Hemodynamic instability following intravenous dexmedetomidine infusion for sedation under brachial plexus block: Two case reports.

BACKGROUND: Dexmedetomidine (DMED) is frequently used as a sedative in several medical fields. The benefits of DMED include enhanced quality of regional anesthesia, prolonged analgesia, and postoperative opioid-sparing when administered intravenously or perineurally in combination with regional anesthesia. Severe hemodynamic complications, such as profound bradycardia and hypotension, can occur after DMED administration in critically ill patients or overdosage; however, there are few reports of complications with DMED administration following brachial plexus block (BPB). CASE SUMMARY: We present two cases of hemodynamic instability that occurred following the initial loading of DMED under supraclavicular BPB. A healthy 29-year-old man without any medical history showed profound bradycardia after receiving a loading dose of DMED 0.9 µg/kg for 9 min. DMED administration was promptly stopped, and after receiving a second dose of atropine, the heart rate recovered. A 62-year-old woman with a history of cardiomyopathy became hypotensive abruptly, requiring the administration of inotrope and vasopressors after receiving a reduced loading dose of 0.5 µg/kg for 10 min. Half of the recommended loading dose of DMED was administered due to the underlying heart dysfunction. Decreased blood pressure was maintained despite the intravenous administration of ephedrine. With continuous infusion of dopamine and norepinephrine, the vital signs were maintained within normal ranges. Inotropic and vasopressor support was required for over 6 h after the initial loading dose of DMED. CONCLUSION: DMED administration following BPB could trigger hemodynamic instability in patients with decreased cardiac function as well as in healthy individuals.

Measurement of S1 foramen depth for ultrasound-guided S1 transforaminal epidural injection.

Background: Ultrasound-guided first sacral transforaminal epidural steroid injection (S1 TFESI) is a useful and easily applicable alternative to fluoroscopy or computed tomography (CT) in lumbosacral radiculopathy. When a needle approach is used, poor visualization of the needle tip reduces the accuracy of the procedure, increasing its difficulty. This study aimed to improve ultrasound-guided S1 TFESI by evaluating radiological S1 posterior foramen data obtained using three-dimensional CT (3D-CT). Methods: Axial 3D-CT images of the pelvis were retrospectively analyzed. The radiological measurements obtained from the images included 1st posterior sacral foramen depth (S1D, mm), 1st posterior sacral foramen width (S1W, mm), the angle of the 1st posterior sacral foramen (S1A, °), and 1st posterior sacral foramen distance (S1ds, mm). The relationship between the demographic factors and measured values were then analyzed. Results: A total of 632 patients (287 male and 345 female) were examined. The mean S1D values for males and females were 11.9 ± 1.9 mm and 10.6 ± 1.8 mm, respectively (P < 0.001); the mean S1A 28.2 ± 4.8° and 30.1 ± 4.9°, respectively (P < 0.001); and the mean S1ds, 24.1 ± 2.9 mm and 22.9 ± 2.6 mm, respectively (P < 0.001); however, the mean S1W values were not significantly different. Height was the only significant predictor of S1D (ß = 0.318, P = 0.004). Conclusions: Ultrasound-guided S1 TFESI performance and safety may be improved with adjustment of needle insertion depth congruent with the patient's height.

Medial Branch Radiofrequency Treatment for Low-Back Pain in Cancer Patients: A Case Series.

Cancer patients are increasing in number, with an increased lifespan and advances in cancer treatment. Palliative care physicians often encounter difficulties in caring for patients with pain. In addition to cancer-related pain, patients with cancer may suffer from various musculoskeletal diseases, resulting in significant functional limitations of physical activities of daily living. We present three cases illustrating methods to deal with nonspecific mechanical low-back pain in patients with advanced cancer. We provide our therapeutic experiences, focusing on the usefulness of radiofrequency treatment in palliative care in patients with cancer.

A case report of refractory otalgia after Ramsay Hunt syndrome successfully treated by applying pulsed radiofrequency to the great auricular nerve: A CARE-compliant article.

