bluuebunny/crossref_metadata_2025 huggingface dataset:
Thoracic Erector Spinae Block as Treatment for Pain Related to Inoperable Desmoid Fibromatosis: A Case Report
Authors: Langley Farris
Published: October 2024

BACKGROUND: Desmoid fibromatosis is a rare, sarcoma-like neoplasm that aggressively invades surrounding soft tissue and is often quite painful. Surgery has historically been the mainstay of treatment. Given the high rates of recurrence and unpredictable nature of the lesions, multidisciplinary therapy may be needed to provide adequate analgesia. CASE REPORT: A 35-year-old woman with a history of inoperable desmoid fibromatosis was evaluated in our chronic pain clinic for chest wall and axillary pain due to tumor recurrence. An erector spinae plane block markedly improved her level of pain and functional status. CONCLUSION: This case report highlights the use of a thoracic erector spinae plane block (ESPB) for an inoperable desmoid tumor of the chest wall. Thoracic ESPB is growing in popularity in the field of interventional pain management, but has few definitive indications due to its relative newness. This case report demonstrates that a thoracic ESPB can be a viable, multiregional pain relief strategy for chest wall tumors since our patient reported enduring pain relief, an improved quality of life, and decreased opioid use as a result of the procedure. KEY WORDS: Erector spinae plane block, desmoid fibromatosis, chronic pain, desmoid tumor, regional anesthesia, case report
Botulinum Toxicity Managed With Pyridostigmine Following Botulinum Toxin Injections for Bilateral Neurogenic Thoracic Outlet Syndrome: A Case Report
Authors: Bhullar Ravneet
Published: October 2024

BACKGROUND: Botulinum toxin injections have been increasingly used in the treatment of different painful conditions, including thoracic outlet syndrome (TOS). Guidelines to manage adverse effects or toxicity from botulinum toxin injections in these cases are not well established. CASE REPORT: A female patient in her forties with bilateral arm pain secondary to bilateral neurogenic TOS (NTOS) presented to the pain clinic for botulinum toxin injections to the scalene muscles. Several hours after receiving the injections, the patient experienced dysphagia, hoarseness, and facial paresthesia suspicious for botulinum toxicity. She was administered pyridostigmine for symptom management and for approximately one month until symptom resolution. CONCLUSIONS: To our knowledge, this is the first case report to discuss the presentation of botulinum toxicity and its management following botulinum toxin injections for pain relief in bilateral NTOS. Botulinum toxicity may be managed with pyridostigmine with some benefit, but further research is needed to establish guidelines. KEY WORDS: Botulinum toxin injection, botulinum toxicity, pyridostigmine, thoracic outlet syndrome
Sphenopalatine Ganglion Block With Lidocaine Drops Relieves Lower Extremity Complex Regional Pain Syndrome: A Case Report
Authors: Levin Danielle
Published: October 2024

BACKGROUND: Lower extremity complex regional pain syndrome (CRPS) is a debilitating, neuropathic pain disorder that may develop into a refractory, chronic condition, which currently has no gold-standard treatment. We would like to share the first report of a transnasal sphenopalatine ganglion block with lidocaine that effectively relieved the pain of a patient suffering from lower extremity CRPS. CASE REPORT: A 48-year-old man with CRPS suffered from pain that was resistant to analgesic medications, spinal blocks, and a spinal cord stimulator. A sphenopalatine ganglion block was administered to the patient via long, hollow cotton-tip applicators with lidocaine drops. After just one block, for the first time in 10 years, he was 100% pain free for 5 days. CONCLUSIONS: This case report demonstrates that the lidocaine sphenopalatine ganglion block could be a simple, safe, inexpensive, and noninvasive treatment option for those affected by lower extremity CRPS. KEY WORDS: Sphenopalatine ganglion block, lidocaine, chronic pain, complex regional pain syndrome
Chronic Musculoskeletal Pain in a Case of Larsen Syndrome: Role of Myofascial Trigger Points
Authors: Garg Keshav Kumar
Published: October 2024

Background: Larsen syndrome is an extremely rare congenital disorder characterized by craniofacial anomalies and multiple skeletal deformities such as short stature, kyphoscoliosis of the spine, cervical spine instability, clubfeet, and joint dislocations especially of the knee and hip joints. Musculoskeletal pain in a case of Larsen syndrome signals red flags as these patients have various congenital anomalies. However, myofascial trigger points could be a cause of chronic musculoskeletal pain in these patients. Myofascial trigger points are easy to diagnose and treat. Case Report: We are presenting a 29-year-old man, diagnosed as a case of Larsen syndrome, who came to us with complaints of bilateral shoulder pain and right thigh pain for 4 years and 5 months, respectively. Examination of the patient revealed faulty joint mechanics along with the presence of trigger points in adjoining muscles. The trigger points were injected with local anesthetic followed by stretching and muscle-strengthening exercises, which led to pain relief. Conclusion: In the present case report, we wish to highlight that myofascial pain could be a cause of pain and functional limitation in patients suffering from Larsen syndrome. Key words: Larsen syndrome, myofascial trigger point
Intrathecal Baclofen to Improve Functional Status in ALS: A Case Report
Authors: Mendelson Andrew
Published: October 2024

