Analgesic effect of ultrasound-guided transversus abdominis plane block with or without rectus sheath block in laparoscopic cholecystectomy: a randomized, controlled trial.

BACKGROUND: Ultrasound-guided transversus abdominis plane (TAP) block is commonly used for pain control in laparoscopic cholecystectomy. However, significant pain persists, affecting patient recovery and sleep quality on the day of surgery. We compared the analgesic effect of ultrasound-guided TAP block with or without rectus sheath (RS) block in patients undergoing laparoscopic cholecystectomy using the visual analog scale (VAS) scores. METHODS: The study was registered before patient enrollment at the Clinical Research Information Service (registration number: KCT0006468, 19/08/2021). 88 American Society of Anesthesiologist physical status I-III patients undergoing laparoscopic cholecystectomy were divided into two groups. RS-TAP group received right lateral and right subcostal TAP block, and RS block with 0.2% ropivacaine (30 mL); Bi-TAP group received bilateral and right subcostal TAP block with same amount of ropivacaine. The primary outcome was visual analogue scale (VAS) for 48 h postoperatively. Secondary outcomes included the use of rescue analgesics, cumulative intravenous patient-controlled analgesia (IV-PCA) consumption, patient satisfaction, sleep quality, and incidence of adverse events. RESULTS: There was no significant difference in VAS score between two groups for 48 h postoperatively. We found no difference between the groups in any of the secondary outcomes: the use of rescue analgesics, consumption of IV-PCA, patient satisfaction with postoperative pain control, sleep quality, and the incidence of postoperative adverse events. CONCLUSION: Both RS-TAP and Bi-TAP blocks provided clinically acceptable pain control in patients undergoing laparoscopic cholecystectomy, although there was no significant difference between two combination blocks in postoperative analgesia or sleep quality.

Comparison of postoperative nausea and vomiting between Remimazolam and Propofol in Patients undergoing oral and maxillofacial surgery: a prospective Randomized Controlled Trial.

BACKGROUND: Remimazolam is a recently approved, ultra-short-acting benzodiazepine. However, few studies have investigated remimazolam in relation to postoperative nausea and vomiting (PONV). This study aimed to compare the effects of remimazolam and propofol on PONV in patients undergoing oral and maxillofacial surgery. METHODS: Patients (n = 206) aged 19-65 years who were scheduled for oral and maxillofacial surgery were randomized into two groups, the remimazolam (R) and propofol group (P). In the R group (n = 94), remimazolam was used to induce anesthesia at 12 mg/kg/h and to maintain anesthesia at 1-2 mg/kg/h. In the P group (n = 95), anesthesia was induced and maintained with propofol (target effect-site concentration: 3-5 µg/ml). In both groups, remifentanil was administered at a target effect-site concentration of 2.5-4 ng/ml. The primary outcome was the overall incidence of PONV during the first 24 h after surgery. Secondary outcomes included the severity of nausea, use of rescue antiemetics, severity of postoperative pain, use of rescue analgesia, and quality of recovery. RESULTS: The incidence of PONV during the first 24 h after surgery was 11.7% and 10.5% in the R group and P group, respectively, and there was no significant difference in the severity of nausea (P > 0.05). Ten patients in the R group and ten patients in the P group required rescue antiemetics during the first 24 h after surgery (P = 0.98). No inter-group differences were observed in terms of postoperative pain score, use of rescue analgesia, and quality of recovery (P > 0.05). CONCLUSIONS: In this study, remimazolam did not increase the incidence and severity of PONV compared with propofol. TRIAL REGISTRATION: KCT0006965, Clinical Research Information Service (CRIS), Republic of Korea. Registration date: 26/01/2022.

Early extubation after left ventricular assist device implantation in a patient with Duchenne muscular dystrophy: a case report.

Management of Duchenne muscular dystrophy (DMD) cardiomyopathy is increasingly important for the survival of these patients. Left ventricular assist device (LVAD) is an alternative treatment for refractory heart failure in DMD. A 20-year-old man with DMD and dilated cardiomyopathy underwent surgery for LVAD implantation. Respiratory failure may occur due to muscle weakness after surgery under general anesthesia in patients with DMD, and weaning from mechanical ventilation may be delayed or difficult. Considering the application of fast-track anesthesia (FTA), preoperative pulmonary rehabilitation which includes thoracic expansion exercise, air stacking exercise with manual resuscitation bag and manually assisted cough technique, hight-frequency chest wall oscillation, and mechanical insufflation-exsufflation was performed. We report on a patient with DMD in whom FTA and early extubation within 6 h after LVAD implantation was successfully performed without complications.

