Abstract Introduction: High thoracic or cervical epidural analgesia (HTCEA) causes motor paralysis of the diaphragm and intercostal muscles, and impairs ventilatory parameters. Despite many reports about pulmonary dysfunction under HTCEA, little information is available on estimating the time course and degree of ventilatory impairment when different concentrations of lidocaine are administered. We performed this study to clarify how different concentrations of lidocaine used in upper-thoracic epidural anesthesia affect patients' ventilatory impairment. Patients and methods: Ten patients scheduled for epidural catheterization to treat their pain were enrolled. Epidural catheterization was established between the C7 and T3 intervertebral spaces. Using a cross-over design, each subject was randomly assigned to one of two groups. A single shot of 10 ml of lidocaine was injected through each patient's catheter on three consecutive days: day 1, the day after the catheter had been inserted; day 2, the day follo...
Objectives: Epidural phenol neurolysis for severe cancer pain has been linked to complications such as paraplegia and urinary incontinence. Given the ease of administration of epidural injections, proof of the safety and efficacy of epidural phenol injection would increase the popularity of this procedure for cancer pain relief. This study was conducted to evaluate the analgesic effects and histopathological changes in the spinal nervous system of rabbits after epidural administration of phenol. Materials and methods: Under pentobarbital anesthesia, percutaneous epidural catheterization at the level of the L6–L7 lumbar interspace was conducted in 16 rabbits. After epidurography using 0.3 ml of iopamidol, 0.3 ml of 7% phenol in saline was injected through the catheter into the epidural space of 15 rabbits, and 0.3 ml saline was epidurally injected in one rabbit serving as control. Motor function and analgesia were investigated on days 1 and 14. On day 14, the spinal cords were resected and processed for histopathological study. Results: The analgesic area extended over 4.9 ± 1.2 spinal segments (mean ± SD) on day 14. Motor weakness was seen in 5 of 15 rabbits on day 14. Histopathological examination revealed spinal cord and root damage in all phenol-injected rabbits. Discussion: Damage to the spinal cord and anterior roots were seen in all phenol-injected rabbits, suggesting that epidural phenol neurolysis ought to be used in only those areas where the resultant motor weakness can be ignored.Keywords: CANCER PAINEPIDURAL PHENOL NEUROLYSISANIMAL STUDYRABBIT
'Oh what a pain is pain!' sighed my friend as we prepared for our vivas. 'I wish there was just a little less to remember' he cried. Yes, you guessed it right, we were indeed trying to remember all that we need to ask a patient who comes to a clinician with some kind of pain. Though I did not see a way to reduce the number of things to remember, I seemed to have some solace for him. I had resorted to the use of mnemonics long before I stepped into medical school and, oh my, did it help! The magic word was actually my friend's name 'OSCAR'.
Spinal canal endoscopy is recognised as a new technique for treatment of chronic low back and leg pain due to lumbar epidural adhesions involving nerve roots. In this paper, the cases of two patients who received orthopaedic surgery combined with spinal canal endoscopy are discussed. In case 1, the patient had a cauda equina tumour and underwent extirpation of the tumour assisted by spinal canal endoscopy. In case 2, the patient was suffering from extensive epidural abscess. He was treated with antibiotics and underwent single-level laminectomy and drainage assisted by spinal canal endoscopy. In case 1, small tumours that could not be identified by magnetic resonance imaging were identified with spinal canal endoscopy: the tumours were then partially removed from the T12 vertebral level to the S1 vertebral level by right hemilaminectomy of S1, and laminectomy of L5 and T12. In case 2, the use of spinal canal endoscopy enabled drainage and lavage of the wide lesion of the abscess by the single-level laminectomy and a minimally invasive operation. Spinal canal endoscopy, a new, diagnostic and therapeutic technique, may be useful not only for low back pain and leg pain but also for strategic treatment of cauda equina tumours and epidural abscess.
Abstract Aims and Objective: In this small case series, we evaluated the effects and safety of injecting botulinum toxin type A (BoTN/A; Botox) and botulinum toxin type B (BoTN/B; Myobloc) into the sacroiliac joints, cervical/lumbar facet joints, C-2 roots, sternoclavicular joint and lumbar disc in patients with refractory pain. Methods: Eleven adult patients with refractory pain were injected with BoTN/A or BoTN/B. Results: All 11 patients had either a decrease (8 out of 11) or no change (3 out of 11) in their pain score after BoTN injection. All patients who responded to the injections noted improved function in activities of daily living and range of motion because of pain reduction. No side effects were noted. The mean duration of pain relief for the first BoTN treatments was 2.0 months. The median difference of duration of pain relief between BoTN and previous steroid injection was 1.6 months with BoTN being superior. The median change in pain score (0 to 10) after BoTN injection was −3. Conclusions:...