Background: Intrathecal pumps are well known to benefit patients with chronic pain as well as spasticity. Intrathecal baclofen (ITB) can offer doses 100-1000 times smaller with similar efficacy, compared to oral baclofen. Only 2 previous reports detailed improvement in functional status after patients with amyotrophic lateral sclerosis (ALS) received ITB. Case Report: Our patient presented with progressive bulbar palsy, further progressing to ALS. His lower extremity spasticity and tremors continued to progress over 3 years despite increased baclofen. At the time of implant, he expressed whole body tremors and spasticity to bilateral lower extremities, complicated by falls. Prior to the trial, the patient ambulated 50 feet. ITB was started at a rate of 100 mcg/day. After the implant, the patient’s ambulation distance increased to 100 feet. Conclusion: The patient and his wife reported resolution of his tremors and improvement in spasticity. This report details the functional improvement obtained from ITB in a patient with ALS. Key words: Amyotrophic lateral sclerosis (ALS), intrathecal, baclofen, functional status, chronic pain, interventional pain
Perineural Botulinum Toxin Injection for Cancer-related Pain: Case Report of Two Patient
Authors: Bohren Yohann
Published: October 2024

BACKGROUND: Management of cancer-related pain is an important public health issue, with significant impacts on patient quality of life. Interventional techniques for pain relief, such as perineural catheters, are widespread in clinical practice, allowing the reduction of reliance on morphine. However, their use can result in difficulties, such as catheter dislodgement, leading to a loss of efficacy. Alternative techniques may therefore be advantageous. One such technique is the perineural injection of botulinum toxin (BoNT), a neurotoxin with motor blocking properties, which is reported to exert long-term analgesic effects. CASE REPORT: Herein, we describe 2 cases of patients with refractory cancer-related pain, of differing origin, treated by perineural BoNT injection. In both cases, medium-term analgesic effects were achieved from a single injection. CONCLUSION: These case reports add to the growing literature on the use of BoNT for cancer-related pain relief, and support calls for future randomized clinical trials in this area. KEY WORDS: Botulinum toxin, cancer-related pain, perineural block, interventional pain management.
A Sudden Change in Vertebroplasty Candidacy in an Elderly Man with Lumbar Compression Fractures: A Cautionary Case Report
Authors: Parekh Yashesh
Published: October 2024

BACKGROUND: Osteoporosis is the leading cause of vertebral fractures, often requiring multimodal and interventional pain management, in elderly adults. Selection of vertebroplasty candidates, timing, and evaluation for risk factors is crucial for optimal results. CASE REPORT: A 73-year-old man with acute on chronic lower back pain with radicular symptoms, was found to have osteoporotic lumbar vertebral compression fractures with anterior and posterior column involvement. Initially an optimal vertebroplasty candidate, after re-evaluation with a computed tomography scan, showed significant displacement. Given the patient’s radicular pain, he was successfully treated with transforaminal epidural steroid injections. CONCLUSION: The selection of vertebroplasty candidates is a delicate process to prevent complications. This case opens the discussion for the need to further study the profiling and monitoring of patients for potential changes in candidacy, a current gray area. KEY WORDS: Back pain, case report, compression fracture, osteoporosis, vertebroplasty
Successful Stellate Ganglion Block in Patients with Treatment Resistant Post-Traumatic Stress Disorder: A Case Series and Recent Literature Review
Authors: Sanderson Miles
Published: October 2024

BACKGROUND: Post-traumatic stress disorder (PTSD) is an increasing health concern in both those with and without previous military experience. There is a growing body of evidence for the use of stellate ganglion block (SGB), a procedure performed to treat pain conditions and cardiac arrythmias, in the treatment of PTSD. There have been multiple clinical studies, randomized and nonrandomized, that have demonstrated positive results for the use of SGB. CASE REPORT: In this case series, we present 3 patients with military background and treatment resistant PTSD who underwent SGBs. All 3 patients experienced a decrease in their clinical symptoms and improved quality of life. CONCLUSION: Patients with refractory PTSD may benefit from SGB for treatment of their symptoms. PTSD symptoms may be sympathetically mediated, lending to the effect of SGB for symptom management. Data from recent clinical trials demonstrate a statistically significant reduction in PTSD symptoms when compared to sham procedures. KEY WORDS: Case series, literature review, local anesthetic, post-traumatic stress disorder, randomized control trial, stellate ganglion block, superficial cervical ganglion block, trauma
Seroma Formation 20 Years After Spinal Cord Stimulator Insertion: A Case Report
Authors: Thomas Coco , Mangla Dipty
Published: October 2024

BACKGROUND: Spinal cord stimulation is a common treatment modality for chronic neuropathic pain. Device complications can include infection, hardware malfunction, and seroma formation. CASE REPORT: A 78-year-old woman presented to the pain management clinic 20 years after spinal cord stimulator insertion with 6 months of pain and swelling around the stimulator insertion site. Aside from localized pain and swelling, the patient did not experience any neurological or musculoskeletal symptoms. A computed tomography scan revealed a large seroma around both the spinal cord stimulator and the extension wiring. The patient was referred to neurosurgery, where she underwent successful explant of the stimulator without further complication. CONCLUSIONS: This case is an excellent example of complications that can occur with the extension wiring of spinal cord stimulators. Many physicians are aware of the complications that occur with the generator and electrodes, but extension wiring is a forgotten source of adverse outcomes. KEY WORDS: Neuropathic pain, seroma, spinal cord stimulator
Breaking the Press Ganey Patient Satisfaction Survey Code
Authors: Kennedy Alvin
Published: October 2024

