Varicella (chickenpox) is a highly contagious airborne disease caused by primary infection with the varicella zoster virus (VZV). Following the resolution of chickenpox, the virus can remain dormant in the dorsal sensory and cranial ganglion for decades. Shingles (herpes zoster [HZ]) is a neurocutaneous disease caused by reactivation of latent VZV and may progress to postherpetic neuralgia (PHN), which is characterized by dermatomal pain persisting for more than 120 days after the onset of HZ rash, or "well-established PHN", which persist for more than 180 days. Vaccination with an attenuated form of VZV activates specific T-cell production, thereby avoiding viral reactivation and development of HZ. It has been demonstrated to reduce the occurrence by approximately 50-70%, the duration of pain of HZ, and the frequency of subsequent PHN in individuals aged ≥ 50 years in clinical studies. However, it has not proved efficacious in preventing repeat episodes of HZ and reducing the severity of PHN, nor has its long-term efficacy been demonstrated. The most frequent adverse reactions reported for HZ vaccination were injection site pain and/or swelling and headache. In addition, it should not be administrated to children, pregnant women, and immunocompromised persons or those allergic to neomycin or any component of the vaccine.
chickenpox; herpes zoster; herpes zoster vaccine; human herpesvirus 3; postherpetic neuralgia
It is easy to overlook osteochondral lesions (OCLs) of the ankle in patients with chronic lower limb pain, such as complex regional pain syndrome (CRPS) or thromboangiitis obliterans (TAO, Buerger's disease). A 57-year-old woman diagnosed with type 1 CRPS, and a 58-year-old man, diagnosed with TAO, complained of tactile and cold allodynia in their lower legs. After neurolytic lumbar sympathethic ganglion block and titration of medications for neuropathic pain, each subject could walk without the aid of crutches. However, they both complained of constant pain on the left ankle during walking. Focal tenderness was noted; subsequent imaging studies revealed OCLs of her talus and his distal tibia, respectively. Immediately after percutaneous osteoplasties, the patients could walk without ankle pain. It is important to consider the presence of a hidden OCL in chronic pain patients that develop weight-bearing pain and complain of localized tenderness on the ankle.
ankle; cementoplasty; complex regional pain syndrome; osteochondritis dissecans; thromboangiitis obliterans
The cervical spine is a less common site for metastatic disease than is the thoracolumbar spine. Percutaneous vertebroplasty (PVP) in the cervical spine can be performed using an anteromedial or lateral approach. A 51-year-old woman with breast cancer had been experiencing severe weight-bearing neck pain for 2 months, even after undergoing radiation therapy. Imaging studies revealed an osteolytic compression fracture in the C7 vertebra. For performing PVP at C7 using the anteromedial approach, a needle was inserted from the left side of the patient's neck. The needle was advanced to the anterior 1/3 anterior 1/3 or 1/2 of the vertebral body by hammering, and approximately 2 ml of cement was injected. Immediately after the operation, the patient could move her neck without pain. In conclusion, PVP using an anterolateral approach may be an option for treating metastatic osteolytic vertebral lesions in the cervical spine for alleviating intractable axial neck pain.
Breast neoplasm; Cervical vertebrae; Neoplasm metastasis; Pain; Palliative care; Vertebroplasty
In discography performed during percutaneous endoscopic lumbar discectomy (PELD) via the posterolateral approach, it is difficult to create a fluoroscopic tunnel view because a long needle is required for discography and the guide-wire used for consecutive PELD interrupts rotation of fluoroscope. A stereotactic system was designed to facilitate the determination of the needle entry point, and the feasibility of this system was evaluated during interventional spine procedures.
A newly designed stereotactic guidance system underwent a field test application for PELD. Sixty patients who underwent single-level PELD at L4-L5 were randomly divided into conventional or stereotactic groups. PELD was performed via the posterolateral approach using the entry point on the skin determined by premeasured distance from the midline and angles according to preoperative magnetic resonance imaging (MRI) findings. Needle entry accuracy provided by the two groups was determined by comparing the distance and angle measured by postoperative computed tomography with those measured by preoperative MRI. The duration and radiation exposure for determining the entry point were measured in the groups.
