bluuebunny/crossref_metadata_2025 huggingface dataset:
Epidural Dexamethasone Influences Postoperative
Analgesia after Major Abdominal Surgery
Authors: Lee Hyeon-Jeong
Published: January 2020

Background: Epidurally administered dexamethasone might reduce postoperative pain. However,
the effect of epidural administration of dexamethasone on postoperative epidural analgesia in
major abdominal surgery has been doubtful.
Objectives: To investigate the effects and optimal dose of epidural dexamethasone on pain after
major abdominal surgery.
Study Design: A prospective randomized, double-blind study.
Setting: University hospital.
Methods: One hundred twenty ASA physical status I and II men, scheduled for gastrectomy, were
enrolled. Patients were randomly assigned to receive one of 3 treatment regimens (n = 40 in each
group): dexamethasone 5 mg (1 mL) with normal saline (1 mL) (group D) or dexamethasone 10 mg
(2 mL) (group E) or 2 mL of normal saline (group C) mixed with 8 mL of 0.375% ropivacaine as a
loading dose. After the surgery, 0.2% ropivacaine - fentanyl 4 μg/mL was epidurally administered
for analgesia. The infusion was set to deliver 4 mL/hr of the PCEA solution, with a bolus of 2 mL
per demand and 15 minutes lockout time. The infused volume of PCEA, intensity of postoperative
pain using visual analogue scale (VAS) during rest and coughing, incidence of postoperative nausea
and vomiting (PONV), usage of rescue analgesia and rescue antiemetic, and side effects such as
respiratory depression, urinary retention, and pruritus were recorded at 2, 6, 12, 24, and 48 hours
after the end of surgery.
Results: The resting and effort VAS was significantly lower in group E compared to group C at
every time point through the study period. On the contrary, only the resting VAS in group D was
lower at 2 hours and 6 hours after surgery. Total fentanyl consumption of group E was significantly
lower compared to other groups. There was no difference in adverse effect such as hypotension,
bradycardia, PONV, pruritis, and urinary retention among groups.
Limitations: Use of epidural PCA with basal rate might interrupt an accurate comparison of
dexamethasone effect. Hyperglycemia and adrenal suppression were not evaluated.
Conclusions: Epidural dexamethasone was effective for reducing postoperative pain. Especially,
an epidural dexamethasone dose of 10 mg was more effective than a lower dose in patients
undergoing gastrectomy which was associated with moderate to severe postoperative pain.
IRB approval: D-1507-019-042
Clinical trials registration: KCT0001754
Key words: Patient controlled epidural analgesia, opioid, fentanyl, local anesthetic, ropivacaine,
dexamethasone
Pain Physician 20
Angiotensin-Converting Enzyme Inhibitors and
Angiotensin Receptor Blockers Modulate the
Function of Myelinated Fibers after Chemotherapy:
A Quantitative Sensory Testing Study
Authors: Roldan Carlos J.
Published: January 2020

Background: Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers
(ARB) have sufficient scientific support for their use as tissue protectors. Preliminary studies suggest
that their angiotensin-II type 2 receptor (AT2R)-blocking properties have a beneficial profile in the
treatment of neuropathic pain.
Objectives: The purpose of the current study was to quantify the extent of the somatosensory
effects of ACEI and ARB in cancer patients with chemotherapy-induced peripheral neuropathy.
Study Design: We performed a retrospective review of cancer patients with peripheral
neuropathy of the upper limbs induced by known neurotoxic anti-cancer agents.
Setting: Pain Medicine department at academic tertiary care cancer center.
Methods: Using our quantitative sensory testing (QST) data bank, we retrospectively compared
the tactile function and the touch, sharp, and thermal thresholds of patients who were previously
receiving ACEI or ARB for high blood pressure with these variables in controls who were not
receiving ACEI or ARB.
Results: Of the 209 patients available for analysis, 145 met inclusion criteria. Baseline
characteristics of patients included were generally similar. We identified 29 patients who were
receiving AT2R inhibitors prior to starting chemotherapy. Touch thresholds were statistically lower
in the thenar aspect of hand in the study group (patients who received AT2R inhibitors) than in
the control group [mean (± SD), median 3.03 g (± 11.05), median 0.56 g and 6.75 g (± 18.28),
0.56 g, respectively (P = 0.0441)]. Similarly, the cold pain threshold was statistically higher at the
thenar area for the study group [mean (± SD), median 13.23°C (± 8.02), 11.73°C] than for controls
[9.89°C (± 6.62), 10.05°C (P = 0.0369)].
Limitations: Inadequacies in the original data acquisition and documentation of the QST and
the medical records could not be addressed due to the retrospective nature of the study. Similarly,
a discrepancy on the size of the comparison groups could not be reconciled. In addition, based on
the available information and the lack of documented concomitant pain levels, we did not find an
objective parameter able to correlate the QST findings with pain levels.
Conclusions: AT2R inhibitors might offer partial and selective neuroprotective qualities of the
myelinated fibers A-β and A-δ in cancer patients who receive neurotoxic chemotherapy.
Key words: Quantitative sensory testing, chemotherapy-induced peripheral neuropathy,
angiotensin-II type 2 receptor (AT2R)
Percutaneous Sacroplasty for Non-neoplastic
Osteoporotic Sacral Insufficiency Fractures
Authors: Heo Dong Hwa
Published: January 2020