BACKGROUND: Several leading patient satisfaction assessment tools have emerged, one of the most common surveys is conducted by Press Ganey. The use of patient satisfaction surveys has been controversial with correlation inconsistencies with outcomes, accuracy, and bias. CASE REPORT: We seek to review changes in the patient satisfaction scores over time as measured through Press Ganey® surveys. Some changes include increasing access to care, improving scheduling, decreasing wait times, improving communication between patient and staff, increased staffing, and conducting team building activities. CONCLUSION: The overall standard mean score through the entire study period was 88.6 (range, 77-94.3, SD 3.4). After the implemented changes, plotting the quarterly scores over the study period demonstrated a steady improvement over time with a linear trend line demonstrating a R² value of 0.3052. KEY WORDS: Posttraumatic neuralgia, common peroneal nerve injury, neuromuscular electrical stimulation, neuralgia, neuromodulation
Case Series: Spinal Cord Stimulator Therapy Alleviates Neuropathic Pain in Patients with Failed Back Surgery Syndrome in the Setting of Spinal Cord Injury
Authors: Yazdi Cyrus
Published: October 2024

BACKGROUND: Spinal cord stimulation (SCS) is a minimally invasive neuromodulation treatment modality primarily indicated for failed back surgery syndrome (FBSS). When FBSS occurs in the setting of spinal cord injury (SCI) it can often be refractory to treatment with opioids and anticonvulsants; in such cases, SCS has demonstrated promising results. Here, we present a case series of 2 patients with FBSS in the setting of SCI who received pain relief with SCS therapy. CASE REPORT: Our first patient is a 49-year-old man with a history of SCI (T10-11) with resulting paraplegia, who presented after failure of conservative management of his neuropathic abdominal and lumbar back pain with radiculopathy to the right groin. Our second patient is a 50-year-old man with a history of insulin-dependent diabetes mellitus, coronary artery disease, and thoracic arachnoid cyst excision, who presented for treatment of worsening intractable neuropathic pain in his thorax, abdomen, and midback. Both patients received SCS therapy with significant improvement in their neuropathic pain. CONCLUSION: By delivering targeted electrical stimulation to the spinal cord, SCS can improve the pain resulting from FBSS. Recent literature has highlighted the successful use of SCS in alleviating neuropathic pain following SCI; our case series further adds to the literature supporting the use of SCS in this pain setting. SCS continues to offer chronic pain physicians alternative, effective options for patients suffering from FBSS in the setting of SCI. KEY WORDS: Spinal cord stimulator, failed back surgery syndrome, spinal cord injury, neuropathy
Acute Precipitated Opioid Withdrawal With Akathisia, Delirium, and Lactic Acidosis from Low-Dose Naltrexone for Chronic Pain: Case Report
Authors: Naumann Jesse
Published: October 2024

BACKGROUND: Low-dose naltrexone (LDN) is an increasingly popular medication to enhance analgesia and decrease opioid reliance in patients with chronic pain. CASE REPORT: We present the case of a 66-year-old man on long-term opioids for chronic pain who was initiated on 1 mg of LDN for enhanced analgesia and subsequently went into severe precipitated opioid withdrawal (POW), a reaction understood to be rare at such low doses. CONCLUSION: LDN has been introduced into pain medicine as a safe and effective adjunct for the treatment of chronic pain conditions in both opioid-naive patients and those on concomitant opioid therapy. While this is generally considered a safe practice, LDN initiation can cause acute precipitated withdrawal in certain individuals already on opioids, even at low doses previously thought to be free from this risk. We recommend pain providers consider this effect and be prepared to manage POW when prescribing LDN. KEY WORDS: Low-dose naltrexone, LDN, chronic pain, precipitated opioid withdrawal, case report
Retrospective Analysis of Naltrexone for Persistent Neuropathic Pain Case Series
Authors: Lee Michael
Published: October 2024

BACKGROUND: Persistent neuropathic pain (NP) is a prevalent and debilitating problem, often resistant to first-line treatment. Low-dose naltrexone (LDN) has shown promise in treating fibromyalgia and other forms of chronic pain. CASE REPORT: Retrospective analysis was performed on 14 of 18 patients with diverse forms of NP who met inclusion criteria by using LDN (1.5-4.5 mg) as a second-line medical pain therapy. Pain Numeric Rating Scale (NRS-11) in all patients decreased from 6.29 ± 2.20 to 3.71 ± 2.89 (P = 0.001) from initiation to final visit. Median treatment length was 252 days with longest being 1,054 days. All 6 patients who remained on LDN > 1 year reported reduced pain NRS-11 at last visit. Side effects were mild and did not result in cessation of therapy. CONCLUSIONS: LDN may show promise in treating persistent NP. KEY WORDS: Case series, naltrexone, neuropathic pain, chronic pain syndrome
Left Sixth Nerve Palsy and Subdural Hygroma Following Intrathecal Morphine Pump Placement: A Case Report
Authors: Creamer Michael
Published: October 2024

BACKGROUND: An intrathecal (IT) pump is an effective drug delivery system that assists patients with chronic pain management. However, due to the invasive nature of the procedure, a complication that could arise is cerebrospinal overdrainage or leak, which could lead to adverse effects. CASE REPORT: The patient underwent an IT morphine pump implant for treatment of his chronic, intractable low back pain. Following the procedure, he developed persistent headaches and diplopia and was found to have left lateral rectus palsy. Imaging studies showed the development of bilateral subdural hygromas. His condition was resolved with surgical intervention and time. CONCLUSIONS: After an extensive literature search and review, to our knowledge, this is the first reported case of sixth nerve palsy and subdural hygromas following the implant of a drug delivery system. KEY WORDS: Abducens palsy, IT pump, subdural hydrgomas, intrathecal drug delivery system, lateral rectus palsy
Transdermal Buprenorphine in the Treatment of Chronic Abdominal Pain Syndrome
Authors: Dave Om
Published: October 2024

