Fluoroscopy-Guided Transgluteal Pudendal Nerve Block for Pudendal Neuralgia: A Retrospective Case Series.

Background/Objective: Pudendal neuralgia is a distressing condition that presents with pain in the perineum. While a positive anesthetic pudendal nerve block is one of the essential criteria for diagnosing this condition, this block can also provide a therapeutic effect for those afflicted with pudendal neuralgia. There are multiple ways in which a pudendal nerve block can be performed. The objective of this study is to share our results and follow-up of fluoroscopy-guided transgluteal pudendal nerve blocks. Methods: This is a retrospective case series. Included were 101 patients who met four out of the five Nantes criteria (pain in the anatomical territory of the pudendal nerve, pain worsened by sitting, pain that does not wake the patient up at night, and no objective sensory loss on clinical examination) who did not respond to conservative treatment and subsequently underwent a fluoroscopy-guided transgluteal pudendal nerve block. Therapeutic success was defined as a 30% or greater reduction in pain. Success rates were calculated, and the duration over which that success was sustained was recorded. Results: For achieving at least 30% relief of pain, using worst-case analysis, the success rate at two weeks was 49.4% (95% CI: 38.5%, 60.3%). In addition to pain relief, patients experienced other therapeutic benefits, such as reductions in medication use and improvements in activities of daily living. Conclusions: Fluoroscopy-guided transgluteal pudendal nerve block appears to be effective in patients who have pudendal neuralgia that is resistant to conservative therapy, with good short-term success.

Chronic Abdominal Discomfort Syndrome (CADS): Defining and Discussing a Novel Diagnosis.

In this article, we propose a new diagnostic paradigm known as Chronic Abdominal Discomfort Syndrome (CADS). Patient's presentation centers around chronic abdominal pain not explained by acute pathology with or without accompanying dyspepsia, bloating, nausea and vomiting among other symptoms. The pathophysiology is noted to be neurogenic, possibly stemming from visceral sympathetic nerves or abdominal wall afferent nerves. Diagnosis is supported by signs or symptoms traversing clinical, diagnostic and functional criteria. Included is a tool which can assist clinicians in diagnosing patients with CADS per those domains. We hope to facilitate primary care physicians' and gastroenterologists' utilization of our criteria to provide guidance for selecting which patients may benefit from further interventions or evaluation by a pain physician. The pain physician may then offer interventions to provide the patient with relief.

A Rare Intrathecal Pump Complication Caused by Prolonged Seroma Leading to a Potential Pump Pocket Fill: A Near Miss.

Intrathecal drug delivery systems have been used with increasing frequency in patients with chronic intractable pain. Common complications of intrathecal drug delivery systems include surgical bleeding, spinal cord injury, fractured or migrated catheter, meningitis, pump failure, granuloma formation, cerebral spinal fluid leak, and hygroma formation. We present a rare near-miss case that could have led to the inadvertent filling of an intrathecal pump pocket with a high concentration of narcotic and local anesthetic. This situation arose due to the discovery of a prolonged intrathecal pump pocket seroma during a routine maintenance and refill procedure.

A Case Report of Sphenopalatine Ganglion Block Relieving Chronic Pain Post-Dental Bone Graft Surgery.

Chronic orofacial pain, by definition, is a pain that can anatomically extend anywhere between the area just under the orbitomeatal line, anterior to the pinnae, and above the neck. It occurs for 15 days or more per month, lasting four or more hours daily, for at least three months. Chronic orofacial pain, including persistent idiopathic facial pain syndrome, can significantly impact patients' quality of life and pose challenges for effective management. This case report describes a successful transnasal approach in treating a patient with severe oral pain following a bone graft surgery by blocking the sphenopalatine ganglion. The block provided significant pain relief and improved the patient's daily functioning. This minimally invasive treatment option offers an alternative for managing chronic orofacial pain after dental procedures such as bone graft surgery.

Persistent Coronavirus Disease 2019 Headache Relieved with Sphenopalatine Ganglion Block.

