L4-L5 Intervertebral Space Research Articles

Transforaminal posterior lumbar interbody fusion microscopic safe operating area: a three-dimensional model study based on computed tomography imaging

BackgroundEndoscopic spine lumbar interbody fusion (Endo-LIF) is well-regarded within the academic community. However, it presents challenges such as intraoperative disorientation, high rates of nerve damage, a steep learning curve, and prolonged surgical times, often occurring during the creation of the operative channel. Furthermore, the undefined safe operational zones under endoscopy continue to pose risks to surgical safety. We aimed to analyse the anatomical data of Kambin’s triangle via CT imaging to define the parameters of the safe operating area for transforaminal posterior lumbar interbody fusion (TPLIF), providing crucial insights for clinical practice.MethodsWe selected the L4–L5 intervertebral space. Using three-dimensional (3D), we identified Kambin’s triangle and the endocircle within it, and recorded the position of point ‘J’ on the adjacent facet joint as the centre ‘O’ of the circle shifts by angle ‘β.’ The diameter of the inscribed circle ‘d,’ the abduction angle ‘β,’ and the distances ‘L1’ and ‘L2’ were measured from the trephine’s edge to the exiting and traversing nerve roots, respectively.ResultsUsing a trephine with a diameter of 8 mm in TPLIF has a significant safety distance. The safe operating area under the TPLIF microscope was also clarified.ConclusionsThrough CT imaging research, combined with 3D simulation, we identified the anatomical data of the L4–L5 segment Kambin’s triangle, to clarify the safe operation area under TPLIF. We propose a simple and easy positioning method and provide a novel surgical technique to establish working channels faster and reduce nerve damage rates. At the same time, according to this method, the Kambin’s triangle anatomical data of the patient’s lumbar spine diseased segments can be measured through CT 3D reconstruction of the lumbar spine, and individualised preoperative design can be conducted to select the appropriate specifications of visible trephine and supporting tools. This may effectively reduce the learning curve, shorten the time operation time, and improve surgical safety.

Comparison of neuraxial acoustic target window of the spine among rider sitting, cross leg, hamstring stretch, and classical sitting position: An observational study.

To compare ultra-sonographic dimensions of acoustic target window of the spine in the participants at four different sitting positions namely cross leg sitting (CLP), hamstring stretch (HSP), classical sitting (CSP) and riders sitting position (RSP). The primary objective of this study was to measure the neuraxial acoustic target window (defined as interlaminar distance between L3-L4 lamina). The secondary objective was to compare ultra-sonographic measurements of the depth of ligamentum flavum from the skin, and to compare the diameter of intrathecal space and comfort score in the four different sitting positions. This study is a prospective observational study. Eighty participants were included and positioned in four different sitting positions to perform an ultra-sonographic scan and measure various parameters of the acoustic neuraxial window. The interlaminar distance, the distance of skin from the ligamentum flavum, and the diameter of the spinal canal or intrathecal space was measured in the L3-L4 intervertebral space in different positions. The mean value of interlaminar distance among four sitting positions was ranging from 1.40 cm to 1.44 cm (P value 0.725.) The distance of ligamentum flavum from skin and diameter of intrathecal space was also comparable in all the groups. The comfort score in CSP was significantly better when compared to other groups with a median score of 4 (P value < 0.001). There is no statistically significant difference in interlaminar distance in various sitting positions. All four positions are equally effective and can be used as an alternative to spinal/epidural intervention, but the CSP came out to be the most comfortable and more emphasis should be given to the comfort as it increases the chance of success rate of the procedure.

A Novel Ultrasound Software System for Lumbar Level Identification in Obstetric Patients

(Can J Anaesth. 2022;69:1211–1219) Manual palpation is the primary method that obstetric anesthesiologists use to identify the optimal point of neuraxial anesthesia placement. As it is unreliable, especially when performed in patients with a higher body mass index (BMI), lumbar ultrasound (LUS) is an intriguing option. LUS for neuraxial labor anesthesia and analgesia has improved accuracy in lumbar vertebral level identification and improved first-pass success rate. Despite potential LUS benefits, many physicians continue using manual palpation because they are not proficient in the technical skills required to perform or interpret LUS images. To make LUS simpler and more user-friendly, automated ultrasound software known as Spine Level Identification (SLIDE) system was developed. SLIDE automatically identifies vertebral landmarks in real-time as the ultrasound transducer moves over the skin. This study aimed to determine whether SLIDE accurately identifies the L3-L4 intervertebral space in healthy term parturient women compared with the manual palpation method.

EFFECT OF INTRAVENOUS ONDANSETRON PREMEDICATION ON SPINAL ANESTHESIA INDUCED HYPOTENSION IN CESAREAN SECTION - A RANDOMIZED CONTROLLED STUDY.

