Does a Positive Response to Transforaminal Epidural Steroid Injection Identify Patients Who Can Avoid Surgery for Two Years?

Background: Transforaminal epidural steroid injection (TFESI) is widely used to manage lumbar radiculopathy. In clinical settings, patients often undergo repeated transforaminal epidural injections with or without steroid administration. Objectives: To examine whether a positive response to TFESI at the first month, can in clinical settings, identify patients with radiculopathy who can avoid surgery for two years. Study Design/Setting. This prospective observational study was conducted at an academic medical center. Methods: Individuals aged ≥20 years who had been referred to our pain center by spine surgeons were enrolled. All patients were assessed using the Numerical Rating Scale (NRS) at baseline and 1 month after the first TFESI. Patients were divided into two groups according to the NRS decrement: the positive response (PR) group achieved a ≥2.0 decrease on the NRS 1 month after the first TFESI compared to baseline and the no response (NR) group achieved a <2.0 decrease on the NRS. The incidence rates of surgery over two years were compared between the two groups. In addition, we calculated the hazard ratio of the PR group to the NR group regarding the incidence of surgery over two years using the Cox proportional hazard model, adjusting for baseline NRS. Results: Seventy-six patients completed the two-year follow-up. In total, 8 and 68 patients had bilateral and unilateral radiculopathy, respectively. The PR and NR groups included 35 and 41 patients, respectively. The rate of surgery avoidance was 85.7% and 73.2% in the PR and NR groups, respectively. This difference was not statistically significant (p=0.26). After adjusting for baseline NRS, the hazard ratio of the PR group to the NR group regarding the incidence of surgery within two years was 0.35 (95% confidence interval: 0.11-1.11, p=0.08). Conclusion: A positive response to TFESI may not identify patients who can avoid surgery for two years.

Correlation between pain catastrophizing in acute herpes zoster and postherpetic neuralgia: a retrospective analysis.

PURPOSE: The objective of this study was to examine the association between pain catastrophizing in acute phase herpes zoster and the development of postherpetic neuralgia. METHODS: The medical records of all patients diagnosed with herpes zoster between February 2016 and December 2021 were retrieved. Inclusion criteria were patients aged > 50 years who visited our pain center within 60 days after rash onset and reported a pain intensity of ≥ 3 in a numerical rating scale. Patients with a score of 30 or more in the pain catastrophizing scale at baseline were assigned to the catastrophizer group, and those with a score < 30 were assigned to the non-catastrophizer group. We defined patients with "postherpetic neuralgia" and "severe postherpetic neuralgia" as those with a numerical rating scale score of 3 or more and 7 or more at 3 months after baseline, respectively. RESULTS: Data of 189 patients were available for complete analysis. Age, baseline numerical rating scale, and prevalence of anxiety and depression were significantly higher in the catastrophizer than those in the non-catastrophizer group. Incidence of postherpetic neuralgia did not differ significantly between the groups (p = 0.26). Multiple logistic regression analysis showed that age, severe pain at baseline, and immunosuppressive state were the factors which were independently associated with developing postherpetic neuralgia. Severe pain at baseline was the only factor related to developing severe postherpetic neuralgia. CONCLUSION: Pain catastrophizing in the acute phase of herpes zoster may not be related to the development of postherpetic neuralgia.

Prevalence and associated factors of disability in patients with chronic pain: An observational study.

