Effect of dexamethasone and ramosetron on the prevention of postoperative nausea and vomiting in low-risk patients: a randomized, double-blind, placebo-controlled, multicenter trial.

BACKGROUND: Several studies have investigated the effect of antiemetics on postoperative nausea and vomiting (PONV) in high-risk groups. However, few studies have investigated the effect of antiemetics in patients at low risk of developing PONV. METHODS: In this prospective, randomized, double-blinded trial, 177 patients undergoing surgery under general anesthesia were randomly allocated to three groups. Patients allocated to group C (control group) received 2 mL of intravenous 0.9% saline, those allocated to group R (ramosetron group) received 0.3 mg of intravenous ramosetron, and those allocated to group DR (ramosetron plus dexamethasone group) received 5 mg of intravenous dexamethasone and 0.3 mg of intravenous ramosetron. RESULTS: Finally, 174 patients completed the study, and the types of surgeries were orthopedic (n = 80), rhinologic (n = 47), urologic (n = 29), and others (n = 18). The incidence of PONV up to 48 h postoperatively was significantly lower in group DR than in group C. The incidence of PONV up to 0-1 h postoperatively was significantly lower in groups R and DR than in group C. The usage pattern of rescue antiemetics was consistent with the incidence of PONV. The percentage of patients requiring rescue analgesics 0-1 h postoperatively was significantly lower in groups R and DR than in group C. CONCLUSIONS: The combination of dexamethasone and ramosetron demonstrated a superior effect in preventing PONV for 48 h after surgery under general anesthesia than saline in patients at low risk of developing PONV. Compared with saline injections, ramosetron injections yielded better outcomes for the incidence of PONV and the use of rescue antiemetics and rescue analgesics 0-1 h postoperatively. TRIAL REGISTRATION: Clinical trial registration number: criskorea@korea.kr, KCT0006749.

Changes in pain scores and walking distance after transforaminal epidural steroid injection in patients with lumbar foraminal spinal stenosis.

Transforaminal epidural steroid injections (TFESI) are widely used in patients with lumbar foraminal spinal stenosis. Previous studies have evaluated the effects of TFESI on lumbar foraminal spinal stenosis using only pain scores. However, no study has evaluated the effect of TFESI on pain scores and walking distance in patients with lumbar foraminal spinal stenosis. This study aimed to assess the effect of TFESI on pain scores and walking distance in patients with lumbar foraminal spinal stenosis stratified according to disease severity. This retrospective study reviewed the medical records of patients who received TFESI for lumbar foraminal spinal stenosis. A total of 128 patients were divided into the moderate and severe groups based on the extent of fat obliteration and the presence of nerve root compression. A significant decrease in the numeric rating scale (NRS) scores was observed in the moderate and severe groups compared with the corresponding baseline values 4 weeks after TFESI; however, the NRS pain scores were lower in the moderate group than those in the severe group. In addition, the proportion of patients who experienced pain reduction (≥50%) was higher in the moderate group than that in the severe group. The moderate and severe groups showed a significant increase in walking distance compared with the baseline values 4 weeks after the treatment. However, the walking distance values did not differ significantly between the moderate and severe groups. Furthermore, the degree of satisfaction was higher in the moderate group than that in the severe group. Lumbar TFESI may reduce pain scores and increase walking distance in patients with moderate or severe lumbar foraminal spinal stenosis. Patients with moderate foraminal stenosis had better pain relief outcomes than those with severe foraminal stenosis.

Serratus anterior plane block with ultrasound-guided hydrodissection for lateral thoracic pain caused by long thoracic nerve neuropathy - A case report.

