Comparación de secuencias volumétricas con técnicas convencionales en resonancia magnética de columna lumbar / Comparison of volumetric and conventional sequences for the evaluation in magnetic resonance of the lumbar spine

Objetivo: Comparar el protocolo que incluye la secuencia tridimensional SPACE-3D con el protocolo convencional en el estudio imagenológico por resonancia magnética (RM) del paciente con dolor lumbar. Metodología: Se realizó un estudio prospectivo de pruebas diagnósticas, en el que se tomaron imágenes por RM de la columna lumbar de 40 pacientes utilizando un protocolo convencional y otro protocolo que incluyera una secuencia volumétrica (SPACE-3D) en conjunto con secuencia axial con información T1 y sagital STIR, en un resonador de 1,5T. Las imágenes fueron interpretadas por dos radiólogos de manera independiente, empleando tanto el protocolo convencional como el protocolo que incluía la secuencia volumétrica, con un mes de diferencia. Se compararon ambos protocolos calculando la sensibilidad y la especificidad con el intervalo de confianza (IC 95 %), se consideró significación estadística un valor de p≤ 0,05 utilizando la prueba de Chi-cuadrado. Se evaluaron para ambas técnicas variables como presencia o no de artefactos, protrusión/extrusión discal, estrechez del canal neural central, receso lateral o foramen de emergencia radicular, radiculopatía. Se calculó la concordancia inter e intraobservador utilizando el índice Kappa con un IC 95 %. Resultados: Se encontró que el protocolo que incluye la secuencia SPACE-3D presenta rendimiento diagnóstico similar (no inferior) frente al protocolo con las secuencias convencionales para las variables evaluadas; igualmente, se detectaron los hallazgos anormales, lo cual permitió un estudio completo y un diagnóstico en menor tiempo. Conclusiones: El rendimiento diagnóstico del protocolo que incluye la secuencia volumétrica SPACE-3D es similar (no inferior) al protocolo con las secuencias convencionales utilizadas en RM de columna lumbar y acorta el tiempo total del estudio

Objective: To compare the protocol that includes the three-dimensional SPACE-3D sequence with the conventional protocol in the magnetic resonance imaging (MRI) study of patients with low back pain. Methods: A prospective study of diagnostic tests was carried out, in which MR images of the lumbar spine were taken from 40 patients using a conventional protocol and another protocol that included a volumetric sequence (SPACE-3D) in conjunction with axial T1 and sagittal STIR sequences, in a 1.5T resonator. The images were interpreted by two radiologists independently, both the conventional protocol and the protocol that included the volumetric sequence, one month apart. Both protocols were compared, calculating the sensitivity and specificity with the confidence interval (CI 95%), a value of p ≤0.05 using the Chi-square test was considered statistically significant. Variables such as the presence or absence of artifacts, disc protrusion/extrusion, narrowing of the central neural canal, lateral recess or root emergence foramen, and presence of radiculopathy, among others, were evaluated for both techniques. Inter- and intra-observer agreement was calculated using the Kappa index with a 95% CI. Results: it was found that the protocol that included the SPACE-3D sequence presents similar diagnostic performance (not inferior) when compared to the protocol with the conventional sequences for the variables evaluated, similarly, abnormal findings were detected, which allowed a complete study and diagnosis in less time. Conclusions: The diagnostic performance of the protocol that includes the SPACE-3D volumetric sequence is similar (not inferior) to the protocol with conventional sequences used in MRI of the lumbar spine and shortens the total study time.

Dorsal Root Entry Zone Lesioning: Systematic Review

Introduction Dorsal root entry zone (DREZ) leasioning (DREZ-otomy) is considered an effective treatment for chronic pain due to spinal cord injuries, brachial and lumbosacral plexus injuries, postherpetic neuralgia, spasticity, and other conditions. The objective of the technique is to cause a selective destruction of the afferent pain fibers located in the dorsal region of the spinal cord. Objective To identify and review the effectiveness and the main aspects related to DREZ-otomy, as well as the etiologies that can be treated with it. Methods The PubMed, MEDLINE and LILACS databases were used as bases for this systematic review, having the impact factor as the selection criteria. The 23 selected publications, totalizing 1,099 patients, were organized in a table for systematic analysis. Results Satisfactory pain control was observed in 70.1% of the cases, with the best results being found in patients with brachial/lumbosacral plexus injury (70.8%) and the worst, in patients with trigeminal pain (40% to 67%). Discussion Most of the published articles observed excellent results in the control of chronic pain, especially in cases of plexus injuries. Complications are rare, and can be minimized with the use of new technologies for intraoperative monitoring and imaging. Conclusion DREZ-otomy can be considered a great alternative for the treatment of chronic pain, especially in patients who do not tolerate the side effects of the medications used in the clinical management or have refractory pain.

