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367 IDENTIFICATION OF AGGRAVATING FACTORS IN PATIENTS WITH CHRONIC NEUROPATHIC PAIN FOLLOWING SPINAL CORD INJURY
Posters / European Journal of Pain Supplements 4 (2010) 47–146
total control of allodynia and hyperalgesia; bolus of Tramadol was used until the total control of the pain was achieved. Conclusions: Acute Neuropathic pain manifestations can be very well controlled by using low dosis of ketamine I.V. after failure of the more common medications used in the perioperative period. 367 IDENTIFICATION OF AGGRAVATING FACTORS IN PATIENTS WITH CHRONIC NEUROPATHIC PAIN FOLLOWING SPINAL CORD INJURY R. Palazon1 , A. Esclarin1 , A. Benavente2 , M. Alcobendas1 , E. Gonzalez1 , S. Ceruelo1 , R. Casado1 . 1 Hospital Nacional de Parapl´ejicos, 2 Hospital Virgen de la Salud, Toledo, Spain Introduction: Neuropathic pain (NP) is a persistent and severe complication of spinal cord injury (SCI) that is difficult to treat. Objectives: To identify the prevalence of NP following SCI and to characterize associated aggravating factors. Methods: Data from patients who attended an annual checkups at the Hospital Nacional de Paraplejicos, ´ Toledo, Spain, were collected. Data from those who complained of either nociceptive pain or neuropathic pain, defined as the description of a “burning” sensation at or below the SCI, were analyzed, specifically using the numerical rating scale (0–10) for intensity and interference for each pain subtype. Quality of life and functional capacity was assessed with the SF-36 and FIM questionnaire, respectively. Statistical analysis was performed with SPSS 15.0 and the significance level was set at p < 0.05. Results and conclusions: 100 chronic patients were studied, with a mean of 6 years following SCI. Non-evoked NP was present in 62 patients and was shown to worsen over the one year period in 37 patients. In the latter group the majority of patients were diagnosed with frequent neurogenic bowel disturbances and lower quality of life. Furthermore half of these patients presented a partial preservation zone of sensory function. No relationship was identified with the ASIA grade, neurological level, FIM scores, interference with daily activities, spasticity or nociceptive pain. We propose that diagnosis and treatment of bowel and bladder dysfunction as an aggravating factor for NP will improve quality of life for patients with chronic SCI. 368 NEUROPATHIC PAIN FOLLOWING CERVICAL EPIDURAL STEROID INJECTION (CESI) C. Gosavi1 , A. Mowat1 , S. Marland1 , R.K. Poddar2 . 1 Anaesthetics and Pain Management, Pilgrim Hospital, Boston, 2 Department Of Anaesthesia And Pain Management, University Hospitals Of Leicester NHS Trust, Leicester, UK Introduction: Cervical epidural steroid injections (CESI) are used for the treatment of cervical radiculopathy. Case: A 61 year lady with a history of whiplash injury. CESI was performed with the patient sitting. A 17G Tuohy needle was inserted through the C6-C7 interspace, the patient experienced paraesthesiae to the right hand. Needle witdrawn, second attempt made. 3 mls of 1% lignocaine and 4 mg of dexamethasone injected. Following the procedure patient developed tingling sensation in right hand, subsided in 10 minutes. Next day patient presented with shooting pain in left hand and “tight band” around wrist. Left hand was erythemaous and swollen. MRI scans were normal. Six months later patient is still complaining of pain in left hand. Nerve conduction studies awaited. Discussion: Two mechanisms can explain the neuropathic pain. As patient reported paraesthesia during CESI, suggesting that nerve tip was closer to the exiting nerve root. Perhaps deposition of steroid may cause neural toxicity. Compromise of the spinal canal by a large herniated intervertebral disc causing posterior displacement of the spinal cord toward the ligamentum flavum can result in spinal cord damage during the epidural placement, without dural puncture. In our case MRI was
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normal. The fact that we fail to explain is patient had paraesthesia to the right hand during the injection but subsequent symptoms observed are in left hand. Reference(s) [1] Abram SE: Complications associated with epidural steroid injections. Reg Anesth 1996; 21: 149–62. [2] Hodges SD et al: Cervical epidural steroid injection with intrinsic spinal cord damage: Two case reports. Spine 1998; 23: 2137–42.
