A Narrative Review on Pain Management in Head and Neck Cancer: Integrating Multimodal Analgesia and Interventional Procedures.

Surgical interventions and radiotherapy for head and neck cancer frequently result in substantial instances of acute and chronic discomfort. Optimizing pain management techniques stands as a pivotal factor in enhancing the well-being and overall quality of life for patients. This comprehensive review discusses various pain conditions encountered after head and neck cancer and explores a multidimensional approach to pain management. The review highlights the significance of incorporating multimodal analgesia, physical therapy, psychological support, palliative care, and emerging techniques including nerve blocks to achieve efficacious pain control. Such an endeavor necessitates cooperation among head and neck surgeons, radiotherapists, and pain specialists.

Robotic Pediatric Urologic Surgery-Clinical Anesthetic Considerations: A Comprehensive Review.

Minimally invasive robotic approaches have become standard in many institutions over the last decade for various pediatric urological procedures. The anesthetic considerations for common laparoscopic and robotic-assisted surgeries are similar since both require the insufflation of CO2 to adequately visualize the operative area. However, few studies exist regarding anesthesia for robotic procedures in children. We hypothesized that pediatric patients undergoing robotic urologic surgeries would require specific anesthetic strategies, especially given the inherently longer durations of these procedures. This study aimed to evaluate anesthetic considerations, current robotic procedures, optimal patient positioning, and port placement for robotic-assisted surgery in pediatric patients. A comprehensive literature review of all published manuscripts from PubMed, EMBASE database, and Google Scholar was performed, focusing on robotic procedures involving pediatric patients, anesthesia for pediatric urology patients, and related topics from 1996 to 2023. Forty published manuscripts were identified and reviewed in depth. In pediatric cases, insufflation pressures and volumes are lower due to the laxity of the abdominal wall. However, the increase in intra-abdominal pressure and absorption of CO2 may result in disproportionate changes in cardiopulmonary function. Specific patient positioning for robotic approaches may further compound these physiological changes. Correct patient positioning is essential to facilitate surgery optimally and safely. Understanding the physiological changes that can occur during a pediatric patient's robotic urologic surgery allows for safer anesthesia management.

Comparison of Clinical Effects and Physical Examination of Transforaminal and Caudal Steroid Injection With Targeted Catheter in Lumbar Radiculopathy: A Single-Blind Randomized Clinical Trial.

BACKGROUND: Transforaminal and caudal epidural injections are two methods of steroid injection in lumbar radiculopathy. Using a targeted catheter with the possibility of accessing the involved spinal roots and steroid administration selectively next to them during the caudal procedure may achieve the benefits of both transforaminal and caudal procedures. The aim of this study was to investigate the clinical effects and physical examinations of transforaminal steroid injection compared to caudal through a targeted catheter in lumbar radiculopathy. METHODS: Fifty patients with lumbar radiculopathy candidates for epidural steroid injection were divided into transforaminal (T) and caudal (C) groups. Steroid injection under fluoroscopic guidance was performed in group T with the transforaminal method and in group C with the caudal method using a targeted catheter for each involved spinal nerve root. Pain intensity visual analog scale (VAS), Oswestry Disability Index (ODI), daily analgesic consumption, and physical examinations on four follow-ups (before injection, second week, first and third month) were evaluated. RESULTS: Pain score (VAS) and functional disability index (ODI) were similar in both groups, and there was no significant difference between the two groups (p > 0.05). The positive Lasègue test was significantly higher in the caudal group than in the transforaminal group only in the third month (p < 0.05). Other physical examinations in both groups did not have significant differences in all the follow-ups. Moreover, there was no difference in the amount of analgesic consumption in the two groups. No complications were observed in both groups. CONCLUSION: This study showed that transforaminal and caudal steroid injection (with a targeted catheter) in patients with lumbar radiculopathy had similar effects in controlling pain and improving functional disability of patients in the short term. Cases of recurrence of positive Lasègue test in physical examinations in the long term (third month) in the caudal group may indicate the preference of the transforaminal approach. TRIAL REGISTRATION: Iranian Registry of Clinical Trials (IRCT) number: IRCT20111102007984N31.

