La vena varicosa epidural imita el prolapso de disco y causante de un dolor radicular severo: Reporte de un caso / Epidural varicose vein mimic disc prolapse and causing a severe radicular pain: A case report

Venous varicose of epidura is considered a rare cause of nerve root and thecal sac compression and impingement that leads to lower limb radiculopathy. The purpose of this study is to draw attention to this problem during operation. It also aims to focus shed a light on using magnetic resonance imaging (MRI) before the operation. This research also attempts to evaluate the outcome of the surgery. Symptoms of epidural varicose with radiculopathy are rare and the diagnosis is often inaccurate by preoperative clinical examination and radiology investigations. Thus, in many cases the diagnosis is made intra- operatively. The case was a 40 years old female who consulted our outpatient clinic complaining from acute radicular pain in the lower back and down of her right lower limb. MRI was done for her and showed paracentral disc herniation. Intra operatively, an abnormal dilatation of epidural vein impingement on L4 nerve root with no foraminal stenosis was seen. We initiated a thermo coagulation of the epidural vein from proximal to distal ends at disc level and used gel foam patch to control bleeding that was removed all at the end of operation. Then, coagulation ablation was performed. The operation resulted in relief of symptoms and neurologic recovery occurred during follow up period. According to our case and previously published case reports, the outcome is good with recovery of neurological signs and symptoms that can be obtained by coagulation ablation of epidural varicose vein.

Percutaneous Epidural Neuroplasty

The percutaneous epidural neuroplasty is recently accepted as a useful interventional tool for management of chronic low back pain and radicular pain, which is refractory to other conservative treatments. The epidural adhesion is thought to be a cause of the refractory spinal pain because it could be a barrier preventing drug from reaching target lesion. It has been known that the adhesion is a result of post-operative scar change, fibrosis and chronic inflammatory response around the intervertebral disc and nerve root. The epidural neuroplasty is a catheterization technique for injecting therapeutic drug accurately into lesions of epidural space. Although the exact mechanisms of action of the procedure are unknown, the adhesiolysis could be induced by two postulated mechanisms, mechanical lysis by hydraulic pressure and catheterization, and chemical lysis by injected drugs. Normal saline, local anesthetics, and steroid are injected via the catheter. The large volume of injectant could wash out the pain substances and the pharmacologic effects of the injectant could relieve the pain. some possible adverse reactions of the procedure are known, but they could be prevented by exact technique and careful monitoring.

Effect of osthole on p38 MAPK signaling related pathway of rat model with inflammatory radicular pain induce by nucleus pulposus in the spinal horn / 中国药理学通报

Aim To observe the effect of epidurally application of osthole on the model of nucleus pulposusinduced inflammatory radicular pain and the expression of p38 MAPK signaling related pathway in the spinal dorsal horn of rats.Methods The model of radicular pain was generated by putting nucleus pulposus to the L5 dorsal root ganglion (DRG).50％ MWT was measured using Von Frey filaments to calculate mechanical pain threshold before and after operation.50 μL of 20 g · L-1 osthole was administered epidurally in group Ost and 50 μL of 100 mL · L-1 DMSO in group DMSO at postoperative day (POD).The expression of phosphorylated p38 (p-p38),IL-18 and IL-18R in the lumbar spinal dorsal horn was detected by Western blot.IL-18 mRNA was assessed by real-time PCR.Results The mechanical pain threshold significantly decreased after operation (P ＜ 0.05),while the expression of protein p-p38 MAPK,IL-18,IL-18R and IL-18 mRNA was significantly different.Compared with DMSO group,50％ MWT was significantly increased and accompanied with the decrease of protein p-p38,IL-18,IL-lgR and IL-18 mRNA in Ost group after drug administration (P ＜ 0.05).The correlation analysis between protein concentration of p38 MAPK and IL-18 mRNA showed that the Spearman correlation coefficient was 0.9 (P ＜ 0.05).Conclusion p-p38 and IL-18 of spinal dorsal horn participate in the rat model with inflammatory radicular pain induced by nucleus pulposus,and IL-18R plays a role in maintenance of the pain.Osthole administered epidurally in the early stage of pain could alleviate the pain for a long time,which may be related with inhibiting p38 MAPK signaling related pathways.