Background: Osteoporosis is an important problem in those of advanced age. Osteoporosis can
induce sacral insufficiency fractures (SIFs). As average life expectancy increases, the number of
patients with osteoporotic SIFs also increases. Osteoporotic SIFs cause severe low back pain and
immobilization. Treatment of SIFs varies from analgesia to surgery.
Objectives: To describe our experience and assess the safety and effectiveness of minimally
invasive percutaneous sacroplasty in patients with osteoporotic SIFs.
Study Design: Retrospective evaluation.
Setting: The spine and joint specialized hospital’s research center.
Methods: We reviewed cases of percutaneous sacroplasty performed since 2009. We used data
only from patients with osteoporotic SIFs who were followed for more than 12 months after
sacroplasty. Tumor-related SIFs were excluded from our analysis. The following clinical parameters
were investigated: initial diagnosis, symptoms, visual analog scale (VAS) of pain, functional mobility
scale (FDC) score, past history of illness, amount of bone cement infused, and complications
related to sacroplasty. Also, the following radiological parameters were analyzed: the pattern of
SIFs, T-score cement leakage, and concomitant fractures in other sites.
Results: Sixty-eight patients were enrolled in our study (4 men and 64 women). The mean age of
the patients was 76.8 ± 6.2 years. All patients had severe osteoporosis (mean T score: -3.9 ± 0.5).
Percutaneous sacroplasty was performed under fluoroscopic guidance. No major complications or
procedure-related morbidity occurred. FDS and VAS scores significantly improved after sacroplasty,
and the improvements lasted through the final follow-up period (P < 0.05).
Limitations: This study is a retrospective analysis without a control group.
Conclusion: Percutaneous sacroplasty is an effective minimally invasive treatment for osteoporotic
SIFs refractory to conservative management. The study patients experienced significant relief of
pain and increased mobility.
Key words: Sacrum, sacroplasty, insufficiency fractures, osteoporosis, minimally invasive surgery
Factors Affecting Delayed Union of Vertebral
Fractures Following Percutaneous Kyphoplasty
Authors: He Xin
Published: January 2020

Background: Although percutaneous kyphoplasty (PKP) could achieve rapid pain relief for the
elderly with osteoporotic vertebral compression fracture (OVCF), some patients still had risks of
suffering vertebrae delayed union which led to persisting pain and vertebral collapse. Preventing
the delayed vertebral union could reduce the further morbidities and medical costs for patients
with OVCF after PKP.
Objectives: To explore the factors involved in delayed vertebral union after PKP in patients with
OVCF.
Study Design: Retrospective analysis.
Setting: All data were from Hong-Hui hospital in Xi’an.
Methods: There were 580 patients treated using single-segment PKP between January 2011
and January 2012. Demographics, clinical data, types of vertebral fracture, and surgical data were
collected to analyze the factors associated with delayed vertebral union after PKP.
Results: Twenty-nine patients (5%) experienced delayed vertebral union. Univariate analyses
showed that preoperative bone mineral density (BMD), cement consumption, intravertebral cleft,
restoration rate of vertebral height, and improvement in kyphotic angle were associated with
delayed union of vertebrae after PKP (P < 0.05). Multivariate analysis revealed that preoperative
BMD (odds ratio (OR) = 0.452, 95% confidence interval (CI): 0.207 – 0.987, P = 0.046),
intravertebral cleft (OR = 9.156, 95% CI: 3.712 – 22.585, P < 0.001), and restoration rate of
vertebral height (OR = 2.731, 95% CI: 1.622 – 4.599, P < 0.001) were independently associated
with delayed union of vertebrae.
Limitation: A multi-center study is recommended to confirm our findings and explore the factors
related to vertebrae delayed union.
Conclusions: Preoperative BMD, intravertebral cleft, and restoration rate of vertebral height
could be factors independently associated with delayed union of vertebrae after PKP in patients
with OVCF.
Key words: Percutaneous kyphoplasty, delayed union, osteoporotic vertebral compression
fracture
Prevalence of Specific Types of Pain Diagnoses
in a Sample of United States Adults
Authors: Lad Shivanand P.
Published: January 2020

Background: Patients with pain conditions place significant demands on health care services
globally. Health economists have reported the annual economic cost of pain in the United States
as high as $635 billion. A common challenge in treating patients suffering from chronic pain
conditions is accurate diagnosis and treatment.
Objective: The aim of this study was to determine the modern-day prevalence of individual types
of pain diagnoses in adults.
Study Design: Retrospective analysis of Truven MarketScan® Commercial and Medicare
Supplemental database.
Setting: United States patient population with pain diagnoses from 2000 to 2012.
Methods: Multivariate analysis was used to determine the individual prevalence of specific types
of pain diagnoses over a 13-year period. We grouped the 6,575,999 patients with ICD-9 pain
diagnoses into pain groupings.
Results: We determined the prevalence of pain groupings as back pain (74.7%), chronic pain
(10.4%), complex regional pain syndrome (1.2%), degenerative spine disease (63.6%), limb pain
(50.0%), neuritis/radiculitis (52.8%), and post-laminectomy syndrome (14.8%).
Limitations: Retrospective and non-randomized study with a patient cohort that is weighted
towards recent years and commercial insurance. Coding discrepancies that are recorded and
collected for patients.
Conclusions: The demographic differences and similarities within the subgroups highlight that
pain diagnoses should be considered as separate, but related entities. The present study helps
us to better understand the frequency of specific pain diagnoses, and directs future studies to
appropriately focus on pain diagnoses based on prevalence. This will allow increased understanding
of the variation in pain diagnoses and prevent over-generalization in studies examining pain
patients to more accurately reflect the varied subtypes and their economic impact.
Duke University Institutional Review Board Protocol: 00053624
Key words: Pain diagnoses, CRPS, neuritis, radiculitis, limb pain, degenerative spine disease,
back pain, chronic pain, post-laminectomy pain, prevalence, MarketScan
Pneumocephalus Following Unidentified Dural
Puncture: A Case Report with an Unusual
Neurological Presentation
Authors: Figueira Helena Dutra
Published: January 2020

