Earticle

Following the COVID-19 pandemic in 2020, encounters with patients experiencing post-vaccination pain have become increasingly common in outpatient settings. This case report highlights a 47-year-old male, initially devoid of any underlying conditions, presenting with persistent lower back and bilateral thigh pain following his third COVID-19 vaccination. Despite analgesics, his pain intensified, prompting further investigation. Lumbar MRI revealed mild disc protrusion at L4-L5 and widespread signal intensity abnormalities in the vertebrae and pelvis, suggesting a hematogenous disorder. Subsequent blood tests showed decreased platelets and atypical leukocytes, leading to a final diagnosis of acute myeloblastic leukemia after being transferred to the department of hematology. This case underscores the importance of comprehensive assessment in patients with post-vaccination symptoms, where seemingly routine pain may indicate underlying severe conditions. It highlights the necessity for pain physicians to consider a broad differential diagnosis, including serious hematological diseases, when evaluating post-vaccination complaints.

This case report discusses a 63-year-old male with chronic refractory musculoskeletal pain and muscle cramps in both calves, persisting for 20 years despite various treatments like nerve blocks and trigger point injections. Initial evaluations showed no specific findings. After ineffective management with vitaminmagnesium therapy, pramipexole, tizanidine, and transcutaneous electrical nerve stimulation, the patient underwent intramuscular collagen injections in the gastrocnemius and soleus muscles. Following a total of eight injections, there was a significant improvement in muscle spasm and pain. The report suggests that type 1 collagen may be a promising treatment for refractory chronic musculoskeletal pain by promoting tissue recovery, serving as a scaffold for repair, or directly reducing inflammation.

We report a case of sternoclavicular joint infection with chest wall abscess in a 54-year-old female with right shoulder pain for one month. The patient had hypertension and newly diagnosed diabetes. Laboratory findings showed elevated inflammatory markers. Chest MRI confirmed infectious arthritis with abscess, and blood cultures isolated Methicillin-sensitive Staphylococcus aureus. After surgical drainage and 7-week antibiotic therapy, the patient improved. This case emphasizes considering sternoclavicular joint infection in persistent shoulder pain, especially with risk factors like diabetes.

Fabry disease is an X-linked recessive disorder of glycosphingolipid metabolism resulting from the deficient activity of the lysosomal enzyme, α-galactosidase A. It leads to the systemic accumulation of glycosphingolipids including globotriaosylceramide (GL3) in the plasma and tissue lysosomes. Classically affected hemizygous males, with no residual α-galactosidase Aactivity may display all the characteristic sign, including neurological (pain), cutaneous (angiokeratoma), renal (proteinuria, kidney failure), cardiovascular (cardiomyopathy, arrhythmia), cochleo-vestibular and cerebrovascular (transient ischemic attacks, strokes) features of the disease. While, heterozygous females have symptoms ranging from very mild to severe. Thus, it is not easy to diagnose Fabry disease in female patients, because of the variable clinical features. This case is a patient who was considered to have an ordinary fibromyalgia but was found to have a Fabry disease by detailed history taking and examination. We herein report a case of chronic somatic pain due to Fabry disease without other systematic manifestations.

Failed back surgery syndrome has been defined as persistent low back pain with or without radiating pain despite previous spine surgery, and it has various etiologies. Given the high probability that the pain would be chronic and intractable, it is essential to employ a broad range of therapeutic strategies. Radiofrequency ablation (RFA) may serve as one of the treatment options. A 64-year-old woman who had undergone lumbar fixation (L4–5) surgery five years ago visited our multidisciplinary pain center, complaining of back pain with radiating pain to both lower extremities (NRS 8) despite receiving medications at a local clinic. Following a positive diagnostic medial branch block, we decided to perform RFA using a novel multitined (Diros TridentTM) radiofrequency needle device, which has been reported to be more effective than conventional single-tined needles. Heat RFA was conducted on the right L3, L4, and L5 medial branches of the patient after nerve stimulation for localization. One month after the procedure, the patient reported a reduction in pain intensity (NRS 5 from 8). The patient is being followed up to evaluate the long-term effects. Additional comparative research is required to validate the therapeutic and side effects of multitined needles.