Feasibility of Ultrasound-Guided Lumbar and S1 Nerve Root Block: A Cadaver Study

OBJECTIVE: This study evaluated the feasibility of ultrasound-guided lumbar nerve root block (LNRB) and S1 nerve root block by identifying spread patterns via fluoroscopy in cadavers.METHOD: A total of 48 ultrasound-guided injections were performed in 4 fresh cadavers from L1 to S1 roots. The target point of LNRB was the midpoint between the lower border of the transverse process and the facet joint at each level. The target point of S1 nerve root block was the S1 foramen, which can be visualized between the median sacral crest and the posterior superior iliac spine, below the L5-S1 facet joint. The injection was performed via an in-plane approach under real-time axial view ultrasound guidance. Fluoroscopic validation was performed after the injection of 2 cc of contrast agent.RESULTS: The needle placements were correct in all injections. Fluoroscopy confirmed an intra-foraminal contrast spreading pattern following 41 of the 48 injections (85.4%). The other 7 injections (14.6%) yielded typical neurograms, but also resulted in extra-foraminal patterns that occurred evenly in each nerve root, including S1.CONCLUSION: Ultrasound-guided injection may be an option for the delivery of injectate into the S1 nerve root, as well as lumbar nerve root area.

The effect of needle tip position on the analgesic efficacy of pulsed radiofrequency treatment in patients with chronic lumbar radicular pain: a retrospective observational study / 대한통증학회지

BACKGROUND: Pulsed radiofrequency (PRF) is a treatment modality that alleviates radicular pain by intermittently applying high-frequency currents adjacent to the dorsal root ganglion. There has been no comparative study on analgesic effect according to the position of the needle tip in PRF treatment. The objective of this study is to evaluate the clinical outcomes of PRF according to the needle tip position. METHODS: Patients were classified into 2 groups (group IP [group inside of pedicle] and group OP [group outside of pedicle]) based on needle tip position in the anteroposterior view of fluoroscopy. In the anteroposterior view, the needle tip was advanced medially further than the lateral aspect of the corresponding pedicle in group IP; however, in group OP, the needle tip was not advanced. The treatment outcomes and pain scores were evaluated at 4, 8, and 12 weeks after applying PRF. RESULTS: At 4, 8, and 12 weeks, there were no significant differences between the successful response rate and numerical rating scale score ratio. CONCLUSIONS: The analgesic efficacy of PRF treatment did not differ with the needle tip position.

Lumbar foraminal neuropathy: an update on non-surgical management / 대한통증학회지

Lumbar foraminal pathology causing entrapment of neurovascular contents and radicular symptoms are commonly associated with foraminal stenosis. Foraminal neuropathy can also be derived from inflammation of the neighboring lateral recess or extraforaminal spaces. Conservative and interventional therapies have been used for the treatment of foraminal inflammation, fibrotic adhesion, and pain. This update reviews the anatomy, pathophysiology, clinical presentation, diagnosis, and current treatment options of foraminal neuropathy.

