Tehran University Medical Journal

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There are many studies about epidural fibrosis after surgical manipulation of the spine. We have studied formation of the post laminectomy epidural fibrosis after application of two materials (Silicone and Teflon) in this report. This expriment is on two groups of rats. Two separated laminectomies were done in each rat, one serving as control while in the other laminectomy spaces Silicone was used in group A and Teflon in group B. Laminectomy spaces were evaluated with gross dissection and histologic studies after 6 weeks. Silicone decreased intermuscular scar, deep scar, dural adhesion and collagen fiber density in epidural space. Teflon decreased dural adhesion and collagen fiber density but did not decrease intermuscular and deep scar formation in epidural space.

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Introduction: It is suggested that quadriceps muscle has an important role in stability & mobility of Knee joint in athletics and normal individuals therefore, the purpose of this study was evaluation of the strength in Power Athletics (PA) and Normal Un-trained Individuals (NUI) groups.

Methods and Materials: 31 Females (20 NUI & 11 PA) participated in this study. For measuring the strength, each individual performed 5 continuous concentric-eccentric maximal contraction at angular velocities of 90°/s, 135°/s. Twenty five percent of each individual (Maximum Voluntary Isometric Contraction) MVIC was determined and used as Pre-load force.

Results: Averages concentric & eccentric torques were greater in PA group in comparison with NUI group. The significant difference (P<0.02) existed between PA and NUI groups. Average concentric torques of quadriceps muscle decreased (with increasing of speed from 90°/s to 135°/s) and average eccentric torques increased. Average eccentric torques were greater (P<0.01) in PA & NUI groups in comparison with average concentric torques.

Conclusion: PA group strength was greater in comparison with NUI group. This is possibly due to the type of muscle fibers in this group have (greater type II fibers). Accordingly, it is critical to consider the role of eccentric exercise in PA group for preventing sport injury.

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Background: Epidural injection of the drugs such as opioids has rather been a successful method in controlling post operative pain.

Materials and Methods: In a clinical trial study, 50 Female patients, in a range of 20-40 years old and ASA class I, who were scheduled for gynecologic operation were investigated. They were randomly divided in two groups. Before induction of general anesthesia, an epidural catheter was placed for each patient. Sixty minutes after the end of operation, a 15-ml solution containing 50-microgram clonidine was injected through the epidural catheter in the first group. In the second group, a similar volume solution containing 50- microgram fentanyl was injected. The catheter was removed after all the patients were followed for 4 hours and their pain was assessed by VAS (Visual Analogue Scale) method.

Results: Our findings revealed that the clonidine group had more intense pain however they had fewer complications than the opioid group.

Conclusion: We concluded that although clonidine might act as an analgesic drug, but epidural injection of a single dose of 50 microgram of the drug could not be effective enough for postoperative analgesia.

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Background: The incidence of inguinal hernia is 15 cases per 1,000 populations. The most common surgical methods of hernia repair are conventional open hernioplasty and laparoscopic hernioplasty. The advantages of laparoscopic hernioplasty are that the regional anatomy is observable, and bilateral herniorrhaphy can be performed at the same time. Since laparoscopic hernia is usually performed under general anesthesia, to shorten the length of hospital stay and to prevent complications, in this study, we evaluated the use of epidural anesthesia during hernioplasty.
Methods: This study included 20 male patients treated by a single surgeon. We recorded the PCO2 levels before, during and after surgery, as well as the pain and intra-abdominal pressure.
Results: Only one patient required conversion to general anesthesia. Three patients had hernia on the left side only, 14 patients on the right only and three patients had bilateral hernia. The PCO2 levels did not change (P=0.789). Fifty percent of patients had no postoperative pain. The median time to return to work or normal physical activity was 7 days.
Conclusion: Laparoscopic inguinal herniorrhaphy is a feasible alternative to open surgical hernia repair. Employing epidural anesthesia prevents the complications of general anesthesia. This method achieves a shorter hospital stay and time to return to normal activity, as well as reduction in pain. Controlled trials comparing laparoscopic and tension-free open herniorrhaphy are needed to further assess the relative benefits of this procedure.

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Background: Total spinal anesthesia is a complication of lumbar epidural anesthesia following undiagnosed subarachnoid or subdural injection of local anesthetic. Although many achondroplastic dwarfs have a normal spine, catheter insertion may be more problematic with a narrow epidural space making a subarachnoid tap more probable.  Other malformations associated with achondroplasia, such as prolapsed intervertebral discs, reduced interpedicular distance, shortened pedicles, and osteophyte formation, combined with a narrow epidural space may make identification of the space difficult and increases the risk of dural puncture. Furthermore, subarachnoid tap or dural puncture may be hard to recognize if a free flow of CSF is difficult to achieve due spinal stenosis. Yet, for those who meet the criteria, epidural regional anesthesia is frequently preferred over other forms, which often have more or more dangerous side effects in this type of patient.