The effect of resolvin D2 on radicular pain caused by lumbar disc herniation / 中华物理医学与康复杂志

Objective To explore the effect of resolvin D2 ( RvD2) on radicular pain induced by interver-tebral disc herniation. Methods Thirty-six male Sprague-Dawley rats were randomly divided into a sham opera-tion group, a model group and an RvD2 group, each of 12. Non-compressive lumbar disc herniation was induced in the rats in the model and RvD2 groups using the autologous nucleus pulposus filling method. Those in the sham group had the surgical site exposed without any other treatment. After the modeling, 10μl of phosphate-buffered sa-line solution was administered intrathecally to the rats in the sham and model groups for 3 days, while the rats in the RvD2 group received 10 ng/10 μl of RvD2 intrathecally as well. Paw withdrawal thresholds (50％PWT) were ob-served 1 day before modeling and 7 days afterward for the rats of all three groups. On the 7th day after modeling, the L4 to L6 spinal dorsal horns on the surgery side were resected to detect the protein expression of phosphorylated protein kinase B ( p-AKT) , protein kinase B ( t-AKT) , phosphorylated glycogen synthase kinase 3β( p-GSK-3β) and glycogen synthase kinase 3β( GSK-3β) using western blotting. The protein levels of tumor necrosis factor alpha ( TNF-α) , interleukin-6 ( IL-6) , transforming growth factor-β1 ( TGF-β1) and interleukin-10 ( IL-10) were de-termined using enzyme-linked immunosorbent assays. Results On the 1st and 7th day after modeling, significant differences were observed between the model and sham groups in terms of the 50％PWT. From the 3rd day the aver-age 50％PWT in the RvD2 group was significantly higher than that of the model group at the same time points. On the 7th day after the modeling the average p-AKT and p-GSK-3βprotein levels of the model and RvD2 groups were significantly different from that of the sham group, and the model group′s average was also of significantly different from that of the RvD2 group. The average protein levels of the pro-inflammatory cytokines TNF-αand IL-6, as well as of the anti-inflammatory factors TGF-β1 and IL-10 in the dorsal horns of the model group and the RvD2 group were also significantly different on the 7th day, and both were significantly different from the sham group′s average. Conclusion RvD2 can alleviate radicular pain in rats with non-compressive disc herniation. The mechanisms might involve inhibition of GSK-3β activity, down-regulation of pro-inflammatory factors and up-regulation of anti-inflammatory factors.

Guía práctica para el tratamiento intervencionista del síndrome radicular lumbosacro (SRL) / Practical guide for interventional treatment of lumbosacral radicular syndrome (LRS)

Introducción: El Síndrome Radicular Lumbosacro (SRL) es una consulta frecuente de dolor neuropático causado por hernias y protrusiones discales o fenómenos degenerativos de la columna lumbosacra. Las técnicas intervencionistas de tratamiento se indican cuando otras terapéuticas no invasivas no alcanzan alivio satisfactorio. Dentro de ellas, las Inyecciones Epidurales de Corticoides (IEC) y la Radiofrecuencia Pulsada del Ganglio de la Raíz Dorsal (RPGRD) son las más indicadas en nuestro Servicio. No disponemos de guías nacionales para su utilización, basándonos habitualmente en las recomendaciones internacionales. Objetivo: Realizar una revisión bibliográfica que apoye la confección de una guía para la toma de decisiones, en cuanto a los aspectos prácticos de las técnicas disponibles, de manera de aplicarlas obteniendo el máximo beneficio posible, reduciendo al mínimo sus riesgos. Discusión: Se discuten las ventajas y desventajas de los abordajes más utilizados para la aplicación de las IEC, así como los agentes farmacológicos disponibles para este fin. Finalmente, se realiza también una puesta al día de los aspectos técnicos de la RPGRD para el tratamiento del SRL refractario al tratamiento con corticoides epidurales.

