Interventional Modalities to Treat Complex Regional Pain Syndrome.

PURPOSE OF REVIEW: Complex regional pain syndrome (CRPS) is a debilitating pain condition that often requires a multidisciplinary approach including medication, physical therapy, occupational therapy, psychological therapy, and interventional procedures to restore the patient's quality of life. This article reviews the interventional treatments for pain resulting from CRPS. RECENT FINDINGS: Sympathetic nerve blocks (stellate ganglion and lumbar sympathetic) are the first-line interventional treatment options for patients with CRPS of the upper and lower extremities, respectively. Fluoroscopic techniques for lumbar sympathetic blocks have not significantly changed throughout the years. However, both novel fluoroscopic and ultrasound approaches to stellate ganglion blockade have arisen. In addition, novel neuromodulation therapies to treat CRPS have been developed to include new waveforms with dorsal column stimulation and entirely new nerve targets such as dorsal root ganglion stimulation. This paper will review the latest interventional treatment options available for the treatment of CRPS.

Comparison between local infiltration analgesia with combined femoral and sciatic nerve block for pain management after total knee arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is usually associated with moderate to severe postoperative pain. Peripheral nerve block (PNB) and local infiltration analgesia (LIA) are two major methods for postoperative analgesia. Femoral nerve block (FNB) leads to residual posterior knee pain; thus, currently sciatic nerve block (SNB) and LIA are two major options for supplementing FNB. However, the efficacy and safety of LIA compared with combined femoral and sciatic nerve block still remain controversial. Here, we conducted a study to analyze the postoperative analgesic efficacy of these two methods. METHOD: Two hundred six patients undergoing TKA were enrolled in a retrospective cohort study. The patients received either PNB or LIA. All patients in PNB group were conducted combined femoral and sciatic nerve block. All patients were encouraged to use patient-controlled analgesia (PCA) after surgery. The postoperative visual analog scale (VAS) at rest or with movement during the first 24 h and 48 h was recorded. We analyzed the VAS of 24 h, VAS of 48 h, opioid consumption, and adverse effects between PNB group and LIA group. Chi-square test and nonparametric test were used in this study. RESULTS: There were 82 patients in the PNB group and 124 patients in the LIA group. The patients' characteristics such as age, height, weight, and ASA showed no significant difference (P > 0.05). No significant differences were found (P > 0.05) between the two groups regarding VAS score at rest or with movement. The LIA group had less opioid consumption than the PNB group but without significant difference (P > 0.05). In both groups, the most common side effect was nausea, and the side effects showed no significant differences between groups (P > 0.05). CONCLUSION: Local infiltration analgesia provided a similar analgesic effect and complications compared with combined femoral and sciatic nerve block in the short term. Considering less opioid consumption with local infiltration analgesia though without significant difference and its convenience, local infiltration analgesia provided better postoperative analgesia.

Efficacy and safety of periprostatic nerve block combined with perineal subcutaneous anaesthesia and intrarectal lidocaine gel in transrectal ultrasound guided transperineal prostate biopsy: A Prospective Randomised Controlled Trial.

BACKGROUND: To determine the efficacy and safety of a periprostatic nerve block combined with perineum subcutaneous anaesthesia and intrarectal lidocaine gel for transrectal ultrasound-guided transperineal prostate biopsy (TPBx) through a prospective randomised controlled trial. METHODS: In total, 216 patients from May 2018 to November 2018 were randomly assigned to the experimental group and the control group at a ratio of 1:1. The experimental group received a periprostatic nerve block combined with subcutaneous perineal anaesthesia and intrarectal lidocaine gel. The control group received total intravenous anaesthesia. A visual analogue scale (VAS) score (0-10) was used to evaluate pain at different stages. The operative time, duration of hospitalisation, intraoperative vital signs, perioperative complications and clinicopathological features were recorded. RESULTS: The overall detection rate of prostate cancer was 40.74%, and the median Gleason score was 8 for all patients diagnosed with prostate cancer. No significant differences in terms of detection rates, Gleason scores and ISUP/WHO Grade Groups were found between the two groups (P > 0.05). The experimental group had no pain or just met the criteria for mild pain during the biopsy, which was significantly alleviated after the biopsy, and had a shorter operation time compared with that of the control group (P < 0.05). Compared with the control group, the experimental group had more stable haemodynamics and respiratory status and fewer surgical complications (P < 0.05). CONCLUSIONS: In multiple aspects, a periprostatic nerve block combined with subcutaneous perineal anaesthesia and intrarectal lidocaine gel is a safer and more efficient approach to local anaesthesia for TPBx that can almost replace total intravenous anaesthesia and is worthwhile applying in the clinical setting.

