State of education regarding ultrasound-guided interventions during pain fellowships in Korea: a survey of recent fellows

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.

Psoas compartment block for treatment of motor weakness and pain following herpes zoster

Reactivation of the latent varicella zoster virus in the sensory ganglion causes herpes zoster (HZ). Its characteristic symptom is a painful rash in the involved dermatome. HZ-induced motor weakness is rare and is usually resolved within one year of the onset, but some patients permanently experience motor dysfunction. Epidural steroid administration, with antiviral therapy, can be effective in treating pain from HZ and preventing postherpetic neuralgia. But an epidural block is contraindicated in patients receiving thromboprophylaxis. A psoas compartment block (PCB) provides equivalent analgesic efficacy with significantly low incidence of complication, compared to an epidural block. A 68 year old male patient recieving thromboprophylaxis presented with motor weakness following painful rash in his left L4 dermatome. Ten days before presentation, herpetic rash occurred on his left leg. We performed PCB with a steroid and local anesthetic, which successfully and safely alleviated the pain and motor weakness from HZ.

Neurogenic muscle hypertrophy: a case report

Muscular hypertrophy is caused mainly due to myopathic disorder. But, it is also rarely produced by neurogenic disorder. A 74-year-old woman complained of right calf pain with hypertrophy for several years. Recent lumbar spine magnetic resonance imaging (MRI) showed central and lateral canal narrowing at the L4-L5 intervertebral space. Lower extremity MRI revealed fatty change of right medial head of the gastrocnemius and soleus, causing right calf hypertrophy. Electrodiagnostic examinations including electromyography and nerve conduction velocity testing demonstrated 5(th) lumbar and 1(st) sacral polyradiculopathy. Integrating all the results, the diagnosis was neurogenic muscle hypertrophy. Neurogenic muscle hypertrophy is very rare, but we recommend that clinicians consider this problem when a patient complains of lower limb hypertrophy and pain.

Detection Rate of Intravascular Injections during Cervical Medial Branch Blocks: A Comparison of Digital Subtraction Angiography and Static Images from Conventional Fluoroscopy

BACKGROUND: The most definitive diagnosis of neck pain caused by facet joints can be obtained through cervical medial branch blocks (CMBBs). However, intravascular injections need to be carefully monitored, as they can increase the risk of false-negative blocks when diagnosing cervical facet joint syndrome. In addition, intravascular injections can cause neurologic deficits such as spinal infarction or cerebral infarction. Digital subtraction angiography (DSA) is a radiological technique that can be used to clearly visualize the blood vessels from surrounding bones or dense soft tissues. The purpose of this study was to compare the rate of detection of intravascular injections during CMBBs using DSA and static images obtained through conventional fluoroscopy. METHODS: Seventy-two patients were included, and a total of 178 CMBBs were performed. The respective incidences of intravascular injections during CMBBs using DSA and static images from conventional fluoroscopy were measured. RESULTS: A total of 178 CMBBs were performed on 72 patients. All cases of intravascular injections evidenced by the static images were detected by the DSAs. The detection rate of intravascular injections was higher from DSA images than from static images (10.7% vs. 1.7%, P < 0.001). CONCLUSIONS: According to these findings, the use of DSA can improve the detection rate of intravascular injections during CMBBs. The use of DSA may therefore lead to an increase in the diagnostic and therapeutic value of CMBBs. In addition, it can decrease the incidence of potential side effects during CMBBs.

Radiculopathy Caused by Discal Cyst

Discal cyst is an intraspinal cyst with a distinct communication with the corresponding intervertebral disc. It is a rare condition and could present with radiculopathy similar to that caused by lumbar disc herniation. We present a patient with a large discal cyst in the ventrolateral epidural space of the 5th lumbar vertebral (L5) level that communicated with the adjacent 4th lumbar and 5th lumbar intervertebral disc, causing L5 radiculopathy. We alleviated the radiating pain with selective transforaminal epidural blocks.

Pitfall of bispectral index during intraoperative seizure: a case report / 대한마취과학회지

We report a case of a 42-year-old male who developed generalized tonic-clonic seizure with sudden, brief decrease in bispectral index (BIS) value while undergoing emergency kidney transplantation. Few reports have been made on intraoperative pitfall of BIS value associated with seizure. This case report suggests seizure should be taken into account as a reason for such brief fall of BIS, especially while under general anesthesia or in other specific cases in which clinical signs of seizure are unseen.

