An alternative approach for lumbar transforaminal epidural steroid injection-Far lateral approach.

INTRODUCTION: Transforaminal epidural steroid injection (TFESI) is one of the nonoperative interventions for lower back pain. In this study, we presented an alternative approach for TFESI, far lateral lateral recess TFESI (FLLR TFESI), which is targeted on lateral recess and anterior epidural space in patients with degenerative lumbar spondylosis-related radiculopathy. TECHNIQUE: Under fluoroscopy, needle entry site and pathway are drawn according to the spinal anatomy. The needle is advanced toward the lateral recess and the needle tip is placed medially to the medial border of the pedicle under anteroposterior view and posteriorly to the posterior border of the upper endplate under lateral view. After checking optimal contrast spread, steroids and local anesthetics are injected. CASE ILLUSTRATION: An 86-year-old woman who suffered from lower back pain with radiculopathy received interventional treatment. Comparing the "traditional" supraneural approach with the FLLR approach, the difference in contrast enhancement to lateral recess is clearly shown. DISCUSSION: Compared to the pre-existing approaches, the FLLR approach may provide better ventral epidural and lateral recess enhancement. Furthermore, with the advanced needle tip, the injectate may enhance not only the at-level nerve root but also the nerve root of adjacent level during their existence in a single injection. With blunt needle usage, no nerve root injury or dura puncture was noted so far. CONCLUSION: FLLR TFESI is a modified fluoroscopic technique targeted on lateral recess and anterior epidural space. However, subsequent trials are needed to confirm its efficacy in pain reduction and the rate of complications.

Effect of the infusion rate of propofol on the onset time of rocuronium.

BACKGROUND: Administration of propofol, especially rapid administration, decreases patient cardiac output (CO) to various degrees. CO might influence the buildup of an effective drug level within the neuromuscular junction and affect the onset time of neuromuscular blockers. The present study aimed to investigate the effects of different infusion rates of propofol on patient CO and the onset time of rocuronium. METHODS: A total of 90 patients were randomly assigned to receive propofol (2.5 mg/kg) at an infusion rate of 480 mg/min (group A), 240 mg/min (group B), or 120 mg/min (group C). After the administration of propofol, rocuronium (0.6 mg/kg) was administered to facilitate tracheal intubation. The Finometer monitor was used to obtain the cardiovascular profile during the induction of general anesthesia. Neuromuscular relaxation was monitored by acceleromyography using the ulnar nerve at the wrist surface and electrodes with repeated single twitches. Onset time was defined as the time from the beginning of rocuronium injection until 95% twitch depression. The onset time of rocuronium in the three groups was compared using analysis of variance with the post-hoc Tukey test. A p-value <0.05 was considered statistically significant. RESULTS: After induction, a significant decrease in CO was observed in group A (21.6% ± 4.6%) when compared with the findings in group B (11.6% ± 4.5%) and group C (9.8% ± 4.6%). The onset time of rocuronium was significantly longer in group A (177.7 ± 17.6 seconds) than in group B (121.3 ± 18.3 seconds) and group C (118.3 ± 12.3 seconds). CONCLUSION: Rapid administration of propofol significantly delays the onset time of rocuronium by altering CO as measured with the Finometer monitor.

Interventional Treatments for Postherpetic Neuralgia: A Systematic Review.

