Anesthesiology and Pain Medicine
Year:2012 | Volume:2 | Issue:5 (1)|Papers Count:13

We as regional anesthesiologists often use peripheral nerve blocks as a modality for intraoperative analgesia, but it is not well understood whether regional anesthesia can play a role beyond simple interruption of peripheral nerve conduction. Several published manuscripts in recent years on the potential non-analgesic applications of regional anesthesia encourage us to expand its role from intraoperative to the perioperative period. However, its clinical advantages are not fully disclosed and even its overall beneficial effect on patient outcome is still controversial (1).

The purported mechanism underlying the development and progression of cervicogenic headache (CEH) is the convergence of sensory inputs at the trigeminocervical nucleus.This mechanism explains the radiation of pain from the neck or the occipitonuchal area and its spread to the oculo-fronto-temporal region, it also explains the recurrent headaches caused by improper neck postures or external pressure to the structures in the neck and the occipital region. These neural connectivity mechanisms involving the trigeminal nucleus are also evident from the eye blink reflex and findings of quantitative sensory testing (QST). Understanding the mechanisms underlying the development of CEH is important because it will not only provide a better treatment outcome but will also allow practitioners to appreciate the variability of symptomatic presentations in these patients.

Based on the conducted anatomic studies at our institutions as well as clinical experience with migraine surgery, we have refined our onobotulinumtoxin A (BOTOXâ) injection techniques. Pain management physicians are in unique position to be able to not only treat migraine patient, but also to be able to collaborate with neurologists and peripheral nerve surgeons in identifying the migraine trigger sites prior to surgical deactivation.The constellation of migraine symptoms that aid in identifying the migraine trigger sites, the potential pathophysiology of each trigger site, the effective methods of botulinumtoxin and nerve block injection for diagnostic and treatment purposes, as well as the pitfalls and potential complications, will be addressed and discussed in this paper.

Background: Post-operative pain and the administration of opioids to relieve it, is considered to be one of the important issues in surgery wards. This issue is even more significant in obese patients, because of the side effects of opioids. Pregabalin is an analog of gamma amino butyric acid (GABA) which can be effective in dealing with post-operative pain.Objectives: This study will consider the effect of oral pregabalin in relieving the pain of obese patients after gastric bypass surgery.Patients and Methods: In a double blind clinical trial, 60 candidates for laparoscopic gastric bypass surgery were enrolled in the study through convenience and non-random sequential sampling, into two groups, pregabalin group and control group. Inclusion criteria consisted of: morbid obesity with a body mass index (BMI)>35, age 18-50, American Society of Anesthesiologists (ASA) status I or II, and willingness to take part in the study. Patients in the pregabalin group received 300 mg of oral pregabalin on the morning of the surgery. Post-operative pain was controlled by the patient-controlled intravenous analgesia (PCIA) method, an Auto Med infusion pump containing 20 mg of morphine and normal saline (total volume 100 cc) was administered to all patients after surgery. Patients' level of pain were compared by considering their pain intensity on a visual analog scale (VAS), and the occurrence of nausea/ vomiting from recovery, until 24 hours after surgery.Results: A total of 60 patients were compared, 30 patients in each of the pregabalin and control groups. Both groups were similar in age and sex distribution. Mean pain intensity levels during the whole follow up were lower in the pregabalin group than in the control group, up to a maximum of 24 hours after the operation (P<0.001). Incidence of nausea/vomiting was greater in the control group than in the pregabalin group (P<0.001).Conclusions: The findings of this study indicate that oral pregabalin (300 mg dose) can alleviate patients' pain and nausea/vomiting and notably reduce adverse effects.