Background:- Spinal anesthesia is the most common anaesthesia technique for cesarean section. In this technique injection of a local anesthetic agent is injected into the subarachnoid space. The most common complication of spinal anesthesia is hypotension which is due to sympathetic blockade and activation of the Bezold Jarisch reex which leads to the utilization of higher doses of vasopressors for the maintenance of blood pressure. The present study was conducted to compare the effect of intravenous ondansetron premedication on spinal anesthesia-induced hypotension with normal saline. An observa methodology:- tional study was conducted in 180 term parturients of ASA - ІІ, scheduled for elective LSCS under spinal anesthesia. The patients were divided into two equal age groups: ondansetron 4mg (group O, n= 90) and saline group (group S, n= 90). Ondansetron 4mg (2ml) was given 10 min before the procedure in group O and group S received 2ml normal saline. Under all aseptic precautions, subarachnoid space was accessed through L3-L4 or L4-L5 intervertebral space using 25G Quincke's spinal needle. After conrmation of the free ow of CSF, a 2ml hyperbaric injection of bupivacaine 0.5% (Heavy) was administered in the subarachnoid space. Mean arterial pressure less than 65mmHg was considered as hypotension and treated with iv mephentermine 6mg bolus. The Occurrence of hypotension in Group O (22.22%) was signicantly l Result- ower than in group S(61.11%)(p&lt;0.001). The MAP was signicantly higher in Group O at 2,4,6,8,10,12,14,16,20 and 25 minutes (p&lt;0.005). 18 (20%) patients required one dose of mephentermine 6mg, and 2(2.22%) patients required two doses in group O. In group S 40 patients ((44.44%) required one dose of mephentermine 10 patients ((11.11%) ) required two doses and 5 patients (5.55%) required 3 doses. In group O 3 patients (3.33%) and in group S, 12 patients (13.33%) had nausea which was statistically signicant with a P value of 0.01. In group S 12 patients (13.33%) and 4 patients (4.44%) in group O had shivering. Which was statistically signicant with a P value of 0.03. Ondansetron is effective in Conclusion – preventing spinal-induced hypotension in elective cesarean section

Efficacy of Intrathecal Bupivacaine with Dexmedetomidine and Bupivacaine Alone in Lower Segment Caesarian Section Patients

Objective: This research aims to compare the effectiveness of intrathecal bupivacaine combined with dexmedetomidine to bupivacaine alone in patients having caesarian procedures. Methods: This randomized, controlled study was conducted at in operation theatre in Liaquat national hospital, with the agreement of the hospital's institutional review board. There were 272 patients total, and they were split evenly in two groups of 136 using non-probability consecutive sampling technique. Group A: Patients received subarachnoid block (2 ml of 0.5 % hyperbaric bupivacaine and 10 micrograms of normal saline). Group B: Patients received subarachnoid block (2 ml of 0.5 % hyperbaric bupivacaine and 10 micrograms of dexmedetomidine at L3-L4 or L4-L5 inter-vertebral space). Before the induction of anaesthesia, the patient's systolic blood pressure (BP), diastolic blood pressure (BP), mean arterial pressure (MAP), heart rate (HR), and peripheral capillary oxygen saturation (SPO2) will be monitored Results: The mean age of the participants in both study groups were 27.14±5.3 and 25.9±3.65 years. A significant difference in the mean systolic blood pressure of the participants in both groups as observed at 15-, 45- and 60-minutes interval (p=0.000). The mean time interval from blocks to shivering occurrence in the participants in both study groups were 57.08±3.8 and 81.03±2.8minutes. A significant difference (P=0.000) in the mean time interval from blocks to shivering occurrence in the participants in both study groups was observed. 49% participants in the groups experienced shivering while 24% in group B. Conclusion: From our findings, we infer that adding 10µg of dexmedetomidine to strong bupivacaine in SA may reduce the frequency and severity of shivering without causing any serious side effects.

Relationship of Abdominal Circumference and Trunk Length With Spinal Anesthesia Block Height in Geriatric Patients Undergoing Transurethral Resection of Prostate.

Spinal anesthesia is commonly used for various surgical procedures. Prediction of spinal anesthesia block height is always a challenging task for anesthetists. Higher than desired levels of spinal anesthesia blocks are associated with serious side effects, while inadequate block height does not provide satisfactory surgical anesthesia. In this study, we observed the relationship between the ratio of trunk length (TL) and square of the abdominal circumference (AC2) and spinal anesthesia sensory block height in geriatric patients undergoing transurethral resection of the prostate (TURP). This is a cross-sectional study conducted at the Aga Khan University Hospital Karachi, Pakistan, on geriatric patients undergoing TURP under spinal anesthesia. Forty-three elderly patients (American Society of Anaesthesiology levelI-III)between 60 and 80 yearswere recruited for the study. In hospital wards, trunk length (TL) and abdominal circumference were recorded before the procedure. In the operating rooms, spinal anesthesia was performed at L3-L4 intervertebral space with 0.5% hyperbaric bupivacaine 10mg (2mls). Block height was measured by the placement of ice pads at different dermatomes. Spearman rank correlation coefficient was used to analyze the physical parameters (TL/AC2) and spinal anesthesia block height. Results: The ratio of trunk length and square of the abdominal circumference (TL/AC2) correlates with spinal anesthesia block height in geriatric patients, where the spearman rank correlation coefficient was r =-0.284 with p = 0.015. The ratio of the long axis (TL) and transection area of the abdomen (AC2), which coincides with (TL/AC2), correlated with spinal anesthesia sensory block height. Hence, elderly patients with a low TL/AC2ratio will have higher block height after spinal anesthesia.