BACKGROUND: Postherpetic neuralgia, a persistent pain condition often characterized by allodynia and hyperalgesia, is a deleterious consequence experienced by patients after an acute herpes zoster vesicular eruption has healed. The pain associated with postherpetic neuralgia can severely affect a patient's quality of life, quality of sleep, and ability to participate in activities of daily living. Currently, first-line treatments for this condition include the administration of medication therapies such as tricyclic antidepressants, pregabalin, gabapentin, and lidocaine patches, followed by the application of tramadol and capsaicin creams and patches as second- or third-line therapies. As not all patients respond to such conservative options, however, interventional therapies are valuable for those who continue to experience pain. OBJECTIVE: This review focuses on interventional therapies that have been subjected to randomized controlled trials for the treatment of postherpetic neuralgia, including transcutaneous electrical nerve stimulation; local botulinum toxin A, cobalamin, and triamcinolone injection; intrathecal methylprednisolone and midazolam injection; stellate ganglion block; dorsal root ganglion destruction; and pulsed radiofrequency therapy. STUDY DESIGN: Systematic review. SETTING: Hospital department in Taiwan. METHODS: Search of PubMed database for all randomized controlled trials regarding postherpetic neuralgia that were published before the end of May 2017. RESULTS: The current evidence is insufficient for determining the single best interventional treatment. Considering invasiveness, price, and safety, the subcutaneous injection of botulinum toxin A or triamcinolone, transcutaneous electrical nerve stimulation, peripheral nerve stimulation, and stellate ganglion block are recommended first, followed by paravertebral block and pulsed radiofrequency. If severe pain persists, spinal cord stimulation could be considered. Given the destructiveness of dorsal root ganglion and adverse events of intrathecal methylprednisolone injection, these interventions should be carried out with great care and only following comprehensive discussion. LIMITATIONS: Although few adverse effects were reported, these procedures are invasive, and a careful assessment of the risk-benefit ratio should be conducted prior to administration. CONCLUSION: With the exception of intrathecal methylprednisolone injection for postherpetic neuralgia, the evidence for most interventional procedures used to treat postherpetic neuralgia is Level 2, according to "The Oxford Levels of Evidence 2". Therefore, these modalities have received only grade B recommendations. Despite the lack of a high level of evidence, spinal cord stimulation and peripheral nerve stimulation are possibly useful for the treatment of postherpetic neuralgia. KEY WORDS: Interventional treatment, postherpetic neuralgia, botulinum toxin, steroid, stellate ganglion block, peripheral nerve stimulation, paravertebral block, radiofrequency, spinal cord stimulation.

Patient-controlled analgesia for background pain of major burn injury.

BACKGROUND: Studies have suggested that intravenous patient-controlled analgesia (IV-PCA) can be used safely for the treatment of background pain in burn patients. However, no comprehensive protocols have been published. How patient or surgical factors correlate with the amount of opioid consumption remains unclear. The aim of this study is to provide an IV-PCA protocol for alleviating pain for burn injuries, and to assess factors correlated with opioid consumption. METHODS: At the Mackay Memorial Hospital, a retrospective analysis from June 27th to October 31st of 2015 was carried out to investigate the use of IV-PCA in relation to the demographic and clinical data of patients who suffered from burn injuries due to a massive explosion of flammable powder. A standardized morphine IV-PCA protocol with rapid escalation was implemented. Variables assessed included age, weight, gender, days of usage, total surface area burned (TBSAB) and operations. RESULTS: Among the 23 patients who received IV-PCA for burn pain control, it was noted that the larger the TBSAB and the higher the visual analogue scale (VAS), the more amount of morphine was consumed. Correlations between morphine consumption positively with weight (P < 0.01), female gender (P < 0.01), severity of injury (P = 0.01), and negatively with receiving operations (P = 0.01) were statistically significant. CONCLUSION: As the daily morphine consumption was positively correlated with TBSAB, VAS, weight, female gender, the use of our IV-PCA protocol was sufficient in the management of background pain for patients with major burn injury.

Treatment by ultrasound-guided local infiltration in adhesion-related abdominal pain and intractable hiccups: A case report.

RATIONALE: Abdominal pain and hiccups secondary to intra-abdominal adhesion are surgical complications that are often treated by painkillers and secondary surgeries with an unsatisfactory therapeutic effect. This study presents a new treatment method that uses ultrasound-guided local infiltration in peritoneal and abdominal wall adhesions in patients with hiccups and abdominal pain. PATIENT CONCERNS: A 62-year-old patient presented to our hospital with a history of intractable hiccups and abdominal pain for 30 years. DIAGNOSES: Her abdominal examination revealed a scar with an approximate length of 10 cm on the abdominal umbilical plane; pressing the right scar area could simultaneously induce abdominal pain and hiccups. Intraperitoneal computed tomography examination clearly demonstrated that the bowel had no obvious expansion. Ultrasonographic examination found that peritoneal motility below the normal peritoneal adhesion regions was significantly slower than in the normal regions. The diagnosis of chronic postoperative pain syndrome was clear. INTERVENTIONS: The symptoms were significantly alleviated by a successful treatment with ultrasound-guided local infiltration in the peritoneal and abdominal wall scar adhesions. OUTCOMES: After 3 stages of hospitalization and 1 year of follow-up, the patient's abdominal wall pain was relieved by approximately 80% and hiccups were relieved by approximately 70%. LESSONS: The above treatment is a useful option for managing abdominal adhesion and accompanying pain or hiccups resulting from abdominal surgery. This method could ease the psychological and economic burden of patients and improve their quality of life.