BACKGROUND: Long thoracic nerve (LTN) neuropathy occasionally occurs in young people who engage in various sports. It may have a traumatic or non-traumatic etiology. The landmark manifestation of LTN neuropathy is scapular winging; however, it can also occur without scapular winging and specific magnetic resonance imaging findings. CASE: An 18-year-old male complained of right-sided lateral chest pain for 7 months. He was treated with medication, trigger point injection, and physical therapy but showed no improvement. Electromyelogram findings suggested LTN neuropathy in the right lateral chest. We performed a serratus anterior (SA) plane block with ultrasound (US)-guided hydrodissection and achieved pain relief. CONCLUSIONS: We report the successful treatment of LTN neuropathy with an SA plane block and US-guided hydrodissection.

Comparison between GlideRite® rigid stylet and Parker Flex-It™ stylet to facilitate GlideScope intubation in simulated difficult intubation: a randomized controlled study.

BACKGROUND: The GlideScope® videolaryngoscope (GVL) is widely used in patients with difficult airways and provides a good glottic view. However, the acute angle of the blade can make insertion and advancement of an endotracheal tube (ETT) more difficult than direct laryngoscopy, and the use of a stylet is recommended. This randomized controlled trial compared Parker Flex-It™ stylet (PFS) with GlideRite® rigid stylet (GRS) to facilitate intubation with the GVL in simulated difficult intubations. METHODS: Fifty-four patients were randomly allocated to undergo GVL intubation using either GRS (GRS group) or PFS (PFS group). The total intubation time (TIT), 100-mm visual analog scale (VAS) for ease of intubation, success rate at the first attempt, use of laryngeal manipulation, tube advancement rate by assistant, and complications were recorded. RESULTS: There was no significant difference between the GRS and PFS groups regarding TIT (50.3 ± 12.0 s in the GRS group and 57.8 ± 18.8 s in the PFS group, P = 0.108). However, intubation was more difficult in the PFS group than in the GRS group according to VAS score (P = 0.011). Cases in which the ETT was advanced from the stylet by an assistant, were more frequent in the GRS group than in the PFS group (P = 0.002). The overall incidence of possible complications was not significantly different. CONCLUSIONS: In patients with a simulated difficult airway, there was no difference in TIT using either the PFS or GRS. However, endotracheal intubation with PFS is more difficult to perform than GRS.

Changes in pain scores and walking distance after epidural steroid injection in patients with lumbar central spinal stenosis.

ABSTRACT: Lumbar spinal stenosis is a common degenerative disorder that is characterized by pain and neurogenic claudication. Previous studies have evaluated the effects of an epidural steroid injection (ESI) on spinal stenosis, based on changes to the spinal canal diameter.This study aimed to examine the impact of the ESI on pain scores and walking distance in patients with lumbar central spinal stenosis, stratified based on disease severity, which was graded according to the degree of cauda equina separation.We reviewed the medical records of patients who received the ESI for lumbar spinal central canal stenosis. A total of 128 patients were divided into moderate and severe groups, based on the degree of cauda equina separation.Relative to baseline values, 2 weeks after the ESI, the moderate group showed a significant decrease in the numeric rating scale (NRS) scores and an increase in walking distance. Meanwhile, the severe group showed a significant decrease in the NRS scores and no significant change in walking distance. The moderate group had lower NRS scores and a longer walking distance than did the severe group 2 weeks after the ESI. The proportion of patients with improved levels of satisfaction was higher in the moderate group than in the severe group.Lumbar interlaminar ESI may reduce pain scores and increase walking distance in patients with moderate lumbar spinal central canal stenosis. Patients with moderate spinal stenosis achieved better outcomes than did patients with severe stenosis.

Effect of two-week continuous epidural administration of 2% lidocaine on mechanical allodynia induced by spinal nerve ligation in rats.

