Unilateral isolated alar ligament rupture in an adult female patient.

Only seven cases of isolated unilateral rupture of the alar ligament had been previously reported. The authors report the first adult female case of this rare injury. The patient in their case, a 36-year-old female presented after a trauma due to falling, and at that moment, she had fainted due to a sudden pain between the neck and head. The radiological examinations [magnetic resonance imaging (MRI) and X-rays] had been interpreted as normal. She had a positive Alar ligament test at the right side, and a thin section craniovertebral junction computed tomography was obtained which revealed an asymmetrically left-sided odontoid process and a new MRI revealed a right-sided alar ligament rupture. Thus she underwent a bilateral greater occipital nerve block together with pulse radiofrequency and trigger point injection at splenius capitis, levator scapula, and trapezius followed by the application of a halo orthosis to be worn for 3 months. The patient was found to be pain-free in the follow-up examinations. With pure unilateral alar ligament rupture, the atlantooccipital joint is not disrupted and the craniovertebral junction is not destabilized. To date, only eight cases of isolated unilateral alar ligament rupture have been reported one of which was a 25 years old male; all of whom presented with marked neck pain and treated by external immobilization for 4 weeks to 4 months and our case is the first adult female patient.

Nitroglycerin challenge induces lateralized headache in nasociliarynerve-ligated rats: implications for chronic migraine.

BACKGROUND/AIM: Chronic migraine is a common debilitating disease with limited treatment options. We aimed to develop a novel model for chronic migraine by ligating the nasociliary nerve (NCL) and administering nitroglycerin (NTG) to exacerbate acute headache attacks. MATERIALS AND METHODS: Exacerbation of the headache was induced by NTG (10 mg/kg, subcutaneously) administered to male Wistar rats (n = 36) 14 days following unilateral NCL. Cutaneous and cold allodynia was tested using Von Frey (VF) filaments and acetone, respectively. Elevated plus maze (EPM) results and c-fos immunoreactivity of TNC were investigated. RESULTS: NTG administration significantly decreased VF threshold values only in the nasociliary nerve (NCN) territory and the ipsilateral forepaw (P = 0.0001, P = 0.02). Cold allodynia developed in bilateral NCN territories (P = 0.013). The number/rate of entrance to open arms in the EPM was significantly decreased in NCN-ligated rats (P = 0.042, P = 0.035). Immunohistochemistry disclosed significantly increased c-fos-positive neurons in ipsilateral brainstem TNC compared to the contralateral side (brain stem LI ipsilateral 25.4 ± 4.7, contralateral 11.8 ± 1.9, P < 0.05) in chronic NCN-ligated rats exposed to acute NTG. CONCLUSION: The presented model provides a valid chronic migraine model relevant to humans, as NTG challenge in chronic NCL rats generated lateralized headache with cephalic and extracephalic allodynia, altered cold sensitivity, anxiety, and neuronal activation in the nociceptive laminae of brainstem trigeminal pain nuclei.

Comparison of Parasacral and Posterior Sciatic Nerve Blocks Combined with Lumbar Plexus Block.

OBJECTIVE: The aim of this study is to compare the effects of parasacral and posterior Winnie approaches when combined with the inguinal paravascular approach for lumbar plexus block. METHODS: After the approval of the Ethics Committee, 40 patients scheduled to undergo arthroscopic knee surgery were enrolled. The patients were randomly assigned into two groups in a double-blind manner to perform sciatic nerve block either by the parasacral technique (Group I) or by the posterior approach (Group II). RESULTS: The obturator nerve motor block success rate was found to be 80% (16/20) in Group I, whereas it was 10% (2/20) in Group II (p<0.05). CONCLUSION: Inguinal paravascular block with parasacral sciatic nerve block led to a much higher incidence of obturator nerve motor block when compared to the inguinal paravascular block with posterior sciatic nerve block during knee arthroscopies.

