Epiduralna primjena steroida nasuprot perkutane laserske dekompresije diska kod liječenja lumbalne radikularne boli

Cilj istraživanja: Usporediti učinkovitost epiduralne primjene steroida (ESI) i perkutane laserske dekompresije diska (PLDD) kod bolesnika s lumbalnom radikularnom boli, kojima je navedena radikularna bol uzrokovana hernijom intervertebralnog diska. Utvrditi postoji li razlika u učinkovitosti obje metode kod hernije intervertebralnog diska s i bez radikularnog kontakta. Nacrt studije: prospektivna kohortna studija. Ispitanici i metode: Ispitanici su bolesnici liječeni na Zavodu za liječenje boli KBC-a Osijek u periodu od siječnja do lipnja 2018. godine. Kod 18 ispitanika primijenjena je metoda ESI, a druga skupina od 10 ispitanika liječena je metodom PLDD-a. U skupini kod koje je primijenjena ESI, 9 od 18 ispitanika imalo je diskoradikularni kontakt, a u skupini liječenih PLDD-om, njih 6 od 10 imalo je diskoradikularni kontakt. Metode koje smo koristili u procjeni uspješnosti liječenja jesu Lasegueov test, Pain Detect upitnik i Oswestry upitnik kojima su rezultati prikupljani prije samog zahvata te 15. i 30. dan. Rezultati: Prema Pain Detect upitniku, u skupini ispitanika bez diskoradikularnog kontakta, a kod kojih je primijenjena ESI, došlo je do značajnog smanjenja ukupne neuropatske boli, kao i u skupini ispitanika s diskoradikularnim kontaktom, kod kojih se primijenila PLDD. Oswestry upitnik zabilježio je značajno smanjenje stupnja invalidnosti u skupini ispitanika bez diskoradikularnog kontakta, a kod kojih je primijenjena ESI, kao i u skupini ispitanika s diskoradikularnim kontaktom, kod kojih se primijenila PLDD. Lasegueov test kod obje metode doveo je do povećanja stupnja pri kojem se javlja bol. Zaključak: Obje metode bile su uspješne u ispitanika kod kojih ne postoji diskoradikularni kontakt. PLDD jest uspješnija metoda liječenja kod ispitanika s diskoradikularnim kontaktom. ESI metoda liječenja pokazuje rezultate već nakon 2 tjedna, dok PLDD ima bolje rezultate nakon 4 tjedna.Objective: The aim of the study was to compare the efficacy of epidural steroid injection (ESI) and percutaneous laser disc decompression (PLDD) in patients with lumbar radicular pain. Radicular pain in patients was caused by hernia of intervertebral disc. Furthermore, the aim was to determine whether there is a difference in the efficacy of both methods in treating hernia of intervertebral disc with and without radicular conflict. Study design: prospective cohort study Participants and Methods: Subjects were patients treated at the Clinical Hospital Center Osijek at the Department for Pain Treatment from January to June 2018. 18 patients were treated with ESI method and 10 were treated with PLDD method. In the group where ESI was administered, 9 out of 18 subjects recorded discoradicular conflict, and in the group treated with PLDD, 6 out of 10 recorded discoradicular conflict. The methods used to evaluate the success of the treatment included: the Lasegue test, the Pain Detect questionnaire, and the Oswestry questionnaire. The data from the questionnaires were collected prior to the procedure and on the 15th and 30th day. Results: According to the Pain Detect questionnaire, in patients without discoradicular conflict treated with ESI there was a significant reduction in total neuropathic pain. Significant reduction in pain was also recorded in in patients with discoradicular conflict, treated with PLDD. The Oswestry questionnaire also recorded a significant reduction in the degree of disability in both patients without discoradicular conflict treated with ESI and in patients with discoradicular conflict treated with PLDD. Conclusion: Both methods were successful in subjects without discoradicular conflict. PLDD is a more successful method of treatment in subjects with discoradicular conflict. The ESI method records improvement after 2 weeks, while PLDD has better results after 4 weeks

