A Preliminary Study of the Efficacy of Transcranial Direct Current Stimulation in Trigeminal Neuralgia.

The purpose of this study is to assess the efficacy of transcranial direct current stimulation (tDCS) in patients with treatment-refractory trigeminal neuralgia (TN) and examine the utility of neuroimaging methods in identifying markers of such efficacy. Six patients with classical TN refractory to maximal medical treatment, underwent tDCS (three cases inhibitory/cathodic and three cases excitatory/anodic stimulation). All patients underwent pre- and posttreatment functional magnetic resonance imaging (fMRI) during block-design tasks (i.e., Pain, Pain + tDCS, tDCS) as well as single-shell diffusion MRI (dMRI) acquisition. The precise locations of tDCS electrodes were identified by neuronavigation. Five therapeutic tDCS sessions were carried out for each patient with either anodic or cathodic applications. The Numeric Rating Scale of pain (NRS) and the Headache Disability Index (HDI) were used to score the subjective efficacy of treatment. Altered activity of regional sites was identified by fMRI and associated changes in the spinothalamocortical sensory tract (STCT) were measured by the dMRI indices of fractional anisotropy (FA) and mean diffusivity (MD). Fiber counts of the bilateral trigeminal root entry zone (REZ) were performed as an added measure of fiber loss or recovery. All patients experienced a significant reduction in pain scores with a substantial decline in HDI (P value < 0.01). Following a course of anodic tDCS, the ipsilateral caudate, globus pallidus, somatosensory cortex, and the contralateral globus pallidus showed a significantly attenuated activation whereas cathodic tDCS treatment resulted in attenuation of the thalamus and globus pallidus bilaterally, and the somatosensory cortex and anterior cingulate gyrus contralaterally. dMRI analysis identified a substantial increase (>50%) in the number of contralateral sensory fibers in the STCT with either anodic or cathodic tDCS treatment in four of the six patients. A significant reduction in FA (>40%) was observed in the ipsilateral REZ in the posttreatment phase in five of the six patients. Preliminary evidence suggests that navigated tDCS presents a promising method for alleviating the pain of TN. Different patterns of activation manifested by anodic and cathodic stimulation require further elaboration to understand their implication. Activation and attenuation of responses at various sites may provide further avenues for condition treatment.

Is trigeminal neuralgia the only definitive diagnosis for pain in a tooth extraction site?

Knowing the International Classification of Orofacial Pain helps pain specialists to differentiate types of orofacial pain. It is important to select the best treatment or intervention for the patients based on the diagnosis. As part of our study, we reviewed the article published in BMC Oral Health, titled "Clinical characteristics and associated factors of trigeminal neuralgia: Experience from Addis Ababa, Ethiopia" by Ayele et al. (Ethiopia BMC Oral Health 20(1):7, 2020). For patients suffering from Classical Trigeminal Neuralgia taking a suitable dose of Carbamazepine or Gasser Ganglion radiofrequency could be helpful. Patients complaining Trigeminal neuralgia who had a history of a dental extraction in the painful region should be categorized in other group as Complex Regional Pain Syndrome type 1, who need larger dose of carbamazepine with anticonvulsant or tricyclic agent drugs (e.g. pregabalin or doxepin) or intervention (PPG radiofrequency).

Sacroiliac Joint Intraarticular Injection in True Anteroposterior View: Description of a New C-Arm Guided Method.

