A&A practice
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We report the case of a patient with a right-sided L4 synovial cyst, which had been causing significant pain, who had a successful transfacet epidural steroid injection to rupture the cyst. Using fluoroscopy, the needle was advanced through the right L4 facet joint and the cyst was ruptured using saline. ⋯ Repeat magnetic resonance imaging (MRI) done 2 years later showed no recurrence of the cyst. We discuss the role of transfacet epidural steroid injection in synovial cysts treatment.
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We present 4 cases of dorsal root ganglion stimulation lead fracture. In these cases, the surgical technique involved (1) traversing fascial layers for placement of leads via a Tuohy needle in the upper low back, (2) subcutaneous tunneling from the implantable pulse generator site to the lead puncture site without dissecting below the superficial fascial plane at the puncture site, and (3) connection of the lead/extension with the generator. All fractures occurred adjacent to the original lead puncture site. These cases suggest lead entrapment within the membranous fascial plane, with tension on a thin lead, is a mechanism underlying lead fracture.
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Case Reports
Anesthetic Management of Reversible Cerebral Vasoconstriction Syndrome During Vaginal Delivery: A Case Report.
Reversible cerebral vasoconstriction syndrome (RCVS) is a rare group of vascular disorders characterized by severe headache with or without other neurologic symptoms. Pregnancy is known to precipitate RCVS, typically in the postpartum period. ⋯ Labor and vaginal delivery are characterized by fluctuations in hemodynamic and intracerebral pressures and present challenges for intrapartum anesthetic management. We report our experience with a patient with RCVS admitted for external cephalic version and subsequent vaginal delivery.
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Case Reports
Transitioning From Intrathecal Hydromorphone to Sublingual Buprenorphine-Naloxone Through Microdosing: A Case Report.
A 76-year-old woman with chronic noncancer pain and an intrathecal hydromorphone-bupivacaine pump was admitted for acute exacerbation of heart failure. Her pump was unable to be replaced due to medical comorbidities. She was unable to tolerate oral opioids due to ventilatory depression. ⋯ Microdosing of sublingual buprenorphine-naloxone was initiated while decreasing intrathecal hydromorphone. This successfully weaned the patient off intrathecal hydromorphone with adequate pain relief and prevented both opioid withdrawal and ventilatory depression. To our knowledge, microdosing buprenorphine-naloxone to assist with discontinuing intrathecal opioids has not been previously reported in the literature.