Spinal Dorsal Rami Injection and Radiofrequency Neurolysis for Low Back Pain Caused by Osteoporosis-Induced Thoracolumbar Vertebral Compression Fractures.

OBJECTIVE: Low back pain caused by osteoporosisinduced thoracolumbar vertebral compression fractures is a common debilitating disorder. The aims of this study were to determine the accuracy and efficacy of spinal dorsal ramus injection and radiofrequency neurolysis for pain reduction in patients with this condition. METHODS: This study was a retrospective chart review of 46 patients with low back pain caused by osteoporosis-induced thoracolumbar vertebral compression fractures. All patients had been treated with spinal dorsal ramus injection with mixed Sensorcaine (Fresenius Kabi, USA) and Depo-Medrol (Pfizer, USA). In some patients further treatment with radiofrequency neurolysis had been required after the initial injection wore off. RESULTS: Out of a total of 46 patients, 45 (97.7%) had ≥ 50% reduction in low back pain immediately after injection. After the initial injection wore off, 18 patients remained pain free and 27 required radiofrequency neurolysis. The follow-up period ranged from 60 to 1,440 days (mean 335 days). The intensity of low back pain decreased from 7.09 ± 0.84 (numerical pain scale of 0-10) before treatment to 1.39 ± 1.51 immediately after the injection, and to 0.96 ± 1.36 at the last office visit. CONCLUSION: Spinal dorsal ramus injection and radiofrequency neurolysis are effective and accurate therapies for low back pain caused by osteoporosis-induced thoracolumbar vertebral compression fractures.

Abdominal wall Type-I complex regional pain syndrome treated effectively with peripheral nerve field stimulation: a case report.

Chronic abdominal wall pain is a well-documented complication of abdominal surgery. However, abdominal wall complex regional pain syndrome (CRPS) is a rare medical condition. We present a case of abdominal wall CRPS and its treatment with peripheral nerve field stimulation (PNfS). A 34-year-old female presented with right periumbilical pain for 2 years. She developed burning, sharp and stabbing pain with allodynia (extremely sensitive to wind and light touch) and erythema or pallor 2 weeks after an exploratory appendectomy. The extensive evaluation ruled out the underlining pathology. After she failed conservative therapies, she underwent a 7-day trial of thoracic spinal cord stimulation (SCS) and abdominal wall PNfS. Thoracic SCS failed to provide pain relief; however, PNfS provided significant relief (>90%) of burning sensation. It has now been 5 years since the PNfS was implanted and she continues to demonstrate substantial pain relief.

Long-Term Clinical Outcome of Peripheral Nerve Stimulation for Chronic Headache and Complication Prevention.

BACKGROUND: Subcutaneous peripheral nerve stimulation (PNS) has emerged as a useful tool in the treatment of intractable headaches. However, complications such as skin erosion, infection and lead migration have adversely affected clinical outcome, and occasionally led to treatment cessation. OBJECTIVES: Here we report the results of peripheral nerve stimulator implantation performed on 24 patients with various chronic headaches at our center over a period of 9 years. We describe the complications of the procedure and their prevention with a modified surgical technique. PATIENTS AND METHODS: We searched our database for patients with chronic refractory headaches who had undergone PNS. Patients were assessed before being considered for PNS, and their pain characteristics were reviewed. Following a successful trial, patients were implanted with a permanent peripheral nerve stimulator. Selection of target nerves was based on headache diagnosis and head pain characteristics. Patients were followed for an average of 4.9 years. Headache characteristics before and after treatment were compared. RESULTS: Twenty four patients were included in the study. All patients reported on improvement in head pain intensity, duration and frequency three months after permanent device implantation Mean total pain index (TPI) decreased significantly, from 516 ± 131 before the procedure to 74.8 ± 61.6 at the last follow up (P < 0.00001). There were no acute post-operative infections. Three patients had their stimulator removed. The self-rated treatment satisfaction was excellent in 54% of the patients, very good or good in 42%, and fair in 4%. CONCLUSIONS: Our results support the use of PNS in some patients with refractory chronic headaches. Appropriate surgical planning and technique are important to achieve good clinical outcome and to minimize complications.

