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Lymphedema is characterized by localized tissue swelling due to excessive interstitial space retention of lymphatic fluid. Lymphedema is easy to be misdiagnosed since itresembles other conditions of extremity swelling. We present a case of complex regionalpain syndrome (CRPS) type I with secondary lymphedema that was successfully managedwith spinal cord stimulation (SCS).Case: A 39-year-old female patient came to our pain clinic with complaints of lower extremity pain and edema. To find out reason of leg edema, computed tomography of extremity angiography and blood test were performed. However, all of evaluations were normal. Lastlyperformed lymphoscintigraphy showed secondary lymphedema. SCS was performed and itshowed dramatic reduction subsequent to implantation of SCS.Conclusions: We could successfully manage the intractable pain and edema in CRPS combined with lymphedema. If a patient presents different nature of edema, coexistence of other disease needs to be considered.
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Background@#Spontaneous intracranial hypotension occurs due to cerebrospinal fluid leakage from the spinal column, and orthostatic headache is the most common clinical presentation. Recent studies showed that bilateral greater occipital nerve blockade demonstrated clinical efficacy in relieving post-dural puncture headache after caesarean section. CaseA 40-year-old male who presented severe orthostatic headache was consulted to our pain clinic from neurology department. He initially felt a dull nature pain over the whole occipital area which then spread over the frontal and parietal areas. His headache was combined with nausea and vomiting. An epidural blood patch was delayed until final cisternography, and bilateral greater occipital nerve blockade using ultrasound guidance was performed instead. After the blockade, the previously existing headache around the occipital and parietal areas disappeared completely, but mild headache persisted around the frontal area. @*Conclusions@#Greater occipital nerve blockade could be a good therapeutic alternative to improve headache resulting from spontaneous intracranial hypotension.
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Background@#Gasserian ganglion radiofreqeucy thermoablation is a good treatment option for the management of pain in trigeminal neuralgia. We report a case in which the patient of trigeminal neuralgia combined with anterior cerebral artery aneurysm was treated successfully by gasserian ganglion thermoablation without any complication.CaseAn 85-year-old female presenting with electric shock like sensation in the gum and molar teeth was diagnosed as trigeminal neuralgia. Carbamazepine medication and trigeminal nerve blockade relieved her pain partially, but severe side effects of carbamazepine occurred. Magnetic resonance angiography of the brain showed saccular aneurysm in inferior aspect of the anterior communicating artery. Gasserian ganglion thermoablation under sedation anesthesia using nicardipine was performed carefully without any rupture of the cerebral aneurysm. @*Conclusions@#Gasserian ganglion thermoablation could be performed safely in a patient with cerebral aneurysm without any inadvertent event.
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Background@#Robot-assisted laparoscopic radical prostatectomy is an advanced and popular surgical technique. However, increased intracranial pressure which is caused by CO2 pneumoperitoneum and Trendelenburg position is the main cerebrovascular effect. Measurement of optic nerve sheath diameter using ocular ultrasound is a noninvasive and reliable method for the assessment of intracranial pressure. The primary endpoint of this study was to identify whether low blood pressure regulation has any benefit in attenuating an increase of optic nerve sheath diameter during robot-assisted laparoscopic radical prostatectomy. @*Methods@#Optic nerve sheath diameter and cerebral oxygen saturation were measured at baseline (supine position), one and two hours after pneumoperitoneum and Trendelenburg position respectively, and after return to supine position in normal (n = 27) and low blood pressure groups (n = 24). @*Results@#Mean optic nerve sheath diameter values measured at one and two hours after pneumoperitoneum and Trendelenburg position were significantly increased compared to the baseline value (P < 0.001 in normal blood pressure group; P = 0.003 in low blood pressure group). However, the mean optic nerve sheath diameter and cerebral oxygen saturation measured at any of the time points as well as degrees of change between the two groups did not show any significant changes. The peak values of optic nerve sheath diameter in normal and low blood pressure groups demonstrated 14.9% and 9.2% increases, respectively. @*Conclusions@#Low blood pressure group demonstrated an effect in maintaining an increase of optic nerve sheath diameter less than 10% during CO2 pneumoperitoneum and Trendelenburg position.