Stepwise Local Anesthesia for Percutaneous Endoscopic Interlaminar Discectomy: Technique Strategy and Clinical Outcomes.

BACKGROUND: Due to suboptimal pain control under conventional local anesthesia, percutaneous endoscopic interlaminar discectomy is typically performed under general anesthesia. The purpose of this study was to develop a stepwise approach of local anesthesia for endoscopic interlaminar discectomy and evaluate its efficacy. METHODS: A stepwise local anesthesia was developed, which mainly includes 3 steps: conventional local anesthesia from skin to laminae, epidural injection, and nerve root block. From June 2015 to May 2017, consecutive patients who underwent endoscopic interlaminar discectomy were included. Local anesthesia or general anesthesia was used based on patients' preference. Anesthetic effectiveness was evaluated as excellent, good, or poor, and adverse events were recorded. Hospitalization expense was compared between the 2 groups. Clinical outcomes were assessed using the Visual Analog Scale and the Oswestry Disability Index. RESULTS: There were 98 patients included in the study. Among them, 48 received stepwise local anesthesia and the other 50 received general anesthesia. In the stepwise local anesthesia group, 40 (83.3%) patients rated anesthetic effectiveness as excellent, 7 (14.6%) as good, and 1 (2.1%) as poor. Nine patients had complications that may be associated with local anesthesia, including dyspnea, temporary paresis of legs, and temporary worsened dysesthesia or numbness in legs. After surgery, the patients' leg pain and Oswestry Disability Index significantly improved in both groups. On average, hospitalization expense was approximately 20% less when local anesthesia was used, as compared with using general anesthesia. CONCLUSIONS: The stepwise local anesthesia can achieve satisfactory pain control and seems to be a good choice for endoscopic interlaminar discectomy.

Comparison Between the Effectiveness of Complex Decongestive Therapy and Stellate Ganglion Block in Patients with Breast Cancer-Related Lymphedema: A Randomized Controlled Study.

BACKGROUND: Breast cancer-related lymphedema (BCRL) of the upper extremities often follows breast cancer treatment. Although complex decongestive therapy (CDT) is currently the standard treatment for BCRL, stellate ganglion block (SGB) has also been reported to be effective. OBJECTIVES: This study aimed to determine the effectiveness of SGB in the treatment of BCRL, and to assess the impact of the treatment on the quality of life (QoL) compared to CDT. STUDY DESIGN: A randomized controlled trial. SETTING: A single academic hospital, outpatient setting. METHODS: A total of 38 patients with BCRL were recruited. Patients were randomly divided into 2 groups. Patients enrolled in the CDT group underwent 10 sessions of CDT for 2 weeks, whereas patients in the SGB group received 3 consecutive SGBs every 2 weeks. Changes in circumference, volume, and bioimpedance in the upper extremity were measured at baseline and 2 weeks after treatment and compared between the 2 groups. EuroQol-5 dimensions (EQ-5D) and EuroQol visual analog scale (EQ VAS) for QoL and subjective improvement were monitored. RESULTS: In both groups, side-to-side difference of circumference after the treatment was decreased significantly from baseline (P < 0.05), and side-to-side difference of volume was reduced significantly in the SGB group (P < 0.05). No statistically significant difference was noted in the treatment effect between the 2 groups. Results of the EQ-5D, EQ VAS, and questionnaires regarding subjective symptoms administered at baseline and 2 weeks after each intervention revealed no statistically significant difference in the treatment effects between CDT and SGB. LIMITATIONS: Further long-term follow-up studies with a greater number of patients that include analysis according to the severity and duration of symptoms are needed. CONCLUSIONS: The results of this study suggest that SGB is an effective treatment for BCRL and may be considered as an alternative to CDT. KEY WORDS: Stellate ganglion block, complex decongestive therapy, breast cancer, lymphedema, breast cancer-related lymphedema, quality of life, bioimpedance, secondary lymphedema.