Introduction: Lumbosacral Radicular Syndrome (LRS) is a frequent neuropathic pain due to disc herniation, disc protrusions or degenerative changes of the lumbosacral spine. Interventional Pain Management techniques for its treatment are indicated when conservative management fails in provide satisfactory pain relief. Epidural Steroid Injections (ESI) and Pulsed Radiofrequency of the Dorsal Root Ganglion (PRDRG) are the procedures most frequently performed in our Service, for LRS treatment. Since guidelines for its use are lacked in our Country, international recommendations are usually followed. Objectives: The aim of this article is to perform a literature search to give evidence support to National guidelines related to available Interventional Pain Management techniques for LRS treatment, in order to balance risks and benefits of each technique in the decision making process. Discussion: Advantages and disadvantages of the different approaches for ESI are discussed and the pharmacologic aspects of the available agents for its use are summarized. Finally, an update of technical aspects of PRGDR for ESI refractory LRS is performed.

Effect of Cervical Interlaminar Epidural Steroid Injection: Analysis According to the Neck Pain Patterns and MRI Findings

BACKGROUND: It is widely accepted that cervical interlaminar steroid injection (CIESI) is more effective in treating radicular pain than axial neck pain, but without direct comparison. And the differences of effect after CIESI according to MRI findings are inconsistent. In this retrospective study, we evaluated the therapeutic response of CIESI according to pain sites, durations, MRI findings, and other predictive factors altogether, unlike previous studies, which evaluated them separately. METHODS: The medical records of 128 patients who received fluoroscopy guided CIESI were analyzed. We evaluated the therapeutic response (more than a 50% reduction on the visual analog scale [VAS] by their second visit) after CIESI by (1) pain site; neck pain without radicular pain/radicular pain with or without neck pain, (2) pain duration; acute/chronic (more than 6 month), and (3) findings of MRI; herniated intervertebral disc (HIVD)/spinal stenosis, respectively and altogether. RESULTS: Eighty-eight patients (68%) responded to CIESI, and there were no significant differences in demographic data, initial VAS score, or laboratory findings. And there were no significant differences in the response rate relating to pain site, pain duration, or MRI findings, respectively. In additional analysis, acute radicular pain with HIVD patients showed significantly better response than chronic neck pain with spinal stenosis (P = 0.04). CONCLUSIONS: We cannot find any sole predictive factor of therapeutic response to the CIESI. But the patients having acute radicular pain with HIVD showed the best response, and those having other chronic neck pain showed the worst response to CIESI.

Comparative Effectivenesses of Pulsed Radiofrequency and Transforaminal Steroid Injection for Radicular Pain due to Disc Herniation: a Prospective Randomized Trial

Transforaminal Epidural steroid injections (TFESI) have been widely adopted to alleviate and control radicular pain in accord with current guidelines. However, sometimes repeated steroid injections have adverse effects, and thus, this prospective randomized trial was undertaken to compare the effectivenesses of pulsed radiofrequency (PRF) administered to a targeted dorsal root ganglion (DRG) and TFESI for the treatment of radicular pain due to disc herniation. Subjects were recruited when first proved unsuccessful (defined as a score of > 4 on a visual analogue scale (VAS; 0-10 mm) and of > 30% according to the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI)). Forty-four patients that met the inclusion criteria were enrolled. The 38 subjects were randomly assigned to receive either PRF (PRF group; n = 19) or additional TFESI (TFESI group; n = 19) and were then followed for 2, 4, 8, and 12 weeks. To evaluate pain intensity were assessed by VAS. ODI and NDI were applied to evaluate functional disability. Mean VAS scores for cervical and lumbar radicular pain were significantly lower 12 weeks after treatment in both study groups. NDI and ODI scores also declined after treatment. However, no statistically significant difference was observed between the PRF and TFESI groups in terms of VAS, ODI, or NDI scores at any time during follow-up. PRF administered to a DRG might be as effective as TFESI in terms of attenuating radicular pain caused by disc herniation, and its use would avoid the adverse effects of steroid.

