Greater trochanteric pain syndrome (GTPS) is a term used to describe chronic pain overlying the lateral aspect of the hip. This regional pain syndrome, once described as trochanteric bursitis, often mimics pain generated from other sources, including, but not limited to myofascial pain, degenerative joint disease, and spinal pathology. The incidence of greater trochanteric pain is reported to be approximately 1.8 patients per 1000 per year with the prevalence being higher in women, and patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity. Symptoms of GTPS consist of persistent pain in the lateral hip radiating along the lateral aspect of the thigh to the knee and occasionally below the knee and/or buttock. Physical examination reveals point tenderness in the posterolateral area of the greater trochanter. Most cases of GTPS are self-limited with conservative measures, such as physical therapy, weight loss, nonsteroidal antiinflammatory drugs and behavior modification, providing resolution of symptoms. Other treatment modalities include bursa or lateral hip injections performed with corticosteroid and local anesthetic. More invasive surgical interventions have anecdotally been reported to provide pain relief when conservative treatment modalities fail.

Background and Objectives-Previous studies have concluded that transforaminal epidural steroid injections (ESIs) are more effective than interlaminar injections in the treatment of radiculopathies due to lumbar intervertebral disk herniation. There are no published studies examining the depth of epidural space using a transforaminal approach. We investigated the relationship between body mass index (BMI) and the depth of the epidural space during lumbar transforaminal ESIs.

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INTRATHECAL drug delivery systems are frequently used to treat chronic pain and spasticity conditions. One of the first clinical uses of an implantable intrathecal opioid delivery device occurred in 1981 for the management of chronic malignant pain, 1 although trials of opioids for intractable cancer pain began with Wang in 1979.2 Initially utilized as a means of pain amelioration in cancer patients, intrathecal therapy now has indications that have expanded to include nonmalignant chronic pain conditions.3-6 Opioids are often utilized as an infusion agent, with the principal advantage of intrathecal delivery near the site of action within the central nervous system, increasing the therapeutic efficacy, and thus reducing the likelihood of side effects associated with other delivery modalities. The implementation of intrathecal drug delivery systems has shown efficacy in many pain states, 7,8 but complications or adverse effects may arise. Aprili et al., in a recent systematic review and metaanalysis, examined the potential risks of intrathecal catheters in cancer patients and reported rates of 2.3% (95% CI, 0.8 -6.1) and 1.4% (95% CI, 0.5-3.8) for superficial and deep infections, respectively; bleeding was found to be 0.9% (95% CI, 0 -2.0) and neurologic injury 0.4% (95% CI, 0 -1.0). 9The most significant adverse event of mortality can be associated with intrathecal opioids, and mortality rates have been reported of 0.088% at 3 days after implantation, 0.39% at 1 month, and 3.89% at 1 yr, a higher mortality rate than after spinal cord stimulation implants or after lumbar discectomy in community hospitals. 10 The purpose of presenting this case is to highlight key points essential for the diagnosis and treatment of intrathecal granulomatous masses and the vigilance required by physicians managing patients with intrathecal drug delivery systems. Case ReportA 38-yr-old female registered nurse presented to the pain medicine clinic for continued management of her chronic thoracic spine pain and possible malfunction of her intrathecal drug delivery system. The patient's past medical history was significant for depression, anterior cervical discectomy with fusion, and a SynchroMed EL Infusion Pump (Medtronic Neurologic, Minneapolis, MN) placement for chronic pain related to T4 and T5 vertebral hemangiomas. The intrathecal pump was placed 9 months before her initial visit in our clinic. She was previously evaluated by multiple pain medicine specialists, with failure to attenuate her pain complaint. Upon initial evaluation she was receiving 40 mg/ day of intrathecal morphine at a concentration of 50 mg/ml. At implantation she began therapy at 10 mg/day (20 mg/ml) but escalated to 40 mg/day. The high concentration, daily dose, and lack of analgesia prompted further evaluation of the system, which included cannulation of the catheter access port to evaluate patency of the intrathecal catheter. A lack of cerebral spinal fluid back-flow necessitated further evaluation, which included a catheter-access-port myelogram showing ...

Pneumocephalus may occur after inadvertent injection of air into the subarachnoid space while performing epidural anesthesia using a loss-of-resistance technique with air in the syringe. We report a case of pneumocephalus after an interlaminar epidural steroid injection using the loss-of-resistance to air technique. In this report, we examine the etiology, the expected course of symptoms, and resolution, as well as treatment, of pneumocephalus following a systematic literature review.

We report a case of catheter obstruction due to complete narrowing of the lumen of a connecting pin, and catheter disconnection in a patient undergoing intrathecal Baclofen pump exchange. The patient underwent intrathecal baclofen pump implantation for treatment of lower extremity spasticity and hypertonia secondary to congenital tetraplegia. Intrathecal baclofen dose escalation occurred over the course of treatment (73 mo) from 80 to 708 mcg/d representing a 189% increase in dose. The pump had neared the manufacturer's recommended exchange interval; therefore, a pump exchange was scheduled to surgically replace the device. One week before surgery, the patient noted a distinct increase in his symptomatology and began enteral baclofen therapy. During the surgery, the pump catheter was noted to be disconnected from the pump. Upon further examination, the lumen of the connection pin positioned between the pump catheter and intrathecal catheter was completely obstructed. Postsurgically, the patient's intrathecal baclofen dose was substantially reduced from 708 to 527 mcg/d (25.6% reduction) to control hypotonicity and to reestablish an Ashworth score of 2. We discuss intrathecal baclofen therapy and a unique complication associated with a catheter connecting pin.

Patients with a lateral lumbar shift are often managed with a frontal plane, manual correction first described by McKenzie. However, there is a subset of patients that require a frontal plane correction who do not demonstrate a lateral shift. Both of these patient groups have what is termed a relevant lateral component (RLC). The subset of patients who have an RLC, without a shift, has received very little attention in the literature to date. This case report describes a patient with no shift who had a remarkable disc extrusion identified by magnetic resonance imaging (MRI). The patient responded nicely to a combination of frontal and transverse plane loading strategies in six treatments using the mechanical diagnosis and treatment (MDT) evaluation and treatment system. The case report is unique in the literature in that it describes a patient with no apparent frontal plane, lumbar deformity that had documented evidence of a large disc extrusion and who responded to a variation of McKenzie's flexion-rotation mobilization. The centralization phenomenon was demonstrated immediately when a non-weight bearing, multiplanar, loading strategy was administered.

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