A case of transient hemiplegia after cervical transforaminal epidural injection with dexamethasone: What actually happened?

Cervical transforaminal epidural steroid injections (TESIs) have technical difficulties and a risk of complications due to the cervical spine anatomy. A 52-year-old female patient was admitted to our outpatient clinic with complaint of neuropathic pain radiating to her right arm. Right C7 TESI was planned for patient who did not respond to conservative treatment. Immediately after the procedure, flaccid paralysis was detected in the right side and, at the end of 24 h, the patient completely regained her former muscle strength. In conclusion, patient selection for the cervical TESI should be done carefully and kept in mind that transient spinal cord ischemia may develop.

Comparison of Radiation Doses of Contralateral Oblique and Lateral View for Fluoroscopy-Guided Lumbar Interlaminar Epidural Steroid Injection.

BACKGROUND: Despite newly developing technologies and techniques, the use of fluoroscopic guidance in spinal interventional treatments remains popular. Therefore, it is essential to set reference standards and techniques for reducing radiation exposure in fluoroscopy-guided procedures. OBJECTIVE: The aim of this study was is to compare the radiation doses and procedure time of the contralateral oblique (CLO) view to  lateral view imaging during fluoroscopy-guided spinal procedures. STUDY DESIGN: A retrospective study. SETTING: Pain management unit of a tertiary care center. METHODS: An evaluation of patients who received epidural steroid injections between May 2021 and May 2023 in a university hospital interventional pain management center was performed. This observational study was conducted with 248 patients aged 18 and older who underwent lumbar interlaminar epidural injections (ILESI) confirmed by CLO or lateral oblique imaging. The primary outcomes were the comparison of radiation dose and procedure time between the 2 groups. The secondary outcome was the comparison of complication rates. RESULTS: There were no significant differences between the two groups in terms of age, gender, diagnosis, body mass index, procedure level, Numeric Rating Scale, and procedure time. Although the radiation dose was lower in the CLO group, there was no significant difference between the 2 groups. However, there was a significant difference between the 2 groups in terms of complications (P < 0.001). LIMITATIONS: The study was designed in a single center and performing all the procedures with the same fluoroscopy device makes it difficult to generalize our results. CONCLUSIONS: Although there was no difference in terms of radiation dose and duration of procedure between lumbar ILESI conducting using the CLO or lateral view fluoroscopy imaging, there was a significant difference in terms of complications. Therefore, conducting lumbar ILESI using a CLO view minimizes the complication rate.

Intravenous methylprednisolone as a transition treatment in red ear syndrome: A case report.

Red ear syndrome (RES) is a rare condition of unknown etiology characterized by episodic attacks of unilateral ear pain, redness, and burning sensation. A 31-year-old male patient was admitted to our clinic with a severe headache reaching up to 5 h, presenting with short bursts of electric shock-like sensation, burning, and tingling in the left side of his face. The patient was unresponsive to previous medical treatments. Lidocaine 10% through the intranasal route for sphenopalatine ganglion and stellate ganglion blockade under the guidance of fluoroscopy also failed. Given that the Red-Ear syndrome shares similar pathophysiological pathways with trigeminal autonomic cephalalgias, the patient was treated with high-dose intravenous methylprednisolone, and since then, he has been symptom-free for 6 months. High-dose steroid therapy might be a good alternative in late-onset RES as a transition treatment.

Fluoroscopic Confirmation of Needle Location in Ultrasound-guided Genicular Nerve Radiofrequency Thermocoagulation.

BACKGROUND: Radiofrequency thermocoagulation of genicular nerves is an effective treatment for chronic pain due to knee osteoarthritis. The procedure can be performed under fluoroscopic or ultrasonographic guidance. OBJECTIVES: The aim of this study was to fluoroscopically check the final location  of the needle in ultrasound-guided genicular nerve radiofrequency thermocoagulation and evaluate the treatment's success in patients with knee pain. STUDY DESIGN: A 2-center, prospective study. SETTING: A private clinic and a tertiary care health center. METHODS: Thirty-two patients who had unilateral knee pain, and grade 3-4 knee osteoarthritis according to the Kellgren-Lawrence classification were included. Following diagnostic genicular nerve blocks in patients whose knee pain was relieved by >= 50%, radiofrequency thermocoagulation was applied to these nerves. The final position of the needle was checked via fluoroscopy in anteroposterior and lateral planes. RESULTS: The needle was located in the one-third anterior portion of the bone shaft in 69 of 96 patients (71.9%), between one-third and two-thirds in 21 (21.9%), and in the one-third posterior portion in 6 (6.3%). The mean Numeric Rating Scale score for pain was 7.69 ± 0.99 before treatment, 4.03 ± 1.26 at one week, 2.53 ± 1.24 at one month, and 2.19 ± 1.71 at 3 months, indicating a statistically significant decrease (P < 0.001). LIMITATIONS: The lack of a study group in which genicular nerve radiofrequency thermocoagulation was performed under fluoroscopy guidance could be cited among the limitations of this clinical study. CONCLUSIONS: The final position of the needle tip in radiofrequency thermocoagulation of genicular nerves can exist at the one-third anterior of the bone shaft, without a need for further advancing the needle to the posterior portion. Although performed more distally compared to fluoroscopy guidance, ultrasound-guided genicular nerve radiofrequency thermocoagulation still provides effective analgesia.

