[A case of malignant psoas syndrome diagnosed while treating sciatica].

While attempting to treat a 71-year-old male patient who had been diagnosed with sciatica from spinal canal stenosis, we discovered his prior cancer metastasizing to the psoas. We initially administered epidural block to him after confirming his prior rectal cancer had not metastasized to lumbar vertebral bones, but the block did not satisfactorily alleviate his pain, and he had difficulty stretching his lower limbs. CT scan to re-examine the cause revealed a metastasized cancer in the psoas. From this experience, we believe malignant psoas syndrome should be considered in addition to metastasis to lumbar vertebral bones, when evaluating lower back to lower limb pain in patients with previous cancer history.

[Case of two-stage carotid artery stenting managed with ultrasound-guided carotid sinus nerve block].

We report the use of ultrasound-guided carotid sinus nerve block for circulatory management during two-stage carotid artery stenting (CAS) in a patient with symptomatic carotid stenosis complicated with decreased cerebral perfusion reserve. The patient was a 70-year-old man with symptoms of ocular ischemia and markedly decreased perfusion of the left cerebral hemisphere observed in single photon emission computed tomography. Ultrasound-guided carotid sinus nerve block was conducted to prevent CAS perioperative circulatory fluctuations caused by carotid sinus reaction (CSR). We did not observe any hemodynamic instability during CAS. There were no complications associated with the nerve block. Although further research is required, the present findings suggest that ultrasoundguided carotid sinus nerve block may safely and effectively prevent CSR in CAS.

[Effect of the sacroiliac ligament block on intractable low back pain in elderly patients].

BACKGROUND: Lumbar spine disease in the elderly people is complicated by a variety of pathophysiology in the spine and the cause of the pain is unclear. Diagnosis of pain may be difficult in patients with pain in the thigh and groin area. Sacroiliac joint is supporting the trunk and movable joint. We examined the effect of the sacroiliac joint block for intractable low back pain. METHODS: Retrospectively we examined the duration of disease in patients with hip and leg pain visiting the hospital for eight months, and we questioned the site of pain awareness. Newton test, Gaenslen test, Patrick test and Fadire test were carried out for sacroiliac joint pain in patients with at least one positive finding. When performing sacroiliac ligaments block local anesthetics was injected to check the position of the dorsal sacroiliac ligaments under ultrasonic echo whenever possible. The block is performed with the patients prone at a point one finger from the posterior superior iliac spine level at an angle of 30-45 degrees downward toward the outside. Injecting the drugs penetrating the ligament continued to give a feel slightly outward to avoid the iliac Cattelan 23 G needle. We confirmed pain assessment NRS at 11 (0-10), and the improvement of pain was assessed with the change of the NRS on the next return. RESULTS: NRS showed a significant decrease at all points in time before block, their pain decreased gradually. The patients showed NRS improvement of more than 50% of the first block in 15 of 24 patients. CONCLUSIONS: Block at the posterior sacroiliac ligament region significantly reduced pain for chronic intractable low back pain. The block was shown to be effective as a treatment and for diagnosis.

[Development and evaluation of a patient-reported outcome measure of pain-related sleep disturbances for pain clinic patients].

BACKGROUND: The purpose of this study was to develop a new tool, the Pain Sleep questionnaire, consisting of 20 items (PS-20) for measuring pain-related sleep disturbances in pain clinic patients, and to examine its reliability and validity. METHODS: The internal consistency, criterion validity compared with the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36v2), and construct validity of the PS-20 were tested. RESULTS: A total of 125 patients participated in this study. Cronbach's alpha coefficient was 0.969, indicating good internal consistency. The PS-20 score correlated moderately with the physical component summary of SF-36v2 and correlated weakly with the mental component summary of SF-36v2. From the graphical model using the Akaike information criterion and the Categorical principal component analysis, the items were divided into four domains: physical pain, trouble falling asleep, awakened by pain, and general health problems. CONCLUSIONS: The PS-20 was shown to be a valid and reliable questionnaire scale for measuring pain-related sleep disturbances among pain clinic patients.

Replacement of gabapentin with pregabalin in postherpetic neuralgia therapy.

