MRI is the modality of choice when diagnosing spinal stenosis but it also shows that stenosis is prevalent in asymptomatic subjects over 60. The relationship between preoperative health-related quality of life, functional status, leg and back pain, and the objectively measured dural sac area in single and multilevel stenosis is unknown. We assessed this relationship in a prospective study.2, and spondylolisthesis was measured in mm. For comparison, the area of the most narrow level, the number of levels with dural sac area < 70 mm2, and spondylolisthesis were studied. The cohort included 109 consecutive patients with central spinal stenosis operated on with decompressive laminectomy or laminotomy. Preoperatively, all patients completed the questionnaires for EQ-5D, SF-36, Oswestry disability index (ODI), estimated walking distance and leg and back pain (VAS). The cross-sectional area of the dural sac was measured at relevant disc levels in mm Before surgery, patients with central spinal stenosis had low HRLQoL and functional status, and high pain levels. Patients with multilevel stenosis had better general health (p = 0.04) and less leg and back pain despite having smaller dural sac area than patients with single-level stenosis. There was a poor correlation between walking distance, ODI, the SF-36, EQ-5D, and leg and back pain levels on the one hand and dural sac area on the other. Women more often had multilevel spinal stenosis (p = 0.05) and spondylolisthesis (p < 0.001). Spondylolisthetic patients more often had small dural sac area (p = 0.04) and multilevel stenosis (p = 0.06). Our findings indicate that HRQoL, function, and pain measured preoperatively correlate with morphological changes on MRI to a limited extent. MRI plays a central role in the diagnosis of spinal stenosis. Despite this, the correlation between MRI characteristics and clinical symptoms remains elusive as a considerable number of asymptomatic subjects have MRI-verified spinal stenosis . The rel2    and somestenosis . Since M2), number of levels with stenosis, and spondylolisthesis in relation to preoperative subjective measures of disease in terms of: self reported walking distance, the visual analog scale (VAS) for leg and back pain, Oswestry disability index, the 4 physical domains of the SF-36, and the EQ-5D.We therefore investigated the relationship between the minimal dural sac area  years. 53 patients were male. All the patients were diagnosed and operated at the Department of Orthopaedic Surgery in Lund, Sweden. Preoperative MRI was performed on all patients and dural sac area and number of stenotic levels was evaluated. The “critical size” of 70 mmstenosis .2) at the disc levels in the lumbar spine was measured on axial T1 images using a region of interest (ROI) application on a workstation specially designed for such purposes, using SECTRA software. Spondylolisthesis was measured in mm. Difficult measurements were discussed and a subset of 20 random cases were measured independently by 3 of the authors and the correlation between the observations was calculated.All MRIs were evaluated by one of the authors (XK). The dural sac area . The SF-36 measures both physical and mental health components over the preceding week, covering 8 dimensions : physical functioning (PF), social functioning (SF), role physical (RF), role emotional (RE), mental health (MH), vitality (VT), bodily pain (BP), and general health (GH). The item scores for each dimension were coded and summed and transformed into a scale from 0 (maximum disability) to 100 (no disability).The ODI is a 10-question low back-specific instrument designed to measure disability in spine patients . The ODIThe EQ-5D is a standardized quality of life instrument to measure health outcomes. The instrument has 5 dimensions: mobility, self-care, daily activities, pain/discomfort, and anxiety/depression. Each dimension has 3 possible answers  of which only 1 can be selected .Visual analog scale scores for leg and back pain were obtained on the preoperative day by measuring the distance in mm from the origin of a horizontal line  and the point indicated by the patient as representing their level of pain during the previous week. Zero represented “no pain at all” and 100 represented “the worst pain imaginable”.STATA 10 statistical software was used. Parametric tests were used when only SF-36 variables were involved in the analysis. When comparison with other variables was done, for which no assumption of normal distribution could be made, non-parametric tests were used . When investigating correlation between functional measures—HRLQoL and pain to minimal dural sac area—Pearson's correlation was performed, controlling for levels involved. Values of p < 0.05 were regarded as statistically significant. The interclass correlation coefficient (ICC) was used in the reability assessment of minimal dural sac area measurements.The patient group was part of the Swedish Spine Register and as such had given consent for participation in this study. The Swedish Spine Register is the property of the Swedish Society for Spinal Surgery and is funded by the National Board of Health and Welfare .A high to moderate correlation was found between observers  measuring the subset of 20 patients , . Intercl2 , 40 mm2 (SD 16) in women and 46 mm2 (SD 18) in men , followed by the L3–L4 level in 36 patients. Minimal dural sac area was less often localized at the L2–L3 level (8 patients) followed by the L5–S1 level in 2 patients. 4 patients had a minimal dural sac area of > 70 mm2. 51 patients had 1 level with a dural sac area of < 70 mm2; the remaining 54 had 2 or more levels < 70 mm2. Mean number of levels with stenosis below 70 mm2 was 1.5 (SD 0.8)  in men . 105 pat(SD 0.8) .35 patients had concomitant low-grade spondylolisthesis and 6 had spondylolisthesis at more than 1 level. Spondylolisthesis was most common at the L4–L5 level, where 27 patients had a mean olisthesis of 6.2 mm (SD 2.5), followed by the L3–L4 level, where 9 patients had a mean olisthesis of 5.7 mm (SD 2.1). The third most common level was L2–L3, where 5 patients had a mean olisthesis of 5 mm (SD 1.9). At the L5–S1 level, 4 patients had olisthesis of mean 5.5 mm (SD 2.4). 1 patient had 3 mm of olisthesis at the L1–L2 level.s = 0.35; p < 0.001). The mean age of patients with spondylolisthesis was 75 years (SD 7.1), and it was 69 years (SD 10) in patients without spondylolisthesis .Spondylolisthesis was more common in women (27) than in men (8)  and the corresponding score for back pain was 54 (SD 28). For EQ-5D, the mean preoperative score was 0.41 (SD 0.29). The physical subscale and general health scores of the SF-36 were generally low . Mean prPreoperative walking distance was subjectively recorded by 105 patients . There ws = –0.43; p < 0.001). Patients with three-level stenosis had less pain on the VAS scale (54 (SD 30)), than patients with one-level (70 (SD 21)) and two-level stenosis (68 (SD 23)). The mean VAS leg pain score for patients with single-level stenosis was 72 (SD 21), as compared to 64 (SD 26) for the whole group of patients with multilevel stenosis (p = 0.1). The corresponding values for back pain were 56 (SD 25) for single-level stenosis and and 51 (SD 31) for multilevel stenosis (p = 0.4). As number of stenotic levels increased, leg pain levels deteriorated . The same kind of relationship was not observed between age and multilevel stenosis . Visual analog scores for leg or back pain were not related to age . Older patients had shorter percieved walking distance (p = 0.07).The minimal dural sac area became increasingly reduced with increasing age . Low-grade spondylolisthesis was 5 times more common in women . There was a difference in the degree of stenosis between the sexes, although this was not statistically significant (p = 0.07) . Women h53 patients answered questions on comorbidity as a factor affecting quality of life. 31 reported no other disease affecting quality of life, but 22 named heart disease as a factor affecting their quality of life.2 (SD 16), as compared to 45 mm2 (SD 17) in patients without spondylolisthesis . The mean number of levels with stenosis in patients with low-grade spondylolisthesis was 1.8 (SD 0.82) as compared to 1.5 (SD 0.76) in patients without spondylolisthesis .The minimal dural sac area in patients with low-grade spondylolisthesis was 38 mmNo difference was found in visual analog score values for leg and back pain, EQ-5D, and the physical dimensions of SF-36 in patients with and without spondylolisthesis .Our cohort of patients is unique, as we could obtain well-documented data on preoperative HRLQoL, functional status, pain, and measured MRI characteristics.Our main findings are the high disability, low HRQoL, and high age of this population of patients, and that a very small dural sac area is more common in multilevel disease and in spondylolisthesis. We have also confirmed that there is an increased prevalence of spondylolisthesis in women  and we hOur results for the physical dimensions of the SF-36 are similar to the preoperative results reported by 2. Experimental studies have shown reduced blood flow in nerve roots in two-level, experimentally induced spinal stenosis (2 at more than 2 of 3 intervertebra levels; however, multilevel affection was rare in patients with radicular-type pain (Multilevel spinal stenosis is common in the degenerative spine, which is confirmed by our study where 50% of patients had more than one level with dural sac area of < 70 mmstenosis  and Olmastenosis . In a frype pain . Sato anype pain . Our finStudies on the relationship between ODI and spinal stenosis have yielded varied results, and in our study ODI scores were not statistically significantly affected by spondylolisthesis, multilevel disease, or the degree of stenosis. Subjectively estimated walking distance in patients with spinal stenosis is probably somewhat inaccurate, and can be influenced by factors other than spinal stenosis, and is therefore unspecific . In the We found no difference in the baseline HRLQoL indices for patients with spinal stenosis with and without spondylolisthesis, which corresponds to recently published data . We founWhy is there a lack of correlations between the hard pathomorphological data of the MRI and the outcome tools we used? The answer can perhaps be found in the critical size defined by