ABSTRACT: The primary treatment goal of patients experiencing chronic pain has shifted from pain reduction to functional status improvement. However, the prevalence of disability and its associated factors in patients with chronic pain remain unknown.Individuals aged ≥50 years who visited the Pain Center at Nara Medical University with chronic pain from June 2019 to May 2020 were eligible for enrollment. Patients were asked to complete the Japanese version of the 12-item World Health Organization Disability Assessment Schedule 2.0. Patient demographics, pain intensity, level of catastrophizing, anxiety, depression, and exercise habits were assessed. Multivariate logistic regression analysis was used to identify the factors associated with disability.Of the 551 patients with a median age of 73 years, 51.5% experienced disability. Fixed factors such as age (odds ratio [OR], 1.03; 95% confidence interval [CI] 1.01-1.06, P = .002) and lumbar and lower limb pain (OR, 3.10; 95% CI, 1.83-5.24, P < .001) and some modifiable factors, including anxiety (OR, 2.06; 95% CI, 1.06-3.98, P = .03), depression (OR, 3.62; 95% CI, 1.92-6.82, P < .001), pain catastrophizer (OR, 2.94; 95% CI, 1.88-4.61, P < .001), numeric rating scale at the most painful site (OR, 1.29; 95% CI, 1.18-1.42, P < .001), exercise habits (walking (OR, 0.52; 95% CI, 0.33-0.83, P = .006) and working out (OR, 0.58; 95% CI, 0.34-0.99, P = .046), were found to be independently associated with disability.This cross-sectional study revealed a high prevalence of disability in patients with chronic pain and identified the factors associated with disability.

The short-term effect of COVID-19 pandemic on disability, pain intensity, psychological status, and exercise habits in patients with chronic pain.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has affected the lives of people worldwide. The first declaration of a state of emergency in Japan, based on the Act on Special Measures for the Prevention and Control of the Novel Coronavirus, was issued from 16 April 2020 to 14 May 2020 to reduce person-to-person contact. Restrictions on going out, participating in community activities, and visiting hospitals were in place. This study investigates the short-term effects of the COVID-19 pandemic on patients with chronic pain. METHODS: This study included outpatients with chronic pain undergoing treatment at the Pain Center of Nara Medical University Hospital. The patients had completed questionnaires for a disability during the study period, from 1 July to 30 September 2019 (baseline), 1 October to 31 December 2019 (pre-pandemic), and 1 July to 30 September 2020 (during the pandemic). The questionnaire covered changes in disability, pain intensity, health-related quality of life (QOL), anxiety, depression, catastrophic thinking, and the presence/absence of exercise habits at baseline, pre-pandemic, and during the pandemic. RESULTS: Of the 245 eligible patients, there was no significant disability difference between baseline, pre-pandemic, and during the pandemic (p = 0.14). Similarly, pain intensity, health-related QOL, anxiety, depression, and the presence/absence of exercise habits did not significantly differ between baseline, pre-pandemic, and during the pandemic either. The current study observed significant differences in terms of catastrophic thinking (p = 0.02). CONCLUSION: The effects of the COVID-19 pandemic on patients with chronic pain were not apparent in the short-term. Clinical trail registration: UMIN000043174.

Genistein inhibits chondrogenic differentiation and mineralization of ATDC5 cells.

Isoflavones are phytoestrogens abundant in leguminous crops and are used to prevent a variety of hormonal disorders. In the present study, the effects of genistein and daidzein on the chondrogenic differentiation of ATDC5 cells were investigated. Genistein (10 µM) treatment markedly reduced production of sulfated proteoglycans and collagen fibers in the ATDC5 cells. Genistein suppressed the expression of genes involved in chondrocyte differentiation such as Sox9, Col2a1, Col10a1, Acan, and Tgfb1. Additionally, genistein significantly decreased calcium deposition in ATDC5 cells during chondrogenic differentiation; however, it increased calcification under non-chondrogenic mineralizing conditions. Daidzein exhibited a similar effect of suppressing chondrogenesis in ATDC5 cells, although its efficacy was 10-times lower than that of genistein. These findings suggest that a high concentration of genistein inhibits chondrogenesis and chondrogenic mineralization, whereas it enhances non-chondrogenic mineralization.

Regulatory Role of Orexin in the Antistress Effect of "Press Tack Needle" Acupuncture Treatment.