BACKGROUND: The anatomic characteristics of the sacroiliac joint (SIJ) make it difficult to achieve intraarticular injection without radiologic guidance. The classic C-arm guided SIJ intervention technique is difficult. Here we describe a new and simple method for SIJ intraarticular intervention. OBJECTIVE: This study aims to introduce a new, simple approach for SIJ intraarticular intervention. STUDY DESIGN: An observational case series study. SETTING: The study was conducted at an academic medical center in a major metropolitan city. METHODS: This method of intervention was performed on 57 patients (a total of 73 joints) who were selected for diagnostic and therapeutic SIJ intervention. The procedure was done in anteroposterior (AP) view, without any C-arm angulation. The accuracy of the intraarticular injection was confirmed by using intraarticular contrast material. A numerical rating scale (NRS) score was recorded for each joint before and after the procedure; the number of x-ray exposures and number of attempts were recorded for each procedure as well. RESULTS: Successful intraarticular contrast spread was obtained in all SIJs. The number of x-ray exposures was about 9 ± 3, and there was not a remarkable difference between cases according to gender of the patient (P = 0.1) or side of the joint (P = 0.2). In 5 cases, the first needle placement was not correct; there were no differences between gender (P = 0.4) and side of the joint (P = 0.4) regarding the first successful attempt. The NRS pain scores decreased in all of the patients more than 50% after the procedure; the pain scores were similar to the results of classic methods of intraarticular interventions with successful contrast spread, and there were no remarkable differences considering gender (P = 0.5) or side of the joint (P = 0.8). LIMITATIONS: This is a very small, nonrandomized, and controlled study; further blinded clinical trials are needed to clarify the probable advantages of this method compared with conventional ones. CONCLUSION: This observational study introduces a new and simple approach for SIJ intraarticular intervention, with a high success rate. KEY WORDS: Low back pain, sacroiliac joint, C-arm, new technique, intraarticular, injection.

The effect of intravenous dextrose administration for prevention of post-operative nausea and vomiting after laparoscopic cholecystectomy: A double-blind, randomised controlled trial.

Background and Aims: Post-operative nausea and vomiting (PONV) is a common and distressing complication after laparoscopic cholecystectomy (LC). The aim of this study was to evaluate the effect of intravenous (IV) dextrose administration for the prophylaxis of PONV after LC. Methods: In a double-blind, randomised controlled trial, a total of 150 female patients who were scheduled for elective LC were randomly assigned into two groups (A and B). Thirty minutes before induction of anaesthesia, patients received an infusion of 500 cc lactated Ringer's solution (Group A) and 5% dextrose in lactated Ringer's solution (Group B) and over a period of 30 min. All patients rated their nausea and vomiting intensity using the verbal rating scale immediately at post-anaesthesia care unit (PACU) arrival; 30, 60, 90 and 120 min after arriving at the PACU and 6, 12 and 24 h after surgery. Results: There was a statistically significant time trend and group effect along with significant differences in time/group interaction effect in both groups for nausea and vomiting scores (P < 0.05). A low negative correlation coefficient was found (r = -0.394, P < 0.001) between blood glucose levels and nausea scores upon PACU arrival. Dextrose administration reduced the odds of vomiting events compared to placebo (estimate: -0.87, odds ratio = 0.42, 95% confidence interval: 0.28-0.64). Conclusion: Administration of IV dextrose before anaesthesia induction may be recommended as an effective, and safe method for the prophylaxis of PONV after LC.

Could the Addition of Alexander Technique Improve the Effectiveness of Physical Therapy in Reducing Violinists' Neck Pain in Comparison to Physical Therapy Alone?

One hypothesis for the mechanism of neck pain in musicians, particularly string players, is changed behavior of the superficial neck flexor muscles and impairment of the cervical stabilization system. To restore the supporting capacity of neck muscles and reduce neck pain, various types of physical therapies and pain educational modalities have been recommended. However, considering the physio-psychological nature of violinists' neck pain, its treatment may benefit from addition of therapies that address postural and movement habits. In this regard, we suggest that management of violinists' neck pain might benefit from additional approaches that may help to decrease muscle overactivity during performance movements.

Clinical Evaluation of Percutaneous Caudal Epidural Adhesiolysis With the Racz Technique for Low Back Pain Due to Contained Disc Herniation.

