Inflammatory responses cause pain associated with disc herniation. Recent studies have showed that autoimmune-mediated inflammation was evoked by herniated discs because nucleus pulposus is among the sequestered antigens that do not provoke immune reaction in normal conditions. Some nucleus pulposus cells, like cells in the ocular anterior chamber, express Fas-ligand on the cell surface, which can cause apoptosis of Fas-positive immune cells, resulting in the inhibition of autoimmune reactions. However, a secondary infiltration of neutrophils can cause inflammation. Our recent studies showed that the pain associated with disc herniation was related to cell-mediated immune responses with both macrophages and natural killer cells. These results suggest that specific ligands or blockers, which inhibit Toll-like receptor-mediated immune responses, may be a new therapeutic tool for pain associated with herniated discs.

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We retrospectively investigated the incidence of adverse effects of postoperative epidural morphine analgesia. Methods: Epidural morphine analgesia was performed in 227 patients undergoing open chest or open abdominal surgery. General anesthesia was induced with thiamylal or propofol, and maintained with sevoflurane after a successful epidural catheterization. Morphine, 2 to 4 mg with 1% mepivacaine 2 ml was injected into the epidural space before start of the operation; thereafter, morphine 2 to 4 mg a day with 0.2% ropivacaine 12 to 24 ml a day was continuously infused into the epidural space. Any unfavorable symptoms or signs recorded in the patients' medical charts during morphine analgesia were adopted as adverse effects.
Results: The adverse effects included nausea and/or vomiting (18.5%), pruritus (16.3%), vertigo/dizziness (9.7%), hallucination/confusion (7.9%), somnolence (7.0%), perspiration (3.1%), and myoclonus (0.4%). Respiratory depression caused by epidural morphine was not present. The incidence of discontinuation of epidural analgesia by the next day was 4.4%. The reasons were hypotension (1.3%), nausea and/or vomiting (1.3%), pruritus (0.9%), vertigo/dizziness (0.4%), and hallucination/confusion (0.4%).
Conclusions: The major adverse effects of epidural morphine analgesia were nausea and/or vomiting, pruritus, and vertigo/dizziness.

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We prospectively studied the effects of intermittent (n=13) and continuous (n=7) femoral nerve blocks on postoperative pain after total knee arthroplasty. All patients were managed with general anesthesia. An indwelling catheter for femoral nerve block was inserted under ultrasound echography with the aid of electrical nerve stimulation, after completion of the surgery. After bolus injection of 0.3% ropivacaine 20 ml, 13 patients received 0.2% ropivacaine 4 ml every hour (intermittent group), and 7 received 0.2% ropivacaine at a rate of 4 ml/hour (continuous group). Patients were given pentazocine 15 mg when pain occurred. Postoperative pain was assessed with a numerical rating scale (NRS), number of pentazocine injections, range of passive movement of the knee joint, and satisfaction of patients. Pain intensity, range of passive knee-joint movement, and satisfaction did not differ among the groups. The intermittent group received significantly less pentazocine than the continuous group did on the next day after surgery. The frequency of patients unsatisfied with pain treatment was 50% for the intermittent group and 29% in the continuous group. We conclude that because neither intermittent nor continuous femoral nerve block give sufficient pain relief for total knee arthroplasty, other methods of pain treatment should be studied.

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Although spinal epidural abscess is a rare disease causing back pain, it often results in severe and irreversible neurological deficits. We retrospectively studied 16 in-patients with spinal epidural abscess who were treated during eight years since 2001 at Iizuka Hospital. We reviewed the medical records of the patients with spinal epidural abscess, focusing on the underlying diseases, symptoms and signs, laboratory results, treatments, and outcomes. The frequency of spinal epidural abscess in our hospital was one patient in 7,000 in-patients. The mean age was 66 years. Most patients had one or more predisposing disorders including diabetes mellitus, chronic alcohol consumption, and injections. All patients suffered from back pain and had signs and laboratory results suggesting the presence of inflammation. Magnetic resonance imaging studies confirmed the presence of spinal epidural abscess in all patients. Staphylococcus aureus was the most frequent pathogen. All patients received antibiotics, and eight underwent surgical decompression. The patients who showed minimal neurological abnormalities received only antibiotics and neurologic outcomes were good. The outcomes of the patients who had severe neurological abnormalities were bad, whether surgical decompression was or was not done. Physicians should have spinal epidural abscess in mind when patients have back pain with laboratory evidence of inflammation. Early magnetic resonance imaging study confirms the presence of spinal epidural abscess. Immediate surgical decompression of the spinal cord should be performed as early as possible for patients with severe neurological abnormalities.

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Patients with fibromyalgia syndrome (FMS) have not only pain but also various somatic and psychiatric symptoms. Reports of patients with FMS having been analyzed by psychological scales were few in Japan. The purpose of this study was to investigate the psychological aspects of patients with FMS. We used the general health questionnaire (GHQ) and Hamilton's rating scale for depression (HRSD) to investigated mental health degrees in patients with FMS (n=20) , and the results were compared with those of chronic pain patients without FMS (non-FMS, n=20). The durations of illness were 24.1 months and 54.1 months for patients with FMS and non-FMS, respectively. The GHQ total scores and all subordinate scale scores of FMS patients were significantly higher than those of non-FMS patients, suggesting that the mental health degree of patients with FMS was lower than that of non-FMS patients. Moreover the patients with FMS had moderate degrees of depression. These results indicated that patients with FMS were exhausted physically and mentally. Evaluating the mental and psychosocial aspects of patients with FMS is equally essential to treatment for pain.