Comparative Effectivenesses of Pulsed Radiofrequency and Transforaminal Steroid Injection for Radicular Pain due to Disc Herniation: a Prospective Randomized Trial

Transforaminal Epidural steroid injections (TFESI) have been widely adopted to alleviate and control radicular pain in accord with current guidelines. However, sometimes repeated steroid injections have adverse effects, and thus, this prospective randomized trial was undertaken to compare the effectivenesses of pulsed radiofrequency (PRF) administered to a targeted dorsal root ganglion (DRG) and TFESI for the treatment of radicular pain due to disc herniation. Subjects were recruited when first proved unsuccessful (defined as a score of > 4 on a visual analogue scale (VAS; 0-10 mm) and of > 30% according to the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI)). Forty-four patients that met the inclusion criteria were enrolled. The 38 subjects were randomly assigned to receive either PRF (PRF group; n = 19) or additional TFESI (TFESI group; n = 19) and were then followed for 2, 4, 8, and 12 weeks. To evaluate pain intensity were assessed by VAS. ODI and NDI were applied to evaluate functional disability. Mean VAS scores for cervical and lumbar radicular pain were significantly lower 12 weeks after treatment in both study groups. NDI and ODI scores also declined after treatment. However, no statistically significant difference was observed between the PRF and TFESI groups in terms of VAS, ODI, or NDI scores at any time during follow-up. PRF administered to a DRG might be as effective as TFESI in terms of attenuating radicular pain caused by disc herniation, and its use would avoid the adverse effects of steroid.

The effect of Resolvin D1 on the radicular pain induced by herniated nucleus pulposus / 中华物理医学与康复杂志

Objective To investigate the analgesic effect of Resolvin D1 (RvD1) on radicular pain induced by herniated nucleus pulposusand its underlying mechanism.Methods Fifty-six male rats were randomly divided intoa sham group,a model group,a 10 ng group anda 100 ng group,each of 14.The rat model of non-compressive lumber disc herniation was established in all except the sham group.The former two groups were then injected with 10 μl of phosphate buffer solution (PBS) while the latter 2 groups were injected with 10 μl of PBS containing 10 and 100 ng of RvD1 respectively daily for three successive days.The rats' 50％ paw withdrawal threshold (PWT) was evaluated 1 day before and on 7 successive days after surgery.On day 7 the rats' spinal cords were removed to assess the expression of tumor necrosis factor-or (TNF-α),interlukin-1β (IL-1β) and interlukin-10 (IL-10) using ELISA methods.The levels of ERK and NF-κB/p65 were measured using Western blotting.Results Theaverage 50％PWT of the model group decreased significantly from day 1 to day 7 compared with the sham group,but was significantly lower thanthe RvD1 10 ng group from day 3 to day 7.Moreover the 50％PWT in the RvD1 100 ng group increased significantlyfrom day 2 to day 7 compared with the model group (P＜0.05).The average expression of both TNF-α and IL-1β of the model group was upregulated significantly and that of IL-10 decreased significantly compared with the sham group.Compared with the model group,the expression of TNF-α and IL-1β decreased significantly (P＜0.05)and the level of IL-10 was significantlyup-regulated (P＜0.05) both in the RvD1 10 ng group and 100 ng group.Moreover,the changes were larger in the RvD1 100 ng group (P＜0.05).Compared with the sham group,the levels of p-ERK and NF-κB/p65 in the model group were significantly up-regulated (P＜0.05).Compared with the model group,intrathecal injection of RvD1 (10 ng or 100 ng) significantly decreased the expressions of p-ERK and NF-κB/p65 (P＜0.05).Moreover,the decrease wasgreater in the RvD1 100 ng group (P＜0.05).Conclusions RvD1 might alleviate the radicular inflammation and pain byregulating the balance of inflammatory mediators and activation of p-ERK and NF-κB/p65 pathways.It may offer novel therapeutic approaches for the management of lumbar disc herniation.

