H. Evren Eker

Management of Neuropathic Pain with Methylprednisolone at the Site of Nerve Injury

OBJECTIVE Peripheral nerve blocks with methylprednisolone may provide effective pain therapy by decreasing ectopic neuronal discharge and the release of local inflammatory mediators at the site of nerve injury. In this study, we aimed to compare the efficacy of lidocaine alone with a combination of depo-methylprednisolone plus lidocaine in the management of neuropathic pain due to peripheral nerve damage. DESIGN Randomized, double-blind comparator trial. SETTING Group control (N = 44) received 0.5% lidocaine and group methylprednisolone (N = 44) received 80 mg depo-methylprednisolone + 0.5% lidocaine proximal to the site of nerve injury with a total amount of 10-20 mL solution according to the type of peripheral nerve block with nerve stimulator. OUTCOME MEASURES Demographic data, preblock numerical rating scales (NRSs), the Leeds assessment of neuropathic symptoms and signs (LANSS(0) ) score, accompanying symptoms, and analgesic requirements were recorded. Postblock NRS scores were noted following peripheral nerve block and after 3 months. LANSS(1) , accompanying symptoms, and analgesic requirements were also reevaluated 3 months after the injection. RESULTS Demographic data, preblock NRS (8 ± 1.5 and 8.1 ± 1.2, respectively), postblock NRS (2.1 ± 1.2 and 2.4 ± 1.4, respectively), LANSS(0) (18.4 ± 2.2 and 18.2 ± 2.1, respectively), and accompanying symptoms were comparable between groups. Scores for the methylprednisolone group were significantly improved at 3-month postblock for NRS (2 ± 1.4 vs 5.2 ± 1.7) and LANSS(1) scores (4.14 ± 2.7 vs 14.1 ± 2.8), accompanying symptoms, and analgesic requirements (P < 0.0001). CONCLUSIONS Our results suggest that peripheral nerve block with 80 mg depo-methylprednisolone plus 0.5% lidocaine provides effective management in the treatment of neuropathic pain due to peripheral nerve damage.

Is There a Place for β-Mimetics in Clinical Management of Neuropathic Pain? Salbutamol Therapy in Six Cases

THE Adrenergic system, because of its reported implication in pain mechanisms, may be a potential target for chronic pain treatment. A genetic polymorphism of catechol-O-methyltransferase, an enzyme that metabolizes catecholamines, is related with higher pain perception and persistent pain conditions because patients with higher pain sensitivity are more likely to develop chronic pain conditions. Moreover, catechol-O-methyltransferase inhibition increases pain sensitivity through augmented catecholamines and activation of -adrenergic ( -AR) receptors. Furthermore, a polymorphism of 2-adrenoceptors ( 2-AR) has been associated with the risk for developing musculoskeletal pain disorders. In agreement, clinical studies reported that -AR antagonists were effective in chronic musculoskeletal pain conditions, such as fibromyalgia or temporomandibular disorder. This effect on myalgic pain was observed in patients with altered sympathetic nervous function. In addition to musculoskeletal pain disorders, neuropathic pain is another major type of chronic pain. Neuropathic pain arises as a direct consequence of a lesion or a disease affecting the somatosensory system. The prevalence of neuropathic pain has been reported to be around 6.9 and 8.2% in two large prevalence studies, and the annual incidence rate was estimated at 1%. Even though patients with neuropathic symptoms are rather frequent, neuropathic pain is often challenging to treat and is generally resistant to commonly used therapeutics. Treatment difficulties may be due to various underlying pathophysiologic mechanisms. Indeed, neuropathic pain can be initiated not only by various diseases such as diabetes or cancer but also by trauma, postsurgical injuries, or drug treatment of cancer or human immunodeficiency virus infection. Currently, antidepressants are one of the first-line treatment options in neuropathic pain management. These drugs are indirect adrenergic agonists because they act through the blockade of aminergic reuptake sites and thus increase endogenous levels of noradrenaline. Recent studies on the action mechanisms of antidepressants in neuropathic pain revealed the critical role played by 2-AR. 13,14 The absence or blockade of 2-ARs suppresses the antiallodynic effects of a chronic antidepressant treatment in a neuropathic pain model. Interestingly, preclinical studies have also reported that the chronic direct stimulation of 2-ARs by agonists can alleviate neuropathic pain symptoms in a murine neuropathic pain model, whereas a -AR antagonist had no effect. Thus, these findings differ from what was observed in musculoskeletal pain. In this report, we show that the use of salbutamol, a shortacting 2-AR agonist, provided satisfying symptom management in six patients with severe neuropathic pain resistant to previous therapy.

Abnormal Uterine Bleeding: Is It an Under‐Reported Side Effect after Epidural Steroid Injection for the Management of Low Back Pain?

