Impact of coronavirus disease 2019 on patients with chronic pain: multicenter study in Korea

Background@#The coronavirus disease 2019 (COVID-19) pandemic has caused significant changes. This study aimed to investigate the impact of COVID-19 on patients with chronic pain. @*Methods@#Patients with chronic pain from 23 university hospitals in South Korea participated in this study. The anonymous survey questionnaire consisted of 25 questions regarding the following: demographic data, diagnosis, hospital visit frequency, exercise duration, time outside, sleep duration, weight change, nervousness and anxiety, depression, interest or pleasure, fatigue, daily life difficulties, and self-harm thoughts. Depression severity was evaluated using the Patient Health Questionnaire-9 (PHQ-9). Logistic regression analysis was used to investigate the relationship between increased pain and patient factors. @*Results@#A total of 914 patients completed the survey, 35.9% of whom had decreased their number of visits to the hospital, mostly due to COVID-19. The pain level of 200 patients has worsened since the COVID-19 outbreak, which was more prominent in complex regional pain syndrome (CRPS). Noticeable post-COVID-19 changes such as exercise duration, time spent outside, sleep patterns, mood, and weight affected patients with chronic pain. Depression severity was more significant in patients with CRPS. The total PHQ-9 average score of patients with CRPS was 15.5, corresponding to major depressive orders. The patients’ decreased exercise duration, decreased sleep duration, and increased depression were significantly associated with increased pain. @*Conclusions@#COVID-19 has caused several changes in patients with chronic pain.During the pandemic, decreased exercise and sleep duration and increased depression were associated with patients’ increasing pain.

Epidural hematoma treated by aspiration after transforaminal epidural steroid injection - A case report -

Background@#Spinal epidural hematoma is rare condition that can rapidly develop into severe neurologic deficits. The pathophysiology of this development remains unclear. There are several case reports of emergency hematoma evacuations after epidural steroid injection. Case: We report on two patients who developed acute, large amounts of epidural hematoma without neurological deficits after transforaminal epidural steroid injection. After fluoroscopy guided aspiration for epidural hematoma was performed, neurological defects did not progress and the hematoma was shown to be absorbed on magnetic resonance imaging. @*Conclusions@#These reports are believed to be the first of treating epidural hematoma occurring after transforaminal epidural steroid injection through non-surgical hematoma aspiration. If large amounts of epidural hematoma are not causing neurological issues, it can be aspirated until it is absorbed.

Multicenter survey of symptoms, work life, economic status, and quality of life of complex regional pain syndrome patients

Background@#Complex regional pain syndrome (CRPS) is an intractable pain disease with various symptoms. Here, we investigated the disease status, work life, sleep problems, medical insurance, economic status, psychological problems, and quality of life (QOL) of CRPS patients. @*Methods@#CRPS patients from 37 university hospitals in South Korea were surveyed.The survey questionnaire consisted of 24 questions on the following aspects of CRPS patients: sex, age, occupation, cause of injury, activities of daily living (ADL), pain severity, sleep disturbance, level of education, economic status, therapeutic effect, and suicidal ideation. Additionally, the abbreviated World Health Organization Quality of Life (WHOQOL-BREF) questionnaire, consisting of 26 questions, was used to identify the status of QOL. @*Results@#A total of 251 patients completed the questionnaire. According to the survey, 54.2% patients could not perform ADL on their own. Over the previous week, the mean pain score was 7.15 ± 1.78 (out of a total of 10 points); 92.1% of patients had sleep disorders and 80.5% had suicidal ideation, with most patients suffering from psychological problems. The average for each domain of WHOQOL-BREF was as follows: 21.74 ± 14.77 for physical, 25.22 ± 17.66 for psychological, 32.02 ± 22.36 for social relationship, and 30.69 ± 15.83 for environmental (out of a total of 100 points each). Occupation, ADL, sleep time, therapeutic effect, and suicidal ideation were statistically correlated with multiple domains. @*Conclusions@#Most patients had moderate to severe pain, economic problems, limitations of their ADL, sleep problems, psychological problems, and a low QOL score.