Case report: A 22-year-old achondroplastic male dwarf patient was scheduled for pelvic mass resection and was considered a candidate for continuous epidural anesthesia. The anesthesia became complicated by total spinal anesthesia, which was reversed following supportive management for about two hours.

Conclusion: There is significant debate over the composition and volume of the test dose, especially for patients with achondroplasia. We nevertheless recommend repeated test-doses during the accomplishment of epidural anesthesia to exclude unintended intravascular, intrathecal or subdural injection, keeping in mind that a test dose of local anesthetic does not completely prevent complications.

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Background: Transfusion-Transmitted Virus (TTV) is a nonenveloped, single-stranded and circular DNA virus belongs to circuviridae family genus Anellovirus, discovered by Nishizawa in 1997. As the usage of common syringes is the known and most common route of the virus transmission, and because of increasing population of Injection drug users (IDU) we decided to study infection rate in IDU population of our Society.
Methods: In a cross-sectional study at Infectious ward of Imam Khomeini hospital, 60 IDU patients were studied. Blood samples were dispatched to lab in citrated test tube for Genome Virus isolation operation, using boiling method, then PCR assay performed based on their available primers. Patient's information gathered by interview and questionnaire methods.
Results: All of our 60 patients were men and their age average was 35.30(SD±9.68) years old. 26(43.3%) patients had positive TTV PCR and 24(92.30%) of them had prison history. 23(88.50%) of these 26 patients had positive HCV Ab, 17(65.40%) had positive HIV Ab and 8(30.80%) had positive HBS Ag. Of 60 study patients 48(80%) had HCV Ab+, 43(71.70%) HIV Ab+, 26(43%) TTV PCR and 43(26.70%) had HBS Ag+ Of 26 patients who had TTV, 34.60% of them had no contemporary sickness and 11.50% of them displayed clear sign of hepatitis (fever, abdominal pain, nausea, vomiting, RUQ tenderness and Icter). 34.60% of them had LFT more than Upper limit normal (45u/l). Time average of injection in 26 TTV patient was 9 years (SD±7.16) and the patient's age average was 36.35%(SD±9.2).
Conclusions: One of the most important route of TTV infection is use of common syringes, TTV infection transmission chance is less than HIV and HCV infection and is more than HBV. In regard to high prevalence of TTV infection in IDU population and because there is no comprehensive information about pathogenesis of this virus in addition to another way of transmission of the virus, the fecal-oral way, we must make plans and policies to decrease danger of transmission of this virus to health care workers, their families and other near relatives.

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Background: post operative pain is an essential problem. Epidural infusion of two different doses of bupivacaine in pain management of post orthopedic surgeries was studied.

Methods: In this double blinded randomized clinical trial we studied two groups of 42 patients undergone knee surgery. Based on block randomization, patients received two different concentration of bupivacaine (0.1% or 0.125%) in combination with fentanyl (1.7µg/ml). The beginning infusion rate was 5ml/h. Pain scores were documented by a blinded researcher 6, 12, 18, 24 and 48 hours after completion of surgery according to VAS tool. Patient satisfaction, complications and treatment failure (when increased volume of epidural infusion or other analgesics were required) were evaluated.

Results: In higher bupivacaine dose group, post operative pain scores were not significantly lower in different hours and during the follow up (both p values less than 0.001). After 48 hours, patients satisfaction were more in the higher bupivacaine group. There were no significant differences in complications. Treatment failure was more significant in lower bupivacaine dose (33.3% versus 11.9%, p=0.03).

Conclusion: continuous epidural infusion of both bupivacaine and fentanyl provide acceptable post operative pain control in orthopedic patients. Although higher concentrations of bupivacaine during first hours are more effective, lower concentrations are as effective as the higher one, during subsequent hours.

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Background: Epidural fibrosis (EF) is a part of normal physiological tissue response to laminectomy and it may be an important cause of failed back surgery syndrome (FBSS). The objective of this study was to evaluate the effect of using gel foam after laminectomy on reduction of epidural fibrosis.

Methods: In this prospective study forty five rabbits were recruited. The cases undergone bilateral laminectomy at the L4 and L5 lumbar levels under an approved surgical protocol. After eight weeks the rabbits were sacrificed and the spinal segments from L3 to L6 were removed en bloc. The amount of scar tissue at the laminectomy defect was scored. The fibroblast and inflammatory cell counts were also compared between two groups.