BACKGROUND: Centrally mediated abdominal pain syndrome (CAPS) is a condition that has traditionally been treated with first-line agents, such as tricyclic anti-depressants and serotonin and norepinephrine reuptake inhibitors. However, in the setting of pain refractory to these primary agents, there is little evidence in support of alternative regimens, especially opioid analgesics. CASE REPORT: This case examines the utility of weekly 10 mcg transdermal buprenorphine patches as an additional treatment modality for CAPS, specifically in the setting of a 27-year-old woman with intractable abdominal pain following a cholecystectomy. In < 1 week, the patient had significant improvement in pain control without any of buprenorphine’s potential side effects. CONCLUSION: Given the debilitating pain CAPS causes alongside the widespread economic burden it puts on both patients and hospital systems, transdermal buprenorphine can be a transformative approach to mitigating the consequences of this syndrome. KEY WORDS: Abdominal pain, buprenorphine, opioids, chronic pain, interventional pain
Lidocaine and Botulinum Injections at Tender Points of Fibromyalgia May Result in Immediate and Long-term Pain Relief: A Case Report
Authors: Punj Jyotsna
Published: October 2024

BACKGROUND: Pharmacological treatment alone is found inadequate for patients of fibromyalgia (FM) syndrome. For prolonged pain relief, either injections of lidocaine or botulinum toxin A were previously injected at tender points of FM with varied results. CASE REPORT: We present a case where a mixture of lidocaine and botulinum A was injected at tender points in a young woman patient with FM, which resulted in immediate and extended pain relief with improvement in quality of life. CONCLUSIONS: Mixture of lidocaine and botulinum toxin injections at tender points in FM may provide immediate and long-lasting pain relief. KEY WORDS: Fibromyalgia, lidocaine, botulinum, injection
Dorsal Root Ganglion Stimulation in a Refractory Case of Complex Regional Pain Syndrome Types I and II in an Isolated Extremity
Authors: Vangeison Christian
Published: October 2024

BACKGROUND: The treatment of complex regional pain syndrome (CRPS) is a difficult endeavor. The advent of neuromodulation interventions has led to new therapeutic options for chronic pain syndromes. Coinciding neuromodulation devices, such as spinal cord stimulation (SCS) and dorsal root ganglion stimulation (DRGS), may have a part in refractory CRPS. CASE REPORT: The authors present a case of a 50-year-old man status post a traumatic skiing accident 3 years prior to presentation with residual CRPS symptoms after an SCS implant. Additional multilevel coverage for refractory chronic neuropathic pain was achieved with the implantation of multiple DRGS devices. DISCUSSION: This case provides support for the use of DRGS in patients needing supplementary neuropathic pain coverage. Outcomes were reflected in diminished pain scores, an enriched quality of life, and enhanced functional capacity measures. KEY WORDS: Complex regional pain syndrome, dorsal root ganglion stimulator, dorsal root ganglion stimulation, neuromodulation, spinal cord stimulator, spinal cord stimulation, chronic pain, case report
Anterior Spinal Artery Syndrome following Splanchnic Nerve Cryoablation for Oncological Pain: A Case Report
Authors: Catalanatto Marissa
Published: October 2024

BACKGROUND: Anterior spinal artery syndrome is a diagnosis associated with high morbidity, mortality, and long-term disability. It is a known complication following conventional celiac plexus and splanchnic nerve blocks. The popularity of minimally invasive pain procedures is growing, especially in the domain of oncology, and the interventions are being performed by specialists with varying backgrounds. Complications such as anterior spinal artery syndrome need to be at the forefront of specialists’ minds whenever there is manipulation of the celiac plexus or splanchnic nerves. These structures play an integral role in maintaining circulatory perfusion. The earlier hypoperfusion is suspected or confirmed, the better the prognosis, as steps can be taken to immediately correct this deficit. CASE REPORT: We present a case of a 65-year-old man with a history of poorly differentiated metastatic pancreatic adenocarcinoma who suffered a thoracic anterior spinal artery infarction following a splanchnic nerve cryoablation. Noninvasive methods to control pain prior to the procedure were unsuccessful. Prior to becoming a paraplegic this patient was independent in all activities of daily living and ambulation. CONCLUSIONS: This case report aims to prove the importance of being familiar with the early signs associated with spinal cord infarction and the importance of completing a thorough, transparent informed consent process when manipulating the celiac plexus or splanchnic nerves. Cryoablation procedures of such structures remain relatively novel compared to conventional blocks. Few case reports have documented anterior spinal artery syndrome following cryoablation. This unfortunate complication results in permanent, life-altering damage. We also propose steps that can be taken to minimize this risk. KEY WORDS: Splanchnic nerve cryoablation, anterior spinal artery syndrome, pancreatic adenocarcinoma
Management of Persistent Cerebrospinal Fluid Leak With an Epidural Blood Patch Following Removal of Lumbar Drain and Failed Neurosurgical Intervention: Case Report
Authors: Knezevic Nebojsa Nick
Published: October 2024

