Chronic Pain Complaints Research Articles

Non-surgical improvement of cervical lordosis is possible in advanced spinal osteoarthritis: a CBP® case report.

[Purpose] To present a case of the non-surgical improvement in cervical kyphosis in a patient with history of cervical spine trauma and advanced osteoarthritis. [Subject and Methods] A 38 year old male presented with a chief complaint of chronic neck pain that was not substantially relieved by recent previous traditional physiotherapy and chiropractic manipulation. The cervical radiograph demonstrated a cervical hypolordosis of 5° as measured by the Harrison posterior tangent method from C2–C7. There was a 15° kyphosis at C4–C6 with advanced degenerative changes consistent with previous spine trauma. The patient was treated by CBP® methods incorporating cervical extension traction, extension exercises, and spinal manipulation for 30 sessions over an 18 week period. [Results] After the treatment sessions, there was a substantial (27°) increase in global C2–C7 lordosis, and 5° decrease in C4–C6 degenerative kyphosis corresponding to the reduction in neck pain and disability, and an improvement in overall health status as indicated on the SF-36 health questionnaire. [Conclusion] Although degenerative spondylosis of the cervical spine will have physical limitations to non-surgical correction, this case serves as an example that it is possible to reduce degenerative kyphosis and increase global cervical lordosis corresponding to health improvements in these patients.

Trauma and Pain in Family-Orientated Societies.

People from family-oriented societies in particular, in addition to having a post-traumatic stress disorder (PTSD) suffer from chronic pain and physical complaints. Such people have a different understanding of physical illness and pain and, compared to patients from western societies, have different ideas on healing, even when confronted with the therapist. Hitherto, these factors have not been sufficiently taken into account in modern, multi-module therapy approaches. Trauma can be perceived via pain and physical complaints, whereby the pain is not restricted to one part of the body but is seen as covering the body as a whole. Therefore, in the treatment and above all in the patient-therapist relationship, it is necessary to understand what importance is attached to the perceived pain in relation to the trauma. The afflicted body expresses the trauma in the shape of its further-reaching consequences such as the patient’s social, collective, economic and cultural sensitivity. Therefore, for the effective treatment of trauma and chronic pain, it is necessary to use a multi-modal, interdisciplinary, and culture-sensitive approach when treating patients from traditional cultural backgrounds.

Impact of a chronic pain management pathway on opioid administration and prescribing in an Emergency Department

Context: Prescription opioid abuse and misuse is a significant public health crisis. In 2012, an opioid prescribing pathway for patients with chronic pain presenting to the Emergency Department (ED) was implemented. The objective of this study is to determine the impact of the pathway for administration of opioids in the ED as well as the prescribing of opioids for home use after discharge.Methods: Retrospective pre- and post-intervention time series study of consecutive patients presenting to the ED with acute and chronic pain complaints before and after implementation of the pathway. For the purposes of this study, we included patients with chronic abdominal or back pain – defined as pain present for greater than three months – and acute pain as acute long bone fracture.Results: Before pathway implementation, there was no statistically significant difference in the mean morphine equivalent (MEQ) dose administered for chronic or acute pain patients. After pathway implementation, there was a decrease in IV/IM morphine administered to patients with chronic pain (p = .0200) but not to patients with acute pain (p = .0820). Overall, MEQs administered did not change in either group. In the acute pain group, no significant differences were found in the number of patients who received opioid prescriptions upon discharge (p = .7749). However, in the chronic pain group, the number of patients who received opioid prescriptions upon discharge decreased with statistical significance (p = .0017).Conclusions: After the implementation of a chronic pain management pathway in an ED, there is a decrease noted in opioids administered to patients with chronic pain both in the ED and prescriptions on discharge. In patients presenting with acute pain, there was no change in administration or prescription of opioids.

