Epidural spinal cord stimulation (ESCS) is one of the treatments for refractory pain, and its effect depends on its indication. It is well known that ESCS effects are associated with psychological factors. However, it is not clear whether there is a correlation between ESCS effects and the self-rating depression scale (SDS). Purpose: The present study investigated SDS scores in patients who decided to undergo or reject permanent ESCS operations after ESCS trials. Methods: Twenty five patients who underwent ESCS trials at the NTT east corporation, Kanto Medical Center, during the period between August 2004 and December 2005 were reviewed based on their medical records retrospectively. The patients were grouped in either a successful group (Group S) or a failed group (Group F), depending on whether they underwent permanent ESCS operations or not, respectively. A comparative study between the groups was made based on the age, sex, period of pain, regions of pain, primary disease, preoperative face scale (FS), preoperative prescribed analgesics, and preoperative SDS scores. Results: Two males and three females were classified in Group S, and 12 males and 8 females were classified in Group F. The age range of each group were 662±4.7 and 59.1±14.9, the periods of pain were 7.8±4.4 and 4.4±3.7 months, and preoperative FS values were 2.6±0.9 and 3.1±0.8 for group S and group F, respectively. The region of pain, primary disease and preoperative prescribed analgesics show no significant differences between the groups. However, SDS scores were 31.4±3.1 for group S and 44.0±11.5 for group F, being significantly higher in Group F (p=0.0003). There was no correlation between SDS scores and FS. Conclusions: The data obtained from the ESCS trials indicate that patients deciding not to under go permanent ESCS operations had significantly higher SDS scores compared to patients willing to have the operations.

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The authors believe that pain clinicians are the most appropriate specialists to undertake home visit treatments for pain control, particularly in the elderly, because they are well trained in nerve blockade, drug titration and emergency care techniques. Nevertheless, there have been no reports regarding the application and outcome of nerve block techniques for treatment in the home. We therefore visited patients in their homes where we applied nerve block techniques in 11 patients over a period of two years. Our patients and their families have been pleased with the results. Several factors which might influence the results of treatment at home in general and also in nerve block technique are discussed in terms of technical problems, social or socioeconomic status of the patients, patient-to-family relationships and patient-to-doctor relationships.

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Ramachandran et al. reported that mirror visual feedback therapy reduces phantom limb pain, supposedly training the brain via the reconciliation of motor output and sensory feedback and thereby alleviating the pain. However, this treatment has been anecdotal because controlled data and re-examinations are lacking. In this report, we treated two amputees suffering from refractory phantom limb pain with mirror visual feedback therapy. Using a mirror, they superimposed the visual image of their existing limb on their phantom limb and exercised both the mirror-reflected limb and the unaffected limb for 10 minutes once a day. The mirror visual feedback therapy did not have any immediate analgesic effect, however, the patients could exercise their phantom limbs voluntarily without mirror visual feedback and the phantom spasms or their associated pain were relieved after successive 2- to 3-week daily mirror exposures. These observations strongly support the previous hypothesis that disorganized cortical representations may lead to the experience of peripheral pain, and a mismatch between motor intention and predicted proprioceptive or visual feedback of the affected limb may drive this process. Our observations indicate that phantom limb pain is not only derived from peripheral and somatosensory abnormalities, but also from cognitive disturbances. Mirror visual feedback therapy can be applied as a cognitive treatment for phantom limb pain because it is non-invasive, inexpensive, easily performed at home, and, of most importance clinically, patient-oriented.

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Recently, mirror visual feedback therapy (MVFT) was reported to have a beneficial effect on complex regional pain syndrome as well as phantom limb pain, suggesting that MVFT can be applied as a cognitive treatment for several pain disorders. Traction lesions of the brachial plexus very often result in severe refractory pain associated with deafferentation; therefore, we applied MVFT to two patients with post-brachial plexus injury pain, who were not conscious of a phantom limb. In one patient who could exercise the paralyzed limb via mental imagery during MVFT, the pain ameliorated immediately. The other patient did not establish any movement representations of the affected limb, and the treatment was ineffective. Artificial visual feedback on movements of the affected limb may re-establish the original hand/arm cortical representation. Our cases support the idea that MVFT may have a potential to treat several refractory pain disorders, although further investigations are needed.

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A 48-year-old male presented with pain in his temple, orbit, and jaw on the right side which immediately occurred after the intraoral injection of a local anesthetic in a general dental clinic. The pain was decreased by pterygopalatine anesthetics and subsequent Eletriptan which was prescribed for cluster headache by the referring internist. His pain was ameliorated within 3 days.

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Intravenous regional sympathetic block (IRSB) with reserpine is one of therapeutic strategies for patients with complex regional pain syndrome (CRPS). This therapy is generally performed safely on out-patient basis, and there is no report of a severe adverse effect relating to this therapy. However, we experienced a case with severe adverse effects of headache and orthostatic hypotension, and the patient was forced to be hospitalized. There has been a report that lower levels of catecholamine and serotonin are associated with autonomic dysfunction. In this case, it was speculated that this severe adverse effect was related to such a condition. Therefore, it might be important to pay attention to the management of IRSB with reserpine when treating patients with autonomic dysfunction.

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Carotid-cavernous fistula (CCF) is an uncommon vascular condition characterized by chemosis, proptosis, bruit, and paralysis of structures innervated by the cranial nerves passing through the cavernous sinus. We describe a woman in her seventies woman with a 7-month history of headache, double vision, and tinnitus aurium, who was successfully treated with nerve blocks and transvenous endovascular occlusion. On initial examination, Tolosa-Hunt syndrome was suspected, and the patient was treated with supraorbital nerve block, near-infrared irradiation, and administration of betamethasone. The nerve blocks considerably improved her headache and tinnitus aurium, though her double vision persisted. Eventually, CCF was diagnosed based on MRI and cerebral angiography, and the patient underwent intravascular coil embolization, with nearly complete resolution of the remaining symptoms. Patients complaining of headache and unilateral ophthalmoplegia should be carefully examined for CCF.

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