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2019 Volume 26 Issue 2 Pages 157-166
日 時：2019年2月9日（土）
会 場：長崎大学病院第4講義室（教育棟2階）
会 長：原 哲也（長崎大学麻酔科）
Young Woo Cho Hee-won Son A Ran Lee
Department of Anesthesiology and Pain management, Ulsan University Hospital, Ulsan, Korea
1. Hiccup
A hiccup is the involuntary and sudden contraction of the diaphragm and intercostal muscles, followed by abrupt glottis closure, generating the characteristic sound. Hiccups are usually common, transient, and self-limited1. Based on the duration, hiccups can be categorized as temporary (＜48 hours), persistent (48 hours–1 month), or intractable (≥1 month)2.
Temporary hiccups are not very harmful and remedies such as drinking water or holding the breath can alleviate the symptoms. However, persistent or intractable hiccups can induce sleep disorders, exhaustion, fatigue, depression, malnutrition, weight loss, and dehydration. Furthermore, hiccups may induce opening of abdominal or thoracic open surgical wounds, and these patients require active treatment for hiccup symptoms3,4.
Although the pathophysiology of hiccups is not well defined, the hiccup reflex arc has been considered to play an important role. The hiccup reflex arc consists of the afferent limb, central hiccup center, and efferent limb.
Etiology of Persistent and Intractable Hiccups2
・Central nervous system
Vascular disease: Stroke, infarct, systemic lupus erythematosus related vascular disorders aneurysms
Tumor: Astrocytoma, carvenoma, brain stem tumors
Inflammation: Neuromyelitis optica, multiple sclerosis
Trauma; Brain injury
Miscellaneous: Seizure, cranial nervous herpes infection, parkinsonism
・Peripheral pathway
Chest cavity: Mediastinal diseases, lymphadenopathy, diaphragmatic tumors
Heart: Myocardial ischemia
Gastrointestinal tract: Esophageal tumors, gastroesophageal reflux diseases, stomach volvulus, H. pylori infection
Lower abdomen: Gynecologic tumors
Miscellaneous: Cancers
・Procedure
Surgery: Anesthetic agents, post-operative disturbances
Chemotherapy: Chemotherapeutic agents, steroids
Drugs: Anti-parkinsonism treatment, psychiatric medications, azithromycin, morphine
Instrumentation; Atrial pacing, catheter ablation, central venous catheterization, esophageal stent placement, bronchoscopy, tracheostomy, shaving beards
Miscellaneous: Electrolyte imbalance, ethanol users, tuberculosis, chronic renal failure
Treatment of persistent hiccups is nonspecific. Nonpharmacological treatments involve stimulation and suppression of the vagus nerve, with tongue lifting, ingestion of highly-concentrated sugar water, stimulation of the pharynx, compression over the eyeball or carotid artery, a Valsalva maneuver, and rebreathing. Pharmacological treatments include anticonvulsants (i.e., phenytoin, carbamazepine, and valproic acid), gamma-aminobutyric acid analogues (i.e., baclofen and gabapentin), and dopamine receptor antagonists (i.e., haloperidol, metoclopramide, and chlorpromazine). If these fail, nerve blocking procedures and surgical treatments can be performed2. Nonetheless, no treatment method ensures complete cure for the majority of patients5.
2. 6 Cases
3. Stellate Ganglion Block (SGB)
The mechanism of action of the SGB is not completely understood, but it has been widely used to treat sympathetically maintained pain, vascular disease and CRPS involving the face and upper arms, such as migraines, trigeminal neuralgia, atypical facial pain, hot flashes in postmenopausal women, PTSD and postherpetic neuralgia6–8.
Yusom Shin
Department of Anesthesiology and Pain Medicine, Kosin University College of Medicine, South Korea
Pain management is essential in palliative care for cancer patients. Of the methods of managing cancer pain, the role of an anesthesiologist or pain specialist in the field of interventional therapy is very important. Except for simple injections, interventional procedures such as nerve block require training and high level of expertise.
According to clinical practice guidelines for the palliative care of cancer patients of the National Comprehensive Cancer Network (NCCN®), cancer patients with pain are recommended to be frequently reassessed their pain on an ongoing basis for proper pain management.
The NCCN guidelines for adult cancer pain are designed to allow referrals to pain specialists for moderate to severe pain. If patient-specific goals are not achieved when the pain is re-evaluated, interventional strategies should be applied and the interventional procedures suggested by the NCCN guidelines are as follows:
・Regional infusions (requires infusion pump)
Epidural: easy to place, requires the use of an externalized catheter/pump; for infusions of opioids, local anesthetics, and clonidine; useful for acute postoperative pain; use beyond several days to a few weeks is limited by concerns for catheter displacement and infection
Intrathecal: easy to internalize to implanted pump; for infusions of opioids, local anesthetics, clonidine, and ziconotide; implanted infusion pumps may be costly, refills require technical expertise
Regional plexus: for infusions of local anesthetics, to anesthetize single extremity; use beyond several days to a few weeks is limited by concerns for catheter displacement and infection
・Percutaneous vertebroplasty/kyphoplasty
・Neurodestructive procedures for well-localized pain syndrome (spinal analgesics are used more frequently)
Head and neck: peripheral neurolysis generally associated with sensory and/or motor deficit
Upper extremity: brachial plexus neurolysis
Thoracic wall: epidural or intrathecal, intercostals, or dorsal root ganglion neurolysis
Upper abdominal pain (visceral): celiac plexus block, thoracic splanchnicectomy
Midline pelvic pain: superior hypogastric plexus block
Rectal pain: intrathecal neurolysis, midline myelotomy, superior hypogastric plexus block, or ganglion impar block
Unilateral pain syndromes: cordotomy
Consider intrathecal L/S phenol block
・Neurostimulation procedures for cancer-related symptoms (ie, peripheral neuropathy, neuralgias, complex regional pain syndrome)
・Radiofrequency ablation for bone lesions
When planning interventional procedures, indications, risks, and benefits must be considered. An interventional procedure can be tried in cases when the medication is not successful, when a patient without contraindications has severe adverse drug reactions, or when its benefits are greater than its risks. Especially, celiac plexus block (pancreas/upper abdomen) and superior hypogastric plexus block (lower abdomen) are useful.
