- Email: [email protected]
Response to Drs. Ackerman and Ahmad
324
Regional
Anesthesia
and Pain Medicine
Vol. 25 No. 3 May-June
2. Bouaziz H, Paqueron X, Bur ML, Merle M, Laxenaire MC, Benhamou D. No enhancement of sensory and motor blockade by neostigmine added to mepivacaine axillary plexus block. Anesthesiology 1999;91:78-83. 3. Zar JH. Biostatistical Analysis. Upper Saddle River, NJ: PrenticeHall; 1998. Accepted for publication December 22, 1999. doi:l0.1053/xr.2000.5689
Lumbar Spine Pain Originating Vertebral Osteophytes
From
To the Editor: We read with interest the article by Dr. Lamer conceming the injection of painful osteophytes with local anesthetic and corticosteroid.’ The author did not address the reason for his successful block. Needle placement was done with fluoroscopic guidance with needle position at the anterolateral border of the vertebral body. The innervation to the anterior compartment of the spine is from the sympathetic and sinuvertebral nerves.2 Therefore, we believe that the area injected by Dr. Lamer (the osteophyte) was a result of the block of the sympathetic chain and ventral ramus innervating the osteophytes since 3 to 4 mL of the local anesthetic-corticosteroid solution was injected. Similar to Dr. Lamer, we have had 3 patients with multiple-level unilateral anterior lumbar osteophytes. Lumbar sympathetic blocks provided significant pain relief in each of these patients for approximately 3 weeks. The blocks were repeated in 2 of the 3 patients because of the return of a significant degree of pain, At the 3-month follow-ups of these patients, we observed some degree of persistent pain, which was not severe enough to warrant repeat injections. We recommend consideration of sympathetic block on the side of the osteophyte for pain believed to originate from multiple osteophytes. William E. Ackerman IJL M.D. Pain Medicine Consultants Group PA Little Rock, Arkansas
Mahmood Ahmad, M.D. Department of Anesthesiology University of Arkansas Medical Sciences Center Little Rock, Arkansas References 1. Lamer TJ. Lumbar spine pain origfnating from vertebral osteophytes.RegAnesth Pain Med 1999;24:347-351. 2. Bbgduk N. Clinical Anatomy of the Lumbar Spine and Sacrum. 3rd
ed. Edinburgh, Scotland:Churchill Livingstone; 1997. Acceptedfor publication October26, 1999. doi: 10.1053/xr.2000.4159
2000
Response
to Drs. Ackerman
and Ahmad
To the Editor:
I wish to thank Drs. Ackerman and Ahmad for their interest in the vertebral osteophyte article.’ Ln that report I briefly described the innervation of the lumbar spine structures. Drs. Ackerman and Ahmad correctly point out, as I did, that injecting lumbar spine osteophytes may block adjacent nociceptive afferent and/or sympathetic efferent fibers. The report also discussed that subsequent symptomatic relief from such an injection may be due to a direct effect of the injectant on the osteophyte, block of the somatic or sympathetic nerves, a systemic effect of the injectant, a placebo effect, or some combination of these mechanisms. All of the patients discussed in the article failed to respond to previous block of somatic and sympathetic nerves (i.e., epidural block), which is why I am inclined to believe that the therapeutic result is more likely from a direct local affect of the injectant. Pain relief after injection of osteophytes in other areas of the body including the feet, hands, knees, and shoulders is well described in the orthopedic, rheumatology, and podiatry literature, and some studies have shown a preventative effect of corticosteroids on osteophyte formation.2-5 It may be that a lumbar sympathetic block as described by Drs. Ackerman and Ahmad provides relief of lumbar osteophytic pain by spread of the injectant from the area of the lumbar sympathetic chain directly to the area of the osteophyte.
Tim J. Lamer, M.D. Department of Anesthesiology and Division of Pain Management Mayo Clinic Jacksonville, FL
References 1. Lamer TJ. Lumbar spine pain originating from vertebral osteophytes. Reg Anesth Pain Med 1999;24:347-35 1. 2. Davis PP, Severud E, Baxter DE. Painful heel syndrome: Result of non-operative treatment. Foot Ankle Int 1999;15:531535. 3. Boxer MC. Osteoarthritisinvolving the metatarsophalangeal joints and management of metatarsophalangeal joint pain via injection therapy. Clin PodiatrMed 1994;11:125-132.
4. PelletierJp,Martell-Pelletier3. Protectiveeffectsof corticosteroids on cartilagelesionsand osteophyteformation in the Pond-Nuki dog model of osteoarthritis. Arthritis Rheum 1989;32:181-193. 5. Williams JM, Brandt RD. Triamcfnolone hexacetonide protects against fibrillation and osteophyte formation following chemically induced articular cartilage damage. Arthriti Rheum 1985;28:1267-1274.