BACKGROUND: Persistent cerebrospinal fluid (CSF) leak is a complication of a dural puncture that can be idiopathic, traumatic, or iatrogenic in nature. CASE REPORT: We present a case of a 43-year-old woman, diagnosed with a spontaneous CSF rhinorrhea that was treated with temporary placement of a lumbar drain. Upon discharge, the patient experienced a persistent CSF leak from the lumbar drain site, as well as a positional headache and vertigo that persisted even after application of reinforcement sutures at the lumbar drain site by the neurosurgery team. The patient was subsequently treated with an epidural blood patch (EBP) at L3-L4 interspace with autologous venous blood injected into the epidural space. During the follow-up 2 weeks after the intervention, there was a complete resolution of her symptoms, as well as the CSF leakage. CONCLUSIONS: A CSF leak after lumbar drain removal that persists even after neurosurgical intervention can be successfully treated with an EBP. KEY WORDS: CSF leak, rhinorrhea, epidural blood patch, lumbar drain, case report
Buprenorphine Microinduction to Mitigate Withdrawal Symptoms During Abrupt Discontinuation of Intrathecal Fentanyl: A Case Report
Authors: Moore Arnold
Published: October 2024

BACKGROUND: Intrathecal pumps provide effective analgesia for many patients living with chronic pain. However, pump removal can present significant challenges from the pain management perspective, as patients are often highly opioid-tolerant and at significant risk of withdrawal. Buprenorphine microinduction has shown promise as a strategy for mitigating withdrawal symptoms while avoiding the respiratory depression associated with full agonist opioids. However, reports of its usage in patients undergoing intrathecal pump removal are limited. CASE REPORT: We present the case of a 56-year-old woman with chronic non-cancer back pain who was successfully transitioned to oral buprenorphine using a microinduction protocol when her longstanding intrathecal pump was abruptly discontinued. CONCLUSIONS: This case demonstrates that buprenorphine microinduction may be a safe and effective method of mitigating opioid withdrawal symptoms in non-cancer pain patients undergoing abrupt intrathecal pump discontinuation. KEY WORDS: Intrathecal pump, buprenorphine, chronic pain
Acute Guillain-Barré Syndrome After Sacroiliac Joint Fusion
Authors: Varatharajan Aaran
Published: October 2024

BACKGROUND: Guillain-Barré syndrome (GBS), also called acute inflammatory demyelinating polyradiculopathy (AIDP), is one of the most common causes of acute, acquired weaknesses. GBS is an acute immune-mediated polyneuropathy that presents with progressive weakness of the arms or legs. GBS presents after infection; however, there are few reports that describe acute GBS after chronic pain procedures. CASE REPORT: A 70-year-old man with a past medical history of spinal stenosis status post anterior cervical discectomy and fusion, sacroiliac joint (SIJ) dysfunction status post SIJ fusion presented with imbalance, weakness, and difficulty walking. The patient underwent SIJ fusion one week prior; his weakness progressively worsened, requiring a walker. He underwent a series of labs and diagnostic tests, which were consistent with AIDP/GBS. He was placed on respiratory and cardiac monitoring and started on intravenous immunoglobulin treatment. He started developing bilateral facial palsies and started on plasmapheresis. His symptoms have improved and he was discharged from our inpatient rehab facility on after 28 days. CONCLUSIONS: This case report aims to highlight a rare, but potentially dangerous, complication of AIDP/GBS following an SIJ fusion. KEY WORDS: Sacroiliac joint fusion, sacroiliac joint pain, Guillain-Barré syndrome, case report
Vacuum Disc Phenomenon Turned Gassy Disc Herniation: A Case Report
Authors: Benedetti Edmond
Published: October 2024

BACKGROUND: The vacuum phenomenon is a radiologic finding that results from gas accumulation within degenerated discs, joints, or vertebrae. This gas can herniate, causing back pain and/or radiculopathy. Asymptomatic imaging abnormalities can be coincidental and/or non-concordant with clinical presentation therefore warranting close evaluation. CASE REPORT: This 45-year-old man, previously diagnosed with lumbar facet arthropathy, returned to the clinic for left-sided axial low back pain. Imaging revealed that a gas filled mass in the right lateral recess was affecting the traversing right L5 and S1 nerve roots. Given the exclusive axial symptoms consistent with lumbar zygapophyseal joint arthropathy, the patient was treated with a repeat L3-4 medial branch and L5 dorsal ramus radiofrequency ablation and experienced subsequent near-complete pain resolution. CONCLUSIONS: Careful consideration must be taken when conducting clinical evaluation, imaging, diagnosis, and treatment of patients with low back pain given the significant frequency of abnormal, often nonconcordant, radiological findings. KEY WORDS: Pneumorrhachis, vacuum disc phenomenon, low back pain, case report
Stellate Ganglion Blocks for Post-COVID-19 Headaches: Case Report
Authors: Kim Chong
Published: October 2024

BACKGROUND: Long COVID can impact patients with a wide range of new, returning, or ongoing health symptoms, lasting for months to years despite recovery from the acute infection. One of the symptoms is headaches. Post-COVID-19 headaches can affect the quality of life for many patients, and as a result, the management and treatment of the symptoms have become important issues. CASE REPORT: We present a case series of patients with varying presentations of post-COVID-19 symptoms, including headaches, who responded positively to the use of stellate ganglion blocks (SGBs). CONCLUSIONS: We report the successful use of a right-sided SGB for varying post-COVID-19 symptoms. KEY WORDS: Long COVID, post COVID, post-COVID headache, headaches, stellate ganglion block, case report
Ketamine Infusion for Refractory Post-COVID-19 Fatigue: Case Report
Authors: Kim Chong
Published: October 2024