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Background@#Hypotension following spinal anesthesia of Cesarean section is mainly caused by peripheral vasodilation and venous pooling due to sympathetic blockade. The degree of sympathetic blockade is known to affect the occurrence of hypotension after spinal anesthesia. The perfusion index (PI) and plethysmographic variability index (PVI) are non-invasive tools for measuring the vasomotor tone and volume status, respectively. The purpose of this study is to compare the trends of PI and PVI values between hypotension and normotension groups during Cesarean section following spinal anesthesia. @*Methods@#Fifty-one parturients were divided into two groups whether they developed hypotension or maintained normotension after spinal anesthesia. Spinal anesthesia was performed with 0.5% hyperbaric bupivacaine (10 mg) and fentanyl (15 μg) at the L3-4 intervertebral space. The data of blood pressure, heart rate, PI and PVI were recorded every minute until delivery of baby. @*Results@#Hypotension occurred in 61% of parturients during Cesarean section. The overall PI and PVI value after spinal anesthesia have gradually increased and decreased, respectively. The degree of increase and decrease in PI (p = 0.31) and PVI value (p = 0.35) was not significant between hypotension and normotension groups. @*Conclusions@#The trend of PI value has gradually increased while the PVI value has decreased, regardless of whether the parturient has experienced hypotension or not.
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Background@#Hypotension following spinal anesthesia of Cesarean section is mainly caused by peripheral vasodilation and venous pooling due to sympathetic blockade. The degree of sympathetic blockade is known to affect the occurrence of hypotension after spinal anesthesia. The perfusion index (PI) and plethysmographic variability index (PVI) are non-invasive tools for measuring the vasomotor tone and volume status, respectively. The purpose of this study is to compare the trends of PI and PVI values between hypotension and normotension groups during Cesarean section following spinal anesthesia. @*Methods@#Fifty-one parturients were divided into two groups whether they developed hypotension or maintained normotension after spinal anesthesia. Spinal anesthesia was performed with 0.5% hyperbaric bupivacaine (10 mg) and fentanyl (15 μg) at the L3-4 intervertebral space. The data of blood pressure, heart rate, PI and PVI were recorded every minute until delivery of baby. @*Results@#Hypotension occurred in 61% of parturients during Cesarean section. The overall PI and PVI value after spinal anesthesia have gradually increased and decreased, respectively. The degree of increase and decrease in PI (p = 0.31) and PVI value (p = 0.35) was not significant between hypotension and normotension groups. @*Conclusions@#The trend of PI value has gradually increased while the PVI value has decreased, regardless of whether the parturient has experienced hypotension or not.
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Thoracic epidural anesthesia (TEA) is an efficient procedure for managing intraoperative and postoperative pain caused by liver resection, gastrectomy, or lung surgery. Precise difficulty prediction of TEA has the advantage of reducing the risk of complications. The purpose of this study was to identify factor correlated with TEA performance time under fluoroscopic guidance. From September 2017 to May 2018, 39 patients who were scheduled to receive TEA under fluoroscopic guidance for postoperative pain control were enrolled for this study. All thoracic epidural catheterization was performed by one physician who had more than 5 years of experience in spine intervention. TEA was performed one day before the elective surgery in the outpatient pain clinic. Body mass index (BMI) was found to be a factor associated with TEA procedure time. Correlation coefficients of procedure time with age, height, weight and BMI were 0.099, -0.129, 0.346, and 0.575, respectively. BMI needs to be considered as one factor that affects the difficulty of TEA.
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Background@#Sympathetic blocks (SBs) have been used widely to relieve the symptoms of sympathetically maintained pain (SMP). The thoracic sympathetic ganglion is not separated from somatic nerves by muscles and connective tissue. The upper thoracic ganglion runs along the posterior surface of the vertebral column in close proximity to the adjacent epidural region. This anatomical difference leads to frequent epidural and intercostal spread in cases of thoracic SBs. The purpose of this study was to investigate the incidence of inadvertent intercostal and epidural injections during thoracic SBs. @*Methods@#Twenty-two patients who were suffering from complex regional pain syndrome or lymphedema after breast cancer surgery were managed with two or three times of thoracic SBs. Therefore, injections of 63 thoracic SBs from 22 patients were enrolled in this study. An investigator who did not attend the procedure evaluated the occurrence of intercostal or epidural spread using anteroposterior fluoroscopic images. @*Results@#The overall incidence of inadvertent intercostal or epidural spread of contrast was 47.5%. Among the inadvertent injections, intercostal spread (34.9%) was more frequent than epidural spread (12.6%). Only 52.5% of the thoracic SBs demonstrated successful contrast spread without any inadvertent spread. The mean difference in skin temperature between the blocked and unblocked sides was 2.5 ± 1.8ºC. Fifty-nine (93.6%) injections demonstrated more than 1.5ºC difference. @*Conclusions@#Thoracic SBs showed a high incidence (47.5%) of inadvertent epidural or intercostal injection. Thus, special attention is required for the diagnosis of SMP or the injection of any neurolytic agent around sympathetic ganglion.