Low back pain vs. leg dominant pain

Bolovi lumbosakralne kralježnice se klinički manifestiraju: a) slikom križobolje, kao dominantnim simptomom ili sa 2) slikom dominantne boli u nozi, koja je značajnija od križobolje (1). Križobolja je simptom čiji su uzroci vrlo raznoliki i brojni, ali u većini slučajeva su vertebralne geneze, a rjeđe su odraz visceralne boli. Kod slike gdje je bol u nozi intenzivnija u usporedbi s lumbalnom boli, iradijacija boli je obično po radikularnoj distribuciji. Radikulopatija označava disfunkciju odnosno kronično oštećenje spinalnih korjenova kao posljedicu prolongirane iritacije ili kompresije, uzrokovane primarno vertebralnom degenerativnom bolesti (diskogeno ili u okviru spinalne stenoze). Iznimno je uzrok nevertebralne geneze, te u oko 1 % slučajeva to mogu biti infekcija, maligni proces ili prijelom. Postoji i niz uzroka pseudoradikularne boli u nogama kao što su lezije perifernih živaca nogu, miofascijalni sindromi, vaskularne bolesti, osteoartitisi zglobova zdjelice i nogu. U diferencijalnoj dijagnostici nužno je misliti i na upalne spondilartropatije. Radi što učinkovitije terapije, nužno je anamnezom i kliničkim fizikalnim pregledom adekvatno usmjeriti dijagnostičku obradu u smislu što boljeg definiranja etiopatogeneze boli a potom, planiranja problemu usmjerene terapije.There are two patterns of back pain: 1) back-dominant pain and 2) leg pain dominant, greater than back pain (1). The causes of back pain are very different and numerous, but mostly are due to vertebral, mechanical etiology, and rarely because of non vertebral, visceral etiology. Leg pain greater than back pain is mostly disease of spinal nerve root, generally presented by radicular pain in a dermatomal distribution. Mechanical compression of spinal roots, caused by disc herniation or by spinal stenosis, results in radicular symptoms. Rarely, in about 1 % of patients, there are some other reasons except vertebral mechanical cause, like infection, tumor or fracture. There are several causes of pseudoradicular pain like periferal neuropathy, myifascial syndromes, vascular diseases, osteoarthritis. Spondylarthropathies should be taken in cosideration as well. A complete history and physical examination is important to t determine further diagnostic evaluation and to provide eficient therapy

Epiduralna primjena steroida nasuprot perkutane laserske dekompresije diska kod liječenja lumbalne radikularne boli

