“Chronic pain after spinal surgery” (CPSS) is a nonspecific term for cases in which the end result of surgery generally does not meet the preoperative expectations of the patient and surgeon. This term has replaced the previous term i.e., failed back surgery syndrome. CPSS is challenging for both patients and doctors. Despite advancements in surgical techniques and technologies, a subset of patients continue to experience persistent or recurrent pain postoperatively. This review provides an overview of the multimodal management for CPSS, ranging from conservative management to revision surgery. Drawing on recent research and clinical experience, we aimed to offer insights into the diverse strategies available to improve the quality of life of CPSS patients.

Patients with heart failure undergoing surgery that requires general anesthesia face substantial perioperative risks; however, clear guidelines are not available for anesthesia management in patients with a reduced left ventricular ejection fraction. Traditional intravenous and volatile anesthetics require careful administration to prevent severe hypotension and bradycardia in patients with heart failure. Remimazolam has emerged as a promising alternative to conventional anesthetics because of its reduced cardiovascular depressive effects. We present three cases illustrating the successful use of remimazolam to induce and maintain general anesthesia in patients with heart failure and reduced cardiac function. Our cases demonstrate the safe use of remimazolam for general anesthesia in patients with heart failure and a reduced ejection fraction.

Tetanus is a bacterial infection by Clostridium tetani. Its neurotoxin causes spastic paralysis and autonomic dysfunction. Intrathecal infusion of baclofen has been suggested as a pertinent treatment for generalized spasm. Our case describes a patient who had a severe generalized form of tetanus, and was effectively treated with intrathecal baclofen infusion. He showed cerebral and brainstem dysfunction during baclofen infusion, which were reversed without sequelae when baclofen was discontinued.

Selection and insertion of an endotracheal tube (ETT) of appropriate size for airway management during general anesthesia in pediatric patients is very important. A very small ETT increases the risk of inadequate ventilation, air leakage, and aspiration, whereas a very large ETT may cause serious complications including airway damage, post-intubation croup, and, in severe cases, subglottic stenosis. Although the pediatric larynx is conical, the narrowest part, the rima glottidis, is cylindrical in the anteroposterior dimension, regardless of development, and the cricoid ring is slightly elliptical. A cuffed ETT reduces the number of endotracheal intubation attempts, and if cuff pressure can be maintained within a safe range, the risk of airway damage may not be greater than that of an ETT without cuff. The age-based formula suggested by Cole (age/4 + 4) has long been used to select the appropriate ETT size in children. Because age-based formulas in children are not always accurate, various alternative methods for estimating the ETT size have been examined and suggested. Chest radiography, ultrasound, and a three-dimensional airway model can be used to determine the appropriate ETT size; however, there are several limitations.

Background: Despite significant technological advances in the implantable pulse generator (IPG), complications can still occur. We report a case that unexpected extrusion of the IPG of spinal cord stimulation (SCS) was promptly identified and successfully removed without any complications. Case: After a car accident 4 years ago, a 55-year-old man who was diagnosed with complex local pain syndrome in his right leg. The SCS was inserted with 2 leads, with the IPG being implanted in the right lower abdomen region. Four years later, he developed extrusion of the IPG from his abdominal region. This unexpected extrusion may have been related to pressure necrosis caused by continued compression of pocket site where a belt was frequently tied. The IPG and the leads were successfully removed without infection occurring. Conclusions To prevent unexpected extrusion of IPG, it is necessary to consider in advance whether the pocket site is pressed against the belt.

Purpose: The aim of this study was to investigate celiac plexus neurolysis (CPN) for the treatment of cancerous upper abdominal pain in a tertiary university hospital in Korea. Methods: At the tertiary university hospital in Korea, electronic medical records of cancer patients who underwent CPN and died in the hospital from November 2009 to June 2018 were retrospectively analyzed. Results: The total number of subjects was 51. The 17 patients were from the Department of Gastroenterology (33.0%), followed by 11 patients from the Department of Hemato-oncology (21.6%), 11 patients from the Department of Anesthesia and Pain Medicine (21.6%), 9 patients from the Department of General Surgery (17.6%). The diagnosis was pancreatic cancer in 15 patients (29.4%), stomach cancer in 8 patients (15.7%), hepatobiliary cancer in 20 patients (39.2%), colon cancer in 1 patient (2.0%), esophageal cancer in 2 patient (3.9%) and intra-abdominal metastasis in 5 patients (9.8%). The mean survival time after the surgery was 66.4±55.0 days. The pain intensity before and 1 week after the procedure significantly decreased, but the amounts of opioids consumed before and 1 week after the procedure were not statistically significant. Side effects occurred after the procedure including temporary localized pain in 24 patients (47.0%), hypotension in 12 (23.5%), and diarrhea in 6 (11.8%). Conclusion CPN is an effective and safe procedure for reducing upper abdominal pain caused by cancer, and it is necessary to perform CPN within the appropriate time by establishing a system of interdepartmental cooperation.

