Comparison of the Severity of Zoster-Associated Pain and Incidence of Postherpetic Neuralgia in Patients with and without Pre-Existing Spinal Disorders at the Same Spinal Nerve Level: A Retrospective Multicenter Study.

The incidences of herpes zoster (HZ) and postherpetic neuralgia (PHN) are significantly influenced by age. As individuals age, the occurrence of spinal disorders increases, thereby raising the likelihood of HZ and PHN coexistence. Considering this, our study aimed to explore the potential impact of pre-existing spinal disorders at the nerve level where HZ developed, on the severity of zoster-associated pain (ZAP) and the incidence of PHN. For our investigation, we retrospectively analyzed a total of 237 patients who presented with HZ and ZAP at various sensory levels (cervical, thoracic, lumbar, and sacral) with or without pre-existing spinal disorders. The presence or absence of spinal disorders at the sensory level affected by HZ was determined using computed tomography or magnetic resonance imaging. Our study results revealed that the group with spinal disorders at the sensory level where HZ developed did not exhibit an increased incidence of PHN. However, 3-6 months after HZ onset, this same group showed significantly higher ZAP scores compared to the group without spinal disorders. It implies a need for heightened pain management, as the coexistence of these conditions can increase pain severity. This study furnishes an initial standpoint to delve into intricate interactions between two diseases.

Efficacy of scrambler therapy in patients with painful diabetic peripheral neuropathy: A single-arm, prospective, pilot study.

BACKGROUND: A variety of medications are available to manage painful diabetic peripheral neuropathy (DPN), but the proper treatment remains challenging. Accordingly, various neuromodulation modalities have been used. However, no prospective clinical trials have evaluated the use of scrambler therapy (ST) in painful DPN. This study aimed to explore the long-term effects of ST in managing painful DPN. METHODS: The patients received 10 consecutive STs of 45 minutes every 1 to 2 days. The primary outcome was pain score. We measured the visual analog scale (VAS) pain scores at baseline, during ST, immediately after ST, and at 1, 2, 3, and 6 months after ST. The secondary outcomes were Michigan Neuropathy Screening Instrument (MNSI), Semmes-Weinstein monofilament test, and Leeds Assessment of Neuropathic Symptoms and Signs pain scores, which were measured at baseline, immediately after ST, and at 1, 2, 3, and 6 months after ST. RESULTS: VAS scores showed significant improvement at the 8th, 9th, and 10th sessions during ST and 1 month after ST. The MNSI self-report component score was decreased 1 month after the ST. However, all other outcomes did not show significant differences compared to the baseline. CONCLUSION: ST may have short-term effects and limited long-term effects on painful DPN.

Intravenous Versus Perineural Dexamethasone for Reducing Rebound Pain After Interscalene Brachial Plexus Block: A Randomized Controlled Trial.

BACKGROUND: Interscalene brachial plexus block (ISB) is a common regional technique to manage acute postoperative pain for arthroscopic rotator cuff tear repair. However, rebound pain may compromise its overall benefit. Our aim was to investigate the primary hypothesis that perineural and intravenous dexamethasone have different effects on rebound pain after resolution of ISB for arthroscopic rotator cuff tear repair. METHODS: Patients aged ≥ 20 years scheduled for elective arthroscopic rotator cuff tear repair under general anesthesia with preoperative ISB were included. The participants were randomized to receive dexamethasone either perineurally (perineural group) or intravenously (intravenous group). In the perineural group, patients received ISB with 12 mL of 0.5% ropivacaine containing 5 mg of dexamethasone; simultaneously, 1 mL of 0.9% normal saline was administered intravenously. In the intravenous group, patients received ISB with 12 mL of 0.5% ropivacaine; simultaneously, 1 mL of dexamethasone 5 mg was administered intravenously. The primary outcome was the difference in the pain score (0-10 on numeric rating scale) between before and after ISB resolution. The secondary outcomes were the incidence of rebound pain; onset, duration, and intensity of rebound pain; time to the first analgesic request; and pain-related sleep disturbance. RESULTS: A total of 71 patients were randomized to either perineural group (n = 36) or intravenous group (n = 35). After block resolution, pain scores increased significantly more in the perineural group (mean ± standard deviation, 4.9 ± 2.1) compared to the intravenous group (4.0 ± 1.7, P = 0.043). The duration of ISB was more prolonged in the perineural group (median [interquartile range], 19.9 [17.2-23.1] hours) than the intravenous group (15.1 [13.7-15.9] hours, P < 0.001). The incidence of rebound pain and pain-related sleep disturbance during the first postoperative week was significantly higher in the perineural group than in the intravenous group (rebound pain: 44.4% vs. 20.0%, P = 0.028; sleep disturbance: 55.6% vs. 25.7%, P = 0.011). The duration and intensity of rebound pain were similar between the two groups. CONCLUSION: Although perineural dexamethasone provided longer postoperative analgesia, intravenous dexamethasone was more beneficial in reducing pain increase after ISB resolution, incidence of rebound pain, and pain-related sleep disturbance. TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0006795.