The aim of this research was to investigate the antistress effect of press tack needle (PTN) acupuncture treatment using rats with social isolation stress (SIS). Rats were divided into non-stress group (Grouped+sham), stress group (SIS+sham), and PTN-treated SIS group (SIS+PTN). Rats in the SIS+PTN and SIS+sham groups were housed alone for eight days. For the SIS+PTN group, a PTN (length, 0.3 or 1.2 mm) was fixed on the GV20 acupoint on day 7. We measured stress behavior based on the time the rats showed aggressive behavior and the levels of plasma corticosterone and orexin A on day 8. In addition, the orexin-1 receptor or orexin-2 receptor antagonist was administered to rats that were exposed to SIS. The duration of aggressive behavior was significantly prolonged in the SIS+sham group, and the prolonged duration was inhibited in the SIS+PTN (1.2 mm) group. The levels of plasma corticosterone and orexin A were significantly increased in the SIS+sham group; however, these increases were inhibited in the SIS+PTN group. The aggressive behavior was significantly reduced after the orexin-2 receptor antagonist was administered. These findings suggest that PTN treatment at GV20 may have an antistress effect, and the control of orexin is a mechanism underlying this phenomenon.

Feasibility, reliability, and validity of the 12-item World Health Organization Disability Assessment Schedule 2.0 in patients attending the pain clinic.

PURPOSE: In the cohort of patients attending pain clinic, the primary goal has been shifting from pain reduction to improving activities of daily living and functional status. The 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is one of the useful tools for assessment of functional status across all psychiatric and medical diseases; however, its feasibility, reliability, and validity have not been assessed in these patients. Thus, in this study, we evaluated the feasibility, reliability, and validity of the 12-item WHODAS 2.0 in patients attending the pain clinic at our university hospital. METHODS: This is a prospective observational study including the patients aged 50 years or older who were attending the pain clinic at Nara Medical University between April 2019 and May 2019. Patient-related outcomes including functional status and activities of daily living were assessed with the 12-item WHODAS 2.0, EuroQol-5 dimension 5 levels, and the Tokyo Metropolitan Institute of Gerontology Index. RESULTS: The response rate was 99.7%. The 12-item WHODAS2.0 had a floor effect but no ceiling effect and its Cronbach's α coefficient was 0.909. The correlation coefficients between the 12-item WHODAS 2.0 score and the EuroQol-5 dimension 5 levels and the Tokyo Metropolitan Institute of Gerontology Index were -0.66 and -0.67, respectively. CONCLUSIONS: The 12-item WHODAS 2.0 is a useful measurement tool to assess disability of pain patients with high reliability and validity.

A Prospective Comparison of CT-Epidurogram Between Th1-Transforaminal Epidural Injection and Th1/2-Parasagittal Interlaminar Epidural Injection for Cervical Upper Limb Pain.

