Clinical Effectiveness of Ultrasound-guided Costotransverse Joint Injection in Thoracic Back Pain Patients

Because of its anatomical location and function, the costotransverse (CTRV) joint can be a source of thoracic back pain. In this retrospective observational study, we evaluated the clinical effectiveness of the CTRV joint injection in thoracic back pain patients with suspected CTRV joint problems. We enrolled 20 thoracic back pain patients with localized tenderness that was provoked by the application of pressure on the affected CTRV joints. We injected it with 0.5 ml of a ropivacaine and triamcinolone mixture at each level. The mean pre-injection pain score decreased by 37.9% (7.2 ± 1.5 to 4.5 ± 1.7, P < 0.001) two weeks after CTRV joint injection. In addition, 70% of patients reported an excellent or good level of satisfaction. We demonstrated that an ultrasound-guided injection of the CTRV joint reduced patients' pain scores and led to a high level of satisfaction at short-term follow-ups in patients with suspected CTRV joint problems.

Cross-cultural Adaptation and Linguistic Validation of the Korean Version of the Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale

Distinction between neuropathic pain and nociceptive pain helps facilitate appropriate management of pain; however, diagnosis of neuropathic pain remains a challenge. The aim of this study was to develop a Korean version of the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale and assess its reliability and validity. The translation and cross-cultural adaptation of the original LANSS pain scale into Korean was established according to the published guidelines. The Korean version of the LANSS pain scale was applied to a total of 213 patients who were expertly diagnosed with neuropathic (n = 113) or nociceptive pain (n = 100). The Korean version of the scale had good reliability (Cronbach's alpha coefficient = 0.815, Guttman split-half coefficient = 0.800). The area under the receiver operating characteristic curve was 0.928 with a 95% confidence interval of 0.885-0.959 (P or = 12, sensitivity was 72.6%, specificity was 98.0%, and the positive and negative predictive values were 98% and 76%, respectively. The Korean version of the LANSS pain scale is a useful, reliable, and valid instrument for screening neuropathic pain from nociceptive pain.

Risk Factors Associated with Clinical Insomnia in Chronic Low Back Pain: A Retrospective Analysis in a University Hospital in Korea

BACKGROUND: Insomnia is becoming increasingly recognized as a clinically important symptom in patients with chronic low back pain (CLBP). In this retrospective study, we have determined risk factors associated with clinical insomnia in CLBP patients in a university hospital in Korea. METHODS: Data from four-hundred and eighty one CLBP patients was analyzed in this study. The Insomnia Severity Index (ISI) was used to determine the presence of clinical insomnia (ISI score > or = 15). Patients' demographics and pain-related factors were evaluated by logistic regression analysis to identify risk factors of clinical insomnia in CLBP. RESULTS: It was found that 43% of patients reported mild to severe insomnia after the development of back pain. In addition, 20% of patients met the criteria for clinically significant insomnia (ISI score > or = 15). In a stepwise multivariate analysis, high pain intensity, the presence of comorbid musculoskeletal pain and neuropathic pain components, and high level of depression were strongly associated with clinical insomnia in CLBP. Among these factors, the presence of comorbid musculoskeletal pain other than back pain was the strongest determinant, with the highest odds ratio of 8.074 (95% CI 4.250 to 15.339) for predicting clinical insomnia. CONCLUSIONS: Insomnia should be addressed as an integral part of pain management in CLBP patients with these risk factors, especially in patients suffering from CLBP with comorbid musculoskeletal pain.