According to the World Health Organization, as of September 2021, there have been over 226.8 million people diagnosed with coronavirus disease 2019 and over 4.6 million deaths from this disease. Out of those who have survived the coronavirus disease 2019 infection, many individuals have symptoms that linger on. We would like to describe the first report of a patient with a 5-month history of a persistent coro- navirus disease 2019 headache, which was finally successfully aborted with a single transnasal sphenopalatine ganglion block. A female in her early 50s presented to our pain clinic after suffering from a new, debilitating headache that began with the coronavirus disease 2019 illness and persisted for 5 months. Every evening the patient would experience a severe headache located deep inside/behind the left eye that would be resistant to analgesic medications. After 1 transnasal sphenopalatine ganglion block, the patient's coronavirus disease 2019 headache was completely resolved.

Sphenopalatine ganglion block for ipsilateral shoulder pain following open pancreaticoduodenectomy.

A 59-year-old woman underwent an open pancreaticoduodenectomy. Thoracic patient controlled-epidural anaesthesia provided excellent incisional pain relief; however, the patient experienced intractable left shoulder pain (10/10 on the Numerical Rating Scale). To our knowledge, there is no effective established treatment for patients experiencing shoulder pain after an open pancreaticoduodenectomy. The patient's shoulder pain did not respond to medical management with acetaminophen, ketorolac, lidocaine transdermal patch, oxycodone and hydromorphone. Then, on postoperative day 2, the acute pain service was consulted. Considering that the sphenopalatine ganglion block has been previously reported to be helpful in a number of painful conditions, including shoulder tip pain after thoracic surgery, we offered this treatment to the patient. After just one topical sphenopalatine ganglion block, using a cotton-tipped applicator, the patient's shoulder pain entirely resolved and did not return. This is the first report of a successful treatment of intractable ipsilateral shoulder pain following an open pancreaticoduodenectomy with transnasal sphenopalatine ganglion block.

Images in anesthesiology: three safe, simple, and inexpensive methods to administer the sphenopalatine ganglion block.

The sphenopalatine ganglion (SPG) block is a simple and valuable technique that was discovered over a century ago, but, unfortunately, very few anesthesiology providers are familiar with this block. After some of our recent publications, physicians from different countries have reached out to us requesting more specifics on how we perform our version of the block. In this report, we provide a brief history of the block and demonstrate our three effective, simple, readily available, and inexpensive methodologies with images. We are proud to share that our three SPG block techniques have so far effectively relieved patients of chronic migraines, acute migraines, tension headaches, moderate-to-severe back pain, and post-dural puncture headaches.

Management of peripartum intra-abdominal hypertension and abdominal compartment syndrome.

Normal pregnancy leads to a state of chronically increased intra-abdominal pressure. Obstetric and non-obstetric conditions may increase intra-abdominal pressure further, causing intra-abdominal hypertension and abdominal compartment syndrome, which leads to maternal organ dysfunction and a compromised fetal state. Limited medical literature exists to guide treatment of pregnant women with these conditions. In this state-of-the-art review, we propose a diagnostic and treatment algorithm for the management of peripartum intra-abdominal hypertension and abdominal compartment syndrome, informed by newly available studies.

Effectiveness of P6 Stimulation for Reduction of Nausea and Vomiting During Caesarean Section Under Combined Spinal-Epidural Anaesthesia: A Randomised Controlled Trial.

