Postoperative Headache Research Articles

Laparoscopic Cholecystectomy Under Spinal Anesthesia: A Feasibility Study

Laparoscopic cholecystectomy has traditionally been performed under general anesthesia. In spite of the emerging evidence it can be performed safely under regional anaesthesia. It has not gained widespread acceptance.ObjectivesGenerally, spinal anesthesia has lower postoperative mortality and fewer complications than general anesthesia, so it seems more suitable for the laparoscopic surgery. We designed a prospective observational study to determine the feasibility of spinal anesthesia for laparoscopic cholecystectomy as a routine in clinical practice.MethodsA total of 164 patients planned to undergo elective laparoscopic cholecystectomy for cholecystitis, with inclusion criteria of ASA grade I or II and ages 18–60 years were included in this study. Subarachnoid block was performed at the level of L2-L3 interspace with 0.5% hyperbaric Bupivacaine. After placement of the subarachnoid block, all patients were placed in a 20°–30° Trendelenburg position until the level of sensory anesthesia reached the T4 dermatome level. CO2 insufflation was started using pressure limit of 12 mmHg. Oxygen was given via face mask at 4 liters /minute. Heart rate, blood pressure, and spO2 were recorded every 3 minutes. During the procedure, anxiety was treated with 2 mg Midazolam and pain with 50 μg intravenous boluses of Fentanyl. Bradycardia was treated with 0.3-0.6 mg of intravenous Atropine. Continuous monitoring of hemodynamic parameters was done using noninvasive multiparameter monitor. Duration of anaesthesia, operative time, and duration of pneumoperitoneum were recorded. Postoperative pain, drug consumption, shoulder pain, anxiety, headache, nausea, vomiting, and abdominal discomfort were also recorded.ResultsLaparoscopic cholecystectomy is feasible and safe under spinal anaesthesia, and it can be recommended as anaesthesia of choice for conducting laparoscopic cholecystectomy in hospital setups of developing countries. Laparoscopic cholecystectomy has traditionally been performed under general anesthesia. In spite of the emerging evidence it can be performed safely under regional anaesthesia. It has not gained widespread acceptance. ObjectivesGenerally, spinal anesthesia has lower postoperative mortality and fewer complications than general anesthesia, so it seems more suitable for the laparoscopic surgery. We designed a prospective observational study to determine the feasibility of spinal anesthesia for laparoscopic cholecystectomy as a routine in clinical practice. Generally, spinal anesthesia has lower postoperative mortality and fewer complications than general anesthesia, so it seems more suitable for the laparoscopic surgery. We designed a prospective observational study to determine the feasibility of spinal anesthesia for laparoscopic cholecystectomy as a routine in clinical practice. MethodsA total of 164 patients planned to undergo elective laparoscopic cholecystectomy for cholecystitis, with inclusion criteria of ASA grade I or II and ages 18–60 years were included in this study. Subarachnoid block was performed at the level of L2-L3 interspace with 0.5% hyperbaric Bupivacaine. After placement of the subarachnoid block, all patients were placed in a 20°–30° Trendelenburg position until the level of sensory anesthesia reached the T4 dermatome level. CO2 insufflation was started using pressure limit of 12 mmHg. Oxygen was given via face mask at 4 liters /minute. Heart rate, blood pressure, and spO2 were recorded every 3 minutes. During the procedure, anxiety was treated with 2 mg Midazolam and pain with 50 μg intravenous boluses of Fentanyl. Bradycardia was treated with 0.3-0.6 mg of intravenous Atropine. Continuous monitoring of hemodynamic parameters was done using noninvasive multiparameter monitor. Duration of anaesthesia, operative time, and duration of pneumoperitoneum were recorded. Postoperative pain, drug consumption, shoulder pain, anxiety, headache, nausea, vomiting, and abdominal discomfort were also recorded. A total of 164 patients planned to undergo elective laparoscopic cholecystectomy for cholecystitis, with inclusion criteria of ASA grade I or II and ages 18–60 years were included in this study. Subarachnoid block was performed at the level of L2-L3 interspace with 0.5% hyperbaric Bupivacaine. After placement of the subarachnoid block, all patients were placed in a 20°–30° Trendelenburg position until the level of sensory anesthesia reached the T4 dermatome level. CO2 insufflation was started using pressure limit of 12 mmHg. Oxygen was given via face mask at 4 liters /minute. Heart rate, blood pressure, and spO2 were recorded every 3 minutes. During the procedure, anxiety was treated with 2 mg Midazolam and pain with 50 μg intravenous boluses of Fentanyl. Bradycardia was treated with 0.3-0.6 mg of intravenous Atropine. Continuous monitoring of hemodynamic parameters was done using noninvasive multiparameter monitor. Duration of anaesthesia, operative time, and duration of pneumoperitoneum were recorded. Postoperative pain, drug consumption, shoulder pain, anxiety, headache, nausea, vomiting, and abdominal discomfort were also recorded. ResultsLaparoscopic cholecystectomy is feasible and safe under spinal anaesthesia, and it can be recommended as anaesthesia of choice for conducting laparoscopic cholecystectomy in hospital setups of developing countries. Laparoscopic cholecystectomy is feasible and safe under spinal anaesthesia, and it can be recommended as anaesthesia of choice for conducting laparoscopic cholecystectomy in hospital setups of developing countries.

