Background: Epidural venous plexus (EVP) engorgement has been rarely reported as a cause of radiculopathy and back pain with different possible underlying pathologies. Because of their rarity, these cases can be easily missed on imaging due to a lack of awareness. Case Report: We present a case of a 58-year-old, obese woman with a history of treated breast cancer who had been experiencing lower back pain and bilateral sciatica for one year. Clinical examination showed positive signs of neurotensin with no neurological deficit. Magnetic resonance imaging (MRI) with contrast showed substantial engorgement of the epidural veins, causing lumbar canal stenosis at the level of L5 and S1. Non-operative treatment with pain medications and pregabalin was successful and improved her symptoms significantly. Conclusion: Lumbar canal stenosis secondary to epidural varicose veins is a rare cause, and it can be easily missed on imaging. An engorged EVP should be considered in the differential diagnosis of radiculopathy in obese patients. There is an increased risk of bleeding with surgical treatment of such a condition.

Context: Lumbar central Spinal stenosis is common and often results in chronic persistent pain and disability, which can lead to multiple interventions. After the failure of conservative treatment, either surgical or nonsurgical modalities such as epidural Injections are contemplated in the management of lumbar Spinal stenosis.Evidence Acquisition: Recent randomized trials, systematic reviews and guidelines have reached varying conclusions about the efficacy of epidural Injections in the management of central lumbar Spinal stenosis. The aim of this systematic review was to determine the efficacy of all three anatomical epidural injection approaches (caudal, interlaminar, and transforaminal) in the treatment of lumbar central Spinal stenosis. A systematic review was performed on randomized trials published from 1966 to July 2014 of all types of epidural Injections used in the management of lumbar central Spinal stenosis. Methodological quality assessment and grading of the evidence was performed.Results: The evidence in managing lumbar Spinal stenosis is Level II for long-term improvement for caudal and lumbar interlaminar epidural Injections. For transforaminal epidural Injections, the evidence is Level III for short-term improvement only. The interlaminar approach appears to be superior to the caudal approach and the caudal approach appears to be superior to the transforaminal one.Conclusions: The available evidence suggests that epidural Injections with local anesthetic alone or with local anesthetic with steroids offer short- and long-term relief of low back and lower extremity pain for patients with lumbar central Spinal stenosis. However, the evidence is Level II for the long-term efficacy of caudal and interlaminar epidural Injections, whereas it is Level III for short-term improvement only with transforaminal epidural Injections.

Background: Delirium is a common complication after proximal femoral fracture surgery, with pain and opioid consumption as the contributing factors. The administration of intrathecal morphine may decrease these factors postoperatively and potentially reduce delirium. Objectives: This research aimed to study the association between the use of intrathecal morphine and the occurrence of delirium. Methods: A retrospective analysis of a prospective register kept in a non-academic hospital in the Netherlands was performed. The register contained data of all patients with proximal femur fractures that were surgically treated with osteosynthesis or prosthesis. Patients receiving Spinal anesthesia (SA group) were compared with patients receiving Spinal anesthesia with the addition of intrathecal morphine (SIM group). The administration of either SA or SIM was based on the preference of the anesthesiologist. The primary outcome was the incidence of delirium, as defi ned by the DSM-V classifi cation. The follow-up lasted until hospital discharge. Both univariate and multivariate analyses were performed. Results: The SA group consisted of 451 patients, and the SIM group included 34 patients. Delirium occurred in 19. 7% in the SA group versus 5. 9% in the SIM group (P = 0. 046). This association remained signifi cant after correction in multivariate analysis (OR of delirium in the SA group, 95% CI: 1. 062-21. 006, P = 0. 041). Additionally, multivariate analysis revealed that age, gender, preoperative cognitive impairment, and fracture treatment (osteosynthesis or prosthesis) were independently associated with delirium. Conclusions: This retrospective study found an independent association between the use of intrathecal morphine and a lower incidence of delirium. This clinically relevant decrease in delirium should be studied in a prospective randomized study.

