J Neurosurg Anesthesiol
Volume 26, Number 3, July 2014
Young-Sung Kim, MD Byung-Gun Lim, MD, PhD Il-Ok Lee, MD, PhD Department of Anesthesiology and Pain Medicine, Guro Hospital, College of Medicine, Korea University, Seoul, Korea
REFERENCES 1. Nelson P, Nelson JA, Chen AJ, et al. An alternative position for the BIS-Vista montage in frontal approach neurosurgical cases. J Neurosurg Anesthesiol. 2013;25: 135–142. 2. Bruhn J, Bouillon TW, Shafer SL. Electromyographic activity falsely elevates the bispectral index. Anesthesiology. 2000;92: 1485–1487. 3. Liu N, Chazot T, Huybrechts I, et al. The influence of a muscle relaxant bolus on Bispectral and Datex-Ohmeda entropy values during propofol-remifentanil induced loss of consciousness. Anesth Analg. 2005; 101:1713–1718. 4. Hemmerling TM, Migneault B. Falsely increased bispectral index during endoscopic shoulder surgery attributed to interferences with the endoscopic shaver device. Anesth Analg. 2002;95:1678–1679. 5. Puri GD, Nakra D. ECG artifact and BIS in severe brain injury. Anesth Analg. 2005; 101:1566–1567.
Pulsed Radiofrequency for the Suprascapular Nerve for Patients With Chronic Headache To the Editor: We read the article by Shabat et al1 with interest. Authors have attempted to evaluate the beneficial effects of pulsed radiofrequency (RF) on suprascapular nerve in patients with chronic headache associated with shoulder or suprascapular region pain with a hypothesis that the lower cervical roots might be the causative factor for chronic headache in such patients. A detailed clinical examination of shoulder focused on those muscles innervated by the suprascapular nerve, particularly abduction (supraspinatus) and external rotation (infraspinatus), along with cervical spine could have given a valuable insight to the diagnosis (shoulder pathology vs. radiculopathy). Unlike The authors have no funding or conflicts of interest to disclose. r
2014 Lippincott Williams & Wilkins
the study by Persson et al,2 where the occurrence of cervical radiculopathy was confirmed with selective nerve root blocks (SNRB), Shabat et al1 did not contemplate SNRB for suspected C5 or C6 root involvement, although they have attributed the headache to the lower cervical nerve roots (C5, C6, C7). Without a positive diagnostic test the methodology presented in the study for diagnosing lower cervical root involvement was overly dependent on the computed tomography/ magnetic resonance imaging which could be inaccurate. RF of suprascapular nerve (following the standard approach,3,4 which is essentially the RF of suprascapular nerve at suprascapular notch) is unlikely to provide relief from chronic headache if the musculoskeletal causes were responsible for shoulder region pain. It is unclear what exactly the authors meant by “postprocedure discomfort in the same innervated region,” whether it was the back of head, shoulder region or C5, C6, C7 dermatomal distribution? The described techniques of pulsed RF application (120 s, 421C; nothing has been mentioned about the pulse width and repetition) could be insufficient to effect the suprascapular nerve at the target site as the described “standard approaches”3,4 employed a wider duration (480 s), repeat PRF application, and combination of PRF and conventional thermal RF. Two issues need to be resolved if authors intended to demonstrate that lower cervical roots compression is the cause of headache: (i) why patients did not have complaints of distal pain, but only shoulder pain; and (ii) what could be the probable mechanism by which treatment at a distal site (RF of suprascapular nerve at suprascapular notch) can treat a pain condition for which the pathology is far more proximal (cervical root compression). Nilay Chatterjee, MD, DM* Chinmoy Roy, MD, FIPPw *Department of Neuroanesthesiology Sree Chitra Tirunal Institute for Medical Science and Technology, Trivandrum wDepartment of Pain Medicine, Institute of Neurosciences, Kolkata, West Bengal India
Correspondence
REFERENCES 1. Shabat S, Leitner J, Folman Y. Pulsed radiofrequency for the suprascapular nerve for patients with chronic headache. J Neurosurg Anesthesiol. 2013;25:340–343. 2. Persson LC, Carlsson JY, Anderberg L. Headache in patients with cervical radiculopathy: a prospective study with selective nerve root blocks in 275 patients. Eur Spine J. 2007;16:953–959. 3. Simopoulos TT, Nagda J, Aner MM. Percutaneous radiofrequency lesioning of the suprascapular nerve for management of chronic shoulder pain: a case series. J Pain Res. 2012;5:91–97. 4. Luleci N, Ozdemir U, Dere K, et al. Evaluation of patients’ pulsed radiofrequency treatment applied to the suprascapular nerve in patients with chronic shoulder pain. J Back Musculoskelet Rehabil. 2011;24:189–194.
Anesthetic Management of an Acromegalic Patient With McCune Albright Syndrome for Endoscopic Transsphenoidal Adenoma Removal To JNA Readers: McCune Albright syndrome (MAS) is a genetic disease characterized by fibrous dysplasia of bone, cafe´ au lait skin spots, and precocious puberty.1 Patients with this syndrome usually require general anesthesia for repair of bone lesion–related fractures, but may also require surgery for treatment of endocrine disorders. We describe perioperative management of a 15-year-old female patient with MAS who underwent transsphenoidal resection of pituitary adenoma. A sellar mass suggestive of pituitary macroadenoma compressing the optic chiasma was shown on magnetic resonance imaging and her insulin-like growth factor 1 level was raised up to 840 ng/mL (normal range, 126 to 261 ng/mL). Results of The authors have no funding or conflicts of interest to disclose.
