All posts by Nadia

Laminectomy

A lumbar laminectomy, or lumbar decompression, is performed to treat spinal stenosis, a narrowing of the spinal canal that puts pressure on the nerves in the lower back, which causes symptoms in nearly 500,000 Americans over the age of 50. Used to manage related conditions involving deformities of the vertebrae, such as spondylolisthesis or scoliosis, a transforaminal lumbar interbody fusion (TLIF) is an innovative, sometimes safer, more efficient alternative to other anterior and posterior-approach fusion procedures. Both conditions cause pain and weakness in the lower back and legs, leading to walking difficulty in many patients. The conditions occur as people age because ligaments around the spine thicken and the discs, or cushions, between the vertebrae start to deteriorate.

During the surgery, an incision will be made in the patient’s back, but surgeons will approach the spine from the side, minimizing the nerve manipulation required to access the vertebrae, discs and nerves. They will remove bone and ligament from the spine to open the spinal canal and relieve pressure on the nerve roots which has been caused by stenosis.

Next, the surgeons will perform a TLIF to fuse the spine where one vertebra has slipped forward onto the vertebra below it. (This generally occurs with spondylolisthesis, but in the case of the webcast patient it has been caused by complications from scoliosis.) Some vertebral bone will be removed to reduce nerve exposure, and then the pain-causing disc will be taken out. A spacer and bone from the patient’s extracted vertebra will then be manipulated to fuse the two surrounding vertebrae together. Finally, rods and screws will be put in place to support the spine over the next several months as bone generates and connects to the vertebra.

Most patients are out of bed and walking the morning after surgery, and typically spend three to five days in the hospital. After discharge, they require three to six months of outpatient rehabilitation, but are able to care for themselves at home with the exception of heavy lifting. Generally after six months, patients are able to do any type of activity excluding those that pose high physical risk

Loin Pain Hematuria Syndrome (LPHS)

Loin Pain Hematuria Syndrome (LPHS) is an extremely rare disease, where there is unexplained flank pain and Haematuria. Often misdiagnosed as a hypermobile kidney has the same symptoms. This is poorly understood condition for which specific diagnostic criteria are lacking.

Here are some facts about LPHS:

  • LPHS was first identified in England in 1967 among women who were taking birth control pills.
  • Approximately 90% of the reported cases of LPHS are female.
  • LPHS was first noted in men in the 1980’s.
  • LPHS was first noted in the USA in the 1980’s.
  • The first renal autotransplatation for LPHS was done in 1982.
  • Cases of LPHS have been reported from England, Canada, USA, India, Australia, Ireland, Scotland and Germany.
  • The age range for LPHS is from 6 to 50 years.
  • There are approximately 200 cases of LPHS in the world; no doubt, there are more undocumentated cases.
  • Pain attacks due to LPHS can occur several times per week, every few weeks, or every few months. These pain attacks can last from hours to weeks.

    Here are some guidelines to help you decide if you think you need to investigate this problem with your doctor.

  • The condition is mainly characterized by intractable pain involving the kidney and abdominal areas.
  • Microscopic blood or blatantly obvious amounts of it can be seen in the urine. Clot retention can also occur.
  • It is extremely important that physicians recognize the need for adequate pain medication for this disorder.
  • Forcing fluids by mouth or I.V. are very helpful in decreasing the hematuria and in reducing the risk of clot retention.
  • Be prepared to see several doctors and yield to psychiatric exams before you get a correct diagnosis. This is common with any disease that is not common, such as diabetes. LPHS has only been diagnosed in a few hundred people around the entire world, so this is one disease that is not likely to pop into a physician’s head.

    related articles

    Department of Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia. agrs@liver.rpa.cs.nsw.gov.au

    Some patients with the loin pain/hematuria syndrome suffer incapacitating flank pain. No effective therapy has been reported. Uncertainty persists concerning the authenticity of the pain and the role of surgery in treatment.

    Forty-six patients with loin pain/hematuria syndrome and intractable pain were evaluated following treatment either by renal autotransplantation (30 patients, 10 bilaterally) or by renal denervation (20 patients, four bilaterally) over a 13-year period.

    All patients had concomitant renal nerve excision and ligation and capsulotomy. There were 37 (80%) women and nine men aged 18 to 61 years (mean age, 33 years).

