Anatomical Flow Pattern of Contrast in Lumbar Epidural Space: A Human Study with a Midline vs. Parasagittal Interlaminar Approach under Fluoroscopy.

BACKGROUND: Epidural injections for managing chronic back pain are one of the most commonly performed interventions; however, controversy continues regarding the most effective method of epidural injections. A ventral distribution of epidural injected drug plays a significant role in its effectiveness. OBJECTIVE: To determine the distribution of a drug in the epidural space after parasagital and midline epidural injection. SETTING: Academic hospital. STUDY DESIGN: In randomized double-blind clinical trial, patients with a diagnosis of low back pain (LBP) and unilateral lumbosacral radicular pains were randomized to receive drug through either parasagital or midline approach. METHODS: Patients were assessed for anterior epidural spread of contrast under fluoroscopy in anteroposterior and lateral views. After epidural space confirmation, triamcinolone (80 mg) plus bupivacain was injected and patients were followed up for 2 weeks. RESULTS: Fifty-six patients enrolled in the study. Successful infiltration of the drug into the ventral epidural space was successfully achieved in 75% of cases in the parasagital group but in only 25% of the cases in using a midline approach. Effective pain relief (numeric rating scale [NRS] < 3) was observed in 76.5% of patients in the parasagital group and 24.5% of patients in the midline group (P = 0.001) at 2 weeks. Number of patients with improved disability (measured by Oswestry Disability Index [ODI] < 20%) was significantly higher in the parasagital group (78%) compared to the midline group (26%) at 2 weeks (P = 0.002). LIMITATIONS: The results of the current study should be interpreted in relation to the study design and future studies should include larger patient numbers and longer follow-up time. However, the results are consistent with previous studies. CONCLUSION: Parasagital epidural injection showed higher infiltration of the drug to the ventral epidural space compared to the midline approach. The higher infiltration of the ventral epidural space provides better improvement of clinical disability and pain in the parasagital group.

Effect of cryoanalgesia on post-thoracotomy pain.

We prepared this study to determine the effect of cryoanalgesia on post-thoracotomy pain. In this double-blinded randomized clinical trial, 60 patients who underwent thoracotomy were divided into two groups (control and cryoanalgesia). Visual Analogue Scale (VAS, 0-10) was used for the measurement of severity of post-thoracotomy pain. It was classified into three categories: 0-1 (mild), 2-3 (moderate), and 4-10 (severe). Pethidine (0.5-1 mg/kg) was administered in case of need for both groups. Patients were visited at the hospital a week later, and were contacted by phone at the first, second, and third months post-operatively. Intensity of pain in the control group was higher than the cryoanalgesia group in all visits the follow-up period. On the second day, the frequencies of severe pain (4-10) were 33.3% and 0 in the control and cryoanalgesia groups, respectively. The mild pain on the seventh day was 13.3% and 83.3% in the control and cryoanalgesia groups, respectively (P < 0.01). Pethidine consumption was 151.6 ± 27 mg in the control group and 87.5 ±48 mg in the cryoanalgesia group on the first day post-operation (P < 0.001). Cryoanalgesia is a useful technique with not serious side effects in order to alleviate post-thoracotomy pain and reduce the need for opiate consumption.

Tracheobronchopathia osteochondroplastica: presentation of ten cases and review of the literature.

Tracheobronchopathia osteochondroplastica (TO) is a rare benign disease of the endobronchial system with nonspecific symptoms and different treatment approaches. We report on a group of patients with TO and discuss their presentation and their treatment modalities. Between 2000 and 2006, the medical records of patients with TO were studied at the Interventional Pulmonary Unit of the Tracheal Disease Research Center at Masih Daneshvary Hospital, a referral center for respiratory diseases in Tehran, Iran. We analyzed and studied patients' demographics, symptom presentation, radiographic appearance, bronchoscopic findings, and their subsequent treatment. Of the 8,760 patients who underwent flexible bronchoscopy (FOB) at our center over 6 years, 10 were diagnosed with TO; their median age was 51 years (range = 16-68 years) and 6 were men. Computerized tomography (CT) revealed mucosal irregularity and calcified nodules. Histopathologic examination of tissue biopsy through bronchoscopy was used for definitive diagnosis of TO. Bronchoscopy findings showed the endobronchial lesions to be firm and glossy. Cartilaginous nodules were present in central airways. Treatment included endobronchial Nd:YAG laser photoevaporation (LPE) (n = 10), coring of the lesions with the tip of the rigid bronchoscope (n = 4), and endobronchial stent placement (n = 1). Symptoms were considerably relieved in six cases but there was no significant improvement noted in three patients. One patient died after 6 years of treatment and follow-up. TO is a rare disease and the diagnosis should be suspected based on CT findings or bronchoscopic examination of the airways. Histopathologic examination is required for confirmation of diagnosis. Treatment is palliative and it includes LPE, coring through a rigid bronchoscope, and endobronchial stent placement.