A retrospective analysis of spinal canal endoscopy and laminectomy outcomes data.

Disability from back pain has continued to increase at a steady pace since the 1950's. While no study has associated chronic disability with physical factors, numerous studies have correlated chronic disability with psychological factors and surgical intervention. Even though most common surgical interventions for spinal pain pertain to the herniated disc, numerous studies have indicated that only 1% of severe episodes of low back pain is attributable to herniated discs. With the advent of spinal canal endoscopy, an additional option is available for medical management of disc disease, which facilitates irrigation, dilution, and removal of inflammatory mediators, thus decreasing the chance of reactivity to chemical and biological mediators, and facilitating administration of corticosteroid medication with specificity to site of action. This pilot study included two groups of patients, Group 1 with 22 patients treated via spinal endoscopy and Group 2 with 13 patients treated via laminectomy. After spinal canal endoscopy, only 31.8% of Group 1 patients were continued on opioid medication, whereas, 92.3% of Group 2 patients were continued on opioid medication after laminectomy. In addition, 72% from spinal canal endoscopy group and only 28% from laminectomy group returned to work. In conclusion, this study suggested remarkable differences in outcomes when comparing patients who underwent spinal canal endoscopy to a similar population who underwent lumbar laminectomy.

Sphenopalatine ganglion block for treatment of sinus arrest in postherpetic neuralgia.

A 64-year-old woman presented with bradycardia from sinus pauses during exacerbations of postherpetic trigeminal distribution neuralgia. She had underlying systemic lupus erythematosus. Sphenopalatine ganglion blockade was employed to treat her pain. The episodes of bradycardia resolved with successful alleviation of pain. This report emphasizes that a sphenopalatine ganglion blockade can be employed in the treatment and prevention of sinus arrest associated with postherpetic trigeminal distribution neuralgia.

Identification of the epidural space: is loss of resistance to air a safe technique? A review of the complications related to the use of air.

BACKGROUND AND OBJECTIVES: The major determinant of successful epidural anesthesia is the localization of the epidural space. The manual loss of resistance technique is widely used by anesthesiologists in identifying the epidural space. Should air or saline be used in detecting the point of loss of resistance? No consensus exists as to which technique is superior, and individual providers currently use the technique with which they are most comfortable. The incidence of adverse effects associated with the use of epidural air is unknown and may be underreported as the effects may be unrecognized or considered trivial. The authors comprehensively review the complications of epidural air from published reports. METHODS: Using the appropriate key words, the authors searched the Medline (National Library of Congress) scientific data bank from 1966 to 1995, for case reports of epidural complications. RESULTS: There are few prospective, controlled, double-blinded studies comparing the relative merits of using air versus saline for the loss of resistance technique of epidural placement. There are, however, numerous case reports. Complications associated with the use of air for the loss of resistance technique included pneumocephalus, spinal cord and nerve root compression, retroperitoneal air, subcutaneous emphysema, and venous air embolism. Additionally, inadequate analgesia and paresthesia have been associated with the loss of resistance technique using air. Transient and permanent neurologic sequelae have been attributed to some of the complications. The simultaneous administration of nitrous oxide and positive. Pressure ventilation has also been reported to expand localized collections of air, resulting in heightened symptoms. CONCLUSIONS: The potential complications associated with the use of air for identifying the epidural space with the loss of resistance technique may outweigh the benefits. The use of saline to identify the epidural space may help to reduce the incidence of these complications.

Assessment of diurnal variation of cerebrospinal fluid tryptophan and 5-hydroxyindoleacetic acid in healthy human females.

The role of serotonin (5-HT) in the pathogenesis and treatment of major neuropsychiatric disorders, including mood and anxiety disorders, continues to be the subject of extensive research. Previous studies examining central 5-HT functioning measured cerebrospinal fluid (CSF) levels of 5-hydroxyindoleacetic acid (5-HIAA) by using single or multiple lumbar punctures. A number of investigators have demonstrated the feasibility of continuous CSF sampling via an indwelling lumbar catheter to study CSF neurochemistry in healthy subjects and patients with neuropsychiatric illness. Four healthy female volunteers, aged 21-34 years, underwent continuous CSF sampling. CSF was collected at a constant rate of 1 ml every 10 minutes over a 30-hour period, with levels of tryptophan (TRP) and 5-HIAA measured every hour. Plasma was also obtained hourly for TRP determination. The results of this study indicate that CSF 5-HIAA, CSF TRP, and plasma TRP levels showed variation over time, but failed to show diurnal fluctuation. Intra-individual coefficients of variation determined for CSF 5-HIAA, CSF TRP, and plasma TRP ranged from 9.2 to 14.9%, 8.8 to 14.6%, and 14.7 to 19.0%, respectively. Continuous CSF sampling is safe and feasible in humans, and may prove useful for studies of central 5-HT neurotransmission in neuropsychiatric illness.

Complex regional pain syndrome type I (RSD) or peripheral mononeuropathy? A discussion of three cases.

OBJECTIVE: Peripheral nerve pathology commonly results in symptoms that suggest a diagnosis of complex regional pain syndrome (CRPS) type I (RSD). We briefly review common symptoms of peripheral nerve pathology (referred pain, hyperpathia, and autonomic changes) and present three illustrative cases of peripheral nerve injury misdiagnosed and treated as RSD. The nonspecificity of current taxonomy regarding CRPS as it relates to the three cases is emphasized. DESIGN: The study is case series. SETTING: All three of the cases were diagnosed and treated for their painful symptoms at a university hospital clinic that provides multispecialty evaluations for painful conditions. PATIENTS: The three patients all had work-related injuries resulting in pain, hyperpathia, and autonomic changes in one of their upper extremities. Their injuries were representative of common peripheral nerve lesions, one being a neuroma, one an irritative lesion, and one an entrapment. RESULTS AND CONCLUSIONS: The clinical entity of CRPS quite apparently encompasses symptomatology caused by peripheral nerve entrapment, irritative lesions, and neuroma. As such, its use as a diagnostic end point may overlook these treatable conditions. As illustrated in these cases, peripheral nerve pathology may prove a diagnostic challenge and alternative techniques of investigation other than electrophysiologic studies are often helpful.

Review of the clinical basis and protocol for epidural endoscopy.

Epidural endoscopy is a minimally invasive technology that is now in active clinical trials. This new technique allows the operator to visualize directly the epidural space and contiguous structures, thus allowing for detailed examination leading to a better understanding of the role of epidural adhesion in the development of sciatica.

Oral capsaicin provides temporary relief for oral mucositis pain secondary to chemotherapy/radiation therapy.

Pain from oral mucositis afflicts from 40% to 70% of patients receiving chemotherapy or radiation therapy. Current methods of clinical pain management (for example, topical anesthetics, systemic analgesics) have limited success. In a pilot study, we examined the ability of oral capsaicin to provide temporary relief of oral mucositis pain. Capsaicin, the active ingredient in chili peppers, desensitizes some neurons and has provided moderate pain relief when applied to the skin surface. Oral capsaicin in a candy (taffy) vehicle produced substantial pain reduction in 11 patients with oral mucositis pain from cancer therapy. However, this pain relief was not complete for most patients and was only temporary. Additional research is needed to fully utilize the properties of capsaicin desensitization and thus optimize analgesia.