Successful treatment with spinal cord stimulation for pain due to eosinophilic granulomatosis with polyangiitis: a case report.

BACKGROUND: Although most patients of eosinophilic granulomatosis with polyangiitis (EGPA) experience a reduction in pain within several weeks to months of the initiation of immunotherapies, some suffer from residual neuropathic symptoms for a long time. CASE PRESENTATION: A 28-year-old woman diagnosed with EGPA visited. She had been treated with steroid pulse therapy, intravenous immunoglobulin, and mepolizumab (antiinterleukin-5 agent). Her symptoms other than peripheral neuropathy improved, but posterior lower thigh pain and weakness of the lower legs worsened. At the initial visit, she used crutches and complained of numb pain in both posterior lower thighs, especially the left one. She also presented with left foot drop and reported a decreased tactile sensation on the lateral sides of both lower thighs. We performed spinal cord stimulation (SCS) at the L1 level on both sides. Her pain remarkably decreased, her tactile sensation improved, her muscle strength increased, and she was able to walk without crutches. CONCLUSIONS: We herein report the first case of lower extremity pain being successfully treated with SCS in an EGPA patient who did not respond well to drug therapy. Because the cause of pain in EGPA is neuropathy induced by vasculitis, there is ample ability for SCS to improve this pain. When pain is neuropathic, whatever the cause, SCS may be worth trying, even for pain from disorders other than EGPA.

Risk Factors of Hyperglycemia After Nerve Blockade with Dexamethasone in Non-Diabetes Mellitus Patients: A Cohort Study.

BACKGROUND: Glucocorticoids (GCs) are expected to inhibit the synthesis and release of proinflammatory cytokines, which induces local pain. Serious side effects or complications are considered rare with single-dose GC use. However, the amount of systemic absorption and the side effects induced by local GC injections are not well understood. OBJECTIVES: We measured the changes in glucose levels after single-does dexamethasone injection with nerve blockade using a continuous glucose monitoring system (CGMS) in non-diabetes mellitus (DM) patients and investigated the risk factors for hyperglycemia. STUDY DESIGN: This is a cohort study. SETTING: This study was conducted at Gifu University Hospital in Japan. METHODS: Forty-six non-DM patients who underwent elective lumbar or sacral nerve root pulsed radiofrequency or lumbar medial branch of the posterior primary rami conventional radiofrequency with dexamethasone (0.1 mg/kg) were analyzed. The patients underwent monitoring of their interstitial glucose using a CGMS. Hyperglycemia was defined as a blood glucose level >= 200 mg/dL. The area under the curve (AUC) where the blood glucose level was over 200 mg/dL was calculated and analyzed. The risk factors of hyperglycemia were determined using an applied ordinal regression model analysis with the AUC as the objective variable and 4 factors (age, body mass index, glucose level just before GC injection, and glycosylated hemoglobin) as explanatory variables. The blood glucose levels were predicted by a nonlinear regression model. RESULTS: The AUC and maximum glucose level were higher on the first day than after the second day. None of the 4 factors were predictors of hyperglycemia. The glucose level before the procedure was associated with the predicted blood glucose level on the first day (P = 0.042). However, the 95% upper confidence limit of the maximum predicted blood glucose level was less than the safety margin. The predicted blood glucose levels returned to the usual level after the second day. LIMITATIONS: First, GCs are metabolized by cytochrome p450 3A4, and it is possible that the inhibition of this pathway decreases the clearance of GCs. Some of our patients were taking medications that influence this cytochrome pathway. Second, we cannot eliminate the possibility of stress-induced hyperglycemia. Finally, we were unable to record the exact meal timing and calories the patients had consumed. CONCLUSIONS: The blood glucose levels were higher than usual on the first day following a local dexamethasone injection, but the levels were not critical in most cases. Because we cannot predict which patients will develop hyperglycemia, we must determine whether or not GCs can be safely administered and inform patients about potential complications.

Effect of Postoperative Administration of Pregabalin for Post-thoracotomy Pain: A Randomized Study.

OBJECTIVE: The present study was performed to evaluate the effect of postoperative administration of pregabalin in patients who reported moderate-to-severe pain after epidural analgesia following thoracotomy. DESIGN: An open-label, randomized, controlled, parallel-group study. SETTING: A single center in Japan. PARTICIPANTS: Consecutive patients (aged≥20 years) who reported moderate-to-severe pain after effectual 2-day epidural analgesia post-thoracotomy for lung cancer from February 2012 to March 2013. INTERVENTIONS: Patients were assigned to 2 groups: control (control treatment: acetaminophen, 400 mg, and codeine phosphate powder, 20 mg) or pregabalin (pregabalin, 75 mg, plus control treatment). The 12-week study period included 2-week study treatment and 10-week follow-up. MEASUREMENTS AND MAIN RESULTS: For efficacy, the primary endpoint was the visual analog scale (VAS) scores for pain at rest and with coughing at week 2, and secondary endpoints were the VAS scores for pain and the neuropathic pain questionnaire at week 12. Fifty patients were randomized (25 per group). At week 2, the VAS scores for pain at rest (mean [SD]) were 29.5 (21.9) in the control group and 16.3 (15) in the pregabalin group (p = 0.02); for pain with coughing, the scores were 45.2 (20.9) and 28.8 (25.9), respectively (p = 0.02). VAS scores improved more in the pregabalin group than in the control group over the 12 weeks. Patients free from possible neuropathic pain were 48% of the control group and 88% of the pregabalin group, respectively (p = 0.001). CONCLUSIONS: Postoperative administration of pregabalin effectively reduced post-thoracotomy pain.

Successful treatment by adding duloxetine to pregabalin for peripheral neuropathy induced by paclitaxel.

Although paclitaxel is a commonly used anticancer drug, peripheral neuropathy may develop as a side effect. Worsening of the symptoms with time may cause patients who receive paclitaxel to give up their chemotherapy. Duloxetine, a serotonin- and norepinephrine-reuptake inhibitor, has been used to treat peripheral neuropathic pain. We report the case of a 68-year-old man with gastric cancer, who underwent gastrectomy and then received 8 cycles of chemotherapy involving weekly administrations of paclitaxel. Under this paclitaxel treatment, he complained of severe peripheral neuropathy, leading to a diminished quality of life. Following treatment with a combination of duloxetine and pregabalin, a remission of his symptoms was achieved. Duloxetine plus pregabalin therapy may be useful for the peripheral neuropathy induced by paclitaxel.