The effect of lipoxin A4 on radicular pain caused by intervertebral disc herniation / 中华物理医学与康复杂志

Objective To investigate the effect of lipoxin A4 LXA4) on radicular pain caused by intervertebral disc herniation.Methods Non-compressive intervertebral disc herniation was induced into forty-eight adult male Sprague-Dawley rats,and they were divided into a sham group (sham operation + 10 μl normal saline),a control group (modeled + 10 μl normal saline),an LXA4 10 ng group (modeled + 10 ng LXA4) and an LXA4 100 ng group (modeled + 100 ng LXA4),with 12 rats in each group.The normal saline (10 μl) or LXA4 (10 μl) was administered intrathecally right after the operation and on each of the three succeeding days.General behavior was observed and the 50％ paw withdrawal threshold (50％ PWT) was measured.On postoperative day 7 all the rats were killed and the ipsilateral lumbar (L4~) segments of their spinal dorsal horns were removed for determination of the expression of p-JNK,t-JNK,p-ERK and t-ERK proteins using western blotting.TNF-α,IL-1β and TGF-β1 expression were determined using ELISA.Results There was no significant difference in the 50％PWT of the sham group before and after surgery,but the 50％ PWTs of the control group and the LXA4 10 ng group were significantly decreased after the operation compared with their values beforehand and significantly lower than the value of the sham group at all time points.Moreover,the 50％ PWT of the LXA4 10 ng group on postoperative days 3 and 5 was significantly higher than the control group;as was the value of the LXA4 100 ng group on postoperative days 2,3,4,5,6 and 7.The p-JNK and p-ERK expression in the control group,the LXA4 10 ng group and the LXA4 100 ng group were all increased significantly more than in the sham group,but their expression in the LXA4 10 ng group and LXA4 100 ng group were decreased significantly more in a dose-dependent manner compared with the control group,with the LXA4 100 ng group showing the greatest decrease.There were no significant differences in t-JNK or t-ERK expression within each group.Conclusion LXA4 can alleviate radicular pain caused by non-compressive lumbar intervertebral disc herniation.The underlying mechanism involves inhibiting the activation of the ERK and JNK pathways,reducing the expression of pro-inflammatory cytokines and increasing the expression of anti-inflammatory cytokines.

Radiofrecuencia pulsada del ganglio de la raiz dorsal cervical: presentacion de un caso clinico

El tratamiento estándar del dolor radicular cervical, que acompaña a la patología discal o la estenosis neuroforaminal, se realiza con un enfoque multidisciplinario, que incluye medicación efectiva para el dolor neuropático, fisioterapia y la inyección epidural de esteroides. Cuando el dolor es refractario a este tipo de abordaje, la cirugía se propone como opción terapéutica. La radiofrecuencia pulsada del ganglio de la raíz dorsal de las raíces afectadas es una alternativa válida para tratar el dolor radicular cervical refractario. Se presenta un caso clínico de dolor radicular cervical por estenosis neuroforaminal, donde se utilizó la radiofrecuencia pulsada del ganglio de la raíz dorsal con buenos resultados, evaluados mediante la versión en español del Brief Pain Inventory

Standard treatment of cervical radicular pain due to cervical disc disease or neuroforaminal stenosis is performed utilizing a multidisciplinary approach, including neurophatic pain killers, physical therapy and epidural steroid injections. When cervical radicular pain is refractory to this treatment approach, spine surgery is often proposed. Pulsed radiofrequency of the cervical dorsal root ganglion is a valid alternative treatment to refractory cervical radicular pain. A clinical case is reported, where pulsed radiofrequency of the dorsal root ganglion was used with good results, utilizing the spanish version of the Brief Pain Inventory as an outcome evaluation tool

Role of the Self-Administered, Self-Reported History Questionnaire to Identify Types of Lumbar Spinal Stenosis: A Sensitivity Analysis

