Pain physician
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Case Reports
Posttraumatic and postsurgical neuropathic pain responsive to treatment with capsaicin 8% topical patch.
Capsaicin 8% patch (Qutenza) is mainly used to treat postherpetic neuralgia and human immunodeficiency virus-associated neuropathy. However, evidence of the efficacy of Qutenza in other forms of neuropathic pain is lacking. A 24-year old Libyan man, with no previous medical history, sustained multiple wounds in the right side of the chest and back after a bomb explosion. ⋯ Interestingly, the most important finding was that capsaicin 8% patch showed a more than 80% reduction of the area of allodynia associated with the pain, when other treatments failed. Moreover, although recent data showed that in patients who respond to Qutenza, analgesia starts within a few days of treatment and lasts on average 5 months, our patient showed an initial response within 7 days of treatment but a longer duration of more than 18 months. Although further controlled studies are needed to explore the efficacy of the capsaicin 8% patch in patients who experience posttraumatic neuropathic pain, we encourage clinicians to try the capsaicin 8% patch when alternative treatments fail.
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Image guided intercostal blocks are commonly performed and considered relatively safe. Chemical denervation is commonly used in clinical practice for treatment of chronic non-cancer associated pain. ⋯ This case offers several lessons for a pain specialist including 1) the potential for a neurologic catastrophe (spinal cord injury) from aqueous neurolytic intercostal blocks despite "safe" contrast spread; 2) potential mechanisms of neurogenic injury with intercostal blocks; 3) review of modifiable factors to decrease the risk of neurogenic injury; and 4) review of potential interventions (steroids, lumbar drain) to improve outcome in the setting of iatrogenic procedural related spinal cord injury.
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Cervical epidural steroid injections can be performed through either interlaminar or transforaminal approaches, although the interlaminar approach is more frequently used, for cervical radicular pain as a result of cervical disc herniation or spinal stenosis. Cervical selective nerve root block (CSNRB) is an injection that uses a similar approach to that of cervical transforaminal epidural steroid injection (CTFESI) but CSNRB is mainly used for diagnostic injection, often with local anesthetic only. ⋯ This is the first study investigating the optimal needle entry angle for performing CTFESIs or CSNRB. Based on a patient population of 190, the optimal entry angle using the anterior oblique approach appears to be between the range of 33 to 68 degrees with an average of slightly less than 50 degrees. Further research with angle of needle entry and/or initial fluoroscopic alignment of approximately 50 degrees in CTFESI or CSNRB is warranted to confirm the usefulness of these findings.
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A few studies on the depth from the skin to the cervical epidural space (DSES) have been reported from the United States, South Korea, Japan, and Taiwan. There are no published reports from mainland China. ⋯ DSES varied with the cervical intervertebral level in those patients studied from the population of mainland China. The greatest DSES was noted at C7-T1 in men and T1-2 in women, and the least was at C5-6 in both men and women. DSES had a significant relationship with neck circumference and BMI in both genders. We suggest that the DSES be measured with MRI before performing epidural puncture. The lower cervical and upper thoracic intervertebral spaces appear to provide a greater margin of safety for epidural puncture.
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The epidemic of medical use and abuse of opioid analgesics is linked to the economic burden of opioid-related abuse and fatalities in the United States. Multiple studies have estimated the extent to which prescription opioid analgesics contribute to the national drug abuse problem; studies also assessing the trends in medical use and abuse of opioid analgesics have confirmed the relationship between increasing medical use of opioids and increasing fatalities.The available data is limited until 2002. ⋯ The present trend of continued increase in the medical use of opioid analgesics appears to contribute to increases in misuse, resulting in multiple health consequences.