Feasibility of the Ultrasonic Bone Aspirator in Retrosigmoid Vestibular Schwannoma Removal

Postoperative headache is an undesirable consequence of retrosigmoid vestibular schwannoma (VS) removal. An ultrasonic bone aspirator (UBA) may reduce headache by minimizing subarachnoid bone dust dispersion. The feasibility of removing internal auditory canal (IAC) bone with a UBA is unknown. This study assessed volume and duration of IAC bone removal in clinical and laboratory settings. (1) Retrospective review of radiologic data and intraoperative videos. (2) Cadaveric temporal bone model. (1) Tertiary care medical center. (2) Laboratory. We calculated the volume of IAC bone drilled during retrosigmoid VS removal using postoperative computed tomography scans. We then measured the time spent actively drilling IAC bone by analyzing operative videos. Finally, we measured bone ablation rates in a cadaveric temporal bone model using a drill and UBA. The mean ± SD volume of IAC bone removed during surgery was 0.32 ± 0.17 mL (n = 9). The time spent actively removing IAC bone with a drill was only 10.4 ± 3.5 minutes, less than a third of the total IAC opening time of 34.2 ± 13.1 minutes (n = 5). On cadaveric specimens, the UBA removed bone at 0.21 ± 0.03 or 0.35 ± 0.07 µL/s at 15% or 50% power, respectively (n = 4). This extrapolates to 15.0 ± 3.0 to 25.0 ± 3.9 minutes to remove the same 0.32 mL from surgery. The volume and duration of IAC bone removal during retrosigmoid VS surgery are small. Using a UBA at low power instead of a drill would extend the length of surgery by 5 to 15 minutes, with the theoretical potential for reducing headache.

Novel technique for cranial reconstruction following retrosigmoid craniectomy using demineralized bone matrix

ObjectiveA versatile neurosurgical approach, the retrosigmoid craniectomy (RS) has traditionally been associated with high rates of post-operative cerebrospinal fluid (CSF) leak, headaches, and aesthetic defects. We introduce a simple surgical strategy for bony cranial reconstruction designed to minimize peri-operative complications and improve cosmetic outcomes. MethodsIn accordance with the Institutional Review Board, the senior author's (G.M.M.) records were queried between 2006 and 2014. We identified 50 consecutive patients who underwent demineralized bone matrix (DBM)-augmented cranioplasty after RS for MVD (DBM group) and 92 consecutive patients in whom standard cranial reconstruction was undertaken using autologous bone chips only after RS for MVD (non-DBM group). Demographic and clinical information regarding the laterality of each operation, intra-dural drilling for petrous hyperostosis, method of dural closure, length of hospitalization, presence of post-operative headaches, and procedure-related complications were collected and analyzed. ResultsThe DBM and non-DBM cohorts were well matched for age, laterality of procedure, surgical indications, primary versus revision surgery, intra-dural drilling of petrous hyperostosis, and dural closure techniques. Trigeminal neuralgia was the most common surgical indication (98.6%) in each cohort. Post-operatively, 15% of patients in non-DBM group experienced chronic headaches at the last follow-up compared to only 8% of the patients in the DBM group (p=0.21). The non-DBM patients also suffered more incisional pain in comparison to the DBM patients (7.6% vs. 0%, p=0.045). ConclusionDBM-augmented reconstruction of posterior fossa defects resulted in low rates of post-operative headaches, better cosmetic outcomes, and represents a simple and effective cranioplasty option for skull base surgeons.

Optimization of the Ultrasonic Bone Aspirator in Retrosigmoid Vestibular Schwannoma Removal

Introduction: Postoperative headache is a troublesome side effect of retrosigmoid vestibular schwannoma resection. The ultrasonic bone aspirator (UBA) has been shown in our laboratory to greatly reduce bone dust dispersion, which may subsequently reduce headache incidence. Speed of bone removal is an additional consideration in multidisciplinary skull base surgery. The optimal UBA tips for minimizing bone dust dispersion and maximizing bone removal rate are unknown.