Results: In this study 55% of group A rabbits were placed in grade 0 or I, grade II fibrosis could be detected in the remaining 45%. In group B these amounts were 73.7% and 26.3% respectively, which no significant statistical difference could be detected between two arms (p=0.189). Comparing the quantity of fibroblasts 40% of group A rabbits were recognized as grade I and the other 60% as grade II and grade I fibrosis was discovered in 42.1% of group B rabbits, while other 57.9% suffered from grade II fibrosis, again no significant statistical difference could be attributed between two arms (p=0.576). Also comparing inflammatory cell counts detected in the specimens no significant statistical difference could be detected either (p=0.465).

Conclusion: According to this study using gel foam during the laminectomy surgery in rabbits has no obvious effect in reducing post laminectomy epidural fibrosis after eight weeks of follow-up.

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Background: Epidural catheters are seldom difficult to remove from patients. The breakage of the catheters is uncommon, troublesome and occasionally dangerous. Case presentation: A lumbar epidural catheter inserted in a 17 year-old man for applying anesthesia for internal fixation of femur fracture and subsequent postoperativeepidural analgesia. In the third postoperative day, during unsuccessful attempt for removing the catheter, it was broken and was retained in his back. A CT- scan was performed and shows a fragment of catheter in the sub- laminar ligament between L3 and L4 without any connection with epidural space. As the patient had no complaint the fractured fragment was left in site and he was just followed up in the clinic. Conclusion: The knowledge of practical method in locating the retained epidural catheter, and the indication for surgical removal are very important. CT- scan is useful in showing the mechanism and locating the epidural catheter entrapment and facilitating surgical follow-up.

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800x600 Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Diabetes insipidus is a rare disease which can be considered as a part of broad spectrum of preeclampsia manifestations.
Case presentation : A 39-year old primigravid woman, with an unremarkable past medical history, was admitted in the 33rd week of gestation for elevated blood pressure. On admission, her blood pressure was 140/90 mmHg and the only abnormal laboratory findings were trace proteinuria and elevated liver enzymes. During the following days her blood pressure rose to 150/100 mmHg with deterioration of clinical and paraclinical status of the patient characterized by excessive thirst, polydipsia and excretion of large amounts of diluted urine. Having considered the patient's aggravating status, termination of pregnancy was planned. Fortunately, all the clinical and paraclinical presentations, including those related to the probable diabetes insipidus disappeared on the second day of postpartum period.
Conclusion: Sign and symptoms of diabetes insipidus should be considered in all cases admitted for preeclampsia.

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Background: A variety of endocrine disorders can complicate pregnancy. Diabetes insipidus although uncommon, may have devastating effect on pregnancy outcome, if unrecognized and untreated. The etiology of diabetes insipidus is often unknown, many cases are likely autoimmune, with lymphocytic infiltration of the posterior pituitary gland. Massive polyuria, caused by failure of the renal tubular concentrating mechanism, and dilute urine, with a specific gravity 1.005, are characteristic of diabetes insipidus. The diagnosis of diabetes insipidus relies on the finding of continued polyuria and relative urinary hyposmolarity when water is restricted. Most women require increased doses Desmopressin Acetate during pregnancy because of an increased metabolic clearance rate stimulated by placental Vasopressinase. By this same mechanism, subclinical diabetes insipidus may become symptomatic during pregnancy. Transient diabetes insipidus is associated with acute fatty liver and HELLP syndrome as well as twin gestation. Increased placental Vasopressinase activity, along with insufficient liver degradation in HELLP syndrome and acute fatty liver, may unmask this condition. Diabetes insipidus in pregnancy is rare. The disease results from inadequate or absent antidiuretic hormone (vasopressin) production by the posterior pituitary gland. The increased glomerular filtration rate seen in pregnancy may increase the requirement for antidiuretic hormone. Case presentation: We present a 39 years old woman, gravida3 para3, was admitted to Akbarabadi Teaching Hospital in september 2013. She was admitted due to polyuria, malaise, thirst with slight fever, six days after normal vaginal delivery. The urine volume was 8 lit/day and the specific gravity (S.G.) of the urine was 1.010. The urine osmolarity was lower than the plasma osmolarity. Electrolyte serum examination showed hypernatremia. The patient received 5 µg/day of synthetic vasopressin, in the form of l- deamino-8-Darginine vasopressin (DDAVP). This drug was given as intranasal spray in doses 0.25 mg twice daily. Plasma electrolytes and fluid status monitored carefully with initiation of therapy. DDAVP was used because it was not degraded by vasopressinase. Treatment was continuing, when the symptoms of central diabetes insipidus resolve and urinary concentrating ability was preferred. Maximum urinary osmolality over the next 11 hours was assessed, 730 mosm/kg was considered normal. Conclusion: Close attention to electrolyte and fluid balance is important in the postpartum period. The symptoms of transient vasopressin-resistant diabetes insipidus resolve in few days to a few weeks after vaginal delivery or when hepatic function returns to normal.

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