Regional Anesthesia and Pain Medicine最新文献

Background: There is potential for adverse events from corticosteroid injections, including increase in blood glucose, decrease in bone mineral density and suppression of the hypothalamic-pituitary axis. Published studies note that doses lower than those commonly injected provide similar benefit.

Methods: Development of the practice guideline was approved by the Board of Directors of American Society of Regional Anesthesia and Pain Medicine with several other societies agreeing to participate. The scope of guidelines was agreed on to include safety of the injection technique (landmark-guided, ultrasound or radiology-aided injections); effect of the addition of the corticosteroid on the efficacy of the injectate (local anesthetic or saline); and adverse events related to the injection. Based on preliminary discussions, it was decided to structure the topics into three separate guidelines as follows: (1) sympathetic, peripheral nerve blocks and trigger point injections; (2) joints; and (3) neuraxial, facet, sacroiliac joints and related topics (vaccine and anticoagulants). Experts were assigned topics to perform a comprehensive review of the literature and to draft statements and recommendations, which were refined and voted for consensus (≥75% agreement) using a modified Delphi process. The United States Preventive Services Task Force grading of evidence and strength of recommendation was followed.

Results: This guideline deals with the use and safety of corticosteroid injections for sympathetic, peripheral nerve blocks and trigger point injections for adult chronic pain conditions. All the statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Board of Directors of the participating societies also approved all the statements and recommendations. The safety of some procedures, including stellate blocks, lower extremity peripheral nerve blocks and some sites of trigger point injections, is improved by imaging guidance. The addition of non-particulate corticosteroid to the local anesthetic is beneficial in cluster headaches but not in other types of headaches. Corticosteroid may provide additional benefit in transverse abdominal plane blocks and ilioinguinal/iliohypogastric nerve blocks in postherniorrhaphy pain but there is no evidence for pudendal nerve blocks. There is minimal benefit for the use of corticosteroids in trigger point injections.

Conclusions: In this practice guideline, we provided recommendations on the use of corticosteroids in sympathetic blocks, peripheral nerve blocks, and trigger point injections to assist clinicians in making informed decisions.

Background: Intractable hiccups, defined as those persisting for over 1 month, represent a rare but significant clinical challenge often associated with substantial morbidity and refractory to standard treatments.

Case presentation: This case report describes the innovative use of phrenic nerve peripheral neuromodulation for managing chronic intractable hiccups in a 73-year-old male patient with a 6-year history of daily hiccups. Conventional treatments and interventional procedures had failed to provide lasting relief. Bilateral phrenic nerve peripheral nerve stimulation (PNS) placed under ultrasound guidance resulted in immediate and substantial improvement, with the patient's Hiccup Assessment Instrument score decreasing from 6/10 to 2/10. The patient experienced significant enhancements in speech and quality of life without complications.

Conclusions: This novel application of phrenic nerve PNS highlights its potential as a therapeutic strategy for intractable hiccups, underscoring their pathophysiologic involvement of the diaphragm and respiratory muscles. The findings suggest that phrenic nerve PNS could offer a viable treatment option for patients unresponsive to conventional therapies, warranting further research to establish its long-term efficacy and safety.

Introduction: Limited non-opioid analgesic options are available for managing postoperative pain after renal transplantation. We aimed to investigate whether the unilateral anterior quadratus lumborum (QL) block would reduce postoperative opioid consumption after living-donor renal transplantation in the context of multimodal analgesia.

Methods: Eighty-eight adult patients undergoing living-donor renal transplantation were randomly allocated to receive the unilateral anterior QL block (30 mL of ropivacaine 0.375%) or sham block (normal saline) on the operated side before emergence from anesthesia. All patients received standard multimodal analgesia, including the scheduled administration of acetaminophen and fentanyl via intravenous patient-controlled analgesia. The primary outcome was the total opioid consumption during the first 24 hours after transplantation. The secondary outcomes included pain scores, time to first opioid administration, cutaneous distribution of sensory blockade, motor weakness, nausea/vomiting, quality of recovery scores, time to first ambulation, and length of hospital stay.

Results: The total opioid consumption in the first 24 hours after transplantation did not differ significantly between the intervention and control groups (median (IQR), 160.5 (78-249.8) vs 187.5 (93-309) oral morphine milligram equivalent; median difference (95% CI), -27 (-78 to 24), p=0.29). No differences were observed in the secondary outcomes.

Conclusions: The anterior QL block did not reduce opioid consumption in patients receiving multimodal analgesia after living-donor renal transplantation. Our findings do not support the routine administration of the anterior QL block in this surgical population.

Trial registration number: NCT04908761.

With headache being one of the most common chief complaints, it is essential for pain practitioners to interpret and differentiate a variety of headache characteristics to accurately diagnose and treat specific headache disorders. Certain misconceptions often lead to misdiagnosis. This article presents and discusses six myths about several common headache disorders (migraine, tension-type headache, cluster headache, cervicogenic headache, sinus headache, and occipital neuralgia) often encountered in clinical practice. The discussion is based primarily on the International Classification of Headache Disorders, 3rd edition and the latest studies. Recognizing and understanding the intricacies behind key headache diagnoses will help providers devise appropriate plans to better care for their patients.

Introduction: This study aimed to investigate whether low-volume local anesthetic with intravenous dexamethasone can reduce the incidence of diaphragmatic paresis while maintaining the analgesic duration compared with conventional volume of local anesthetic without intravenous dexamethasone when performing ultrasound-guided superior trunk block in patients undergoing arthroscopic shoulder surgery.