Magnetic resonance imaging findings in patients with low backache

Introduction: Low backache is commonly experienced by adults at some time during their lives. Though it is caused by degenerative changes, spinal stenosis, neoplasm, infection and trauma, lumbar disc degeneration is the most commonly diagnosed abnormalities associated. As Magnetic Resonance Imaging (MRI) is non invasive imaging technique with excellent spatial and contrast resolution, it has become the investigation of choice in evaluation of patients with low back pain. This study was designed to determine the patterns of degenerative disc disease on MRI in patients with low backache.Methods: A retrospective hospital based study was done by reviewing MRI report of 202 patients who underwent MRI of lumbar spine for complaint of chronic low back pain, radicular pain, neurogenic claudication or various other symptoms and signs suggestive of lumbar degenerative disc disease from January 2014 till June 2014. The patients having MRI findings of acute spinal infection, recent trauma, tumors, spinal dysraphism and metabolic conditions were excluded from the study.Results: Out of the 202 patients included in the study, 116 patients (57.4%) were male and 86 patients (42.6%) were female. The mean age of the study population was 44.26 ±15.61 (13-83) years. Multiple contiguous level disc disease was the most common type of involvement which was noted in 109 (54%) patients. Grade 4 lumbar disc degeneration (graded as per classification given by Pfirrmann et al) was noted in 65.3% (132) cases followed by Grade 2 in 25.2%(51) cases and Grade 1in 5.5% (11) cases. The most common involvement was observed at L4-L5 level (76.7%) and L5-S1 levels (55.9%) followed by L3-L4 (30.6%) in decreasing order of frequency. The most common category was disc bulge note in 46.5% (94) of cases. Nerve root compression was observed in 56% (114) of the total cases. Nerve root compromise was also noted most frequently compressing L5 nerve (28.23% of cases). Annular tear was observed in 14.4% (29) of cases and among them 20% (6) of cases had torn at two intervertebral discs. It is most frequently noted involving L4-L5 intervertebral disc (72.5% of cases), followed by L5-S1 (24.2% of cases).Conclusion: Disc generation is most common at L4-L5 level with multiple contiguous involvement of grade 4. Annular tear though not common can occur and is also common at L4-L5 level.Journal of Society of Surgeons of Nepal, 2015; 18 (2)

233 Effectiveness of Rural Emergency Department-Based Pain Contract on Emergency Department Visits Among Emergency Department Frequent Users

Caring for patients with non-acute pain in the emergency department (ED) can be particularly challenging, both for patients and for physicians. This study seeks to determine, in a rural setting, the effect of an ED-based pain contract on the rate of ED visits among patients with frequent visits for pain or complaints of chronic pain not related to cancer. This is a multi-ED, retrospective, before-and after chart review assessing the effect of a rural ED-based pain contract on the number of ED visits. The study consisted of 4 rural EDs representing over 80,000 annual visits. Medical records of all patients that were eligible for pain contract were reviewed for the periods between December, 2005 and December, 2015. Only visits with complaints of pain were included. The mean number of visits during the year period to contract initiation was compared with the number of visits during the year after enrollment, using a paired t-test. We enrolled 314 patients, 185 (59%) of whom were female. The median of age was 48 years (48.5 years for female and 46 years for male). The mean ED visits one year pre-contact was 12.4 visits (95% CI 11.5,13.3) and the mean ED visits one year post-contract was 6.5 visits (95% CI 5.6,7.3) with P < .0001. Pain contract protocol implementation was associated with a significant reduction in the number of ED visits to multiple rural EDs. Additional studies using similar protocols are needed to establish the impact on patient well-being, experience, experience and potential to reduce health care costs.