Occipital-device-related pain as a complication of deep brain stimulation

Deep brain stimulation is an established treatment for movement disorders. We reported 4 patients (1.3%) of post-operative occipital headache related to the placement of the connection among 309 patients from 1998 to 2008. The patients were treated successfully by repositioning the connector into a groove created in the bone.

Intraoperative corticosteroid injections in migraine surgery: efficacy in preventing refractory symptoms.

A subset of patients have been noted to have refractory migraine symptoms in site IV (occipital triggers) following primary surgery. It was postulated that the cause of refractory migraine symptoms is new scar tissue formation causing irritation of the greater occipital nerve. The goal of this study was to determine whether intraoperative corticosteroid injections have the potential to prevent these refractory symptoms. A retrospective review of all patients operated on by the senior author (B.G.) from 2000 to 2010 was undertaken. All patients who had site IV decompression and at least 1 year of follow-up were included. Patients were divided into two groups, those who had corticosteroids injected and those who did not. Data analyzed included demographics and preoperative and postoperative migraine headache symptoms review based on the migraine headache questionnaire. A total of 476 patients were included in the study. There were 282 patients in the corticosteroid group and 194 in the no-corticosteroid group. A significant reduction was found in the frequency of migraine headaches (-9.8 versus -8.0; p = 0.03) and the migraine headache index (-92.9 versus -65.2; p = 0.0065). There was no significant reduction in migraine headache duration (-0.50 versus -0.70; p = 0.10) or severity (-3.50 versus -3.80; p = 0.38). Intraoperative injection of corticosteroids during site IV migraine surgery may reduce migraine frequency and migraine headache index postoperatively. Corticosteroid injection in migraine site IV surgery is an effective adjunctive measure in reducing the migraine headache index. Therapeutic, III.

Preservation of the greater occipital nerve during suboccipital craniectomy results in a paradoxical increase in postoperative headaches.

Injury to the greater occipital nerve (GON) during suboccipital/retrosigmoid craniectomy (SOC) has been postulated as an etiology of postoperative headaches (HAs). We hypothesized that severe postoperative HAs may be due to the division of the GON during dissection. To determine whether the GON plays an important role in the development of postoperative HAs. A retrospective review of prospectively accrued patients undergoing SOC by 1 neurosurgeon at Johns Hopkins from 1995 to 2009 was performed. A total of 280 patients were included in the study. HA was categorized into 3 groups according to the severity and impact on daily activities. Data were analyzed using a stepwise multivariate logistic regression analysis to identify independent factors associated with HA development. Patients with a history of preoperative HAs and migraine were excluded from the analysis. In this cohort, new postoperative severe HAs at last follow-up visit were found in 19% of patients. By multivariate analysis, only GON preservation (relative risk: 1.49; 95% confidence interval: 1.00-2.34; P = 0.05) and wound infection (relative risk: 2.29; 95% confidence interval: 0.91-4.25; P = 0.07) were statistically significant. By univariate analysis, positive dependent associations included GON preservation (P < .01), reconstruction of the porus with hydroxyapatite cement (P = 0.02), and wound infection (P < 0.01). Statistically significant differences in the incidence of HA after surgery were found in patients in whom the GON was preserved compared with patients in whom the GON was divided (P = 0.035). Postoperative debilitating HAs are a common complication after SOC. Although these HAs are probably multifactorial in nature, preservation of the GON during SOC is independently associated with postoperative debilitating HAs.

Response to low-dose intrathecal clonidine in septuagenarians undergoing sub-umbilical surgeries: A study.

Clonidine, an alpha-2-adrenergic agonist, may have a clinically relevant analgesic action but also a hypotensive action, when administered spinally.Aim:To evaluate the analgesic and circulatory effects of low-dose intrathecal clonidine co-administered with hyperbaric bupivacaine in septuagenarian patients undergoing sub-umbilical surgeries.Materials and Methods:A total of 20 patients within the age group of 70-80 years of either sex, enrolled in this study, were randomly divided into groups of 10 each. Group I received clonidine 7.5 μg as an adjuvant to 15 mg of hyperbaric bupivacaine and Group II (control group) received 15 mg of bupivacaine with saline to make volume in the two solutions equal.Result:The level of subarachnoid block was comparable in the two groups. Duration of motor blockade was longer in the clonidine group (221.4 ± 35.92 min) compared with the control group (112.3 ± 12.45 min). Request for 1st dose of analgesic was earlier in the control group (135.5 ± 28.52 min) than the clonidine group (295 ± 18.85 min). Mean arterial pressure (clonidine 77.67 ± 6.47 vs. control 93.87 ± 3.03, P = 0.0002) and heart rate (clonidine 65.2 ± 5.20 vs. control 77.4 ± 6.06, P = 0.003) were significantly lower (P < 0.05) in the clonidine group compared with the control group from 20 mins after the block to the end of 3 h. In the clonidine group, 3 patients had postoperative headache, 4 had intra-operative shivering. 2 patients in the clonidine group also developed hypotension and 1 bradycardia and 1 of them developed bradyapnea along with acute hypotension 5 min after shifting to the postoperative ward and later recovered on resuscitation. In the control group 2 patients had bradycardia, 6 had intra-operative shivering and 3 had postoperative headache.Conclusion:We conclude that addition of clonidine in the dose of 7.5 μg to bupivacaine significantly increases the duration of spinal analgesia with clinically insignificant influence on hemodynamic parameters.

