Amaç: Çalýþmamýz alt batýn cerrahisi uygulanacak hastalara preoperatif dönemde oral yoldan verilecek 10 mg flunarizinin, toplam morfin tüketimi ve postoperatif analjezi kalitesi üzerine etkilerini araþtýrmak amacýyla planlandý.
Gereç ve Yöntem: Yaþlarý 18-55 arasýnda deðiþen 30 hasta çalýþmaya dahil edildi. Hastalar rastgele olarak iki gruba ayrýlarak flunarizin grubunda bulunan hastalara 2 adet 5 mg flunarizin kapsül ve plasebo grubuna da 2 adet plasebo kapsül operasyondan 2 saat önce verildi. Ekstübasyondan hemen sonra ve 15. dakikada aldrete post-anestezi skoru ile derlenme durumlarý deðerlendirildi. Postoperatif dönemde analjezi amacýyla intravenöz hasta kontrollü analjezi yöntemi ile morfin baþlandý ve ilk analjezik ihtiyaç zamanlarý kaydedildi. Ekstübasyondan sonra Ramsay sedasyon skalasý, vizüel analog skalasý (VAS) skoru ve morfin tüketimleri belirlendi.
Bulgular: Flunarizin grubunda 5. dakikadaki sistolik arteriyel basýnç deðerlerinin düþüklüðü plaseboya göre anlamlý bulundu. Ýntraoperatif 45. dakikadaki kalp atým hýzý flunarizin grubunda plaseboya göre anlamlý düþüktü. Postoperatif 12. saatteki VAS deðeri, flunarizin grubunda istatistiksel olarak anlamlý düþüktü. Postoperatif sedasyon skorlarý iki grup arasýnda fark göstermedi. Flunarizinin ilk analjezik ihtiyaç zamanýný uzatmadýðý ve benzer þekilde toplam morfin tüketimini azaltmadýðý gözlendi.
Sonuç: Preoperatif dönemde oral yoldan 10 mg tek doz þeklinde verilen flunarizinin klinik parametreler üzerine belirgin etkisinin olmadýðý ve bu dozda analjezik etkisinin bulunmadýðý ya da morfinin analjezik etkisini potansiyalize edici etki göstermediði sonucuna varýldý.

Objectives: This study was designed to document the effects 10 mg flunarizine, administrated in the preoperative period, on postoperative morphine requirement and analgesic quality, in abdominal surgery.
Methods: Thirty patients, aged 18 to 55 years, were studied. Patients were randomly allocated to one of two equally sized groups, and received either 2 capsules of 5 mg flunarizine (Group I) or 2 placebo capsules (Group II) 2 hours before the operation, immediately after the extubation and at the 15th minute, Aldrete postanesthesia recovery scores were assessed. In the postoperative period, patients were connected to a patient-controlled analgesia device for intravenous morphine, and the first analgesic requirement time was recorded.
Ramsay sedation scale, visual analogue pain scale and morphine consumption were assessed after the extubation.
Results: Systolic arterial pressures at the 5th minute of the preoperative period were significantly lower in the flunarizine group than placebo group. Heart rates in the 45th minute were also lower in the flunarizine group. Flunarizine patients reported statistically lower visual analogue pain scale values in the postoperative 12th hour. There was no significant difference in postoperative sedation scores between the groups. Flunarizine did not lengthen the first analgesic requirement time and similarly did not lessen the morphine requirement.
Conclusion: We conclude that 10 mg flunarizine administered in the preoperative period had no significant effects on clinical parameters, had no analgesic effect and did not augment the analgesic effects of morphine at this dose.