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Patient controlled epidural anlagesia is a commonly used method for postoperative pain management. The purpose of this study is to determine the optimal concentration of sufentanil for patient controlled epidural analgesia. Twenty eight patients who underwent elective gastrectomy were enrolled in this study. Patients were randomly assigned to one of two groups of 0.5 µg/mL (group S1) and 0.7 µg/mL (group S2). At 2 hours, 1 day, 2 days and 3 days after surgery, the patient's pain degree was checked by numerical rating scale (NRS) and the presence of side effects was assessed. In both groups, the NRS decreased linearly with time. The NRS of the two groups differed but the trend of decrease did not show significant difference. The overall incidence of side effects was 45.5% (group S1) and 58.8% (group S2), respectively. Patient controlled epidural analgesia using sufentanil was effective in controlling postoperative pain, which was found to decrease with time. When comparing the two concentrations used in this study, 0.5 µg/mL had a lower incidence of side effects than the concentration of 0.7 µg/mL, and the pain relief trends of the two concentrations were similar.
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Humans , Analgesia, Epidural , Analgesia, Patient-Controlled , Gastrectomy , Incidence , Methods , Pain, Postoperative , SufentanilABSTRACT
BACKGROUND: The thoracic transforaminal epidural block (TTFEB) is usually performed to treat herpes zoster or postherpetic neuralgia (PHN). Especially, multiple segmental involvements and approximate contrast medium spread range, according to volume, help to choose the proper drug volume in the transforaminal epidural block. This study investigated the contrast medium spread patterns of 1-ml to 3-ml TTFEBs. METHODS: A total of 26 patients with herpes zoster or PHN were enrolled in this study. All participants received 1 ml, 2 ml, or 3 ml of contrast medium. Results were divided into Groups A, B and C based on the volume (1, 2, or 3 ml), with n = 26 for each group. After the injection of contrast medium, the spread levels were estimated in both the lateral and anteroposterior (AP) images using fluoroscopy. RESULTS: The cephalad spread of contrast medium in the lateral image as expressed by the median (interquartile range) was 2.00 levels (1.00–2.00) for Group A, 2.50 (2.00–3.00) for Group B, and 3.00 (2.00-4.00) for Group C. The caudal spread level of contrast medium was 1.00 (1.00-2.00) for Group A, 2.00 (2.00–3.00) for Group B, and 2.00 (2.00–3.00) for Group C. There was ventral and dorsal spread of the 3-ml contrast medium injection in 88% (23/26) of cases in the lateral image. CONCLUSIONS: Injection of 3 ml of contrast medium through the foramina spread 6 levels in a cephalocaudal direction. Spread patterns revealed a cephalad preference. TTFEB resulted in dorsal and ventral spread in a high percentage of cases. This procedure may be useful for transferring drugs to the dorsal and ventral roots.