Cilj istraživanja: Usporediti učinkovitost epiduralne primjene steroida (ESI) i perkutane laserske dekompresije diska (PLDD) kod bolesnika s lumbalnom radikularnom boli, kojima je navedena radikularna bol uzrokovana hernijom intervertebralnog diska. Utvrditi postoji li razlika u učinkovitosti obje metode kod hernije intervertebralnog diska s i bez radikularnog kontakta. Nacrt studije: prospektivna kohortna studija. Ispitanici i metode: Ispitanici su bolesnici liječeni na Zavodu za liječenje boli KBC-a Osijek u periodu od siječnja do lipnja 2018. godine. Kod 18 ispitanika primijenjena je metoda ESI, a druga skupina od 10 ispitanika liječena je metodom PLDD-a. U skupini kod koje je primijenjena ESI, 9 od 18 ispitanika imalo je diskoradikularni kontakt, a u skupini liječenih PLDD-om, njih 6 od 10 imalo je diskoradikularni kontakt. Metode koje smo koristili u procjeni uspješnosti liječenja jesu Lasegueov test, Pain Detect upitnik i Oswestry upitnik kojima su rezultati prikupljani prije samog zahvata te 15. i 30. dan. Rezultati: Prema Pain Detect upitniku, u skupini ispitanika bez diskoradikularnog kontakta, a kod kojih je primijenjena ESI, došlo je do značajnog smanjenja ukupne neuropatske boli, kao i u skupini ispitanika s diskoradikularnim kontaktom, kod kojih se primijenila PLDD. Oswestry upitnik zabilježio je značajno smanjenje stupnja invalidnosti u skupini ispitanika bez diskoradikularnog kontakta, a kod kojih je primijenjena ESI, kao i u skupini ispitanika s diskoradikularnim kontaktom, kod kojih se primijenila PLDD. Lasegueov test kod obje metode doveo je do povećanja stupnja pri kojem se javlja bol. Zaključak: Obje metode bile su uspješne u ispitanika kod kojih ne postoji diskoradikularni kontakt. PLDD jest uspješnija metoda liječenja kod ispitanika s diskoradikularnim kontaktom. ESI metoda liječenja pokazuje rezultate već nakon 2 tjedna, dok PLDD ima bolje rezultate nakon 4 tjedna.Objective: The aim of the study was to compare the efficacy of epidural steroid injection (ESI) and percutaneous laser disc decompression (PLDD) in patients with lumbar radicular pain. Radicular pain in patients was caused by hernia of intervertebral disc. Furthermore, the aim was to determine whether there is a difference in the efficacy of both methods in treating hernia of intervertebral disc with and without radicular conflict. Study design: prospective cohort study Participants and Methods: Subjects were patients treated at the Clinical Hospital Center Osijek at the Department for Pain Treatment from January to June 2018. 18 patients were treated with ESI method and 10 were treated with PLDD method. In the group where ESI was administered, 9 out of 18 subjects recorded discoradicular conflict, and in the group treated with PLDD, 6 out of 10 recorded discoradicular conflict. The methods used to evaluate the success of the treatment included: the Lasegue test, the Pain Detect questionnaire, and the Oswestry questionnaire. The data from the questionnaires were collected prior to the procedure and on the 15th and 30th day. Results: According to the Pain Detect questionnaire, in patients without discoradicular conflict treated with ESI there was a significant reduction in total neuropathic pain. Significant reduction in pain was also recorded in in patients with discoradicular conflict, treated with PLDD. The Oswestry questionnaire also recorded a significant reduction in the degree of disability in both patients without discoradicular conflict treated with ESI and in patients with discoradicular conflict treated with PLDD. Conclusion: Both methods were successful in subjects without discoradicular conflict. PLDD is a more successful method of treatment in subjects with discoradicular conflict. The ESI method records improvement after 2 weeks, while PLDD has better results after 4 weeks

Most frequent causes that disorder static relations in lumbosacral region

Analizirajući uzroke lumbalnog bola bolesnika hospitalno liječenih, došli smo do zaključka da je od 932 bolesnika, 169 ili 18,3%, imalo poremećaj statičkih odnosa lumbosakralne kralježnice, što je uzrokovalo pojavu lumbalnog bola. Od 169 bolesnika ili 31,95% imalo je povećanu vrijednost L — S kuta, dok je 18,35% imalo smanjenu vrijednost. Poreme­ćaj statičkih odnosa uzrokovan hemisakralizacijom imalo je 28,99% slučajeva, dok je 20,71% bilo sa sakralizacijom L 5 segmenta. Od ukupnog broja bolesnika sa poremećenim statičkim odnosima lumbosakralne kralježnice, 79,29%, imalo je radikularnu bol a 20,71% lokalnu lumbalnu bol.Having analysed the causes of the low back pain in the hospitalized patient, we have found out that 169 or 18.3% out of 932 patients suffered the disorder of the static relations in the lumbosacral region. 31.95% out of 169 patients had the increased value of the lumbosacral angle and 18.35% had the reduced value of the lumbosacral angle. The disorder of the static relations caused by the occurrence of hemisacralization was diagnosed in 28.99% patients, whereas in 20.71% patients it was caused by the sacralization of the fifth lumbar vertebra. 79.28% of patients out of a total number of patients with disordered static relations had radicular pain and 20.71% of them had local low back pain

