Combined Spinal Cord Stimulation and Peripheral Nerve Stimulation for Brachial Plexopathy: A Case Report.

Brachial plexopathy usually results from an iatrogenic brachial plexus injury and can sometimes cause severe chronic pain and disability. There are a number of possible treatments for this condition, including medication, physical therapy, nerve blocks, and neuromodulation, but they are not always successful. Recently, combined spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS) have been tried for various chronic pain diseases because of their different mechanisms of action.Here, we describe the case of a 54-year-old man who was diagnosed with brachial plexopathy 8 years ago. He underwent video-assisted thoracoscopic surgery to remove a superior mediastinal mass. However, his brachial plexus was damaged during the surgery. Although he had received various treatments, the pain did not improve. For the management of intractable severe pain, he underwent SCS 2 years ago, which initially reduced his pain from numeric rating scale (NRS) 10/10 to NRS 4 - 5/10, but the pain then gradually increased, reaching NRS 8/10, 6 months ago. At that time, he was refractory to other treatments, and we therefore applied PNS in combination with SCS. The PNS electrode was positioned on the radial nerve under ultrasound guidance. After combined PNS and SCS, his background pain disappeared, although a breakthrough pain (NRS 3 - 4/10) was caused intermittently by light touch. Furthermore, the patient's need for analgesics decreased, and he was satisfied with the outcome of this combined treatment. We concluded that combined SCS and PNS is a very useful treatment modality, which can stimulate the target nerve both directly and indirectly, and hence, relieve pain from brachial plexopathy.

Prediction of early allograft dysfunction using serum phosphorus level in living donor liver transplantation.

Serum phosphorus is greatly affected by liver surgeries, but its change after liver transplantation has not yet been clarified. We investigated the predictive role of serum phosphorus for early allograft dysfunction (EAD) after living donor liver transplantation (LDLT). Perioperative factors, including serum phosphorus level, of 304 patients who underwent LDLT were retrospectively studied and compared between patients with and without EAD after LDLT. Potentially significant factors (P < 0.15) in univariate comparisons were subjected to multivariate logistic regression analysis to develop a prediction model for EAD. A total of 48 patients (15.8%) met the EAD criteria. Patients with EAD experienced more severe preoperative disease conditions, higher one-month mortality and more elevated serum phosphorus concentrations during the first week after surgery compared with patients without EAD (P = 0.016). Multivariate analysis showed that a serum phosphorus level ≥4.5 mg/dl on postoperative day 2 was an independent predictor of EAD occurrence after LDLT (relative risk: 2.36, 95% confidence interval [1.18-4.31], P = 0.017), together with a history of past abdominal surgery, emergency transplantation and preoperative continuous veno-venous haemodiafiltration. These data indicate that hyperphosphataemia during the immediate postoperative days could be utilized as a predictor of EAD after LDLT.

Amnesia and pain relief after cardiopulmonary resuscitation in a cancer pain patient: a case report.

The mechanism of chronic pain is very complicated. Memory, pain, and opioid dependence appear to share common mechanism, including synaptic plasticity, and anatomical structures. A 48-yr-old woman with severe pain caused by bone metastasis of breast cancer received epidural block. After local anesthetics were injected, she had a seizure and then went into cardiac arrest. Following cardiopulmonary resuscitation, her cardiac rhythm returned to normal, but her memory had disappeared. Also, her excruciating pain and opioid dependence had disappeared. This complication, although uncommon, gives us a lot to think about a role of memory for chronic pain and opioid dependence.