Sometimes (what seems to be) a heart attack is (really) a pain in the neck.

A 31-year-old patient complained of severe crushing chest pain that radiated to his left arm and jaw. After admission to the hospital, tests revealed a normal electrocardiogram, normal treadmill, normal coronary arteriogram, and normal cardiac enzymes. However, the patient continued to have pain, which was relieved by sublingual and intravenous nitroglycerine. He was discharged from the hospital with a diagnosis of "musculoskeletal" chest pain, taking nonsteroidal anti-inflammatory drugs, muscle relaxants, and narcotics. Two weeks later, the patient returned with worsening symptoms. Cardiac work-up was again negative. Thoracic and cervical spine radiographs were ordered for possible discogenic pain. After abnormalities were found on cervical radiographs, magnetic resonance imaging (MRI) was ordered, and the patient was referred to an orthopedic surgeon. Further work-up revealed a herniated disk at C6-C7, with radicular pain. Surgery on the suspect disk totally relieved the patient's pain.

Issues in the clinical use of benzodiazepines: potency, withdrawal, and rebound.

Low and medium potency benzodiazepines were initially introduced for the treatment of insomnia and anxiety. Their therapeutic actions as anxiolytics, sedative hypnotics, anticonvulsants, and muscle relaxants / relaxant (with their low toxicity) have led to their use as first-line treatments, and they have become one of the most prescribed classes of drugs. Novel therapeutic uses of benzodiazepines were discovered with the introduction of the high-potency benzodiazepines (e.g., alprazolam, clonazepam, and lorazepam). They were found to be effective in treating panic disorder and panic attacks with or without agoraphobia, as add-on therapy to selective serotonin reuptake inhibitors in the treatment of obsessive-compulsive disorder and panic disorders, and as adjunctive therapy in treating patients with acute mania or acute agitation. High-potency benzodiazepines have replaced low and medium potency benzodiazepines in all benzodiazepine clinical indications due to their greater therapeutic effects and rapid onset of action. Differences in distribution, elimination half-life, and rate of absorption are important considerations when choosing a high-potency benzodiazepine. Typically, a benzodiazepine with long distribution and elimination half-lives is preferred. A maximum dose of 2 mg/day of any of the high-potency benzodiazepines when given for more than 1 week is recommended. Although as a class benzodiazepines act rapidly and are well tolerated, their use presents clinical issues such as dependence, rebound anxiety, memory impairment, and discontinuation syndrome.

National trends in nonoperative care for nonspecific back pain.

BACKGROUND CONTEXT: Few empirical data are available that document changes in population-based rates for the evaluation and treatment of nonspecific back pain. PURPOSE: To determine the extent of change in the pattern of outpatient evaluation and treatment of nonspecific low back pain in the United States between 1987 and 1997. STUDY DESIGN AND SETTING: The 1987 National Medical Expenditure Survey and the 1997 Medical Expenditure Panel Survey, two nationally representative surveys with similar sampling methods and questions, were used. PATIENT SAMPLE: Noninstitutionalized adults in the United States. OUTCOME MEASURES: Changes in rates of any health service for nonspecific back pain and occurrence of provider-specific care and types of services provided. Changes in the prescription of specific medication classes (ie, nonsteroidal anti-inflammatory drugs [NSAIDs], muscle relaxants, nonnarcotic and narcotic analgesics) were also investigated. RESULTS:Overall rate for outpatient treatment for nonspecific back pain in the US population was relatively stable over the decade (4.48% in 1987, 4.53% in 1997, p=.85). Among those receiving care, the proportion receiving physician care increased from 64% in 1987 to 74% in 1997 (p<.001), whereas those obtaining care from physical therapists increased from 5% to 9% during the same time period (p<.01). The proportion of respondents receiving NSAIDs, muscle relaxants, nonnarcotic analgesics and narcotic analgesics remained stable. However, the mean number of patient visits in which these medications were prescribed increased from 2.0 to 3.9 over the decade (p<.001). The proportion of individuals receiving chiropractic care (p<.01) and X- rays (p<.001) were lower in 1997 than 1987. CONCLUSIONS:The national pattern of health care for nonspecific low back pain observed in the present study serves as a basis for future investigations into the management of this major public health problem. Findings suggest that perhaps a duplication of care is partly responsible for the high degree of health care utilization in this population.