BACKGROUND: Cervical epidural injections for treating neck and upper limb pain are performed by 2 methods: transforaminal and interlaminar. Many serious complications caused by inadvertent intravascular injection have been reported with the use of cervical transforaminal epidural steroid injection through the anterior-lateral approach. Despite international practical guidelines that have been proposed, cervical transforaminal epidural injection is still less recommended than cervical interlaminar epidural injection. OBJECTIVES: The objective of this study is to introduce Th1-transforaminal epidural injection (Th1-TFEI) through the posterior-lateral approach, compare the injectate spread in Th1-TFEI with that of Th1/2-parasaggital interlaminar epidural injection (Th1/2-pILEI), and clarify the clinical characteristics of Th1-TFEI. STUDY DESIGN: This research involved a prospective study of 30 patients receiving both Th1-TFEI and Th1/2-pILEI. METHODS: Thirty patients with unilateral upper limb pain were enrolled for this prospective study. Th1-TFEI and Th1/2-pILEI were administered on each case in random order under fluoroscopy, and computed tomographic (CT) epidurograms were compared. Changes in circulatory dynamics, presence of Horner's syndrome, changes in the Numerical Rating Scale (NRS-11), and adverse events were investigated. RESULTS: Patients included 15 men and 15 women and included 24 cases of cervical spine disease and 6 cases with other upper limb pain. The Th1-TFEI group had significantly higher rates of "Th1 root filling" (100%), "ventral spread" (70.0%), and "lateral limitation" (26.7%) compared to the Th1/2-pILEI group. In the Th1-TFEI group, cephalad spread averaged 2.97 vertebral bodies, reaching approximately up to C6. The Th1/2-pILEI group had an average of 4.76 vertebral bodies, approximately up to C4. The 2 groups showed significant differences in cephalad spread. Horner's syndrome appeared in the Th1-TFEI group at a rate of 56.7%, significantly higher than that in the Th1/2-pILEI group at 17.2%. The presence of Horner's syndrome showed significant correlations with "ventral spread" and "spread up to C6." There were no significant differences in NRS-11 improvement and changes in circulatory dynamics between the groups. There were no major complications. LIMITATIONS: The components of injectate were standardized; however, the needle gauge numbers were varied. In addition, interpretation of the CT-epidurogram was not blinded. The sample size was small; therefore, multivariate analysis was not possible. CONCLUSIONS: CT-epidurogram comparison revealed that Th1/2-pILEI was not localized on the injection side, and there was better dorsal spread - although ventral spread was small. Contrarily, Th1-TFEI was localized on the injection side, and better ventral spread was shown while cephalad spread was limited. We expected the addition of a sympathetic block effect suggested by the Horner's syndrome as well as the merits of the ventral spread. However, short-term clinical effects were equal to those of Th1/2 pILEI. In future research, we need to standardize the diseases to include and to increase the number of cases to enable evaluation of clinical effectiveness. KEY WORDS: Epidural, cervical, transforaminal, interlaminar, fluoroscopy, CT-epidurogram, dorsal, ventral, cephalad, Horner's syndrome.

Transforaminal vs Interlaminar Epidural Steroid Injection for Acute-Phase Shingles: A Randomized, Prospective Trial.

BACKGROUND: The acute phase of shingles is characterized by severe pain, and one of the complications of shingles known as postherpetic neuralgia (PHN) is associated with prolonged pain. Although factors predicting the development of PHN, as well as its preventative measures, have been investigated, there is no single treatment effective for PHN. Some studies showed effectiveness of epidural injection to alleviate pain associated with acute-phase shingles. In these studies, epidural injection was performed by interlaminar (IL) approach. However, transforaminal (TF) approach may be more effective as it enables injection of steroids and local anesthetics closer to the dorsal root ganglion where inflammation primarily occurs. There have not been any studies comparing the analgesic effects of epidural injection approaches for pain associated with acute-phase shingles. OBJECTIVE: We compared the analgesic effects of IL and TF epidural injection approaches for pain associated with acute-phase shingles. STUDY DESIGN: We conducted a randomized prospective trial. SETTING: Nara Medical University Hospital, Department of Anesthesiology. METHODS: Forty patients with acute-phase shingles were randomly assigned to receive epidural steroid injections by TF or IL approaches. Patients were evaluated at the baseline, as well as at 1 month and 3 months after the treatment using the VAS and SF-36 scores. Patients with VAS score of over 40 at the 3-month follow-up were considered as having PHN, and the number of patients with PHN was compared between the IL and TF groups. RESULTS: Except the mental component of the SF-36 score and severity of skin rash, patient characteristics were not significantly different between the groups. VAS scores at 1 and 3-month follow-up were significantly lower than those at the baseline, and there was no difference between the groups. All SF-36 scores were not significantly different between groups at 1- and 3-month. There was no significant difference in the occurrence of PHN between the groups. LIMITATIONS: We had a small sample size that did not reach the number of patients needed by the power analysis in the study. Then, our follow-up period of 3 months was relatively short. CONCLUSIONS: VAS scores, the SF-36 RCS and MCS scores improved in both groups, however, there was no difference in the analgesic effects of the IL and TF epidural steroid injections at 1 and 3 months for acute-phase shingles patients. KEY WORDS: Shingles epidural steroid injection interlaminar approach; transforaminal approach, fluoroscopic, postherpetic neuralgia, VAS, SF-36.