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Amaç: Çalýþmamýzda kliniðimizde umbilikus altý cerrahi için spinal anestezi uyguladýðýmýz pediyatrik hastalarý deðerlendirerek, intraoperatif karþýlaþtýðýmýz problemleri, yan etki ve komplikasyonlarý geriye dönük olarak belirlemeyi, genel anestezi uygulamasý yönünden yüksek riskli olup, hastalarda tekniði güvenilir þekilde uygulayabilmek amacýyla, komplikasyonlarýmýz ve olumlu sonuçlarýmýzý vurgulamayý amaçladýk.
Gereç ve Yöntem: Kliniðimizde 2007-2008 tarihleri arasýnda spinal anestezi uygulanan 86 pediyatrik hastanýn perioperatif bireysel özellikleri, operasyon türleri, anestezi uygulamasý, cerrahi süre, motor blok ve sensoryal bloðun iki dermatom gerileme süresi, postoperatif analjezik gereksinimi ve komplikasyonlar hasta dosyalarý ve anestezi kayýtlarýndan incelenerek kaydedildi.
Bulgular: Ortalama operasyon süresi 49.8±24.1 dk, sensoryal bloðun 2 dermatom gerileme süresi 73.0±21.9 dk olarak bulundu. Cerrahi bitiminde hastalarýn 69’unda motor bloðun devam ettiði, 17 hastada ortadan kalktýðý, bu hastalarda motor bloðun ortadan kalkýþ süresinin 67.3±16.2 dk olduðu görüldü. Ýntraoperatif hipotansiyon görülen 2 hasta ve bradikardi görülen 1 hasta dýþýnda, hemodinamik parametrelerde giriþ deðerinin %20’sinden fazla deðiþiklik saptanmadý. Üç hastada etkisiz spinal anestezi sonucunda genel anesteziye geçildiði saptandý. Postoperatif 46 hastada ek analjezik gereksinimi olduðu ve ilk analjezik gereksinim süresinin 2.3±1.2 saat olduðu görüldü. Hastalarýn hiçbirinde perioperatif dönemde desatürasyon ve apne geliþmezken, postoperatif dönemde 2 hastada bulantý ve kusma, 1 hastada baþ aðrýsý olduðu saptandý. Hemodinamik ve solunumsal komplikasyona rastlanmadý.
Sonuç: Spinal anestezi, özellikle günübirlik pediyatrik cerrahi olgularýnda genel anesteziye alternatif olarak kullanýmý giderek artan bir teknik halini almýþtýr. Bununla beraber pediyatrik hastalarda spinal anestezinin güvenli ve etkin þekilde uygulanabilmesi için, bu konuda deneyim kazanýlmasý, yan etki, komplikasyonlar ve olumlu sonuçlarýn vurgulanmasý gerektiðini düþünüyoruz.

Objectives: The aim of this study was to evaluate the characteristics of spinal anesthesia, including its efficacy, adverse effects and complications, in order to determine if it can be applied safely in pediatric patients at high-risk for general anesthesia. We emphasize our positive outcomes in children undergoing lower abdominal surgery in our previous experience.
Methods: The perioperative data of 86 pediatric patients who received spinal anesthesia between 2007 and 2008 were scanned retrospectively. Demographic data, operation types, anesthetic applications, duration of surgery, motor blockade degree, two dermatomes regression time, postoperative analgesic requirements, adverse effects, and complications were recorded.
Results: The operation time and two dermatomes regression times were found as 49.8±24.1 minutes and 73.0±21.9 minutes, respectively. At the end of the operation, motor blockade had disappeared in 17 patients and persisted in 68 patients. Block time was measured as 67.3±16.2 minutes in these patients. During the intraoperative period, hypotension was observed in two patients, and bradycardia occurred in one patient. Except for these, hemodynamic parameters did not change more than 20% from control values at any time. In three children, surgery was continued under general anesthesia. Forty-six patients required additional analgesic doses in the postoperative period. The time to first analgesic requirement was 2.3±1.2 hours. During the postoperative period, no hemodynamic or respiratory complications were observed.
Conclusion: Spinal anesthesia continues to gain acceptance as an alternative to general anesthesia in children. However, we conclude that accumulated experience is required in order to apply this technique safely in pediatric patients. We emphasize the positive outcomes, adverse events and complications observed in our experience.

