BACKGROUND: Chronic low back pain can be a manifestation of lumbar degenerative disease, herniation of intervertebral discs, arthritis, or lumbar stenosis. When nerve roots are compromised, low back pain, with or without lower extremity involvement, may occur. Local inflammatory processes play an important role in patients with acute lumbosciatic pain. The purpose of this study was to assess the value of erythrocyte sedimentation rate (ESR) and high sensitivity C-reactive protein (hsCRP) measurements in patients with chronic low back pain or radiculopathy. METHODS: ESR and hsCRP were measured in 273 blood samples from male and female subjects with low back pain and/or radiculopathy due to herniated lumbar disc, spinal stenosis, facet syndrome, and other diseases. The hsCRP and ESR were measured prior to lumbar epidural steroid injection. RESULTS: The mean ESR was 18.8 mm/h and mean hsCRP was 1.1 mg/L. ESR had a correlation with age. CONCLUSIONS: A significant systemic inflammatory reaction did not appear to arise in patients with chronic low back pain.
Arthritis ; Blood Sedimentation ; C-Reactive Protein ; Constriction, Pathologic ; Erythrocytes ; Female ; Humans ; Intervertebral Disc ; Low Back Pain ; Lower Extremity ; Male ; Radiculopathy ; Spinal Stenosis

BACKGROUND: Stellate ganglion block (SGB) is known to increase blood flow to the innervations area of the stellate ganglion. Near infrared spectroscopy reflects an increased blood volume and allows continuous, non-invasive, and bedside monitoring of regional cerebral oxygen saturation (rSO2). We investigated the influence of SGB on bilateral cerebral oxygenation using a near infrared spectroscopy. METHODS: SGB was performed on 30 patients with 1% lidocaine 10 ml using a paratracheal technique at the C6 level and confirmed by the presence of Horner's syndrome. The blood pressure (BP), heart rate (HR) and rSO2 were measured before SGB and 5, 10, 15 and 20 minutes after SGB. Tympanic temperature of each ear was measured prior to SGB and 20 minutes after SGB. RESULTS: The increments of the rSO2 on the block side from the baseline were statistically significant at 5, 10, 15 and 20 minutes. The rSO2 on the non-block side compared with the baseline, however, decreased at 15 and 20 minutes. The difference between the block and the non-block sides was significant at 15 and 20 minutes. The BP at 10, 15 and 20 minutes was increased and the HR was increased at 10 and 15 minutes. CONCLUSIONS: We observed an increment of the rSO2 on the block side from the baseline; however, the rSO2 on the non-block side decreased.
Blood Pressure ; Blood Volume ; Ear ; Heart Rate ; Horner Syndrome ; Humans ; Lidocaine ; Oxygen ; Spectrum Analysis ; Stellate Ganglion

BACKGROUND: Facet joint have been implicated as a source of chronic low back pain. Radiofrequency denervation has demonstrated the most solid evidence. To increase safety and efficacy of treatment, computed tomography (CT) guidance injection has been used in several disease. The purpose of this study was to evaluate the efficacy of CT-guided radiofrequency rhizotomy in the treatment of facet joint pain. METHODS: A total of 40 patients were randomized to undergo radiofrequency facet joint denervation under CT guidance or C-arm guidance. All patients were examined visual analogue scale (VAS) score before treatment, 1 month, and 3 months after treatment. RESULTS: The VAS in both groups showed significant improvement over the 1-month interval. No significant difference in the VAS score among the group was observed. CONCLUSIONS: In this study there was no significant difference between CT guidance lumbar rhizotomy and C-arm guidance lumbar rhizotomy. Therefore CT-guided radiofrequency denervation of the lumbar facet joint was a minimally invasive technique that appears effective.
Denervation ; Humans ; Low Back Pain ; Rhizotomy ; Zygapophyseal Joint

BACKGROUND: We prospectively evaluated the incidence and possible factors causing intramuscular injection during lumbar sympathetic ganglion block and compared the multiple needle technique to the single technique to obtain a profound and complete block effect. METHODS: Among 83 patients, 58 patients (group A, n = 27, multiple needle technique and group B, n = 31, single needle technique) were reevaluated for the changes of skin temperature (Ts) and mean segment of longitudinal contrast spread. After injecting the contrast agent, the incidence of psoas muscle injection and the change of Ts was compared between two groups. RESULTS: The incidence of psoas muscle injection was 21.3% (46/216) and it was associated with the level of injection (L2) significantly (chi-square = 14.773, P = 0.001). DT(post) (postblock temperature difference between ipsilateral and contralateral great toe, 4.6 +/- 2.8degrees C, 1.8 +/- 1.6degrees C, P < 0.001 for group A and B) and DT(net) (DT(post) - DT(pre), 3.9 +/- 2.7degrees C, 1.5 +/- 1.5degrees C, P < 0.001 for group A and B) was significantly higher in group A. The mean segment of longitudinal contrast spread was 8.1 +/- 0.9 for group A and 3.2 +/- 1.6 for group B (P < 0.001). CONCLUSIONS: The LSGB at the L2 level showed the lowest incidence of psoas muscle injection of contrast. Multiple needle approach showed more significant increase of DT(net) and DT(post).
Ganglia, Sympathetic ; Humans ; Incidence ; Injections, Intramuscular ; Needles ; Prospective Studies ; Psoas Muscles ; Skin Temperature ; Toes