Minimally invasive transtracheal cardiac plexus block for sympathetic neuromodulation.

BACKGROUND: Bilateral thoracoscopic stellectomy has antiarrhythmic effects, but the procedure is invasive with associated morbidity. Sympathetic nerves from both stellate ganglia form the deep cardiac plexus (CP) in the aortopulmonary window, anterior to the trachea. OBJECTIVE: The purpose of this study was to demonstrate a novel and minimally invasive transtracheal approach to block the CP in porcine models. METHODS: In 12 Yorkshire pigs, right (RSG) and left (LSG) stellate ganglia were electrically stimulated and sympathetic baseline response recorded (hemodynamic parameters and T-wave pattern). Aortopulmonary window was accessed transtracheally with endobronchial ultrasound guidance, and local stimulation of CP confirmed the location. Injection of 1% lidocaine (n = 10) or saline solution (n = 2) was performed, and RSG and LSG responses were re-evaluated and compared with baseline. RESULTS: Transtracheal lidocaine injection into the CP successfully blocked bilateral sympathetic induced changes (%) in T-wave amplitude (282.8% ± 152.2% vs 20.1% ± 16.5%; P <.001 [LSG]; 338.9% ± 189.8% vs 28% ± 18.3%; P <.001 [RSG]), Tp-Te interval (87.9% ± 37.2% vs 6.9% ± 6.7%; P <.001 [LSG]; 32.6% ± 27.4% vs 6.9% ± 4.7%; P <.035 [RSG]), and left ventricular dP/dTmax (148.3% ± 108.5% vs 16.5% ± 13.4%; P <.001 [LSG]; 243.1% ± 105.2% vs 19.0% ± 12.4%; P <.001 [RSG]). RSG-induced elevations of systemic, left ventricular, and pulmonary arterial pressures were blocked by lidocaine injection into CP (P <.005 for all comparisons). Stellate ganglia response was not affected in sham studies. No complications were observed during the procedures. CONCLUSION: Minimally invasive transtracheal injection of lidocaine into the CP blocked the sympathetic response of either RSG and LSG. Transtracheal assessment of CP may allow for minimally invasive and selective ablation of cardiac innervation, extending the cardiac sympathectomy denervation benefits to those not suitable for surgery.

Effect of local infiltration analgesia, peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in unicompartmental knee arthroplasty.

BACKGROUND: The aim of the study was to analyze the effect of local infiltration analgesia (LIA), peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in primary unicompartmental knee arthroplasty (UKA). METHODS: Between January 2016 until August 2016, 134 patients underwent primary UKA and were subdivided into four groups according to their concomitant pain and anesthetic procedure with catheter-based techniques of femoral and sciatic nerve block (group GA&FNB, n = 38) or epidural catheter (group SP&EPI, n = 20) in combination with general anesthesia or spinal anesthesia, respectively, and LIA combined with general anesthesia (group GA&LIA, n = 46) or spinal anesthesia (group SP&LIA, n = 30). Outcome parameters focused on the evaluation of pain (NRS scores), mobilization, muscle strength and range of motion up to 7 days postoperatively. The cumulative consumption of (rescue) pain medication was analyzed. RESULTS: The LIA groups revealed significantly lower (about 50%) mean NRS scores (at rest) compared to the catheter-based groups at the day of surgery. In the early postoperative period, the dose of hydromorphone as rescue pain medication was significantly lower (up to 68%) in patients with SP&EPI compared to all other groups. No significant differences could be detected with regard to grade of mobilization, muscle strength and range of motion. However, there seemed to be a trend towards improved mobilization and muscle strength with general anesthesia and LIA, whereof general anesthesia generally tended to ameliorate mobilization. CONCLUSIONS: Except for a significant lower NRS score at rest in the LIA groups at day of surgery, pain relief was comparable in all groups without clinically relevant differences, while the use of opioids was significantly lower in patients with SP&EPI. A clear clinically relevant benefit for LIA in UKA cannot be stated. However, LIA offers a safe and effective treatment option comparable to the well-established conventional procedures.