OBJECTIVES: The authors evaluated the effectiveness of percutaneous epidural adhesiolysis (PEA) in patients with low back pain due to contained disc herniation. PATIENTS AND METHODS: Twenty patients with low back pain due to contained disc herniation underwent PEA treatment with the Racz technique. The patients were evaluated for pain score, medication intake, significant pain relief, and complications. RESULTS: At three days, one month, three months, and six months after PEA compared to pre-PEA evaluations, the pain scores and medication intake were significantly decreased. Significant pain relief declined from 95% at three days to 75% at six months. CONCLUSIONS: PEA for low back pain due to contained disc herniation is a safe and effective procedure. Therefore, it may be considered as an option for treatment before invasive operations are performed.

The effect of transdermal nitroglycerin on pain control in diabetic patients with peripheral neuropathy.

BACKGROUND: Despite high prevalence of diabetic peripheral neuropathy there is no definite treatment for the condition. The present study was conducted to assess the efficacy of transdermal nitroglycerin patch in pain control of patients with DPN. METHODS: This randomized, double-blind, crossover study was conducted on 30 patients with symmetric distal peripheral neuropathy and good glycemic control. The patients were randomly assigned to receive nitroglycerin transdermal and placebo patches in two 4-week stages. The severity of pain and other neuropathic sensory symptoms were assessed at the end of each course. RESULTS: Mean reduction of pain severity was more prominent in the NTG group compared to placebo group of the study (p = 0.048) at least during the first phase of the study. Except for mood and sleep, a significant reduction in all Brief Pain Inventory scores was noted in the drug group (all corrected p < 0.05). SF-MPQ also showed the drug patch to be effective in improving different aspects of pain measured using McGill Pain Questionnaire, except for Role-emotional. CONCLUSIONS: It could be concluded that nitroglycerin plasters can effectively help alleviate pain in patients with diabetic neuropathy. TRIAL REGISTRATION: IRCT201308223213N1.

EFFECT OF ULTRASOUND-GUIDED SUBSARTORIAL APPROACH FOR SAPHENOUS NERVE BLOCK IN CASES WITH SAPHENOUS NERVE ENTRAPMENT IN ADDUCTOR CANAL FOR CONTROLLING CHRONIC KNEE PAIN.

BACKGROUND: Saphenous nerve neuropathy is one of the causes of chronic pain of the knee. Blockade of saphenous nerve under sonographich guide has been used for controlling pain in recent years. The goal of this study was to evaluate the effect of saphenous nerve block for controlling pain in patients with chronic knee pain. METHOD: Thirty five patients with chronic knee pain referred to Amir Alam hospital during June 2012-June 2013 were enrolled in this study. Under sonographic approach, subsartorial blockade of saphenous nerve conducted and patients were followed up for 3 months after treatment. Demographic data, ASA (American Society of Anesthesiologists) category, weight, height, complications of intervention and pain scores were recorded. RESULTS: In 54%, the NRS was zero 30 minutes after intervention. In one patient (2.8%) all NRSs were 0 after intervention. We observed no sensory dysfunction in enrolled cases. CONCLUSION: The result of current study showed that ultrasound guided subsartorial approach is moderately effective in blockade of saphenous nerve in cases with saphenous nerve entrapment in adductor canal for controlling chronic knee pain.

Effect of low-dose (single-dose) magnesium sulfate on postoperative analgesia in hysterectomy patients receiving balanced general anesthesia.

Background and Aim. Aparallel, randomized, double blinded, placebo-controlled trial study was designed to assess the efficacy of single low dose of intravenous magnesium sulfate on post-total abdominal hysterectomy (TAH) pain relief under balanced general anesthesia. Subject and Methods. Forty women undergoing TAH surgery were assigned to two magnesium sulfate (N = 20) and normal saline (N = 20) groups randomly. The magnesium group received magnesium sulfate 50 mg·kg(-1) in 100 mL of normal saline solution i.v as single-dose, just 15 minutes before induction of anesthesia whereas patients in control group received 100 mL of 0.9% sodium chloride solution at the same time. The same balanced general anesthesia was induced for two groups. Pethidine consumption was recorded over 24 hours precisely as postoperative analgesic. Pain score was evaluated with Numeric Rating Scale (NRS) at 0, 6, 12, and 24 hours after the surgeries. Results. Postoperative pain score was lower in magnesium group at 6, 12, and 24 hours after the operations significantly (P < 0.05). Pethidine requirement was significantly lower in magnesium group throughout 24 hours after the surgeries (P = 0.0001). Conclusion. Single dose of magnesium sulfate during balanced general anesthesia could be considered as effective and safe method to reduce postoperative pain and opioid consumption after TAH.

