Does a Positive Response to Transforaminal Epidural Steroid Injection Identify Patients Who Can Avoid Surgery for Two Years?

Background: Transforaminal epidural steroid injection (TFESI) is widely used to manage lumbar radiculopathy. In clinical settings, patients often undergo repeated transforaminal epidural injections with or without steroid administration. Objectives: To examine whether a positive response to TFESI at the first month, can in clinical settings, identify patients with radiculopathy who can avoid surgery for two years. Study Design/Setting. This prospective observational study was conducted at an academic medical center. Methods: Individuals aged ≥20 years who had been referred to our pain center by spine surgeons were enrolled. All patients were assessed using the Numerical Rating Scale (NRS) at baseline and 1 month after the first TFESI. Patients were divided into two groups according to the NRS decrement: the positive response (PR) group achieved a ≥2.0 decrease on the NRS 1 month after the first TFESI compared to baseline and the no response (NR) group achieved a <2.0 decrease on the NRS. The incidence rates of surgery over two years were compared between the two groups. In addition, we calculated the hazard ratio of the PR group to the NR group regarding the incidence of surgery over two years using the Cox proportional hazard model, adjusting for baseline NRS. Results: Seventy-six patients completed the two-year follow-up. In total, 8 and 68 patients had bilateral and unilateral radiculopathy, respectively. The PR and NR groups included 35 and 41 patients, respectively. The rate of surgery avoidance was 85.7% and 73.2% in the PR and NR groups, respectively. This difference was not statistically significant (p=0.26). After adjusting for baseline NRS, the hazard ratio of the PR group to the NR group regarding the incidence of surgery within two years was 0.35 (95% confidence interval: 0.11-1.11, p=0.08). Conclusion: A positive response to TFESI may not identify patients who can avoid surgery for two years.

Prevalence and associated factors of disability in patients with chronic pain: An observational study.

ABSTRACT: The primary treatment goal of patients experiencing chronic pain has shifted from pain reduction to functional status improvement. However, the prevalence of disability and its associated factors in patients with chronic pain remain unknown.Individuals aged ≥50 years who visited the Pain Center at Nara Medical University with chronic pain from June 2019 to May 2020 were eligible for enrollment. Patients were asked to complete the Japanese version of the 12-item World Health Organization Disability Assessment Schedule 2.0. Patient demographics, pain intensity, level of catastrophizing, anxiety, depression, and exercise habits were assessed. Multivariate logistic regression analysis was used to identify the factors associated with disability.Of the 551 patients with a median age of 73 years, 51.5% experienced disability. Fixed factors such as age (odds ratio [OR], 1.03; 95% confidence interval [CI] 1.01-1.06, P = .002) and lumbar and lower limb pain (OR, 3.10; 95% CI, 1.83-5.24, P < .001) and some modifiable factors, including anxiety (OR, 2.06; 95% CI, 1.06-3.98, P = .03), depression (OR, 3.62; 95% CI, 1.92-6.82, P < .001), pain catastrophizer (OR, 2.94; 95% CI, 1.88-4.61, P < .001), numeric rating scale at the most painful site (OR, 1.29; 95% CI, 1.18-1.42, P < .001), exercise habits (walking (OR, 0.52; 95% CI, 0.33-0.83, P = .006) and working out (OR, 0.58; 95% CI, 0.34-0.99, P = .046), were found to be independently associated with disability.This cross-sectional study revealed a high prevalence of disability in patients with chronic pain and identified the factors associated with disability.

The short-term effect of COVID-19 pandemic on disability, pain intensity, psychological status, and exercise habits in patients with chronic pain.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has affected the lives of people worldwide. The first declaration of a state of emergency in Japan, based on the Act on Special Measures for the Prevention and Control of the Novel Coronavirus, was issued from 16 April 2020 to 14 May 2020 to reduce person-to-person contact. Restrictions on going out, participating in community activities, and visiting hospitals were in place. This study investigates the short-term effects of the COVID-19 pandemic on patients with chronic pain. METHODS: This study included outpatients with chronic pain undergoing treatment at the Pain Center of Nara Medical University Hospital. The patients had completed questionnaires for a disability during the study period, from 1 July to 30 September 2019 (baseline), 1 October to 31 December 2019 (pre-pandemic), and 1 July to 30 September 2020 (during the pandemic). The questionnaire covered changes in disability, pain intensity, health-related quality of life (QOL), anxiety, depression, catastrophic thinking, and the presence/absence of exercise habits at baseline, pre-pandemic, and during the pandemic. RESULTS: Of the 245 eligible patients, there was no significant disability difference between baseline, pre-pandemic, and during the pandemic (p = 0.14). Similarly, pain intensity, health-related QOL, anxiety, depression, and the presence/absence of exercise habits did not significantly differ between baseline, pre-pandemic, and during the pandemic either. The current study observed significant differences in terms of catastrophic thinking (p = 0.02). CONCLUSION: The effects of the COVID-19 pandemic on patients with chronic pain were not apparent in the short-term. Clinical trail registration: UMIN000043174.

Feasibility, reliability, and validity of the 12-item World Health Organization Disability Assessment Schedule 2.0 in patients attending the pain clinic.