To the Editor, We read Dr. Gitkinds report with great interest [1]. Since epidural steroid injection (ESI) is a rational treatment approach for radicular pain due to herniated nucleus pulposus and lumbar stenosis [2], its popularity is rising. It is reported to decrease surgical rates and self-reported pain and disability [3]. Corticosteroids contribute to pain treatment with their ability to decrease inflammation by inhibiting production of prostaglandins and excitation of c-fibers, which is mainly responsible for pain generation. However, ESI is not an option free of side effect due to intervention itself and the drugs used [4]. Here, we describe two patients with abnormal uterine …

Transsacral S2-S4 Nerve Block For Vaginal Pain Due To Pudendal Neuralgia

Pudendal neuralgia is a type of neuropathic pain experienced predominantly while sitting, and causes a substantial decrease in quality of life in affected patients. Pudendal nerve block is a diagnostic and therapeutic option for pudendal neuralgia. Transsacral block at S2 through S4 results in pudendal nerve block, which is an option for successful relief of pain due to pudendal nerve injury. Herein is reported blockade of S2 through S4 using lidocaine and methylprednisolone for successful treatment of pudendal neuralgia in 2 patients with severe chronic vaginal pain. The patients, aged 44 and 58 years, respectively, were referred from the Gynecology Department to the pain clinic because of burning, stabbing, electric shock-like, unilateral pain localized to the left portion of the vagina and extending to the perineum. Their initial pain scores were 9 and 10, respectively, on a numeric rating scale. Both patients refused pudendal nerve block using classical techniques. Therefore, diagnostic transsacral S2-S4 nerve block was performed using lidocaine 1%, and was repeated using lidocaine 1% and methylprednisolone 80 mg after confirming block efficiency as demonstrated by an immediate decrease in pain scores. After 1 month, pain scores were 1 and 0, respectively, and both patients were free of pain at 6-month follow up. It is suggested that blockade of S2 through S4 using lidocaine and methylprednisolone is an effective treatment option in patients with chronic pudendal neuralgia when traditional pudendal nerve block is not applicable.

Thoracic Epidural Anesthesia and Analgesia During the Perioperative Period of Thoracic Surgery: Levobupivacaine Versus Bupivacaine

OBJECTIVES To compare the effects of thoracic epidural anesthesia with levobupivacaine or bupivacaine on block features, intraoperative hemodynamics, and postoperative analgesia for thoracic surgery. DESIGN A prospective, randomized, and double-blind study. SETTING A university hospital. PARTICIPANTS Fifty patients undergoing thoracic surgery. INTERVENTIONS Patients received thoracic epidural catheterization either with levobupivacaine or bupivacaine. A bolus of 0.1 mL/kg of 0.25% levobupivacaine or 0.25% bupivacaine was administered, and infusion of the same drug with 0.25% concentration was started at 0.1 mL/kg/h. General anesthesia was induced after assessing the sensory block and maintained with 0.3% to 0.8% isoflurane and 50% O(2) in air. Epidural patient-controlled analgesia with the same agent was started at the end of the operation for 48 hours postoperatively. MEASUREMENTS AND MAIN RESULTS Sensory block features such as onset time and spread were assessed for the next 20 minutes after the bolus dose. Heart rate and systolic, diastolic, and mean arterial blood pressures were recorded intraoperatively and postoperatively. Pain at rest and activity was evaluated by the visual analog scale (VAS) for 48 hours after the operation. All patients were comparable with respect to the demographic data. Onset time of the block and the number of blocked dermatomes and hemodynamic parameters were similar in both groups. All VAS assessments were comparable between groups except VAS at the 36th hour postoperative, which was higher in the levobupivacaine group (p = 0.039). CONCLUSIONS Thoracic epidural anesthesia with either levobupivacaine or bupivacaine provided comparable sensory block features, intraoperative hemodynamics, and postoperative analgesia for thoracic surgery.

Management of isolated infraorbital neuralgia by ultrasound-guided infraorbital nerve block with combination of steroid and local anesthetic

Patients with isolated peripheral branch neuralgia of trigeminal nerve usually receive traditional treatment such as medical therapy and interventional procedures targeting the entire trigeminal nerve or related ganglions. However, if the intractable pain is limited to a certain branch, the patient may also benefit from a peripheral and nerve-targeted interventional approach. Here, we report the management of a patient with isolated infraorbital neuralgia by ultrasound-guided infraorbital nerve block with steroid and local anesthetic combination. 48years-old male patient diagnosed with trigeminal neuralgia was resistant to medical therapy for 3years. The pain site was isolated to the area of the right nasal wing, right lateral incisor, the upper right canine and the first premolar teeth. His pain was an electric shock-like, throbbing and stabbing with a pain score of 8-9 according to numeric rating scale (NRS) and 18 according to the Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale (LANSS). Following a diagnostic ultrasound-guided infraorbital nerve block with 1% lidocaine, the block was repeated twice with 15mg lidocaine and 1.5mg dexamethasone in a total volume of 1.5mL in a month. The patients NRS and LANSS scores decreased to 2 and 8, for approximately 21months until this report was written. We suggest that ultrasound-guided infraorbital nerve block with dexamethasone and lidocaine combination may present as an initial interventional treatment option in patients with isolated infraorbital neuralgia.