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OBJECTIVES/SPECIFIC AIMS: (1) Characterize the prevalence and initial pharmacological management of chronic pain syndromes during pregnancy in a women’s mental health program. (2) Describe the severity and qualitative characteristics of chronic pain during pregnancy and the acute postpartum period. (3) Compare obstetrical and neonatal outcomes between pregnant women with and without chronic pain syndromes. METHODS/STUDY POPULATION: A chart review was conducted to identify all pregnant women who presented for an initial evaluation to the Women’s Mental Health Program (WMHP) at the University of Arkansas for Medical Sciences from July 2013 to June 2016. We excluded respondents &lt;18 years of age or who did not consent to having their information used for research purposes. Demographic information, past and current medical histories, and medication history were obtained from written and electronic medical records. Chronic pain complaints and medication history are presented as counts and percentages. In an ongoing prospective, longitudinal study of pregnant women with chronic pain, women are enrolled before 20 weeks gestation and followed throughout pregnancy and the first 3 months postpartum. Study visits occur at 4-week intervals; and pain characteristics, analgesic exposures, other medications, and depressive measures are collected. Obstetrical and neonatal outcomes are obtained following delivery. Subjects will be compared based on pain types (ie, neuropathic pain, non-neuropathic pain, and controls) and treatment exposures (eg, +/− opioids). Primary outcome measures include visual analog scale (VAS). Secondary outcome measures include other pain and depression assessments. Data will be analyzed using SAS 9.4. A p-value of&lt;0.05 was considered statistically significant. RESULTS/ANTICIPATED RESULTS: (1) Chronic pain conditions were reported by 28.2% (44/156) of the initial referrals to the WMHP. (2) 95.5% of respondents with chronic pain were taking at least 1 medication, and 59.5% were taking 2 or more medications. Mean number of medications used were 2.6±2.1.3. The most common medications reported were acetaminophen (43.2%), opioids (43.2%), and sedative/hypnotics (36.4%). Non-pharmacological therapy (eg, physical therapy and transcutaneous electrical nerve stimulation) was reported by 20.5% of respondents. (4) We anticipate that measures of pain severity will increase in pregnancy, peak in the third trimester, and decline in the postpartum period. (5) We foresee that the prospective results will confirm the chart review as indicated by a higher rate of medication exposures during pregnancy, including non-analgesic medications in the women with chronic pain syndromes. (6) We expect women with chronic pain syndromes to have a higher rate of obstetrical complications, specifically pre-term delivery and operative delivery. (7) Finally, we anticipate that chronic pain syndromes and management will result in a higher rate of neonatal complications, specifically neonatal intensive care unit admission, neonatal respiratory problems, and small for gestational age infants. DISCUSSION/SIGNIFICANCE OF IMPACT: Chronic pain syndromes are prevalent in more than one-quarter of pregnant women in our study with the majority of women using pharmacological agents to manage their condition. This prevalence is greater or equal to than other common obstetrical conditions, such as gestational diabetes or preterm delivery. The novel prospective data will be germane to the clinical care of pregnant women with chronic pain disorders. Clinical practice will be better informed by our data regarding the potential impact of chronic pain and its management on pregnancy course and perinatal outcomes. These data will provide the initial foundation for the development of treatment guidelines for the management of chronic pain syndromes during the perinatal period.

Tamoxifen Pharmacovigilance: Implications for Safe Use in the Future.

To survey the status of current tamoxifen pharmacovigilance documentation reflecting tamoxifen use in an academic outpatient multispecialty practice in older adults. This data will help provide information to develop improved pharmacovigilance for a growing cohort of older adult users. The data will be utilized by an interdisciplinary team developing new methods of identifying factors for individualized pharmacovigilance in older adults. Retrospective chart review to gather descriptive and quantitative data on tamoxifen pharmacovigilance. Multi-specialty clinic. Ninety-three patients 60 years of age and older. Quantitative report of tamoxifen monitoring as well as descriptive analysis of individual cases. We found 19 cases of serious adverse events possibly related to tamoxifen (thrombi, uterine malignancies). There were 15 cases with no documentation of pharmacovigilance. All cases had incomplete pharmacovigilance documented. There were two cases of hypercalcemia. There was one case of tamoxifen discontinuation resulting from muscle pain and with chronic muscle pain complaints while receiving tamoxifen. We observed a correlation in older age or high comorbidity burden patients and adverse events patients. Some studies direct the important pharmacovigilance toward prevention of thrombi, uterine malignancies, and hypercalcemia; however, it is not easy to identify recommendations for frequency or focus of monitoring to prevent adverse events for individual older adults based on existing recommendations. The data collected and presented in this study serve to heighten awareness of tamoxifen pharmacovigilance and as a starting point for the application of machine learning techniques and modeling to identify high-risk patients and individualized pharmacovigilance recommendations.