Effect of local infiltration analgesia, peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in total knee arthroplasty.

BACKGROUND: Postoperative pain control and enhanced mobilization, muscle strength and range of motion following total knee arthroplasty (TKA) are pivotal requisites to optimize rehabilitation and early recovery. The aim of the study was to analyze the effect of local infiltration analgesia (LIA), peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in primary total knee arthroplasty. METHODS: Between January 2016 until August 2016, 280 patients underwent primary TKA and were subdivided into four groups according to their concomitant pain and anesthetic procedure with catheter-based techniques of femoral and sciatic nerve block (group GA&FNB, n = 81) or epidural catheter (group SP&EPI, n = 51) in combination with general anesthesia or spinal anesthesia, respectively, and LIA combined with general anesthesia (group GA&LIA, n = 86) or spinal anesthesia (group SP&LIA, n = 61). Outcome parameters focused on the evaluation of pain (NRS scores), mobilization, muscle strength and range of motion up to 7 days postoperatively. The cumulative consumption of (rescue) pain medication was analyzed. RESULTS: Pain relief was similar in all groups, while the use of opioid medication was significantly lower (up to 58%) in combination with spinal anesthesia, especially in SP&EPI. The LIA groups, in contrast, revealed significant higher mobilization (up to 26%) and muscle strength (up to 20%) in the early postoperative period. No analgesic technique-related or surgery-related complications occurred within the first 7 days. Due to insufficient pain relief, 8.4% of the patients in the catheter-based groups and 12.2% in the LIA groups resulted in a change of the anesthetics pain management. CONCLUSIONS: The LIA technique offers a safe and effective treatment option concerning early functional recovery and pain control in TKA. Significant advantages were shown for mobilization and muscle strength in the early postoperative period while pain relief was comparable within the groups.

Analgesia of Combined Femoral Triangle and Obturator Nerve Blockade Is Superior to Local Infiltration Analgesia After Total Knee Arthroplasty With High-Dose Intravenous Dexamethasone.

BACKGROUND AND OBJECTIVES: High-dose intravenous dexamethasone reduces the postoperative opioid requirement and is often included in the multimodal analgesia strategy after total knee arthroplasty (TKA). Combined obturator nerve and femoral triangle blockade (OFB) reduces the opioid consumption and pain after TKA better than local infiltration analgesia (LIA). The question is whether preoperative high-dose intravenous dexamethasone would cancel out the superior analgesic effect of OFB compared with LIA. The aim was to evaluate the analgesic effect of OFB versus LIA after TKA when all patients received high-dose intravenous dexamethasone. METHODS: Eighty-two patients were randomly assigned either to OFB or LIA after primary unilateral TKA. All patients received 16 mg dexamethasone. Primary outcome was morphine consumption via patient-controlled analgesia during the first 20 postoperative hours. Secondary outcomes were pain, nausea, dizziness, and length of hospital stay. RESULTS: Seventy-four patients were included in the analysis. Median total intravenous morphine consumption during the first 20 postoperative hours was 6 mg (interquartile range [IQR], 2-18 mg) in the OFB group and 20 mg (IQR, 12-28 mg) in the LIA group. The 14-mg difference (95% confidence interval, 6.4-18.0 mg) was significant (P < 0.001). There was no difference in pain score at rest at 20 hours postoperatively: 2 (IQR, 1-4) in the OFB group and 3 (IQR, 2-5) in the LIA group. CONCLUSIONS: Combined OFB reduces morphine consumption better than LIA after TKA even when all patients received high-dose intravenous dexamethasone. CLINICAL TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov, identifier NCT02374008.

Ultrasound-Guided Interscalene Brachial Plexus Nerve Block With an Ultralow Volume of Local Anesthetic for Post-Thoracotomy Shoulder Girdle Pain.

