1/24. A 15-year-old with back pain, fever, and leg numbness.Spinal epidural abscess (SEA) is an uncommon entity. We report an adolescent presenting with fever and back pain beginning 3 months after a leg abscess. This case highlights several important aspects of the diagnosis and care of patients with SEA. As illustrated by this case, plain radiographs and computed tomography of the spine can miss the diagnosis, thus when spinal epidural abscess is suspected, magnetic resonance imaging is the imaging modality of choice. Epidural abscesses most commonly arise from hematological dissemination, with staphylococcus aureus being the most often cultured organism. Surgical intervention early combined with the administration of proper antibiotics leads to the best outcome.- - - - - - - - - - ranking = 1keywords = administration (Clic here for more details about this article) |
2/24. Spinal epidural abscess complicating chronic epidural analgesia in 11 cancer patients: clinical findings and magnetic resonance imaging.We reviewed the records of all patients who had received an epidural catheter for management of chronic cancer pain in a 3-year period (1993-1996). patients with nervous system infections were identified, and pertinent clinical, radiological (magnetic resonance imaging), and bacteriological data were analyzed. We identified 11 patients who developed spinal epidural abscess (SEA). All of these had back pain; radicular signs occurred in seven patients and spinal cord compression in two patients. magnetic resonance imaging revealed SEA in all 11 patients. SEA was iso- to hypointense on T1-weighted images and hyperintense on T2-weighted images relative to spinal cord. After gadolinium administration seven lesions showed characteristic rim enhancement while three showed minimal enhancement. No signs of diskitis or osteomyelitis were present, and the abscess was always localized to the posterior epidural space. Cultures were positive in all cases and revealed staphylococcus epidermidis in eight and S. aureus in three. All patients were treated with intravenous antibiotics, and four had an additional decompressive laminectomy. Two patients died within 1 week of diagnosis from overwhelming septicemia despite apparently adequate antibiotic treatment. Within 4 weeks after diagnosis of SEA two patients died from widely metastatic disease, although infection may have contributed. One patient developed septicemia while receiving appropriate antibiotics and underwent emergency laminectomy. The neurological deficits recovered in all patients who survived the acute infectious episode. We conclude that patients with chronic epidural catheters for cancer pain require prompt neurological evaluation and magnetic resonance imaging when SEA is suspected. Early evaluation and treatment may lead to full recovery.- - - - - - - - - - ranking = 1keywords = administration (Clic here for more details about this article) |
3/24. Treatment of severe low back pain with opioids during pregnancy in a patient with incomplete tetraplegia.We report a case of severe low back pain during pregnancy in a woman with incomplete tetraplegia due to viral myelitis. The pain was interpreted as a radiculopathy in the presence of multiple herniated discs. Surgical intervention was not indicated and physiotherapy failed; therefore, a symptomatic drug treatment with oral analgesics was initiated. To minimise the total daily opioid dosage and the potential risk of a neonatal withdrawal syndrome due to opioids, the route of administration was changed from oral to epidural. Adequate pain relief was maintained with this regimen until caesarean section was necessary. The neonatal withdrawal symptoms after delivery were mild. Residual pain slowly diminished after delivery and the patient was able to discontinue opioid therapy. The aetiology of low back pain remains unclear and may be multifactorial.- - - - - - - - - - ranking = 1keywords = administration (Clic here for more details about this article) |
4/24. A viable residual spinal hydatid cyst cured with albendazole. Case report.Spinal hydatid disease is a rare entity that frequently yields to severe, acute-onset neurological deficits. Although the gold standard treatment is total surgical removal of the cysts without inducing any spillage, it may not be possible to perform this in patients with multiple and fragile cysts. In such cases, the neural structures should be adequately decompressed and albendazole should be administered promptly. The authors describe the case of a 13-year-old girl who was admitted with a history of back pain and acute-onset lower-extremity weakness. magnetic resonance imaging scans demonstrated severe spinal cord compression caused by multiple cysts involving T-4 and the mediastinum. The patient underwent surgery, and the cysts were removed, except for one cyst that was hardly exposed. Following histopathological confirmation of spinal hydatid disease, she was treated with albendazole for 1 year. One year postoperatively, the residual cyst had gradually shrunk and had almost disappeared. Although a single case is not sufficiently promising, we believe that administration of albendazole is efficient to prevent recurrences in cases in which it is not possible to obtain total removal of the cysts without inducing spillage.- - - - - - - - - - ranking = 1keywords = administration (Clic here for more details about this article) |