Epidural hematoma treated by aspiration after transforaminal epidural steroid injection - A case report -

Background@#Spinal epidural hematoma is rare condition that can rapidly develop into severe neurologic deficits. The pathophysiology of this development remains unclear. There are several case reports of emergency hematoma evacuations after epidural steroid injection. Case: We report on two patients who developed acute, large amounts of epidural hematoma without neurological deficits after transforaminal epidural steroid injection. After fluoroscopy guided aspiration for epidural hematoma was performed, neurological defects did not progress and the hematoma was shown to be absorbed on magnetic resonance imaging. @*Conclusions@#These reports are believed to be the first of treating epidural hematoma occurring after transforaminal epidural steroid injection through non-surgical hematoma aspiration. If large amounts of epidural hematoma are not causing neurological issues, it can be aspirated until it is absorbed.

Multicenter survey of symptoms, work life, economic status, and quality of life of complex regional pain syndrome patients

Background@#Complex regional pain syndrome (CRPS) is an intractable pain disease with various symptoms. Here, we investigated the disease status, work life, sleep problems, medical insurance, economic status, psychological problems, and quality of life (QOL) of CRPS patients. @*Methods@#CRPS patients from 37 university hospitals in South Korea were surveyed.The survey questionnaire consisted of 24 questions on the following aspects of CRPS patients: sex, age, occupation, cause of injury, activities of daily living (ADL), pain severity, sleep disturbance, level of education, economic status, therapeutic effect, and suicidal ideation. Additionally, the abbreviated World Health Organization Quality of Life (WHOQOL-BREF) questionnaire, consisting of 26 questions, was used to identify the status of QOL. @*Results@#A total of 251 patients completed the questionnaire. According to the survey, 54.2% patients could not perform ADL on their own. Over the previous week, the mean pain score was 7.15 ± 1.78 (out of a total of 10 points); 92.1% of patients had sleep disorders and 80.5% had suicidal ideation, with most patients suffering from psychological problems. The average for each domain of WHOQOL-BREF was as follows: 21.74 ± 14.77 for physical, 25.22 ± 17.66 for psychological, 32.02 ± 22.36 for social relationship, and 30.69 ± 15.83 for environmental (out of a total of 100 points each). Occupation, ADL, sleep time, therapeutic effect, and suicidal ideation were statistically correlated with multiple domains. @*Conclusions@#Most patients had moderate to severe pain, economic problems, limitations of their ADL, sleep problems, psychological problems, and a low QOL score.

Patients’ perception about opioids and addiction in South Korea

Background@#Chronic pain affects approximately 22% of the world’s population. Opioids can be useful in chronic pain management. However, some patients have negative perception of opioids. The purpose of this research was to evaluate patients’ perception about opioids and investigate problems associated with prescribing and taking opioids in South Korea. @*Methods@#Patients who visited a pain clinic in 14 university hospitals of South Korea from September through October 2018 were asked to complete anonymous questionnaires about taking opioids. @*Results@#Of the 368 patients that were surveyed (female 53.3%, male 46.7%), 56.8% were prescribed opioids. In the opioid group, 92.8% patients had heard of opioids from their doctor and 72.6% of them had a positive perception about opioids. The side effects associated with opioid use were constipation (35.4%), dizziness (24.6%), nausea and vomiting (17.4%), dysuria (6.2%), and addiction (2.0%). In the no opioid group, the primary sources of information about opioids were doctors (49.2%), mass media (30.8%), and the internet (16.2%). The main reasons why 39.0% patients did not take opioids were fear of addiction (57.7%) and side effects (38.5%). There were 71.5% and 60.9% patients in the opioid and no opioid group, respectively, who wished to take opioids when their numeric rating scale pain score was ≥ 7. @*Conclusions@#Perception of opioids among patients who take them was either neutral or positive. However, 39.0% patients who have not been prescribed opioids did not want an opioid prescription, citing fear of addiction and side effects as the primary reasons.

Painless cervical motor radiculopathy relieved by cervical epidural steroid injection: A case report

A 15-year-old male patient presented with a slow progression of painless right shoulder weakness over the previous six weeks. The magnetic resonance imaging revealed right C4–5 foraminal stenosis caused by right foraminal disc protrusion. The needle electromyography and nerve conduction studies revealed acute C5 and/or C6 radiculopathy. Instead of the initial surgical management modalities, we performed a cervical epidural steroid injection at the C4–5 level. From the day after the patient received the cervical epidural steroid injection, his right shoulder motor weakness improved progressively. Two weeks after the procedure, his right shoulder motor function had fully recovered.

