Clinical Effectiveness of Posterior Annular Targeted Ablative Decompression as an Alleviative Intervention for Lumbosacral Discogenic Pain: Systematic Review and Meta-analysis.

BACKGROUND: Various percutaneous intradiscal procedures have been implemented to manage lumbosacral discogenic pain. But most of these procedures simply end up manipulating the central nucleus pulposus or the inner annulus, instead of accessing the posterior outer annulus where the actual, major pain generators exist. Thus, more localized percutaneous techniques, specifically derived to address the pathologic tissues creeped between the torn, posterior annulus and hyperplastic sinuvertebral nerve, have been devised. However, the clinical effectiveness of these "more" accurate procedures is still skeptical. OBJECTIVES: This study has investigated whether the posterior annular targeted decompression was a useful method to treat lumbosacral discogenic pain in terms of pain control or functional improvement. STUDY DESIGN: A systematic review and meta-analysis. SETTING: Primary clinic and tertiary referral center. PATIENTS: Published past references that have dealt with the issue of clinical effectiveness after the posterior annular targeted decompression as a treatment of discogenic pain in terms of pain control and functional improvement. METHODS: A literature search was performed using MEDLINE, EMBASE, Cochrane Review, and KoreaMed databases from the studies published until December 2022. After reviewing titles, abstracts, and full texts of 65 studies during the initial database search, 12 studies were included in a qualitative synthesis, and 9 trials from 8 studies were in quantitative meta-analysis. Data, including pain and functional scores, were extracted and were analyzed using a random effects model to obtain statistical significance of mean difference. Quality assessment and evidence level were established in accordance with the Grading of Recommendations Assessment, Development and Evaluation methodology. RESULTS: Finally, 12 single-arm studies without the control group were included. All studies showed significant pain reduction and functional improvement from a 1-month to 1-year follow-up period. A meta-analysis showed significant reduction in pain scores at 1 month, 3 months, 6 months, and 1 year and functional scores at 1 month, 6 months, and 1 year. The level of evidence was very low because of the nonrandomized study design and inconsistency and imprecision across studies. LIMITATIONS: Only single-arm studies comparing clinical results before and after treatment without the control group were analyzed. The statistical and clinical heterogeneity, due to different aspect of techniques across the studies and a relatively small number of patients, reduced the evidence level. CONCLUSIONS: Comprehensive reviews of selected articles revealed posterior annular targeted decompression could be recommended as treatment option in the patients with discogenic pain who have failed in attaining clinical improvement after the conservative managements under weak evidential strength support. KEY WORDS: Discogenic pain, minimal invasive technique, percutaneous targeted disc decompression, systematic review, meta-analysis.

Comparison of Clinical Efficacy of Transforaminal and Interlaminar Epidural Steroid Injection in Radicular Pain due to Cervical Diseases: A Systematic Review and Meta-analysis.

BACKGROUND: Cervical epidural steroid injection (ESI) has been used to alleviate axial or radicular pain incurred from various cervical pathologies, including herniated intervertebral disc (HIVD) and spinal stenosis (SS). However, the superiority of the transforaminal ESI (TFESI) method over the interlaminar ESI (ILESI) in terms of clinical effectiveness for the radicular pain is still controversial. OBJECTIVES: This study has compared TFESI and ILESI in terms of clinical effectiveness, such as pain control and functional improvement, as well as the incidence of adverse events in patients with radicular pain secondary to cervical HIVD or SS. STUDY DESIGN: A systematic review and meta-analysis. SETTING: Primary clinic and tertiary referral center. METHODS: A literature search was performed using Medline (PubMed), Embase, Cochrane Review, and KoreaMed databases from the studies published until March 2022. After reviewing titles, abstracts, and full texts of 371 studies during the initial database search, 6 studies were included in a qualitative and quantitative synthesis. Data, including pain score, functional score, and adverse events were extracted from 6 studies and were analyzed using a random-effects model to obtain effect size and its statistical significance. Quality assessment and evidence level were established in accordance with the Grading of Recommendations Assessment, Development and Evaluation methodology. RESULTS: Among 6 studies, including 4 randomized controlled trials (RCTs), only 1 RCT showed that TFESI achieved a significant lower Numeric Rating Scale (NRS-11) at 1 month than ILESI, but no advantage in the NRS-11 at 3 months and the Neck Disability Index at 1 month and 3 months, respectively. Another RCT indicated that ILESI achieved significantly more neck NRS-11 reduction at 1 month and 3 months than TFESI. The other 4 studies revealed no significant difference between the 2 groups. A meta-analysis showed no significance in clinical outcomes, except that ultrasound-guided TFESI featured less intravascular leakage of contrast than ILESI. The level of evidence was low because of inconsistency and imprecision. LIMITATIONS: The feasible clinical heterogeneity from the relatively small number of patients included as well as differences in methodology across the studies. CONCLUSIONS: Comprehensive reviews of selected articles revealed TFESI could not be recommended over ILESI for the sake of a preferential cervical radiculopathy control due to the weak evidential strength.