BACKGROUND: Post-COVID-19 syndrome (PCS) symptoms are common after COVID-19 infections and despite recent efforts to study and treat, limited progress has been made. The most common of the symptoms, fatigue, can be debilitating and lack effective treatment options, and as a result, the need for potential management options is paramount. CASE REPORT: We present a case report of a patient with refractory PCS fatigue. Following intravenous ketamine infusion, the patient noted significant improvement in his energy and fatigue symptoms. CONCLUSIONS: We report the successful use of ketamine infusion for PCS fatigue symptoms. KEY WORDS: Long COVID, post-COVID, ketamine, infusion, fatigue, case report
Effective Management of Recurrent Trauma-Induced Neck Pain With Radiofrequency Neurotomy Using the Nimbus Electrosurgical Radiofrequency Multitined Expandable Electrode: A Case Report
Authors: Block Jon
Published: October 2024

BACKGROUND: Radiofrequency neurotomy (RFN) can be an effective treatment for patients with chronic neck pain and cervicogenic headaches resistant to conservative care. However, the degree and duration of pain relief after RFN is dependent upon the thoroughness of target nerve coagulation. CASE REPORT: This is a case of a 37-year-old patient with debilitating neck pain and headaches following a motor vehicle accident. Successful local anesthetic block of the third occipital nerve (TON) confirmed pain of C2-C3 facet joint origin. An initial RFN treatment of the TON, using standard 18G electrodes in bipolar mode, resulted in complete symptom amelioration for 8 months. Repeat RFN, using the same electrode configuration, was unsuccessful in alleviating the severe neck pain and headaches, and produced no demonstrable sensory loss in the distribution of the TON. RFN was then performed using the Nimbus® electrosurgical RF multitined expandable electrode, which provides a larger zone of coagulation in volume than standard RFN electrodes even when used in bipolar configuration. CONCLUSIONS: The Nimbus procedure resulted in successful coagulation of the TON with sensory loss in the TON distribution and reinstatement of palliative relief. KEY WORDS: Cervical pain, radiofrequency neurotomy, third occipital nerve, Nimbus, case report
Medial and Lateral Burns With Concomitant Infection After Genicular Nerve Radiofrequency Ablation: A Case Report
Authors: Yalamuru Bhavana
Published: October 2024

BACKGROUND: Knee osteoarthritis management might include medication, intraarticular injections, physical therapy, and surgical intervention. Genicular nerve radiofrequency ablation (RFA) is an effective therapy for patients who do not receive benefit from conservative medical management and are not surgical candidates (secondary to medical comorbidity, patient preference, and other factors). Genicular nerve RFA is generally safe and has a low complication rate. However, there have been case reports of minor and major complications after RFA. We report a case of burns after genicular nerve RFA. CASE REPORT: A 49-year-old man (92 kg; body mass index [kg/m2] 28.3), with a history of coronary artery disease and chronic tobacco use, presented with 20 years of chronic knee pain. He previously had short-term relief with an intraarticular steroid knee injection. He was found to be a suitable candidate for genicular nerve RFA and underwent the procedure successfully without any immediate complications. His pain decreased from 9/10 before the procedure to 5/10 after his RFA. On postprocedure day 33, a 1 cm circular lesion with drainage was noted on the medial aspect of his knee. A lateral lesion was discovered at a subsequent follow-up appointment. He was treated with antibiotics, chlorhexidine cleansing, and dressing changes which resolved the lesions without any long-term sequelae. CONCLUSION: Our case represents an instance of full thickness skin burns with concomitant infection post genicular RFA, uniquely in both the medial and lateral sites. Our patient’s risk factors of low body mass index, smoking, and vascular disease may have led to a delayed healing response. In addition, needle depth may also have contributed to his injury. Ensuring adequate needle depth and patient selection can minimize these complications. KEY WORDS: Radiofrequency ablation, knee pain, osteoarthritis, chronic pain, genicular nerve, RFA, adverse event, complication
Spinal Cord Stimulation and Intrathecal Drug Delivery System Therapy in a Pregnant Patient with Complex Regional Pain Syndrome Type II: A Case Report
Authors: Glicksman Michael
Published: October 2024

BACKGROUND: Complex Regional Pain Syndrome (CRPS) is a difficult-to-treat chronic pain condition. When indicated, spinal cord stimulator (SCS) therapy can serve as a solution. Rarely, intrathecal drug delivery system (IDDS) can be used with SCS to enhance analgesia. Given women’s predisposition towards CRPS, there may be an increasing co-existence of pregnancy and CRPS. CASE REPORT: A pregnant woman presented with right lower extremity pain due to CRPS type II. Here, we present the first case of a woman who continued SCS and IDDS therapies throughout pregnancy. She had an uncomplicated pregnancy, labor, and delivery. The baby achieved all developmental milestones at one year. CONCLUSION: Further research on the safety of SCS and IDDS during pregnancy is required to determine their effects on the mother and fetus. Until then, the decision to continue these therapies should be considered individually and with close collaboration among the patient, obstetrics, and pain management teams. KEY WORDS: Pain management, pregnancy, refractory complex regional pain syndrome, CRPS, intrathecal pump therapy, spinal cord simulation
Radiation-Induced Coccydynia and Pelvic Pain From Insufficiency Fracture Treated With Ganglion Impar Block
Authors: Osuagwu Uzondu
Published: October 2024