Pain control in children is still a therapeutic dilemma. Preschool patients are affected from undesirable effects of postoperative pain more than adults. Tonsillectomy is associated with a high incidence of postoperative pain, not only complicating the recovery, but also delaying patients discharge.Despite employing different surgical and anesthetic strategies in post-tonsillectomy pain relief, this is still a clinical problem. The study was designed to evaluate the efficacy of a low dose ketamine in post tonsillectomy pain relief.Our prospective randomized double blinded study enrolled 75 pediatric patients (3-10 years old) who were scheduled for a tonsillectomy procedure. Patients were randomly assigned to one of three groups receiving; intravenous (IV) ketamine 0.5mg/kg, subcutaneous (SC) ketamine 0.5 mg/kg and placebo at the end of the operation. Post-operative pain score was assessed using modified CHEOPS.In our study we did not find any significant difference among the three groups regarding sex, age, and weight, duration of operation, hemodynamic stability, and nausea and vomiting. However, in ketamine groups, pain score and analgesic consumption were significantly lower (P < 0.00). The efficacy of the both ketamine groups was similar.The study demonstrated that the both subcutaneous and intravenous injections of ketamine, at the end of the operation, were safe and effective for post-tonsillectomy pain control. Ketamine reduced postoperative analgesic medications consumption without increasing the risk of complications. Tonsillectomy is associated with a high incidence of postoperative pain -4 not onThe aim of this study was to evaluate the effect of low-dose subcutaneous (SC) and intravenous (IV) administration of ketamine, at the end of the operation, on post tonsillectomy pain relief. The preventive analgesic properties of ketamine in the first six hours of tonsillectomy were investigated. Postoperative pain score, adverse effects, hemodynamic changes, recovery from anesthesia, postoperative analgesic requirement, and complications were also evaluated.In our prospective randomized double blinded clinical trial study with a parallel design, 75 pediatric patients, ASA class of I and II and aged 3-10, who were scheduled for a tonsillectomy procedure were enrolled. Approval for the study was obtained from the Ethics Committee of Tehran University of medical sciences. Moreover a written informed consent was obtained from the patients` family. Exclusion criteria included patients with psychiatric disorders and chronic pain syndrome. The study was conducted in Imam Khomeini Medical center Valiasr hospital from December 2010 to November 2011. A power analysis was performed to determine a sufficient sample size to establish a significant difference in the incidence of need for rescue analgesia based on the results of a preliminary study, using a p-value of 0.05 and a power of 0.8. The incidence of need for rescue analgesia was 70% in placebo group and 35% in ketamine group in our preliminary study. This determined that 25 patients per group were adequate. The patients were randomly assigned to one of the three groups of 25 patients using block randomization method. Group I received 1ml normal saline IV and S.C as well, at the end of the operation. Group II received 0.5 mg/kg ketamine as 1ml IV and 1ml normal saline S.C. Group III received 0.5 mg/kg ketamine as 1ml S.C and 1ml normal saline IV. Same technique of anesthesia was performed in all groups. Anesthesia was induced after establishment of a peripheral 24-Gauge IV catheter, ECG monitoring, pulse oximetry, NIBP and scenography. Fentanyl 2 µg/kg and atropine 0.02 mg/kg were administered as premedication. Sodium thiopental 5 mg/kg and atracurium 0.6 mg/kg were administered for induction of anesthesia. The patients were intubated using spiral cuffed oral tracheal tube. The size of OTT was determined using the formula (age/4) +3. Anesthesia was maintained with isoflurane 1% and nitrous oxide 50% in oxygen. No extra muscle relaxant was administered intra operatively. Neither opioids nor local anesthetics were administered during the operation. Ketamine and placebo was administered at the end of the operation. Ventilation was controlled mechanically. Patients received serum 0.3 NaCl with 3.3% dextrose according to 4-2-1 formulation during post-operative period. All of the operations were performed by the same surgeon and with a standardized method of surgery. All the evaluation was performed by an anesthesiologist who was blinded to the groups’ allocation. Systolic blood pressure [SBP], diastolic blood pressure [DBP], heart rate (HR) and oxygen saturation (Spo2) were recorded every five minutes. The primary outcome in this study was to evaluate postoperative pain score, while the other measured variables considered as the secondary outcome. In this double blinded trial, both the operating room anesthesiologist and the anesthesiologist who evaluated the patients postoperatively and the parents of patients were blinded to the evaluation groups. Postoperative pain score (0-10) was assessed by an anesthesiologist who was blinded to the groups allocation at 5, 15, 30, 60 and 360 minutes using standard modified CHEOPS  Table 1Table 1. The analyses were performed using the SPSS, Version 11.5. P value less than 0.05 was considered significant. The distribution of quantitative data was analyzed using the one sample Kolmogorov-smirnov test, and accordingly the data among three groups was analyzed using Kruskal-Wallis test, and Pairwise Comparisons was performed using the Mann-Whitney Test. Data trend for each variable within or among groups were compared with each other by repeated measurement test, and for Pairwise Comparisons, the Least Significant Difference (LSD) Test was applied.Patients` characteristics  were similar among groups . HemodynKetamine is a potent noncompetitive antagonist of NMDA at sub anesthetic dosage and it reduces the need for post-operative analgesic consumption . Studies


A consistent line of investigation suggests that autonomic nervous system dysfunction may explain the multi-system features of fibromyalgia (FM); and that FM is a sympathetically maintained neuropathic pain syndrome. Dorsal root ganglia (DRG) are key sympathetic-nociceptive short-circuit sites. Sodium channels located in DRG (particularly Nav1.7) act as molecular gatekeepers for pain detection. Nav1.7 is encoded in gene SCN9A of chromosome 2q24.3 and is predominantly expressed in the DRG pain-sensing neurons and sympathetic ganglia neurons. Several SCN9A sodium channelopathies have been recognized as the cause of rare painful dysautonomic syndromes such as paroxysmal extreme pain disorder and primary erythromelalgia. The aim of this study was to search for an association between fibromyalgia and several SCN9A sodium channels gene polymorphisms.We studied 73 Mexican women suffering from FM and 48 age-matched women who considered themselves healthy. All participants filled out the Fibromyalgia Impact Questionnaire (FIQ). Genomic DNA from whole blood containing EDTA was extracted by standard techniques. The following SCN9A single-nucleotide polymorphisms (SNP) were determined by 5' exonuclease TaqMan assays: rs4371369; rs4387806; rs4453709; rs4597545; rs6746030; rs6754031; rs7607967; rs12620053; rs12994338; and rs13017637.P = 0.036) mostly due to an absence of the GG genotype in controls. Interestingly; patients with this rs6754031 GG genotype had higher FIQ scores  than patients with the GT genotype  and the TT genotype .The frequency of the rs6754031 polymorphism was significantly different in both groups (In this ethnic group; a disabling form of FM is associated to a particular SCN9A sodium channel gene variant. These preliminary results raise the possibility that some patients with severe FM may have a dorsal root ganglia sodium channelopathy. The background information leading to the present investigation has been already published as a hypothesis  and is sDRG are nodules that lie along the spinal column. They play a key role in pain perception. DRG house the cell bodies of sensory neurons; the dendrites of which are located in the skin; muscles; tendons; joints; and internal organs. DRG act also as viral sanctuaries. Under normal circumstances; DRG have scant sympathetic innervation. Nevertheless; trauma and/or infection trigger sympathetic sprouting within DRG via nerve growth factor over-expression. Such aberrant neuroplasticity enables catecholamines and sympathetic traffic to induce sensory neuron firing. Sodium channels play a pivotal role in this hyperexcitability. These mechanisms are the basis of the sympathetically-maintained pain concept .Sodium channels located in DRG act as molecular gatekeepers of pain detection at peripheral nociceptors. Nine sodium channel subunits have been identified (Nav1.1-Nav1.9); each with a unique central and peripheral nervous system distribution. An isoform Nav1.7) encoded in gene SCN9A of chromosome 2q24.3 is predominantly expressed in the DRG pain-sensing neurons and sympathetic ganglia neurons . Several encoded This information lead us to the present investigation whose objective was to search for an association between several SCN9A sodium channels gene polymorphisms and fibromyalgia.We studied 73 Mexican women suffering from FM according to the 1990 American College of Rheumatology criteria. These patients were referred from different private rheumatology practices in Mexico. As controls; we studied 48 Mexican women who considered themselves to be healthy and who denied having chronic pain. Patients and controls were matched by age. Mexicans have diverse ethnicity. The great majority have European and Native American background. "Mestizo" is the term used to name this mixed heritage. All individuals included in the study were born in Mexico and were catalogued