Lumbar Spinal Stenosis and Minimally Invasive Lumbar Decompression: A Narrative Review.

Background: Lumbar spinal stenosis (LSS) is a common pain condition that causes lumbar back pain, radiating leg pain, and possible functional impairment. MILD is an emerging minimally invasive treatment for LSS. It is an image-guided percutaneous procedure designed to debulk hypertrophied ligamentum flavum. However, the exact short- and long-term efficacy, safety profile, indication criteria, and certain procedure details reported in medical literature vary. Objective: This narrative review was to elucidate efficacy, safety profile, certain procedure details, advantages, and limitations of MILD. Study Design: This is a narrative review. Setting: All included articles are clinic trials including analytic studies and descriptive studies. Methods: PubMed, Cochrane Library, and Scopus were searched. Only clinical trials of MILD procedure were included. Information of indications, contraindications, VAS scores, ODI scores, effective rate, efficacy durations, and certain procedure details was focused on. Results: According to the literature, for the MILD procedure, the VAS score could be reduced from a pre-treatment level of 6.3-9.6 to a post-treatment level of 2.3-5.8. The ODI score could be reduced from a pre-treatment level of 38.8-55.3 to a post-treatment level of 27.4-39.8. The effective rate of the MILD procedure was reported to be 57.1%-88%. A 2-year postoperative stability of efficacy was also supported. One RCT study testified superior efficacy of MILD over epidural steroid injection. Limitations: There is few high-quality literature in the review. Moreover, the long-term efficacy of MILD cannot be revealed according to the current literature. Conclusion: Based on the reviewed literature, MILD is an effective and safe procedure. MILD can reduce pain intensity and improve functional status significantly. Therefore, it is a preferable option for LSS patients who failed conservative treatments, but not for those who require immediate invasive decompression surgery.

Cervicogenic headache in patients with presumed migraine: missed diagnosis or misdiagnosis?

UNLABELLED: The differential diagnosis of headache is often challenging, with significant clinical and socioeconomic consequences of incomplete or inaccurate diagnosis. Overlapping symptoms contribute to the diagnostic challenge. Four female patients, ages 26 to 69 with standing diagnoses of migraine, were evaluated and treated for complaints of chronic, severe headaches. All had obtained limited relief from migraine therapies. On physical examination, all had occipital nerve tenderness or positive Tinel sign over the occipital nerve. All responded well to occipital nerve blocks with local anesthetic, achieving complete or substantial pain relief lasting up to 2 months. We conclude that accurate diagnosis of occipital neuralgia or cervicogenic headache as contributing factors can lead to substantial headache relief through occipital nerve blocks in patients with coexisting or misdiagnosed migraine. PERSPECTIVE: The pathophysiology of many types of chronic headaches is not well understood. Mixed mechanisms such as neurovascular, neuropathic, myofascial, and cervicogenic may all contribute. Our four patients with chronic headaches responded well to occipital nerve blocks. The neuroanatomical relationship between the trigeminocervical nucleus and occipital nerve may serve as the basis of efficacy for these blocks.

Microcirculatory changes identified by photoacoustic microscopy in patients with complex regional pain syndrome type I after stellate ganglion blocks.

Complex regional pain syndrome (CRPS) is a chronic pain syndrome that causes intractable pain, disability, and poor quality of life for patients. The etiology and pathophysiology of CRPS are still poorly understood. Due to a lack of proper diagnostic tools, the prognosis of CRPS is primarily based on clinical observation. The objective of this work is to evaluate a new imaging modality, photoacoustic microscopy (PAM), for assisting diagnoses and monitoring the progress and treatment outcome of CRPS. Blood vasculature and oxygen saturation (sO2) were imaged by PAM from eight adult patients with CRPS-1. Patients' hands and cuticles were imaged both before and after stellate ganglion block (SGB) for comparison. For all patients, both vascular structure and sO2 could be assessed by PAM. In addition, more vessels and stronger signals were observed after SGB. The results show that PAM can help diagnose and monitor CRPS.

Intracranial hypotension headache caused by a massive cerebrospinal fluid leak successfully treated with a targeted c2 epidural blood patch: a case report.

Cervical epidural steroid injections, administered either interlaminarly or transforaminally, are common injection therapies used in many interventional pain management practices to treat cervicalgia or cervicobrachial pain secondary to spondylosis or intervertebral disc displacement of the cervical spine. Among the risks associated with these procedures are the risk for inadvertent dural puncture and the development of positional headache from intracranial hypotension. We report the case of a 31-year-old woman with a history of migraine and cervicalgia from cervical spine spondylosis and cervical disc degenerative disease that developed an intractable orthostatic headache accompanied by nausea and vomiting after a therapeutic high cervical intralaminar epidural steroid injection was administered directly to the C1-C2 spinal level. Although the initial magnetic resonance imaging of the brain was unremarkable, a computed tomography myelogram study revealed a massive cerebrospinal fluid (CSF) leak from the cervical spine.  Repeated cervical epidural blood patches using a catheter targeted to the high cervical spine (C2) to inject 15 mL of autologous blood was required to totally alleviate her symptoms after she failed conservative therapy. Determining the optimal location or approach to administer an epidural blood patch can be a challenge depending on the location of the CSF leak. Our case demonstrates that targeted cervical epidural blood patch placement using an easily manipulated catheter under fluoroscopic guidance is a safe and effective approach to treat a massive CSF leak in the high cervical spine region caused by prior therapeutic cervical spine epidural steroid injection.

Necrotic arachnidism and intractable pain from recluse spider bites treated with lumbar sympathetic block: a case report and review of literature.