BACKGROUND: Pelvic insufficiency fractures can be a delayed effect from radiation therapy. As a result, significant pain, debility, and reduction in quality of life can occur. We describes the utility of ganglion impar blockade in the treatment of coccydynia and pelvic pain related to insufficiency fracture. CASE REPORT: The patient is a 71-year-old woman with stage 2 grade II endometrial cancer that presented with pelvic and tailbone pain approximately 4 years after completing radiation therapy and was found to have a sacral insufficiency fracture. She underwent ganglion impar blockade on 2 occasions with marked improvement in her pain and functionality after each injection. CONCLUSIONS: Fluoroscopic-guided ganglion impar block may be a safe and useful intervention to reduce pain in cancer patients with pelvic and/or tailbone pain related to insufficiency fracture KEY WORDS: Cancer pain, pelvic pain, tailbone pain, insufficiency fracture, ganglion impar block
Effectiveness of Transforaminal, Interlaminar, and Caudal Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Network Meta-analysis
Authors: Kwak Sang Gyu , Choo Yoo Jin , Kwak Soyoung , Chang Min Cheol
Published: October 2024

BACKGROUND: Epidural injection (EI) has been used to manage lower back and radicular leg pain caused by a herniated lumbar disc. There are 3 types of EI techniques currently being used: transforaminal (TFEI), interlaminar (ILEI), and caudal epidural injections (CEI). OBJECTIVES: To evaluate the comparative effectiveness of TFEI, ILEI, and CEI in reducing pain and improving function in patients with HLD. STUDY DESIGN: Systematic review and meta-analysis. METHODS: The PubMed, Embase, Cochrane Library, and Scopus databases were searched from the earliest records up to August 2022 for randomized controlled trials (RCTs) and non-RCTs. The standard mean differences (SMDs) in the changes in the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores were calculated from one week through one month posttreatment (short-term) and from 4 months through 6 months posttreatment (long-term). RESULTS: In total, 11 studies comprising 1,050 patients were included. Network meta-analysis showed that the improvement in the VAS scores was better with TFEI than with CEI (SMD = -1.16, 95% CI = -2.10 to -0.23). Ranking probability analysis showed that TFEI had the highest probability of being the best treatment for reducing pain and improving function in the short- and long-term evaluation periods. LIMITATIONS: Only a small number of previous studies were included in our analysis. Also, subgroup analysis according to the injection volume, material type, or pain onset could not be conducted. CONCLUSIONS: TFEI had the best potential of the 3 EI techniques to reduce pain and improve function in patients with a herniated lumbar disc. Further qualified trials comparing the effects of these 3 techniques are warranted to derive definitive conclusions. KEY WORDS: Disc herniation, back pain, radicular pain, epidural injection, transforaminal injection, interlaminar injection, caudal injection, lumbar spine
The Utilization of Radiofrequency Techniques for Upper Extremity Pain Management
Authors: Albishi Waleed , AbuDujain Nasser , bin Dakhil Abdulaziz , Alzeer Meshari
Published: October 2024

BACKGROUND: In the 1990s, radiofrequency ablation emerged as a novel therapeutic approach tool for pain alleviation that did not result in neurological harm. Radiofrequency techniques are emerging methods as a possible option for upper extremity pain management. Furthermore, joint pain can result from multiple etiologies, and the management can differ based on what joint is affected. With the various management methods available to treat joint pain, radiofrequency ablation could be an effective, minimally invasive, promising intervention. OBJECTIVES: This study aimed to review the current and historical uses of radiofrequency in upper extremity pain compared to other management methods and to address the utilization of radiofrequency in upper extremity pain management. STUDY DESIGN: This is a narrative review of relevant studies on using radiofrequency techniques in upper extremity pain management. METHODS: On June 26, 2022, Medline/PubMed, Google Scholar, ERIC, and the Cochrane Database of Systematic Reviews were searched for relevant literature documenting the use of radiofrequency techniques in treating upper extremity pain. The terms “radiofrequency,” “pain,” “upper extremity,” “shoulder,” “elbow,” and “wrist” were used, resulting in 61 studies fitting the inclusion criteria. A narrative review was then undertaken. RESULTS: Radiofrequency ablation and its techniques are among the contemporary medical procedures that could be cost-effective solutions for patients suffering from chronic and postoperative pain. Its utilization for shoulder-related pain has been frequently studied, as it showed significant improvement with a high satisfaction rate as a solo procedure. When compared to intraarticular corticosteroid injections or local anesthetics, it was found to be more effective than local anesthetics. Although it did not appear superior to intraarticular corticosteroid injections, it had the advantage of infrequent repeat treatment. By comparison, studies involving the elbow and wrist showed promising results but were not as thorough as studies on the shoulder. Therefore, considering the possible side effects and complications, caution is warranted. LIMITATIONS: The paucity of articles available on its application to the elbow and wrist joints. More articles are necessary for the generalizability of the results. CONCLUSION: Radiofrequency techniques are a promising, minimally invasive procedure for controlling upper extremity pain. More studies on the topic, especially on elbow and wrist pain, are warranted for the generalizability of the results. KEY WORDS: Radiofrequency, pain management, upper extremity, shoulder, elbow, wrist, corticosteroid injection, local anesthetics
Ultrasound-guided Techniques for Perioperative Analgesia in Pediatric Lower Abdominal Surgeries: Quadratus Lumborum Block with Bupivacaine versus Caudal Bupivacaine and Neostigmine
Authors: Esmat Ibrahim
Published: October 2024