BACKGROUND: The aim of this study was to compare the efficacy of ketorolac, paracetamol, and paracetamol plus morphine on pain relief after thyroidectomy. METHODS: Eighty patients were randomly allocated to one of the 4 groups: normal saline (group C), ketorolac 30 mg (group K), paracetamol 1 g (group P), and paracetamol 700 mg plus morphine 3 mg (group PM). Each regimen was administered intravenously (IV) 30 min. before the end of surgery. If pain was not relieved, patients received an IV bolus of pethidine hydrochloride 25 mg. Pain intensity using a visual analogue scale (VAS) was recorded at 0.5, 1, 2, 4, and 6 hr after the end of surgery. RESULTS: VAS at 0.5 and 1 hr after the end of surgery were significantly lower in group K, group P, and group PM than in group C (P < 0.05). The number of patients receiving pethidine hydrochloride at 0.5 and 1 hr after the end of surgery was significantly lower in group K, group P, and group PM than in group C (P < 0.05). There was no significant difference among the groups in the incidences of adverse events associated with study medications and patient satisfaction (P > 0.05). CONCLUSIONS: Paracetamol 1 g IV possesses a similar analgesic efficacy to ketorolac 30 mg IV after thyroidectomy. Paracetamol may represent an alternative to ketorolac for pain prevention after mildly to moderately painful surgery in situations where the use of NSAIDs is unsuitable.
Acetaminophen ; Analgesics ; Anti-Inflammatory Agents, Non-Steroidal ; Humans ; Incidence ; Ketorolac ; Meperidine ; Morphine ; Patient Satisfaction ; Thyroidectomy

BACKGROUND: Pamidronate is a potent inhibitor of osteoclast-mediated bone resorption. Recently, the drug has been known to relieve bone pain. We hypothesized that direct epidural administration of pamidronate could have various advantages over oral administration with respect to dosage, side effects, and efficacy. Therefore, we evaluated the neuronal safety of epidurally-administered pamidronate. METHODS: Twenty-seven rats weighing 250-350 g were equally divided into 3 groups. Each group received an epidural administration with either 0.3 ml (3.75 mg) of pamidronate (group P), 0.3 ml of 40% alcohol (group A), or 0.3 ml of normal saline (group N). A Pinch-toe test, motor function evaluation, and histopathologic examination of the spinal cord to detect conditions such as chromatolysis, meningeal inflammation, and neuritis, were performed on the 2nd, 7th, and 21st day following administration of each drug. RESULTS: All rats in group A showed an abnormal response to the pinch-toe test and decreased motor function during the entire evaluation period. Abnormal histopathologic findings, including neuritis and meningeal inflammation were observed only in group A rats. Rats in group P, with the exception of 1, and group N showed no significant sensory/motor dysfunction over a 3-week observation period. No histopathologic changes were observed in groups P and N. CONCLUSIONS: Direct epidural injection of pamidronate (about 12.5 mg/kg) showed no neurotoxic evidence in terms of sensory/motor function evaluation and histopathologic examination.
Administration, Oral ; Animals ; Bone Resorption ; Diphosphonates ; Inflammation ; Injections, Epidural ; Neuritis ; Neurons ; Rats ; Spinal Cord

BACKGROUND: The pathophysiological and neurochemical changes following spinal injury are not yet elucidated. This study was designed to evaluate the morphological changes of the dorsal horn of the spinal cord and profiles of pain behaviors following intraspinal injection of NMDA in rats. METHODS: Rats were randomized into three groups: a sham-operated control group and groups where the rats received 10 mM or 100 mM N-methyl-D-aspatate (NMDA) injected into their spinal dorsal horn. Following injection, hypersensitivity to cold and mechanical stimuli and excessive grooming behaviors were assessed serially for four weeks. Morphological changes of the spinal cord were evaluated four weeks after intraspinal injection. RESULTS: Few animals in the NMDA groups developed hypersensitivity to cold and mechanical stimuli. The number of groomers and the severity of excessive grooming were significantly higher in the 100 mM NMDA group than those values of the control and 10 mM NMDA groups. The size of the neck region (lamina III-IV) was significantly smaller in the 100 mM NMDA group than in the control and 10 mM NMDA groups. CONCLUSIONS: In conclusion, intraspinal injection of NMDA in rats leads to the pathological sequela in the spinal cord and to excessive grooming behavior. These results support the use of NMDA and excessive grooming behavior after excitotoxic SCI as a model to study chronic pain after SCI.
Animals ; Chronic Pain ; Cold Temperature ; Grooming ; Horns ; Hypersensitivity ; Injections, Spinal ; N-Methylaspartate ; Neck ; Pilot Projects ; Rats ; Spinal Cord ; Spinal Cord Injuries ; Spinal Injuries

