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• Professor, Neurology UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA

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When the disc material syndrome demonstrated paraspinal muscle spasms purchase 5mg clarinex mastercard allergy forecast alabama, tail protrudes clarinex 5 mg visa allergy symptoms after quitting smoking, it is mostly expelled to buy clarinex 5 mg cheap allergy bumps the lateral side of the contractures buy 5 mg clarinex free shipping allergy shots rush immunotherapy, pain behaviors, tactile allodynia, epidural spinal canal because of the posterior longitudinal liga and perineural scarring, and nerve root adherence to ment directly compressing the exiting nerve root, which the underlying disc and pedicle (614-616,619,622,625 leads to cytokine release and chemical irritation of the 628,1625-1627). In addition, paresthesia, cilitation potentiated by inflammatory and nerve injury with or without pain, occurs in 90% of patients with mechanisms (614-616,619,622,625-628,1626-1628). Approximately 45% of patients are unable to the mechanism of post operative axial neck pain which vocalize the paresthesia to a distinct region; and they is a common complication (1629-1631) even though neu present with diffuse, nondermatomal symptoms. In rological recovery after laminoplasty is excellent (1632 general, paresthesia affecting the thumb or index 1634). They described that even though multiple fac finger is attributed to the C6 dermatome; the middle tors, including surgical trauma to the posterior cervical finger, with or without involvement of the index finger, muscles and the period of external immobilization, have is assigned to the C7 dermatome; and the little finger is been suggested as causative factors for the development assigned to the C8 dermatome (Fig. They described that post operative axial history may not be reliable in assessing cervical spine pain is multifactorial in nature with soft tissue injuries, pathology in reference to diagnostic procedures. Ru such as those that occur due to intraoperative damage binstein and van Tulder (401), in a best evidence review, of the posterior extensor musculature, are considered to showed that a positive Spurling�s, traction/neck distrac be a major mechanical factor in the development of post tion, and Valsalva can be used to establish a diagnosis operative axial pain (1635,1636). The existing literature damage, nerve tissue injuries sustained during surgery appears to indicate high specificity, low sensitivity, and also have been suggested as a causative factor of post good to fair interexaminer reliability for Spurling neck operative axial pain (1629,1630). Numbness a patient�s history and an extensive physical examina in the upper limb is a reasonably reliable sign (1640), tion which includes a neurological examination; motor even though it is not a universal feature in patients examination; sensory examination; reflex assessment; with radiculopathy. The prevalence rate of numbness application of provocative maneuvers, including Spurl has varied significantly from 24% to 48%, and 60% to ing�s neck compression test, shoulder abduction test, as high as 86% (1641). Numbness is most often seen in neck distraction test, Lhermitte sign, Hoffman sign, and the C6 and C7 dermatomes, indicating the most frequent Addison�s test (1637). The predictive validity the distinguishing features of cervical radicular of numbness was calculated to be 0. While pain secondary to either the disc or facet with regard to cervical radiculopathy, many investiga joints is limited to the neck, upper back, and head as tors believe that, �Given the paucity of evidence, the sociated with referred pain into the upper extremity, true value of the clinical examination is unknown at discogenic pain may present as radicular pain and facet this time. Radicular pain is most likely to (401), in a best-evidence review of diagnostic proce travel below the elbow, and somatic referred pain is dures for neck and low back pain, concluded that in most often limited to above the elbow, but radicular patients 50 years of age or older, plain spinal radiogra pain may be restricted to the upper back or shoulder phy together with standard laboratory tests are highly girdle, and somatic pain may radiate below the elbow. They also showed that no paresthesia is considered to be more valid than the dis systematic reviews were identified which examined the tribution