Lumbosacral paraspinal interfascial plane blocks for pain control after feminizing genital gender affirmation surgery.

Aim: Feminizing genital gender affirmation surgery (fgGAS) is increasing in prevalence in the USA. Management of postoperative pain following fgGAS is challenging. We report a series of patients where post-fgGAS pain was adequately controlled with paraspinal blocks. Materials & methods: This is a case series of three patients who received bilateral lumbar and sacral erector spinae plane blocks after fgGAS. Block techniques, medications administered, opioid requirements and pain scores were reviewed. Results: Erector spinae plane blocks provided adequate analgesia for 24-48 h following the block. Conclusion: Currently, there are two regional anesthetic techniques described for the treatment of postoperative pain after fgGAS. We describe two additional approaches as options for improved pain management in this patient population.

Relief of Secondary Headaches with High Thoracic Erector Spinae Plane Block.

Intractable headaches can be debilitating, often leading to significant distress, prolonged medical treatment, and unanticipated hospital admissions. There have been significant advances in the treatment of primary intractable headaches such as migraines, tension headaches, and cluster headaches beyond medical management. Treatments may now include interventional strategies such as trigger-point injections, peripheral nerve stimulators, or peripheral nerve and ganglion blocks. There are few studies, however, describing the use of interventional techniques for the management of intractable secondary headaches, including those attributed to injury or infection. A new regional anesthetic technique, the erector spinae plane (ESP) block, was initially used for neuropathic thoracic pain. ESP block has since been reported to provide acute and chronic pain relief of the shoulder, spine, abdomen, pelvis, thorax, and lower extremity. Additionally, there has been one case report to describe the use of the ESP block in the treatment of refractory tension headache. We report four cases of effective analgesia for intractable secondary headache resistant to medical management with high thoracic ESP blocks. In each case, the ESP block provided instant pain relief. We suggest that the findings of this case series indicate that the ESP block may be a useful intervention in patients with severe secondary headache or posterior cervical pain where conventional therapies have limited success, though more studies are necessary.

T4 Erector Spinae Plane Block Relieves Postdural Puncture Headache: A Case Report.

Postdural puncture headache (PDPH) is a common complication of neuraxial anesthesia. The gold standard treatment for PDPH is an epidural blood patch (EBP). However, the risks of EBP, and patient willingness to undergo another attempted neuraxial procedure, can prevent patients from receiving this treatment. The erector spinae plane (ESP) block has been used in the treatment of acute postoperative and chronic pain secondary to many indications at many vertebral levels, and a prior case series describes two patients in which ESP block relieved tension headache. In our case report, we describe a novel use of the ESP block at the fourth thoracic vertebral level to relieve PDPH in a super morbidly obese patient with two prior inadvertent dural punctures.

Recent technological advancements in regional anesthesia.

Just two decades ago, regional anesthesia was performed blindly with dubious outcomes and little support from surgeons and patients. Technological advances in regional anesthesia have revolutionized techniques and largely improved outcomes. Ultrasound (US) technology continues to advance and has become more affordable. Improvements have come in the form of picture quality, resolution, portability, and smaller equipment. The US technology can identify otherwise unrecognized pathology and can help to optimize patient flow by allowing for more accurate triage and effective treatments and providing timelier interventions. In recent years, several different strategies to help improve and ease US-guided needle identification and placement have been developed, including magnetically guided needle US technology. Three-dimensional (3D) and four-dimensional (4D) US use is another potential way to help improve first-pass success and limit patient harm for regional anesthetics. The advent of echogenic needles and the resulting improvement in needle visualization under US has had a positive impact on physician comfort in performing regional anesthesia and on visualization time of the needle during US-guided procedures. To reduce variability and to reduce the anesthesiologist's workload, the use of robots in regional anesthesia has been assessed in recent years. Peripheral nerve stimulation (PNS) has also demonstrated efficacy in acute and chronic pain settings. Additional research and randomized controlled trials are necessary to evaluate novel technologies.

A phase 2a study of toreforant, a histamine H4 receptor antagonist, in eosinophilic asthma.

BACKGROUND: Data from preclinical and clinical studies support the evaluation of histamine 4 receptor antagonists in the treatment of asthma. Toreforant is a selective histamine 4 receptor antagonist that could be effective in patients with eosinophilic asthma. OBJECTIVE: To evaluate the efficacy and safety of toreforant in patients with eosinophilic, persistent asthma that was inadequately controlled despite current treatment. METHODS: In this phase 2a, multicenter, randomized, double-blinded, parallel-group, placebo-controlled, proof-of-concept study, 162 eligible patients were randomized (1:1) to placebo or 30 mg of toreforant once daily through week 24 and followed for 4 weeks. The primary end point was change from baseline in pre-bronchodilator percent-predicted forced expiratory volume in 1 second at week 16. Secondary end points included change from baseline at week 16 in postbronchodilator percent-predicted forced expiratory volume in 1 second, Asthma Control Questionnaire scores, weekly averages of Daytime and Nighttime Asthma Diary Symptom Scores, and weekly average of number of puffs in a day that rescue medication was used. RESULTS: There was no significant difference between groups in pre-bronchodilator percent-predicted forced expiratory volume in 1 second at week 16 (difference in least-square means -0.19%; 95% confidence interval -3.01 to 2.64; P = .90). Similarly, there were no significant differences between groups at week 16 in changes from baseline in the secondary end points (P ≥ .30). Toreforant was generally well tolerated. No deaths or serious adverse events were reported at any time point. CONCLUSION: Toreforant, at the dose tested, failed to provide therapeutic benefit in this population of patients with uncontrolled, eosinophilic, persistent asthma. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01823016.