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Amaç: Bu çalýþmanýn amacý, serebral paralizili (SP) bireylerde aðrýnýn aktivite baðýmsýzlýðý ve saðlýkla ilgili yaþam kalitesi (HRQoL) üzerine etkisini incelemektir.
Gereç ve Yöntem: Çalýþmaya yaþ ortalamasý 22.18±7.77 yýl olan 15 yaþ ve üstü 50 SP’li birey dahil edilmiþtir. Çalýþmaya dahil edilen bireylerin demografik bilgileri alýndýktan sonra aðrýyý deðerlendirmek için Vizüel Analog Skalasý (VAS), günlük yaþam aktivite baðýmsýzlýðý Fonksiyonel Baðýmsýzlýk Ölçümü (FIM), saðlýkla ilgili yaþam kalitesi ise Nottingham Saðlýk Profili (NHP) ile deðerlendirilmiþtir. Ayrýca, aðrýnýn zamanla deðiþimi, aðrýnýn yürüme fonksiyonunu ve günlük aktiviteleri ne kadar kýsýtladýðý sorgulanmýþtýr.
Bulgular: Aðrý prevelansý %36 olarak bulunmuþtur. Aðrý lokalizasyonu bel, kalça, omuz ve alt ekstremite aðrýsý þeklinde belirlenmiþtir. Aðrý þiddeti þu anda hissedilen aðrý ortalamasý 4±2.02, en az hissedilen 2.88±1.77, ortalama hissedilen 4.77±1.55 ve en þiddetli hissedilen ortalama aðrý þiddeti 6.88±2.02 olarak belirlenmiþtir. Bireyler aðrýnýn yürüme fonksiyonunda (6.55±3.27) ve günlük aktivitelerde orta derecede (5.22±2.55) kýsýtlýlýklara yol açtýðýný ifade etmiþlerdir. Aðrýsý olan ve olmayan bireylerde NHP’nin enerji seviyesi ve toplam NHP deðerleri arasýnda anlamlý bir fark bulunmuþtur (p<0.05). FIM’nin alt parametreleri ve toplam FIM arasýnda bir fark bulunmamýþtýr (p>0.05).
Sonuç: Aðrýnýn SP’li bireylerde günlük aktiviteleri ve yürümeyi hafiften þiddetli dereceye varan yoðunlukta etkilediði, bunun da bireylerin HRQoL’ni etkilediði bulunmuþtur. SP’li bireylerde aðrýnýn belirlenmesi ve tedavisine yönelik yaklaþýmlarýn aktivite katýlýmý ve HRQoL’ni arttýracaðýný düþünüyoruz.

Objectives: The aim of this study was to determine the effect of pain on activity independence and health-related quality of life (HRQoL) in cerebral palsied (CP) individuals.
Methods: Individuals with CP aged 15 and above 50 with an average age of 22.18±7.77 years were included in the study. After obtaining demographic information of the individuals who joined the study, Visual Analogue Scale (VAS), Functional Independence Measurement (FIM) and Nottingham Health Profile (NHP) were used for the evaluation of pain, daily living activity and HRQoL, respectively. Changes in pain with time and the limiting magnitude of pain in ambulation and daily activities were also questioned.
Results: Pain prevalence was found as 36%. Pain localization was determined in the lower back, hip, shoulder, and lower extremity. Average pain magnitude was determined as: current (4±2.02), minimal (2.88±1.77), moderate (4.77±1.55), or intense (6.88±2.02) pain. Individuals stated that the pain limited their ambulation (6.55±3.27) and daily activities (5.22±2.55) moderately. A significant difference was found among the energy level of the NHP and total NHP in individuals with pain versus those having no pain (p<0.05); there was no significant difference between the sub-parameters of FIM and total FIM (p>0.05).
Conclusion: Pain was found to affect daily activities and ambulation ranging in degree from mild to severe, leading to an effect on HRQoL of the individuals with CP. We suggest that approaches oriented to the determination and treatment of pain in CP individuals will increase activity participation and HRQoL.