A Novel Approach for Ultrasound Guided Axillary Nerve Block: The Inferior Axilla Technique.

.

The association between frequent alcohol drinking and opioid consumption after abdominal surgery: A retrospective analysis.

AIMS: It is perceived that patients with a history of frequent alcohol consumption require more opioids for postoperative pain control and experience less postoperative nausea and vomiting than patients without such a history. However, there is scarce evidence supporting this notion. The aim of this study was to assess association between frequent alcohol consumption and opioid requirement for postoperative pain control and occurrence of postoperative nausea and vomiting. METHODS: The medical records for 4143 patients using intravenous patient-control analgesia with opioids after abdominal surgery between January 2010 and September 2013 were obtained, and associations were sought between the cumulative opioid consumption (in intravenous morphine equivalence) per body weight (mg/kg) in the first 2 days after abdominal operation and several demographic and clinical variables by multiple regression analysis. The association between the occurrence of postoperative nausea and vomiting and several demographic and clinical variables was also sought by multiple logistic regression analysis. RESULTS: Frequent alcohol drinking, among other previously reported factors, was associated with increased opioid consumption for postoperative pain control (p < 0.001). The estimate effect of frequent alcohol drinking was 0.117 mg/kg. Frequent alcohol drinking was also associated with decreased risks of postoperative nausea (odds ratio = 0.59, p = 0.003) and vomiting (odds ratio = 0.49, p = 0.026). CONCLUSIONS: Frequent alcohol drinking was associated with increased opioid consumption for postoperative pain control and decreased risks of postoperative nausea and vomiting after abdominal surgery.

Caudal Epidural Block: An Updated Review of Anatomy and Techniques.

Caudal epidural block is a commonly used technique for surgical anesthesia in children and chronic pain management in adults. It is performed by inserting a needle through the sacral hiatus to gain entrance into the sacral epidural space. Using conventional blind technique, the failure rate of caudal epidural block in adults is high even in experienced hands. This high failure rate could be attributed to anatomic variations that make locating sacral hiatus difficult. With the advent of fluoroscopy and ultrasound in guiding needle placement, the success rate of caudal epidural block has been markedly improved. Although fluoroscopy is still considered the gold standard when performing caudal epidural injection, ultrasonography has been demonstrated to be highly effective in accurately guiding the needle entering the caudal epidural space and produce comparative treatment outcome as fluoroscopy. Except intravascular and intrathecal injection, ultrasonography could be as effective as fluoroscopy in preventing complications during caudal epidural injection. The relevant anatomy and techniques in performing the caudal epidural block will be briefly reviewed in this article.

Sonographic tracking of trunk nerves: essential for ultrasound-guided pain management and research.

Delineation of architecture of peripheral nerves can be successfully achieved by high-resolution ultrasound (US), which is essential for US-guided pain management. There are numerous musculoskeletal pain syndromes involving the trunk nerves necessitating US for evaluation and guided interventions. The most common peripheral nerve disorders at the trunk region include thoracic outlet syndrome (brachial plexus), scapular winging (long thoracic nerve), interscapular pain (dorsal scapular nerve), and lumbar facet joint syndrome (medial branches of spinal nerves). Until now, there is no single article systematically summarizing the anatomy, sonographic pictures, and video demonstration of scanning techniques regarding trunk nerves. In this review, the authors have incorporated serial figures of transducer placement, US images, and videos for scanning the nerves in the trunk region and hope this paper helps physicians familiarize themselves with nerve sonoanatomy and further apply this technique for US-guided pain medicine and research.

Treating a patient with intractable paralytic ileus using thoracic epidural analgesia.

Postoperative ileus is considered an undesirable response to major abdominal surgery that leads to discomfort, complications, morbidity, and the prolongation of hospital stays. Although thoracic epidural analgesia has been introduced to prevent and/or reduce postoperative ileus, it is rarely used as a way to treat postoperative ileus. A 65-year-old man developed paralytic ileus after undergoing a colectomy. Despite conservative and surgical management, postoperative morbidity persisted. A continuous infusion of 0.2% levobupivacaine at a rate of 4 mL/hour was administered for 4 days via a thoracic epidural catheter that had been percutaneously tunneled into the T11-T12 epidural space. With this treatment, daily drainage from a nasogastric tube was gradually decreased and flatus was noted. A week later, the patient could start receiving a liquid diet. Therefore, thoracic epidural analgesia can be used to treat or alleviate paralytic ileus.

Specialty differences in the association between health care climate and patient trust.

