Pain physician
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Anecdotal report suggests that provocation of pain during epidural steroid injection (ESI) that is concordant with typical radicular symptoms predicts pain outcome following injection. However, limited evidence exists that substantiates this theory. Additionally, there is a paucity of literature investigating factors associated with the provocation of pain during ESI. ⋯ Provocation of concordant radicular pain does not predict pain relief at short-term follow-up after a transforaminal ESI. Foraminal stenosis, nerve root impingement, and lack of a medial-superior contrast flow pattern are associated with pain during the transforaminal ESI. Thus, clinicians should be aware of these radiologic and procedural risk factors for inciting pain during transforaminal ESI.
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Randomized Controlled Trial Comparative Study
Comparison of the effects of adding dexmedetomidine versus midazolam to intrathecal bupivacaine on postoperative analgesia.
Dexmedetomidine and midazolam both modulate spinal analgesia by different mechanisms, and yet, no human studies are available to compare them for postoperative analgesia after neuraxial administration. ⋯ The addition of dexmedetomidine (5 mcg) to 3 mL of intrathecal hyperbaric bupivacaine (0.5%) significantly prolongs the duration of effective analgesia in comparison to 1 mg midazolam or placebo (0.9% normal saline) with a comparable incidences of side effects.
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Case Reports
Successful treatment of post thrombotic syndrome with sequential lumbar sympathetic block.
An underappreciated sequelae of deep venous thrombosis (DVT) is the pain associated with the blood clot in the peripheral extremity. Although most frequently acute in nature, DVT occasionally presents with chronic pain in the affected limb. Furthermore, many individuals suffering from prothrombotic states often have recurring pain from DVT. ⋯ Compression boot/stocking therapy was not combating the discomfort associated with the PTS, often increasing the severity of the patient's pain. Sequential right lumbar sympathetic blocks were performed, which nearly completely resolved the patient's symptoms and improved the patient's ambulatory status and ability to perform activities of daily living. Sympathetic nerve blocks should be considered as a treatment option for patients who suffer with pain from PTS.
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Observational Study
Volume of contrast and selectivity for lumbar transforaminal epidural steroid injection.
It has been shown that L4/L5 selective nerve root blocks become nonselective after injecting 1 mL and 0.5 mL of contrast. Volumes of less than 0.5 mL have not been used to determine a volume of definite specificity. ⋯ Diagnostic selective nerve root blocks limiting injectate to a single, ipsilateral segmental level cannot reliably be considered diagnostically selective with volumes as low as 0.2 mL. Also, spread of the contrast to the superior nerve root was more likely than spread to the inferior nerve root.
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There has been a recent surge in the literature highlighting the association of fentanyl as precipitating serotonin syndrome in patients on a serotonergic agent. ⋯ The incidence of serotonin syndrome in patients who receive both fentanyl and a serotonergic agent is low.