For reference: https://www.kenhub.com/thumbovcoXMm8HT526DKeDZcadaZTLC4o=/fit-in/413x413/filters:fill(FFFFFF,true):watermark(/images/watermark_only_413.png,0,0,0):watermark(/images/logo_url_sm.png,-10,-10,0):format(jpeg)/images/anatomy_term/s1-dermatome-2/AhKyWm0pjlutFvNECTTtzA_S1.png
Left half is the Foerster map and the right half is the Keegan and Garrett map.

I need to vent, and potentially hear about other similar experiences.
I appear to be in the beginning stages of a potential shingles outbreak. For the second time. On my face.
On Sunday evening (it's Wednesday evening as I write this), I started having some pain in the area that I had shingles 5 years ago. That's all fine and dandy, sometimes it randomly hurts. But, this time it started spreading.
The initial spot was on my cheekbone, right under the outside corner of my eye. That's where I had shingles last time, it pretty well stayed there.
The spread of the pain slowly creeped up and then settled on the right half of my forehead, starting at the cheekbone spot. Essentially, where the trigeminal nerve V1 area is. Basically follows the map to a t.
The pain started as a kind of painful sensitivity, a bit worse when stroked (testing the dermatome.. I'm in school for massage therapy in Ontario Canada and of course once this pain started I'd obviously start doing whatever tests on myself I've been taught). As the past few days have progressed, the pain has continued. Sometimes it's worse, and sometimes I get a bit of a reprieve, giving me a little bit of hope that it isn't shingles.
However, the pain started to change just a little bit yesterday (Tuesday) where I can only describe it as a feeling of a surface headache in the affected area. Not an actual headache, but a headache-y feel just under the skin. It also sometimes feels like it's cold, but not cold. Very hard to describe.
Today (Wednesday) my right eye has started to feel a bit heavy. There's not yet any sign of actual swelling, but it feels like it's probably started. (Last time, my eye swelled completely shut). It also seems that the rash may have started, as out of seemingly nowhere, there are several very itchy bumps that have begun on my forehead.
Currently, as I am typing this out, the top quarter of the ride side of my face just feels... Weird. There's pain, but also almost a numbness, and it also feels heavy all over that area.
Obviously I intend to make my way to a doctor if the rash is actually a rash, but unfortunately, it will potentially not do me any good because I'm a broke college student and I'll probably be unable to afford the antivirals, though I'll definitely try.
I'm still holding out hope that it's all in my head, that I'm being a hypochondriac and it isn't actually shingles though.
I'm curious for anyone who has had shingles begin on their face, if this description is close to what you had.
Anywho. That's...my long winded rambling rant.

The Book of Vile Darkness is an artifact in DnD dating back to the days of Gary Gygax, first cropping up in 1979 (as far as I am aware). The book was originally written by Vecna, though other sinister mages who have gotten their hands on it since his ascension to godhood have added their own vile spells, rituals, and pieces of arcane history. Incidentally, it's also going to be popping up very soon in my DnD campaign, and I'd love to have a list of 100 things that could be in it should my players choose to delve deep into it's sinister bindings. I'll start us off with the first 9, and y'all can help me fill it in.