CONTEXT: Previous studies have suggested that there is a positive correlation between doctors' emotional intelligence (EI) and patients' trust in their attending physicians; however, there is only limited evidence of specialty differences between internists and surgeons for such an association. OBJECTIVES: This study examined the association of nursing director assessments of doctors' EI, outside observer assessments of doctors' health care climate (HCC) in the examining room and patient-rated trust in internists and surgeons. Health care climate refers to a key component in communication and reflects the extent to which patients perceive their health care providers as supporting patient autonomy rather than controlling the provision of treatment. METHODS: In this observational study, 2702 patients seen by 110 internists and 2642 patients seen by 101 surgeons were surveyed in face-to-face interviews by trained nurses in two teaching hospitals in Taiwan. Using hierarchical linear modelling, we examined the association between EI and HCC as well as patient trust in doctors working in the specialties of internal medicine and surgery. RESULTS: We found a significantly positive correlation between doctor EI and patient trust for all patients (p<0.01). In addition, although HCC was positively associated with patient trust for internists (p<0.01), it was not so for surgeons. CONCLUSIONS: We conclude that doctors might benefit from training programmes aimed at improving EI and that differences in patient expectations might be considered when hospitals attempt to evaluate doctors in different specialties.

Difficult removal of an epidural catheter in the anterior epidural space.

When administering postoperative acute pain services, particularly regarding patient- controlled epidural analgesia, difficulties may occasionally be encountered during removal of the epidural catheter. In this report, we present an instance of difficult removal of epidural catheter in a female patient undergoing open reduction and internal fixation of the femoral neck with patient-controlled epidural analgesia as the means of postoperative pain control. The patient had satisfactory analgesia for 3 days; however, during the removal of the epidural catheter, difficulties were encountered and epidurogram revealed that the epidural catheter had become anchored in the anterior epidural space without kinking or knotting. Subsequently, the patient was requested to lie prone on the surgical table with a pillow placed beneath her lower abdomen and catheter removal was tried again. Fortunately, the epidural catheter was removed easily without the need for a guided stylet. We believe that the cause of the difficult removal of the epidural catheter in this case might have resulted from an unusual and unwanted deeper anchorage of the catheter along the anterior epidural space during placement. We also include some discussion on the management of problematic removal.

Ultrasound-guided ganglion impar block: a technical report.

BACKGROUND AND OBJECTIVES: Ganglion impar block is an uncommon procedure that has been performed traditional with fluoroscopy. One approach is the trans-sacrococcygeal approach. Sometimes this can be difficult because the sacrococcygeal joint (SCJ) cannot be readily seen on anteroposterior (AP) and lateral fluoroscopy. This technical report describes the feasibility of ultrasound in assisting ganglion impar blocks. METHODS: We performed ganglion impar block using ultrasound as the primary imaging tool, with fluoroscopic confirmation in 15 patients. We used a linear array transducer (5-12 MHz) to obtain sonographic transverse and longitudinal views at the sacral cornua; we identified the first cleft below the sacral hiatus as the SCJ. Then we inserted a 23-gauge (7 cm in length) needle into the SCJ under sonographic guidance. Then we confirmed proper needle depth by lateral fluoroscopy and injection of contrast agent. RESULTS: In all 15 procedures, we accurately located and passed the needle into the patients' SCJs under real time sonographic guidance. CONCLUSIONS: In cases where the cleft cannot be readily seen on AP and lateral fluoroscopy, we have found ultrasound to be of assistance. Ultrasound does not replace fluoroscopy, because lateral fluoroscopy is still required to establish safe depth, and correct site of injection. However, ultrasound can be helpful when fluoroscopy alone is insufficient.

Intrathecal gabapentin does not act as a hyperpolarization-activated cyclic nucleotide-gated channel activator in the rat formalin test.