Effects of Body Roundness Index on Spinal Anesthesia Block Characteristics

Body roundness index (BRI) is based on the assumption that the human body's shape is an ellipse, which combines height and waist circumference. We aimed to investigate the effect of BRI on spinal anesthesia [SA] sensory levels and hypotension in patients undergoing elective surgery. In this observational study, we prospectively enrolled 18-80 years old patients with ASA physical status I-III who underwent single-shot spinal anesthesia using 15 mg 0.5% hyperbaric bupivacaine at L3–L4 intervertebral space for transurethral and lower limb surgery. Maximum sensory blockade level at 15th and 30th min, block regression time to L2 level, hypotension, bradycardia occurrence were recorded. BRI, waist, and hip circumference were found as independent predictive factors in a maximum sensory blockade level at 15th min [OR=65.7 95% CI: 1.304-3310, p=0.036; OR=0.733 95% CI: 0.558-0.963, p=0.026; OR=1.065 95% CI: 1.001-1.133, p=0.047; respectively]. Hypotension after SA was not associated with anthropometric variables. BRI can be used as a new practical tool to predict the increased cephalic spread of local anesthetic in patients undergoing SA.

Comparing cholecystectomy in patients with chronic obstructive pulmonary disease under spinal anaesthesia and general anaesthesia

Introduction: The prevalence of Chronic obstructive lung disease has been increased globally. We compared the effectiveness of SA versus GA for open cholecystectomy with regards to post operative pain reduction, analgesia requirement, respiratory complications and length of hospital stay in chronic obstructive lung disease patients. Materials and Methodology: Group 1 (the GA group) received 0.6 mg/kg rocuronium bromide, 2 mg/kg propofol, and 2 μg/kg fentanyl. After 90-120 seconds 100% oxygenation, these patients underwent endotracheal intubation. Maintenance of anaesthesia was performed using 1 – 2% sevoflurane in 50% nitrous oxide/50% oxygen. Group 2 (the SA group) received their anaesthesia while sitting. Patients underwent lumbar puncture using a 25 - gauge needle in the L3-L4 intervertebral space and were given an intrathecal injection of 25 mg fentanyl and 3ml hyperbaric bupivacaine (0.5%), following which they were told to lay supine for 5 minutes. Results: There was no significant difference between the GA and SA groups, postoperative pulmonary functions were impaired more frequently in the GA group, and 4 GA patients required mechanical ventilation. There was no significant difference in operation duration between the SA and GA groups. Conclusion: Cholecystectomy could be performed safely under GA and SA in patients with COPD.

Importance of Aortic Bifurcation for Pelvic Radiotherapy in Cervical Cancer Patients

Purpose: Radiotherapy is a major modality for treating cervical cancer patients. Conventionally, superior border of treatment portal in cervical cancer is kept at L4-L5 intervertebral spaces; however, newer concepts suggest that aortic bifurcation should be the determining factor for the superior border. This study aims to observe the level of aortic bifurcation in cervical cancer patients. Methods and materials: A retrospective observational study was conducted in cervical cancer patients undergoing radiotherapy between July 2019 and August 2020 in B.P. Koirala Memorial Cancer Hospital, Bharatpur. Histologically confirmed International Federation of Gynecology and Obstetrics (FIGO) stages II and III carcinoma cervix patients referred for radiation therapy were included in the study. Baseline variables including age group, FIGO stages were noted from the hospital record. Computed Tomography (CT) simulation images were reviewed from the treatment planning system to detect the levels of aortic bifurcations. Results: Total 281 patients of carcinoma cervix were registered for the study with age ranging from 29 years to 87 years and the commonest age group being 51-60. The maximum patients were of stage IIB (46.6%). The aortic bifurcations levels varied from mid L3 to L5-S1 intervertebral space and the commonest level observed was mid L4 vertebra in 70 (24.9%) patients. Conclusion: Anatomical variation in the level of aortic bifurcation, considered as the superior CTV border in pelvic radiotherapy in cervical cancer, demands the conventional superior border, L4-L5 intervertebral space, to be shifted more superior to include common iliac nodes in the treatment field.