The Effect of Super-Repressor IkB-Loaded Exosomes (Exo-srIκBs) in Chronic Post-Ischemia Pain (CPIP) Models.

Complex regional pain syndrome (CRPS) is a condition associated with neuropathic pain that causes significant impairment of daily activities and functioning. Nuclear factor kappa B (NFκB) is thought to play an important role in the mechanism of CRPS. Recently, exosomes loaded with super-repressor inhibitory kappa B (Exo-srIκB, IκB; inhibitor of NFκB) have been shown to have potential anti-inflammatory effects in various inflammatory disease models. We investigated the therapeutic effect of Exo-srIκB on a rodent model with chronic post-ischemia pain (CPIP), a representative animal model of Type I CRPS. After intraperitoneal injection of a vehicle, Exo-srIκB, and pregabalin, the paw withdrawal threshold (PWT) was evaluated up to 48 h. Administration of Exo-srIκB increased PWT compared to the vehicle and pregabalin, and the relative densities of p-IκB and IκB showed significant changes compared to the vehicle 24 h after Exo-srIκB injection. The levels of several cytokines and chemokines were reduced by the administration of Exo-srIκB in mice with CPIP. In conclusion, our results showed more specifically the role of NFκB in the pathogenesis of CRPS and provided a theoretical background for novel treatment options for CRPS.

Predictability of Radiologically Measured Psoas Muscle Area for Intraoperative Hypotension in Older Adult Patients Undergoing Femur Fracture Surgery.

This retrospective study aimed to determine the predictive value of radiologically measured psoas muscle area (PMA) for intraoperative hypotension (IOH) using receiver operating characteristic (ROC) curves in older adult patients with hip fractures. The cross-sectional axial area of the psoas muscle was measured by CT at the level of the 4th lumbar vertebrae and normalized by body surface area (BSA). The modified frailty index (mFI) was used to assess frailty. IOH was defined as an absolute threshold of mean arterial blood pressure (MAP) < 65 mmHg or a relative decrease in MAP > 30% from baseline MAP. Among the 403 patients, 286 (71.7%) had developed IOH. PMA normalized by BSA in male patients was 6.90 ± 0.73 in the no-IOH group and 4.95 ± 1.20 in the IOH group (p < 0.001). PMA normalized by BSA in female patients was 5.18 ± 0.81 in the no-IOH group and 3.78 ± 0.75 in the IOH group (p < 0.001). The ROC curves showed that the area under the curve for PMA normalized by BSA and modified frailty index (mFI) were 0.94 for male patients, 0.91 for female patients, and 0.81 for mFI (p < 0.001). In multivariate logistic regression, low PMA normalized by BSA, high baseline systolic blood pressure, and old age were significant independent predictors of IOH (adjusted odds ratio: 3.86, 1.03, and 1.06, respectively). PMA measured by computed tomography showed an excellent predictive value for IOH. Low PMA was associated with developing IOH in older adult patients with hip fractures.

Evaluation of lung function and clinical features of interlaminar cervical epidural steroid injections: a randomized controlled trial.

