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Analgesia after Epidural Dexamethasone is Further Enhanced by IV Dipyrone, but Not IV Parecoxibe Following Minor Orthopedic Surgery.

Gabriela R LAURETTI ; Claudia C F RIGHETI ; Antonio T KITAYAMA

The Korean Journal of Pain.2014;27(4):345-352. doi:10.3344/kjp.2014.27.4.345

BACKGROUND: Epidural administration of dexamethasone has been suggested for pain control after minor orthopedic surgery. This study was conducted to assess its efficacy after such surgery, combined or not to IV dipyrone, IV parecoxibe or their combination. METHODS: 91 patients were randomly assigned to seven groups. Patients were submitted to spinal bupivacaine anesthesia combined to epidural administration of either 10 ml saline or 10 mg dexamethasone diluted to 10-ml volume. Patients also received 10 ml IV saline or 1 gr dipyrone and/or 40 mg parecoxibe diluted to 10 ml with saline. Control group (CG) received epidural and IV saline. Dexamethasone group (DexG) received epidural dexamethasone and IV saline. Dipyrone group (DipG) received epidural saline and IV dipyrone. Dex-Dip G received epidural dexamethasone and IV dipyrone. Parecoxibe group (ParG) received epidural saline and IV parecoxibe. Dex-ParG received epidural dexamethasone and IV parecoxibe. Finally, Dex-Dip-ParG received epidural dexamethasone and IV dipyrone plus IV parecoxibe. RESULTS: The CG expressed 4h of analgesia and sooner requested pain killer. DexG was similar to DipG or ParG or Dex-ParG (7-hours), and they requested less ketoprofen compared to the CG (P < 0.05). However, the Dex-DipG and the Dex-Dip-ParG resulted in longer time to demand pain killer (17-hours) and less ketoprofen consumption in 24-hours (P < 0.002). Adverse effects were similar among groups. CONCLUSIONS: The analgesia secondary to epidural dexamethasone was enhanced by IV dipyrone, while no effects were observed by the addition of IV parecoxibe.
Analgesia* ; Anesthesia ; Bupivacaine ; Dexamethasone* ; Dipyrone* ; Humans ; Ketoprofen ; Orthopedics* ; Pain, Postoperative

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Do Severity Score and Skin Temperature Asymmetry Correlate with the Subjective Pain Score in the Patients with Complex Regional Pain Syndrome?.

Seung Gyu JEON ; Eun Joo CHOI ; Pyung Bok LEE ; Young Jae LEE ; Min Soo KIM ; Joung Hwa SEO ; Francis Sahngun NAHM

The Korean Journal of Pain.2014;27(4):339-344. doi:10.3344/kjp.2014.27.4.339

BACKGROUND: The diagnostic criteria of complex regional pain syndrome (CRPS) have mainly focused on dichotomous (yes/no) categorization, which makes it difficult to compare the inter-patient's condition and to evaluate the intra-patient's subtle severity over the course of time. To overcome this limitation, many efforts have been made to create laboratory methods or scoring systems to reflect the severity of CRPS; measurement of the skin temperature asymmetry is one of the former, and the CRPS severity score (CSS) is one of the latter. However, there has been no study on the correlations among the CSS, temperature asymmetry and subjective pain score. The purpose of this study was to evaluate whether there is any correlation between the CSS, skin temperature asymmetry and subjective pain score. METHODS: Patients affected with CRPS in a unilateral limb were included in this study. After making a diagnosis of CRPS according to the Budapest criteria, the CSS and skin temperature difference between the affected and unaffected limb (DeltaT) was measured in each patient. Finally, we conducted a correlation analysis among the CSS, DeltaT and visual analogue scale (VAS) score of the patients. RESULTS: A total of 42 patients were included in this study. There was no significant correlation between the DeltaT and VAS score (Spearman's rho = 0.066, P = 0.677). Also, the CSS and VAS score showed no significant correlation (Spearman's rho = 0.163, P = 0.303). CONCLUSIONS: The DeltaT and CSS do not seem to reflect the degree of subjective pain in CRPS patients.
Diagnosis ; Extremities ; Humans ; Pain Measurement ; Severity of Illness Index ; Skin Temperature*

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The Effects of a Forceful Transforaminal Epidural Steroid Injection on Radicular Pain: A Preliminary Study.

