Persistent Localized Pain Research Articles

Report on initial experience with transradial access for carotid artery stenting

Carotid artery stenting is emerging as an attractive alternative to surgical endarterectomy for the treatment of carotid artery disease. This study reports our initial experience using the radial artery as access for carotid stenting. A retrospective study was performed in which 20 consecutive patients at high risk for carotid endarterectomy underwent carotid stenting with cerebral protection using radial artery access. All procedures were performed in the operating room from March 2006 to December 2006. Seven lesions were symptomatic, and 13 lesions were asymptomatic. Patients were evaluated for development of stroke or transient ischemic attacks, myocardial infarction, access site complications, procedural success, time to patient mobilization, and need for intravenous analgesia. Procedural success was achieved in 18 patients (90%). Intense radial artery vasospasm resulted in one failure, and the second failure occurred in a patient with a left-sided carotid lesion and type I arch. The 30-day incidence of stroke, transient ischemic attacks, myocardial infarction, and death was 0%. Radial artery occlusion only occurred in the one patient because of the development of intense vasospasm during the procedure. One patient had persistent local pain requiring intravenous medication for relief. All patients were mobilized <or=2 hours of intervention and were discharged on the first postoperative day. Carotid artery stenting with cerebral protection devices can be safely and effectively performed, with acceptable morbidity and high technical success, by using radial artery access. We recommend obtaining imaging of the aortic arch and supra-aortic trunks with computed tomography, as well as a duplex scan of radial artery, before attempting carotid artery stenting using radial artery access. Further study is needed before recommending that femoral access be replaced by radial access for carotid artery intervention.

Biological and biochemical properties of Scatophagus argus venom

Scatophagus argus of the family Scatophagidae inflicts painful wounds in fishermen during handling. The clinical picture is characterized by excruciating and persistent local pain disproportionate to the size of injury, redness, swelling and a throbbing sensation that extends to the limbs, followed by dizziness. The biological properties of the S. argus venom were studied to assess its risk and lethal factors with regard to human welfare. In contrast to other fish venoms, S. argus showed relatively low LD 50 (9.8 mg/kg via i.p.). Haemolytic activity in human erythrocytes was recorded. Platelet lysis expressed as LDH activity of lysed cells was dose dependent. S. argus venom failed to induce any clot in human plasma. No PLA 2 activity was found in S. argus venom. Mild proteolytic activity was observed. The injection of venom in mice produced lesions and nociception, which were not inhibited by antihistamine pheniramine maleate, suggesting that histamine was not involved in the inflammatory process. The increase in serum creatine kinase activity indicated myotoxicity. Cytotoxicity on HeLa cells was observed. The spectrum of activity in experimental animals of S. argus crude venom resembles those of other fish venoms previously studied and well correlated to the systemic manifestations that are described for S. argus envenomation.

Persistent Local Pain After Posterior Spine Surgery for Thoracic Lesions

Many surgeons have investigated local pain associated with posterior spine surgery for cervical or lumbar lesions. However, little information is available concerning local pain after posterior thoracic spine surgery. This prospective study was, thus, performed to investigate the frequency and clinical features of local pain after posterior spine surgery for thoracic lesions. In 29 consecutive patients undergoing posterior spine surgery for various thoracic spinal disorders, local pain was investigated before and after surgery. In all 19 patients with preoperative back pain presumably due to thoracic lesions, pain was well alleviated after surgery. In contrast, 6 patients (21%) newly developed persistent shoulder angle pain after surgery, which resembled axial pain after cervical laminoplasty. In 5 of these 6 patients surgical exposure was extended to the cervicothoracic junction, whereas persistent shoulder angle pain was independent of disease etiologies and surgical procedure, and all of the 5 patients had no other etiologies of local pain such as surgical site infections, hardware failures, pseudoarthrosis, other metastasis, and vertebral fractures. These results suggest that dissection of muscle attachments to the cervicothoracic junction would play some part in the development of persistent local pain after posterior spine surgery for thoracic lesions, although surgical exposure of the zygapophysial joints at the cervicothoracic junction might be a possible source of postoperative shoulder pain. Therefore, to minimize such surgical complications, muscle insertions into the cervicothoracic junction should be preserved as far as possible.

