Comparison of Lidocaine and Bupivacaine in Lumbar Medial Branch Block

STUDY DESIGN: This is a retrospective clinical study. OBJECTIVES: To compare the efficacy of lidocaine and bupivacaine for the ultrasound-guided lumbar medial branch block in chronic low back pain. SUMMARY OF LITERATURE REVIEW: There is no study for comparison of the efficacy between lidocaine and bupivacaine for the medial branch block. MATERIALS AND METHODS: From August 2011 to May 2013, 186 patients were assigned 0.5% lidocaine(n=136) or 0.25% bupivacaine(n=45) for the ultrasound-guided lumbar medial branch block. All procedures have been performed by the same operator, and 23G, 10 cm needle was placed and drug was injected under ultrasound guide. To target medial branches from lumbar spinal nerve, the groove at the root of transverse process and the base of superior articular process has been identified on transverse scan. Patients were evaluated by pre- and post-interventional(1 hour) Visual Analog Scale and analyzed statistically. RESULTS: Reduction of VAS score in bupivacaine group is significantly greater than that in lidocaine group and post-interventional VAS score in bupivacaine group is significantly lower than that in lidocaine group through analysis of covariance test with adjusted pre-interventional VAS score. In multivariate analysis, while age, sex and treatment level were not significant factors, pre-interventional VAS score and the kind of drug were significant factors. Severe pain before treatment and bupivacaine was indicator of better result. Bupivacaine group reduced pain score in the VAS 2.285 more than lidocaine group with adjustment with other factors. CONCLUSIONS: Bupivacaine is more effective than lidocaine in the reduction of pain after ultrasound-guided lumbar medial branch blocks in posterior facet joint syndrome.

Effect of Ultrasound-guided Lumbar Medial Branch Block in Chronic Low Back Pain / 대한정형외과연구학회지

PURPOSE: To examine the use of ultrasound as an alternative imaging technique to block lumbar medial branches in chronic low back pain. MATERIALS AND METHODS: From August 2011 to September 2012, 27 patients with lumbar facet joint syndrome diagnosed by strict inclusion criteria among chronic low back pain patients have undergone medial branch block. All procedures have been performed by the same operator, and 23G, 10cm needle was placed and 0.5% lidocine was injected under ultrasound guide. To target medial branches from L1 to L5, the groove at the root of transverse process and the base of superior articular process has been identified on transverse scan. Patients were followed up by Visual Analog Scale and Oswestry Disability Index at 1 week after medial branch block. RESULTS: VAS showed that preprocedure pain(7.0+/-1.4; mean+/-SD) significantly decreased after block(1.8+/-1.6)(p=0.0000). ODI also showed that preprocedure score(30.3+/-6.4) significantly decreased(9.0+/-7.7)(p=0.0000). Analysis of patient-reported pain and functional scores measured with VAS and ODI showed definite improvements after ultrasound-guided medial branch block. There was one complication of dizziness and weakness in both lower extremities immediate after procedure. CONCLUSION: Ultrasound guidance offers a reliable alternative to fluoroscopy or computed tomography for lumbar medial branch blocks and can be safely performed without radiation exposure.

Effect of Ultrasound-guided Lumbar Medial Branch Block in Chronic Low Back Pain / 대한정형외과연구학회지

PURPOSE: To examine the use of ultrasound as an alternative imaging technique to block lumbar medial branches in chronic low back pain. MATERIALS AND METHODS: From August 2011 to September 2012, 27 patients with lumbar facet joint syndrome diagnosed by strict inclusion criteria among chronic low back pain patients have undergone medial branch block. All procedures have been performed by the same operator, and 23G, 10cm needle was placed and 0.5% lidocine was injected under ultrasound guide. To target medial branches from L1 to L5, the groove at the root of transverse process and the base of superior articular process has been identified on transverse scan. Patients were followed up by Visual Analog Scale and Oswestry Disability Index at 1 week after medial branch block. RESULTS: VAS showed that preprocedure pain(7.0+/-1.4; mean+/-SD) significantly decreased after block(1.8+/-1.6)(p=0.0000). ODI also showed that preprocedure score(30.3+/-6.4) significantly decreased(9.0+/-7.7)(p=0.0000). Analysis of patient-reported pain and functional scores measured with VAS and ODI showed definite improvements after ultrasound-guided medial branch block. There was one complication of dizziness and weakness in both lower extremities immediate after procedure. CONCLUSION: Ultrasound guidance offers a reliable alternative to fluoroscopy or computed tomography for lumbar medial branch blocks and can be safely performed without radiation exposure.