Vertebral level of tuffier's line measured by ultrasonography in parturients in the lateral decubitus position

Tuffier's line intersects the spine at the L4 spinous process or at the L4-L5 intervertebral space. Full-term parturient women undergo various physical changes. Therefore, determining the vertebral level with Tuffier's line based on palpation inevitably is not very accurate. This study aimed to use ultrasound to verify the difference between vertebral levels for the palpated Tuffier's line in parturient and non-parturient women in the lateral decubitus position. In this study, consecutively enrolled 20 parturient women at 27-35 weeks of gestation and 20 non-parturient women scheduled for regional anesthesia. In the left lateral position, the location of the vertebra was identified using ultrasonography. We marked every intervertebral space from L5 to L2 vertebra, divided each spinous process into two equal parts, and numbered the spaces sequentially from 1 to 9. A Tuffier's line was drawn by palpating, recorded the vertebral level that this line intersected. The mean value of an arbitrary number of vertebral level of Tuffier's line was 5.4 ± 0.9 in the non-pregnant group and this represents L4-lower vertebral level. In the pregnant group, the mean value was 2.0 ± 1.0 which represents L3-lower vertebral level. There was a significant difference between the two groups (P &lt; 0.05).

Biomechanical Evaluation of an Oblique Lateral Locking Plate System for Oblique Lumbar Interbody Fusion: A Finite Element Analysis

The oblique lateral locking plate system (OLLPS) is a novel internal fixation with a locking and reverse pedicle track screw configuration designed for oblique lumbar interbody fusion (OLIF). The OLLPS is placed in a single position through the oblique lateral surgical corridor to reduce operative time and complications associated with prolonged anesthesia and prone positioning. The purpose of this study was to verify the biomechanical effect of the OLLPS. An intact finite element model of L1-S1 (intact) was established based on computed tomography images of a healthy male volunteer. The L4-L5 intervertebral space was selected as the surgical segment. The surgical models were established separately based on OLIF surgical procedures and different internal fixations: 1) stand-alone OLIF (SA); 2) OLIF with a 2-screw lateral plate; 3) OLIF with a 4-screw lateral plate; 4) OLIF with OLLPS; and 5) OLIF with bilateral pedicle screw fixation (BPS). After validation of the intact model, physiologic loads were applied to the superior surface of L1 to simulate motions such as flexion, extension, left bending, right bending, left rotation, and right rotation. The evaluation indices included the L4/5 range of motion, the L4 maximum displacement, and the maximum stresses of the superior and inferior end plates, the cage, and the supplemental fixation. During OLIF surgery, the OLLPS provided multiplanar stability similar to that provided by BPS. Compared with 2-screw lateral plate and 4-screw lateral plate, OLLPS had better biomechanical properties in terms of enhancing the instant stability of the surgical segment, reducing the stress on the superior and inferior end plates of the surgical segment, and decreasing the risk of cage subsidence. With a minimally invasive background, the OLLPS can be used as an alternative to BPS in OLIF and it has better prospects for clinical promotions and applications.

Comparison of 0.5% levobupivacaine alone and 0.5% levobupivacaine with butorphanol given intrathecally in infraumbilical surgeries.