Clinical features and treatment of lumboischialgia

Bol u donjem dijelu leđa vrlo je učestala među populacijom i smatra se da čini trećinu svih reumatskih bolesti. Ishialgija se pojavljuje kod 1-3% opće odrasle populacije. Između trupova kralježaka se nalaze intervertebralni diskovi koji su građeni od središnjeg želatinoznog dijela, nucleus pulposus, okruženog fibroznim prstenom, anulus fibrosus. Poremećaji intervertebralnog diska smatraju se najčešćim uzrokom boli u donjem dijelu leđa i radikularne boli. Kod dijagnosticiranja ovog stanja možemo koristiti se anamnezu, fizikalni nalaz, slikovne prikaze, minimalno invazivne dijagnostičke postupke poput segmentalne blokade živaca i neurofiziološka ispitivanja. Postoji nekoliko provocirajućih testova na donjim ekstremitetima u kojima određeni položaji ekstremiteta mogu umanjiti ili povećati lumbosakralnu radikularnu bol, te tako ukazati na određenu patologiju. Magnetna rezonancija(MR) je metoda izbora za dijagnozu lumboishijalgije zbog toga što dobro prikazuje meka tkiva. Za razlikovanje oštećenja perifernog živca od oštećenja spinalnog korijena koristimo elektrofiziološke metode, a kada želimo odredit na kojoj se razini u kralježnici nalazi patološki proces koji uzrokuje bol koristimo segmentalnu blokadu živaca. Liječenje je u akutnoj fazi bolesti uvijek konzervativno. Ukoliko se ono ne pokaže učinkovitim prelazi se na kirurško liječenje koje može biti klasično i minimalno invazivno.Low back pain is common among population and it makes up to one third of all rheumatic diseases. Sciatica appears in 1% -3% of the general adult population. There are intervertebral discs between the vertebral bodies that are made of the central gelatinous part, nucleus pulposus, surrounded by fibrous ring, anulus fibrosus. Intervertebral disc disorders are considered to be the most common cause of pain in the lower back and radicular pain. In diagnosing this condition we can use patient history, physical examination, imaging techniques and minimally invasive diagnostic procedures such as segmental nerve blockage and neurophysiological examination. There are several provocative tests at the lower extremities in which some extremity positions can reduce or increase lumbosacral radicular pain and point to a particular pathology. Magnetic Resonance (MR) is the method of choice for diagnosing lumbosacral radicular syndrome because the soft tissue is shown well. To differentiate the peripheral nerve pathology from spinal nerve root pathology, we use electrophysiological methods. When we want to determine at which level of the spine is pathological process, which causes pain, we use segmental nerve blockage. Treatment in the acute phase of the disease is always conservative. If it does not prove effective, it is recommended to start considering a surgical treatment. Surgical approach can be classical and minimal invasive