Preliminary study on contrast flow analysis of thoracic transforaminal epidural block

BACKGROUND: The thoracic transforaminal epidural block (TTFEB) is usually performed to treat herpes zoster or postherpetic neuralgia (PHN). Especially, multiple segmental involvements and approximate contrast medium spread range, according to volume, help to choose the proper drug volume in the transforaminal epidural block. This study investigated the contrast medium spread patterns of 1-ml to 3-ml TTFEBs. METHODS: A total of 26 patients with herpes zoster or PHN were enrolled in this study. All participants received 1 ml, 2 ml, or 3 ml of contrast medium. Results were divided into Groups A, B and C based on the volume (1, 2, or 3 ml), with n = 26 for each group. After the injection of contrast medium, the spread levels were estimated in both the lateral and anteroposterior (AP) images using fluoroscopy. RESULTS: The cephalad spread of contrast medium in the lateral image as expressed by the median (interquartile range) was 2.00 levels (1.00–2.00) for Group A, 2.50 (2.00–3.00) for Group B, and 3.00 (2.00-4.00) for Group C. The caudal spread level of contrast medium was 1.00 (1.00-2.00) for Group A, 2.00 (2.00–3.00) for Group B, and 2.00 (2.00–3.00) for Group C. There was ventral and dorsal spread of the 3-ml contrast medium injection in 88% (23/26) of cases in the lateral image. CONCLUSIONS: Injection of 3 ml of contrast medium through the foramina spread 6 levels in a cephalocaudal direction. Spread patterns revealed a cephalad preference. TTFEB resulted in dorsal and ventral spread in a high percentage of cases. This procedure may be useful for transferring drugs to the dorsal and ventral roots.

Lumbar burner and stinger syndrome in an elderly athlete

Burner or stinger syndrome is a rare sports injury caused by direct or indirect trauma during high-speed or contact sports mainly in young athletes. It affects peripheral nerves, plexus trunks or spinal nerve roots, causing paralysis, paresthesia and pain. We report the case of a 57-year-old male athlete suffering from burner syndrome related to a lumbar nerve root. He presented with prolonged pain and partial paralysis of the right leg after a skewed landing during the long jump. He was initially misdiagnosed since the first magnet resonance imaging was normal whereas electromyography showed denervation. The insurance company refused to pay damage claims. Partial recovery was achieved by pain medication and physiotherapy. Burner syndrome is an injury of physically active individuals of any age and may appear in the cervical and lumbar area. MRI may be normal due to the lack of complete nerve transection, but electromyography typically shows pathologic results.

Oxytocin produces thermal analgesia via vasopressin-1a receptor by modulating TRPV1 and potassium conductance in the dorsal root ganglion neurons

Recent studies have provided several lines of evidence that peripheral administration of oxytocin induces analgesia in human and rodents. However, the exact underlying mechanism of analgesia still remains elusive. In the present study, we aimed to identify which receptor could mediate the analgesic effect of intraperitoneal injection of oxytocin and its cellular mechanisms in thermal pain behavior. We found that oxytocin-induced analgesia could be reversed by d(CH₂)₅[Tyr(Me)²,Dab⁵] AVP, a vasopressin-1a (V1a) receptor antagonist, but not by desGly-NH₂-d(CH₂)₅[DTyr², Thr⁴]OVT, an oxytocin receptor antagonist. Single cell RT-PCR analysis revealed that V1a receptor, compared to oxytocin, vasopressin-1b and vasopressin-2 receptors, was more profoundly expressed in dorsal root ganglion (DRG) neurons and the expression of V1a receptor was predominant in transient receptor potential vanilloid 1 (TRPV1)-expressing DRG neurons. Fura-2 based calcium imaging experiments showed that capsaicin-induced calcium transient was significantly inhibited by oxytocin and that such inhibition was reversed by V1a receptor antagonist. Additionally, whole cell patch clamp recording demonstrated that oxytocin significantly increased potassium conductance via V1a receptor in DRG neurons. Taken together, our findings suggest that analgesic effects produced by peripheral administration of oxytocin were attributable to the activation of V1a receptor, resulting in reduction of TRPV1 activity and enhancement of potassium conductance in DRG neurons.

Protein Kinase C Mediates the Corticosterone-induced Sensitization of Dorsal Root Ganglion Neurons Innervating the Rat Stomach