Drug treatment and prevention of postoperative headache

Headache frequently occurs after spinal anesthesia or after craniotomy, especially after removal of acoustic neuroma. Headache after spinal anesthesia is caused by leakage of liquor through dural puncture and decrease of intracranial pressure, while pain after craniotomy is consequence of operative injury of peri-cranial muscles and soft tissues. Epidural administration of morphine and intravenous administration of cosyntropine or aminophylline at the end of a surgical intervention may prevent postoperative headache, while caffeine, gabapentin, pregabalin, theophylline, hydrocortisone or cosyntropine are efficient in the treatment. Drugs are not efficient for prevention of headache after craniotomy, while parenteral codeine and/or acetaminophen can terminate this type of pain. Non-steroid antiinflammatory drugs should be avoided for treatment of post-craniotomy headache, due to their extraand intra-cranial adverse effects. Timely administration of appropriate drugs for prevention or treatment of postoperative headache significantly decreases suffering, hastens recovery and prevent chronic headache.

The big "little problem" with postoperative nausea and vomiting prophylaxis.

Sir, We wish to report a case of severe headache in the immediate post-operative period in 35 years old, 56 kg, smoker, American Society of Anaesthesiologists physical status I, male patient scheduled for fistulectomy for fistula-in-ano. On patient's request, general anaesthesia (GA) was administered. Anaesthesia was induced with injection fentanyl 60 μg and propofol 100 mg and maintained with isoflurane to achieve an end tidal concentration of 1.5-2% in an oxygen/nitrous oxide mixture. Proseal® laryngeal mask airway was inserted and surgery was conducted under spontaneous respiration. Injection ondansetron 4 mg was administered for prevention of post-operative nausea and vomiting (PONV). Intraoperatively, approximately 500 ml of Ringer lactate solution was administered. Surgery lasted for 20 min and remained uneventful. In post-operative period, patient complained of severe headache which was more in the frontal area and was not positional. Patient gave no such history of headache in the past. Injection diclofenac 75 mg was given as intravenous (IV) infusion and on follow-up, headache subsided completely in 6 h. Factors that may operate in regard to perioperative headache under GA include cerebral vasodilatation, any history of previous headache and administration of certain drugs. Cerebral vasodilatation may occur due to hypoxia, hypercarbia, dehydration, prolonged fasting period, caffeine withdrawal, hypertension, pre-eclampsia and sepsis.[1] Pre-operative headache and lack of sleep, the previous night are also strong predictors of post-operative headache. None of these factors were present in our patient. Drugs such as antihypertensives (nitrates), steroids, metronidazole, muscle relaxants and 5 HT3 antagonists used in perioperative period can also cause headache in the post-operative period.[1] On retrospective analysis, we speculated the cause of headache to be ondansetron, a 5 HT3 anatagonist in our patient. The recommended prophylactic dose of ondansetron is 4 mg with number needed to treat (NNT) of six for the prevention of vomiting (0-24 h) and NNT of seven for the antinausea effect.[2] However it may be associated with certain side effects e.g. headache, elevated liver enzymes and constipation etc. Headache following use of ondansetron for PONV prophylaxis has been reported earlier in literature.[3] The exact mechanism of this side effect is not known; however, it could be due to weak 5 HT1 antagonistic action. Various tools exist to stratify the risk of developing PONV; however, no uniform and standardised approach has been utilised to evaluate and manage PONV in clinical practice.[4] Apfel's simplified risk score includes female sex, prior history of motion sickness or PONV, non-smoking status and the use of post-operative opioids as the independent predictors. The estimated probability of PONV was 10%, 21%, 39%, and 78% with one, two, three, and four risk factors, respectively.[5] Prophylaxis with dexamethasone and serotonin antagonist and use of total IV anaesthetic technique are justified in patients with moderate to high risk (e.g. risk score 2/3/4).[4] However, it may not be warranted in patients at low risk as it may unnecessarily expose the patients to the risk of associated side effects.[6] On retrospective assessment, our patient's baseline risk for PONV was found to be very low; hence, PONV prophylaxis was probably not required. We emphasize that Apfel scoring system should be used in all patients receiving GA. Drugs for PONV prophylaxis should be used in minimal effective doses only when the patient's individual risk is sufficiently high as we must not forget that each antiemetic has its own side effects.