Appendagite épiploïque primitive : un diagnostic non chirurgical souvent méconnu

Primary epiploic appendagitis (PEA) is characterized by the association of localized abdominal pain with guarding. Depending on its localization, it may simulate acute appendicitis or diverticular sigmoiditis. Symptoms correspond to necrosis of the epiploic appendix due the torsion and vascular occlusion of the main epiploic pedicle. A 34-year-old man (BMI=29.38) was examined for persistent localized abdominal pain of the left lower quadrant three days after receiving systemic antibiotic therapy for what was diagnosed as mild diverticular sigmoiditis. Abdominal examination showed localized guarding in the left lower quadrant, with no fever, vomiting or diarrhea. Laboratory results showed no inflammatory response. Abdominal ultrasound showed no evidence of left hydronephrosis. Helical CT showed a localized zone of necrosis of the epiploic appendix of the sigmoid colon and thus confirmed the diagnosis without surgical exploration. Symptoms regressed after a week of analgesic treatment. PEA is a rare disease. It often occurs in mildly overweight adult men (around 35 years of age). The combination of acute abdomen with localized abdominal guarding and no evidence of fever or inflammation is the typical presentation. Surgical exploration (laparoscopy) can be avoided for diagnosis if helical CT shows a localized fatty zone situated outside the colon wall with a high attenuating dot point that corresponds to central necrosis of the epiploic appendix.

Arthroscopic Transfer of the Long Head Biceps to the Conjoint Tendon

Abstract Pathology of the biceps tendon is often a factor in the etiology of shoulder pain. However, diagnosis and treatment of such pathology remains controversial. When conservative management fails to relieve symptoms, surgical options include tenotomy or tenodesis. Tenotomy has provided excellent results with regard to local pain relief, but a potential cosmetic deformity and occasional painful cramping are common in younger patients. Tenodesis has also had high failure rates resulting from persistent local pain. We have used an all-arthroscopic technique for transfer of the long-head biceps to the conjoint tendon instead of traditional tenodesis. We believe that this transfer more closely recreates the normal axis of the biceps muscle and may offer improved results over conventional tenodesis.

Postlymphoproliferative Disorder Affecting Bone After A Renal Transplantation

To illustrate a posttransplant lymphoproliferative lymphoma presenting as a solitary osseous lesion situated in the rib. A 53-year-old man was referred to a surgical department because of persistent local pain over the lower part of his left posterior hemithorax. Due to a previous history of chronic glomerulonephritis, a renal transplant was performed 7 years previously, followed by immunosuppressive therapy with azathioprine cyclophosphamide. Surgical removal of the rib lesion was performed because of the patient's history of the organ transplant. The histological study of the surgically removed tissue revealed diffuse infiltration of the marrow by lymphoid-like cells. There was evidence of interstitial fibrosis, and further immunohistochemical examination showed the presence of B cells in the specimen confirming the diagnosis of B-cell lymphoma. This case report discusses an unusual presentation of a lymphoma induced by immunosuppressive therapy in a patient who had received an organ transplant. Such lesions may appear in any organ or system, although this is distinctively unusual to involve the skeletal system.

Fibular nonunion after closed rotational ankle fracture.

Historically, the standard of care for minimally or nondisplaced, closed, distal fibula fractures has been short-term immobilization and progressive weightbearing. The vast majority of such patients are expected to heal with excellent functional outcome after such treatment. There exists a subpopulation of patients sustaining these fibular fractures who develop symptomatic incomplete union or nonunion despite appropriate management, and later require operative intervention to eliminate pain. A retrospective review of 17 referred patients with rotational fibular fractures between August 1999 and July 2003 identified six persistently symptomatic distal fibular fractures after an adequate trial of conservative treatment. Due to their persistent localized pain and difficulty with ambulation, five patients underwent operative treatment of the nonunion with autologous bone grafting with plate and screw osteosynthesis. The sixth patient has refused operative intervention despite persistent symptoms. All six of these patients were identified as low risk for nonunion. Two fibular nonunions were found to be complete and four were partial nonunions. One hundred percent of these patients presented with a chief complaint of pain, had reproducible tenderness with palpation directly at the fracture site, and exhibited a persistent antalgic gait pattern. Four of six patients who underwent surgery noticed complete resolution of their pain and return of their normal gait within an average of 2.3 months postoperatively, with an average follow-up of 19.5 months (range, 2-53 months). Distal fibula nonunion appears to be a relatively common cause of persistent lateral ankle symptoms in patients who do not enjoy a satisfactory recovery after appropriate conservative treatment. The authors believe that the persistent lateral pain in such patients results from micromotion strain at the incomplete fracture union site. Surgical stabilization of fibular nonunion seems to be a reliable means of resolving these symptoms when conservative measures fail.