STUDY DESIGN: Case-control design. PURPOSE: To evaluate the role of the self-administered, self-reported history questionnaire (SSHQ) in identifying types of lumbar spinal stenosis (LSS). OVERVIEW OF LITERATURE: Diagnosis of types of LSS is controversial. METHODS: A total of 235 patients with LSS were asked to respond to the SSHQ. All of these patients recovered following surgical treatment. The classification of LSS patients was based on history, physical examinations, and imaging studies. It is considered to be the gold standard. Radicular and neurogenic claudication types of LSS were based on the SSHQ developed by Konno et al. Two categories of LSS were determined based on the SSHQ tool and gold standard. Finally, a sensitivity analysis was carried out to evaluate the diagnostic value of the SSHQ. RESULTS: The mean age of patients was 59.4 years. According to the criteria for gold standard, patients were diagnosed with the radicular type (n=103), and neurogenic claudication type (n=132). The questionnaire had desirable sensitivity, specificity, and accuracy in categorizing the two types of LSS: 97.8%, 66.6%, and 96.8% for the radicular type, and 97.0%, 80.0%, and 95.7% for the neurogenic claudication type. CONCLUSIONS: Our findings indicate that the SSHQ is a reliable and a valid measure and it may be a clinical diagnosis support tool for identifying patients with two types of LSS.

Acute Motor Weakness of Opposite Lower Extremity after Percutaneous Epidural Neuroplasty

Recently, percutaneous epidural neuroplasty has become widely used to treat radicular pain caused by spinal stenosis or a herniated intervertebral disc. A 19-year-old female patient suffering from left radicular pain caused by an L4-L5 intervertebral disc herniation underwent percutaneous epidural neuroplasty of the left L5 nerve root using a Racz catheter. After the procedure, the patient complained of acute motor weakness in the right lower leg, on the opposite site to where the neuroplasty was conducted. Emergency surgery was performed, and swelling of the right L5 nerve root was discovered. The patient recovered her motor and sensory functions immediately after the surgery. Theoretically, the injection of a large volume of fluid in a patient with severe spinal stenosis during epidural neuroplasty can increase the pressure on the opposite side of the epidural space, which may cause injury of the opposite nerve by barotrauma from a closed compartment. Practitioners should be aware of this potential complication.

Quiste de Tarlov bilateral, presentación de un caso / Tarlov cyst bilateral, case report

Los quistes de Tarlov, son crecimientos quísticos benignos sub diagnosticados y no reportándose ningún caso en Bolivia. Son clasificados como quistes meníngeos tipo II, infrecuentes (incidencia estimada de 4,6% - 9%), de características benignas, en su mayoría localizados en región sacra. Asintomáticos, en su gran mayoría diagnosticados de manera incidental. Se presenta el caso de una paciente con dolor crónico de tipo radicular en fosa iliaca izquierda sin mejoría ni explicación del mismo. Se le realizó tomografía computarizada y resonancia magnética por las cuales se llegó al diagnóstico. Posteriormente se da tratamiento conservador sintomatológico con mejoría evidente de las misma. No requiriendo tratamiento quirúrgico.

Tarlov cyst is a benign cystic growth usually underdiagnosed. No case has been reported so far in Bolivia. Classified as a Type II meningeal cysts, rare (estimated incidence of 4,6% - 9%), of benign characteristics, most commonly located in the sacral region. Asymptomatic and diagnosed incidentally most of the times. The patient comes with a chief complaint of chronic radicular back pain in the left iliac fossa with no improvement or explanation thereof. The patient underwent CT and MRI leading us to the diagnosis. The patient is managed with conservative treatment targeting the symptoms, with notorious improvement not requiring surgical treatment.

On the Variations of Cervical Dermatomes.

Background: Nerve-root related dermatomes have been considered to have quite solid anatomical framings. However, especially in the lumbar region, studies have questioned such firm anatomy. Regarding the cervical nerve roots, many studies have shown an overlap between different dermatomes, which of course affects decisions taken in the clinical work. All the same, dermatome drawings with clear borders are still widely used. Context and purpose of the study: We conducted a literature review in order to find today’s state of the art, including the methods on which the anatomical atlases have been based. The overall pragmatic thoughts were to create summarized guide for clinicians when trying to correlate an MRI-demonstrated prolapse/recess stenosis to pain and neurologic findings, particularly if the nerve root’s peripheral neurology does not follow conventional anatomy. Results: We isolated 24 studies that sufficiently dealt with the issue of cervical dermatomes. Pain and sensory disturbance caused by cervical root affection could deviate from the dermatomal patterns. We found indications that sometimes no paralysis or anaesthesia would be seen after section of a single root. Because the fraction of cases without classical fit between nerve root and anatomical level cannot be given, studies should go into this issue. Conclusion: There are many studies showing that dermatomal distributions are varying, and not only overlapping. We therefore mean that new studies, with modern imaging and surgical techniques, are much needed.

