Medical cannabis for refractory cancer-related pain in a specialised clinical service: a cross-sectional study.

BACKGROUND AND OBJECTIVES: Cancer-related pain management in advanced stages presents a significant challenge that often requires a multidisciplinary approach. Although advancements in pharmacological and interventional therapies, a considerable number of patients still suffer from refractory pain, leading to unmet clinical needs. This study shares our experience with medical cannabis (MC) as a potential therapy for this specific population of patients with cancer-related refractory pain. METHODS: In a cross-sectional study, 252 consecutive refractory cancer-related pain patients (mean age=61.71, SD=14.02, 47.6% males) filled out detailed self-report questionnaires. Of these, 126 patients (55%) were treated with MC and 105 patients (45%) were not. RESULTS: Most patients received pain management from their oncologist, not a pain specialist. MC was mainly started for pain relief, sleep difficulties and anorexia. About 70% of patients reported subjective improvement from MC, with almost 40% reporting a significant improvement in coping with their illness. Side effects were generally mild, with fatigue and dizziness being the most common (21.78% and 23.46%, respectively). No patient required dedicated medical care for side effects. Of non-users, 65% had tried MC before and stopped due to lack of effectiveness or side effects (39.7% and 34.6%, respectively). CONCLUSION: Refractory cancer pain necessitates innovative approaches. This registry highlights that MC can effectively improve symptoms in non-responsive patients, with favourable safety profiles for this vulnerable population.

Ultrasound-guided Cervical Retro-laminar Block for Cervical Radicular Pain: A Comparative Analysis.

STUDY DESIGN AND OBJECTIVE: Cervical radiculopathy is a common clinical condition, often treated with cervical epidural steroid injections (ESI). Retro-laminar cervical blocks (RLCB) may be considered safer than ESI as they do not require entering the neuroaxis.In this study, we evaluated the outcome of RLCB in patients with cervical radiculopathy who had failed conservative treatment and were candidates for cervical spine decompression surgery. BACKGROUND DATA: Recently, we reported a clinical pilot study investigating the treatment of cervical radiculopathy with an ultrasound-guided RLCB. MATERIALS AND METHODS: A retrospective, comparative analysis of prospectively collected data was carried out on the medical records of all patients who underwent RLCB for cervical radicular pain, between August 2019 and March 2021. RESULTS: Ninety-eight patients were included in the analysis, with a total of 139 procedures.A significant pain reduction was achieved for most patients immediately after the procedure and at the final follow up (16.9±13.4 wk). The mean numerical rating scale for the whole cohort changed from 7.21±2.51 to 4.04±2.51 ( P -value <0.01) at the time of discharge, with similar patterns at the subgroup level. A functional evaluation was carried out by a questionnaire (Neck Disability Index-NDI). Overall, 83% of patients had a lower postprocedural NDI than preprocedural NDI. For 80% of patients, the improvement of NDI surpassed the minimal clinically important change at the final assessment. Most patients (61%) were discharged after just one RLCB. Eight patients (8%) eventually underwent surgery. The most frequent complaint was injection site soreness; however, there were no major adverse events reported. CONCLUSIONS: These findings suggest that RLCB can be performed as an alternative to cervical ESI and decompressive surgery in patients with cervical radicular pain that's refractory to noninvasive treatment. More comparative and prospective studies are needed to confirm our results.

A New Solution to an Old Problem: Ultrasound-guided Cervical Retrolaminar Injection for Acute Cervical Radicular Pain: Prospective Clinical Pilot Study and Cadaveric Study.

STUDY DESIGN: Prospective clinical pilot study and cadaveric study. OBJECTIVE: The aim of this study was to evaluate the spread of an ultrasound-guided interfascial plane blocks (UGIPBs) and its potential efficacy for cervical radiculopathy. SUMMARY OF BACKGROUND DATA: Cervical radiculopathy is a common disorder, potentially leading to severe pain and disability. Conservative treatment with cervical epidural steroid injections (ESI) is limited by concerns regarding their safety. UGIPBs are used in cervical surgical procedures as part of the multimodal postoperative analgesia regimen however, were not described for cervical radiculopathy. METHODS: Twelve patients with acute cervical radicular pain who failed conservative treatment and were candidates for surgery were offered a cervical retrolaminar injection. A solution of 4 mL lidocaine 0.5% and 10 mg dexamethasone was injected, assisted by ultrasound guidance, at the posterior aspect of the cervical lamina corresponding to the compressed nerve root level. Additionally, a cadaver study was carried to evaluate the contrast spread and infiltration into near structures, both anatomically and radiographically. RESULTS: Twelve patients underwent the procedure, with a mean follow-up time of 14.5 weeks. Average numerical rating scale improved from 7.25 at baseline to 2.83 following the injection (P < 0.001). Three patients received 2 to 3 injections without significant improvement and were eventually operated. No adverse events were reported.In the cadaver study, fluoroscopy demonstrated contrast spread between T1 and T3 caudally, C2 to C5 cranially and facet joints laterally. Anatomically, the dye spread was demonstrated up to C2 cranially, T1 caudally, the articular pillars of C4 to C7, and the neural foramen of C6 laterally. CONCLUSION: A solution injected into the cervical retrolaminar plane can diffuse in the cranial-caudal axis to C2-T3 and laterally to the facet joints and the cervical neural foramen. Our pilot study confirmed the feasibility of our study protocol. Future studies are needed to support our early results.Level of Evidence: 4.

