Ultrasound-guided Perineural Dextrose Injection for Treatment of Superior Cluneal Nerve Entrapment: Serial Case Report

Background: Superior cluneal nerve entrapment is a neuropathic condition caused by the inclusion of the superior cluneal nerve that contributes to one of the causes of lower back pain leading to high morbidity. Several therapeutic modalities are available for superior cluneal nerve entrapment, including medications, physiotherapy, perineural injection, and surgery. Perineural injection with 5% dextrose has become therapeutic alternative in many cases of neuropathy, but its long-term effectiveness is unknown. Case Presentation: This study described four patients with superior cluneal nerve entrapment with severe pain intensity treated with ultrasonography guided perineural 5% dextrose injection, resulting in significant clinical improvement during the 6-month evaluation. Conclusion: Perineural injection can be considered as long-term therapy in patients with superior cluneal nerve entrapment who have failed other conventional therapies.

Comparison of Effects of Two Drugs (Pregabalin & Celecoxib) on 24 hours Post-Operative Pain Intensity in Patients Undergoing Tibia Fracture Surgery

Background: Celecoxib is widely used in post-operative cases because of its ability to reduce postoperative opioid drug use. Currently, the use of this drug is common in post-operative cases. In various studies, pregabalin was used for the management of pain after spinal surgery to reduce the need for opioids. Objectives: Since the treatment of tibia fractures and surgery is painful and has a long-term recovery, this study aimed to compare the effect of two drugs (pregabalin and celecoxib) on pain severity at 24 h postoperatively in patients having tibia fracture surgery. This would mark significant progress in taking the proper drug. Methods: In this probability clinical experiment, the sample consisted of 50 patients scheduled for tibia fractures, who were selected from the table of random numbers. Then, the patients were assigned into two groups: celecoxib (Group C) and pregabalin (Group P). In the first group, celecoxib was administered to patients at 1 h pre-operatively at a dose of 200 mg and 1 h post-operatively at a dose of 200 mg. In the second treatment group, patients received pregabalin at 1 h pre-operatively at a dose of 200 mg and 1 h post-operatively at a dose of 200 mg orally. Then VAS (visual analog scale) scores were recorded at 6, 12, and 24 h after surgery. Finally, using SPSS software, qualitative variables were compared according to their percentage by the Chi-square test. For quantitative analysis of variables, the mean value of each group was calculated. The comparison of means was made by t-test. Results: The VAS score was considerably lower at 24 hours after surgery in the pregabalin group than in the celecoxib-treated group. However, after 6 and 12 h of surgery, no statistically meaningful difference was observed. A less analgesic effect was observed in the group treated with celecoxib than pregabalin, which was statistically significant. Conclusion: Pregabalin improves postoperative pain, and it has more analgesic effects than celecoxib.

A Systematic Review of Pain Assessment in Mechanically Ventilated Patients

Introduction: Pain self-report is the gold standard of pain assessment. Mechanically ventilated patients cannot self-report the pain due to the presence of a tracheal tube and changes in the level of consciousness caused by sedation, exposing them to the risk of inadequate pain management that leads to psychological and physiological consequences. This study aimed to present a review of the published evidence and studies concerning the scales used in pain assessment in mechanically ventilated patients according to their psychometric characteristics and application in the nursing practice. Methods: We conducted a systematic review following PRISMA guidelines. National and international journals in such databases as Science Direct, PubMed, EMBASE, Pro Quest Central, Web of Science, SID, and Magiran were searched using Persian and English keywords, and retrieved articles were included in this review based on the inclusion and exclusion criteria. Results: 22 articles were included in this review based on the inclusion and exclusion criteria. According to the research objectives, findings were extracted from selected articles and reviewed in two sections: 1] validity and reliability, and 2] clinical application. Conclusion: Scales of CPOT and BPS are superior to NVPS, and a combination of BPS and CPOT improves the pain detection accuracy, and vital symptoms should be used cautiously for pain assessment along with objective measures due to poor evidence. Moreover, rapid and effective pain relief plays an important role in the improvement of psychological and physiological consequences.