Chronic pain is a multifactorial condition with both physical and psychological symptoms, and it affects around 20% of the population in the developed world. In spite of outstanding advances in pain management over the past decades, chronic pain remains a significant problem. This article provides a mechanism- and evidence-based approach to improve the outcome for pharmacologic management of chronic pain. The usual approach to treat mild to moderate pain is to start with a nonopioid analgesic. If this is inadequate, and if there is an element of sleep deprivation, then it is reasonable to add an antidepressant with analgesic qualities. If there is a component of neuropathic pain or fibromyalgia, then a trial with one of the gabapentinoids is appropriate. If these steps are inadequate, then an opioid analgesic may be added. For moderate to severe pain, one would initiate an earlier trial of a long term opioid. Skeletal muscle relaxants and topicals may also be appropriate as single agents or in combination. Meanwhile, the steps of pharmacologic treatments for neuropathic pain include (1) certain antidepressants (tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors), calcium channel alpha2-delta ligands (gabapentin and pregabalin) and topical lidocaine, (2) opioid analgesics and tramadol (for first-line use in selected clinical circumstances) and (3) certain other antidepressant and antiepileptic medications (topical capsaicin, mexiletine, and N-methyl-d-aspartate receptor antagonists). It is essential to have a thorough understanding about the different pain mechanisms of chronic pain and evidence-based multi-mechanistic treatment. It is also essential to increase the individualization of treatment.
Analgesics, Opioid ; Antidepressive Agents ; Calcium Channels ; Capsaicin ; Chronic Pain ; Fibromyalgia ; Lidocaine ; Ligands ; Mexiletine ; N-Methylaspartate ; Neuralgia ; Neuromuscular Agents ; Norepinephrine ; Pain Management ; Serotonin ; Sleep Deprivation ; Tramadol

Recently, percutaneous epidural neuroplasty has become widely used to treat radicular pain caused by spinal stenosis or a herniated intervertebral disc. A 19-year-old female patient suffering from left radicular pain caused by an L4-L5 intervertebral disc herniation underwent percutaneous epidural neuroplasty of the left L5 nerve root using a Racz catheter. After the procedure, the patient complained of acute motor weakness in the right lower leg, on the opposite site to where the neuroplasty was conducted. Emergency surgery was performed, and swelling of the right L5 nerve root was discovered. The patient recovered her motor and sensory functions immediately after the surgery. Theoretically, the injection of a large volume of fluid in a patient with severe spinal stenosis during epidural neuroplasty can increase the pressure on the opposite side of the epidural space, which may cause injury of the opposite nerve by barotrauma from a closed compartment. Practitioners should be aware of this potential complication.
Barotrauma ; Catheters ; Constriction, Pathologic ; Emergencies ; Epidural Space ; Female ; Hemiplegia ; Humans ; Intervertebral Disc ; Leg ; Lower Extremity* ; Sensation ; Spinal Stenosis ; Young Adult

BACKGROUND: Insomnia is becoming increasingly recognized as a clinically important symptom in patients with chronic low back pain (CLBP). In this retrospective study, we have determined risk factors associated with clinical insomnia in CLBP patients in a university hospital in Korea. METHODS: Data from four-hundred and eighty one CLBP patients was analyzed in this study. The Insomnia Severity Index (ISI) was used to determine the presence of clinical insomnia (ISI score > or = 15). Patients' demographics and pain-related factors were evaluated by logistic regression analysis to identify risk factors of clinical insomnia in CLBP. RESULTS: It was found that 43% of patients reported mild to severe insomnia after the development of back pain. In addition, 20% of patients met the criteria for clinically significant insomnia (ISI score > or = 15). In a stepwise multivariate analysis, high pain intensity, the presence of comorbid musculoskeletal pain and neuropathic pain components, and high level of depression were strongly associated with clinical insomnia in CLBP. Among these factors, the presence of comorbid musculoskeletal pain other than back pain was the strongest determinant, with the highest odds ratio of 8.074 (95% CI 4.250 to 15.339) for predicting clinical insomnia. CONCLUSIONS: Insomnia should be addressed as an integral part of pain management in CLBP patients with these risk factors, especially in patients suffering from CLBP with comorbid musculoskeletal pain.
Back Pain ; Demography ; Depression ; Humans ; Korea ; Logistic Models ; Low Back Pain* ; Multivariate Analysis ; Musculoskeletal Pain ; Neuralgia ; Odds Ratio ; Pain Management ; Retrospective Studies* ; Risk Factors* ; Sleep Initiation and Maintenance Disorders*