BACKGROUND/AIMS: Gastric hypersensitivity contributes to abdominal pain in patients with functional dyspepsia. Recent studies showed that hormones induced by stress are correlated with visceral hypersensitivity. However, the precise mechanisms underlying gastric hypersensitivity remain largely unknown. The aim of the present study was designed to investigate the roles of corticosterone (CORT) on excitability of dorsal root ganglion (DRG) neurons innervating the stomach. METHODS: DRG neurons innervating the stomach were labeled by DiI injection into the stomach wall. Patch clamp recordings were employed to examine neural excitability and voltage-gated sodium channel currents. Electromyograph technique was used to determine the responses of neck muscles to gastric distension. RESULTS: Incubation of acutely isolated DRG neurons with CORT significantly depolarized action potential threshold and enhanced the number of action potentials induced by current stimulation of the neuron. Under voltage-clamp mode, incubation of CORT enhanced voltage-gated sodium current density of the recorded neurons. Pre-incubation of GF109203X, an inhibitor of protein kinase C, blocked the CORT-induced hyperexcitability and potentiation of sodium currents. However, pre-incubation of H-89, an inhibitor of protein kinase A, did not alter the sodium current density. More importantly, intraperitoneal injection of CORT produced gastric hypersensitivity of healthy rats, which was blocked by pre-administration of GF109203X but not H-89. CONCLUSIONS: Our data strongly suggest that CORT rapidly enhanced neuronal excitability and sodium channel functions, which is most likely mediated by protein kinase C but not protein kinase A signaling pathway in DRG neurons innervating the stomach, thus underlying the gastric hypersensitivity induced by CORT injection.

Ultrasonography Evaluation of Vulnerable Vessels Around Cervical Nerve Roots During Selective Cervical Nerve Root Block

OBJECTIVE: To evaluate the prevalence of vulnerable blood vessels around cervical nerve roots before cervical nerve root block in the clinical setting. METHODS: This retrospective study included 74 patients with cervical radiculopathy who received an ultrasonography-guided nerve block at an outpatient clinic from July 2012 to July 2014. Before actual injection of the steroid was performed, we evaluated the vulnerable blood vessels around each C5, C6, and C7 nerve root of each patient's painful side, with Doppler ultrasound. RESULTS: Out of 74 cases, the C5 level had 2 blood vessels (2.7%), the C6 level had 4 blood vessels (5.45%), and the C7 level had 6 blood vessels (8.11%) close to each targeted nerve root. Moreover, the C5 level had 2 blood vessels (2.7%), the C6 level 5 blood vessels (6.75%), and the C7 level had 4 blood vessels (5.45%) at the site of an imaginary needle's projected pathway to the targeted nerve root, as revealed by axial transverse ultrasound imaging with color Doppler imaging. In total, the C5 level had 4 blood vessels (5.45%), the C6 level 9 blood vessels (12.16%), and the C7 level 10 had blood vessels (13.51%) either at the targeted nerve root or at the site of the imaginary needle's projected pathway to the targeted nerve root. There was an unneglectable prevalence of vulnerable blood vessels either at the targeted nerve root or at the site of the needle' projected pathway to the nerve root. Also, it shows a higher prevalence of vulnerable blood vessels either at the targeted nerve root or at the site of an imaginary needle's projected pathway to the nerve root as the spinal nerve root level gets lower. CONCLUSION: To prevent unexpected critical complications involving vulnerable blood vessel injury during cervical nerve root block, it is recommended to routinely evaluate for the presence of vulnerable blood vessels around each cervical nerve root using Doppler ultrasound imaging before the cervical nerve root block, especially for the lower cervical nerve root level.

Inhibiting Vascular Endothelial Growth Factor in Injured Intervertebral Discs Attenuates Pain-Related Neuropeptide Expression in Dorsal Root Ganglia in Rats