The correlation between conventional coagulation tests and thromboelastography in each phase of liver transplantation.

INTRODUCTION: Thromboelastography (TEG) is gaining increasing acceptance in liver transplantation (LT) with conventional coagulation tests (CCTs) such as prothrombin time (PT), activated partial thromboplastin time (aPTT), antithrombin III (ATIII), platelet count (PLT), and fibrinogen concentration. The purpose of this study was to evaluate the clinical utility of TEG in LT and investigate the correlation between TEG and CCT values during each phase of LT. MATERIALS AND METHODS: Medical records of patients who underwent deceased donor LT at a single, university hospital between October 2010 and July 2015 were retrospectively reviewed. Blood samples were obtained at each phase of LT (pre-anhepatic, anhepatic, and neo-hepatic phase) according to our institutional LT protocol and utilized for analysis of TEG and CCTs. The Spearman correlation coefficient between TEG and CCT values were obtained. RESULTS: During the pre-anhepatic phase, the reaction time (R), PT, and aPTT did not correlate with each other, but demonstrated a negative correlation with PLT. Clot formation time (K) demonstrated a similar correlation with R and a negative correlation with fibrinogen. The maximal amplitude (MA) and α-angle (α) were positively correlated with PLT and fibrinogen and inversely correlated with aPTT. During the anhepatic phase, MA was significantly correlated with PLT and inversely correlated with aPTT; other parameters had weak or indistinct correlation. During the neo-hepatic phase, R and K were significantly correlated with aPTT and inversely correlated with PLT and fibrinogen. A correlation of MA and α with PLT, aPTT, and fibrinogen was also observed. Clot lysis at 30 minutes and estimated percent lysis were inversely correlated with levels of ATIII and fibrinogen. CONCLUSIONS: Conventional coagulation tests and TEG show particularly poor comparability during the anhepatic period of liver transplantation. TEG can be most reliable in the anhepatic phase, during which dynamic hemostatic changes occur.

The effect of sevoflurane on retinal angiogenesis in a mouse model of oxygen-induced retinopathy.

BACKGROUND: Sevoflurane is commonly used in general anesthesia for premature neonates. The main mechanism of retinopathy of prematurity (ROP) is increased levels of vascular endothelial growth factor (VEGF). For the investigation of sevoflurane's effect on angiogenesis, the angiogenesis and VEGF expression in the retina were measured after administering sevoflurane in an oxygen-induced retinopathy mice model. MATERIALS AND METHODS: The mice were divided into the normoxic group (Nc and Ns group; n = 6) and the ROP group (C, Rc, and Rs group; n = 6). Rc group were exposed to 75% oxygen for 5 days beginning on postnatal day (P) 7, and then returned to room air. Age-matched mice in the C group were exposed to room air. To observe angiogenesis of the retina, the mice were sacrificed on P16. The Rs group was exposed to 2 vol% sevoflurane for 2 h on P12, P13, and P14 with 40% oxygen. RESULTS: The angiogenic area and the spreading distance of vessels on P4 were statistically decreased in the Ns group, compared to the Nc group. The avascular area on P16 was significantly increased and the expression of VEGF was suppressed in the Rs group compared to the Rc group. CONCLUSIONS: Sevoflurane can inhibit retinal angiogenesis via suppressing VEGF expression in an OIR mice model with exposure to relative hypoxia. Nevertheless, it is still difficult to apply the results of this study immediately to humans because of the heterogeneity of responses to sevoflurane.

Mechanical Antiallodynic Effect of Intrathecal Nefopam in a Rat Neuropathic Pain Model.