Pneumocephalus is a rare consequence of epidural anesthesia, which may occur following
inadvertent or unidentified dural puncture when the loss of resistance to air technique is
applied to identify the epidural space. Headache is the most common symptom presented
in this condition, usually with sudden onset. This case report describes an unusual
presentation of diffuse pneumocephalus after an unidentified dural puncture. The patient
(male, 67 years old) was submitted to epidural catheter placement for the treatment of
acute exacerbation of ischemic chronic pain using loss of resistance to air technique. No
cerebrospinal fluid or blood flashback was observed after needle withdrawal. Shortly after
the intervention, the patient presented symptoms of lethargy, apathy, and hypophonia,
which are not commonly associated with pneumocephalus. No motor or sensory deficits
were detected. Cranial computed tomography showed air in the frontal horn of the left
ventricle, subarachnoid space at interhemispheric fissure and basal cisterns, confirming
the diagnosis of diffuse pneumocephalus. The patient remained under vigilance with
oxygen therapy and the epidural catheter left in place. After 24 hours, cranial computed
tomography showed air in the temporal and frontal horns of the left ventricle, with no air
in the subarachnoid space. The patient presented no neurological signs or symptoms at
this time. Although headache is the most common symptom presented in reported cases
of pneumocephalus, this case shows the need for the clinician to be aware of other signs
and symptoms that may be indicative of this condition, in order to properly diagnose and
treat these patients.
Key words: Pneumocephalus, continuous epidural analgesia, ischemic chronic pain, lossof-resistance to air technique, dural puncture, headache, unusual presentation
Impact of Celiac Plexus Neurolysis on Survival
in Patients with Unresectable Pancreatic
Cancer: A Retrospective, Propensity Score
Matching Analysis
Authors: Kim Dae Hyun
Published: January 2020

Background: Pain caused by pancreatic cancer (PC) is difficult to control. Celiac plexus neurolysis
(CPN) can effectively control the pain and reduce the use of opioids. However, the effect of CPN
on survival for patients with unresectable PC remains controversial.
Objectives: To determine if CPN is associated with survival benefits for these patients.
Study Design: Retrospective, observational cohort study.
Setting: National Cancer Center in Korea.
Methods: The CPN group included patients who were diagnosed with unresectable PC and
underwent fluoroscopically guided bilateral CPN (10 mL dehydrated alcohol each side) once
between January 1, 2006, and December 31, 2013. Patients with PC who did not undergo CPN
were in the control group; for the final control group, 1:1 propensity score (PS) matching was
conducted with the CPN group. The main outcome was median survival (PC diagnosis to death)
after PS matching, assessed using Kaplan-Meier curves.
Results: For the primary overall survival analysis, the CPN and control groups included 110 and
258 patients, respectively. The median survival period was not significantly different between the
CPN and control groups (278 vs. 203 days, P = 0.246), even after PS matching (278 vs. 180 days,
P = 0.127), or based on time to CPN from diagnosis (≤ 6 vs. > 6 months; 255 vs. 310 days, P =
0.147).
Limitations: Retrospective design, small sample size, and inconsistent timing of CPN after the
diagnosis date.
Conclusion: CPN did not affect survival for patients with unresectable PC. Considering the
limitations of the retrospective design, a well-designed prospective design study should be
conducted.
Key words: Celiac plexus, pancreatic neoplasms, survival, neurolysis, pain, propensity score
matching, opioids, cancer
The Role of Autonomic Function in Exerciseinduced Endogenous Analgesia: A Case-control
Study in Myalgic Encephalomyelitis⁄Chronic
Fatigue Syndrome and Healthy People
Authors: Nijs Jo
Published: January 2020

Background: Patients with myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS) are
unable to activate brain-orchestrated endogenous analgesia (or descending inhibition) in response
to exercise. This physiological impairment is currently regarded as one factor explaining postexertional malaise in these patients. Autonomic dysfunction is also a feature of ME/CFS.
Objectives: This study aims to examine the role of the autonomic nervous system in exerciseinduced analgesia in healthy people and those with ME/CFS, by studying the recovery of autonomic
parameters following aerobic exercise and the relation to changes in self-reported pain intensity.
Study Design: A controlled experimental study.
Setting: The study was conducted at the Human Physiology lab of the Vrije Universiteit Brussel.
Methods: Twenty women with ME/CFS- and 20 healthy, sedentary controls performed a
submaximal bicycle exercise test known as the Aerobic Power Index with continuous cardiorespiratory
monitoring. Before and after the exercise, measures of autonomic function (i.e., heart rate variability,
blood pressure, and respiration rate) were performed continuously for 10 minutes and self-reported
pain levels were registered. The relation between autonomous parameters and self-reported pain
parameters was examined using correlation analysis.
Results: Some relationships of moderate strength between autonomic and pain measures were
found. The change (post-exercise minus pre-exercise score) in pain severity was correlated (r = .580,
P = .007) with the change in diastolic blood pressure in the healthy group. In the ME/CFS group,
positive correlations between the changes in pain severity and low frequency (r = .552, P = .014),
and between the changes in bodily pain and diastolic blood pressure (r = .472, P = .036), were seen.
In addition, in ME/CHFS the change in headache severity was inversely correlated (r = -.480, P =
.038) with the change in high frequency heart rate variability.
Limitations: Based on the cross-sectional design of the study, no firm conclusions can be drawn
on the causality of the relations.
Conclusions: Reduced parasympathetic reactivation during recovery from exercise is associated
with the dysfunctional exercise-induced analgesia in ME/CFS. Poor recovery of diastolic blood
pressure in response to exercise, with blood pressure remaining elevated, is associated with
reductions of pain following exercise in ME/CFS, suggesting a role for the arterial baroreceptors in
explaining dysfunctional exercise-induced analgesia in ME/CFS patients.
Key words: Aerobic exercise, aerobic power index, autonomic nervous system, exercise-induced
analgesia, exercise-induced hypoalgesia, fibromyalgia, heart rate variability, stress-induced analgesia,
pain
Pain
Clinical Outcome of Full-endoscopic Interlaminar
Discectomy for Single-level Lumbar Disc
Herniation: A Minimum of 5-year Follow-up
Authors: Wang Bing
Published: January 2020