The new stereotactic guidance system and the conventional method provided similarly accurate entry points for discography and consecutive PELD. However, the new stereotactic guidance system lowered the duration and radiation exposure for determining the entry point.
The new stereotactic guidance system under fluoroscopy provided a reliable needle entry point for discography and consecutive PELD. Furthermore, it reduced the duration and radiation exposure associated with determining needle entry.
equipment design; fluoroscopy; needle; percutaneous discectomy; stereotactic technique
Postherpetic neuralgia (PHN) is usually managed pharmacologically. It is not uncommon for patients with chronic kidney disease (CKD) to suffer from PHN. It is difficult to prescribe a sufficient dose of anticonvulsants for intractable pain because of the decreased glomerular filtration rate. If the neural blockade and pulsed radiofrequency ablation provide only short-term amelioration of pain, spinal cord stimulation (SCS) with a low level of evidence may be used only as a last resort. This study was done to evaluate the efficacy of spinal cord stimulation in the treatment of PHN in patients with CKD.
PHN patients with CKD who needed hemo-dialysis who received insufficient relief of pain over a VAS of 8 regardless of the neuropathic medications were eligible for SCS trial. The follow-up period was at least 2 years after permanent implantation.
Eleven patients received percutaneous SCS test trial from Jan 2003 to Dec 2007. Four patients had successfully received a permanent SCS implant with their pain being tolerable at a VAS score of less than 3 along with small doses of neuropathic medications.
SCS was helpful in managing tolerable pain levels in some PHN patients with CKD along with tolerable neuropathic medications for over 2 years.
anticonvulsants; kidney disease; postherpetic neuralgia; spinal cord; therapeutic electric stimulation
Lidocaine patch (L5P) has demonstrated short-term efficacy in treating both acute surgical pain and chronic neuropathic pain with tolerable side effects. Percutaneous endoscopic lumbar discectomy (PELD) is the mainstay of minimally invasive spine surgery (MISS). Sufficient analgesia during PELD surgery makes the patient consider it real MISS. This study was performed to evaluate the efficacy and adverse effects of lidocaine patch in patients who underwent PELD under local anesthesia.
L5P (L group) or placebo (P group) was randomly applied on the skin of the back covering the anticipated path of the working channel before 1 hour of surgery in 100 patients who underwent a single level PELD at L4-L5. Efficacy of the lidocaine patch was assessed by patient's numeric rating scale (NRS) of pain at each stage during the surgery and by a 5-scale grading of the satisfaction with the anesthesia of the operator and patients after surgery.
Mean NRS scores at the stages of needle insertion, skin incision, serial dilation and insertion of working channel, and subcutaneous suture were significantly lower in the L group than the P group. Postoperative operator's and patients' satisfaction scores were also significantly higher in L group than in the P group. There were subtle adverse effects in both groups.
L5P provided better pain relief during PELD, especially at the stage of needle insertion, skin incision, serial dilation and insertion of working channel, and subcutaneous suture. It also provided higher patient and operator postoperative satisfaction, with only subtle adverse effects.
analgesia; endoscopy; lidocaine; percutaneous discectomy; transdermal patch
Rocker bottom shoes (RBS) are popular among patients with different foot, leg, or back problems in Korea. Patients with knee osteoarthritis concurrent weakness in the quadriceps femoris muscle, who wear these shoes, are often assumed to develop piriformis syndrome (PS). This study was performed to improve the understanding about the effect of wearing such shoes on duration of the syndrome in knee osteoarthritis.
We randomly assigned 150 patients with PS, who had used RBS daily for at least 6 months, to 2 groups, the S (stopped wearing) and K (kept wearing) groups. Both the groups were subdivided into the O and N groups, comprising patients with and without knee osteoarthritis, respectively. The effects of the treatment, including piriformis muscle injections and a home exercise program, were compared between the 2 groups by using a flexion-adduction-internal rotation (FAIR) test, a numeric rating scale (NRS), and the revised Oswestry disability index (ODI) during the 12-week follow-up.
The positive FAIR test ratios, mean NRS scores, and revised ODIs were higher in the KO group than the SN group from 4?12 weeks after treatment.