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Humans , Contrast Media , Fluoroscopy , Herpes Zoster , Injections, Epidural , Nerve Block , Neuralgia, Postherpetic , Spinal Nerve Roots , SpineABSTRACT
BACKGROUND: Recently, the use of ultrasound (US) techniques in regional anesthesia and pain medicine has increased significantly. However, the current extent of training in the use of US-guided pain management procedures in Korea remains unknown. The purpose of the present study was to assess the current state of US training provided during Korean Pain Society (KPS) pain fellowship programs through the comparative analysis between training hospitals. METHODS: We conducted an anonymous survey of 51 pain physicians who had completed KPS fellowships in 2017. Items pertained to current US practices and education, as well as the types of techniques and amount of experience with US-guided pain management procedures. Responses were compared based on the tier of the training hospital. RESULTS: Among the 51 respondents, 14 received training at first- and second-tier hospitals (Group A), while 37 received training at third-tier hospitals (Group B). The mean total duration of pain training during the 1-year fellowship was 7.4 months in Group A and 8.4 months in Group B. Our analysis revealed that 36% and 40% of respondents in Groups A and B received dedicated US training, respectively. Most respondents underwent US training in patient-care settings under the supervision of attending physicians. Cervical root, stellate ganglion, piriformis, and lumbar plexus blocks were more commonly performed by Group B than by Group A (P < 0.05). CONCLUSIONS: Instruction regarding US-guided pain management interventions varied among fellowship training hospitals, highlighting the need for the development of educational standards that mandate a minimum number of US-guided nerve blocks or injections during fellowships in interventional pain management.
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Anesthesia, Conduction , Anonyms and Pseudonyms , Education , Fellowships and Scholarships , Korea , Lumbosacral Plexus , Nerve Block , Neuronavigation , Organization and Administration , Pain Management , Spinal Nerve Roots , Spine , Stellate Ganglion , Surveys and Questionnaires , UltrasonographyABSTRACT
As the treatment of chronic non-cancer pain gradually increases, clinicians have more opportunities to encounter opioid prescription. However, guidelines for prescribing opioids for chronic non-cancer pain have never been published in Korea. The present guidelines were prepared by reviewing various research data. In cases in which the data were insufficient, recommendations were presented following discussion among experts affiliated with the Opioids Research Group in the Korean Pain Society. The present guidelines may need to be continuously revised and amended as more clinical evidence is acquired.
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Analgesics, Opioid , Korea , PrescriptionsABSTRACT
BACKGROUND: The transforaminal (TF) epidural steroid injection (ESI) is suggested as more effective than the interlaminar (IL) route due to higher delivery of medication at the anterior epidural space. However, serious complications such as spinal cord injury and permanent neural injury have been reported. The purpose of this study is to evaluate and compare the clinical effectiveness, technical ease, and safety of the TF and parasagittal IL (PIL) ESI. METHODS: A total of 72 patients were randomized to either the PIL group (n = 41) or the TF group (n = 31) under fluoroscopic guidance. Patients were evaluated for effective pain relief by the numerical rating scale (NRS) and Oswestry Disability Index (ODI) (%) before and 2 weeks after the ESI. The presence of concordant paresthesia, anterior epidural spread, total procedure time, and exposed radiation dose were also evaluated. RESULTS: Both the PIL and TF approach produced similar clinically significant improvements in pain and level of disability. Among the 72 patients, 27 PIL (66%) and 20 TF (64%) patients showed concordant paresthesia while 14 (34%) and 11 (36%) patients in the same respective order showed disconcordant or no paresthesia. Radiation dose and total procedure time required were compared; the PIL group showed a significantly lower radiation dose (30.2 ± 12 vs. 80.8 ± 26.8 [Cgy/cm²]) and shorter procedure time (96.2 ± 31 vs. 141.6 ± 30 seconds). CONCLUSIONS: ESI under fluoroscopic guidance with PIL or TF approach were effective in reducing the NRS and ODI. PIL ESI was a technically easier and simple method compared to TF ESI.
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Humans , Epidural Space , Methods , Paresthesia , Spinal Cord Injuries , Treatment OutcomeABSTRACT
BACKGROUND: Thoracic epidural anesthesia is frequently used to maintain intraoperative and postoperative analgesia. Frequently, 3 ml of local anesthetic is used as a test dose, or for intermittent epidural injection. We assessed the extent of the spread of 3 ml of contrast medium in the thoracic epidural space and attempted to identify any correlating factors affecting the epidurography. METHODS: A total of 70 patients were enrolled in the study, and thoracic epidural catheterizations were performed under fluoroscopic guidance. Using 3 ml of contrast medium, epidurography was evaluated to confirm the number of spinal segments covered by the contrast medium. Correlation analysis was performed between patient characteristics (sex, age, body mass index, weight, height, and location of catheter tip) and the extent of the contrast spread. RESULTS: The mean number of vertebral segments evaluated by contrast medium was 7.9 ± 2.2 using 3 ml of contrast medium. The contrast spread in the cranial direction showed more extensive distribution than that in the caudal direction, with statistical significance (P < 0.01). Patient height demonstrated a negative correlation with the extent of distribution of contrast medium (r = −0.311, P < 0.05). CONCLUSIONS: Thoracic epidurography using 3 ml of contrast medium results in coverage of a mean of 7.9 ± 2.2 spinal segments, with more extensive cranial spread, and patient height showed a weak negative correlation with the distribution of contrast medium.