Mirror Therapy for Phantom Limb Pain

Phantom limb pain is a painful sensation that is perceived in a body part that no longer exists. To control this pain, many methods have been used such as medication, physical treatment, nerve block, neuromodulation, surgical treatment and mirror therapy. However, until now, there effects have been uncertain. We report the successful reduction of phantom limb pain using mirror therapy when other treatments initially failed to control the pain.

A symptomatic lumbosacral perineural cyst: A case report / 대한마취과학회지

Lumbosacral perineural cysts are formed by the arachnoid membrane of the nerve root at the lumbosacral level. Most of these cysts are asymptomatic and are found incidentally during computed tomography (CT) or magnetic resonance imaging (MRI) for other causes of chronic lower back pain. This type of cyst requires a differential diagnosis to distinguish it from other causes of radiating pain and neurological symptoms. In the present case, a symptomatic lumbosacral perineural cyst was found, and pain relief was achieved by non-surgical treatment. A lumbosacral perineural cyst was identified from a differential diagnosis of a lumbar disc disorder that presented as radiating pain and neurological symptoms.

Incidence of intravascular insertion in thoracic epidural catheterization by using real time fluoroscopy / 대한마취과학회지

BACKGROUND: Epidural analgesia is commonly used to provide several types of pain relief. Although this technique has been widely used with many advantages, currently the complications appear to be increasing. Especially, inadvertent intravascular cannulation and intravascular local anesthetic administration can lead to fatal consequences. METHODS: Data was collected on 296 patients undergoing elective thoracic or abdominal surgery. Two detection methods were utilized to confirm the epidural intravascular cannulation; flashback and aspiration of indwelling catheter, and injection of a contrast agent through the catheter under fluoroscopy were used to guide the placement of the catheter and to examine the intravascular cannulation. RESULTS: Epidural intravascular cannulation was reported in 4 out of 296 cases (1.4%), and 1 patient underwent subdural cannulation. Among the 4 cases of epidural intravascular cannulation, two were confirmed by the flashback and aspiration methods, while the remaining cases were only detected by real time fluoroscopy. CONCLUSIONS: In this study, inadvertent epidural intravascular cannulation occurred by as much as 1.4% of thoracic epidural catheterization. Utilizing real time fluoroscopy in addition to flashback and aspiration can enhance the sensitivity of detection.

Anaphylaxis induced by hydroxyethyl starch during general anesthesia: A case report / 대한마취과학회지

Hydroxyethyl starch (HES) solutions are synthetic non-protein colloid solutions used to treat hypovolemia. However, their use is not free from the risk of allergic reactions. A 42-year-old male was scheduled to undergo aortic-iliac-femoral bypass surgery for the treatment of arteriosclerosis obliterans. He had no history of allergy. Two hours after the start of surgery, and within minutes after HES administration, facial erythema, hypotension and bronchospasm developed. HES infusion was discontinued under the estimation of anaphylaxis. The patient received phenylephrine, ephedrine, diphenhydramine and hydrocortisone with hydration. After restoration of vital signs, surgery was performed without complications.

The Shoulder Pain due to Metastatic Breast Cancer: A Case Report

A rotator cuff tear causes shoulder pain and limits movement of the shoulder joint. A chronic degenerative change or impingement is the reason for a rotator cuff tear. Diagnosis is made based on medical history and, physical and radiological examinations. Other causes of shoulder pain include calcific tendinitis, degenerative arthropathy, joint dislocation, fracture, and primary or metastatic neoplasm. However, metastatic cancer in the shoulder joint is difficult to diagnosis. We experienced a case in which a 46-year-old female patient complained of left shoulder pain and limited joint mobility, and these symptoms were due to metastatic breast cancer in the shoulder.