Evaluation of protective equipment for the reduction of radiation exposure to physicians performing fluoroscopically guided lumbar transforaminal epidural steroid injections: A randomized controlled trial.

BACKGROUND: Spine interventionists frequently employ fluoroscopy to guide injection procedures. The increase in fluoroscopically guided procedures in recent years has led to a growing concern about radiation exposure. A new method of covering the C-arm tube with a lead apron has been suggested to reduce radiation exposure. This study aimed to compare the radiation exposure when performing lumbar transforaminal epidural steroid injections (TFESIs) using this new method to a control group. METHODS: A total of 200 patients who underwent lumbar TFESIs by a single physician were recruited. Patients were divided into 2 groups, the new method group (group A) and the control group (group C), and the amount of radiation exposure was compared. The dosimetry badge locations were marked as outside of apron, inside of apron, outside of thyroid collar, inside of thyroid collar, ring, and glasses. RESULTS: The cumulative dose equivalents of all the measurement sites were reduced in group A compared with group C, and the most reduced site was inside the thyroid collar. CONCLUSIONS: Covering the C-arm tube with a lead apron can be effective in reducing the cumulative radiation exposure when performing fluoroscopically guided TFESIs.

The effect of needle tip position on the analgesic efficacy of pulsed radiofrequency treatment in patients with chronic lumbar radicular pain: a retrospective observational study.

BACKGROUND: Pulsed radiofrequency (PRF) is a treatment modality that alleviates radicular pain by intermittently applying high-frequency currents adjacent to the dorsal root ganglion. There has been no comparative study on analgesic effect according to the position of the needle tip in PRF treatment. The objective of this study is to evaluate the clinical outcomes of PRF according to the needle tip position. METHODS: Patients were classified into 2 groups (group IP [group inside of pedicle] and group OP [group outside of pedicle]) based on needle tip position in the anteroposterior view of fluoroscopy. In the anteroposterior view, the needle tip was advanced medially further than the lateral aspect of the corresponding pedicle in group IP; however, in group OP, the needle tip was not advanced. The treatment outcomes and pain scores were evaluated at 4, 8, and 12 weeks after applying PRF. RESULTS: At 4, 8, and 12 weeks, there were no significant differences between the successful response rate and numerical rating scale score ratio. CONCLUSIONS: The analgesic efficacy of PRF treatment did not differ with the needle tip position.

Scrambler therapy for the treatment of diabetic peripheral neuropathy pain: A case report.

RATIONALE: Neuropathy secondary to diabetes mellitus often does not respond well to conventional therapy. Scrambler therapy may be an alternative treatment for otherwise intractable neuropathy. PATIENT CONCERNS: A 45-year-old female complained of bilateral plantar foot pain. She had been treated for diabetes mellitus for 5 years. Oral analgesics did not resolve her pain. Even nerve block therapy did not adequately relieve her pain. DIAGNOSES: Diabetic peripheral neuropathy. INTERVENTION: Scrambler therapy. OUTCOME: Pain reduction; the treatment effect was based around the location of the scrambler patch. LESSONS: Scrambler therapy is effective for the treatment of diabetic peripheral neuropathy. Moreover, effective pain management can be achieved for patients who complain of general pain of the sole, including the toe, by attaching scrambler patches around the ankle.