    Excretion urography and angiography were normal in all patients. Nineteen of 25 (76%) patients in whom renal autotransplantation was successfully accomplished and who completed a follow-up questionnaire were free of pain, including eight of 10 with bilateral procedures.

    The follow-up periods ranged from 1 to 13 years (mean, 8.4 years). Six patients have been free of pain for 10 to 13 years.

    Of 18 patients treated with renal neurectomy who were available for follow-up examination, 12 (67%) developed recurrent renal pain, including four who had pain relief on the other side following previous renal autotransplantation.

    The follow-up period for these patients ranged from 6 to 9.9 years (mean, 8.0 years). Three of four patients with recurrent renal pain following neurectomy were treated successfully by renal autotransplantation.

    The loin pain/hematuria syndrome is a rare cause of incapacitation, predominantly of relatively young females. The pain of the syndrome is organic.

    Renal autotransplantation achieves pain relief in three quarters of patients, but the procedure is often (30%) required bilaterally and has significant complications.

    Renal neurectomy is followed by an excessive incidence of recurrent renal pain.


    What is Loin Pain Hematuria Syndrome?

    by Marc F. Brazie, MD
    Division of Nephrology
    University of Maryland Medical Center, Baltimore, MD

    What is Loin Pain Hematuria Syndrome (LPHS)?

    LPHS is a rare kidney disorder causing attacks of severe flank pain and blood in the urine.

    Who gets LPHS?

    LPHS was first reported in three patients in 1967 who were found to have recurrent attacks of severe flank pain and blood in the urine (hematuria) in whom no other explanation could be found [2]. Since that time, it has been reported in several hundred people worldwide, although it is likely that there are many more unreported cases. It is more common in women (70% of all cases) [3-5], and has been seen mostly in the United States, Great Britain, Australia, and Canada, suggesting a white predominance. While it can start at almost any age, most patients will first develop symptoms in their 20’s [6].

    How do I know if I have LPHS?

    The predominant features of LPHS are recurrent flank pain and blood in the urine. The pain can occur on only one side or both, and may radiate to the abdomen, groin, or inner thigh. Pain episodes may be associated with low-grade fevers and a burning discomfort with urination. The blood in the urine may be overt (called “macroscopic hematuria”), or only detectible on a urine dipstick test or by examining the urine through a microscope (called “microscopic hematuria”). Up to 47% of patients with LPHS also have a history of kidney stones [7], but stones must be absent during pain episodes for LPHS to be diagnosed.

    What causes LPHS?

    As LPHS is a rare disorder, not much is known about the underlying causes. It is thought that there may be a problem with the glomerular basement membrane (GBM), which is the blood “filter” in the kidney, causing bleeding into the kidney tubules. These tubules can then become blocked by the blood cells, causing swelling and increased pressure in the kidney. This in turn leads to stretching of the outer layer of the kidney, called the “capsule,” and pain. Indeed, studies examining biopsies of patients thought to have LPHS have shown that in over 50% of patients, the GBM is abnormally thick or thin [7].

    What should I do if I think I might have LPHS?

    There are many disorders that can cause flank pain and blood in the urine, and as there is no specific test to confirm LPHS, it is considered a diagnosis of exclusion. It is very important to have a thorough evaluation by a kidney doctor (nephrologist) to be sure there is no other cause for the symptoms. This evaluation may involve laboratory tests, radiology studies, or even a kidney biopsy.

    What can be done for LPHS?

    Again, as LPHS is a rare disorder, it is not clear what the optimal treatment is. What is known is that patients with LPHS tend to have normal kidney function, which does not deteriorate over time. Thus, treatment is aimed at pain control and improvement in quality of life. Multiple therapies have been tried, all with mixed results. These include:
    • Medications such at angiotensin-converting enzyme inhibitors (a family of blood pressure medicines which reduce the pressure in the kidney and have been shown to be of benefit to some patients [8]), non-steroidal anti-inflammatory drugs (such as ibuprofen, naproxen, or ketorolac), and narcotic pain medications.
    • Nerve block procedures to decrease the pain signal from the effected kidney, and
    • Surgery to strip the nerves from the kidney, “autotransplant” the kidney (in which it is removed from its normal position and reinserted in the lower abdomen – this has been shown to relieve pain in up to 70% of patient in some reports [3,4]), or in extreme cases, remove the kidney altogether.

