Motohiro Kawasaki

Analgesic effects of ketamine ointment in patients with complex regional pain syndrome type 1

Objective Ketamine hydrochloride (KET), an agent used for general anesthesia, has local anesthetic effects and N-methyl-d-aspartate (NMDA) receptor antagonist action. Because recent studies emphasized the role of peripherally distributed NMDA receptors in processing the nociceptive information, we investigated whether peripheral application of the ointment containing KET is able to attenuate the symptoms of local neuropathic pain. Case Reports We applied ointment containing KET (0.25%-1.5%) to the affected area on limbs in 5 patients with complex regional pain syndrome type I (CRPS I) and in 2 patients with type II (CRPS II). One to 2 weeks later, we observed improvement of the report of pain intensity, measured by the visual analog scale, in 4 patients with acute early dystrophic stage of CRPS I. Swelling of the affected limbs subsided as well. No apparent changes were noticed in 1 patient with chronic atrophic stage of CRPS I and in both patients with CRPS II. Conclusion Topical application of KET appears to be beneficial for the patients with acute early dystrophic stage of CRPS I because of either its local anesthetic effect or NMDA receptor antagonist action. Patients with chronic atrophic stage of CRPS I and CRPS II patients do not appear to respond to this treatment.

Peripheral administration of an N-methyl-d -aspartate receptor antagonist (MK-801) changes dorsal horn neuronal responses in rats

Due to the discovery of peripheral N-methyl-D-aspartate (NMDA) receptors, the effects of peripherally administrated MK-801, a non-competitive NMDA receptor antagonist, and phosphate buffered saline were tested by using the response changes of wide-dynamic range cells in the lumbar enlargement of the spinal cord in Sprague-Dawley rats. MK-801 (1 microM, 50 microl) administered directly into the subcutaneous tissue of the receptive field (n = 7), produces a reversible reduction of responses to noxious and innocuous stimuli by a peripheral action. There was no change in the responses to cutaneous stimuli following injection of phosphate buffered saline (n = 7) or following administration of MK-801 into the contralateral foot (n = 7). The present study suggests that MK-801 produces a local anesthetic like effect in the peripheral tissue.

Functional importance of degenerative spondylolisthesis in cervical spondylotic myelopathy in the elderly.

Study Design. A correlation was studied between degenerative spondylolisthesis (DSL) of the cervical spine and spinal-evoked potentials intraoperatively recorded in elderly patients who had surgical treatment for cervical spondylotic myelopathy. Objective. To investigate the functional importance of cervical DSL in elderly patients with cervical spondylotic myelopathy. Summary of Background Data. Cervical DSL has received insufficient attention in contrast to the lumbar DSL. The authors are unaware of any journal article in which this condition has been evaluated electrophysiologically. Methods. This study investigated 47 patients with 68 DSL of 2 mm or more (3.1 ± 0.9 mm; range, 2–6 mm) who underwent serial intervertebral recording of spinal-evoked potentials from either the intervertebral disc or the ligamentum flavum after epidural stimulation. Results. All the study patients had unequivocal evidence of a focal conduction block, with the area of negative evoked potential peak reduced to less than 60% that of the immediately caudal level: 31 at C3–C4, 12 at C4–C5, and 1 each at C1–C2, C2–C3, C5–C6, and C6–C7. The site of conduction block matched the level of DSL in 30 patients, but not in 17 patients. The DSL accompanied by conduction block had significantly greater displacement with greater angular mobility than that without conduction block. Conclusions. A significant association between DSL and conduction block in the face of a relatively wide canal indicates the functional importance of DSL in elderly patients with cervical spondylotic myelopathy. In this age group, a high incidence of both DSL (81%) and focal conduction block (91%) at the upper cervical level (C3–C4 or C4–C5) is of clinical interest.

Changes in calcitonin gene-related peptide expression following joint immobilization in rats

Long-term immobilization by casting can occasionally cause pathologic pain states in the immobilized side. The underlying neurophysiological mechanisms of immobilization-related pain are not well understood. For this reason, we specifically examined changes of calcitonin gene-related peptide (CGRP) expression in the dorsal root ganglion (DRG), spinal dorsal horn and posterior nuclei (cuneate nuclei) in a long-term immobilization model following casting for 5 weeks. A plastic cast was wrapped around the right limb from the forearm to the forepaw to keep wrist joint at 90 degrees of flexion. In this model, CGRP in immobilized (ipsilateral) side was distributed in larger DRG neurons compared with contralateral side, even though the number of CGRP-immunoreactive (CGRP-IR) neurons did not differ. Spinal laminae III-V, not laminae I-II in ipsilateral side showed significantly high CGRP expression relative to contralateral side. CGRP expression in cuneate nuclei was not significantly different between ipsilateral and contralateral sides. Long-term immobilization by casting may induce phenotypic changes in CGRP expression both in DRG and spinal deep layers, and these changes are partly responsible for pathological pain states in immobilized side.

An Intramedullary Free Vascularized Fibular Graft Combined with Pasteurized Autologous Bone Graft in Leg Reconstruction for Patients with Osteosarcoma

The use of pasteurized autologous bone graft has been an innovation in limb-salvage surgery; however, its principal disadvantage is fracture, infection, pseudoarthrosis, and bone resorption. We present two cases in which an intramedullary free vascularized fibular graft combined with pasteurized autologous bone graft was performed for immediate femur or tibia reconstruction following osteosarcoma resection. The rationale of this method is to combine the mechanical strength of a pasteurized bone with the biological activity of a vascularized bone. The pasteurized bone graft provides bone stock and early stability and the addition of the vascularized bone graft substantially facilitates host-pasteurized bone union. This combination procedure may be a recommended option for reconstruction of the lower leg, preserving knee joint function for patients with osteosarcoma.