Optic nerve sheath diameter changes during gynecologic surgery in the Trendelenburg position: comparison of propofol-based total intravenous anesthesia and sevoflurane anesthesia.

BACKGROUND: Elevated intracranial pressure (ICP), a disadvantage of laparoscopic or robotic surgery, is caused by the steep angle of the Trendelenburg position and the CO2 pneumoperitoneum. Recently, sonographically measured optic nerve sheath diameter (ONSD) was suggested as a simple and non-invasive method for detecting increased ICP. This study aimed to explore the changes in ONSD in relation to different anesthetic agents used in gynecologic surgery. METHODS: Fifty patients were randomly allocated to two groups, sevoflurane (group SEV, n = 25) and propofol-based total intravenous anesthesia (TIVA) group (group TIVA, n = 25). The ONSD was measured at five time points (T0-T4): T0 was measured 5 min after induction of anesthesia in the supine position; T1, T2, and T3 were measured at 5, 15, and 30 min after CO2 pneumoperitoneum induction in the Trendelenburg position; and T4 was measured at 5 min after discontinuation of CO2 pneumoperitoneum in the supine position. Respiratory and hemodynamic variables were also recorded. RESULTS: The intra-group changes in mean ONSD in the Trendelenburg position were significantly increased in both groups. However, inter-group changes in mean ONSD were not significantly different at T0, T1, T2, T3, and T4. Heart rates in group TIVA were significantly lower than those in group SEV at points T1-T4. CONCLUSIONS: There was no significant difference in the ONSD between the two groups until 30 min into the gynecologic surgery with CO2 pneumoperitoneum in the Trendelenburg position. This study suggests that there is no difference in the ONSD between the two anesthetic methods.

Comparison of Epidural Spreading Patterns and Clinical Outcomes of Transforaminal Epidural Steroid Injection with High-Volume Injectate via the Subpedicular Versus the Retrodiscal Approach.

BACKGROUND: The effect of transforaminal epidural steroid injection (TFESI) appears to be influenced by the volume of the injected material because there is a positive correlation between injection volume and extent of pain relief. OBJECTIVES: The purpose of this study was to examine how many vertebral segments are covered by the subpedicular (SP) approach and the retrodiscal (RD) approach and to compare the clinical outcomes of the 2 approaches in TFESI with high-volume injectates. STUDY DESIGN: A randomized, active control trial. SETTING: Medical University centers. METHODS: Fifty patients were randomly assigned to either the SP group or the RD group. TFESI was performed with high-volume injectates. A total of 9 mL injectate was divided into 3 injections (0.5 mL, 2.5 mL, and 6 mL) given at 10-second intervals. The primary outcome measure was injectate distribution. The spreading patterns were described as unilateral, bilateral, ventral, or dorsal. Ventral or dorsal flow was also described as being cephalad or caudad, respectively. The secondary outcome measures were pain relief and reduction of functional disability at 4 weeks after the procedure. RESULTS: The total numbers of vertebral segments and median levels of contrast spread from the injection site were not significantly different between the 2 groups. However, in 3 mL of injectate, the injectate spread showed more extensive bilateral distribution in the RD group. At 4 weeks after treatment, both groups demonstrated statistically significant pain relief and improvement in functional status. No significant differences were observed between the 2 groups. LIMITATIONS: We enrolled only a small number of patients and did not analyze long-term outcomes. Patients with severe spinal stenosis or herniated nucleus pulposus were included. Slightly different methods were used in the 2 groups to determine the number of levels at which the injectate was spread. CONCLUSIONS: Epidural spreading patterns and clinical outcomes of lumbar TFESI with high-volume injectate were not significantly different between the SP approach and the RD approach.Institutional Review Board (IRB) approval: Institutional Review Board of Ewha Womans University Hospital (EUMC 2015-05-003-003). Clinical trials registration number: Clinical Research Information Service (CRIS, registration number: KCT0002288; RCT URL: https://cris.nih.go.kr/cris/search/search_result_st01.jsp?seq=7309)KEY WORDS: Epidural injections, epidural space, low back pain, radiating pain, disability evaluation, steroids, local anesthetics, intervertebral disc disease, spinal stenosis.