[The role of pericranial muscles in the succesful management of episodic tension type headache]. / Epizodik gerilim tipi basagrisinin basarili tedavisinde perikraniyal kaslarin rolü

OBJECTIVES: Peripheral and central nociceptive mechanisms are responsible for the development of Tension Type Headache (TTH). Analgesics are frequently used in the treatment of acute TTH. Antidepressants are used in prevention. In this study, the therapeutic efficacy of local application of lidocaine was investigated in Episodic Tension Type Headache (ETTH) patients. METHODS: ETTH patients with pericranial tenderness (n=20, Group 1) and without pericranial tenderness (n=20, Group 2) were included in our study. Three sessions of local injection of 1% lidocaine were performed in both groups. Two-sided intramuscular injections of 1 mL were applied for each patient. The muscles treated were the frontal, temporal, masseter, sternokloidomastoid, semispinalis capitis, splenius capitis and trapezius muscles. Patients were evaluated in 1st, 2nd, and 3rd months. The number of painful days per month and pain intensities were recorded according to Visual Analog Scale (VAS) before and after the treatment. RESULTS: 11 male and 29 female patients were included in the study. The mean ages of Group 1 and Group 2 were 35.95 ± 9.85 (18-53) and 34.85 ± 10.04 (20-54) years, respectively. There was no difference between the groups in terms of age, gender, pain frequency and pain intensity (p>0.05). The frequency and severity of pain was significantly lower in pericranial-sensitive ETTH patients at the 1st, 2nd, and 3rd months after local lidocaine injections compared to ETTH patients having pericranial tenderness (p<0.05). CONCLUSION: Local lidocaine application can be used as an effective method in the treatment of ETTH patients with pericranial tenderness.

Effects of perineural tramadol on nerve conduction of sural nerve.

OBJECTIVES: The aim of this study was to investigate whether tramadol had a dose-dependent blocking effect on nerve conduction when administered perineurally to the sural nerve of healthy volunteers. METHODS: Twenty-four informed healthy subjects were randomized into four equal groups [Saline (placebo), 0.5% tramadol, 1% tramadol and 1.5% tramadol]. The study was designed to be double-blinded. Sensory nerve action potentials were recorded electroneurographically. Two milliliters of study solution was administered to the sural nerve perineurally at the level of the ankle with the guidance of a nerve stimulator. A sensory block was assumed to have developed when the amplitude of the averaged sensory nerve action potentials diminished below 80% of the baseline value in the subsequent recordings. RESULTS: According to the electroneurographical recordings, none of the volunteers in the saline group had block. However, the block rates with 0.5%, 1% and 1.5% tramadol were 1/6, 4/6 and 6/6, respectively (p<0.05). The maximum decrement in the sensory action potential amplitudes with respect to baseline amplitudes (given as median values) were as follows: 7.8% with saline; 12.5% with 0.5% tramadol; 38.5% with 1% tramadol; and 77.5% with 1.5% tramadol (p<0.05). While the median duration of sensory block with 0.5% tramadol was 5 minutes, it was 15 minutes with 1% tramadol and 35 minutes with 1.5% tramadol. CONCLUSION: Perineurally administered tramadol blocks sensory nerve conduction of the sural nerve in a dose-dependent manner.

[Burnout in healthcare workers in the Anesthesiology and Algology Departments in the Middle Anatolian region of Turkey]. / Iç Anadolu Bölgesinde anesteziyoloji ve algoloji çalisanlarinda tükenmislik durumu.

OBJECTIVES: Anesthesiology and Algology healthcare workers work under difficult conditions a majority of the time, and their physical and mental status must be determined in order to improve working conditions. In this study, the main goal was to evaluate the burnout level of Anesthesiology and Algology healthcare workers in the Middle Anatolian region of Turkey. METHODS: A questionnaire was sent to Anesthesiology and Algology healthcare workers of hospitals with an Algology clinic in the Middle Anatolian region and were returned by e-mail in March and April 2008. In the questionnaire, descriptive features and the Turkish validated Maslach burnout inventory (MBI) were evaluated. The MBI has 3 aspects: emotional exhaustion (EE), depersonalization (D) and personal accomplishment (PA). All questionnaires were evaluated by SPSS 11.5 program. RESULTS: 113 people were enrolled, of whom 18.8% (21) were specialist doctors and 41.1% (46) were residents. Among the doctors, the mean daily and weekly working periods were 10.3+/-2.3 and 61.3+/-19 hours, respectively. The period spent by doctors in Algology was 100% in 9.6%, 75% in 9.7% and 25% in 61.5%. Working conditions were evaluated, and 20.9% of healthcare workers were unsatisfied with the physical conditions, 19.3% with the working period and 52.5% with wages. MBIs in doctors were calculated as EE 14.7+/-5, D 5.7+/-3.5, and PA 21.6+/-4.2. CONCLUSION: This study revealed similar high burnout scores among healthcare workers, which reflect a serious burnout in the Anesthesiology and Algology group in Turkey. Burnout may be affected by dissatisfaction with working conditions. Improvement in physical conditions and reorganization to achieve psychological support might be helpful towards improving the health of healthcare workers.