OBJECTIVES: To evaluate the efficacy of ultrasound-guided interscalene nerve block using an ultralow volume of local anesthetic (5 mL of ropivacaine, 0.75%) for the management of post-thoracotomy shoulder girdle pain. DESIGN: Open-cohort, prospective, single-center study. SETTING: University hospital. INTERVENTIONS: Patients with post-thoracotomy shoulder girdle pain (visual analog scale [VAS] ≥5) received an ultrasound-guided interscalene nerve block. MEASUREMENTS AND MAIN RESULTS: Thirty minutes after block implementation, the VAS was used to quantify pain across the shoulder girdle. The index (I) was calculated to indicate improvement of pain as follows: [Formula: see text] Nerve bocks resulting in I ≥75% were considered excellent. Total tramadol consumption 36 hours after nerve blocks, patients' satisfaction, and complications related to the procedure also were assessed. Patients were segregated in the following 2 groups: group A, which comprised patients with pain in the shoulder area (glenohumeral and acromioclavicular joints) (n = 30), and group B, which comprised patients with pain in the scapula (n = 17). I was significantly greater in group A (88.3% ± 14%) than in group B (43.2% ± 22%). In groups A and B, 90% and 11% of patients, respectively, demonstrated excellent pain control. Total tramadol consumption in group A, 25 (0-100) mg, was significantly less that of group B, 250 (150-500) mg. Patients' satisfaction also was significantly higher in group A compared with group B. No complications were recorded. CONCLUSIONS: Ultrasound-guided interscalene nerve block can substantially alleviate post-thoracotomy pain in the shoulder but not in the scapular area.

A lateral paracarotid approach for ultrasound-guided stellate ganglion block with a linear probe.

Recent reports suggest that ultrasound-guided stellate ganglion block (SGB) is safer and more accurate than classic SGB by the using the surface anatomical landmark. However, previous reports concern the classic paratracheal approach using a small specialized curved probe, which may not be appropriate in some patients. The authors have attempted several approaches, including paratracheal, trans-thyroidal, lateral paracarotid, and lateral approaches, to find a safe and suitable method for real-time ultrasound-guided SGB using a standard high-frequency linear probe. A total of 27 injections were performed on 27 patients with sensorineural hearing loss. The lateral paracarotid out-of-plane and lateral in-plane approaches were identified as the easiest and safest methods among the four tested. In this report, we describe a new lateral paracarotid approach for ultrasound-guided SGB. An ipsilateral paratracheal short-axis transverse scan was acquired at the C6 level with a linear probe (6-13 MHz). The probe was moved laterally, scanning the thyroid, carotid artery, internal jugular vein, longus colli muscle, and the transverse process of the C6, placing the carotid artery in the middle of the view. Light pressure was applied to the probe postero-medially to displace the carotid artery medially and completely compress the internal jugular vein. The needle was inserted out-of-plane between the lateral margin of the carotid artery and Chassaignac's tubercle, traversing the collapsed internal jugular vein, and targeted between the longus colli muscle and the prevertebral fascia. A total of 4 ml of 0.2% ropivacaine was injected for each procedure after a negative aspiration test. Successful blockade was confirmed with the onset of Horner's sign. All 27 injections resulted in successful blockade with Horner's sign presenting within 5 min after injection. Side effects were minor and caused minimal discomfort; they included hoarseness and a foreign body sensation. No hematomas formed after any injections. We suggest that this new lateral paracarotid approach, with out-of plane needle insertion at the C6 tubercle under transverse scan, is a convenient and safe method for performing real-time ultrasound-guided SGB, as it provides a wide, safe space for needle passage without risking thyroid or esophageal injury.

Efficacy of Stellate Ganglion Blockade Applied with Light Irradiation: A Systemic Review and Meta-analysis.