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Amaç: Transforaminal epidural steroid enjeksiyonu (TFESE) bel aðrýsýnda kullanýlan minimal invaziv bir tedavi yöntemidir. Bu çalýþmada, konservatif tedavi yöntemleri ya da cerrahi tedaviyle iyileþmeyen bel aðrýsý þikayeti olan hastalara uyguladýðýmýz TFESE tedavisinin etkinliðini incelemeyi amaçladýk.
Gereç ve Yöntem: Çalýþma, kliniðimizde bel aðrýsý nedeniyle TFESE tedavisi uygulanan 37 hastaya (yaþlarý 24-80 arasý) ait kayýtlarýn retrospektif olarak incelenmesi ile gerçekleþtirildi. Aðrý þiddeti 3. hafta ve 6. ayda Vizüel Analog Skala (VAS) ile deðerlendirildi.
Bulgular: Hastalarýn yaþ ve þikayet süreleri ortanca olarak 50 yýl ve 48 ay bulundu. Hastalarýn tanýlarýnýn %51’inin lomber disk hastalýðý (LDH), %38’inin baþarýsýz bel cerrahisi sendromu (BBCS) ve %11’inin de spinal stenoz (SS) olduðu tespit edildi. Üç grupta da iþlem öncesi VAS skorlarý birbirine benzerdi. TFESE tedavisi sonrasý LDH ve BBCS tanýlý olgularýn 3. hafta ve 6. ay VAS deðerleri, geliþ VAS deðerlerine göre istatistiksel olarak anlamlý derecede düþük bulundu (p<0.001, p=0.001) ve 3. hafta ile 6. ay VAS deðerleri benzerdi (p>0.05). Tedavi uygulamasý sonrasý aðrý düzeyinin %50 ve daha fazla düþmesi baþarýlý olarak kabul edildiðinde, uyguladýðýmýz tedavi tüm olgularda VAS-0’a göre VAS-3 haftada %84, VAS-6 ayda %78 baþarýlý bulundu.
Sonuç: TFESE tedavisinin LDH, BBCS ve SS’ye baðlý bel aðrýsý olan hastalarýn çoðunda uzun süren bir aðrýsýz dönem oluþturmasý uygulanan iþlemin etkinliðini göstermektedir. Minimal invaziv bir yöntem olan TFESE tedavisinin LDH, BBCS ve SS’ye baðlý radikülopatik bel aðrýsý olan hastalara uygulanmasýyla baþarýlý sonuçlara ulaþabileceðimiz kanýsýndayýz.

Objectives: Transforaminal epidural steroid injection (TFESI) is a minimally invasive technique used for low back pain. We aimed to assess the efficiency of TFESI in patients with low back pain who did not respond to conservative or surgical methods.
Methods: This study was a retrospective analysis of the records of 37 patients (range: 24-80 years) who presented to our clinic with low back pain and were treated by TFESI. Outcomes were assessed by Visual Analog Scale (VAS) measured at the 3rd week and 6th month.
Results: Median age of the patients was 50 years, and mean duration of symptoms was 48 months. Diagnosis was lumbar disc herniation (LDH) in 51%, failed back surgery syndrome (FBSS) in 38%, and spinal stenosis (SS) in 11% of the patients. Baseline VAS scores were similar between the three groups. The 3rd week and 6th month VAS scores of LDH and FBSS cases were significantly decreased compared to baseline scores (p<0.001, p=0.001), and no significant change was observed between the VAS scores at the 3rd week and 6th month (p>0.05). If success is defined as 50% or more decrease in VAS scores, the success rate of TFESI was 84% at the 3rd week and 78% at the 6th month.
Conclusion: TFESI significantly reduced the intensity of low back pain in most of the patients with LDH, FBSS or SS; thus, it may be considered as an effective method in the treatment of low back pain.