Jong Min BYUN ; Hahck Soo PARK ; Jae Hee WOO ; Jin KIM

The Korean Journal of Pain.2014;27(4):334-338. doi:10.3344/kjp.2014.27.4.334

BACKGROUND: Lumbar transforaminal epidural steroid injections (TFESIs) are performed to provide symptom relief in patients with radicular pain. Recent articles suggested that injected volume itself have analgesic effects and higher volumes are associated with better outcomes. To date, few studies have been conducted to investigate the effects of volume. Therefore, well-designed controlled studies were necessary to confirm the effect of volume itself on pain relief. The purpose of this study was to examine the effectiveness of a forceful saline injection on lumbar TFESI using non-particulate steroids. METHODS: Fifty consecutive patients with lumbar radicular pain were enrolled. The participants were allocated into one of two groups: dexamethasone with volume (Group DV) and dexamethasone alone (Group DO). The volume was delivered by a forceful injection of 5ml of normal saline. The primary end-point for this study was a VAS pain score and modified MacNab score indicating the rate of effectiveness at the four-week follow-up. RESULTS: There were no significant post-procedural VAS differences between two groups (P = .252). The effectiveness rate among the patients was 47.8% in DV group, 34.8% in DO group, measured by modified MacNab score. The difference was not statistically significant (P = .117). CONCLUSIONS: A forceful saline injection did not have a significant effect during the treatment of radicular pain. Further studies with greater volumes and with additional techniques would offer a more conclusive perspective.
Dexamethasone ; Follow-Up Studies ; Humans ; Radiculopathy ; Steroids

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Effects of Nefopam on Streptozotocin-Induced Diabetic Neuropathic Pain in Rats.

Jae Sik NAM ; Yu Seon CHEONG ; Myong Hwan KARM ; Ho Soo AHN ; Ji Hoon SIM ; Jin Sun KIM ; Seong Soo CHOI ; Jeong Gil LEEM

The Korean Journal of Pain.2014;27(4):326-333. doi:10.3344/kjp.2014.27.4.326

BACKGROUND: Nefopam is a centrally acting non-opioid analgesic agent. Its analgesic properties may be related to the inhibitions of monoamine reuptake and the N-methyl-D-aspartate (NMDA) receptor. The antinociceptive effect of nefopam has been shown in animal models of acute and chronic pain and in humans. However, the effect of nefopam on diabetic neuropathic pain is unclear. Therefore, we investigated the preventive effect of nefopam on diabetic neuropathic pain induced by streptozotocin (STZ) in rats. METHODS: Pretreatment with nefopam (30 mg/kg) was performed intraperitoneally 30 min prior to an intraperitoneal injection of STZ (60 mg/kg). Mechanical and cold allodynia were tested before, and 1 to 4 weeks after drug administration. Thermal hyperalgesia was also investigated. In addition, the transient receptor potential ankyrin 1 (TRPA1) and TRP melastatin 8 (TRPM8) expression levels in the dorsal root ganglion (DRG) were evaluated. RESULTS: Pretreatment with nefopam significantly inhibited STZ-induced mechanical and cold allodynia, but not thermal hyperalgesia. The STZ injection increased TRPM8, but not TRPA1, expression levels in DRG neurons. Pretreatment with nefopam decreased STZ-induced TRPM8 expression levels in the DRG. CONCLUSIONS: These results demonstrate that a nefopam pretreatment has strong antiallodynic effects on STZ-induced diabetic rats, which may be associated with TRPM8 located in the DRG.
Animals ; Ankyrins ; Chronic Pain ; Diabetic Neuropathies ; Diagnosis-Related Groups ; Ganglia, Spinal ; Humans ; Hyperalgesia ; Injections, Intraperitoneal ; Models, Animal ; N-Methylaspartate ; Nefopam* ; Neuralgia* ; Neurons ; Rats* ; Streptozocin

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Anatomic Variations of Cervical and High Thoracic Ligamentum Flavum.