BACKGROUND: Lidocaine is an effective against certain types of neuropathic pain. This study aimed to investigate whether timing of initiating continuous epidural infusion of lidocaine affected the glial activation and development of neuropathic pain induced by L5/6 spinal nerve ligation (SNL) in rats. METHODS: Following L5/6 SNL, rats were epidurally infused 2% lidocaine (drug infusion initiated on days 1, and 7 post SNL model establishment) or saline (saline infusion initiated on day 1 post SNL model establishment) continuously for 14 days. Mechanical allodynia of the hind paw to von Frey filament stimuli was determined prior to surgery, postoperative day 3, and once weekly after SNL model establishment. At 7 days after the infusion of saline or lidocaine ended, spinal activation of proinflammatory cytokines and astrocytes was evaluated immunohistochemically, using antibodies to interleukin-6 (IL-6) and glial fibrillary acidic protein (GFAP). RESULTS: Continuous epidural administration of 2% lidocaine for 14 days increased the mechanical withdrawal threshold regardless of the difference in timing of initiating lidocaine administration. Epidurally infusing 2% lidocaine inhibited nerve ligation-induced IL-6 and GFAP activation. In the 2% lidocaine infusion group, rats maintained the increased mechanical withdrawal threshold even at 7 days after the discontinuation of 2% lidocaine infusion. CONCLUSIONS: Continuous epidural administration of 2% lidocaine inhibited the development of SNL-induced mechanical allodynia and suppressed IL-6 and GFAP activation regardless of the difference in timing of initiating lidocaine administration.

Postoperative pulmonary edema following vitrectomy in patients with ischemic heart disease and diastolic dysfunction in the post-anesthetic care unit: Two case reports.

RATIONALE: The increasing incidence of cardiac comorbidities in the elderly population has led to an increasing demand for vigilance of cardiac dysfunction induced by surgery. Favorable outcomes can be ensured in such cases by an increased awareness of cardiogenic complications, early identification of the problem, and appropriate treatment. PATIENT CONCERNS: This study presents 2 cases of acute pulmonary edema (PE) that were likely caused by ischemic heart disease and diastolic dysfunction in postoperative patients, following vitrectomy, in the post-anesthetic care unit. DIAGNOSES: Chest x-ray and computed tomography indicated PE. INTERVENTIONS: Following the diagnosis of PE, patients were intubated and transferred to the intensive care unit where 20 mg furosemide was injected and 10 µg/kg/min dobutamine was infused intravenously. OUTCOMES: On postoperative day 2, the patients' vital signs were stable and there were no signs of respiratory disturbance. LESSONS: Physicians should be alert to the potential development of PE as a postoperative complication in patients with left ventricular (LV) diastolic dysfunction and ischemic heart disease, even if the patient has undergone a procedure with mild hemodynamic change and minimal surgical stimulation such as vitrectomy. We propose that physicians treating elderly patients with LV diastolic dysfunction and ischemic heart disease undergoing vitrectomy should consider the use of intraoperative transthoracic echocardiogram or transesophageal echocardiogram with continuous monitoring of blood pressure, using devices such as arterial catheter devices.

Effect of Lumbar Epidural Steroid Injections on Osteoporotic Fracture and Bone Mineral Density in Elderly Women with Diabetes Mellitus.

The incidence of osteoporosis and diabetes mellitus (DM) is known to increase with aging. DM is associated with osteoporotic fractures and decreased bone mineral metabolism. However, no studies have compared the effects of DM on the changes in bone mineral density (BMD) and osteoporotic fracture after epidural steroid injections (ESIs). The present study aimed to analyze the relationship between ESI and BMD changes in elderly women with and without DM. The medical records of elderly women who underwent ESI were retrospectively analyzed. All patients had radiographic and BMD assessments performed before and after receiving lumbar ESIs. A total of 172 patients were divided into two groups according to the presence of DM. The duration of BMD monitoring was 16.1 and 16.8 months in the non-DM and DM groups, respectively. The mean total number of ESIs was 3.4 and 3.2, and the mean cumulative administered dose of glucocorticoids (dexamethasone) was 17 and 16 mg in the non-DM and DM groups, respectively. There were no significant differences between baseline and posttreatment BMD in the lumbar spine, total femur, and femoral neck region in either group. The incidence of osteoporotic fractures at the hip joint and thoracolumbar spine was not significantly different in both groups. ESIs could be used without concerns regarding osteoporosis and fractures in elderly women with DM if low doses of glucocorticoids are used.

