Seminars in Pain Medicine最新文献

Since August Bier reported the first case in 1898, postdural puncture cephalgia (PDPC) has been a problem for patients after dural puncture. Bier’s article discussed the pathophysiology of low-pressure headache caused by the leaking of cerebrospinal fluid (CSF) from the subarachnoid to the epidural space. Clinical and laboratory research for the last 30 years has shown that use of small-gauge needles, particularly of the pencil-point design, is associated with a lower risk of PDPC than traditional cutting-point needle tips (Quincke-point needle). The taking of a thorough history can rule out other causes of headache. A postural component of headache is the sine qua non of PDPC. In high-risk patients, that is, those younger than 50 years of age, postpartum, large-gauge needle puncture, epidural blood patch should be performed within 24 to 48 hours of dural puncture. The optimum volume of blood has been shown to be 12 to 20 mL for adult patients. Complications resulting from autologous epidural blood patch are rare.

Spinal hematoma is a very rare neurologic disorder with the potential to cause paralysis or death if not treated appropriately. Prompt diagnosis appears to be the most important aspect of assuring successful treatment and positive outcomes. There are several etiologies of spinal hematoma, such as spontaneous bleeding, trauma, coagulopathies, vascular malformations, and iatrogenic hemorrhage during lumbar puncture or neuraxial anesthesia. Although a spinal hematoma can occur in the pain clinic during procedures such as epidural steroid injections, it is very rare. Most of the available clinical information comes from small case series and isolated case reports of patients undergoing neuraxial anesthesia procedures. This article will not only offer the reader general information about spinal hematomas, it will summarize the current literature with respect to recommendations regarding neuraxial procedures during anticoagulant administration.

Vertebral augmentation with percutaneous vertebroplasty or kyphoplasty is rapidly becoming a preferred intervention for the treatment of pain associated with vertebral body disruption. Vertebral integrity can be compromised by a variety of processes, including vertebral compression fractures, which account for the majority of vertebral augmentation procedures performed each year. Most published outcome studies of vertebroplasty reveal improvement in short-term pain reduction. Long-term follow-up studies are lacking. Complications arising from these procedures are uncommon and most often involve leakage of cement into the perivertebral tissues. Cardiovascular, neurologic, and severe hypotensive complications are also seen with these procedures and can result in significant morbidity and mortality. Complication incidence studies are needed.

Interventions for chronic pain are important in the diagnosis and treatment of many disorders causing chronic pain and suffering. Injury to the peripheral or central nervous system is a rare but important cause of morbidity and mortality following chronic pain interventions. Mechanisms of neural injury include neural ischemia, compression from hematoma, abscess, granuloma, and neurotoxicity. This review will highlight the pathophysiology of neural injuries, review the literature regarding specific injuries and mechanisms, and suggest practical guidelines for injury prevention.

Corticosteroids are commonly injected in the lumbar and cervical epidural space as a treatment for radiculitis. Historically, the epidural injections have been via an interlaminar technique but the transforaminal approach is becoming more prevalent. As the number of transforaminal procedures has increased, there have also been an increasing number of case reports of anterior spinal artery ischemic events leading to temporary and permanent neurological deficits or death. Aside from death, neurological compromise is the most feared complication of all for interventional pain physicians, and strategies to avoid the occurrence of these events are necessary. This review of complications will focus on the type and location of complications, anatomy of anterior spinal cord blood supply, description of the anterior spinal artery syndrome, discussion of potential etiologies, and suggested preventative strategies.

The intention of this article is to review complications associated with the more commonly used nonopioid medications prescribed for pain control. The medications discussed are limited to those commonly prescribed to the adult patient in the outpatient setting and include nonsteroidal antiinflammatory drugs, acetaminophen, anticonvulsants, tricyclic antidepressants, and topical agents. Only limited discussion is given to medication administered intravenously, intramuscularly, epidurally, intrathecally, or injected. Emphasis is placed on common reactions, life-threatening reactions, drug interactions, and safety in pregnancy.

Infections after spinal injections are rare but devastating complications. The purpose of this review is to provide an evidence-based assessment of the case report literature to characterize the predisposing epidemiological and clinical features of patients who developed infectious complications after commonly performed spinal injections. All patients received a corticosteroid as part of the injection. The mean time to symptom onset from the last injection was 14 days, during which patients presented with worsening spinal pain and the onset of new neurological symptoms. The most common type of infection was an epidural abscess, while the most frequently cultured organism was Staphylococcus aureus. The presence of an underlying medical illness that adversely impacts immune function could represent a potential risk factor for development of an epidural abscess. Immunocompromised patients should be identified before performing an epidural injection, and antibiotic prophylaxis for S. aureus should be considered.