RATIONALE: Ramsay Hunt syndrome is a type of herpes zoster infection involving geniculate ganglion and facial nerve. Unilateral facial palsy, otalgia, and painful vesicular rash on the auricle and external auditory canal are the typical symptoms. Although postherpetic neuralgia (PHN) is a devastating complication of herpes zoster infection, PHN following Ramsay Hunt syndrome has rarely been reported. PATIENT CONCERNS: A 55-year-old immunocompetent female patient visited our pain clinic, for left-sided refractory otalgia (PHN) that persisted for 3 months after she was diagnosed with Ramsay Hunt syndrome. Although facial palsy and tinnitus had recovered within 2 to 4 weeks after symptom onset, the patient had been experiencing a persistent and severe otalgia radiating to mandibular angle, temporal and upper cervical area of neuropathic nature. DIAGNOSES: The patient's pain persisted despite conservative medication and administration of ultrasound-guided stellate ganglion block, facial nerve block, and great auricular nerve block several times. INTERVENTIONS: The patient was treated with the application of ultrasound-guided pulsed radiofrequency (PRF) to the great auricular nerve. OUTCOMES: The patient experienced significant pain reduction more than 50% on a numeric rating scale after 2 weeks of PRF treatment. LESSONS: Chronic otalgia might be a type of PHN after Ramsay Hunt syndrome with cervical nerve involvement. PRF treatment to the great auricular nerve can be a therapeutic option for refractory otalgia following Ramsay Hunt syndrome.

Prediction of successful caudal epidural injection using color Doppler ultrasonography in the paramedian sagittal oblique view of the lumbosacral spine.

BACKGROUND: Ultrasound-guided caudal epidural injection (CEI) is limited in that it cannot confirm drug distribution at the target site without fluoroscopy. We hypothesized that visualization of solution flow through the inter-laminar space of the lumbosacral spine using color Doppler ultrasound alone would allow for confirmation of drug distribution. Therefore, we aimed to prospectively evaluate the usefulness of this method by comparing the color Doppler image in the paramedian sagittal oblique view of the lumbosacral spine (LS-PSOV) with the distribution of the contrast medium observed during fluoroscopy. METHODS: Sixty-five patients received a 10-mL CEI of solution containing contrast medium under ultrasound guidance. During injection, flow was observed in the LSPSOV using color Doppler ultrasonography, following which it was confirmed using fluoroscopy. The presence of contrast image at L5-S1 on fluoroscopy was defined as "successful CEI." We then calculated prediction accuracy for successful CEI using color Doppler ultrasonography in the LS-PSOV. We also investigated the correlation between the distribution levels measured via color Doppler and fluoroscopy. RESULTS: Prediction accuracy with color Doppler ultrasonography was 96.9%. The sensitivity, specificity, positive predictive value, and negative predictive value were 96.7%, 100%, 100%, and 60.0%, respectively. In 52 of 65 patients (80%), the highest level at which contrast image was observed was the same for both color Doppler ultrasonography and fluoroscopy. CONCLUSIONS: Our findings demonstrate that color Doppler ultrasonography in the LS-PSOV is a new method for determining whether a drug solution reaches the lumbosacral region (i.e. , the main target level) without the need for fluoroscopy.

The prevalence and clinical significance of transitional vertebrae: a radiologic investigation using whole spine spiral three-dimensional computed tomographic images.