Dry sauna therapy is beneficial for patients with low back pain.

BACKGROUND: Dry sauna has been very popular as an alternative therapy for promoting health among people who want to improve their health condition without relying on pharmaceuticals. The aim of this study was to investigate whether dry sauna therapy improved quality of life and reduced pain in participants with low back pain. METHODS: Study participants comprised a total of 37 consecutive patients who were over 20 years of age with low back pain. Dry sauna therapy was performed twice per day for 5 consecutive days over the course of 1 week, thus comprising a total of 10 sessions each of 15 min of exposure to a 90°C dry sauna. RESULTS: The verbal numerical rating scale (VNRS) and Oswestry disability index (ODI) scores were significantly reduced after dry sauna therapy (P < 0.001 for both). VNRS pain scores had a median (range) of 5 (2-8) before dry sauna therapy and 3 (0-8) after dry sauna therapy. ODI scores had a median (range) of 12 (2-24) before dry sauna therapy and 8 (1-17) after dry sauna therapy. The proportion of participants who reported successful treatment (excellent + good) was 70%. No adverse effects were observed related to dry sauna therapy. CONCLUSIONS: Our results suggest that dry sauna therapy may be useful to improve quality of life and reduce pain in patients with low back pain. Therefore, pain physicians can recommend dry sauna therapy as an alternative and complimentary therapy for patients with low back pain.

Effect of medications and epidural steroid injections on fractures in postmenopausal women with osteoporosis.

Osteoporosis is a common problem, especially among postmenopausal women. Postmenopausal women with osteoporosis have major risk factors for osteoporotic fractures. The abuse of epidural steroid injections (ESIs) or the misunderstanding of their proper use could cause osteoporotic fractures. Therefore, we aimed to investigate whether ESIs are associated with osteoporotic fractures in postmenopausal women with low back pain and osteoporosis. Furthermore, we aimed to provide evidence on whether ESIs could be used in postmenopausal women with osteoporosis who are at high risk for osteoporotic fractures.We reviewed the medical records of postmenopausal women with osteoporosis but no fractures. A total of 172 postmenopausal women were divided into 2 groups. Group 1 comprised patients receiving medications and Group 2 comprised patients receiving ESIs. All participants received medications for treating osteoporosis. Each patient's age, bone mineral density, body mass index, medical history, and status with respect to smoking, drinking, physical activity, and exercise were obtained using a questionnaire and medical records.The mean total number of ESIs was 6.2, and the mean cumulative administered dose of glucocorticoids (dexamethasone) was 31 mg. The incidences of fractures in the medication and ESI groups were 22% and 24%, respectively, in the thoracolumbar spine, and 2% and 5%, respectively, in the hip joint.There was no significant difference in the incidences of osteoporotic fractures at the thoraco-lumbar spine and hip joint in postmenopausal women with osteoporosis between those who received ESIs (a mean of 6.2 ESIs, a cumulative dexamethasone dose of 31 mg) and those who did not, with both groups taking anti-osteoporotic medications for low back pain. Our data suggest that ESI treatment using a mean of 6.2 ESIs to deliver a maximum cumulative dexamethasone dose of 31 mg could be safely used in postmenopausal women with osteoporosis, without any significant impact on the their risk for osteoporotic fractures.

Relationship between bone mineral density and the frequent administration of epidural steroid injections in postmenopausal women with low back pain.