STUDY DESIGN: An experimental animal study. PURPOSE: To evaluate effects of anti-vascular endothelial growth factor (VEGF) on the content and distribution of the calcitonin gene-related peptide (CGRP) in the dorsal ganglia in a rat model. OVERVIEW OF LITERATURE: Increased expression of VEGF in degenerative disc disease increases the levels of inflammatory cytokines and nerve ingrowth into the damaged discs. In animal models, increased levels of VEGF can persist for up to 2 weeks after an injury. METHODS: Through abdominal surgery, the dorsal root ganglia (DRG) innervating L5/L6 intervertebral disc were labeled (FluoroGold neurotracer) in 24, 8-week old Sprague Dawley rats. The rats were randomly allocated to three groups of eight rats each. The anti-VEGF group underwent L5/6 intervertebral disc puncture using a 26-gauge needle, intradiscal injection of 33.3 µg of the pegaptanib sodium, a VEGF165 aptamer. The control-puncture group underwent disc puncture and intradiscal injection of 10 µL saline solution, and the sham-surgery group underwent labeling but no disc puncture. Two rats in each group were sacrificed on postoperative days 1, 7, 14, and 28 after surgery. L1–L6 DRGs were harvested, sectioned, and immunostained to detect the content and distribution of CGRP. RESULTS: Compared with the control, the percentage of CGRP-positive cells was lower in the anti-VEGF group (p<0.05; 40.6% and 58.1% on postoperative day 1, 44.3% and 55.4% on day 7, and 42.4% and 59.3% on day 14). The percentage was higher in the control group compared with that of the sham group (p<0.05; sham group, 34.1%, 40.7%, and 33.7% on postoperative days 1, 7, and 14, respectively). CONCLUSIONS: Decreasing CGRP-positive cells using anti-VEGF therapy provides fundamental evidence for a possible therapeutic role of anti-VEGF in patients with discogenic lower back pain.

Incarceration of Spinal Nerve Root through Incidental Durotomy as a Cause of Sciatica

Incidental durotomies are a frequent complication during spinal surgery. Cerebrospinal fluid (CSF) leakage from a dural tear may be visually apparent intraoperatively, but occasionally, a tear may not be recognized during the procedure. We report our experience in 2 cases of postoperative incarceration of nerve root as a cause of sciatica, without CSF leakage intraoperatively. When durotomy attributable to surgical manipulation does occur, intraoperative identification is mandated. If a patient develops unexplainable postoperative pain and neurological deficits after lumbar discectomy, incarceration of nerve root should be considered in the differential diagnosis.

State of education regarding ultrasound-guided interventions during pain fellowships in Korea: a survey of recent fellows

BACKGROUND: Recently, the use of ultrasound (US) techniques in regional anesthesia and pain medicine has increased significantly. However, the current extent of training in the use of US-guided pain management procedures in Korea remains unknown. The purpose of the present study was to assess the current state of US training provided during Korean Pain Society (KPS) pain fellowship programs through the comparative analysis between training hospitals. METHODS: We conducted an anonymous survey of 51 pain physicians who had completed KPS fellowships in 2017. Items pertained to current US practices and education, as well as the types of techniques and amount of experience with US-guided pain management procedures. Responses were compared based on the tier of the training hospital. RESULTS: Among the 51 respondents, 14 received training at first- and second-tier hospitals (Group A), while 37 received training at third-tier hospitals (Group B). The mean total duration of pain training during the 1-year fellowship was 7.4 months in Group A and 8.4 months in Group B. Our analysis revealed that 36% and 40% of respondents in Groups A and B received dedicated US training, respectively. Most respondents underwent US training in patient-care settings under the supervision of attending physicians. Cervical root, stellate ganglion, piriformis, and lumbar plexus blocks were more commonly performed by Group B than by Group A (P < 0.05). CONCLUSIONS: Instruction regarding US-guided pain management interventions varied among fellowship training hospitals, highlighting the need for the development of educational standards that mandate a minimum number of US-guided nerve blocks or injections during fellowships in interventional pain management.

Correlation: impedance and tomography in implants insertion in lumbar arthrodesis / Correlação: impedância e tomografia na inserção de implantes em artrodese lombar / Correlación: impedancia y tomografía en la inserción de implantes en artrodesis lumbar

ABSTRACT Objective: To define whether the electroneurophysiological stimulation would be a safe method for reducing injuries in nerve roots during surgery of lumbar spine arthrodesis, as well as verify whether there is a direct correlation between the intraoperative impedance values and the distance from the medial cortical pedicle screw. Methods: Randomized retrospective multicenter study of 10 patients who underwent arthrodesis of lumbar spine after conservative treatment failure, with a total of 50 pedicle screws instrumented. Reliable and safe impedance values were measured in order to reduce the risk of injury to nerve roots in the perioperative period, and these values were compared with the distance between the screw and the medial cortical of the pedicle by CT scan, measured in the immediate post-operative period. Results: There is no direct correlation between the intraoperative impedance values and the distance from the screw to the medial cortical of the pedicle. Conclusion: The electroneurostimulation proved to be a reliable quantitative method to reduce the risk of injury to nerve roots during surgery of lumbar spine arthrodesis when the measured values are greater than 10mA.

