Earticle

The prevalence of chronic pain patients is steadily increasing every year due to the aging population and the increase of various chronic diseases. According to the study on the “condition of the elderly population” published in 2008, about 82% of the 65-year-old population complained of pain, and it is known that 93% of the elderly suffer from pain diseases in their daily life. Various drugs used for pain control include acetaminophen, non-steroidal anti-inflammatory drugs, steroids, antidepressants, and opioids. The use and necessity of opioid analgesics are gradually increasing worldwide, and the side effects are also growing yearly. Therefore, efforts are being made to reduce opioid analgesics, and research for developing new drugs is being conducted steadily. Antidepressants are known to be effective in neuropathic pain. This article discusses the primary mechanism of neuropathic pain, effective drug treatment, essential characteristics of tianeptine sodium among antidepressants, and reported clinical effects.

A 77-year-old male with a past medical history of posterior lumbar interbody fusion(L4/5) presented with a 6 months history of lower back and left leg (lateral thigh) pain. Preoperative MRI imaging revealed left neural foraminal stenosis at L4-5 with spondylolisthesis. On the first visit, a transforaminal epidural block was performed at the L4/5 level using a mixture of 0.4% lidocaine 5ml with dexamethasone 2.5mg, hyaluronidase 5cc. On the second visit, an L4/5 interlaminar epidural block was performed in order to improve the flow of the injectate. 15 minutes after the injection, the patient complained of persistent numbness in both legs with motor function intact. Blood pressure and heart rate dropped slightly, but soon recovered without any treatment given. The patient’s speech became slurred after 40 minutes, then his behavior became violent and aggressive. After about 60-80 minutes, his behavior was not controlled. We consulted a neurologist, who gave an opinion that despite having no obvious neurological abnormalities, the violent behavior might have been caused by lidocaine CNS toxicity. The neurologist suggested a MRI diffusion of the brain to be done to rule out any acute lesions. 2mg of midazolam was administered to control the violent behavior prior to the MRI diffusion. No abnormalities were found on the MRI, and the patient returned home after regaining consciousness.

A somatovisceral reflex is a reflex elicited by stimulation of the somatic tissues, that is, the tissues of the musculoskeletal system or skin, and manifesting as alterations in the functions of visceral organs. Somatovisceral reflexes are often mediated by way of the autonomic nervous system.

Medial epicondylitis (golfer’s elbow) is very common disease at the primary medical institutions. Recently, the number of patients is increasing rapidly due to the increase in the golf and tennis population. Initially, it responds well to steroid injection and Extracorporeal Shock Wave Therapy. However, if it becomes chronic, such as tearing of tendons or calcification, the response to conventional treatments will decrease. In this report, we describe a case of successful treatment of the severe calcific tendinitis using platelet-rich plasma (PRP) injection. A 56-year-old female patient who showed severe medial epicondyle pain with a torn common flexor tendon with calcification received five times of PRP treatment every 2 weeks. After PRP treatment, it can be seen that the shading inside the tendon increased and calcification findings decreased. The symptoms of the patient were relieved after the treatment, without any complications. In conclusion, PRP injection can be a successful way to treat chronic elbow tendinitis

Buttock pain is a common complaint of patients in the pain clinic. However, assessment of fractures can be difficult if there is no trauma history. A 65-year-old woman with rheumatoid arthritis complained of bilateral pains in the buttocks for a month. She didn’t have a history of falls or other traumas and no fracture line was visible in plain lumbar X-rays. Although the patient had taken analgesics for two weeks, her pain persisted even with newly developed severe pain in the left groin. Magnetic resonance imaging of the pelvis revealed fragility fractures of the left parasymphyseal area and bilateral sacral ala. In addition, previously unrecognized osteoporosis was detected. Fragility fracture of the pelvis are rare, but we recommend that clinicians may consider these problems when an elderly patient complains of the motion-related sacrum or groin pain.

Cervical Epidural Steroid Injection (CESI) is generally performed as a conservative treatment for neck pain or radiating pain in the upper extremity due to cervical disc herniation and stenosis. Although the incidence of complications after an epidural steroid injection is reported to be relatively low, various side effects such as traumatic damage to the spinal nerve, dural puncture, and infection may occur. However, permanent nerve damage and neurological side effects are known to be very rare, with an approximate level of 1:100,000. In the case of nerve damage, a single nerve may be affected, causing temporary paralysis or muscle weakness. Still, these effects are usually temporary and will fully recover within a few days or weeks. Permanent nerve damage is sporadic. Moreover, the development of persistent allodynia after epidural injection is a much rarer complication, and only a few cases have been reported in the literature. Therefore, we would like to share our experience against the occurrence of persistent allodynia without any evidence of nerve damage during cervical epidural steroid injections for patients with cervical disc herniation.

Despite advancements in device and implantation techniques, complications related to intrathecal drug delivery systems are common and may also produce acute withdrawal syndromes. Catheter-related problems are one of the main causes of these complications. The authors present a case of repeated loss of effectiveness of an intrathecal morphine pump following successful implantation in a patient with chronic pancreatitis. The patients experienced pain relief after implantation, but after 3 months, he complained of a sudden worsening of pain. We checked pump-catheter system based on the protocol. Lumbar spine radiographs were obtained to confirm the correct placement of both the pump and the catheter. Pump malfunction was excluded by activating the bolus mode to rotate the pump’s roller. The entire length of the catheter from the pump to the tip was then examined under fluoroscopy and a myelogram was obtained. There was no evidence of a fracture or kink, nor was there leakage at the catheter’s lumen or tip. The patient’s pain was well controlled for a short period, but the patient suffered episodes of repeated aggravation. Despite retraction of the catheter by a few centimeters, his pain recurred. A surgical exploration of the pump-catheter system was then scheduled based on our suspicion that the catheter was partially clogged. The catheter showed no apparent defects or leakage. After the replacement, the patient’s pain decreased substantially. When intrathecal drug delivery systems failure is suspected and all troubleshooting steps have failed to identify the defect, replacing the catheter system may be the final option.