Ultrasound-guided lateral branch radiofrequency ablation for sacroiliac joint pain.

Sacroiliac joint (SIJ) pain is one of the leading causes of mechanical low back pain. Treatment includes conservative methods, surgery, and radiofrequency thermocoagulation (RFTC) as a novel therapeutic approach. Herein, we present a 71-year-old female patient who was first admitted to the outpatient clinic about four years ago. The medical history and physical examination findings were compatible with SIJ pain. After unresponsiveness to previous treatments, the patient successfully underwent ultrasound-guided RFTC using the lateral crest technique. This case report demonstrates, for the first time, the long-term efficacy of ultrasound-guided RFTC using the lateral crest technique in the management of SIJ pain.

The lumbar erector spinae plane block: a cadaveric study.

BACKGROUND: The aim of this cadaveric study was to investigate the erector spinae plane block (ESPB) in lumbar region and to elucidate the possible mechanisms of action of these injections in lumbar radicular pain by means of detecting expected dye dispersion to the neural structures. METHODS: Ultrasound-guided lumbar ESPB was performed in three formaldehyde-embalmed human cadavers. For this purpose, a 10 mL of methylene blue was injected into the fascial space between the L4 transverse process and the erector spinae muscles. T hen, the cadavers were dissected, the cephalocaudal and lateral spread of the dye was examined, and the involvement of the dorsal rami, dorsal root ganglia and ventral rami were analyzed. The distribution into the epidural space was also evaluated. RESULTS: The involvement of the dorsal rami was found to extend up to the T12 level and down to the L5 spinal nerves. Although dye dispersion was detected on the dorsal root ganglion in all specimens, it was found to be limited to one or two levels, unlike the dorsal rami. In half of the specimens, distribution to the ventral ramus and posterior epidural space was observed.

Do informative leaflets affect pre-procedural anxiety and immediate pain after transforaminal epidural steroid injections? A prospective randomized controlled study.

OBJECTIVES: The aim of this study was to evaluate the effect of an informative leaflet provided to patients before a lumbar transforaminal epidural steroid injection (TFESI) on the level of immediate pain and pre-procedural anxiety. METHODS: A total of 166 patients were randomized into 2 groups: a group that received an explanatory leaflet (LG) and a control group. Both groups were given verbal information, while the LG was also given an illustrated leaflet describing the injection process. All of the patients were evaluated with the Hospital Anxiety and Depression Scale before the TFESI. The numerical rating scale and the Oswestry Disability Index (ODI) were used to assess disability and pain before and after the TFESI. Major complications that occurred before and during the procedure were recorded and analyzed. RESULTS: The patient characteristics were similar in both groups (age, body mass index, depression level, pre-procedural pain, and ODI). The anxiety level was also similar in both groups (p>0.05). When both groups were evaluated at the first hour after the procedure, the numerical rating scale level of pain intensity was also similar (p>0.05). No major complication was observed in either group. CONCLUSION: The detailed leaflet did not affect the patients' pre-procedural anxiety or acute post-procedural pain level. However, the importance of informed consent and comprehensive information should not be overlooked.

The Role of Sacroiliac Joint Steroid Injections in the Treatment of Axial Spondyloarthritis.

OBJECTIVES: This study aims to investigate the effects of fluoroscopy-guided sacroiliac joint steroid injection in patients with acute bilateral sacroiliitis diagnosed with axial spondyloarthritis (axSpA) and how those injections affect the current need for nonsteroidal anti-inflammatory drug (NSAID) usage. PATIENTS AND METHODS: We retrospectively evaluated 43 patients (28 males, 15 females; mean age, 31.7±6.3 years; range, 18 to 44 years) fulfilling the Assessment of SpondyloArthritis international Society 2009 criteria for axSpA between June 2015 and May 2016. One group included 22 patients (injection group) treated with sacroiliac joint steroid injection (triamcinolone acetonide) and the other group included 21 patients (non-injection group) not receiving the injection. All 43 patients in both groups were treated with indomethacin peroral. Pre-treatment, first week and first, third and sixth month follow-up examinations were evaluated. RESULTS: A ≥50% reduction in the numeric rating scale score compared with the baseline was considered as significant pain relief. The mean pain relief rates in patients receiving injections were higher at all inspections. This difference was statistically significant at first week (p<0.05). When groups were compared, no difference was found in the Bath Ankylosing Spondylitis Disease Activity Index scores (p>0.05). There was no statistically significant difference between the two groups when indomethacin dose was evaluated cumulatively for six months (p>0.05). CONCLUSION: Fluoroscopy-guided sacroiliac joint steroid injections can be recommended in patients with active sacroiliitis, particularly in those with severe axial pain, for rapid analgesia in the initial term. It was concluded that steroid injections applied to the sacroiliac joint did not affect disease activity. It is noteworthy that there is a trend to reduce the use of NSAIDs in patients receiving these injections, although it does not make a statistically significant difference in the long term.