The effects of vitamin B6 compounds on cell proliferation and melanogenesis in B16F10 melanoma cells.

B16F10 murine melanoma cells are frequently used for the study of cancer and melanogenesis. The cells are usually cultured in Dulbecco's Modified Eagle Medium, with the addition of 20 µM pyridoxal (PL) or pyridoxine (PN) for vitamin B6. The difference between these vitamin B6 compounds is thought not to affect cell proliferation, whereas their influence on other physiological effects is poorly understood. In the present study, the effects of PL and PN on cell proliferation and melanogenesis in B16F10 cells were compared. At 500 µM PL significantly suppressed cell growth but the growth inhibitory effect of PN was weak. Although neither of the vitamin B6 compounds affected cell growth at 20 µM, melanogenesis was suppressed by 20 µM PL compared with the effect of PN. In addition, the expression levels of tyrosinase, which is the rate-limiting enzyme, correlated with the melanin content. The results of the present study indicate that PL may be more useful for melanoma therapy and suppression of skin pigmentation than PN. The results also signify the importance of medium selection for cell culture.

Cervical Castleman's disease mimicking lymph node metastasis of esophageal carcinoma.

Castleman's disease (CD) is an uncommon benign lymphoproliferative disorder of unknown etiology. A rare case of cervical CD diagnosed at lymph node dissection for esophageal carcinoma is reported. An esophageal tumor was identified in a 67-year-old man during a follow-up examination after surgery for oral carcinoma. Esophagoscopy revealed a type 1 tumor in the cervical esophagus. Histology of esophagoscopic biopsies indicated squamous cell carcinoma. Contrast-enhanced computed tomography revealed swollen lymph nodes of the right cervical region. No distant metastasis was detected. Esophageal carcinoma, T2N2M0, Stage IIIA was diagnosed. Neoadjuvant chemotherapy was recommended, but the patient rejected the chemotherapy. The patient underwent laparoscopic-assisted transhiatal esophagectomy. The histopathological diagnosis was moderately differentiated squamous cell carcinoma with pT1bN0M0, Stage IA. On histology, the swollen lymph nodes of the right cervical region revealed CD. The patient's postoperative course was relatively good.

[Duchenne Muscle Dystrophy Caused Bronchial Obstruction].

Duchenne muscle dystrophy (DMD), X-linked recessive genetic disorder, causes a variety of complications including scoliosis. We report a case of bronchial obstruction and hemorrhage caused by scoliosis with DMD. A man in his forties having been hospitalized due to DMD since the age of 6, produced bloody sputum. A chest X-ray showed atelectasis in his right lower lung. A computed tomography and bronchoscopy indicated that scoliosis and thoracic deformity due to muscle dystrophy caused compression of a right main bronchus by the vertebra, leading to bronchial obstruction and bleeding. We decided to follow closely without therapy because the bleeding had stopped as of the bronchoscopy. A high-risk surgery or bronchial stenting may be needed if he presents with severe bleeding or infection.

Transforaminal epidural blood patch for intractable spontaneous cerebrospinal fluid leak: a case report.