Buprenorphine/naloxone maintenance therapy in patients with meperidine use disorder

Meperidine hydrochloride is a synthetic opioid and a weak µ receptor agonist. Meperidine use disorder is mostly iatrogenic and is common in health care workers. In addition, it is prescribed in acute and chronic pain complaints, and has a high potential for creating addiction. Treatment of meperidine use disorder is a challenging issue and there is no standardised treatment for meperidine addiction. Buprenorphine is a μ receptor partial agonist, a long-acting synthetic opioid for the treatment of opioid dependence and has a buprenorphine/naloxone (BN) form combined with naloxone. Buprenorphine maintenance therapy is one of the treatment options performed in opiate use disorder. But there is a paucity of data about treatment of meperidine use disorder. Here, a full remission case report is presented with BN maintenance treatment for a patient with meperidine use disorder diagnosis.

Effect Of A "No Superuser Opioid Prescription" Policy On ED Visits And Statewide Opioid Prescription.

IntroductionThe U.S. opioid epidemic has highlighted the need to identify patients at risk of opioid abuse and overdose. We initiated a novel emergency department- (ED) based interventional protocol to transition our superuser patients from the ED to an outpatient chronic pain program. The objective was to evaluate the protocol’s effect on superusers’ annual ED visits. Secondary outcomes included a quantitative evaluation of statewide opioid prescriptions for these patients, unique prescribers of controlled substances, and ancillary testing.MethodsPatients were referred to the program with the following inclusion criteria: ≥ 6 visits per year to the ED; at least one visit identified by the attending physician as primarily driven by opioid-seeking behavior; and a review by a committee comprising ED administration and case management. Patients were referred to a pain management clinic and informed that they would no longer receive opioid prescriptions from visits to the ED for chronic pain complaints. Electronic medical record (EMR) alerts notified ED providers of the patient’s referral at subsequent visits. We analyzed one year of data pre- and post-referral.ResultsA total of 243 patients had one year of data post-referral for analysis. Median annual ED visits decreased from 14 to 4 (58% decrease, 95% CI [50 to 66]). We also found statistically significant decreases for these patients’ state prescription drug monitoring program (PDMP) opioid prescriptions (21 to 13), total unique controlled-substance prescribers (11 to 7), computed tomography imaging (2 to 0), radiographs (5 to 1), electrocardiograms (12 to 4), and labs run (47 to 13).ConclusionThis program and the EMR-based alerts were successful at decreasing local ED visits, annual opioid prescriptions, and hospital resource allocation for this population of patients. There is no evidence that these patients diverted their visits to neighboring EDs after being informed that they would not receive opioids at this hospital, as opioid prescriptions obtained by these patients decreased on a statewide level. This implies that individual ED protocols can have significant impact on the behavior of patients.

Study of outcome of conservative management in osteochondritis dissecans of trochlea

Introduction: Osteochondritis dissecans (OCD) of elbow has been known to be one of the causes of chronic pain in elbow region, targeted population being children and adolescents. Usual location was thought to be capitellum but rarely trochlea. Conservative and operative treatments have been studied and published. Aim of this study is to discuss outcome in conservatively managed 8 cases in our institution. Materials and Methods: Prospective analysis has been done in our study over 8 children of age in range between 11-17 who presented to our outpatient department between the years 2009 to 2016 with complaints of chronic elbow pain and no history of trauma. Nelsons classification for staging OCD appreciable on MRI is used. Results: There were 8 children with age varying from 11-17 years, 6 being boys and 2 girls. 5 cases had flexion contracture ranging from 5-10 degrees in the affected elbow. 2 cases (female) had hyperextension in the contra lateral un-affected elbow of 5 and 10 degrees respectively. After 3 months, 3 patients developed flexion contracture. 6 months later flexion contracture was seen in 2 patients. Motion pain of the joint disappeared and full range of movements were achieved at 6 months after first visit. Conclusion: In conclusion OCD of trochlea though an infrequent occurrence, is important differential diagnosis in chronic elbow pain. Reviewing the elbows both clinically and radiologically would lead to early diagnosis and effectiveness of conservative management.