Background: Full-endoscopic interlaminar discectomy (FEID) is widely applied for the treatment of
lumbar disc herniation (LDH) and satisfactory short-term outcomes have been achieved. However,
the long-term evaluation for this technique is still lacking, especially the comparison between FEID
and microendoscopic discectomy (MED).
Objective: To evaluate the clinical outcome of FEID technique in comparison with MED for singlelevel LDH with a minimum of 5-year follow-up.
Study Design: Retrospective study.
Setting: Inpatient surgery center.
Methods: A total of 152 patients with single-level LDH located at either L4-L5 or L5-S1 who
underwent either FEID or MED from August 2008 to April 2011 at our hospital were enrolled
in this study. General parameters including operative time, length of hospital stay, mean time to
return to work, complications, and recurrences were recorded. Clinical outcomes were evaluated
using visual analog scale (VAS) for low back and leg pain, Oswestry Disability Index (ODI) for
functional assessment, and modified MacNab criteria for patient satisfaction.
Results: At the final follow-up, the VAS of leg and back pain decreased from 7.6 ± 1.6 and 3.1 ±
2.2 points preoperatively to 1.6 ± 1.2 and 1.7 ± 0.9 at the final follow-up, respectively (P < 0.05).
The ODI score was 69.5% ± 10.5% preoperatively, and declined to 21.8% ± 7.0% at the final
follow-up (P < 0.05). VAS, ODI, and modified MacNab criteria of the FEID group were improved
compared to the control group though there were no statistically significant differences between
the 2 groups.
Limitations: This was a retrospective study with a relatively small sample size. Additionally, this
study contained only clinical outcomes, without long-term radiological outcomes.
Conclusions: The application of FEID achieved similar satisfactory long-term clinical outcomes
for the surgical treatment of LDH as MED. However, compared with MED, FEID exhibits advantages
including less operation time, shorter hospital stay, and faster postoperative recovery.
Key words: Lumbar disc herniation, full-endoscopic interlaminar discectomy, microendoscopic
disectomy, long-term
Pain Physician 2017
Transforaminal Endoscopic Decompression for
a Giant Epidural Gas-Containing Pseudocyst: A
Case Report and Literature Review
Authors: Liu Xiao Guang
Published: January 2020

The isolated epidural gas-containing pseudocyst is an uncommon pathogenic factor for severe
pain of the lower limb as a result of nerve root compression. After reviewing these rare cases
reported in the literature, we found that the name, pathogenesis, and treatment strategy of
this pathology remained controversial. The most common treatment is conservative treatment
or percutaneous aspiration which might result in poor pain relief and high recurrence rates.
Moreover, the patient who received open surgery had good clinical outcome; however, he or
she might experience a significant soft tissue injury.
In this study, we report the first case of a patient who had a giant epidural gas-containing
pseudocyst and received percutaneous endoscopic surgery. This 57-year-old man had been
complaining of severe radicular pain in his right ankle for one year. According to computed
tomography (CT) and magnetic resonance imaging (MRI) prior to the surgery, the results
showed an isolated epidural gas-containing pseudocyst was located in the right lateral recess of
S1. At the last follow-up period, postoperative CT scan showed the gas-contained pseudocyst
was completely resected and this patient was free from the pain.
Due to the great advances in endoscopic techniques and equipment, it is easier to perform
lumbar surgery through the endoscope. With this first case of percutaneous endoscopic
treatment for the symptomatic epidural gas-containing pseudocyst reported in this study, we
believe that this surgical method provides an option to treat this rare condition because it
provides sufficient decompression, has a low recurrence rate, and is minimally invasive.
Key words: Endoscopic surgery, pseudocyst, epidural gas, intraspinal gas, radiulopathy
Efficacious Dorsal Root Ganglion Stimulation
for Painful Small Fiber Neuropathy: A Case
Report
Authors: Koetsier Eva
Published: January 2020

Small fiber neuropathy is a disorder of the peripheral nerves with typical
symptoms of burning, sharp, and shooting pain and sensory disturbances in
the feet. Pain treatment depends principally on the underlying etiology with
concurrent administration of antidepressants, anticonvulsants, opioids, and
topical treatments like capsaicin and local anesthetics. However, treatments for
pain relief in these patients frequently fail. We describe the first case of intractable
painful small fiber neuropathy of the foot successfully treated with spinal cord
stimulation of the left L5 dorsal root ganglion.
A 74-year-old man presented at our clinic with severe intractable pain,
dysesthesia, and allodynia of the left foot caused by idiopathic small fiber
neuropathy, confirmed by skin biopsy. His pain score was 8 on a standard 0 – 10
numeric rating scale. As the pain was not satisfactorily controlled by conventional
therapy, dorsal root ganglion stimulation was proposed to the patient and,
after informed consent, a specifically designed percutaneous stimulation lead
was placed over the left L5 dorsal root ganglion and connected to an external
neurostimulator. After a positive trial of 10 days, a permanent neurostimulator
was implanted. Twenty months post-implantation the patient continued to
experience stimulation-induced paresthesia covering the entire pain area and
reported a pain rating of 4.
Results from the case report demonstrate that the dorsal root ganglion is a
promising neural stimulation target to treat neuropathic pain due to intractable
small fiber neuropathy. Prospective controlled studies are warranted to confirm
the efficacy of this treatment as an option for the aforementioned condition.
Key words: Dorsal root ganglion stimulation, small fiber neuropathy,
neuropathic pain
Reversal of Progressive Conscious Disturbance
with Epidural Blood Patch for Cerebrospinal
Fluid Leakage at C2 Level
Authors: Lien Wei-Hung
Published: January 2020