OBJECTIVE: Obstetric patients who receive combined spinal-epidural (CSE) anaesthesia for elective caesarean section (CS) frequently experience intraoperative nausea and vomiting (N&V). Prophylactic therapy with antiemetic agents can have multiple adverse effects to the mother and baby. We designed a randomised clinical trial to evaluate the efficacy of electrical P6 stimulation for prophylactic N&V treatment for scheduled elective CS performed under CSE anaesthesia. METHODS: Following the Institutional Review Board approval and informed consent, a total of 180 patients were randomly allocated into three groups: (1) P6 stimulation (via a peripheral nerve stimulator), (2) intravenous (IV) antiemetics (metoclopramide and ondansetron), and (3) control (no IV antiemetic medications and no P6 stimulation), with 60 parturients in each group. RESULTS: Significantly fewer patients experienced intraoperative N&V in the P6 group (nausea 36.7% and vomiting 13.3%) and IV antiemetic group (nausea 23.3% and vomiting 16.7%) than those in the control group (nausea 73.3% and vomiting 45%; p<0.001). In addition, significantly fewer patients required rescue antiemetic medications in the P6 group (35%) and the IV antiemetic group (31.7%) than those in the control group (73.3%; p<0.001). There was no significant difference in the overall anaesthetic care satisfaction reported between the three study groups. CONCLUSION: Our data suggest that P6 stimulation is as simple and as effective as our routine prophylactic IV antiemetic treatment for prevention of N&V during CS performed under CSE anaesthesia that could be of great interest to patients and obstetric anaesthesiologists who prefer treatments with fewer potential side effects.

Topical Sphenopalatine Ganglion Block Compared With Epidural Blood Patch for Postdural Puncture Headache Management in Postpartum Patients: A Retrospective Review.

BACKGROUND AND OBJECTIVES: Postdural puncture headache (PDPH) is a severe and debilitating complication of unintentional dural puncture. The criterion-standard treatment for PDPH has been epidural blood patch (EBP), but it is an invasive intervention with the potential for severe complications, such as meningitis and paralysis. We believe this is the first ever 17-year retrospective chart review in which we compare the effectiveness of sphenopalatine ganglion block (SPGB) to EBP for PDPH treatment in postpartum patients. METHODS: We conducted a chart review of the first authors' obstetric patients who experienced PDPH from an unintentional dural puncture from a 17-gauge Tuohy needle for labor epidural from January 1997 to July 2014. Demographic characteristics, headache severity, and associated symptoms were collected prior to treatment. Forty-two patients who received SPGB and 39 patients who received EBP were identified. Residual headache, recovery from associated symptoms, and new treatment complications were compared between the 2 groups at 30 minutes, 1 hour, 24 hours, 48 hours, and 1 week posttreatment. RESULTS: A greater number of patients showed significant relief in their PDPH and associated symptoms at 30 and 60 minutes after treatment with SPGB than after treatment with EBP (P < 0.01). Only the EBP patients complained of posttreatment complications, which all resolved in 48 hours. CONCLUSIONS: A greater number of patients experienced a quicker onset of headache relief, without any new complications, from treatment with SPGB versus EBP. We believe that SPGB is a safe, inexpensive, and well-tolerated treatment. We hope that clinical trials will be conducted in the future that will confirm our findings and allow us to recommend SPGB for PDPH treatment prior to offering patients EBP.

Spinal Cord Neuromodulation Therapy for Levofloxacin-Reinduced Complex Regional Pain Syndrome and Neurotoxicity: A Case Report.

Fluoroquinolones are a class of popular outpatient antimicrobial agents with a wide spectrum of therapeutic indications for respiratory and genitourinary infections. Though the most common side effects are gastrointestinal, fluoroquinolones have been increasingly associated with neurotoxicity including peripheral neuropathy and seizures. We present here a case of a 43-year-old woman with previously resolved type I complex regional pain syndrome (CRPS) who presented with symptoms of CRPS and neurotoxicity in the setting of levofloxacin administration. Our aim is to advocate for increased caution in prescribing to patients with a history of neuropathology including CRPS.

Sphenopalatine Ganglion Block Successfully Treats Migraines in a Type 1 Arnold Chiari Malformation Pregnant Patient: A Case Report.

A 32-year-old woman at 36 weeks gestation with a medical history of corrected Type 1 Arnold Chiari malformation presented with an intractable headache. When methylprednisolone and morphine treatment provided no relief, we performed 2 topical transnasal sphenopalatine ganglion blocks by applying 4% lidocaine drops into each nostril via a cotton-tipped applicator. The patient's symptoms significantly improved, and she was discharged home the same day. She has been without relapse of headaches during the 6 months of follow-up by our pain service.