Pain physician
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Review Case Reports
Epidural blood patch for chronic daily headache with postural component: a case report and the review of published cases.
Post dural puncture headache (PDPH) can be observed after any trauma to the dura. The hallmark of PDPH is an increasing headache when assuming the upright position and improvement with the supine position. Diagnosis of PDPH is essentially based on history of dural puncture and clinical presentation. ⋯ Epidural blood patch is a safe and effective treatment for PDPH and routinely done for acute onset of postural headache after spinal or epidural anesthesia or analgesia. Here, we report the successful treatment of chronic daily headache with a postural component via an epidural blood patch one year after the onset. We also review the literature pertinent to the use of epidural blood patch in chronic daily headache patients with postural component.
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Congenital lumbar spinal stenosis is an uncommon condition that is often asymptomatic in young adults. Herein, we document the first reported occurrence of acute radicular back pain and associated congenital lumbar spinal stenosis in a healthy 24-year-old woman undergoing an epidural blood patch for treatment of a post-dural puncture headache related to an accidental dural puncture sustained during placement of a labor epidural catheter. The acute pain symptoms were elicited twice with injection of less than 1 mL of fluid into the epidural space during the fluoroscopically assisted epidural blood patch. ⋯ The prominent epidural fat could have prevented rapid disbursement of the injected fluid which could have further served to propagate the pressure increase throughout the epidural compartment. The unique radiographic features of congenital spinal stenosis could predispose some patients with this unrecognized condition to develop acute pain upon injection of a small amount of fluid into the epidural compartment. Unrecognized congenital lumbar spinal stenosis is an important addition to the differential diagnosis of acute radicular pain elicited during an epidural blood patch in previously asymptomatic patients.
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Headache following interventional procedures is a diagnostic challenge due to the multitude of possible etiologies involved. Presentation can be simple (PDPH alone) or complex (exacerbation of pre-existing chronic headache along with PDPH) or headache associated with a new onset intracranial process. Subdural hematoma is a rare complication of cranio-spinal trauma. ⋯ We report a case of acute intracranial subdural hematoma secondary to unintentional dural puncture during placement of a permanent spinal cord stimulator lead for refractory angina. There is need for careful follow-up of patients with a known post-dural tear. Failure to identify uncommon adverse events in patients with complicated spinal cord stimulator implantation may lead to permanent injury.
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Case Reports
Successful treatment of digital ulcers in a scleroderma patient with continuous bilateral thoracic sympathetic block.
Raynaud's phenomenon (RP) associated with connective tissue disease (secondary RP) may be difficult to manage with conservative therapy. A combination of sympathetically mediated vasospasm and vaso-occlusion has been implicated as the etiology of digital ischemic phenomenon. Thoracic sympathetic outflow blocking has been performed with various techniques. However, there have been some limitations in all treatment options. ⋯ Continuous infusion of mepivacaine into the thoracic sympathetic ganglionic space led to the healing of the medically refractory gangrenous ulcer of the fingers in the patient with scleroderma.
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Spinal pain is common in all age groups. While the research has focused primarily on incidence and prevalence in younger working adults, there is evidence that spinal pain is one of the most frequent complaints in older persons and is responsible for functional limitations. While facet arthrosis is a common radiographic finding, which has been suggested to be a potential cause of spinal pain, nearly 10% of all adults show signs of degeneration by the time they reach age 30. Radiographic changes of osteoarthritis have been shown to be equally common in patients with and without low back or neck pain. The studies of low back pain have shown the prevalence of facet joint involvement to be approximately 15% to 45%. However, age related prevalence of facet joint neck pain has not been studied. ⋯ This study demonstrated a variable age-related prevalence of facet joint pain in chronic low back pain, whereas in the cervical spine it was similar among all the age groups.