BACKGROUND: Epidural steroid injection (ESI) is one of the most common nonsurgical treatments for low back pain. In general, corticosteroid therapy often results in bone loss and osteoporosis. In previous studies, bone mineral density (BMD) was evaluated after epidural injections of relatively small numbers and relatively low total doses of corticosteroids. However, the relationship between BMD and multiple ESIs remains to be elucidated. OBJECTIVE: To explore the relationship between BMD and multiple ESIs in postmenopausal women with low back pain. METHODS: Medical records of postmenopausal women with low back pain treated with or without ESIs were reviewed. BMD was measured in the lumbar spine, femoral neck and total femur after the treatments. A total of 71 patients were divided into two groups: group 1 included patients who had received non-ESI medications; and group 2 included those who had received ESIs >10 times, with a cumulative administered triamcinolone dose >200 mg. RESULTS: Patients in group 2 showed lower BMD in the femoral neck and total femur. However, no significant intergroup differences in the BMD of the lumbar spine were observed. The prevalences of osteoporosis and osteopenia in the lumbar spine and femoral neck were significantly higher in group 2; these patients also had lower femoral neck BMD Z-scores. CONCLUSIONS: Multiple ESIs (approximately 14 injections with a cumulative triamcinolone dose of approximately 400 mg) can reduce BMD in postmenopausal women with low back pain.

Drug overdose due to malfunction of a patient-controlled analgesia machine -A case report-.

Patient-controlled analgesia (PCA) provides excellent pain control and high stability, thereby minimizing the incidence of adverse effects. However, one of our patients experienced respiratory depression and hypotension within 30 minutes of initiation of PCA therapy. We discovered that machine malfunction caused continuous activation of the PCA button, resulting in a drug overdose. The PCA machine was sent to the manufacturer, who found an electrical short in the PCA button. All PCA units of the same make and model were immediately removed from hospitals and replaced with redesigned units without defects in the PCA button. We have used the improved machines without any problems. The purpose of this report is to raise awareness of this type of malfunction in PCA units in order to help prevent adverse events in the future.

Association between bispectral index and age and use of sedative drugs in high spinal anaesthesia.

OBJECTIVES: A prospective, randomized, double-blind study using bispectral index values to objectively quantify the sedative effect of high spinal anaesthesia in patients stratified according to age, and to determine whether sedative drugs are associated with additional adverse respiratory and haemodynamic effects in older patients. METHODS: Patients who were electively scheduled for lower limb or abdominal surgery were recruited and allocated into one of three groups according to their age and whether midazolam and fentanyl were used: younger (20-40 years); and older (61-80 years) with or without midazolam and fentanyl intravenous infusion. RESULTS: The study recruited a total of 90 patients (n = 30 per group). Intraoperative bispectral index values were significantly lower than preoperative values in all groups. Patients in the older age group had significantly lower intraoperative bispectral index values than younger patients. Older patients were significantly more likely to experience respiratory depression (arterial oxyhaemoglobin saturation <90%) than younger patients. CONCLUSIONS: The sedative effect of high spinal anaesthesia is greater in older patients than in younger patients, with an increase in respiratory instability.

Low bone mineral density, but not epidural steroid injection, is associated with fracture in postmenopausal women with low back pain.

BACKGROUND: Therapy with glucocorticoids often results in bone loss and glucocorticoid-induced osteoporosis. However, the relationship between epidural steroid injection (ESI), bone mineral density (BMD), and vertebral fracture remains to be determined. OBJECTIVE: To establish a relationship between ESI, BMD, and vertebral fracture in postmenopausal women with low back pain. STUDY DESIGN: This study was a retrospective, nonblinded, cross-sectional clinical study. SETTING: University-based pain management center. METHODS: We reviewed the medical records of postmenopausal women with low back pain who were treated with ESI. A total of 352 postmenopausal women were divided into 2 groups. Group 1 consisted of patients without fracture and Group 2 consisted of those with fractures. The results of BMD measurements, as well as any fragility fractures, the anatomical site involved, and the treatment administered, were also recorded. BMD was measured in the lumbar spine, femoral neck, and total femur after the treatment. RESULTS: Of the 352 patients, 218 (62%) had no fractures while 134 (38%) sustained a fracture. The age was significantly higher among patients who sustained fractures, and BMD at the lumbar spine, total femur, and femoral neck regions was significantly lower among patients who sustained fractures. In each region, the prevalence of osteoporosis was significantly higher in patients with fracture than in patients without fracture (all P < 0.05). Age, height, and weight were associated with low BMD. However, our study showed no consistent correlation between BMD and the mean number of ESIs, mean total dose of glucocorticoids, or mean duration of ESIs. LIMITATIONS: First, this study is limited by the fact that it was retrospective. Second, the number of cases receiving very frequent, high-dose glucocorticoid injections was very small. CONCLUSIONS: Older age and lower BMD were associated with osteoporotic fracture in postmenopausal women treated for low back pain with ESI. The ESIs were not associated with low BMD or fracture.