Background: An effective pain therapy to block or modify the physiological responses to stress has become an essential component of modern pediatric anesthesia and surgical practice.Objectives: The goal of this study was to compare the analgesic effects of the spray forms of, lidocaine, morphine, ketamine, and normal saline on post-tonsillectomy pain scores in children.Patients and Methods: A total of 120 children, American Society of Anesthesiologist (ASA) class I-II, scheduled for elective tonsillectomy were enrolled in this double-blind, clinical trial study. They were randomly divided into 4 groups, each receiving one of the following drugs at the end of operation, lidocaine spray (2 mg/kg), morphine spray (0.05 mg/kg), ketamine spray (0.5 mg/kg), or normal saline spray (8 puffs). For comparison of postoperative pain, the face, legs, activity, cry, consolability (FLACC) pain scale was evaluated during the first one hour of recovery period at 20 minutes intervals. The data was transferred to SPSS-10 software and analyzed statistically with the Scheffe test and Dunnett's T3 test. P value less than 0.05 was considered significant.Results: In the early postoperative period (time: 0) and at 20, 40 and 60 minutes of recovery time, FLACC scale scores in the control group were higher than in the three other groups. At 20 minutes, the FLACC scale score in the lidocaine group was lower than in the other groups. At 40 minutes, the statistical differences between FLACC scales of the lidocaine, morphine and ketamine groups were not significant (P>0.05). Finally, at 60 minutes, the FLACC scale scores of the ketamine and morphine groups were lower than in the other groups.Conclusions: The results of this study showed that lidocaine spray had the best pain controlling effect at 20 minutes in the recovery room, but after 40 minutes, ketamine and morphine sprays were more effective than the lidocaine spray.

Background: Opium is a unique substance, regarding its analgesic effects. This may change the deteriorating effects of coronary artery disease (CAD) on quality of life (QOL) in addicted patients.Objectives: We studied the QOL in opium-addicted and non-addicted CAD patients so as to determine the relationship between CAD risk factors and the subscales of their QOL.Patients and Methods: Demographic and laboratory data as well as coronary artery risk factors were obtained and SF-36 questionnaire was completed through interviews with 268 (38 opium-addicted and 230 non-addicted) patients with CAD who were candidates for isolated coronary artery bypass at Tehran Heart Center.Results: Mean Euro SCORE in addicted and non-addicted patients were 3.7±7.6 and 2.4±2.2 respectively (P=0.036). In addicted group, higher preoperative HbA1c was associated with low physical function score (b=-0.395, P=0.021). Low ejection fraction could negatively affect the general health (b=0.394, P=0.014) and mental health (b=0.292, P= 0.015) subscales in the addicted group.Conclusions: Despite higher rate of morbidities in opium-addicted patients compared to non-addicted ones, subscales of QOL were similar between the two groups. High preoperative HbA1c and low ejection fraction appeared to be determinants of poor QOL in the opium-addicted patients.

Background: Intra-articular analgesia is a pain reliever that is frequently administered following arthroscopic knee surgery.Objectives: The purpose of this study was to compare the efficacy of intra-articular application of morphine and tramadol on postoperative pain after arthroscopic knee surgery.Patients and Methods: For this randomized double blinded clinical trial, 132 patients undergoing minor arthroscopic knee surgery were randomly assigned to receive either, 5 mg morphine or 50 mg tramadol intra-articularly. Pain was evaluated by means of the verbal pain rating score (VRS) preoperatively (at rest and on movement of the knee joint) and postoperatively at 0, 1, 2, 3, 4, 6, 12 and 24 hours. Meanwhile, the time of the first analgesic request and need for supplemental analgesic were also recorded.Results: There was no statistically significant difference in VRS scoring between the two groups during the preoperative period either at rest or on knee movement. Meanwhile, VRS scores did not differ significantly between the morphine and tramadol treated groups postoperatively, except for in the one-hour post-operative scores in which the tramadol-treated group experienced less pain (P<0.007). Post-operative VRS scores at 6, 12, and 24 hours were significantly decreased when compared with previous scores in both morphine and tramadol prescribed subjects (P<0.001), hence, both local analgesics can significantly reduce pain after minor knee surgery.Conclusions: We have found a postoperative analgesic effect of intra-articularly administered morphine and tramadol following minor arthroscopic knee surgeries with a maximum effect 6 hours post injection.

