Intralesional Injection of Ketamine in Postburn Neuropathic Pain: Two cases report / 대한마취과학회지

The scarring process of burns can be accompanied by pain and/or paresthetic sensation which may persist after completion of scar formation. Once the wound is healed, it is possible that paresthetic and/or painful sensations persist as a result of abnormalities in the newly regenerated nerve endings or because of deficient reinnervation of the scarred tissue, that may give rise to abnormal inputs. Existence of glutamate receptors in peripheral nerves innervating normal and inflamed skin has been well addressed. Therefore we tried ketamine in postburn neuropathic pain expecting the antagonistic effect as a NMDA antagonist. We experienced two postburn pain patients who were successfully managed without any significant sign of side effects by an intralesional injection of ketamine and bupivacaine.

The Efficacy of Radiofrequency Neurotomy of the Ramus Communicans Nerve for Intractable Chronic Discogenic Pain / 대한마취과학회지

BACKGROUND: Chronic discogenic pain is commonly intractable to various conservative treatments and anatomic correction through operation. Nowadays, a radiofrequency thermocoagualation technique applying the pathophysiologic mechanism that cause discogenic pain and the pathways of transmission of discogenic pain have been successfully tried. This study was performed to evaluate the efficacy of radiofrequecy thermocoagulation of the ramus communicans nerve in patients who suffered from intractable discogenic pain even after intradiscal electrothermal therapy. METHODS: The authors evaluated 13 cases in which radiofrequency thermocoagulation of the ramus communicans nerve was used for patients suffering from chronic discogenic pain even after intradiscal electrothermotherapy. Ten weeks after the procedure, we compared VAS scores of the pre- procedure and post-procedure state. RESULTS: Fifty-four percent of patients had an excellent decrease in the VAS score (VAS < 3). One patient complained of a mild motor weakness of the lower extremity but recovered completely by postoperative day 26. CONCLUSIONS: In the cases of intractable chronic discogenic pain, it is valuable to perform a rhizotomy of the ramus communicans nerve with radiofrequency.

Psoas Abscess and Discitis after Intradiscal Nucleoplasty / 대한마취과학회지

Nucleoplasty is a newly developed minimal invasive spinal surgery using a coblation technique. The complications of this new spinal surgery are trauma to retroperitoneal organs involving the kidney, discitis, menigitis, and epidural abscess. Recently, postoperative psoas abscess and discitis appears to have increased in frequency, in part because procedures performed on the spine have been more frequent and improvements in diagnostic capabilities have been made. Antibiotic therapy, abscess drainage, or a surgical procedure is required to treat discitis and psoas abscess. We encountered one case of postoperative psoas abscess and discitis after a nucleoplasty that had not responded to antibiotics but which responded successfully to treatment by spinal surgery.

Radiofrequency Rhizotomy of the Sacroiliac Joint with S2 Ganglionotomy / 대한마취과학회지

The sacroiliac joint possesses all the characteristics of a true joint and can produce symptoms quite similar to facet joint abnormalities. Pain originating from the sacroiliac joint usually causes buttock and referral pain: hip, groin, anterior thigh and calf. The second sacral nerve level contributes heavily to the innervation of the sacroiliac joint and a second sacral nerve ganglionotomy can be an important adjunct to sacroiliac joint rhizotomy. The fact that capsule and ligaments contain nociceptors suggests that the sacroiliac joint is a possible source of low back pain and also plays a role in somatic referred pain. The patient usually experiences buttock discomfort and referred posterior thigh pain following a sacroiliac joint rhizotomy. We can lessen the residual symptoms after a sacroiliac joint rhizotomy by applying a second sacral nerve ganglionotomy. We experienced a patient with the sacroiliac joint originated pain who was successfully treated with sacroiliac joint rhizotomy and second sacral ganglionotomy without any residual sequelae and tolerates well after 4 months.