Intradermal capsaicin inhibits lumbar dorsal horn neuronal responses to colorectal distention.

&NA; The purpose of this study was to examine the effect of cutaneous inflammation on the responses of viscerosomatic convergent dorsal horn neurons to graded colorectal distension (CRD) and cutaneous mechanical stimulation. Responses of single viscerosomatic neurons in the lumbar dorsal horn of the rat spinal cord to CRD and to cutaneous stimuli were recorded before and 50 min after cutaneous inflammation induced by intradermal injection of capsaicin in the receptive field (RF) or in the ipsilateral and contralateral forepaw. Capsaicin injection in the RF induced an increase in the spontaneous activity of dorsal horn neurons, an expansion in the size of their RF and facilitated their responses to cutaneous stimuli. An injection placed in the center of the RF attenuated the responses to noxious CRD. Capsaicin injection in the forepaw caused a significant decrease in the responses to CRD but not to cutaneous stimuli. These results indicate that the inhibitory effects, evoked by cutaneous inflammation, can modulate the responses of dorsal horn neurons to CRD, independent of its effect on the responses to cutaneous mechanical stimuli. NeuroReport 14:985–989

Health Survey of Numbness/Pain and Its Associated Factors in Kotohira, Japan

We conducted a survey of adults in Kotohira, a town of about 10,000 people located in the Nakatado District of Kagawa Prefecture, Japan. The survey was distributed to 8184 individuals, and effective responses were received from 3863 persons (response rate, 47.2%) during the survey period. Results regarding numbness and pain showed numbness alone in 7.7%, pain alone in 7.2%, both numbness and pain in 6.0%, and neither numbness nor pain in 79.6%. Spine and spinal cord damage was reported present by 5.4%, and absent by 94.6%. Analysis using the Short-Form Health Survey questionnaire, with comparison between subjects reporting both numbness and pain in the extremities and subjects with either numbness or pain alone, showed lower scores for in Short-Form Health Survey subscales (physical functioning, role [physical, emotional], bodily pain, vitality, and mental health). Subjects with numbness alone generally reported no disability in daily life. In a secondary survey, analysis of neurological findings by specialists identified 6 cases of “pain following spinal cord damage” in which spinal cord-related pain developed in the hands or feet. This represented 0.15% of the survey population starting from the primary survey.

Evaluation of the pain and local tenderness in bone metastasis treated with magnetic resonance-guided focused ultrasound surgery (MRgFUS)

It has been reported that MRgFUS has pain palliative effects on the local pain in patients with bone metastasis. In general, a severity of pain has been evaluated using only subjective method with numerical rating scale (NRS) or visual analogue scale (VAS). It is important to evaluate local pain-palliative effects of MRgFUS treatment with objective and quantitative method. The aim of this study is to investigate changes in the severity of local pain of bone metastasis before and after MRgFUS treatments, measuring pressure pain threshold (PPT) using pressure algometer, and pain intensity using electrical stimulation device (the Pain Vision system) at most painful site of bone metastasis. We have conducted MRgFUS for pain palliation of bone metastasis for 8 patients, and evaluated the local tenderness quantitatively for 8 patients, and evaluated local pain intensity for 7 patients. Before the treatments, PPTs were 106.3kPa [40.0-431.5] at metastatic site and 344.8 kPa [206.0-667.0] at normal control site, w...

A Delayed Postoperative C5 Palsy due to Spinal Cord Lesion: A Typical Clinical Presentation but Unusual Imaging Findings

Postoperative C5 palsy (C5 palsy) is a troublesome complication after cervical spine surgery and its etiology is still unclear. We experienced a case of C5 palsy after anterior decompression with fusion for cervical ossification of posterior longitudinal ligament with the typical clinical presentation of left deltoid and bicep weakness and left-arm pain without deterioration of myelopathy symptoms, albeit with the unusual imaging findings not shown preoperatively of a swelling in the spinal cord, and intramedullary high intensity change on T2-weighed MRI. The additional posterior surgery was carried out to decompress the swollen spinal cord. The abnormal findings disappear on MRI taken three weeks following the second surgery and the weakness improved fully within three months after the second surgery. This case report highlights the possibility of spinal cord lesion due to circulatory impairment as a cause of C5 palsy.

Pain alleviation and QOL improvement of MR-guided focused ultrasound surgery (MRgFUS) treatment for painful medial compartment of knee osteoarthritis

A major symptom of knee osteoarthritis (OA) in the elderly is chronic knee pain, which has a significant effect on patients’ quality of life (QOL). Although total knee arthroplasty (TKA) is the validated and reliable treatment for alleviating refractory knee pain, this is often not an option for patients with poor health status or unwillingness to undergo major surgery. Therefore, alternative approaches to alleviate knee pain other than conventional treatments are necessary. Now, we are performing a prospective, non-randomized, single-arm study to evaluate the safety and efficacy of MRgFUS using the ExAblate 2100 conformal bone system (InSightec Ltd.) in the treatment of pain resulting from medial compartment of knee osteoarthritis.