: This study aimed to investigate the preventive effect of thrombin-containing local hemostatics (TCLH) on postoperative spinal epidural hematoma (POSEH) in biportal endoscopic spinal surgery (BESS). This study compared the incidence of morphometric and symptomatic POSEH with or without TCLH in BESS. Overview of Literature: POSEH is reported not uncommon in BESS when compared with conventional spine surgery (CSS). TCLH achieves hemostasis with a high success rate in CSS. However, few studies have examined the effect of TCLH on BESS. Methods: Patients with and without TCLH were assigned to groups A and B, respectively. POSEH between the two groups was compared morphometrically and symptomatically. The risk factors for symptomatic and morphometric POSEH in BESS were identified. Results: The morphometric POSEH was greater in group B, and the difference was significant (p =0.019). The incidence of symptomatic POSEH was lower in group A with 4.6% (5/109) than in group B with 9.5% (9/95); however, the rate was not significantly different (p =0.136). The morphometric POSEH was classified into two small (hG1 and hG2) and large (hG3 and hG4) and were compared between groups A and B, and the difference was significant (p =0.02). In the multivariable logistic regression, nonuse of TCLH (p =0.004) and preoperative diagnosis of stenosis (p =0.016) were variables found to be significant risk factors of morphometric POSEH. Conclusions: Severe compression of the thecal sac by POSEH is more common in patients without TCLH. The risk of hematoma formation was higher when bilateral decompression was needed and the cut bone surface was more exposed. [ABSTRACT FROM AUTHOR]

Combined Spinal Epidural Anaesthesia (CSEA) combines advantages of both component techniques while precluding their known disadvantages. Further, a low dose intrathecal Bupivacaine followed by sequential epidural doses calculated as per the unblocked number of segments may provide sufficient volume extension to precisely and adequately target the required surgical field. 66 patients scheduled for major surgeries under neuraxial anaesthesia were randomized into two groups. GROUP A (n=33) received CSEA with 1.5 ml 0.5% Hyperbaric Bupivacaine (7.5 mg) intrathecally at L3-L4 site followed by 0.75 ml (16 patients) to 1.5 ml (17 patients) 0.5% plain Bupivacaine per unblocked segments through epidural catheter. GROUP B (n=33) received only 2.5 ml 0.5% Hyperbaric Bupivacaine (12.5 mg) intrathecally at L3-L4 site. The maximun level of sensory block was T11 after spinal component of CSEA in group A and T6 in group B. In group a, subsequent epidural dosing of 0.5% Bupivacaine with 1.5 ml per unblocked segments (stat/increment) in 17 patients raised the level by 6-segments. In the other subgroup of 16 patients who received 0.75 ml per segment epidural dose, there was 4-segment raise in block level. Time for 2-segment regression was 0.6±0.2 hours (Group A) compared to 2.4±0.5 hours (Group B) with p<0.001. The total duration of sensory block was 1.9±0.4 hours (Group A) and 4.8 ± 1 hours (Group B) with p< 0.001. For CSEA in major abdominal surgeries, an intrathecal dose of 1.5 ml 0.5% Hyperbaric Bupivacaine (7.5 mg) is sufficient as initialising dose. The surgical need of analgesia for uncovered segments can be provided predictably with epidural 0.5% plain Bupivacaine as increments of 0.75 ml per required segment. [ABSTRACT FROM AUTHOR]

Background and Aims: Maternal hypotension is a common and dangerous consequence after a subarachnoid block for a caesarean section. Combining pharmacological methods such as norepinephrine infusion, ondansetron and non-pharmacological methods in delayed supine positioning better impacts the maternal haemodynamic profile. The present study assessed the benefits and adverse effects of combining pharmacological and non-pharmacological methods in hypotension prophylaxis. Methods: This randomised controlled trial was conducted at Cairo University Hospital's obstetric theatre from January to October 2020. The study included 85 parturients who were randomised to two groups. Group Sitting was left seated for 2 min after injection, and Group Control was made to lie down in the supine position immediately after the subarachnoid block. Both groups received prophylactic intravenous norepinephrine infusion, in addition to an ondansetron bolus, before surgery. Patients' systolic blood pressure (SBP) from intrathecal injection until delivery of the foetus, was documented. Results: The Sitting group's SBP (122 (14) mmHg) till delivery was statistically higher than the Control group's readings (114 (10) mmHg) (P = 0.004). The Sitting group's intraoperative SBP values were often greater than the Control group values. In addition, the Sitting group had a reduced hypotension incidence and a lower rate of ephedrine use than the other group, but bradycardia incidence was comparable between both groups. Conclusion: In elective caesarean delivery, combining pharmacological and non-pharmacological methods achieve better results regarding maternal hypotension, vasopressor consumption, nausea and vomiting, and foetal outcomes. [ABSTRACT FROM AUTHOR]

