Kyung Ream Han

Intravascular Flow Patterns in Transforaminal Epidural Injections: A Comparative Study of the Cervical and Lumbar Vertebral Segments

BACKGROUND: Transforaminal epidural injection (TEI) is commonly used in the treatment of radicular pain. However, there have been many published cases of serious complications after a TEI, occurring most often in cervical levels. One of the presumptive reasons for this complication is inadvertent intravascular injection. We sought to identify the incidence of intravascular injections in cervical and lumbar spinal segments during TEI. METHODS: All patients with radicular symptoms or herpes zoster-associated pain underwent cervical and lumbar TEIs (LTEIs) prospectively by one of the authors. After an ideal needle position was confirmed by biplanar fluoroscopy, 3 mL of a mixture containing nonionic contrast and normal saline was continuously injected at the rate of 0.3–0.5 mL/s with real-time fluoroscopic visualization. RESULTS: One hundred eighty-two TEIs were performed. Fifty-six cases (30.8%) showed intravascular spreading patterns, 45 cases occurring during a cervical TEI (CTEI) and 11 during a LTEI. The incidences of simultaneous perineural and vascular injection in cervical and LTEIs were 52.1% and 9%, respectively, and pure vascular flow pattern rates in cervical and LTEIs were 11.3% and 0.9%, respectively. CONCLUSION: The incidence of vascular injection in CTEIs is significantly higher than in LTEIs, suggesting that CTEIs should be performed more cautiously. Furthermore, the vascular injection rate of CTEIs is much higher than that previously reported. This finding suggests the need for a proper volume of contrast injection (3 mL) to detect vascular flow, especially in simultaneous perineural and vascular injections.

Severe Pain Attack Associated with Neurocardiogenic Syncope Induced by Glossopharyngeal Neuralgia: Successful Treatment with Carbamazepine and a Permanent Pacemaker -A Case Report-

Glossopharyneal neuralgia (GPN) is generally considered to be a pain disease. However, it can be also be a life-threatening cardiac cause of syncope. Neuralgia in the throat and neck can trigger severe bradycardia up to the point of asystole, which can progress to cardiac syncope with or without seizures. A 65 year-old male patient diagnosed with glossopharyngeal neuralgia complained of severe paroxysmal pain in his right chin and ear followed by bradycardia, aystole and syncope. We report a case successfully treated with a permanent pacemaker and carbamazepine in a patient with GPN who had syncopal attacks preceded by paroxysms of pain.

Early Diagnosis of Fabry Disease in a Patient with Toe Tip Pain

Fabry disease is an X-linked lysosomal disease caused by deficiency of α-galactosidase, in which early diagnosis may be missed due to the wide variety of clinical symptoms presenting during disease progression. A 13 year-old boy visited our pain clinic complaining of pricking and burning pain in the toe tips of both feet. Continuous epidural infusion for pain management was performed because of oral analgesics ineffectiveness. The patient underwent α-galactosidase A (GLA) enzyme analysis based on the clinical impression of Fabry disease from pain with a peripheral neuropathic component and history of anhidrosis. He was diagnosed with Fabry disease after confirming mutation of the GLA gene through a screening test of GLA activity. Enzyme replacement therapy was initiated and pain was tolerated with oral analgesics.

Uncommon Cause of Trigeminal Neuralgia: Tentorial Ossification over Trigeminal Notch

Ossification of the tentorium cerebelli over the trigeminal notch is rare, but it may cause compression of the trigeminal nerve, leading to trigeminal neuralgia (TN). We were unable to find any previously reported cases with radiological evaluation, although we did find one case with surgically proven ossification of the tentorium cerebelli. Here, we present a case of TN caused by tentorial ossification over the trigeminal notch depicted on magnetic resonance imaging (MRI) and computed tomography (CT).

Repetitive single subarachnoid injections for trial administration of the intrathecal morphine pump in patients with intractable non-cancer pain -A case report-

Since the early 1980s, the implantable intrathecal drug pump (ITDP) has been used increasingly to manage chronic pain. Prior to making a decision to implant an ITDP, trial administration of the intrathecal (IT) drug should be performed to estimate the effective dose for a starting set of implantable ITDPs. There is no standard method of trial IT drug administration, though. Therefore, this paper reports 20 cases of IT morphine trial with single and repetitive injections until the appropriate dose was attained with respect to analgesia and its side effects. The trial procedure was performed with daily sequential IT injections using morphine and 0.3% mepivacaine. Twelve out of the total of 20 patients had positive responses. Thus, it is inferred that daily sequential IT morphine injections combined with a placebo injection as a trial ITDP would be useful in evaluating the effectiveness and adverse effects of IT morphine infusion with clinically insignificant side effects.