RBS may extend duration of the PS in osteoarthritis patients.
back pain; gait disorders; knee osteoarthritis; piriformis syndrome; shoes
It is surprising that about 24% of patients with benign osteoporotic vertebral fracture die within a year from respiratory infection and urinary tract infection because of coughing and voiding difficulties, depending on the sites of compression fractures. We reviewed 500 patients on whom percutaneous vertebroplasty (PVP) was performed, at 612 levels in terms of patient selection, operation technique, medication, and clinical outcomes during the follow-up course for 2 yr study period. To confirm the most painful level among the multiple fracture sites, physical examination after facet joint block under the fluoroscope was the most reliable method. The mean total lumbar spine fracture threshold of bone mineral density was 0.81±0.05 g/cm2. The mean changes of numeric rating scale scores, Oswestry Disability Index except sex life, and Karnofsky performance status were -72.00, -83.50 and +60.62% in the osteoporosis group and -51.89, -45.02, and 69.03% in the tumor group. Complications related to the procedure were lateral spinal cord damage, transient paresthesia and transient hypotension. PVP with facet joint block is a profitable method for the vertebral compression fracture because of low risk and short duration of procedure with a high chance to result in pain relief and early mobilization.
Zygapophyseal Joint; Facet Joint Block; Percutaneous Vertebroplasty; Pain Clinics; Spinal Fractures
This study was undertaken to prove that the selectively infiltrated parts of nucleus pulposus with indigo carmine was degenerated parts of nucleus pulposus. This study was done, between August and October 2002, in 5 patients, who received endoscopic discectomy, due to intervertebral disc herniation. Discogram was done with mixture of indigo carmine and radioactive dye. Blue discolored part was removed through endoscope, and small undiscolored part was removed together for the control. The two parts were stained with hematoxylin and eosin and compared under the microscope. Undiscolored part was normal nucleus pulposus, composed of chondrocytes with a matrix of type II collagen and proteoglycan, mainly aggrecan. However, in discolored part, slits with destruction of collagen fiber array and ingrowth of vessel and nerve were observed. Using indigo carmine in endoscopic discectomy gives us selective removal of degenerated disc.
Indigo Carmine; Indigotindisulfonate Sodium; Intervertebral Disk; Diskectomy, Percutaneous
The effects from cervical facet joint injections in those patients who have been complaining cervical zygapophyseal joint pain were compared. The patients were diagnosed originally as myofascial pain syndrome (MPS), cervical herniated nucleus pulposus (HNP), and whiplash-associated disorders (WAD). Patients with the zygapophyseal joints pain of C5-6 and C6-7 were classified by their pain origin as MPS, HNP, and WAD. All patients had been undergone cervical zygapophyseal joints injections with the mixture of lidocaine and triamcinolone unilaterally or bilaterally through the posterior approach under C-arm imaging guide. The therapeutic effects were compared with reduction of numeric rating scale (NRS) of pain before and immediately after blockade and symptom-free periods in each group after 12 months. Symptom durations before injections were 16.1±9.6, 4.6±1.9 and 4.1±1.1 months in each MPS, HNP, and WAD groups. The reductions of NRS immediately after the blockade among the three groups were not different. However, the symptom-free duration after blockade lasted longer in the HNP group than the other two groups. In patients with cervical zygapophyseal pain syndromes, the analgesic effect from cervical facet joint blocks lasted longer in cervical HNP than MPS or WAD.
Arthralgia; Cervical Vertebrae; Injections, Intraarticular; Zygapophyseal Joint
Gabapentin is a safe and well-tolerated anticonvulsant with a wide therapeutic index, and it is used for neuropathic pain. The aim of this study was to compare previous dosing methods with the administration of four different doses of gabapentin while maintaining the same maximum daily dose for the safe administration of high doses of the medication.
The subjects were outpatients with various neuropathic pain syndromes, with at least two of the following symptoms: allodynia, burning pain, shooting pain, or hyperalgesia. The TID group received equal doses of gabapentin 3 times per day, while the QID group received 4 different doses of gabapentin per day. The pain score, frequency of breakthrough pain (BTP), severity and the duration of pain, sleep disturbance due to nocturnal pain, and adverse effects were recorded each day.
The average daily pain score and sleep disturbance were significantly reduced in the QID group between days 3 and 10 of the experiment. The adverse effects of the medication were also reduced in the QID group. However, the frequency of BTP and severity and duration of pain were not significantly different between two groups.