RESUMO Objetivo: Definir se a estimulação eletroneurofisiológica seria um método seguro para redução de lesões em raízes nervosas no intraoperatório de artrodese de coluna lombar, bem como verificar se há correlação direta entre os valores de impedância transoperatória e a distância do parafuso e a cortical medial do pedículo. Métodos: Estudo retrospectivo, multicêntrico com seleção randômica consecutiva de 10 pacientes que realizaram artrodese de coluna lombossacra após falha de tratamento conservador, com um total de 50 parafusos pediculares instrumentados. Os valores confiáveis e seguros de impedância para diminuir os riscos de lesão em raízes nervosas foram aferidos no período perioperatório, sendo esses valores comparados com os da distância entre o parafuso e a cortical medial do pedículo na tomografia computadorizada, aferida no pós-operatório imediato. Resultados: Não há correlação direta entre os valores de impedância transoperatória e a distância do parafuso até a cortical medial do pedículo. Conclusão: A eletroneuroestimulação mostrou ser um método quantitativo seguro para diminuir os riscos de lesões em raízes nervosas no intraoperatório de artrodese de coluna lombar quando os valores aferidos são maiores que 10mA.

RESUMEN Objetivo: Definir si la estimulación electroneurofisiológica sería un método seguro para reducir las lesiones en las raíces nerviosas durante la cirugía de artrodesis de columna lumbar, así como verificar si hay correlación directa entre los valores de impedancia perioperatoria y la distancia entre tornillo y la cortical medial del pedículo. Métodos: Estudio retrospectivo, multicéntrico, con selección aleatoria consecutiva de 10 pacientes que fueron sometidos a la artrodesis de columna lumbosacra después de falla del tratamiento conservador, con un total de 50 tornillos pediculares instrumentados. Valores fiables y seguros de impedancia para reducir el riesgo de lesiones a las raíces nerviosas se midieron en el periodo perioperatorio, y estos valores se compararon con la distancia entre el tornillo y la cortical medial del pedículo en la tomografía computarizada, medida en el período postoperatorio inmediato. Resultados: No existe una correlación directa entre los valores de impedancia perioperatoria y la distancia desde el tornillo hasta la cortical medial del pedículo. Conclusión: La electroneuroestimulación mostró ser un método cuantitativo fiable para reducir el riesgo de lesiones a raíces nerviosas durante la cirugía de artrodesis de columna lumbar cuando los valores medidos son mayores que 10mA.

Diffuse Large B-Cell Lymphoma Mimicking Schwannoma of Lumbar Spine

A rare case of solitary diffuse large B-cell lymphoma arising from the lumbar spinal nerve root is reported. A 37-year-old man presented with a 3-month history of progressive numbness and paraparesis in both legs. The initial diagnosis was benign primary intradural extramedullary tumor including schwannoma and meningioma. Histopathological examination revealed diffuse large B-cell lymphoma. While a well-defined T1 isointense mass is common in primary spinal schwannoma, the present case was atypical and had a yellowish neural component. The pathogenesis and radiological findings of spinal diffuse large B-cell lymphoma are discussed and related literature is reviewed.

Comparison with Magnetic Resonance Three-Dimensional Sequence for Lumbar Nerve Root with Intervertebral Foramen

STUDY DESIGN: Prospective study based on magnetic resonance (MR) imaging of the lumbar spinal root of the intervertebral foramen. PURPOSE: This study was to compare MR three-dimensional (3D) sequences for the evaluation of the lumbar spinal root of the intervertebral foramen. OVERVIEW OF LITERATURE: The diagnosis of spinal disorders by MR imaging is commonly performed using two-dimensional T1- and T2-weighted images, whereas 3D MR images can be used for acquiring further detailed data using thin slices with multi-planar reconstruction. METHODS: On twenty healthy volunteers, we investigated the contrast-to-noise ratio (CNR) of the lumbar spinal root of the intervertebral foramen with a 3D balanced sequence. The sequences used were the fast imaging employing steady state acquisition and the coherent oscillatory state acquisition for the manipulation of image contrast (COSMIC). COSMIC can be used with or without fat suppression (FS). We compared these sequence to determine the optimized visualization sequence for the lumbar spinal root of the intervertebral foramen. RESULTS: For the CNR between the nerve root and the peripheral tissue, these were no significant differences between the sequences at the entry of foramen. There was a significant difference and the highest CNR was seen with COSMIC-FS for the intra- and extra-foramen. CONCLUSIONS: In this study, the findings suggest that the COSMIC-FS sequences should be used for the internal or external foramen for spinal root disorders.