BACKGROUND: Epidural blood patch (EBP) is a recognized treatment for spontaneous cerebrospinal fluid leak (SCFL) and is typically administered by the interlaminar approach. Here, we report a case of a patient in whom SCFL failed to resolve after three applications of interlaminar EBPs before finally being successfully treated with transforaminal EBP. CASE PRESENTATION: We report a case of a 41-year-old female with a definitive diagnosis of SCFL according to computed tomography (CT) myelography. A fluoroscopy-guided interlaminar EBP was applied three times without resolution of her orthostatic headache. A second myelography was therefore performed demonstrating a leak point on the ventral side of the dura mater. To close the ruptured ventral dura mater, it was necessary to fill the ventral epidural space with blood. Therefore, transforaminal EBP was performed. On spinal CT performed immediately after treatment, the ventral epidural space was observed to be filled with injected blood. Her headache improved the following day, and her symptoms completely subsided after 5 days. CONCLUSION: Transforaminal epidural blood patch is appropriate for patients with intractable cerebrospinal fluid leak. Patients with cerebrospinal fluid leakage due to rupture of the ventral side of the dura mater may be particularly good candidates for this procedure.

Pancreatic Pseudocyst Ruptured due to Acute Intracystic Hemorrhage.

Rupture of pancreatic pseudocyst is one of the rare complications and usually results in high mortality. The present case was a rupture of pancreatic pseudocyst that could be treated by surgical intervention. A 74-year-old man developed abdominal pain, vomiting, and diarrhea, and he was diagnosed with cholecystitis and pneumonia. Three days later, acute pancreatitis occurred and computed tomography (CT) showed slight hemorrhage in the cyst of the pancreatic tail. After another 10 days, CT showed pancreatic cyst ruptured due to intracystic hemorrhage. Endoscopic retrograde cholangiopancreatography revealed leakage of contrast agent from pancreatic tail cyst to enclosed abdominal cavity. His left hypochondrial pain was increasing, and CT showed rupture of the cyst of the pancreatic tail into the peritoneal cavity was increased in 10 days. CT showed also two left renal tumors. Therefore we performed distal pancreatectomy with concomitant resection of transverse colon and left kidney. We histopathologically diagnosed pancreatic pseudocyst ruptured due to intracystic hemorrhage and renal cell carcinoma. Despite postoperative paralytic ileus and fluid collection at pancreatic stump, they improved by conservative management and he could be discharged on postoperative day 29. He has achieved relapse-free survival for 6 months postoperatively. The mortality of pancreatic pseudocyst rupture is very high if some effective medical interventions cannot be performed. It should be necessary to plan appropriate treatment strategy depending on each patient.

Time-dependent transition of the immunoglobulin G subclass and immunoglobulin E response in cancer patients vaccinated with cholesteryl pullulan-melanoma antigen gene-A4 nanogel.

A phase I+II clinical trial of vaccination with MAGE-A4 protein complexed with cholesteryl pullulan melanoma antigen gene-A4 nanogel (CHP-MAGE-A4) is currently underway in patients with MAGE-A4-expressing cancer. In the present study, the primary phase I endpoint was to test the safety of the administration of 300 µg CHP-MAGE-A4 with and without OK-432. Another aim of the study was to clarify the details of the specific humoral immune response to vaccination. The 9 patients enrolled for phase I were vaccinated 6 times, once every 2 weeks: 3 patients with 100 µg and 3 patients with 300 µg CHP-MAGE-A4, and 3 patients with 300 µg CHP-MAGE-A4 plus 0.5 clinical units of OK-432. Toxicities were assessed using Common Terminology Criteria for Adverse Events v3.0. Clinical response was evaluated by modified Response Evaluation Criteria in Solid Tumours. Immunological monitoring of anti-MAGE-A4-specific antibodies was performed by ELISA of pre- and post-vaccination patient sera. The 6 vaccinations produced no severe adverse events. Stable disease was assessed in 4/9 patients. Anti-MAGE-A4 total immunoglobulin (Ig)G titers increased in 7/9 patients. Efficacious anti-MAGE-A4 IgG1, 2 and 3 antibody responses were observed in 7/9 patients. Among them, positive conversions to T helper 2 (Th2)-type antibody responses (IgG4 and IgE) were observed after frequent vaccination in 4/7 patients. The Th2 conversion was possibly associated with undesirable clinical observations, including progressive disease and the appearance of a new relapse lesion. The present study suggested that frequent vaccinations activated a Th2-dominant status in the cancer patients. The identification of a time-dependent IgG subclass and IgE antibody production during vaccination protocols may be a useful surrogate marker indicating a potentially undesirable change of the immunological environment for an effective antitumor immune response in cancer patients.