Sacralisation of Lumbar Vertebrae.

Background: Lumbar backache is a very common problem nowadays. Sacralisation of lumbar vertebrae is one of the cause for that. During routine osteology teaching a sacrum with incomplete attached lumbar 5 vertebrae is seen. Observation: Incompletely fused L 5 vertebrae with sacrum is seen. The bodies of the vertebrae are fused but the transverse process of left side is completely fused with the ala of sacrum.But on the right side is incompletely fused. Conclusion: The person is usually asymptomatic or may present with symptoms which include spinal or radicular pain, disc degeneration, L4/L5 disc prolapse, lumbar scoliosis and lumbar extradural defects. In transitional lumbosacral segmentation, it was observed that the lumbosacral intervertebral disc is significantly narrowed. The incidence of disc herniation is found to be higher and can occur even at young ages. There was also relationship established between transitional vertebrae and the degree of slippage in spondylolytic spondylolisthesis. In addition, this anomaly has known implications in the field of disc surgery.

Use of Magnetic Resonance Imaging to Identify Outcome Predictors of Caudal Epidural Steroid Injections for Lower Lumbar Radicular Pain Caused by a Herniated Disc

OBJECTIVE: We used lumbar magnetic resonance image (MRI) findings to determine possible outcome predictors of a caudal epidural steroid injection (CESI) for radicular pain caused by a herniated lumbar disc (HLD). METHODS: Ninety-one patients with radicular pain whose MRI indicated a HLD were enrolled between September 2010 and July 2013. The CESIs were performed using ultrasound (US). A responder was defined as having complete relief or at least a 50% reduction of pain as assessed by the visual analog scale (VAS) and functional status on the Roland Morris Disability Questionnaire (RMDQ); responder (VAS n=61, RMDQ n=51), and non-responder (VAS n=30, RMDQ n=40). MRI findings were analyzed and compared between the two groups with regard to HLD level, HLD type (protrusion or exclusion), HLD zone (central, subarticular, foraminal, and extraforaminal), HLD volume (mild, moderate, or severe), relationship between HLD and nerve root (no contact, contact, displaced, or compressed), disc height loss (none, less than half, or more than half ), and disc degeneration grade (homogeneous disc structure or inhomogeneous disc structure-clear nucleus and height of intervertebral disc). RESULTS: A centrally located herniated disc was more common in the responder group than that in the non-responder group. Treatment of centrally located herniated discs showed satisfactory results. (VAS p=0.025, RMDQ p=0.040). Other factors, such as HLD level, HLD type, HLD volume, relationship to nerve root, disc height loss, and disc degeneration grade, were not critical. CONCLUSION: The HLD zone was significant for pain reduction after CESI. A centrally located herniated disc was a predictor of a good clinical outcome.

The Efficacy of Pulsed Radiofrequency Treatment of Cervical Radicular Pain Patients