Brown recluse (Loxosceles reclusa) spider bites mainly occur in the southern and Midwestern United States. The clinical manifestation of brown recluse spider bites varies from skin irritation, a small area of tissue damage to neuropathic pain, necrotic arachnidism and severe systemic reactions such as acute renal failure and even death. Treatment is controversial and nonspecific. We describe a case of extensive right lower extremity tissue necrosis and intractable neuropathic pain treated with lumbar sympathetic block in a patient with a documented brown recluse spider bite. Both his pain and tissue necrosis improved significantly with lumbar sympathetic block with local anesthetic. After a series of lumbar sympathetic blocks, his symptoms resolved and lower extremity wound healed rapidly. We discuss the benefit of sympathetic blockade not only for neuropathic pain but also possibly as a treatment for necrotic arachnidism from a brown recluse spider bite.

Application of X STOP device in the treatment of lumbar spinal stenosis.

Low back pain is exceptionally ubiquitous, complex, and costly. Nevertheless, lumbar spinal stenosis (LSS) with neurogenic intermittent claudication (NIC) is a frequent cause of low back and lower extremity pain. Although the phenomena and pathophisiology of lumbar spinal stenosis has been described for decades, therapeutic treatment options remain considerably limited. Current care consists of conservative measures including physical therapy, rest, medications, and epidural steroid injection therapy or invasive surgical treatment including laminectomy with or without fusion. Despite standard of care intervention, many patients are often left inadequately treated and suffer from debilitating low back and lower extremity pain as a result of lumbar spinal stenosis. Interspinous process distraction (IPD) devices were originally described in the 1950s, but technological advances, which have contributed to improved safety and efficacy, have rekindled an interest in IPD implantation. By mimicking lumbar flexion at affected levels of stenosis, it is thought these devices decompress neural structures within the neural foramina and therefore provide pain relief. X-STOP is one such device that is currently approved in the United States for the treatment of mild to moderate NIC resulting from LSS. This manuscript presents a focused review of NIC and LSS and comprehensively presents literature related to the use of the X-STOP IPD device.

Acupuncture in modern society.

For at least 2,500 years, acupuncture has been an integral part of traditional Chinese medicine. However, recently as more people in western countries are diagnosed with chronic disease poorly treated with modern medical therapies, many are turning to acupuncture and other forms of alternative medical treatments. Based on the theory of harmonious flowing qi being the basis of good health, acupuncture focuses on restoring qi by manipulation of the complementary and opposing elements of yin and yang. However, in the modern medical community we struggle to with the concept of qi, given a lack of anatomic and histological evidence supporting its existence. However, with the surge in public interest in acupuncture, the scientific community begun heavy investigation of acupuncture's efficacy, as well as the physiologic basis behind it. Thus far, evidence supports the use of acupuncture in post-operative nausea and vomiting, postoperative dental pain, chronic pain conditions such as lower back pain, and possibly also such psychologic conditions as addiction. It is possible that by affecting afferent nerve signaling, acupuncture may influence the release of endogenous opioids to promote pain relief. This effect may be augmented by release of ACTH and cortisol, as well as through down-regulation of signaling through pain fibers. When treating patients who may utilize alternative forms of medicine, it is important that medical practitioners be educated in regards to the basic fundamental beliefs behind acupuncture, as well as the scientific evidence supporting its use and revealing its efficacy. The purpose of this review is to give western trained physicians exposure to history, basic knowledge and its clinical applications of acupuncture to accommodate accelerating interests in acupuncture in modern society.

Inhibitory role of Ser-425 of the alpha1 2.2 subunit in the enhancement of Cav 2.2 currents by phorbol-12-myristate, 13-acetate.

Voltage-gated calcium channels (Ca(v)) 2.2 currents are potentiated by phorbol-12-myristate, 13-acetate (PMA), whereas Ca(v) 2.3 currents are increased by both PMA and acetyl-beta-methylcholine (MCh). MCh-selective sites were identified in the alpha(1) 2.3 subunit, whereas the identified PMA sites responded to both PMA and MCh (Kamatchi, G. L., Franke, R., Lynch, C., III, and Sando, J. J. (2004) J. Biol. Chem. 279, 4102-4109; Fang, H., Franke, R., Patanavanich, S., Lalvani, A., Powell, N. K., Sando, J. J., and Kamatchi, G. L. (2005) J. Biol. Chem. 280, 23559-23565). The hypothesis that PMA sites in the alpha(1) 2.2 subunit are homologous to the PMA-responsive sites in alpha(1) 2.3 subunit was tested with Ser/Thr --> Ala mutations in the alpha(1) 2.2 subunit. WT alpha(1) 2.2 or mutants were expressed in Xenopus oocytes in combination with beta1b and alpha2/delta subunits. Inward current (I(Ba)) was recorded using Ba(2+) as the charge carrier. T422A, S1757A, S2108A, or S2132A decreased the PMA response. In contrast, S425A increased the response to PMA, and thus, it was considered an inhibitory site. Replacement of each of the identified stimulatory Ser/Thr sites with Asp increased the basal current and decreased the PMA-induced enhancement, consistent with regulation by phosphorylation at these sites. Multiple mutant combinations showed (i) greater inhibition than that caused by the single Ala mutations; (ii) that enhancement observed when Thr-422 and Ser-2108 are available may be inhibited by the presence of Ser-425; and (iii) that the combination of Thr-422, Ser-2108, and either Ser-1757 or Ser-2132 can provide a greater response to PMA when Ser-425 is replaced with Ala. The homologous sites in alpha(1) 2.2 and alpha(1) 2.3 subunits seem to be functionally different. The existence of an inhibitory phosphorylation site in the I-II linker seems to be unique to the alpha(1) 2.2 subunit.