Potential therapeutic effects of apigenin for colorectal adenocarcinoma: A systematic review and meta-analysis.

PURPOSE: Therapeutic management of colorectal cancer (CRC) does not yet yield promising long-term results. Therefore, there is a need for further investigation of possible therapeutic options. Various experiments have studied the effects of apigenin on CRC and have shown conflicting results. This systematic review and meta-analysis investigates the currently existing evidence on the effect of apigenin on CRC. METHODS: Medline, Embase, Scopus, and Web of Science databases were searched for articles related to apigenin and its effect on CRC in the preclinical setting. Cell viability, growth inhibition, apoptosis, and cell cycle arrest for in-vitro, and body weight, tumor size, and mortality in in-vivo studies were extracted as outcomes. RESULTS: Thirty-nine articles investigating colorectal adenocarcinoma were included in this meta-analysis. Thirty-seven of these studies had data for in vitro experiments, with eight studies having data for in vivo experiments. Six articles had both in vitro and in vivo assessments. Our analysis showed apigenin reduces cell viability and induces growth inhibition, apoptosis, and cell cycle arrest in in vitro studies. The few in vivo studies indicate that apigenin decreases tumor size while showing no effects on the body weight of animal colorectal adenocarcinoma models. CONCLUSION: Our results demonstrated that apigenin, through reducing cell viability, inducing growth inhibition, apoptosis, and cell cycle arrest, and also by decreasing the tumor size, can be considered as a possible adjuvant agent in the management of colorectal adenocarcinoma. However, further in vivo studies are needed before any efforts to translate the current evidence into clinical studies.

Comparing the Efficacy of Transforaminal and Caudal Epidural Injections of Calcitonin in Treating Degenerative Spinal Canal Stenosis: A Double-Blind Randomized Clinical Trial.

Background: Lumbar spinal stenosis (LSS) is the most common indication for lumbar surgery in elderly patients. Epidural injections of calcitonin are effective in managing LSS. Objectives: This study aimed to compare the efficacy of transforaminal and caudal injections of calcitonin in patients with LSS. Methods: In this double-blind randomized clinical trial, LSS patients were divided into two equal groups (N = 20). The first group received 50 IU (international units) of calcitonin via caudal epidural injection (CEI), and the second group received 50 IU of calcitonin via transforaminal epidural injection (TEI). The Visual Analogue Scale (VAS) and Oswestry Low Back Pain Disability Questionnaire (ODI) were used to assess the patient's pain and ability to stand, respectively. Visual Analogue Scale and ODI scores were recorded and analyzed. Results: The results showed that caudal and TEIs of calcitonin significantly improved pain and ability to stand during follow-up compared to before intervention (P < 0.05). Additionally, CEI of calcitonin after 6 months significantly reduced pain in LSS patients compared to TEI of calcitonin (P < 0.05). However, no significant difference was observed between the two epidural injection techniques in improving the patient's ability to stand (P > 0.05). Conclusions: The results of the study indicate that epidural injection of calcitonin in long-term follow-up (6 months) had a significant effect on improving pain intensity and mobility in patients with LSS, and its effect on pain in the TEI method was significantly greater than that in the CEI method.

Anesthetic Considerations for Cataract Surgery in Patients with Parkinson's Disease: A Narrative Review.

Parkinson's disease (PD) is a chronic neurological degenerative disease affecting the central nervous system, which is responsible for progressive disorders such as slow movements, tremors, rigidity, and cognitive disorders. There are no specific recommendations and guidelines for anesthetic management of patients with PD undergoing ophthalmic procedures. This narrative review aims to summarise the anesthetic considerations in patients with PD presenting for cataract surgery.

Veno-venous Extracorporeal Membrane Oxygenation: Anesthetic Considerations in Clinical Practice.