Nefopam has a pharmacologic profile distinct from that of opioids or other anti-inflammatory drugs. Several recent studies demonstrate that nefopam has a mechanism of action similar to those of anti-depressants and anticonvulsants for treating neuropathic pain. The present study investigates the mechanical antiallodynic effect of nefopam using immunohistochemical study and western blot analysis in a rat neuropathic pain model. Twenty-eight male Sprague-Dawley rats were subjected to left fifth lumbar (L5) spinal nerve ligation and intrathecal catheter implantation, procedures which were not performed on the 7 male Sprague-Dawley rats in the sham surgery group (group S). Nefopam, either 10 or 100 µg/kg (group N10 or N100, respectively), and normal saline (group C) were intrathecally administered into the catheter every day for 14 days. The mechanical allodynic threshold of intrathecal nefopam was measured using a dynamic plantar aesthesiometer. Immunohistochemistry targeting cluster of differentiation molecule 11b (CD11b) and glial fibrillary acidic protein (GFAP) was performed on the harvested spinal cord at the level of L5. Extracellular signal-regulated kinase 1/2 (ERK 1/2) and cyclic adenosine monophosphate response element binding protein (CREB) were measured using western blot analysis. The N10 and N100 groups showed improved mechanical allodynic threshold, reduced CD11b and GFAP expression, and attenuated ERK 1/2 and CREB in the affected L5 spinal cord. In conclusion, intrathecal nefopam reduced mechanical allodynia in a rat neuropathic pain model. Its mechanical antiallodynic effect is associated with inhibition of glial activation and suppression of the transcription factors' mitogen-activated protein kinases in the spinal cord.

Effective analgesia with ultrasound-guided interscalene brachial plexus block for postoperative pain control after arthroscopic rotator cuff repair.

PURPOSE: Ultrasound (US)-guided continuous interscalene brachial plexus block (CBPB) is known to provide effective pain relief for arthroscopic rotator cuff repair. This study was conducted to compare analgesic efficacy and forearm muscle tone of the basal infusion rate and bolus dose of 0.2 % ropivacaine for US-guided CBPB with intravenous patient-controlled analgesia (IV-PCA). METHODS: In a prospective trial, 99 patients scheduled to undergo arthroscopic rotator cuff repair were divided into three groups. In groups A and B, an US-guided 17-gauge Tuohy needle was inserted into the interscalene brachial plexus. A loading dose of 10 ml 0.2 % ropivacaine was administered via the needle. A 19-gauge perineural catheter was then inserted through the needle and advanced to a depth of 1.5 cm beyond the needle tip between the C5 and C6 nerve trunks. After surgery, groups A and B received a continuous infusion of 0.2 % ropivacaine at 4 or 0 ml/h, a bolus of 0 or 4 ml, and a lockout time of 60 min through the catheter, respectively. Group C received IV-PCA. Pain scores and the forearm muscle tone of patients were compared using a numeric rating scale (NRS), rates of patients taking supplementary opioid analgesics, and manual muscle test (MMT) scoring. RESULTS: The NRS scores and rate of patients taking supplementary opioid analgesics in groups A and B were lower than those in group C after surgery. Groups A and B showed similar clinical efficacy. There were no significant differences in MMT scoring among the three groups. CONCLUSIONS: The bolus dose of 0.2 % ropivacaine using US-guided CBPB would provide equivalent analgesic efficacy comparable with the basal infusion and motor weakness comparable with IV-PCA after arthroscopic rotator cuff repair.

Multimodal management strategies for chronic pain after spinal surgery: a comprehensive review.

"Chronic pain after spinal surgery" (CPSS) is a nonspecific term for cases in which the end result of surgery generally does not meet the preoperative expectations of the patient and surgeon. This term has replaced the previous term i.e., failed back surgery syndrome. CPSS is challenging for both patients and doctors. Despite advancements in surgical techniques and technologies, a subset of patients continue to experience persistent or recurrent pain postoperatively. This review provides an overview of the multimodal management for CPSS, ranging from conservative management to revision surgery. Drawing on recent research and clinical experience, we aimed to offer insights into the diverse strategies available to improve the quality of life of CPSS patients.

Concordance of esophageal and tracheal temperatures in patients using breathing circuit with heated wire humidifier: A prospective observational study.