[Reflex sympathetic dystrophy secondary to piriformis syndrome: a case report]. / Piriformis sendromuna ikincil gelisen refleks sempatik distrofi: Olgu sunumu.

Piriformis syndrome is a rare cause of hip and foot pain which may be due to sciatic nerve irritation because of anatomic abnormalities of sciatic nerve and piriformis muscle or herniated disc, facet syndrome, trochanteric bursit, sacroiliac joint dysfunction, endometriosis and other conditions where sciatic nerve is irritated. There has been no reflex sympathetic dystrophy (RSD) case presented due to piriformis syndrome before. A sixty-two-year-old female patient had right foot and hip pain (VNS: 8), redness and swelling in the foot since 15 days. Her history revealed long walks and travelling 3 weeks ago and sitting on the foot for a long time for a couple of days. Physical examination revealed painful hip movement, positive straight leg rise. Erythema and hyperalgesia was present in dorsum of the right foot. Right foot dorsiflexion was weak and hyperesthesia was found in right L4-5 dermatome. Medical treatment and ultrasound treatment to piriformis muscle was not effective. The patient was injected 40 mg triamcinolon and local anesthetic in right piriformis muscle under floroscopy by diagnosis of piriformis syndrome, neuropathic pain and RSD. Pain and hyperalgesia resolved and motor weakness was better. During follow-up right foot redness resolved and pain decreased (VNS: 1). In this case report, there was vascular, muscle and skeletal signs supporting RSD, which shows us the therapoetic effect of diagnostic piriformis injection. The patient history, physical examination and diagnostic tests were evaluated by a multidisciplinary team which contributed to the treatment.

Percutaneous pulsed radiofrequency reduces mechanical allodynia in a neuropathic pain model.

BACKGROUND: Neuropathic pain is a result of a primary lesion or dysfunction of the peripheral or central nervous system, and its treatment is challenging. Animal models have been helpful in understanding mechanisms of neuropathic pain and in developing new treatment strategies. In this study, we examined the effect of percutaneous pulsed radiofrequency (PRF), which is a minimally invasive pain treatment method, on mechanical allodynia in a neuropathic pain rat model. METHODS: Neuropathic pain was achieved in a peripheral nerve pain model by performing L5-6 spinal nerve ligation. On the 14th postoperative day, percutaneous PRF was applied to the plantar side of the left rear paw. Animals were evaluated for mechanical allodynia with both dynamic plantar aesthesiometer (DPA) (weight and paw withdrawal time) and von Frey filaments (VF) on the 14th postoperative day and 1, 3, 5, 7, 10, and 14 days after PRF treatment. Experiments were conducted in six groups: Sham-operated+placebo PRF 6 min, sham-operated+PRF 6 min, neuropathic (NP)+2 min placebo PRF, NP+2 min PRF, NP+6 min placebo PRF, and NP+6 min PRF. RESULTS: Allodynia developed in all animals in the NP groups compared to sham-operated animals (P=0.0001). DPA and VF showed that PRF application for 2 min significantly improved allodynia on 1-14th post-PRF day, compared to placebo PRF (P=0.0001). Although DPA (both weight and paw withdrawal time) did not show any therapeutic effect from 6 min PRF application on 1-14th post-PRF days (P=1.00), VF demonstrated transient improvement for the first week, which disappeared on later evaluations of the 6 min PRF group. CONCLUSIONS: Percutaneous PRF is an effective treatment option in the NP pain model, and further studies are needed to clarify its underlying mechanisms of action.