Context: After the COVID-19 pandemic, multiple reviews have documented the success of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Patients who experience hypoxemia but have normal contractility may be switched to veno-venous-ECMO (VV-ECMO). Purpose: In this review, we present three protocols for anesthesiologists. Firstly, transesophageal echocardiography (TEE) aids in cannulation and weaning off inotropes and fluids. Our main objective is to assist in patient selection for the Avalon Elite single catheter, which is inserted into the right internal jugular vein and terminates in the right atrium. Secondly, we propose appropriate anticoagulant doses. We outline day-to-day monitoring protocols to prevent heparin-induced thrombocytopenia (HIT) or resistance. Once the effects of neuromuscular paralysis subside, sedation should be reduced. Therefore, we describe techniques that may prevent delirium from progressing into permanent cognitive decline. Methods: We conducted a PubMed search using the keywords VV-ECMO, TEE, Avalon Elite (Maquet, Germany), and quetiapine. We combined these findings with interviews conducted with nurses and anesthesiologists from two academic ECMO centers, focusing on anticoagulation and sedation. Results: Our qualitative evidence synthesis reveals how TEE confirms cannulation while avoiding right atrial rupture or low flows. Additionally, we discovered that typically, after initial heparinization, activated partial thromboplastin time (PTT) is drawn every 1 to 2 hours or every 6 to 8 hours once stable. Daily thromboelastograms, along with platelet counts and antithrombin III levels, may detect HIT or resistance, respectively. These side effects can be prevented by discontinuing heparin on day two and initiating argatroban at a dose of 1 µg/kg/min while maintaining PTT between 61 - 80 seconds. The argatroban dose is adjusted by 10 - 20% if PTT is between 40 - 60 or 80 - 90 seconds. Perfusionists assist in establishing protocols following manufacturer guidelines. Lastly, we describe the replacement of narcotics and benzodiazepines with dexmedetomidine at a dose of 0.5 to 1 µg/kg/hour, limited by bradycardia, and the use of quetiapine starting at 25 mg per day and gradually increasing up to 200 mg twice a day, limited by prolonged QT interval. Conclusions: The limitation of this review is that it necessarily covers a broad range of ECMO decisions faced by an anesthesiologist. However, its main advantage lies in the identification of straightforward argatroban protocols through interviews, as well as the discovery, via PubMed, of the usefulness of TEE in determining cannula position and contractility estimates for transitioning from VA-ECMO to VV-ECMO. Additionally, we emphasize the benefits in terms of morbidity and mortality of a seldom-discussed sedation supplement, quetiapine, to dexmedetomidine.

The Effects of Opioid Dependency Use on Postoperative Spinal Surgery Outcomes: A Review of the Available Literature.

There is a lack of evidence to support the effectiveness of long-term opioid therapy in patients with chronic, noncancer pain. Despite these findings, opioids continue to be the most commonly prescribed drug to treat chronic back pain and many patients undergoing spinal surgery have trialed opioids before surgery for conservative pain management. Unfortunately, preoperative opioid use has been shown repeatedly in the literature to negatively affect spinal surgery outcomes. In this review article, we identify and summarize the main postoperative associations with preoperative opioid use that have been found in previously published studies by searching on PubMed, Google Scholar, Medline, and ScienceDirect; using keywords: Opioid dependency, postoperative, spinal surgery, specifically (1) increased postoperative chronic opioid use (24 studies); (2) decreased return to work (RTW) rates (8 studies); (3) increased length of hospital stay (LOS) (9 studies); and (4) increased healthcare costs (8 studies). The conclusions from these studies highlight the importance of recognizing patients on opioids preoperatively to effectively risk stratify and identify those who will benefit most from multidisciplinary counseling and guidance.

Comparison of Perioperative Pregabalin and Duloxetine for Pain Management After Total Knee Arthroplasty: A Double-Blind Clinical Trial.