    It is best to discuss all the treatment options with your doctor, and ideally as part of a “multidisciplinary” approach involving primary care doctors, nephrologists, psychiatrists, and chronic pain specialists.


    References
    1. Dube GK, Hamilton SE, Ratner LE, Nasr SH, Radhakrishnan J. Loin pain hematuria syndrome. Kidney Int. 2006; 70: 2152-2155.
    2. Little PJ, Sloper JS, deWardener HE. A syndrome of loin pain and haematuria associated with disease of peripheral renal arteries. Q J Med. 1967; 36: 253-259.
    3. Sheil AG, Chui AK, Verran DJ et al. Evaluation of the loin pain/hematuria syndrome treated by renal autotransplantation or radical renal neurectomy. Am J Kidney Dis. 1998; 32: 215-220.
    4. Chin JL, Kloth D, Paulter SE, Mulligan M. Renal autotransplantation for the loin pain-hematuria syndrome: long-term followup of 26 cases. J Urol. 1998; 160: 1232-1235.
    5. Greenwell TJ, Peters JL, Neild GH, Shah PJ. The outcome of renal denervation for managing loin pain haematuria syndrome. BJU Int. 2004; 93: 818-821.
    6. Weisberg LS, Bloom PB, Simmons RL, Viner ED. Loin pain hematuria syndrome. Am J Nephrol. 1993; 13: 229-237.
    7. Spetie DN, Nadasdy T, Nadasdy G, et al. Proposed pathogenesis of idiopathic loin pain-hematuria syndrome. Am J Kidney Dis. 2006; 47: 419-427.
    8. Hebert LA, Betts JA, Sedmak DD, et al. Loin pain-hematuria syndrome associated with thin glomerular basement membrane disease and hemorrhage into renal tubules. Kidney Int. 1996; 49: 168-173.

  • Oxytrex – better than oxycodone?

    Pain Therapeutics said it would start testing Oxytrex in the second half of 2007, enrolling into the “Extreme Study” about 120 patients who depend on large daily doses of oxycodone — or doses greater than or equal to 120 mg — to treat severe chronic pain, whom the company said are particularly prone to physical dependence and withdrawal.

    There is reason to believe that Oxytrex will produce greater analgesia, while producing lower levels of tolerance and dependence, than oxycodone.


    Pain Therapeutics website.

    About Oxytrex from Pain Therapeutics, Inc.

    “Oxytrex is a unique oral painkiller that preferentially inhibits an excitatory effect of opioid receptors. This excitatory effect is believed to counteract analgesia (pain relief) and cause tolerance. Its inhibition enhances pain relief and minimizes opioid tolerance. We believe Oxytrex represents the first new mechanism of action by an opiate drug since morphine was discovered over 100 years ago.

    We are developing Oxytrex to treat moderate-to-severe chronic pain, such as osteoarthritic pain or low-back pain. We believe Oxytrex could be an effective substitute for oxycodone, a leading opioid painkiller, with U.S. sales of nearly $2 billion for the 12-months ending August 2005, according to IMS Health data.”

    OH – The Pelvic Pain Specialty Center

    The Pelvic Pain Specialty Center is located on the Akron City Hospital Campus at 75 Arch Street, Suite 101, and can be contacted at (330) 762-0954. www.summahealth.org

    Approximately 20 Percent of Women Affected by Chronic Pelvic Pain

    Summa Health System recently became one of the few healthcare providers in the U.S. to offer a program dedicated to the treatment of chronic pelvic pain when its Women’s Health Services opened a Pelvic Pain Specialty Center (PPSC). The PPSC offers a multidisciplinary team of gynecology, psychiatry and traumatic stress specialists in an evidence-based approach to the assessment and treatment of pelvic pain, which affects approximately 15 – 20 percent of all women.

    Chronic pelvic pain in women is defined as pain either starting in or projecting to the pelvis for at least six months, although some women suffer with the disorder for much longer periods of time. The chronic pelvic pain can include depression, pain before during or after menstruation, pain associated with sexual intercourse, pain before, during or after urination, difficulties passing stool and pain syndromes such as fibromyalgia.

