Ultrasound-guided peripheral nerve stimulation for neuropathic pain after brachial plexus injury: two case reports.

Brachial plexus injury (BPI) often causes severe neuropathic pain that becomes chronic and difficult to treat pharmacologically or surgically. Here, we describe two cases of successful treatment of BPI with peripheral nerve stimulation (PNS). Both patients had experienced severe neuropathic pain after incomplete BPI for a long time (32 and 17 years) and did not response to medication, radiofrequency neuroablation, or spinal cord stimulation. After PNS using ultrasound, their pain was relieved by more than 50% over the course of 1 year. Both patients were satisfied with their improved sleep and quality of life. We conclude that PNS could be an alternative therapeutic modality for neuropathic pain after BPI as it provides direct nerve stimulation, has few complications, and is easy to perform.

Combined Spinal Cord Stimulation and Peripheral Nerve Stimulation for Brachial Plexopathy: A Case Report.

Brachial plexopathy usually results from an iatrogenic brachial plexus injury and can sometimes cause severe chronic pain and disability. There are a number of possible treatments for this condition, including medication, physical therapy, nerve blocks, and neuromodulation, but they are not always successful. Recently, combined spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS) have been tried for various chronic pain diseases because of their different mechanisms of action.Here, we describe the case of a 54-year-old man who was diagnosed with brachial plexopathy 8 years ago. He underwent video-assisted thoracoscopic surgery to remove a superior mediastinal mass. However, his brachial plexus was damaged during the surgery. Although he had received various treatments, the pain did not improve. For the management of intractable severe pain, he underwent SCS 2 years ago, which initially reduced his pain from numeric rating scale (NRS) 10/10 to NRS 4 - 5/10, but the pain then gradually increased, reaching NRS 8/10, 6 months ago. At that time, he was refractory to other treatments, and we therefore applied PNS in combination with SCS. The PNS electrode was positioned on the radial nerve under ultrasound guidance. After combined PNS and SCS, his background pain disappeared, although a breakthrough pain (NRS 3 - 4/10) was caused intermittently by light touch. Furthermore, the patient's need for analgesics decreased, and he was satisfied with the outcome of this combined treatment. We concluded that combined SCS and PNS is a very useful treatment modality, which can stimulate the target nerve both directly and indirectly, and hence, relieve pain from brachial plexopathy.

Pulsed radiofrequency under ultrasound guidance for the tarsal tunnel syndrome: two case reports.

Tarsal tunnel syndrome (TTS) is a compression neuropathy that results from entrapment of the posterior tibial nerve or its branches. TTS may be treated either by conservative measures, including physical therapy, medications, and steroid injections, or by surgical decompression. Despite a variety of treatments, a few cases of TTS will relapse, and many cases of recurrent TTS will require re-operation. Pulsed radiofrequency (PRF) is known to have a number of advantages for pain management, particularly as this technique does not cause neural compromise such as motor weakness. Here, we report a new application of ultrasound-guided PRF in two cases of intractable TTS. Both patients had a long duration of severe foot pain and had been treated with various therapeutic modalities without lasting relief. We applied ultrasound-guided PRF to the affected posterior tibial nerve in each patient, and both had significantly reduced pain intensity scores and analgesic requirements without any complications. Ultrasound-guided PRF for intractable TTS relieved severe foot pain. It may supersede surgery as a reliable treatment for intractable TTS.

Long-term Results of Stellate Ganglion Block in Patients with Olfactory Dysfunction.

BACKGROUND: Olfactory dysfunction, including anosmia and hyposmia is difficult to treat. Although the mechanism is not well known, stellate ganglion block (SGB) is used to treat olfactory dysfunction. There are no prior studies on the long-term effects of SGB on olfactory dysfunction. The purpose of this study was to evaluate the continuity of therapeutic effects and patient satisfaction with SGB treatment. METHODS: This was a follow-up study carried out via a telephonic survey. The olfactory function of the patient was evaluated using a visual analog scale (VAS). We checked VAS three times: VAS-I (pre-treatment VAS), VAS-A (post-treatment VAS), and VAS-C (VAS at follow up telephone survey). We divided the subjects into 2 groups according to their responsiveness to SGB: the responsive (R group) and the unresponsive groups (UR group). Patient satisfaction was evaluated using a Likert scale. RESULTS: Out of the 40 subjects, 37 responded to the telephone survey. In the UR group, there was difference in the olfactory function. However, in the R group, there were significant VAS differences; VAS-I was 9.6 ± 0.7, VAS-A was 5.1 ± 4.2, and VAS-C was 2.7 ± 2.7 (P < 0.05). On the Likert scale, patient satisfaction was as follows: grade 1, 17 patients (45.9%); grade 2, 6 patients (16.2%); grade 3, 6 patients (16.2%); and grade 4, 8 patients (21.6%). CONCLUSIONS: SGB is a safe, long-lasting, and effective therapeutic modality for olfactory dysfunction treatment.

TGFBR2 gene polymorphism is associated with ossification of the posterior longitudinal ligament.