OBJECTIVE: Interlaminar cervical epidural steroid injections (ICESIs) are commonly used to treat axial neck pain and cervical radicular pain. However, local anesthetics can spread to and block the phrenic nerve and upper segments of the thoracic spinal cord where the sympathetic innervation of the lungs emerges. Therefore, changes in lung function may occur following ICESIs. METHODS: The primary outcome measure was the pulmonary function test (PFT) result 30 minutes before and after ICESI with ropivacaine (0.1875% or 0.25%). The secondary outcome measure was the comparison of the pain scores and functional disability between the two concentrations of ropivacaine 4 weeks after the ICESIs. RESULTS: Fifty patients were randomly assigned to either the R1 (0.1875% ropivacaine) or R2 (0.25% ropivacaine) group. No significant difference was observed between the pre-ICESI and 30-minute post-ICESI PFT results within each group, and no difference was observed between the two groups. After 4 weeks of treatment, both groups showed a significant decrease in pain scores and functional disability; however, no significant differences were observed between the two groups. CONCLUSIONS: This study showed no significant change in lung function after ICESIs in either group and no local anesthetic concentration-based difference in the clinical efficacy of the ICESIs.

Facet Joint Versus Transforaminal Epidural Steroid Injections in Patients With Cervical Radicular Pain due to Foraminal Stenosis: A Retrospective Comparative Study.

BACKGROUND: A cervical transforaminal epidural (TFE) steroid injection is a useful treatment option for cervical radicular pain, but it carries a small risk of catastrophic complications. Several studies have reported that cervical facet joint (FJ) steroid injection can reduce cervical radicular pain through an indirect epidural spread. The aim of this retrospective comparative study was to evaluate the pain scores and functional disability in subjects receiving cervical FJ or TFE steroid injection for the treatment of cervical radicular pain due to foraminal stenosis (FS). METHODS: We selected 278 patients 18 years of age and older who underwent cervical FJ (n = 130) or TFE (n= 148) steroid injection for cervical radicular pain. The primary outcomes included pain scores and functional disability during hospital visits one, three, and six months after the initial injection. Secondary outcomes were the proportion of responders and Medication Quantification Scale (MQS) scores. Adverse events and variables correlating with effectiveness one month after the initial injection were also evaluated. RESULTS: The Numeric Rating Scale and Neck Disability Index scores showed a significant improvement one, three, and six months after the initial injection in both groups, with no significant differences between the groups. No significant differences were observed in the success rates of the procedure one, three, and six months after the initial injection for either group. There were no significant differences in MQS between the groups during the follow-up period. Univariate and multivariate logistic regression analyses revealed that the injection method, age, sex, number of injections, FS severity, MQS, pain duration, and the presence of cervical disc herniation were not independent predictors of treatment success. CONCLUSION: The efficacy of FJ steroid injection may not be inferior to that of TFE steroid injection in patients with cervical radicular pain due to FS.

Effects of Local Anesthetics With or Without Steroids in High-Volume Transforaminal Epidural Blocks for Lumbar Disc Herniation: A Randomized, Double-Blind, Controlled Trial.

BACKGROUND: Lumbar transforaminal epidural block (TFEB) is an effective treatment modality for radicular pain due to lumbar disc herniation (LDH). The addition of steroids is more effective than local anesthetic alone in TFEBs for patients with LDH. Moreover, the efficacy of TFEBs has been reported to be positively correlated with the volume of injectate. We hypothesized that high-volume TFEBs without steroids effectively alleviate axial back and radicular pain associated with LDH. This study compared the efficacy of high-volume TFEBs with vs. without steroids for the management of the axial and radicular pain caused by LDH. METHODS: A total of 54 patients were randomly assigned to either group L or group D. Patients in group L received 8-mL injections of 0.33% lidocaine only. Patients in group D received 8-mL injections of 0.33% lidocaine with 5 mg of dexamethasone. The primary outcomes were pain intensity at baseline and 4 weeks after the procedure. The secondary outcomes included the change of functional disability between baseline and 4 weeks after the procedure, pain scores during injection, and adverse effects. RESULTS: Both groups showed a significant reduction in axial and radicular pain and improvement in the functional status at the outpatient visit 4 weeks after TFEB. However, there were no significant differences between the groups in terms of changes in back pain (10.00 [20.00] vs. 10.00 [22.50]; P = 0.896) or radicular pain (5.00 [20.00] vs. 10.00 [12.50]; P = 0.871). CONCLUSION: High-volume TFEBs with and without steroid administration yielded similar significant pain reductions and functional improvements among LDH patients 4 weeks after the procedure.

Strategy to Reduce Hypercapnia in Robot-Assisted Radical Prostatectomy Using Transcutaneous Carbon Dioxide Monitoring: A Prospective Observational Study.

