Chronic pain is a multifactorial condition with both physical and psychological symptoms, and it affects around 20% of the population in the developed world. In spite of outstanding advances in pain management over the past decades, chronic pain remains a significant problem. This article provides a mechanism- and evidence-based approach to improve the outcome for pharmacologic management of chronic pain. The usual approach to treat mild to moderate pain is to start with a nonopioid analgesic. If this is inadequate, and if there is an element of sleep deprivation, then it is reasonable to add an antidepressant with analgesic qualities. If there is a component of neuropathic pain or fibromyalgia, then a trial with one of the gabapentinoids is appropriate. If these steps are inadequate, then an opioid analgesic may be added. For moderate to severe pain, one would initiate an earlier trial of a long term opioid. Skeletal muscle relaxants and topicals may also be appropriate as single agents or in combination. Meanwhile, the steps of pharmacologic treatments for neuropathic pain include (1) certain antidepressants (tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors), calcium channel alpha2-delta ligands (gabapentin and pregabalin) and topical lidocaine, (2) opioid analgesics and tramadol (for first-line use in selected clinical circumstances) and (3) certain other antidepressant and antiepileptic medications (topical capsaicin, mexiletine, and N-methyl-d-aspartate receptor antagonists). It is essential to have a thorough understanding about the different pain mechanisms of chronic pain and evidence-based multi-mechanistic treatment. It is also essential to increase the individualization of treatment.
Analgesics, Opioid ; Antidepressive Agents ; Calcium Channels ; Capsaicin ; Chronic Pain ; Fibromyalgia ; Lidocaine ; Ligands ; Mexiletine ; N-Methylaspartate ; Neuralgia ; Neuromuscular Agents ; Norepinephrine ; Pain Management ; Serotonin ; Sleep Deprivation ; Tramadol

Toxic methemoglobulinemia is a rare disease and poses great risks in anesthesia because the oxygen carring capacity of the blood is reduced. This condition may be idiopathic or result from exposure to grugs or chemical agents and is treasted by the intravenous injection of methylene blue. This 17 year-old male was admitted to St. Mary Hospital for right nephrectomy because of rupture of the right kidney after accidental ingestion of Diaminodiphenyl sulfate and then falling down. The patient appeared cyanosed and dark brown tinged blood was ween at the site of skin incision. The result of arterial blood gas analysis was relatively normal and no specific problem was detected during anesthesia. This patient was successfully trated with ascorbic acid, methylene blue and oxygenation.
Adolescent ; Anesthesia ; Ascorbic Acid ; Blood Gas Analysis ; Eating ; Humans ; Injections, Intravenous ; Kidney ; Male ; Methemoglobinemia* ; Methylene Blue ; Nephrectomy ; Oxygen ; Rare Diseases ; Rupture ; Skin ; Tolnaftate

The complex regional pain syndromes (CRPS I and CRPS II), also known as reflex sympathetic dystrophy and causalgia, have been recognized for the past 2,500 years. Despite its long history, the diagnosis and treatment of CRPS are still challenging. These syndromes can be characterized by discrete sensory, motor, and autonomic findings, but many patients with CRPS continue to suffer for years without the diagnosis. Although much progress has been made in the understanding of CRPS, many questions still remain unanswered. CRPS is probably a disease of the central nervous system. Yet, peripheral inflammatory processes, abnormal sympathetic- afferent coupling, and adrenoreceptor pathology may also be part of the picture. A close multidisciplinary approach amongst the pain medicine consultants, psychologist, physical and occupational therapists, and neurologist is necessary to achieve the maximum treatment outcomes. If conventional treatment (e.g. pharmacotherapy) fails to show a significant response within 12 weeks, an interventional technique such as spinal cord stimulation (SCS) needs to be tried. The current concepts of CRPS could be replaced by a new mechanism-based term or group of terms in the near future leading to improved clinical guidelines. This article reviews the different aspects of CRPS including its definition, classification, epidemiology and natural history, clinical presentation, pathophysiology and management.
Causalgia ; Central Nervous System ; Classification ; Complex Regional Pain Syndromes ; Consultants ; Diagnosis* ; Epidemiology ; Humans ; Natural History ; Pathology ; Psychology ; Reflex Sympathetic Dystrophy ; Spinal Cord Stimulation

Chronic perineal pain is an often encountered problem, which produces a great degree of functional impairment and frustration to the patient and a challenge to the treating physician. The reason for this problem is that the region contains diverse anatomic structures with mixed somatic, visceral and autonomic innervations affecting bladder and bowel control and sexual function. A blockade of nociceptive and sympathetic supply to the perineal region, supplied through the ganglion impar has been shown to benefit patients with chronic perineal pain. Several options to this block have been described that chemical neurolysis, radiofrequency ablation etc. Although the analgesic effect of Botulinum toxin type A (BoNT-A) has long been considered secondary to its action for muscle relaxation, BoNT-A also affects the release of the neurotransmitters that are involved in pain perception. We describe a patient who was successfully given ganglion impar block with BoNT-A.
Botulinum Toxins ; Botulinum Toxins, Type A ; Frustration ; Ganglion Cysts ; Humans ; Muscle Relaxation ; Nerve Block ; Neurotransmitter Agents ; Pain Perception ; Urinary Bladder