Acceptedfor publication November 24, 1999. doi:10.1053/xr.2000.5655
Regional
Anesthesia
and Pain Medicine
Vol. 25 No. 3 May-June
2. Bouaziz H, Paqueron X, Bur ML, Merle M, Laxenaire MC, Benhamou D. No enhancement of sensory and motor blockade by neostigmine added to mepivacaine axillary plexus block. Anesthesiology 1999;91:78-83. 3. Zar JH. Biostatistical Analysis. Upper Saddle River, NJ: PrenticeHall; 1998. Accepted for publication December 22, 1999. doi:l0.1053/xr.2000.5689
Lumbar Spine Pain Originating Vertebral Osteophytes
From
To the Editor: We read with interest the article by Dr. Lamer conceming the injection of painful osteophytes with local anesthetic and corticosteroid.’ The author did not address the reason for his successful block. Needle placement was done with fluoroscopic guidance with needle position at the anterolateral border of the vertebral body. The innervation to the anterior compartment of the spine is from the sympathetic and sinuvertebral nerves.2 Therefore, we believe that the area injected by Dr. Lamer (the osteophyte) was a result of the block of the sympathetic chain and ventral ramus innervating the osteophytes since 3 to 4 mL of the local anesthetic-corticosteroid solution was injected. Similar to Dr. Lamer, we have had 3 patients with multiple-level unilateral anterior lumbar osteophytes. Lumbar sympathetic blocks provided significant pain relief in each of these patients for approximately 3 weeks. The blocks were repeated in 2 of the 3 patients because of the return of a significant degree of pain, At the 3-month follow-ups of these patients, we observed some degree of persistent pain, which was not severe enough to warrant repeat injections. We recommend consideration of sympathetic block on the side of the osteophyte for pain believed to originate from multiple osteophytes. William E. Ackerman IJL M.D. Pain Medicine Consultants Group PA Little Rock, Arkansas
Mahmood Ahmad, M.D. Department of Anesthesiology University of Arkansas Medical Sciences Center Little Rock, Arkansas References 1. Lamer TJ. Lumbar spine pain origfnating from vertebral osteophytes.RegAnesth Pain Med 1999;24:347-351. 2. Bbgduk N. Clinical Anatomy of the Lumbar Spine and Sacrum. 3rd
ed. Edinburgh, Scotland:Churchill Livingstone; 1997. Acceptedfor publication October26, 1999. doi: 10.1053/xr.2000.4159
2000
Response
to Drs. Ackerman
and Ahmad
To the Editor:
I wish to thank Drs. Ackerman and Ahmad for their interest in the vertebral osteophyte article.’ Ln that report I briefly described the innervation of the lumbar spine structures. Drs. Ackerman and Ahmad correctly point out, as I did, that injecting lumbar spine osteophytes may block adjacent nociceptive afferent and/or sympathetic efferent fibers. The report also discussed that subsequent symptomatic relief from such an injection may be due to a direct effect of the injectant on the osteophyte, block of the somatic or sympathetic nerves, a systemic effect of the injectant, a placebo effect, or some combination of these mechanisms. All of the patients discussed in the article failed to respond to previous block of somatic and sympathetic nerves (i.e., epidural block), which is why I am inclined to believe that the therapeutic result is more likely from a direct local affect of the injectant. Pain relief after injection of osteophytes in other areas of the body including the feet, hands, knees, and shoulders is well described in the orthopedic, rheumatology, and podiatry literature, and some studies have shown a preventative effect of corticosteroids on osteophyte formation.2-5 It may be that a lumbar sympathetic block as described by Drs. Ackerman and Ahmad provides relief of lumbar osteophytic pain by spread of the injectant from the area of the lumbar sympathetic chain directly to the area of the osteophyte.
Tim J. Lamer, M.D. Department of Anesthesiology and Division of Pain Management Mayo Clinic Jacksonville, FL
References 1. Lamer TJ. Lumbar spine pain originating from vertebral osteophytes. Reg Anesth Pain Med 1999;24:347-35 1. 2. Davis PP, Severud E, Baxter DE. Painful heel syndrome: Result of non-operative treatment. Foot Ankle Int 1999;15:531535. 3. Boxer MC. Osteoarthritisinvolving the metatarsophalangeal joints and management of metatarsophalangeal joint pain via injection therapy. Clin PodiatrMed 1994;11:125-132.
4. PelletierJp,Martell-Pelletier3. Protectiveeffectsof corticosteroids on cartilagelesionsand osteophyteformation in the Pond-Nuki dog model of osteoarthritis. Arthritis Rheum 1989;32:181-193. 5. Williams JM, Brandt RD. Triamcfnolone hexacetonide protects against fibrillation and osteophyte formation following chemically induced articular cartilage damage. Arthriti Rheum 1985;28:1267-1274.
Acceptedfor publication November 24, 1999. doi:10.1053/xr.2000.5655