Intracranial hypotension syndrome (IHS) is generally caused by cerebrospinal fluid (CSF)
leakage. Complications include bilateral subdural hygroma or haematoma and herniation
of the cerebellar tonsils. Epidural blood patch (EBP) therapy is indicated if conservative
treatment is ineffective. We reported the case of a 46-year-old man with a history
of postural headache and dizziness. The patient was treated with bed rest and daily
hydration with 2000 mL of fluid for 2 weeks. However, dizziness and headache did not
resolve, and he became drowsy and disoriented with incomprehensible speech. Magnetic
resonance imaging demonstrated diffuse dural enhancement on the postcontrast study,
sagging of the midbrain, and CSF leakage over right lateral posterior thecal sac at C2
level. We performed EBP at the level of T10-T11. We injected 14 mL of autologous blood
slowly in the Trendelenburg position. Within 30 minutes, he became alert and oriented
to people, place, and time. We chose thoracic EBP as first line treatment in consideration
of the risk of cervical EBP such as spinal cord and nerve root compression or puncture,
chemical meningitis. Also we put our patient in Trendelenburg position to make blood
travel towards the site of the leak. Untreated IHS may delay the course of resolution and
affect the patient’s consciousness. Delivery of EBP via an epidural catheter inserted from
the thoracic spine is familiar with most of anesthesiologists. It can be a safe and effective
treatment for patients with IHS caused by CSF leak even at C2.
Key words: Anaesthetic techniques, regional, thoracic; cerebrospinal fluid leakage;
epidural blood patch; heavily T2-weighted magnetic resonance myelography; intracranial
hypotension syndrome; Trendelenburg position
Effectiveness of Lateral Decubitus Position for
Preventing Post-Dural Puncture Headache: A
Meta-Analysis
Authors: Zorrilla-Vaca Andres
Published: January 2020

Background: Post-dural puncture headache (PDPH) is a relatively common complication of
lumbar punctures for spinal anesthesia or neurologic diagnosis. For many years, a high number
of drugs has been evaluated to treat PDPH, yet there is a minority to prevent this complication.
The lateral decubitus position instead of sitting position during lumbar puncture has become an
interesting approach because of its feasibility and patient satisfaction.
Objectives: In this meta-analysis we hypothesized that lateral decubitus position is an effective
manner to prophylactically reduce the incidence of PDPH.
Study Design: This meta-analysis pooled all data published in randomized controlled trials
(RCTs) examining the impact of position (sitting versus lateral decubitus) during lumbar puncture
and the incidence of PDPH.
Settings: This work was performed at Universidad del Valle, in Cali, Colombia, in collaboration
with the Department of Anesthesiology at The Johns Hopkins Hospital.
Methods: Our group searched in PubMed, EMBASE, Cochrane Library and Google Scholar for
relevant RCTs, dating from 1990 to July 2016, that compared the sitting and lateral decubitus
position with regards to the incidence of PDPH in adult patients (age > 18 years) undergoing
lumbar puncture for spinal anesthesia or neurologic diagnosis.
Results: Literature search identified 7 eligible RCTs (6 on spinal anesthesia and only one on
neurologic diagnosis) with 1,101 patients, of which 557 had lumbar punctures in lateral decubitus
position and 544 in sitting position. Only 3 (out of 7) RCTs favored the lateral decubitus position
to significantly reduce the PDPH. Meta-analysis showed that the lateral decubitus position was
associated with a significant reduction of the incidence of PDPH (risk ratio [RR] = 0.61, 95%
confidence interval [CI] = 0.44-0.86, P = 0.004, I2 = 25%, P for heterogeneity = 0.24) compared
with the sitting position. Subgroup analysis showed that lateral decubitus position is also associated
with reduction of PDPH in spinal anesthesia (RR = 0.69, 95% CI = 0.50-0.95, I2 = 0%, P for
heterogeneity = 0.42). We found no statistically significant association between lateral decubitus
position and successful placement of spinal needle at first attempt (RR = 1.00, 95% CI = 0.92-
1.09, P = 0.94, I2 = 73%, P for heterogeneity = 0.01). There was no evidence of publication bias in
our analyses (Egger’s bias = -0.05, P = 0.96).
Limitations: The low number of RCTs might be an important limitation on our results.
Conclusion: Our results indicate that lateral decubitus position during lumbar puncture seems to
be a good alternative for preventing PDPH. Further research should focus on the new prophylactic
alternatives to reduce the incidence of PDPH.
Keywords: Post-dural puncture headache, sitting, lateral decubitus, meta-analysis
Radiation Dose and Procedure Time for 994
CT-guided Spine Pain Control Procedures
Authors: Lazarus Matthew S.
Published: January 2020

