Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks for chronic pain after inguinal hernia repair.

PURPOSE: The aim of this study was to evaluate the outcome of ilioinguinal and iliohypogastric nerve blocks in patients with chronic pain after herniorrhaphy, by comparing nerve stimulator and ultrasound guidance to administer the block. METHODS: A total of 43 patients who received nerve blocks for chronic inguinal post-herniorrhaphy pain received standardized questionnaires. Nerve stimulator-guided blocks were performed prior to January 2009, and thereafter, ultrasound-guided blocks were performed using a local anaesthetic solution and a corticosteroid. RESULTS: The questionnaire was completed by 38 patients (88 %). The inguinal hernia repair was performed for a median 16 months (range 3-219) ahead of the nerve blocks. A median of 2 pain treatments (range 1-7) was calculated. Median follow-up was 21 months (range 3-68). According to the DN4, 21 patients (55.3 %) no longer reported neuropathic pain. Subjectively, 32 % no longer reported moderate-to-severe pain. After ultrasound-guided blocks, a higher VAS score (at rest and during activities), a higher proportion of daily pain and more anxiety and depression are reported compared to blocks performed after nerve stimulator guidance. CONCLUSIONS: Ilioinguinal/iliohypogastric nerve blocks can be effective to treat chronic inguinal pain following surgery of the groin. The use of ultrasound was not superior to nerve stimulator-guided blocks. These blocks could be considered prior to more invasive procedures such as neurectomy.

[Myotonic dystrophy as a contraindication for electroconvulsive therapy?]. / Myotone dystrofie als contra-indicatie voor elektroconvulsietherapie?

A 57-year-old woman with medication-resistant major depression was referred to our clinic for electroconvulsive therapy. After an extensive evaluation of our patient's condition we concluded that in this case the comorbid myotonic dystrophy was a contraindication for the performance of electroconvulsive therapy. However, in the current Dutch Psychiatric Association guidelines this illness is not mentioned as a possible contraindication for electroconvulsive therapy. This raises the question of whether myotonic dystrophy should now be incorporated in these guidelines and makes us wonder to what extent our conclusion could have consequences for the treatment of other neuromuscular illnesses.

Cervicogenic headache: techniques of diagnostic nerve blocks.

Ther term cervicogenic headache (CEH) was introduced by Sjaastad and co-workers in 1983. In 1990 Sjaastad et al. published diagnostic criteria for CEH. In 1998 refinements of these criteria were published, emphasising the use of diagnostic nerve blocks in patients with CEH as important confirmatory evidence. However, the standardisation of diagnostic nerve blocks in the diagnosis of CEH remains to be defined. Herein we present an overview of diagnostic nerve blocks in the cervical area. Suggestions as to their role in the diagnosis of CEH are given.

Interobserver reliability of diagnostic criteria for cervicogenic headache.

To assess the interobserver reliability in distinguishing cervicogenic headache (CEH) from migraine without aura and tension-type headache we conducted a study keeping as closely as possible to daily clinical practice. In contrast to other reliability studies, which use data from clinical patient records or semi-structured interviews recorded on videotape ('in vitro' design), we examined 'live' patients ('in vivo' design). Twenty-four headache patients participated in our 'in vivo' design experiment. During a session, each physician performed a physical examination and queried six patients in succession using a semi-structured interview. Diagnosis was carried out in accordance with the International Headache Society (IHS) criteria and the criteria from Sjaastad and co-workers. Kappa statistics were used: 0.83 between the expert headache neurologists; 0.74/0.73 between the expert anesthesiologist in (head) pain treatment and both expert neurologists respectively; kappa ranged from 0.43 to 0.62 between the other physicians. The results of our 'in vivo' design study show that the reliability in diagnosing CEH, when strictly applying the criteria from Sjaastad and co-workers, is similar to the reliability in diagnosing migraine and tension-type headache according the IHS criteria.