Advances in Pain Medicine – International Winter Symposium

The London Pain Forum “Advances in Pain Medicine” International Winter Symposium will be returning to the Hotel Village Montana, Tignes Le Lac, France on 20-25 January 2019 with a six day programme of lectures and expert discussions.

Programme

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PAIN MANAGEMENT MEETINGS 

7th London Pain Forum “Advances in Pain Medicine” Winter Symposium
20-25 January 2019
Hotel Village Montana, Tignes Le Lac, France
Web: www.winterpainsymposium.com

12th RA-UK/ESRA/LPF Ultrasound in Chronic Pain Medicine Course
22-23 March 2019
Dept of Anatomy, St George’s Hospital, London, U
Web: www.uspmlondon.com

Headache and Facial Pain Treatment Symposium
5 April 2019
Park Plaza Victoria, Amsterdam Centraal, The Netherlands
Web: www.painways.com

British Pain Society Annual Scientific Meeting
1-3 May 2019
Hilton Tower Bridge Hotel, London, UK
Web: www.britishpainsociety.org


12th Annual Leeds Hands-on Interventional Workshop
9-10 May 2019
University of Leeds, Leeds, UK
Web: www.painandneuromodulationlondon.com

6th SUA Ultrasound Guided Chronic Pain Interventions Workshop
3 September 2019
Royal College of Physicians, London, UK
Web: www.painandneuromodulationlondon.com

Neuromodulation Society of the UK & Ireland Annual Scientific Meeting
and Hands-on Cadaver Workshop
15-17 November 2019
Aspire Conference Centre & Dept of Anatomy, Univ. of Leeds, Leeds, UK
Web: www.painandneuromodulationlondon.com

Thoracic radiculopathy

Thoracic radiculopathy is the pain and resulting symptoms associated with compression on the nerve or nerve roots of the thoracic spine. When the symptoms radiate or refer distally from the spine into the back and outward along the ribs to the anterior chest wall it is considered radiculopathy.

Epidemiology

Thoracic radiculopathy represents an uncommon spinal disorder that is frequently overlooked in the evaluation of spinal pain syndromes 1).

Etiology

Anything that encroaches on, or presses on a nerve, and disrupts its function at the nerve root can be considered a cause of nerve root entrapment.

Degenerative disc disease that results in wear on the intervertebral disc, and a reduction in disc height may result in loss of space at the intervertebral foramen. Herniated discs can place pressure on the nerve in addition to inflammation that irritates the nerve. Degenerative joint disease that results in the formation of bony spurs on the facet joints can narrow the intervertebral space placing pressure on the exiting nerve. Trauma or muscle spasm can put pressure on the peripheral nerve, producing symptoms along that nerve’s distribution path.


The symptoms of thoracic radiculopathy, regardless of the cause, are often not recognized, as there is typically no associated motor deficit. When the etiology is disc herniation or trauma, motor deficit or myelopathy may be observed in the advanced stages.

Furthermore, the typical presentation of band-like thoracic or abdominal pain can mimic a myriad of conditions 2).

With many differential diagnoses to consider, it is not surprising that thoracic radiculopathy is often not discovered for months, or years, after symptoms arise 3).

Rarer causes of thoracic radiculopathy described in the literature include post-thoracotomy, paravertebral mesothelial cyst, and myodil cyst 4).


Thoracic radiculopathy has been reported as a complication of spinal cord stimulation (SCS) paddle lead implantation by several authors and commonly presents as abdominal pain.

Lee et al., from the Houston Methodist Hospital performed a search of all patients who underwent either placement of a new epidural paddle lead electrode or revision of an epidural paddle lead electrode for SCS in the thoracic region from January 2017 to January 2018. They then investigated all cases of immediate postoperative abdominal pain.

They identified 7 patients who had immediate postoperative abdominal pain among 86 cases of epidural SCS procedures. Most patients were discharged on postoperative days 1-3. No patients required revisions or removals of their SCS for any reason.