A survey of patients’ perspectives of steroid injection (ppyeojusa) in Korea

BACKGROUND: Steroid injections are commonly used in pain clinics to relieve pain and treat inflammation. In Korea, these steroid injections are well known as ‘ppyeojusa’, which means to inject into the bone in Korean. Some patients often have a negative perception of this treatment method due to inaccurate information about the treatment and side effects of steroids. The purpose of this study is to investigate patients’ perception and knowledge of ppyeojusa. METHODS: A questionnaire about ppyeojusa was completed by patients who visited one of the pain clinics in nine university hospitals, from August 1 to September 10, 2017. RESULTS: Three-hundred seventy-four patients completed the survey. Eighty-five percent of patients had had ppyeojusa, and 74% of the respondents had heard of ppyeojusa from the mass media, friends or relatives. Only 39% of the patients answered that this injection was safe without side effects if properly spaced. Of the patients surveyed, 21% responded that ppyeojusa are “injections into the bone”; while 15% responded that ppyeojusa are “terrible injections that melted ‘the bone if used a lot’”. Half of the patients did not know what the active constituent is in ppyeojusa. If steroid injections are advised by the pain specialists, 89% of the patients would consent. CONCLUSIONS: Most pain clinic patients have heard of ppyeojusa. Most patients obtained information about ppyeojusa from mass media, rather than their physicians. Therefore, it is likely that most patients have inaccurate knowledge.

Sufficient explanation of management affects patient satisfaction and the practice of post-treatment management in spinal pain, a multicenter study of 1007 patients

BACKGROUND: Spinal pain is most common symptom in pain clinic. In most cases, before the treatment of spinal pain, physician explains the patient's disease and treatment. We investigated patient's satisfaction and physician's explanation related to treatments in spinal pain patients by questionnaires. METHODS: Anonymous questionnaires about physician's explanation and patient's satisfaction in each treatment and post-treatment management were asked to individuals suffering from spinal pain. Patients who have spinal pain were participated in our survey of nationwide university hospitals in Korea. The relationships between patient's satisfaction and other factors were analyzed. RESULTS: Between June 2016 and August 2016, 1007 patients in 37 university hospitals completed the questionnaire. In the statistical analysis, patient's satisfaction of treatment increased when pain severity was low or received sufficient preceding explanation about nerve block and medication (P < 0.01). Sufficient explanation increased patient's necessity of a post-treatment management and patients' performance rate of post-treatment management (P < 0.01). CONCLUSIONS: These results show that sufficient explanation increased patients' satisfaction after nerve block and medication. Sufficient explanation also increased the practice of patients' post-treatment management.

Percutaneous bipolar radiofrequency T3 sympathicotomy in Raynaud's disease: A case report / 대한마취과학회지

A 54-year-old female was suffering from cold-induced Raynaud's attacks in her both hands with symptoms most severe in her left hand. As the patient did not respond to previous medical treatments and endoscopic thoracic sympathectomy, we performed percutaneous bipolar radiofrequency thoracic sympathicotomy at the left T3 vertebral level. After the procedure, the patient obtained a long duration of symptom relief over 3 years. Percutaneous bipolar radiofrequency T3 sympathicotomy is minimally invasive and effective technique by creating large continuous strip lesion.

Percutaneous aspiration of lumbar zygapophyseal joint synovial cyst under fluoroscopic guidance: A case report / 대한마취과학회지

A 51-year-old man with a 1-month history of lower back pain and radiating pain visited to our pain clinic. A magnetic resonance imaging (MRI) scan demonstrated a cyst like mass at the level of the L4-5 interspace and compression of the thecal sac and the nerve root on the right side. We performed percutaneous needle aspiration of the lumbar zygapophyseal joint synovial cyst under fluoroscopic guidance. The patient felt an immediate relief of symptoms after the aspiration, and had no signs or symptoms of recurrence at the follow-up 6 months later. No demonstrable lesion was found in the 6 months follow-up MRI.

Symptomatic epidural gas cyst treated with epidural block and percutaneous needle aspiration: A case report / 대한마취과학회지

A 68-year-old woman suffered from lower back and radiating pain on her right buttock and posterior calf. Axial magnetic resonance imaging showed a 7 x 7 mm nodular lesion (T1 and, T2 low signal intensity) at the epidural space between the L5-S1 level and computed tomography revealed it was an epidural gas cyst. The authors performed an epidural block and percutaneous needle aspiration of the epidural gas cyst. The patient showed almost complete resolution of symptoms one year later. The authors suggest that an epidural nerve block with needle aspiration of a gas cyst could be an alternative treatment option for patients with a symptomatic epidural gas cyst before surgery.