Administration of 4 different doses of gabapentin during the initial titration in outpatients with neuropathic pain resulted in a significant reduction in awakening from breakthrough pain and a reduction in the adverse effects of the medication.
Ambulatory care; Drug administration schedule; Gabapentin; Neuropathic pain
Sedation in spinal anesthesia can reduce patient's anxiety and discomfort. Dexmedetomidine has a sedative, hypnotic, analgesic, and minimal respiratory depression effect. However, use of the dexmedetomidine is associated with prolonged recovery. This study was designed to investigate the optimal dose of intravenous dexmedetomidine for proper sedation with minimal recovery time in spinal anesthesia.
One hundred twenty eight patients, aged 20-70 years (58.8 ± 0.7), were recruited. After performing the spinal anesthesia with hyperbaric bupivacaine (13 mg), a loading dose of dexmedetomidine (1 µg/kg) was administered for 10 min, followed by the maintenance infusion of the following: Group A (n = 33; normal saline), Group B (n = 35; dexmedetomidine 0.2 µg/kg/hr), and Group C (n = 39; dexmedetomidine 0.4 µg/kg/hr). Heart rate, blood pressure, and the bispectral index score (BIS) were recorded during the operation. In the recovery room, modified aldrete score (MAS) was measured.
There were no significant differences in mean blood pressure and heart rate among the three groups. BIS was not significantly different among the three groups from baseline to 60 min after the infusion of dexmedetomidine. BIS were significantly increased in Group A after 70 and 80 min, and Group A and B after 90, 100, 110 min of dexmedetomidine infusion (P < 0.05). MAS was higher in Group A as compared to Group B and C, within 30 min after admission in the recovery room (P < 0.05).
The loading dose (1 µg/kg/10 min) of dexmedetomidine was sufficient for surgery of less than 60 min. Dexmedetomidine infusion followed by maintenance dose (0.2 µg/kg/hr) was sufficient for surgery within 90 min.
Dexmedetomidine; Sedation; Spinal anesthesia
In patients with primary aldosteronism who have bilateral adrenal incidentalomas, it is important to identify which adrenal gland is secreting excess aldosterone. Traditionally, adrenal vein sampling (AVS) has been performed for lateralization despite its invasiveness. Here we report a case of bilateral adrenal incidentaloma in which 18-Fluorodeoxyglucose (FDG)-positron emission tomography (PET) was used to identify the functional adrenal mass. A 53-yr-old man was referred to our clinic due to bilateral adrenal incidentalomas (right: 1 cm, left: 2.5 cm) on computed tomography (CT). Given his history of colon cancer, FDG-PET/CT scanning was used to rule out metastasis. Although there was focal hot uptake lesion in the right adrenal gland, the patient was suspected primary aldosteronism clinically more than metastasis because of the patient's underlying hypertension with hypokalemia. It was consistent with the results of AVS. Based on these findings, we propose that FDG-PET/CT can be used instead of AVS to identify the source of primary aldosteronism between two bilateral adrenal incidentalomas.
Bilateral Adrenal Incidentaloma; FDG-PET/CT; Primary Aldosteronism
Percutaneous endoscopic lumbar discectomy (PELD) can be performed under local anesthesia with intravenous analgesics. To define the incidence of piriformis syndrome (PS) after PELD via the posterolateral approach under local anesthesia compared to that of general patients presenting with low back pain with/without lower leg pain. The incidence and time of occurrence of positive FAIR test after PELD within a 3-month follow-up period were evaluated retrospectively, and compared with the prevalence of general patients who visited the pain clinic for LBP with/without lower leg pain. Factors that may increase the incidence of PS after PELD were also evaluated. There was no patient with positive FAIR test immediately after PELD in the operation room and before walking. The prevalence of PS in general patients was 317/2,320 (13.7%); however, the incidence of PS after PELD within a 3-month follow-up period was 61/151 (40.4%), peaking at 32 days. High anxiety scale scores during operation led to increased incidence of PS after PELD. PELD under local anesthesia with high level of anxiety may increase the incidence of PS after walking, peaking around the first month, compared with the results for general patients with low back pain with/without lower leg pain.