A Historical Note on the Treatment of Trigeminal Neuralgia

Trigeminal neuralgia, otherwise known under the French denomination of tic douloureux, is a chronic painful condition of a particular severity. Its descriptions are numerous and date back to centuries before. Although the anatomy of the trigeminal nerve has been well known, the pathophysiology and hence the treatment of this disease has been largely fortuitous. Disparate pharmacological and surgical approaches have been tried, some of them heralding a much-required therapeutic success. The authors make a brief description of the first sources that have systematized the disease, along with all therapies documented in a written form, especially from indexed journals of the two last centuries. Very few remnants of the previous therapies, actually considered obsolete, have survived to the proof of time; one of them relies on the possible role of the autonomic nervous system and anticholinergic therapies, later replaced from modern conservative and interventional approaches. Anticonvulsants have been, since 1940, the mainstay of the therapy, however, progressions in neurosurgery and mini-invasive procedures have substantially improved the quality of life and the prognosis of an otherwise very painful and chronic condition.

Practice of Regional Anesthesia and Its Associated Factors among Anesthesia Professionals Working in Teaching Referral Hospitals of Ethiopia; A Multi-center Study

Background: Regional Anesthesia (RA) provides site-specific, complete pain relief, early mobilization, and rehabilitation; and it is preferred than general anesthesia due to associated risks in the later technique. It also ensures prolonged analgesia while reducing the need for systemic drugs with their side effects. Despite these advantages, the techniques have not been embraced as alternatives to general anesthesia in Ethiopia. Objective: The study aimed to assess the magnitude of regional anesthesia practice and its associated factors among Anesthesia Care Providers (ACPs) working in Ethiopian teaching referral hospitals, 2019. Materials and Methods: Multi-center-based crossectional study was conducted among all ACPs working in three institutions (Jimma Medical Center, Black Lion hospital and Wolaita Sodo teaching referral hospital) which were randomly selected among six government teaching referral hospitals running postgraduate anesthesia programs; from August 1-September 1, 2019. The practice of RA was considered significant if the participants performed >5 types of RA, assuming as minimum representation (30%) of all types of RA. Data were entered into Epidata manager version 4.3 and exported to SPSS version 22 for further analysis. Logistic regression was applied to determine predictors of RA practice. Adjusted odds ratio and 95% CI interval were used to measure the association and P-value <0.05 was declared as statistically significant. Results: Out of 143 participants, a total of 130 anesthesia professionals participated in the study, making the response rate of 90% . The mean age was 30.77±7.049 years that ranges from 22-56 years. Majority of the respondents were males, 88(67.7%). About 59.2% of ACPs practiced RA. The most performed types of RA were spinal anesthesia (98.5%), caudal anesthesia (72.3%) and axillary block (69.2%), while sub gluteal sciatic block and IV RA were the least practiced types of RA (8.5% each). Finally, two variables (years of experience (1-5 years) and academic qualification (above MSc)) were identified as the independent predictors of RA practice among ACPs with AOR of 6(1.7-21.6), p-v =0.005 and 10.4(1.9-56.9), p-v =0.007 respectively. Conclusion: In a nutshell, the practice of RA in teaching government hospitals of Ethiopia was relatively low despite some RA types like SA were almost practiced well. Thus, ACPs were expected to practice all types of RA than routinely abusing GA for patient safety and welfare in all dimensions.

Nutritional Intervention in Chronic Fatigue Syndrome and Fibromyalgia (CFS/FMS) A Unique Porcine Serum Polypeptide Nutritional Supplement