Background: Image guidance for spine pain control procedures, including epidural steroid injection,
nerve root block, and facet block, can be performed with either computed tomography (CT) or
conventional fluoroscopy. CT has the advantage of improved anatomic localization and use of air for
contrast; however, there are concerns that CT leads to higher radiation dose and longer procedure
time.
Objective: To evaluate procedure time and radiation dose for multiple types of spine pain control
procedures performed under CT guidance.
Study Design: Retrospective evaluation.
Setting: Department of radiology in single academic medical center.
Methods: Institutional review board approval was obtained. We reviewed CT-guided spine procedures
performed over a 12-month period from January 2012 to December 2012. Procedure type, procedure
time, and dose-length product were recorded. Patient age and gender were recorded for each case;
additionally, demographic and medical history data were obtained for a sub-group of patients.
Results: Nine hundred ninety-four studies (performed in 699 patients) were reviewed, including 585
epidural steroid injections, 228 nerve root blocks, and 90 facet blocks. For all studies, procedure time
averaged 7:34 ± 5:05, and dose-length product averaged 75 mGy·cm ± 61. Additional medical history
(available for 483 patients) revealed high rate of obesity (body mass index [BMI] = 30 ± 6.8, with 76%
of patients overweight [BMI > 25] and 42% obese [BMI > 30]), and frequent medical comorbidities
(including hypertension [n = 179], diabetes [n = 101], renal failure [n = 30], and heart failure [n = 17]).
Limitations: This study was performed retrospectively, and limited to a single institution.
Conclusion: These findings add to the growing evidence that CT guidance is a safe and effective
technique for epidural steroid injection. These results further demonstrate that other spine intervention
procedures, including nerve root block and facet block, can also be performed under CT guidance with
short procedure time and reasonable levels of radiation exposure. This approach can be effectively
used in a patient population with a high rate of obesity and medical comorbidities.
Key words: Epidural steroid injection, nerve root block, facet block, CT-guidance, spine intervention,
radiation dose
Reinstituting the Bolus – New Reasoning for an
Existing Technique
Authors: McRoberts Porter W
Published: January 2020

Improved intrathecal (IT) pump technology is increasing the accuracy of IT opioid
bolus dosing and promising advances in pain therapy. Opioid bolus dosing can be
used with a minimal continuous infusion or it can function as the sole therapy.
Bolus-only dosing is characterized by minimal use of opioid (often less than 1
mg of IT morphine). It achieves adequate pain control while reducing tolerance
and possibly opioid-induced hyperalgesia. It may prevent receptor saturation, and
provide a “washing out” of the opioid receptor that prevents the observed dose
escalation resulting from continuous infusions. With new bolus dosing possibilities,
IT pumps can be used earlier in the treatment algorithm instead of being a latestage treatment for patients who responded poorly to conservative treatments.
We hypothesize that morphine bolus-only IT dosing will have comparable adverse
effect rates, and possibly increased safety as compared to the more conservative
continuous delivery method. We further predict that bolus-only delivery will
provide better therapy satisfaction, improved functional scores, lower 24 hour
opioid dose, and less dose escalation.
Key words: Intrathecal morphine, patient-controlled analgesia, microdosing,
decreased tolerance, bolus only - no continuous dosing
Repeated Quantitative Urine Toxicology
Analysis May Improve Chronic Pain Patient
Compliance with Opioid Therapy
Authors: Knezevic Nebojsa Nick
Published: January 2020

Background: Even though serious efforts have been undertaken by different medical societies
to reduce opioid use for treating chronic benign pain, many Americans continue to seek pain relief
through opioid consumption. Assuring compliance of these patients may be a difficult aspect of
proper management even with regular behavioral monitoring.
Objective: The purpose of this study was to accurately assess the compliance of chronic opioidconsuming patients in an outpatient setting and evaluate if utilizing repeated urine drug testing
(UDT) could improve compliance.
Study Design: Retrospective analysis of prospectively collected data.
Setting: Outpatient pain management clinic.
Methods: After Institutional Review Board (IRB) approval, a retrospective analysis of data for
500 patients was conducted. We included patients who were aged 18 years and older who
were treated with opioid analgesic medication for chronic pain. Patients were asked to provide
supervised urine toxicology specimens during their regular clinic visits, and were asked to do so
without prior notification. The specimens were sent to an external laboratory for quantitative
testing using liquid chromatography-tandem mass spectrometry.
Results: Three hundred and eighty-six (77.2%) patients were compliant with prescribed
medications and did not use any illicit drugs or undeclared medications. Forty-one (8.2%) patients
tested positive for opioid medication(s) that were not prescribed in our clinic; 8 (1.6%) of the
patients were positive for medication that was not prescribed by any physician and was not present
in the Illinois Prescription Monitoring Program; 5 (1%) patients tested negative for prescribed
opioids; and 60 (12%) patients were positive for illicit drugs (8.6% marijuana, 3.2% cocaine, 0.2%
heroin). Repeated UDTs following education and disclosure, showed 49 of the 77 patients (63.6%)
had improved compliance.
Limitations: This was a single-site study and we normalized concentrations of opioids in urine
with creatinine levels while specific gravity normalization was not used.
Conclusions: Our results showed that repeated UDT can improve compliance of patients on
opioid medications and can improve overall pain management. We believe UDT testing should
be used as an important adjunctive tool to help guide clinical decision-making regarding opioid
therapy, potentially increasing future quality of care.
Key words: Urine toxicology analysis, chronic pain, opioids, compliance, pain management,
urine drug testing, urine drug screening
Oral Oxycodone for Acute Postoperative Pain:
A Review of Clinical Trials
Authors: Cheung Chi-Wai
Published: January 2020