    “The creation of the center is significant because it provides a true multidisciplinary approach to treatment and offers real options for women affected by chronic pelvic pain,” said Bradford Fenton, M.D.,Ph.D., medical director of the PPSC. “Research shows treatment through a multidisciplinary approach is significantly more effective than treatment without a pelvic pain center.”

    Summa’s PPSC evaluates its patients through the use of a validated survey instrument, a complete physical examination with pain mapping, laboratory and imaging studies and a mental health examination. Individual treatment plans are developed following completion of the comprehensive examination, ranging from treatment of a disorder of pain processing and pain perception to surgery for things such as endometriosis, fibroids or adhesions.

    As part of the Summa Minimally Invasive Surgery Center, the PPSC is able to offer patients with complex surgical needs the very latest in advanced laparoscopic techniques. Since many patients with endometriosis or adhesions have undergone multiple surgeries in an attempt to relieve their symptoms, the availability of advanced minimally invasive surgery offers them an opportunity to avoid open surgery and return to a normal lifestyle more quickly.

    Prialt

    PRIALT (Ziconotide Intrathecal Infusion) for Severe Chronic Pain in patients for whom intrathecal (IT) therapy is warranted, and who are intolerant of or refractory to other treatment, such as systemic analgesics, adjunctive therapies or IT morphine.

    PRIALT is a Novel Non-Narcotic Treatment Based on Marine Snail Peptide Blocks Pain Signals.

    PRIALT(R) is Approved for use only in the Medtronic SynchroMed(R) EL, SynchroMed(R) II Infusion System and Simms Deltec Cadd Micro(R) External Microinfusion Device and Catheter.

    Prialt selectively blocks the nerve channels responsible for transmitting pain signals. This drug is part of a new class known as N-type calcium channel blockers. It is known chemically as ziconotide.

    Prialt has been studied in patients with cancer, AIDS and other chronic pain, such as back pain. More than 1,200 patients took part in three clinical trials.

    There are side effects, and the FDA is including a “black box” warning – the government’s strongest warning short of a ban. The four most frequently reported adverse events associated with PRIALT were dizziness, nausea, confusion, and headache. When PRIALT was used with an external pump, there was a higher incidence of meningitis.

    PRIALT has been evaluated as an IT infusion in more that 1,200 patients participating in chronic pain trials. The longest treatment duration to date is more than seven years. Severe psychiatric symptoms and neurological impairment may occur during treatment with PRIALT. Patients with a pre-existing history of psychosis should not be treated with PRIALT. All patients should be monitored frequently for evidence of cognitive impairment, hallucinations, or changes in mood or consciousness. PRIALT therapy can be interrupted or discontinued abruptly without evidence of withdrawal effects in the event of serious neurological or psychiatric signs or symptoms.

    The idea for the drug came from a snail called the Conus magus that lives in the South Pacific, which paralyzes its victims with venom after capturing them, the company said. Researchers set out learning how to develop a drug based on this venom and eventually copied the amino acid sequence.

    http://www.elan.com/

    Information on drugs that can and do cause dystonia

    A person with medication induced dystonia.
    Every now and then folks ask me to list the list of meds that can and do cause drug-induced movement disorders. This is to educate you, if you are concerned about the side effects of a drug you are currently taking, speak up, talk with your doctor. If you are starting a new one, you will be the only one to investigate it. Arm yourself with knowledge. Be an informed consumer. Listen to that little voice in your head, and be in tune with your body.

    Remember, this is YOUR body. You have the right to ask questions and ultimately decide if a med is right for you. Please know that this list is limited and does NOT include all of them…for eg. Risperdal is not on it, but it does cause it. If I can help in any way with questions about this list or my other post, ask away.

    *By the way, it does not take extended lengths of time taking these medications in order to experience acute dystonic reactions…for lots of folks, ONE pill is all it takes!

    This drug list page is intended to provide information only! We do not advocate any particular treatment option. Therefore, it is strongly urged that patients do not change their method of treatment without first consulting with their physician.