Methods: Eighty-four adult patients undergoing arthroscopic shoulder surgery under general anesthesia were randomly assigned to receive ultrasound-guided superior trunk block using 7 mL of 0.5% ropivacaine with 0.15 mg/kg of intravenous dexamethasone (treatment group), or 15 mL of 0.5% ropivacaine with intravenous normal saline (control group). The co-primary outcomes were (1) the duration of analgesia (time between block completion and onset of surgical pain with a Numeric Rating Scale pain score of 4 or higher), which was compared against a non-inferiority margin of 3 hours, and (2) the incidence of diaphragmatic paresis evaluated using M-mode ultrasonography in the post-anesthesia care unit.

Results: The mean duration of analgesia was 12.4 (6.8) and 11.2 (4.6) hours in the treatment and control groups, respectively (mean difference: -1.2 hours; 95% CI -3.8 to 1.3]; p for non-inferiority<0.001), meeting the non-inferiority criteria. The incidence of diaphragmatic paresis was 45.2% and 85.4% in the treatment and control groups, respectively (relative risk: 0.53; 97.5% CI 0.35 to 0.80; p<0.001).

Conclusions: Superior trunk block using low-volume local anesthetic with intravenous dexamethasone can reduce the incidence of diaphragmatic paresis while providing non-inferior analgesic duration compared with the conventional volume of local anesthetic in patients undergoing arthroscopic shoulder surgery.

Trial registration number: Clinical Research Information Service of Republic of Korea Registry (KCT0005998).

Introduction: Osteoarthritis (OA) of the thumb carpometacarpal (CMC) joint is a common disorder that negatively impacts hand function. Denervation of the thumb CMC joint has emerged as a viable treatment option. However, the innervation pattern of the thumb CMC joint is controversial. Therefore, the objective of this study was to identify the articular branches supplying the thumb CMC joint and to document their relationship to anatomical landmarks to provide the foundation for image-guided diagnostic block and denervation procedures.

Methods: In 10 formalin-embalmed upper limb specimens articular branches supplying the thumb CMC joint were dissected from their origin to termination. A frequency map documenting the number of articular branches was generated. The frequency map enabled visualization and comparison of the relative area of innervation of the thumb CMC joint by each articular branch.

Results: The thumb CMC joint received innervation from six nerves. These were the deep branch of ulnar nerve (DBUN), dorsal articular nerve (DAN) of the first interosseus space, thenar branch of median nerve (TBMN), palmar cutaneous branch of median nerve (PCBMN), lateral antebrachial cutaneous nerve (LACN) and superficial branch of the radial nerve (SBRN) and/or their branches. Each nerve was found to innervate different aspects of the joint. The DBUN and DAN were found to innervate the posteromedial aspect of the thumb CMC joint, the TBMN and PCBMN anterior/anteromedial aspects, LACN posterolateral/lateral/anterior aspects and SBRN posterolateral/anterolateral aspects.

Conclusions: The thumb CMC joint was innervated by articular branches originating from the SBRN, DAN, LACN, PCBMN, TBMN and DBUN. The documented anatomical relationships provide the foundation to inform selective diagnostic block and denervation of the thumb CMC joint. Further investigations are needed to assess the clinical implications of the current study.

Introduction: Complex Regional Pain Syndrome (CRPS) is a debilitating neuropathic condition often refractory to conventional treatments. N-methyl-D-aspartate (NMDA) receptor antagonists have a well-established role in the development and modulation of chronic neuropathic pain. Nitrous oxide is widely used and generally safe anesthetic gas with NMDA receptor antagonist activity. We therefore tested the hypothesis that brief periods of nitrous oxide exposure reduce pain in patients with CRPS.

Methods: Patients with a diagnosis of CRPS were randomized to either 2 hours of nitrous oxide exposure on three alternating days (Nitrous Oxide) versus a placebo air/oxygen mixture (Air-Oxygen). Our primary outcome was patient-reported pain scores at 1 week and 1 month. Secondary and exploratory outcomes were physical and mental health (PRMOIS-29 v2 survey), specific neuropathic pain symptoms (McGill short-form questionnaire), and opioid consumption.

Results: 44 patients participated in the study; 20 were randomized to Nitrous Oxide and 24 were assigned to Air-Oxygen. Pain scores did not differ significantly, with the estimated difference in means (Nitrous Oxide-Air-Oxygen) of -0.57 (95% CI: -1.42 to 0.28) points, p=0.19. There were also no differences detected in secondary outcomes, with the estimated difference in mean Z-scores for physical health (Nitrous Oxide-Air-Oxygen) of 0.13 (95% CI: -0.16 to 0.43), mental health 0.087 (95% CI: -0.31 to 0.48), and Patient Global Impression of Change score -0.7 (95% CI: -1.85 to 0.46).

Conclusions: Compared with air/oxygen, 2 hours of nitrous oxide/oxygen exposure for three sessions did not provide meaningful therapeutic potential for patients with chronic CRPS. Our results do not support using nitrous oxide for the treatment of CRPS.

Radiofrequency denervation of lumbar medial branches is a viable treatment option to manage chronic facetogenic low back pain. Traditionally, lumbar medial branch denervation involves placement of the electrode's active tip at a 20-degree angulation away from the parasagittal plane. However, more recent anatomical studies have provided evidence supporting the feasibility of an alternative parasagittal approach targeting the posterior half of the lateral neck of the superior articular process to capture the lumbar medial branches. Currently, there is a lack of clinical data on the effectiveness of the alternative parasagittal needle placement technique. Therefore, in this brief technical report, the parasagittal needle placement technique and the pain relief outcomes in four consecutive patients following treatment with the parasagittal approach are described.