We experienced a complication of brachial plexus palsy secondary to operative position during thoracoscopic thoracic sympathectomies. His general health was excellent and no previous histories vulnerable to peripheral nerve systems were observed. The thoracic sympathectomies were done under general anesthesia. The patient was placed left lateral position with his right arm abduced 150o on padded arm board. An operation was lasted 2 hours and 30 minutes at this position because of severe right apical lung adhesion. The controlateral side was performed same procedure and lasted 20 minutes. After the patient recovered from the anesthesia, the patient had a complete paralysis of right arm. There was also slightly diminished sensation to pinprick on the arm and hand. Neurologic examination and EMG study revealed brachial plexus palsy. Nerve blocks and physiotherapy were performed to treat brachial plexus injuries. His motor functions were improved day by day and he was discharged with a complete range of motion against gravity on 14th. postoperation day. However, there were loss of muscle powers against some resistances and tingling sensations of fingertips. Two months later, he was recovered completely and there was no residual disabilities.
Anesthesia ; Anesthesia, General ; Arm ; Brachial Plexus* ; Gravitation ; Hand ; Humans ; Lung ; Nerve Block ; Neurologic Examination ; Paralysis* ; Peripheral Nerves ; Range of Motion, Articular ; Sensation ; Sympathectomy*

Intraperitoneal hyperthermic perfusion(IPHP) was performed under combined epidural & general anesthesia in 57 year old female patient with recurrent ovarian cancer. She had past history of diabetes mellitus. Metabolic acidosis & hypokalemia were already developed before IPHP and aggravated during IPHP. NaHCO3 300mEq & KCl 40mEq were administered intravenously for three hours. In this case, we deduced that the causes of metabolic acidosis may be anaerobic glycolysis due to peripheral circulatory impairment from hypothermia, degradation of tumor cells by hyperthermia, and poor general condition with prolonged operation. The causes of hypokalemia were suspected to be continuous infusion of regular insulin, massive NaHCO3 administration, and diabetic ketoacidosis. Therefore, we recommend when performing IPHP in DM patient, precise preoperative evaluation and careful monitoring of arterial blood gas & electrolyte.
Acid-Base Equilibrium ; Acidosis* ; Anesthesia, General ; Diabetes Mellitus ; Diabetic Ketoacidosis ; Female ; Fever ; Glycolysis ; Humans ; Hypokalemia ; Hypothermia ; Insulin ; Middle Aged ; Ovarian Neoplasms* ; Perfusion*

Thyrotoxic crisis is a life-threatening exacerbation of hyperthyroidism seen during periods of stress, which requires early recognition and adequate treatment. A 52-year-old female who suffered from severe right thoracic pain due to postherpetic neuralgia with hyperthyroidism, has been initially treated with antiviral agent and anticonvulsant in the department of neurology. She was transfered to our pain clinic because of uncontrolled severe pain. In our pain clinic, continuous thoracic epidural administration of bupivacaine and clonidine and oral analgesic medications produce visual analog scale from 8-9 to 5-6. She was admitted because of partially controlled pain and she was performed intercostal neurolysis with 10% phenol. As a result, visual analog scale was decreased from 5-6 to 2-3. After 3 days admission, extreme irritability, delirium, tachypnea, mild fever and tachycardia(heart rate: 160-180/min) were developed suddenly. Three hours later of proper treatment with oxygen inhalation, rapid fluid administration, diazepam 10 mg injection and antithyroid drug medication, heart rate and consciousness were returned to normal. Thoracic sympathetic ganglion neurolysis with absolute alcohol was performed without any sequelaes for the treatment of remnant visceral pain. And then, she was discharged with the relief of pain. The purpose of the present report is to review our experience with the clinical manifestations and management of thyrotoxic crisis developed during the treatment of postherpetic neuralgia, and to review of the treatment of thyrotoxic crisis and postherpetic neuralgia.
Bupivacaine ; Clonidine ; Consciousness ; Delirium ; Diazepam ; Ethanol ; Female ; Fever ; Ganglia, Sympathetic ; Heart Rate ; Humans ; Hyperthyroidism ; Inhalation ; Middle Aged ; Neuralgia, Postherpetic* ; Neurology ; Oxygen ; Pain Clinics ; Phenol ; Tachypnea ; Thyroid Crisis* ; Visceral Pain ; Visual Analog Scale