Skeletal Muscle Metastasis from Transitional Cell Carcinoma of the Urinary Bladder: Clinicoradiological Features

AIM: To define the clinicoradiological characteristics of skeletal muscle metastasis from transitional cell carcinoma of the urinary bladder. MATERIALS AND METHODS: A retrospective review of all patients with skeletal muscle metastasis was undertaken between January 1999 to December 2001. Patients suspected of having a metastasis on radiological examinations, and subsequently proven to have metastatic disease on histological examination were included in study. The clinical presentation and radiological features of five patients with skeletal muscle metastasis from bladder tumours were reviewed from hospital records. RESULTS: Twenty-four patients had skeletal muscle metastasis from various primaries. Of these five patients had previous or concurrent primary tumours in the bladder. Patients were aged between 27–70 years (mean 52 years), and all had persistent, localized pain with or without accompanying swelling. The muscles involved were psoas in three patients, adductor muscles of thigh in one and rectus abdominis in one. Four patients had radical cystectomy with urinary diversion (two ileal conduit and two orthotopic sigmoid neobladder). One patient presented with bladder tumour and concomitant muscular metastasis. All patients underwent helical computed tomography (CT) before confirmation of diagnosis by fine-needle aspiration (FNA) or biopsy. The typical appearance of low-density enhancing lesions on CT was mistaken for abscess in two patients and failure to respond to conservative treatment led to suspicion of metastasis. Diagnosis was proven histologically in all patients (FNA in three and biopsy in two). All patients had palliative chemotherapy (Mitomycin, Vincristine, Adriamycin and Cyclophosphamide). Two patients had local palliative 3500 rad radiotherapy for persistent pain. Mean survival was 8 months (range 6–12 months). CONCLUSION: Muscular metastasis from urothelial tumours typically presents with persistent localized pain with or without swelling. The characteristic low-density, ring-enhancing lesions on CT in a patient with previous or concomitant urothelial tumours should raise the suspicion of metastasis until proven otherwise. Prognosis is dismal.

Nonunion of the isolated capitate waist fracture

AbstractWe report a patient with nonunion of an isolated fracture of the capitate. A male 17-year-old high school student directly hit the dorsal aspect of the carpal with the wrist in flexion position against another player’s shoulder during a rugby football game. Radiographs did not show a fracture of the capitate on the day after the injury, but nonunion was distinct across the waist at the middle one-third of the capitate 4 months later. The fixation using two cannulated Herbert-Whipple screws with iliac cancellous bone graft led to sound union of the capitate and the patient’s ability to return to sporting activities. Although the initial plain radiographs do not show a fracture of the capitate, we should consider the capitate fracture and check the patient by repeated physical examinations and radiographs if the patient suffers from persistent localized pain and tenderness over the capitate.

Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost

Objective: To compare tension-free open mesh hernioplasty under local anaesthetic with transabdominal preperitoneal laparoscopic hernia repair under general anaesthetic.Design: A randomised controlled trial of 403 patients with inguinal hernias.Setting: Two...

Outcome of Patients Hospitalized for Complications after Outpatient Liver Biopsy

To determine the safety of outpatient liver biopsies by analyzing the outcome of patients hospitalized for complications. Retrospective review. Large clinic referral center. All patients admitted after outpatient liver biopsy at the Mayo Clinic from 1 April 1989 to 1 April 1991. During this period, 405 outpatients underwent biopsy. Of the 405 patients, 13 (3.2%) were admitted with complications after biopsy. Five patients (38%) were admitted with persistent localized pain, five (38%) with orthostatic hypotension, one (8%) with both pain and hypotension, one (8%) with peritoneal signs, and one (8%) with lightheadedness but no orthostatic changes. All complications were noted within 3 hours after the biopsy. Bleeding, potentially the most serious complication, was radiographically defined in 5 of the 13 patients (38%) admitted. Only two patients, however, required blood transfusions. No patient required invasive management such as surgery or chest tube placement. The average length of the hospital stay was 1.5 days. Complications after outpatient liver biopsy occur early and rarely require invasive management. Outpatient liver biopsy is safe when done on carefully selected patients in a setting that provides close observation for at least 3 hours after liver biopsy.