They conclude that the etiology of immediate postoperative abdominal pain after thoracic paddle lead implantation for SCS is most likely thoracic radiculopathy. They hypothesized that small, transient epidural hematomas could be the cause of this thoracic radiculopathy. They argue that all patients with immediate postoperative abdominal pain and no other neurologic deficits after thoracic paddle lead implantation for SCS should first be treated conservatively with observation and pain management 5).

References

1) , 3)

O’Connor RC, Andary MT, Russo RB, DeLano M. Thoracic radiculopathy. Phys Med Rehabil Clin N Am. 2002 Aug;13(3):623-44, viii. Review. PubMed PMID: 12380552.
2) , 4)

Mammis A, Bonsignore C, Mogilner AY. Thoracic radiculopathy following spinal cord stimulator placement: case series. Neuromodulation. 2013 Sep-Oct;16(5):443-7; discussion 447-8. doi: 10.1111/ner.12076. Epub 2013 May 17. PubMed PMID: 23682904.
5)

Lee JJ, Sadrameli SS, Desai VR, Austerman RJ, Leonard DM, Dalm BD. Immediate Abdominal Pain after Placement of Thoracic Paddle Leads for Spinal Cord Stimulation: A Case Series. Stereotact Funct Neurosurg. 2019 Jan 3:1-6. doi: 10.1159/000495415. [Epub ahead of print] PubMed PMID: 30605913.

Mastoid cells

A section of the mastoid process of the temporal bone of the cranium shows it to be hollowed out into a number of spaces, the mastoid cells, which exhibit great variety in their size and number.

MAC: mastoid air cells; SH: spine of Henle; SMC: suprameatal crest.

At the upper and front part of the process they are large and irregular and contain air (a form of skeletal pneumaticity), but toward the lower part they diminish in size, while those at the apex of the process are frequently quite small and contain marrow; occasionally they are entirely absent, and the mastoid is then solid throughout. At birth the mastoid is not pneumatized, but becomes aerated over the first year of life. Poor pneumatization is associated with eustachian tube dysfunction.


Lin et al., from the Guangdong Second Provincial General Hospital, analyzed treatment of microvascular decompression using the retrosigmoid approach (RA) in primary trigeminal neuralgia and hemifacial spasm using preoperative images combined with intraoperative microscopic navigation to avoid unnecessarily opening the mastoid air cells (MACs).

Ten patients with primary trigeminal neuralgia and 20 patients with hemifacial spasm (test group) were treated using retrosigmoid approach (RA) for microvascular decompression. Preoperative head magnetic resonance angiography and temporal bone computed tomography were performed and the images registered using SPM12 and fused with MRIcron to determine the relationship between mastoid air cells (MACs) and sigmoid sinuses. An O-arm was used for navigation, and the transverse sinussigmoid sinus was projected under a microscope to guide RA. A control group comprised 139 patients who had the same surgical procedure as the test group but without image processing or intraoperative navigation.

The relationship between mastoid air cells (MACs) and the ipsilateral sigmoid sinus was classified as follows: I, MACs did not exceed the lateral edge of the ipsilateral sigmoid sinus (10/60); II, MACs exceeded the ipsilateral lateral edge of the sigmoid sinus but did not exceed the medial edge (42/60); and III, MACs exceeded the medial edge of the ipsilateral sigmoid sinus (8/60). Test and control groups showed significant differences in the incidences of opening MACs (P = 0.003). There was no cerebrospinal fluid leakage or scalp and intracranial infection at follow-up.

Image processing and intraoperative microscopic navigation can avoid unnecessarily opening MACs and might reduce postoperative cerebrospinal leakage and scalp infection after RA craniotomy 1).

1)

Lin J, Zhang Y, Peng R, Ji X, Luo G, Luo W, Wang M, Zhu M, Sun X, Zhang Y. Preoperative Imaging and Microscopic Navigation During Surgery Can Avoid Unnecessarily Opening the Mastoid Air Cells Through Craniotomy Using the Retrosigmoid Approach. World Neurosurg. 2019 Jan;121:e15-e21. doi: 10.1016/j.wneu.2018.08.181. Epub 2018 Sep 3. PubMed PMID: 30189308.
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