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Background: Chronic motor cortex stimulation (MCS) has been used to treat medically refractory neuropathic pain over the past 20 years. We investigated this procedure using a prospective multicentre randomized blinded crossover trial. Methods: Twelve subjects with three different neuropathic pain syndromes had placement of MCS systems after which they were randomized to receive low ("subtherapeutic") or high ("therapeutic") stimulation for 12 weeks, followed by a crossover to the other treatment group for 12 weeks. The primary outcome measure was the pain visual analogue scale (VAS). Secondary outcome measures included McGill Pain Questionnaire (MPQ), Beck Depression Inventory-II, medication log, work status, global impression of change, and SF-36 quality of life scale. Results: The trial was halted early due to lack of efficacy. One subject withdrew early due to protocol violation and five subjects withdrew early due to transient adverse events. Six subjects with upper extremity pain completed the study. There was no significant change in VAS with low or high stimulation and no significant improvement in any of the outcome measures from low to high stimulation. SF-36 role physical and mental health scores were worse with high compared to low stimulation (p = 0.024, p = 0.005). Conclusions: We failed to show that MCS is an effective treatment for refractory upper extremity neuropathic pain and suggest that previous studies may have been skewed by placebo effects, or ours by nocebo. We suggest that a healthy degree of skepticism is warranted when considering this invasive therapy for upper extremity pain syndromes.RÉSUMÉ: Stimulation du cortex moteur pour traiter la douleur neuropathique: une étude randomisée avec permutation. Contexte: La stimulation chronique du cortex moteur (SCM) a été utilisée pour traiter la douleur neuropathique réfractaire au traitement médical au cours des 20 dernières années. Nous avons étudié cette technique au moyen d'un essai prospectif multicentrique randomisé à double insu avec permutation. Méthode: Un système de SCM a été mis en place chez douze sujets atteints de trois syndromes différents de douleur neuropathique. Ils ont été assignés au hasard au groupe recevant une stimulation faible (« sous-thérapeutique ») ou élevée (« thérapeutique ») pendant 12 semaines avec permutation des groupes et traitement pendant 12 semaines additionnelles. Le critère d'évaluation primaire était le résultat obtenu à l'échelle visuelle analogue (EVA). Les critères d'évaluation secondaires comprenaient le questionnaire McGill sur la douleur, l'Inventaire de dépression de Beck II, un journal de la médication, la situation d'emploi, l'impression globale de changement et l'échelle SF-36 de qualité de vie. Résultats: L'étude a été interrompue précocement en raison du manque d'efficacité. Un sujet a été exclu tôt pour cause de non-respect du protocole et 5 sujets se sont retirés peu de temps après le début du traitement en raison d'effets indésirables passagers. Six sujets présentant de la douleu...

Occipital neuralgia is a paroxysmal jabbing pain in the distribution of the greater or lesser occipital nerves accompanied by diminished sensation in the affected area. Occipital nerve block is a common diagnostic and therapeutic tool used in the course of occipital neuralgia and is considered a safe treatment with few localized adverse events. Occipital nerve block is also indicated for cervicogenic and cluster headache and is often used as a rescue treatment for headaches not responding to conventional therapies. We describe a case of epidural abscess formation 16 days following occipital nerve block in a patient with no underlying medical conditions. This case report emphasizes the importance of strict aseptic technique to reduce infection rates in patients undergoing this procedure, despite the overall safety of occipital nerve block. Clinicians must remain aware of acute and late complications arising postprocedure for the safe practice of this technique. RÉSUMÉ La névralgie occipitale est une douleur lancinante paroxystique dans la distribution des nerfs du grand ou du petit occipital qui s'accompagne d'une diminution des sensations dans la zone affectée. Le bloc du nerf occipital, un outil diagnostique et thérapeutique communément utilisé dans le cadre d'une névralgie occipitale, est considéré comme un traitement sécuritaire qui n'entraine que peu d'effets indésirables localisés. Le bloc du nerf occipital, également indiqué pour traiter la céphalée cervicogénique et la céphalée vasculaire de Horton, est souvent utilisé en tant que traitement de secours pour les céphalées qui ne répondent pas aux thérapies conventionnelles. Nous décrivons un cas de formation d'un abcès épidural 16 jours après le bloc du nerf occipital chez un patient sans affection médicale sous-jacente. L'étude de cas met l'accent sur l'importance d'une stricte conformité aux techniques d'asepsie afin de réduire les taux d'infection chez les patients soumis à cette procédure, malgré le caractère sécuritaire du bloc du nerf occipital. Les cliniciens doivent demeurer vigilants quant aux complications aigues et tardives qui peuvent survenir après la procédure afin d'appliquer cette technique de manière sécuritaire.

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The use of prepared endotracheal tubes (PETTs) for unanticipated difficult intubation is common. However, the storage time of PETTs is highly variable and institution dependent since there is no standardized protocol. We sought to determine firstly if open, unused PETTs are a potential source of pathogenic microorganisms and secondly if PETTs can provide a medium for bacterial survival after deliberate contamination. M ME ET TH HO OD DS S An intubating stylet was inserted into a 7mm ETT and this system was ethylene oxide sterilized. The PETTs were placed in twenty different locations, including 14 operating rooms, 4 labour and delivery suites and 2 epidural carts. In phase one, the PETTs (n=20) were sampled at time zero, 24, 48 and 72 hours, and 1, 2, 3, and 4 weeks. The presence or absence of growth was determined after 48 hours incubation and the microorganism identified. For phase two, the distal end of the PETT (n=40) was swabbed with a fresh suspension of H. influenzae, P. aeruginosa, S. aureus, E. faecium or a negative control. The sampling and culturing of the PETTs was repeated as described in phase one. R RE ES SU UL LT TS S Non-virulent bacteria were cultured from 13 of 160 (8.1%) samples and from 15 of 320 (4.7%) samples in phases one and two respectively. No PETT grew the same bacteria more than once. In phase two, E. faecium was consistently recovered from the PETTs throughout the one month period. After 24 hours, the other three microorganisms were not recovered. D DI IS SC CU US SS SI IO ON N Our findings suggest that the pathogenic potential of open, unused PETTs is very low. The practice of storing PETTs as backup airway equipment for a period up to four weeks carries minimal risk of bacterial contamination. Based on this study PETTs can be safely used for up to one month. This practice could translate to significant cost reduction for operating room budgets.

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The purpose of this study was to evaluate the effects of preemptive and postlesion sympathectomy in the sciatic cryoneurolysis (SCN) model of neuropathic pain in rats. SCN in rats produces a prolonged significant mechanical allodynia (hypersensitivity to previously non-noxious mechanical stimuli) with no thermal hyperalgesia. In at least two other models, sympathectomy is effective in attenuating existing mechanical allodynia and thermal hyperalgesia or deterring their development after nerve injury. These models appear to mimic the direct sympathetic involvement characteristic of the clinical syndrome termed sympathetically maintained pain (SMP). To investigate these concepts in the SCN model, sympathectomy was performed prior to SCN in animals with established SCN-induced allodynia. Sympathectomy did not alter the pattern of existing allodynia or its development in this model. The results suggest that SCN is a useful and easily reproducible model of sympathetically independent pain (SIP).