OBJECTIVE: Stellate ganglion block has mostly been used to relieve symptoms of neuropathic pain; several potential complications have been reported. Noninvasive stellate ganglion block application using light irradiation (SG-LI) can be used as an alternative to conventional injection blockades. Based on the variety of application protocols among previous studies, it was needed to further identify the clinical efficacy of SG-LI in managing neuropathic pain or other disorders associated with sympathetic hyperactivity. DESIGN: A comprehensive search of online databases was performed to identify experimental or observational studies reporting the efficacy of SG-LI in treating patients with disorders requiring sympatholytic management. The included studies were subjected to a meta-analysis and risk-of-bias assessment. RESULTS: Twenty-one experimental studies with a Physiotherapy Evidence Database score of 6/10 and 5 observational studies with a Newcastle-Ottawa scale score of 7/9 were included in the analysis. A significant effect on pain relief favoring SG-LI was identified at a standard mean difference (SMD) of -2.05 [95% confidence interval (CI), -2.49 to -1.61; P < 0.00001]. Similar effects favoring SG-LI were found in peripheral blood flow (SMD, 1.26; 95% CI, 0.26-2.25; P = 0.01) and skin temperature (SMD, 1.31; 95% CI, 0.55, 2.08; P = 0.0007). CONCLUSIONS: Stellate ganglion block application using light irradiation effectively relieves pain of various etiologies and successfully induces a sympatholytic response. Stellate ganglion block application using light irradiation may be a valuable addition to the contemporary pain management armamentarium.

Stellate Ganglion Block in the Treatment of Post-traumatic Stress Disorder: A Review of Historical and Recent Literature.

Concerns over the rising prevalence of post-traumatic stress disorder (PTSD), particularly among military service members returning from combat, and over barriers that hinder individuals from seeking out or adhering to standard therapies have contributed to interest in alternative therapies for the disorder. A novel alternative therapy for PTSD-stellate ganglion block (SGB)-may be considered lacking in formal evidence of efficacy despite having shown considerable promise. This review of the recent and historical literature related to SGB finds evidence of substantial beneficial psychiatric effects and substantiates that this fast-acting, somatic treatment may provide positive results for patients with PTSD and may reduce barriers to therapy, particularly among military populations.

Efficacy of Noninvasive Stellate Ganglion Blockade Performed Using Physical Agent Modalities in Patients with Sympathetic Hyperactivity-Associated Disorders: A Systematic Review and Meta-Analysis.

BACKGROUND: Stellate ganglion blockade (SGB) is mainly used to relieve symptoms of neuropathic pain in conditions such as complex regional pain syndrome and has several potential complications. Noninvasive SGB performed using physical agent modalities (PAMs), such as light irradiation and electrical stimulation, can be clinically used as an alternative to conventional invasive SGB. However, its application protocols vary and its clinical efficacy remains controversial. This study investigated the use of noninvasive SGB for managing neuropathic pain or other disorders associated with sympathetic hyperactivity. MATERIALS AND METHODS: We performed a comprehensive search of the following online databases: Medline, PubMed, Excerpta Medica Database, Cochrane Library Database, Ovid MEDLINE, Europe PubMed Central, EBSCOhost Research Databases, CINAHL, ProQuest Research Library, Physiotherapy Evidence Database, WorldWideScience, BIOSIS, and Google Scholar. We identified and included quasi-randomized or randomized controlled trials reporting the efficacy of SGB performed using therapeutic ultrasound, transcutaneous electrical nerve stimulation, light irradiation using low-level laser therapy, or xenon light or linearly polarized near-infrared light irradiation near or over the stellate ganglion region in treating complex regional pain syndrome or disorders requiring sympatholytic management. The included articles were subjected to a meta-analysis and risk of bias assessment. RESULTS: Nine randomized and four quasi-randomized controlled trials were included. Eleven trials had good methodological quality with a Physiotherapy Evidence Database (PEDro) score of ≥6, whereas the remaining two trials had a PEDro score of <6. The meta-analysis results revealed that the efficacy of noninvasive SGB on 100-mm visual analog pain score is higher than that of a placebo or active control (weighted mean difference, -21.59 mm; 95% CI, -34.25, -8.94; p = 0.0008). CONCLUSIONS: Noninvasive SGB performed using PAMs effectively relieves pain of various etiologies, making it a valuable addition to the contemporary pain management armamentarium. However, this evidence is limited by the potential risk of bias.