Scrambler therapy for the treatment of neuropathic pain related to leukemia in a pediatric patient: A case report.

RATIONALE: Cancer-related neuropathic pain often responds poorly to standard pain treatments. Scrambler therapy has relieved refractory chronic pain in several uncontrolled clinical trials. PATIENT CONCERNS: An 11-year-old female patient was suffering from left groin and medial thigh pain after irradiation to the knee. The girl was diagnosed with precursor B-cell lymphoblastic leukemia 2 years ago. Extramedullary relapse of leukemia developed 1 month ago and pain had started. She was treated with oral medications, but she was continuously complaining of severe pain. DIAGNOSIS: Neuropathic pain caused by obturator nerve involvement in leukemia. INTERVENTION: Scrambler therapy. OUTCOME: Pain reduction. LESSONS: Scrambler therapy is noninvasive, is not associated with any complications, causes minimal discomfort during treatment, and is very effective in a pediatric patient with cancer-related neuropathic pain.

Evaluation of Lung Function and Clinical Features of the Ultrasound-Guided Stellate Ganglion Block With 2 Different Concentrations of a Local Anesthetic: A Randomized Controlled Trial.

BACKGROUND: One possible complication of stellate ganglion block (SGB) is respiratory compromise. No study has yet addressed the comparison of its effect on lung function and clinical features, including Horner's syndrome, changes in temperature, sensory and motor functions, and adverse events of lower versus higher concentrations (LC and HC, respectively) of local anesthetics in an ultrasound-guided SGB. METHODS: Fifty patients were randomized into 1 of 2 groups: the LC group (5 mL of 0.5% mepivacaine) and the HC group (5 mL of 1% mepivacaine). One anesthesiologist performed a C6- SGB under ultrasound guidance. Our primary objective was to compare LC and HC of a local anesthetic in terms of its effect on lung function, and the secondary objective was to compare the clinical features between LC and HC of a local anesthetic. Lung function was compared between the 2 groups using the Mann-Whitney U test. RESULTS: The forced vital capacity at 20 minutes post-SGB was not significantly different between the HC and the LC groups (P = .360); the median difference (95% confidence intervals [CI]) was 1 (-1 to 8). Other parameters of lung function were comparable with the forced vital capacity. Patients in the HC group had significantly greater sensory changes than those in the LC group (% decrease compared with the unblocked side); 95.4 ± 2.1 (CI: 91.11-99.73) vs 87.3 ± 3.5 (CI: 80.12-94.49). CONCLUSIONS: Lung function between the LC and HC groups after SGB did not differ significantly. Clinical features between the 2 groups also did not differ clinically, except that patients in the HC group had significantly greater sensory loss in the C6 dermatomes.

Tageted bipolar radiofrequency decompression with vertebroplasty for intractable radicular pain due to spinal metastasis: a case report.

Metastatic spinal tumors are usually quite difficult to treat. In patients with metastatic spinal tumors, conventional radiotherapy fails to relieve pain in 20-30% of cases and open surgery often causes considerable trauma and complications, which delays treatment of the primary disease. Percutaneous vertebroplasty (PVP) is considered to be useful in achieving rapid pain control and preventing further vertebral collapse due to spinal metastasis. However, symptoms of intraspinal neural compression can be contraindications to PVP. To overcome this problem, we performed PVP following targeted bipolar radiofrequency decompression, and examined the effect of the combined treatment in relieving severe radicular pain related to spinal cord compression caused by malignant metastatic tumors.

Dexmedetomidine-ketamine versus Dexmedetomidine-midazolam-fentanyl for monitored anesthesia care during chemoport insertion: a Prospective Randomized Study.

