Hemmo A. Bosscher

Incidence and Severity of Epidural Fibrosis after Back Surgery: An Endoscopic Study

Background:  Epidural fibrosis has been implicated in the etiology of persistent pain after back surgery (Failed Back Surgery Syndrome [FBSS]). Using spinal endoscopy to view the lumbosacral epidural cavity, the incidence, severity, and appearance of epidural fibrosis was evaluated in patients with FBSS.

Blockade of the Superior Hypogastric Plexus Block for Visceral Pelvic Pain

Abstract: Visceral pelvic pain is a common problem with variable etiology. The sympathetic nervous system plays an important role in the transmission of visceral pain independent of its etiology. Five major pathways by which pelvic pain is transmitted can be identified. One of them, the superior hypogastric plexus, an extension of the preaortic plexus, is easily assessable to blockade by local anesthetics and neurolytic agents. Several techniques have been described. Long‐lasting pain relief with this procedure has been achieved in patients with pelvic cancer pain. However, there is a discrepancy between diagnostic and therapeutic blockade in patients with nonmalignant pain. Because a diagnostic blockade can give significant pain relief in a large variety of patients, it is worthwhile to investigate new methods that provide lasting neural blockade of the superior hypogastric plexus and long‐lasting relief of this devastating condition.

Ultrarapid opiate detoxification: a review

PurposeThis review on ultrarapid detoxification examines the pharmacology, techniques, and efficacy of this potentially promising technique and contrasts it with conventional treatment modalities.SourceThe information found here is derived from experiences at the Texas Tech University, government reports, and peer reviewed journals.Principal findingsIncidence and prevalence of heroin use is on the rise. Social and treatment costs suggest that this problem is staggering. Approximately 400,000 patients are enrolled in or are actively seeking methadone therapy. While many of these individuals want to undergo detoxification, traditional techniques, including methadone tapering are usually unsuccessful. The withdrawal syndrome is extremely unpleasant, may be fatal, and deters patients from completing the detoxification process. Ultrarapid detoxification entails general anesthesia in conjunction with large boluses of narcotic antagonists. This combination allows the individual to completely withdraw from the opiate without suffering the discomfort of the withdrawal syndrome. Unless performed properly, this procedure can be dangerous due to the sympathetic outflow. However, with proper support, this danger can be mitigated.ConclusionUltrarapid opiate detoxification, performed under the proper circumstances, is associated with few adverse events and is relatively comfortable for patients who seek treatment for their addition.RésuméObjectifLa présente étude portant sur la désintoxication ultrarapide revoit la pharmacologie, les techniques et l’efficacité de cette technique potentiellement prometteuse et la compare avec les modalités thérapeutiques traditionnelles.SourceNos informations sont tirées des expériences à la Texas Tech University, des rapports officiels et des journaux scientifiques. Constatations principales : L’incidence et la prévalence de l’usage d’héroïne sont en hausse. Les coûts sociaux et thérapeutiques de ce problème sont renversants. Environ 400 000 patients suivent, ou cherchent activement, un traitement à la méthadone. Beaucoup acceptent une désintoxication, mais les techniques traditionnelles, incluant l’approche dégressive avec la méthadone, sont habituellement infructueuses. Le syndrome de sevrage est très désagréable, peut être fatal et décourage les patients d’aller jusqu’au bout. La désintoxication ultrarapide nécessite une anesthésie générale conjointement avec d’importants bolus d’antagonistes narcotiques. Cette combinaison permet la suppression complète des opiacés sans subir l’inconfort du syndrome de sevrage. Si elle n’est pas réalisée correctement, cette intervention comporte un danger, lié à l’influx sympathique, danger réduit par une assistance appropriée.ConclusionLa désintoxication ultrarapide aux opiacés, réalisée dans des conditions appropriées, est associée à peu d’événements indésirables et est relativement confortable pour les patients qui cherchent un traitement à leur dépendance.