Background: Intravenous dexmedetomidine has been reported to potentiate the anesthetic effect of local anesthetics and improve the quality of postoperative analgesia when used as an adjuvant in neuraxial block. We compared the effects of intravenous dexmedetomidine and midazolam for sedation on combined spinal-epidural (CSE) anesthesia. Methods: This study included 50 patients undergoing total knee arthroplasty. CSE anesthesia was given using 10 mg bupivacaine for all patients. After checking the maximum sensory and motor levels, the patients were randomly allocated into two groups of 25 each to receive intravenous continuous infusion of dexmedetomidine (Group D) or midazolam (Group M) for sedation during surgery. Regression block level, hemodynamic changes, and sedation score were compared between the groups when the patients entered the postanesthetic care unit (PACU). For patient-controlled epidural analgesia, 0.2% levobupivacaine with 650 μg of fentanyl (150 ml in total) was infused at a rate of 1 ml/h, in addition to a 3-ml bolus dose with a 30-min lockout time. The visual analogue scale scores, additional analgesic demand, patient satisfaction, and adverse events between the two groups were also compared postoperatively. Results: A significant difference was observed in relation to the sensory block level in the PACU (Group D: 6.3 ± 2.1; Group M: 3.2 ± 1.9) (P = 0.002). The motor block level and other outcomes showed no significant intergroup differences. Conclusions Intravenous injection of dexmedetomidine, rather than midazolam, for procedural sedation is associated with prolonged sensory block, with comparable incidences of adverse events during CSE anesthesia.

A 38-year-old female patient had bradycardia in the preoperative electrocardiogram (ECG), and she showed severe bradycardia, with the heart rate (HR) under 40 beats per minute (bpm) even after arrival in the operating room. Immediately after endotracheal intubation, ventricular tachycardia with HR over 200 bpm occurred, but it disappeared voluntarily. The surgery was postponed for additional cardiac evaluation because of the persistent severe bradycardia. On postanesthesia day 2, complete atrioventricular (AV) block appeared. We expected spontaneous recovery over 2 weeks, but the complete AV block persisted. A permanent pacemaker was eventually inserted, and the patient was discharged without other complications on day 4 after insertion of the pacemaker. We report this case because complete AV block has commonly occurred in patients with risk factors such as first AV block, secondary AV block, or bundle branch block, but complete AV block has occurred despite the absence of arrhythmia in this patient.
Adult ; Anesthesia, General ; Arrhythmias, Cardiac ; Atrioventricular Block ; Bradycardia ; Bundle-Branch Block ; Electrocardiography ; Female ; Heart Rate ; Humans ; Intubation, Intratracheal ; Operating Rooms ; Risk Factors ; Tachycardia, Ventricular

Remifentanil is commonly used in operating rooms and intensive care units for the purpose of anesthesia and sedation or analgesia. Although remifentanil may significantly affect the bone regeneration process in patients, there have been few studies to date on the effects of remifentanil on bone physiology. The purpose of this study was to investigate the effects of remifentanil on osteoclast differentiation and bone resorption. Bone marrow-derived macrophages (BMMs) were cultured for 4 days in remifentanil concentrations ranging from 0 to 100 ng/ml, macrophage colony-stimulating factor (M-CSF) alone, or in osteoclastogenic medium to induce the production of mature osteoclasts. To determine the degree of osteoclast maturity, tartrate-resistant acid phosphatase (TRAP) staining was performed. RT-PCR and western blotting analyses were used to determine the effect of remifentanil on the signaling pathways involved in osteoclast differentiation and maturation. Bone resorption and migration of BMMs were analyzed to determine the osteoclastic activity. Remifentanil reduced the number and size of osteoclasts and the formation of TRAP-positive multinuclear osteoclasts in a dose-dependent manner. Expression of c-Fos and NFATC1 was most strongly decreased in the presence of RANKL and remifentanil, and the activity of ERK was also inhibited by remifentanil. In the bone resorption assay, remifentanil reduced bone resorption and did not significantly affect cell migration. This study shows that remifentanil inhibits the differentiation and maturation of osteoclasts and reduces bone resorption.
Acid Phosphatase ; Analgesia ; Anesthesia ; Blotting, Western ; Bone Regeneration ; Bone Resorption* ; Cell Movement ; Humans ; Intensive Care Units ; Macrophage Colony-Stimulating Factor ; Macrophages ; Operating Rooms ; Osteoclasts* ; Physiology

BACKGROUND: Sedation during epidural anesthesia can reduce patients' anxiety and discomfort. Dexmedetomidine has sedative, hypnotic, and analgesic effects, with minimal respiratory depression. However, the use of dexmedetomidine is associated with prolonged recovery. This study investigated the optimal dose of intravenous dexmedetomidine for proper sedation with minimal recovery time in epidural anesthesia. METHODS: Sixty-three patients (American Society of Anesthesiologists physical status I/II) were randomized into two groups. Following epidural anesthesia, a loading dose (1 µg/kg) of dexmedetomidine was administered for 10 min followed by maintenance infusion as follows: Group A (n = 32; dexmedetomidine 0.6 µg/kg/h) and Group B (n = 31; dexmedetomidine 1.0 µg/kg/h). Heart rate, blood pressure, and bispectral index score (BIS) were recorded during surgery. The length of stay and modified Aldrete score (MAS) were measured in the postanesthesia care unit (PACU). RESULTS: Length of stay in the PACU was longer in Group B than in Group A (P < 0.05). The MAS was higher in Group A after 30 min in the PACU (P < 0.05). The BIS did not significantly differ between the two groups from baseline to 150 min after infusion of dexmedetomidine. BIS values were significantly higher in Group A at 160 min (P < 0.05). The mean arterial pressure in Group B was significantly lower in the PACU. CONCLUSIONS: Length of stay in the PACU was longer in Group B than in Group A (P < 0.05). The MAS was higher in Group A after 30 min in the PACU (P < 0.05). The BIS did not significantly differ between the two groups from baseline to 150 min after infusion of dexmedetomidine. BIS values were significantly higher in Group A at 160 min (P < 0.05). The mean arterial pressure in Group B was significantly lower in the PACU.
Anesthesia, Epidural* ; Anxiety ; Arterial Pressure ; Arthroplasty, Replacement, Knee ; Blood Pressure ; Dexmedetomidine* ; Heart Rate ; Humans ; Length of Stay ; Respiratory Insufficiency