For diagnosis of failed back syndrome (FBS), we should consider the following three points; 1) possibility of change in the pathogenesis, 2) limitations of imaging (x-ray, CT, MRI, etc) and 3) psychosomatic problems. Regarding pathogenesis, FBS is divided into three groups; 1) organic pain possible to treat by surgery, 2) organic pain impossible to treat by surgery and 3) subjective symptoms mainly affected by psychosomatic problems. Epiduroscopy may be useful to treat some kinds of FBS, especially that caused by epidural inflammation and adhesion. There are many unresolved issues regarding treatment using epiduroscopy, such as the mechanisms of therapeutic effects and clinical evidence of the outcome, however, epiduroscopy may have some value and is expected to develop further in the future.

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To explore the potential role of nitric oxide (NO) production in patients with pain, the relation between pain and serum NO production was evaluated by changes in pain reactions and serum levels of NOx before and after the nerve block in patients with herpes zoster. Twenty patients aged 68.6±4.0 (seven males and thirteen females) and diagnosed as having herpes zoster infection between C6 and L2 were enrolled in this study. The visual analogue scale (VAS) score of each patient was more than 3. The nerve block was performed by the epidural administration of 6ml of 0.375% ropivacaine. In order to acknowledge pain relief, the VAS value in each patient was recorded before, 30 and 90min after nerve blocking. A each time point, blood samples were obtained from by all patients venipuncture needling. Serum NOx levels were then assessed by a highly sensitive HPLC-UV method. Results were statistically analyzed by two-way ANOVA. (1) In all patients, the VAS value was significantly lowered 30 and 90min after nerve blocking when compared to the value obtained before nerve blocking; (2) The serum NOx level measured 90min after nerve blocking was also significantly less than that measured before nerve blocking. However, these levels in the healthy volunteers did not show any significant change. (3) By studying the three different stages of herpes zoster, such correlation between pain relief and the reduction of serum NOx levels was observed in the middle and later stages of herpes zoster, but not in the early stage. These findings indicate that the progress of the neuropathic pain relates the serum NO productions and that the measurement of serum NOx levels can be an indicator of dolorimetry.

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We investigated whether patient-controlled epidural analgesia (PCEA) with programmable maximal diluted bolus volume of bupivacaine plus fentanyl mixture has clinical advantages compared with an equivalent-dose, of an undiluted minimal mixture after gastrectomy. We randomly allocated 40 patients under general anesthesia to two groups in a randomized, double-blind study: one received a 9.9ml incremental bolus of diluted solution containing 0.051% bupivacaine and 2.53μg/ml fentanyl, and the other received a 2.5ml incremental bolus of a solution of 0.2% bupivacaine and 10μg/ml fentanyl with programmable maximal volume. We assessed analgesic efficacy and side effects. The number of deliveries for each 6h interval, the hourly drug consumption during the 48h postoperative period, and the VAS pain scales did not significantly differ between the two groups. The incidence of pruritus was significantly higher (p=0.039) in the 9.9ml group than in the 2.5ml group. The maximal diluted bolus volume of bupivacaine 5mg and fentanyl 25μg has no clinical advantages and produced a minor side effect in this post-gastrectomy PCEA regimen.

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We performed percutaneous epidural drainage and ablution for the treatment of an idiopathic epidural abscess.
A healthy 17-year-old man consulted our hospital with a chief complaint of severe back pain and fever. Magnetic resonance imaging study showed a thoracic epidural abscess.
The patient had no apparent infectious site as the source of the abscess nor immunological deficiency as the background. We performed percutaneous drainage and ablution with an epidural needle and yellowish pus was drained. Staphylococcus aureus was detected as the pathogen. Antibiotic therapy was administered after drainage. The epidural abscess had disappeared on magnetic resonance imaging study performed 10 days after percutaneous drainage.
This case may suggest that percutaneous drainage and ablution is indicated for the early phase of epidural abscess without neurological complications.

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Antipsychotic drugs are sometimes necessary as a adjuvant analgesic for patients with intractable chronic pain. We report 3 cases in which improvements in QOL, previously reduced by pain, were seen following the use of quetiapine fumarate, an atypical antipsychotic. Quetiapine fumarate is a serotonin dopamine antagonist that has both antiserotonin and antidopaminergic actions, and is presumed to improve both positive (delusion, agitation) and negative (apathy, reduced thinking, hypobulia) symptoms. The degree of pain was reduced in only one of the patients; therefore, the direct analgesic effect remains unknown. However, from our results, we consider that the QOL could be improved by the use of quetiapine fumarate through amelioration of such symptoms as nocturnal unrest and low level of motivation to live in patients with intractable chronic pain.

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A 58-year-old man had herpetic zoster pain in the right Th 7-9 dermatomes. He had a history of leukemia and had undergone peripheral blood stem cell transplantation 9 months prior to the onset of zoster symptoms. He was admitted to our hospital and treated by patient-controlled epidural analgesia (PCEA). After 10 days, myositis appeared and PCEA was discontinued. The herpetic pain was controlled by iontophoresis of ropivacaine for 40 days till he was diagnosed as having chronic GVHD and recovered from it.