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Electroconvulsive therapy (ECT) has been used for intractable chronic pain. We compared the mental health state of chronic pain patients with ECT (n=37) and of those without it (n=37) to learn if intractable chronic pain deteriorates mental health. The Cornell medical index and Hamilton's rating scale for depression were used. As a result, we found that ECT patients are neurotic and in moderate to severe depression. They need more intensive psychological support than the non-ECT patients do.

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The author reports a patient with postherpetic neuralgia who attempted suicide. A 79-year-old woman with no psychiatric disorders developed herpes zoster with severe pain, which made sleep difficult for her. The pain was not lessened by analgesics, and was so severe that the patient's daily living activities were impaired. She was referred to the author for the treatment of the pain. Side-effects lessened after a withdrawal from medication, but the pain remained difficult to control. The author recommended her to receive nerve blocks, but she wanted to be discharged. Then attempted suicide by taking an excess of prescribed medications on the first morning after discharge. The patient had showed no signs of depression or psychiatric symptoms during admission, and she was re-admitted. She then received cervical epidural and stellate ganglion blocks, and was evaluated and treated by a psychiatrist. Because patients with chronic severe pain sometimes tend to commit suicide, physicians taking care of them should keep this risk in mind.

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Pain-alleviating effect of spinal cord stimulation (SCS) is established for neuropathic pain. Recent reports suggested beneficial effects of SCS on neurologic degenerative diseases, such as Parkinson disease. We report a 61-year-old man with degenerative spinal cord disorder causing spastic paraparesis of the lower limbs, who was treated with SCS. His capabilities of motor performances were evaluated with three dimensional optical motion-capture system. The patient also had severe low back pain resistant to medications. The pain intensity was 8 on an eleven-point numerical rating scale (NRS). The stimulating electrode of SCS was positioned at the level of 10th thoracic vertebra. The pain lessened to 5 on NRS after SCS. The time needed to standing from sitting position improved from 5.5±0.5 seconds before SCS to 4.0±0.1 seconds after SCS (P<0.05). The alignment of the pelvis and trunk became 10.0±6.8 degrees lordotic after SCS (P<0.05). His ambulation improved markedly. We conclude that SCS can not only improve pain but also motor function in some patients with degenerative spinal cord diseases. Three-dimensional optical motion-capture system is useful for objective evaluation of motor improvement.

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We report a patient who developed compartment syndrome and was treated with intravenous regional block. A 32-year-old man with Marfan syndrome presented with acute aortic dissection and underwent a Bentall Operation. The extracorporeal circulation lasted 7 hours and 33 minutes. His postoperative course was complicated with compartment syndrome of the right leg and received decompression fasciotomy. He developed sensorimotor neuropathy, edema of the right foot and leg, and drop foot. He was referred to us for treatment of pain. Treatment with nerve block was avoided since he was under antithrombotic treatment. We chose intravenous regional block for his pain. Intravenous regional blocks with lidocaine and dexamethasone were performed 8 times, with a tourniquet cuff over the lower leg. The duration of tourniquet application was 5 min, and the cuff pressure was set at 250 mmHg. His pain decreased, and insomnia resulting from pain, edema of the leg, and motor function of the leg improved after the blocks. Pain relief allowed more active physiotherapy. Intravenous regional block may be effective in some patients with compartment syndrome.

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We report a patient whose pain reduced after negative-balance isolated pelvic perfusion (NIPP). A 51-year-old man with infiltration of transverse colon cancer to the sacrum presented with severe pain and a growing tumor after conventional chemotherapies had failed. He had severe sacral pains (9 on a numerical rating scale : NRS) despite a high dose of intravenous morphine. He underwent 2 courses of NIPP. The pain reduced 1 to 2 on NRS. NIPP can reduce pain in some selected patients with severe pain and growing tumors despite conventional chemotherapies.

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The most frequent cause of trigeminal neuralgia is arterial compression, which can be caused by venous compression, tumor, or arachnoid adhesion. In our hospital, both plain and contrast-enhanced MRIs are taken for patients with trigeminal neuralgia. Furthermore, Gamma Plan^®, a software for Gamma knife surgery, is adopted for creating a 3-dimensional image around the trigeminal nerve. The author reports 3 patients with trigeminal neuralgia caused by venous compression, which was confirmed by surgery. The 3 were from 114 patients with intractable trigeminal neuralgia. Some patients with trigeminal neuralgia caused by venous compression do not have typical lancinating pain, and plain MRI rarely detects small paraneural veins. Transposition of the responsible vein is frequently difficult when the vessel joins the superior petrosal sinus. Physicians should suspect venous compression in patients whose MRIs reveal no typical arterial compression.

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