Background: Chronic residual pain after total knee arthroplasty (TKA) is one of the challenges of postoperative pain management. Duloxetine, by controlling neuropathic pain, and pregabalin, by affecting nociceptors, can effectively manage postoperative pain. Objectives: This study aimed to compare the effect of perioperative oral duloxetine and pregabalin in pain management after knee arthroplasty. Methods: In this clinical trial, 60 patients scheduled for TKA under spinal anesthesia were randomly assigned to one of three groups A (pregabalin 75 mg), B (duloxetine 30 mg), and C (placebo). Drugs were administered 90 minutes before, 12, and 24 hours after surgery. The visual analog scale (VAS) score for pain, the first analgesic request time, postoperative analgesic consumption (i.v. paracetamol), and WOMAC score six months after surgery were recorded. Results: The VAS score and analgesic consumption 48 hours after TKA in groups A and B significantly decreased compared to the placebo (P < 0.05). The first analgesic request time was longer in groups A and B than in group C (P < 0.05). While the differences were statistically significant, they are most likely not clinically significant. The WOMAC score before and six months after arthroplasty did not differ between the groups (P > 0.05). Conclusions: Perioperative oral pregabalin and duloxetine similarly reduce pain and the need for analgesic consumption within 48 hours after TKA but do not affect knee mobility status.

The effect of Trolox on the rabbit anal sphincterotomy repair.

INTRODUCTION: Fecal incontinence (FI) is caused by external anal sphincter injury. Vitamin E is a potential strategy for anal sphincter muscle repair via its antioxidant, anti-inflammatory, anti-fibrotic, and protective properties against myocyte loss. Thus, we aimed to evaluate the water-soluble form of vitamin E efficacy in repairing anal sphincter muscle defects in rabbits. METHODS: Twenty-one male rabbits were equally assigned to the intact (without any intervention), control (sphincterotomy), and Trolox (sphincterotomy + Trolox administration) groups. Ninety days after sphincterotomy, the resting and squeeze pressures were evaluated by manometry, and the number of motor units in the sphincterotomy site was calculated by electromyography. Also, the amount of muscle and collagen in the injury site was investigated by Mallory's trichrome staining. RESULTS: Ninety days after the intervention, the resting and squeeze pressures in the intact and Trolox groups were significantly higher than in the control group (P = 0.001). Moreover, the total collagen percentage of the sphincterotomy site was significantly lower in the Trolox group than in the control group (P = 0.002), and the total muscle percentage was significantly higher in the Trolox group compared to the control group (P = 0.001). Also, the motor unit number was higher in the Trolox group than in the control group (P = 0.001). CONCLUSION: Trolox administration in the rabbit sphincterotomy model can decrease the amount of collagen and increase muscle, leading to improved anal sphincter electromyography and manometry results. Therefore, Trolox is a potential treatment strategy for FI.

Dural Puncture During Spinal Cord Stimulator Lead Insertion: Analysis of Practice Patterns.

Background: Spinal cord stimulation (SCS) is an important modality for intractable pain not amenable to less conservative measures. During percutaneous SCS lead insertion, a critical step is safe access to the epidural space, which can be complicated by a dural puncture. Objectives: In this review, we present and analyze the practices patterns in the event of a dural puncture during a SCS trial or implantation. Methods: We conducted a survey of the practice patterns regarding spinal cord stimulation therapy. The survey was administered to members of the Spine Intervention Society and American Society of Regional Anesthesia specifically inquiring decision making in case of inadvertent dural puncture during spinal cord stimulator lead insertion. Results: A maximum of 193 responded to a question regarding dural punctures while performing a SCS trial and 180 responded to a question regarding dural punctures while performing a SCS implantation. If performing a SCS trial and a dural puncture occurs, a majority of physicians chose to continue the procedure at a different level (56.99%), followed by abandoning the procedure (27.98%), continuing at the same level (10.36%), or choosing another option (4.66%). Similarly, if performing a permanent implantation and a dural puncture occurs, most physicians chose to continue the procedure at a different level (61.67%), followed by abandoning the procedure (21.67%), continuing at the same level (10.56%), or choosing another option (6.11%). Conclusions: Whereas the goals of the procedure would support abandoning the trial but continuing with the permanent in case of inadvertent dural puncture, we found that decision choices were minimally influenced by whether the dural puncture occurred during the trial or the permanent implant. The majority chose to continue with the procedure at a different level while close to a quarter chose to abandon the procedure. This article sets a time stamp in practice patterns from March 20, 2020 to June 26, 2020. These results are based on contemporary SCS practices as demonstrated by this cohort, rendering the options of abandoning or continuing after dural puncture as reasonable methods. Though more data is needed to provide a consensus, providers can now see how others manage dural punctures during SCS procedures.