BACKGROUND: Dexmedetomidine as a sole agent showed limited use for painful procedures due to its insufficient sedative/analgesic effect, pronounced hemodynamic instability and prolonged recovery. The aim of this study was to compare the effects of dexmedetomidine-ketamine (DK) versus dexmedetomidine-midazolam-fentanyl (DMF) combination on the quality of sedation/analgesia and recovery profiles for monitored anesthesia care (MAC). METHODS: Fifty six patients undergoing chemoport insertion were randomly assigned to group DK or DMF. All patients received 1 µg.kg(-1) dexmedetomidine over 10 min followed by 0.2-1.0 µg.kg(-1)h(-1) in order to maintain 3 or 4 of modified Observer's Assessment of Analgesia and Sedation score checked every 3 min. At the start of dexmedetomidine infusion, patients in group DK or DMF received 0.5 mg.kg(-1) ketamine or 0.05 mg.kg(-1) midazolam + 0.5 µg.kg(-1) fentanyl intravenously, respectively. When required, rescue sedatives (0.5 mg.kg-1 of ketamine or 0.05 mg.kg-1 of midazolam) and analgesics (0.5 mg.kg-1 of ketamine or 0.5 µg.kg-1 of fentanyl) were given to the patients in DK or DMF group, respectively. The primary outcome of this study was the recovery parameters (time to spontaneous eye opening and the length of the recovery room stay). The secondary outcomes were parameters indicating quality of sedation/analgesia, cardiorespiratory variables, and satisfaction scores. RESULTS: There were no significant differences in the onset time, time to spontaneous eye opening, recovery room stay, the incidences of inadequate analgesia, hypotension and bradycardia between the two groups. Despite lower infusion rate of dexmedetomidine, more patients in the DMF group had bispectral index (BIS) < 60 than in the DK group and vice versa for need of rescue sedatives. The satisfaction scores of patients, surgeon, and anesthesiologist in the DMF group were significantly better than the DK group. CONCLUSIONS: The DK and DMF groups showed comparable recovery time, onset time, cardiorespiratory variables, and analgesia. However, the DMF group showed a better sedation quality and satisfaction scores despite the lower infusion rate of dexmedetomidine, and a higher incidence of BIS < 60 than the DK group. TRIAL REGISTRATION: Clinical Trial Registry of Korea KCT0000951 , registered 12/12/2013.

Percutaneous Sacroplasty under Fluoroscopic Guidance Combined with Epidurogram for Sacral Insufficiency Fracture Resulting from Metastatic Tumor and Osteoporosis.

Sacral insufficiency fracture resulting from a metastatic tumor or an osteoporotic fracture causes severe low back pain and radiating pain mass effect on neural foramen and chemical irritants. Percutaneous sacroplasty is one of the effective treatment modalities for sacral insufficiency fracture and its pain. Because of the structural complexity of the sacrum, obtaining an epidurogram of the S1 and S2 nerve roots before the start of the procedure can be helpful to avoid nerve injury. We present 2 successful cases of percutaneous sacroplasty performed under fluoroscopic guidance. A 65-year-old man with sacral metastasis from stomach cancer and a 52-year-old man with sacral insufficiency fracture were suffering from severe buttock pain and radiating pain. After epidurography of the S1 and S2 nerve roots with steroid and contrast dye, percutaneous sacroplasty with fluoroscopy on the S1 or S2 body and alae was performed on both patients. There was no cement leakage or any other major complications. Both patients experienced significant reduction in pain.

Percutaneous Epidural Adhesiolysis with Epidural Steroid Injection: A Non-inferiority Test of Non-particulate Steroids Versus Particulate Steroids.