The Success Rate of Caudal Block Under Ultrasound Guidance and the Direction of the Needle in the Sacral Canal / 대한통증학회지

BACKGROUND: Caudal block is useful when anesthesia for surgery or treatment for chronic pain is needed, but this procedure has a failure rate of up to 25% even when it performed byan experienced physician. This high failure rate is usually due to improper needle placement. METHODS: After gaining approval of the ethics committee, 46 patients received caudal blocks under ultrasound guidance; these were performed after the anatomical structures in the sacral hiatus had been measured with ultrasound. All these procedures were performed by the same anesthesiologist. The position and direction of the needle were identified using fluoroscopy by injecting a radio-opaque contrast through the needle. The time taken from thelidocaine injection to verification of the needle was measured and the planned nerve block was then carried out. RESULTS: All cases of needle insertion into the sacral canal under ultrasound guidance were successful. The average duration of the procedure and the trial count were 134.1 +/- 10.1 seconds and 1.2 +/- 0.1, respectively. In 12 of the 46 cases (26%), the needle deviated either left or right in the sacral canal, so the direction of the needle had to be adjusted. The distance between two cornua, the depth of the sacral hiatus and the thickness and length of the sacrococcygeal ligament were 17.1 +/- 0.4, 3.9 +/- 0.3, 2.3 +/- 0.1 and 24.9 +/- 0.9 mm, respectively. CONCLUSIONS: Ultrasound guidance can increase the success rate of inserting a needle into the sacral canal. However, even when ultrasound is used, the needle can deviate either left or right in the sacral canal.

Spontaneous Intracranial Hypotension and Epidural Blood Patch: A case report / 대한마취과학회지

Spontaneous intracranial hypotension (SIH), a syndrome of low CSF pressure, occurs without preceeding events such as lumbar puncture, back trauma, an operative procedure, or medical illness. Postural headache, the most characteristic symptom, usually resolves spontaneously or with bed rest, hydration, and medication. Autologous epidural blood patch is an effective management of headache in SIH patients, and here we describe a one case successfully treated 5 times with an epidural blood patch. The patient had a cardinal feature of a postural headache, low CSF pressure, and showed CSF leakages on RI cisternography. The first three epidural blood patches improved the patient's headache markedly, but the headache recurred in one month. On her second RI cisternography, we found other CSF leakage sites. After a fifth epidural blood patch the patient became asymptomatic and remained so throughout 4 months of follow up. Epidural blood patches are considered the treatment of choice in SIH patients.

The Analgesic Interaction between Ketorolac and Morphine in Radiant Thermal Stimulation Rat / 대한통증학회지

BACKGROUND: Previous studies have suggested synergistic analgesic drug interactions between NSAIDs and opioids in neuropathic and inflammatory pain models. The aim of this study was to investigate the analgesic drug interaction between intraperitoneal (IP) ketorolac and morphine in radiant thermal stimulation rat. METHODS: Initially, we assessed the withdrawal latency time of the hindpaw to radiant thermal stimulation every 15 min for 1 hour and every 30 min for next 1 hour after IP normal saline 5 ml (control group). The latency time was changed into percent maximal possible effect (%MPE). Next, IP dose response curves were established for the %MPE of morphine (0.3, 1, 3, 10 mg/kg) and ketorolac (3, 10, 30 mg/kg) to obtain the ED50 for each agent. And we confirmed that the IP morphine effect was induced by opioid receptor through IP morphine followed by IP naloxone. At last, we injected three doses of IP ketorolac (3, 10, 30 mg/kg) mixed with one dose of morphine (2 mg/kg) for fixed dose analysis. RESULTS: IP morphine delayed the paw withdrawal latency time dose dependently, but not ketorolac. ED50 of IP morphine was 2.1 mg/kg. And the IP morphine effect was reversed to control level by IP naloxone. IP ketorolac + morphine combination showed no further additional effects on paw withdrawal latency time over morphine only group. CONCLUSIONS: IP ketorolac did not produce antinociceptive effect during radiant thermal stimulation. There was neither additional nor synergistic analgesic interaction between IP morphine and ketorolac in thermal stimulation rat.