Lumbar percutaneous epidural neuroplasty (L-PEN) may be an effective treatment for lumbar disc herniation (LDH) symptoms such as ongoing neuropathic pain brought on by spinal root compression and spinal canal stenosis. L-PEN is a minimally invasive therapy that involves inserting a specially made catheter right into the pathological spinal canal site in order to both manually remove soft tissue adhesions and effectively administer medication to the desired region. We use a mixture of various medication including local anesthetics for reducing the pain during L-PEN. However, unexpected intrathecal or intravascular uptake of local anesthetics can happen occasionally and this may cause adverse reactions. In this report, we would like to share our experience concerning the occurrence of systemic toxicity of local anesthetics during L-PEN.

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.

Spinal nerve root metastases are extremely rare and have only been reported as individual cases, while metastases to non-primary sites are common in malignant tumors. Metastatic breast cancer often spreads to bones, liver, lungs, and brain. Among these, the bones metastasized by cancer cells include commonly the rib, vertebra, pelvis, and long bone in arm or leg. We report here a rare case that breast cancer metastasized S1-3 nerve roots. An involving patient showed thick nerve roots at the sacral intervertebral regions, which was a strong enhancement in contrast-enhanced magnetic resonance imaging. Based on a pathological examination, primary lesions of the patient were revealed as breast cancer and additional multiple metastases were founded within the brain. The clinical process was characterized by worsening radiculopathy, especially intractable pain. Radiological appearance may be similar to neurogenic tumors of lesions in the intervertebral region, because of an enlargement of the nerve root and its marked contrast enhancement. Local tumor control and pain relief can be performed through radiation therapy, but it is only palliative treatment. Thus, a metastatic possibility of malignant neoplasm should be considered in patients with radiological sign of radiculopathy.

Chronic pain after spinal surgery, which is called failed back syndrome, is known as chronic pain developing or increasing in intensity after surgery that persists or recurs for longer than 3 months following spinal surgery. This type of pain remains challenging to treat with medications and interventions including conventional spinal cord stimulation (SCS) particularly when it involves intractable axial pain. Recently, Differential Target Multiplexed (DTM) SCS has been introduced, which is a new stimulation paradigm with the aim of modulating glial cells and neurons to rebalance their interactions. DTM SCS has been mainly applied to patients with low back and lower extremity pain, and its use in cervical or upper extremity pain has been rarely reported. In this report, we present a case of DTM SCS, which successfully treat the patient with intractable chronic cervical axial pain after cervical spinal surgery.

A 69-year-old man visited multidisciplinary pain center as an out-patient, complaining of back pain (NRS 9) after trauma 15 days ago. The pain was exacerbated by position change and cough. Percussion tenderness was present at mid-thoracic level, but neurologic exam was normal. T-spine image revealed compression fracture at T6 and 7. Ultrasound-guided paravertebral block at right T7 level was performed in a prone position. The patient coughed during injection, and presented severe chest pain and shortness of breath. The patient was transferred to ER under doubt of pneumothorax. Initial vital sign at ER was BP 172/84mmHg, HR 155/min. Chest X-ray revealed tension pneumothorax at right upper lung field. 16G needle was inserted Right 5~6th rib and simultaneously thoracic surgeon was called. After needle insertion, chest pain and shortness of breath were improved and vital sign was improved to BP 136/68mmHg, HR 92/min. Atelectasis of right lung was improved after chest tube drainage by thoracic surgeon. After admission, osteoporotic compression fracture was diagnosed based on MRI and DXA finding. The patient presented worsened back pain (NRS 10) and epidural steroid injection at T6-7 had no effectiveness. Percutaneous balloon kyphoplasty was done at T6 and T7 using extrapedicular approach. After kyphoplasty, back pain was improved to NRS 2/10, and no other complication was seen. Eight days after, chest tube was removed after confirmation of no drainage. The patient was discharged the next day. After 2 weeks, patient visited multidisciplinary pain center, no pain remained and CXR was normal.