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A 38-year-old male, 168cm tall, weighing 124kg, and a 51-year-old male weighing 75kg with severe atrophy of the lower extremities after poliomyelitis in infancy were scheduled for perianal fistulectomy. Extreme obesity obscured the usual landmarks of the lumbar vertebral bones and the iliac crest. Subarachnoidal punctures with an 89mm needle from an estimated median line, as well as a paramedian line, were unsuccessful. For caudal epidural anesthesia, no sacro-coccygeal bones were palpable. The landmarks were eventually obtained by trans-anal digital palpation. In contrast to the external morphology of obesity, the pre-sacro-coccygeal region was relatively free of excessive tissue. The contours of the sacro-coccygeal bones were felt easily with the finger tip through the rectal wall. A successful puncture via the sacro-coccygeal ligament was made for epidural anesthesia using these internal landmarks. Pain-clinicians and anesthesiologists can benefit from occasional trans-anal digital exams to refresh their approach to caudal anesthesia.

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Nerve block for a patient with a bleeding disorder should be performed with caution due to the risks of bleeding and hematoma formation. We report a case of successful management of lumbar sympathetic ganglion block for a patient with von Willebrand's disease.
A 68-year-old man with von Willebrand's disease consulted our pain clinic complaining of pain and numbness in lower limbs due to spinal canal stenosis. Because conservative therapies were not effective, the patient consented to undergo a lumbar sympathetic ganglion block after being informed about possible complications.
Supplementary therapy with coagulation factors (combined factor VIII and vW factor concentrate) was planned to maintain coagulability during the nerve block. A pilot study was performed prior to the block to investigate the pharmacokinetics of the coagulation factors. The pilot study revealed that, administration of 5, 000IU of combined factor VIII-vW factor concentrate induced adequate coagulability within one hour, and this effect continued for 6 hours. One hour before the block, 5, 000IU of combined factor VIII-vW factor concentrate was administered, and right-sided lumbar sympathetic ganglion block was performed under radiographic control. After the block, three further doses of 5, 000IU of combined factor VIII-vW factor concentrate were administered at 6 hourly intervals. The patient's recovery was uneventful and he was discharged one day after the block without major complaints.
The present case showed that the lumbar sympathetic ganglion block is feasible for a patient with von Willebrand's disease using supplementary therapy with coagulation factors.

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Acute lumbar pain in should be carefully examined detect early stage infectious disease of the joints or spine. Here we report two cases. The first patient, a 57-year-old woman with diabetes mellitus had pyogenic sacroilliac arthritis, and she initially complained of focal lumbar pain, that was aggravated by percussion in a fit of coughing. The second patient who also complained of focal lumbar pain aggravated by percussion, was a 46-year-old man who had pyogenic discitis, with severe pulmonary and urinary infections.
The prevailing clinical symptom of infectious disease included focal pain, fever and leukocytosis. In particular, focal pain that was aggravated by percussion was the most important symptom to suspect infection of the spine. In order to observe these clinical signs, we must carefully perform hematological and radiological examinations as soon as possible. While bone scintigraphy was a possible examination for pyogenic sacroilliac arthritis, magnetic resonance imaging (MRI) was also an available examination for pyogenic discitis in the two patients reported.

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Trigeminal neuralgia and glossopharygeal neuralgia include severe paroxysmal pains. Carbamazepine is used for treatment of these disorders, but has many side effects and the efficacy may decline over time.
A 65-year-old male with severe pain of trigeminal neuralgia (VAS=100mm) experienced a general eruption due to a side effect of carbamazepine. We prescribed baclofen (10mg/day) for the pain. After increasing baclofen to 15mg/day, the pain disappeared completely.
A 76-year-old male was diagnosed as having glossopharyngeal neuralgia from left pharyngeal pain on swallowing and the efficacy of nerve block by topical application of local anesthetic. The combined treatment with carbamazepine and repetitive nerve block using local anesthetics was not effective for pain relief (VAS=96mm). Baclofen was started from 15mg/day in addition to carbamazepine and herbal medicine. After increasing baclofen to 20mg/day, the pain was reduced to VAS 36mm.
Baclofen was effective to treat pain caused by trigeminal neuralgia and glossopharyngeal neuralgia.

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Percutaneous vertebroplasty is a procedure in which bone cement is injected into a fractured vertebral body in an attempt to stabilize fractured segments and alleviate pain. During this procedure, leakage of bone cement outside the vertebral body should be avoided. We experienced epidural leakage of bone cement upward from the injection level in a case guided by fluoroscopic CT to treat a Th6 spinal lesion caused by metastases. During the procedure, we did not notice bone cement leakage outside the vertebra within the region visible by CT. During percutaneous vertebroplasty guided by fluoroscopic CT, we must considered the possibility of bone cement leakage beyond the region visible by CT.

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