Enhanced Expression of TREK-1 Is Related with Chronic Constriction Injury of Neuropathic Pain Mouse Model in Dorsal Root Ganglion

Neuropathic pain is a complex state showing increased pain response with dysfunctional inhibitory neurotransmission. The TREK family, one of the two pore domain K+ (K2P) channel subgroups were focused among various mechanisms of neuropathic pain. These channels influence neuronal excitability and are thought to be related in mechano/thermosensation. However, only a little is known about the expression and role of TREK-1 and TREK-2, in neuropathic pain. It is performed to know whether TREK-1 and/or 2 are positively related in dorsal root ganglion (DRG) of a mouse neuropathic pain model, the chronic constriction injury (CCI) model. Following this purpose, Reverse Transcription Polymerase Chain Reaction (RT-PCR) and western blot analyses were performed using mouse DRG of CCI model and compared to the sham surgery group. Immunofluorescence staining of isolectin-B4 (IB4) and TREK were performed. Electrophysiological recordings of single channel currents were analyzed to obtain the information about the channel. Interactions with known TREK activators were tested to confirm the expression. While both TREK-1 and TREK-2 mRNA were significantly overexpressed in DRG of CCI mice, only TREK-1 showed significant increase (~9 fold) in western blot analysis. The TREK-1-like channel recorded in DRG neurons of the CCI mouse showed similar current-voltage relationship and conductance to TREK-1. It was easily activated by low pH solution (pH 6.3), negative pressure, and riluzole. Immunofluorescence images showed the expression of TREK-1 was stronger compared to TREK-2 on IB4 positive neurons. These results suggest that modulation of the TREK-1 channel may have beneficial analgesic effects in neuropathic pain patients.

Acupuncture combined with moxibustion plaster for nerve-root type cervical spondylosis / 中国针灸

<p><b>OBJECTIVE</b>To compare the clinical efficacy differences between acupuncture combined with moxi-bustion plaster and electroacupuncture (EA) for nerve-root type cervical spondylosis.</p><p><b>METHODS</b>A total of 60 casesof nerve-root type cervical spondylosis were randomly divided into a plaster group and an EA group, 30 cases ineach one. Patients in the plaster group were treated with regular acupuncture at Jiaji(EX-B 2) points and ashipoints, combined with moxibustion plaster at Gaohuang (BL 43); patients in the EA group were treated with EAat identical acupoints as plaster group. The treatment was given once a day, and 5 days were taken as one course;there was an interval of 2 days between courses and totally 2 courses were performed. The pain questionnaires andquantitative score of signs and symptoms were observed before and after treatment in the two groups. The clinicalefficacy of the two groups was compared.</p><p><b>RESULTS</b>The total effective rate was 96. 7% (29/30) in the plastergroup, which was not significantly different from 93. 3% (28/30) in the EA group (P>0. 05). After treatment,PRI, VAS and PPI were all reduced in the two groups (all P<C. 01), which were also significantly different be-tween the two groups (all P<0. 05). The quantitative score of each sign and symptom was increased after treat-ment in the two groups (all P<0. 01). Compared with the EA group, the work and life ability, function, feelingand strength of hand were increased in the plaster groups (all P<. 05). Pain score of neck and shoulder aftertreatment in the EA group was higher than the plaster group (all P<0. 05).</p><p><b>CONCLUSION</b>Acupuncture combinedwith moxibustion plaster and EA both have superior clinical efficacy for nerve-root type cervical spondylosis; EA issuperior to acupuncture combined with moxibustion plaster on relieving pain, while acupuncture combined withmoxibustion plaster is superior to EA on improving life quality, muscle strength and feeling.</p>