Effects of ultrasound-guided stellate ganglion block on autonomic nervous function during CO2-pneumoperitoneum: A randomized double-blind control trial.

BACKGROUND: CO2-pneumoperitoneum can cause sympathetic nerve activity increased and is likely to causes severe stress-related homeostatic disorders. OBJECTIVE: Patients undergoing elective laparoscopic cholecystectomy were administered type-B ultrasound-guided stellate ganglion block (SGB) to observe the effects on autonomic nervous system during CO2- pneumoperitoneum. DESIGN: A randomized, double-blinded, and placebo-controlled study. SETTING: University-affiliated teaching hospital. PATIENTS: Eighty patients (aged 32-75 years; weight, 45-80 kg; American Society of Anesthesiologists (ASA) physical status classification, class I or II) undergoing elective laparoscopic cholecystectomy. INTERVENTIONS: The RSGB group was administered lidocaine 1% 7 ml under ultrasound guidance. MAIN OUTCOME MEASURES: The low frequency (LF), high frequency (HF), total power (TP) and LF/HF ratio were recorded before the block (T0), 5 min (T1) and 30 min (T2) following pneumoperitoneum, 5 min after deflation of pneumoperitoneum (T3) and after surgery (T4). The low-frequency normalized unit (LFnu) and high-frequency normalized units (HFnu) were calculated. RESULTS: Compared with T0, LF, LFnu and LF/HF ratio were significantly elevated at T1-4 (all P< .05 or .01). HFnu was significantly decreased at T2-4 in control group (P< .05) while HF was significantly elevated (P< .01). The LF/HF ratio was significantly decreased (P< .05) at T1-4 in RSGB group. Compared with control group, the LF, LFnu and LF/HF ratio were significantly decreased (P< .05) and HF and HFnu was significantly elevated (P< .05 or .01) at T1-4 in RSGB group. CONCLUSION: Ultrasound-guided RSGB inhibited CO2-pneumoperitoneum-induced sympathetic neural excitation, upregulated vagal nerve stimulation and maintained stable autonomic nervous function.

Minimally invasive procedures for neuropathic pain.

Neuropathic pain is "pain arising as a direct consequence of a lesion or disease affecting the somatosensory system". The prevalence of neuropathic pain ranges from 7 to 11% of the population and minimally invasive procedures have been used to both diagnose and treat neuropathic pain. Diagnostic procedures consist of nerve blocks aimed to isolate the peripheral nerve implicated, whereas therapeutic interventions either modify or destroy nerve function. Procedures that modify how nerves function include epidural steroid injections, peripheral nerve blocks and sympathetic nerve blocks. Neuroablative procedures include radiofrequency ablation, cryoanalgesia and neurectomies. Currently, neuromodulation with peripheral nerve stimulators and spinal cord stimulators are the most evidence-based treatments of neuropathic pain.

[Stellate ganglion catheter retention with discontinuous block on efficacy and safety in the treatment of sudden deafness].

OBJECTIVE: To investigate effect and safty evaluation of stellate ganglion catheter retention with discontinuous block on sudden deafness. METHOD: One hundred and twenty-six patiens with sudden monaural deafness were randomly divided into Catheterp and block and control groups with 42 cases in each group. All patients' throats were given conventional blood activating drugs, hormone and hyperbaric oxygen therapy. stellate ganglion puncture retained catheter were administrated to the patients in catheter group followed by ropivacaine block 1 times/day, block group stellate ganglion puncture and ropivacaine block 1 times/day. The patients in control group were only received routine comprehensive treatment. Patients in both catheter group and block groups were treated by hyperbaric oxygen therapy after the block treatment. Curative effects of three groups were observed. The patients' satisfaction, heart rate, the chages of blood pressure before and after the block, detachment of tubes, and adverse drug reaction were recorded. RESULT: The effect of the treatment in both catheter group, block group was better than in control group (85.7%, 37 cases); 83.3%, 35 cases) vs 64.3%, 27 cases, P < 0.05). The satisfactory rate in the patients in catheter group was significantly higher than block group (83.3%, 35 cases vs 61.9%, 26 cases, P < 0.05). The heart rate and the blood pressure before and 5 minutes after catheterization in catheter group and block groupwere changed obviously. Moreover, no adverse drug reaction and detachment of tubes were observed. CONCLUSION: It is a safe and effective administration of stellate ganglion catheter retention with interrupted ropivacaine block.