BACKGROUND: Errors in counting spinal segments are common during interventional procedures when there are transitional vertebrae. In this study, we investigated the prevalence of the transitional vertebrae including thoracolumbar transitional vertebra (TLTV) and lumbosacral transitional vertebrae (LSTV). The relationship between the existence of TLTV and abnormal rib count or the existence of LSTV were also evaluated. METHODS: The vertebral levels were counted craniocaudally, starting from C1, based on the assumption of 7 cervical, 12 thoracic, and 5 lumbar vertebrae, using whole spine spiral three-dimensional computed tomographic images. The 20th and 25th vertebrae were defined as L1 and S1, respectively. RESULTS: In total, 150 patients had TLTV, with a prevalence of 11.2% (150/1,340). LSTV was observed in 111 of 1,340 cases (8.3%). Sacralization was observed in 68 of 1,340 cases (5.1%) and lumbarization in 43 of 1,340 cases (3.2%). There was a significant relationship between the existence of TLTV and the abnormal rib count (odds ratio [OR]: 117.26, 95% confidence interval [95% CI]: 60.77-226.27; P < 0.001) and LSTV (OR: 7.38, 95% CI: 3.99-13.63; P < 0.001). CONCLUSIONS: Our study results suggest that patients with TLTV are more likely to have an abnormal rib count or LSTV. If a TLTV or LSTV is seen on the fluoroscopic image, a whole spine image is necessary to permit accurate numbering of the lumbar vertebra.

The effect of the type of anesthesia on the quality of postoperative recovery after orthopedic forearm surgery.

BACKGROUND: Although the quality of postoperative recovery may be affected by factors, there are few investigations whether the type of anesthesia also affects it. In this single-blinded, prospective, observational study, we compared the quality of postoperative recovery in patients undergoing orthopedic forearm surgery under general or regional anesthesia (brachial plexus block). METHODS: Ninety-seven subjects, aged 18-65 years and American Society of Anesthesiologists physical status I or II, undergoing orthopedic forearm surgery, were allocated to general or regional anesthesia group. The quality of postoperative recovery was assessed using a validated Korean version of Quality of Recovery-40 (QoR-40K) questionnaire. Patients were surveyed three times, the day before surgery (baseline) and 1st and 7th day after the surgery, and the scores of both groups were compared. RESULTS: We analyzed 47 and 50 patients in general and regional anesthesia, respectively. The global QoR-40K score and those of each of its five dimensions were not significantly different between the two groups at baseline, 1st and 7th day postoperatively. In two-way RM ANOVA, the global QoR-40K score at postoperative 1st day was significantly lower than that of baseline (P < 0.001) and postoperative 7th day (P < 0.001), respectively, in both general and regional anesthesia groups. However, there was no significant difference at each timepoint between the two groups. CONCLUSIONS: The present study suggests that brachial plexus block with intravenous dexmedetomidine infusion does not improve the quality of postoperative recovery compared to sevoflurane inhalation anesthesia with remifentanil infusion in patients undergoing orthopedic forearm surgery.

The efficacy of selective nerve root block for the long-term outcome of postherpetic neuralgia.

BACKGROUND: Several nerve blocks can reduce the incidence of postherpetic neuralgia (PHN) as well as relieve acute zoster-related pain, but the long-term outcome of PHN has not been clearly determined. This study investigated the efficacy of selective nerve root block (SNRB) for herpes zoster (HZ) on the long-term outcome of PHN. METHODS: We prospectively conducted an interview of patients who had undergone an SNRB for HZ from January 2006 to December 2016 to evaluate their long-term PHN status. The relationship between the time from HZ onset to the first SNRB and the long-term outcome of PHN was investigated. RESULTS: The data of 67 patients were collected. The patients were allocated to acute (SNRB ≤ 14 days, n = 16) or subacute (SNRB > 14 days, n = 51) groups. The proportions of cured patients were 62.5% and 25.5% in the acute and subacute groups (P = 0.007), respectively. In logistic regression, an SNRB >14 days was the significant predictor of PHN (adjusted odd ratio, 3.89; 95% confidence interval, 1.02-14.93; P = 0.047). Kaplan-Meier analysis revealed that time from the SNRB to the cure of PHN was significantly shorter in the acute group (2.4 ± 0.7 yr) than in the subacute group (5.0 ± 0.4 yr; P = 0.003). CONCLUSIONS: An early SNRB during the acute stage of HZ (within 14 days) appears to decrease the incidence and shorten the duration of PHN, with a median of 5.0 years of follow-up.