Three kinds of operation method in the treatment of Chiari I malformation with syringomyelia curative effect contrast

Objective To investigate effects of three operation methods in treatment of Chiari Ⅰ with syringomyelia.Methods Retrospective study of patients betwenJune 2005 and June 2012 in The department of Neurosurgery,People's Hospital of Xinjiang Uygur Autonomous Region for a total of 133 cases patient of Chiari Ⅰ malformation with syrigomyelia.Group A was performed in 20 cases for simple posterior bony decompression; group B was performed in 65 cases for posterior bony decompression + dural enlargement repair;group C was performed in 48 cases for posterior bony decompression + dural enlargement repair + resection of the cerebellar tonsils.To comparison the effect of the operation,syringomyelia resolution and the rate of postoperative complications.Results Outpatient follow up for 6 months-9 years,a total of 118 patients were followed up for.According to the criteria of Tator,A,B,C three groups in the superior,good,poor rate was significant difference (P ＜ 0.05).Promote syringomyelia regression had significant difference(P ＜0.05).Group B and C have the same effect of operation,better than group A.A,B,C three groups of infection were 1 case,2 cases,1 case; postoperative transient headache were 6 cases,30 cases,25 cases;early postoperative cerebrospinal fliud leakage and subcutaneous effusion were 0 case,8 cases,6 cases ; 1 case of death in group C.The total complication rate had no significant difference (P ＞ 0.05).Conclusion Posterior bony decompression plus dural enlargement repair,posterior bony decompression withdural enlargement repair andResection of the cerebellar tonsils were the same effect,arereliable methods for Chiari Ⅰ with syringomyelia,better than soly posterior bony decompression. Key words: Chiari Ⅰ with syringomyelia; Operation type; Postoperative complications

Safety of a novel formulation of ibuprofen sodium compared with standard ibuprofen and placebo

Background: Ibuprofen (IBU) is an efficacious over-the-counter analgesic/antipyretic with adverse event (AE) rates comparable to placebo. IBU sodium (IBUNa) is a newer, more soluble form that is absorbed faster than standard IBU, leading to more rapid analgesia. Although its safety and tolerability are expected to be comparable to standard IBU, this has not yet been reported. Methods: Pooled analysis comparing the safety of single-dose IBUNa (512 mg; equivalent to 400 mg IBU free acid; n = 362) with standard IBU tablets (400 mg; n = 342) and placebo (n = 187) across five Phase III, randomized, placebo-controlled, double-blind studies evaluating IBUNa for treatment of postoperative dental pain, tension-type headache, or fever. Results: Treatment-emergent AEs (TEAEs) occurred in 5% of cases in the IBUNa group (25 events), 6.4% of cases in the standard IBU group (41 events), and 10.2% of cases in the placebo group (31 events). The most frequent TEAEs were in the following Medical Dictionary for Regulatory Activities (MedDRA) System Organ Classes: gastrointestinal disorders (2.8, 3.2, and 5.9% for IBUNa, standard IBU, and placebo, respectively), nervous system disorders (1.4, 3.5, and 3.7% for IBUNa, standard IBU, and placebo, respectively), and general disorders and administration-site conditions (1.1, 1.5, and 2.1% for IBUNa, standard IBU, and placebo, respectively). Nausea was the most common TEAE (2.5, 2.6, and 5.9% for IBUNa, standard IBU, and placebo, respectively). Only two AEs were considered related to treatment: pruritus (n = 1, IBUNa) and nausea (n = 1, placebo). Of those subjects reporting ≥ 1 TEAE, 44.4, 36.4, and 89.5% of subjects in the IBUNa, standard IBU, and placebo groups, respectively, received rescue medication. Conclusion: IBUNa has a favorable safety profile comparable to those of standard IBU tablets and placebo in single-dose studies evaluating analgesic or antipyretic efficacy. ClinicalTrials.gov Registry Numbers: Dental pain studies: NCT01098747 and NCT01216163; headache studies: NCT01077973 and NCT01362491; pyresis study: NCT01035346.

Caffeine as an analgesic adjuvant for acute pain in adults.