Burst Spinal Cord Stimulation in the Management of Chronic Pain: Current Perspectives.

Over the last several decades, opioid diversion, misuse, and over-prescription have run rampant in the United States. Spinal cord stimulation (SCS) has been FDA approved for treatment for a primary indication of neuropathic limb pain that is resistant to more conservative medical therapy. The disorders qualified for treatment include neuropathic, post-surgical, post-amputation, osteodegenerative, and pain related to vascular disease. Some of the most frequently cited conditions for treatment of SCS include failed back surgery syndrome, complex regional pain syndrome (CRPS) Type I and Type II, and post-herpetic neuralgias. Developments in SCS systems have led to the differentiation between the delivered electromechanical waveform patterns, including tonic, burst, and high-frequency. Burst SCS mitigates traditional paresthesia due to expedited action potential and offers improved pain relief. Burst SCS has been shown in available studies to be non-inferior to the traditional SCS, which can cause pain paresthesia in patients who already have chronic pain. Burst SCS does not seem to cause or need the paresthesia seen in traditional SCS, making SCS not tolerable to patients. Moreover, some studies suggest that burst SCS may decrease opioid consumption in patients with chronic pain. This can make burst SCS an extremely useful tool in the battle against chronic pain and the raging opioid epidemic. As of now, more research needs to be performed to further delineate the effectiveness and long-term safety of this device.

Effects of Ketamine and Lidocaine Infusion on Acute Pain after Elective Open Abdominal Surgery, a Randomized, Double-Blinded Study.

Background: Most patients suffer from moderate to severe pain after elective laparotomy. They often require opioids to alleviate their pain. Opiates invariably induce certain side effects and, occasionally, dependence. Intraoperative infusion of lidocaine and low-dose ketamine reduces postoperative pain and analgesic requirements. This study aims to evaluate the effects of simultaneous infusion of lidocaine and ketamine during open abdominal surgery on the postoperative pain severity and analgesic consumption. Methods: In this randomized, double-blinded, single-center study that was performed in Iran, 80 patients scheduled for elective open abdominal surgery under general anesthesia were enrolled in two LK and P groups. Group LK (n=40) received lidocaine-ketamine infusion, and group P (n=40) received placebo (normal saline). Both infusions were started thirty minutes after initiation of surgery and were terminated once the surgery was completed. For postoperative pain management, patient-controlled analgesia (PCA), including fentanyl and paracetamol, was administered for both groups. All patients were evaluated for pain visual analogue scale (VAS) and total adjunctive analgesic (diclofenac suppository) consumption within the first 24 hours after the surgery. The data were analyzed using SPSS. P values <0.05 were considered significant. Results: Intraoperative infusion of Lidocaine and Ketamine resulted in desirable postoperative pain control. Patients of LK group demonstrated a significant reduction in the pain score at 1, 6, 12, 18, and 24 hours after termination of surgery (p<0.001). It also resulted in a decreased requirement for postoperative analgesics, as cumulative analgesic consumption was decreased meaningfully in the patients of LK group (p<0.001). Conclusion: Intravenous infusion of lidocaine and ketamine during elective open abdominal surgery reduces pain intensity and analgesic requirements in the first 24 hours postoperatively, without major additional side effects.

Management of pain using magnesium sulphate: a narrative review.