Preemptive intraarticular tramadol for pain control after arthroscopic knee surgery.

The purpose of this study was to determine the effectiveness of intraarticular (ia) bupivacaine and tramadol injection and preemptive intraarticular tramadol in providing pain control after arthroscopic knee surgery. Following local research ethics committee approval, 60 patients were assigned in a randomized manner into three groups: Group I received ia 20 ml of 0.25 % bupivacaine at the end of the operation, Group II received ia 20 ml of 0.25 % bupivacaine and 100 mg of tramadol at the end of the operation and Group III received ia 100 mg of tramadol diluted in 20 ml of saline solution 30 minutes before skin inscision and 20 ml of 0.25% bupivacaine at the end of the operation as well. Analgesic duration, total analgesic consumption and postoperative VAS pain scores recorded at rest and with movement were significantly lower and patient satisfaction was significantly higher in Group II and III, compared to Group I. Total analgesic consumption and the number of patients requiring supplementary analgesics were significantly lower in the preemptive tramadol group compared to the postoperative tramadol group. In conclusion, preemptive ia tramadol provided effective and reliable pain control after artroscopic knee surgeries and may be preferred to postoperative administration.

Postoperative analgesic effects of lornoxicam after thyroidectomy: a placebo controlled randomized study.

The purpose of the present study was to determine the postoperative analgesic effects of lornoxicam and the reduction in tramadol consumption. Fourty patients of ASA class I-II, 18-70 years of age, undergoing thyroidectomy were assigned in a randomized manner into two groups: GroupL received 8 mg of lornoxicam i.v. at the end of the operation followed by 8 mg of lornoxicam b.i.d., i.v. for 24 hours postoperatively. GroupP received 4 ml of saline solution i.v. at the end of the operation and the same amount b.i.d., i.v. for 24 hours postoperatively. The requirements for supplemental analgesics were recorded at 0-6, 6-12 and 12-24 hour intervals. Postoperative pain scores were evaluated at 15th min. and 1, 2, 4, 6, 8, 12, 18 and 24th hours using Visual Analogue Scale (VAS). The time to first analgesic requirement was significantly longer in GroupL compared to GroupP (101.7 vs 37.9 min, p<0.001). Pain scores were significantly lower in GroupL compared to GroupP at 15th min, 1, 8 ,12 and 18th hours. Twenty four hour analgesic consumption was significantly lower in GroupL compared to GroupP (p<0.05). The amount of tramadol consumed in GroupL was 60% lower compared to GroupP (100 mg and 250 mg (mean), respectively). 100% of the patients in GroupL and 60 % of the patients in GroupP needed supplemental analgesics. The degree of satisfaction with postoperative pain management was excellent in 95 % of patients in GroupL and 25 % of patients in GroupP. Eighteen patients in GroupP and 9 patients in GroupL had nausea (p=0.002), and fifteen patients in GroupP and 8 patients in GroupL had vomiting (p=0.025). Lornoxicam decreased the opioid need, the incidence of nausea and vomiting and postoperative pain scores. Moreover, it was observed that the time needed for the first analgesic requirement was prolonged following thyroidectomies.

Effect of Calcium Entry Blocking Agents (Nifedipine and Verapamil) on Myocardial Recovery during Reperfusion.

A comparative study on isolated guinea pig hearts was carried out to determine the effect of calcium entry blocking agents: nifedipine- and verapamil-added reperfusion solutions on myocardial recovery after global ischemia. After 20 min of normothermic ischemia, three groups of solutions were used for reperfusion (10 animals each): (1) Nifedipine-added (10--8 mmol L(minus sign1)) Krebs--Henseleit solution; (2) verapamil-added (10--8 mmol L(minus sign)) Krebs-Henseleit solution; (3) Krebs--Henseleit solution. Postischemic myocardial functions (ventricular contractile force and heart work) and enzyme activities were compared with their preischemic values. The addition of calcium entry blocking agents does not have any significant advantage over control solutions in myocardial recovery.