Trigeminal nerve block with alcohol for medically intractable classic trigeminal neuralgia: long-term clinical effectiveness on pain.

BACKGROUND: Trigeminal nerve block (Tnb) with alcohol for trigeminal neuralgia (TN) may not be used widely as a percutaneous procedure for medically intractable TN in recent clinical work, because it has been considered having a limited duration of pain relief, a decrease in success rate and increase in complications on repeated blocks. OBJECTIVES: To evaluate the clinical outcome of the Tnb with alcohol in the treatment of medically intractable TN. METHODS: Six hundred thirty-two patients were diagnosed with TN between March 2000 and February 2010. Four hundred sixty-five out of 632 underwent Tnb with alcohol under a fluoroscope. Pain relief duration were analyzed and compared in the individual branch blocks. Outcomes were compared between patients with and without a previous Tnb with alcohol. RESULTS: Tnb with alcohol were performed in a total 710 (1st-465, 2nd-155, 3rd-55, 4th-23, 5th-8, 6th-4) cases for a series of consecutive 465 patients during the study period. Forty hundred sixty two out of the 465 patients experienced immediate complete pain relief (99%) at the first Tnb. Of the 465 patients, 218 patients (46.9%) did not require any further treatment after the first Tnb with alcohol during an entire study period. One hundred fifty nine (34.2 %) out of the 465 patients experienced recurring pain after the first block, among whom 155 patients received subsequent blocks, and the remaining 4 patients decided to take medication. According to the Kaplan-Meier analysis, the probabilities of remaining pain relief for 1, 2, 3, and 5 years after the procedures were 86.2%, 65.5%, 52.5%, and 33.4%, respectively. There was no significant difference in the probability of pain relief duration between patients with and without previous Tnb with alcohol. Median (95% CI) pain relief durations of the first and repeated blocks were 39 (36-51) and 37 (28-54) months, respectively. There was no significant difference in occurrence of complications between patients with and without previous Tnb with alcohol (p <0.076). All the complications recovered spontaneously within 6 months. There was no mortality related to the procedure. CONCLUSIONS: Tnb with alcohol for the pain management of TN can provide considerably long lasting pain relief. Repeated Tnb with alcohol has pain relief duration as long as the first block, and seems to produce less complication as well. Tnb with alcohol is a valuable treatment modality of TN as a percutaneous procedure.

Paraplegia following cervical epidural catheterization using loss of resistance technique with air: a case report.

We report a case of paraplegia without neurologic deficit of upper extremities following cervical epidural catheterization using air during the loss of resistance technique. A 41-year-old woman diagnosed with complex regional pain syndrome had upper and lower extremity pain. A thoracic epidural lead was inserted for a trial spinal cord stimulation for treating lower extremity pain and cervical epidural catheterization was performed for treating upper extremity pain. Rapidly progressive paraplegia developed six hours after cervical epidural catheterization. Spine CT revealed air entrapment in multiple thoracic intervertebral foraminal spaces and surrounding epidural space without obvious spinal cord compression before the decompressive operation, which disappeared one day after the decompressive operation. Her paraplegia symptoms were normalized immediately after the operation. The presumed cause of paraplegia was transient interruption of blood supply to the spinal cord through the segmental radiculomedullary arteries feeding the spinal cord at the thoracic level of the intervertebral foramen caused by the air.

Uncommon Cause of Trigeminal Neuralgia: Tentorial Ossification over Trigeminal Notch.

Ossification of the tentorium cerebelli over the trigeminal notch is rare, but it may cause compression of the trigeminal nerve, leading to trigeminal neuralgia (TN). We were unable to find any previously reported cases with radiological evaluation, although we did find one case with surgically proven ossification of the tentorium cerebelli. Here, we present a case of TN caused by tentorial ossification over the trigeminal notch depicted on magnetic resonance imaging (MRI) and computed tomography (CT).

Distribution range of cervical interlaminar epidural injections: a comparative study with 2.5 mL, 5 mL, and 10 mL of contrast.