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Amaç: Miyofasyal aðrýlar en sýk görülen temporomandibular bozukluklardýr. Bu çalýþmada, miyofasyal temporomandibular aðrýnýn tedavisinde kombine tedavi yöntemlerinin etkinliði karþýlaþtýrýldý.
Gereç ve Yöntem: Klinik ve radyolojik olarak miyofasyal temporomandibular bozukluk tanýsý almýþ 50 hasta (44 kadýn, 6 erkek) çalýþmaya alýndý ve randomize olarak her grupta 25 hasta olacak þekilde iki gruba ayrýldý. Grup 1 stabilizasyon splinti (SS) ile Grup 2 ise SS tedavisi ile kombine olarak tetik nokta enjeksiyonlarýyla tedavi edildi.
Bulgular: Genel bulgu ve belirtilerin düzelmesinde her iki grup arasýnda istatistik olarak önemli farklar bulundu. VAS skorlarýnda Grup 2’de önemli azalma görüldü ve istatistitiksel analiz sonucu tedavinin 4. ve 12. haftasýnda yapýlan deðerlendirmelerde Grup 1 ve Grup 2 arasýnda VAS skorlarý açýsýnda önemli farklar bulundu (p<0.001).
Sonuç: Bizim sonuçlarýmýz miyofasyal temporomandibular bozukluklarda splint tedavisiyle kombine edilen tetik nokta enjeksiyon tedavisinin etkili olduðunu gösterdi. Özellikle bu yöntemin diðer tedavi yöntemleri üzerine etkinliðini belirlemek için daha fazla sayýda randomize kontrollü çalýþma yapýlmalýdýr.

Objectives: Myofascial pain is the most common temporomandibular disorder. The objective of this study was to compare the effectiveness of combined treatment modalities in the management of myofascial temporomandibular pain.
Methods: Fifty patients (44 female, 6 male) clinically and radiologically diagnosed with myofascial temporomandibular disorder (TMD) were selected for the study and randomly assigned to two groups of 25 patients. Group 1 patients were treated with stabilization splint (SS) and Group 2 patients were treated with trigger point injection combined with SS therapy.
Results: Positive improvement in overall signs and symptoms with statistically significant differences was observed in both groups. Group 2 showed significant reduction in visual analogue scale (VAS) scores, and statistical analysis revealed a significant difference between the VAS scores of Group 1 and Group 2 at the 4th and 12th weeks of treatment follow-up (p<0.001).
Conclusion: Our results indicate that trigger point injection therapy combined with splint therapy is effective in the management of myofascial TMD pain. Further research, especially randomized controlled trials, should be carried out to ascertain its effectiveness over other treatment modalities.

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Morton nöroma özellikle 3. ayak parmaðý ve bu bölge ayak tabanýný etkileyen paroksismal bir nevraljidir. Aðrý nedeniyle hastalar genellikle yürümek ve yere basmakta tereddüt ederler. Bu yazýda, Morton nöroma nedeniyle diðer bacaða aþýrý yüklenen ve bunun sonucunda da stres fraktürü geliþen 40 yaþýnda bir hasta sunuldu.

Morton neuroma is a paroxysmal neuralgia form pain usually occurs at the 3rd finger and sole of the foot. The patient mostly suffer from pain while walking. In this report a 40-year-old man with Morton neuroma who has a stress fracture in the other leg because of not using the affected painful foot.

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Sakrokoksigeal dislokasyon nadir rastlanan bir yaralanmadýr. Ýmpar ganglion (Walther ganglion olarakta bilinen) rektumun arkasýnda sakrokoksigeal bileþke veya koksiksin önünde yerleþen tek küçük soliter sempatik bir gangliondur. Perine bölgesinin nosiseptif ve sempatik duyusunu saðlar. Ýmpar ganglion blokajý klinik pratikte rutin olarak kullanýlan analjezi ve anestezi yöntemi deðildir. Beþ gün önce sandalyeden düþme sonucu koksiks dislokasyonu geliþen kadýn hastaya elektif intrarektal manuel düzeltme planlandý. Rutin monitorizasyondan sonra fluoroskopi eþliðinde 22 gauge spinal iðne kullanýlarak sakrokoksigeal yaklaþýmla impar ganglion bloðu uygulandý. Bloktan önce ve blok sonrasý üç dakika aralýklarla kan basýncý, kalp hýzý, periferik oksijen satürasyonu ve vizüel analog skala (VAS) kaydedildi. Bloktan önce VAS’si 8 olan hastanýn 6 dakika sonra VAS’si %50 azaldý. Dokuzuncu dakikada VAS 0 olan hastaya intrarektal manuel düzeltme uygulandý. Ýþlem sýrasýnda ve sonrasýnda hemodinamik veriler normal sýnýrlarda kaydedildi ve motor blok geliþmedi. Bloktan sonra 2. ve 6. saatlerde VAS 0 olan hasta evine taburcu edildi. Bloktan sonra 24. ve 48. saatlerde telefonla VAS 0 olarak belirlendi. Sonuç olarak, impar ganglion bloðu, koksiks dislokasyonlu hastada intrarektal düzeltme sýrasýnda ve sonrasýnda herhangi bir komplikasyona neden olmadan yeterli analjezi saðladý. Fakat bu tekniðin perianal bölgedeki yapýlacak diðer iþlemlerde de güvenirlilik ve etkinliðinin kanýtlanmasý için daha ileri klinik çalýþmalara ihtiyaç olduðunu düþünmekteyiz.