Patient-controlled Epidural Analgesia with Ropivacaine and Fentanyl: Experience with 2,276 Surgical Patients

BACKGROUND: Good postoperative pain control is an important part of adequate postoperative care. Patient-controlled epidural analgesia (PCEA) provided better postoperative analgesia compared to other conventional analgesic methods, but several risks have been observed as well. We therefore surveyed the efficacy and safety of PCEA in this retrospective observational study. METHODS: We analyzed collected data on 2,276 elective surgical patients who received PCEA with ropivacaine and fentanyl. Patients were assessed by a PCA service team in the post-anesthesia care unit (PACU), at 1-6 h, 6-24 h, and 24-48 h postoperatively for adequate pain control. The presence of PCEA-related adverse events was also assessed. RESULTS: Numerical pain score (median [interquartile range]) were 3 [1-4], 5 [4-7], 4 [3-5], and 3 [3-5] in the PACU, at 1-6 h, 6-24 h, and 24-48 h postoperatively. Median pain scores in patients underwent major abdominal or thoracic surgery were higher than other surgical procedure in the PACU, at 1-6 h after surgery. Nausea and vomiting (20%) and numbness and motor weakness (15%) were revealed as major PCEA-related adverse events during the postoperative 48 h period. There were 329 patients (14%) for whom PCEA was ceased within 48 h following surgery. CONCLUSIONS: Our data suggest that the use of PCEA provides proper analgesia in the postoperative 48 h period after a wide variety of surgical procedures and that is associated with few serious complications. However, more careful pain management and sustainable PCEA monitoring considering the type of surgical procedure undergone is needed in patients with PCEA.

Concomitant Glomus Tumor with CRPS in the Hand

Glomus tumors are benign tumors that account for 1% to 5% of all soft tissue tumors of the hand and are characterized by a triad of sensitivity to cold, localized tenderness and severe paroxysmal pain. Paroxysmal pain is a symptom common not only in glomus tumors but also in CRPS, and the hand is one of the commonly affected sites in patients with both glomus tumors and CRPS. Therefore, it is not easy to clinically diagnose glomus tumors superimposed on already affected region of CRPS patients. We report a case of glomus tumor concomitantly originating with CRPS at the hand.

Secondary Erythromelalgia: A Case Report

Erythromelalgia is a rare neurovascular pain syndrome characterized by a triad of redness, increased temperature, and burning pain primarily in the extremities. Erythromelalgia can present as a primary or secondary form, and secondary erythromelalgia associated with a myeloproliferative disease such as essential thrombocythemia often responds dramatically to aspirin therapy, as in the present case. Herein, we describe a typical case of a 48-year-old woman with secondary erythromelalgia linked to essential thrombocythemia in the unilateral hand. As this case demonstrates, detecting and visualizing the hyperthermal area through infrared thermography of an erythromelalgic patient can assist in diagnosing the patient, assessing the therapeutic results, and understanding the disease course of erythromelalgia.

Popliteal Fossa Pain in 24 Year-old Female

The pain around the posterior knee, called 'popliteal fossa', has been known to be caused by a variety of disease entities. Venous malformation is a very rare cause of popliteal area pain, and its diagnosis is frequently delayed, missed, or given incorrectly. Here, we report a case of a patient with popliteal fossa pain for 2 years and was diagnosed as intramuscular venous malformation using ultrasound.

Epidural Blood Patch for the Treatment of Abducens Nerve Palsy due to Spontaneous Intracranial Hypotension: A Case Report

Intracranial hypotension is characterized by a postural headache which is relieved in a supine position and worsened in a sitting or standing position. Although less commonly reported than postural headache, sixth nerve palsy has also been observed in intracranial hypotension. The epidural blood patch (EBP) has been performed for postdural puncture headache, but little is known about the proper timing of EBP in the treatment of sixth nerve palsy due to intracranial hypotension. This article reports a case of sixth nerve palsy due to spontaneous intracranial hypotension which was treated by EBP 10 days after the onset of palsy.

Allergic reactions to hyaluronidase in pain management: A report of three cases / 대한마취과학회지

Hyaluronidase has been gaining interest because it reduces tissue edema and fibrosis. Although rare, hyaluronidase has been shown to cause allergic reactions. A few cases of allergic reactions following hyaluronidase administration have been reported. Most of the described patients presented allergic reactions after peribulbar anesthesia for eye surgery. In this report, we describe three patients who experienced with allergic reactions to hyaluronidase following pain management. Two of the patients had a history of uneventful injection with hyaluronidase. All patients were afebrile and blood tests results were normal. Intradermal skin tests were positive. These clinical findings were helpful in establishing the differential diagnosis of infection. Although allergic reaction to hyaluronidase is rare and mostly benign, this must be considered before treating patients.