PURPOSE: Although both gabapentin and pregabalin are first-line drugs for neuropathic pain including postherpetic neuralgia (PHN), no report has directly compared the magnitude of pain relief and the incidence of side effects of both drugs. By substituting gabapentin with pregabalin in postherpetic neuralgia therapy, we can compare the two drugs. METHODS: In 32 PHN patients being administered gabapentin, without changing the frequency of dosing, the drug was substituted with pregabalin at one-sixth dosage of gabapentin. After 2 weeks, an interview was conducted about the visual analog scale (VAS) pain score, changes in the time of onset of action and duration of action after the substitution of drug and side effects (such as somnolence, dizziness, and peripheral edema). In addition, the dosage was increased while paying careful attention to the side effects (titration) in 22 patients who requested a dosage increase among those whom VAS pain score of ≥25 mm remained even after the substitution. RESULTS: No significant changes were observed in VAS pain scores after the substitution of gabapentin with pregabalin. Regarding the time of onset of action and the duration of action after the substitution, the highest number of patients answered that no change occurred compared with the previous drug, followed by the patients who answered that the time of onset of action became quicker, and the duration of action became longer. The incidence of somnolence and dizziness showed no significant difference before and after the substitution, but peripheral edema showed a significant increase after the substitution. The level of side effects of both drugs was mild, and continued medication was possible. In the patient group where pregabalin dosage was increased, the VAS pain score decreased significantly compared with that before and after increase the dosage (P < 0.05). On the other hand, in nine out of 22 patients in the group where the dosage was increased, side effects appeared or were exacerbated. In two out of nine patients, it was necessary to reduce the dosage to the initial volume. CONCLUSION: It was suggested that the analgesic action of pregabalin in PHN was six times that of gabapentin in terms of effectiveness in dosage conversion. Regarding the side effects, although the incidence of the peripheral edema was higher with pregabalin compared with gabapentin, this finding is not conclusive because the present study was conducted in a small number of subjects. Although pain reduction can be expected to increase with pregabalin dosage, it is necessary to increase the dosage gradually and carefully because of exacerbation of side effects.

Efficacy of limited-duration spinal cord stimulation for subacute postherpetic neuralgia.

Excellent outcomes were achieved with spinal cord stimulation (SCS) for 7 to 10 days on 2 patients who developed postherpetic neuralgia. Both patients were within 2 to 3 months of the onset of the condition, and nerve blocks provided only temporary pain relief and drug therapies had poor efficacy. The authors believe that limited-duration SCS for subacute postherpetic neuralgia is a useful treatment approach that may prevent the pain from progressing to chronic postherpetic neuralgia.

[Efficacy of oral balance gel for dry mouth in preoperative patients].

BACKGROUND: Following anticholinergic premedication and preoperative fasting, preoperative patients with a potential xerostomia have complaints associated with oral dryness. Xerostomia may lead to risk of mucosal burning and secondary infection. The purpose of this prospective study was to assess the effect of oral balance gel on dryness of the mouth in preoperative patients. METHODS: Thirty nine patients scheduled for elective surgery were randomly assigned to either of the group with or without using the oral balance gel. Severity of the dry mouth was assesed using a 4-point scale (0=none, 1=mild, 2=moderate, 3=severe) and diadochokinesis test was performed on the day before surgery and on arrival at the OR. RESULTS: Comparing results of the two stages, we found that patients with no treatment had significantly deteriorated state of dry mouth, but patients who had received the oral balance gel had no significantly worse dry mouth compared with the preoperative state. CONCLUSIONS: In this study, patients without the oral balance gel frequently reported oral symptons and oral dysfunction associated with xerostomia. We conclude that the use of oral balance gel in preoperative patients is effective for the prevention of dryness of the dry mouth.

[Assessment of preoperative anxiety in patients entering the operating room on foot using state-trait anxiety inventory].

The purpose of this prospective study was to assess the effect of walking into the operating room on preoperative anxiety level. Sixty non-premedicated patients scheduled for elective surgery were randomly divided into two groups based on how they were transported into the operating room. One group was carried on a stretcher (n = 30) and the other entered on foot under their own power (n = 30). A subjective assessment of anxiety was performed using a state-trait anxiety inventory (STAI) the day before surgery and on arrival at the operating room. STAI values were not increased in the operating room as compared to the day before surgery for either group and did not differ between groups, though they showed a high level of anxiety throughout the preoperative period. We conclude that walking into the operating room has no significant influence on preoperative anxiety level.