5/24. The long-term antinociceptive effect of intrathecal S( )-ketamine in a patient with established morphine tolerance.IMPLICATIONS: Our report describes for the first time the continuous long-term intrathecal application of S( )-ketamine in a patient with chronic pain and morphine tolerance. Intrathecally applied S( )-ketamine led to a significant pain reduction and consecutively reduced the doses of intrathecal morphine required for pain relief even several weeks after the cessation of the 24-day period of intrathecal S( )-ketamine administration.- - - - - - - - - - ranking = 1keywords = administration (Clic here for more details about this article) |
6/24. Transient blindness after lumbar epidural steroid injection: a case report and literature review.STUDY DESIGN: A case report of transient blindness after lumbar epidural steroids is presented. OBJECTIVE: To report the diagnosis and treatment of a case of blindness after administration of lumbar epidural steroids. SUMMARY OF BACKGROUND DATA: Nine previous cases of blindness after lumbar epidural injection for back pain were identified. Retinal hemorrhages were identified on ophthalmologic examination in all cases. methods: The 1-year follow up evaluation of a 39-year-old male who sustained transient blindness after administration of lumbar epidural steroids is reported. RESULTS: At 1 year, the patient had significant return of vision, but it did not improve back to baseline. CONCLUSIONS: Transient blindness is a rare complication of lumbar epidural injection. The pathophysiology and prevention of this rare entity is reviewed.- - - - - - - - - - ranking = 2keywords = administration (Clic here for more details about this article) |
7/24. Perispinal TNF-alpha inhibition for discogenic pain.OBJECTIVE: To examine the potential of etanercept, a biological inhibitor of tumour necrosis factor-alpha (TNF), delivered by perispinal administration, for the treatment of pain associated with intervertebral disc disease. methods: charts from 20 selected patients treated at our private clinic by perispinal delivery of etanercept 25 mg for severe, chronic, treatment-resistant discogenic pain were reviewed. Therapeutic benefit was assessed clinically and was documented by changes in a validated pain instrument, the Oswestry Disability Index. The patients were treated off-label with etanercept as part of our usual practice of medicine. Five detailed case reports are presented, including three additional patients. RESULTS: Rapid, substantial and sustained clinical pain reduction was documented in this selected group of patients. The cohort of 20 patients had a mean age of 56.5 and mean duration of pain of 116 months. Nine of the patients had undergone previous spinal surgery; 17 had received an epidural steroid injection or injections (mean 3.2). This group of patients received a mean of 1.8 doses (range 1-5, median 1.0) of etanercept during the observation period. The mean length of follow-up was 230 days. Clinical improvement was confirmed by a decrease in the calculated Oswestry Disability Index from a mean of 54.85 /- 12.5 at baseline, improving to 17.2 /- 15.3 (p <0.003) at 24 days and ending at 9.8 /- 13 (p <0.003) at 230 days. CONCLUSIONS: TNF inhibition by etanercept delivered by perispinal administration may offer clinical benefit for patients with chronic, treatment-resistant discogenic pain. Further study of this new treatment modality is warranted.- - - - - - - - - - ranking = 2keywords = administration (Clic here for more details about this article) |
8/24. portal vein thrombosis.portal vein thrombosis (PVT) is a complication of hepatic disease and a potentially lethal complication of splenectomy. The reported incidence of this complication is low (approximately 1%). However, its true incidence may have been underestimated due to difficulty in making the diagnosis. Herein we report the case of a 19 year-old woman who presented with a 2-year history of idiopathic thrombocytopenic purpura (ITP). Because she had become refractory to medical therapy, she underwent laparoscopic splenectomy. She was discharged on postoperative day 2 after an uncomplicated procedure. She did well, complaining only of mild backache, until postoperative day 21, when she presented with nausea, vomiting, and leukocytosis. CT showed PVT and superior mesenteric vein thrombosis. Despite heparin and fluid administration, her condition