The Change of Cervical Epidural Pressure according to Infused Normal Saline in Epiduroscopy / 대한마취과학회지

BACKGROUND: Normal saline is used to dilate the epidural space to provide a focal length for the lens and to wash the epidural adhesive neural tissue in an epiduroscopy. Saline infusion into the epidural space during an epiduroscopy might affect pressure-volume compliance of the CSF which has a high compliance; therefore, it might cause neurological sequelaes. The purpose of this study was to investigate the change of cervical epidural pressure according to the volume of infused saline during epiduroscopy. METHODS: Twenty-one patients who complained of low back pain with radiculopathy that did not respond to conservative pain management and underwent an epiduroscopy were included in this study. The epidural catheter was placed between the 5th and 6th cervical epidural space under fluoroscopic guidance and cervical epidural pressure was monitored. Next, an epiduroscopy via caudal route was performed and cervical epidural pressure was measured after each 10 ml of infused saline. We also checked neurological sequelaes that might be resulted from increased epidural pressure. RESULTS: All patients except two showed no difference in basal cervical epidural pressure. One patient who had failed back surgery syndrome complained of a headache and dizziness when the cervical epidural pressure was rapidly increased from 90 mmHg to 5 mmHg following an infusion of 27 ml of saline. One patient who had a herniated disc showed posterior nuchal pain and stiffness following an infusion of 48 ml of saline despite a stable cervical epidural pressure (range: 0 - 3 mmHg) during the procedure. There were no residual neurological sequelaes in this study. CONCLUSIONS: There are variable patterns in cervical epidural pressure according to the volume of infused saline. Close monitoring of intracranial pressure is therefore neccessary during an epiduroscopy.

Intradiscal Electrothermal Annuloplasty in Chronic Discogenic Low Back Pain / 대한마취과학회지

Chronic discogenic low back pain remains a difficult treatment challenge. Also, Internal disc derangement in the lumbar spine is a common yet difficult clinical condition to treat. The reported prevalence of chronic low back pain due to intrinsic disc mediated pain is at least 40%. Internal disc derangement has characteristics such as degeneration of the collagen of the disc annulus, fissures, global disc degeneration, and herniation with or without root compression. The common treatment for chronic discogenic low back pain has been conservative, including physical therapy and pharmacological management but the effectiveness remians controversial. Surgical fusion offers modest results at best, but often fails, and is associated with complications and postoperative continued pain. The intradiscal electrothermal annuloplasty has become known as a safe and effective treatment for patients suffering from discogenic pain and offers the advantage of potentially repairing the damaged disc while maintaining normal disc function. We applied a navigable catheter with a temperature controlled thermal resistive coil, deployed intradiscally through a percutaneous extrapedicular approach under two plane fluoroscopic guidance in chronic low back patients. The authors experienced two cases of chronic discogenic pain that had failed to respond to any kind of conservative treatment but which was successfully relieved by the intradiscal electrothermal annuloplasty.

Percutaneous Vertebroplasty in a Patient with an Osteolytic Spinal Metastatic Tumor: A case report / 대한마취과학회지

Percutaneous vertebroplasty was first introduced in 1984. It allows reduction in pain and strengthening of bone. Main indications for this procedure are an osteoporotic compression fracture, hemangioma or a malignant spine tumor. Metastases to the vertebrae are not rare and often painful. Radiation therapy results in delayed (10 14 days) pain relief and minimal bone strengthening. Surgical procedures require significant postoperative recovery and have associated morbidity and mortality. However, a percutaneous vertebroplasty in patients with an osteolytic spinal metastatic tumor results in quick (1 3 days) disappearance of pain, vertebral consolidation, and spinal stability. We encontered a patient with severe back pain due to an osteolytic spinal metastatic tumor that had not responded to radiation therapy but which responded successfully to pain relief by a percutaneous vertebroplasty.

Application of Polarized Light Irradiation to Meralgia Paresthetica / 대한마취과학회지

Meralgia Paresthetica is an uncommon and rare entrapment neuropathy involving the lateral femoral cutaneous nerve of the thigh. A lateral femoral cutaneous block has been used in order to alleviate pain and paresthesia in the affected area, but this procedure seems likely to be invasive or involve side effects. We performed a polarized light irradiation (SUPER LIZER HA-550(R), Tokyo Iken Co., Ltd, Japan) for a patient with Meralgia Paresthetica after the patient gave her informed consent. An entry was chosen 2.5 cm below and medial to the anterior superior iliac spine, and irradiation was applied with a cycle of 1 second on and 3 seconds off at 80% output for 8 minutes with 1200 mW output using a type-B probe a sum of eight times. Consequently, mild or moderate pain alleviation was obtained. When compared to pre-irradiation, the patient's symptoms were alleviated and satisfaction was high.