Thin steel plate with thumbtack fixation in the treatment of massive presacral venous plexus hemorrhage.

BACKGROUND: Massive presacral venous plexus hemorrhage during radical resection of rectal carcinoma is rare, but when it occurs, bleeding can be uncontrollable, leading to death in some cases. Medical adhesive gauze sticking and packing and thumbtack compressive fixation are often used for hemostasis, but these methods are not effective in cases of uncontrollable massive hemorrhage. Therefore, identifying a practical, accurate, and reliable method of hemostasis in these cases is essential. METHODS: Between January 2004 and December 2009, we treated 3 patients with massive presacral venous plexus hemorrhage during resection of rectal carcinoma by placing small, trimmed thin steel plates at the bleeding sites. The plates were fixed with a saddle-type application of thumbtacks. RESULTS: Bleeding was successfully controlled in all 3 patients, and intestinal anastomosis was carried out after hemostasis. No complications were observed. CONCLUSIONS: Application of a small, thin steel plate to the bleeding site with thumbtack fixation is a simple and effective method of hemostasis in patients with massive presacral venous plexus hemorrhage during resection of rectal carcinoma.

Upper cervical facet joint and spinal rami blocks for the treatment of cervicogenic headache.

OBJECTIVE: To evaluate the efficacy of upper cervical facet joint injections and spinal rami blocks in the treatment of cervicogenic headache. BACKGROUND: Cervicogenic headache has been recognized as a common and often disabling disorder. The treatment of this headache type remains challenging. METHODS: We conducted a retrospective chart review of 31 patients with refractory cervicogenic headache who underwent fluoroscopically guided C(1/2), C(2/3) facet joint injections and C(2), C(3) spinal rami blocks using a mixture of 0.25% bupivacaine and 3 mg betamehtasone. The outcome measures were the change in headache severity, assessed using an 11-point numerical pain scale, after treatment, and the duration of head pain relief. RESULTS: Twenty-eight (90.3%) patients experienced >50% headache relief after treatment, with an average duration of 21.7 (1-90) days. Mean (+/-SD) head pain intensity decreased from 7.5 +/- 1.3 before treatment to 2.7 +/- 1.9 immediately after it (P < .0001). The procedures were well tolerated. CONCLUSIONS: C(1/2), C(2/3) facet joint injections and C(2), C(3) spinal rami blocks were effective and well tolerated for the treatment of cervicogenic headache in this study. The procedures provided significant and prolonged pain relief in the majority of patients. Larger controlled studies are needed to further evaluate the efficacy of this treatment modality in cervicogenic headache.

Acute exacerbation of hereditary coproporphyria mimics early surgical infection following intrathecal pump implantation for chronic abdominal pain: A case report.

OBJECTIVE: Pain physicians should also be aware of rare complications that can occur after intrathecal pump (ITP) placement. One such rare complication includes an acute exacerbation of hereditary coproporphyria (HCP). METHODS: We present a case report that illustrates how an acute exacerbation of HCP can mimic an early surgical post-procedure infection after ITP implantation. RESULTS: The patient's rapid onset of symptoms two hours after the procedure keyed into HCP as the underlying cause, as acute wound infections rarely occur in the several hours following surgery. After symptomatic treatment of her HCP acute exacerbation, the patient clinically improved without the development of further symptoms or adverse sequelae. She reported considerable pain relief with the implanted drug delivery system. CONCLUSION: In a setting with multiple confounders, a methodical history and physical examination, close monitoring, and a comprehensive understanding of potential complications can prevent unnecessary ITP extraction and streamline the delivery of appropriate care.

Revision of a superficially migrated percutaneous occipital nerve stimulator electrode using a minimally invasive technique.