Early detection of neuropathy in patients with type 2 diabetes with or without microalbuminuria in the absence of peripheral neuropathy and retinopathy.

PURPOSE: Our goal is early detection of neuropathy in patients with type 2 diabetes with or without microalbuminuria in the absence of diabetic retinopathy and peripheral neuropathy by using in vivo corneal confocal microscopy (IVCCM). METHODS: A total of 60 type-2 diabetic patients, assigned to either a diabetes mellitus (DM) with microalbuminuria group (DM/MA+, n=30) or a DM without microalbuminuria group (DM/MA-, n=30), and 30 age-matched control subjects were enrolled in this study. All cases underwent evaluation of blood glucose level, HbA1c, lipid fractions, body mass index (BMI), and corneal sensitivity (CS). Corneal nerve fiber length (NFL), nerve fiber density (NFD), nerve branch density (NBD), and tortuosity coefficient (TC) were quantified by IVCCM. None of the patients had peripheral neuropathy or retinopathy. RESULTS: Compared with the healthy subjects, NFL and NFD were reduced in both diabetic groups (P<0.0001), while NBD was significantly reduced in the DM/MA+ group. Between the diabetic groups, NFL, NFD, and NBD were significantly higher in the DM/MA- group (all P's<0.001). CS was significantly lower in DM/MA+ compared with DM/MA- and controls (both P's<0.0001). NFD and NFL were inversely correlated with age, triglyceride level, and BMI. CONCLUSION: These results indicate that significant damage to small nerves, quantified using IVCCM, can be detected in the absence of retinopathy, peripheral neuropathy or microalbuminuria in type 2 diabetic patients. The severity of corneal nerve involvement may further increase in the presence of nephropathy. This feature may also be valuable for early detection of microvascular complications of DM, allowing for the prevention of progression of life threatening microvascular complications.

Telephone versus self administration of outcome measures in low back pain patients.

OBJECTIVES: Comparison of self-rating method and telephone interview method on outcome measures' results. METHODS: This cross-sectional study included 100 patients aged 18-40 years who applied to Physical Medicine and Rehabilitation outpatient clinics with mechanical low back pain. Outcome measures [Oswestry Disability Index (ODI), Roland Morris Disability Questionnaire (RMDI), Numeric Pain Rating Scale (NPRS), Istanbul Low Back Pain Disability Index (ILBPD] were administered, and the duration of administration was recorded by two different methods. The self-assessment method and scales were administered by patients in the outpatient clinic and the telephone interview method; scales were administered by the researcher via telephone-calls 24 hours after the out-patient visit. RESULTS: There were no significant differences observed in the results of outcome measures by the method of administration except the Istanbul Low-Back-Pain Disability Index (p=0.030). Outcome measures' results were highly correlated with one another when administered by different methods and orders of administration. Duration of administration was significantly shorter when outcome measures were administered by telephone interview (p<0.001). CONCLUSION: Different methods of administration usually do not have an impact on outcome measure results. However, in some scales like ILBPDI, it may emerge as a factor affecting outcome measures' results. Therefore, adherence to an initially preferred administration method throughout the follow-up period is important regarding the reliability of the results.

The Effect of Pre-Treatment Depression, Anxiety and Somatization Levels on Transforaminal Epidural Steroid Injection: A Prospective Observational Study.