as Mestizo. No further genealogical characterization was done. Both patients and controls filled out a validated Spanish translation of the Fibromyalgia Impact Questionnaire (FIQ) [This research complies with the Helsinki Declaration. Informed consent was obtained from all participants; and the Human Research Committee of the National Institute of Cardiology of Mexico approved the study. This group of subjects is the same reported in our previous genetic studies in FM looking for polymorphisms of the adrenergic receptor  and cateGenomic DNA from whole blood containing EDTA was extracted by standard techniques . Ten difP > 0.05 by Shapiro-Wilk statistics); therefore; data were measured as median and interquartile range. The Kruskal-Wallis test was used to compare visual analog scale (VAS) scores on the FIQ with SNPs and genotypes. Proportions of patients and controls per SNP were estimated and compared using chi square or Fisher's exact tests; as required; and presented as absolute frequencies and proportions. Statistical significance was set at an alpha level of less than or equal to 0.05. Pair wise linkage disequilibrium  estimations between polymorphisms and haplotype reconstruction were performed with Haploview version 3:32 .Statistical analysis was carried out with Stata 8.0 software for Windows . A chi-square test was used to evaluate Hardy-Weinberg equilibrium for each polymorphism. In the exploratory analysis; numeric data showed a non-normal (non-Gaussian) distribution (P = 0.036) mostly due to an absence of the GG genotype in controls. Correlation analysis between SNPs and total FIQ score showed that patients with the rs6754031 GG genotype had higher total FIQ scores  than patients with the GT genotype  or the TT genotype   had strong LD. One SNP (rs6746030) was not studied because too few individuals were determined for this variant. In light of the strong LD; we analyzed the most frequent haplotypes in patients and healthy controls to determine whether some of these haplotypes could be associated with the risk of developing FM. The distribution of the different haplotypes was similar in patients and healthy controls (data not shown).This group of Mexican patients suffering from FM displayed different distribution of SCN9A rs6754031 genotypes when compared to ethnic; age; and gender matched controls. The difference was due mostly to the absence of the rs6754031 GG genotype in controls. Additionally; in this group of FM patients; the rs6754031 GG genotype is associated with severe disease; as assessed by the FIQ. To our knowledge there is no prior research linking rs6754031 with any particular illness. Although no causality could be derived from the present investigation; these preliminary results raise the possibility that some patients with severe FM may have a DRG sodium channelopathy.We are not aware of previous studies looking at SCN9A sodium channels gene variation in FM. However; Reimann et al. studied several SCN9A polymorphisms in patients with different painful syndromes; including osteoarthritis; sciatica; amputee phantom pain; spine surgery and pancreatitis. They found a link of rs6746030 with pain intensity. They did not study the SNP rs6754031 that we found associated to FM severity . Nav1.7 After the submission of this manuscript Faber et al. published a gain of function SCN9A mutation associated to idiopathic small fiber neuropathy. This novel finding points to a broader role of Na(V) 1.7 mutations in painful neurological disease than previously considered from studies on rare genetic syndromes .Our previous genetic studies in this group of patients found an association of two catechol-o-methyl transferase (COMT) enzyme gene polymorphisms with FIQ subscales. COMT rs6269 was associated with pain and fatigue; and COMT rs165599 with morning stiffness and disability . The resWe recognize limitations in this pilot study. The sample size is not large enough to withstand multiple comparisons of common gene polymorphisms; therefore a type II statistical error is possible. Nevertheless; the following two findings favor a real linkage between rs6754031 GG genotype and Mexican FM patients: 1) rs6754031 polymorphism was significantly different in both groups mostly due to an absence of the GG genotype in controls. 2) In the patients group the same rs6754031 GG genotype was associated to a severe disease. Studies in other ethnic groups with a larger sample size are needed to verify or amend these preliminary observations.Another limitation of our study is the lack of rs6754031 functional profiling. Techniques such as patch methods or functional expression assays are beyond our capabilities. So; at the present time; the link between SCN9A polymorphism and severe FM is just associative. Nevertheless; our findings raise the possibility that DRG could be an important element in the pathogenesis of FM; a site in which physical; emotional; or infective stimuli could be converted into chronic pain . GeneticThe results of the present investigation may have potential therapeutic implications. If future investigations confirm the Nav1.7 sodium channels dysfunction in FM; then sodium channel blockers may become a therapeutic option. Preliminary evidence supports this contention. Lignocaine; a non-specific sodium channel blocker; appears to reduce FM pain . DuloxetOur results show that; in this group of Mexican women; there is an association of the rs6754031 polymorphism with the risk of developing FM; as well as with the FIQ score. This association raises the possibility that some patients with severe FM may have a DRG sodium channelopathy.FM: Fibromyalgia; DRG: Dorsal root ganglia; FIQ: Fibromyalgia Impact Questionnaire; SNP: Single nucleotide polymorphism; COMT: Catechol o methyl transferase; VAS: Visual analogue scale; AR: Adrenergic receptorThe authors declare that they have no competing interests.GVA; EAL and VMF carried out the genetic studies. AM and AG recruited patients and were involved in the clinical part of the investigation. MV performed the statistical analysis. All authors read and approved the final manuscript. MML conceived the study; participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.We gratefully recognize the financial support of the American Fibromyalgia Syndrome Association.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/13/23/prepub


Involvement of the cervical spine is common in rheumatoid arthritis. Clinical presentation can be variable, and symptoms may be due to neck pain or compressive myeloradiculopathy. We discuss the pathology, grading systems, clinical presentation, indications for surgery and surgical management of cervical myelopathy related to rheumatoid arthritis in this paper. We describe our surgical technique and results. We recommend early consultation for surgical management when involvement of the cervical spine is suspected in rheumatoid arthritis. Even patients with advanced cervical myelopathy should be discussed for surgical treatment, since in our experience improvement in function after surgery is common. This paper will consider the surgical management of patients with rheumatoid arthritis (RA), in particular the management of RA patients with a cervical myelopathy.RA is a chronic inflammatory disorder of joints. The aetiology is unknown. It is characterised by an erosive synovitis. Synovial inflammation can lead to joint erosions, erosions of periarticular soft tissues, and pannus formation. The cervical spine requires soft tissue integrity for stability. Damage to ligaments and joints can cause different types of instability , 2. RadiAny orthopaedic surgery in patients with RA is challenging, given the potential problems of osteoporosis, immunocompromise and poor wound healing. If to those general problems we add the potentially severe neurological problems in RA patients with a myelopathy, we can see that RA myelopathic patients are a particular challenge.Synovitis develops in the facet joints, in the synovial tissue adjacent to the odontoid, and in uncovertebral joints at the lateral margins of the intervertebral discs. There is erosion of adjacent ligaments, the annulus, disc spaces, and bone , 10, 11.There is progressive instability with typical radiographic features. As set out above, there are three patterns of instability which occur either singly, or together: the atlas shifts forward on the axis ; one vertebral body shifts forward on the body of another at lower levels which may be seen at multiple levels and produces a stepladder deformity ; the axis telescopes into the atlas, driving the odontoid upwards  . AtlantoNeck pain may be a consequence of the primary inflammatory disorder. Neck pain is a potential consequence of subaxial instability. It can be difficult to distinguish these two causes of neck pain. We have relied upon the extent of peripheral joint disease. If an RA patient has a severe neck pain, if neck pain tends to occur at a time when peripheral joint disease is severe, and if it waxes and wanes with a similar pattern to the peripheral joint disease, we consider that, probably, neck pain is a consequence of the primary rheumatoid disorder. By contrast, where neck pain is severe but peripheral joint problems are mild then we consider that it is more likely that subaxial subluxation is the cause of neck pain. The localisation of neck pain in patients with RA is as difficult as it is in all patients with neck pain.Suboccipital pain, typically a consequence of C2 nerve root involvement, is almost always associated with subluxation, most commonly, AA (C1-C2) subluxation, occasionally vertical subluxation. Subluxation, causing C2 radicular pain, is the commonest radiculopathy that occurs in RA [rs in RA , 14.Subaxial radiculopathy does occur but it is relatively uncommon in RA patients.Myelopathy is common. Patients present with the classical symptoms of gait disturbance, loss of fine motor control in the hands, numbness in the hands, and balance disturbance. It is held by some that it can be difficult to differentiate myelopathic problems in the hands from the problems that are a consequence of joint