BACKGROUND: Cervical interlaminar epidural injection (CIEI) is widely used in the management of acute or chronic neck and upper extremity pain. There is no consensus regarding the optimal volume of solution to be used for CIEI. STUDY DESIGN: Randomized, double blind controlled trial. OBJECTIVE: The purpose of this study was to evaluate how many spinal segments would be covered with different volumes of contrast medium, given by fluoroscopically guided CIEI, in efforts to establish the optimal volume of medication with consideration of clinical pathologic lesions. METHODS: One hundred and twenty-six CIEI were performed at C7-T1 in 133 patients. All patients were divided into 3 groups (A, B, and C) according to the amount of contrast medium used: 2.5 mL for group A, 5 mL for group B, and 10 mL for group C. The extent of contrast medium spread was determined by anteroposterior and lateral view under fluoroscopy. LIMITATION: We did not evaluate the clinical outcomes with pain measurements during the study period. RESULTS: The total number of vertebral segments of contrast media spread and spreading range of caudad or cephalad were significantly different among the 3 groups (P < 0.001). However, groups B and C in cephalad spreading and groups A and B in caudad spreading did not show any significant difference. A proportion of the patients with a cephalad spread of up to C4 and C2 in group A (59.5% and 31%) was significantly different from that in the other 2 groups (92.9% and 69.1% in group B and 97.6% and 73.8% in group C) (P < 0.001). CONCLUSION: Five mL for CIEI at C7-T1 could be an optimal volume for distribution to the lower cervical spine for degenerative cervical spinal diseases, as well as to the upper cervical spine for head and facial pain.

Repetitive single subarachnoid injections for trial administration of the intrathecal morphine pump in patients with intractable non-cancer pain -A case report-.

Since the early 1980s, the implantable intrathecal drug pump (ITDP) has been used increasingly to manage chronic pain. Prior to making a decision to implant an ITDP, trial administration of the intrathecal (IT) drug should be performed to estimate the effective dose for a starting set of implantable ITDPs. There is no standard method of trial IT drug administration, though. Therefore, this paper reports 20 cases of IT morphine trial with single and repetitive injections until the appropriate dose was attained with respect to analgesia and its side effects. The trial procedure was performed with daily sequential IT injections using morphine and 0.3% mepivacaine. Twelve out of the total of 20 patients had positive responses. Thus, it is inferred that daily sequential IT morphine injections combined with a placebo injection as a trial ITDP would be useful in evaluating the effectiveness and adverse effects of IT morphine infusion with clinically insignificant side effects.

Early diagnosis of fabry disease in a patient with toe tip pain.

Fabry disease is an X-linked lysosomal disease caused by deficiency of α-galactosidase, in which early diagnosis may be missed due to the wide variety of clinical symptoms presenting during disease progression. A 13 year-old boy visited our pain clinic complaining of pricking and burning pain in the toe tips of both feet. Continuous epidural infusion for pain management was performed because of oral analgesics ineffectiveness. The patient underwent α-galactosidase A (GLA) enzyme analysis based on the clinical impression of Fabry disease from pain with a peripheral neuropathic component and history of anhidrosis. He was diagnosed with Fabry disease after confirming mutation of the GLA gene through a screening test of GLA activity. Enzyme replacement therapy was initiated and pain was tolerated with oral analgesics.

Severe pain attack associated with neurocardiogenic syncope induced by glossopharyngeal neuralgia: successful treatment with carbamazepine and a permanent pacemaker -a case report-.

Glossopharyneal neuralgia (GPN) is generally considered to be a pain disease. However, it can be also be a life-threatening cardiac cause of syncope. Neuralgia in the throat and neck can trigger severe bradycardia up to the point of asystole, which can progress to cardiac syncope with or without seizures. A 65 year-old male patient diagnosed with glossopharyngeal neuralgia complained of severe paroxysmal pain in his right chin and ear followed by bradycardia, aystole and syncope. We report a case successfully treated with a permanent pacemaker and carbamazepine in a patient with GPN who had syncopal attacks preceded by paroxysms of pain.

Brief report: the long-term outcome of mandibular nerve block with alcohol for the treatment of trigeminal neuralgia.

Ninety-eight patients received 160 mandibular nerve (V3) blocks with alcohol for the treatment of trigeminal neuralgia in this prospective study. According to the Kaplan-Meier analysis, the probabilities of remaining pain free for 1, 2, 3, and 7 years after the procedures were 90.4%, 69%, 53.5%, and 33%, respectively. There was no significant difference in the probability of pain-free duration and complications between patients with repeat versus single V3 block with alcohol. We conclude that single and repeat V3 alcohol block for trigeminal neuralgia can provide long-lasting pain relief.

An epidemiological study of hyperhidrosis patients visiting the Ajou University Hospital hyperhidrosis center in Korea.