OBJECTIVES: To evaluate the efficacy of dexamethasone sodium phosphate (DSP), a non-particulate steroid, during percutaneous epidural adhesiolysis (PEA), as compared with triamcinolone acetate (TA). DESIGN: Retrospective observational study. SETTING: Interventional pain management clinic in a tertiary care center. SUBJECTS: Patients scheduled to receive PEA between March 2011 and January 2014. METHODS: 47 patients underwent the procedure with TA (TA group), and 26 patients underwent the procedure with DSP (DSP group). At the end of the procedure, 20 ml of 0.18% ropivacaine containing 3000 units of hyaluronidase and 80 mg of TA or 10 mg of DSP was injected. Success rates and means of percent decreases in terms of verbal numerical rating scale (VNRS) of pain and Oswestry Disability Index (ODI) at follow-up visits 3 and 6 months after PEA were compared. Non-inferiority test was used for statistical analysis. RESULTS: At 3 months, the success rate in VNRS of TA group and DSP group were 59.6% and 53.8%. The mean percent decreases of VNRS were 42.4% and 46.1% in TA group and DSP group, respectively. At this time point, non-inferiority was not demonstrated. In contrast at 6 months, the success rate in aspect of VNRS was 45.2% in TA group and 62.5% in DSP group. The mean of percent decreases in the VNRS was 34.9% in TA group and 52.8% in DSP group. The non-inferiority was met in two measurements. CONCLUSIONS: DSP presents non-inferiority to TA in terms of success rate and percentage decrease of the VNRS 6 months after PEA.

A Modified Approach of Percutaneous Endoscopic Lumbar Discectomy (PELD) for Far Lateral Disc Herniation at L5-S1 with Foot Drop.

Foraminal or extraforaminal Far Lateral Disc Herniations (FLDH) extending into or beyond the foraminal zone have been recognized as between 7-12% of all lumbosacral disc herniations. Conventional posterior laminectomy may not provide good access to a herniation that lies far lateral to the lateral margin of the pedicle. Use of the endoscopic technique through a percutaneous approach to treat such FLDH patients can decrease the surgical morbidity while achieving better outcomes. We made an effort to utilize the advantages of percutaneous endoscopic lumbar discectomy (PELD) and to determine the appropriate approach for FLDH at the level between the 5th Lumbar and first Sacral vertebrae(L5-S1). The authors present a case of an endoscopically resected lumbar extruded disc of the left extraforaminal zone with superior foraminal migration at the level of L5-S1, which had led to foot drop, while placing the endoscope in the anterior epidural space without facetectomy.

Effect of High-Volume Injectate in Lumbar Transforaminal Epidural Steroid Injections: A Randomized, Active Control Trial.

BACKGROUND: There have been many studies proving the effectiveness of lumbar transforaminal epidural steroid injections (TFESIs) for the treatment of radicular pain. Dexamethasone has been suggested as an alternative to particulate steroids. However, no controlled trials have investigated the effect of different injected volumes for a same dose of dexamethasone. OBJECTIVE: To compare the effects of a high-volume injectate with those of a low-volume injectate using the same dose of dexamethasone for 2 groups in lumbar TFESI. STUDY DESIGN: A prospective, randomized, active control trial. SETTING: The outpatient clinic of a single academic medical center. METHODS: A total of 66 patients were randomized to receive lumbar transforaminal epidural dexamethasone injections with either a low-volume injectate (3 mL, N = 30) or a high-volume injectate (8 mL, N = 32). The primary outcome measures for this study were the incidence of the patients achieving meaningful pain relief and a reduction on the Visual Analogue Scale (VAS, range 0-100) at 4 weeks after the procedure. The definition of "meaningful pain relief" was ≥ 50% from baseline. The secondary outcomes included the Roland-Morris Disability Questionnaire (RMDQ, range 0-24) score and adverse effects. The outcomes were assessed 4 weeks after the procedure. RESULTS: Four weeks after the procedure, in the DL8 group, the incidence of achieving meaningful pain relief was higher compared with DL3 group (19, 59.4% vs. 9, 30%, P = 0.024). Both groups demonstrated a significant improvement in their VAS and RMDQ scores (P < 0.05). The VAS of the high-volume injectate group (DL8) was significantly lower than that of the low-volume injectate group (DL3) (33.3 ± 25 vs. 46.3 ± 25, P = 0.036). There was no significant difference in the RMDQ score between the 2 groups. LIMITATIONS: We enrolled a small number of patients and did not check the long-term outcomes. CONCLUSIONS: Injectate at a volume of 8 mL was more effective than injectate at a volume of 3 mL for radicular pain in a lumbar transforaminal steroid injection, although both of the injectates contained the same dose of dexamethasone.