1. The book contains information on the proper casting of the ritual to transform one's own self into a lich, including the process of crafting a phylactery, and the best ways to conceal it to ensure your continued survival.
2. The book contains a cook-book style guide on how to craft the best flesh golems, including what meaty bits of what creatures to use, a precise measurement on how much arcane energy should be pumped into the body, and exactly where to connect each piece (like meat Legos!).
3. The book contains the true names of a vast array of devils, yugoloths, dragons, fey, and other creatures with the belief that knowing a being's true name gives you power over it.
4. The book contains a section which acts as a zoological research guide regarding various eldritch horrors from the far realm. There is a clear purpose, intelligence, and intent to the writing, but 90% of it is just nonsense, buzz words, and technical jargon indecipherable to anyone who doesn't already have a grasp of the field.
5. The book contains one of the last remaining guides to casting a 10th level spell, a class of magic forbidden from being cast by the sovereign governing powers of the modern world. The spell requires vigorous preparation to cast, an exorbitant casting time, and an incredible toll on the caster's body, but the end results can be absolutely devastating should it be properly performed.
6. The book contains a slew of curses crafted from a slurry of words in infernal, abyssal, and sylvan dialects, with a range of effects bordering on cruel pranks to serious disfiguration of your enemies, and everything in between.
7. The book contains the means to traverse and map out the Domains of Dread within the shadowfell, revealing clear-cut pathways connecting places like Barovia and Lamordia together which otherwise would be impossible to identify.
8. The book contains the means to craft a tincture which acts as a love potion, though less in the vein of "true love and happiness" and more the in the vein of "obsessive devotion bordering on ritualistic worship".
9. The book contains a section that magically writes and rewrites itself with the passage of time, containing an innumerable number of longggg lists detailing every single immoral, unscrupulous, and downright vile thing each high ranking political figure globally has done over the course of their entire lives, with timestamps.
10. The book contains a detailed, extensive, and convincing philosophical dialogue asserting the moral superiority of self-interest, might-makes-right, and willingness to disregard societal norms to pursue one’s goals. This is often one of the first passages the book’s infinite pages show to a new holder, and the author of the dialogue is listed only as “Myself”. Inspired by u/THEChanger7
11. The book contains an entire section devoted to cannibalism, giving information on how to properly prepare the meat of your own species for consumption. It looks like it was initially a small section devoted solely to humans, but has slowly evolved over many hundreds of years to include a vast selection of recipes and notes critiquing past authors, going through nearly all the various sentient races of the world. Inspired by u/Bub_the_Zombie
12. The book contains an Ikea-style guide on creating an innumerable amount of torture devices, each more devastating than the last. Devices include (but are not limited to) nerve pullers, barbed nerve extractors, trepans (skull drills), dermatomes (designed to harvest sheets of skin), etc. etc. The majority of these devices include side sections detailing how to infuse them with restorative magics, healing or reviving the victims to artificially extend the torture duration. Inspired by u/Bub_the_Zombie and u/Clickclacktheblueguy
13. The book contains a discussion piece weighing the pros and cons of various soul trapping methods, reading like a well-written review judging and evaluating several products made for the same purpose. Methods include but are not limited to soul dissection, a night hag's soul bag, infernal soul coins, etc. etc. Inspired by u/Bub_the_Zombie and u/Ungodly01
14. The book contains, oddly enough, sheet music for a song called the "Caelum Dolor Maximus" (Heaven's Greatest Sorrow in Latin). The song is beautiful, and can automatically corrects itself on the page to be readable by any musician for their preferred instrument. The song was written by an imprisoned fallen angel, and details their fall from grace. Performing the song requires a high DC Performance check to play, and forces all who can hear it to make a high DC Charisma saving throw. Failure of this saving throw drives people into deep states of depression, eventually leading to suicidal ideations. Inspired by u/Bub_the_Zombie
15. The book possesses one, and only one, page with various fractal patterns drawn onto it which appear similar to the letter S. They are clearly drawn with purpose and intent, and seem important. Viewing this page serves as a memetic hazard affecting the subconscious mind; you are compelled, perhaps without even realizing it, to draw the very same S-like shapes on other pages you view or documents you write, which have the same contagious effect on others. This effect is incurable, and permanent. Inspired by u/felagund
16. The book contains various scientific articles from different time periods and geographic regions postulating on the most effective means of eliminating all life in the multiverse in the shortest amount of time possible while also expending the fewest resources. Inspired by u/DonQuixoteDesciple
17. The book contains a scrawled out note, in big letters, sort of a reminder for some malicious mage who held this tome previously. In hastily scribbled text, it reads "DON'T FORGET: HEALING SPELLS CAN BE COUNTERED". Directly under it, in smaller text, it says "that means revivify too!!!". Both notes are underlined several times. Inspired by u/hcsLabs
18. The book contains a detailed guide to psychological manipulation. The earlier portions of this section are effectively a textbook description of malignant narcissism rephrased into a how-to manual, but later on it gets more extreme, explaining how to trigger Stockholm syndrome with 98% effectiveness, how to break a servant’s self esteem and ambition without hamstringing their capabilities, and even an algorithm to determine whether a given atrocity is more likely to break the spirits of the oppressed masses or trigger a revolt. Inspired by u/Clickclacktheblueguy
19. The book contains an incredibly vast list of baby names with the most rude, cruel nicknames for each name listed beneath each one. If you look up your own name, you must succeed on a high DC Wisdom save or become stunned as you are wracked with childhood trauma. You make remake this save every minute, ending the effect on yourself on a successful save. Inspired by u/sonofabutch
20. The book contains a massive ink blot, similarly to a Rorschach test. Gazing upon it and attempting to discern it's shape brings up traumatic memories repressed throughout your life. Attempting your first long rest after gazing upon the Rorschach test fills your dreams with nightmares of the aforementioned traumatic events, preventing you from receiving the benefits of a long rest for that night and giving a point of exhaustion to yourself. Inspired by u/sonofabutch
21. The book contains what is, more than likely, the largest repository of knowledge on poison crafting in existence. It lists out materials, costs, where to find each ingredient, and of course how to combine these ingredients for the most potent effect possible. Inspired by u/sonofabutch and u/oliviajoon
22. The book contains scientific research on what is, in most societies within the realm, considered the ultimate sin: the killing and dissection of celestial beings. Inside you find information detailing the various organs, body composition, and a complete anatomical map of an angel's muscular and bone structure. It further goes into information regarding "scientific tests" on various celestial's resilience and regeneration levels when exposed to certain negative stimuli, to include blunt force trauma, the flaying and removal of flesh and organs, and the effects of poisons or diseases on their bodies. Inspired by u/Erivandi and u/ManCalledTrue
23. The book contains several advanced version of certain enchantment spells, namely those with the ability to impose dominating effects. These upcast versions of these spells are indeed more powerful and potent than their typical sibling spells, but take a greater toll on the caster than just a spell slot; they, slowly, carve away pieces of the caster's humanity. Inspired by u/oliviajoon
24. The book contains a slurry of arcane runes of infernal and, interestingly enough, giant origin, which can be inscribed into the deceased bodies of your foes. This serves a number of uses, to include preventing revival or resurrection, binding the soul of another creature to the body, or turning the decaying cadaver into a ticking time bomb. Inspired by u/SanguineBanker
25. The book contains a cookbook of feasts made to impress extraplanar visitors whom travel to your abode. While it starts harmless, detailing the best ores to bring for dao to snack on or how to properly prepare sushi for a marid, it quickly devolves into controlled mania, detailing how much infant blood to pour for each glass at a feast for devils, the exact temperature your home should be at before you host an ifrit (spoiler: it'll kill you!), and eventually just random eldritch psychobabble for the section of slaadi. Inspired by u/SanguineBanker
26. The book contains information on how to create summoning circles, not for extraplanar beasts or eldritch powers, but for people on the material plane. With this, you could kidnap any person from anywhere, regardless of how well defended they are. There are additional runes which can be placed into the summoning circle to generate additional effects. Just make sure you don't go too crazy on the runes; if they conflict, it could have gruesome results... for the purpose you're summoning. Inspired by u/Ungodly01
27. The book contains a built in defense, a trap of composed of a blot of ink which threatens to suck those into it who do not have pure evil in their hearts. It is unclear how to remove those who are absorbed into the blot from the book, or even where it is they go. Inspired by u/Ungodly01
28. Similarly to the prior notation, the book contains another trap, though this one is specifically designed to inhibit inhabitants of mechanus who may seek to destroy the book. It reads like gibberish, equal parts Shakespearean writing piece and insanely elaborate mathematical equation. This has absolutely no effect on flesh and blood beings, but constructs who read it lose control of their logic core, delving into a state akin to madness before finally suffering the effects of what is essentially a Power Word: Kill spell. Inspired by u/Ungodly01
29. The book contains many dark spells lost to time, the vast majority of which have had sections of them worn away to the point they'd be impossible to replicate, though some do still remain. The Veins of Tar spell is a 4th level transmutation spell available to sorcerers, warlocks, and wizards, which (as an action) instantly transforms the blood of your target to hot molten tar. The spell forces a target to make a Constitution saving throw, or begin taking 1d12 fire damage as well as having their movement speed halved. This spell requires concentration. Inspired by u/Ungodly01
30. The book contains a live devil of decent renown and power trapped within ink. The devil has been there for centuries and is desperate to get out, though his tricksy and malicious nature has been accentuated by the dark dealings of those he has been forced to interact with each time the book is opened. Perhaps finally dealing with kinder souls such as your party's will soften his heart? Inspired by u/Ungodly01
31. The book contains a disjointed collection of pages scattered throughout. Each page is arcanely enhanced with divination magic and precise geolocation capabilities, revealing to the reader every single awful, inhumane thing that has happened in the particular regions it correlates to in the last year in vivid detail, including specific names. Inspired by u/Haydeos
32. The book contains a large number of pages which appear to be a diary. At some point in the book's seasoned history it seems a demon got ahold of it. The demon is of no real renown or significance to the world, and how it got access to the book is a mystery. The sadistic abyssal ramblings go into excruciating detail about various murders and atrocities and tortures the demon had committed over it's life. Inspired by u/Haydeos
33. The book contains many dark spells lost to time, the vast majority of which have had sections of them worn away to the point they'd be impossible to replicate, though some do still remain. The Malignant Light spell is a 5th level evocation spell available to clerics and paladins. This spell can be cast as a reaction to a creature casting a healing spell on a target, transforming the total amount of healing done into necrotic damage. The healing spell initially cast can be of a level no greater than 6th. Additionally, you can cast this spell as a response to your own healing magic. Inspired by u/Haydeos
34. The book contains information on performing a ritual which the world largely believes to be impossible, allowing you to artificially create the virus needed to convert creatures into vampires. What makes this so interesting is it does not require the presence of another vampire, and there is no thrall period; the ritual is perfected in such a way that allows for immediate high-grade vampirism night instantaneously. Inspired by u/bhelhop
35. The book contains research on various elder evils, primordial beings of pure entropy which threaten the existence of the multiverse at large. It seems like the original researcher went a step beyond this however... it seems they were postulating and hypothesizing on means to bring the ones identified to be closest to our plane of existence here, either to extract their power for themselves, or to commit mass genocide on a planar scale. Elder evils include Atropus, Hadar, Father Llymic, and Pandorym. Inspired by u/PumpkinSpiceAngel
36. The book contains (what seems to be) the true story of Graz'zt, Demon Prince of Indulgence. Starting from his life prior to his death and rebirth in Hell, it appears to be a rather well detailed biography of his early days as a devil, his true reasons for defecting to the Abyss, and his true thoughts and feelings regarding Iggwilv, the witch-queen who bound him to her service and with whom he sired children. Such information could be damning to him and his conspirators within the hells who actively plot against Asmodeus.
37. The book contains a very large chunk of pages that have been cleanly removed from within. This would not be strange, if not for the fact that pages which are removed are immediately replace by new blank pages, showing the book's infinite nature. From what little remains of these pages, you can see detailing regarding the abyss and it's inhabitants. Perhaps information on a demon lord, or a hidden layer Demogorgon or Orcus wish to remain that way? Regardless, the pages appear singed by arcane fire, preventing their regeneration. Inspired by u/ManCalledTrue
38. The book contains a beautiful poem, a soliloquy commemorating the rise of Asmodeus, the Horned King, into the realm of divinity. Reading the poem aloud causes one to witness that very event, in all it's infernal glory. Perhaps coincidentally, one of the book's previous owners was found dead, eyes burned out of his sockets, with the book opened to this page. Inspired by u/ManCalledTrue
39. The book contains a yugoloth's bounty list. It appears that the majority of creatures on this list are warlocks who broke their infernal pacts or devils whom those same warlocks are looking to be freed from. The prices listed by many of them are enticingly large, and all list "DEAD" as the broker's preferred end status. Each time a creature on the 100-name-long list perishes, a new contract soon takes it's place. Killing a creature on the list immediately transfers the funds to you directly. Inspired by u/Tommy-Lee-Gio
40. The book contains an entire section devoted to a former author's ridiculously bad fanfiction, detailing a high fantasy erotic romance plot between in which the reader is in a love triangle with Asmodeus and Ygorl, Lord of Entropy. The fan fiction, regardless of it's atrocious subject matter, has innumerable misspellings, is grammatically incorrect, and contains several glaringly obvious plot holes. Inspired by u/InuGhost
41. The book contains, stitched into it's flesh-colored pages, and immaculate treatise writ onto parchment crafted from the golden trees of Celestia. The treatise details numerous things, chiefly among them the good aligned deities list of conditions that would need to be met before Asmodeus would be allowed to to call upon them to aid in ending the Blood War. Players who have a good deal of knowledge regarding the Blood War will be among the first to realize that the the conditions have all been met, many many centuries ago. The treatise has been hidden here, lost to time, in an effort to prevent Asmodeus from receiving aid. This could change everything. Inspired by u/InuGhost
42. The book contains what appears to be a treasure map writ upon tanned human flesh and nailed through several pages in the book. The map seems to lead to some ancient lost treasure hidden by an infamous dreadpirate decades ago. The lands depicted on the map appear strange, with odd topography and naming conventions. A character who succeeds on a high DC Arcana check is able to properly identify that the map depict a section of the planar cosmology unfamiliar to most, up to the DM's discretion: either the Nine Hells, the Abyss, Gehenna, Limbo, or the Far Realm. Inspired by u/pokemonbard
43. The book contains a lengthy passage written in an archaic and lesser spoken dialect of infernal, barely legible to most modern speakers. A literate speaker of infernal who succeeds on a high DC History check can discern, with some difficulty, that this is an ancient manuscript detailing to new archdevils the process of writing powerful binding contracts facilitating and governing the exchange of souls. Given enough time, there is potential you could transcribe this into a more standard format, allowing you to craft your own soul contracts. Inspired by u/pokemonbard
44. The book contains many dark spells lost to time, the vast majority of which have had sections of them worn away to the point they'd be impossible to replicate, though some do still remain. The Soul Grinder spell is a 9th level necromancy spell with the potential to completely destroy a creature's soul, destroying them on a level thought impossible by most scholars. This spell is available to clerics and warlocks. As a reaction to a creature you can see within 50 ft. of yourself perishing, you may begin casting this spell, which takes 1 uninterrupted minute to perform. Successfully completing the casting of this spell immediately destroys the target's soul, preventing resurrection, reincarnation, and ascension to the higher and lower planes. Casting this spell has a steep cost; an emerald worth at least 1000gp, and a fragment of your own soul. You can cast this spell up to three times in your life, and upon completing your third casting you die instantly, unable to be resurrected as your soul is destroyed entirely. Inspired by u/bhelhop
45. The spell contains a list of dark rituals crafted by an author who claims to be Iggwilv, the Witch Queen. The rituals are extensive and strange, all written in a dialect of sylvan primarily spoken by hags, and are absolutely vile. Some of the more interesting rituals within this section include a curse to spread painful misfortune across an entire bloodline, a ritual to convert someone the caster loves into pure arcane energy and use it to boost their own magical potential, and a ritual to summon some far realm horror referred to both as a Dros'khanar and a "Void Dreadnought", described as a terrible amalgam of broken bone, twisted flesh and shadow from the space between worlds. Inspired by u/DracoAdamantus
46. The book contains a single question on a page, with two checkboxes beneath saying "yes" and "no" respectively. The question asks "Do you wish to know what more you could be?". If answered yes, visions of every possible life better than your own you could have lived floods your mind in less than a second, before immediately leaving. Though not physically damaged, such visions destroy any joy you may have had, leaving you to realize how cruelly unfair reality is that you could not be the best version of yourself. You gain the flaw "Life is unfair, so why try? Nothing I do is right anyways.". This flaw is removed upon being targeted by a Greater Restoration spell. Inspired by u/soshp
47. The book contains a subsection that looks like it was, at least at one point, connected to the flesh golem section, before more and more pages filled the space between the two. The subsection contains the precise surgical practices required to extract an intact nervous system from a living humanoid, or rather extricate that humanoids flesh, bones, and viscera. The subsection then explains, in gruesome detail, the science behind how the incredible pain an exposed nervous system is constantly in can be used to power enchantments that animate golems, greatly increasing their ferocity as well as their durability. Inspired by u/monkeymichael117
48. The book contains a chapter discussing the metamorphoses from good to evil as a graph theory problem, where each node on the graph represents a moral dilemma, paradox or compromise that tests the subject's morals (with test results shown from previous tests). The chapter ends with a theorem postulating that a path from absolute good to absolute evil exists for any subject, but the parts with the formal proof have been scratched out. Perhaps you aren't the first people with good in their heart to find this horrid manuscript? Inspired by u/Dryu_nya
49. The book contains instructions and research on what seems to be attempted improvement on the classic chimera creation process, including a ritual that can surgically and conceptually combine two beings into a single creature under the caster's control regardless of creature type. The minds of both creatures are kept entirely intact inside of the bodies while a gestalt enslaved consciousness pilots it at the casters will. The experiments of what happens when two diametrically opposed beings are combined, such as celestials and fiends, are truly maddening. Inspired by u/zenerift
50. The book contains many dark spells lost to time, the vast majority of which have had sections of them worn away to the point they'd be impossible to replicate, though some do still remain. The Temporal Loop spell is a 9th level transmutation spell with the capacity to turn even the most beautiful moment into a prison. This spell is available to sorcerers and wizards. Over the course of 24 hours, you can cast this spell to create a time loop in a selected area no larger than 5 miles. Over the course of these 24 hours you forge a diadem of pure temporal energy, using a casing crafted from pure sapphire worth no less than 3000gp. The diadem is diamond shaped, and about as large as a fist. The time loop ranges from 12am on the day the diadem is hidden within the center of the 5 mile area, going up until 11:59pm the following night. Each day when creatures within the area awake, they perform the same duties they did the day prior, feeling a strange sense of deja vu. If a creature chooses to make a check to attempt to identify the effects, they must instead succeed on a DC 25 Wisdom saving throw. A success on this save allows the creature to properly identify they are in a time loop and that they must break free to continue unto the next day, while a creature who fails cannot realize this (even if informed by another creature who did succeed), they can remake the save each following loop until they do. To end this spell, a creature must destroy the diadem, which has an AC of 18 and 50 hit points. The diadem is immune to divination magic used to determine it's location. Creatures which leave the time loop before the diadem is destroyed are returned to their same position in the time loop the following day. Inspired by u/zenerift

