Drug management of low back pain.
Matsudaira K, Kawaguchi H.
Department of Orthopedic Surgery, Faculty of Medicine, The University of Tokyo.
NSAIDs and muscle relaxants / relaxant effectively reduce acute nonspecific low back pain (LBP), different types of both drugs being equally effective. In general, there is no strong evidence for the effectiveness of medication for chronic nonspecific LBP. However, there is a possibility that administration of antidepressants is an intervention worthy of consideration in cases of LBP with no identifiable organic cause and resistant to other treatments.


Approach to the rehabilitation of spasticity and neuromuscular disorders in children.

The management of children and adults with upper motor neuron disorder is complex and multifaceted. This article reviews new information and potential treatment. As part of the upper motor neuron syndrome (UMNS), spasticity may occur in cerebral palsy, congenital brain malformation, head injury, or other etiologies. Within the UMNS the most recognizable clinical concern is the frequent abnormality of tone, which may have a significant functional impact. Tone reduction is not itself a goal, but is performed for the functional benefits it may allow. New approaches to treatment and management of hypertonia recently have become available. There are many other associated features of the UMNS that affect patient functioning. Ones that frequently occur are abnormalities of speech and other areas of oral motor control. A new area of intervention combines the use of botulinum toxin and ultrasonography to address the common problem of slalorrhea, which is a potential medical issue and a substantial social barrier in affected patients. This article also reviews new information and potential treatment for neuromuscular disorders.

The histaminergic system of the brain: its roles in arousal and autonomic regulation.
Szabadi E, Bradshaw CM, Freeman C, Scaife J, Hou RH, Langley RW.
Psychopharmacology Section, Division of Psychiatry, University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK.


Calcium release from sarcoplasmic reticulum is facilitated in human myotubes

Malignant hyperthermia (MH) is caused by increased calcium release from sarcoplasmic reticulum, triggered by volatile anesthetics or depolarizing muscle relaxants. Numerous mutations associated with MH have been detected in the skeletal muscle type ryanodine receptor gene (RyR1), but so far facilitated calcium release has only been demonstrated for a few of them. This is a prerequisite for confirming the causative role of an RyR1 mutation for MH. Calcium release from sarcoplasmic reticulum induced by 4-chloro-m-cresol (4CmC), caffeine, and halothane was determined in human myotubes by calcium imaging. The RyR1 Ile2182Phe mutation and the RyR1 Gly2375Ala mutation have been identified in individuals susceptible to MH. In myotubes of individuals carrying the RyR1 Ile2182Phe or the RyR1 Gly2375Ala mutation, the EC(50) for caffeine and halothane was reduced; in the Ile2182Phe myotubes, the EC(50) for 4CmC was also reduced, all consistent with facilitated calcium release from the sarcoplasmic reticulum. From these data we conclude that both mutations are pathogenic for MH.

Impact of anesthesia management characteristics on severe morbidity and mortality.
Arbous MS, Meursing AE, van Kleef JW, de Lange JJ, Spoormans HH, Touw P, Werner FM, Grobbee DE.
Julius Center for Patient Oriented Research, Dutch Association for Anesthesiology, Utrecht, The Netherlands.
BACKGROUND: Quantitative estimates of how anesthesia management impacts perioperative morbidity and mortality are limited. The authors performed a study to identify risk factors related to anesthesia management for 24-h postoperative severe morbidity and mortality. METHODS: A case-control study was performed of all patients undergoing anesthesia (1995-1997). Cases were patients who either remained comatose or died during or within 24 h of undergoing anesthesia. Controls were patients who neither remained comatose nor died during or within 24 hours of undergoing anesthesia. Data were collected by means of a questionnaire, the anesthesia and recovery form. Odds ratios were calculated for risk factors, adjusted for confounders. RESULTS: The cohort comprised 869,483 patients; 807 cases and 883 controls were analyzed. The incidence of 24-h postoperative death was 8.8 (95% confidence interval, 8.2-9.5) per 10,000 anesthetics. The incidence of coma was 0.5 (95% confidence interval, 0.3-0.6). Anesthesia management factors that were statistically significantly associated with a decreased risk were: equipment check with protocol and checklist (odds ratio, 0.64), documentation of the equipment check (odds ratio, 0.61), a directly available anesthesiologist (odds ratio, 0.46), no change of anesthesiologist during anesthesia (odds ratio, 0.44), presence of a full-time working anesthetic nurse (odds ratio, 0.41), two persons present at emergence (odds ratio, 0.69), reversal of anesthesia (for muscle relaxants / relaxant and the combination of muscle relaxants / relaxant and opiates; odds ratios, 0.10 and 0.29, respectively), and postoperative pain medication as opposed to no pain medication, particularly if administered epidurally or intramuscularly as opposed to intravenously. CONCLUSIONS: Mortality after surgery is substantial and an association was established between perioperative coma and death and anesthesia management factors like intraoperative presence of anesthesia personnel, administration of drugs intraoperatively and postoperatively, and characteristics of delivered intraoperative and postoperative anesthetic care.