Purpose: Monitoring end-tidal carbon dioxide partial pressure (PETCO2) is a noninvasive, continuous method, but its accuracy is reduced by prolonged capnoperitoneum and the steep Trendelenburg position in robot-assisted radical prostatectomy (RARP). Transcutaneous carbon dioxide partial pressure (PTCCO2) monitoring, which is not affected by ventilator-perfusion mismatch, has been suggested as a suitable alternative. We compared the agreement of noninvasive measurements with the arterial carbon dioxide partial pressure (PaCO2) over a long period of capnoperitoneum, and investigated its sensitivity and predictive power for detecting hypercapnia. Patients and Methods: The patients who underwent RARP were enrolled in this study prospectively. Intraoperative measurements of PETCO2, PTCCO2, and PaCO2 were analyzed. The primary outcome was the agreement of noninvasive monitoring with PaCO2 during prolonged capnoperitoneum. Bias and precision between noninvasive measurements and PaCO2 were assessed using Bland-Altman analysis. The bias and mean absolute difference were compared using a two-tailed Wilcoxon signed-rank test for pairs. The secondary outcome was the sensitivity and predictive power for detecting hypercapnia. To assess this, the Yates corrected chi-square test and the area under the receiver operating characteristic curve were used. Results: The study analyzed 219 datasets from 46 patients. Compared with PETCO2, PTCCO2 had lower bias, greater precision, and better agreement with PaCO2 throughout the RARP. The mean absolute difference in PETCO2 and PaCO2 was larger than that of PTCCO2 and PaCO2, and continued to exceed the clinically acceptable range of 5 mmHg after 1 hour of capnoperitoneum. The sensitivity during capnoperitoneum and overall predictive power of PTCCO2 for detecting hypercapnia were significantly higher than those of PETCO2, suggesting a greater contribution to ventilator adjustment, to treat hypercapnia. Conclusion: PTCCO2 monitoring measured PaCO2 more accurately than PETCO2 monitoring during RARP requiring prolonged capnoperitoneum and a steep Trendelenburg position. PTCCO2 monitoring also provides more sensitive measurements for ventilator adjustment and detects hypercapnia more effectively than PETCO2 monitoring.

Pre-anaesthesia ultrasonography of the subclavian/infraclavicular axillary vein for predicting hypotension after inducing general anaesthesia: A prospective observational study.

BACKGROUND: Bedside sonography of the inferior vena cava has been demonstrated to be a reliable tool for assessing intravascular volume status. Subclavian vein (SCV) assessment was proposed as a reasonable adjunct for measuring the inferior vena cava. OBJECTIVE: We examined whether the preoperative diameter and collapsibility index of the SCV or the infraclavicular axillary vein could predict the incidence of hypotension after induction of general anaesthesia in patients undergoing laparoscopic cholecystectomy. DESIGN: Prospective, observational study. SETTING: Tertiary university hospital. PATIENTS: Adults scheduled for laparoscopic cholecystectomy. INTERVENTION: Sonographic evaluation of the SCV or the axillary vein (SCV-AV) before induction of anaesthesia. MAIN OUTCOME MEASURES: The main outcome was the association between the SCV-AV measurements (diameter an collapsibility index) and intra-operative hypotension (IOH) after induction of anaesthesia. RESULTS: Patients who developed IOH had a higher collapsibility index of the SCV-AV during spontaneous breathing (P = 0.009) and deep inspiration (P = 0.002). After adjusting for confounding variables, the collapsibility index of the SCV-AV during spontaneous breathing was not a significant predictor of a decrease in mean arterial blood pressure (MAP) after inducing anaesthesia (P = 0.127), whereas the collapsibility index of the SCV-AV during deep inspiration was a significant predictor (P < 0.001). CONCLUSION: The collapsibility index of the SCV-AV during deep inspiration was a significant predictor of IOH occurrence and the percentage decrease in MAP after inducing anaesthesia. Further studies in patients with higher collapsibility index are needed to confirm our findings, before the collapsibility index of the SCV-AV can be recommended unequivocally for clinical use. TRIAL REGISTRATION: This trial was registered on 8 September 2017 at the Clinical Trial Registry of Korea (https://cris.nih.go.kr/cris/index.jsp; Identifier: KCT0001078KCT0002457), and the first patient was enrolled on 14 October 2017.