Background: Clinical experience suggested that a unique porcine serum polypeptide extract, used in hospitals for people with severe malnutrition, serendipitously resulted in a dramatic improvement in many fibromyalgia cases. Aims: The study aims to determine the effectiveness of a unique polypeptide serum extract in improving the symptoms of CFS and fibromyalgia (CFS/FMS). Methods: An open-label prospective study of 43 people with CFS or Fibromyalgia recruited worldwide. Interventions: Four 500 mg tablets twice daily for five weeks. Outcome Measures: Assessed baseline at five weeks of treatment using a VAS(1-10 points) rating energy, sleep, cognitive function, pain, overall well-being, anxiety, and digestive health, as well as the FIQR. The primary outcome measure was the pre- and post-treatment VAS composite score for the first five symptoms. Results: 43 subjects completed the three-week treatment trial. 60.5% of subjects rated themselves as improved, with 18.6% rating themselves as much better. In the 60.5% of subjects that rated themselves as improved, the significant average improvement was seen in all categories: 1. 69.4% increase in energy(p<.001) 2. 69.2% increase in overall well-being(<.001) 3. 53.8% improvement in sleep(<.001) 4. 60.5% improvement in mental clarity(<.001) 5. 37.9% decrease in pain(<.013) 6. 34.8% decrease in anxiety(<.001) 7. 54.6% improvement in digestive symptoms(<.001) 8. FIQR 59.2 to 39.3(<.001) In six individuals who also had pre- and post IgG antibody levels, total IgG increased by 13.8% on average, with similar improvements seen in the IgG 1-4 subsets. Conclusion: Recovery Factors® resulted in markedly improved energy, sleep, cognition, pain relief, calming, digestion and overall well-being in those with CFS/FMS. Clinical Trial Registration Number: NCT04381793.

Pilot Randomized Clinical Trial Study: Comparative Study of 10% Lidocaine Hydrochloride Solution with Lidocaine Prilocaine Emulsion Prior to Local Anesthetic Injection

Background: The pain caused by the injection of local anesthetic has been reported as one of the main complaints of dental patients. Topical anesthetics are widely used drugs in dentistry, mainly to control pain associated with the needle penetration in the administration of local anesthesia. Objective: The present study aimed to evaluate (5%,7.5% and 10%) concentrations of lidocaine/prilocaine agent, compared to the common 10% lidocaine hydrochloride spray in the oral cavity. Materials and Methods: This was a split-mouth double-blind, randomized clinical trial pilot study. We randomized 15 patients, ages 35 to 64 years, with American Society of Anesthesiologists I and II with severe chronic periodontitis who were referred to the dental clinic for surgery, to receive 4 topical anesthetics (5%, 7.5%, and 10%) lidocaine prilocaine emulsion and 10% lidocaine hydrochloride topical anesthetic agent before local infiltration. Primary outcomes were assessing drug safety and pain level that measured by assessment of visual analog scale (VAS) scores of pain during LA injection in the first premolar and second molar in each maxillary quadrant in 15 patients corresponding to the posterior superior alveolar nerve (PSA) and secondary outcome was the relationship between age and gender regarding pain perception, and a total of 60 regions were analyzed. Results: Results revealed that there was no statistically significant difference between lidocaine hydrochloride and (5%,7.5% and 10%) lidocaine prilocaine in terms of pain reduction when the 4 different compounds were compared. According to Spearman's rank correlation coefficient and Friedman test, the age and gender of the patients had an insignificant correlation with the anesthetic effects of the four studied solutions. Conclusion: Based on these results, age and gender have insignificant effects on the pain scores and it can be said that the four solutions do not have significant differences regarding their anesthetic effects; also, we did not find any adverse reactions by using 7.5% and 10% lidocaine/prilocaine agent.

Effects of Dexamethasone on Post-dural Puncture Headache in Patients Undergoing Orthopedic Surgery

Background: The effect of Dexamethasone on Post-Dural Puncture Headache (PDPH) after spinal anesthesia has not been well elucidated. The aim of the current study was to evaluate the effect of prophylactic intravenous dexamethasone on the incidence and severity of PDPH in patients undergoing orthopedic surgery. Methods: This randomized, double-blind, placebo-controlled trial was carried out in patients undergoing orthopedic surgery. The subjects were randomly divided into a placebo (n=140) and a dexamethasone (n=140) group. During the surgery, the control group participants were injected 2cc of distilled water, and the dexamethasone group participants were injected 2cc (8mg) of dexamethasone as an infusion in the veins. The incidences of PDPH on the first, third and seventh postoperative days were studied. Data were analyzed using SPSS version 22. Results: A total of 280 patients with a mean age of 32.7 ± 11.0 years were studied. The incidence of PDPH on the first day of post-operative period was lower in the dexamethasone group than the control group (21 vs. 34, P<0.05). This difference was disappeared on days 3 and 7. Nausea or vomiting occurred less in the dexamethasone group (9 vs. 26, P<0.05). However, no statistically significant association was found between study groups and the incidence of back pain (P>0.05). Conclusion: Although the frequency of PDPH was less in patients receiving dexamethasone, the incidence increased days after the operation and reached the level of the placebo group. We do not recommend prophylactic intravenous dexamethasone for the prevention of PDPH.

