Comparing the Efficacy of Combined Treatment with Medial Branch Block and Facet Joint Injection in Axial Low Back Pain.

Introduction: Medial branch nerve block (MBB) and facet joint injections (FJIs) can be used to manage axial low back pain. Although there have been studies comparing the MBB and FJI effects, a few studies have compared the therapeutic effects of both interventions combined with each separate intervention. This study aimed to compare the pain relief effect of MBB, FJI, and combined treatment with MBB and FJI in patients with axial low back pain. Methods: We conducted a retrospective review of patients with axial low back pain who had chart records of the Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI) scores measured before treatment and within 6 weeks after treatment. The proportion of patients with successful responses (>30%) was calculated and is presented with Wald confidence intervals. Results: We included 66 patients (33, 17, and 16 patients in the MBB, FJI, and combined treatment with MBB and FJI groups). All the patient groups showed significant posttreatment improvements in the NRS [(proportion >30% decrease: MBB 24.2% (9.6-38.9), FJI 29.4% (7.8-51.1), and MBB + FJI 25.0% (3.8-46.2)] scores and the ODI [proportion >30% decrease: MBB 39.4% (22.7-56.1), FJI 23.5% (3.4-43.7), and MBB + FJI 37.5% (13.8-61.2)] scores. Furthermore, there was no significant among-group difference in the ODI and NRS scores. Conclusion: MBB, FJI, and combined treatment with MBB and FJI can reduce axial low back pain and improve secondary functional degradation. Although combined treatment with MBB and FJI required a longer intervention time, it did not have a pain relief effect superior to that of MBB or FJI alone.

Transdermal opioid patch in treatment of paroxysmal autonomic instability with dystonia with multiple cerebral insults: A case report.

RATIONALE: Paroxysmal autonomic instability with dystonia (PAID) is an underdiagnosed syndrome that describes a collection of symptoms following diverse cerebral insults, such as traumatic brain injury, hydrocephalus, hemorrhagic stroke, or brain anoxia. It is manifested by systemic high blood pressure, hyperthermia, tachycardia, tachypnea, diaphoresis, intermittent agitation, and certain forms of dystonia. PATIENT CONCERNS: A semi-comatose 46-year-old man was transferred from the regional rehabilitation hospital with various complaints involving fluctuating vital signs, including uncontrolled hyperthermia, hypertension, tachycardia, and tachypnea, and dystonia in all extremities. The patient underwent brain surgery for astrocytoma in 1996. The patient also had a history of first ischemic stroke on the basal ganglia in 2008 and a second one in the same area in 2017. DIAGNOSIS: The laboratory, electrocardiography, and radiologic findings were normal. Brain imaging indicated an old infarction on the basal ganglia with hydrocephalus. Tractography using diffusion tensor imaging showed discontinuity of multiple tracts, and electrophysiologic tests, such as evoked potentials, displayed an absent response. Based on the dysautonomic symptoms and brain evaluations, the physiatrist diagnosed the patient with PAID. INTERVENTIONS: Bromocriptine, propranolol, and clonazepam were administered sequentially, but autonomic instability persisted. Then, intravenous opioid was administered, and fluctuations in body temperature, heart rate, and respiratory rate, as well as decerebrate-type dystonia were improved. However, simultaneously, drug-induced severe hypotension developed (systolic blood pressure, 57 mm Hg). Subsequently, a transdermal opioid (fentanyl) patch for PAID was applied once every 3 days. OUTCOMES: Ultimately, all vital signs and dystonia were managed without further complications, and the patient was discharged. LESSONS: A patient diagnosed with PAID following multiple cerebral insults was observed, whose condition was controlled by application of opioid patch rather than by intravenous or oral routes. A transdermal opioid patch, such as fentanyl patch, can thus be effective in the treatment of patients with PAID following multiple cerebral insults.

Minimal weight loss related to a short fasting period causes superior mesenteric artery syndrome in a patient with amyotrophic lateral sclerosis: A case report.

INTRODUCTION: Superior mesenteric artery syndrome (SMAS) is rare cause of small bowel obstruction and is characterized by an extrinsic vascular compression of the duodenum. The most common cause of SMAS is known as rapid and significant weight loss. PATIENT CONCERNS: A 61-year-old man who was diagnosed with amyotrophic lateral sclerosis and maintained a stable diet before admission. When the patient re-started feeding by gastrostomy tube after 5 days of therapeutic fasting due to gastric ulcer caused by gastrostomy tube irritation, he presented postprandial vomiting, abdominal distention, and tachycardia. Since fasting, his weight has been reduced by about 3 kg. DIAGNOSIS: Based on clinical symptoms and radiological findings, diagnose of SMAS was finally made. Abdomen computed tomography confirmed decreased aortomesenteric distance and tubography confirmed gastric and proximal duodenum distension above the compressed part. INTERVENTIONS: We performed jejunal tube insertion and the amount of feeding through the jejunal tube was gradually increased while maintaining parenteral nutrition. OUTCOMES: The presenting symptoms of the patient gradually improved. Follow-up abdomen computed tomography and tubography showed improvement in duodenal narrowing and stomach distension. CONCLUSION: SMAS should be considered when there is an abrupt observation of symptom of gastrointestinal obstruction in patients with predisposing condition such as a low body weight, even if the weight loss is relatively small.

An Unusual, Intermediate-Sized Lesion Affecting Motor Organization in a Patient With Schizencephaly: A Case Report.

Schizencephalies are abnormal clefts of the cerebral hemispheres that result from abnormal late neuronal migration and cortical organization. In the present study, we report a different type of unusual motor organization in a patient with a schizencephalic cleft in the right hemisphere and polymicrogyria in the opposite hemisphere. Despite similar brain pathology affecting the sensorimotor cortex, motor organization differed from previously known bilateral congenital brain lesions. We conducted a transcranial magnetic stimulation (TMS) and diffusion tensor image (DTI) study to confirm the motor organization. In this case, ipsilateral corticospinal projections to the paretic hands were observed during TMS of the less affected hemisphere, along with polymicrogyria, similar to the previous study. However, a crossed corticospinal tract to the paretic hand from the more severely affected hemisphere was observed in this case-a pattern of motor organization that has yet to be reported in this patient population. Our findings indicate that motor organization after early brain injury may be affected by the interhemispheric competition of the corticospinal system and bilateral brain lesions, thereby resulting in unilateral hemiparesis.