of pain. The distribution of paresthesia in the diagnostic accuracy of diagnostic imaging in those with hand is also considered more valid than the distribution neck pain. Medical Management of Acute Cervical Radicular Pain: An Evidence-based Approach, 1st edition. Maps of the distribution of pain evoked by mechanical stimulation of the C4, C5, C6, and C7 spinal nerves. Root Location of Sensory Referred Pain Motor Dysfunction Reflex Changes Involvement Lesion Dysfunction Shoulder muscles vUpper and Shoulder and C5 C4/5 (deltoid-supraspinatus-infraspinatus) lateral aspect of v Biceps reflex upper arm v abduction and external rotation the shoulder Radial aspect of Biceps and brachialis muscles Radial aspect of v Thumb reflex and C6 C5/6 forearm v flexion of the elbow and supination forearm brachioradialis reflex Dorsal aspect Triceps muscle v Index and C7 C6/7 v Triceps reflex of forearm v extension of the elbow middle digits Ulnar aspect of Intrinsics of the hand v Ring and little C8 C7/T1 No change forearm v adduction and abduction digits Thus, plain radiography is not of any significant use high risk, and more commonly, cervical provocation dis in neck pain or radiculopathy. However, when there is no correlation the cervical spine nerves poorly, if at all (1643). Thus, it appears that cervical provoca and nerve conduction studies offer no advantage in tion discography can diagnose discogenic pain without radiculopathy. Widespread variations in criteria exist not only compression are cervical spondylosis, disc degeneration, for pain provocation. However, numerous and threshold for a positive response), but also for other causes exist. While some investigators ing pain that extends into the hand, or with paresthesia have interpreted certain patterns of contrast dispersion in forearm and hand, accompanied by objective neuro as being indicative of disc pathology, others have found logic signs with sensory loss, objective motor weakness, a lack of correlation between morphology and pain re or hyporeflexia. In difficult cases, without radicular production (697,700,1588,1659-1662,1693-1695). Bogduk and Aprill (1697) determined the prevalence Validity is exemplified by disc stimulation symp of discogenic pain in 56 patients with post-traumatic tom mapping (541,1663) in patients with pain and neck pain that had undergone provocation discography. Conversely, 78% of disrupted discs were clini ent causes of neck pain in a private practice pain clinic. Viikari-Juntura et al (696) They showed the prevalence of discogenic pain to be demonstrated that discography provides additional 16%. These investigators showed that in those subjects information regarding structural changes not avail who completed controlled blocks or more than one able by any other non-invasive methods of examina invasive test, a pathoanatomic diagnosis was obtained tion. The results showed be considered pathologic, and that discography is nec that provocation discography provided unambiguous essary to identify a painful disc(s). There were 23 studies evaluat cation discography are a serious concern, with cited ing the accuracy of discography. Schellhas et al (1663) (382,1697,1698) meeting inclusion criteria for assessing found that the numerical rating pain score produced by Table 31. Study Methodological Criteria Number of Subjects Prevalence Estimates Bogduk &Aprill, 1993 (1697) 7/9 56 20% Yin & Bogduk, 2008 (382) 7/9 88 16% Aprill & Bogduk, 1992 (1698) 7/9 318 40% Adapted and Modified from: Onyewu O, et al. An update of the appraisal of the accuracy and utility of cervical discography in chronic neck pain. Cervical epidural raphy procedure is bacterial discitis, with a reported steroid injections, specifically utilizing the transforami incidence that is typically less than 1% (1699-1704). How epidermidis, but streptococcus and Escherichia coli are ever, significant complications also have been reported also frequently implicated. Escherichia coli can be in with interlaminar epidurals with spinal cord damage oculated from the hypopharynx (1705). Complications of Further complications include a vasovagal re fluoroscopically guided interlaminar cervical epidural sponse, a hematoma that can include neural compro injections have been reported to be much less frequent mise within the spinal canal, an allergic drug reaction, and major complications are rare (899,1413,1741-1759). Diwan et al (9) in recent systematic review with literature included through December 2011 assessed 1.