369 THE RELATIONSHIP OF PAIN SEVERITY TO CEREBRAL WHITE MATTER ABNORMALITIES IN PATIENTS WITH PRIMARY SJOGREN’S SYNDROME B. Segal1,2 , B. Mueller1,3 , K. Lim4 . 1 Medicine, Minnesota, 2 Hennepin County Medical Center, Minneapolis, 3 Center for Magnetic Resonance Imaging, Minneaplis, 4 Psychiatry, Minnesota, Minneapolis, MN, USA Introduction: As many as 70% of PSS patients report persistent fatigue often accompanied by poor sleep quality, widespread pain and cognitive symptoms. Objectives: To investigate the neuro-anatomic correlate of psychological symptoms and pain severity in patients with PSS. Methods: Subjects: Patients with PSS according to the AmericanEuropean Consensus Group criteria were invited to participate. Age (within 5 years) and gender-matched control subjects were recruited from the University of Minnesota community. Subjects completed measures of Fatigue (FSS), Pain (BPI), Depression (CES-D) and Perceived Cognitive Abilities (Prof-M) and underwent neurologic exam and quantitative multi-sequence brain imaging. Image acquisition: Performed on a 3-T Siemens Trio MR scanner. Scan sequence: Diffusion tensor imaging (DTI). Image processing: FDT was used to first correct the diffusionweighted images for motion and eddy current distortion and then to compute the diffusion tensor and MD and FA maps. Statistical methods: Spearman correlation coefficient calculated to test for relationship between neuropsychological measures and MR parameters. Results: 13 PSS patients and 7 controls completed the scan protocol. In the pSS patients L hemisphere caudal anterior cingulate FA correlated with fatigue (−0.71, p-value 0.0069), pain (−0.73, p−0.0072) and depression (−0.74, p = 0.0036). Conclusions: Previous studies have demonstrated the prevalence of diffuse pain, negative emotion, decreased coping, anxiety, depression and cognitive symptoms in PSS. The finding in this exploratory suggests that abnormal white matter architecture in the limbic system is associated with altered pain sensitivity in PSS. 370 TRANSCRANIAL DIRECT CURRENT STIMULATION (TDCS) AND VIRTUAL REALITY (VR) TECHNIQUES FOR TREATMENT NEUROPATHIC CENTRAL PAIN IN SPINAL CORD INJURY (NP_SCI) D. Soler1 , H. Kumru1 , J. Vidal1 , F. Fregni2 , J.M. Tormos1 , X. Navarro3 , A. Pascual Leone2 . 1 Institute Neurorehabilitation Guttmann, Badalona, Spain; 2 Harvard Center for Noninvasive Brain Stimulation, Harvard University, Boston, MA, USA; 3 Universidad Aut´ onoma Barcelona, Barcelona, Spain Objectives: To evaluate the analgesic effect of tDCS in the motor cortex and techniques of visual illusion applied isolated or jointly, in patients with NP_SCI. Methods: Clinical trial (phase II), double-blind randomized with control group study. Patients were randomized into the following four groups: tDCS+VR visual feedback, tDCS+TV movie, tDCSsham+VR and tDCS sham+TV movie. The tDCS was anodal stimulation of primary M1 (2 mA, 20 minutes). Each patient received 10 sessions of treatment. After the treatment a follow-up at 2 and at 4 weeks was performed.
total control of allodynia and hyperalgesia; bolus of Tramadol was used until the total control of the pain was achieved. Conclusions: Acute Neuropathic pain manifestations can be very well controlled by using low dosis of ketamine I.V. after failure of the more common medications used in the perioperative period. 367 IDENTIFICATION OF AGGRAVATING FACTORS IN PATIENTS WITH CHRONIC NEUROPATHIC PAIN FOLLOWING SPINAL CORD INJURY R. Palazon1 , A. Esclarin1 , A. Benavente2 , M. Alcobendas1 , E. Gonzalez1 , S. Ceruelo1 , R. Casado1 . 1 Hospital Nacional de Parapl´ejicos, 2 Hospital Virgen de la Salud, Toledo, Spain Introduction: Neuropathic pain (NP) is a persistent and severe complication of spinal cord injury (SCI) that is difficult to treat. Objectives: To identify the prevalence of NP following SCI and to characterize associated aggravating factors. Methods: Data from patients who attended an annual checkups at the Hospital Nacional de Paraplejicos, ´ Toledo, Spain, were collected. Data from those who complained of either nociceptive pain or neuropathic pain, defined as the description of a “burning” sensation at or below the SCI, were analyzed, specifically using the numerical rating scale (0–10) for intensity and interference for each pain subtype. Quality of life and functional capacity was assessed with the SF-36 and FIM questionnaire, respectively. Statistical analysis was performed with SPSS 15.0 and the significance level was set at p < 0.05. Results and conclusions: 100 chronic patients were studied, with a mean of 6 years following SCI. Non-evoked NP was present in 62 patients and was shown to worsen over the one year period in 37 patients. In the latter group the majority of patients were diagnosed with frequent neurogenic bowel disturbances and lower quality of life. Furthermore half of these patients presented a partial preservation zone of sensory function. No relationship was identified with the ASIA grade, neurological level, FIM scores, interference with daily activities, spasticity or nociceptive pain. We propose that diagnosis and treatment of bowel and bladder dysfunction as an aggravating factor for NP will improve quality of life for patients with chronic SCI. 368 NEUROPATHIC PAIN FOLLOWING CERVICAL EPIDURAL STEROID INJECTION (CESI) C. Gosavi1 , A. Mowat1 , S. Marland1 , R.K. Poddar2 . 