Introduction: Spinal anaesthesia is the most common neuraxial block used in surgical setting. The main advantage is the high success rate, safety record, rapid onset, predictable duration, minimal side effect and reliable offset. Study aimed to compare Levobupivacaine and Levobupivacaine with Butorphanol in terms of onset of sensory and motor blockade, duration of sensory and motor block, two segment regression time, hemodynamic changes, time for first rescue analgesia and complications in infraumbilical surgeries. Materials and methods: 60 patients of ASA class 1 and 2 of age between 19 to 65 years were selected in the study and divided them into two groups with 30 patients each. Group A - 15 mg (3 ml) of 0.5% Levobupivacaine + 0.1 ml Normal saline. Group B- 15 mg (3 ml) of 0.5% Levobupivacaine + 100 g (0.1 ml) of Butorphanol. All groups received drug at L2-L3 intervertebral space. Result: On comparing both the groups, the duration of sensory and motor blockade was more in group B. The two-segment regression time was more isn group B and the time for the first rescue analgesia was also more in group B. Hemodynamic stability was achieved in group B with minimal change in the parameters and with fewer complications. Conclusion: we concluded that addition of injection Butorphanol with Levobupivacaine gives hemodynamic stability as compared to Levobupivacaine alone intrathecally and also provides longer duration of sensory and motor blockade and superior analgesia than intrathecal levobupivacaine alone. Keywords: spinal anesthesia, analgesia, intrathecal, Levobupivacaine, Butorphanol. Reference: 1. Casey WF. Spinal anaesthesia-A practical guide. Update Anaesth. 2000;12:1-7. 2. Foster RH, Markham A. Levobupivacaine. Drugs. 2000 Mar;59(3):551-79. 3. Attri JP, Kaur G, Kaur S, Kaur R, Mohan B, Kashyap K. Comparison of levobupivacaine and levobupivacaine with fentanyl in infraumbilical surgeries under spinal anaesthesia. Anesthesia, essays and researches. 2015 May;9(2):178. 4. Stoelting RK, Hillier SC. Pharmacology and physiology in anesthetic practice. Lippincott Williams &amp; Wilkins; 2012 Jan 11. 5. Eledjam JJ, de la Coussaye JE, Bassoul B, Brugada J. Mechanisms of the cardiac toxicity of bupivacaine. InAnnales Francaises D'anesthesie et de Reanimation 1988 Jan 1 (Vol. 7, No. 3, pp. 204-210). 6. Bardsley H, Gristwood R, Baker H, Watson N, Nimmo W. A comparison of the cardiovascular effects of levobupivacaine and rac‐bupivacaine following intravenous administration to healthy volunteers. British journal of clinical pharmacology. 1998 Sep;46(3):245-9 7. McLeod GA. Density of spinal anaesthetic solutions of bupivacaine, levobupivacaine, and ropivacaine with and without dextrose. British Journal of Anaesthesia. 2004 Apr 1;92(4):547-51. 8. Singh A, Gupta A, Datta PK, Pandey M. Intrathecal levobupivacaine versus bupivacaine for inguinal hernia surgery: a randomized controlled trial. Korean Journal of Anesthesiology. 2018 Jun;71(3):220. 9. Fattorini F, Ricci Z, Rocco A, Romano R, Pascarella MA, Pinto G. Levobupivacaine versus racemic bupivacaine for spinal anaesthesia in orthopaedic major surgery. Minerva Anestesiologica. 2006 Jul 1;72(7-8):637-44. 10. Şahin AS, Türker G, Bekar A, Bilgin H, Korfalı G. A comparison of spinal anesthesia characteristics following intrathecal bupivacaine or levobupivacaine in lumbar disc surgery. European Spine Journal. 2014 Mar;23(3):695-700. 11. Glaser C, Marhofer P, Zimpfer G, Heinz MT, Sitzwohl C, Kapral S, Schindler I. Levobupivacaine versus racemic bupivacaine for spinal anesthesia. Anesthesia &amp; Analgesia. 2002 Jan 1;94(1):194-8. 12. Singh V, Gupta LK, Singh GP. Comparison among intrathecal fentanyl and butorphanol in combination with bupivacaine for lower limb surgeries. Journal of Anaesthesiology Clinical Pharmacology. 2006 Oct 1;22(4):371- 13. Singh SN, Subedi A, Prasad JN, Regmi MC. A comparative study to assess the effect of intrathecal bupivacaine with morphine or butorphanol

Elective Cesarean Section in Obstetric COVID-19 Patients under Spinal Anesthesia: A Prospective Study.

Background:Managing obstetric emergencies in COVID-19 pandemic is a real challenge as these patients need timely intervention to save the life of the mother and the baby. Hence, to avoid life-threatening challenges, all pregnant patients were electively admitted and tested for COVID-19 near term to anticipate the difficulties and prevent complications.Aim:Our aim was to assess the impact of COVID-19 infection on maternal morbidity and mortality as well as the effect on the neonate under spinal anesthesia.Settings and Design:This was a prospective observational study.Materials and Methods:One hundred and fifteen COVID-19-positive pregnant patients in the age group of 20–40 years from July 2020 to December 2020 were electively taken for cesarean section under spinal anesthesia. Patients who needed emergency cesarean delivery were excluded from the study. Emergency cesarean delivery was avoided to reduce the risk of aerosol generation under general anesthesia as endotracheal intubation of COVID-19 patients poses a significant risk of viral exposure to doctors and staff. Written informed consent was obtained from all patients. Spinal anesthesia was given at L4–L5 intervertebral space. Demographic parameters, anesthetic and surgical parameters, and neonatal parameters were observed. Any inadvertent event was noted.Statistical Analysis:Data were expressed as mean, median, percentage, or number.Results:All pregnancies were singleton. None of the patients was converted to general anesthesia. One hundred and ten were either mildly symptomatic or asymptomatic. Five of our patients had severe symptoms and needed intensive care unit care preoperatively and postoperatively. Seven patients developed spinal hypotension and were managed by vasopressors. No significant thrombocytopenia was noted in any of our patients. None of our patients developed symptomatic thromboembolism. Vertical transmission was not reported in any of the cases. All babies were born with weight >2500 g and good APGAR score.Conclusion:Spinal anesthesia for LSCS is safe and effective for obstetric anesthesia in COVID-19 both for the parturient and the newborn.