Neural Blockade under the Hypnotic Sedation Using Target Controlled Infusion of Propofol / 대한마취과학회지

BACKGROUND: The use of sedative and analgesic adjuncts during local and regional anesthesia can enhance patient comfort and improve operative conditions. Because propofol has well-known rapid recovery characterized by "clear-headedness", its use intraoperatively may result in less postoperative sedation and thus shorten the time for discharge from the hospital. The purpose of this study was designed to evaluate the patient's satisfaction of hypnotic neural blockade using target controlled infusion (TCI) of propofol. METHODS: Sixty-two patients scheduled to undergo elective neural blockade in the operating room were selected for this study. They had taken previous neural blockade in the awakening state. Without premedication, they arrived at the operating room via pain clinic. After proper positioning, vital signs, pulse oximetry and respiratory rate were monitored. TCI of propofol was started at a target concentration of 3.0 microgram/ml and an induction time of 3 minutes. We regarded loss of hand grasping power as induction of hypnosis. Subsequently, target concentration was adjusted to a range of 0.8+/-1.6 times the effector site concentration at induction. Propofol infusion was stopped when the procedure was finished and the patients were transported to the recovery room and discharged. The satisfaction of patients concerning hypnotic neural blockade were evaluated by a six point numerical rating scale (6:best-1:worst) RESULTS: Patient withdrawal movement during local anesthetic infiltration occured in 17 patients. Recovery time was 4.7 +/-3.0 min (mean +/- S.D.). Patient's satisfaction for hypnotic neural blockade was 5 [3-6] (median [range]). CONCLUSION: Patient's satisfaction for hypnotic neural blockade was high. TCI of propofol serves as a safe sedation model during neural blockade without any residual sequelae.

Effect of Fentanyl on the TNF-alpha and IL-1beta Level during Global Ischemia/reperfusion in Rats / 대한마취과학회지

BACKGROUND: To reduce surgical stress, fentanyl is frequently used for neurosurgical procedure where focal and/or global ischemia may occur. However, the effect of fentanyl on the cytokine level during ischemia/reperfusion is still uncertain. The goal of this study was to evaluate the effect of fentanyl infusion on the proinflammatory cytokine, TNF-alpha and IL-1beta, levels during global cerebral ischemia/reperfusion (I/R) in rats using the intracerebral microdialysis technique. METHODS: Forty male S-D rats weighing 280 320 g were randomly assigned to four groups. Group 1: no fentanyl infusion and only I/R, Group 2: 1.5 ng/ml of fentanyl infusion during I/R, Group 3: 3.0 ng/ml of fentanyl infusion during I/R (n = 10 in each group). Rats were anesthetized with a intraperitoneal injection of pentobarbital (50 mg/kg), intubated and ventilated with room air using an animal ventilator. Two femoral arteries and one femoral vein were cannulated with PE-50 tubing for hemorrhagic hypotension, drug infusion and hydration. Both carotid arteries were dissected and a sling was placed for brain ischemia. The head was fixed on a stereotaxic device and a small burrhole was made for probe insertion. A CMA-12 probe was inserted into the left hippocampal CA-1 region according to the guidelines. Artificial CSF was run from the inserted microdialysis probe and infused with or without fentanyl at 3 microliter/min using a microinjection syringe pump during I/R. Ischemia was induced by clamping the carotid arteries while hemorrhagic hypotension for 17 min via the femoral artery and reperfusion were accomplished by the unclamping of the sling and reinfusing the blood via the femoral artery. Nasopharyngeal and rectal temperatures were maintained within the normal range during the whole procedure. After 2 hours of stabilization, the microdialysate was collected every 17 min just before (control) and during I/R and stored at 80oC until analysis using HPLC. RESULTS: During global I/R, TNF-alpha and IL-1 beta significantly increased at reperfusion (R5) compared to the control value (P < 0.05). However, in both cases of fentanyl infusion, TNF-alpha and IL-1 beta did not increase compared to the control value. CONCLUSIONS: Fentanyl inhibited the increase of proinflammatory cytokine TNF-alpha and IL-1 beta levels during global cerebral ischemia/reperfusion in rats.