Commonly buy clarinex 5 mg with amex allergy treatment clinic, such programmes are carried out for a considerable number of hours per week buy 5mg clarinex free shipping allergy job chicago, sometimes even on an inpatient basis trusted 5 mg clarinex allergy treatment 5 shaving. The content of these programmes and the way they are labelled or described varies widely buy clarinex 5 mg amex allergy forecast minneapolis. True multidisciplinary treatment programs have to include medical (pharmacological treatment, education), physical (exercise), vocational and behavioural components and have to be provided at least by three health care professionals with different clinical backgrounds (physician, physiotherapist, psychologist). Result of search Systematic reviews Five reviews of multidisciplinary treatment were retrieved through the search (Di Fabio 1995, Guzman et al 2001, Scheer et al 1997, Staal et al 2002, Teasell and Harth 1996), and an additional review was identified from the working group�s knowledge of the literature (Schonstein et al 2003). The remaining two systematic reviews (both Cochrane reviews) were considered further (Guzman et al 2001, Schonstein et al 2003). These included 10 randomized, controlled trials (Alaranta et al 1994, Basler et al 1997, Bendix et al 1995, Bendix et al 1996, Harkapaa et al 1990, Jackel et al 1990, Lukinmaa 1989, Mitchell and Carmen 1994, Nicholas et al 1991, 1992). One additional paper provided a health economic assessment of multidisciplinary treatment (Skouen et al 2002). Quality assessment of the evidence Systematic reviews 122 the two Cochrane reviews (Guzman et al 2001, Schonstein et al 2003) were of high quality. One low quality trial (Turner et al 1990) was excluded because the treatment was not really multidisciplinary (was provided by just one healthcare professional). Effectiveness Effectiveness of multidisciplinary treatment versus sham procedures No studies were found on this issue. Effectiveness of multidisciplinary treatment programmes versus other treatments. The conclusions from the review were: � There is strong evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain and improves function in patients with chronic low back pain (level A). Additional studies Effectiveness of multidisciplinary treatment programmes vs controls One study compared a multidisciplinary rehabilitation program (n=36) in an outpatient setting (2 hours treatment, three times a week for 6 weeks) with a control group of patients on a waiting list (these served as controls only for the immediate post treatment effects) (Keller et al 1997). Although no psychologists were directly involved in the treatment, both the physicians and physiotherapists had received training in pain management by an experienced psychologist and were closely supervised by clinical psychologists to ensure a strict application of operant techniques for the modification of the patient�s behaviour. At the end of the program pain frequency, pain intensity and disability caused by pain (scale of functional capacity) improved significantly in the treatment group only. Up to 6 months after treatment, patients in the treatment group continued to show beneficial effects in terms of pain intensity, pain frequency, posture, self-efficacy, well-being, strength and endurance, compared with their pre-treatment status. Effectiveness of multidisciplinary treatment programmes versus less intensive programmes Two trials were carried out by one research group (Bendix et al 1998a, Bendix et al 1998b, Bendix et al 1997). The results were presented for the one-year follow up (Bendix et al 1997), 2-year follow up (Bendix et al 1998b), and five-year follow up (Bendix et al 1998a). At all follow up times the functional restoration program was superior to the other programs except in relation to the variables leg pain and medication use. Another high additional study combined the effects of functional restoration versus 3 hours per week physical therapy: a randomized controlled study (Jousset et al 2004). It found that the mean number of sick-leave days was significantly lower in the functional restoration group. Physical criteria and satisfaction with the treatment were also better, but there was no significant difference in the intensity of pain, the quality of life and functional indexes, the number of contacts with the medical system or the medication intake. Nonetheless, the results for the back patients and non-back patients were given separately. However, the follow-up included only in 74 patients with treatment and 64 controls. At one year, the treatment group had not returned to work at a higher rate but had an improved work potential, quality of life, and physical and psychological health. Together these studies strengthen the evidence for the Cochrane review for the greater effectiveness of intensive multidisciplinary treatments compared with less 124 intensive treatments, especially in relation to return to work or work capacity (level A). Effectiveness of group vs individual multidisciplinary treatment programmes One study examined the differences in outcome between group programs (N=26) and individual treatment (n= 24) (Rose et al 1997). The second part of the study (with other patients n= 60) was concerned with identifying the optimum duration of treatment. The study showed no differences between group or individual treatment and between 15-, 30-, or 