Background: Spinal adhesive arachnoiditis is a chronic inflammatory process of the leptomeninges and intrathecal neural elements. The possible causes of arachnoiditis are: infections, injuries of spinal cord, surgical procedures and intrathecal administration of therapeutic substances or contrast. Case presentation: We present a case of 56-old woman with spinal muscular atrophy type 3 who developed a severe back pain in the lumbosacral region after the fifth dose of nusinersen given intrathecally. Magnetic resonance of lumbosacral spine showed spinal adhesive arachnoiditis. She received high doses of methylprednisolone intravenously, and later non-steroidal anti-inflammatory drugs, alpha lipoic acid, vitamins and rehabilitation with slight improvement. Conclusions: The authors summarize that scheduled resonance imaging of the lumbosacral spine may be an important element of the algorithm in the monitoring of novel, intrathecal therapy in patients with spinal muscular atrophy. [ABSTRACT FROM AUTHOR]

Summary: We aimed to test whether bilateral injection of bupivacaine 0.25% in the transversalis fascia plane reduced 24 h opioid dose after singleton caesarean section, under spinal anaesthesia with intrathecal morphine, compared with saline 0.9% injectate. We allocated randomly 52 women to bilateral injection of 20 ml saline 0.9% on arrival in the post‐anaesthesia care unit and 54 women to bilateral injection of 20 ml bupivacaine 0.25% (with adrenaline 2.5 μg.ml‐1). Mean (SD) cumulative morphine equivalent opioid dose 24 h after saline injection was 32.3 (28.3) mg and 18.7 (20.2) mg after bupivacaine injection, a mean (95%CI) difference of 13.7 (4.1–23.2) mg (p = 0.006). Median (IQR [range]) time to first postoperative opioid dose was 3.0 (1.5–10.3 [0.0–57.4]) h after saline 0.9% and 8.2 (2.7–29.6 [0.2–55.4]) h after bupivacaine 0.25% (p = 0.054). Transversalis fascia plane with bupivacaine 0.25% with adrenaline reduced postoperative pain at rest during 48 h (0–10‐point scale) by a mean (95%CI) of 0.9 (0.2–1.6) points (p = 0.013) and on movement by 1.2 (0.4–2.1) points (p = 0.004). We conclude that transversalis fascia plane bupivacaine 0.25% with adrenaline reduces pain and opioid dose after caesarean section compared with saline 0.9%. [ABSTRACT FROM AUTHOR]

Introduction: Despite preventive strategies, vomiting is an adverse event affecting patients with cancer. However, literature on the incidence and risk factors for vomiting in pediatric patients with cancer are scarce. Aim: To assess the incidence and risk factors for vomiting within 24 h and goodness of fit for the Eberhart score in pediatric patients with hematologic cancers after receiving intrathecal chemotherapy under deep sedation. Methods: This prospective cohort study included patients under 20 years of age with hematologic cancers who were scheduled to undergo intrathecal chemotherapy under anesthesia. The primary outcome was the occurrence of vomiting within 24 h after the end of anesthesia. Sociodemographic and procedure data and underlying diseases were collected. Patients were monitored during the procedure, in the postanesthesia care unit, and the day after (by phone call). Results: A total of 139 patients were included, and the incidence of vomiting was 30.9% within 24 h after intrathecal chemotherapy under anesthesia, with 90.7% of vomiting prior to 6 h. Prophylactic ondansetron was administered prior to the procedure to 45.3% of patients. Risk factors for vomiting were female gender (hazard ratio: 2.47, 95% confidence interval: 1.35–4.53, p:.003), consolidation phase of treatment (hazard ratio: 2.16, 95% confidence interval: 1.10–4.24, p:.025), and history of kinetosis (hazard ratio: 2.49, 95% confidence interval: 1.31–4.70, p:.005). Incidence of vomit was higher than estimated by the Eberhart score distribution (observed incidence in patients with a score of zero: 33.3%; with a score of one: 28.8%; with a score of two: 60%). Conclusion: A high incidence of vomiting was observed within 24 h after intrathecal chemotherapy under propofol deep sedation. Risk factors for this outcome were established (being female, consolidation phase of treatment, and previous kinetosis), and evidence suggested that the Eberhart score was not suitable for the studied population. [ABSTRACT FROM AUTHOR]

Background: Many adjuvants have been used to increase the analgesic duration of intrathecal bupivacaine. Objective: This work was aimed at comparing intrathecal ketamine vs dexmedetomidine for patients with lower limb surgery regarding advantages, efficacies, and hemodynamic stability. Patients and Methods: This prospective randomized double-blind study involved 100 individuals whose ages ranged from eighteen to fifty years, both sexes, who underwent orthopedic lower limb surgeries. All participants went through an even categorization into two groups: Group D: administering calculated dosage of intrathecal hyperbaric bupivacaine 0.5 % according to body weight and 5µg dexmedetomidine and Group K: administering calculated dosage of intrathecal hyperbaric bupivacaine 0.5 % according to body weight and 0.1 mg/kg of ketamine. Results: Intraoperative HR as well as MAP measurements were significantly higher during 15 min, 30min, 45min and end of surgery within group K as opposed to group D (P value <0.05). Postoperative HR, MAP, SaO2 as well as VAS measurements were significantly less during 30 min, 2h, 4h and 6h within group K as opposed to group D (P value <0.05). Time to first analgesic request was significantly delayed within group K as opposed to group D (P value<0.001). Complications (bradycardia as well as hypotension) were insignificantly varied among two groups. Respiratory depression occurrence was not present in both groups. Conclusions: Ketamine produces better analgesic outcomes compared to dexmedetomidine in patients with lower limb surgery. However, it is associated with higher intraoperative HR and MAP and lower postoperative HR and MAP compared to dexmedetomidine with no difference in complications among them. [ABSTRACT FROM AUTHOR]

