Effectiveness of virtual reality immersion on procedure-related pain and anxiety in outpatient pain clinic: an exploratory randomized controlled trial.

BACKGROUND: The study investigated virtual reality (VR) immersion in alleviating procedure-related pain in patients with chronic pain undergoing fluoroscopy-guided minimally-invasive intervention in a prone position at an outpatient clinic. METHODS: In this prospective randomized controlled study, 38 patients undergoing lumbar sympathetic ganglion block were randomized into either the VR or the control group. In the VR group, procedure-related pain was controlled via infiltration of local anesthetics while watching a 30-minute VR hypnotic program. In the control group, the skin infiltration alone was used, with the VR device switched off. The primary endpoint was an 11-point score on the numerical rating scale, indicating procedure-related pain. Patients' satisfaction with pain control, anxiety levels, the need for additional local anesthetics during the procedure, hemodynamic stability, and any adverse events were assessed. RESULTS: Procedure-related pain was significantly lower in the VR group (3.7 ± 1.4) than in the control group (5.5 ± 1.7; P = 0.002). Post-procedural anxiety was lower in the VR group than in the control group (P = 0.025), with a significant reduction from pre-procedural anxiety (P < 0.001). Although patients' satisfaction did not differ significantly (P = 0.158) between the groups, a higher number of patients required additional local anesthetics in the control group (n = 13) than in the VR group (n = 4; P = 0.001). No severe adverse events occurred in either group during the study. CONCLUSIONS: VR immersion can be safely used as a novel adjunct to reduce procedural pain and anxiety during fluoroscopic pain intervention.

Spinal nerve signal intensity on Dixon T2-weighted water-only sequence: an important outcome predictor after lumbar transforaminal epidural injection.

OBJECTIVES: To evaluate the role of Dixon T2-weighted water-fat separation technique in predicting the outcome of lumbar transforaminal epidural injections (TFESIs). METHODS: Patients who underwent TFESI of a single spinal nerve within 3 months after magnetic resonance imaging (MRI) exam between August 2018 and April 2020 were identified. The patients were classified into positive or negative outcome groups based on the response to the TFESI procedure. Two musculoskeletal radiologists measured the signal intensity of the injected side spinal nerves, contralateral side spinal nerves, and subcutaneous fat on axial Dixon T2-weighted water-only images, and the diameter of spinal nerve on axial Dixon T2-weighted in-phase images of the pre-procedural MRI. The measured values of the injected side spinal nerves were compared between the two groups and with the contralateral side spinal nerve. RESULTS: A total of 94 patients were included, 76 in the positive outcome group and 18 in the negative outcome group. The mean signal intensity and the nerve-to-fat signal ratio of the injected side spinal nerve were significantly higher in the positive outcome group than in the negative outcome group (793.78 vs. 679.19, p = 0.016; 4.21 vs. 3.28, p = 0.003). In the positive outcome group, the diameter of the spinal nerve was significantly higher on the injected side than on the contralateral side (6.91 mm vs. 6.37 mm, p = 0.016). CONCLUSIONS: The mean signal intensity and the nerve-to-fat signal ratio of the spinal nerve on axial Dixon T2-weighted water-only images can help predict patient response to the TFESI. KEY POINTS: • Applying the Dixon technique to lumbar spine MRI can help predict patient response to the TFESI procedure. • An increased nerve-to-fat signal ratio and mean spinal nerve signal intensity on axial Dixon T2-weighted water-only images predicted favorable TFESI outcomes.

Electroacupuncture May Improve Burning and Electric Shock-Like Neuropathic Pain: A Prospective Exploratory Pilot Study.

Objective: To test the effectiveness of electroacupuncture (EA) for managing intractable neuropathic pain (NeP) and assess the protocol for a larger confirmatory trial. Design: A prospective, multicenter, single-armed, add-on, pilot study. Settings/location: At two tertiary university-based hospitals in Seoul, Republic of Korea. Subjects: Patients with chronic peripheral NeP, who have received conventional oral medications but complained of moderate to severe pain. Interventions: Two Korean medicine doctors conducted 12 sessions of EA (2 sessions per week for 4 weeks, followed by 1 session per week for the second month) in addition to conventional treatment. Outcome measures: During the 8-week treatment period, pain intensity, pain natures such as burning, electric shock-like, temperature or mechanical hyperalgesia, and numbness, Short Form of the McGill Pain Questionnaire (SF-MPQ) and the Brief Pain Inventory (BPI-SF), the EuroQol five dimensions questionnaire, patients' satisfaction, and adverse events were evaluated. The primary endpoint was a change in pain intensity (%) at 4 weeks from the baseline. Results: Among 22 patients, 19 finished the protocol. The eight EA sessions over a month reduced pain intensity from 6.0 ± 1.6 at baseline to 3.2 ± 0.9 at 4 weeks, which was a 46.7% reduction (p < 0.001). The incidences of severe burning, electric shock-like pain, and mechanical hyperalgesia reduced at 8 weeks [36%-16% (p = 0.04), 53%-21% (p = 0.009), and 53%-26% (p = 0.03), respectively]. The affective dimensions in the SF-MPQ (p = 0.007) and the pain interference parameters, including mood (p = 0.02), relations with other people (p = 0.03), and enjoyment of life (p = 0.002) in the BPI-SF, were improved at 4 and 8 weeks. The majority of patients (68%) responded that their pain was "much or somewhat improved." Overall, 84.2% expressed "satisfaction" with their multidisciplinary management. Conclusions: EA might decrease the intensity of NeP, in particular, such as burning, electric shock-like pain, and mechanical hyperalgesia, which was accompanied by psychosocial and functional improvement. A larger study is warranted to prove the effectiveness of EA for managing refractory NeP. Trial registration: ClinicalTrials.gov: NCT03315598. Retrospectively registered on October 20, 2017.