Chronic painful tendinosis is a recalcitrant disease. Recent research using grey-scale ultrasound + colour Doppler complemented with immunohistochemical analyses of tendon tissue biopsies confirmed the presence of neovessels juxtapositioned to nerves in chronic painful Achilles and patellar tendinosis. There are relatively few nerves inside the tendon, but there are multiple nerves outside especially on the deep side of the tendon. These nerve fascicles contain sympathetic and sensory fibers. Ultrasound and Doppler-guided injections of polidocanol, targeting the region of neovascularisation (and nerves) outside the tendon, afford scientifically proven good clinical short- and mid-term effects in patients with chronic Achilles and patellar tendinosis. Remodeling of successfully treated Achilles tendons has been demonstrated.
Introduction: Osteoporotic vertebral compression fractures (VCFs) in the elderly patient can cause significant pain and lead to restrictions in daily life activities. Augmentation procedures (vertebroplasty and kyphoplasty) have been reported as a standard treatment of VCFs in cases of unresponsiveness to conservative treatment. However, patients who have remnant pain after augmentation procedures are a challenge to doctors and require the definite treatment. We have injected hyperosmolar dextrose solution into the lumbosacral medial branch and bilateral sacro-iliac joint for remnant buttock pain and report our results. Patients and methods: Thirty-six patients with remnant pain were identified after augmentation procedures on 321 patients. Remnant pain was defined as occurring when patients complained of pain 2 days postoperatively. Patients were treated with bilateral lumbosacral (L4, L5, S1) medial branch injections and bilateral sacro-iliac joint injection using hyperosmolar dextrose solution. Injection was given 3–5 days following vertebroplasty and kyphoplasty procedures. All remnant pain patients were evaluated at intervals of 1–2 weeks and received additional injections if they still reported pain. Results: The average number of injections was 2.31. Pain intensity measured using a visual analogue scale (VAS) decreased from 8.78 before augmentation procedures to 4.33 after augmentation procedures to 2.67 after the first injection procedure and 1.97 after the second injection procedure. Successful outcome was determined if the pain reduction exceeded 50% relief from the postaugmented buttock pain state. Five of the 36 patients (13.9%) did not respond favourably to injection (pain reduction less than 50%), and 31 patients (86.1%) showed successful responses. Conclusions: Hyperosmolar dextrose solution injection into the lumbosacral medial branch and bilateral sacro-iliac joint of the patient who has a remnant pain after augmentation procedures for VCFs is one method that decreases the symptoms.Keywords: OSTEOPOROTIC VERTEBRAL COMPRESSION FRACTURESREMNANT SACRO-ILIAC JOINT REFERRED PAINHYPEROSMOLAR DEXTROSE SOLUTION INJECTIONMEDIAL BRANCH INJECTIONSACRO-ILIAC JOINT INJECTION
Supra-orbital neuralgia is an uncommon disorder specified by severe pain in the frontal region of the head and originates from the supra-orbital nerve. Supra-orbital neuralgia is defined as tenderness and pain above nerves that can be abolished easily by a local anesthetic blockade. Conventional radiofrequency (CRF) application has been used for trigeminal neuralgia for years and it is an ablative method but pulsed radiofrequency (PRF) is not. Many clinical studies have shown that PRF is safer than conventional radiofrequency but as effective. Although there are many trials on the relief of pain due to gonarthrosis and lumbar facet hypertrophy showed that PRF application is not only safe but effective, few previous studies have evaluated the efficacy and safety of PRF for supra-orbital nerve treatment. There is need for high-quality, controlled, clinical studies evaluating the long-term effects of this technique to supra-orbital neuralgia.
Epiduroscopy is a minimally invasive procedure of the lumbar spine that is performed using a fibre-optic device which is inserted through the sacral hiatus into the lower epidural space. Indications for the epiduroscopy include patients with epidural inflammation, adhesions, or other tissue obstructions which are directly or indirectly causing pain in the back or leg. Epiduroscopy can be recommended as a valuable, safe, and cost-effective technique for relieving chronic, intractable pain non-responsive to all other conservative modalities of treatments. In this review, the development and clinical aspects of epidural adhesiolysis and epiduroscopy will be discussed.
Palatal lesions and associated palatal pain are a common occurrence, whereas spontaneous aneurysm of a cerebral artery is rare. We report a case involving a spontaneous aneurysm of the middle cerebral artery that manifested initially as palatal pain. It is important for dental practitioners to be familiar with unusual causes of palatal pain. Those cases that cause palatal pain must be evaluated appropriately to avoid potentially serious complications.