Bark Constituents from Mushroom-detoxified Rhus verniciflua Suppress Kainic Acid-induced Neuronal Cell Death in Mouse Hippocampus

Urushinol, a plant allergen, has significantly restricted the medical application of Rhus verniciflua, although it has been reported to possess a wide variety of biological activities such as anti-inflammatory, antioxidant, and anti-cancer actions. To reduce the urushinol content while maintaining the beneficial biological activities, mushroom-mediated fermentation of Rhus verniciflua was carried out and this method resulted in significantly attenuated allergenicity [1]. In the present study, to examine the neuroprotective properties of mushroom-fermented stem bark of Rhus verniciflua, two constituents were isolated from mushroom-fermented bark and their neuroprotective properties were examined in a mouse model of kainic acid (KA)-induced excitotoxicity. KA resulted in significant apoptotic neuronal cell death in the CA3 region of mouse hippocampus. However, seven daily administrations of RVH-1 or RVH-2 prior to KA injection significantly attenuated KA-induced pyramidal neuronal cell death in the CA3 region. Furthermore, pretreatment with RVH-1 and RVH-2 also suppressed KA-induced microglial activation in the mouse hippocampus. The present study demonstrates that RVH-1 and RVH-2 isolated from Rhus verniciflua and detoxified using mushroom species possess neuroprotective properties against KA-induced excitotoxicity. This leads to the possibility that detoxified Rhus verniciflua can be a valuable asset in herbal medicine.

Continuous infusion of two doses of remifentanil immediately after laparoscopic-assisted vaginal hysterectomy / 대한마취과학회지

BACKGROUND: We evaluated the effect and safety of the immediate postoperative continuous infusion of remifentanil at two doses in patients undergoing laparoscopic-assisted vaginal hysterectomy (LAVH) with alfentanil-based patient-controlled analgesia (PCA). METHODS: The study enrolled 50 ASA physical status 1 or 2 patients scheduled to undergo LAVH. Anesthesia was maintained with sevoflurane-remifentanil-air. At the last skin suture, the sevoflurane was discontinued, and patients were randomized to receive remifentanil 0.05 microgram/kg/min (group I) or 0.1 microgram/kg/min (group II). PCA was started at the time of eye opening and response to a verbal command. In the recovery room, we monitored the mean arterial blood pressure (MAP), heart rate (HR), respiratory rate (RR), SpO2, and bispectral index (BIS) at 5-minute intervals. Thirty minutes after starting PCA, the remifentanil was discontinued. Pain was assessed using a visual analog scale (0 = no pain; 100 = the worst possible pain) at 0, 5, 10, and 30 minutes after stopping the remifentanil infusion. RESULTS: The eye opening time, BIS, MAP, and HR did not differ significantly between the two groups, and pain scores were similar between the two groups. Respiratory depression (SpO2 < 90% or RR < 8/min) did not occur in group I but did occur in three patients in group II. CONCLUSIONS: Continuous remifentanil infusion (0.05 microgram/kg/min) immediately postoperatively with alfentanil-based PCA had a similar effect as a 0.1 microgram/kg/min infusion with respect to pain control without side effects. However, special attention must be given to respiratory depression.

Erratum: Continuous infusion of two doses of remifentanil immediately after laparoscopic-assisted vaginal hysterectomy (Korean J Anesthesiol 2010; 58(6): 537-541) / 대한마취과학회지

No abstract available.

Recurrent spinal myoclonus after two episodes of spinal anesthesia at a 1-year interval: A case report / 대한마취과학회지

Spinal myoclonus is an unusual, self-limiting, adverse event that may occur during spinal anesthesia. The exact cause and underlying biochemical mechanism of spinal myoclonus remain unclear. A few cases of spinal myoclonus have been reported after administration of intrathecal bupivacaine. We report a case in which spinal myoclonus recurred after two episodes of spinal anesthesia with bupivacaine at a 1-year interval in a 35-year-old woman. The myoclonus was acute and transient. The patient recovered completely, with no neurologic sequelae.

Spontaneous Retropharyngeal Hematoma: A Case Report

Spontaneous retropharyngeal hematoma is rare and difficult to diagnosis early. A 23-year-old male spontaneously developed acute onset of neck pain, limitation of neck motion, and mild dysphagia. Magnetic resonance imaging demonstrated blood products in prevertebral space from C2 to C4, suggesting a diagnosis of retropharyngeal hematoma. We report a rare case of spontaneous retropharyngeal hematoma causing neck pain.

