The Clinical Features, Risk Factors, and Surgical Treatment of Cervicogenic Headache in Patients With Cervical Spine Disorders Requiring Surgery.

OBJECTIVE: To clarify the clinical features and risk factors of cervicogenic headache (CEH; as diagnosed according to the International Classification of Headache Disorders-Third Edition beta) in patients with cervical spine disorders requiring surgery. BACKGROUND: CEH is caused by cervical spine disorders. The pathogenic mechanism of CEH is hypothesized to involve a convergence of the upper cervical afferents from the C1, C2, and C3 spinal nerves and the trigeminal afferents in the trigeminocervical nucleus of the upper cervical cord. According to this hypothesis, functional convergence of the upper cervical and trigeminal sensory pathways allows the bidirectional (afferent and efferent) referral of pain to the occipital, frontal, temporal, and/or orbital regions. Previous prospective studies have reported an 86-88% prevalence of headache in patients with cervical myelopathy or radiculopathy requiring anterior cervical surgery; however, these studies did not diagnose headache according to the International Classification of Headache Disorders criteria. Therefore, a better understanding of the prevalence rate, clinical features, risk factors, and treatment responsiveness of CEH in patients with cervical spine disorders requiring surgery is necessary. METHODS: We performed a single hospital-based prospective cross-sectional study and enrolled 70 consecutive patients with cervical spine disorders such as cervical spondylotic myelopathy, ossification of the posterior longitudinal ligament, cervical spondylotic radiculopathy, and cervical spondylotic myeloradiculopathy who had been scheduled to undergo anterior cervical fusion or dorsal cervical laminoplasty between June 2014 and December 2015. Headache was diagnosed preoperatively according to the International Classification of Headache Disorders-Third Edition beta. The Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire, Neck Disability Index, and a 0-100 mm visual analog scale (VAS) were used to evaluate clinical features, and scores were compared between baseline (ie, preoperatively) and 3, 6, and 12 months post-surgery. RESULTS: The prevalence of CEH in our population was 15/70 (21.4%, 95%CI: 11.8% to 31.0%). The main clinical features were dull and tightening/pressing headache sensations in the occipital region. Headache severity was mild (VAS, 32 ± 11 mm) and only one patient reported use of an oral analgesic. Compared to patients without CEH, patients with CEH had higher frequencies of neck pain (86.7% vs. 50.9%; P = .017), cervical range of motion limitation (ROM) (66.7% vs. 38.2%; P = .049), and higher Neck Disability Index scores (14 vs. 3; P < .001). Among the different cervical spine disorders, the prevalence of CEH was highest in cervical spondylotic myeloradiculopathy patients (60%), being ≤ 20% for all other disorders. Surgical treatments including cervical laminoplasty to relieve abnormal pressure on the spinal cord via a posterior approach, were associated with initial improvements in headache VAS that slightly diminished by 12 months post-surgery (P < .001). CONCLUSIONS: We report a lower prevalence of CEH in patients with cervical spinal disorders requiring surgery than that reported previously. The main clinical features of CEH were mild, dull, and tightening/pressing headache sensations in the occipital region. Potential risk factors for CEH included neck pain, limited cervical ROM, high Neck Disability Index score, and a diagnosis of cervical spondylotic myeloradiculopathy. The further accumulation of patients in a multi-institutional study may be required in order to discuss the diagnostic criteria and pathophysiology of this condition.

[Effectiveness of low dose PCEA for postoperative pain after laparoscopic gynecological surgeries--a comparison of laparoscopic ovarian cystectomy and myomectomy].

BACKGROUND: We evaluated the effectiveness of low-dose patient-controlled epidural analgesia (PCEA) in the patients undergoing laparoscopic gynecological surgery, and investigated the difference of postoperative pain between patients for laparoscopic ovarian cystectomy and those for myomectomy. METHODS: Thirteen patients (ASA PS 1 or 2), scheduled for laparoscopic surgery, were enrolled in this study. They were divided into two groups of ovarian cystectomy (group C, n=17) and myomectomy (group M, n=13). After administering epidural bolus of 0.2% ropivacaine 6 ml, droperidol 2.5 mg, and buprenorphine hydrochloride 0.1 mg, PCEA was started: 1 ml x hr(-1) background infusion; 0.2% ropivacaine 54 ml, droperidol 5 mg, and buprenorphine hydrochloride 0.3 mg; 1 ml epidural bolus with a 30-minute lockout interval. We evaluated postoperative pain using visual analogue scale (VAS) at rest and on movement, adverse effects such as respiratory and cardiovascular depression, nausea and vomiting for 48 hours after surgery. RESULTS: VAS at rest with group M was significantly higher than that of group C (11 +/- 2 vs. 6 +/- 2, P=0.048), and VAS on movement of group M was also higher than that of group C (25 +/- 3 vs. 18 +/- 2, P=0.023): however, we found good analgesic effect of less than VAS 3 in both groups. Severe adverse effects were not observed. CONCLUSIONS: These findings suggest that low dose PCEA is effective for patients who undergo laparoscopic gynecological surgery.