Acute appendicitis in children with leukemia and other malignancies: Still a diagnostic dilemma

Of 6,099 children treated for malignancy, 16 (ages 3.5 to 18 years) developed acute appendicitis between 1962 and 1989. Fourteen had leukemia (ALL 10, AML 4). One each had rhabdomyosarcoma and Ewing's sarcoma. Active malignancy at diagnosis was noted in 10, 4 of whom had severe neutropenia (absolute neutrophil count <500/mm 3). Of all the leukemics ( 2,794 6,099 ), abdominal pain during induction was a frequent complaint. The incidence of appendicitis, however, was low (0.5%). Nine of the 16 patients presented classically, facilitating prompt diagnosis and treatment. Six diagnoses were delayed. Three of these patients presented atypically with vague, nonlocalized pain, abdominal distention, lack of abdominal guarding, fever, dehydration, diarrhea, and unusual symptoms such as upper gastrointestinal bleeding. In each of these 6 patients the appendix was ruptured. Delays led to complications and deaths. Three patients required perioperative transfusions to treat excessive bleeding and two patients with ruptured appendicitis developed wound abscesses. Two patients died; in one, ruptured appendix was diagnosed only at autopsy. The other patient died of uncontrolled sepsis. Typhlitis occurring during induction chemotherapy may present similarly and is the main differential diagnosis. Typhlitis will usually improve with medical treatment alone. Nausea and vomiting ( 13 16 ), right lower quadrant pain ( 13 16 ), guarding ( 14 16 ), tachycardia ( 12 16 ), fever ( 10 16 ), and rebound tenderness ( 10 16 ) were the most frequent signs and symptoms of appendicitis. Persistent localized abdominal pain and guarding, lack of improvement with medical treatment, clinical deterioration, and the development of a mass were our indications for laparotomy. Despite major improvements in therapy, there is still a 37.5% error rate in our ability to accurately diagnose appendicitis in pediatric cancer patients.

Unnecessary Operation?-Reply

In Reply .—Dr Johansen's letter regarding our article concerning HSP is of interest. I believe he is focusing more than necessary on defending the right to perform a laparotomy in which the results are negative for suspected appendicitis. The differential diagnosis of abdominal pain in children is broad, and we agree with Dr Johansen that performing an operation for persistent localized right lower quadrant pain and tenderness is certainly an accepted surgical practice. The bottom line, however, is that children with HSP rarely have localized pain. Their pain is often diffuse and out of context with the clinical findings on physical examination. Furthermore, we could find only one case report of acute appendicitis coexisting with HSP. Appendicitis therefore almost never occurs with this condition. Whether one wishes to use the term unproductive or unrevealing following a laparotomy in which the results are negative for suspected appendicitis is not the

Delayed Union of Fibular Fractures Accompanying Fractures of the Tibial Shaft

Among 440 adult patients with tibial shaft fracture and accompanying fibular fracture there were eight cases with radiographically ununited fibulae 4 months after the injury, each with uneventful tibial union. Fractures with severe soft-tissue injuries were excluded from this study. In 293 patients the treatment method of the tibial fracture was conservative, comprising closed reduction and immobilization by long plaster cast. In 147 patients it was intramedullary Küntscher nailing, and all the eight cases with delayed fibular union occurred among these, the frequency being 5.4%. The typical accompanying fibular fracture to develop delayed union was a comminuted one in the middle or distal third of the bone. At a followup examination 5 to 8 years after the original injury four of the eight fractures were found to have ultimately spontaneously united, while three showed a radiographically indisputable nonunion. One patient had undergone segmental fibular ostectomy because of persistent local pain but in the remaining patients the subjective symptoms were negligible. The occurrence of delayed fibular union in association with rigid intramedullary nailing of concomitant tibial shaft fracture is a phenomenon of which trauma surgeons should be aware even if the natural course of the condition often seems to be benign.

Chronic painful sesamoids of the thumb

In patients with persistent localized pain at the level of a sesamoid bone of the thumb not obviously related to trauma, sesamoidectomy gives excellent results. Often no X-ray or histological abnormalities are found, leaving the origin of pain problems still unsolved.

Fracture of the dorsoulnar tubercle of the trapezium

The dorsoulnar tubercle of the trapezium may fracture, and this fracture may be missed without precise physical examination and correct radiographic studies. If there is persistent localized pain and tenderness in this region and the results of routine wrist radiographic examination are normal, a bone scan should be performed. If there is localized uptake in the area of the trapezium, additional radiographic studies may be necessary to confirm or exclude this fracture. Four patients with this previously unreported fracture and a method for its detection are presented.

Spigelian Hernia: Uncommon or Unrecognized?

Spigelian hernia may be a more common clinical entity than previously recognized or reported. We report seven cases, four diagnosed and treated in the past 12 months at a large military hospital. Diagnosis can be difficult because of failure to consider it, incomplete understanding of the anatomy, and the nonpalpable intraparietal nature of the hernia. A careful history and physical examination are essential. Any patient with persistent localized pain in the proper anatomic location--just lateral to the outer border of the rectus muscle and usually below the umbilicus--warrants surgical exploration.