60-hour programs. Effectiveness of intensive physical conditioning (�work hardening�) programs for workers with back and neck pain A Cochrane systematic review evaluated the effectiveness of physical conditioning programs for workers with back and neck pain in reducing time lost from work (Schonstein et al 2003). These programs aim to facilitate return to work, improve the status of workers performing modified duties, or enable the achievement of a higher level of function by increasing strength, endurance, flexibility, and cardiovascular fitness. Such programs simulate work or functional tasks in a supervised environment and may include workplace visits and ergonomic adaptations of the workplace. So-called work hardening or work conditioning is also used for decreasing fear-avoidance behaviour (Vlaeyen and Linton 2000). The authors stated that, unlike earlier reviews, they were able to perform a meta-analysis because they had obtained additional information and data from the authors of the original trials. The authors concluded that physical conditioning programs for chronic back pain patients can be effective in reducing the number of sick days lost due to back pain when compared with usual care. A closer analysis of the trials that showed positive results revealed that all had significant cognitive-behavioural components (such as teaching the patients that it was safe to move) combined with intensive physical training that included training of aerobic capacity, muscle strength and endurance, and coordination. All subjects included in trials that showed a treatment effect were either off work or on modified duties, with an explicit capacity to return to their previous jobs. There is strong evidence that �work hardening� programs with a cognitive behavioural component are more effective than usual care in reducing work absenteeism in workers with back pain (level A). Cost-effectiveness Unknown (no studies were found on this issue) Safety Unknown (no studies were found on this issue) 125 Subjects (indications) All ten trials included in the Cochrane review (Guzman et al 2001), and also the additional studies described above, excluded patients with significant radiculopathy or other indications for surgery. In the Cochrane review, most subjects were workers selected from insurance listings (Alaranta et al 1994, Harkapaa et al 1989, Mitchell and Carmen 1994) or patients referred to pain centres (Basler et al 1997, Bendix et al 1995, Bendix et al 1996, Jackel et al 1990, Lukinmaa 1989, Nicholas et al 1991, 1992). Because of the high costs of treatment, a screening instrument addressing the prognosis of the individual patient (see (Haldorsen et al 2002)) is necessary to avoid under or over treatment. Comments 1) In all studies, the treatment, patient characteristics, treatment modalities and treatment intensity varied substantially.

Paraganglioma Paragangliomas are rare tumors that are found in the cauda equina and filum ter minale [37] clarinex 5 mg otc allergy testing new orleans. Differential Diagnosis Differential diagnosis includes rare non-neoplastic causes of diffuse nerve root enlargement or thickening such as: toxic neuropathy inflammatory neuritis sarcoidosis (Fig buy generic clarinex 5 mg on-line allergy treatment xanax. Since 1 year previously the thoracic back pain had worsened associated with paresthesias in both legs 5mg clarinex otc allergy symptoms vertigo, more on the right side buy clarinex 5 mg without prescription allergy medicine bee sting. Fifteen and 8 years previously, she had microdiscectomies at the level of L4/5 and L5/S1. The myelography (a, b) demon strated the tumor and the cord contour and the contrast block at the level of the caudal tumor pole at T8. Two days after surgery the motor weakness of the lower extremity was improved so that she could ambulate without aid. At 12 months follow-up she had no back pain and a nor mal gait but still had a sensory disturbance at the thoracic level due to the sacrificed dorsal roots. Differential diagnosis A differential diagnosis is mandatory because various diseases can mimick a primary spinal tumor. Frozen section biopsy revealed a sarcoidosis and further surgery was stopped subsequent to the biopsy. Myxopapillary ependymo mas occur exclusively in the conus medullaris and filum terminale. Ependymomas account for 60% of glial spinal cord tumors and comprise 90% of primary tumors in the filum terminale and cauda equina [30, 31]. For myxopapillary ependymomas of the cauda equina region the mean age is 28 years with a slight male predominance. Complaints of back pain or neck pain are found in 65% of patients with intramedullary ependymo mas. Previous history is usually often long, because these tumors are slow grow ing and there are often mild objective neurological deficits. The average reported Symptoms precede duration between the onset of such symptomatology and diagnosis has been diagnosis by years reported to be around 3. Intradural Tumors Chapter 35 1003 Low back pain or sacral pain, leg weakness and sphincter dysfunction are the Ependymomas (in adults) complaints and signs found in patients with myxopapillary ependymomas of the and astrocytomas cauda equina region. Some sacral and presacral lesions can behave aggressively (in children) are the two and can metastasize to the lymph nodes, the lung and the bone [34]. Malignant gliomas are rare: 15% are anaplastic astrocytoma