Hyperhidrosis is a disorder of perspiration in excess of the body's physiologic need and significantly impacts one's occupational, physical, emotional, and social life. The purpose of our study was to investigate the characteristics of primary hyperhidrosis in 255 patients at Ajou University Hospital Hyperhidrosis Center from March 2006, to February 2008. Information collected from the medical records was: sex, sites of hyperhidrosis, age at visit, age of onset, aggravating factors, hyperhidrosis disease severity scale (HDSS) rank, family history, occupation, and past treatment. A total of 255 patient records were reviewed; 57.6% were male. Patients with a family history (34.1%) showed a lower age of onset (13.21+/-5.80 yr vs. 16.04+/-9.83 yr in those without family history); 16.5% had previous treatment, most commonly oriental medicine. Palmar and plantar sites were the most commonly affected, and 87.9% of patients felt their sweating was intolerable and always interfered with their daily activities. Our study provides some original information on the Korean primary hyperhidrosis population. Patients who have a family history show signs of disease in early age than those without family history.

Intravascular flow patterns in transforaminal epidural injections: a comparative study of the cervical and lumbar vertebral segments.

BACKGROUND: Transforaminal epidural injection (TEI) is commonly used in the treatment of radicular pain. However, there have been many published cases of serious complications after a TEI, occurring most often in cervical levels. One of the presumptive reasons for this complication is inadvertent intravascular injection. We sought to identify the incidence of intravascular injections in cervical and lumbar spinal segments during TEI. METHODS: All patients with radicular symptoms or herpes zoster-associated pain underwent cervical and lumbar TEIs (LTEIs) prospectively by one of the authors. After an ideal needle position was confirmed by biplanar fluoroscopy, 3 mL of a mixture containing nonionic contrast and normal saline was continuously injected at the rate of 0.3-0.5 mL/s with real-time fluoroscopic visualization. RESULTS: One hundred eighty-two TEIs were performed. Fifty-six cases (30.8%) showed intravascular spreading patterns, 45 cases occurring during a cervical TEI (CTEI) and 11 during a LTEI. The incidences of simultaneous perineural and vascular injection in cervical and LTEIs were 52.1% and 9%, respectively, and pure vascular flow pattern rates in cervical and LTEIs were 11.3% and 0.9%, respectively. CONCLUSION: The incidence of vascular injection in CTEIs is significantly higher than in LTEIs, suggesting that CTEIs should be performed more cautiously. Furthermore, the vascular injection rate of CTEIs is much higher than that previously reported. This finding suggests the need for a proper volume of contrast injection (3 mL) to detect vascular flow, especially in simultaneous perineural and vascular injections.

Successful treatment of digital ulcers in a scleroderma patient with continuous bilateral thoracic sympathetic block.

BACKGROUND: Raynaud's phenomenon (RP) associated with connective tissue disease (secondary RP) may be difficult to manage with conservative therapy. A combination of sympathetically mediated vasospasm and vaso-occlusion has been implicated as the etiology of digital ischemic phenomenon. Thoracic sympathetic outflow blocking has been performed with various techniques. However, there have been some limitations in all treatment options. OBJECTIVE: We report on a patient with medically refractory digital ulceration and gangrene caused by scleroderma who was successfully treated with a continuous infusion of mepivacaine into the thoracic sympathetic ganglions as a means to improve finger circulation. CASE REPORT: We are reporting on a 32-year-old female patient suffering from a medically intractable gangrenous ulcer in the right third finger and the left second and third fingers, accompanied by aching pain (VAS, visual analogue scale, 5 - 6/10) and numbness in both forearms. She underwent continuous infusion of mepivacaine through the thoracic sympathetic catheter placed in T2 vertebral segment for 13 days on the right and for 11 days on the left and cervical epidural infusion of mepivcaine with fentanyl for 10 days after the medical treatment failed. Her finger temperature increased 2 degrees C - 5 degrees C during the thoracic sympathetic block with continuous infusion of mepivacine. Her finger wounds healed completely with 13 days of the continuous thoracic sympathetic block without any complications. CONCLUSIONS: Continuous infusion of mepivacaine into the thoracic sympathetic ganglionic space led to the healing of the medically refractory gangrenous ulcer of the fingers in the patient with scleroderma.

N-terminally truncated variant of the mouse GAIP/RGS19 lacks selectivity of full-length GAIP/RGS19 protein in regulating ORL1 receptor signaling.