Background: Opioids are the mainstay of pain management for acute postsurgical pain. Oral
oxycodone is an opioid that can provide effective acute postoperative pain relief.
Objectives: To evaluate the use of oral oxycodone for acute postoperative pain management.
Study Design: This is a narrative review based on published articles searched in PubMed and
Medline from 2003 to 2015 on oral oxycodone for acute postoperative pain management.
Methods: Clinical trials related to the use of oral oxycodone for acute postoperative pain
management were searched via PubMed and Medline from 2003 to 2015. The search terms
used were “oral strong opioids,” “postsurgical,” “postoperative,” “post-surgical,” and “postoperative.” Treatment interventions were compared for analgesic efficacy, rescue medication use,
side effects, recovery, length of hospital stay, and patient satisfaction.
Results: There were 26 clinical trials included in the review. Oral oxycodone showed superior
postoperative analgesic efficacy compared with placebo in patients undergoing laparoscopic
cholecystectomy, abdominal or pelvic surgery, bunionectomy, breast surgery, and spine surgery.
When compared with intravenous opioids, oral oxycodone provided better or comparable pain
relief following knee arthroplasty, spine surgery, caesarean section, laparoscopic colorectal surgery,
and cardiac surgery. One study of dental postsurgery pain reported inferior pain control with oral
oxycodone versus rofecoxib. (withdrawn from the US market due to cardiac safety concerns). In
many studies, the demand for rescue analgesia and total opioid consumption were reduced in the
oxycodone treatment arm. Patients receiving oral oxycodone experienced fewer opioid-related
side effects than those on other opioids, and had a similar occurrence of postoperative nausea
and vomiting as patients on placebo. Furthermore, oral oxycodone did not prolong hospital stay
and was associated with lower drug costs compared with epidural and intravenous analgesics.
Oxycodone administered as part of a multimodal analgesic regimen produced superior pain relief
with fewer side effects and a reduced hospital stay.
Limitation: There is a limited number of randomized double blinded studies in individual surgical
operations, thus making it more difficult to come up with definitive conclusions.
Conclusion: Oral oxycodone appears to offer safe and effective postoperative analgesia, and is a
well-accepted and reasonable alternative to standard intravenous opioid analgesics.
Key words: Postoperative, pain, analgesia, oral oxycodone, opioid
Immunoassay-Based Drug Tests Are
Inadequately Sensitive for Medication
Compliance Monitoring in Patients Treated for
Chronic Pain
Authors: Melanson Stacy
Published: January 2020

Background: Enzyme immunoassays (EIA) have notable limitations for monitoring therapeutic
compliance in pain management. Chromatography coupled with mass spectrometry provides
definitive results and superior sensitivity and specificity over traditional EIA testing.
Objective: To analyze and compare the sensitivity of EIA results together with known
prescriptions to liquid chromatography-tandem mass spectrometry (LC-MS/MS) for monitoring
drug use (and abuse) in patients treated for chronic pain.
Study Design: A total of 530 urine samples from patients being treated for chronic pain
were studied.
Setting: Pain management clinic in the United States.
Methods: The samples were tested for a profile of chronic pain medications and illicit drugs
with commercially available EIA kits followed by analysis with Agilent LC-MS/MS system.
Results: The EIAs exhibited poor sensitivity and high rates of false negative results in the pain
management setting. For example, 21% of EIA for opiates show false negative results. Mass
spectrometry methods were more sensitive, detected a broader range of drugs and metabolites,
and could detect non-prescribed drug use and simulations in compliance.
Limitations: Patients do not always accurately report drug use information, and some drugs
do not have EIA methods available for comparative purposes.
Conclusions: Mass spectrometry is a more robust and reliable method for detection of drugs
used in the pain management setting. Due to the extent of undisclosed use and abuse of
medications and illicit drugs, LC-MS/MS testing is necessary for adequate and accurate drug
detection. In addition, LC-MS/MS methods are superior in terms of sensitivity and number of
compounds that can be screened, making this a better method for use in pain management.
Key words: Pain management, enzyme immunoassays, mass spectrometry, urine drug
testing, prescription status, compliance
The influence of delayed sample processing time on PO2 values in critically ill patients with sepsis-induced leucocytosis
Authors: Myburgh A , Kassanjee R , Pretorius PR
Published: January 2020

Background: The extent of error, from collection to processing, when measuring PO2, PCO2 and pH in arterial blood samples drawn from critically ill patients with sepsis and leucocytosis, is unknown.

Methods: Twenty-nine patients with sepsis and a leucocyte count > 12 000/mm3, who had routine arterial blood analysis were included in the study. Blood was drawn into two 1 ml heparinised glass syringes. One syringe was cooled on ice and tested at 60 minutes. The other syringe was used for analysis at 0, 10, 30 and 60 minutes. Differences in measurements, from the Time-0 results, were described. For PO2, linear mixed models estimated the impact of time to processing, controlling for the potentially confounding and moderating effects of Time-0 leucocyte count and fractional inspired oxygen concentration respectively.

Results: PO2 exhibited the most pronounced changes over time at ambient temperature: The mean (SD) relative differences at 10, 30 and 60 minutes were -4.72 (8.82), -13.66 (10.25), and -25.12 (15.55)% respectively; and mean (SD) absolute differences -0.88 (1.49), -2.37 (1.89) and -4.32 (3.06) kPa. For pH, at 60 minutes, the mean (SD) relative and absolute differences were -0.27 (0.45)% and -0.02 (0.03) respectively; for PCO2, 6.16 (7.80)% and 0.25 (0.35) kPa. The median differences for the on-ice 60-minute sample for pH and PCO2 were 0.019 and -0.12 (both P < 0.001), and for PO2 0.100 (P: 0.216). The model estimated that average PO2 decreased by 5% per 10 minute delay in processing (95% CI for effect: 0.94 to 0.96; P < 0.001) at the average leucocyte count, with more rapid declines at higher counts, though with substantial inter-patient variation.