RESULTS: After excluding 4 patients with an anesthesia duration of < 2 hours, data from 34 patients (1163 sets of tracheal and esophageal temperatures) were analyzed. Concordance correlation coefficient was 0.78. The overall mean bias (95% limits of agreement) between the tracheal and esophageal temperatures was -0.16°C (-0.65°C to 0.34°C). The percentage of temperature differences within ±â€…0.25°C was 73.5% ± 32.3, with a median of 89.4% [0,100]. The linear mixed-effects model revealed that the estimated intercept was 0.17°C with a 95% confidence interval (CI) of 0.13°C to 0.22°C. The duration of anesthesia and the number of temperature measurements were associated with higher concordance between the tracheal and esophageal temperatures in univariate analysis.

Effect of local warming for arterial catheterization in adult cardiac surgery: a randomized controlled trial.

Background: The increase in internal diameter (ID) and cross-sectional area (CSA) may facilitate better arterial catheterization. Since an increase in body temperature can cause peripheral vasodilation, we aimed to determine if local warming of the radial artery (RA) catheterization site could improve the success rate of catheterization. Methods: This randomized, controlled study enrolled 160 patients aged >18 years who were scheduled for heart surgery. They were randomized into non-warming palpation (NP), non-warming ultrasonography-guided (NU), warming palpation (WP), and warming ultrasonography-guided (WU) groups. After induction, the baseline RA ultrasonography images were collected. In the warming groups (WP, WU), local warming was applied on the catheterization site. Before catheterization, the RA ultrasonography images were collected. The primary outcome was the first-attempt success rate. The secondary outcomes included the ID and CSA of the RA and overall complications. Results: Totally 152 adults were included in the analysis. The first-attempt success rates in each of the four groups were not significantly different (P=0.985). The rates in the non-warming (NP + NU) and warming (WP + WU) groups were also not different (P=0.827). Unlike non-warming group, the warming group had increased ID (3.34±0.78 vs. 3.02±0.73 mm; P<0.001) and CSA (6.9±2.8 vs. 5.8±2.4 mm2; P<0.001) compared with baseline. Conclusions: Local warming for peripheral artery catheterization does not increase the first-attempt success rate in adults undergoing cardiac surgery; however, it can increase the ID and CSA of the RA and prevent vasospasm. Trial Registration: ClinicalTrials.gov NCT04969692.

Availability of a 5% lidocaine patch used prophylactically for venipuncture- or injection-related pain in children.

PURPOSE: Venipuncture- or injection-related pain is still major problem during anesthetic induction in children. This study was designed to determine the availability of a 5% lidocaine patch used prophylactically for venipuncture- or injection-related pain during the induction of anesthesia. METHODS: In a randomized, double-blind study, 72 pediatric patients were allocated to one of two groups: pretreatment with a 5% lidocaine patch (Lidoderm(®), Endo Pharmaceuticals, Chadds Ford, PA, USA) (group A) or pretreatment with a placebo patch (group B). Pain severity was evaluated on the Faces, Legs, Activity, Cry, and Consolability Scale (FLACC) during venipuncture, and a 4-point scale during the injection of rocuronium. RESULTS: The FLACC score during venipuncture was significantly lower for group A than group B (p < 0.001). There was no significant difference in the grades of the 4-point scale observed during the injection of rocuronium between groups A and B. No significant adverse effect was noted for the groups. CONCLUSION: Although pretreatment with a 5% lidocaine patch was found to be a safe, effective, and simple method of preventing venipuncture pain in children, this method did not reduce drug injection pain during the induction of anesthesia.

Comparison of Continuous and Programmed Intermittent Bolus Infusion of 0.2% Ropivacaine after Ultrasound-Guided Continuous Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery.