The regulators of G protein signaling (RGS) are a family of proteins with conserved RGS domains and play essential roles in regulating G protein-mediated signal transduction and physiological events. GAIP/RGS19 (G alpha interacting protein, also classified as RGS19), a member of the RGS family, has been shown to negatively regulate the signaling of many G protein-coupled receptors, including the opioid receptors. Two GAIP/RGS19 mRNA variants, resulted from an alternative splicing of exon 2 of the GAIP/RGS19 gene, were identified in multiple mouse tissues. One of the transcripts consists of a complete set of exons and encodes a full-length GAIP/RGS19 protein, and the other does not have exon 2 and therefore encodes an N-terminal 22 residue truncated short GAIP/RGS19 protein. When co-expressed with either the opioid-receptor-like (ORL1) receptor or one of the mu, delta, and kappa opioid receptors, by transfecting dual-expression plasmids into COS-7 cells, the full-length GAIP/RGS19 was more effective than the N-terminally truncated variant and was more selective in regulating the ORL1 receptor signaling than in regulating the mu, delta, and kappa opioid receptors, as measured by the effectiveness to increase the agonist-stimulated GTPase activity and to reverse the agonist-induced inhibition of cyclic AMP accumulation. In the same assays, the N-terminally truncated GAIP/RGS19 did not distinguish ORL1 from the mu, delta, and kappa opioid receptors. In contrast, co-expression of RGS4 with either ORL1 or opioid receptors showed the selectivity of RGS4 for regulating opioid receptors was mu > kappa > delta > ORL1, an order completely different from that of GAIP/RGS19. The results suggest that GAIP/RGS19 prefers regulating ORL1 receptor signaling over other opioid receptors, and that the N-terminal domain of GAIP/RGS19 plays a crucial role in its receptor preference.

Differential expression of the regulator of G protein signaling RGS9 protein in nociceptive pathways of different age rats.

Regulators of G protein signaling (RGS) proteins are GTPase-activating proteins which act as modulators of G-protein-coupled receptors. RGS9 has two alternative splicing variants. RGS9-1 is expressed in the retina. RGS9-2 is expressed in the brain, especially abundant in the striatum. It is believed to be an essential regulatory component of dopamine and opioid signaling. In this study, we compared the expression of RGS9 proteins in the nervous system of different age groups of rats employing immunocytochemistry. In both 3-week- and 1-year-old rats, RGS9 is expressed abundantly in caudate-putamen, nucleus accumbens, and olfactory tubercle. It is also expressed abundantly in the ventral horn of the spinal cord and the dorsal root ganglion (DRG) cells. Quantitative analysis showed that the intensities of RGS9 expression in 1-year-old rats are higher than those in the 3-week-old rats in caudate-putamen, nucleus accumbens, olfactory tubercle, periaqueductal gray, and gray matter of the spinal cord. In contrast, in thalamic nuclei and locus coeruleus, the intensities of RGS9 immunostaining in 3-week-old rats are higher than in 1-year-old rats. In DRG cells, there is no significant difference between the two age groups. These data suggest that RGS9 is differentially expressed with age. Such differential expression may play an important role in neuronal differentiation and development as well as in neuronal function, such as dopamine and opioid signaling.

Distance to the adult cervical epidural space.

BACKGROUND AND OBJECTIVES: Cervical epidural block is useful in the management of a variety of acute, chronic, and cancer-related pain syndromes involving the head, face, neck, and upper extremities. Knowledge of the depth from the skin to the cervical epidural space (DSES) may be helpful when performing cervical epidural block and may reduce the possibility of complications. We studied DSES in adults and its relationship with patient age, height, weight, and neck circumference. METHODS: The study included 816 patients. Cervical epidural block was performed at the C5-6, C6-7, and C7-T1 intervertebral space by a midline approach under fluoroscopic guidance. The depth to the epidural space from the skin was measured. RESULTS: DSES at C5-6, C6-7, and C7-T1 was 4.7 +/- 0.6 cm, 5.1 +/- 0.6 cm, 5.6 +/- 0.8 cm in males and 4.0 +/- 0.6 cm, 4.6 +/- 0.6 cm, 5.0 +/- 0.6 cm in females (mean +/- SD). Linear regression analysis revealed significant correlations between DSES and weight, neck circumference, and body mass index. CONCLUSION: DSES varies with cervical intervertebral space. DSES increases as one moves caudally. The greatest DSES was noted at C7-T1 in men, and the least was at C5-6 in women. DSES had a significant relationship with weight, neck circumference, and body mass index in both genders.