Çiðneme kaslarý ve temporomandibular eklemde görülen aðrý, temporomandibular rahatsýzlýklarýn en belirgin semptomudur. Temporomandibular rahatsýzlýklarda meydana gelen aðrýnýn oluþmasýnda birçok faktörün etkili olduðu düþünülmektedir. Yapýlan çalýþmalar hastalýðýn oluþumunda hazýrlayýcý, baþlatýcý ve ilerletici faktörler olduðunu belirtmektedir. Travma, oklüzal uyumsuzluklar, stres, parafonksiyon, hipermobilite, yaþ, cinsiyet ve kalýtým gibi faktörlerin temporomandibular rahatsýzlýklarýn oluþumunda etkili olduðu öne sürülmekle birlikte, etkinliði tartýþmalýdýr. Bu derlemede, eklem içi ve kas kaynaklý temporomandibular aðrýnýn etyolojisi ile ilgili geçmiþ ve yeni görüþler özetlenecektir.

Pain in the masticatory muscles and temporomandibular joint is the main symptom of temporomandibular disorders. The etiology of temporomandibular disorder pain is multifactorial. Several studies have reported that there are predisposing, initiating and aggravating factors contributing this disorder. Although factors such as trauma, occlusal discrepancies, stress, parafunctions, hypermobility, age, gender and heredity has been implicated in the maintenance of temporomandibular disorder pain, there are still controversies for the actualy etiology. This review will summarize the past and current concepts that is related to the etiology of arthrogenic and myogenic originated temporomandibular pain.

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Amaç: Miyofasiyal aðrý sendromu, bir veya birkaç kas ve/veya bað dokusunda bulunan ve tetik nokta denilen hipersensitif bölgelerle kendini gösteren; aðrý, kas spazmý, hassasiyet, sertlik, hareket kýsýtlýlýðý, güçsüzlük ve nadiren otonomik disfonksiyon yapabilen bir rahatsýzlýktýr. Miyofasiyal aðrý sendromunun tedavisinde çeþitli tedavi yöntemleri kullanýlmýþtýr. Bu tedaviler arasýnda germe ve sprey tekniði, tetik nokta enjeksiyonu, kuru iðneleme, çeþitli ilaç tedavileri ve fizik tedavi yöntemlerinin etkinliði gösterilmiþtir.
Gereç ve Yöntem: Çalýþmaya akut miyofasiyal aðrý sendromulu 65 hasta alýndý. Hastalar üç gruba randomize edildi. Ýlk gruba tetik noktalar üzerine tiyokolþikosid merhem, ikinci gruba tetik noktalar üzerine tiyokolþikosid ampul intramuskuler, üçüncü gruba ikisi birlikte uygulandý. Tedaviler beþ gün boyunca yapýldý. Algometrik ve goniometrik ölçümler, vizüel analog skala (VAS) ile aðrý þiddeti deðerlendirimi birinci, üçüncü ve beþinci günde yapýldý.
Bulgular: VAS ile ölçülen aðrý þiddeti birinci günden itibaren monoterapi gruplarýnda, üçüncü günden itibaren tüm gruplarda anlamlý oranda düþtü. Her üç grupta da saða lateral fleksiyonda anlamlý düzelme gözlenirken, kombine tedavi grubunda sola lateral fleksiyonda anlamlý düzelme saptanmadý.
Sonuç: Tiyokolþikosid, miyofasiyal aðrý sendromu tedavisinde kullanýlabilir ve merhem formu özellikle enjeksiyon uygulanamayan hastalar için iyi bir alternatif oluþturabilir.