The Effect of Induction Mode on Various Parameters and Vital Signs during Anesthesia Induction with Propofol Using a Target Contolled Infusion / 대한마취과학회지

BACKGROUND: Anesthesia induction time is related to speed of injection, injected volume, and Keo. In the case of target controlled infusion, induction time can be controlled by adjusting the induction time mode. The aim of this study was to estimate the effect of induction time mode on variable parameters and vital signs during anesthesia induction with propofol using a target controlled infusion (TCI). METHODS: Sixty unpremedicated adult patients (ASA class I or II, 18 55 yrs) scheduled for elective surgery were randomly allocated to four groups according to induction mode. Group 1 was assigned a flash induction mode, and groups 2, 3 and 4 were assigned 2, 3 and 4min respectively. The end point of anesthesia induction was loss of eyelash reflex. Various parameters including induction time, infused volume, current/effect concentration at induction, and vital signs were compared. RESULTS: As the induction time mode was prolonged, induction time was delayed, but there was no difference in infused volume. Also, the current concentration decreased gradually, but the effect concentration did not show any difference. The vital signs were more stable in groups 3 and 4 compared with groups 1 and 2. CONCLUSIONS: For anesthesia induction, a rapid induction mode showed more rapid induction and low current concentration, but vital signs were relatively unstable and the effect concentration at induction showed no difference. For critically ill patients or patients with unstable hemodynamics, a more gradual induction mode for anesthesia induction in propofol TCI is recommended.

Effects of Nitric Oxide Synthase Inhibition on Hydroxyl Radical Production during Global Cerebral Ischemia/Reperfusion in Rats / 대한마취과학회지

BACKGROUND: Free radical-mediated oxidative damage has been implicated in ischemic brain injury. There are also increasing evidences that nitric oxide is involved in the mechanisms of cerebral ischemia. To elucidate the effect of nitric oxide synthesis inhibition on the hydroxyl radical formation, we used a method based on the chemical trapping of hydroxyl radical in the form of the stable adducts 2,3-DHBA following salicylate adminstration. METHODS: Sprague-Dawley rats were subjected to 15 min of global cerebral ischemia by both carotid artery occlusion plus systemic hemorrhagic hypotension (35 mmHg). Artificial CSF including salicylate (5 mM) was continuously infused through a microdiaysis probe implanted in the left hippocampus CA1. Hippocampal extracellular fluid was sampled at regular intervals before, during, and after ischemia. The levels of 2,3-DHBA were assayed by HPLC with electrochemical detection during 15 minutes of ischemia and reperfusion period. RESULTS: Cerebral blood flow was reduced to 5% level of control in ischemic period, but increased 3 or 4 times in early phase of reperfusion period, and returned to normal 50 to 60 minutes after the cessation of ischemia. Inhibition of NOS by L-NAME did not prevent ischemia-induced 2,3-DHBA elevation, but increased its level during reperfusion. This increase in 2,3-DHBA could be reversed by L-arginine. The elevated 2,3-DHBA after IR in L-NAME treated rats was not due to either changes in CBF or local blood brain barrier permeability. CONCLUSIONS: The above results indicate NO protects brain from damages by hydroxyl radical, at least less than one hour after initiation of reperfusion.

Effects of Variable Infusion Rates of Propofol on Arterial Baroreflex Sensitivity / 대한마취과학회지

BACKGROUND: Induction of anesthesia with propofol caused a decrease in arterial blood pressure and systemic vascular resistance. This effects of propofol on the circulation can be more clarified by studying cardiovascular control mechanism such as baroreflex sensitivity during variable rate infusion of propofol. METHODS: The effects of three infusion rates of propofol (3, 6, 12 mg/kg/hr) to supplement 66% nitrous oxide in oxygen anesthesia on baroreflex sensitivity were studied and compared with awake value in 80 ASA I or II patients (20-55 years old, n=20 in each group). Baroreflex control of heat rate was studied by pertubing the patients' arterial pressure with 100 microgram of phenylephrine in each three infusion rates of propofol which was maintained at least 30 min without any surgical stimulation. RESULTS: Baroreflex slope representing baroreflex sensitivity among three infusion rates of propofol did not show any significant differences. The slope of each infusion rate was 8.4+/-0.7 at awake, 8.9+/- 1.7 at 3 mg/kg/hr, 8.0+/-1.3 at 6 mg/kg/hr, 7.2+/-1.0 at 12 mg/kg/hr, respectively. But, resetting of the reflex occured at low heart rates. CONCLUSIONS: Usual propofol-nitrous oxide-oxygen anesthesia was not associated with impairment of baroreflex sensitivity, but showed reflex resetting at low heart rates.