Background: Despite the clinical effectiveness of the programmed intermittent bolus (PIB) method for epidural analgesia, evidence for this method in continuous interscalene brachial plexus block (CIBPB) is unclear. This study aimed to investigate the pain relief effect after arthroscopic shoulder surgery according to the administration method by comparing the PIB and continuous infusion methods among the administration methods of local anesthetics. Methods: Sixty-four patients aged >19 years scheduled for elective arthroscopic shoulder surgery were enrolled and divided into two groups. Ultrasound-guided CIBPB was performed to control postoperative pain. The infusion pump was programmed so that 0.2% ropivacaine was continuously injected at 1.1 mL/h in group A, whereas in group B, 0.1 mL/h was continuously injected and 4 mL was periodically injected at 4 h intervals. In both groups, a further infusion of 4 mL of 0.2% ropivacaine was administered if the patient requested additional analgesia, and the lockout time was set at 30 min. Postoperative pain quality was assessed using a visual analog scale (VAS), and the incidence of patients requiring additional analgesics, motor blockade using a modified Bromage scale (MBS), and consumed doses of local anesthetic were assessed. Results: The VAS and incidence of rescue analgesics were performed when the patient could communicate voluntarily after admission to the post-anesthetic care unit, and at 24 and 48 h after surgery showed no significant difference between the two groups. The MBS at 24 h after surgery was significantly higher in group B (p = 0.038). In the comparison of consumed doses of local anesthetic, group B had a significantly higher bolus injection dose (p = 0.047) and frequency of bolus use in the 24 h after surgery (p = 0.034). Conclusion: The PIB method in CIBPB after arthroscopic shoulder surgery provided a similar analgesic effect, with a higher bolus injection dose of local anesthetic and increased motor blockade than the continuous infusion method.

Choice of the correct size of endotracheal tube in pediatric patients.

Selection and insertion of an endotracheal tube (ETT) of appropriate size for airway management during general anesthesia in pediatric patients is very important. A very small ETT increases the risk of inadequate ventilation, air leakage, and aspiration, whereas a very large ETT may cause serious complications including airway damage, post-intubation croup, and, in severe cases, subglottic stenosis. Although the pediatric larynx is conical, the narrowest part, the rima glottidis, is cylindrical in the anteroposterior dimension, regardless of development, and the cricoid ring is slightly elliptical. A cuffed ETT reduces the number of endotracheal intubation attempts, and if cuff pressure can be maintained within a safe range, the risk of airway damage may not be greater than that of an ETT without cuff. The age-based formula suggested by Cole (age/4 + 4) has long been used to select the appropriate ETT size in children. Because age-based formulas in children are not always accurate, various alternative methods for estimating the ETT size have been examined and suggested. Chest radiography, ultrasound, and a three-dimensional airway model can be used to determine the appropriate ETT size; however, there are several limitations.

Comparison of programmed intermittent epidural bolus injection and continuous epidural injection in controlling nighttime pain and improving sleep quality after thoracotomy.

BACKGROUND: Postoperative pain after open thoracotomy is known to be very severe and affects sleep quality. This study aimed to investigate the effects of a programmed intermittent epidural bolus injection versus continuous epidural injection for controlling nighttime pain and improving sleep quality after thoracotomy. METHODS: Seventy-six patients scheduled for open thoracotomy for lung cancer or other lung diseases were enrolled. The participants were divided into 2 groups. Group A was continuously injected with 0.2% levobupivacaine at 1.1 mL/h, and group B was injected intermittently with 3 mL 0.2% levobupivacaine at 3 hours intervals through a thoracic epidural catheter via a programmed infusion pump. Within 48 hours after surgery, the degree of pain control using visual analog scale and the patients' sleep conditions on postoperative day (POD) 0 and 1 were evaluated, and other adverse events were investigated. RESULTS: On POD 1 night, the visual analog scale in group B showed lower than group A (P = .009). Comparison of time to fall asleep showed no differences between 2 groups. Total sleep time was no difference on POD 0 but was longer in group B than that in group A on POD 1 (P = .042). Awakening from sleep on POD 0 was lower in group B than that in group A (P = .033), and satisfaction with sleep quality on POD 0 was superior in group B compared to group A (P = .005). Postoperative nausea and vomiting occurred more frequently in group B than in group A (P = .018). CONCLUSION: The programmed intermittent epidural bolus technique of patient-controlled epidural analgesia reduces postoperative nighttime pain and improves sleep quality in patients undergoing thoracotomy for lung cancer or other lung diseases.

The influence of circulating fibrinogen level on postoperative blood loss and blood transfusion in pediatric cardiac surgery: a retrospective observational study.