This preliminary study assessed the association between ossification of the posterior longitudinal ligament (OPLL) and the transforming growth factor ß receptor type 2 (TGFBR2) gene, with autoimmune disease examined as a possible underlying factor. Twenty-one patients diagnosed with OPLL and 42 control patients without OPLL (non-OPLL) were enrolled in the study. The TGFBR2 gene, composed of one promoter and seven exons, including the 5' untranslated region and flanking introns of each exon, was sequenced. Laboratory tests, including indirect immunofluorescence, were performed to detect autoimmune antibodies. The most common types of OPLL were the continuous (n=8, 38.1%) and segmental (n=8, 38.1%) types, with the fifth cervical veterbra (C5) the most common level of cervical spine involvement (n=15, 71.4%). In addition, significant associations between 455-4T→A (p=0.007) and 571G→A (p=0.024) gene variation and OPLL were found. The 95-35C→T variation in intron 1, a previously unreported variation, was also found in all patients with OPLL. Four patients revealed positive results for autoimmune antibodies and exhibited a nucleolar pattern by indirect immunofluorescence. Of these four patients, two were diagnosed with Sjogren's syndrome. The previously reported association of 455-4T→A and 571G→A polymorphisms of the TGFBR2 gene with OPLL was confirmed in this study. In addition, the 95-35C→T polymorphism in intron 1, which to our knowledge is a novel, previously unreported, nucleotide variation, was detected in all patients. Additional functional studies are required to verify the association between OPLL and the genetic variations found in this study.

Amnesia and pain relief after cardiopulmonary resuscitation in a cancer pain patient: a case report.

The mechanism of chronic pain is very complicated. Memory, pain, and opioid dependence appear to share common mechanism, including synaptic plasticity, and anatomical structures. A 48-yr-old woman with severe pain caused by bone metastasis of breast cancer received epidural block. After local anesthetics were injected, she had a seizure and then went into cardiac arrest. Following cardiopulmonary resuscitation, her cardiac rhythm returned to normal, but her memory had disappeared. Also, her excruciating pain and opioid dependence had disappeared. This complication, although uncommon, gives us a lot to think about a role of memory for chronic pain and opioid dependence.

Post-traumatic Back Pain Revealed as Tuberculous Spondylitis -A Case Report-.

Tuberculous spondylitis is a very rare disease, but it can result in bone destruction, kyphotic deformity, spinal instability, and neurologic complications unless early diagnosis and proper management are done. Because the most common symptom of tuberculous spondylitis is back pain, it can often be misdiagnosed. Atypical tuberculous spondylitis can be presented as a metastatic cancer or a primary vertebral tumor. We must make a differential diagnosis through adequate biopsy. A 30-year-old man visited our clinic due to back and chest pain after a recent traffic accident. About 1 year ago, he had successfully recovered from tuberculous pleurisy after taking anti-tuberculosis medication. We performed epidural and intercostal blocks but the pain was not relieved. For the further evaluation, several imaging and laboratory tests were done. Finally, we confirmed tuberculous spondylitis diagnosis with the biopsy results.

Post-radiation Piriformis Syndrome in a Cervical Cancer Patient -A Case Report-.

The piriformis syndrome is a condition allegedly attributable to compression of the sciatic nerve by the piriformis muscle. Recently, magnetic resonance neurography and electrophysiologic study have helped to diagnose piriformis syndrome. High dose radiotherapy could induce acute and delayed muscle damage. We had experienced piriformis syndrome with fatty atrophy of piriformis muscle after radiotherapy for recurrent cervical cancer.

Changes in IP3 receptor are associated with altered calcium response to cholecystokinin in diabetic rat pancreatic acini.

OBJECTIVES: Pancreatic acini of diabetic rats release amylase less than normal acini on cholecystokinin (CCK) stimulation. Pancreatic enzyme secretion by CCK is closely related to the second messenger inositol 1,4,5-trisphosphate (IP3), which mobilizes intracellular calcium stores via the endoplasmic reticulum-located receptor IP3 (IP3R). Recently, we observed altered intracellular calcium response on CCK-8 stimulation in streptozotocin (STZ)- treated diabetic rat acini. METHODS: To determine whether IP3R is involved in altered calcium response, we measured inositol phosphate (IP) formation and the expression and phosphorylation of type III IP3R protein in diabetic acini. Also, CCK receptor mRNA expression was examined to determine whether the changes in IP formation and IP3R protein phosphorylation in diabetic acini might result from the defect at the postreceptor level. RESULTS: CCK-8-induced IP formation at all concentrations used was significantly reduced in diabetic acini, though IP formation was increased in a concentration-dependent manner. The expression of type III IP3R protein was significantly reduced in diabetic acini. Additionally, CCK-8-stimulated phosphorylation of type III IP3R protein was not observed in diabetic acini. However, the reduction of CCK receptor mRNA expression was not detected in diabetic acini. CONCLUSION: Our results indicate that altered calcium response to CCK-8 in diabetic acini might be associated with a post-CCK receptor defect including the changes in IP formation, type III IP3R protein expression, and phosphorylation of type III IP3R protein.