Context: Spinal anesthesia is the most preferred method for cesarean section. This meta-analysis was performed to determine the effect of minimum and maximum intrathecal doses of meperidine (pethidine) [5 to 40 mg] on the maternal and newborn outcomes after cesarean section. Evidence Acquisition: The data were collected through the systematic search in the ISI, PubMed, Scopus, Google Scholar, Barakat, MagIran, SID, Irandoc, and EMBASE medical databases. Eighteen clinical trial studies with 1, 494 patients were included. Results: Patients who had received intrathecal meperidine had experienced lower shivering, relative risk [RR] = 0. 34 (95% CI = 0. 23, 0. 48) and longer analgesia, [standard mean difference (SMD)] = 7. 67 (95% CI = 1. 85, 13. 49) after the surgery. Moreover, RR of nausea = 1. 37 (95% CI = 1. 13, 1. 66), vomiting RR = 2. 02 (95% CI = 1. 28, 3. 20), and pruritus RR = 9. 26 (95% CI = 4. 17, 20. 58) was higher in the pethidine group than in the control group. There was no statistically significant difference in the Apgar score at one-minute RR = 0. 99 (95% CI = 0. 9, 1. 09), at five-minute RR = 0. 93 (95% CI = 0. 87, 1. 08), maternal hypotension RR = 1. 00 (95% CI = 0. 87, 1. 15), and maternal sensory and motor blockade durations, SMD =-1. 72 (95% CI =-3. 78. 0. 34) and SMD =-4. 38 (95% CI =-9. 19, 0. 44), respectively in the two pethidine and control groups. Conclusions: Intrathecal meperidine can reduce shivering and increase the duration of postoperative analgesia, though it increases the relative risk of nausea, vomiting, and pruritus. No significant difference was found both in the Apgar score, maternal hypotension, and duration of the motor and sensory block.

Background: Lumbar Spinal stenosis (LSS) is the most common indication for lumbar surgery in elderly patients. Epidural Injections of calcitonin are effective in managing LSS. Objectives: This study aimed to compare the efficacy of transforaminal and caudal Injections of calcitonin in patients with LSS. Methods: In this double-blind randomized clinical trial, LSS patients were divided into two equal groups (N = 20). The first group received 50 IU (international units) of calcitonin via caudal epidural injection (CEI), and the second group received 50 IU of calcitonin via transforaminal epidural injection (TEI). The Visual Analogue Scale (VAS) and Oswestry Low Back Pain Disability Questionnaire (ODI) were used to assess the patient's pain and ability to stand, respectively. Visual Analogue Scale and ODI scores were recorded and analyzed. Results: The results showed that caudal and TEIs of calcitonin significantly improved pain and ability to stand during follow-up compared to before intervention (P < 0.05). Additionally, CEI of calcitonin after 6 months significantly reduced pain in LSS patients compared to TEI of calcitonin (P < 0.05). However, no significant difference was observed between the two epidural injection techniques in improving the patient's ability to stand (P > 0.05). Conclusions: The results of the study indicate that epidural injection of calcitonin in long-term follow-up (6 months) had a significant effect on improving pain intensity and mobility in patients with LSS, and its effect on pain in the TEI method was significantly greater than that in the CEI method.

Background: The use of epidural steroid injection in Spinal stenosis pain management has expanded greatly. Calcitonin is also effective in relieving neuropathic pain in Spinal canal stenosis through the mechanisms of arterial dilation, anti-inflammation, anti-edema, and rises in beta endorphin levels. The current study was designed to evaluate the effect of mesotherapy with calcitonin compared with epidural steroid injection for pain relief and functional improvement in patients with lumbosacral canal stenosis. Methods: A total of 39 patients comparable in age and gender with signs and symptoms of lumbosacral canal stenosis participated in this randomized control trial. Group A comprised patients receiving mesotherapy of 100 IU Calcitonin+Marcaine 0. 5% (4 mL) in three repeated Injections in the lumbosacral area,group B received a single caudal epidural injection of Marcaine 0. 5% (4 mL)+80 mg methyl prednisolone (2 mL) under the guide of a fluoroscope. Patients were evaluated before and 4 and 8 weeks after intervention using the visual analog scale (VAS), Oswestry Disability Index (ODI), Quebec back pain disability scale (QBPD), and Ronald-Morris Disability Questionnaire (RMDQ). Results: Based on the VAS, ODI, QBPD, and RMDQ scales, a significant improvement in pain and functional disability was observed in both groups 4 and 8 weeks after intervention (P<0. 05), which was comparable between the two groups (P>0. 05). Conclusion: Mesotherapy with calcitonin Marcaine is just as effective as caudal epidural steroid injection,considering its advantages, mesotherapy can be a proper alternative method for managing pain and functional impairment in patients with lumbosacral canal stenosis.