BACKGROUND: Results of the lumbar transforaminal epidural steroid injection (L-TFESI) used in the treatment of lumbar radiculopathy may be affected by the current psychiatric condition of the patient. OBJECTIVES: The study aimed to assess the effects of pretreatment comorbid psychiatric conditions on patient outcomes in patients with lumbar disc herniation and radiculopathy. STUDY DESIGN: The study used a prospective-observational study design. SETTING: Research was conducted at a university hospital international pain management center. METHODS: In this observational study, 103 patients were included. All patients were evaluated with the Hospital Anxiety and Depression scale (HADS) for depression and anxiety levels and the Somatosensory Amplification Scale (SSAS) for somatization levels before the L-TFESI. The treatment results were evaluated with the Numeric Rating Scale (NRS) and the Oswestry Disability Index (ODI) at baseline, the third week, and the third month. Relative to baseline, a 50% reduction in the NRS was accepted as a successful treatment. RESULTS: HADS-depression, HADS-anxiety, and SSAS levels were similar between the patients with successful treatment outcome and the patients in whom treatment failed. However, there were negative correlations between percent reduction in the NRS and the HADS-depression levels at 3 weeks (r = -0.182, P = .022) and 3 months (r = -0.204, P = .037). Also, there were positive correlations between patients' pre-injection ODI scores and both the HADS-anxiety (r = 0.271, P = .001) and SSAS (r = 0.201, P = .013) scores. LIMITATIONS: The study was limited by a relatively short-term follow-up period. CONCLUSIONS: Although psychiatric conditions affected the pain and disability of patients before and after the L-TFESI, and may have an impact on patient-related outcomes, they should not be a reason to not treat patients or expect a lower chance of success. KEY WORDS: Anxiety, depression, disc herniation, low-back pain, lumbar radiculopathy, patient-related outcomes, somatization, transforaminal epidural steroid injection.

Factors influencing sexual functions in Turkish female patients with migraine.

OBJECTIVES: Recent studies have shown a more frequent occurrence of sexual dysfunction in patients with headache. The aim of this study was to assess the effects of demographic and clinical characteristics and psychiatric symptoms on sexual dysfunction in Turkish female patients with migraine. METHODS: In all, 18 sexually active patients with episodic migraine (EM), 12 patients with chronic migraine (CM), and 22 healthy controls of similar age were enrolled in the study. A numeric rating scale was administered to assess pain intensity. The psychiatric symptoms and sexual function of all of the participants were evaluated using the Beck depression and anxiety scales and the Golombok-Rust Inventory of Sexual Satisfaction (GRISS). RESULTS: The mean GRISS subscale scores did not differ significantly between the migraine groups and the control group (all p values <0.05). A positive correlation was found between the duration of headache and GRISS subscales of noncommunication, dissatisfaction, vaginismus, and anorgasmia in EM patients. In addition, there was a negative correlation with the infrequency and avoidance subscales. No correlation was detected between the GRISS subscale scores and the demographic and clinical characteristics of the patients with CM, with the exception of the level of education. Higher pain intensity scores and the presence of anxiety or depression among the EM and CM patients significantly affected all of the subscale scores of the sexual function inventory. CONCLUSION: Although there was no relationship between migraine chronicity and sexual dysfunction, our data indicated that patient demographic characteristics, greater pain severity, and comorbidities of depression or anxiety were associated with greater sexual dysfunction among patients with EM and CM.

Comparison of the effectiveness of orthotic intervention, kinesiotaping, and paraffin treatments in patients with carpal tunnel syndrome: A single-blind and randomized controlled study.

PURPOSE: The aim of the study was to compare different conservative treatments in patients with carpal tunnel syndrome (CTS). STUDY DESIGN: A single-blind randomized controlled study. METHODS: Patients (n = 169) diagnosed with mild or moderate CTS were screened; 110 met study requirements. The patients were randomized into 3 groups. The control (CON) comparison provided to all patients was a fabricated night orthotic which held the wrist in a neutral position. The second group received adjunctive kinesiotaping (KIN) and the third group received paraffin (PARA). All patients were evaluated clinically, electrophysiologically, and ultrasonographically before treatment and at 3 weeks, 3 months, and 6 months. RESULTS: There were 36 patients in CON, 37 in KIN, and 37 in PARA. Pain reduction in KIN was better than the other groups at 3 weeks (mean difference [MD] in CON 2.4 ± 2.5, KIN 3.7 ± 2.0, PARA 2.7 ± 2.3; P < .01) and 6 months (MD in CON 3.4 ± 3.0, KIN 4.9 ± 3.1, PARA 3.7 ± 2.9; P < .05). KIN pain reduction was better than CON at 3 months (MD in CON 3.8 ± 2.8, KIN 5.0 ± 2.5; P < .05). Reduction of the cross-sectional area of median nerve at the level of radioulnar joint was greater for KIN than CON at 3 weeks (MD in CON 0.0 ± 0.5, KIN 0.3 ± 0.7; P < .01) than PARA at 3 months (MD in KIN 0.3 ± 0.8, PARA 0.0 ± 0.8; P < .05) and both groups at 6 months (MD in CON 0.1 ± 0.8, KIN 0.5 ± 0.9, PARA 0.0 ± 1.0 P < .05). CONCLUSION: Adding KIN to night use of an orthotic was more effective in achieving symptomatic and structural improvements than either the orthotic alone or adjunctive use of paraffin in patients with mild and moderate CTS.