The influence of Body Roundness Index on sensorial block level of spinal anaesthesia for elective caesarean section: an observational study

In this prospective trial, we investigate the effectiveness of maternal Body Roundness Index in predicting the spread of spinal anaesthesia and vasopressor requirement in parturients receiving spinal anaesthesia during the elective caesarean section. We prospectively enrolled 175 parturients. Spinal anaesthesia performed with 10 mg 0.5% hyperbaric bupivacaine at the L3–L4 intervertebral space and the optimal cut-off points of the BRI evaluated as 6.59 by receiver operating characteristic analysis calculating area under the curve. Parturients were divided into two groups with BRI <6.59 and BRI ≥6.59 for analyses. Multivariate logistic regression analysis was used to test for a relationship between variables and maximum sensory block level and vasopressor requirement. BRI was found as an independent risk factor associated with maximum sensory block level (OR = 1.378, 95% CI: 1.125–1.687, p = 0.002). Hypotension and bradycardia events after spinal anaesthesia was not associated with BRI and other variables. The present study indicates that BRI was a practical tool to predict spinal drug distribution in term parturients undergoing caesarean delivery.Impact statementWhat is already known on this subject? Spinal anaesthesia is a commonly used anaesthetic technique for the caesarean section. However, the spinal drug distribution is highly unpredictable. Anthropometric variables may predict the intrathecal drug distribution in parturients. Body Roundness Index (BRI) captures body circumference regarding height to predict body fat percentage, consider the shape of the human body as an ellipse. An ellipsoid body shape might affect the spread of spinal anaesthesia.What do the results of this study add? Our results show that the BRI was as an independent risk factor associated with maximum sensory block level in term parturients undergoing caesarean delivery.What are the implications of these findings for future clinical practice and/or further research? A future study would present the possibility to design a formula for the exact amount of local anaesthetic to be used in spinal anaesthesia with the aid of maternal BRI.

Ultrasound assessment of the anatomic landmarks for spinal anesthesia in elderly patients with hip fracture: A prospective observational study.

Tuffier line is a common landmark for spinal anesthesia. The 10th rib line has been suggested as a new landmark to predict the intervertebral levels. We evaluated the accuracy of these 2 anatomic landmarks for identifying the L4-L5 intervertebral space using ultrasonography in elderly patients with hip fracture.Seventy-nine elderly patients scheduled for hip fracture surgery under spinal anesthesia were included. In the lateral decubitus position with the fracture side up, the L4-L5 intervertebral space was identified alternately using Tuffier line, a line drawn between the highest points of both iliac crests, and the 10th rib line. The 10th rib line, an imaginary line that joints the 2 lowest points of the rib cage, passes through the L1-L2 intervertebral space or the body of L2. The L4-L5 intervertebral space was determined by the counting-down method from the 10th rib line. Then, the estimated intervertebral spaces were evaluated using ultrasonography.The L4-L5 intervertebral space was correctly identified in 47 (59%) patients with Tuffier line and 45 (57%) patients with the 10th rib line (P = .87). The estimation ratio related to the intervertebral levels was not different between the 2 landmarks (P = .40). The wrong identifications of intervertebral level with Tuffier line and the 10th rib line was observed in the following order: L3-L4 intervertebral space: 27% vs 24%, L5-S1 intervertebral space: 9% vs 16%, and L2-L3 intervertebral space: 5% vs 3%, respectively.Tuffier line and the 10th rib line may be unreliable to estimate the intervertebral space for spinal anesthesia in elderly patients with hip fracture.

Comparative study of intrathecal fentanyl mixed with bupivacaine, tramadol mixed with bupivacaine, midazolam mixed with bupivacaine for peri and post-operative pain relief in lower limb and lower abdominal surgery

Background: Pain relief is of much importance in patients undergoing surgery during perioperative and post-operative period. Various methods have been evolved for providing post-operative pain relief. After effective pain relief a smoother post operative period and early discharge from the hospital is anticipated. Intrathecal and epidural narcotics have been widely used to relieve pain and provide post-operative analgesia. Intrathecal and epidural narcotics have been widely used to relieve pain and provide post-operative analgesia. Here three drugs tramadol, fentanyl, and midazolam used as adjuvant with bupivacaine in intrathecal injection for post operative pain lelief and comparative study had been done. Material and Methods: After the study protocol was approved by the Ethical clearance committee of the IGIMS, Sheikhpura, Patna. Study design was prospective, randomised and double blind techniques. A group of 100 patients undergoing lower abdominal and lower limb surgery were included in the study. Every patient was fully explained about the anaesthesia and surgical procedure before inclusion in the study. The patients were in the (25 – 65) years age group and belonged to the American Society of Anaesthesiologist (ASA) physical status class I- II and scheduled for lower abdominal and lower limbs surgery were randomly allocated to four groups with equal number: group B [Bupivacaine (0.5)% 3 cc +.4 cc normal saline], group BT [Bupivacaine (0.5)% 3 cc + 25 mg tramadol], BM [Bupivacaine (0.5)% 3 c.c + 2 mg midazolam], BF [Bupivacaine (0.5)% 3 cc + 20 μg fentanyl]. All additive drugs used intrathecally were preservative free. All intrathecal punctures were performed in the lateral (Right or Left) position with a (25G) Quinke needle, using the midline approach at the L3-L4 intervertebral space. Results: The study revealed that administration of additives in group BM and group BF did prolong analgesia. In group B, duration of analgesia and mean duration of rescue analgesic requirement was (3.22 + 1.16) hrs. For group BM it was (12.1+ 2.34) hrs, for group BF (7.6 + 2.86) hrs, for group BT (3.65 + 1.42) hrs. Degree and duration of motor blockade was slightly prolonged in group BM and there was mild modulation in group BF. Conclusion: Addition of adjuvants (fentanyl, midazolam) to intrathecal bupivacaine for perioperative pain relief does prolong postoperative analgesia and improves the intraoperative quality of analgesia than bupivacaine alone.