Onset and duration of rocuronium-induced neuromuscular blockade in patients with Duchenne muscular dystrophy.
Wick S, Muenster T, Schmidt J, Forst J, Schmitt HJ.
Department of Anesthesiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.
BACKGROUND: In patients with Duchenne muscular dystrophy (DMD) the response to nondepolarizing muscle relaxants / relaxant is scarcely documented and conflicting. The current study was conducted to determine the time to peak effect and the time for complete spontaneous recovery after a single dose of 0.6 mg/kg of rocuronium in patients with DMD. METHODS: Twenty-four patients (12 with DMD, 12 controls, aged 10-16 yr) were studied. All patients were anesthetized with propofol and fentanyl/remifentanil. Neuromuscular transmission was monitored by acceleromyography. After induction all patients received a single dose of 0.6 mg/kg of rocuronium. The complete time course of onset and spontaneous recovery were recorded RESULTS: Significant (P < 0.01) increase in the onset times to 95% neuromuscular block was observed in DMD patients (median, 203 s; range, 90-420 s) compared with controls (median, 90 s; range, 60-195 s). The time between rocuronium administration and recovery of first twitch of the train-of-four to 90% was significantly (P < 0.01) prolonged in DMD compared with controls (median, 132 min; range, 61-209 min versus 39 min; 22-55 min). The recovery index was also significantly prolonged in the DMD group compared with controls (median, 28 min, range, 15-70 min versus 8 min; 3-14 min). CONCLUSIONS: The most striking and surprising result of this study is the delayed onset of blockade in DMD after a standard dose of rocuronium. This effect should be kept in mind in situations when a rapid airway protection is necessary in DMD patients. The documented very long recovery from rocuronium-induced block emphasizes the need for careful assessment of neuromuscular function in DMD patients.


Intrathecal baclofen for treatment of spasticity in patient with cerebral palsy--a preliminary report

Spasticity is a common symptom of upper neuron damage which requires continuous research for new treatment strategies. The aim of this paper is to present the result of intrathecal baclofen infusion in treatment of spasticity in patients with cerebral palsy. Three patients (aged 16 to 21 years) in whom baclofen pumps were implanted underwent clinical and neurophysiological assessment both before and after pump implantation. Early results of spasticity treatment in cerebral palsy with intrathecal baclofen infusions are very promising.

Status dystonicus and Hallervorden-Spatz disease: treatment with intrathecal baclofen and pallidotomy.

Severe dystonia or status dystonicus is a life threatening disorder that develops in patients with both primary and secondary dystonia. We present the case of a 9-year-old boy with Hallervorden-Spatz disease (HVS) who developed status dystonicus, failing to respond to high dose oral therapy with multiple antidystonic agents. High dose intravenous sedating agents combined with endotracheal intubation and mechanical ventilation were required to control the spasms. Alleviation of the spasms was achieved by a combination of temporary intrathecal baclofen infusions and bilateral pallidotomy. Although it could be argued this is a situation where only palliative measures should be used, we believe a relatively aggressive approach was justified. It relieved the intense pain associated with the spasms and allowed the child to be discharged home without the prolonged stay in intensive care, morbidity and mortality, which characterize status dystonicus.

