123. The extended use of otfc forrehabilitation ofchronically painfulshoulder joints

A. Karmarkar1, I. Lieberman2

1Anaesthetic Department, Hope Hospital, Manchester, UK,2Anaesthetic Department, Wythenshawe Hospital,Manchester, UK

Background: Oral transmucosal fentanyl citrate (OTFC) has beenlicensed by FDA for the use in breakthrough cancer pain in 1998.It is contraindicated for acute postoperative pain and in opioid non-tolerant patients. We present a case where it was used successfullyfor the rehabilitation of a painful shoulder following an arthro-scopic sub-acromial decompression.

Case: A 40 years old patient was diagnosed to have a left sidedrotator cuff tear along with swelling of the sub-acromial bursa. Heunderwent an arthroscopic sub-acromial decompression with cap-sular release following which he had good range of movements forthe first two weeks. But then he developed musculoskeletal painand stiffness which was not relieved by simple analgesics, localanaesthetic and steroid injections, nortriptyline and Oxycontin. Hefound it very painful to undergo physiotherapy and the pain wasaffecting his sleep, mood, energy and was unable to work. At thisstage he was referred to the pain clinic and was then commencedon 100 mcg fentanyl lozenge slowly increasing to a 400 mcg loz-enge. He continues to show improvement in his chronic pain andwith the range of shoulder movements.

Discussion: Early physiotherapy is vital after sub-acromial decom-pression in order to prevent fibrosis and stiffness. Pain is the majorfactor preventing the rehabilitation of the shoulder joint. Conven-tional analgesics are sometimes ineffective, cause undesirable sideeffects and their effect may not coincide with the timing of thepainful stimuli i.e. physiotherapy. We used the quick onset andshort duration of action of fentanyl lozenges effectively to coincidewith the onset and duration of the painful stimulus.

Conclusion: Currently OTFC is licensed to be used only for break-through cancer pain but we feel that they might have a wider useprovided they are used safely and appropriately i.e. for short pain-ful procedures.

124. Meningitis following facet jointinjection

S. Brichant, P-Y. Lequeux, P. BredasAnesthesiology, CHU Tivoli, La Louviere, Belgium

Background: The lumbar facet joint may be a significant source ofback pain(1). Facet joint injection of local anesthetics and steroı̈dsare commonly used in chronic pain therapy(2).

Case Report: A 58 year-old female presented with fever, headacheand back pain exacerbation, six days after a paraspinal steroı̈dsinjection performed by her rheumatologist. A lumbar punctureshowed a cloudy CSF and a high leukocytes count but CSF culturewas negative. However, Staphylococcus Aureus grew in thehemocultures. The patient was successfully treated by intravenousceftriaxone. The MRI revealed no lumbar tissue infection.

Discussion: The most common complications of lumbar facet blockare an immediate transient increase in back pain (1), epidural orsubcutaneous abscesses (3), dural puncture and chemical meningism(1) and only one described bacterial meningitis associated with lumbarsubcutaneous infection (3). In our case, the meningitis is very probablyiatrogenic because of the short delay between the puncture and thesymptoms. Besides, Staphylococcus Aureus is responsible for only 5%of meningitis in non iatrogenic conditions (3).

Conclusion(s): This is the first described case of isolated meningitisfollowing lumbar facet joint injection. This invasive technique re-quires a rigorous asepsis during all the procedure from the disin-fection of the skin and the field to the preparation and injection ofdrugs. This case argues for the realization of the facet block only inmedical centers that benefit from the optimal equipment (X-raycontrol, sterility facilities, patient monitoring after the procedure)rather than in any consulting room.

References1. P.Prithvi Raj et al. Facet block and denervation. In: Churchill Livingstone,

editor. Textbook of Regional Anesthesia. Philadelphia, 2002:703-732.2. Alcock E et al. Facet joint injection: a rare cause of epidural abscess formation.

Pain 2003;103:209-103. Gaul C et al. Iatrogenic (para)spinal abscesses and meningitis following injec-

tion therapy for low back pain. Pain 2005;116:407-410

56 Posters • Chronic Pain Management