Oya Yalcin Cok

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.

Children on phenobarbital monotherapy requires more sedatives during MRI.

Background:  Phenobarbital induces specific hepatic cytochrome P‐450 enzyme pathways causing increased clearance of hepatically metabolized drugs. In this study, we investigated the duration and additional anesthetic requirement during Magnetic resonance imaging (MRI) in epileptic children with or without phenobarbital monotherapy.

The effect of paracetamol on postoperative nausea and vomiting during the first 24 h after strabismus surgery: a prospective, randomised, double-blind study.

Context Strabismus surgery is one of the most common ophthalmic surgical procedures in children and is associated with significant postoperative nausea and vomiting (PONV). Objective We evaluated the effect of intravenous paracetamol on PONV in children after strabismus surgery. Design Prospective, placebo-controlled, randomised double-blind study. Setting University hospital. Patients Ninety children, between 2 and 14 years scheduled for strabismus surgery, were recruited. Eighty-six completed the study. Interventions After induction of anaesthesia, intravenous dexamethasone 0.1 mg kg−1 was administered to all. The patients were enrolled to receive either intravenous physiological saline (group S) or paracetamol 15 mg kg−1 (group P). Main outcome measure Incidence of PONV in the first 24 h postoperatively. Results General and clinical characteristics of the children were similar in both groups. PONV during the first 24 h was significantly higher in group S in comparison with group P (group S vs. group P, 33 vs. 14.6%, respectively, P = 0.038 for nausea; 24.4 vs. 7.3%, respectively, P = 0.030 for vomiting). The number of analgesic administrations during the first 24 h was higher in group S compared with group P (1.31 ± 0.85 and 0.73 ± 0.6, respectively, P = 0.001). The repeat number of postoperative analgesic administrations was significantly different between groups during the first 24 h (P = 0.005), but during 24–48 h was not significant. Conclusion Intraoperative administration of intravenous paracetamol decreases the incidence of PONV during the first 24 h in children after strabismus surgery.

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.

Effect of Intraoperative Paracetamol on Catheter-Related Bladder Discomfort: A Prospective, Randomized, Double-Blind Study

BACKGROUND The insertion of urinary catheters during urinary surgical interventions may lead to catheter-related bladder discomfort (CRBD) in the postoperative period. OBJECTIVE We aimed to evaluate the effect of single-dose intravenous paracetamol on CRBD. METHODS In this randomized, controlled, double-blind study, 64 patients (age >18 years, American Society of Anesthesiologists Physical Status I-II) requiring urinary bladder catheterization for percutaneous nephrolithotomy were assigned to groups that received either intravenous paracetamol (15 mg/kg) (group P) or NaCl 0.9% solution (control group [group C]) 30 minutes before the end of surgery. Patients received patient-controlled analgesia (10-mg bolus of meperidine, without infusion, 20-minute lock out) postoperatively. CRBD and pain status were assessed at 30 minutes and 1, 2, 4, 6, and 12 hours postoperatively. Postoperative meperidine requirement and patient and surgeon satisfaction were assessed. RESULTS Group P had significantly lower CRBD scores at all time points except at 12 hours postoperatively compared with group C (P < 0.05). Total meperidine consumption was significantly higher in group C (P < 0.05). Patient and surgeon satisfaction scores were significantly higher in group P (P < 0.05). CONCLUSIONS Intraoperative single-dose paracetamol was found to be effective in reducing the severity of CRBD and pain in urologic surgery. We suggest that it may be an efficient, reliable, easy-to-apply drug for CRBD. ClinicalTrials.gov identifier: NCT01652183.

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.

Effect of low dose dexmedetomidine premedication on propofol consumption in geriatric end stage renal disease patients

BACKGROUND AND OBJECTIVE Sedation in dialysis dependent end-stage renal disease patients requires caution as a result of performing high doses of sedatives and its complications. Multidrug sedation regimens might be superior and advantage on lesser drug consumption and by the way adverse events which occur easily in end-stage renal disease patients. We evaluated the effects of dexmedetomidine premedication on propofol consumption, sedation levels with Observers Assessment of Alertness and Sedation scores and the bispectral index and the hemodynamic changes, potential side effects in geriatric patients with end-stage renal disease who underwent hip fracture surgery under spinal anesthesia. METHOD In this randomized, controlled, double-blind study 60 elderly patients (age≥65 years) with end-stage renal disease and hip fracture scheduled for anterograde femoral intramedullary nailing were assigned to groups that received either intravenous saline infusion (Group C) or dexmedetomidine 0.5μg/kg/10min infusion for premedication (Group D). All the patients received propofol infusion after the induction of the spinal anesthesia. RESULTS Total propofol consumption, propofol dose required for targeted sedation levels according to Observers Assessment of Alertness and Sedation scores and bispectral index levels, recovery times were significantly lower in Group D (p<0.001). The time to reach to Observers Assessment of Alertness and Sedation score 4 and to achieve bispectral index≤80 was significantly lower in Group C compared with Group D (p<0.001). Adverse events were similar in both groups. CONCLUSION Dexmedetomidine premedication lowers intraoperative propofol consumption to maintain targeted level of sedation. Therefore low dose dexmedetomidine premedication in addition to propofol infusion might be an alternative in geriatric patients with end-stage renal disease for sedation.