disease. Our experience has been different. We have found that most patients readily distinguish the long-term joint disorder from a new myelopathic disorder. Nevertheless we would agree that in some cases it may be difficult to distinguish between the two problems. In a similar fashion, neurological examination can be more difficult because of the rheumatoid joint involvement, particularly where there have been fusions, for example, of fingers or the wrist. We have found that careful neurological examination does allow us to attribute new functional problems to a new neurological disorder (as opposed to long-term persistent joint problems). The risk of an RA patient developing a myelopathy progressively increases as the residual canal diameter is reduced [ reduced .Brainstem compression is less common. It can produce facial sensory disturbance, dysphagia, or abnormalities in the lower cranial nerves. Objective signs of a myelopathy, including hyperreflexia, extensor plantar responses, positive Hoffman's signs or clonus, together with objective motor and sensory losses will be found in the majority of patients.Sudden death is reported; it is rare [ is rare .Deformity can cause substantial disability in the absence of myelopathy, particularly where the deformity is severe, as in the chin-on-chest deformity.In determining the severity of any disease process, the effects of surgical intervention, or the factors that influence prognosis and survival, it is helpful to have objective and reproducible means of measuring the patient's disability.Pain can be reliably assessed by means of a visual analogue scale .Various clinical grading systems have been used to describe the neurological .AADI is the distance from the posterior margin of the anterior ring of C1 to the anterior surface of the odontoid. A distance of more than 3 mm in an adult or 4 mm in a child is abnormal [The abnormal , 21. ThePADI is the distance from the posterior aspect of the odontoid to the anterior margin of the lamina of C1. The PADI is a good measure of the space available for the spinal cord in relation to the bony elements. The PADI is most accurately assessed with CT imaging in the subluxed, usually flexed, position. A PADI of 13 mm or less is associated with an increased risk of myelopathy [The elopathy , 22. TheSubaxial subluxation may be measured as either (i) the extent of subluxation measured in millimetres or (ii) the percentage of slip of one vertebra upon another. The sagittal diameter of the subaxial spinal canal better correlates with the presence and/or extent of myelopathy. Patients with subaxial canal diameters of 13 mm or less are at increased risk of myelopathy [elopathy , 22.There are several measurements that attempt to quantify the extent of vertical subluxation of the odontoid. No single measure has a high sensitivity or specificity; a combination of measurements has the greatest predictive power . The fouThe indications for surgical treatment include the following: (i) to treat C2 root pain; (ii) to prevent any myelopathy; (iii) to prevent further neurological deterioration in patients with a progressive cervical myelopathy; (iv) to treat deformity.Prophylactic surgery to prevent any myelopathy is indicated where subluxation  has reduced the residual canal diameter to such an extent that there is a significant risk of a myelopathy developing in the future. It is the residual diameter of the spinal canal in the subluxed position that predicts myelopathy. The residual canal diameter is the bony PADI corrected for any additional soft tissue compromise. If the residual canal diameter is 13 mm or less, we would recommend prophylactic stabilisation [lisation , 22.Surgery can be indicated to treat deformity, and/or C2 root pain, and/or progressive myelopathy.AA or subaxial deformity may be wholly asymptomatic. If the residual canal diameter is above 13 mm, such patients can be observed , 22. SerDeformity itself can be disabling, particularly where the deformity is severe as in the chin-on-chest deformity. Such a severe deformity can be painful; it can limit swallowing and eventually it can limit breathing. In such patients we would recommend reduction of the deformity in a halo, progressively, followed usually, by posterior long-segment stabilisation.A-A subluxation is commonly associated with C2 radicular pain. In common with other cervical radiculopathies, pain can be severe and disabling. Posterior C1-C2 fixation and fusion lead to improvement or cure in C2 root pain in over 90% of cases , 25.RA patients with a progressive cervical myelopathy typically require treatment to prevent progression of the myelopathy. Reduction of deformity and/or surgical decompression of the spinal cord usually prevents further neurological deterioration. There can be a surprising degree of functional recovery. Some have suggested that where an RA patient has a severe, nonambulant (Ranawat IIIB) myelopathy, surgical treatment is futile –27. ThatRA patients have comorbidities that are potentially a consequence of their disease and/or their age. Cardiac, pulmonary, and renal comorbidities should be assessed jointly by the surgical and anaesthetic staff. Any problems that can be corrected, should be. For transoral surgery the surgeon must assess the degree of mouth-opening (which may be reduced because of temporomandibular joint disease) and the presence/absence of permanent teeth. We have, once, had to abandon proposed transoral surgery because the transoral access proved to be insufficient.We prefer (if time permits) to immobilise the patient in a halo preoperatively. This has some advantages: (i) safe intraoperative transfers and positioning; (ii) putting the patient into a fully functional position preoperatively; (iii) careful neurological observation during reduction of a deformity . A halo put on three or four days preoperatively can be adjusted so that the best degree of vertical distraction and lordosis is attained in an ambulant and functioning patient. If, when reducing a deformity in a myelopathic patient there is an increased neurological deficit, the reduction can be reversed with, usually, recovery of neurological function. The authors are aware of several patients whose deformity has been reduced under anaesthetic immediately prior to decompression, fixation, and fusion where the patient has woken up quadriplegic. It is of course impossible to say which part of the procedure led to quadriplegia, but reduction of deformity intraoperatively is at least one potential cause, the risk of which can be minimised by reduction in a halo preoperatively. We have also found that putting the patient's head and neck in a functional position preoperatively is easier to judge than trying to do so intraoperatively with the patient prone.As for all spinal procedures, we need to consider (i) the approach; (ii) decompression; (iii) fixation; (iv) fusion. In RA patients the principles are not different from spinal patients as a whole although a special consideration is required in relation to fixation and fusion.anterior approach for decompression is appropriate for (i) anteriorly placed pathologies such as odontoid pannus  has made mistakes in his practice in relation to fixation in RA patients it is in underdoing, not overdoing the fixation. Fixation with screws into osteoporotic bone can lead to screw pullout; short segment posterior fixation, when long segment fixation is required; or posterior fixation only, when simultaneous anterior and posterior fixation were the preferred option which have all led to implant failure. A huge variety of implants are available; it is outwith the remit of this paper to review them all. Briefly, posterior fixation includes rods or occipital paddles fixed with screws, hooks, or wires. Screws can be into the occiput, directly into the lateral masses of C1 below and/or the pedicles of C2. Anterior fixation is typically via cages and/or anterior cervical plates and screws. Experienced spinal surgeons will have found methods that best suit themselves and their patients.The nature, length, and position of Our most common construct is a posterior hook/rod construct . In the For both reducible and irreducible A-A subluxation a variety of posterior constructs have been described. The key issue is to create a construct that controls the C1-C2 motion segment until solid fusion occurs.For all fixations fusion is normally required. Internal fixation without fusion will usually fail in time, particularly in this group of patients, where bone quality is poor. As with other spinal patients, anterior fusions are more likely to be successful than posterior fusions, although posterior fixation and therefore fusion are more commonly needed in RA patients. For occiput-C1-C2 fixation/fusions onlay graft to the occiput and laminae of C1 and C2 is used. For posterior subaxial fusions, lateral mass fusions are standard. Autologous bone grafts are the gold standard, but long segment fusions (and indeed even some occiput-C1/C2 fusions) require more bones than is locally available . The surgeon then needs to decide whether to augment local bone with autologous bone, for example, from the iliac crest (which carries its own morbidity ) or whetTreatment of radiculopathy leads to high rates of improvement in radicular pain. In the commonest radiculopathy, the C2 radiculopathy from A-A subluxation, posterior stabilisation leads to improvement, and most commonly cure, of C2 root pain in over 90% of patients.In patients with other compressive myelopathies, it is generally held that decompressive procedures halt neurological deterioration but improvement in neurological function is unpredictable , 35. We Cervical myelopathy in RA patients should be diagnosed and treated as early as possible to reduce preventable morbidity. However, diagnosis at an advanced stage should not preclude consideration of surgical treatment. Surgical considerations include (i) approach; (ii) decompression; (iii) fixation; (iv) fusion. We would recommend surgical treatment even in severe grades of myelopathy (Ranawat IIIB) to preserve life and improve function.