Sixty patients, undergoing major gynecologic surgery with lumbar epidural anesthesia, were randomly selected 32 patients to apply a transdermal scopolamine patch (Kimite MyoungMoon, Korea) on the skin behind one ear. We were divided into 2 groups. Control group; epidural morphine 4mg were given and not applied scopolamine patch. Experimental group; epidural morphine 4mg were given and applied transdermal scopolamine patch on the skin behind her ear at the night before surgery. They were followed up for 3 days postoperatively and statistical analysis was done. There was a significant (p<0.05) reduction in nausea and vomiting between experimental group and control group. There was no significant incresed incidence in scopolamine side effects. However, despite receiving transderrnal scopolamine patch there was still a high incidence (43.8%) of nausea and vomiting.
Anesthesia, Epidural ; Ear ; Female ; Gynecologic Surgical Procedures ; Humans ; Incidence ; Injections, Epidural* ; Morphine* ; Nausea* ; Scopolamine Hydrobromide* ; Skin ; Vomiting*

In transmembrane and intracellular sites of neurom, calcium ion(Ca(++)) has been known to have an important role of signalling process. It is naw well accepted that calcium binding proteins, calbindin D-28K (calbindin) and parvalbumin, modulate and mediate above aclcium ionss action as a second messenger. Although it has been reported that calbindinergic and parvalbuminergic neurons comprise different subpopulations in the cat and rat spinal cords, the studies of their morphology, topographical distribution and ultrastructural features have not been done extensively in the mammalian spinal cords until now. This study was conducted to localize calbidinergic and parvalbuminergic neurons and to define their morphology, topographical distribution and ultrastructural features in the rabbit cervical cord by the preembedding immunocytochemical method using anti-calbindin and anti-parvalbumin antisera. In the rabbit cervical cord, calbindin immunoreactive neurons were mainly distributed in the dorsal horn, especially in lamina II, and a smaI1 number of labelled neurons were observed in the intermediate gray matter (IGS), but calbindin immunoreactivities were not observed in the intermediate gray substance(IGS), but calbindin immunoreactiveties were not observed in thr ventral horn. The somata of calbindin immunoreactive neurons received synaptic inputs from non-immunoreactive axon terminals in the dorsal horn and in the IGS. Parvalbumin immunoreactive neurons were mainly observed in the IGS and in the ventral horn, but only a few of parvalbumin immunoreactive neurons were distributed in the dorsal horn. In the ventral horn, two types of parvalbumin immunoreactive neurons were identified according to the sizes of the somata and labelled motor cells received synaptic inputs from labelled and unlabelled axon terminals. These results demonstrate that calbindinergic neurons are a number of neurons located in lamina II of dorsal horn and a few of neurons located in the intermediate gray and parvalbuminergic ne.urons are laocated in the intermediate gray substance and in the ventral horn, and these neurons comprise different subpopulations of neurons. It was suggest that calbindinergic neurons might play an important role in the process of pain modulation and parvalbumiergic neurons in the control of motor activity with their specific synaptic circuitry in the spinal cord.
Animals ; Calbindins ; Calcium ; Calcium-Binding Proteins ; Cats ; Horns ; Immune Sera ; Motor Activity ; Neurons* ; Presynaptic Terminals ; Rats ; Second Messenger Systems ; Spinal Cord

MRI(Magnetic Resonance Imaging) have provided for greater image resolution, detailed tissue contrast without use of contrast media and images acquired in any plane. The purpose of this study was to examine the anatomy and dimension of the epidural space using MRI(Magnetic Resonance Imaging) and to compare the information obtained with that from other investigative technique. The anatomy of the lumbar epidural space was studied retrospectively using lumbar MRI scans of 90 patients. The epidural width(E.W.) is divided into three distance between the anterior surface of the ligamentum flavum and the dura at the caudal end of the lumbar segment(A), at the mid point of the ligamentum flavum(B) and at the cranial end of the lumbar segment(C). The distance from skin to supraspinous ligament(S-L) and from supraspinous ligament to epidural space(L-E) were measured. And then with adding both the distance, We measured the distance from skin to epidural space(S-E). Results were as follows; I) Posterior to the dural sac, epidural fat which is of high signal(white) on Tlw(T1 weighted) image is demonstrated at levels Tl I-T12 to L5-Sl giving 'Saw toothed' pattem to the epidural space. The fat is divided into segments by the interposing laminar, and the epidural space is deeper at cranial end than caudal end. 2) It was the relatively wide epidural space in L2-3 and L3-4 level, and the narrowest epidural space in L5-Sl level. 3) The distance from skin to supraspinous ligament was noted marked variation(2-40mm) according to the individual disparity. And the distance from supraspinous ligament to epidural space is 17-43mm. In distance from skin to epidural space, the most narrow place is Ll-21evel (37.95+/-7.65mm). The most deep place is IA-5 level(46.35+/-7.20mm). As the age increase, epidural width is decreased at L3-4 level (p<0.05).
Contrast Media ; Epidural Space* ; Humans ; Investigative Techniques ; Ligaments ; Ligamentum Flavum ; Magnetic Resonance Imaging* ; Retrospective Studies ; Skin