Magnetic resonance volumetry of the hippocampus in familial spontaneous epileptic cats.

A strain of familial spontaneous epileptic cats (FSECs) with typical limbic seizures was identified in 2010. The electroencephalographic features suggested that an epileptogenic zone is present in the mesial temporal structures (i.e., amygdala and/or hippocampus). In this study, visual evaluations and quantitative analyses were performed by using 3D MR hippocampal volumetry in comparing FSECs with age-matched controls. Visual hippocampal asymmetries were seen in 8 of 14 (57.1%) FSECs. The FSEC group showed a significantly higher asymmetric ratio (4.15%) than the control group (0.99%). The smaller side of hippocampal volume (HV) (0.206 cm(3)) in FSECs was significantly smaller than the mean HV in controls (0.227 cm(3)). However, the means of left and right HVs and total HVs in FSECs showed no differences because the laterality of hippocampal atrophy was different in each individual. Therefore, since FSECs represent a true model of spontaneous epilepsy, hippocampal volumetry should be evaluated in each individual as well as in human patients. The significant asymmetry of HV suggests the potential for hippocampal atrophy in FSECs.

Evaluation on a clinical course of subdural hematoma in patients undergoing epidural blood patch for spontaneous cerebrospinal fluid leak.

OBJECTIVE: Subdural hematoma (SDH) is a frequent complication of spontaneous intracranial hypotension (SIH), in which epidural blood patch (EBP) may be applied as a treatment to stop cerebrospinal fluid (CSF) leak. However, a clinical course of SDH in SIH patients has not been sufficiently evaluated. We retrospectively evaluated the temporal relationships between EBP and SDH in the patients with SIH. METHODS: Twenty-nine consecutive patients, diagnosed as SIH, were studied. Clinical records and images were retrospectively evaluated. When orthostatic headache continued for 2 weeks regardless of conservative treatment, EBP was performed under fluoroscopy. RESULTS: We detected 13(45%) cases of SDH (mean age 44 years, 8 males and 5 females). In 6 patients, SDHs disappeared after effective EBP, i.e., after the disappearance of orthostatic headache. In 3 patients, SDHs were enlarged or recurred after effective EBP, and in 4 patients, SDHs were first detected after effective EBP. CONCLUSION: The knowledge of the presence of these types of SDH (enlarged or recurred or detected after EBP) may deserve clinical attention.

Comparison between computed tomography-myelography and radioisotope-cisternography findings in whiplash-associated disorders suspected to be caused by traumatic cerebrospinal fluid leak.

STUDY DESIGN: A retrospective observational study. OBJECTIVE: To investigate the traumatic cerebrospinal fluid (CSF) leak in whiplash-associated disorders (WADs) by comparing radioisotope-cisternography (RIC) and computed tomography (CT)-myelography (CTM) findings. SUMMARY OF BACKGROUND DATA: WAD has been considered to be caused by traumatic CSF leak and termed as traumatic CSF hypovolemia. Several studies have reported that CSF leak was detected on RIC in the lumbosacral region of patients with WAD. However, recent evidence has indicated that RIC sometimes creates false-positive results by detecting nerve roots or cysts as CSF leak, whereas the appearance of contrast medium in the epidural space on CTM demonstrates CSF leak directly. So far there have been no data to compare the RIC and CTM findings in patients with WAD. METHODS: RIC and CTM were performed on 36 patients with WAD, and the RIC and CTM findings were compared. In RIC, 37 MBq (111)In was injected, and paraspinal RI accumulation was evaluated as a direct sign of CSF leak. In CTM, 10 mL of iohexiol (240 mg I/mL) was infused via lumbar puncture, and multislice CT scan of the whole spine was acquired. Epidural collection of contrast medium, nerve root morphology, and cystic structures were investigated. RESULTS: Paraspinal RI accumulation was observed in 19 patients on RIC, and it was located in the lumbosacral region in 18 patients. In contrast, no epidural collection was observed on CTM. CTM findings revealed that root sleeves and cystic structures were observed at the locations in which paraspinal RI accumulation was noted on RIC. CONCLUSION: The results in this study indicated that traumatic CSF leak was not observed on CTM in patients with WAD, in whom CSF leak was suspected on RIC.