Objective. Percutaneous techniques for occipital nerve stimulation have been in the literature since 1999. Lead migration continues to be the most common complication to the technique. The authors would like to introduce a new technique for revision of a superficially migrated occipital nerve stimulator electrode. Materials and Methods. Technical report of initial case where revision was performed. Results. The patient had successful revision of his superficially migrated occipital nerve stimulator using a new percutaneous approach. He had no signs of infection and full return of prior function of the stimulator at two weeks and three-month follow-up visits. Conclusion. This case demonstrates a new safer technique for revision of a superficially migrated occipital nerve stimulator lead. The technique is a more direct and simple solution to a common problem in the percutaneous placement of occipital nerve stimulators.

Gabapentin and sexual dysfunction: report of two cases.

Gabapentin has been used effectively for neuropathic pain with mild side effects. Two cases of gabapentin-induced sexual dysfunction are reported and discussed.

Controlling cancer pain with pharmacotherapy.

Cancer remains the second most common cause of death in the United States despite advances in prevention, early detection, and newer treatment protocols. Pain continues to be the most feared complication of this diagnosis. Numerous studies have shown that when the World Health Organization treatment guidelines are followed, 90% of patients are pain-free. Although clinical evidence is convincing that opioids are effective in treating patients for cancer pain, physician reluctance to prescribe them and patient unwillingness to take such medication continue. Barriers to opioid use are multifactorial, but with education of healthcare providers and patients, pharmacotherapy for pain management will be more effective.

Pharmacologic management of cancer pain.

Cancer remains the second most common cause of death in the United States despite advances in prevention, early detection, and newer treatment protocols. Pain continues to be the most feared complication of this diagnosis. Numerous studies have shown that when the World Health Organization treatment guidelines are followed, 90% of patients are pain-free. Although evidence is convincing that opioids are effective in the treatment of patients with cancer pain, reluctance to use them continues. Barriers to opioid use are multifactorial, but with education of healthcare providers and patients, treatment to manage pain will be more effective.

Electrotherapy reverses inframalleolar ischemia: a retrospective, observational study.

OBJECTIVE: To determine if high-voltage pulsed current (HVPC) augments ischemic wound healing and increases periwound perfusion. DESIGN: A 5-year, retrospective, observational study was conducted on successive patients with ischemic wounds who were poor candidates for revascularization. INTERVENTION: HVPC was applied directly to wounds at greater than 100 volts, 100 pulses per second, 1 hour per day. In addition to HVPC, patients received standard care for ischemic wounds at the study facility. Ischemic wounds for which HVPC was not clinically indicated or not available received standard care alone. MAIN OUTCOME MEASURES: Wound area measured by planimetry, wound appearance observed by digital imaging techniques, and microcirculation monitored by transcutaneous oxygen (TcPo(2)) levels. RESULTS: The group that received HVPC plus standard care showed smaller wound areas from weeks 20 though 52 after the start of treatment compared with the group that received standard care alone (P <.05; Mann-Whitney test). One year after the start of treatment, 90% of HVPC-treated wounds were healed, compared with 29% of the wounds that received only standard care (P <.05; Fisher exact test). For the HVPC group, maximum periwound TcPo(2) improved during electrotherapy (6 +/- 8 mm Hg [standard deviation; SD] at baseline improved to 26 +/- 20 SD, during HVPC, P <.05; Wilcoxon signed rank test). CONCLUSION: The results of this retrospective trial demonstrate that HVPC plus standard care improved the healing rate of high-risk ischemic wounds. A direct relationship was shown between improved healing rates and increased periwound perfusion. A prospective randomized controlled trial is needed to further support these observational, preliminary findings.

Cryoanalgesia: electrophysiology at different temperatures.

Somatosensory evoked potentials (SEP) and sensory conduction velocity (SCV) were measured in rabbit sciatic nerves following graded cold lesioning. The SEP disappeared when injury was induced at temperatures below -60 degrees C, but returned on day 41+/-4 (mean+/-SD). SEP returned on day 56+/-11 days when the lesion was induced at 100 to -180 degrees C. The SEP latency was prolonged after creating lesions at -100 to -180 degrees C, compared with both the sham operated and the -20 degrees C groups. These experiments suggest the cryolesions produced at temperatures between -60 and -100 degrees C are most suitable for altering the electrophysiological conduction of the nerve, and may result in suitable post-operative analgesia.