worsened. At laparotomy, she had diffuse small bowel edema and congestion. At a second-look procedure 24 h later, nearly all her jejunum and ileum were necrotic. After three procedures, she was left with 45 cm of proximal and 10 cm of distal small bowel. Bowel continuity was restored 8 weeks later. She continued on warfarin anticoagulation therapy for 1 year. Postsplenectomy PVT is most often seen following splenectomy for myeloproliferative disorders and almost never after trauma. The large splenic vein stump and the hypercoagulable state in patients with splenomegaly are thought to be contributory. The presentation of PVT is vague, without defining signs or symptoms. color-flow Doppler and contrast-enhanced CT scans are the best methods for the nonoperative diagnosis of PVT. Aggressive thrombolysis offers the best hope for clot lysis and maintenance of bowel viability. Even vague symptoms must be considered seriously following splenectomy.- - - - - - - - - - ranking = 1keywords = administration (Clic here for more details about this article) |
9/24. Early detection measures and triage procedures for suicide ideation in chronic pain patients.There is a dearth of writings about early detection of potential suicide patients in chronic pain centers. Early detection measures used at the Vanderbilt Pain Control Center include a Symptom checklist-90, with questions about depressive symptomatology and "Thoughts of Ending Your Life"; medical and psychological interviews; monitoring of changes in emotional disturbance; and, if warranted, administration of the Scale of suicidal ideation. Three case studies are presented that indicate that the results of an assessment measure should be tempered with clinical judgment. Suicidal behavior, including suicidal ideation, is a medical emergency; therefore, there is great need for early detection and triage measures.- - - - - - - - - - ranking = 1keywords = administration (Clic here for more details about this article) |
10/24. Efficacy of etanercept delivered by perispinal administration for chronic back and/or neck disc-related pain: a study of clinical observations in 143 patients.OBJECTIVE: documentation of the clinical results obtained utilizing perispinal etanercept off-label for treatment-refractory back and neck pain in a clinical practice setting. research design AND methods: The medical charts of all patients who were treated with etanercept for back or neck pain at a single private medical clinic in 2003 were reviewed retrospectively. patients were treated if they had disc-related pain which was chronic, treatment-refractory, present every day for at least 8 h, and of moderate or severe intensity. patients with active infection, demyelinating disease, uncontrolled diabetes, lymphoma or immunosuppression were excluded from treatment with etanercept. Etanercept 25 mg was administered by subcutaneous injection directly overlying the spine. Visual Analogue Scales (VAS, 0-10 cm) for intensity of pain, sensory disturbance, and weakness prior to and 20 min, 1 day, 1 week, 2 weeks, and 1 month after treatment were completed. Inclusion criteria for analysis required baseline and treatment VAS data. MAIN OUTCOME MEASURES: Before and after treatment VAS comparisons for intensity of pain, sensory disturbance, and weakness. RESULTS: 143 charts out of 204 met the inclusion VAS criteria. The 143 patients had a mean age of 55.8 /- 14, duration of pain of 9.8 /- 11 years, and an initial Oswestry Disability Index of 42.8 /- 18, with 83% having back pain, 61% sciatica, and 33% neck pain. 30% had previous spinal surgery, and 69% had previously received epidural steroid injections (mean 3.0 /- 3). The patients received a mean of 2.3 /- 0.7 doses of perispinal etanercept separated by a mean interval of 13.6 /- 16.3 days. The mean VAS intensity of pain, sensory disturbance, and weakness were significantly reduced after perispinal etanercept at 20 min, 1 day, 1 week, 2 weeks, and 1 month with a p < 0.0001 at each time interval for the first dose in this patient population. CONCLUSIONS: Perispinal etanercept is a new treatment modality which can lead to significant clinical improvement in selected patients with chronic, treatment-refractory disc-related pain. Generalizability of the present study results is limited by the open-label, uncontrolled methodology employed. Based on this and other accumulating recent studies, etanercept may be useful for both acute and chronic disc-related pain. Further study of this new treatment modality utilizing double-blind placebo controlled methodology is indicated. NOTE: This treatment method is protected by multiple patents awarded to Edward Tobinick MD, including U. S. patents 6 015 557; 6 177 077; 6 419 944; 6 537 549 and Australian patent 758 523.- - - - - - - - - - ranking = 4keywords = administration (Clic here for more details about this article) |
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