Diagnosis of the Vertebral Level from Which Low Back or Leg Pain Originates. A Comparison of Clinical Evaluation, MRI and Epiduroscopy

Background:  The precise localization of painful structures in the spine of patients with low back pain and/or pain radiating (LBP/RP) to the lower extremities is important for targeted therapeutic intervention. The aim of the study reported here was to determine and compare the spinal segment(s) where pain was elicited via endoscopic evaluation vs. the vertebral level from where the pain was thought to originate as determined by clinical evaluation and by MRI.

The Peridural Membrane of the Spinal Canal: A Critical Review

Abstract:  There exists substantial evidence that a peridural membrane (PM) is present in the spinal canal of humans and, like the pleura and peritoneum, has one or more physiologic functions. Innervation of the PM suggests that it may become a source of pain if injured. Although debated, the physiology of this structure has important implications with respect to neuraxial distribution of drugs and for back and radiating pain. This review, separated into embryological, anatomic, and physiologic discussions, provides an in‐depth summary of the observations of this connective tissue. The discrepancies between accounts are highlighted within each section. Focused research to clearly elucidate the true nature of the PM, especially as related to neuraxial distribution of drugs and back and radiating pain, is warranted.▪

Cell Types Obtained from the Epidural Space of Patients with Low Back Pain/Radiculopathy

Background:  We investigated if correlations exist between medical history, tissue abnormalities, and cell types retrieved from the epidural space of patients with chronic low back pain (LBP) and chronic radicular pain (RP).

Xanthosis in the Spinal Epidural Space—An Epiduroscopy Finding

Abstract: We report the presence of yellow pigment (xanthosis) in the eqidural space of a patient with a chronic painful radiculopathy. A 55‐year‐old Caucasian male patient with a left L5, S1 radiculopathy underwent epiduroscopy and epidural neurolysis. Epiduroscopy findings in the area of the nerve root associated with the radiculopathy included the presence of diffuse perivascular yellow pigments, increased vascularity and diffuse increased presence of sheets of fibrous tissue. This is a novo epiduroscopy finding. The case demonstrates the potential for epiduroscopy to expand our knowledge about pathological changes associated with some chronic painful conditions.

The MILD procedure.

We are following with great interest the increasing generally favorable impressions of the long‐term results of the MILD (minimally invasive lumbar decompression) procedure for treating spinal stenosis due to hypertrophied ligamentum flavum (LF). We are also influenced by the cautionary surgical observations and opinions of Tumialan et al and publications about the lack of efficacy or placebo effect. The impression indeed has been virtual safety of the MILD procedure, but Tumialan et al describe some major complications resulting from the procedure. An algorithm for clinical use is needed.

The peridural membrane of the human spine is well innervated

There is evidence that low back pain may originate from a peridural membrane (PDM) at the inferior and medial aspect of neural foramen of the lumbar spine. The objective of this investigation was to determine if this membrane contains neural elements suggestive of sensory innervation with nociceptive function. Spines of four embalmed and three non‐embalmed human cadavers were dissected using a sagittal approach to the neural foramen. Seventeen samples of the peridural membrane overlying the neural foramen were collected for immunohistochemistry (IHC) examination by light microscopy and transmission electron microscopy (TEM). Chromagin tagged antibodies to protein gene product 9.5 (PGP9.5) and S‐100, and fluorescent antibodies to substance P and calcitonin gene related peptide (CGRP) were used to label neural structures in tissue sections cut from paraffin embedded blocks. This approach allows good visualization of all neural elements, small sensory, and nociceptive nerve fibers in particular. Neural elements were found in all samples. Marked presence of small nerve fibers was observed in 12 of 15 samples. IHC and TEM evaluation revealed myelinated as well as unmyelinated fibers in the peridural membrane. CGRP and substance P immunoreactive fibers indicative of nociceptive function were abundant. These findings confirm and expand evidence that the peridural membrane in human is well innervated and contains sensory nociceptive nerve fibers suggestive of a nociceptive function of the membrane. Anat Rec, 299:484–491, 2016.