Changes in bone mineral density in postmenopausal women treated with epidural steroid injections for lower back pain.

BACKGROUND: Therapy with corticosteroids often results in bone loss and corticosteroid-induced osteoporosis. In previous studies, bone mineral density (BMD) has been examined after administration of relatively high oral doses of corticosteroids. However, practitioners use comparatively lower doses of corticosteroids for epidural steroid injections (ESI). The interactions and relationships between BMD and ESI remain to be determined. OBJECTIVE: The aim of this study was to explore the relationship between BMD and ESI in postmenopausal women treated for lower back pain. STUDY DESIGN: This study was a retrospective evaluation. METHODS: We reviewed the medical records of postmenopausal women with lower back pain who were treated with or without ESI. BMD was measured before treatment and one year after treatment in the lumbar spine, femoral neck, and total femur. A total of 90 postmenopausal women were divided into 2 groups. Group 1 patients received medications without ESI; Group 2 patients received ESI more than 4 times, with a cumulative administered triamcinolone dose of > 120 mg. RESULTS: Decreased BMD was observed in patients treated with ESI. However, no significant difference was observed between or within the groups in terms of mean percentage change from baseline BMD. LIMITATIONS: First, this study is limited by the fact that it was retrospective. Second, our study did not consider the use of ESI with high-dose corticosteroids. Third, our study did not include any long-term assessments of the effects of ESI on BMD. CONCLUSIONS: These data suggest that ESI using triamcinolone (over 200 mg) for a period of one year will have a negative effect on BMD in postmenopausal women treated for lower back pain. However, ESI therapy using a maximum cumulative triamcinolone dose of 200 mg in one year would be a safe treatment method with no significant impact on BMD.

The dosages of corticosteroid in transforaminal epidural steroid injections for lumbar radicular pain due to a herniated disc.

BACKGROUND: Intervertebral disc herniations are the most common cause of lumbosacral radiculopathy, and transforaminal epidural steroid injection (TFESI) is an important tool in treating lumbosacral radiculopathy. But the ideal dose of corticosteroid in the epidural management of lumbosacral radiculopathy has yet to be determined. OBJECTIVE: The aim of this study was to determine the effective dose of steroids in TFESI for pain reduction in patients with lumbosacral radiculopathy. STUDY DESIGN: A randomized, double blind, controlled trial. SETTING: An interventional pain management practice center. METHODS: A total of 160 participants received 2 epidural injections of either 5 mg, 10 mg, 20 mg, or 40 mg of triamcinolone in one week intervals via TFESI. The degree of participant satisfaction and verbal numerical rating scale (VNRS) were assessed at pretreatment, one week, and 2 weeks after the first TFESI. RESULTS: The number of participants experiencing pain relief was significantly less than in other groups in the 5 mg triamcinolone group at one week after the first TFESI. There were no significant differences among the groups at one week after the second TFESI. VNRS decreased in the other groups except the triamcinolone 5 mg group at one week after the first TFESI. VNRS decreased in all groups at one week after the second TFESI. LIMITATIONS: The limitations include lack of placebo control group and lack of long-term follow-up. CONCLUSIONS: We recommend a minimal effective dose of corticosteroid (triamcinolone 10 mg) in TFESI for patients with lumbosacral radiculopathy.