Objectives: Myofascial pain syndrome is a disorder characterized by hypersensitive sites called trigger points at one or more muscles and/or connective tissue, leading to pain, muscle spasm, sensitivity, rigor, limitation of movement, weakness, and rarely, autonomic dysfunction. Various treatment methods have been used in the treatment of myofascial pain syndrome. Among these, stretch and spray technique, trigger point injection, dry needling, pharmacological agents, and physical therapy modalities have been proven effective.
Methods: Sixty-five patients with acute myofascial pain syndrome were recruited into the study. Patients were randomized into three groups. The first group received thiocolchicoside ointment onto the trigger points, the second group received 8 mg thiocolchicoside intramuscular injection to the trigger points, and the third group received both treatments. Treatment was applied for 5 consecutive days. Algometric and goniometric measurements and pain severity assessments with visual analog scale (VAS) were repeated on the first, third, and fifth days of the treatment.
Results: Pain severity measured with VAS significantly improved after the first day in the mono-therapy groups and after the third day in all groups. While significant improvement was observed in all three groups in right lateral flexion measurements, no significant changes were observed in the combined treatment group in left lateral flexion measurements.
Conclusion: Thiocolchicoside can be used in the treatment of myofascial pain syndrome. The ointment form may be a good alternative, particularly in patients who cannot receive injections.

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Bu çalýþmada, miyofasiyal aðrý sendromlu (MAS) hastalarda non-invazif teknikler olan transkütanöz elektriksel sinir stimülasyonu (TENS) ve lazer tedavileri ile invazif teknikler olan lidokain ve botulinum toksin-A tetik nokta enjeksiyonlarýnýn etkinliði karþýlaþtýrýldý.
Çalýþmaya Fýrat Üniversitesi Hastanesi Algoloji polikliniðine baþvuran ve MAS tanýsý konulan 100 hasta alýndý. Hastalar rastgele 25’er kiþilik dört gruba ayrýldý. Birinci ve ikinci gruba bir ay boyunca sýrasý ile 60 seans TENS ve 20 seans lazer tedavisi, üçüncü ve dördüncü gruba ise lidokain ve botulinum toksin-A tetik nokta enjeksiyonu uygulandý. Lidokain, her hasta için haftada 2 kez olmak üzere toplam 8 kez ve her tetik nokta için %1’lik lidokain solüsyonundan 2 ml (20 mg) yapýldý. Botulinum toksin-A ise her hasta için bir kez olmak üzere her tetik noktaya 25 U (0.5 ml) yapýldý. Hastalarýn aðrý deðerlendirmesi baþlangýç, 15., 30. ve 45. günlerde olmak üzere vizüel analog skala (VAS), palpabl kas spazmý derecelendirmesi (PKSD) ve anesteziyometre ölçüm yöntemleri ile yapýldý.
Gruplar arasýnda yaþ, cinsiyet ve eðitim düzeyleri açýsýndan istatistiksel olarak anlamlý bir farklýlýk yoktu. Tedavi sonrasý VAS, PKSD ve anesteziyometre skorlarýnýn hepsinde, botulinum toksin-A tetik nokta enjeksiyon tedavisinin lidokain tetik nokta enjeksiyonu, TENS ve lazer tedavilerine göre istatistiksel olarak daha olumlu sonuçlar verdiðini tespit ettik.
Sonuç olarak, botulinum toksin-A tetik nokta enjeksiyonunun, lidokain tetik nokta enjeksiyonuna ve non-invazif tedavi yöntemlerinden TENS ve lazere göre daha etkili olduðunu düþünmekteyiz.

The efficiency of non-invasive techniques including transcutaneous electrical nerve stimulation (TENS) and laser treatments and invasive techniques including lidocaine and botulinum toxin-A injection, in the patients with myofascial pain syndrome (MPS) were compared in this study.
Hundred patients who admitted to Firat University Hospital Pain Department and who were diagnosed as MPS were included in the study. Patients were randomized into four groups and each group consisted of 25 patients. 60 sessions of TENS and 20 sessions of laser treatments were performed to the first and second groups, respectively. Lidocaine and botulinum toxin-A were injected to the third and fourth groups, respectively. 2ml (20 mg) %1 lidocaine was injected to each patient twice a week for one month in Group I. 25 U (0.5 ml) of botulinum toxin-A was injected to each patient only once in Group II. Pain was evaluated with visual analogue scale (VAS), palpable muscle spasm scoring (PMSS) and anesthesiometer at baseline, 15, 30 and 45 days.
There was no statistically significant difference between the groups with respect to age, sex and education level. Pain control was statistically better in Group III compared with the other groups with respect to VAS, PMSS and anesthesiometer scores.
In conclusion, botulinum toxin-A injection provided better pain control when compared to trigger point injection with lidocaine and non-invasive techniques including TENS and laser treatments.