This is an updated version of the original Cochrane review published in Issue 3, 2012. Caffeine has been added to common analgesics such as paracetamol, ibuprofen, and aspirin, in the belief that it enhances analgesic efficacy. Evidence to support this belief is limited and often based on invalid comparisons. To assess the relative efficacy of a single dose of an analgesic plus caffeine against the same dose of the analgesic alone, without restriction on the analgesic used or the pain condition studied. We also assessed serious adverse events. We searched CENTRAL, MEDLINE, and EMBASE from inception to 28 August 2014, the Oxford Pain Relief Database, and also carried out Internet searches and contacted pharmaceutical companies known to have carried out trials that have not been published. We included randomised, double-blind studies that compared a single dose of analgesic plus caffeine with the same dose of the analgesic alone in the treatment of acute pain. Two review authors independently assessed the eligibility and quality of studies, and extracted data. Any disagreements or uncertainties were settled by discussion with a third review author. We sought any validated measure of analgesic efficacy, but particularly the number of participants experiencing at least 50% of the maximum possible pain relief over four to six hours, participants reporting a global evaluation of treatment of very good or excellent, or headache relief after two hours. We pooled comparable data to look for a statistically significant difference, and calculated numbers needed to treat to benefit (NNT) with caffeine. We also looked for any numerical superiority associated with the addition of caffeine, and information about any serious adverse events. We identified no new studies with available results for this update. The earlier review included 20 studies (7238 participants) in valid comparisons, but because we used different outcomes for some headache studies, the number of participants in the analyses of the effects of caffeine is now 4262 when previously it was 5243. The studies were generally of good methodological quality, using standard designs and mostly standard scales of pain measurement, although many of those treating postoperative pain were small.Most studies used paracetamol or ibuprofen, with 100 mg to 130 mg caffeine, and the most common pain conditions studied were postoperative dental pain, postpartum pain, and headache. There was a small but statistically significant benefit with caffeine used at doses of 100 mg or more, which was not dependent on the pain condition or type of analgesic. About 5% to 10% more participants achieve a good level of pain relief (at least 50% of the maximum over four to six hours) with the addition of caffeine, giving a NNT of about 14 (high quality evidence).Most comparisons individually demonstrated numerical superiority with caffeine, but not statistical superiority. One serious adverse event was reported with caffeine, but was considered unrelated to any study medication.We know of the existence of around 25 additional studies with almost 12,500 participants for which data for analysis were not obtainable. The additional analgesic effect of caffeine remained statistically significant but clinically less important even if all the known missing data had no effect; the bulk of the unobtainable data are reported to have similar results as this review. The addition of caffeine (≥ 100 mg) to a standard dose of commonly used analgesics provides a small but important increase in the proportion of participants who experience a good level of pain relief.

Pediatric and adult Chiari malformation Type I surgical series 1965-2013: a review of demographics, operative treatment, and outcomes.

Chiari malformation Type I (CM-I) is a hindbrain disorder associated with elongation of the cerebellar tonsils, which descend below the foramen magnum into the spinal canal. It occurs in children and adults. Clinical symptoms mainly develop from alterations in CSF flow at the foramen magnum and the common subsequent development of syringomyelia. The authors reviewed English-language reports of pediatric, adult, and combined (adult and pediatric) surgical series of patients with CM-I published from 1965 through August 31, 2013, to investigate the following: 1) geographical distribution of reports; 2) demographics of patients; 3) follow-up lengths; 4) study durations; 5) spectrum and frequency of surgical techniques; 6) outcomes for neurological status, syrinx, and headache; 7) frequency and scope of complications; 8) mortality rates; and 9) differences between pediatric and adult populations. Research and inclusion criteria were defined, and all series that contained at least 4 cases and all publications with sufficient data for analysis were included. The authors identified 145 operative series of patients with CM-I, primarily from the United States and Europe, and divided patient ages into 1 of 3 categories: adult (>18 years of age; 27% of the cases), pediatric (≤18 years of age; 30%), or unknown (43%). Most series (76%) were published in the previous 21 years. The median number of patients in the series was 31. The mean duration of the studies was 10 years, and the mean follow-up time was 43 months. The peak ages of presentation in the pediatric studies were 8 years, followed by 9 years, and in the adult series, 41 years, followed by 46 years. The incidence of syringomyelia was 65%. Most of the studies (99%) reported the use of posterior fossa/foramen magnum decompression. In 92%, the dura was opened, and in 65% of these cases, the arachnoid was opened and dissected; tonsillar resection was performed in 27% of these patients. Postoperatively, syringomyelia improved or resolved in 78% of the patients. Most series (80%) reported postoperative neurological outcomes as follows: 75% improved, 17% showed no change, and 9% experienced worsening. Postoperative headaches improved or resolved in 81% of the patients, with a statistical difference in favor of the pediatric series. Postoperative complications were reported for 41% of the series, most commonly with CSF leak, pseudomeningocele, aseptic meningitis, wound infection, meningitis, and neurological deficit, with a mean complication rate of 4.5%. Complications were reported for 37% of pediatric, 20% of adult, and 43% of combined series. Mortality was reported for 11% of the series. No difference in mortality rates was seen between the pediatric and adult series. Before undergoing surgical treatment for CM-I, symptomatic patients and their families should be given clear information about the success of treatment and potential complications. Furthermore, surgeons may benefit from comparing published data with their own. In the future, operative CM-I reports should provide all details of each case for the purpose of comparison.