Dorsal Root Ganglion Stimulation for the Management of Chronic Neuropathic Pain: A Retrospective Case Series during Four Years follow-up in a Single Center

Objectives: The dorsal root ganglion (DRG) is involved in the transduction of pain signals to the central nervous system (CNS) and undergoes a number of physiopathological changes during chronic pain. The purpose of this data collection was to evaluate the long-term safety and efficacy of DRG stimulation for the treatment of chronic pain and its impact on functional aspects. Materials and Methods: Forty-four subjects with non-reactive chronic neuropathic pain syndrome were implanted with DRG stimulation. Patients were evaluated at baseline as well as at 15, and 30 days, and at 3, 6, 12, 24, 36 and 48 months after medical intervention/surgery using the Visual Analogic Scale (VAS), which measures pain intensity, and the Oswestry Scale, for the estimation of disability (ODI). Results: After four years of simulation, VAS and ODI showed a statistically significant reduction throughout the follow-up period. The average pain relief obtained after 48 months of treatment was 74.1% ± 3.4. Conclusion: The results of this data collection demonstrate the feasibility of DRG stimulation, the correspondence between the clinical indications at the DRG implant and what is commonly found in the literature on this technique.(18,20) Patients defined as clinical responders to DRG stimulation and so implanted with definitive IPG showed a sustained and long term efficacy. Eight patients had previously been implanted with a traditional SCS without any clinically relevant efficacy; they were then explained for unsatisfactory results. Six of them (75%) were later implanted with DRG, with long-term effectiveness. Another advantage of this therapy is the absence of positional effects and lead migration. The adverse events proved to be independent of the anatomical level of insertion; moreover, this series of cases show a lower incidence of lead migration than reported in the literature. In summary, DRGs have been ignored for too long, probably due to the technical difficulty of reaching their deep, almost extra-spinal anatomical position.

Pharmacological Aspects of Phyllanthus fraternus Standardized Extract (Rich in Lignans and Tannins) as a Pain Modulator

Background: The standardized extracts of P. fraternus were previously reported by us for its anti-inflammatory, analgesic, and anti-arthritic biological potentials. However, we have not reported for a consequence of P. fraternus on chronic inflammatory muscle hyperalgesia. Herein, we have demonstrated chronic pain modulating effect of standardized extracts of P. fraternus. Materials and Methods: Firstly, we have collected various parts of P. fraternus plant including the dried stems, leaves, and roots. In order to produce chronic inflammations, we further allowed injection to the left gastrocnemius muscle belly of rats with a freshly prepared solution of 3% carrageenan in normal saline (100µL). Thermal/heat hyperalgesia, mechanical hyperalgesia and muscle circumferences were determined in the current experimental model. In order to estimate, chronic pain modulating potential of P. fraternus, we have also studied histopathological studies and measurement of prostaglandin E-2 (PGE2). Results: After administration of 3% carrageenan intramuscular injection, we investigated the chronic thermal and mechanical hypersensitivity of aforementioned test sample i.e. standardized extracts of P. fraternus in terms of adopting 2 gradual dosings of 200 and 400 mg/kg (administered intraperitoneally) from day 14th to 22nd. From our study, we observed significant antihyperalgesic activity; when we allowed administering standardized extracts of P. fraternus intraperitoneally. Conclusion: To conclude, we have investigated the antihyperalgesic and anti-inflammatory potentials of standardized extracts of P. fraternus. These effects might be having mediation via supraspinal or spinal neuronal mechanisms, and mainly observed due to evidence of PGE2 inhibitions.