Diskectomy; Endoscopy; Lumbar vertebrae; Percutaneous; Piriformis syndrome
Etomidate frequently induces myoclonus, so it may affect electromyographics (EMG). And EMG commonly has an effect on the bispectral index scale (BIS) and spectral entropy. This study was performed to compare the effect of etomidate on BIS, response entropy (RE) and state entropy (SE) during induction of anesthesia.
Fifty patients (ASA I or II) scheduled for elective surgery were included in this study. Anesthesia was induced with etomidate (0.3 mg/kg) and rocuronium (0.6 mg/kg). Patients also inhaled 4 vol% sevoflurane and 100% oxygen and, then intubated. BIS, RE, SE and Modified Observer's Assessment of Alertness/Sedation Scale (MOAA/S) were measured 4 times (before injection of etomidate [T0], at loss of eyelash reflex [T1], 90 seconds after rocuronium injection [T2], and after intubation [T3]). We also checked whether myoclonus occurred.
Baseline values (T0) were 93.1 ± 4.7 for BIS, 95.8 ± 3.7 for RE and, 87.3 ± 3.5 for SE. In comparison with T0, there were significantly differences in BIS (50.2 ± 16.3), RE (76.8 ± 18.5) and SE (66.3 ± 17.4) at T1 (all P < 0.05). There were no significant differences at T2 and T3. Thirty one patients had myoclonus. At the occurrence of myoclonus, RE and SE values significantly increased but not BIS (P < 0.05).
In patients with myoclonus, at the loss of consciousness, spectral entropy did not decrease where as BIS did, suggesting that BIS may evaluate hypnotic levels better than spectral entropy during induction of anesthesia with etomidate.
Bispectral index scale; Electromyography; Entropy; Etomidate; Myoclonus
Pegylated interferon (peginterferon) and ribavirin combination therapy is less effective and associated with a higher frequency of serious complications in chronic hepatitis C patients with cirrhosis than in noncirrhotic patients. This study evaluated the efficacy and tolerability of peginterferon and ribavirin treatment in patients with hepatitis C virus (HCV)-related cirrhosis.
Eighty-six patients with clinically diagnosed liver cirrhosis were treated with either peginterferon alpha-2a (n=51) or peginterferon alpha-2b (n=35) plus ribavirin. The sustained virologic response (SVR) and adverse effects were analyzed retrospectively.
Of the 86 patients (55 males), 48 patients (55.8%) had HCV genotype 1 infection and 38 (44.2%) had genotype non-1 infection. The overall SVR rate was 34.9% (30/86), and the rates of SVR in the genotype 1 and non-1 patients were 20.8% (10/48) and 52.6% (20/38), respectively. The multivariate analysis revealed that having HCV genotype 1 (P=0.003) and high baseline viral load (>8.0×105 IU/mL, P=0.012) were the independent predictive factors for SVR failure. In 20.9% (18/86) of the patients, treatment was not completed due to adverse events (27.8%), loss to follow-up (50.0%), and other reasons (22.2%).
Peginterferon and ribavirin combination therapy was relatively effective and feasible for clinically diagnosed HCV patients, especially in those with genotype non-1 infection and low baseline viral load.
Pegylated interferon; Ribavirin; Hepatitis C; Cirrhosis
The cyclin-dependent kinase (Cdk) inhibitor p27Kip1 (p27) is a marker of prognosis in many cancers, including breast cancer. Low p27 expression correlates with poor prognosis, especially in hormone receptor positive breast tumors. This association suggests a role for p27 in hormone-dependent cancer. We used the Wnt-1 transgenic mouse model to further explore the role of p27 in hormone-driven breast cancer. We found that p27 deficiency did not alter breast cancer rate in either male or female Wnt-1 mice. However, we did find p27−/− females had reduced levels of serum progesterone (P) and increased variability in estradiol (E), which could have affected their cancer susceptibility. To equalize hormone levels, an additional cohort of Wnt-1 female mice was ovariectomized and implanted with slow release pellets of E and P. Although this treatment did not alter the breast cancer rate, it did accelerate the development of pituitary and gastric tumors in p27−/− mice. This study shows that while not a significant inhibitor of Wnt-1-driven breast cancer, p27 inhibits gastric tumors, whose latency is modulated by sex steroids.