Went down a small rabbit hole (fueled by caffeine) of wanting to know how Dermatomes became established as I've been working with a few radicular low back pain patients recently.
Turns out the dermatome maps we used were developed in the late 19th/early 20th century. JOSPT did an article on it that I glazed through and it went into the history of the development of our Dermatome charts and that with our technological advances we should re visit them.
https://www.jospt.org/doi/epdf/10.2519/jospt.2011.3506
As an alternate question/discussion I'm having some trouble with the biological portion of back injuries and maybe I just haven't read anything new that's come out.
Patient feels 'the pop' in their back, sometimes they were lifting something heavy, sometimes they were sneezing, sometimes they were just getting out of a chair and then varying symptoms of varying intensities appear and they come to see us. This raises several questions. This is pushing pain science and the psychosocial portion aside to focus on the pathology/anatomy of the injury.
If the spine is supposed to be as resilient as we claim it to be how can something as simple as getting out of a chair cause enough pain for someone to come see us? This seems contradictory.
How can we declare possible disc injury or an inflammatory process at certain levels when most people have some sort of disc insult already? Or what if the injury is bilateral but the symptoms are unilateral? What if the symptoms are presenting as single level but there are multiple levels of injury? [I am aware of the story of the patient who got 10 MRIs and over 70 different diagnoses and that imaging/imaging interpretation is not a great science either]
If a patient claims they felt 'the pop' let's say lateral to the spine closer to the iliac crest but has numbness/tingling or some sort of radicular pain in the lower extremity, how does that match up to what we have as evidence?
As a disclaimer I understand that our job is to promote function, movement, encouragement, and education so I would not excuse myself from seeing a patient because I don't understand something.
This discussion comes from a place of curiosity/ignorance because I feel like I'm missing something or we are just faking it till we make it with the evidence we have so far.
What are your theories on the pathoanatomy on LBP based on what you've seen in the clinic even if it's only anecdotal and not necessarily evidence based? I'd love to hear them and your though processes around them.

For the men in the group.
I needed to fix my earlier post.
I had herpes for 2 years now and I get my Outbreaks mostly on Dermatome T12 (pubic bone area) - you can see the Dermatome Map here.
Is there anyone else here with the same phenomenon? Can I assume that outbreaks will never be on pines as they haven't been there for 2 years now?

I lost touch sensation along the T12 dermatome). I felt an odd numbness running my finger along that part of my abdomen which sort of comes around my side and down to near my navel. This was made all the more apparent when I had to use an injectable medication and found I absolutely could not feel injections along that line.
Wondering if this is related to my SFN. Anyone else lose sensation along a single dermatome?
(Dermatome is the medical term for the area of skin innervated by a single sensory nerve as it branches off from the spine. If mapped, these dermatomes make a zebra stripe like pattern.)

So I've been experiencing acute onset sciatica for 2 months, that's down both legs but significantly worse on the right. I was sure it was a disc herniation. MRI says all clear- the only abnormalities on MRI are 3 small (less than 1 cm) tarlov cysts, 1 on S1 on the left, and bilaterally on S2. But my pain maps better on a dermatome over the L5/S1 region and not S2. For example I get foot pain/numbness/tingling not at all in the S2 region on the right. My physio thinks it might be piriformis syndrome because my glutes and piriformis are tight, but does piriformis cause numbness and tingling even after just a few minutes of walking? Stumped as to what's going on. I'm obviously seeing doctors in followup to help with diagnosis but just confused and wondering if others on here have MRI confirmed no disc problems or significant arthritis and what did it end up being? The sciatica is disabling- I'm essentially housebound because I have trouble walking any long distances.

I was diagnosed with vulvodynia, but upon penetration I'm also experiencing a severe shooting pain radiating to my foot (peroneal nerve pain I believe). Based on the dermatome maps I think it may have something to do with my S1-S3 spine but I'm really discouraged because I was given nerve creams but they haven't really helped. Anyone else experience this..? Help!!!

Hey guys, 2nd year student heading to placement soon.
I’d really appreciate it if you guys/gals can give me some advice as to how I can remember my dermatomes and myotomes.
How did you do it? What helped you the most? Did you use any aids to help you?
Your help is very much appreciated!
edit: I also noticed a bit of a conflict when my profs are discussing certain neuro topics with us and everyone has different answers as to which body part the dermatome covers. Is there a standardized one (Keegan and Garret - 1948 —> but apparently this map doesnt translate well clinically.)

Hi,
This is my first post.
I have one leg 3/4” shorter than the other for over 30 years. I’ve been wearing a shoe lift over 30 years.
A few years ago I was picking up a heavy object and felt a pop and experienced instant pain and tingling in my mid to low back only. Within 48-72 hours the pain radiated into oblique muscle and hip.
To this day (years later) my oblique is stuck in a constant inflammatory state with the muscle bulging out, pressing into the skin. Then exactly 10 days following injury the pain went into the groin/testicle.
I have only a small lumbar disc bulge according to a neurosurgeon who doesn’t believe the pain is coming from the spine. The radiology report states “right paracentral disc herniation with 10mm central canal stenosis.”
Land therapy and water therapy didn’t help. I saw several neurosurgeons and they all have the same opinion that it’s probably—probably—not a back problem.
Ortho did MRA which revealed labrum tear. Alpha angle on CT suggests/supports cam deformity.
Low back PT and hip PT didn’t relieve the flank/groin/hip and mid/low back pain.
Is there a way to know if the pain is coming from that herniated disc? I tried to convince the neurosurgeon that the specific disc herniated and where the pain is experienced makes total sense based on a dermatome map.
He wasn’t buying my theory. Neither did the spinal physiatrist. However the pain management doctor believes the pain is discogenic in nature.
When I’m laying in bed totally flat and lift and rotate my leg into the air I get a click in my hip 10 out of 10 times in two different locations. The first pop feels like it’s very near the hip but the location of the second pop is harder to discern.
Just undergo the hip arthroscopy and hope for the best?
Isn’t it true you could MRA 1,000 people and 700 of them would be positive for a labrum tear? Therefore is there a way to confirm pain is labrum tear related and not actually lumbosacral radiculopathy?
And what about the 24/7 years-long inflamed oblique? I’ve never heard of a labrum tear affecting the oblique (L1 innervates our obliques).
And since the origin of the pain was initially only the mid to low back it seems odd this would be a hip injury, no?
Maybe this is a bizarre rare injury unrelated to lumbar spine or hip?
Any ideas most welcome. Thanks a lot. I’ll try to give input to others if I believe what I have to contribute is helpful.

30M, 6'0", 140 lbs, Caucasian, No alcohol/smoking/drugs (prescription or recreational), Pre-existing conditions: GERD.
Primary Complaint: For the past 2.5 months, I have had episodes of mild-moderate burning and/or aching pain on the upper half of my inner right thigh (roughly along the L2/L3 dermatomes, based on the maps I've seen). This pain seems to be tied to an unremitting focal sensitivity and soreness in my upper thing in the inguinal region, roughly within the femoral triangle. There are a few masses in that region that are readily palpable (presumably lymph nodes). I have no sense for whether they are enlarged. While the masses themselves do not seem to be sore, the lower portion of this femoral triangle region does. In addition, if I manipulate the masses in this region even a fairly limited amount, the lower thigh pain recurs within a few hours. In addition, in some instances I can trigger brief but very acute pain by only lightly touching this region (even when pressing more firmly is not acutely painful).
Other Considerations: I have unintentionally lost 6 lbs in the past month. However, as that is the amount of time I have been in COVID-related lockdown, it may not be related. In addition, the pain is unrelated to exercise or activity, and does not clearly respond to low-dose ibuprofen treatment.
Previous Medical Diagnosis: Before the COVID-related lockdown began, I saw my doctor who speculated that this was some form of sciatica as I was experiencing lower back pain at the same time. However, the LBP has now gone away and the thigh-related discomfort has only grown worse. In addition, I was not experiencing soreness in the inguinal region during my last visit, and so no extensive lymph node examination was conducted.
As Boston has a relatively high COVID caseload right now, I am trying to avoid returning to the doctor without a definitive need. Therefore I would appreciate input as to whether you think these symptoms are related to some form of nerve pain, and/or whether the relationship of this pain to inguinal masses may suggest a possibility of malignancy that warrants further in-person evaluation.

