Inadvertent Penetration Research Articles

Transient Paralysis Associated with Epidural Steroid Injection

Epidural steroid therapy is a commonly applied “conservative” therapy, but it is not inherently benign. Although arachnoiditis, infection, and meningitis have been reported, acute paraplegia has not been reported as a complication of either caudal or spinal epidural steroid injection. A unique case of transient, profound paralysis after epidural steroid injection is reported here. The procedure was carried out without fluoroscopic control and was complicated by a puncture of the thecal sack. Radiographic studies demonstrated a focal, space-occupying lesion in the spinal canal at the level corresponding to the neurologic deficit, which spontaneously resolved over the next 2–3 h. Surgical decompression was initially considered and then deferred in favor of observation. The patient recovered motor, sensory, and bowel and bladder function over the next 48 h. The period of recovery was consistent with an acute but brief compressive injury and inconsistent with an anesthetic effect. Radiographic studies suggest three possible explanations: (a) inadvertent thecal penetration during injection may have produced an atypical anesthetic block; (b) loculation of the injected fluid may have caused a transient compressive lesion; or (c) intrathecal injection may have produced an iatrogenic arachnoid cyst. Although pathologic confirmation of the cause was not possible, the potential for this alarming complication should be recognized by physicians prescribing epidural steroid therapy. We do not suggest that epidural steroid therapy is the treatment of choice for patients with multiple back operations or that it is efficacious for these patients. Our purpose is to alert surgeons and therapists to a rare but potentially devastating complication and to provide our experience in treating it.

Holmium YAG laser-assisted osteotomies in plastic and reconstructive surgery: a preliminary report.

An Omnipulse holmium-yttrium aluminum garnet (YAG) laser was used to assist in the harvesting of outer table or split calvarial bone grafts in cadaver skulls. Two- or 4-mm depth and 0.55-mm width holes in the outer cortex of cadaveric calvarium were formed without apparent gross periosteal or bony injury. Osteotomes were then used to shave or split calvarial grafts by connecting the 2- and 4-mm depth holes, respectively. The procedure was efficient as well as precise. We believe that this method of bone graft harvesting may have the added benefit of safety by decreasing the incidence of inadvertent dural penetration. This study will lead to further analysis of the potential use for additional bony work with the Omnipulse holmium-YAG laser.

Inadvertent Penetrating Injury to the Globe With Periocular Corticosteroid Injection

We surveyed 488 physicians regarding their experience with inadvertent ocular penetration with steroid injections over a 5-year period. Sixty-six cases of ocular penetration were reported by the 209 physicians who responded. Of the 18 patients whose retinal status was known, 12 (67%) had retinal detachments resulting from the penetration. Final visual acuities in 85% of the 26 cases were worse than 20/100.

Inadvertent submucosal penetration with a minitracheostomy cannula inserted by the Seldinger technique

Inadvertent submucosal penetration with a minitracheostomy cannula inserted by the Seldinger technique

Lateral orbitotomy without removal of the lateral orbital rim.

Lateral orbitotomy is used for the removal of orbital tumors and for orbital decompression. Most surgeons make saw cuts through the lateral orbital rim and remove and rewire the bone. This procedure is time-consuming and requires repair of the lateral canthal structures. We describe a technique using an air-driven "acorn-tipped" bur that removes the posterolateral lip of the frontal process of the zygomatic bone and effectively straightens the external surface of the lateral orbital wall. This permits removal of the bone without serious injury to the periorbita. The technique creates a trapezoidal orbitotomy measuring approximately 20 mm anteroposterior, 25 mm at the anterior vertical base, and 6 mm at the posterior base. The orbital soft tissues can thus be safely exposed without removal of the lateral rim. We operated on one patient with cavernous hemangioma (27 X 21 X 19 mm) and three patients with bilateral Graves' ophthalmopathy. We discuss anatomic considerations for the prevention of complications, including injury to the frontotemporal branches of the facial nerve, injury to the superior head of the lateral pterygoid muscle, and inadvertent penetration of the dura.

A Complication of Posterior Glenoid Osteotomy for Recurrent Posterior Shoulder Instability

Posterior glenoid osteotomy (posterior glenoplasty) is a standard surgical reconstructive operation for recurrent posterior instability of the shoulder. A 34-year-old man was treated by glenoid osteotomy and subsequently developed significant glenohumeral arthritis. Following several surgical procedures, only total shoulder arthroplasty gave substantial pain relief and restored stability. Inadvertent penetration of the glenohumeral joint at the time of osteotomy may have predisposed the patient to glenohumeral arthritis. Extreme care should be exercised not to damage the shoulder joint during this procedure.

Nasal septum osteotome.

A new chisel for nasal septum osteotomy in craniofacial surgery is reported. With the aid of a guide wire, the cranial base is completely protected from inadvertent penetration. The direction of osteotomy can be changed because of the chisel's central fenestration, even if placed incorrectly at the beginning.

On problems of flight over an extended angle-of-attack range

To ensure successful operation of aircraft at high angles of attack (or high lift) conditions, attention must be paid to two basic design aims. These are the ability to achieve an adequate high lift performance and the need to ascertain that inadvertent penetration of the post-stall regime (or more generally any critical condition, which may for a particular aircraft be considered as replacing the conventional stall) does not lead to uncontrollable and thus potentially dangerous flight conditions.The first aim is concerned primarily with the maintenance of the flow pattern associated with the normal flight regime and the augmentation of the lifting capability of the wings to sufficiently high lift coefficients. It, therefore, relates to the design of the wings, leading-edge devices and the flap system, if any, in respect of the onset of the flow breakdown.

Liver Biopsy During Peritoneoscopy

To the Editor:— Dr. Robert Wilber and Dr. William Faulk's otherwise excellent review of liver biopsy ( 202 :53, 1967) is remiss, I believe, in not including reference to biopsy under direct vision at peritoneoscopy. Among its other advantages, peritoneoscopy allows one to aim the biopsy needle directly into a mass or other area of abnormality, thus increasing the likelihood of accurate diagnosis. Avoiding the liver edge lessens the chance of inadvertent penetration through the liver into colon or other viscus. If bleeding at the biopsy site does not cease in three to four minutes, direct pressure with the peritoneoscope or externally can be helpful, contributing further to safety. While not indicated in every patient requiring liver biopsy, peritoneoscopy can often enhance diagnostic accuracy and safety.

VITAMIN-RESISTANT RICKETS

Most series found in the literature on peritrochanteric fractures report failure rates of 9% to 35% for nonsliding fixation and 5% to 12% for devices that allow collapse about the axis of the barrel of the device, indicating that the concept of load sharing is a valid principle in the management of these injuries. Reviewing our experience with the fully collapsible devices reveals a remarkably low incidence of complications related to both metal failure and postoperative penetration of the femoral head. Most of the failures in our series occurred before the routine use of fluoroscopic operative placement control and can be related to inadvertent intraoperative penetration of the femoral head. With modern techniques, therefore, these complications are largely preventable. Despite those failures, which cannot be explained by technical error, we are extremely pleased with our overall results because the fully collapsible devices appear to allow early weight bearing without fear of fixation complications, even in unstable fractures. This concept allows for easier postoperative rehabilitation and attendant diminished mortality rates as compared with other devices currently used. Although no study can conclusively demonstrate the clear superiority of the slotted Richards screw and Ken-Pugh nail over other forms of sliding fixation, we believe that if the concept of load sharing is valid, this modification is a simple, sensible, and effective addition to most nail plate devices used today.