1 Anaesthetics and Pain Management, Pilgrim Hospital, Boston, 2 Department Of Anaesthesia And Pain Management, University Hospitals Of Leicester NHS Trust, Leicester, UK Introduction: Cervical epidural steroid injections (CESI) are used for the treatment of cervical radiculopathy. Case: A 61 year lady with a history of whiplash injury. CESI was performed with the patient sitting. A 17G Tuohy needle was inserted through the C6-C7 interspace, the patient experienced paraesthesiae to the right hand. Needle witdrawn, second attempt made. 3 mls of 1% lignocaine and 4 mg of dexamethasone injected. Following the procedure patient developed tingling sensation in right hand, subsided in 10 minutes. Next day patient presented with shooting pain in left hand and “tight band” around wrist. Left hand was erythemaous and swollen. MRI scans were normal. Six months later patient is still complaining of pain in left hand. Nerve conduction studies awaited. Discussion: Two mechanisms can explain the neuropathic pain. As patient reported paraesthesia during CESI, suggesting that nerve tip was closer to the exiting nerve root. Perhaps deposition of steroid may cause neural toxicity. Compromise of the spinal canal by a large herniated intervertebral disc causing posterior displacement of the spinal cord toward the ligamentum flavum can result in spinal cord damage during the epidural placement, without dural puncture. In our case MRI was
105
normal. The fact that we fail to explain is patient had paraesthesia to the right hand during the injection but subsequent symptoms observed are in left hand. Reference(s) [1] Abram SE: Complications associated with epidural steroid injections. Reg Anesth 1996; 21: 149–62. [2] Hodges SD et al: Cervical epidural steroid injection with intrinsic spinal cord damage: Two case reports. Spine 1998; 23: 2137–42.
369 THE RELATIONSHIP OF PAIN SEVERITY TO CEREBRAL WHITE MATTER ABNORMALITIES IN PATIENTS WITH PRIMARY SJOGREN’S SYNDROME B. Segal1,2 , B. Mueller1,3 , K. Lim4 . 1 Medicine, Minnesota, 2 Hennepin County Medical Center, Minneapolis, 3 Center for Magnetic Resonance Imaging, Minneaplis, 4 Psychiatry, Minnesota, Minneapolis, MN, USA Introduction: As many as 70% of PSS patients report persistent fatigue often accompanied by poor sleep quality, widespread pain and cognitive symptoms. Objectives: To investigate the neuro-anatomic correlate of psychological symptoms and pain severity in patients with PSS. Methods: Subjects: Patients with PSS according to the AmericanEuropean Consensus Group criteria were invited to participate. Age (within 5 years) and gender-matched control subjects were recruited from the University of Minnesota community. Subjects completed measures of Fatigue (FSS), Pain (BPI), Depression (CES-D) and Perceived Cognitive Abilities (Prof-M) and underwent neurologic exam and quantitative multi-sequence brain imaging. Image acquisition: Performed on a 3-T Siemens Trio MR scanner. Scan sequence: Diffusion tensor imaging (DTI). Image processing: FDT was used to first correct the diffusionweighted images for motion and eddy current distortion and then to compute the diffusion tensor and MD and FA maps. Statistical methods: Spearman correlation coefficient calculated to test for relationship between neuropsychological measures and MR parameters. Results: 13 PSS patients and 7 controls completed the scan protocol. In the pSS patients L hemisphere caudal anterior cingulate FA correlated with fatigue (−0.71, p-value 0.0069), pain (−0.73, p−0.0072) and depression (−0.74, p = 0.0036). Conclusions: Previous studies have demonstrated the prevalence of diffuse pain, negative emotion, decreased coping, anxiety, depression and cognitive symptoms in PSS. The finding in this exploratory suggests that abnormal white matter architecture in the limbic system is associated with altered pain sensitivity in PSS. 370 TRANSCRANIAL DIRECT CURRENT STIMULATION (TDCS) AND VIRTUAL REALITY (VR) TECHNIQUES FOR TREATMENT NEUROPATHIC CENTRAL PAIN IN SPINAL CORD INJURY (NP_SCI) D. Soler1 , H. Kumru1 , J. Vidal1 , F. Fregni2 , J.M. Tormos1 , X. Navarro3 , A. Pascual Leone2 . 1 Institute Neurorehabilitation Guttmann, Badalona, Spain; 2 Harvard Center for Noninvasive Brain Stimulation, Harvard University, Boston, MA, USA; 3 Universidad Aut´ onoma Barcelona, Barcelona, Spain Objectives: To evaluate the analgesic effect of tDCS in the motor cortex and techniques of visual illusion applied isolated or jointly, in patients with NP_SCI. Methods: Clinical trial (phase II), double-blind randomized with control group study. Patients were randomized into the following four groups: tDCS+VR visual feedback, tDCS+TV movie, tDCSsham+VR and tDCS sham+TV movie. The tDCS was anodal stimulation of primary M1 (2 mA, 20 minutes). Each patient received 10 sessions of treatment. After the treatment a follow-up at 2 and at 4 weeks was performed.