Following amputation or lesion in somatosensory pathways, phantom limb pain (PLP) often occurs. Evidence has accumulated that PLP might be a phenomenon of the CNS that is related to plastic changes at several levels of the neuraxis and especially the cortex. Here, we discuss four topics about PLP. First, an intimate relationship between PLP and somatotopy in the primary somatosensory (S1) and motor (M1) cortices; second, using the intact hand for sub-objective assessment of phantom limb perception; third, analgesic effect of mirror visual feedback treatment on PLP and its supraspinal mechanism; and fourth, future therapeutic approach for PLP and other neuropathic pain conditions, being developed by robot engineering. In the present report, we suggest an important role of sensorimotor integration for treating PLP, which has strong potential to induce re-reorganization of somatotopy in S1 and M1.

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Botulinum toxin A (BTA) is a useful treatment against cervical dystonia. Some patients with cervical dystonia complain of neck-shoulder pain and stiffness without head deviation. We conducted the present study to evaluate the efficacy and safety of BTA injection in these patients. A total of 26 patients (M : F, 12 : 14; mean age, 59 years) received BTA 10-20 units/site in the muscle in which tonus continuously increased. The effect of BTA injection was assessed every 4 weeks until 12 weeks after administration. At each evaluation point, we determined severity of shoulder-neck pain and stiffness by VAS score. QOL was scored by SF-36 questionnaire. Although QOL was not improved, the neck-shoulder pain and stiffness were significantly improved at every observation point. No severe adverse side effect was found, although 4 patients had head instability for a short period. These findings suggest that BTA injection into the dystonic muscles is a promising therapy for patients with chronic neck-shoulder pain and stiffness.

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First bite syndrome (FBS) is a rare disease causative of pain in the parotid gland region at the first bite of each meal. We report patient with long-standing idiopathic FBS whose pain disappeared after repeated stellate ganglion blocks (SGB). A man aged in his thirties had 6-month history of pain in the parotid gland region that occurred immediately after the first bite of every meal. He did not have any surgery done on the right parapharyngeal area. Pain in the right parotid gland region developed 6 months before he was referred to us. Medications did not decrease the pain and the pain was so severe that the patient could not have any food. He received enteral alimentation and diclofenac. He rated the first bite pain 80 and the pain after the first bite 100 on a visual analog scale of 100. The pain did not change after 5 repeats of SGB; however, the pain after the first bite decreased after 6 repeats of SGB. The first bite pain decreased later. The pain completely disappeared after 16 repeats of SGB. The pain did not recur 2.5 years after cessation of treatment.

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Factitious disorder is characterized by intentional feigning of physical or psychological symptoms and signs. Munchausen syndrome is a subtype of factitious disorder that shows predominantly physical signs and symptoms. We report a patient with Munchausen syndrome who showed complex regional pain syndrome-like symptoms and signs. A 47-year-old man on a wheelchair, who complained of lumbago, pain in the extremities, and inability to walk, was referred to our department. Lumbar magnetic resonance imaging did not show apparent abnormalities. He happened to be seen walking without difficulty outside the hospital by one of our staff. He continuously complained of various symptoms including discomfort of the pharyngolarynx and abdomen, pain in the upper jaw, pyrexia, and so on. Physical and laboratory examinations did not show any abnormalities. Eight months later, swelling of the right arm developed after he underwent transposition of the ulnar nerve for right cubital tunnel syndrome, suggesting complex regional pain syndrome. He complained of abdominal discomfort 11 months later. CT of the abdomen disclosed clips and nuts in the bowel. Three years later, the swelling of the right upper limb worsened suddenly. He was witnessed squeezing his own right upper limb with a bandage. It is important that medical staff suspect Munchausen syndrome when patients complain of various inexplicable symptoms and signs.

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We observed a case of brainstem and cerebellar infarction that was thought to have been caused by methylpredonisolone suspension (Depo-Medrol^®) used for cervical nerve block. The patient was a 57-year-old women. She was referred from a local clinic to our department for nerve root block due to increased radicular pain at the C6/C7 level caused by cervical intervertebral disk hernia (C5/6, C6/7). We attempted nerve root block under X-ray visualization. Since no vascular shadow was shown by contrast medium and the C6 nerve root sheath was depicted, 1 ml of a mixed solution of 0.75% ropivacaine plus 1 ml of methylprednisolone suspension (40 mg/ml) was injected. No abnormality was noted, and a further 0.5 ml was injected. However, within 30 seconds the patient lost consciousness and stopped breathing. Since magnetic resonance imaging performed 7 hours later showed an infarct of the cerebellum and brainstem and impending herniation, external and internal decompression and ventricular drainage were performed. Intraoperative findings and postoperative CT findings ruled out the possibility of a dissecting aneurysm. The infarct was thought to have been caused by complications arising from retrograde flow of the methylprednisolone suspension from the radicular artery into the left vertebral artery area. Therefore we think that corticosteroid suspensions should not be used for cervical nerve root block.

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A 70-year-old woman, who had severe limb pain with paresis after lumbar spinal column surgery for 8 years, received phantom limb pain protocol of eye movement desensitization and reprocessing (EMDR). She was told that the paresis and pain in the limb was caused by the surgery to the lumbar spine. The pain disappeared after one session of EMDR. Follow-up interview three months after EMDR did not show any recurrence of pain. The phantom limb pain protocol of EMDR is effective for the treatment of chronic pain with psychological factors in some selected patients.

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