Myofascial Pain Syndrome Affecting the Piriformis and the Obturator Internus Muscle

Abstract:   The obturator internus muscle is an external rotator of the hip. Obturator internus injury may occur and be hidden by the piriformis syndrome. Clinical symptoms may offer some clues to the clinician. The selective injection technique described here facilitates precise diagnosis.     

Changes in Quality of Life after 3 months of Usual Care in a Large Sample of Patients with Noncancer Pain: The “QOOL: Quality of Life and Pain” Study

Large‐scale observational studies can provide useful information on changes in health outcomes over time. The aim of this study was to investigate the effect of 3 months of usual care on quality of life (QOL) and pain outcomes in noncancer chronic pain patients managed by pain specialists and to examine factors associated with changes in QOL. This was assessed using the EQ‐5D and pain outcomes using the Brief Pain Inventory (BPI). Changes in QOL and pain were studied for the overall sample and in subgroups defined by baseline pain severity. Multivariate regression was used to investigate factors associated with change on EQ‐5D. Three thousand and twenty‐nine patients were included for analysis. After 3 months of usual care, a mean of 40.9% of patients showed improvement on individual EQ‐5D dimensions, with the highest rates of improvement seen on the pain/discomfort (50.8%) and anxiety/depression (48.3%) dimensions. The EQ‐5D Index increased from a mean (SD) of 0.35 (0.2) to 0.58 (0.21) points between baseline and month 3, and the thermometer from 41.5 (19.4) to 58.7 (17.8), indicating a large effect. Improvements in QOL were larger in those with severe baseline pain. The BPI severity summary score improved from a mean (SD) of 6.5 (1.4) to 4.1 (1.7) and the interference summary score from 6.6 (1.5) to 4.2 (1.9). Changes on the BPI severity and interference scores were associated with changes in the EQ‐5D Index and thermometer. In conclusion, 3 months of usual care in noncancer pain patients led to substantial improvements in QOL and pain outcomes.     

Unintentional Cervical Dural Tap Treated with Lumbar Blood Patch

Cervical radicular pain presents itself as pain radiating from the neck to the arm. If conservative treatment fails, a cervical epidural steroid injection can be considered. A rare but possible complication resulting from the interlaminar approach is unintentional cervical dural puncture that may result in post‐dural puncture headache (PDPH). Dural puncture from an interlaminar cervical epidural injection reportedly range from 0.25% to 2.65%. An epidural blood patch is a possible treatment option when conservative treatment fails. Relief could be secondary to ‘sealing’ of the dural tear from the clotted blood and reestablishment of physiological intracranial pressure. Another theory is an increase in the subarachnoid pressure from the injected blood. The increased pressure may restore normal intracranial pressure. We describe 2 cases of cervical PDPH treated with lumbar epidural blood patch. In 1 case, there was complete resolution of the symptoms and in the other case, there was great improvement of symptoms and a high thoracic blood patch was performed to resolve the remaining headache.     

Ultrasound‐guided Prolotherapy with Polydeoxyribonucleotide Sodium in Ischiofemoral Impingement Syndrome

Ischiofemoral impingement syndrome is an uncommon disorder defined by hip pain caused by the narrowing of the space between the ischial tuberosity and lesser trochanter with associated entrapment of the quadratus femoris muscle. We effectively treated two male patients using ultrasound‐guided prolotherapy with polydeoxyribonucleotide sodium mixed with local anesthetics. A 24‐year‐old male patient with no history of trauma or surgery complained of bilateral hip and groin pain; magnetic resonance imaging demonstrated slight narrowing of the bilateral ischiofemoral spaces with mild enhancement of the left quadratus femoris muscle. A 23‐year‐old male patient with a history of iliotibial band release and iliopsoas tendon release complained of left hip and groin pain; magnetic resonance imaging revealed swelling of the left quadratus femoris muscle. After the fifth treatment session of prolotherapy, the pain severity score using the visual analog scale was found to be minimal (0–1/10), and follow‐up magnetic resonance imaging revealed a slightly decreased enhancement of the quadratus femoris muscle compared with that on previous images. Prolotherapy with polydeoxyribonucleotide sodium was an efficacious treatment for two patients with ischiofemoral impingement syndrome who were not candidates for surgery.     

Epiduroscopy for Patients With Lumbosacral Radicular Pain

Lumbosacral radicular pain is a pain in the distribution area of one of the nerves of the lumbosacral plexus, with or without sensory and/or motor impairment. A major source of lumbosacral radicular pain is failed back surgery, which is defined as persistent or recurrent pain, mainly in the region of the lower back and legs even after technically, anatomically successful spine surgeries. If lumbosacral radicular neuropathic pain fails to respond to conservative or interventional treatments, epiduroscopy can be performed as part of a multidisciplinary approach. Epiduroscopy aids in identifying painful structures in the epidural space, establishing a diagnosis and administering therapy. The novelty consists in the use of an epiduroscope to deliver therapies such as adhesiolysis and targeted administration of epidural medications. Clinical trials report favorable treatment outcomes in 30% to 50% of patients. Complications are rare and related to the rate or volume of epidural fluid infusion or inadvertent dural puncture. In patients with lumbosacral radicular pain, especially after back surgery, epiduroscopy with adhesiolysis may be considered (evidence rating 2 B+).