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Amaç: Eriþkin hastalarda ameliyat öncesi uygulanan lornoksikam ile tramadolün tonsillektomi aðrýsý üzerine etkinliði deðerlendirildi.
Gereç ve Yöntem: Prospektif, çift kör, randomize ve klinik çalýþma, Gazi Üniversitesi Týp Fakültesi Kulak Burun Boðaz Cerrahisi Ameliyathanesinde ASA I-II, 18-55 yaþ arasý, kadýn ve erkek 40 olguda gerçekleþtirildi. Tonsillektomi hastalarý iki gruba ayrýldý. Grup L’deki hastalara 8 mg lornoksikam ve Grup T’deki hastalara 50 mg tramadol genel anestezi indüksiyonundan hemen önce intravenöz yolla uygulandý. Anestezi indüksiyonu ve kontrollü ventilasyon altýnda sürdürülen anestezi idamesi (propofol, atraküryum, nitroz oksit ve sevoflurane) ve cerrahinin tipi standardize edildi.
Bulgular: Anestezi sýrasýnda arter basýncý ve kalp atým hýzý monitorize edildi. Ameliyattaki kanama miktarý ayný operatör tarafýndan 5 nokta skalasý kullanýlarak ameliyat sonunda deðerlendirildi. Ameliyattan sonra yutkunma sýrasýndaki aðrý hastanýn hangi gruba dahil olduðunu bilmeyen araþtýrmacý tarafýndan postanestzi bakým odasýna geliþte (T0), 30. dakikada (T1), 1. saatte (T2), 2. saatte (T3), 3. saatte (T4), 4. saatte (T5), 5. saatte (T6) ve 6. saatte (T7) deðerlendirildi. Ameliyat sonrasý ilk 6 saatte VRS ≥2 olduðunda 1mg.kg-1 im meperidin ilave analjezik olarak yapýldý. Ameliyat sonrasý ilk 6 saatteki yan etkiler (bulantý kusma ve ameliyat sonrasý kanama) kaydedildi. T1 ve T2 aðrý skorlarý Grup T’de Grup L’den yüksek bulundu (sýrasýyla p=0.049, p=0.007). Ýlk 6 saatte ilave analjezik gereksinimi olan olgu sayýsý Grup L’de Grup T’den düþük bulundu. Bulantý kusma, ameliyattaki ve ameliyat sonrasý kanama verilerinde gruplar arasýnda fark bulunmadý.
Sonuç: Eriþkin hastalarda, posttonsillektomi aðrýsý üzerine ameliyat öncesi uygulanan 8 mg lornoksikam 50 mg tramadolden daha etkin, yan etkileri ise benzerdir.

