A 33-year-old man with chronic back pain was found to have a thoracic disc hernia on magnetic resonance imaging. However, a spinal surgeon made a diagnosis of non-specific back pain because there was no spinal cord or nerve root compression. We performed a diagnostic epidural steroid injection. Although the patient had insufficient pain relief after the interlaminar epidural block, a fluoroscopy-guided transforaminal epidural block provided complete pain relief with the injection of a local anesthetic and corticosteroid in the dorsal epidural space. There is no consensus on whether thoracic disc herniation without nerve compression may cause chronic axial pain. However, this case indicates that chronic inflammation of the dorsal epidural space around the herniated disc may cause chronic axial back pain and the thoracic transforaminal epidural block may be useful for its diagnosis and treatment.
A 51-year-old man who presented with persistent pain in the left mandible at our hospital was diagnosed with trigeminal neuralgia in the otolaryngology department. Ten years later, he relapsed. A close examination revealed that the glossopharyngeal neuralgia was caused by the left anterior inferior cerebellar artery. Owing to drug resistance, he was referred to our department and underwent microvascular decompression via left lateral suboccipital craniotomy. The left anterior inferior cerebellar artery was fixed to the pyramidal bone, and its contact with the glossopharyngeal nerve was released. No postoperative complications were observed, and the left mandibular pain promptly disappeared. No recurrence was observed at the 6-month follow-up.
We encountered a case of repeated subdural hematoma (SDH) caused by spontaneous intracranial hypotension (SIH) that was successfully treated with two epidural blood patches (EBPs). A woman in her 60s developed sudden headaches, nausea, and vomiting. After several visits to the clinic, brain examination showed bilateral SDH, and she came to our referral. Though a burr hole drainage underwent, SDH did not improve, and she complained of orthostatic headaches. SIH with SDH was suspected, and CT myelography showed the findings of contrast medium leakage to the epidural space of T1–8. An EBP underwent checking her increased intracranial pressure. A total of 25 ml of autologous blood was administered at the T3/4 level, but the headache continued. An additional EBP with 20 ml underwent at the T6/7 level the following day, and the headache was relieved. SIH might cause repeated SDH. In cases of SIH with SDH, it is essential to perform EBPs by paying attention to the increase of intracranial pressure.
A 4-year-old boy was diagnosed with a tumor in the left fourth rib. Tumor resection was performed. After induction of general anesthesia, the patient was placed in the right lateral position, and ultrasound-guided paravertebral blockade (PVB) was performed at the left T4 thoracic vertebra level using the left lateral intercostal approach. Ten milliliters of 0.25％ ropivacaine was used for the PVB. Intraoperative analgesia was sufficient. The Faces Pain Rating Scale score was 0 after surgery. Since the patient had no complications throughout the perioperative period, he was discharged from the intensive care unit one day after surgery and returned home two days after surgery. As this surgical procedure involved periosteal damage, severe pain was expected. In addition, there was a possibility of intercostal nerve damage and extensive resection due to intraoperative pathological findings. Although PVB is occasionally performed in children undergoing thoracoscopic surgery, it can provide effective analgesia in patients undergoing rib resection. In conclusion, single-puncture PVB was useful for surgery in our case because it produced a sufficient area and duration of postoperative analgesia.
Polymyositis-dermatomyositis is a disorder of the body's connective tissues, which causes swelling and tenderness in the muscles (polymyositis) and occasionally the skin (dermatomyositis) and weaknesses in the arms and legs. We have described cases of two patients with severe whole-body muscle pain who were diagnosed with polymyositis-dermatomyositis. Both patients showed excellent response to linear polarized infrared irradiation of the stellate ganglion (SGI) and xenon light irradiation (Xe), which was performed instead of a nerve block. SGI and Xe promote analgesia, anti-inflammatory effects, and tissue healing and may be a safe and effective treatment for muscle pain in patients with polymyositis-dermatomyositis.
C-arm fluoroscopy is a standard apparatus for neuroplasty using Racz catheter. We reported two cases of performing that treatment with O-arm fluoroscopy. Case 1: A 75-year-old man with C8 root area pain. Although he had previously undergone conventional therapies, his pain has remained for 5 years. We applied neuroplasty using Racz catheter with O-arm fluoroscopy. It was difficult to detect where the catheter was through lateral imaging because of overlapping humeral and shoulder bones. But CT imaging by O-arm fluoroscopy could show location of the catheter easily. Case 2: A 60-year-old woman with L5 root area pain. The pain was due to pelvic fractures by traffic accident and it remained for 2 years. We applied neuroplasty using Racz catheter with O-arm fluoroscopy. CT imaging by O-arm fluoroscopy showed the catheter was located in intervertebra foramen. O-arm can be a useful fluoroscopy when performing neuroplasty using Racz catheter.
There is little evidence that spinal cord stimulation (SCS) is effective for chronic abdominal pain (CAP). Here we report a case of SCS for CAP due to biliary dyskinesia. The patient had a history of cholecystectomy 18 years ago, and suddenly developed biliary dyskinesia. Celiac plexus block was performed total 10 times, but as the effect of treatment was diminishing, we conducted a trial of SCS. The epidural lead was placed at the Th5 level, and after 13 trial days pain intensity decreased and opioid usage was decreased. Convention-SCS or high-frequency stimulation were introduced. Since the sympathetic nervous system is related to pain derived from the visceral nerve, the SCS system may be effective for reducing CAP and represents a promising treatment option.