    INFORMATION ON DRUGS THAT CAN AND DO CAUSE DYSTONIA

    “Some drugs in the neuroleptic category (psychiatric drugs) may cause acute dystonic reactions: thorazine, Haldol, etc. Ten to twenty percent of patients experience acute dystonic symptoms at the initiation on treatment. Some drugs that are used for nausea and gastrointestinal problems are also neuroleptic so they can cause the same problems – drugs like Reglan and Stematil. These can induce acute dystonia. All of these drugs, when they’re used over long term, carry a 20 to 30 % risk of long-term abnormal movements called tardive dyskinesia, and some people with tardive dyskinesia get a form of dystonia, called tardive dystonia. It’s an extremely difficult problem to treat.”

    “Alcohol is a recognized precipitant of paroxysmal dystonia, which is a very uncommon form. On the whole, alcohol in moderation does not have an adverse effect. There is an alcohol-responsive myoclonic dystonia, which responds very well to alcohol. People who chronically abuse alcohol can get a series of involuntary movements-tremors, Parkinsonism, and tardive dyskinesia. So chronic heavy alcohol intake is still not being recommended.”

    Drug Induced Dystonic Reactions:

    Certain drugs have been implicated as causing dystonic reactions or dystonia. These agents are not routinely the cause of SD, but can potentiate or aggravate the preexisting disorder. The following is a listing of the drugs which have been reported OR have the potential to cause dystonic reactions. Whenever possible, dystonia patients should avoid the following agents, except at the recommendation of a physician knowledgeable in the treatment of dystonia.


    GENERIC NAME TRADE NAME CLASSIFICATION
    alprazolam Xanax Antianxiety agent
    amitriptyline Elavil, Endep antidepressant
    amoxapine Asendin antidepressant
    benzquinamide Emete-Con anti-nausea/vomiting agent
    bupropion Wellbutrin antidepressant
    buspirone Buspar antianxiety
    carbamazepine Tegretol anticonvulsant
    chlorprothizene Taractan neuroleptic
    chlorpromazine Thorazine neuroleptic
    clomipramine Anafranil antidepressant
    clozapine Clozaril neuroleptic
    desipramine Norpramin antidepressant
    diphenhydramine Benadryl antihistamine (Increases the
    effect of other pain medications)
    doxepin Adapin, Sinequan antidepressant
    droperido Innovar antianxiety; anesthetic adjunct
    fluoxetine Prozac antidepressant
    fluphenazine Prolixin neuroleptic
    haloperidol Haldol neuroleptic
    imipramine Tofranil antidepressant
    levodopa Larodopa, Sinemet antiparkinson agent
    lithium Eskalith, Lithobid antimanic agent
    loxapine Loxitane neuroleptic
    mesoridazine Serentil neuroleptic
    metoclopramide Reglan gastrointestinal motility stimulant;
    anti-nausea/vomiting agent
    midazolam Versed induction anesthetic agent
    molindone Moban neuroleptic
    nortripyline Aventyl, Pamelor antidepressant
    perhenazine Trilafon neuroleptic
    phenytoin Dilantin anticonvulsant
    pimozide Orap neuroleptic
    prochlorperazine Compazine anti-nausea/vomiting agent
    promazine Sparine neuroleptic
    promethazine Phenergan antihistamine
    protriptyline Vivactil antidepressant
    thiethylperazine Torecan anti-nausea/vomiting agent
    thiothixene Navane neuroleptic
    trifluoperazine Stelazine neuroleptic
    triflupromazine Vesprin neuroleptic
    thioridazine Mellaril neuroleptic
    trazadone Desyrel antidepressant
    trifluoperazine Stelazine neuroleptic
    trimipramine Surmontil antidepressant
    verapamil Calan, Isoptin antianginal, antihypertensive

    Dopamine antagonists which are generally used to treat psychotic disorders and have been reported to make dystonia worse, should be used with caution. They include phenothiazine, haloperidol, tetrabenazine and pimozide. These drugs are usually avoided in the treatment of one with dystonia due to the potential to worsen dystonia. But in some cases they may be useful. It is important that the doctor prescribing these types of drugs be familiar with dystonia.

    More information on drugs that can and do cause dystonia: www.wemove.org



    This message was posted on MGH Message Board by hilltopok

    If you would like more information about tardive syndromes and the drugs that cause them, contact her at hilltopok@msn.com or visit her website at tardivedystonia.org Remember, you could be the one to save another from a life-long painful disorder. Please educate, then pass it along. Thanks so much!