Abstract
Introduction: The purpose of this study was to investigate the effect of adding different doses of meperidine to intrathecal hyperbaric bupivacaine on anesthetic characteristics and postoperative pain relief in patients undergoing elective transurethral resection of prostate (TURP) surgery.
Methods: ASA I-III 90 patients undergoing elective transurethral resection surgery with spinal anesthesia were included in this prospective, randomized, double-blinded study. Following a spinal tap, patients were randomly divided into 3 equal groups: In group B; 12.5 mg of 0.5% hyperbaric bupivacaine was given intrathecally. In BM15 and BM30 groups, meperidine with dose of 15 mg or 30 mg was added to 10 mg hyperbaric bupivacaine, respectively.
Results: The maximum sensory block level is T8 in all groups and the duration time to reach to T8 was found shortest in Group B (Compared to Group BM 30 and Group BM 15) (p = 0.029, p = 0.017 respectiveliy). In Group B, motor block level is higher and termination time of motor block is longer compared to both meperidin added groups (p = 0.019, p = 0.022). Sensory block levels of Group BM 15 and Group BM 30 were found longer compared to Group B (p = 0.004, p = 0.006 respectively) and motor block levels of theese groups were found more shorter compared to Group B (p=0,048). In BM15 and BM30 Groups, postoperative pain scores were found lower (p≤0,001) and side effects and complications were similar between theese groups.
Discussion and Conclusion: Combination of hyperbaric bupivacaine with meperidine may offers the advantage of better postoperative analgesia and it may be used as an alternative to pure hyperbaric bupivacaine solution in spinal anesthesia, for TURP surgery.
Keywords: Spinal anaesthesia; Transurethral resection of the prostate; Meperidine.

Introduction

Transurethral resection of prostate (TURP) surgery has still continued to be the gold standard among the surgical treatments applied for benign prostatic hyperplasia (BPH), today [1]. TURP operations, it is more commonly preferred compared to general anaesthesia since it allows the early diagnosis of negativities such as regional anaesthesia fluid loading, bladder perforation, and TURP Sydrome. When the local anaesthetics are used appropriately and attentively in spinal anaesthesia, they have very few side effects. [2-4] Most of the patients who underwent a TUR-P operation are in their advanced ages and have respiratory and cardiac comorbidities. Therefore, it is important for such patients to prevent hypotension, bradycardia, and respiratory distress related to spinal anaesthesia [4]. (4) In order to achieve an efficient anaesthesia for the TUR-P operation, it is required to form the block at T10 level. Insufficient anaesthesia causes additional problems for the patient. Injection of low dose opioids together with local anaesthetics in regional blocks increases the potency of analgesia [5-7].
One of postoperative pain treatment methods is intrathecal multimodal analgesia [8]. It has been shown through experimental studies that the application of analgesia before the surgical trauma may reduce post-traumatic sensitivity and secondary hyperalgesia in the spinal cord [9,10]. For this purpose, multimodal or balance analgesia occupies a significant place recently in the postoperative pain treatment [11,12]. The main purpose of postoperative pain treatment is to reduce and eliminate the discomfort, contribute to the recovery period, reduce the side effects caused by the treatment or control them efficiently and reduce the costs of the treatment. Nowadays, spinal anaesthesia has still maintained its popularity method in lower abdominal, orthopaedic, obstetric and gynaecologic surgeries, elective, emergency or ambulatory surgery [13].
Sensory block level is important for a successful spinal anaesthesia. As is known, sensory block is affected by these factors: baricity, dose, volume, concentration, and injection rate of the local anaesthetic, patient's position, barbotage, patient's characteristics (such as height, body weight, and age) and other adjuvant agents. Among these factors; the baricity of the local anaesthetic which is associated with the patient’s position is defined as the most important factor in the distribution of the local anaesthetic [14]. An undesirable hypotension is encountered as a result of the cardiovascular effect associated with the sympathetic blockage caused by the spinal anaesthesia, and this rate is reported to be 33% in a study [15]. This creates a secondary ischemia risk especially in the advanced age group with high incidence of coronary disease [16]. Considering that most of cases undergoing TURP operations are old patients with low cardiac reserves, this presents importance. Therefore, dose of the local anaesthetic used for protection from hypotension was reduced; however, this time the aimed sensory block could not be reached. Due to this problem, the aimed sensory block was tried to be reached through minimal hemodynamic exposure by providing synergistic analgesia after adding opioid into the local anaesthetic agent used intrathecally [17,18].
The purpose of this study was to investigate the effect of adding different doses of meperidine to intrathecal hyperbaric bupivacaine on anesthetic characteristics and postoperative pain relief in patients undergoing elective TURP surgery.

Materials and Methods

After receiving an ethical committee approval from Ondokuz Mayis University and written consents of patients, a total of 90 male patients between 50-80 years of age and ASA (American Society of Anesthesiologists) I-III undergone elective endoscopic TUR surgery under spinal anaesthesia were included in the study. Patients, who refused the spinal anaesthesia, with motor or sensory deficit and contraindications to spinal anesthesia such as coagulaton disorder and infection at the puncture site were excluded from the study. It was also planned to exclude the patients, who demonstrated insufficient block after the practice, whose preoperative VAS score was 4 and above, or who needed the use of additional analgesic during surgery and were required to be transferred to general anaesthesia, from the study. Preoperatively, 10ml/kg of 0.9% NaCl solution was infused to patients before spinal anaesthesia and no additional premedication was used. In the operating room, standard monitoring including non-invasive arterial pressure, electrocardiography (ECG) and pulse oximetry (SPO2) was established for all patients. Spinal anaesthesia was applied using a midline approach from the 4th-5th lumbar segment in sitting position with a 22 G Quincke type spinal needle (B Braun, Spinocan, Melsungen, Germany). Patients were divided into 3 groups randomly using a computer generated random number table: In group B (n=30); 12.5 mg of 0.5% hyperbaric bupivacaine (Bustesin® Spinal Heavy 0.5%, VEM llaf, Istanbul, Turkey) was given intrathecally.In group BM15 (n=30), 15 mg meperidine (Aldolan®, 100 mg, G.L. Pharma GmbH, Lannach, Austria) and in group BM30 (n=30), 30 mg meperidine with 10 mg of 0.5% hyperbaric was administered intrathecally. Patients' blood pressure, heart rate and oxygen saturation were monitored and recorded every 5 minutes during the operation. While sensory block level was evaluated by using pin prick test, motor block degree was assessed by using Bromage scale. (Bromage scale 0: no motor block; 1: cannot move hip, can move knees and feet; 2: cannot move knees and hip, can move feet; 3: cannot move hip, knees and feet). Disintegration of the motor block was recorded as the period that Bromage scale regressed to point 0. Sensory block's duration of reaching to T8 dermatome, the maximum sensory block level, the maximum motor block level and the duration of reaching to this level were recorded. Surgery was initiated when sensory block formed at T8 level. At the beginning of the surgery, the pain level was scored with VAS scale. After spinal anaesthesia, the decrease of the Mean Arterial Pressure (MAP) above the rate of 25% compared to the measurement before administration or the decrease of systolic blood pressure below 90mmHg considered as hypotension and 5mg iv ephedrine doses were injected in order to bring the blood pressure to normal limits. The decrease of heart apex beat under 40 beats/minute was accepted as bradycardia and atropine doses of 0.5mg were injected in order to increase the heart beat rates above 50 beats/minute. Within the period until the sensory and motor block effects of spinal anaesthesia disappeared; patients were followed up in terms of side effects such as hypotension, bradycardia, nausea, vomiting, uneasiness, and shivering; and problems such as headache, back and leg pain, loss of strength, urination and fecal incontinence until being discharged from the hospital. In the first 24 postoperative hours, VAS scores of patients were assessed for 7 times in post-operative 1st, 2nd, 4th, 6th, 12th and 24th hours with the first assessment being in the hour 0 in the recovery unit; patients who needed additional analgesic, the first minute that the need for analgesic was arisen and the total amount of analgesic used as mg were recorded. 50 mg of dexketoprofen trometamol was administered intravenously to patients who needed analgesic (Leodex 50 mg /2ml ampoules, Bilim llaf, Istanbul, Turkey). SPSS (Statistical Package for Social Sciences) for Windows 19.0 program was used to conduct statistical analyses. Regarding assessment of the data of the study; along with descriptive statistical methods (mean, Standard deviation), Oneway Anova test was used to compare parameters demonstrating normal distribution among groups for comparing quantitative data, and Tukey HDS test was used for the determination of the group that caused difference. On the other hand, Chi-Square test was used to compare qualitative data. While the presence of a difference between groups in terms of VAS was examined by using MannWhitney U-test, changes within groups were assessed by using Friedman test. Significance level was accepted as p<0.05.

Results

The demographic data of patients and surgery periods were found to be similar among groups. It is shown in Table 1. (p>0.05) The maximum sensory block level was T8 in all 3 groups. Sensory block’s duration of reaching to T8 dermatome and the total sensory block duration were 8.4±1.3 minute and 186.8±36.2 minute in Group B; 7.3±0.9 minute and 210.2±41.5 minute in Group BM15; and 6.1±1.2 minute and 231.9±59.5 minute in Group BM30. The durations of reaching T8 dermatome of Group B were moderate higher than Group BM15 (p=0.029) and Group BM 30 (p=0.017). Sensory block duration of Group B was lower than Group BM15 and Group BM30 (p=0.004, p=0.006; respectively). The longest sensory block duration was found in Group BM30. The sensory block duration in Group BM 15 was shorter than Group BM30 and longer than Group B (Table 2). Post-operative average VAS (Visual analogue scale) values were significantly lower in Group BM15 and Group BM30 compared to Group B in second, fourth, sixth and twelfth hours. (p< 0.001) (Table 3) VAS scores were found to be similar in all 3 groups in recovery unit (hour 0) and post-operative 1st and 24th hours (Figure 1).
Our perioperative vital results, MAP; heart rate (HR) values,were recorded separately for all 3 groups. Measurement times of vital results were realised for 6 times with 15-minute intervals. The first measurement time was preoperative value; measurement value right after applying spinal anaesthesia was accepted as minute 0 of the operation. Following measurements were recorded as perioperative results of 0. ,15th, 30th, 45th, 60th minutes. Postoperative results were recorded as 60th, and 70th minutes in the recovery unit. Mean Arterial Pressure (MAP) was similar among the groups in all measurement times (Figure 2). Similarly, heart rate (HR) values have also been found to be similar in all measurement times among groups (Figure 3). Perioperative hemodynamic findings were observed to be more stable in the groups to which intrathecal meperidine was administered as a clinical observation in Groups BM15 and BM30. Especially after spinal anaesthesia was used, the bradycardia and hypotension appearing depending on sympathetic blockage were not observed at all in Groups BM15 and BM30. Postoperative pain scores were significantly low in terms of both statistics and clinical observation in the groups to which intrathecal meperidine was added.
Satisfaction level was very good among all cases and surgeons in Group BM30. One surgeon reported a moderate level of satisfaction and two cases again reported a moderate level of satisfaction in Group B. One surgeon reported a moderate level of satisfaction and patient satisfaction was very good among all patients in Group BM15. Bradycardia and hypotension developed in three patients in the 13th, 16th and 21st minutes of the operation in perioperative Group B, 5 mg ephedrine i.v was administered and fast responses were received. No significant perioperative side effect was observed in other groups. Serious side effects such as nausea, vomiting, itching, and hypotension were not observed in all 3 groups in the postoperative period. Itching complication was observed in only one case in Group BM30 and itching was recovered with administration of 10 mg oral antihistaminic cetirizine. 3 patients needed additional analgesic (10%) in Group BM15 within the first 24 hours in the postoperative period; whereas, only 2 patients (6.6%) in Group BM30 and 18 patients (60%) in Group B needed additional parenteral analgesic.