The effect of intraoperative remifentanil infusion on analgesic requirements after laparoscopic cholecystectomy / 대한마취과학회지

BACKGROUND: This study was designed to evaluate the effect of intraoperative remifentanil infusion on postoperative analgesics requirements after laparoscopic cholecystectomy. METHODS: One hundred adult patients scheduled for elective laparoscopic cholecystectomy were enrolled. Patients were randomly allocated to 2 groups to receive sevoflurane with remifentanil infusion (Group R) or not (group C). Sevoflurane concentration and remifentanil dose were adjusted to maintain BIS 40-60 and blood pressure within 20% of the preoperative value, respectively. We assessed the pain intensity by using the four-point verbal rating scale (VRS) (0 = no pain. 1 = slight pain, 2 = moderate pain, 3 = intense or severe pain) at 15 min intervals for 1 hour in recovery room and then at 3-h intervals for 24 h in surgical ward. The analgesic medication was given when VRS score was > or =2 or patients requested it. RESULTS: There were no differences between the two groups with respect to the requirements for postoperative analgesics in recovery room and surgical ward. CONCLUSIONS: Continuous remifentanil infusion (0.09 +/- 0.05 ug/kg/min) during laparoscopic cholecystectomy does not cause hyperalgesia and more analgesic requirements.

A comparative study on the analgesic effect of continuous intraarticular infusion with ropivacaine, ropivacaine/fentanyl and ropivacaine/fentanyl/ketorolac after arthroscopic shoulder surgery / 대한마취과학회지

BACKGROUND: Arthroscopic shoulder surgery can result in severe postoperative pain. A variety of methods have been used to control pain in postoperative period and the results are variable. The purpose of this study was to compare the relative analgesic efficacies of the postoperative intraarticular infusion of ropivacaine, ropivacaine/fentanyl, and ropivacaine/fentanyl/ketorolac after arthroscopic shoulder surgery. METHODS: Thirty patients undergoing arthroscopic shoulder surgery under general anesthesia were randomly assigned to three groups. At the end of surgery, 0.5% ropivacaine 20 ml was infused into the articular space and a continuous infusion catheter was inserted into intraarticular operated site. After surgery, continuous infusion of 0.5% ropivacaine 100 ml (Group 1, n = 10), 0.5% ropivacaine 100 ml including fentanyl 10 microg/kg (Group 2, n = 10), or 0.5% ropivacaine 100 ml including fentanyl 10 microgram/kg and ketorolac 150 mg (Group 3, n = 10) was started through catheter at rate of 2 ml/hr with bolus dose of 0.5 ml with a lock out time of 15 minutes for 2 days. The level of pain was assessed using a visual analogue scale (VAS) postoperative 2, 6, 12, 24 and 48 hours and the amounts of supplemental analgesics were recorded. RESULTS: The VAS was significantly lower after 2, 6, 12 hours in Group 2 than in Group 1. In Group 3, the VAS was significantly lower all hours than in the other two groups. CONCLUSIONS: The combination of fentanyl and ketorolac with ropivacaine did provide better postoperative analgesia than the other groups after arthroscopic shoulder surgery.

Melatonin Induces Akt Phosphorylation through Melatonin Receptor- and PI3K-Dependent Pathways in Primary Astrocytes

Melatonin has been reported to protect neurons from a variety of neurotoxicity. However, the underlying mechanism by which melatonin exerts its neuroprotective property has not yet been clearly understood. We previously demonstrated that melatonin protected kainic acid-induced neuronal cell death in mouse hippocampus, accompanied by sustained activation of Akt, a critical mediator of neuronal survival. To further elucidate the neuroprotective action of melatonin, we examined in the present study the causal mechanism how Akt signaling pathway is regulated by melatonin in a rat primary astrocyte culture model. Melatonin resulted in increased astrocytic Akt phosphorylation, which was significantly decreased with wortmannin, a specific inhibitor of PI3K, suggesting that activation of Akt by melatonin is mediated through the PI3K-Akt signaling pathway. Furthermore, increased Akt activation was also significantly decreased with luzindole, a non-selective melatonin receptor antagonist. As downstream signaling pathway of Akt activation, increased levels of CREB phoshorylation and GDNF expression were observed, which were also attenuated with wortmannin and luzindole. These results strongly suggest that melatonin exerts its neuroprotective property in astrocytes through the activation of plasma membrane receptors and then PI3K-Akt signaling pathway.