Sympathetic Block as a New Treatment for Lymphedema.

BACKGROUND: Breast cancer-related lymphedema (BCRL) not only has physical implications, but also affects the quality of life in breast cancer survivors. Despite numerous studies of various therapies, the optimal treatment for BCRL is unknown. OBJECTIVE: In this study, we investigated the efficacy of sympathetic blockade (thoracic sympathetic ganglion block, [TSGB]) in treating BCRL. STUDY DESIGN: Retrospective study. SETTING: Tertiary referral center/teaching hospital. METHODS: TSGB was performed in 35 patients under fluoroscopic guidance. First, arm circumference and Lymphedema and Breast Cancer Questionnaire [LBCQ] score were assessed before TSGB and 2 weeks and 2 months after the procedure. Efficacy was defined as a ≥ 50% reduction in the LBCQ score and a ≥ 50% decrease in the circumference difference between the unaffected and affected arms 2 months after TSGB. Second, TSGB efficacy according to the lymphedema stage and the period between BCRL onset and TSGB (< 6 months vs. > 6 months) was evaluated. RESULTS: The arm circumference and LBCQ score significantly decreased at 2 months (P < 0.001), and 65.7% of patients showed good efficacy. Patients with high stage lymphedema showed improved efficacy after TSGB compared to those with low stage disease (P = 0.045). The TSGB efficacy did not differ according to the period between BCRL onset and TSGB. LIMITATIONS: This study was not a randomized prospective controlled study and did not compare the therapeutic outcomes to those in a conservative treatment group. CONCLUSIONS: TSGB in BCRL patients appears to be effective in decreasing the affected arm circumference. TSGB may be an alternative option in BCRL patients who do not respond to conservative therapy.

Effects of stellate ganglion block on sedation as assessed by bispectral index in normal healthy volunteers.

BACKGROUND: The sympathetic nervous system plays an important role in the arousal response. Recently, the stellate ganglion block (SGB) was found to effectively treat anxiety and night awakening in humans and decrease electroencephalogram (EEG) indices of arousal responses in rat. But, the role of the sympathetic block in human arousal responses has not yet been studied. OBJECTIVE: We performed this prospective, double-blinded, controlled volunteer study to investigate the sedative effects and bispectral index (BIS) changes of SGB. STUDY DESIGN: A randomized, double-blind trial. SETTING: Single academic medical center. METHODS: This study was approved by the Ethics Committee of Kyungpook National University Hospital (ref: KNUH-10-1081) and registered with CRiS (Clinical Research Information Service, http://cris.cdc.go.kr, ref: KCT0000036, 2010. 9.24). Twenty healthy volunteers were enrolled in this study. The volunteers were randomly assigned to one of 2 groups: the SGB group (n = 10) and the sham group (n =10). Volunteers in SGB group received SGB and volunteers in the sham group received a sham procedure. BIS value, heart rate, and blood pressure were measured before and 5, 10, 20, and 30 minutes after the procedure. Observer's Assessment of Alertness/Sedation (OAA/S) scores were assessed before and 10 and 30 minutes after the intervention. RESULTS: In the SGB group, BIS values and OAA/S scores significantly decreased after the intervention as compared to baseline (P < 0.05). The values were also significantly decreased in the SGB group when compared to the values in sham group after the intervention (P < 0.05). There was a significant change of mean blood pressure 10 to 30 minutes after SGB (P < 0.05). There were no differences in heart rate during study period between groups. LIMITATIONS: This study is limited by a relatively small sample size. CONCLUSIONS: This study showed that SGB has a sedative effect in normal healthy volunteers, as evidenced by decreased OAA/S scores and BIS values.