Many traumatised refugees suffer from both persistent pain and posttraumatic stress disorder (PTSD). To date, no specific guidelines exist for treatment of this group of patients. This paper presents data on a pilot treatment study conducted with 15 traumatised refugees with persistent pain and PTSD.Participants received 10 sessions of pain-focused treatment with biofeedback (BF) followed by 10 sessions of Narrative Exposure Therapy (NET). Structured interviews and standardised questionnaires were used to assess symptoms of pain intensity, pain disability, PTSD and quality of life directly before and after treatment and at 3 months follow-up.Following the combined intervention, participants showed a significant reduction in both pain and PTSD symptoms, as well as improved quality of life. Additionally, biofeedback increased motivation for subsequent trauma-focused therapy, which in turn was related to larger PTSD treatment gains.This pilot study provides initial evidence that combining BF and NET is safe, acceptable, and feasible in patients with co-morbid persistent pain and PTSD. There are an estimated 15.4 million refugees worldwide  over this time, 18 individuals were preselected based on their referral letter indicating co-morbid persistent pain and PTSD, and asked if they would be willing to participate in the study. All these 18 patients committed to the study and fulfilled inclusion criteria, according to our psychiatric and neuropathic examination. The inclusion criteria were: experience of torture/war; current DSM-IV diagnoses of persistent pain (excluding neuropathic pain) and PTSD; and either no psychoactive medication or a stable dose . Exclusion criteria were: additional pain-/trauma-focused psychotherapy over the course of the study; current psychotic or substance-related disorders; a history of any organic mental disorder; prominent current homicidal or suicidal ideations; severe dissociative symptoms; and any perceived risk of deportation within the next 12 months.n=9). Eight participants originated from Turkey (of which six were of Kurdish descent), three from Bosnia, and one each from Sri Lanka , Iraq, Syria and Vietnam. Participants had an average age of 43.1 years (SD=6.9) and an average of 9.7 years of schooling (SD=4.1), and had lived in Switzerland for an average of 11.0 years (SD=5.8). No patient who was asked to participate had to be excluded due to insecure visa status.Fifteen participants completed the treatment program.. The majority of the participants were male .1 = no current pain to 6 = extreme current pain). The self-reported Pain Disability Index . Only those four of seven items relevant to refugees  were administered. PTSD symptoms were assessed using the Clinician-Administered PTSD Scale . Cronbach's alpha (α=.69) was acceptable.The M.I.N.I. Plus version  to maximise the use of information. As data were missing at random  and poorly (n=8) motivated patients using a median split.Data were analysed using SPSS 19.0 and were performed on completers only. Time courses were performed using the GLM for repeated measures and paired d Cohen, . RegardiGenerally, the procedure was accepted very well; no patient demonstrated any deterioration. Of 18 patients included in the study, 15 completed all treatment sessions, while two had to be excluded due to life crises unrelated to the treatment protocol  and one dropped out after the third session of BF treatment.d=0.45; t(14) = 1.47, p=.164) or PTSD symptoms  = 1.89, p=.79). Motivation for trauma-focused therapy increased significantly from pre to post BF with Cohen's d=–1.01 and t(14) = –3.50, p=.004; T1: M=5.10, SD=2.37; T2: M=7.44, SD=2.24.After completion of the BF intervention, there were no significant reductions in pain intensity  = 3.17, p=.007).In order to examine the impact of BF on NET, participants were divided into groups representing high and poor gains in motivation for trauma-focused therapy during BF, using a median split. Patients with strong BF-related gains in motivation exhibited larger decreases in PTSD symptoms during NET than subjects without pronounced gains in motivation , which is in accordance with previous studies on NET for refugees  BF, (b) NET, or (c) combined BF and NET. The pattern of findings in this pilot study may be interpreted in terms of the key role of NET; one could conclude that BF was unnecessary because symptom reduction was not observed after this intervention. Additionally, it will be necessary to examine if BF is more efficacious than other forms of preparatory skills training that have been found to be very effective in other trauma populations prior to NET, such as the emotion regulation training incorporated within Cloitre's STAIR program (Cloitre et al., One limitation of the current study is that it was an uncontrolled study with a very small sample. Furthermore, we used the CAPS without blinding the assessors; we therefore do not know if their ratings may have been influenced by their assumptions on the efficacy of either intervention. Additionally, as no clear classification or treatment guidelines exist for DESNOS to date, we decided to diagnose persistent pain and PTSD as two distinct co-morbid concepts in our study. However, we are aware that these two disorders are highly interrelated and might be better captured in a single diagnosis, as was suggested for DESNOS (American Psychiatric Association, Despite these limitations, the present study provides initial evidence that combining BF and NET is safe, acceptable, and feasible in patients with co-morbid persistent pain and PTSD. Furthermore, biofeedback increased motivation for subsequent trauma-focused therapy, which in turn was related to larger PTSD treatment gains. Given the prevalence of refugees with these co-morbid conditions and the documented impairment these conditions cause (Dahl et al.,


Recent clinical recommendations still propose active exercises (AE) for CNSLBP. However, acceptance of exercises by patients may be limited by pain-related manifestations. Current evidences suggest that manual therapy (MT) induces an immediate analgesic effect through neurophysiologic mechanisms at peripheral, spinal and cortical levels. The aim of this pilot study was first, to assess whether MT has an immediate analgesic effect, and second, to compare the lasting effect on functional disability of MT plus AE to sham therapy (ST) plus AE.th therapeutic session, and at 3- and 6-month follow-ups.Forty-two CNSLBP patients without co-morbidities, randomly distributed into 2 treatment groups, received either spinal manipulation/mobilization (first intervention) plus AE , or detuned ultrasound (first intervention) plus AE . Eight therapeutic sessions were delivered over 4 to 8 weeks. Immediate analgesic effect was obtained by measuring pain intensity  before and immediately after the first intervention of each therapeutic session. Pain intensity, disability (Oswestry Disability Index), fear-avoidance beliefs (Fear-Avoidance Beliefs Questionnaire), erector spinae and abdominal muscles endurance (Sorensen and Shirado tests) were assessed before treatment, after the 8Thirty-seven subjects completed the study. MT intervention induced a better immediate analgesic effect that was independent from the therapeutic session . Independently from time after treatment, MT + AE induced lower disability  and a trend to lower pain . Six months after treatment, Shirado test was better for the ST group . Insufficient evidence for group differences was found in remaining outcomes.This study confirmed the immediate analgesic effect of MT over ST. Followed by specific active exercises, it reduces significantly functional disability and tends to induce a larger decrease in pain intensity, compared to a control group. These results confirm the clinical relevance of MT as an appropriate treatment for CNSLBP. Its neurophysiologic mechanisms at cortical level should be investigated more thoroughly.Trial registration number: NCT01496144 In developed countries, 60 to 80% of the active individuals suffer from low back pain (LBP) at least once in their life,2. GenerSeveral CNSLBP models have been conceptualized in order to select better appropriate conservative treatments . O’SullA Cortical Dysfunction Model was suggClinically, the literature still recommends active exercises as an efficient conservative treatment to reduce functional disability of CNSLBP patients-14. UnfoThe impact of manual therapy on CNSLBP has been extensively investigated but results are controversial. Randomized controlled trials reported that manual therapy is more effective on physical function, mental health, physical disability and/or pain than no intervention, sham manipulation, light exercises or general active exercises-25. HoweFor these reasons, the use of spinal manipulation/mobilization is favorably recommended,35. TherThe study was held at the rheumatology clinic of the Département de l’appareil locomoteur (DAL), Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland. Patients selection was as follows: inclusion criteria: 1) aged from 20 to 65 year old, male or female, suffering from non specific low back pain with or without symptoms in the lower extremity for a period between 12 and 26 weeks; 2) the usual medication can be continued; exclusion criteria: 1) spinal fracture or surgery within the previous 6 months; 2) pregnancy; 3) neoplasia; 4) spinal infection; 5) spinal inflammatory arthritis; 6) low back pain of visceral origin; 7) severe sensitive and/or motor radicular deficit from nerve root origin of less than 6 months; 8) score of 3/5 or more on the Waddell Score; 9) on sBefore the study, we calculated the sample size needed to detect a predicted effect of an ODI score difference of 5.5 with a SD of 10,37. We pAll eligible patients were given written information about the study and were asked to provide written consent before participating. Afterwards, they were asked to attend an initial evaluation visit in order to perform clinical tests and fill in self-questionnaires, supervised by a physiotherapist not involved in the patients’ therapies and blinded to the treatment groups. The same physiotherapist supervised subsequent patients’ evaluation visit after the 8th therapeutic session, and at 3 and 6 months after the end of the treatment. The study protocol was approved by the Ethics Committee of Clinical Research, Faculty of Biology and Medicine, University of Lausanne, Switzerland.Following the initial evaluation visit, patients were randomly assigned to their treatment group. Concealment allocation was performed by using a randomized table of numbers, from whTreatments consisted of a physiotherapy evaluation and 8 therapeutic sessions (1–2 sessions per week) over a period of 4 to 8 weeks.physiotherapy evaluation (45 minutes) included: 1) a standard physiotherapy assessment for non specific low back pain[rd or 4th therapeutic session, the recommendation of home exercises changes to stretching and motor control exercises (see active exercises for dosage and progression). Home exercises were reviewed at the beginning of each therapeutic session and recorded daily by patients in a diary.The ack pain; 2) an etherapeutic sessions (30 minutes) consisted of: for the MT group, 5 to 10 minutes of MT intervention followed by active exercises (AE); for the ST group, 5 to 10 minutes of ST intervention followed by AE.The The MT intervention, performed by a single physiotherapist of 15 years of experience, comprises the use of one (or more) of the following techniques:•Passive accessory intervertebral movements, a central or unilateral postero-anterior pressure applied on painful or stiffed vertebral segment(s) with the patient lying prone.