Pulsed Radiofrequency Treatment of Pain Relieving Point in a Soft Tissue

Pulsed radiofrequency (PRF) treatment of nervous tissue has been proposed as a less neurodestructive technique alternative to continuous RF heat lesioning. Recently, clinical reports using PRF have shown favorable effects in the treatment of a variety of focal pain areas, even in non-nervous tissues; however, the mechanism of effect underlying this treatment to non-nervous tissue remains unclear. We report the case of a 67-year-old male who presented with pain reliving point in the posterior neck. The patient had pain in the posterior neck for 3 years. The pain subsided with pressure applied to a point in the posterior neck. There were no specific abnormal findings on laboratory testing and radiologic examinations. After PRF treatment to the pain-relieving point, he had pain relief which lasted more than 5 months.

Analgesic therapy according to disease specific pathophysiology

This article reviews the pharmacologic management of osteoarthritis, low back pain, and neuropathic pain. In order to manage chronic pain appropriately, pharmacologic management, such as adequate drug selection, is the most important in clinical situations. Pain is classified as nociceptive, neuropathic, or mixed pain according to its mechanism. For effective pain control, we choose analgesics depending on adequate evaluation and understanding of the pathophysiology of pain. Nociceptive pain like osteoarthritis is controlled by acetaminophen, nonsteroidal antiinflammatory drugs, and opioids according to the pain intensity. However, our recommendation for neuropathic pain is antidepressants and anticonvulsants as first line treatments. Low back pain arises from nociceptive and neuropathic mechanisms, classified as mixed pain syndrome. Therefore, the rational management of low back pain targets the different mechanisms of pain by combining agents with different mechanisms of action.

Estimation of Stellate Ganglion Block Injection Point Using the Cricoid Cartilage as Landmark Through X-ray Review

BACKGROUND: Stellate ganglion block is usually performed at the transverse process of C6, because the vertebral artery is located anterior to the transverse process of C7. The purpose of this study is to estimate the location of the transverse process of C6 using the cricoid cartilage in the performance of stellate ganglion block. METHODS: We reviewed cervical lateral neutral-flexion-extension views of 48 patients who visited our pain clinic between January and June of 2010. We drew a horizontal line at the surface of the cricoid cartilage in the neutral and extension views of cervical lateral x-rays. We then measured the change in the shortest distance from this horizontal line to the lowest point of the transverse process of C6 between the neutral and extension views. RESULTS: There was a statistically significant difference in the shortest distance from the horizontal line at the surface of the cricoid cartilage to the lowest point of transverse process of C6 between neutral position and neck extension position in both males and females, and between males and females in both neutral position and neck extension position. The cricoid cartilage level was 4.8 mm lower in males and 14.4 mm higher in females than the lowest point of transverse process of C6 in neck extension position. CONCLUSIONS: Practitioners should recognize that the cricoid cartilage has cephalad movement in neck extension. In this way, the cricoid cartilage can be still useful as a landmark for stellate ganglion block.

Pulsed Radiofrequency Treatment of Pain Relieving Point in a Soft Tissue / 대한통증학회지

Pulsed radiofrequency (PRF) treatment of nervous tissue has been proposed as a less neurodestructive technique alternative to continuous RF heat lesioning. Recently, clinical reports using PRF have shown favorable effects in the treatment of a variety of focal pain areas, even in non-nervous tissues; however, the mechanism of effect underlying this treatment to non-nervous tissue remains unclear. We report the case of a 67-year-old male who presented with pain reliving point in the posterior neck. The patient had pain in the posterior neck for 3 years. The pain subsided with pressure applied to a point in the posterior neck. There were no specific abnormal findings on laboratory testing and radiologic examinations. After PRF treatment to the pain-relieving point, he had pain relief which lasted more than 5 months.

