Intracerebroventricular morphine for refractory cancer pain: transitioning to the home setting.

Refractory cancer pain may be effectively controlled by titrating intracerebroventricular (ICV) preservative-free opioid. In this case report, a continuous infusion of ICV morphine permitted our patient with lung cancer and painful spinal metastases to be discharged to home hospice with family. The approach exploits the high potency of morphine injected into cerebrospinal fluid (CSF). Sterile, injectable, preservative-free morphine is directly infused into CSF through a subcutaneous Ommaya reservoir placed under the scalp by a neurosurgeon, with an attached catheter passed through a burr hole in the skull with its tip in a cerebral ventricle. Although investigators have described home care of patients receiving intraspinal analgesics, no report describes the process of transitioning the patient receiving continuous ICV morphine infusion to the home setting.

Neuromodulation of neuropathic pain syndrome induced by elapidae (cobra) envenomation.

Objectives. This study aims to demonstrate the utility of spinal cord stimulation in a neuropathic pain syndrome and overall decline in health and functional independence following elapid envenomation in a morbidly obese, insulin-dependent diabetic. Materials and Methods. A two-lead, 16-electrode constant-current, independently controlled system is placed in the mid-cervical spine. Results. Noted were a improvement in overall health status with better glycemic control and return to work status in response to adequate pain control. Conclusions. The case serves as a model for other orphan pain cases with a seemingly esoteric etiology and adds to the existing body of literature that spinal cord stimulation and neuromodulation, in general, has a wide-ranging applicability peripheral neuropathic pain syndromes.

Unintentional vascular uptake in fluoroscopically guided, contrast-confirmed spinal injections: a 1-yr clinical experience and discussion of findings.

OBJECTIVE: Documentation of vascular uptake on spinal injection in the context of negative aspiration and negative passive filling of blood into the hub of the needle. DESIGN: A total of 1,295 consecutive outpatients receiving fluoroscopically guided, contrast-confirmed injection in a multispecialty practice over a 1-yr time frame were retrospectively reviewed with passive observation for inadvertent vascular uptake, passive filling, and required repositioning. RESULTS: Positive vascular uptake was seen in 2-13% of cases with variable degrees of aspiration, passive filling, and required needle repositionings to avoid vascular uptake. CONCLUSION: Negative aspiration and allotment for passive filling is inadequate to confirm the absence of vascular injection. Spinal injection will never be risk free. The safest method is fluoroscopically guided, contrast-confirmed injection, which should be considered the current standard of care.

H-reflex latency and nerve root tension sign correlation in fluoroscopically guided, contrast-confirmed, translaminar lumbar epidural steroid-bupivacaine injections.

OBJECTIVES: To examine the correlation between physical examination parameters, commonly referred to as "nerve root tension signs," and H-reflex latency measurements both pre- and postepidural steroid-bupivacaine (Marcaine) injection, and to propose mechanisms of pain alleviation. DESIGN: Prospective observational, with H-reflex latency measurement and physical examination at baseline and at 10 minutes postinjection. SETTING: Physical medicine and rehabilitation practice, outpatient surgical center, and community setting. PARTICIPANTS: Ten consecutively recruited patients (6 women, 4 men; age range, 40-71 y) with clinical radiculopathy and compatible magnetic resonance imaging findings, who were unaware of the outcome measures. INTERVENTIONS: Patients received a fluoroscopically guided, contrast-confirmed, paramedian translaminar lumbar epidural injection of 120 mg of methylprednisolone acetate (80 mg/mL) and 2.0 mL of .25% preservative-free Marcaine. MAIN OUTCOME MEASURES: Seated slump testing (SST), straight-leg raising (SLR), and H-reflex latency were measured bilaterally both pre- and postinjection. Differences were measured by using the paired t test in an A-B design. RESULTS: All SST of the affected (injected) side improved from pre- to postinjection, with 3 patients reporting discordant hamstring pain and 7 reporting no pain. SLR ability increased by an average of 29 degrees +/-12 degrees, corresponding to an average relative increase of 54% on the affected side. A statistically significant difference was found (Student t test, P=.02) between pre and post H-reflex latency on the affected side but not when comparing changes between affected and unaffected sides (Student t test, P=0.6). CONCLUSIONS: Significant improvements in SST and SLR result from low volume epidural injection of Marcaine, with questionable prolongation of the H-reflex to the gastrocnemius-soleus complex on the affected side.

Medical and rehabilitation issues in classical ballet.

Classical ballet is a demanding professional occupation, with participants who are often underserved in terms of accurate diagnosis and appropriate comprehensive medical care. The view that follows is designed to be as global and insightful as published to date. Specific rehabilitation considerations, dance mechanics, idiosyncratic differential diagnosis, and personality and equipment issues are discussed, and a rational view of dogma is presented.