Pain physician
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A cluster headache (CH) is an excruciating pain centered on the periorbital region and is accompanied by autonomic symptoms. Despite the best currently available medical therapy, many patients still suffer from these headaches. Some patients also experience CH with side shift of attacks, which makes treatment more difficult. In light of the pathophysiological mechanism of CH, the sphenopalatine ganglion (SPG) is a promising therapeutic target for its management. SPG ablation and non-ablation techniques have been the preferred treatment for CH in recent decades. However, few articles have reported the effectiveness of acute SPG stimulation for CH, and no studies have demonstrated the safety and efficacy of bilateral continuous SPG stimulation for CH. In this article, we report on a 59-year-old chronic cluster headache (CCH) patient who had side shifts of attacks and was treated with bilateral continuous SPG stimulation. The patient suffered from CCH for 9 years, and the intensity of pain and the frequency of attacks had gradually increased over time. At the time of admission, he experienced daily attacks. Medical therapy and SPG blocks were offered, but he only achieved transient pain relief. After a careful preoperative examination and discussion with the patient, we provided bilateral SPG stimulation. The electrode was implanted under C-arm fluoroscopic guidance. After continuous stimulation, the patient experienced significant reductions in headache severity. The frequency of attacks was reduced from daily to less than once per week. He also discontinued all of the related drugs that he was taking. This is the first report of bilateral continuous SPG stimulation for CCH. This report indicates that continuous SPG stimulation is a feasible therapeutic option for CCH. However, large-scale and long-term studies are required to elucidate the efficacy of SPG stimulation. ⋯ Cluster headache, sphenopalatine ganglion, SPG, neuromodulation, side shift, stimulation.
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The management of pain due to cancer is challenging and often requires invasive therapy in addition to medication management. Intrathecal drug delivery is a form of advanced therapy that delivers medication locally in the intrathecal space while reducing systemic side effects associated with high doses of opioids. Although risks associated with intrathecal drug delivery are low, some common complications include dislodgement, kinking, or fracture of the catheter, bleeding, neurological injury, infection, and cerebrospinal leaks. We present a case of a 38-year-old woman with a medical history significant for stage IV breast cancer, L2 metastatic lesion, opioid tolerance, and chronic neck and low back pain who was admitted to the hospital for intractable pain. She had failed multiple interventional procedures in the past including lumbar medial nerve radiofrequency ablation, epidural steroid injection, and trigger point injections as well as a kyphoplasty at the L2 level. Failing both oral and parenteral opioid treatments, the decision was made to place an intrathecal pump in the patient. After placement of the intrathecal catheter and prior to any bolus of medication being given, the patient became bradycardic with a heart rate in the 20s and experienced a 10 second pause. The patient had intermittent bradycardia over the following days and symptoms resolved only after removal of the intrathecal catheter itself. To our knowledge, this is the first reported case with a complication of recurrent bradycardic and asystolic episodes prior to the administration of intrathecal opioid but shortly after placement of the intrathecal catheter itself. ⋯ Intrathecal drug delivery, complications, cancer pain, intrathecal analgesia, bradycardia, opioids.
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Case Reports
Pain Relief in CRPS-II after Spinal Cord and Motor Cortex Simultaneous Dual Stimulation.
We describe a case of a 30-year-old woman who suffered a traumatic injury of the right brachial plexus, developing severe complex regional pain syndrome type II (CRPS-II). After clinical treatment failure, spinal cord stimulation (SCS) was indicated with initial positive pain control. However, after 2 years her pain progressively returned to almost baseline intensity before SCS. Additional motor cortex electrode implant was then proposed as a rescue therapy and connected to the same pulse generator. This method allowed simultaneous stimulation of the motor cortex and SCS in cycling mode with independent stimulation parameters in each site. At 2 years follow-up, the patient reported sustained improvement in pain with dual stimulation, reduction of painful crises, and improvement in quality of life. The encouraging results in this case suggests that this can be an option as add-on therapy over SCS as a possible rescue therapy in the management of CRPS-II. However, comparative studies must be performed in order to determine the effectiveness of this therapy. ⋯ Chronic neuropathic pain, Complex regional pain syndrome Type II, brachial plexus injury, motor cortex stimulation, spinal cord stimulation.
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In modern medicine, obstructive sleep apnea syndrome (OSAS) is a commonly described sleep disorder with airway obstruction, disrupted sleep, and excessive daytime sleepiness. Since its description in 1976 by Guilleminault et al, numerous epidemiologic studies and systematic reviews, with multiple comorbidities related to cardiovascular sequelae, altered cognitive function, and multiple other potential complications have been described. Multiple risk factors have been identified included obesity, smoking, alcohol consumption, and other factors. Chronic pain and chronic opioid therapy also have been described to contribute to a large proportion of patients with OSAS. Chronic pain, obesity, smoking, and chronic opioid therapy are often found together, yet there is a paucity of literature describing OSAS in chronic pain patients. ⋯ Obstructive sleep apnea syndrome, chronic pain, chronic spinal pain, chronic opioid therapy, obesity, smoking, cardiovascular risk factors, pulmonary risk factors.
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Lumbar spinal stenosis is one of most common pathologic conditions affecting the lumbar spine. Pain and/or disability in the low back and lower extremities with or without neurogenic claudication may occur as a result of compression of dural sac contents or nerve roots in the narrowed space. Bulging and protrusion, facet joint hypertrophy, and disc herniation combined with osteophytes and arthritic changes of facet joints can be the cause of lumbar spinal stenosis. Medical/interventional treatment may be considered as an initial treatment for patients with mild symptoms of lumbar spinal stenosis. Surgery is usually considered when medical/interventional treatment has failed. Even though surgery has been considered to be the definitive treatment for spinal stenosis conventionally, it has potential problems including general anesthesia related complications and failed back surgery syndrome. For that reason, minimally invasive techniques such as percutaneous endoscopic lumbar discectomy (PELD), epiduroscopic laser neural decompression (ELND), and nucleoplasty with radiofrequency have been developed as alternatives to surgery.The authors present a case of treating lumbar spinal stenosis by using radiofrequency thermocoagulation. Radiofrequency therapy is used for spinal pain, usually in forms of neurotomy or nucleoplasty. The patient in this case had leg pain with neurogenic claudication caused by lumbar spinal stenosis from facet joint hypertrophy. His pain did not respond to conservative treatment including epidural steroid injection, but he didn't want to get surgery. As an alternative to surgery, we applied radiofrequency thermocoagulation with high temperatures of electrode to the hypertrophied facet joint for the decompressing of the spinal nerve and the patient's pain was improved without any complications after the treatment. ⋯ Low back pain, neurogenic claudication, lumbar spinal stenosis, facet joint hypertrophy, radiofrequency thermocoagulation, minimally invasive technique.