Oxcarbazepine for trigeminal neuralgia may induce lower extremity weakness: A case report.

BACKGROUND: Although few studies have reported hyponatremia due to carbamazepine or oxcarbazepine in patients with epilepsy, no study has investigated cases of carbamazepine- or oxcarbazepine-induced hyponatremia or unsteady gait in patients with neuropathic pain. Herein, we report a case of oxcarbazepine-induced lower leg weakness in a patient with trigeminal neuralgia and summarize the diagnosis, treatment, and changes of clinical symptoms. CASE SUMMARY: A 78-year-old male with a history of lumbar spinal stenosis was admitted to the hospital after he experienced lancinating pain around his right cheek, eyes, and lip, and was diagnosed with trigeminal neuralgia at the right maxillary and mandibular branch. He was prescribed oxcarbazepine (600 mg/d), milnacipran (25 mg/d), and oxycodone/naloxone (20 mg/10 mg/d) for four years. Four years later, the patient experienced symptoms associated with spinal stenosis, including pain in the lower extremities and unsteady gait. His serum sodium level was 127 mmol/L. Assuming oxcarbazepine to be the cause of the hyponatremia, oxcarbazepine administration was put on hold and the patient was switched to topiramate. At subsequent visit, the patient's serum sodium level had normalized to 143 mmol/L and his unsteady gait had improved. CONCLUSION: Oxcarbazepine-induced hyponatremia may cause lower extremity weakness and unsteady gait, which should be differentiated from those caused by spinal stenosis.

The effect of lidocaine on apoptotic neurodegeneration in the developing mouse brain.

BACKGROUND: General anesthetics induce neuronal apoptosis in the immature brain. Regional anesthesia using local anesthetics can be an alternative to general anesthesia. Therefore, this study investigated the possible effect of lidocaine on neuronal apoptosis. METHODS: Fifty-one 7-day-old C57BL6 mice were allocated into control (group C), lidocaine (group L), lidocaine plus midazolam (group LM) and isoflurane (group I) groups. Group C received normal saline administration. Groups L and LM were injected with lidocaine (4 mg/kg, subcutaneously) only and the same dose of lidocaine plus midazolam (9 mg/kg, subcutaneously). Group I was exposed to 0.75 vol% isoflurane for 6 h. After 6 h, apoptotic neurodegeneration was assessed using caspase-3 immunostaining and terminal deoxynucleotidyl transferase dUTP nick-end labelling (TUNEL) staining. RESULTS: For the entire brain section, neuronal cells exhibiting caspase-3 activation were observed more frequently in group I than in group C (P < 0.001). In the thalamus, apoptosis of group L was more frequent than that of group C (P < 0.001), but less freqent than that of groups LM and I (P = 0.0075 and P < 0.001, respectively). In the cortex, group I experienced more apoptosis than group L and C (all Ps < 0.001). On TUNEL staining, the difference in apoptosis between the lidocaine and control groups was marginal (P = 0.05). CONCLUSIONS: Lidocaine induced minimal apoptosis in the developing brain compared with isoflurane and lidocaine plus midazolam. However, we cannot fully exclude the possible adverse effect of subcutaneously administered lidocaine on the developing brain.

The accuracy of noninvasive hemoglobin monitoring using the radical-7 pulse CO-Oximeter in children undergoing neurosurgery.

BACKGROUND: The most common method for determining the hemoglobin concentration is to draw blood from a patient. However, the Radical-7 Pulse CO-Oximeter (Masimo Corporation, Irvine, CA) can noninvasively provide continuous hemoglobin concentration (SpHb). In our study we compared noninvasive measurements of SpHb with simultaneous laboratory measurements of total hemoglobin in arterial blood samples taken from children (tHb). METHODS: Arterial blood samples were analyzed using a laboratory CO-oximeter, and SpHb was simultaneously recorded in pediatric patients undergoing neurosurgery. When patients met the criteria for hypovolemia, 10 mL/kg of colloids or red blood cells were administered over 10 minutes. SpHb and tHb data were collected before and after intravascular volume resuscitation. The relationship between SpHb and tHb was assessed using a 4-quadrant plot, linear regression, mixed-effect model, and modified Bland-Altman analyses. RESULTS: One hundred nineteen paired samples were analyzed. The correlation coefficient between SpHb and tHb was 0.53 (P < 0.001), whereas that of change in SpHb versus change in tHb was 0.75 (P < 0.001). The average difference (bias) between tHb and SpHb was 0.90 g/dL (95% confidence interval [CI], 0.48-1.32 g/dL) and 1 standard deviation of the difference (sd) was 1.35 g/dL. The concordance rate (a measure of the number of data points that are in 1 of the 2 quadrants of agreement) determined using a 4-quadrant plot was 93%. The correlation coefficient between SpHb and tHb after intravascular volume resuscitation was 0.58 (P < 0.001), whereas that of changes in SpHb and tHb was 0.87 (P < 0.001). The bias immediately after volume resuscitation was 1.18 g/dL (95% CI, 0.81-1.55 g/dL), and sd was 1.28 g/dL with a concordance rate of 94.4%. The bias was -0.03 g/dL when tHb was ≥11 g/dL, which was significantly lower in comparison with biases when tHb <9 g/dL (1.24 g/dL) and tHb was 9-11 g/dL (1.17 g/dL) (P = 0.004). CONCLUSION: The Radical-7 Pulse CO-Oximeter can be useful as a trend monitor in children during surgery even immediately after intravascular volume expanders are administered. However, it is advisable to confirm the baseline hemoglobin level and to consider the influence of tHb level on the bias. In addition, one should be cautious with regard to using SpHb alone when making transfusion decisions.