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Volume 26, Number 3, July 2014
Young-Sung Kim, MD Byung-Gun Lim, MD, PhD Il-Ok Lee, MD, PhD Department of Anesthesiology and Pain Medicine, Guro Hospital, College of Medicine, Korea University, Seoul, Korea
REFERENCES 1. Nelson P, Nelson JA, Chen AJ, et al. An alternative position for the BIS-Vista montage in frontal approach neurosurgical cases. J Neurosurg Anesthesiol. 2013;25: 135–142. 2. Bruhn J, Bouillon TW, Shafer SL. Electromyographic activity falsely elevates the bispectral index. Anesthesiology. 2000;92: 1485–1487. 3. Liu N, Chazot T, Huybrechts I, et al. The influence of a muscle relaxant bolus on Bispectral and Datex-Ohmeda entropy values during propofol-remifentanil induced loss of consciousness. Anesth Analg. 2005; 101:1713–1718. 4. Hemmerling TM, Migneault B. Falsely increased bispectral index during endoscopic shoulder surgery attributed to interferences with the endoscopic shaver device. Anesth Analg. 2002;95:1678–1679. 5. Puri GD, Nakra D. ECG artifact and BIS in severe brain injury. Anesth Analg. 2005; 101:1566–1567.
Pulsed Radiofrequency for the Suprascapular Nerve for Patients With Chronic Headache To the Editor: We read the article by Shabat et al1 with interest. Authors have attempted to evaluate the beneficial effects of pulsed radiofrequency (RF) on suprascapular nerve in patients with chronic headache associated with shoulder or suprascapular region pain with a hypothesis that the lower cervical roots might be the causative factor for chronic headache in such patients. A detailed clinical examination of shoulder focused on those muscles innervated by the suprascapular nerve, particularly abduction (supraspinatus) and external rotation (infraspinatus), along with cervical spine could have given a valuable insight to the diagnosis (shoulder pathology vs. radiculopathy). Unlike The authors have no funding or conflicts of interest to disclose. r
2014 Lippincott Williams & Wilkins
the study by Persson et al,2 where the occurrence of cervical radiculopathy was confirmed with selective nerve root blocks (SNRB), Shabat et al1 did not contemplate SNRB for suspected C5 or C6 root involvement, although they have attributed the headache to the lower cervical nerve roots (C5, C6, C7). Without a positive diagnostic test the methodology presented in the study for diagnosing lower cervical root involvement was overly dependent on the computed tomography/ magnetic resonance imaging which could be inaccurate. RF of suprascapular nerve (following the standard approach,3,4 which is essentially the RF of suprascapular nerve at suprascapular notch) is unlikely to provide relief from chronic headache if the musculoskeletal causes were responsible for shoulder region pain. It is unclear what exactly the authors meant by “postprocedure discomfort in the same innervated region,” whether it was the back of head, shoulder region or C5, C6, C7 dermatomal distribution? The described techniques of pulsed RF application (120 s, 421C; nothing has been mentioned about the pulse width and repetition) could be insufficient to effect the suprascapular nerve at the target site as the described “standard approaches”3,4 employed a wider duration (480 s), repeat PRF application, and combination of PRF and conventional thermal RF. Two issues need to be resolved if authors intended to demonstrate that lower cervical roots compression is the cause of headache: (i) why patients did not have complaints of distal pain, but only shoulder pain; and (ii) what could be the probable mechanism by which treatment at a distal site (RF of suprascapular nerve at suprascapular notch) can treat a pain condition for which the pathology is far more proximal (cervical root compression). Nilay Chatterjee, MD, DM* Chinmoy Roy, MD, FIPPw *Department of Neuroanesthesiology Sree Chitra Tirunal Institute for Medical Science and Technology, Trivandrum wDepartment of Pain Medicine, Institute of Neurosciences, Kolkata, West Bengal India
Correspondence
REFERENCES 1. Shabat S, Leitner J, Folman Y. Pulsed radiofrequency for the suprascapular nerve for patients with chronic headache. J Neurosurg Anesthesiol. 2013;25:340–343. 2. Persson LC, Carlsson JY, Anderberg L. Headache in patients with cervical radiculopathy: a prospective study with selective nerve root blocks in 275 patients. Eur Spine J. 2007;16:953–959. 3. Simopoulos TT, Nagda J, Aner MM. Percutaneous radiofrequency lesioning of the suprascapular nerve for management of chronic shoulder pain: a case series. J Pain Res. 2012;5:91–97. 4. Luleci N, Ozdemir U, Dere K, et al. Evaluation of patients’ pulsed radiofrequency treatment applied to the suprascapular nerve in patients with chronic shoulder pain. J Back Musculoskelet Rehabil. 2011;24:189–194.
Anesthetic Management of an Acromegalic Patient With McCune Albright Syndrome for Endoscopic Transsphenoidal Adenoma Removal To JNA Readers: McCune Albright syndrome (MAS) is a genetic disease characterized by fibrous dysplasia of bone, cafe´ au lait skin spots, and precocious puberty.1 Patients with this syndrome usually require general anesthesia for repair of bone lesion–related fractures, but may also require surgery for treatment of endocrine disorders. We describe perioperative management of a 15-year-old female patient with MAS who underwent transsphenoidal resection of pituitary adenoma. A sellar mass suggestive of pituitary macroadenoma compressing the optic chiasma was shown on magnetic resonance imaging and her insulin-like growth factor 1 level was raised up to 840 ng/mL (normal range, 126 to 261 ng/mL). Results of The authors have no funding or conflicts of interest to disclose.
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