Assessment and Management of Chronic Musculoskeletal Pain Syndrome in Children: A Review

Musculoskeletal pain is a frequent complaint of children, is the most common presenting problem of children referred to pediatric rheumatology clinics. Chronic musculoskeletal (MSK) pain in children is responsible for substantial personal impacts and societal costs, but it has not been intensively or systematically researched. The majority of musculoskeletal pain complaints in children are benign in nature and attributable to trauma, overuse, and normal variations in skeletal growth. There is a subset of children in whom chronic pain complaints develop that persist in the absence of physical and laboratory abnormalities including growing Pain, juvenile fibromyalgia, complex regional pain syndrome. During recent years studies of the epidemiology, etiology and rehabilitation of pain and pain-associated disability in children have revealed a large prevalence of clinically relevant pain, and have emphasized the need for early recognition and intervention.Bangladesh J Child Health 2016; VOL 40 (3) :166-173

Osteitis CondensansIlii - A Rare Presentation

We presented a case of 45 years old unmarried woman who complaints of chronic low back pain and diagnosed as a case of Osteitis CondensansIlii (OCI). We are discussing this rare presentation of OCI to increase awareness among the specialty and primary care physicians, as it may be confused with other conditions like- Ankylosing Spondylitis (AS) and inflammatory arthritis. It also prevents misdiagnosis and extensive investigations that not only increase anxiety but are of little benefit.Medicine Today 2016 Vol.28(2): 89-91

Breaking barriers to novel analgesic drug development.

Acute and chronic pain complaints, although common, are generally poorly served by existing therapies. This unmet clinical need reflects a failure to develop novel classes of analgesics with superior efficacy, diminished adverse effects and a lower abuse liability than those currently available. Reasons for this include the heterogeneity of clinical pain conditions, the complexity and diversity of underlying pathophysiological mechanisms, and the unreliability of some preclinical pain models. However, recent advances in our understanding of the neurobiology of pain are beginning to offer opportunities for developing novel therapeutic strategies and revisiting existing targets, including modulating ion channels, enzymes and G-protein-coupled receptors.

Can we improve pain and sleep in elderly individuals with transcranial direct current stimulation? - Results from a randomized controlled pilot study.

BackgroundThe prevalence of chronic pain and sleep disturbances substantially increases with age. Pharmacotherapy remains the primary treatment option for these health issues. However, side effects and drug interactions are difficult to control in elderly individuals.AimsThe objective of this study was to assess the feasibility of conducting a randomized sham-controlled trial and to collect preliminary data on the efficacy of transcranial direct current stimulation (tDCS) to reduce pain and improve sleep in older adults suffering from chronic pain.MethodsFourteen elderly individuals (mean age 71±7 years) suffering from chronic pain and sleep complaints were randomized to receive either anodal tDCS, applied over the primary motor cortex (2 mA, 20 minutes), or sham tDCS, for 5 consecutive days. Pain was measured with visual analog scales, pain logbooks and questionnaires, while sleep was assessed with actigraphy, sleep diaries and questionnaires.ResultsThere were no missing data for pain and sleep measures, except for actigraphy, that generated several missing data. Blinding was maintained throughout the study, for both the evaluator and participants. Active but not sham tDCS significantly reduced pain (P<0.05). No change was observed in sleep parameters, in both the active and sham tDCS groups (all P≥0.18).ConclusionThe present study provides guidelines for the implementation of future tDCS studies in larger populations of elderly individuals. M1 anodal tDCS in this population appears to be effective to reduce pain, but not to improve sleep.