Carbamazepine toxicity following Oxybutynin and Dantrolene administration: a case report.
Vander T, Odi H, Bluvstein V, Ronen J, Catz A.
Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel.
OBJECTIVE: To report a case of Carbamazepine toxicity following the administration of Oxybutynin and Dantrolene. STUDY DESIGN: A case report. SETTING: The Spinal Rehabilitation Department, Loewenstein Hospital, Raanana, Israel. METHODS: A patient with C6D tetraplegia who sustained intoxication because of drug interaction is presented. She had been treated by Carbamazepine 1000 mg/day for neuropathic pain for 2 years without clinical or laboratory signs of toxicity. After administration of Oxybutynin concomitantly with an increase in the dose of Dantrolene, she presented the clinical symptoms and laboratory finding of Carbamazepine intoxication. Trying to adjust the treatment to the patient's requirements, Carbamazepine together with Oxybutynin and Dantrolene was readministrated in lower doses. RESULTS: The combination of these drugs, even small doses, caused toxicity. Adding Dantrolene and Oxybutynin elevated the blood level of Carbamazepine, possibly by inhibition of cytochrome P450. CONCLUSION: A possible pharmacokinetic interaction between Dantrolene and Oxybutynin should be borne in mind when considering Carbamazepine medication for a patient with a spinal cord lesion.


Skin sensitivity to rocuronium and vecuronium: a randomized controlled prick-testing study in healthy volunteers.

Prick tests are frequently used for the authentication of neuromuscular blocking drugs (NMBDs) as causative drugs for anaphylactic reactions during anesthesia. Unfortunately, the actual threshold concentration for skin testing remains debatable for most NMBDs. We studied the flare and wheal responses to prick tests with rocuronium and vecuronium. Thirty healthy, nonatopic, anesthesia-naive male and female volunteers (14 men and 16 women) from 18 to 40 yr of age were assigned randomly to receive a total of 10 prick tests-4 ascending dilutions (1:1000, 1:100, 1:10, and 1) of rocuronium and vecuronium and 2 controls-on both forearms. An assessor blinded to the assignment monitored systemic and skin responses to NMBDs and measured wheal and flare surfaces immediately after and 15 min after prick tests. None of the volunteers experienced any immediate systemic or cutaneous responses to rocuronium or vecuronium. Although a dilution of 1:1000 of both NMBDs failed to promote any skin response at 15 min, 50% and 40% of the subjects had a positive skin reaction to undiluted rocuronium and vecuronium, respectively. We demonstrated a sex effect related to smaller threshold concentration-induced cutaneous reactions in female volunteers to both muscle relaxants. Our observation questions the reliability of prick testing with undiluted solutions of rocuronium and vecuronium for the diagnosis of allergy. IMPLICATIONS: Building concentration-skin response curves to prick tests with rocuronium and vecuronium in healthy, nonatopic, anesthesia-naive male and female volunteers demonstrated that the nonreactive concentration for both muscle relaxants / relaxant is the 1:1000 dilution of the stock solutions. Our observation calls into question the past practice of prick-testing skin for sensitivity to neuromuscular blocking drugs by using undiluted solutions.

Anesthesia for ambulatory anorectal surgery.

The prevalence of minor anorectal diseases is 4-5% of adult Western population. Operations are performed on ambulatory or 24-hour stay basis. Requirements for ambulatory anesthesia are: rapid onset and recovery, ability to provide quick adjustments during maintenance, lack of intraoperative and postoperative side effects, and cost-effectiveness. Anorectal surgery requires deep levels of anesthesia. The aim is achieved with 1) regional blocks alone or in combination with monitored anesthesia care or 2) deep general anesthesia, usually with muscle relaxants / relaxant and tracheal intubation. Modern general anesthetics provide smooth, quickly adjustable anesthesia and are a good choice for ambulatory surgery. Popular regional methods are: spinal anesthesia, caudal blockade, posterior perineal blockade and local anesthesia. The trend in regional anesthesia is lowering the dose of local anesthetic, providing selective segmental block. Adjuvants potentiating analgesia are recommended. Postoperative period may be complicated by: 1) severe pain, 2) urinary retention due to common nerve supply, and 3) surgical bleeding. Complications may lead to hospital admission. In conclusion, novel general anesthetics are recommended for ambulatory anorectal surgery. Further studies to determine an optimal dose and method are needed in the group of regional anesthesia.

Clinical inquiries. Does quinine reduce leg cramps for young athletes?
Robertson N, Hale W, Mackler L, Poddar S.
Moses Cone Health System, Greensboro, NC, USA.

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.