•Muscle-energy techniques, a hold-relaxed technique performed on an ilium dysfunction with the patient side lying.•High velocity, low amplitude dynamic thrust (manipulation), a rotational-lateral flexion thrust performed on a stiffed vertebral segment(s) with the patient side lying,40.The ST intervention, delivered by 2 physiotherapists of 5 and 25 years of working experience at the rheumatology unit of the DAL (CHUV), relied on detuned ultrasound on the patient’s painful and/or inflammatory site. The patient did not know the ultrasound was inactivated and, therefore, ineffective. The choice of the therapist depended exclusively on immediate availability, work schedule and vacation.Before the start of the clinical phase, the 3 treating therapists agreed on a protocol of therapeutic exercises .•Mobility exercises throughout the 8 therapeutic sessions to improve patient’s spinal range of motion and pain. For the first 2 sessions, pelvic tilt and low back lateral flexion exercises were performed in the supine position, 3 sets of 5 to 10 repetitions. From session 3, the same exercises were adapted in sitting on a stable plane, then on a swiss ball.•Passive stretching exercises after the 2nd session, for muscle groups that tend to shorten , to relieve muscular tension and improve low back mobility. They were performed 3 times for 20 seconds.•Motor control exercises at the 4th session for active recruitment of stabilizing trunk muscles. Patient•Strengthening exercises at the 6th or 7th session to increase strength of weak superficial trunk muscles. They were performed at 60–70% of maximum voluntary contraction, against the resistance of an adapted rubber band, 2 sets of 20 repetitions.The same physiotherapist who performed the preceding MT/ST intervention supervised the active exercises.At the end of the 8 therapeutic sessions, no particular recommendations were given to patients but to continue their exercises if desired. This issue was not investigated at the 3- and 6-month evaluation visits.VAS-pain, immediate effect) before and immediately after the manual therapy or detuned ultrasound intervention at each therapeutic session. To evaluate the treatment efficiency, pain intensity , disability (Oswestry Disability Index - ODI), fear-avoidance beliefs (Fear-Avoidance Beliefs Questionnaire - FABQ) and Sorensen and Shirado tests were determined before treatment, after the 8th therapeutic session, and at 3- and 6-month after the end of treatment.Immediate analgesic effect, evaluating the MT/ST intervention’s efficiency, was obtained by measuring pain intensity , patients were asked to rate their current pain twice at each therapeutic session. Secondly, to evaluate VAS-pain (average 48-hour pain), patients were asked to rate their average pain during the last 48 hours before each evaluation visit. VAS-pain ratings are reported to have good reliability and concurrent validity when compared to other methods of pain measurement[ODI is a self-rating questionnaire used to evaluate functional physical disability[1) he right. Firstlysurement. 2) ODI sability. It inclsability.FABQ measures level of fear and avoidance beliefs about work and physical activity in patients with low back pain[Sorensen test evaluates the erector spinae muscles endurance[Shirado test assesses the abdominal muscles endurance[1) ack pain. The insack pain,47. 2) Sndurance. 3) Shirndurance. SorenseVAS-pain, immediate effect) at each time point (pain after minus pain before) was analysed by means of random coefficient linear mixed models. In these models, the effects of the independent variables are allowed to vary between subjects. In other words, subjects were allowed to have their individual slope for the outcome over time. To control for potential bias due to regression to the mean, pain measured before each therapeutic session was entered in the model as time-varying covariate.The effect of intervention (MT vs. ST), time and the intervention-time interaction on the immediate effect of the intervention , ODI, FABQ-wk, FABQ-pa, Sorensen and Shirado, evaluated after the 8th therapeutic session, and at 3 and 6 months after the end of treatment, were estimated by means of random coefficient linear mixed models. The outcomes’ baseline values (measures before treatment) were entered as a covariate to adjust for baseline differences between treatments. First, the analysis was performed with the interaction. When the effect was not significant, the analysis was repeated without the interaction.The effect of treatment (MT + AE vs. ST + AE), time and the treatment-time interaction on the six outcome variables pain intensity , we considered an alpha level of 0.025 for those two outcomes. The conventional alpha = 0.05 was kept for inference about the secondary outcomes.A total of 42 subjects were eligible for the study: 22 in the MT group, 20 in the ST group. The MT group had one patient stopping his treatment after the sixth session because of severe pain, another being unreachable for the 3-month post-treatment evaluation, and a third patient becoming unreachable for the 6-month post-treatment evaluation. For the ST group, two patients did not attend subsequent evaluations after the end of their therapeutic sessions. One had intense pain and rest was recommended by the doctor, and the other cancelled his appointment and became unreachable Figure . The droFor MT/ST intervention, the immediate effect of intervention was in favor of manual therapy over detuned ultrasound. Independently from the therapeutic session and each session’s baseline measure, MT intervention showed a greater decrease in mean pain level compared to ST intervention    and a statistically significantly reduced disability were observed in favor of the MT group over the ST group . Three months after treatment (time = 2), there was still insufficient evidence for a treatment effect but the MT group has a lower mean compared to the ST group . Six months after treatment (time = 3), the mean Shirado score had dropped further in the MT group compared to the ST group; the group mean differences at this time point are statistically significant .The effect of MT + AE/ST + AE treatment on the Shirado score was dependent on the time of measurement  and specific active exercises, with a comparable design. In theiBesides, this study confirms the immediate analgesic effect of manipulation/mobilization already reported in the literature,28,31. NIn this study, the VAS-pain scores present lower values under the MT group throughout time . However, a comparison of pain reduction between treatments (MT + AE vs. ST + AE) shows a significant difference in slopes in favor of MT group when the interaction is dropped Table . This stThese results in functional disability are quite similar to those of other studies,23,25. OIn the present study, the results on the FABQ questionnaire are interesting. No significant improvement in the FABQ-pa was observed Table . This reThere is not sufficient evidence that MT + AE has a positive influence on the static abdominal endurance, i.e. Shirado test (see Results). For unknown reasons, the patients treated with MT + AE presented a more pronounced drop of abdominal endurance than ST + AE when the treatment sessions were stopped. We cannot explain these results and further studies are clearly needed to better understand the relationship between MT, AE and abdominal endurance.This study presents some limitations. For instance, patient recruitment was provided exclusively by the rheumatology clinic of a University hospital, which does not reflect the whole spectrum of the CNSLBP population. This may have contributed in selecting patients with more inflammatory signs and higher severity of disease. However, strict criteria of selection  were used in order to exclude patients with bad prognosis, e.g., severe disabilities and long-term unemployment. For theBesides, the large standard deviations obtained for the self-questionnaires and clinical tests values indicate the patients were heterogeneous. In addition, the population was smaller than the one estimated prior to study which produces statistical power problems. However, the number of subjects per group was comparable to the studies of Aure et al., RasmussAll data available from patients, even if they dropped out of the study, were integrated in the study analysis. Since the dropped out rate was low and similar in both treatments, no special statistical analyses were performed.The present study confirms the immediate analgesic effect of manual therapy for CNSLBP. Followed by specific active exercises, it reduces significantly functional disability and tends to induce a larger decrease in pain intensity, compared to a control group. However, these results of our pilot study need to be confirmed by future studies with appropriate sample sizes.Recent evidence tend to demonstrate that CNSLBP is largely characterized by structural, functional and neurochemical cortical modifications,57. In tThe authors declare that they have no competing interests.PB participated in the conception, design and coordination of the study, contributed to interpretation of data, and helped to draft the manuscript. GR have been involved in drafting the manuscript or revising it critically for important intellectual content. PD carried out the evaluation of patients and contributed in acquisition of data. PiBall performed the statistical analyses and contributed to the manuscript. PG participated in the initial selection of patients and revisiting the manuscript for important intellectual content. OD participated in the design of the study, helped in the interpretation of data and drafting the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/13/162/prepub


