Prevalence of postherpetic neuralgia after a first episode of herpes zoster: prospective study with long term follow up.
(17/1061)
OBJECTIVE: To estimate the frequency, duration, and clinical importance of postherpetic neuralgia after a single episode of herpes zoster. DESIGN: Prospective cohort study with long term follow up. SETTING: Primary health care in Iceland. PARTICIPANTS: 421 patients with a single episode of herpes zoster. MAIN OUTCOME MEASURES: Age and sex distribution of patients with herpes zoster, point prevalence of postherpetic neuralgia, and severity of pain at 1, 3, 6, and 12 months and up to 7.6 years after the outbreak of zoster. RESULTS: Among patients younger than 60 years, the risk of postherpetic neuralgia three months after the start of the zoster rash was 1.8% (95% confidence interval 0.59% to 4.18%) and pain was mild in all cases. In patients 60 years and older, the risk of postherpetic neuralgia increased but the pain was usually mild or moderate. After three months severe pain was recorded in two patients older than 60 years (1.7%, 2.14% to 6.15%). After 12 months no patient reported severe pain and 14 patients (3.3%) had mild or moderate pain. Seven of these became pain free within two to seven years, and five reported mild pain and one moderate pain after 7.6 years of follow up. Sex was not a predictor of postherpetic neuralgia. Possible immunomodulating comorbidity (such as malignancy, systemic steroid use, diabetes) was present in 17 patients. CONCLUSIONS: The probability of longstanding pain of clinical importance after herpes zoster is low in an unselected population of primary care patients essentially untreated with antiviral drugs. (+info)
Gluteal neuralgia - unusual presentation in an adult with intrasacral meningocele: a case report and review of literature.
(18/1061)
A nineteen year old man with intrasacral meningocele is reported, who presented with long standing episodic gluteal pain and progressive muscle wasting. Magnetic resonance imaging established the diagnosis. Surgical excision relieved the pain but muscle wasting persisted. Pertinent literature is reviewed. (+info)
Intrathecal methylprednisolone for intractable postherpetic neuralgia.
(19/1061)
BACKGROUND: There is no effective treatment for intractable postherpetic neuralgia. Because there is evidence that postherpetic neuralgia has an inflammatory component, we assessed treatment with intrathecally administered methylprednisolone to reduce pain in patients with this disorder. METHODS: We enrolled 277 patients who had had intractable postherpetic neuralgia for at least one year, 270 of whom were followed for two years. The patients were randomly assigned to receive intrathecal methylprednisolone and lidocaine (3 ml of 3 percent lidocaine with 60 mg of methylprednisolone acetate, 89 patients), lidocaine alone (3 ml of 3 percent lidocaine, 91 patients), or no treatment (90 patients) once per week for up to four weeks. Each weekly dose was injected into the lumbar intrathecal space. Pain was evaluated before randomization, at the end of the treatment period, and then four weeks, one year, and two years later. Samples of cerebrospinal fluid were obtained for measurement of interleukin-8 before and at the end of the treatment period. RESULTS: There was minimal change in the degree of pain in the lidocaine-only and control groups during and after the treatment period. In the methylprednisolone-lidocaine group, the intensity and area of pain decreased, and the use of the nonsteroidal antiinflammatory drug diclofenac declined by more than 70 percent four weeks after the end of treatment. No complications related to intrathecal methylprednisolone were observed. Before treatment, the concentrations of interleukin-8 in the cerebrospinal fluid were inversely related to the duration of neuralgia in all the patients (r=-0.49, P<0.001). In the patients who received methylprednisolone, interleukin-8 concentrations decreased by 50 percent, and this decrease correlated with the duration of neuralgia and with the extent of global pain relief (P<0.001 for both comparisons). CONCLUSIONS: The results of this trial indicate that the intrathecal administration of methylprednisolone is an effective treatment for postherpetic neuralgia. (+info)
Herpes zoster--predicting and minimizing the impact of post-herpetic neuralgia.
(20/1061)
Herpes zoster results from reactivation of latent varicella-zoster virus in the dorsal root ganglia and is frequently associated with severe pain. Most patients suffer acute pain during the rash phase, and in many, prodromal pain or discomfort also precedes the rash. The pain of herpes zoster gradually resolves with time, but may persist after the acute disease as post-herpetic neuralgia for weeks, months or even years. Post-herpetic neuralgia, the most common complication of herpes zoster, often results in significant morbidity and healthcare resource usage. Early treatment with oral antivirals has been shown to accelerate the resolution of postherpetic neuralgia, with therapeutic effects particularly evident in the over-50 age group, where pain generally persists for longer. Progressively increasing life expectancy of the population translates to increasing numbers of cases of herpes zoster. The socio-economic gains associated with active management, including use of oral antivirals where indicated, to speed resolution of pain and post-herpetic neuralgia, readily justify additional cost. (+info)
Common infections in older adults.