Discussion

This study has revealed that meperidine added intrathecally in TURP operations ensured a significant hemodynamic stabilisation in the perioperative period and allowed the patient to feel less pain in the postoperative period and therefore ensured a comfortable postoperative period.
In a study conducted by Anaraki et al. [19] 77 cases to undergo open prostatectomy received spinal anaesthesia with hyperbaric lidocaine and half of the cases also received intrathecally 0.3mg/kg meperidine in addition to hyperbaric lidocaine. In the group with a low dose of meperidine; it was observed that there was no difference in terms of hemodynamic stability in the perioprative period; however, there were long painless periods in the postoperative period and blood loss reduced evidently [19]. The study conducted by Anaraki et al., had totally parallel results with our study, because similarly in our study, no difference was observed in terms of hemodynamic stability in groups to which a low dose of meperidine was added; whereas, these groups had a significant advantage in terms of postoperative analgesia (Table 3). In another study conducted by Patel et al. [20] 42 cases, who were planned to undergo endoscopic urological surgery, were divided into two groups; and while one group received intrathecal 0.5 mg/kg 5% lidocaine, the other group received 0.5 mg/kg meperidine intrathecally. The duration of reaching the peak sensory level was found to be significantly short in the group that received lidocaine, and when sensory block termination times and motor block beginning and motor block termination periods were compared, no difference was observed between the two groups. When compared in terms of hemodynamic stability; while the group administered with meperidine was more stabile in hemodynamic aspect, a more significant decrease was observed in mean arterial pressures in the group that received lidocaine and it was observed that there were many patients that needed intervention with intravenous ephedrine [20]. Our clinical observation results showed that hemodynamics were more stabile in groups that received meperidine; because bradycardia and hypotension developed in 3 patients in the group that received 12.5 mg hyperbaric bupivacaine were intervened with 5 mg of ephedrine i.v. In this study, the reason for not finding any significant difference in terms of hemodynamic stability may be associated with the fact that we used hyperbaric agents in all groups. In this study, no bradycardia and hypotension cases that needed intervention with ephedrine were encountered in groups where we added meperidine, because this may be related to the fact that the added meperidine increased bupivacaine baricity even more [21]. In a study conducted by Murto et al., 42 patients to undergo TUR-P operations were divided into three equal groups; one group was administered with 5% lidocaine 75 mg intrathecally, the second group received 0.15 mg /kg meperidine in addition to 75 mg of 5% lidocaine, and the third group received 0.30 mg/kg meperidine along with the same dose of lidocaine. Sensory block's duration of reaching T10 dermatome level was only found faster in the group that received lidocaine, and slower in groups administered with meperidine. In a study conducted by Chun et al., 0.2 mg /kg and 0,4 mg / kg meperidine with 8 mg of 0.5% hyperbaric bupivacaine for 25 cases to undergo TUR-P operation was reported to prevent considerably shivering, which may be a commonly encountered situation of TUR-P operations, in the postoperative period [21]. When Chun et al. [21] compared the group which received only 8 mg of 0.5% hyperbaric bupivacaine with the groups which received meperidine in terms of other side effects, it was observed that there were more itching complication in the group that received meperidine [21]. In our study, only one patient had an itching complication in group BM30, which was recovered by one oral dose of Cetirizine 10mg (Zyrtec®, 10 mg tablets, UCB Pharma, England). In a study conducted by Movafegh et al., [22] 56 patients to undergo an inguinal hernia repair received 15 mg meperidine in addition to 15mg of 0.5% hyperbaric bupivacaine intrathecally and the patients were divided into two equal groups. No premedication was given to the control group while the study group received premedication with 0.1 mg/kg i.v dexamethasone. Possible side effect profiles of the groups (nausea, vomiting, pruritus, and respiratory depression) were observed in the postoperative period. In cases premedicated with dexamethasone, all possible side effects were less observed in the postoperative period and even the patients were reported to have much higher postoperative pain scores [22]. Although it was emphasized that premedication with dexamethasone may not be reliable for every patient (particularly for the patients with diabetes); it was stated that it may have created a synergism with meperidine in the postoperative pain control [22]. In our study, no additional premedication was administered on any of the patients and no serious side effect was observed in all the groups. No respiratory depression was observed in any of 56 cases in the study conducted by Movafegh et al. [22]. Similarly in our study, no respiratory depression was observed among the cases; however when we reviewed the literature, it has been reported that isolated cases have had the respiratory depression with a dose of intrathecal meperidine above 0.5 mg/kg [23].
Comparative studies have been conducted on the elective caesarean section cases related to the use of meperidine as intrathecally isolated or in combination with local anaesthetics. In a study conducted by Kafle, 50 pregnant women who reached the last stage (mature gravida) were divided into two groups and one group received 5% meperidine intrathecally with a dose of 1mgs/kg; whereas, the other group received 5% lidocaine with a volume of 1.2-1.4 ml intrathecally. While pruritus and tendency to sleep were more commonly observed in the group to which meperidine was administered, the hypotension was more commonly encountered in the lidocaine group. The minimum postoperative painless period was 6 hours in the meperidine group; whereas, the postoperative painless period was limited with only one hour in the lidocaine group and therefore, there was a high need for analgesic in the lidocaine group [24]. Similarly, Atalay et al., [25] divided 80 pregnant women, in their term stages among elective caesarean section cases, into 4 equal groups; 10 mg hyperbaric bupivacaine was administered to the first group, 5 mg isobaric bupivacaine and 25 mg meperidine to the 2nd group, and 30 and 35 mg meperidine respectively along with 5 mg isobaric bupivacaine to the last two groups. Hemodynamic stabilities of groups in the perioperative period were noted, and their motor block levels, sensory block levels, side effects such as nausea, vomiting and itching and the Apgar scores of the newborns were compared in the postoperative period by using Bromage scale. Motor block time was found to be better in groups that received meperidine. Postoperative analgesia quality was once again found to be higher in groups that received meperidine; however, no additional benefit was reported when the group receiving 35 and 30 mg meperidine and the group receiving 25 mg meperidine as the lowest dose were compared. Additionally, the group that received a low dose of meperidine (25 mg meperidine) was emphasized to be more advantageous in terms of postoperative side effect profile compared to all groups. These results are in parallel with our study because the group BM15 achieved a postoperative analgesia quality as high as the group BM30, and did not provide any additional advantage in terms of perioperative hemodynamic stability [25]. In a study conducted by YektaŞ [26] for the purpose of intrathecal multimodal analgesia; 100 male cases to undergo inguinal hernia repair were divided into 5 groups that consisted of 20 patients and, 15 mg hyperbaric bupivacaine and 0.5 ml physiological saline solution were administered to the first group, 17.5 mg hyperbaric bupivacaine the 2nd group, 25 mcg fentanyl and 15 mg hyperbaric bupivacaine to the 3rd group, and 2.5 mcg sufentanyl to the 4th group; whereas, the last group received TIVA (Total Intravenous Anaesthesia). When the postoperative pain scores of groups were compared, they were better in the groups, which received fentanyl and sufentanyl (3rd and 4th groups) with the purpose of intrathecal multimodal analgesia, compared to all groups [26]. Similar results were obtained in our study; postoperative analgesia quality was higher in groups in which meperidine was added to intrathecal hyperbaric bupivacaine.
Consequently, low dose of meperidine added to bupivacaine by reducing the hyperbaric bupivacaine dose in TURP operations ensured more reliable hemodynamic conditions in perioperative terms and increased analgesia quality in the postoperative period. Endoscopic urologic interventions are commonly performed on the population of geriatric patients with poor cardiac reserves; therefore, the combination of a low dose of bupivacaine with a low dose of meperidine may be a good option for this patient population. At the same time; it may be an alternative option for lower extremity surgery, inguinal hernia repair, obstetrics and gynaecology for the purpose of intrathecal multimodal analgesia. In our study and in similar studies, it has been reported that the intrathecal use of a high dose of meperidine does not provide any additional advantage; nevertheless future studies are required in order to research the optimum intrathecal dose of meperidine.
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Abstract
Background: Neuraxial techniques are safe and possess many benefits with drawback of short duration of anesthetic action. A small mass of local anesthetic can produce profound and reproducible surgical anesthesia. The present was aimed to compare the clinical efficacy and safety of clonidine versus fentanyl as spinal adjuvant to 0.5% hyperbaric bupivacaine for knee arthroscopy.
Patients and Method:Sixty adult patients of American Society of Anaesthesiologists (ASA) physical status I and II of both genders, aged 18 to 58 years, were randomized into two groups of 30 patients each to receive either with 0.5 ml of clonidine, 30 μg (Group I BC) or 0.5 ml of fentanyl, 25 μg (Group II BF) with 3.5 mL0.5% hyperbaric bupivacaine. Sensory and motor block characteristics and time to first rescue analgesic (i.v. tramadol 100 mg) were recorded as primary end points. Drug related side effects of pruritus, nausea, vomiting and respiratory depression were recorded as secondary outcomes.
Results:The onset of sensory and motor block, cephalic dermatome extension, and the time to two dermatome regression were prolonged in patients of clonidine group with statistical significant difference (p=0.039). Duration of analgesia was also extended in patients of clonidine group (283.00 ± 40.18 min vs 231.50 ± 46.18min in fentanyl group) with statistically highly significant difference. Intraoperative hemodynamic changes were comparable and no medication was required. Mild pruritus observed in 5 patients of fentanyl group. Post spinal shivering, nausea, vomiting and respiratory depression did not occur in any patient.
Conclusion:Clonidine 30 μg as spinal adjuvant to 0.5% bupivacaine was clinically more efficient than fentanyl for potentiating the block characteristics and enhancing the postoperative analgesia.
Keywords: Bupivacaine; Clonidine; Fentanyl; Knee arthroscopy; Subarachnoid block