Comparison Between Intraperitoneal and Intravenous Lidocaine for Postoperative Analgesia After Elective Abdominal Hysterectomy, a Double-Blind Placebo Controlled Study.

OBJECTIVE: To compare the efficacy of intravenous and intraperitoneal injection of lidocaine and normal saline in relieving postoperative pain after elective abdominal hysterectomy. MATERIALS AND METHODS: For this double-blind randomized controlled study 109 patients undergoing elective abdominal hysterectomy were randomly allocated to three groups :1) IV group (intravenous injection group) received intravenous lidocaine %2 bolus 1.5mg/kg 30 min before incision and then a continuous lidocaine infusion of 2mg/kg and before the wound closure an intraperitoneal injection of N/S , 2) IP group (intraperitoneal group) received intravenous N/S and intraperitoneal lidocaine 3mg/kg , 3) P group (placebo, N/S) received both intravenous and intraperitoneal N/S. The pain scores (VAS) at rest, total morphine consumption , the time to first need for rescue analgesic ,incidence of lidocaine related adverse effects and nausea and vomiting were recorded at 0,2,4,8,12 and 24 hrs postoperatively. RESULTS: The VAS scores were significantly lower in IP and IV groups compared with placebo (p = 0.001). Total consumption of morphine (p = 0.001) and time to firs request of recue analgesic (p = 0.001) were lower too in IP and IV groups.Incidence of vomiting was comparable between groups (p < 0.05) but nausea was higher in control group (p > 0.05).There were not notable lidocaine-related adverse effects. IP and IV groups were not statistically different for all investigated variables. CONCLUSION: This study showed lidocaine administration both intravenously and intraperitoneally are effective in reducing the postoperative pain and also have opioid sparing effect and can be safely used in elective abdominal hysterectomy without any major adverse effects.

Nonsurgical treatment of stylohyoid (Eagle) syndrome: a case report.

Eagle syndrome is a rare condition caused by elongation of the styloid process or calcification of the stylohyoid ligament. Patients with Eagle syndrome typically present with dysphagia, dysphonia, cough, voice changes, otalgia, sore throat, facial pain, foreign body sensation, headache, vertigo, and neck pain. Here we report a case in which the patient initially presented with sore throat, left-sided facial pain, and cough. This case report provides a brief review of the diagnosis and nonsurgical management of this rare syndrome.

The effect of oral clonidine premedication on nausea and vomiting after ear surgery.

OBJECTIVE: Postoperative nausea and vomiting (PONV) is a most distressing adverse event for surgical patients with a considerable economic impact .The aim of the present study was to evaluate the effect of clonidine given orally for PONV in patients undergoing anesthesia for outpatient ear surgery. METHODS: Sixty patients 30.2 +/- 9.9 years, scheduled for ear surgery, were randomly assigned to one of two groups (clonidine or placebo) in a double-blinded manner. Anesthesia was standardized laryngeal mask airway, fentanyl, propofol, halothane, nitrous oxide. RESULTS: A complete response, defined as no PONV and no need for rescue antiemetic medication, during the first 24 h after anesthesia was 33% with placebo and 67% with clonidine, respectively (P. 0.01). No clinically adverse event was observed in any of the groups. CONCLUSION: Oral premedication with clonidine reduced the rate of PONV in patients undergoing outpatient ear surgery.