A prospective, randomized, controlled trial of the postoperative analgesic effects of spraying 0.25 % levobupivacaine after bilateral axillo-breast approach robotic thyroidectomy.

Robotic thyroidectomy (RoT) is frequently performed due to its excellent cosmesis and recovery features. However, postoperative pain in the operating field after RoT remains a concern due to extensive tissue dissection and tension during the operation. The aim of this study was to evaluate the anterior chest pain and the effect of levobupivacaine spraying on postoperative pain control after bilateral axillo-breast approach (BABA) RoT. We randomized 55 adult patients scheduled for BABA RoT into the control group (group C, n = 27) or the levobupivacaine group (group L, n = 28). At the end of surgery, patients in groups C and L were sprayed with the same volume (30 ml) of normal saline and 0.25 % levobupivacaine, respectively, on the flap dissection area. Pain scores, the consumption of patient-controlled analgesia (PCA), and other adverse effects were assessed at 1, 6, 24, and 48 h postoperatively. Patients in group L showed lower pain scores than those of group C at 1 h (50 [0-100] vs. 80 [20-100]; p = 0.004), 6 h (30 [0-90] vs. 70 [30-90]; p < 0.001), 24 h (30 [0-80] vs. 50 [10-80]; p = 0.016) and 48 h (10 [0-80] vs. 30 [10-80]; p < 0.001) postoperatively. PCA consumption of group L was less than that of group C at 6, 24, and 48 h after surgery. There were no significant differences in postoperative nausea-vomiting, headache, or dizziness. Local anesthetic-related adverse effects were not reported. Levobupivacaine spray on the operative field at the end of BABA RoT reduced postoperative pain and PCA consumption without adverse events.

Reconstruction after retrosigmoid approaches using autologous fat graft-assisted Medpor Titan cranioplasty: assessment of postoperative cerebrospinal fluid leaks and headaches in 60 cases.

Postoperative cerebrospinal fluid (CSF) leaks and headaches remain potential complications after retrosigmoid approaches for lesions in the posterior fossa and cerebellopontine angle. The authors describe a simple repair technique with an autologous fat graft-assisted Medpor Titan cranioplasty and investigate the incidence of postoperative CSF leaks and headaches using this technique. A retrospective chart review was conducted on all cases (n = 60) of retrosigmoid craniectomy from September 2009 to May 2014 in patients who underwent fat graft-assisted cranioplasty. After obtaining a watertight dural closure and sealing off any visible mastoid air cells with bone wax, an autologous fat graft was placed over the dural suture line and up against the waxed-off air cells. The fat graft filled the retrosigmoid cranial defect and was then bolstered with a Medpor Titan (titanium mesh embedded in porous polyethylene) cranioplasty. A postoperative mastoid pressure dressing was applied for 48 h, and prophylactic lumbar drainage was not used. Factors examined in this study included postoperative CSF leak (incisional, rhinorrhea, otorrhea), pseudomeningocele formation, incidence and severity of postoperative headache, length of hospital stay, and length of follow-up. No patients developed postoperative CSF leaks (0 %), pseudomeningoceles (0 %), or new-onset postoperative headaches (0 %) with the described repair technique. There were no cases of graft site morbidity such as hematoma or wound infection. Mean duration of postoperative hospital stay was 3.8 days (range 2-10 days). Mean postoperative follow-up was 12.4 months (range 2.0-41.1 months). Our multilayer repair technique with a fat graft-assisted Medpor Titan cranioplasty appears effective in preventing postoperative CSF leaks and new-onset postoperative headaches after retrosigmoid approaches. Postoperative lumbar drainage may not be necessary.