Despite the fact that numerous medications have been introduced to treat renal colic, none has been proven to relieve the pain rapidly and thoroughly. In this study, we aimed at comparing the effects of intravenous lidocaine versus intravenous morphine in patients suffering from renal colic.U-test was used in two groups. Consequently, the data were analyzed using the SPSS16 software.In a prospective randomized double-blind clinical trial performed in the emergency department of Imam Reza educational hospital of Tabriz, Iran, we studied 240 patients, 18–65 years old, who were referred due to renal colic. Patients were divided into two groups. In group I (120 people) single-dose intravenous lidocaine (1.5 mg/kg) was administered and in group II (120 people) single-dose intravenous morphine (0.1 mg/kg) was administered slowly. Visual Analogue Pain Scale (VAS) was recorded while admission, 5, 10, 15 and 30 minutes after injection. Statistical data and results were studied using descriptive statistics as percentage and Mean ± SD. To compare the response to treatment, Mann–Whitney Pain score measured in two groups five minutes after the injection of lidocaine and morphine were 65 % and 53 % respectively .108 (90 %) patients (95 % CI 0.84 – 0.95) from group I and 84 (70%) patients (95 % CI 0.62 - 0.78) from group II responded appropriately at the end of the complete treatment. The difference was statistically significant (p = 0.0001).Changing the smooth muscle tone and reducing the transmission of afferent sensory pathways, lidocaine causes a significant reduction in pain.Clinical Trials IRCT138901042496N3 Affecting 1-5 % of the population in industrialized countries, renal colic is considered as a major concern in medicine. Renal colic has been reported to be experienced by 20 % of white males and 5-10 % of white females [To relieve the pain until being discharged or undergoing the required operation is mostly performed in emergency departments . To achiLidocaine, being an appropriate choice in treating visceral and central pain, might also be useful wherever narcotics are inefficient or lead to undesirable side effects. Intravenous lidocaine is effective in controlling neuropathic pains such as: diabetic neuropathy, post-operative pain, post-herpetic pain, headaches and neurological malignancies ,4. ThereTo perform a prospective randomized double-blind clinical trial we evaluated the sample size of 100 people for each group. This study was approved by Ethics Committee of “Tabriz University of Medical Sciences”. The trial was registered in “IRCT”. Additionally, all aspects of the present study plan were explained to patients and written informed consents were obtained consequently.Considering pain incidence ratios of 29.3 % and 12 % for the control and intervention groups respectively, confidence interval of 0.05, power of 20 % and loss probability of 20 % throughout the follow-up period using the following formula, a sample size of 100 people were calculatedAs the number of the patients with renal colic referring to the emergency department of Imam Reza Hospital is abundant , the samhttp://www.randomization.com 240 letters of A and B were evenly (120) produced and patients were allocated to one of the two groups of A (Group I) and B (Group II), in the order provided by the site.Using the website of http://www.randomization.com. Firstly, patients entering emergency department with complaint of flank pain were identified, interviewed and examined. Later, patients with pain radiating to genitalia and groin, nausea, vomiting, urinary irritation symptoms and tenderness in costovertebral angle were selected.Patients were evenly divided into two groups of I, receiving intravenous lidocaine (n = 120), and II, receiving intravenous morphine (n = 120). As previously mentioned the study was double-blind and the executive of the research project was unaware of the obtained figures using online software from To provide the patients with required analgesia and to avoid any inconvenience regarding pain management, initial diagnosis was made based on clinical findings  associated with a positive urine analysis for hematuria. However diagnosis was later confirmed using Kidney, Ureter, and Bladder (KUB) radiographies and sonography studies. Since all patients experienced unilateral abdominal pain and their urine analyses were positive for hematuria, no further diagnostic criteria for renal colic were set throughout the study .All patients aged 18 to 65 years, and did not have history of renal, hepatic or cardiac disease (Ischemic Heart Disease).Patients with history of allergy to lidocaine and morphine, an inability or unwillingness to provide written informed consent and pregnant females were excluded from the study as well. Patients whose pain did not relieve using lidocaine or morphine were administered supplementary drugs. Then, method of drug administration, the reason for prescription and possible complications were explained to the patients and it was emphasized that using either lidocaine or morphine is safe.After explaining method of treatment and obtaining informed written consent, 12 lead electrocardiograms were taken from all patients to make sure no history of heart diseases existed. Later, patients were monitored by an emergency medicine specialist throughout the procedure. Additionally patients were asked to identify the degree of their pain using Visual Analogue Pain Scale (VAS), zero represented painless and 10 was the worst experienced pain. Vital signs and other symptoms of patients including nausea, vomiting, dysuria, hematuria, and etc. were recorded. Firstly, all the enrolled patients received intravenous metoclopramide (0.15 mg/kg). Later, to reduce pain in patients suffering from renal colic in group I lidocaine solution (1.5 mg/kg) and in group II morphine solution (0.1 mg/kg) were administered intravenously slowly ). The trial was considered accomplished when either the patient had a pain score of less than 3 for 30 minutes after the last analgesic dose or the 10 mL of solution in the syringe was used up.As fluid therapy is not commonly used in our center to treat patients with renal colic and it is restored only for patients who are dehydrated or have sepsis, our patients received very little amount of fluid, (10 mL) administered only by injection .All the processes of injection and filling in the questionnaires were performed by another person who was a specialist (not involved in research project) and blinded to the injected drug as well as the patients groupings. Patients were blinded to the injected medications as well. The doses required for the administered medication were calculated by another colleague. Hence; neither the patients nor the administrator were aware of the medications used.U-test was performed in two groups. Kolmogroff Smirnov test was used for normality of variables and QQ plot test was used in cases of necessity. The data were analyzed using the SPSS16 software.Consequently, 5, 10, 15 and 30 minutes after injection, incidence of pain in patients was recorded based on Visual Analog Scale (VAS). Statistical data and results were expressed using descriptive statistics as percentage and Mean ± SD. To compare the response to treatment, statistical Mann–Whitney Eighty six patients of studied samples were male and thirty four were female in group I. In group II, ninety patients were male and thirty were female. There was no statistically significant difference between them regarding gender distribution (p = 0.559) Table .Mean ages of the patients were 35.23 ± 12.37 years and 37.71 ± 11.08 years in group I and II respectively. The differences was not statistically significant (p = 0.104) . Pain relief in lidocaine group was statistically significant compared to the morphine group (p = 0.0001) Table .108 patients (90 %) in group I responded to lidocaine successfully whereas in group II, 84 patients (70 %) responded properly to morphine, at the end of the study it was demonstrated that there were more considerable respond and pain relief in lidocaine group which was statistically significant (p = 0.0001).In the present study, patients were also evaluated regarding having history of kidney stone, renal colic as , side effects , stone side and hydronephrosis Tables ,3.Since renal colic pain caused by urinary stones is severe and sudden, an appropriate treatment is of great necessity. Narcotics have been considered as main treatment of renal colic for years; they relieve pain with central effects on narcotic receptors. Although narcotics have adequate effects, there is possibility of their being misused, excessive drowsiness, and other central nervous system and gastrointestinal complications .Recently, the benefits of non-steroidal anti-inflammatory drugs (NSAIDS) in renal colic have been reported suggesting them to be more effective compared to narcotic analgesics ,9.Renal colic pain is caused by endopelvic pressure and ureteral obstruction. Increase in renal blood flow following obstruction increases urine and endopelvic and ureter pressure. Prostaglandins cause increase in renal blood follow and smooth muscle spasm .Nonsteroidal anti-inflammatory drugs, inhibiting cyclooxygenase enzyme, relieve colic pain. Their pain relief mechanism however differentiates them from narcotic analgesics. NSAIDs can relieve pain locally and centrally inhibiting prostaglandin synthesis .In spite of the beneficial effects of nonsteroidal anti-inflammatory drugs on pain, NSAIDs can reduce renal blood flow and ureter pressure in acute ureteral obstruction .Therefore, because in our country (Iran), intravenous nonsteroidal anti-inflammatory drugs are not available, we thought of an alternative intravenous drug, i.e. lidocaine, whose analgesic effects on various pains  have been proven .Being an amino amide local anesthetic, Lidocaine blocks the voltage dependant sodium channels and impulses in axons . LidocaiLidocaine is an effective and cheap drug with few side effects including dizziness, nausea and constipation. Prevalence of these complications however is less with lidocaine compared to narcotics and other analgesics .On the other hand, side effects of lidocaine are predictable with a wide range of confidence. Due to the low half life, toxicity symptoms of lidocaine are transient and rapidly reversible. Based on the results of Rebecca Ferrini’s study on 100 patients, in most patients having received narcotics infusion of intravenous lidocaine was effective when the pain was central or visceral, and even when narcotics were not effective or accompanied unwanted and