Background: Hip fracture–related pain both before and after surgery is generally reported as severe by most patients. Various regional pain control modalities have been described in order to reduce pain in these patients.Objectives: Because of the challenges of lumbar plexus block (LPB) and the fact that the effect of combined femoral nerve block/spinal anesthesia in controlling pain after orthopedic surgeries has not been investigated, in this study, we compared the feasibility and efficacy of the 2 techniques in the perioperative management of proximal hip fractures.Patients and Methods: The study included 32 patients with femoral intertrochanteric fracture who were randomly divided into the following 2 groups of 16 patients each: combined femoral nerve block/spinal anesthesia group (group I) and LPB group (group II). Patients in group I received 0.17% bupivacaine with 0.7% lidocaine, 20–25 mL for femoral nerve block and bupivacaine 0.5% plus 0.5 mL pethidine (25 mg) for spinal block and patients in group II received 0.17% bupivacaine with 0.7% lidocaine, 30–35 mL.Results: The time for performing the block (12.2±3.3 vs. 4.93±1.6 min, P=0.001) and achieving the block (7.7±0.9 vs. 2.4±1.0 min, P=0.001) were significantly longer in the combined femoral nerve block/spinal anesthesia group than in the LPB group. Duration of analgesia in the combined femoral nerve block/spinal anesthesia group was longer than that in the LPB group, but the difference was not significant (17±7.3 vs. 16.5±8.5 h, P=0.873). There were no significant differences in hemodynamic parameters regarding the method of anesthesia in the 2 groups.Conclusions: This study confirms that the combination of femoral nerve block with spinal anesthesia is safe and comparable with LPB and can provide more effective anesthesia and longer lasting analgesia for intertrochanteric surgery.

Background: Lumbar spinal stenosis (LSS) is a disabling medical condition in which narrowing of the spinal canal compresses the spinal cord and nerves causing a condition called neurogenic intermittent claudication (NIC). Decompressive spine surgery is the standard of care for patients who fail to improve with conservative management.However, oftentimes, patients who suffer from LSS are elderly individuals with multiple co-morbidities who cannot withstand the risks of decompressive surgery. X-Stop, a novel and minimally invasive FDA approved interspinous process implant, has come into the scene as an alternative to decompressive surgery, and can be inserted under local anesthetic with minimal blood loss.Objectives: Despite its growing support in medical literature as an effective and conservative treatment of NIC, X-Stop remains a fairly new form of treatment. The aim of this study is to assess the clinical efficacy of its use.Patients and Methods: Fifty consecutive patients with at least two-year follow-up had a confirmed diagnosis of NIC secondary to LSS by computed tomography or magnetic resonance imaging (MRI) and subsequently received an X-Stop implant. Subjects ages ranged from 64 to 95 with a mean age of 79, while the gender distribution comprised of 23 males and 27 females. Zurich Claudication Questionnaire (ZCQ) was used to assess patient outcome measures in three domains: physical function (PF), patient satisfaction (PS), and symptom severity (SS). The visual analog scale (VAS) was used to assess trends in pain with a scale from 0-10, with 0 defined as "pain-free" and 10 designated as "the worst pain imaginable".Results: Compared to pre-op scores, PF, SS, and VAS scores for back, buttock and leg pain had a significant mean decrease at 6, 12, 24 months post-op (P<0.05). Based on the ZCQ and VAS scores, a success rate of 79% (27.34), 78% (30.38) and 74% (17.23) were achieved at six months, 12 months, and 24 months respectively.Conclusions: X-Stop is a safe and effective treatment for NIC that provides marked relief of symptoms with sustained beneficial outcomes at up to two years of follow-up. In addition, X-Stop permits implantation under local anesthetic with minimal blood loss".