Conclusion: Delayed blood gas analysis in samples stored at ambient temperature results in a statistically and clinically significant progressive decrease in arterial PO2, which may alter clinical decision-making in septic patients.
Anaesthetic management of a three-month-old baby for cervical limited dorsal myeloschisis repair using propofol and alfentanil infusions guided by pharmacokinetic simulation software: A case report
Authors: Coetzee E , Gray R , Hollmann C , Enslin NJM , Coetzee JF
Published: January 2020

We present an uncommon case of limited dorsal myeloschisis in a 3-month-old infant requiring repair guided by intraoperative neuromonitoring (IONM) and therefore avoidance of volatile anaesthetic agents. The case presented challenges in positioning, airway management, a lack of age appropriate pharmacokinetic models in target-controlled infusion (TCI) syringe pumps and unavailability of remifentanil, considered to be an essential drug in this setting. We overcame these challenges using manually controlled infusions of propofol and alfentanil guided by pharmacokinetic simulation software (Stelsim).
Cyclomydril® eye drops: An unusual contributing factor to postoperative apnoea
in a neonate – A case report
Authors: Pfister C , Timmerman K
Published: January 2020

Premature neonates presenting for surgery are at risk for postoperative apnoeas for various reasons, including their immature physiology, general anaesthesia, opiates and other drugs administered during a procedure.

An ex-premature baby presented for a laparotomy following a complication of necrotising enterocolitis (NEC) at 39 weeks postconceptual age. An opthalmological procedure was planned to follow the laparotomy under general anaesthetic.

Postoperatively the neonate remained apnoeic and the anaesthetists were unable to safely extubate her. She required ventilation in the intensive care unit (ICU) overnight. After considering all causes of postoperative apnoea in this neonate, an overdose of Cyclomydril® eye drops was thought to be a significant contributing factor.

Cyclomydril® eye drops consist of cyclopentolate, an anticholinergic, and phenylephrine, an adrenergic drug. The combination produces mydriasis of short duration that is superior to that of either drug alone at the same concentration, with little or no cycloplegia.

Infants are especially sensitive to cardiopulmonary and neurological side-effects of cyclopentolate due to their immature cardiovascular and neurological systems, and their immature metabolic pathways. Although very rare, Cyclomydril® drops have been known to cause apnoea, and even hypoxic arrest, in outpatient ophthalmology clinics at routine screening for retinopathy of prematurity.

Anaesthetists should be aware of the potential dangers of Cyclomydril® drops and plan accordingly. It is the authors’ recommendation that neonates receiving Cyclomydril® during the course of a procedure should be admitted to a high care unit or ICU for 24 hours postoperatively for observation and apnoea monitoring.
الوعي بالفحص الطبي ودوره في الصحة الإنجابية (دراسة ميدانية للطالبات الجامعيات المتزوجات في جامعة الشارقة)
Authors: الطائي آلاء
Published: January 2020

تهدف الدراسة الحالية إلى التعرف إلى تصورات الطالبات المتزوجات نحو الوعي بالفحص الطبي للمقبلين على الزواج وانعكاساته على واقع الصحة الإنجابية، عليه تبنت الدراسة نظرية الاختيار العقلاني مدخلاً يمكن من خلاله تفسير هذه الظاهرة، وتعد هذه الدراسة من الدراسات الوصفية التي اعتمدت على منهج المسح الاجتماعي بالعينة. ولتحقيق أهداف الدراسة الحالية تم إعداد استبانة تضمنت محورين الأول معلومات عامة عن خصائص العينة ومستويات وعي المبحوثات المتزوجات بالفحوصات الطبية القبلية، والثاني للتعرف إلى الصحة الإنجابية لنفس المبحوثات. وقد جرى استخراج الخصائص الإحصائية للاستبانة من صدق وثبات، ولغرض جمع البيانات اختيرت عينة قصدية بلغت (150) طالبة متزوجة في جامعة الشارقة. وقد توصلت الدراسة إلى عدد من النتائج منها: كان للوعي المرتفع بأهمية الفحص الطبي لدى الطالبات دورواضح بتمتعهن بصحة إنجابية جيدة، أما الطالبات من ذوات الوعي المنخفض يعانين من صحة إنجابية متردية. وقد توصل البحث إلى عدد من التوصيات والمقترحات.
ممارسات القيادة الإستراتيجية وعلاقتها بتوسيع القاعدة الضريبية- دراسة ميدانية على دوائر ضريبة الدخل في فلسطين.
Authors: الكببجي مجدي , الهيموني ساندي
Published: January 2020

هدفت الدراسة إلى التعرف على علاقة ممارسات القيادة الإستراتيجية بتوسيع القاعدة الضريبية، وذلك من خلال قياس أهم ممارسات القيادة الإستراتيجية لدى دوائر ضريبة الدخل، ووسائل توسيع القاعدة الضريبية. ولتحقيق أهداف الدراسة قام الباحثان بتصميم استبانة تم توزيعها على جميع موظفي دوائر ضريبة الدخل في الضفة الغربية الحاصلين على صلاحيات مأمور تقدير والبالغ عددهم ( 135) موظفا، وقد تم استرداد ( 96 ) استبانة صالحة للتحليل الإحصائي. وقد أظهرت النتائج أن درجة تطبيق ممارسات القيادة الإستراتيجية في ضريبة الدخل كانت متوسطة، وأن هناك علاقة طردية بين أبعاد ممارسات القيادة الإستراتيجية وبين توسيع القاعدة الضريبية والمتمثلة بـ (الحد من التهرب الضريبي، تخفيض وتسهيل الإجراءات، تشجيع الالتزام الطوعي، زيادة الجباية والتحصيل للخزينة العامة، زيادة الوعي الضريبي). وقد قدم الباحثان مجموعة من التوصيات من أهمها: وضع آليات لدى دوائر ضريبة الدخل في فلسطين مفصلة وواضحة ومحددة بإطار زمني ومتابعة لتنفيذها لتوسيع القاعدة الضريبية من خلال الحد من التهرب الضريبي وتخفيض وتسهيل الإجراءات وتشجيع الالتزام الطوعي وزيادة الوعي الضريبي.