Serious gaming during multidisciplinary rehabilitation for patients with complex chronic pain or fatigue complaints: study protocol for a controlled trial and process evaluation

IntroductionMany individuals suffer from chronic pain or functional somatic syndromes and face boundaries for diminishing functional limitations by means of biopsychosocial interventions. Serious gaming could complement multidisciplinary interventions through enjoyment...

Fear of pain changes movement: Motor behaviour following the acquisition of pain-related fear.

According to current fear-avoidance models, changes in motor behaviour (e.g. avoidance) are a key component in the development and maintenance of chronic pain complaints. Yet, experimental research assessing actual behavioural changes following painful events is relatively sparse. This study investigated the effects of pain anticipation on changes in motor behaviour using a fear conditioning paradigm and robot-generated standardized movement trajectories of the upper extremities. Pain-free participants (N=20) performed clockwise and counterclockwise fixed, circular movements with a robotic arm without receiving visual feedback. During fear acquisition, moving in one direction (CS+) was paired with a painful stimulus (pain-US) whereas moving in the other direction (CS-) was not. During the subsequent extinction phase, the pain-US was omitted. We assessed self-reported pain-related fear and urge to avoid the movement, as well as several behavioural measures: Velocity, acceleration, exerted force and force direction. Movements that were paired with pain were associated with increased self-reported pain-related fear and urge to avoid. Moreover, movements that were associated with pain were performed faster, more forcefully and more accurately than movements that were not associated with pain. All these differences diminished during the extinction phase. The present study demonstrates the utility of robot-generated force feedback in the study of pain-related fear and associated changes in motor behaviour. Fear of pain changes movement: Movements associated with pain are performed faster, with more force and higher accuracy than movements that are not associated with pain. These changes can inform us how fear of pain translates into avoidance and escape behaviour, two important constructs in the maintenance of chronic pain.

Is There a Link Between Obstructive Sleep Apnea Syndrome and Fibromyalgia Syndrome?

Fibromyalgia syndrome (FMS) is characterized by complaints of chronic musculoskeletal pain, fatigue, and difficulty in falling asleep. Obstructive sleep apnea syndrome (OSAS) is associated with symptoms, such as morning fatigueness and unrefreshing sleep. We aimed to investigate the presence of OSAS and objectively demonstrate changes in sleep pattern in patients with FMS. Polysomnographic investigations were performed on 24 patients with FMS. Patients were divided into two groups: patients with and without OSAS (Group 1 and Group 2, respectively). A total of 40 patients without FMS who presented to the sleep disorders polyclinic with an initial diagnosis of OSAS were included in Group 3. Based on their apnea hypopnea index (AHI), OSAS in the patients were categorized as mild (AHI, 5-15), moderate (30), or severe (>30). OSAS was detected in 50% of patients with FMS. The most prominent clinical findings were morning fatigue and sleep disorder, which were similar in three groups. In polysomnography (PSG) evaluation, patients with FMS had mild (33%), moderate (25%), and severe (42%) OSAS. In correlation analyses, negative correlations were observed between fibromyalgia impact questionnaire (FIQ) and mean oxygen saturation, visual analogue scale (VAS), and minimum oxygen saturation, whereas a positive correlation was found between FIQ and desaturation times in patients with FMS. Detection of OSAS in 50% of the patients with FMS, and similar rates of complaints of sleep disorder and morning fatigue of OSAS and FMS cases are important results. Detection of correlation between the severity of hypoxemia and FIQ and VAS scores are significant because it signifies the contribution of increased tissue hypoxemia to the deterioration of clinical status. Diagnosis and treatment of OSAS associated with FMS are important because of their favorable contributions to the improvement of the clinical picture of FMS.

Association between serum vitamin B12 level and frailty in older adults.