Introduction

Subarachnoid block is commonly used regional anesthetic technique for patients who require surgical anesthesia for lower extremities, perineum, pelvic girdle or lower abdomen. It may be useful in patients with difficult airway or suffered from co-morbidities of severe respiratory disease. Spinal anesthesia covering the mid-thoracic level yields a contracted small intestine to provide superior surgical conditions in combination with profound muscle relaxation of abdominal muscles.
Local anesthetic reversibly blocks the nerve conduction by blocking the sodium and potassium ion channels in the nerve membrane. Blockade of neural transmission in the posterior nerve root fibres interrupts somatic and visceral sensation and blockade of anterior nerve root fibres prevents efferent motor and autonomic outflow. Thus local anesthetic progressively inhibits the transmission of autonomic, sensory and motor impulses, resulting in sympathetic blockade, analgesia and anesthesia.
Subarachnoid blockade with 0.5% hyperbaric bupivacaine provides sensory and motor blockade for surgeries lasting for about 2 hours but co-administration of spinal adjuvants allow reduction in the required dose of local anesthetics with the advantage of generating the same degree of analgesia. Several adjuvants such as opioids and alpha-2 agonists are used to enhance the onset and duration of spinal anesthesia and sedation along with their ability to provide enhanced post-operative analgesia [1].
The highly lipid soluble drugs such as fentanyl and sufentanil have a more rapid onset than hydrophilic opioids such as morphine. Fentanyl acts primarily as agonist at μ-opioid receptors to produce analgesia of long duration and reduces the systemic toxicity by allowing dose reduction of local anesthetic. But this combination of local anesthesia with opioids may lead to undesirable effects of pruritus, nausea, vomiting, urinary retention and respiratory depression [2,3].
Alpha-2 adrenoceptor agonists are also used as spinal adjuvant. They act on pre-junctional and post-junction α-2 adrenoreceptors in the dorsal horn of spinal cord. Clonidine is a centrally acting selective partial α2 adrenergic agonist and prolongs the duration of sensory and motor blockade by virtue of its ability to decrease sympathetic nervous system outflow. It increases the duration of analgesia, intensify the motor block and prolongs the duration of postoperative analgesia but it can cause hypotension and bradycardia [4].
Addition of clonidine or fentanyl has been shown to be beneficial, based on prior studies. In our place, the practice of spinal anesthesia does not include intrathecal clonidine, though clonidine is freely available. Intrathecal fentanyl is frequently administered but the availability of fentanyl is restricted. The present study may support the prior research of other countries.
The present prospective randomized double blind study was aimed to compare the clinical efficacy and safety of intrathecalclonidine versus fentanyl as adjuvant to 0.5% hyperbaric bupivacaine in patients undergoing knee arthroscopy.

Patients and Method

After approval from Institutional Ethical Committee and written informed consent, 60 adult patients of American Society of Anaesthesiologists (ASA) physical status I and II of both genders, aged 18 to 58 years, weighing 45-85 kg with height of 150-175 cm, scheduled for elective infraumblical surgery under subarachnoid block, were enrolled for present prospective randomized double blind study, conducted at Department of Anaesthesiology and Critical Care, Chattrapati Shivaji Subharti Hospital associated to Subharti Medical college, Meerut, India.
The patients with history of severe cardiac or pulmonary disease, poorly controlled hypertension, morbid obesity, neurologic disease, hepatic or renal dysfunction, metabolic disorders, and deformity of spinal column, bleeding or coagulation disorder, known hypersensitivity to study drugs or using any drug that modifies pain perception or infection at site of lumbar puncture were excluded from study. Refusal to technique and uncooperative patients were also excluded from study.
All patients were admitted prior to day of surgery and were premedicated with tablet alprazolam 0.5mg and tablet ranitidine 150mg on the night before surgery. Six hours fasting was ensured before the surgery.
All selected sixty patients were randomized into two equal groups of 30 patients each according to computer generated random number table. Patients of Group I were given intrathecal 3.5mL of 0.5% hyperbaric bupivacaine with 0.5ml of clonidine (30μg) and patients of Group II were given intrathecal 3.5mL of 0.5% hyperbaric bupivacaine with 0.5ml of fentanyl (25μg). The total volume of drug was kept 4mL to ensure the blinding of study. Study medication was prepared by an anaesthesiologist who was neither aware of the study protocol nor further involved for data collection.
After arrival in the operation theatre, standard monitors for heart rate, electrocardiogram, pulse oximetry and non-invasive blood pressure were attached for monitoring of vitals parameters. Intravenous line with 18 G intracath was secured and lactated Ringer solution was infused at rate of 10mL/kg over 15 minutes, before initiation of subarachnoid block. Patients were instructed on the methods of sensory and motor assessments and were explained regarding the visual analogue scale (VAS) scoring system.
The subarachnoid block was carried out under all strict aseptic precaution in sitting position by midline approach at L2-3 or L3-4 intervertebral space using the 25 G Quincke’s spinal needle. After identification of the correct space, 4 ml of study drug solution was injected slowly according to group allocation. Immediately after intrathecal injection, the patient was made to lie supine and 10° Trendelenberg tilt of table was done to achieve the adequate level of surgical anesthesia (T10 dermatome). All patients were supplemented with 100% oxygen at the rate of 4L/min via the venti face mask.

Sensory and motor blockade characteristics

The subarachnoid block was carried out under all strict aseptic All time intervals were calculated from the time of end of intrathecal injection. The sensory and motor block characteristics were assessed at 2 minute interval till the surgical anesthesia was achieved. The segmental level of sensory block was assessed by pin prick method bilaterally along the mid clavicular line using short bevelled 26 G hypodermic needle. The motor block of the lower extremities was evaluated bilaterally by modified Bromage Scale (0-3): 0 = full movement and able to raise straight leg against resistance; 1= unable to raise extended leg at the hip but able to flex knee; 2= unable to flex the knee but able to move ankle joint; 3= unable to move hip, knee or ankle (no motor activity).
The subarachnoid block was carried out under all strict aseptic The onset time of sensory blockade at T10 dermatome, maximum cephalic dermatome level, and time taken to two dermatome regression of sensory analgesia were recorded. Time taken to achieve complete motor blockade and total recovery time from motor blockade was also recorded. The surgical anesthesia was considered when T10 dermatome was anesthetized.
The subarachnoid block was carried out under all strict aseptic Postoperatively the sensory and motor block levels were assessed at 15 minutes intervals until normal sensations are returned. Duration of sensory analgesia was taken from onset of spinal anesthesia to time of administration of first rescue analgesic, reflected on visual analogue scale (VAS >3).
The subarachnoid block was carried out under all strict aseptic VAS is a psychometric response scale and patients specified their level of pain by indicating a position along a continuous line between two endpoints of 0 -10 where 0=no pain to 10=worst possible pain.

Hemodynamic parameters

The subarachnoid block was carried out under all strict aseptic The hemodynamic parameters of systemic arterial pressure, heart rate, pulse oximetry and electrocardiography (ECG) were monitored preoperatively and then at every 5 minute intervals after initiation of subarachnoid block, till end of surgery and followed by at every 15 minutes interval in postoperative room. For the present study, hypotension was defined as systolic blood pressure of less than 20% of base line value or less than 100 mm Hg. It was treated primarily by increasing the rate of infusion and additionally with bolus of mephenteramine 6mg intravenously if required further. Bradycardia was defined as heart rate less than 60 beats per minute and was treated with intravenous atropine 0.6mg.

Level of sedation

The subarachnoid block was carried out under all strict aseptic The sedation score was evaluated by Ramsay Sedation Scale at every 30 minutes considering the time of giving the study drug as zero. Ramsay Sedation Scale: 1-Patient anxious, agitated or restless; 2. Patient co-operative, oriented and tranquil alert; 3-Patient responds to commands; 4-Asleep but arousable with brisk response; 5-Asleep with sluggish response; 6-Asleep with no response.

Adverse events

The subarachnoid block was carried out under all strict aseptic All patients were observed for pruritus, nausea, vomiting, respiratory depression (defined as respiratory rate less than 10 breaths/ minute), shivering or any other adverse effects. Respiratory discomfort was managed by increasing the flow of oxygen. Nausea and vomiting was treated by intravenous ondansetron (4 mg).
The subarachnoid block was carried out under all strict aseptic After the end of surgery, the patients were shifted to the recovery room and monitored for any changes in vital signs. Postoperative analgesia was monitored at every 15 minutes interval for the 1st hour and then at every 30 minute interval for next two hours. Rescue analgesia was given with inj. tramadol 100mg with ondansetron 4 mg intravenously when VAS score was ≥ 3.

Study Population Size

The subarachnoid block was carried out under all strict aseptic The sample size was calculated with standard computer programme which computed that approximately 23 to 25 patients should be included in each group in order to detect at least clinically significant difference of 30 min in mean duration of postoperative analgesia between the groups for type 1 error of 0.05 with power of 80% and 95% confidence limit. Assuming a 5% drop out rate, the final sample size was set at 60 patients for better validation of results.

Statistical analysis

The subarachnoid block was carried out under all strict aseptic The results obtained in the study are presented in a tabulated manner as Mean ± Standard Deviation (SD) considering the later as the best predictor for statistical analysis. Data was analyzed using Stat graphic centurion, version 16 (Stat point Technologies INC, Warrenton). The demographic data for categorical variables were compared using chi-square test and statistical significance in mean difference was done by using analysis of variance (ANOVA). A p value of 0.05 was considered to indicate statistical significance.