Low-dose, low-concentration levobupivacaine plus fentanyl selective spinal anesthesia for knee arthroscopy: a dose finding study.

BACKGROUND: Selective sensory spinal anesthesia preserves lower limb motor function and thus facilitates postanesthesia care unit (PACU) bypass and reduces ambulation recovery time. METHODS: We compared the ambulation time and PACU bypass rate after using 3 low-dose, low-concentration levobupivacaine-fentanyl spinal solutions (5, 4, and 3 mg + 10 µg) in a double-blind study consisting of 90 patients (ASA physical status I and II) scheduled to undergo knee arthroscopy. RESULTS: The 3-mg dose was halted because of a large number of inadequate blocks (50%). Twenty-three percent and 80% of patients from groups 5 mg and 4 mg, respectively, bypassed the PACU (P = 0001). Ambulation took place after 70 minutes (30-130 minutes) (median [range]) in group 5 mg and 45 minutes (23-120 minutes) in group 4 mg (P = 0006). CONCLUSION: Four milligrams levobupivacaine plus 10 µg fentanyl produced adequate surgical anesthesia with the shortest time to ambulation and the highest PACU bypass rate.

Low-dose 3 mg levobupivacaine plus 10 microg fentanyl selective spinal anesthesia for gynecological outpatient laparoscopy.

BACKGROUND: Lidocaine selective spinal anesthesia has been effective for short-duration gynecological outpatient laparoscopy. We compared the intraoperative effectiveness, anesthetic recovery times, and patient satisfaction after levobupivacaine-fentanyl versus lidocaine-fentanyl spinal anesthesia during short-duration gynecological laparoscopy. METHODS: In this double-blind study, 52 healthy women scheduled to undergo tubal sterilization were randomly assigned to receive either intrathecal 10 mg lidocaine 2% plus 10 microg fentanyl (Group I) or intrathecal 3 mg levobupivacaine 0.5% plus 10 microg fentanyl (Group II), each solution made to a total volume of 3 mL with sterile water. The following variables were monitored intraoperatively: anesthesia onset time, need for anesthesia-analgesia supplementation, depth of sedation, surgical conditions, and occurrence of hemodynamic events. After surgery, motor block, proprioception, vibration sense, light touch, and Romberg's test were performed to evaluate whether the patients could bypass the postanesthesia care unit and be allowed to walk by themselves. Sensory block level was determined at 5, 10, and 15 min after anesthetic injection, and then every 15 min until resolution was complete. A difference of 25 min in sensory block resolution time was considered clinically relevant. RESULTS: Onset time and intraoperative conditions were comparable in both groups. No patient required general anesthesia to complete surgery. All patients from both groups bypassed the postanesthesia care unit. Ambulation took place after 27 (18-45) min in Group I and 30 (18-56) min in Group II (P = 0.24). Complete regression of spinal anesthesia occurred after 93 (65-120) min in Group I and 105 (78-150) min in Group II (P = 0.019); however, no differences were observed in time for home discharge 185 (150-300) min in Group I and 188 (125-300) min in Group II (P = 0.62). Global patient satisfaction was comparable between both groups. CONCLUSIONS: Levobupivacaine 3 mg plus 10 microg fentanyl may be used as a suitable alternative to 10 mg lidocaine plus 10 microg fentanyl for spinal anesthesia of short duration. It achieved a clinically equivalent time for resolution of sensory block, similar intraoperative conditions, and comparable patient satisfaction..

Prophylactic recombinant factor VIIa administration to an infant with congenital systemic juvenile xanthogranuloma.

We report the case of an infant affected with congenital systemic juvenile xanthogranuloma scheduled for central venous access system implantation (Port-a-Cath) and a liver and bone marrow biopsy. The patient had impaired liver function, thrombocytopenia, and coagulopathy which was refractory to daily fresh-frozen plasma and platelet infusions: 80 microg x kg(-1) dose(-1) of recombinant factor VIIa (rFVIIa) was administered i.v. every 2 h starting 30 min before the procedure and ending 6 h afterwards. Very minor bleeding was observed during the procedure. In conclusion, rFVIIa therapy was effective as prophylaxis for both invasive procedures in this patient with a coagulopathy which was refractory to other different therapies.