Pain is one of the most complex and unpleasant sensory and emotional human experiences. Pain relief continues to be a major medical challenge. The application of systemic opioid and regional analgesia techniques has facilitated a decrease in the occurrence and gravity of pain. Magnesium has an evolving role in pain management. Magnesium sulfate (MgSO4), the pharmacological form of magnesium, is a physiological voltage-dependent blocker of N-methyl-D-aspartate (NMDA)-coupled channels. In terms of its antinociceptive role, magnesium blocks calcium influx, which inhibits central sensitization and decreases preexisting pain hypersensitivity. These properties have encouraged the research of magnesium as an adjuvant agent for intra- and post-operative analgesia. Moreover, the mentioned magnesium impacts are also detected in patients with neuropathic pain. Intravenous magnesium sulfate, followed by a balanced analgesia, decreases opioid consumption. This review has focussed on the existing evidence concerning the role of magnesium sulfate in pain management in situations including neuropathic pain, postherpetic neuralgia, trigeminal neuralgia, migraine, and post-operative pain. Additional studies are required to improve the use of magnesium sulfate for pain to increase the quality of life of patients.

A Multimodal Clinical Approach for the Treatment of Bone Metastases in Solid Tumors.

Context: Bone metastasis (BM) is a frequent complication of cancer, representing the third most common site of secondary spread in solid cancers behind the lung and liver. Bone metastasis is found in up to 90% of prostate and breast cancer patients. They can cause significant complications, such as pathological fractures and paralysis of the spine, which decrease daily functioning and quality of life (QoL) and worsen prognosis. The growing life expectancy of cancer patients due to improvements in systemic therapies may further increase BM's eventuality and clinical burden in cancer patients. Evidence Acquisition: Four physicians from five different specialties were interviewed and resumed the most relevant literature of the last 20 years focusing on pain treatment in BM patients. Results: Treatment for BM ideally involves various types of specialists and assessments. The disease status and patient background should be considered, requiring holistic care and expertise from various medical specialties. Conclusions: Interventional, nuclear medicine, radiotherapy, and mini-invasive techniques can be safe and effective for relieving pain and modifying health-related QoL in BM patients.

Current Strategies in Pain Regimens for Robotic Urologic Surgery: A Comprehensive Review.

Context: Robotic surgery is becoming the most common approach in minimally invasive urologic procedures. Robotic surgery offers less pain to patients because of smaller keyhole incisions and less tissue retraction and stretching of fascia and muscular fibers. Tailored pain regimens have also evolved and allowed patients to feel minimal to no discomfort after robotic urologic surgery, allowing in parallel better surgical outcomes. This study aims to analyze the most current pain regimens in robotic urologic surgery and to evaluate the most current pain protocols and corresponding outcomes. Evidence Acquisition: A literature review was performed of published manuscripts utilizing Pubmed and Google Scholar on pain protocols for patients undergoing robotic urologic surgery. Results: Multimodal analgesia is gaining ground in robotic urologic surgery. Regional analgesia includes four major modalities: Neuroaxial analgesia, intercostal blocks, tranvsersus abdominis plane blocks, and paravertebral blocks. Each approach has a different injection site, region of analgesia coverage, and duration of coverage depending upon local anesthesia and/or adjuvant utilized with advantages and disadvantages that make each modality unique and efficacious. Conclusions: Robotic urologic surgery has offered the advantage of smaller incisions, faster recovery, less postoperative opioid consumption, and better surgical outcomes. Neuraxial, intercostal, transversus abdominis plane, and quadratus lumborum blocks are the best and most adopted approaches which offer optimal outcomes to patients.

Efficacy of Oxygen-Ozone Therapy and Platelet-Rich Plasma for the Treatment of Knee Osteoarthritis: A Meta-analysis and Systematic Review.