Discal Cyst: a Rare Cause of Neurologic Compression in the Young Adult

INTRODUCTION: discal cysts are rare pathology. Its clinical presentation can be mistaken for disc herniation, with back pain, radiculopathy and neurological deficit. It is more common in male patients in their fourth life decade. Because they are rare, there is no consensus about the treatment. A great variety of procedures, from medication for the pain to endoscopic or microdiscectomy excision, have been described. OBJETIVE: Describe a case of discal cyst on the l4-l5 level with compression of l5 right nerve root treated successfully with a minimal invasive procedure. : Case report. METHODS: Review medical records, pertinent images, interview with the patient and surgical team, intraoperative and histopathological findings. The surgical technique used was minimally invasive. RESULTS: Magnetic resonance imaging (MRI) demonstrated a cystic lesion imaging at the level of the L4-L5 disc. The cystic mass displaced the thecal sac dorsally compressed the L5 transversing root. The patient was submitted to a minimally invasive microendoscopic technique using a tubular retractor. He recovered completely after the procedure, presenting absence of leg pain and went back to his regular activities 3 weeks after the surgery. Histopathological examination of the cyst revealed thick fibrous connective tissue interspersed with areas of chronic inflammation. CONCLUSION: Discal cysts are rare intraspinal lesions. They can trigger severe neurological symptoms, and should be differentiated from other forms of epidural cysts and tumors. There are many treatment options that can be chosen from but no consensus. We used a treatment that was less invasive than the ones described in the literature.

INTRODUÇÃO: cistos discais são patologia rara. Sua apresentação clínica pode ser confundida com hérnia de disco, com dor nas costas, radiculopatia e déficit neurológico. É mais comum em pacientes do sexo masculino em sua quarta década de vida. Porque eles são raros, não há consenso sobre o tratamento. Uma grande variedade de procedimentos, de medicação para a dor para a endoscopia ou excisão microdiscectomy, têm sido descritas. OBJETIVO: descrever um caso de cisto discal no nível L4-L5 com compressão da raiz nervosa L5 di-reita tratada com sucesso com um procedimento minimamente invasivo. Desenho do estudo: Relato de caso. MÉTODO: revisão de registros médicos, imagens pertinentes, entrevista com o paciente e equipe cirúrgica, intra e histopatológicos. A técnica cirúrgica utilizada foi minimamente invasiva. : A ressonância magnética (MRI) demonstrou uma imagiologia lesão cística ao nível do disco L4-L5. A massa cística deslocou o saco tecal dorsal comprimido a transversing raiz L5. O paciente foi submetido a uma técnica microendoscópica minimamente invasiva utilizando um afastador tubular. Ele se recuperou completamente após o procedimento, apresentando ausência de dor nas pernas e voltou às suas atividades regulares 3 semanas após a cirurgia. O exame histopatológico do cisto revela tecido conjuntivo fibroso de espessura intercaladas com áreas de inflamação crónica. CONCLUSÃO: cistos discais são lesões intra-espinhais raras. Eles podem desencadear os sintomas neurológicos graves, e deve ser diferenciada de outras formas de cistos epidurais e tumores. Há muitas opções de tratamento que podem ser escolhidos a partir de, mas não há consenso. Utilizou-se um tratamento que era menos invasiva do que os descritos na literatura.

Calcific Tendinopathy of the Gluteus Medius Mimicking Lumbar Radicular Pain Successfully Treated With Barbotage: A Case Report

We report a case of calcific tendinopathy of the gluteus medius initially misdiagnosed as a lumbar herniated intervertebral disc. It was successfully treated with barbotage under ultrasonographic guidance finally. A 56-year-old woman was referred to interventional pain clinic for right hip pain due to an L5-S1 disc herniation. Serial L5 and S1 spinal nerve root blocks and epidural steroid injections were administered. However, pain relief was sustained only for a very short period. Plain radiography of the right hip revealed a solid calcific nodule at adjacent to the insertion site of the gluteus medius tendon. Physical modalities and extracorporeal shock wave therapy failed to improve the pain. Therefore, we attempted ultrasound-guided barbotage of the calcification. Barbotage was performed twice serially and her pain was considerably improved. At 6-month follow-up, the calcification was completely resolved.