The effect of anesthetic agents on cerebral vasospasms after subarachnoid hemorrhage: A retrospective study.

Cerebral vasospasm is the most important cause of morbidity after an aneurysm clipping in the early postoperative period. The aim of this retrospective study was to evaluate whether the incidence of vasospasms differs when using propofol or desflurane for an emergent aneurysm clipping.The data from 102 patients (50 in the propofol group, 52 in the desflurane group) were analyzed. The occurrence of vasospasm based on daily transcranial Doppler, angiography, and cerebral infarction during 14 days after surgery were compared by anesthetic agents. Postoperative data including Glasgow Coma Scale (GCS) score on day 14 after surgery, and the Glasgow Outcome Scale (GOS) score at 3 months were documented.Patients that intraoperatively received propofol for anesthesia maintenance, had higher incidence of transcranial Doppler (TCD)-evident vasospasm than those that received desflurane (54% vs 30.8%, P = .027). The occurrence of TCD-evident vasospasm was still higher (odds ratio: 2.84; 95% confidence interval: 1.12-7.20) in the propofol group than in the desflurane group after adjusting for confounding factors. However, the incidence of angiographic vasospasm, cerebral infarction, and interventions to treat cerebral vasospasms were similar between both groups. GCS score on day 14 after surgery and the GOS score at 3 months were similar between groups.No effect of anesthetic agents on angiographic vasospasm, cerebral infarction, or clinical outcome was observed, whereas desflurane anesthesia was associated with a lower incidence of TCD-evident vasospasms compared to propofol anesthesia. Our study provides a basis for further randomized controlled studies in a larger patient population to clarify the effects of anesthetic agents on the occurrence of cerebral vasospasms.

Lead fracture of peripheral nerve stimulator for brachial plexopathy -a case report.

Peripheral nerve stimulation (PNS) is a useful treatment for chronic pain, but it can cause damage depending on its application site. Here, we describe the case of a 54-year-old man who underwent PNS for brachial plexopathy in 2015. One lead was implanted on the left medial cord to stimulate the medial antebrachial cutaneous nerve, and the other was implanted on the radial nerve to stimulate the posterior antebrachial cutaneous nerve. Both leads were inserted near the shoulder joint but did not cross it. Before PNS, the patient did not move his shoulder and elbow because of severe pain, but the treatment greatly alleviated this pain. Twenty months after the operation, both leads were fractured, and the severe pain returned. Repetitive motion near the joint was closely related to the lead fractures. In conclusion, large joints as the insertion sites of PNS leads should be avoided to prevent lead fractures.

Compression stockings reduce the incidence of hypotension but not that of cerebral desaturation events in the beach-chair position: a randomized controlled trial.

BACKGROUND: The beach-chair position (BCP) results in decreases in venous return, cardiac output, and cerebral perfusion pressure. In this randomized, prospective study, we investigated whether applying thigh-high compression stockings affected the maintenance of regional cerebral tissue oxygen saturation (rSO2) in the BCP. METHODS: Patients undergoing orthopedic surgery in the BCP under general anesthesia were included and assigned randomly to the control or the compression stocking group. Appropriately sized thigh-high compression stockings were applied to the patients in the stockings group. All patients were tilted, up to 45°, throughout the operation. Non-invasive blood pressure, invasive arterial blood pressure zeroed at the external auditory meatus, and rSO2 were recorded. RESULTS: Data were analyzed from 19 patients per group. In the BCP, the values of rSO2 and blood pressure decreased significantly compared with those at baseline, with no significant difference between the groups. The incidences of cerebral desaturation events (CDEs) were similar between the groups; however, that of hypotension was significantly lower in the compression stocking group. During 36 CDEs, the levels of rSO2 and blood pressure decreased significantly compared with those at baseline in both groups. No significant correlation was found between rSO2 and blood pressure. CONCLUSIONS: Thigh-high compression stockings reduced the incidence of hypotension but not that of CDEs. Our results suggest that other factors, beyond hypotension itself, contribute to CDEs and in other words, efforts just to reduce the incidence of hypotension may not mainly contribute to a reduction of CDEs occurrence in the BCP under general anesthesia.