Reduction of propofol injection pain by utilizing the gate control theory / 대한마취과학회지

BACKGROUND: Propofol is the most commonly using intravenous hypnotic for the induction and maintenance of general anesthesia. However, pain on propofol injection is a well known adverse event. Currently, acute and chronic pain can be controlled by utilizing the "gate control" theory. METHODS: Patients were randomized to receive lidocaine (0.5 mg/kg; Group L), touch on IV injection site (Group T), combination lidocaine (0.5 mg/kg) and touch on IV injection site (Group B), or normal saline (Group S) with venous occlusion for 1 minute, followed by administration of propofol (0.5 mg/kg) into the largest dorsal vein of the hand. Immediately after administering propofol, an investigator blinded to the group assignments asked the patient about pain at the injection site and assessed pain intensity using a 4-point verbal rating scale (0 = none, 1 = mild, 2 = moderate, 3 = severe). RESULTS: A significant decrease in the incidence of pain on propofol injection was achieved in group L (37%) and group B (23%) compared to either group T (80%) and group S (83%) (P < 0.001). But, the incidence of moderate and severe pain was significantly lower in group L (7%), group T (20%) and group B (0%) when compared to group S (53%) (P < 0.05). CONCLUSIONS: Light touch and rubbing reduced pain, although while, they did not reduce the incidence of pain, they reduced the intensity of pain. This method might be considered as an alternative to other treatments but may be contraindicated for use with other drugs.

A direct tying loop of silk sutures on the electrode / 대한마취과학회지

No abstract available.

Epidural Blood Patches in a Patient With Multi-level Cerebrospinal Fluid Leakage That Was Induced by Spontaneous Intracranial Hypotension

Spontaneous intracranial hypotension (SIH) is considered to be a very rare disorder. It is characterized by an orthostatic headache that is aggravated with the patient in the upright position and it is relieved by the patient assuming the supine position. SIH is caused by a spontaneous spinal cerebrospinal fluid leakage without the patient having undergone trauma, surgery or dural puncture or having any other significant medical history. An autologous epidural blood patch (EBP) is effective in relieving SIH. We report here on a case of SIH with cerebrospinal fluid leakage at the upper cervical vertebral level and the middle thoracic vertebral level. The points of leakage were identified by radionuclide cisternography, and this patient was successfully managed by injecting an EBP at each level of leakage.

Generalized infection following facet joint injection: A case report / 대한마취과학회지

Facet joints have been shown to be a source of chronic low back pain, and it is generally accepted in clinical practice that diagnostic and therapeutic facet joint injections are the most reliable technique for the treatment of facet joint pain, which is considered to be an easy and safe procedure. Serious complications and side effects are uncommon after facet joint injection. However, infectious complications including septic arthritis, epidural abscess, meningitis and endocarditis have been reported following facet joint injections. We report here the first case of death following lumbar facet joint injection due to generalized infection.

Spinal Epidural Lipomatosis: A case report

Spinal epidural lipomatosis (SEL) is a rare condition of pathological overgrowth of fat tissue in the vertebral canal. SEL leads to back pain, radiculopathy or paraparesis. Glucocorticoids seem to play a major role in the development of SEL. SEL is best diagnosed by magnetic resonance imaging. The treatment of SEL is directed at reducing the body weight and decreasing the excess glucocorticoid. In severe cases, decompressive laminectomy with removal of the excess epidural fat might become necessary to alleviate the neurological symptoms caused by spinal cord compression.

The Effectiveness of a Three Phase Bone Scan for Making the Diagnosis of Complex Regional Pain Syndrome

BACKGROUND: Complex regional pain syndrome (CRPS) is still difficult to diagnose in the field of chronic pain management. CRPS is diagnosed by purely clinical criteria based on the characteristic signs and symptoms, which have to be differentiated from similar pain conditions like posttraumatic neuropathic pain. Until now, there has been a lack of objective diagnostic tools to confirm the diagnosis of CRPS. The aim of this study was to evaluate the usefulness of a three phase bone scan (TBS) for making the diagnosis of CRPS. METHODS: A total of 121 patients who had been diagnosed with CRPS were evaluated. All the patients were examined by performing a TBS as a part of the diagnostic work-up. A diffuse increased tracer uptake on the delayed image (phase III) was defined as a positive finding for CRPS. RESULTS: Forty-one patients (33.9%) out of 121 showed the positive results on the TBS. The patients with a duration of pain of less than 24 months had a significantly higher positive result (43.4%) on the TBS than did the patients with duration of pain longer than 24 months (12.1%). CONCLUSIONS: A TBS could give a better objective result for diagnosing CRPS for patients with a shorter duration of pain and a TBS gives little information for the diagnosis of CRPS in patients with a duration of pain longer than 24 months.