and 1% are glioblastoma multiforme. Intramedullary astrocytomas diffusely expand the spinal cord, cyst formation is common and there is often an associated syrinx. Tumor cysts are often eccentri cally positioned within the cord, whereas the syrinx and benign cysts are rostral or caudal to the tumor and cause symmetric cord expansion. Symptoms or signs of neurological dysfunction are often lacking early in the course of disease. About one About one-third of patients third of patients with hemangioblastomas have von Hippel-Lindau disease. Ret with hemangioblastomas inal or cerebellar involvement often precedes spinal cord symptoms. A highly suffer from von Hippel vascular nodule with an extensive cyst is found in around half of cases (Case Lindau disease Study 2), usually emerging at the dorsal portion of the spinal cord. Half of hemangioblastomas are found at the thoracic level followed by the cervical level. Astrocytoma A case of cervical astrocytoma with cyst formation at the caudal tumor pole and within the tumor. Intraoperatively, no clear cleavage plane could be found, so the surgery ended up with partial removal and remnant tumor left to the anterior part. The postoperative follow-up revealed only slight sensory disturbance and no other neurological abnormalities. Conventional vertebral angiography (c) in the lateral view displaying the tumor staining supplied by radicular arteries and the anterior spinal artery. Postopera tive T1W sagittal (e)andT2 axial(f) images revealed complete removal of the tumor with disappearing hydromyelia. At 3 years follow-up the patient presented with good recovery of neurological findings and no signs of recurrence depicted on neuroimagings. Intradural Tumors Chapter 35 1005 Other Intramedullary Tumors Oligodendroglioma, ganglioglioma and intramedullary neurinoma can occur Although intramedullary but are rare. Intramedullary metastasis metastases are very rare, occurs as a result of primary malignancies such as: they must be considered as an important differential breast cancer diagnosis lung cancer lymphomas leukemia malignant melanoma (Fig. They are similar to intracranial cavernous angio mas of typical blackberry appearance associated with localized hemorrhage in different ages. They become symptomatic between the 3rd and 6th decades and have a female predominance of 2:1. They are found most frequently at the tho racic level followed by the cervical level [31]. Clinical Presentation History the key feature of slowly growing tumors is the long history of signs and symp the symptoms of a slowly toms due to the substantial plasticity of the spinal cord. The time course of symp growing tumor are insidious toms and signs is very insidious and longstanding but can be of abrupt onset due to hemorrhage in cases of ependymomas and cavernous angiomas. Acute onset with a subarachnoid hemorrhage can also be a rare presentation of spinal cord tumors such as neurinomas, cavernous angiomas and ependymomas. The signs and symptoms differ depending on: level location size of tumor speed of growth In general, intramedullary tumors produce segmental deficits while extramedul lary tumors produce radicular and segmental deficits.

Less common causes are central retinal artery or vein occlusion and occipital lobe infarct generic clarinex 5 mg overnight delivery allergy treatment nasal spray. We favor the use of the Mayfield head clamp for posterior cervical spine procedures because pressure on eyes discount clarinex 5 mg amex allergy medicine like benadryl, nose clarinex 5 mg lowest price allergy treatment bee stings, and chin can be avoided purchase clarinex 5 mg fast delivery allergy testing sioux falls sd. Established in July 1999, the registry col lects information anonymously (http:depts. Maintenance of Anesthesia Maintenance of anesthesia is intended to provide good surgical (a dry field, good neuromonitoring, adequate muscle relaxation when needed) and anesthetic con ditions (amnesia, nociceptive suppression, temperature preservation, hemody namic and organ function stability). Remifentanil is an Intraoperative Anesthesia Management Chapter 15 397 ultrashort acting and potent opiate that is completely metabolized and elimi nated from the circulation in 3�6 min by plasma esterases. It has been our experience that for thoracolumbar and lumbar spine surgery the use of intrathecal single shot morphine (0. Using this approach for the last 5 years we have had no infections attributed to the technique and both surgeons and patients appreciate it in equal measure. The same result is achieved with high thoracic epidural analgesia (catheter at C6�T5) for thoracolumbar procedures where a thoracotomy and chest drain are required. Any choice of maintenance drugs must aim to give a stable depth or level of anesthesia. Neuromuscular relaxant drugs should be used to facilitate airway control and then only as necessary according to the surgical conditions. A theoretical advantage of having some degree of muscle relaxation in major posterior procedures is better abdominal decompression as opposed to the abdominal tightness of an unre laxed patient. Intraoperative Monitoring Techniques Advanced Monitoring of Vital Functions Advanced monitoring of vital cardiopulmonary functions is suggested only in patients with systemic pathology or those scheduled to have major spine proce dures. In anterior lumbar spine surgery, monitoring hemoglobin