Results

The present study compared the clinical efficacy and safety of clonidine versus fentanyl as spinal adjuvant to 0.5% hyperbaric bupivacaine for subarachnoid block on 60 adult consenting patients. There was no protocol deviation and study was successfully completed. Data of all patients were included for statistical analysis. They were cooperative with subsequent assessment of subarachnoid block characteristics and VAS score.
The demographic data for age, weight, height, BMI, American Society of Anaesthesiologist (ASA) physical status classification and duration of surgery were comparable between the groups

Sensory blockade profile

The subarachnoid block was carried out under all strict aseptic The mean time required to achieve complete sensory blockade was 1.94 ±1.06 min in patients of Group I and 2.45 ± 0.78 min in patients of Group II with statistically significant difference (P=0.039). Mean maximal cephalic dermatome level was comparable between the groups. Mean time for two segment regression was 121.33± 14.31 min in patients of Group I and 102.00 ± 33.05 min in patients of Group II. The duration of two segment regression varied significantly between the groups (p=0.05). Mean duration of sensory analgesia was 283.00 ± 40.18 min with clonidine and 231.50 ± 46.18 min with fentanyl and showed statistically significant difference (P=0.000) (Table 2).
The subarachnoid block was carried out under all strict aseptic Data are expressed as Mean and Standard deviation (SD);*P Value <0.05 is statistically significant; **P value < 0.001 is statistically highly significant.
The subarachnoid block was carried out under all strict aseptic Mean time to achieve complete motor block was 2.8 ± 1.2 min in patients of Group I and 3.5 ± 1.06 min in patients of Group II with statistically significant difference (P=0.021). Mean duration of complete motor block was 242.53±29.32 min in patients of Group I and 188.50±40.06 min in patients of Group II with statistically highly significant difference (P=0.000) (Table2).

Hemodynamic profile

The subarachnoid block was carried out under all strict aseptic The hemodynamic parameters of mean arterial blood pressure, mean heart rate, respiratory rate and oxygen saturation at baseline were comparable.
The subarachnoid block was carried out under all strict aseptic After 5 min of subarachnoid block (SAB), the mean heart rate and mean systolic blood pressure showed gradual decline in patients of both group until after 30 min of SAB [Graph 1,2]. After 5 min of subarachnoid block, the mean arterial pressure of all patients was decreased till 15 min with statistically highly significant difference. Later on, the mean arterial pressure (MAP) became stable in patients of both groups and the difference between the groups was comparable. [Graph 3] Incidence of hypotension and bradycardia during the intraoperative period was minimal and did not require any medical intervention.
The subarachnoid block was carried out under all strict aseptic Sedation score was recorded every 30 min for two hours, considering the time of study drug given as zero. Mean sedation score was 1.063±0.4 in patients of Group I and 1.133±0.50 in patients of Group II, which was comparable (p=0.606), which signifies negligible sedation by clonidine and fentanyl. All patients were calm and cooperative.
The subarachnoid block was carried out under all strict aseptic Mild pruritus was observed in 5(16.7%) patients of Group II which was successfully treated with intravenous inj. phentermine. The respiratory rate in patients of both groups was comparable and no episodes of respiratory depression or tachypnoea occurred in either group. Peripheral oxygen saturation remained well within normal limits with mild fluctuations. No patient suffered from post spinal shivering, nausea, vomiting or respiratory depression. None of the patient needed supplemented analgesia during surgery.

Visual analogue scale

The subarachnoid block was carried out under all strict aseptic Visual Analogue Scale (VAS) in each patient of Group I and II was recorded every 15 minutes for first hour after surgery followed by every 30mins for next two hours. The difference in the intensity of pain was statistically highly significant between the groups. It was higher in patients of Group II. Rescue analgesia was not required in any patient till 3 hours after surgery [Graph 4].

Discussion

Neuraxial anesthetic techniques are preferred for infraumblical surgeries due to rapid onset of surgical anesthesia and complete muscular relaxation. It is beneficial in patients of anticipated difficult airway or suffering from comorbid conditions such as respiratory diseases. The technique is simple, economical, and reproducible with reduction in the incidences of venous thrombosis. The postoperative analgesia can be extended by using spinal adjuvants without affecting their early mobilization.
The subarachnoid block was carried out under all strict aseptic In augmentation strategies wide variety of opioids and non-opioids are used as an adjuvant to subarachnoid block to improve the quality of block and surgical anaesthesia with prolongation of postoperative analgesia. Clinical studies have shown that opioids and alpha 2 adrenergic agonist administered intrathecally were able to relieve visceral pain [5].
The subarachnoid block was carried out under all strict aseptic In present study, 17.5mg hyperbaric bupivacaine was used to establish the subarachnoid block because10mg hyperbaric bupivacaineor less carry a risk of inadequate block as proven by Pederson et al while generous dosages guaranteed the effective surgical anesthesia [6]. In the present study we have used both clonidine and fentanyl as spinal adjuvant to hyperbaric bupivacaine and achieved a comparable higher level of sensory blockade. But the onset and duration of sensory and motor blockade showed statistically significant difference between the groups. The onset of sensory blockade was rapid and duration of sensory blockade was enhanced by clonidine when compared to fentanyl.
The subarachnoid block was carried out under all strict aseptic The clonidine is lipid soluble and easily penetrates the blood–brain barrier to provide effective and extended analgesia by binding to presynaptic C-fibres and postsynaptic dorsal horn neurons. Its analgesic action is a result of decreased release of C-fiber transmitters and hyperpolarisation of postsynaptic dorsal horn neurons. The prolongations of blockmay result from synergism between bupivacaine and clonidine to motor neurons in the dorsal horn. Intrathecal clonidine has antinociceptive action for both somatic and visceral pain.
The subarachnoid block was carried out under all strict aseptic In our study, clonidine in dose of 30μg was chosen which favoured the study of Prabha P et al. [7] They concluded that 30μg of clonidine has significantly increased the cephalic spread and duration of analgesia as compared to bupivacaine alone [7]. This is also supported by the study carried out by Chiari et al. [8]. These authors reported that the risk of hypotension is more with higher dosages of clonidine (150μg).
The subarachnoid block was carried out under all strict aseptic Fentanyl is a lipophilic μ-receptor agonist opioid and intrathecal fentanyl exerts its affect by combining with opioid receptors in the dorsal horn of spinal cord with supra spinal spread to provide good perioperative analgesia. We used 25μg fentanyl in another group as spinal adjuvant to 0.5% hyperbaric bupivacaine for subarachnoid block. Ramchandra VS et al. [9] also concluded that intrathecal 25μg fentanyl to bupivacaine provides good analgesia with less sedation and is a better option where sedation is not desirable [9].
The subarachnoid block was carried out under all strict aseptic In present study, the sensory blockade profile was significantly better in patients with clonidine when compared to fentanyl. Similar results were also observed by Strebel et al. [10] Gecaj-Gashi et al. [11] and Singh et al. [12]. They all reported the rapid onset of sensory block in patients receiving intrathecal clonidine. The mean time of two segment regression and complete sensory blockade was also significantly prolonged with clonidine when compared to fentanyl. This was also in accordance to the study of Tilker et al. [13] who reported that the time taken for regression of sensory block was statistically higher in clonidine group [13].
The subarachnoid block was carried out under all strict aseptic In our study, the duration of postoperative analgesia showed statistically significant extension in patients of clonidine group as compared fentanyl group, which is also supported by the study of Strebel et al. [10] and Tilker et al. [13] The complementary action of local anesthetics and α-2 adrenoreceptors agonists accounts for their profound analgesic properties.
The subarachnoid block was carried out under all strict aseptic Gupta K et al. [14] studied the analgesic efficacy of intrathecal clonidine 30μg versus butorphanol 0.20mg during orthopaedic surgeries. Though both drugs have intensified the sensory block and increased the duration of analgesia but clonidine was considered as better alternative to opioids as spinal adjuvant for orthopaedic surgeries [14]. The onset of motor block was significantly earlier in patients of clonidine group and our results are similar to the studies conducted by Singh et al. [12] Strebel et al. [10] and Gecaj-Gashi et al. [11] However in the study conducted by Tilker et al, the onset time of motor block was comparable in patients of both the groups.
The subarachnoid block was carried out under all strict aseptic In our study, clonidine significantly prolonged the duration of motor block which is also supported by the studies of Elia et al. [15] and Jain et al. [16] who reported 0 pain score in clonidine with bupivacaine as compared to 0.5% bupivacaine alone [16]. The prolongation of the motor block of spinal anesthesia may be the result of binding of α2 adrenoreceptors agonists to the motor neurons in the dorsal horn.
The subarachnoid block was carried out under all strict aseptic Hypotension was observed in 1(3.3%) patient of clonidine group and 3(10%) patient of fentanyl group which was managed by increasing the rate of crystalloid solution infusion and no vasopressor medication was required. It could be due to adequate preloading prior to institution of subarachnoid block. Bradycardia did not occur in either group reflecting the safety of low doses of spinal adjuvant. The results of present study are in accordance with Singh et al [12] & Nazareth et al. [17]. They also reported stable hemodynamic parameters in the groups receiving intrathecal clonidine and fentanyl. No significant changes in the respiratory rate and oxygen saturation were observed in any patients of both the groups.
The subarachnoid block was carried out under all strict aseptic Postoperatively, significantly lower VAS scores were observed in patients receiving intrathecal clonidine, indicating good postoperative analgesic effect. Our results are comparable to those of Strebel et al. [10] Merivirta et al. [18] and Tilkar et al. [13]. There was no incidence of post-spinal shivering, nausea and vomiting in either group. All patients were calm and comfortable.

Conclusion

Clonidine, 30μg as spinal adjuvant to 0.5% bupivacaine was clinically more efficient than fentanyl 25μg for potentiating the subarachnoid block characteristics and enhancement of postoperative analgesia. All patients were calm and cooperative during surgery and no respiratory depression occurred in any patient. The incidences of hypotension or bradycardia were comparable and needed no medical intervention.