BACKGROUND: Ultrasound-guided regional anesthesia techniques for perioperative analgesia in pediatric patients scheduled for lower abdominal surgeries can be achieved either by quadratus lumborum block (QLB) or caudal block (CB). Neostigmine was co-administered with caudal bupivacaine to shorten the onset and extend the duration of analgesia. OBJECTIVES: This study aimed to compare between 2 ultrasound-guided techniques used for perioperative analgesia (QLB with bupivacaine vs. CB with bupivacaine/neostigmine) regarding the total amount of rescue analgesic (acetaminophen mg/kg) used for pain relief at 24 hours postsurgery in pediatric patients undergoing lower abdominal surgeries in a developing country and to discuss existing barriers during the implementation of both techniques. STUDY DESIGN: A randomized, double-blind, prospective, single-center study. SETTING: Ain-Shams University Hospitals METHODS: Eighty pediatric patients scheduled for lower abdominal surgeries under general anesthesia were randomly allocated to receive either ultrasound-guided QLB using bupivacaine or ultrasound-guided CB using a bupivacaine/neostigmine mixture. The total amount of rescue analgesic (acetaminophen mg/kg) 24 hours postsurgery was considered as the primary outcome while the time to first rescue analgesia, pain score, postoperative nausea and vomiting, bradycardia, hypotension, and urinary retention were considered as secondary outcomes. RESULTS: In the QLB group, the time to first rescue analgesia was longer whereas the total analgesic dose (mg/kg) was lower than the CB group (P < 0.001, P = 0.007, respectively). While, on the other hand, in CB group, the time to perform the block was shorter and Parents Satisfaction Score 24 h postsurgery was lower than the QLB group (P < 0.001, P < 0.001, respectively). Side effects were infrequent and comparable between the study groups. LIMITATIONS: First, the researchers did not assess the dermatomal level before or after the operation in either group. Second, the investigators should have noticed the first voiding time to demonstrate accurately the incidence of urine retention. Third, a cost-effectiveness analysis of perioperative costs (drugs, staff, resources being used) of these regional anesthesia techniques when applied in an ambulatory setting should have been done, which would be helpful for those in resource-limited settings. CONCLUSIONS: Postoperative analgesia for pediatric patients undergoing lower abdominal surgeries can be safely and effectively achieved by QLB with bupivacaine and a CB with a bupivacaine/neostigmine mixture with priority given to CB, especially in resource-limited settings. KEY WORDS: Quadratus lumborum, caudal, bupivacaine, neostigmine, ultrasound, pediatric, postoperative, pain
The Efficacy of Erector Spinae Plane Block Compared With Intrathecal Morphine in Postoperative Analgesia in Patients Undergoing Lumbar Spine Surgery: A Double-blind Prospective Comparative Study
Authors: Mahmoud Atef Mohamed
Published: October 2024

BACKGROUND: Severe postoperative pain is experienced by most patients who undergo spine surgery. Erector spinae plane block (ESPB) is a successful method for postoperative analgesia and has only minor complications. Intrathecal morphine (ITM) demonstrates high efficacy for analgesia up to 24 hours postsurgery. ESPBs and ITM for postoperative analgesia in lumbar spine surgeries have never been compared in prior studies. OBJECTIVES: This study aimed to compare the efficacy of ESPB and ITM in postoperative analgesia after lumbar spine surgeries. STUDY DESIGN: A double-blind prospective comparative study. SETTING: This study was performed at Al Fayoum University Hospital after being confirmed by the local institutional ethical committee (#80) with approval number M520 and retrospectively registered at clinicaltrials.gov number (NCT05123092). METHODS: A prospective randomized double-blinded interventional trial was conducted with 82 patients, 41 in each group. In the ESPB group, a 0.25% bupivacaine injection was used to conduct a bilateral ultrasound-guided ESPB. In the ITM group, an injection of 0.3 mg morphine intrathecally was done. The Visual Analog Scale (VAS) was recorded as the primary outcome. The time to the first analgesic request, intra- and postoperative opioid consumption, hemodynamics, sedation score, and complications were also recorded as secondary outcomes. RESULTS: Postoperative VAS scores were significantly lower in the intrathecal group throughout the postoperative period at all recorded study time points until 48 hours (P < 0.001). Time to the first rescue analgesia and doses of postoperative analgesic required were significant, with a P value of 0.000. Significant differences were found in postoperative oxygen saturation up to 24 hours (P < 0.001) and the sedation score up to 6 hours (P < 0.01). A higher incidence of complications was recorded in the ITM group (P = 0.000). LIMITATIONS: We did not measure patient preoperative VAS scores to ensure that the 2 groups were matched in pain severity. Also, we did not compare patient satisfaction. Another limitation was the inability to determine the degree of pain relief of ESPB since there was no control group in our study. CONCLUSION: We concluded that ITM 0.3 mg provides more potent analgesia up to 48 hours postoperatively than an ESPB, based upon VAS score, analgesic durations, and postoperative analgesic requirements. KEY WORDS: Intrathecal morphine, erector spinae, spine, Visual Analog Scale