Perineural treatment with anti-TNF-α antibody ameliorates persistent allodynia and edema in novel mouse models with complex regional pain syndrome.

Complex regional pain syndrome (CRPS) is an intractable chronic pain syndrome with various signs and symptoms including allodynia/hyperalgesia, edema, swelling, and skin abnormalities. However, a definitive therapeutic treatment for CRPS has not been established. In CRPS patients, inflammatory cytokines such as TNF-α and IL-1ß have been shown to increase in affected areas, suggesting that these molecules may be potential therapeutic targets for CRPS. Here, we first created a novel CRPS mouse model (CRPS-II-like) via sciatic nerve injury and cast immobilization, which was characterized by mechanical allodynia, local edema, and skin abnormalities, to evaluate the pathophysiology and pharmacotherapy of CRPS. When an anti-TNF-α antibody was consecutively administered near the injured sciatic nerve of CRPS model mice, persistent allodynia and CRPS-related signs in the ipsilateral hindpaw were markedly attenuated to control levels. Perineural administration of anti-TNF-α antibody also suppressed the upregulation of inflammatory cytokines as well as the activation of macrophages and Schwann cells in the injured sciatic nerve. These findings indicate that persistent allodynia and CRPS-related signs in CRPS models are primarily associated with TNF-α-mediated immune responses in injured peripheral nerves, suggesting that perineural treatment with anti-TNF-α antibody might be therapeutically useful.

Case report: Favorable outcomes of spinal cord stimulation in complex regional pain syndrome Type II consistent with thermography findings.

BACKGROUND: Complex regional pain syndrome (CRPS) is a chronic pain disorder that develops as a consequence of trauma to one or more limbs. Despite the availability of multiple modalities to diagnose CRPS, a gold standard technique for definitive diagnosis is lacking. Moreover, there are limited reports describing the use of spinal cord stimulation (SCS) to treat CRPS Type II, given the low prevalence of this condition. Herein, we present the case of a patient with CRPS Type II with novel thermography findings who underwent SCS for pain management after an Achilles tendon repair surgery. CASE DESCRIPTION: A 38-year-old woman was referred to our institute because of chronic left leg pain after Achilles tendon rupture repair surgery. Her case was diagnosed as CRPS Type II based on the International Association for the Study of Pain diagnostic criteria. After an epidural block, thermography showed a significant increase in the body surface temperature of the foot on the observed side. She was subsequently treated with SCS, following which her pain ameliorated. She reported no pain flare-ups or new neurological deficits over 2 years of postoperative follow-up assessments. CONCLUSION: SCS could be a useful surgical treatment for medication refractory CRPS Type II as supported by our thermography findings. We may refine surgical indication for permanent implantation of SCS with the presented method.

Risk Vessels of Retropharyngeal Hematoma During Stellate Ganglion Block.

BACKGROUND AND OBJECTIVE: Bleeding into the retropharyngeal space is a potential complication in stellate ganglion block (SGB). Retropharyngeal hematoma formation is considered to be due to damage of small arteries in the region, although only scanty details of the region are available. The aim of this study was to map the risk blood vessels in the retropharyngeal space to avoid accidental damage during SGB. METHODS: Contrast-enhanced 3-dimensional computed tomography images performed on 80 patients were reanalyzed retrospectively to construct detailed map of cervical blood vessels that are prone to damage and bleeding during SGB. RESULTS: Of the 160 bilateral necks, 6 (3.8%) and 82 (51.3%) small arteries were identified in the medial portions of the ventral surface of the transverse processes of the sixth and seventh cervical vertebrae, respectively. In particular, 5 of the 6 small arteries detected in the medial portion of the ventral surface of the transverse process of the sixth cervical vertebra were the inferior thyroid artery (ITA). Of the 160 vertebral arteries, 2 arteries were missing, 4 (2.5%) entered the transverse foramen of the fifth cervical vertebra, whereas 1 artery (0.6%) entered the transverse foramen of the fourth cervical vertebra. CONCLUSIONS: Three-dimensional computed tomography identified the ITA in the medial portion of the ventral surface of the transverse process of the sixth cervical vertebra. The risk vessels of retropharyngeal hematoma during SGB could include the ITA.

A patient with urinary tract tuberculosis during treatment with etanercept.

BACKGROUND: Tumor necrosis factor (TNF)-α inhibitors are widely used for rheumatoid arthritis (RA). However, there are several risks to use TNFα inhibitors. Given the properties of TNF-α inhibitors, prevention and early detection of tuberculosis (TB) are especially important. Even among TNF-α inhibitors, the risk of TB infection differs according to each drug. The incidence of TB is lowest with etanercept (ETN). We present a case of urinary tract TB during treatment with ETN. CASE REPORT: A 58-year-old woman was receiving ETN for RA. Before starting ETN, isoniazid (INH) prophylaxis was started. RA was well controlled by ETN. However, 32 months after starting ETN, she noticed urinary frequency and a sensation of residual urine. The diagnosis was elusive, and it took 3 months until urinary tract TB was finally diagnosed. The TB resolved with antituberculosis medication, but RA disease activity flared up after ETN was discontinued. ETN was resumed with careful monitoring for TB recurrence. After resuming ETN, the RA was again well controlled, with no recurrence of TB. CONCLUSIONS: Patients should be monitored for development of TB during ETN treatment, but ETN can be used safely with careful management.

[Atelectasis after induction of general anesthesia in an infant with cleft palate].

We report an infant with cleft palate who developed atelectasis as a result of aspiration of food residue after induction of general anesthesia. A 12-month-old girl with cleft palate was scheduled for palatoplasty. The trachea was intubated after 6.5-hour fasting. Breath sounds were not audible on the left. Chest X-ray demonstrated complete atelectasis of the left lung. Bronchoscopy revealed that the left primary bronchus was blocked by a white stick. Pathological examination showed that the white stick consisted of milk residue with abundant candida species. It was speculated that the milk residue accumulated in the cleft palate had been aspirated during induction of general anesthesia.

[Severe hypotension after induction of general anesthesia in a patient receiving an angiotensin II receptor antagonist and an alpha-blocker].

We report severe hypotension after induction of general anesthesia in a patient receiving an angiotensin II receptor antagonist and an alpha-blocker. A 50-year-old man with diabetes mellitus who had been treated with candesartan cilexetil and doxazosin was scheduled for vitreous surgery. He was operated on for vitreous surgery three times. He developed severe hypotension after induction of anesthesia with propofol and fentanyl on two occasions, when he was taking candesartan cilexetil and doxazosin. Repeated injections of intravenous ephedrine could not raise the blood pressure. After discontinuation of both drugs, although he developed hypotension after induction of anesthesia with propofol and fentanyl, hypotension was mild and responded promptly to intravenous ephedrine.