Molecular cloning and characterization of canine fractalkine and its receptor CX3CR1.

Fractalkine, also known as CX(3)CL1, is a unique chemokine that mediates inflammatory responses and is involved in the pathogenesis of several inflammatory disorders, including inflammatory bowel disease (IBD) in humans. In this study, we isolated cDNAs encoding canine fractalkine and its receptor CX(3)CR1, and assessed the biological activity of these molecules. The deduced amino acid sequence of the canine fractalkine cDNA showed 66% and 57% identity to human and mouse homologs, respectively. The N-terminal chemokine domain of the canine fractalkine showed 68% and 65% identity to human and mouse counterparts, respectively. The canine CX(3)CR1 amino acid sequence showed close homology to its human (83% identity) and mouse (81% identity) counterparts. Fractalkine and CX(3)CR1 mRNA were detected in all tissues in this study. Relatively higher expression levels of fractalkine mRNA were observed in the brain, medulla spinalis, small intestine, and mesenteric lymph nodes (MLNs), whereas higher expression levels of CX(3)CR1 mRNA were observed in the medulla spinalis, brain, liver, small intestine, and MLNs. The cross-reactivities of anti-human fractalkine antibody and anti-rat CX(3)CR1 antibody to canine proteins were confirmed using recombinant canine fractalkine and a cell line overexpressing canine CX(3)CR1, respectively. A transwell chemotaxis assay showed that the recombinant canine fractalkine induced migration in canine lymphoid cells expressing CX(3)CR1. The present study will be useful in understanding the canine immune system and the immunopathogenesis of canine inflammatory diseases.

Fluoroscopically guided epidural blood patch with subsequent spinal CT scans in the treatment of spontaneous cerebrospinal fluid hypovolemia.

OBJECT: Recent evidence has indicated that the efficacy of the epidural blood patch (EBP) in the treatment of spontaneous CSF hypovolemia (SCH) is still limited. Therefore, further improvement of the EBP technique is an important clinical challenge. The authors describe a series of cases of SCH treated with fluoroscopically guided placement of an EBP and followed up with subsequent spinal CT scans. METHODS: Thirteen patients with SCH that was proven on CT myelography studies underwent epidural puncture under fluoroscopic guidance and received an injection of a mixture of contrast medium and autologous blood. Contrast medium was injected to cover the area of CSF leakage during EBP guided by fluoroscopy, and the spread of the blood was subsequently evaluated using spinal CT scanning. If the amount of blood injected was insufficient to cover the leakage area, a second EBP was performed at a later date. RESULTS: At the first EBP procedure, a mixture with a mean volume of 9.4 ml (range 3-20 ml) was injected, and subsequent spinal CT scans revealed contrast enhancement in the desired epidural space in 12 of 13 patients. In 2 patients, a second EBP was required because of insufficient coverage of the leakage area or delayed recurrence of headache. In all patients, a complete recovery from orthostatic headache was obtained after the last EBP. CONCLUSIONS: The results indicated that fluoroscopically guided EBP and subsequent spinal CT scans may provide a highly effective therapy in patients with SCH proven on CT myelography studies.