Background: Pediatric patients are at high risk of massive bleeding after cardiac surgery under cardiopulmonary bypass (CPB). Fibrinogen is essential for coagulation; however, pediatric patients with congenital heart disease (CHD) present abnormal fibrinogen function. The pre- and post-operative fibrinogen level may affect the bleeding and transfusion amount in patients undergoing cardiac surgery. However, the relationship between plasma fibrinogen levels and the bleeding and transfusion amount in pediatric cardiac surgery remains unclear. This study aimed to assess the association of pre-CPB fibrinogen levels (PreFib) and post-CPB fibrinogen levels (PostFib) with postoperative bleeding and transfusion volume in pediatric cardiac surgery. Methods: We reviewed the medical records of 375 newborns and infants who underwent cardiac surgery under CPB for CHD. The primary endpoint was the correlation of the PreFib and PostFib values, as well as their difference (FibGap), with the bleeding and transfusion amount within 24 postoperative hours. Results: There was no correlation of the PreFib, PostFib, and FibGap values with the bleeding and transfusion amounts at postoperative 24 hours. However, patients with PreFib and PostFib values of <150 and <100 mg/dL, respectively, showed a significantly higher frequency of postoperative platelet (PLT) transfusion. In patients with complex CHD, PreFib showed a weak negative correlation with the bleeding amount at postoperative 24 hours and the number of PLT-transfused patients. Conclusions: Our findings suggest that in pediatric patients with CHD who cannot undergo point-of-care (POC) tests, those presenting PreFib and PostFib values of <150 and <100 mg/dL, respectively, have a significantly higher frequency of postoperative PLT transfusion.

The impact of pretransplant hepatic encephalopathy, model for end-stage liver disease (MELD) scale on long-term survival following deceased donor liver transplantation: a retrospective study.

BACKGROUND: Liver transplantation (LT) has the incidence of 30-day mortality about 5-10%, Jo et al. reported that 30-day mortality and 1-year mortality for DDLT were 30%, and 39% respectively. It is not easy to create a model for predicting post-transplantation outcomes based on pretransplant variables. MELD does not take into account individual complications such as hepatic encephalopathy (HE), and research has shown that the greater the severity of pretransplant HE, the lower the survival rate after LT; the importance of monitoring for HE is therefore emphasized. METHODS: The medical records of adult patients who underwent deceased donor LT (DDLT) were retrospectively reviewed for analysis of the effect of HE on the long-term survival rate of post-transplant for more than 1 year. RESULTS: Presence of HE is not statistically associated to patient survival (P=0.062), but the hazard ratio is 1.954 (95% CI, 0.968, 3.943). In addition, the severe HE group significantly decreased survival compared to the non-HE group, and the cumulative 1- and 3-year overall survival rates were 80.9% and 78.7%, respectively, in non HE group, and 65.7% and 56.1%, respectively, in severe HE group (P=0.031). CONCLUSIONS: Severe HE is a factor influencing the long-term survival over 3 years in the patients who underwent DDLT. Although prospective validation should be conducted to determine the prognostic value of HE severity, efforts could be made to reduce the severity of HE before DDLT, and consider severity of HE rather than MELD score in DDLT allocation.

Comparison of catheter-over-needle and catheter-through-needle methods in ultrasound-guided continuous femoral nerve block: A prospective, randomized controlled trial.

BACKGROUND: The catheter-through-needle (CTN) method involves the insertion of a catheter with an outer diameter smaller than the initial puncture hole. We investigated whether the catheter-over-needle (CON) method is more effective than the CTN method in local anesthetic leakage at the catheter insertion site and catheter dislodgement, and how it affects postoperative pain management. METHODS: Seventy patients scheduled to undergo continuous femoral nerve block for pain control following total knee arthroplasty were enrolled and randomized to receive a perineural catheterization with either the CTN method (group CTN) or CON method (group CON). After ultrasound-guided catheterization, the transparent securement dressing was attached. The study compared the CON and CTN methods in terms of leakage at the catheter insertion site, catheter dislodgement, and postoperative analgesic efficacy for 48 hours postoperatively. RESULTS: Leakage at the catheter insertion site was significantly lower in the group CON (P < .05), while catheter dislodgement was not significantly different between the groups. The other adverse events were not different between the groups. The procedure time was significantly shorter in group CON (P < .05). No significant intergroup differences were observed 48 hours postoperatively in the visual analog scales, the number of patients requiring additional analgesics, and the number of times a bolus dose was injected with an injection pump. CONCLUSION: The CON method was able to shorten the procedure time while reducing the incidence of leakage at the catheter insertion site than the CTN method, and showed similar effects in postoperative pain management.