Analysis of Intravascular Flow Patterns following Cervical Transforaminal Epidural Injection

BACKGROUND: Transforaminal epidural injection (TEI) may be useful to treat unilateral pain that has a dermatomal distribution. In this approach, the needle tip can be placed closer to the dorsal root ganglion and ventral aspect of the nerve root. However many studies have reported that serious complications following TEI occurred more frequently when it was conducted at the cervical level. One of the presumptive mechanisms of the complication is intravascular injection. Therefore this study was conducted to identify the incidence of complications in response to intravascular injections at cervical segments. METHODS: This study included all patients, who visited our pain clinic and had radicular symptoms or herpes zoster associated pain. All procedures were conducted under fluoroscopic guidance with contrast enhancement by one of the authors. After the ideal needle position was confirmed by biplanar fluoroscopy, the blood aspiration through the needle hub was evaluated, and a 3 ml mixture of nonionic contrast (2 ml) with normal saline (1 ml) was injected at a rate of 0.3-0.5 ml/sec continuously under real time fluoroscopic visualization. We then classified the contrast spreading pattern as neural, simultaneous neural and vascular, or vascular. RESULTS: A total 71 cervical TEIs were performed. In 26 cases (36.6%), the contrast only spread to the nerve sheath. However, 45 cases (63.4%) showed an intravascular spreading pattern, 37 (52.1%) of which showed a neural and vascular pattern and 8 (11.3%) of which showed only a vascular pattern. CONCLUSIONS: Approximately two thirds of the cases of cervical TEI were found to lead to intravascular spreading, which is much higher than the incidence reported in previous studies.

Implantable Intrathecal Drug Delivery Pump in Complex Regional Pain Syndrome Patient : A case report

Implantable intrathecal pump is one of the therapeutic options for intractable pain. A 24-year-old male with complex regional pain syndrome was suffering from right lower extremity pain. He had all modalities of treatment including spinal cord stimulator. However, his pain had been worse in the past 6 months. His visual analogue pain scale (VAS) was 8-10 and he could not sit or walk. Only opioid was thought to be effective. Then, intrathecal pump was considered. We estimated the minimal effective dose of spinal morphine before implantation. 0.3 mg of morphine was injected intrathecally as a starting dose. Dosage had been increased up to 0.8 mg in 10 days. His VAS score decreased from 8 to 5. He could sleep without pain and walk with crutch. Therefore, intrathecal pump was inserted. He could tolerate to pain. This case suggests that intrathecal morphine delivery can provide effective treatment for intractable non-malignant pain.

The Effects of Lumbar Sympathetic Ganglion Block in the Patients with Spinal Stenosis and the Skin Temperature Changes according to the Contrast Spread Patterns

BACKGROUND: We hypothesized that if a fluoroscopic image of the lumbar sympathetic ganglion block (LSGB) showed the spread patterns of contrast at both the L2/3 and L4/5 disc areas, then this would demonstrate a more profound blockade effect because the spread patterns are close to sympathetic ganglia. In addition, we compared the effects of LSGB and transforaminal epidural steroid injection (TFESI) for the patients suffering with spinal stenosis. METHODS: Eighty patients were divided into two groups (Group S: the patients treated with TFESI, Group L: the patients treated with LSGB). The patients of group L were classified into three groups (groups A, B and, C) according to their contrast spread pattern. The preblock and postblock temperature difference between the ipsilateral and contralateral great toe (DT(pre), DT(post), degrees C), and the DTnet were calculated as follows. DT(net) = DT(post) - DT(pre). RESULTS: Both group showed a significant reduction of the visual analogue score (VAS) and the Oswestry disability index (ODI) score. Only the patients of group L showed a significant increase of their walking distance (WD). Group A showed the most significant changes in the DT(post) (6.1 +/- 1.2degrees C, P = 0.021), and the DTnet (6.0 +/- 1.0degrees C, p = 0.023), as compared to group C. CONCLUSIONS: LSGB showed a similar effect on the VAS, and ODI, and a significant effect, on WD, compared with TFESI. Group A showed a significant sympatholytic effect, as compared to group C.