saturation and plethysmographic curves from the ipsilateral toes to the surgical access to the spine are recom mended (Fig. This simple measure can provide early warning of vascular com pression with retractors [33]. Cardiovascular System Cardiac compromise may be a direct result of the underlying pathology, for Consider cardiac compromise exampleinpatientswithDuchenne�smusculardystrophyorfromunrelatedcar in patients with Duchenne�s diovascular disease such as hypertension or coronary artery disease. Cardiac muscular dystrophy dysfunction may also result from severe scoliosis or kyphosis, which causes dis tortion of the mediastinum, and cor pulmonale secondary to chronic hypoxemia and pulmonary hypertension. A direct arterial blood pressure line will be required in the case of major surgery, patients with preoperative cardiopulmo nary pathologies or other anesthetic considerations (Table 2). An arterial catheter is usually inserted in the radial or femoral arteries for this purpose. Plethysmography of the toe Simultaneous monitoring of the Hbsat and plethysmography in the toe and finger to detect arterial compression in the anterior lumbar approach. Pulmonary artery catheters are controversial because they do not decrease perioperative mortality and can cause significant morbidity. In healthy adults Prone patient position [73], the face-down position reduces the cardiac index (15�25%) and increases reduces cardiac function systemic vascular resistance possibly due to a decrease in venous return and ven tricular compliance. The main take-home message from this study is that greater changes should be expected in individuals with established preoperative cardiorespiratory pathology. This is a noninvasive device for following brain Hb-oxygen mixed satura tion in the territories supplied by the anterior and middle cerebral arteries. This method has been extensively used in cardiac anesthesia to reduce postoperative strokes and provides a transcranial reading of brain tissue O2sat that is made up of 75% venous blood and 25% arterial blood, allowing the anesthesiologist to adjust the brain blood flow and oxygenation to a safe level. Maintenance Fluids the type and volume of fluid maintenance will vary depending upon the magni tude of blood loss, the preoperative intravascular filling status, the systemic pre operative condition of the individual and the length of the procedure. Patients scheduled for discectomy or simple hardware removal with minimal blood loss can receive �normal� saline or balanced solutions (lactated Ringer�s, Hartmann�s solution, etc. Those that will be fast-tracked in day-surgery programs should have (under normal conditions) no bladder catheter and crystalloid volumes below 1000�1500 ml perioperatively. Balanced crystalloid solutions are recommended to avoid hyperchloremic acidosis induced by the so-called �normal� saline due to the high content of chloride in it [8]. Preoperative fasting is usually replaced in the first hour of surgery with 10 ml/kg of Ringer�s lactate solution. Recent publi cations [28] have raised concern about the potential harm of overloading patients with fluids; therefore fluid volume therapy must follow a rational indica tion to replace preoperative negative balance, intraoperative maintenance, intra operative blood loss and postoperative requirements. Bladder catheters are routinely inserted before procedures lasting for more than 3 h to preclude bladder distension and to monitor urine output. Large blood volume changes and the frequent use of vasoactive drugs make their use manda tory to observe urine output in these situations. Foley catheters are also recom mended to be inserted in elderly male patients who suffer from prostate hyper plasia and patients with urinary incontinence. Body Temperature Mild perioperative hypothermia (reductions of core body temperature of 1�2�C) is associated with [64]: increased postoperative cardiac complications impaired hemostasis impaired neutrophil function wound area hypoxia increased postoperative protein wasting altered pharmacodynamics of muscle relaxants delayed discharge from recovery room increased infectious complications [24] A temperature probe should be placed, particularly in juvenile and infantile patients undergoing scoliosis surgery as well as in patients expecting to have large blood volume changes. Body temperature decreases very quickly in uncov ered and anesthetized children and elderly patients; the main mechanisms are redistribution of heat from the core compartment to the periphery along with decreased heat production. Routine use of air-warming blankets and intrave nous blood/liquid warming systems is recommended. Unless they are warmed, each unit of blood or 1000 ml of crystalloid solution at room temperature will reduce body temperature by 0. Patients that are only partially paralyzed 400 Section Peri and Postoperative Management produce more heat compared with those fully paralyzed. Although malignant hyperthermia nowadays is a very rare condition, its incidence is increased in patients with scoliosis because of their association with neuromuscular pathology. Monitoring Depth of Anesthesia (Consciousness) Since the introduction of anesthesia almost 150 years ago, the depth of anesthesia has been monitored through surrogate variables (heart rate, arterial pressure, eye behavior, etc.

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