Radiation Exposure to Physicians During Interventional Pain Procedures

BACKGROUND: Fluoroscopy has been an integral part of modern interventional pain management. Yet fluoroscopy can be associated with risks for the patients and clinicians unless it is managed with appropriate understanding, skill and vigilance. Therefore, this study was designed to determine the amount of radiation received by a primary operator and an assistant during interventional pain procedures that involve the use of fluoroscopy METHODS: In order to examine the amount of radiation, the physicians were monitored by having them wear three thermoluminescent badges during each single procedure, with one under a lead apron, one under the apron collar and one on the leg during each single procedure. The data obtained from each thermoluminescent badge was reviewed from September 2008 to November 2008 and the annual radiation exposure was subsequently calculated. RESULTS: A total of 505 interventional procedures were performed with C-arm fluoroscopy during three months. The results of this study revealed that the annual radiation exposure was relatively low for both the operator and assistant. CONCLUSION: With proper precautions, the use of fluoroscopy during interventional pain procedures is a safe practice.

The Change in Regional Cerebral Oxygen Saturation after Stellate Ganglion Block

BACKGROUND: Stellate ganglion block (SGB) is known to increase blood flow to the innervations area of the stellate ganglion. Near infrared spectroscopy reflects an increased blood volume and allows continuous, non-invasive, and bedside monitoring of regional cerebral oxygen saturation (rSO2). We investigated the influence of SGB on bilateral cerebral oxygenation using a near infrared spectroscopy. METHODS: SGB was performed on 30 patients with 1% lidocaine 10 ml using a paratracheal technique at the C6 level and confirmed by the presence of Horner's syndrome. The blood pressure (BP), heart rate (HR) and rSO2 were measured before SGB and 5, 10, 15 and 20 minutes after SGB. Tympanic temperature of each ear was measured prior to SGB and 20 minutes after SGB. RESULTS: The increments of the rSO2 on the block side from the baseline were statistically significant at 5, 10, 15 and 20 minutes. The rSO2 on the non-block side compared with the baseline, however, decreased at 15 and 20 minutes. The difference between the block and the non-block sides was significant at 15 and 20 minutes. The BP at 10, 15 and 20 minutes was increased and the HR was increased at 10 and 15 minutes. CONCLUSIONS: We observed an increment of the rSO2 on the block side from the baseline; however, the rSO2 on the non-block side decreased.

Ultrasonic doppler flowmeter-guided occipital nerve block / 대한마취과학회지

BACKGROUND: Greater occipital nerve block is used in the treatment of headaches and neuralgia in the occipital area. We evaluated the efficacy of ultrasonic doppler flowmeter-guided occipital nerve block in patients experiencing headache in the occipital region in a randomized, prospective, placebo-controlled study. METHODS: Twenty-six patients, aged 18 to 70, with headache in the occipital region, were included in the study. Patients received a greater occipital nerve block performed either under ultrasonic doppler flowmeter guidance using 1% lidocaine or the traditional method. Sensory examination findings in the occipital region were evaluated. RESULTS: The complete block rate of greater occipital nerve blockade in the doppler group was significantly higher than in the control group respectively (76.9% vs. 30.8%, P < 0.05). Only one patient in the control group had a complication (minimal bleeding). CONCLUSIONS: Ultrasonic doppler flowmeter-guided occipital nerve block may be a useful method for patients suffering headache in the occipital region.

An Analysis of Location of Needle Entry Point and Palpated PSIS in S1 Nerve Root Block