Maxillary sinus pathology of odontogenic origin

Maksilarni sinusitis definira se kao simptomatska upala maksilarnih paranazalnih sinusa. Odontogena upala sinusa proizlazi iz bolesti zuba tako da se u mikrobiologiji i patofiziologiji razlikuje od drugih sinusitisa. Incidencija je odontogenog sinusitisa niska s obzirom na učestalost dentalnih infekcija. Intimni anatomski odnos gornjih zuba i maksilarnog sinusa potiče razvoj periapikalne ili parodontne dentalne infekcije u maksilarni sinusitis. On se također može razviti zbog upalnih cisti, mehaničkih ozljeda sluzice tijekom liječenja korijenskog kanala, prepunjenja korijenskog kanala endodontskim materijalom, nepravilno postavljenih dentalnih implantata, perforacije sinusa pri ekstrakciji ili potiskivanju korijena ili cijelog zuba u sinus. Simptomi na temelju kojih je moguće dijagnosticirati OMS jesu unilateralna purulentna rinoreja, maksilarna bol, postnazalna sekrecija, unilateralna nazalna kongestija te glavobolja. Razlike u simptomima OMS-a i drugih vrsta upala sinusa nisu značajne, ali je bila veća učestalost jednostranih simptoma. Uz anamnezu i klinički pregled, ortopantomogram, CT i CBCT primjenjuju se u radiološkoj dijagnostici. Terapija se izvodi na više načina, a podrazumijeva uklanjanje infekcije, primjenu antibiotika te kiruršku metodu, Caldwell-Lucovu operaciju ili FESS tehniku. Komplikacije koje mogu nastati zbog OMS-a jesu orbitalni apsces ili endokranijalne komplikacije, a mogu biti opasne i za život. Od odontogenih lezija, odontogene ciste nikad neće invadirati u maksilarni sinus, nego će ga svojim rastom i povećanjem pomicati. Ciste mogu biti upalne, odontogena keratocista i folikularna cista. Odontogeni tumori u maksili rijetko se javljaju, a slučajevi sa zahvaćenošću maksilarnog sinusa vrlo su rijetki. Benigni tumori koji se mogu pojaviti jesu ameloblastom, Pindborgov tumor, Gorlinova cista, odontom, odontoameloblastom, odontogeni miksom te cementoblastom. Od zloćudnih tumora u literaturi se navode ameloblastični karcinom i ameloblastični fibrosarkom, ali i maligne promjene odontogenih cista.Maxillary sinusitis is defined as a symptomatic inflammation of maxillary sinuses. Odontogenic sinusitis develops as a result of tooth disease, therefore distinguishing its microbiology and pathophysiology from other forms of sinusitis. The incidence of odontogenic sinusitis is low compared to the incidence of dental infections. The close anatomic relation of the upper teeth and the maxillary sinus allows easy progression of periapical or periodontal infections into maxillary sinusitis. It can also be caused by inflammed cysts, mechanical injury to the membrane during root canal treatment, ovefilling the root canal with endodontic material, improper placement of implants, sinus perforation during tooth extraction, or pushing the root or a whole tooth into the sinus. The symptoms that indicate odontogenic maxillary sinusitis are unilateral purulent rhinorrhea, maxillary pain, postnasal secretion, unilateral nasal congestion, and headache. The difference between symptoms of odontogenic maxillary sinusitis and other types of sinusitis is not significant, however there is a higher incidence of unilateral symptoms in odontogenic maxillary sinusitis. In addition to medical history and clinical examination, orthopantomogram, computed tomography and cone beam computed tomography are used as part of diagnostic radiology. Therapy for odontogenic maxillary sinusitis is multifaceted and it includes the elimination of the infection, antibiotics, surgical methods, Caldwell-Luc antrostomy, and functional endoscopic sinus surgery. Complications that may ensue due to odontogenic maxillary sinusitis are orbital abscesses or endocranial complications, which can be dangerous and life-threatening. A cyst coming from odontogenic lesions will never invade a maxillary sinus; however it may push on the sinus through its formation and enlargement. Cysts can be classified as inflammatory, odontogenic keratocysts, and follicular cysts. Odontogenic tumors in maxilla are generally rare, and cases involving maxillary sinuses are very rare. Among the benign tumors that may occur are ameloblastomas, Pindborg tumor, Gorlin cyst, odontoma, odontoameloblastoma, odontogenic myxoma, and cementoblastoma. In terms of malignant tumors, the literature mentions ameloblastic carcinoma and ameloblastic fibrosarcoma, as well as malignant changes in odontogenic cysts