Background: This study compared rapid and slow intrathecal fentanyl injection followed by a slow injection of bupivacaine to estimate the duration of postoperative analgesia in lower-segment caesarean sections (LSCS). Methods: The study was performed on 60 parturient aged 18-35 years undergoing LSCS and was divided equally into two groups. Group A (Normal Sequential) received slow sequential intrathecal injections of fentanyl and hyperbaric bupivacaine and Group B (Rapid Sequential) received a rapid intrathecal injection of fentanyl followed by a slow injection of hyperbaric bupivacaine. We compared the duration of postoperative analgesia, time of onset of sensory and motor block attained, the highest level of sensory block attained, duration of motor block, Visual Analogue Scale (VAS) scores, spinal anaesthesia-related complications and haemodynamic parameters between both the groups. Results: The duration of postoperative analgesia was longer (P < 0.001) in group B (3.22 ± 0.66 hrs) as compared to group A (2.53 ± 0.41 hrs.) The onset of sensory block was faster (P < 0.001) in group B (1.01 ± 0.29 min) as compared to group A (1.32 ± 0.08 min). More patients in group B achieved higher levels of sensory blockade as compared to group A (5 patients in group A and 12 patients ofgroup B achieved a sensory block up to the T2 dermatome). VAS scores and the requirement of rescue analgesia were significantly lower (10 in group B and 19 in group A). Conclusion: Rapid sequential intrathecal injection of fentanyl and hyperbaric bupivacaine provided better anaesthesia and postoperative analgesia than the normal group. [ABSTRACT FROM AUTHOR]

Vasospasm following an aneurysmal subarachnoid hemorrhage (SAH) causes serious neurological complications, despite surgical clipping of the aneurysm. Intrathecal urokinase (UK) infusion has been shown to effectively prevent symptomatic vasospasm in patients who have undergone endovascular obliteration of the ruptured aneurysms. To investigate whether intrathecal UK infusion can prevent symptomatic vasospasm in patients undergoing surgical or endovascular treatment. A total of 90 patients with severe aneurysmal SAH were enrolled and assigned to a surgical neck clipping (n = 56) or an endovascular coil embolization (n = 34) groups. After treatment, UK infusion from the lumbar drain was repeated in 32 patients in the surgical neck clipping group (group B) and all in the endovascular coil embolization group (group C) until complete resolution of the SAH was observed on computed tomography. The remaining 24 of the surgical neck clipping group, without UK infusion, were assigned to group A. Symptomatic vasospasm occurred in 7 (29.2%) patients in group A, 2 (6.3%) in group B, and none in group C (group A vs. group B [ P = 0.02]; group B vs. group C [ P = 0.14]). Excellent clinical outcomes (modified Rankin score, 0 or 1) were observed in 37.5%, 59.4%, and 76.5% of patients in group A, B, and C, respectively (group A vs. group B [ P = 0.11]). Clearance of SAH via intrathecal UK infusion significantly reduced symptomatic vasospasm in patients in both UK groups, resulting in better clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Intrathecal infusion therapy is widely accepted for cancer pain patients when conventional analgesic treatments are not sufficient. There are different types of devices for carrying out this therapy: partially externalized devices (PED), used when life expectancy is under 3 months, and totally implanted devices (TID), when it is larger. Our objective is to compare the efficacy, functionality, and complication rate in both types. Methods: We included 132 patients with mild–severe cancer pain, treated with intrathecal infusion therapy by fixed flow devices, PED, or TID, during the study time. Demographic, physical oncologic, and pain control data of the patients were recorded prior to starting therapy and at months 1, 3, and 6. Functionality status and complications were also collected from the patient's medical records and clinical files. Results: Pain control improved after starting therapy, with an overall reduction of 4.75 points in VAS score at 1 month in the both groups, without significant differences between them, keeping it at 3 months and 6. 33.3% of the patients developed complications and were more frequent in the PED group, being catheter dislocation the most common. Patients with TID required more often hospital admission to solve the complication. Conclusions: Intrathecal infusion therapy has been shown to be a very effective and safe therapy for the treatment of moderate to severe oncologic pain. There are no significant differences between PED and TID in terms of degree of pain control, therapeutic success, efficacy on episodic or nocturnal pain, or the presence of serious complications. [ABSTRACT FROM AUTHOR]