OBJECTIVE: Cervical radicular pain is defined as pain arising in the arm caused by irritation of a cervical spinal nerve or its roots. Although many treatment modalities are described in the literature, the available evidence for efficacy is not sufficient to allow definitive conclusions. The goal of this study was to establish the benefits and prognostic factors of pulsed radiofrequency (PRF) on the adjacent cervical dorsal root ganglia (DRG) of cervical radicular pain patients. METHODS: A retrospective study of PRF treatment of patients with cervical radicular pain was carried out. Two times diagnostic block of cervical DRG were performed before PRF. PRF was applied for 2 minutes at a setting of 2 Hz and 45 V by two times on the same targets, with the end point being an electrode tip temperature 42degrees C. Numerical rating scale (NRS) score was evaluated post-treatment 2 week, 1 month, 3 months and 6 months, which were compared with pretreatment value. A successful outcome was defined that NRS change was improved more than 50% at 6 months. RESULTS: The mean age was 54 years. The success rate was 68%(15/22) after six months of follow-up. PRF induced complications were not observed. Between success and failure group, we do not find any positive outcome prognostic factor. Interestingly, PRF treatment on foraminal stenosis is better outcome than herniated cervical disc. CONCLUSION: PRF on adjacent cervical DRG is effective and safe treatment option for cervical radicular pain patients. However, more long-term follow up and larger patients are needed to establish effectiveness PRF treatment on cervical radicular pain patients.

Effect of osthole on ERK/MAPK signaling pathway and the expression of COX-2 mRNA in the spinal dorsal horn of rats with nucleus pulposus-induced inflammatory radicular pain / 中国药理学通报

Aim Toinvestigatetheanalgesiceffectsof epidural osthole application on the mechanical allodyn-ia and the ERK/MAPK signaling pathway and the expression of COX-2 mRNA in the spinal dorsal horn.Methods 125adultmaleSDratswererandomizedin-to five groups( n=25 each) :Blank, Sham, NP, Ost and vehicle. At postoperative day 6, 1mg/rat osthole 50 μl was injected epidurally into group Ost and the same volume of vehicle was given into group vehicle. The mechanical pain threshold was measured by 50%MWT at 1 day before operation and the 3 rd,6 th,7 th, 14 th,21 st day after operation. After the measurement of pain threshold on postoperative day 14 , the L4-6 segment of spinal dorsal horn was removed for determi-nation of the expression of ERK, pERK and COX-2 mRNAbyWesternblotandRT-PCR.Results Com-pared with blank group, the mechanical pain threshold was only down-regulated at day 1 after operation in sham group, the expression of pERK and COX-2 mR-NA in sham group showed no significant difference ( P>0. 05 ); the mechanical pain threshold was signifi-cantly down-regulated after operation in NP, Ost and vehicle groups( P0. 05). The correla-tion analysis on pERK1/2 and COX-2 mRNA revealed the Pearson correlation coefficient was 0 . 878 and 0 . 910 , suggesting a strong positive correlation between pERKandCOX-2mRNA.Conclusions Ostholead-ministrated in the early stage after surgery can alleviate the nucleus pulposus-induced radicular inflammatory pain probably by inhibiting the expression of pERK and COX-2 mRNA in spinal dorsal horn.

Comparison of Morphine and Tramadol in Transforaminal Epidural Injections for Lumbar Radicular Pain

BACKGROUND: Transforaminal epidural steroid injections are known to reduce inflammation by inhibiting synthesis of various proinflammatory mediators and have been used increasingly. The anti-inflammatory properties of opioids are not as fully understood but apparently involve antagonism sensory neuron excitability and pro-inflammatory neuropeptide release. To date, no studies have addressed the efficacy of transforaminal epidural morphine in patients with radicular pain, and none have directly compared morphine with a tramadol for this indication. The aim of this study was to compare morphine and tramadol analgesia when administered via epidural injection to patients with lumbar radicular pain. METHODS: A total of 59 patients were randomly allocated to 1 of 2 treatment groups and followed for 3 months after procedure. Each patient was subjected to C-arm guided transforaminal epidural injection (TFEI) of an affected nerve root. As assigned, patients received either morphine sulfate (2.5 mg/2.5 ml) or tramadol (25 mg/0.5 ml) in combination with 0.2% ropivacaine (1 ml). Using numeric rating scale was subsequently rates at 2 weeks and 3 months following injection for comparison with baseline. RESULTS: Both groups had significantly lower mean pain scores at 2 weeks and at 3 months after treatment, but outcomes did not differ significantly between groups. CONCLUSIONS: TFEI of an opioid plus local anesthetic proved effective in treating radicular pain. Although morphine surpassed tramadol in pain relief scores, the difference was not statistically significant.