Anesthetic management of two patients with amyotrophic lateral sclerosis (ALS).
Otsuka N, Igarashi M, Shimodate Y, Nakabayashi K, Asano M, Namiki A.
Department of Anesthesia, Muroran City General Hospital, Muroran 051-8512.
We experienced anesthetic management of two cases of amyotrophic lateral sclerosis (ALS). Case 1. A 46-year-old woman underwent emergency operation for ileus. Abdominal muscle relaxation and analgesia were obtained by combined spinal and epidural anesthesia. To avoid prolongation of muscle relaxation, awake intubation without muscle relaxants / relaxant was performed. After the operation, she awoke smoothly and was extubated without any complications. Case 2. A 65-year-old woman underwent emergency operation for gastric fistula malfunction. We performed anesthetic management only with epidural anesthesia. During and after the operation, she was in good general condition and had no pain. For the patients with ALS, prolongation of muscle relaxation and residual neuromuscular block effect may cause difficult tracheal extubation and postoperative respiratory complications. We observed carefully the condition of the patients with ALS, and were able to choose the minimum invasive anesthetic methods for each case.


Prolonged paralysis related to mivacurium: a case study.
Kendrick K.
PACU and Day Surgery, Children's Healthcare of Atlanta at Egleston, 1405 Clifton Road NE, Atlanta, GA 30322, USA. kathy.kendrick@choa.org
Pseudocholinesterase deficiency is usually identified when an anesthetized patient has prolonged paralysis after receiving neuromuscular blocking agents dependent on pseudocholinesterase enzymes for hydrolysis. This rare complication, most frequently associated with succinylcholine, can occur with the use of mivacurium, one of the newer nondepolarizing muscle relaxants / relaxant also hydrolyzed by pseudocholinesterase. Prolonged paralysis has occurred 3 times in the past 2 years at this pediatric hospital after administration of mivacurium. The following case study describes causality and interventions for a patient with prolonged paralysis after receiving mivacurium.


Total knee replacement in patients with multiple sclerosis.
Shannon FJ, Cogley D, Glynn M.
Department of Orthopaedic Surgery, Tullamore Regional Hospital, Tullamore, County Offaly, Ireland. fjshannon@eircom.net
Total knee replacement was performed on two patients with Multiple sclerosis. Severe hamstring spasticity was encountered in both patients in the immediate post-operative period requiring further surgery. Both patients remain ambulatory at follow-up. The disease, and its implications in patients warranting total joint replacement are discussed.


Analysis of the pharmacodynamic parameters in a model for neuromuscular block.
Nigrovic V, Anton A, Bengez R.
Department of Anesthesiology, Medical College of Ohio, Toledo, OH 43614-2598, USA. vnigrovic@mco.edu
BACKGROUND: The study examines the roles of the pharmacodynamic parameters and of the assumptions underlying the pharmacokinetic-pharmacodynamic model proposed by Sheiner and coworkers to interpret the time course of neuromuscular block (NMB) produced by nondepolarizing muscle relaxants. MATERIAL/METHODS: The model of Sheiner et al. was modified by considering (a) a multiexponential equation for the time course of the relaxant's concentrations in plasma, (b) the transport of a hypothetical muscle relaxant / relaxants from plasma to the site of action via diffusion, and (c) NMB as a function of the relaxant's concentration at the site of action, of gamma and IC50. The feasibility of obtaining reliable estimates of the PD parameters was evaluated for either a complete or an incomplete NMB. RESULTS: The results confirmed that reliable estimates of the PD parameters, i.e., of the transport rate constant, gamma, and IC50, may be obtained simultaneously if NMB is incomplete. Estimates of the same parameters obtained from a complete NMB are interdependent and, hence, unreliable. The assumptions in the original model of (i) a negligibly small amount of the relaxant in the effect compartment, (ii) steady state plasma concentration at half-maximal NMB, Cp(ss)(50), and (iii) transport of the muscle relaxant / relaxants from the effect compartment to "Outside", are neither needed nor are justified. CONCLUSIONS: The model proposed by Sheiner et al. interprets well the time course of an incomplete NMB even without the three assumptions. The simulations suggest methods to verify independently the estimates for the transport rate constant and gamma.