Objectives: This study assessed the efficacy and adverse effects of preoperatively administered lornoxicam versus tramadol in adults, for post-tonsillectomy pain.
Methods: This prospective, double blind, randomized, clinical research was performed in the Ear, Nose and Throat Surgery Room in the Department of Anesthesia and Reanimation, Gazi University Faculty of Medicine. Forty American Society of Anesthesiologists (ASA) status I-II patients of both gender, aged 18-55 years, were included.
Results: Tonsillectomy patients were divided into two groups: Those in Group L received 8 mg lornoxicam and in Group T received 50 mg tramadol intravenously just before induction of general anesthesia. Induction and maintenance of anesthesia (propofol, atracurium, nitrous oxide and sevoflurane) were standardized. Heart rate and systolic and diastolic arterial pressure data were monitored during the anesthesia. Intra-operative bleeding was scored by the same operator using a 5-point scale at the end of the surgery. Postoperative pain on swallowing was scored by a blinded anesthesiologist using Verbal Rating Scale (VRS) on arrival in the Post Anesthesia Care Unit (T0), at 30 min (T1), 1h (T2), 2h (T3), 3h (T4), 4h (T5), 5h (T6), and 6h (T7) thereafter. During the first postoperative 6 hours, when VRS ≥2, 1mg.kg-1 im meperidine was used as a rescue analgesic. Adverse effects in the postoperative 6h period were noted. T1 and T2 pain scores in Group T were higher than in Group L (p=0.049, p=0.007, respectively). The number of patients requiring rescue analgesics during the first 6 hours in Group L was lower than in Group T. Nausea-vomiting, bleeding and postoperative hemorrhage values were similar between Group L and Group T.
Conclusion: Preoperative 8 mg lornoxicam was more effective than 50 mg tramadol with respect to early postoperative tonsillectomy pain in adult patients, and side effects were similar.

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Spondilodiskit, iyatrojenik giriþimler sonrasý geliþebilen ve göz önünde bulundurulmasý gereken ciddi ve önemli bir klinik sorundur. Transrektal ultrasonografi (TRUS) eþliðinde yapýlan prostat biyopsisi sonrasýnda spondilodiskit çok nadir olarak görülmektedir. TRUS eþliðinde yapýlan prostat biyopsisi sonrasýnda ciddi sýrt aðrýsý, intermitant yüksek ateþ, iþtahsýzlýk ve yorgunluk semptomlarý geliþen 70 yaþýndaki hastaya yapýlan klinik, laboratuvar ve radyolojik deðerlendirme sonucunda spondilodiskit (T6-7) tanýsý konuldu ve cerrahi olarak tedavi edildi. TRUS eþliðinde yapýlan prostat biyopsisi çok sýk kullanýlan bir yöntem olmakla beraber, bu giriþimden sonra ani baþlayan sýrt veya bel aðrýsýnda spondilodiskiti göz önünde bulundurmamýz açýsýndan bu olgu sunuldu.

Spondylodiscitis is a serious and important clinical problem that can occur after iatrogenic interventions and should be kept in mind. Spondylodiscitis after transrectal ultrasonography (TRUS)-guided prostate biopsy is an extremely rare complication. A 70-year-old patient who presented with severe back pain, intermittent high fever, loss of appetite, and fatigue following TRUS-guided prostate biopsy was diagnosed with thoracic spondylodiscitis (T6-7) after clinical, laboratory and radiological assessments and he was treated surgically. We present this case to remind medical professionals to keep spondylodiscitis in mind in the presence of sudden onset back and low-back pain, since TRUS-guided prostate biopsy is a frequently used procedure.

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The use of ultrasound provides clinicians the ability of doing nerve blocks that would not be feasible with the aid of nerve stimulator alone. It is helpful when motor response to nerve stimulation is difficult or even impossible to evaluate in cases like arthrodesis, total absence of a joint or already blocked extremity during ongoing surgery. A 28 years old ASA I female patient presented for right forearm surgery for nerve and tendon injury due to trauma. She had an ultrasound guided lateral sagittal infraclavicular block (LSIB) using a relatively low dose local anesthetic mixture (10 ml of lidocaine 2% and 10 ml of 0.75% levobupivacaine). Twenty minutes after block pain free surgery started. Two hours after the start of surgery patient had some pain on surgical site. Instead of converting to general anesthesia we decided to supplement the block with the guidance of ultrasound. Using LSIB technique 10 ml of lidocaine 2% was administered directly posterior to axillary artery. Patient was pain free within a few minutes and surgery was completed uneventfully within 45 minutes. Although incomplete blocks before surgery starts can be supplemented by different means, intraoperative pain perception often results in conversation to general anesthesia. We believe that with the aid of ultrasound guidance intraoperative block supplementation is possible thus the need to convert to general anesthesia during prolonged surgery or incomplete blocks can be avoided during hand surgery.

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