Sang Pil YOON ; Hyun Jung KIM ; Yun Suk CHOI

The Korean Journal of Pain.2014;27(4):321-325. doi:10.3344/kjp.2014.27.4.321

BACKGROUND: Epidural blocks are widely used for the management of acute and chronic pain. The technique of loss of resistance is frequently adopted to determine the epidural space. A discontinuity of the ligamentum flavum may increase the risk of failure to identify the epidural space. The purpose of this study was to investigate the anatomic variations of the cervical and high thoracic ligamentum flavum in embalmed cadavers. METHODS: Vertebral column specimens of 15 human cadavers were obtained. After vertebral arches were detached from pedicles, the dural sac and epidural connective tissue were removed. The ligamentum flavum from C3 to T6 was directly examined anteriorly. RESULTS: The incidence of midline gaps in the ligamentum flavum was 87%-100% between C3 and T2. The incidence decreased below this level and was the lowest at T4-T5 (8%). Among the levels with a gap, the location of a gap in the caudal third of the ligamentum flavum was more frequent than in the middle or cephalic portion of the ligamentum flavum. CONCLUSIONS: The cervical and high thoracic ligamentum flavum frequently has midline intervals with various features, especially in the caudal portion of the intervertebral space. Therefore, the ligamentum flavum is not always reliable as a perceptible barrier to identify the epidural space at these vertebral levels. Additionally, it may be more useful to insert the needle into the cephalic portion of the intervertebral space than in the caudal portion.
Analgesia, Epidural ; Cadaver ; Chronic Pain ; Connective Tissue ; Epidural Space ; Humans ; Incidence ; Ligamentum Flavum* ; Needles ; Spine

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Safe Sedation and Hypnosis using Dexmedetomidine for Minimally Invasive Spine Surgery in a Prone Position.

Kyung Hoon KIM

The Korean Journal of Pain.2014;27(4):313-320. doi:10.3344/kjp.2014.27.4.313

Dexmedetomidine, an imidazoline compound, is a highly selective alpha2-adrenoceptor agonist with sympatholytic, sedative, amnestic, and analgesic properties. In order to minimize the patients' pain and anxiety during minimally invasive spine surgery (MISS) when compared to conventional surgery under general anesthesia, an adequate conscious sedation (CS) or monitored anesthetic care (MAC) should be provided. Commonly used intravenous sedatives and hypnotics, such as midazolam and propofol, are not suitable for operations in a prone position due to undesired respiratory depression. Dexmedetomidine converges on an endogenous non-rapid eye movement (NREM) sleep-promoting pathway to exert its sedative effects. The great merit of dexmedetomidine for CS or MAC is the ability of the operator to recognize nerve damage during percutaneous endoscopic lumbar discectomy, a representative MISS. However, there are 2 shortcomings for dexmedetomidine in MISS: hypotension/bradycardia and delayed emergence. Its hypotension/bradycardiac effects can be prevented by ketamine intraoperatively. Using atipamezole (an alpha2-adrenoceptor antagonist) might allow doctors to control the rate of recovery from procedural sedation in the future. MAC, with other analgesics such as ketorolac and opioids, creates ideal conditions for MISS. In conclusion, dexmedetomidine provides a favorable surgical condition in patients receiving MISS in a prone position due to its unique properties of conscious sedation followed by unconscious hypnosis with analgesia. However, no respiratory depression occurs based on the dexmedetomidine-related endogenous sleep pathways involves the inhibition of the locus coeruleus in the pons, which facilitates VLPO firing in the anterior hypothalamus.
Adrenergic alpha-2 Receptor Agonists ; Analgesia ; Analgesics ; Analgesics, Opioid ; Anesthesia, General ; Anxiety ; Conscious Sedation ; Dexmedetomidine* ; Diskectomy ; Diskectomy, Percutaneous ; Eye Movements ; Fires ; Humans ; Hypnosis* ; Hypnotics and Sedatives ; Hypothalamus, Anterior ; Ketamine ; Ketorolac ; Locus Coeruleus ; Midazolam ; Pons ; Prone Position* ; Propofol ; Respiratory Insufficiency ; Spine* ; Surgical Procedures, Minimally Invasive

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Guides for Pain Clinicians?.