unacceptable complications, intravenous lidocaine could be useful .In the study of Nicky Forov et al. on a pregnant woman with resistant renal colic, subcutaneous paravertebral nerve block was performed using lidocaine, in this study patient’s pain relieved considerably . In our Other case studies have also been reported regarding using lidocaine in relieving pain in cancerous and renal colic patients. In a similar study carried out by Rebecca Ferrini et al. A single dose of lidocain was administered for reducing pain resistant to morphine in a patient suffering from primary neuroectodermal tumor. The patient had received other complementary medicines, in addition to morphine, such as: gabapentin, baclofen, amitriptyline, clonidine and clonazepam. Patient’s pain however considerably relieved after using a single dose of lidocaine (1.5 mg/kg) .The only study which can be compared with ours regarding considerable pain reduction in short time is a study carried out by Mansuri Igochi et al. in which local injection of lidocaine in the most painful point was used in patients suffering from renal colic (control group received scopolamine). Considering response to treatment, lidocaine was more effective than scopolamine .Fortunately, in our study no serious or life threatening complications were observed in patients of lidocaine group, therefore our study is similar to the study of Rebecca Ferrini et al.Lidocaine causes change in sympathetic smooth muscle tone through reducing the transmission of afferent sensory pathways. Intravenous lidocaine causes considerable reduction in pain and can be a suitable alternative for cases in which narcotics are ineffective or associated with undesirable complications .Our study is unique considering the fact that it is the first clinical trial study being carried out on using intravenous lidocaine in patients suffering from renal colic.The results of our study revealed that although morphine is used in patients suffering from renal colic as a drug of choice, due to the rapid response of patients to lidocaine (considering time and reduction in pain intensity compared to morphine) it can be of great importance in patients with renal colic.On the other hand, we should note that the complete response rate to lidocaine treatment was significantly higher compared to morphine which could be considered as a reason for lidocaine to be used as a drug of choice with high priority in patients with renal colic.VAS: Visual Analogue Pain Scale; NSAIDs: Non-steroidal anti-inflammatory drugs.The authors declare that they have no competing interests.HS, KH and HV collected clinical data, reviewed the literature on the topic, and drafted the manuscript. SEJG, MS and RME participated in the design of the study and performed the statistical analysis. All of the authors were involved in patient management or the writing of the manuscript. All authors read and approved the final manuscript.HS is Associate professor of Anesthesiology and Critical Care, Fellowship in Trauma Critical Care and CPR at the Department of Emergency Medicine, Tabriz University of Medical Sciences, Tabriz, Iran. He is also editorial board member of Emergency medicine journal (EGM) and Pakistan Journal of Biological Sciences (PJBS). KH is Associate professor of Urology at the Department of Urology, Tabriz University of Medical Sciences, Tabriz, Iran. HV and SEJG are residents of Emergency Medicine and Anesthesiology at the Department of Emergency Medicine and Anesthesiology depapartment, Tabriz University of Medical Sciences, Tabriz, Iran, respectively. RME is member of Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. MS is member of Gastroenterology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2490/12/13/prepub


Treatment options for trigeminal neuralgia (TN) must be customized for the individual patient, and physicians must be aware of the medical, surgical, and radiation treatment modalities to prescribe optimal treatment courses for specific patients. The following case illustrates the potential for gamma knife radiosurgery (GKRS) to be repeated multiple times for the purpose of achieving facial pain control in cases of TN that have been refractory to other medical and surgical options, as well as prior GKRS. The patient described failed to achieve pain control with initial GKRS, as well as medical and surgical treatments, but experienced significant pain relief for a period of time with a second GKRS procedure and later underwent a third procedure. Only a small subset of patients have reportedly undergone more than two GKRS for TN; thus, further research and long-term clinical followup will be valuable in determining its usefulness in specific clinical situations. TN is most commonly idiopathic, but may be caused by pressure from a structure, such as a blood vessel compressing or pulsating on the trigeminal nerve or its vasculature. This condition affects females twice as often as males, with a peak incidence at 60 years of age [Trigeminal neuralgia (TN), also known as visions V–V3. TN iA 72-year-old man was referred to a community oncology center by his neurologist due to complaints of a recurrence of lancinating, “shock-like” pain in the left side of his face from the preauricular area into the left side of his upper and lower jaws. The patient stated that the pain was intermittent, 10/10 in intensity , and was triggered by several actions including eating, brushing gums, cold sensations, and touching his face. The patient stated that the pain was accompanied by tenderness and sensitivity to touch around the outside margin of his left eye, but he denied numbness or other change in sensation in the affected area. The patient stated that his symptoms began as an “annoyance” approximately 4.5 years prior and progressed slowly over the course of the next 3 years, at which time he was diagnosed with TN by his dentist. An MRI of the brain performed at the time of diagnosis demonstrated a tortuous basilar artery abutting the left trigeminal nerve. He was initially started on Gabapentin, which provided only mild relief. Carbamazepine was added later, but it caused him to become excessively drowsy, which resulted in a significant fall and concussion. Due to his fall, the medications were discontinued. Following failure of medical management, the patient was offered further treatment options including microvascular decompression (MVD), radiofrequency gangliotomy, and GKRS. The patient elected to undergo GKRS which was performed with a Leksell model C gamma knife to the trigeminal nerve root entry zone with 201 cobalt sources (4 mm shot size) to a dose of 42 Gy prescribed to the 50% isodose line for a maximum point dose of 84 Gy see . ShortlyMedical, surgical, and radiosurgical pain management options were again discussed with the patient. He stated that he would prefer to avoid surgery and had difficulty tolerating pain medications, which he reported made him feel drowsy and disoriented. The patient stated that he would prefer to have a 3rd GKRS procedure because it was the only treatment that had provided him extended and significant pain relief. The patient underwent his 3rd GK treatment approximately 17 months after his first one. The 3rd treatment was delivered a few millimeters distal from the previous target and was prescribed 20 Gy (with 4 mm shots) to the 50% isodose line see  for a maThe patient was symptom free and reported no side effects or focal neurological problems for 3 months after the procedure. At that point, he experienced recurrence of his pain and underwent a microvascular decompression (MVD). At his 6 month followup from MVD, he reported having no pain or facial numbness. Since initial presentation, the patient has had regular follow-up visits with his primary care physician, neurosurgeon, and radiation oncologist. The patient's reported lack of facial numbness and other side effects were verified through follow-up physical examinations. He will continue to be followed closely by his treating physicians in the future and understands that with retreatment his risks of permanent side effects are increased.Optimal treatment of TN remains challenging, as each clinical situation can vary significantly. This case illustrates a unique approach to the management of TN in that this patient has received 3 separate GKRS treatments to the same nerve root for refractory disease. Patients who suffer from TN have a number of treatment modalities to consider, and treatments should be tailored to the individual situation. Medications in the form of anticonvulsants, such as Gabapentin and Carbamazepine, as well as antidepressants, are the predominant method for treating TN-related facial pain. However, there is a fraction of patients who experience only limited relief from pharmacotherapy or are unable to endure the side effects of the prescribed drugs and, thus, seek other treatment alternatives . Neurosurgical intervention is often the next line of treatment for patients where pharmaceuticals have failed. Microvascular decompression (MVD) is a procedure that involves a craniotomy to locate and separate veins or arteries in contact with the trigeminal nerve, while preserving its function . MVD has GKRS has been shown to be safe and effective in patients with medically  and surgPollock and Stein investigated the effect of different treatment modalities for idiopathic TN in patients who had undergone three or more previous operations of any kind. This study found that posterior fossa exploration resulted in better facial pain outcomes than SRS or percutaneous techniques in this group of patients; however, this paper acknowledges selection bias in their choice of treatment . Based oStudies disagree about the incidence of complications in primary versus repeat GKRS, with some showing no significant increase in incidence of complications beyond that observed in the initial procedure , and othThe radiosurgery target area may also play a significant role in both maximizing pain control and limiting side effects. Zhang et al. showed that increasing the isocenter distance between the two radiosurgeries was associated with improved pain relief, regardless of whether the second isocenter was placed proximal or distal to the first . AlthougThis paper highlights a case of TN refractory to initial medical and surgical management, nonresponsive to an initial GKRS procedure, responsive to second and third GKRS procedures, and having undergone an MVD due to refractory pain after a pain-free interval. This is one of very few reported cases of a patient undergoing three GKRS procedures for TN. Further research will be valuable in determining its usefulness in clinical practice.