BACKGROUND: The first sacral nerve root block (S1NRB) is a common procedure in pain clinic for patients complaining of low back pain with radiating pain. It can be performed in the office based setting without C-arm. The previously suggested method of locating the needle entry point begins with identifying the posterior superior iliac spine (PSIS). Then a line is drawn between two points, one of which is 1.5 cm medial to the PSIS, and the other of which is 1.5 cm lateral and cephalad to the ipsilateral cornu. After that, one point on the line, which is 1.5 cm cephalad to the level of the PSIS, is considered as the needle entry point. The purpose of this study was to analyze the location of needle entry point and palpated PSIS in S1NRB. METHODS: Fifty patients undergoing C-arm guided S1NRB in the prone position were examined. The surface anatomical relationships between the palpated PSIS and the needle entry point were assessed. RESULTS: The analysis revealed that the transverse and vertical distance between the needle entry point and PSIS were 28.7 +/- 8.8 mm medially and 3.5 +/- 14.0 mm caudally, respectively. The transverse distance was 27.8 +/- 8.3 mm medially for male and 29.5 +/- 9.3 mm medially for female. The vertical distance was 1.0 +/- 14.1 mm cranially for male and 8.1 +/- 12.7 mm caudally for female. CONCLUSIONS: The needle entry point in S1NRB is located on the same line or in the caudal direction from the PSIS in a considerable number of cases. Therefore previous recommended methods cannot be applied to many cases.

An Analysis of the Surface Anatomical Location of the Posterior-inferior Margin of the Sacroiliac Joint

BACKGROUND: The blind sacroiliac joint (SIJ) block cannot always be performed accurately; it is commonly performed in the office based setting because intraarticular and periarticular injections are effective for SIJ pain. However, knowledge on the surface anatomy of the SIJ is lacking. The purpose of this study was to analyze the surface anatomical location of the posterior-inferior margin of the SIJ. METHODS: After informed consent was obtained, fifty patients undergoing SIJ block in the prone position were examined. The oblique angles where the anterior-inferior margin and the posterior-inferior margin of the SIJ overlap on X-ray were evaluated. In addition, the surface anatomical relationships between the posterior-inferior margin of the SIJ on X-ray and the posterior superior iliac spine (PSIS) and sacral hiatus by palpation were assessed. RESULTS: The oblique angle was 5.4 +/- 2.9degrees. The vertical and transverse distance between the posterior-inferior margin of the SIJ and PSIS were 3.8 +/- 0.8 cm and 0.9 +/- 0.6 cm, respectively. The vertical and transverse distance between the posterior-inferior margin of the SIJ and the midpoint of the sacral hiatus were 3.4 +/- 0.7 cm and 3.9 +/- 0.6 cm, respectively. Only the vertical distance between the posterior-inferior margin of the SIJ and PSIS showed significant difference between the male and the female groups (P = 0.0016). CONCLUSIONS: The measurements in this study can be used as a reference standards for the blind SIJ block.

Nerve Blocks of Cancer Pain in Palliative Care / 한국호스피스완화의료학회지

More than 80% of cancer-related pain is pharmacologically controllable, whereas 10~20% of patients require interventional treatments. Neurolytic nerve block can play a major role in cancer pain treatment, and it has been proposed to prevent the development of pain and improve the quality of life of patients with cancer. If the pain is well localized and restricted to certain peripheral parts of the body, spinal peripheral or sympathetic nerve blocks may result in excellent therapeutic effects. Neurolytic sympathetic block, especially Celiac plexsus block (CPB) performed in earlier stages, is effective with successful long term results. However, selection of patients is critical for succeful outcomes. Neurolytic plexus block significantly improves the quality of life of patients and reduces abdominal and pelvic cancer pain, analgesic consumption and adverse opioids-related side effects. Interventional pain management should be considered at earlier stages to provide patients with the best quality of life possible.

Treatment of a Twelfth Rib Syndrome : A case report

Twelfth rib syndrome is thought to be due to intercostal nerve irritation by a mobile twelfth rib, and presents with upper abdominal pain, or low thoracic pain. This syndrome appears to be a fairly common entity and diagnosis is based on clinical findings. Patients with twelfth rib syndrome can be misdiagnosed when it has been overlooked. We report a case of a 34-year-old male along with a presentation of twelfth rib syndrome. One patient was transferred from urologic clinic to pain clinic due to right flank pain and admitted. The patient had direct tenderness on twelfth rib area and direct tenderness was reproducible. Pain increased when the patient flexed laterally, rotated trunk. There were no specific abnormal findings in laboratory test, electrocardiogram, and radiologic examination. After intercostal nerve block and epidural block, pain decreased and the patient was discharged.