(21/1061)
Infectious diseases account for one third of all deaths in people 65 years and older. Early detection is more difficult in the elderly because the typical signs and symptoms, such as fever and leukocytosis, are frequently absent. A change in mental status or decline in function may be the only presenting problem in an older patient with an infection. An estimated 90 percent of deaths resulting from pneumonia occur in people 65 years and older. Mortality resulting from influenza also occurs primarily in the elderly. Urinary tract infections are the most common cause of bacteremia in older adults. Asymptomatic bacteriuria occurs frequently in the elderly; however, antibiotic treatment does not appear to be efficacious. The recent rise of antibiotic-resistant bacteria (e.g., methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus) is a particular problem in the elderly because they are exposed to infections at higher rates in hospital and institutional settings. Treatment of colonization and active infection is problematic; strict adherence to hygiene practices is necessary to prevent the spread of resistant organisms. (+info)
Pronociceptive actions of dynorphin maintain chronic neuropathic pain.
(22/1061)
Whereas tissue injury increases spinal dynorphin expression, the functional relevance of this upregulation to persistent pain is unknown. Here, mice lacking the prodynorphin gene were studied for sensitivity to non-noxious and noxious stimuli, before and after induction of experimental neuropathic pain. Prodynorphin knock-out (KO) mice had normal responses to acute non-noxious stimuli and a mild increased sensitivity to some noxious stimuli. After spinal nerve ligation (SNL), both wild-type (WT) and KO mice demonstrated decreased thresholds to innocuous mechanical and to noxious thermal stimuli, indicating that dynorphin is not required for initiation of neuropathic pain. However, whereas neuropathic pain was sustained in WT mice, KO mice showed a return to baselines by post-SNL day 10. In WT mice, SNL upregulated lumbar dynorphin content on day 10, but not day 2, after injury. Intrathecal dynorphin antiserum reversed neuropathic pain in WT mice at post-SNL day 10 (when dynorphin was upregulated) but not on post-SNL day 2; intrathecal MK-801 reversed SNL-pain at both times. Opioid (mu, delta, and kappa) receptor density and G-protein activation were not different between WT and KO mice and were unchanged by SNL injury. The observations suggest (1) an early, dynorphin-independent phase of neuropathic pain and a later dynorphin-dependent stage, (2) that upregulated spinal dynorphin is pronociceptive and required for the maintenance of persistent neuropathic pain, and (3) that processes required for the initiation and the maintenance of the neuropathic pain state are distinct. Identification of mechanisms that maintain neuropathic pain appears important for strategies to treat neuropathic pain. (+info)
Upregulation of dorsal root ganglion (alpha)2(delta) calcium channel subunit and its correlation with allodynia in spinal nerve-injured rats.
(23/1061)
Peripheral nerve injury can lead to a persistent neuropathic pain state in which innocuous tactile stimulation elicits pain behavior (tactile allodynia). Spinal administration of the anticonvulsant gabapentin suppresses allodynia by an unknown mechanism. In vitro studies indicate that gabapentin binds to the alpha(2)delta-1 (hereafter referred to as alpha(2)delta) subunit of voltage-gated calcium channels. We hypothesized that nerve injury may result in altered alpha(2)delta subunit expression in spinal cord and dorsal root ganglia (DRGs) and that this change may play a role in neuropathic pain processing. Using a rat neuropathic pain model in which gabapentin-sensitive tactile allodynia develops after tight ligation of the left fifth and sixth lumbar spinal nerves, we found a >17-fold, time-dependent increase in alpha(2)delta subunit expression in DRGs ipsilateral to the nerve injury. Marked alpha(2)delta subunit upregulation was also evident in rats with unilateral sciatic nerve crush, but not dorsal rhizotomy, indicating a peripheral origin of the expression regulation. The increased alpha(2)delta subunit expression preceded the allodynia onset and diminished in rats recovering from tactile allodynia. RNase protection experiments indicated that the DRG alpha(2)delta regulation was at the mRNA level. In contrast, calcium channel alpha(1B) and beta(3) subunit expression was not co-upregulated with the alpha(2)delta subunit after nerve injury. These data suggest that DRG alpha(2)delta regulation may play an unique role in neuroplasticity after peripheral nerve injury that may contribute to allodynia development. (+info)
The value of MR neurography for evaluating extraspinal neuropathic leg pain: a pictorial essay.
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SUMMARY: Fifteen patients with neuropathic leg pain referable to the lumbosacral plexus or sciatic nerve underwent high-resolution MR neurography. Thirteen of the patients also underwent routine MR imaging of the lumbar segments of the spinal cord before undergoing MR neurography. Using phased-array surface coils, we performed MR neurography with T1-weighted spin-echo and fat-saturated T2-weighted fast spin-echo or fast spin-echo inversion recovery sequences, which included coronal, oblique sagittal, and/or axial views. The lumbosacral plexus and/or sciatic nerve were identified using anatomic location, fascicular morphology, and signal intensity as discriminatory criteria. None of the routine MR imaging studies of the lumbar segments of the spinal cord established the cause of the reported symptoms. Conversely, MR neurography showed a causal abnormality accounting for the clinical findings in all 15 cases. Detected anatomic abnormalities included fibrous entrapment, muscular entrapment, vascular compression, posttraumatic injury, ischemic neuropathy, neoplastic infiltration, granulomatous infiltration, neural sheath tumor, postradiation scar tissue, and hypertrophic neuropathy. (+info)