The purpose of this study was to establish new fusion criteria to complement existing Brantigan-Steffee fusion criteria. The primary purpose of intervertebral cage placement is to create a proper biomechanical environment through successful fusion. The existence of a traction spur is an essential predictable radiologic factor which shows that there is instability of a fusion segment. We studied the relationship between the existence of a traction spur and fusion after a posterior lumbar interbody fusion (PLIF) procedure.
This study was conducted using retrospective radiological findings from patients who underwent a PLIF procedure with the use of a cage without posterior fixation between 1993 and 1997 at a single institution. We enrolled 183 patients who were followed for a minimum of five years after the procedure, and used the Brantigan-Steffee classification to confirm the fusion. These criteria include a denser and more mature bone fusion area than originally achieved during surgery, no interspace between the cage and the vertebral body, and mature bony trabeculae bridging the fusion area. We also confirmed the existence of traction spurs on fusion segments and non-fusion segments.
The PLIF procedure was done on a total of 251 segments in 183 patients (71 men and 112 women). The average follow-up period was 80.4 ± 12.7 months. The mean age at the time of surgery was 48.3 ± 11.3 years (range, 25 to 84 years). Among the 251 segments, 213 segments (84.9%) were fused after five years. The remaining 38 segments (15.1%) were not fused. An analysis of the 38 segments that were not fused found traction spur formation in 20 of those segments (52.6%). No segments had traction spur formation with fusion.
A new parameter should be added to the fusion criteria. These criteria should be referred to as 'no traction spur formation' and should be used to confirm fusion after a PLIF procedure.
Posterior lumbar interbody fusion; Instability; Traction spur
To evaluate the structure-function relationships between retinal sensitivity measured by Humphrey visual field analyzer (HVFA) and the retinal nerve fiber layer (RNFL) thickness measured by scanning laser polarimetry (SLP) with variable corneal compensation (VCC) and enhanced corneal compensation (ECC) in glaucomatous and healthy eyes.
Fifty-three eyes with an atypical birefringence pattern (ABP) based on SLP-VCC (28 glaucomatous eyes and 25 normal healthy eyes) were enrolled in this cross-sectional study. RNFL thickness was measured by both VCC and ECC techniques, and the visual field was examined by HVFA with 24-2 full-threshold program. The relationships between RNFL measurements in superior and inferior sectors and corresponding retinal mean sensitivity were sought globally and regionally with linear regression analysis in each group. Coefficients of the determination were calculated and compared between VCC and ECC techniques.
In eyes with ABP, R2 values for the association between SLP parameters and retinal sensitivity were 0.06-0.16 with VCC, whereas they were 0.21-0.48 with ECC. The association of RNFL thickness with retinal sensitivity was significantly better with ECC than with VCC in 5 out of 8 regression models between SLP parameters and HVF parameters (P<0.05).
The strength of the structure-function association was higher with ECC than with VCC in eyes with ABP, which suggests that the ECC algorithm is a better approach for evaluating the structure-function relationship in eyes with ABP.
GDx-ECC; GDx-VCC; Structure-function relationship; Scanning laser polarimetry
According to the three step-ladder analgesics in patients with cancer pain, adjuvant drugs are required for pain relief according to the pain character and also to reduce side effects of opioids. Pain clinicians sometimes want to decide to jump directly from naive and mild opioid to transdermal therapeutic system (TTS) fentanyl with less side effects. We investigated the safety, efficacy, and satisfaction of the patients of TTS fentanyl converting from opioid-naive and mild-opioid with adjuvant drug medications in related to dose cascade of TTS fentanyl. Both opioid-naive (n=3) and opioid-using (n=34) patients started with TTS fentanyl in the lowest available delivery rate (25 microg/hr) with rescue medication. A numeric rating scale (NRS, from 0=no pain to 10=worst pain imaginable), satisfaction of the patients with the transdermal therapy and side effects were recorded everyday during 29 days. Average reductions of NRS scores were 1.79 and 2.77, and the mean doses were 35.14 and 44.12 microg/hr on the 15th and 29th day, respectively. Reported level of satisfaction with the transdermal patch and generalized pain management were 'completely satisfied' and 'satisfied'. Frequent side effects were nausea, vomiting, and constipation. In conclusion, initial application of TTS fentanyl with proper adjuvant medications is effective, safe, and well tolerated.