Effect of intraoperative infusion of ketamine on remifentanil-induced hyperalgesia.

BACKGROUND: Opioid induced hyperalgesia (OIH) is related with high opioid dosage, a long duration of opioid administration, and abrupt discontinuation of infused opioids in anesthetic settings. Ketamine is known to attenuate OIH efficiently, but methods of administration and methods to quantify and assess a decrease in OIH vary. We demonstrated the existence of remifentanil-induced hyperalgesia and investigated the ability of ketamine to attenuate OIH. METHODS: Seventy-five patients undergoing laparoscopic gynecologic surgery under remifentanil-based anesthesia were assigned to one of the following groups: (1) group RL (remifentanil 0.05 µg/kg/min), (2) group RH (remifentanil 0.3 µg/kg/min), or (3) group KRH (remifentanil 0.3 µg/kg/min + ketamine 0.5 mg/kg bolus with 5 µg/kg/min infusion intraoperatively). Desflurane was administered for maintenance of anesthesia to target bispectral index scores (40-60) and hemodynamic parameters (heart rate and blood pressure < ± 20% of baseline values). All parameters related to OIH and its attenuation induced by ketamine were investigated. RESULTS: There was no significant difference among the three groups related to demographic and anesthetic parameters except the end-tidal concentration of desflurane. Additional analgesic consumption, numerical rating scale scores at 6 and 24 h, and cumulative fentanyl dose were significantly higher in group RH than in the other two groups. The value difference of the Touch-Test sensory evaluation was significantly higher negative in group RH than in the other two groups. CONCLUSIONS: Remifentanil-induced hyperalgesia is significantly attenuated by intraoperative bolus and infusion of ketamine. Ketamine also decreased tactile sensitization, as measured by Touch-Test sensory evaluation.

The effect of stellate ganglion block on intractable lymphedema after breast cancer surgery.

Lymphedema of the upper limb after breast cancer surgery is a disease that carries a life-long risk and is difficult to cure once it occurs despite the various treatments which have been developed. Two patients were referred from general surgery department for intractable lymphedema. They were treated with stellate ganglion blocks (SGBs), and the circumferences of the mid-point of their each upper and lower arms were measured on every visit to the pain clinic. A decrease of the circumference in each patient was observed starting after the second injection. A series of blocks were established to maintain a prolonged effect. Both patients were satisfied with less swelling and pain. This case demonstrates the benefits of an SGB for intractable upper limb lymphedema.

Cervical transforaminal epidural block using low-dose local anesthetic: a prospective, randomized, double-blind study.

OBJECTIVES: Intra-arterial injections of local anesthetic during cervical transforaminal epidural block (TFEB) can cause rare but fatal neurologic complications. We hypothesized that using a dose of local anesthetic lower than seizure threshold during cervical TFEB would not be associated with seizure activity in cases of accidental intra-arterial injection. METHODS: Patients were randomized to one of two groups: group I received injections of 1 mL of 1% lidocaine mixed with dexamethasone 2.5 mg (n = 15), and group II received 1 mL of 0.125% lidocaine mixed with dexamethasone 2.5 mg (n = 15). When the numeric rating scale (NRS) for pain was greater than 3, cervical TFEBs were performed three times at 2-week intervals. Patients were evaluated up to 3 months. RESULTS: Thirty patients with cervical radicular pain were enrolled in this study. The NRS pain score on the day of procedure and at 2 weeks, 4 weeks, 6 weeks, and 3 months following the initial procedure were similarly significantly reduced in both groups. The total number of procedures performed and the outcomes evaluated according to Odom's criteria at the 3-month follow-up visit were not different between groups. Overall, 73.3% and 80% patients in groups I and II, respectively, rated the degree of their symptom relief as excellent or good. CONCLUSION: Cervical TFEB performed using 0.125% lidocaine with dexamethasone achieved similar satisfactory effects as 1% lidocaine with dexamethasone for the treatment of cervical radicular pain. Therefore, the use of low-dose lidocaine with dexamethasone is reasonable for cervical TFEB, as this may reduce the incidence of rare but fatal complications.