Neuropathic Pain

Neuropatska bol neugodan je osjetni i emocionalni doživljaj uzrokovan oštećenjem ili bolešću somatosenzornog dijela živčanog sustava. Procjenjuje se da 7 – 8% stanovnika Europe pati od neuropatske boli. Klasični primjeri takve boli jesu bolna dijabetička polineuropatija, postherpetička neuralgija, trigeminalna neuralgija, radikularna bol, bol nakon moždanog udara, bol zbog ozljede leđne moždine te postkirurška bol. Neuropatska bol odraz je patološkog zbivanja u živčanom sustavu, koje ima za posljedicu niz različitih patofizioloških mehanizama u nastanku boli. Bol se javlja spontano, osobito u mirovanju, a doživljava kao pečenje, žarenje, sijevajuća ili oštra ubodna bol. Neuropatska je bol evocirana dodirom (mehanička alodinija) ili promjenom temperature (termička alodinija). Bol remeti san, izaziva tjeskobu i potištenost te smanjuje kvalitetu života bolesnika. U liječenju bolesnika s neuropatskom boli postoje dva cilja. Prvi je postavljanje ispravne dijagnoze i liječenje osnovne bolesti. Drugi je cilj definirati bolni sindrom i provesti simptomatsko liječenje boli. U liječenju neuropatske boli smjernice EFNS-a preporučju antiepileptike (gabapentin, pregabalin), tricikličke antidepresive i SNRI (duloksetin, venlafaksin) kao lijekove prvog izbora. Druga linija liječenja uključuje opioide. Topički lidokain može biti lijek izbora kod bolesnika s mehaničkom alodinijom. Kombinirana terapija može se primijeniti u slučajevima kada se monoterapija pokaže neučinkovitom, a trebali bi se kombinirati lijekovi s međusobno dopunjujućim mehanizmima djelovanja. Transkutana električna živčana stimulacija (engl. transcutaneous electrical nerve stimulation – TENS) ima dokazani analgetski učinak i uz redovitu kineziterapiju znatno pridonosi poboljšanju funkcionalnog stanja bolesnika. Psihoterapijska potpora važna je u liječenju kronične boli. Dijagnostika i liječenje neuropatske boli zahtijevaju interdisciplinarni i multimodalni pristup.Neuropathic pain is an unpleasant sensory and emotional experience caused by a lesion or a disease of the somatosensory nervous system. It is estimated to affect as much as 7-8% of the general population in Europe. Classic examples include painful diabetic polyneuropathy, postherpetic neuralgia, trigeminal neuralgia, and central poststroke and spinal cord injury pain, although traumatic/postsurgical neuropathies and painful radiculopathies represent common conditions in the general population. Neuropathic pain is a reflection of a pathologic event in the nervous system that results in a series of pathophysiological mechanisms involved in the onset of pain. It occurs spontaneously, particularly at rest, and is experienced as a burning, shooting or sharp stabbing pain. It is provoked by touch (mechanical allodynia) or temperature change (thermal allodynia). The pain interferes with sleep and provokes anxiety and depression, reducing a patient’squality of life. There are two goals in neuropathic pain treatment: firstly, establish a correct diagnosis and treat primary disease, and secondly, define painful syndrome and treat pain symptomatically. The EFNS guidelines for the treatment of neuropathic pain recommend the use of antiepileptic drugs (gabapentin, pregabalin), tricyclic antidepressants and SNRIs (duloxetine, venlafaxine) as drugs of first choice. Second-line treatment includes opioids. Topical lidocaine may be a drug of choice in patients with mechanical allodynia. Combined therapy can be used if monotherapy proves unsuccessful, and drugs with mutually supplementary mechanisms of action should be used. Transcutaneous electrical nerve stimulation (TENS) has a proven analgesic effect and, along with regular kinesitherapy, significantly contributes to the improvement of a patient’s functional state. Psychotherapeutic support is important in the treatment of chronic pain. Diagnostics and treatment of neuropathic pain require an interdisciplinary and multimodal approach