Sacrococcygeal dislocation is a rare injury. The ganglion impar (also called the ganglion of Walther) is a single, small solitary, sympathetic ganglion located in the retrorectal space, anterior to the sacrococcygeal joint or coccyx. It provides the nociceptive and sympathetic supply to the perineal structure. Ganglion impar blockade is not a routinely used anesthetic and analgesic procedure in clinical practice. An elective intrarectal manuel treatment was planned for a woman patient with coccyx dislocation due to falling down from a chair 5 days ago. Ganglion impar block was performed with saccrococcygeal approach using 22 gauge spinal needle along with fluoroscopy following routine monitorization. Blood pressure, heart rate, peripheral oxygen saturation and visual analog scale (VAS) were recorded before and, after block with three minute intervals. VAS value of the patient, 8 before the procedure, decreased 50% 6 minutes after block. Intrarectal manuel treatment was applied to the patient with VAS of 0 at 9th minute. Hemodynamic values were within normal limits during and after the procedure and no motor block was observed. The patient with VAS of 0 at 2nd and 6th hour after block was discharged. VAS of 0 was determined at 24th and 48th hour by phone call. In conclusion, ganglion impar block provided adequate analgesia without causing any complications during and after the intrarectal manuel treatment for the patient with coccyx dislocation. However, we believe that further clinical studies are required to establish the safety and efficiency of this technique for other procedures at perianal region.

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The transversus abdominus plane (TAP) block is a relatively new described regional anesthesia technique at the triangle of Petit,[1] in order to block a number of abdominal wall nerves hence providing widespread analgesia. More recently, ultrasound guided TAP block has been described with promises of better localization and deposition of the local anaesthetic with improved accuracy.[2] It’s good postoperative analgesia effect has been shown several times in a variety of lower abdominal procedures;[3,4] however there has been controversy in the literature regarding the spread and level of block achieved with a single TAP injection.[5,6]
We would like to present a 62-year-old female, ASA physical status III patient with cirrhosis, cardiac failure, hypertension and diabetes mellitus, who underwent an incisional hernia repair. The patient had also undergone an umbilical hernia repair 2 months ago. Ultrasound guided TAP block was performed bilaterally as an anesthesia procedure. The block was performed using a high frequency linear probe (10-18 MHz, Esaote My Lab 30, Genoa, Italy). The block was performed at the mid-axillary line between the costal margin and iliac crest (Figure 1).
In plane technique was used and 20 mL of levobupivacaine 0.25% was applied for each side. For skin incision 5 mL of lidocaine 2% was used. In order to provide sedation and analgesia, 50 μcg of fentanyl and 1 mg of midazolam IV were administered. After depleting acid fluid and repairing 0.5 cm fascia defect, the operation was completed in 30 minutes uneventfully. Patient was comfortable during the surgery. The patient was followed for 5 days without any complication.
General anesthesia was not prefered in order to avoid cardiac and hepatic effects of systemic anesthetics. Although coagulation parameters seem to be normal, spinal anesthesia was not prefered because of low platelet counts (80 ×103/U).
This is the first case report presenting the use of TAP block for surgical anesthesia. TAP block could be considered as an anesthetic option for similar cases.

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