OBJECTIVE:Frailty is associated with recurrent falls, fractures, limitation of daily living activities, cognitive impairment, increase in hospitalization, placement in nursing home, and mortality rate in older adults. Although malnutrition is one of the most important etiological factors, role of micronutrients is unclear. The aim of this study was to investigate association between frailty and vitamin B12, which has been demonstrated to be related to numerous geriatric syndromes.METHODS:Total of 335 patients who presented at geriatric outpatient clinic and underwent comprehensive geriatric assessment were included in this study. All patients were evaluated with both Fatigue, Resistance, Ambulation, Illnesses, and Loss of Weight (FRAIL) scale and Fried criteria for frailty. Vitamin B12 deficiency was defined as serum vitamin B12 level of less than 400 pg/mL.RESULTS:In total of 335 patients, 88 (26.3%) were assessed as frail, 156 (46.6%) were prefrail, and 91 (27.2%) were robust. When the 3 groups were compared, it was found that patients in frail group had highest average age and lowest education level (p<0.001) and that complaints of urinary incontinence, balance disorders, recurrent falls, sleep disorders, amnesia, chronic pain, and constipation were more frequent in this group (p<0.05). Albumin and 25-hydroxy vitamin D levels decreased as frailty level increased (p<0.05), but no association between vitamin B12 levels and frailty was found. Patients were divided into 2 groups: vitamin B12 level above and below 400 pg/mL. Groups were then compared in terms of subparameters of both the FRAIL and Fried criteria, and no significant difference between groups was found (p>0.05).CONCLUSION:Results of this study determined no association between vitamin B12 level and frailty in geriatric population; however, longitudinal studies are needed to clarify relationship.

Innovative Treatment for Pre- Operative Occipital Nerve Pain Associated with Chiari 0 Malformation

Chiari 0 malformation is a disorder within the spectrum of Arnold- Chiari malformations characterized by cerebellar changes present during fetal development and early childhood. Specifically, Chiari 0 is classified by characteristics that include either lack of protrusion of the cerebellar tonsils into the foramen magnum or protrusion less than 5 millimeters, which is the current minimum cutoff for Chiari I classification. Due to the subtle changes in the cerebellar region regarding Chiari 0, patients with this malformation often present with neck and occipital pain along with occipital headaches. It is suggested that this may be due to abnormal blockage of cerebrospinal fluid (CSF) that causes entrapment and impingement of the occipital nerve. In the cases of two teenage patients, both were referred to Pediatric Neurosurgery in Lubbock, Texas for complaints of chronic headaches and neck pain. After previous pain remedies proved to be unsuccessful in providing lasting relief, the patients were deemed candidates to receive an innovative treatment option to manage their chronic headaches and neck pain. The patients were referred to receive epidural lysis of adhesions (LOA) which would provide the lasting relief that the patients were seeking. LOA is a procedure that includes using a needle, Racz catheter, and injectable contrast guided with fluoroscopy to locate the entrapment of the occipital nerve. LOA utilizes the injection of hyaluronidase dissolved in normal saline to free the entrapped nerve so that a local anesthetic/steroid solution can be injected to provide pain relief. Lysis of adhesions should be considered as a minimally invasive treatment for Chiari 0 malformations, whose primary symptoms are intractable occipital headaches.

Giant Cell Tumor in a Patient with Osteopetrosis: A Case Report

Introduction: Osteopetrosis, a rare disorder due to osteoclast dysfunction, which causes bone resorption dysfunction. These patients have brittle bones prone to osteomyelitis. Case presentation: A 14-years male referred with complaint of chronic low back pain. He was treated with analgesics but with no pain relief, thus imaging was requested and a mass at the site of left body and pedicle of L5 was detected. The patient underwent tumor resection. The mass was diagnosed as giant cell tumor (GCT). Conclusion: Due to the association of osteoclast dysfunction with both GCT and osteopetrosis, patients with osteopetrosis may be at higher risk of GCT.