Context: This systematic review and meta-analysis evaluated the effect of the intra-articular injection of platelet-rich plasma (PRP) and oxygen-ozone therapy and provided an evidence-based methodology to treat KOA. Method: Databases, including Cochrane Library, PubMed, and EMBASE, were searched. The retrieval period was before 2021. Two reviewers performed the process of screening and data extraction. Mean differences were calculated [95% confidence interval (CI)] with an inverse-variance method and fixed effect model. Meta-analysis was performed using the latest version of STATA version 16. Results: A total of 12 studies out of 769 articles were evaluated. The mean difference of visual analog scale score between ozone and control groups in the first month after injection was -0.02 (MD, -0.02; 95% CI: -0.32, 0.28; P < 0.05). Mean differences of WOMAC pain, stiffness, and physical function score between baseline and after PRP were -3.53 (MD: -3.53; 95% CI: -4.04, -3.02; P = 0.00), -0.60 (MD: -0.60; 95% CI: -4.0 - 0.864, -0.34; P = 0.00), and -5.96 (MD: -5.96; 95% CI: -7.83, -4.09; P = 0.00). Conclusions: Our results showed that to treat knee osteoarthritis, using PRP for a longer period of 6 - 12 months after the intervention shows better clinical results, while oxygen-ozone therapy has short-term results.

The Specifics of Non-specific Low Back Pain: Re-evaluating the Current Paradigm to Improve Patient Outcomes.

Low back pain (LBP) is the leading cause of pain and debility worldwide and the most frequent reason for work-related disability. Global expenditures related to LBP are staggering and amount to billions of dollars each year in the United States alone. Yet, despite the considerable healthcare resources consumed, the care provided to patients with LBP has regularly been cited as both ineffective and exorbitant. Among the myriad reasons for this suboptimal care, the current approach to evaluation and management of patients with LBP is a likely contributor and is hitherto un-investigated. Following the current methodology, over 90% of patients with LBP are provided with no specific diagnosis, are managed inconsistently, and receive no express preventative care. We believed that this approach added costs and promoted chronic unresolved pain and disability. This narrative review highlights problems with the current methodology, proposes a novel concept for categorizing patients with LBP, and recommends strategies for improvement. Stratifying patients according to the etiology, in lieu of the prospects for morbidity, the strategy proposed in this article may help ascertain the cause of patient's LBP early, consolidate treatments, permit timely preventative measures, and, as a result, may improve patient outcomes.

Unilateral Right-Sided Ultrasound-Guided Erector Spinae Plane Block for Post-Laparoscopic Cholecystectomy Analgesia: A Randomized Control Trial.

Background: Post-laparoscopic cholecystectomy (LC) pain control is still an issue postoperatively. Objectives: We investigated the effectiveness of the unilateral right-side ultrasound-guided erector spinae plane block (ESPB) on post-LC pain intensity and opioid consumption. Methods: This is a parallel-arm randomized control trial on 62 adult patients with an American Society of Anesthesiologists (ASA) physical status ≤ 2 who underwent LC. The patients were randomized into 2 groups (the block group [BG] and the control group [CG]; n = 31 per group). BG received a single-shot right-sided T7 ESPB with 20 mL of 0.2% ropivacaine at arrival time in the post-anesthesia care unit (PACU). CG) received no regional anesthesia. Both groups received patient-controlled intravenous fentanyl and rescue meperidine for analgesia. The primary outcome was the pain intensity determined using a Numerical Rating Scale (NRS) in the first 24 hours after surgery. Secondary outcomes included total fentanyl and meperidine consumption within 24 hours. Results: Median pain scores were significantly higher in CG at rest and with coughing up to 12 hours after surgery compared with BG. Pain scores were higher in CG with a cough at 24 hours compared with BG (median 1 [interquartile range (IQR) 1, 2] vs. 1 [1, 0]; P = 0.0005). Total fentanyl consumption and meperidine consumption within 24 hours were significantly lower in BG compared with CG (median 60 µg [IQR 60, 90] vs 250 µg [90, 300]; P < 0.0001 and median 20 µg [IQR 10, 20] vs 25 [20, 25]; P = 0.002, respectively). Conclusions: A single-shot, right-sided, unilateral ESPB decreases post-LC opioid consumption and pain.

Nuts and Bolts of Peripheral Nerve Blocks for Pain After Hip Fracture for Everyday Anesthetist.

A range of peripheral nerve blocks is available to treat hip fracture pain, leaving clinicians confused on choice. No single block appears to be outstanding. The article described the relevant anatomy, technical approach, risk associated, and practicability to facilitate a better understanding of the various approaches available. The clinician should be able to make an informed decision based on local requirements and logistics.