Diagnosis and Treatment of Sciatica in the Netherlands: A Survey among Neurologists and Anesthesiologists

<b><i>Background:</i></b> This study aimed to assess how Dutch neurologists and anesthesiologists diagnose and treat people with sciatica in secondary care and to evaluate their adherence to the newest guidelines. <b><i>Methods:</i></b> We conducted a cross-sectional survey. Respondents were asked about their current clinical practice related to sciatica. Three authors rated the respondents’ adherence to the guidelines on a three-point Likert scale. <b><i>Results:</i></b> Eighty neurologists and 44 anesthesiologists completed the questionnaire. Neurologists diagnose their sciatica patients primarily using a magnetic resonance imaging (89%). Selective diagnostic nerve blocks are considered useful by 81% of the neurologists. Neurologists primarily treat patients with pain medication, and 40% of them think epidural steroid injections are effective in 40–60% of injected patients. Twenty-nine percent of neurologists refer patients to a neurosurgeon after 4 months. Anesthesiologists consider a selective diagnostic nerve root block to have a higher diagnostic value than mapping. The most reported side effect of epidural injections is exacerbation of pain (82%). Pulse radiofrequency is applied in 9–11% of acute cases. The results also indicate that Dutch neurologists and anesthesiologists follow an evidence-based approach that is strictly or broadly in line with the guideline. <b><i>Conclusions:</i></b> Neurologists treat sciatica patients initially with pain medication and physiotherapy, followed by epidural steroid injections and referral for surgery. Anesthesiologists treat sciatica patients with one or more steroid injections or may perform a selective nerve root block. Imaging, selective nerve root blocks, medication, physiotherapy, and pulse radiofrequency are topics of further research.

Application of Nalbuphine in Trigeminal Ganglion Pulse Radiofrequency Surgery in Patients with Postherpetic Neuralgia

This study aimed to explore the application value of nalbuphine in pulsed radiofrequency operation of trigeminal ganglion in patients with postherpetic neuralgia (PHN). Thirty patients with PHN were randomly divided into the nalbuphine (Nalbu) group and ketorolac tromethamine (KT) group and received CT-guided pulsed radiofrequency surgery on trigeminal ganglion. The numeric rating scale (NRS) scores of patients were recorded at preoperative, intraoperative, and postoperative time points, before going to bed, and the next morning after the operation. In addition, the number of breakthrough pain before operation and within 24 hours after operation, the incidence of nausea and vomiting within 24 hours after surgery, and the patient’s sleep quality before and on the day after surgery were evaluated. The outcome data demonstrated that patients treated with nalbuphine had lower NRS scores after the pulse radiofrequency operation during and after the pulse radiofrequency operation compared to those with KT. In addition, nalbuphine effectively decreased the number of breakthrough pain, reduced the occurrence of nausea and vomiting after surgery, and improved the sleep quality. In conclusion, intramuscular injection of nalbuphine 30 min before trigeminal ganglion pulse radiofrequency surgery can be conducive to pain relief and improve the postoperative comfort of patients, providing an effective alternative for the alleviation of PHN in clinic.

Pain Intervention for Trigeminal Neuralgia

In the management of chronic pain, stepwise oral analgesics of graded strength are considered as first-line therapy. Minimally invasive interventional procedures remain an option for its treatment when pharmacological therapy fails to control the pain. We reported three classical cases of chronic trigeminal neuralgia that were managed with two types of pain intervention approaches after failing conservative management. In the first case, percutaneous pulse radiofrequency was directed directly to the trigeminal nerve while the other two patients were approached through Gasserian Ganglion. The first method used a traditional technique of pulse radiofrequency approaches. The nerve was identified using sensory stimulation and pulse radiofrequency was delivered once the nerve was confirmed. The second method was similar to the first one but with different approach. Under fluoroscopic control, a radiofrequency needle was introduced into the cheek’s skin ipsilateral to the pain. The needle was directed towards the cranial base in front of the foramen ovale. The success of a trigeminal nerve block depends on proper identification of the anatomic landmarks and the nerve itself. The two different approaches of pain interventions offer more than 50% pain reduction. The trigeminal nerve approaches offer less risk as compared to Gasserian ganglion which is nearer to the brainstem and subarachnoid area. These procedures offer the ability to limit the sensory deficit to a preselected region of the face and to produce hypoalgesia or analgesia without anesthesia.