The Effect of the Continuous Intravenous Infusion of Magnesium for the Treatment of Postherpetic Neuralgia -A case report- / 대한마취과학회지

Postherpetic neuralgia (PHN) is a chronic pain syndrome associated with the reactivation of a primary varicella zoster virus infection and is one of the most serious complication of herpetic zoster. The clinical features of PHN are ongoing pain accompanied by allodynia, hyperalgesia, and paresthesia. Current treatment options aimed at relieving the symptoms of PHN include oral agents, such as, opioid, NSAIDs, antidepressants, anticonvulsants. And local anesthetics with steroids are used for subcutaneous infiltration, somatic nerve block, sympathetic nerve block and epidural nerve block. However, in some cases, the pain does not respond to this treatment. We report a case in which a patient suffering from PHN did not respond to conventional therapy, but in whom continuous intravenous infusion of magnesium and physiologic N-methyl-D-aspartate (NMDA) receptor antagonist, reduced severe pain.

Pulmonary Lobar Collapse after the Induction of Anesthesia: A Case Report / 대한마취과학회지

Although segmental or subsegmental atelectasis may occur during anesthesia, mucous plugging of a mainstem bronchus has been uncommonly reported in anesthetized patients with chronic respiratory disease. However, pulmonary atelectasis following mucous plugging may rarely result normal patients. We report this case of an allegedly healthy patient was developed a left main stem bronchus obstruction, resulting in subsegmental collapse of left lower lung after the induction of general anesthesia.

Development of Fine Time Controller of a Transtracheal Jet Ventilator and Its Experimental Application / 대한마취과학회지

BACKGROUND: Transtracheal jet ventilation (TTJV) with a large-bore angiocath that is inserted through the cricothyroid membrane can provide immediate oxygenation from a high pressure-oxygen wall outlet, as well as ventilation by means of manual triggering. However, there is widespread agreement that TTJV with a high pressure oxygen system may induce numerous complications including tracheal hemorrhage/ulceration, subcutaneous/mediastinal emphysema, and barotrauma resulting in a pneumothorax. The goal of this study was to highlight the potential effectiveness of a TTJ-ventilator with an oxygen supply pressure lower than 50 psig for proper oxygenation and ventilation avoiding the possibility of complications from a high pressure oxygen supply system. METHODS: Five mongrel dogs were intubated, paralyzed with vecuronium, and mechanically ventilated with enflurane in air maintaining the PaCO2 at 35 - 40 mmHg. A 16 G IV catheter was inserted percutaneously into the trachea below the tip of the endotracheal tube. We measured the injection volumes, entrained air volumes, and peak inflation pressures according to the changes of oxygen supply pressure (10 to 50 psig) with a fixed injection time (1 second). In addition, we evaluated the oxygenation effects of TTJV at 15 breaths per minute and an I : E 1 : 3 on 20 psig of oxygen supply pressure in hypoxic dogs. RESULTS: A 16 G angiocath provided the injected volumes from 139 ml to 595 ml according to the changes of oxygen pressure from 10 to 50 psig. The entrained air volumes were 6.7 48% of total inspirated volumes. The PaO2 was elevated over 300 mmHg and the PaCO2 was reduced to 45 mmHg within 1 minute of TTJV in hypoxic dogs. CONCLUSIONS: A TTJV system equipped with a time-controller and pressure-regulator can provide enough tidal volume to maintain oxygenation, and could minimize the volu/barotrauma of a conventional TTJV.

Successful Weaning after Diaphragmatic Plication in an Infant with Phrenic Nerve Palsy Resulting from Removal of Cavernous Lymphangioma / 대한구급학회지

Phrenic nerve palsy is a well-known complication following cardiac surgery in children. The incidence is approximately 1~2%. In infants and young children, it often causes a life-threatening respiratory distress. They must be treated with mechanical ventilation in the ICU. Many patients with phrenic nerve injury who is impossible to wean from a ventilator are candidates of diaphragmatic plication. Diaphragmatic plication is performed to restore the normal pulmonary parenchymal volume by replacing the diaphragm to its proper location. This is a case of 2-months-old infant who had phrenic nerve palsy after the removal of cavernous lymphangioma of the chest. He underwent 4 operations to remove the mass and to have pericardiotomy. We tried to wean him from the ventilator but failed several times in the ICU. After 4th operation, right diaphragmatic elevation was noted from the chest X ray. Phrenic nerve palsy was confirmed with fluoroscopy and he underwent diaphragmatic plication on 42 days after his 4th operation. Three days after the diaphragmatic plication, weaning was successfully carried out.