Unexpected extrusion of the implantable pulse generator of the spinal cord stimulator - A case report.

BACKGROUND: Despite significant technological advances in the implantable pulse generator (IPG), complications can still occur. We report a case that unexpected extrusion of the IPG of spinal cord stimulation (SCS) was promptly identified and successfully removed without any complications. CASE: After a car accident 4 years ago, a 55-year-old male who was diagnosed with complex local pain syndrome in his right leg. The SCS was inserted with 2 leads, with the IPG being implanted in the right lower abdomen region. Four years later, he developed extrusion of the IPG from his abdominal region. This unexpected extrusion may have been related to pressure necrosis caused by continued compression of pocket site where a belt was frequently tied. The IPG and the leads were successfully removed without infection occurring. CONCLUSIONS: To prevent unexpected extrusion of IPG, it is necessary to consider in advance whether the pocket site is pressed against the belt.

Comparison of the Oblique Interlaminar and Transforaminal Lumbar Epidural Steroid Injections for Treatment of Low Back and Lumbosacral Radicular Pain.

BACKGROUND: Transforaminal epidural steroid injections (TF-ESIs) effectively deliver small amounts of drugs to inflamed sites via the ventral epidural space. However, there is a high risk of nerve damage as the needle narrowly approaches the spinal nerve. Therefore, we devised an oblique interlaminar (OIL) approach as an alternative method. We compared the efficacy of fluoroscopic-guided OIL-ESIs with that of TF-ESIs in the management of lower back and unilateral lumbosacral radicular pain. MATERIALS AND METHODS: Sixty-six patients were randomized to receive a fluoroscopic-guided ESI either through the OIL (n = 33, group OIL) or TF (n = 33, group TF) approach. They were evaluated for effective pain relief using the visual analogue scale (VAS) and for functional improvement using the Oswestry Disability Index (ODI) and Roland Morris Disability Questionnaire (RMDQ). Other outcome measures were the presence of ventral and contralateral spread of contrast, patients' satisfaction, and adverse events. RESULTS: There were no significant differences between the groups in the VAS, ODI, and RMDQ scores during the 12-week period. The differences in the ODI and RMDQ scores before and after the treatment were higher in group TF than in group OIL. The contralateral spread of contrast was higher in group OIL than in group TF. There were no significant differences in the other outcomes between the groups. CONCLUSION: ESIs delivered through the OIL approach are equally effective in pain relief and functional improvement as those delivered via the TF approach in the management of low back and unilateral lumbosacral radicular pain.

The effect of dexmedetomidine and midazolam on combined spinal-epidural anesthesia in patients undergoing total knee arthroplasty.

BACKGROUND: Intravenous dexmedetomidine has been reported to potentiate the anesthetic effect of local anesthetics and improve the quality of postoperative analgesia when used as an adjuvant in neuraxial block. We compared the effects of intravenous dexmedetomidine and midazolam for sedation on combined spinal-epidural (CSE) anesthesia. METHODS: This study included 50 patients undergoing total knee arthroplasty. CSE anesthesia was given using 10 mg bupivacaine for all patients. After checking the maximum sensory and motor levels, the patients were randomly allocated into two groups of 25 each to receive intravenous continuous infusion of dexmedetomidine (Group D) or midazolam (Group M) for sedation during surgery. Regression block level, hemodynamic changes, and sedation score were compared between the groups when the patients entered the postanesthetic care unit (PACU). For patient-controlled epidural analgesia, 0.2% levobupivacaine with 650 µg of fentanyl (150 ml in total) was infused at a rate of 1 ml/h, in addition to a 3-ml bolus dose with a 30-min lockout time. The visual analogue scale scores, additional analgesic demand, patient satisfaction, and adverse events between the two groups were also compared postoperatively. RESULTS: A significant difference was observed in relation to the sensory block level in the PACU (Group D: 6.3 ± 2.1; Group M: 3.2 ± 1.9) (P = 0.002). The motor block level and other outcomes showed no significant intergroup differences. CONCLUSIONS: Intravenous injection of dexmedetomidine, rather than midazolam, for procedural sedation is associated with prolonged sensory block, with comparable incidences of adverse events during CSE anesthesia.