PURPOSE: In the cohort of patients attending pain clinic, the primary goal has been shifting from pain reduction to improving activities of daily living and functional status. The 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is one of the useful tools for assessment of functional status across all psychiatric and medical diseases; however, its feasibility, reliability, and validity have not been assessed in these patients. Thus, in this study, we evaluated the feasibility, reliability, and validity of the 12-item WHODAS 2.0 in patients attending the pain clinic at our university hospital. METHODS: This is a prospective observational study including the patients aged 50 years or older who were attending the pain clinic at Nara Medical University between April 2019 and May 2019. Patient-related outcomes including functional status and activities of daily living were assessed with the 12-item WHODAS 2.0, EuroQol-5 dimension 5 levels, and the Tokyo Metropolitan Institute of Gerontology Index. RESULTS: The response rate was 99.7%. The 12-item WHODAS2.0 had a floor effect but no ceiling effect and its Cronbach's α coefficient was 0.909. The correlation coefficients between the 12-item WHODAS 2.0 score and the EuroQol-5 dimension 5 levels and the Tokyo Metropolitan Institute of Gerontology Index were -0.66 and -0.67, respectively. CONCLUSIONS: The 12-item WHODAS 2.0 is a useful measurement tool to assess disability of pain patients with high reliability and validity.

The ultrasound-guided nerve blocks of abdominal wall contributed to anesthetic management of cholecystectomy in a patient with Becker muscular dystrophy without using muscle relaxants.

Becker muscular dystrophy (BMD) is a progressive neuromuscular disorder caused by mutations in the dystrophin gene. The sensitivity to non-depolarizing muscle relaxant in a patient with muscle dystrophy is reportedly higher than that in normal individuals, and the duration of the effect is known to be prolonged. In this report, we present the case of a 58-year-old man with BMD who underwent laparoscopic cholecystectomy for symptomatic cholelithiasis under total intravenous anesthesia without the use of muscle-relaxant drugs and supplemented with regional anesthesia. Anesthesia was induced and maintained with propofol, remifentanil, and fentanyl; ultrasound-guided bilateral rectus sheath block (RSB) and right-sided subcostal transversus abdominis plane block (TAP) were performed. The procedure required conversion to open surgery because of hard conglutination; intraoperative and postoperative periods were uneventful. Adequate analgesia was maintained after extubation because of the effect of RSB and TAP.

Transforaminal epidural blood patch for intractable spontaneous cerebrospinal fluid leak: a case report.

BACKGROUND: Epidural blood patch (EBP) is a recognized treatment for spontaneous cerebrospinal fluid leak (SCFL) and is typically administered by the interlaminar approach. Here, we report a case of a patient in whom SCFL failed to resolve after three applications of interlaminar EBPs before finally being successfully treated with transforaminal EBP. CASE PRESENTATION: We report a case of a 41-year-old female with a definitive diagnosis of SCFL according to computed tomography (CT) myelography. A fluoroscopy-guided interlaminar EBP was applied three times without resolution of her orthostatic headache. A second myelography was therefore performed demonstrating a leak point on the ventral side of the dura mater. To close the ruptured ventral dura mater, it was necessary to fill the ventral epidural space with blood. Therefore, transforaminal EBP was performed. On spinal CT performed immediately after treatment, the ventral epidural space was observed to be filled with injected blood. Her headache improved the following day, and her symptoms completely subsided after 5 days. CONCLUSION: Transforaminal epidural blood patch is appropriate for patients with intractable cerebrospinal fluid leak. Patients with cerebrospinal fluid leakage due to rupture of the ventral side of the dura mater may be particularly good candidates for this procedure.

[Unilateral Thoracic Paravertebral Block for Effective Control of Pain : A Case Report of a Patient with Esophageal Cancer and Cirrhosis of the Liver.]

We report a case in which unilateral thoracic para- vertebral block was used to effectively control pain in a 78-year-old male patient with Child's A liver cirrhosis and esophageal cancer. Epidural anesthesia was con- sidered risky in this case because of the low platelet count from cirrhosis. Therefore, we performed a unilat- eral thoracic paravertebral block and cannulation under general anesthesia. We administered 0.33% levobupi- vacaine 10 ml through the catheter for intraoperative analgesia. After the operation, we confirmed the place- ment of the catheter with a chest X-ray image : then, the patient was extubated and returned to the ward. Three hours after the operation, the patient com- plained of pain in his wound : hence, 0.33% levobupi- vacaine 5 ml was injected through the catheter, which effectively controlled pain for 10 hours. Further injec- tions were done 13 and 21 hours after the operation, and the catheter was removed 21 hours after the operation. While the catheter was in place, the patient scarcely complained of pain. The unilateral thoracic paravertebral block covered the wide range of wounds and provided good analgesia for the patient.

[Retrospective evaluation of predictors and frequency of hypotension in hypertensive patients after induction of general anesthesia].

BACKGROUND: It is reported that hypotension during general anesthesia is associated with adverse outcomes in patients having both noncardiac and cardiac surgery. The present retrospective study was undertaken to evaluate the incidence and the predictors of hypotension after induction of general anesthesia (GA) until the start of operation. METHODS: After the IRB approval, 157 patients with hypertension who had undergone surgery under general anesthesia were enrolled. Data were collected using medical chart and anesthesia record. We divided the period into two intervals, from entering the operating room to tracheal intubation (first interval) and from tracheal intubation to start of operation (second period). Hypotension was defined when blood pressure decreased more than or equal to 25 percent compared to blood pressure measured at first in operating room. RESULTS: Hypotension occurred in 73.2% during the first interval and 96.8% during the second interval. The age was a significant predictor for hypotension during the second interval (P = 0.0087). CONCLUSIONS: The result in this study indicated that the age was a significant predictor for hypotension from tracheal intubation to start of operation.