Iatrogenic arteriovenous fistula of the iliac artery after lumbar discectomy surgery: a systematic review of the last 18 years.

Patients with iatrogenic iliac arteriovenous fistulas (IAVFs) after lumbar discectomy surgeries (LDSs) from our hospital and the published literature were reviewed in order to better understand this clinical phenomenon. Literature from databases about iatrogenic IAVFs after LDSs were retrieved and a patient from our hospital was reviewed with emphasis placed upon the patient's clinical data. From 31 publications and studies of 44 individuals' data, the study revealed L4-L5 and/or L5-S1 intervertebral space levels were mostly involved (62.0%). Most of the patients underwent computed tomography angiography (CTA) and/or digital subtraction angiography (DSA) examinations to confirm the potential diagnosis and rule out other differential diagnosis (86.4%). Most of the patients (63.6%) developed features of high output heart failure months to years after the LDSs, and the majority of them (88.6%) were treated with endovascular repairs. An iatrogenic IAVF after an LDS is a rare occurrence; however, more attention should be paid to it for the purpose of obtaining accurate diagnosis and proper treatment.

Biomechanical properties of novel transpedicular transdiscal screw fixation with interbody arthrodesis technique in lumbar spine: A finite element study

PurposeThe purpose of this study was to investigate finite element biomechanical properties of the novel transpedicular transdiscal (TPTD) screw fixation with interbody arthrodesis technique in lumbar spine. MethodsAn L4–L5 finite element model was established and validated. Then, two fixation models, TPTD screw system and bilateral pedicle screw system (BPSS), were established on the validated L4–L5 finite element model. The inferior surface of the L5 vertebra was set immobilised, and moment of 7.5 Nm was applied on the L4 vertebra to test the range of motion (ROM) and stress at flexion, extension, lateral bending and axial rotation. ResultsThe intact model was validated for prediction accuracy by comparing two previously published studies. Both of TPTD and BPSS fixation models displayed decreased motion at L4–L5. The ROMs of six moments of flexion, extension, left lateral bending, right lateral bending, left axial rotation and right axial rotation in TPTD model were 1.92, 2.12, 1.10, 1.11, 0.90 and 0.87°, respectively; in BPSS model, they were 1.48, 0.42, 0.35, 0.38, 0.74 and 0.75°, respectively. The screws' peak stress of above six moments in TPTD model was 182.58, 272.75, 133.01, 137.36, 155.48 and 150.50 MPa, respectively; and in BPSS model, it was 103.16, 129.74, 120.28, 134.62, 180.84 and 169.76 MPa, respectively. ConclusionBoth BPSS and TPTD can provide stable biomechanical properties for lumbar spine. The decreased ROM of flexion, extension and lateral bending was slightly more in BPSS model than in TPTD model, but TPTD model had similar ROM of axial rotation with BPSS model. The screws' peak stress of TPTD screw focused on the L4–L5 intervertebral space region, and more caution should be put at this site for the fatigue breakage. The translational potential of this articleOur finite element study provides the biomechanical properties of novel TPTD screw fixation, and promotes this novel transpedicular transdiscal screw fixation with interbody arthrodesis technique be used clinically.

Effectiveness of plethysmographic variability index for prediction of subarachnoid block induced hypotension in caesarean section

