Repeat, Bilateral Femoral Nerve Blocks With Liposomal Bupivacaine for Analgesia in a Patient With Calciphylaxis: A Case Report.

A 39-year-old woman with juvenile idiopathic arthritis complicated by nonuremic calciphylaxis presented for pain management of bilateral lower extremity wounds requiring frequent dressing changes. Bilateral single-shot femoral nerve blocks using liposomal bupivacaine and 0.25% bupivacaine were performed. The patient reported decreased pain scores and had reduced opioid use for 72 hours postblock. Repeat, bilateral single-shot femoral nerve blocks with liposomal bupivacaine and 0.25% bupivacaine were performed approximately every 72 hours to maintain adequate analgesia. We conclude that off-label use of liposomal bupivacaine in femoral nerve blocks results in prolonged block duration without adverse effects or tachyphylaxis.

Transient Right-Sided Hemiparesis and Diplopia in the Setting of a Migrated Cervical Spinal Cord Stimulator Lead: A Case Report.

A 36-year-old man with a history of cervical spinal cord stimulator (SCS) lead placement presented with transient right-sided hemiparesis and diplopia that began 2 days after a coughing episode. Imaging revealed lateral and cranial migration of one of the patient's SCS leads. Deactivation of the SCS resulted in rapid improvement of his nonmotor symptoms but did not resolve his motor deficits. The SCS system was surgically explanted, resulting in resolution of the patient's motor symptoms. The unique neurologic symptomatology demonstrated by this patient is a previously undescribed complication of SCS placement and lead migration.

The addition of intrathecal morphine to a transversus abdominis plane block with liposome bupivacaine provides more effective analgesia than transversus abdominis plane block with liposome bupivacaine alone: a retrospective study.

OBJECTIVE: The purpose of this study was to determine if the standardization of using liposomal bupivacaine in transversus abdominis plane (LB TAP) blocks eliminated the benefit of intrathecal morphine (ITM) in patients after undergoing a cesarean section. METHODS: This was a retrospective review of 358 patients who underwent cesarean section over an 11-month period. Patients were divided into two groups: those who received only an LB TAP (67 patients) vs those who received an LB TAP and ITM (291 patients). All blocks were placed bilaterally under ultrasound guidance after closure of the surgical incision, and morphine was added to the spinal used for the case. RESULTS: The group that received ITM in addition to the LB TAP received less opioids in the first 24 hours (median 5 range 0-150 mg morphine equivalents [ME] vs 15 range 0-76 mg ME; P<0.001) and less opioids overall (35 mg range 0-450 mg ME vs 47.5 mg range 0-189 mg ME; P=0.041) when compared to the LB TAP block only group. There was no difference between the two groups in opioid use from 24 to 48 hours or 48 to 72 hours. CONCLUSION: Patients who received ITM in addition to an LB TAP block received less opioids in the first 24 hours and overall when compared to those who received an LB TAP alone. This suggests that ITM still plays a role in providing analgesia to patients who have also received an LB TAP block as a part of their multimodal pain regimen for cesarean sections.

Postdural Puncture Headache in a Postpartum Female With Previous Spinal Surgery-Successful Treatment With Caudal Epidural Blood Patch: A Case Report.

The occurrence of a postdural puncture headache (PDPH) is a known risk associated with epidural procedures. The primary nonconservative treatment option for PDPH is the performance of an epidural blood patch. This case report describes the use of image guidance for placement of a caudal epidural to treat a PDPH in a postpartum patient. A caudal catheter was placed under real-time guidance and visualization of the deposition of the blood was obtained. By entering via the caudal foramen and utilizing a catheter, manipulations in catheter placement could be performed to adjust deposition of the blood.

Neuropathic pain: Review of mechanisms and pharmacologic management.

Neuropathic pain is a challenge for clinicians because it is resistant to commonly prescribed analgesics, such as opioids and nonsteroidal antiinflammatory drugs. Fortunately, adjuvant analgesics, drugs not typically thought of as pain relievers, may be effective. It is helpful to classify adjuvant analgesics used to treat neuropathic pain into two broad categories: (1) membrane stabilizing agents, which inhibit ectopic discharges on damaged neural membranes, and (2) drugs that enhance dorsal horn inhibition, which may augment biogenic amine or GABAergic mechanisms in the dorsal horn of the spinal cord. Current evidence regarding efficacy generally does not support the use of one drug over another, and selection of a particular drug may depend on experience or expected side effects. The overall efficacy of tricyclic antidepressants for neuropathic pain is modest, and they may produce intolerable side effects. Based on current studies, gabapentin is a reasonable alternative to antidepressants, as initial monotherapy or add-on treatment, particularly for painful diabetic peripheral neuropathy and postherpetic neuralgia. From a practical standpoint, to optimize analgesia more than one drug may be necessary. Although polypharmacy is the result, this approach may improve therapy and minimize side effects. From a safety standpoint, medications generally should be started at low doses and titrated to effect. Although labor-intensive, this strategy can improve compliance and optimize patient care.