[Clinical Aspects of Cervicogenic Headache].

Cervicogenic headache (CEH) is a lateralized non-pulsative headache syndrome caused by cervical spine disorders. The headache is initiated in the neck, which subsequently spreads to the occipital, frontal, and orbital regions, and is accompanied by ipsilateral shoulder pain. The prevalence of CEH is considered to be 15-20% among cases of chronic headache. With regard to the mechanism of CEH, convergence of upper cervical nerves and trigeminocervical complex might play an important role. However, CEH in many patients has been reported to be associated with middle to lower cervical disorders, which cannot be explained by this theory. We therefore proposed the possibility that the condition reported here is another type of CEH. The treatment of CEH requires a multidisciplinary approach, because pharmacological treatment is often ineffective. (Received August 16 2019; Accepted November 25, 2019; Published March 1, 2020).

Nasal sumatriptan as adjunctive therapy for idiopathic trigeminal neuralgia: report of three cases.

We examine the effect of nasal sumatriptan as an adjunctive therapy in 3 patients with idiopathic trigeminal neuralgia refractory to carbamazepine (CBZ) and found that this therapy might be suitable for patients for whom the CBZ dose cannot be increased, who are under poor pain control, and who are not candidates for nerve blocks or surgery.

Addition of 0.1% bupivacaine to buprenorphine and droperidol in patient-controlled epidural analgesia improved postoperative pain scores on coughing after gynecological surgery.

STUDY OBJECTIVE: To compare the analgesic efficacy of additional 0.1% bupivacaine to patient-controlled epidural analgesia (PCEA) using buprenorphine and droperidol after gynecological surgery. DESIGN: Randomized, double-blinded study. SETTING: Operating theater and general ward at Jichi Medical School Hospital. PATIENTS: Thirty patients with American Society of Anesthesiologists physical status I and II scheduled for gynecological surgery. INTERVENTIONS: Patients received combined general and epidural anesthesia for surgery and epidural analgesia for postoperative analgesia. Patients were assigned to receive PCEA with or without 0.1% bupivacaine. Group 1 (n = 15) received buprenorphine 20 microg and droperidol 0.1 mg diluted with saline, and group 2 (n = 15) received bupivacaine 2 mg, buprenorphine 20 microg, and droperidol 0.1 mg diluted with saline (0.1% bupivacaine solution) in a bolus dose of the PCEA, respectively. No background epidural infusion was used. MEASUREMENTS: Visual analog pain scale (VAPS) scores at rest and on coughing, and cumulative frequency of self-administrated analgesic solution in PCEA were recorded at 24 and 48 hours postoperatively. MAIN RESULTS: There were no significant differences noted between the groups in VAPS scores at rest or in cumulative volumes of PCEA solution in 24 or 48 hours postoperatively. Median VAPS scores on coughing in group 2 were significantly lower than those values in group 1 at 24 hours (36 vs 65 mm, P < .001) and 48 hours (32 vs 54 mm, P = .036) postoperatively. CONCLUSIONS: Addition of 0.1% bupivacaine to PCEA using buprenorphine and droperidol provides better analgesia on coughing after gynecological surgery.

[Perioperative management of Parkinson's disease].

Several studies have demonstrated the serious impact of surgeries on patients with Parkinson's disease (PD). In addition, PD is a risk factor for postoperative complications and prolonged hospital stays. Discontinuation of anti-Parkinsonian drugs due to surgery causes an exacerbation of Parkinsonism and sometimes Parkinsonism-hyperpyrexia syndrome (PHS). Therefore, surgeries involving patients with PD require careful perioperative management. During the preoperative period, cooperation among neurologists, surgeons, and anesthesiologists is imperative. Administration of the same oral anti-Parkinsonian drug regimen that was prescribed during home care is important. Methods of both general and regional anesthesia should be chosen based on general health status and symptoms of Parkinsonism and agents should be selected with due consideration of their possible interaction with anti-Parkinsonian drugs. In patients with PD showing autonomic disturbance, changes in blood pressure and body temperature should be monitored. During the postoperative phase, postoperative pain, aspiration pneumonia, ileus, and psychotic symptoms should be managed, taking into consideration the interactions between anti-Parkinsonian drugs and therapeutic agents. Currently, new anti-Parkinsonian drugs, such as rotigotine and apomorphine are available for patients with PD requiring parenteral treatment. It is important that medical experts share awareness about perioperative problems and their management in patients with PD.