Impact of Preoperative Narcotic Use on Outcomes in Migraine Surgery

This study focuses on the impact of preoperative narcotic medication use on outcomes of surgical treatment of migraine headaches. A retrospective comparative review was conducted with patients undergoing migraine surgery. Data gathered included demographic information, baseline migraine headache characteristics, migraine surgery sites, postoperative migraine headache characteristics 1 year or more following surgery, and preoperative migraine medication use. Patients were grouped based on preoperative narcotic medication use. The narcotic users were subdivided into low and high narcotic user groups. Preoperative migraine characteristics were comparable between groups and the outcomes of migraine surgery were compared between the groups. Outcomes in 90 narcotic users were compared with those for 112 patients not using narcotic medications preoperatively. Narcotic users showed statistically significantly less reduction in frequency, severity, and duration of migraine headaches after surgery. Narcotic users had clinical improvement in 66.7 percent of patients and elimination in 18.9 percent versus 86.6 and 36.6 percent, respectively, in the nonnarcotic group. The group that consumed narcotics had significantly lower rates of improvement in all migraine indices. Previous studies have discouraged the routine use of narcotic medications in the management of migraine medications. The authors' study demonstrates that narcotic medication use before migraine headache surgery may predispose patients to worse outcomes postoperatively. Because pain cannot be objectively documented, the question remains of whether this failure to improve the pain was indeed a suboptimal response to surgery or the need for narcotic substances. Risk, II.

Postendarterectomy Cerebral Hyperperfusion Syndrome: The Etiological Significance of "Cerebral Reserve".

Postoperative cerebral hyperperfusion syndrome (CHS) in patients undergoing carotid intervention is thought to be related to the absence of cerebral reserve. Although hyperperfusion syndrome is rare, severe postoperative headache is common and is considered to be a prodromal sign. Cerebral reserve is measured by studying the response of cerebral vessels to a vasodilator such as hypercarbia. We produced hypercarbia by holding respiration for 60 seconds during carotid endarterectomy. We attempted to evaluate the relationship between intraoperatively evaluated cerebral reserve and the development of postoperative headache which was severe enough to require the patient to take an over the counter analgesic (e.g., ibuprofen, acetaminophen, aspirin). Internal carotid artery flow 1 (F1), Pco 2, and blood pressure 1 (BP1) were recorded before and after (F2, Pco 2, and BP2) 60 seconds of apnea. An increase in flow of > 20% was considered indicative of adequate cerebral reserve. Patients were evaluated before discharge and with follow-up calls at 2 to 5 days postdischarge. Fisher exact test was used to evaluate categorical predictors. Unpaired t test was used to compare continuous variables. Results were considered significant when p < 0.05. A total of 30 nonconsecutive patients were evaluated prospectively. Of the 30 patients, 4 (Group I) developed severe postoperative headache; 26 did not (Group II). Demographics were similar in both the groups. Three patients in Group I and 16 patients in Group II had > 20% increase in flow (p = 0.6315). Pco 2 rose in both groups and BP2 was unchanged from BP1 in both groups. Lack of cerebral reserve does not appear to be related to the development of severe postoperative headache.

Erratum to: Incidence and risk factors of postoperative headache after endovascular coil embolization of unruptured intracranial aneurysms

Erratum to: Incidence and risk factors of postoperative headache after endovascular coil embolization of unruptured intracranial aneurysms

Management of intended durotomy in minimally invasive intradural spine surgery: clinical article.

Minimally invasive surgery (MIS) has been increasingly used for the treatment of various intradural spinal pathologies in recent years. Although MIS techniques allow for successful treatment of intradural pathology, primary dural closure in MIS can be technically challenging due to a limited surgical corridor through the tubular retractor system. The authors describe their experience with 23 consecutive patients from a single institution who underwent MIS for intradural pathologies, along with a review of pertinent literature. A retrospective review of a prospectively collected surgical database was performed to identify patients who underwent MIS for intradural spinal pathologies between November 2006 and July 2013. Patient demographics, preoperative records, operative notes, and postoperative records were reviewed. Primary outcomes include operative duration, estimated blood loss, length of bed rest, length of hospital stay, and postoperative complications, which were recorded prospectively. Twenty-three patients who had undergone MIS for intradural spinal pathologies during the study period were identified. Fifteen patients (65.2%) were female and 8 (34.8%) were male. The mean age at surgery was 54.4 years (range 30-74 years). Surgical pathologies included neoplastic (17 patients), congenital (3 patients), vascular (2 patients), and degenerative (1 patient). The most common spinal region treated was lumbar (11 patients), followed by thoracic (9 patients), cervical (2 patients), and sacral (1 patient). The mean operative time was 161.1 minutes, and the mean estimated blood loss was 107.2 ml. All patients were allowed full activity less than 24 hours after surgery. The median length of stay was 78.2 hours. Primary sutured dural closure was achieved using specialized MIS instruments with adjuvant fibrin sealant in all cases. The rate of postoperative headache, nausea, vomiting, and diplopia was 0%. No case of cutaneous CSF fistula or symptomatic pseudomeningocele was identified at follow-up, and no patient required revision surgery. Primary dural closure with early mobilization is an effective strategy with excellent clinical outcomes in the use of MIS techniques for intradural spinal pathology. Prolonged bed rest after successful primary dural closure appears unnecessary, and the need for watertight dural closure should not prevent the use of MIS techniques in this specific patient population.