Subject(s)
Humans , Analgesia , Anesthesia, Epidural , Body Mass Index , Catheterization , Catheters , Epidural Space , Injections, EpiduralABSTRACT
BACKGROUND: Thoracic epidural anesthesia is frequently used to maintain intraoperative and postoperative analgesia. Frequently, 3 ml of local anesthetic is used as a test dose, or for intermittent epidural injection. We assessed the extent of the spread of 3 ml of contrast medium in the thoracic epidural space and attempted to identify any correlating factors affecting the epidurography. METHODS: A total of 70 patients were enrolled in the study, and thoracic epidural catheterizations were performed under fluoroscopic guidance. Using 3 ml of contrast medium, epidurography was evaluated to confirm the number of spinal segments covered by the contrast medium. Correlation analysis was performed between patient characteristics (sex, age, body mass index, weight, height, and location of catheter tip) and the extent of the contrast spread. RESULTS: The mean number of vertebral segments evaluated by contrast medium was 7.9 ± 2.2 using 3 ml of contrast medium. The contrast spread in the cranial direction showed more extensive distribution than that in the caudal direction, with statistical significance (P < 0.01). Patient height demonstrated a negative correlation with the extent of distribution of contrast medium (r = −0.311, P < 0.05). CONCLUSIONS: Thoracic epidurography using 3 ml of contrast medium results in coverage of a mean of 7.9 ± 2.2 spinal segments, with more extensive cranial spread, and patient height showed a weak negative correlation with the distribution of contrast medium.
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Humans , Analgesia , Anesthesia, Epidural , Body Mass Index , Catheterization , Catheters , Epidural Space , Injections, EpiduralABSTRACT
A 55-year-old female with severe herpes zoster related forehead pain radiating to anterior and posterior scalp visited our pain clinic. The right side forehead pain with numerical rating score of 7 had persisted in spite of antiviral and anticonvulsant medication. We blocked the right supraorbital nerve under ultrasound guidance, and obtained the proper pain relief. In this case, we would like to present the method to identify the supraorbital notch or foramen and possible visualization of the supraorbital nerve.
Subject(s)
Female , Humans , Middle Aged , Forehead , Herpes Zoster , Methods , Pain Clinics , Scalp , UltrasonographyABSTRACT
BACKGROUND: To investigate and analyze MRI findings in relation to visual analogue scale (VAS), Oswestry Disability Index (ODI), psychological-factor, sleep-quality, and Short-Form Health Survey (SF-36) scores among patients with central lumbar spinal stenosis (LSS) for the purpose of elucidating a correlation. METHODS: From July 2013 to May 2014, 117 consecutive patients with central LSS were included in this study. All of the MRIs were evaluated by one of the authors, and the evaluated items were the dural sac cross-sectional area (DSCSA), the number of stenotic levels, and the presence and levels of spondylolisthesis. The ODI, VAS, 36-item SF-36, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Pittsburgh Sleep Quality Index (PSQI) questionnaires were used to evaluate the participants. RESULTS: There are no correlations between the ODI, VAS, BDI, BAI, PSQI, and SF-36 scores and the minimum DSCSA; however, a significant correlation was found between the ODI scores and multilevel LSS. The BDI, BAI, and PSQI scores are higher for multilevel LSS compared with single-level LSS, but the difference of this mean value is not statistically significant. CONCLUSIONS: A significant correlation was shown between those patients with multilevel LSS and the ODI scores; however, significant correlations were not found between the MRI findings and the psychological factors pertaining to sleep and life qualities.