Kyung Bong YOON

The Korean Journal of Pain.2014;27(4):311-312. doi:10.3344/kjp.2014.27.4.311

No abstract available.

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Spinal Arteriovenous Malformation Masquerating Zoster Sine Herpete.

Ji Young LEE ; Se Jin OK ; Chang Keun OH ; Sun Kyung PARK ; Do Wan KIM ; Jong Yeun YANG

The Korean Journal of Pain.2013;26(1):72-75. doi:10.3344/kjp.2013.26.1.72

Zoster sine herpete (ZSH) is difficult to diagnosis during an acute period due to the absence of the characteristic zosteriform dermatomal rash; therefore, progression to postherpetic neuralgia is more common than typical zoster. In addition, misdiagnosis of other neuropathic pain as ZSH is common in clinical situations. Here, we report a case of spinal arteriovenous malformation that mimics ZSH. This is a rare condition; therefore, high clinical suspicion for a correct diagnosis and proper examination are not easy. However, early diagnosis and definitive treatment are essential to prevent neurologic deficit and mortality.
Arteriovenous Malformations ; Diagnostic Errors ; Early Diagnosis ; Herpes Zoster ; Neuralgia ; Neuralgia, Postherpetic ; Neurologic Manifestations ; Zoster Sine Herpete

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Scrambler Therapy for Patients with Cancer Pain: Case Series.

Hong Sik PARK ; Woo Kyung SIN ; Hye Young KIM ; Jee Youn MOON ; Soo Young PARK ; Yong Chul KIM ; Sang Chul LEE

The Korean Journal of Pain.2013;26(1):65-71. doi:10.3344/kjp.2013.26.1.65

More than 80% of cancer patients experience cancer pain. Among them, more than 50% experience moderate to severe pain. To control cancer pain, a variety of methods have been used, including medications and nerve blocks. In some patients, however, it is impossible to perform nerve blocks due to caner metastasis into the epidural space, while in other patients, opioid dose escalation is impossible due to opioid side effects; thus, cancer pain management is difficult. Scrambler therapy is a novel approach for pain control that uses EKG-like pads, which are applied above and below the site of pain. Scrambler therapy synthesizes 16 different types of nerve action potentials that provide "non-pain" information via cutaneous nerves. The advantages of this treatment are that it is non-invasive and safe and has no significant side effects. In this case series, we report the treatment results of using scrambler therapy in three cancer patients with intractable pain.
Action Potentials ; Epidural Space ; Humans ; Neoplasm Metastasis ; Nerve Block ; Pain Management ; Pain, Intractable

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Intractable Hemifacial Spasm Treated by Pulsed Radiofrequency Treatment.

Hae Lang PARK ; Seung Mo LIM ; Tae Hwa KIM ; Kyung Ho KANG ; Hyun KANG ; Yong Hun JUNG ; Chong Wha BAEK ; Young Cheol WOO ; Jin Yun KIM ; Gill Hoi KOO ; Hwa Yong SHIN

The Korean Journal of Pain.2013;26(1):62-64. doi:10.3344/kjp.2013.26.1.62

Hemifacial spasm is defined as unilateral, involuntary, irregular twitching of all or parts of the muscles innervated by facial nerves. Here, we present a case of recurrent hemifacial spasm after microvascular decompression (MVD) treated with pulsed radiofrequency (PRF) treatment with good results. A 35-year-old woman suffered from recurrent hemifacial spasm after MVD that was refractory to medical treatment and botulinum toxin injections. We attempted a left facial nerve block twice. Then, we applied PRF at a maximum temperature of 42degrees C for 120 sec. Some response was observed, so we applied PRF two additional times. The frequency of twitch decreased from 3-4 Hz to < 0.5 Hz, and subjective severity on a visual analogue scale also decreased from 10/10 to 2-3/10. PRF treatment might be an effective medical treatment for refractory hemifacial spasm and has fewer complications and is less invasive compared with those of surgery.
Botulinum Toxins ; Facial Nerve ; Female ; Hemifacial Spasm ; Humans ; Microvascular Decompression Surgery ; Muscles ; Pulsed Radiofrequency Treatment

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