Objectives: This study explored how patients with back and knee pain perceived a home exercise programme consisting of isometric and isotonic components using three different prescription methods – brochure, verbal and non-verbal videotapes. Patients and methods: Thirty patients with non-specific low-back pain and knee pain were referred to the physical therapy department for exercise therapy. Subjects were randomly assigned to brochure group, non-verbal group, and verbal videotape group. Each group performed the isometric and isotonic exercises according to assigned instructions. An Exercise Assessment Scale was also developed to measure exercise performance for this study. Results: All demographic parameters were homogeneous in three groups. Isotonic exercises were more effective than isometric exercises in all three prescription methods. The Exercise Assessment Scale showed that the starting positions to both isometric and isotonic exercises were the same and correct in all three prescription conditions. Range of motion and planes of movement were perceived better by the patients during isotonic exercises than those of isometric exercises. In all groups, isotonic exercise compensation scores were higher than the isometric exercises scores. Conclusions: Verbal videotape exercise instructions and dynamic modelling (videotaped) were slightly better than other instructions and static modelling (brochure). The instruction of therapeutic exercises with periodic supervision in physiotherapy out-patient clinics appears to be adequate in assisted home exercise programmes.
Objective: Patients with chronic pain frequently have depression, which may augment their pain. The selective serotonin re-uptake inhibitor, paroxetine, is widely used in the treatment of depression. The purpose of this study was to examine the effectiveness of paroxetine in the treatment of refractory chronic pain. Patients and methods: Fifty patients with a history of at least 6-month persistent chronic pain participated in this study. Paroxetine was orally administered once daily at a dose of 10 mg initially, then increased weekly by 10 mg until a maximum of 40 mg. The dose was reduced when an adverse reaction occurred, and treatment was continued for 2 weeks at the optimal dose. Depression was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The state of depression was evaluated using the Self-Rating Depression Scale (SDS), and that of pain using the Visual Analogue Scale (VAS). Results: Overall, 70% of the patients had depression. The SDS score was higher in patients with depression compared with non-depressed patients. Treatment of patients with depression by paroxetine resulted in reduction of VAS score to less than half, concomitant with a decrease in SDS score. Paroxetine also significantly reduced the VAS scores in non-depressive patients. However, the decrease in VAS score was more marked in patients with depression compared to those without depression. Conclusions: These results suggest that a large proportion of patients with refractory chronic pain has depression and paroxetine improves both the depression and chronic pain.
Improvements in technology have finally enabled direct visualisation of the epidural space, a longed-for requirement. From 1996, an epiduroscope from Myelotec has been employed widely in clinical practice. However, results suggest that further refinements are necessary. In the future, epiduroscopy should be a an integral part of surgery, be less-invasive, and used in conjunction with operative instruments such as a drilling device, an ultrasonic probe, or a laser beam. Such applications will lead to a reduction in medical costs.
Abstract We report an interesting effect noted following denervation of the upper cervical facet joints and third occipital nerves bilaterally in a 58-year-old woman. The patient described postoperative dizziness and blurred vision which was much improved by removal of her glasses. Reduction in myopia was confirmed by optometric testing of her refractive indexes. A substantial improvement lasted approximately 6 months, followed by prolonged partial improvement for 12 months. Possible reasons are discussed.
Introduction: Ketorolac added to morphine solution as a convenient regimen for pain management is common in clinical practice in many centers. However, the analytical confirmation of the compatibility and stability of this combination has rarely been performed. This study examined the compatibility and stability of ketorolac tromethamine and morphine hydrochloride combined in 0.9% sodium chloride injection. Materials and methods: Ketorolac tromethamine and morphine hydrochloride were mixed together in 0.9% sodium chloride injection at pH 5–9 at a final concentration of 2 mg/ml for ketorolac and 1 mg/ml for morphine. In addition, 20 different ketorolac–morphine mixture solutions were prepared by combing various concentrations of each individual drug. The compatibility and stability of these solutions were studied using high performance liquid chromatography. Results: There was no significant loss of drug, neither ketorolac tromethamine nor morphine hydrochloride, with the ketorolac (2 mg/ml) + morphine (1 mg/ml) solution at pH 5–9 at room temperature over a period of 3 days. All solutions with a multiplication product of the initial ketorolac and morphine concentration (the [K] × [M] product) of ≤ 6.25 mg2/ml2 remained stable at room temperature over a period of 14 days. However, solutions with a [K] × [M] product ≥ 7.5 mg2/ml2 were stable for no more than 3 days. Conclusions: A ketorolac (2 mg/ml) + morphine (1 mg/ml) solution can be used at physiological pH and is stable for at least 3 days at room temperature. However, mixture solutions with a [K] × [M] product greater than 7.5 mg2/ml2 may not be suitable for use after a 3-day storage period because of poor drug compatibility and stability.
AbstractThis study evaluated the influence of three different delivery methods (vaginal delivery, caesarean section under general anaesthesia and caesarean section with spinal block) on maternal and neonatal blood levels of nitric oxide and malondialdehyde. Results showed that caesarean section with spinal anaesthesia causes less oxidative stress compared to vaginal delivery with epidural analgesia and elective caesarean section with general anaesthesia.
"Managing chronic pain: finding our way to the land of milk and honey." The Pain Clinic, 19(5), pp. 204–205