Blind Tracheal Intubation through Laryngeal Mask Airway is Dependent on the Types of Tracheal Tube or Introducer? / 대한마취과학회지

BACKGROUND: Tracheal tubes are different on the flexibility, material and bevel angle according to the manufacturers. These may affect the success rate of blind tracheal intubation through laryngeal mask airway (LMA). In addition, using straight-tip exchanger or curved-tip introducer, we tried to compare the success rate of tracheal tube insertion through LMA. METHODS: After receiving informed consents, 30 patients were enrolled. Blind tracheal intubation was tried with reinforced tracheal tube (M group), or one of two kinds of conventional tracheal tube (P group and B group). Tracheal tube was selected in random order and advanced into the trachea through LMA one by one. If all the three attempts was unsuccessful, we considered the blind tracheal intubation through LMA a failure. We also compared the success rate of blind tracheal insertion through LMA using straight-tip exchanger or curved-tip introducer. The first trial was performed on the neutral head position. The exchanger or introducer was rotated during the second trial. If the second attempt was unsuccessful, the exchanger- or intubator-guided intubation was performed on the sniffing position and, as a last and fourth trial, while mandible was being elevated with hands. RESULTS: Success rate of blind tracheal intubation through LMA was 50% (15/50) in group P and 36.7% (11/30) in group M, 33.3% (10/30) in group B (P=0.05). By using curved-tip introducer, intubation through LMA was successful in 80% (16/20), while it was successful only in 35% (7/20) via straight-tip exchanger. CONCLUSION: Blind tracheal intubation through LMA was dependent on the types of tracheal tube. Also, curved tip introducer may be a more valuable aid in performing blind tracheal intubation through LMA. Its use seems to be better technique than directly inserting tracheal tube through LMA.

The Application of Cryoneurolysis in Patients with Intercostal Neuralgia: A Case report / 대한마취과학회지

Cryoneurolysis to peripheral neuralgia has been tried in selected postoperative pain and chronic pain patient; post-thoracotomy pain, post-herniorrhapy pain and trigeminal neuralgia. Here we report first two cases those were effectively controlled by percutaneous cryoneurolysis. Intercostal neuralgia was confirmed by intercostal nerve block with 1% mepivacaine and then we applied cryoneurolysis. Those pains could be relieved for more than two or three months. We suggest that cryoneurolysis can be an useful, simple and safe neurolytic method to intercostal neuralgia in outpatient pain clinic.

Effect of Propranolol on Changes in Sereum K+ Induced by brachial Plexus Block / 대한마취과학회지

When we perform the regional blockade, we usually addit epinephrine to the local anesthetics for the purpose of lengthening anesthesia time and preventing the systemic reaction of local anesthetics. In that situation, epinephrine produces decrease in serum potassium concentration and changes in electrocardiogram. We investigated the influence of propranolol on changes in serum potassium and ECG induced by brachial plexus block with 30ml of mixture of local anesthetic (2% lidocaine +0.5% bupivacaine) which contains 1:200,000 epinephrine. The subjects classified as following two groups: Group l : Brachial plexus block with mixture of local anesthetic and 1:200,000 epinephrine(n=20). Group ll : Pretreated with 2 mg of propranolol(slow intravenous injection for 5 min. before block) and performed as Group l. The results were as follows: 1) Group l showed statistically significant decrease of serum potassium after 10, 20, 30 min. of block(p<0.05). Group ll did not show any significant change. 2) Group l showed progressive flattening of T wave and appearance of U wave (25% of pts) in ECG as the serum-potassium decreased progressively, but Group ll did not sho any significant change. 3) The epinephrine mediated beta-adrenergic stimulation may be considered as the cause of epinephrine induced hypokalemia during brachial plexus block.