Limitation of Study

The present study was conducted on patients with stable cardio respiratory status (ASA I&II). These patients needed spinal adjuvants to enhance the duration of anesthesia with low dosages of local anesthetic drug.
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I have been in severe pain (throughout my body) for over 5 years now. I have paresthesias from head to toe, on every inch of my body. My joints hurt so badly that it feels like there are fire ants inside of them. I've been diagnosed with so many different conditions (that commonly result from Lyme). I've been treated for Lyme before, but it was unsuccessful. I would really appreciate if you guys could look at my symptom/diagnoses history and tell me if it sounds like Neuro-Lyme.
Chronic pain:
I am a 32 yr old male that has suffered with chronic pain in every inch of my body since 2013. I burn, tingle, quiver - all the classic signs of nerve damage/pain. I feel like I am plugged into a large battery all the time. Before I was put on Gabapentin and other nerve/pain meds, I screamed in bed until I was so tired from screaming, I just shivered in my bed. Now, with the enormous amount of meds I am on, it’s a bit better controlled. I was diagnosed with Central Sensitization pain disorder at Cleveland Clinic.
I have no quality of life. I live in my bed, rarely leave the house, walk with a cane, can’t have sex, can’t exercise, can’t go out to eat, can’t stand more than 10 minutes, can’t go to work, can’t drive myself, can’t be driven (while lying on a mattress in the back of a van) more than 30 miles because every little bump in the road feels like a knife in the back, and most anything else a normal 32 year old does.
Herniated Disks/Cord Compression:
Mechanically, I have 8 herniated discs and Degenerative Disk Disease, diagnosed by my neurologist (with concurring opinions from at least four other spine/nerve specialists). The diagnosis was based upon contrasted MRI’s of my entire spine and brain. I’ve been in 5 serious and 1 minor car accident (head on collision, 2 rollovers, hit from behind, and hit another car from behind). I also used to power-lift with very, very heavy weights. My MRIs show minor cord compression in 3 places on my thoracic area, and facet joint changes in my cervical area. However, the neurosurgeons say that it is unlikely the pain is coming from the minor compression because I have it in my thoracic area, and I am feeling numbness/tingling in my arms. So, the dermatomes don’t match up.
Sitting Intolerance:
In 2013 after a 10 hr flight in which I had to sit straight up (as you do on a plane), I felt a horribly painful pressure build up in the lower back of my skull. I then felt that pressure spread to my back, arms, and legs. Finally, the burning in my joints (it feels like fire ants inside all my joints) got so extreme that I had tears coming from my eyes. From that day forward, I have not been able to sit upright in a chair without these symptoms reoccurring. I can only sit in a gravity chair. My question is, is it from the Lyme, or from the minor cord compression?
Exercise Intolerance:
Any time I put forth ANY physical exertion, my symptoms get horribly worse and I am stuck in bed for days. If it is a fall or an accident, my pain increases permanently (not just a “flare”), and my doctors must increase my meds.
Standing Intolerance:
I can only stand for 10 minutes at a time without my back becoming so painful and weak that it cannot hold my body up. I then have to lay in bed for at least 2 hours before I can try standing again. I also use a cane to walk.
High Intracranial Pressure:
I have high intracranial pressure (25 mmHg), tested when I had my last spinal tap.
Ergonomic Accommodations:
I can only sleep in MY bed. It took me years to find a bed that I can actually fall asleep in. It is a firm mattress with a 2 inch memory foam topper. I cannot stay with family for the holidays because I can only sleep in my bed. This last Christmas, I drove down south for Christmas (the car ride was horrible), and we had to travel to 4 different family members houses because I couldn’t sleep in any of the beds. I ended up having to knock myself out with 3 sleeping pills per night because the beds causes me so much pain. I also cannot drive myself. My girlfriend drives me around in a mini-van equipped with a mattress in the back on which I lie. We can drive for a maximum of 30 miles without me feeling like death afterwards.
Falls and Loss of Balance:
My balance is so bad, that my occurrence of falls is increasing. This is a symptom of cord compression. On 3/8/19 I fall backwards into my closet, and immediately, my back (the length of my spine) burned badly and was a bit numb. My right thumb, middle, and ring fingers became numb, and I have severe weakness and loss of pain sensation in my right hand. I cannot light a lighter, write legibly, or make a fist without tremendous effort. Since this injury, my fingers and hands turn blue about once a week. When I run hot water over them, it seems to go away. My right leg now also has severe radiculopathy. Every step I take feels like I am dying. I feel the pain radiating throughout my body, as if I were connected to a large battery, with shocks, burning, pins, and needles from head to toe, including my arms, legs, and groin. I also shuffle as I walk. I shuffle slower than my 80 year old grandpa, except he can exercise and I cannot.
Neurological Lyme Testing & Bartonella:
\*I was initially tested with WB by Quest
Results - IGG: bands 23 & 41 were positive
*Next, I had a WB performed at Igenex.
Results - IGM: band 41 was IND. IGG: bands 23-25, 31, & 39 were all IND, and band 41 was +.
*Finally, my doctor did a spinal tap and tested my CSF (LabCorp I believe)
Results - IGG: bands 18 & 58 were positive
*Next, I was tested for Bartonella through Galaxy labs (considered one of the best for Bartonella testing)
Results: B. Quintana: titer: 1:64 - reactive. B. Henselae: titer: 1:128 - reactive.
Autoimmune Disorder:
I saw an immunologist and did bloodwork, and several markers in my Immunoglobulin Panel were very low. He diagnosed me with CVID (Common Variable Immune Deficiency), for which I received biweekly IVIG infusions). I was on it for 2 years. It increased my immunoglobulin levels to normal, but didn’t help my pain one but. Because it didn’t seem to be doing anything, my LLMD took me off of them.
POTS (Dysautonomia):
My heart is constantly pounding, which I originally attributed to anxiety until I was diagnosed with POTS (Postural Orthostatic Tachycardia Syndrome) with a “tilt-table test” at the Cleveland Clinic. I also have shortness of breath pretty regularly - to the point where I have to stop what I’m doing, catch my breath for about a minute, then proceed to speak. It feels like I’m having panic attacks 24/7, originating in my chest and pulling on all the muscles around it. I find that when I bathe in a hot bath or hot tub, my muscles become so relaxed that my pain decreases noticeably. I’ve had severe, severe anxiety my entire life. However, that still does not explain all my other diagnoses. POTS is a type of dysautonomia. Dysautonomia May be due to spinal cord injury.
High Blood Pressure:
I also have high blood pressure, for which I take 3 bp medications. Even on all these meds, my bp is still elevated. I was also found to have high intracranial pressure, for which I take a deuteric. The intracranial pressure causes nerve pain on my face/top of head, and the deuteric seems to help that pain.
Low Vascularity:
Before I got sick, I was very vascular. It was even commented on, several times, while giving blood on different occasions that my veins were vascular and easy to find a vein to take blood from. Since I’ve gotten sick, my nurses comment how hard it is to find a good vein, and in many occasions they collapse my vein and need to try a new one.
Blurry Vision:
My eyesight is getting worse. No one in my family under the age of 45 has ever needed glasses. I’ve had to get 3 new prescriptions in the last 2 years, and my vision is still getting worse. I was diagnosed with Map-Dot-Fingerprint Dystrophy at the Cleveland Clinic.
Hearing Loss:
My hearing is going in one ear and it “pops” in the other ear. I was diagnosed with premature hearing loss at the Cleveland Clinic, in Ohio.
Treatments Tried:
For the Lyme disease, I tried 6 months of Rocephin (through a picc-line in my neck), intense diets, supplements, cleanses, and heavy metal chelation. For the pain, I've tried myriads of pain/nerve medications, steroid injections, Botox injections, nerve ablations, physical and water therapy, chiropractors (made it worse), massages, acupuncture, psychological therapy to help reduce the pain, TENS units (they help a bit), a pain pump (helps more than oral meds), and more. The meds help to a degree, but my doctors are constantly having to increase the dose (due to pain increase, NOT due to tolerance of the opiates). I know this because I’ve had to increase all my meds, and not just my opiates. Due to my severe sensitivity to activity, I can't do physical therapy properly. I have seen over 30 doctors in the past 5 years, and none have been able to figure out the connection between all these different diagnoses. I have zero family history of any of these diagnoses, so I know it’s not natural. I believe the Lyme/Bartonella has caused many of these health issues (dysautonomia), aside from the herniations (which make sense due to the car accidents).
Thanks for taking the time to read this.
PS. The following are my current medications:
Oral Meds:
-30 mg Oxycodone, 4 x per day (for pain) {2 years}
-200 mg Lyrica, 3 x per day (for pain){4 years}
-800 mg Gabapentin, 2 x per day (for pain){5 years}
-200 mg Carbamazepine, 1 x per day (for pain){5 years}
-100 mg Amitryptaline, 1 x per day {4 years}
-500 mg Chlorzoxazone, 2 x per day per day (for pain){4 years}
-5 mg valium, as needed (usually once every other day) {3 years}
-250 mg Acetazolamide, 3 x per day (to lower my high intracranial pressure){3 years}
-1 mg Guanfacine, 2 x per day (to lower my high blood pressure) {10 years}
-25 mg Metoprolol, 1 x per day (for tachycardia/POTS) {4 years}
-Medical Marijuana for pain{2 years}
Pain Pump (installed July 2018)
-2 mg Morphine per day (for pain)
-30 mcg Clonidine per day (for pain)
-0.30 mg Midazolam per day (for pain)

Hello! Very new here but read through dozens of threads before deciding to ask my question...
I’m 37, in good physical shape, avid mountain biker, hiker, camper, and formerly a very serious weightlifter.
On Valentine’s Day I was lifting when I felt the far-too-familiar sensation of my back “going out”. I’ve had this happen to a degree every 12-18 months for the past 10 years but this started out much more painful, resulted in a trip to the ER and laid me up for a week with severe pain, could barely get in and out of vehicles etc.
March 7th, I was feeling well enough to stretch, so I did some light stretching for about 30 minutes early in the morning. About an hour later my leg began to throb, ache horribly and by the end of that day, I had significant weakness and pins and needles on the outside of my left foot, back of the leg, typical L5/S1 locations according to dermatome maps.
I had an MRI the next week which revealed a 2cm extrusion left L5/S1 and severe foraminal narrowing including severe mass effect on the nerve.
I have had very little pain since March 7th. Most of the time, I would say I am in no pain at all. But, I have persistent weakness that has only slightly recovered and the numbness has never decreased since March 7th.
I had a steroid injection on Monday, April 1st but was told that due to the size of the herniation and the fact that I am experiencing numbness and weakness...they may not do much to help. This far, I have experienced literally nothing from the shots.
So, my question is this...my Dr. says that surgery is the best option to relieve the pressure on the nerve, remove the offending portion of the disc, and open the foramina so my nerve has space. Has anyone else had a Microdisectomy when they are in no pain but are simply weak/numb and did you get the results you were looking for? I am terrified I will have a repeat episode similar to the one in February...it was the worst I have ever been through. But...I don’t want to have surgery if this will either resolve in time, OR if the surgery won’t restore the numbness and weakness because the proverbial ship has sailed.
Thoughts? Experiences? And thank you SO much for this community. Just reading what others have gone through has already helped me so much.

• Adam

Hey.
I'm a current M1 currently in anatomy and am currently workng on the upper limb. I've got a good handle on the dermatomes in this region, but the map of the 10-12 cutaneous nerves and the regions they innervate look foreign to me. Just wandering if anyone has a really good resouce to break it down and what what chord levels go where (or whether it's just brute memorization).
Also if there are any tips for remembering arterial circulation in the UL, it would be helpful.