Background: Hypotension is frequently observed after spinal anaesthesia for cesarean section and canbe detrimental to both mother and baby. The pleth variability index (PVI) is a new algorithm used forautomatic estimation of respiratory variations in pulse oximeter waveform amplitude, which mightpredict fluid responsiveness. Because anaesthesia-induced hypotension may be partly related to patientvolume status. The pleth variability index (PVI) was developed as a noninvasive bedside measurementof this variation in the pulse oximetry waveform. Objective: To observe the hypotension predictive capacity of PVI and to find out association &amp; correlationof PVI with sphygmomanometeric blood pressure measurement. Methods: This observational study was carried out in the department of anaesthesia, Analgesia andIntensive Care Medicine Bangabandu Sheikh Mujib Medical University, Dhaka between July 2015 toDec 2015. A total 100 elective caesarean section patients under subarachnoid block were selected by theinclusion and exclusion criteria. Patients who fulfill the ASA physical status i, ii. and full term singletonpregnancy height from 152cm to160cm. were included and patients suffering from obesity (bodyweight&gt;115 kg), hypertension, COPD, bronchial asthma, haemoglobinopathies, severe anaemia,arrythmia, heart failure, any congenital heart disease, pre-eclampsia, total placenta praevia or patientwho took anti hypertensive medications were excluded from the study. Patients were divided in twogroups, PVI ³22.0 in group-A and PVI &lt;22.0 in group-B.Dehydration was corrected 10 min before sub arachnoid block (sab). Pre–anesthetic Himoglobin% SPO2,Heart rate, PVI &amp; blood pressure was recorded at baseline after 5 minutes of rest by one anesthesiologist.Subarachnoid block performed with 0.5% hyperbaric bupivacaine (12.5 mg) at the L3-L4 intervertebralspace on sitting position. After spinal block patient was returned to supine position with a wedge underbuttock to facilitate left uterine displacement. Oxygen 4 lit/min was administered via face mask.Immediately after sub arachnoid block Spo2, heart rate, SBP and DBP was recorded by anotheranesthesiologist at 2 minutes interval in first 10 minute. Surgical incision was allowed when a blocklevel at least T6 dermatome was obtained with cold &amp; pin prick.All data was recorded by two anesthesiologist who were not involved in the study. The study ended withdelivery of the baby. Chi-Square test was used to analyze the categorical variables, shown with cross tabulation.Student t-test was used for continuous variables. p value &lt;0.05 was considered as statistically significantly. Result: In baseline, majority (58.0%) patients was found PVI e”22 (group A) and 42(42.0%) was PVI &lt;22(group B). Mean age of the patients was 27.5±4.5 years, Mean heart rate was found 93.2±5.8 beats/minin group A and 89.7±12.7 beats/min in group B. The mean systolic BP was found 132.1±7.7 mmHg ingroup A and 128.7±8.5 mmHg in group B. The mean diastolic BP was found 80.9±3.8 mmHg in group Aand 79.1±5.1 mmHg in group B. The mean MAP was found 98.0±5.6 mmHg in group A and 95.6±6.8mmHg in group B. The mean SPO2 was found 97.8±1.4 in group A and 97.4±1.5 in group B. The meanperfusion index was found 5.0±2.6 in group A and 5.4±3.5 in group B. The mean pleth variability index was found 22.5±2.3 in group A and 15.1±3.1 in group B. The mean pleth variability index was statisticallysignificant (p&lt;0.05) between two groups. Conclusion: Higher baseline pleth variability index can associated with hypotension after spinalanaesthesia for cesarean section may be a clinically useful predictor. JBSA 2018; 31(2): 62-66

ANESTHETIC MANAGEMENT OF PREGNANT PATIENT WITH VALVULAR HEART DISEASE

Gebelikle birlikte kan hacmi, kalp debisi, kalp hızı artarken sistemik vasküler direnç azalır. Hemodilüsyon ve fizyolojik anemi görülür. Bu değişiklikler sağlıklı kadınlar tarafından tolere edilebilirken kalp hastalığı olan gebelerde kalp üzerinde ayrı bir yük oluşturmaktadır. Bunun sonucunda peripartum morbidite ve mortalite artmaktadır. Bu hastaların anestezi seçimi kalp hastalığının tipi, kullanılan ilaçlar, cerrahinin aciliyetine göre değişmektedir. 32 yaşında olan hastamızın 4 gebelik, 2 doğum ve 2 abortusu mevcuttu. Hastamıza 39 haftalık gebeliği ne-deniyle sezeryan planlanmıştı. Preoperatif mu-ayenesinde 5 yıl önce perkütan mitral balon valvüloplasti geçirdiği öğrenildi. Ekokardiyog-rafide mitral kapak alanı 1 cm2 olduğu, 30 aort yetmezliği ve pulmoner arter basıncı 35 mm Hg olarak tespit edildi. Hastaya lomber 4-5 verteb-ra aralığından oturur pozisyonda kombine spi-nal–epidural anestezi yapıldı. Epidural katater yoluyla perioperatif ve postoperatif anestezi ve analjezi sağlandı. Sonuç olarak kalp hastalığı olan gebelerde sezaryen uygulamasında düşük doz kombine spinal-epidural anestezi ile hemo-dinaminin daha stabil olacağını ve epidural ka-tater yoluyla da postoperatif analjezi sağlanarak taşikardi, hipertansiyon, ajitasyon gibi olumsuz etkilerin önleneceğini düşünüyoruz.