BACKGROUND AND OBJECTIVE: Gabapentin, an anticonvulsant with analgesic effect, has been reported to be an activator of hyperpolarization-activated cyclic nucleotide-gated (HCN) channels. In this study, we tested the effect of intrathecal ZD7288, an HCN channel inhibitor, and its interaction with intrathecal gabapentin in the rat formalin test. METHODS: Male Sprague-Dawley rats (250-300 g) with an intrathecal catheter were intraplantarly injected with formalin (5% formaldehyde, 50 microl) in the right hindpaw. Ten minutes before formalin injection, gabapentin (100 or 200 microg) was given intrathecally. ZD7288 (50 microg) was administered intrathecally 10 min before paw formalin injection or intrathecal gabapentin. The paw flinch numbers in 1 min were counted at the first minute and every 5 min for 1 h after formalin injection. RESULTS: Biphasic flinching responses were induced by formalin and monitored at 0-9 min (phase 1) and 10-60 min (phase 2) after formalin injection. Gabapentin (100 and 200 microg), given intrathecally 10 min before formalin injection, attenuated the flinching response during phase 2 of the formalin test. ZD7288 (50 microg), given intrathecally 10 min before formalin injection or intrathecal gabapentin injection, did not attenuate the formalin-induced flinching response or reverse gabapentin-induced analgesia. CONCLUSION: Our data suggest that activation of spinal or dorsal root ganglion HCN channels or both is not involved in formalin-induced pain, and intrathecal gabapentin does not act as an HCN channel activator to achieve its antinociceptive effect in the formalin test.

Premedication with mirtazapine reduces preoperative anxiety and postoperative nausea and vomiting.

BACKGROUND: Mirtazapine is a new antidepressant that blocks 5-HT2 and 5-HT3 receptors. With this receptor profile, it is possible that mirtazapine could provide both anxiolysis and efficacy for postoperative nausea and vomiting (PONV). We therefore tested the hypothesis that premedication with mirtazapine can reduce preoperative anxiety and PONV. METHODS: Eighty female patients with at least two PONV risk factors scheduled for gynecological surgery were enrolled. Dexamethasone 8 mg was given before induction of anesthesia and patients were randomly assigned to group M + D (mirtazapine plus dexamethasone) or group dexamethasone. An oral disintegrating mirtazapine 30 mg or placebo tablet was given 1 h before surgery. Preoperative anxiety level was assessed by a visual analog scale (VAS) before mirtazapine administration and 1 h thereafter. General anesthesia was induced with 1% propofol at the rate of 200 mL/h (until loss of consciousness) and was then maintained with sevoflurane in oxygen and air. An auditory evoked potentials index monitor was used to titrate sevoflurane. The incidence of PONV, the use of rescue antiemetic, complete response, postoperative Ramsay Sedation Scores, and VAS pain scores were assessed 1, 2, and 24 h after surgery and compared. RESULTS: The VAS anxiety scale was lower in group M + D after mirtazapine administration. There were no differences in the induction dose of propofol, the concentrations of sevoflurane during anesthesia, and recovery times between the two groups. The incidence of complete response to PONV over 0-24 h was lower in group M + D (80% vs 50%, P < 0.01). CONCLUSIONS: Premedication with mirtazapine 30 mg reduces the level of preoperative anxiety and the risk of PONV in moderate and high-risk female patients.

Chronic intrathecal infusion of minocycline prevents the development of spinal-nerve ligation-induced pain in rats.

BACKGROUND AND OBJECTIVES: Minocycline is a second-generation tetracycline with multiple biological effects, including inhibition of microglial activation. Recently, microglial activation has been implicated in the development of nerve injury-induced neuropathic pain. In this study, the authors examined the effects of continuous intrathecal minocycline on the development of neuropathic pain and microglial activation induced by L5/6 spinal-nerve ligation in rats. METHODS: Under isoflurane anesthesia, male Sprague-Dawley rats (200-250 g) received right L5/6 spinal-nerve ligation and intrathecal catheters connected to an infusion pump. Intrathecal saline or minocycline (2 and 6 microg/h) was given continuously after surgery for 7 days (n = 8 per group). The rat right hind paw withdrawal threshold to von Frey filament stimuli and withdrawal latency to radiant heat were determined before surgery and on days 1 to 7 after surgery. Spinal microglial activation was evaluated with OX-42 immunoreactivity on day 7 after surgery. RESULTS: Spinal-nerve ligation induced mechanical allodynia and thermal hyperalgesia on the affected hind paw of saline-treated rats. Intrathecal minocycline (2 and 6 microg/h) prevented the development of mechanical allodynia and thermal hyperalgesia induced by nerve ligation. It also inhibited nerve ligation-induced microglial activation, as evidenced by decreased OX-42 staining. No obvious histopathologic change was noted after intrathecal minocycline (6 microg/h) infusion. CONCLUSIONS: In this study, the authors demonstrate the preventive effect of continuous intrathecal minocycline on the development of nociceptive behaviors induced by L5/6 spinal-nerve ligation in rats. Further studies are required to examine if continuous intrathecal minocycline could be used safely in the clinical setting.