Introduction: Vertebral body compression fractures due to osteoporosis, often lead to pain and disability which can be successfully treated by injecting cement into the vertebral body, a procedure known as Balloon Kyphoplasty. In this procedure, an inflatable balloon is used to restore vertebral body height before injection of the cement. Vertebral compression fractures have been treated conservatively with the bed rest, pain medications, and back bracing to decrease the patient's pain, but the spine was left in its deformed state. Open surgical treatment can address the deformity, but it is usually reserved for patients with a neurological deficit. Kyphoplasty have been developed as an alternative to surgery for the treatment of painful vertebral compression fractures.Case Presentation: A 65 year-old female had a compression fracture and decrease height of L1 due to falling down. She had a local severe pain (VAS 8) and tenderness over L1 to L4 vertebra and in her physical examination, there were not any neurologic deficits or bowel and bladder dysfunction. She had a severe cardiovascular disease with low ejection fraction (30%) and had a pace maker, hypertension, diabetes, Chronic obstructive pulmonary disease (COPD), and used about 15 drugs daily. The risk of anesthesia and open surgery was high, therefore she was nominated for the Balloon Kyphoplasty as an interventional procedure.Conclusions: After Kyphoplasty, her pain was immediately resolved, vertebral body height was restored to normal, and pain score was reduced from 8 to 1. She was discharged with a normal neurological examination and good general condition, and returned to her normal life. In this case, Balloon Kyphoplasty resulted in the restoration of the vertebral body height, decrease in pain, and returning to daily activity. Therefore, this technique can be an appropriate alternative for surgery in cardio-pulmonary compromised patients.

I read the article by Bangash (1) with great interest, as it reconfirms the repeatedly reported finding of the predominance of affection of the right side of the face in patients with trigeminal neuralgia. This finding is even more intriguing as trigeminal neuralgia behaves quite opposite to many other painful disorders as pain in general was assumed to be more common on the left side of the body (2). This phenomenon was first reported in 1859 (3) and is based on the assumption that the left and right hemispheres differ in their capacity to integrate and discriminate sensory input as well as a proposed dominance of the right hemisphere for emotion processing (2). However, the lateralization of pain was not found in successive studies that tried to reconfirm these findings, so that the assumption of a lateralized pain perception in general could not be sustained (4)...

In your June 2011 issue, we found an interesting study by Farzaneganet al. entitled, "Effects of lumbar discectomy on disability and depression in patients with chronic low back pain." (1). The authors demonstrated the beneficial role of surgery in chronic back pain for patients with disability and depression. Patients with chronic back pain are usually also depressed (2). Evaluating these patients is difficult. Evidence is currently lacking to recommend optimal methods to evaluate these patients. Farzaneganet al.used the Beck depression inventory to evaluate depression and Rolland and Morris's questionnaire to measure disability. These are simple, fast, and reliable methods for screening back pain in the general population (3, 4). Depression and chronic pain have been thought to worsen the prognosis of low-back surgery. Thus, patients with depression spend more time in diagnosis and receive more surgical interventions. Researchers have recommended screening for emotional distress and aggressively treating psychological issues before surgery (3). Contrary to what intuition might tell us, these precautions could actually increase the chronicity of pain and lead to poorer results after surgery...

I read with keen interest the article by Imaniet al. (1) in which the authors compare tracheal intubating conditions following intravenous (IV) administration of remifentanil 5 mg/kg or alfentanil 50 mg/kg followed by induction of anesthesia with propofol 2 mg/kg in 100 adult patients premedicated with IV midazolam 1 mg. Intubating conditions were assessed (scoring 1 to 4) by ease of laryngoscopy, patency of vocal cords, jaw relaxation, and limb movement. Airway reaction to tracheal intubation is an important consideration while assessing intubating conditions. Viby-Mogensenet al. (2) describe a qualitative scoring system graded as excellent, good or poor, respectively, comprising of five variables: 1) Laryngoscopy (easy, fair, difficult) 2) Vocal cord position (abducted, intermediate, closed) 3) Vocal cord movement (none, moving, closing) 4) Coughing (none, diaphragmatic, sustained, >20 s) 5) Movement of the limbs (none, slight, vigorous) Intubating conditions are regarded as excellent (all qualities are excellent), good (all qualities are either excellent or good), and poor (the presence of a single quality listed under poor) (2). They further regard excellent or good intubating conditions as clinically acceptable, and poor intubating conditions as clinically not acceptable.It would be interesting to compare the two narcotic regimens (remifentanilvs. alfentanil) for tracheal intubation without neuromuscular blocking agents (NMBAs) with regard to the incidence of coughing...