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Humans , Anxiety , Depression , Health Surveys , Magnetic Resonance Imaging , Psychology , Quality of Life , Spinal Stenosis , SpondylolisthesisABSTRACT
Temporomandibular joint (TMJ) disorder is clinically important because of its prevalence, chronicity, and therapy-refractoriness of the pain. In this study, we investigated the effect of infliximab in a mouse model of TMJ pain using a specially-engineered transducer for evaluating the changes in bite force (BF). The mice were randomly divided into three groups (7 mice per group): the control group, the complete Freund's adjuvant (CFA) group, and the infliximab group. BF was measured at day 0 (baseline BF). After measuring the baseline BF, CFA or incomplete Freund's adjuvant was injected into both TMJs and then the changes in BF were measured at days 1, 3, 5, 7, 9, and 13 after the TMJ injection. For measuring the BF, we used a custom-built BF transducer. Control, CFA, and infliximab groups showed similar baseline BF at day 0. From day 1, a significant reduction in BF was observed in the CFA group, and this reduction in BF was statistically significant compared to that in the control group (P < 0.05). This reduction in BF was maintained until day 7, and BF started to recover gradually from day 9. In the infliximab group also, the reduction in BF was observed on day 1, and this reduction was maintained until day 7. However, the degree of reduction in BF was less remarkable compared to that in the CFA group. The reduction in BF caused by injection of CFA into the TMJ could be partially alleviated by the injection of anti-tumor necrosis factor alpha, infliximab.
Subject(s)
Animals , Male , Mice , Antirheumatic Agents/therapeutic use , Bite Force , Disease Models, Animal , Freund's Adjuvant/toxicity , Infliximab/therapeutic use , Mice, Inbred ICR , Temporomandibular Joint/pathology , Temporomandibular Joint Disorders/chemically induced , Time FactorsABSTRACT
BACKGROUND: Infrequent but serious complications of transforaminal epidural steroid injection (TFESI) occur due to inadvertent intravascular injections. A few studies reported that the different needle types can influence on the occurrences of intravascular incidence in TFESI. This study prospectively evaluated whether short-bevel needle can reduce the incidences of intravascular injection of TFESI compared to long-bevel needles. METHODS: From March 2013 to December 2013, 239 consecutive patients were enrolled and received 249 fluoroscopically guided TFESI using the classic technique. Confirmation of intravascular spread was done initially with real time fluoroscopy and then with digital subtraction angiography method in a same patient. Injection technique for TFESI was the same for both short-bevel and long-bevel needle types. RESULTS: The incidences of intravascular injections with the long-bevel and short-bevel needles were 15.0% (21/140) and 9.2% (4/140), respectively. More than half of intravascular injections occurred simultaneously with epidural injections (8.0%, 20/249). There were no statistically significant differences between the long-bevel and the short-bevel needles in the rates of intravascular injections (P = 0.17). CONCLUSIONS: Short-bevel needles did not demonstrate any benefits in reducing the incidence of intravascular injection.
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Humans , Angiography, Digital Subtraction , Fluoroscopy , Incidence , Injections, Epidural , Needles , Prospective StudiesABSTRACT
BACKGROUND: Chronic low back pain (CLBP) has a significant effect on quality of life and imposes a great economical burden on society. In a number of studies, validated questionnaires had been given to CLBP patients to determine their health-associated quality of life, sleep disturbance, and psychological status. However, such outcome studies had not been performed previously in Korea. METHODS: We used self-report questionnaires to compare CLBP patients with an age- and sex-matched healthy control group. Between September 2012 and August 2013, we enrolled 47 patients who had CLBP for more than 3 months (group P) and 44 healthy age- and sex-matched controls (group C), who completed the following self-report questionnaires: 36-Item Short Form Health Survey (SF-36), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Oswestry Disability Index (ODI), and Pittsburgh Sleep Quality Index (PSQI). RESULTS: The scores from the ODI, BDI, and BAI were significantly higher in group P than in group C. The SF-36 scores were significantly lower in group P than in group C, suggesting lower quality of life in group P. The incidence of depression and anxiety was significantly higher in group P than in group C. However, neither the PSQI score nor the incidence of sleep disturbance was significantly different between the groups. CONCLUSIONS: Patients with CLBP showed considerable functional disability and significant impairment of psychological status with a low quality of life. Hence, it is important to evaluate CLBP patients to provide adequate psychological support.