Contraindications: infection, coagulopathy, very short life expectancy, distorted anatomy, patient unwillingness, medications that increase risk for bleeding (eg, anti-angiogenesis agent such as bevacizumab), or technical expertise is not available.
Risks (associated with neurolytic blockade): anesthesia of the area innervated by the destroyed nerve, anesthesia dolorodsa (pain superimposed in an area that lacks or has impaired sensation), autonomic dysfunction, motor paresis, bladder/bowel dysfunction, dysesthesias, orthostatic hypotension, neuritis.
Trigger point injection (TPI) is helpful in cancer patients with myofascial pain syndrome characterized by taut bands and palpation-induced radiation of pain in the muscle. If low back pain or neck pain is involved, spine-related injections (epidural steroid injection, facet joint injection, facet denervation approaches, sacroiliac injections, etc.) are needed. Vertebral augmentation procedures (vertebroplasty, kyphoplasty) may be performed if vertebral compression fractures in cancer patients with bone metastases cause severe pain and spinal instability. Neural blockades can be done with the following three purposes: 1) diagnostic, 2) prognostic (for neurolysis), and 3) therapeutic (esp. Celiac plexus neurolysis). At this time, continuous injection through a catheter is possible as well as a bolus injection. Selectable options include sympathetic blocks (stellate ganglion, lumbar sympathetic trunk, celiac plexus, superior hypogastric plexus, ganglion impar block, etc.), somatic nerve blocks (paravertebral or intercostal, brachial plexus block etc.) or neurolytic blocks (celiac plexus neurolysis, superior hypogastric plexus neurolysis). There are also advanced neuraxial techniques (spinal cord stimulation, catheter-based neuraxial infusion).
Two cases are presented below to share the experiences of interventional procedures in cancer pain management.
・Case 1. F/50, Rt. Parapharyngeal mass, s/p transcervical enucleation of neurogenic tumor (parapharyngeal space); ultrasound-guided nerve block via pterygopalatine fossa.
・Case 2. M/40, rectal ca. with lung, pleural, Lt. ureteral metastases; epidural catheter insertion with PCA (2017–06–21).
Successful interventional approaches significantly reduce opioid dosing as well as pain relief in cancer patients. This non-pharmaceutical treatment method is of great help in reducing the administration dose of opioids and minimizing side effects.
References:
1. Levy M, Smith T, Alvarez-Perez A, Back A, Baker JN, Beck AC, et al. Palliative Care Version 1. 2016. J Natl Compr Canc Netw 2016; 14: 82–113.
2. Swarm RA, Abernethy AP, Anghelescu DL, Benedetti C, Buga S, Cleeland C, et al. Adult cancer pain. J Natl Compr Canc Netw. 2013; 11: 992–1022.
3. Portenoy RK, Copenhaver DJ. (2017). Cancer pain management: Interventional therapies. In T.W. Post, Abrahm J, Fishman S, Savarese DM & Crowley M (Eds.), UpToDate, Available from https://www.uptodate.com/contents/cancer-pain-management-interventional-therapiese.
4. Sackheim K. Pain management and palliative care. A comprehensive guide. 1st ed. New York: Spriner; 2015. pp.267–375.
小杉寿文
佐賀県医療センター好生館緩和ケア科
がん患者の約半数に痛みが生じるとされている．わが国では年間に約38万人ががんで死亡していることから，多数のがん性疼痛患者が存在していると予想されるが，必ずしも適切な疼痛治療を受けていない可能性がある．充分量のオピオイドが投与されず，病態を評価せずに鎮痛補助薬が併用され，眠気とふらつきに苛まれながらも痛みが残るような状態が散見される．終末期においては，痛みが取れないという理由で，持続鎮静されている．がん患者の予後は長期化している．再発や増悪の不安を抱えながら抗がん治療を継続し，日常生活を送っているがん患者は，慢性疼痛患者のような心理社会的辛さも同様に経験している．痛みのプロであるペインクリニシャンが，もっと積極的にがん性疼痛治療に関与し，適切なマネジメントと，必要なインターベンションを施行すれば，がん患者の生活は楽になり，穏やかで豊かな最期を迎えることができるのではないだろうか．
石川亜佐子＊1,2 山口静香＊3 上村聡子＊1 塚本絵里＊3 平川奈緒美＊1,2
＊1佐賀大学医学部附属病院ペインクリニック・緩和ケア科，＊2佐賀大学医学部附属病院緩和ケアセンター，＊3佐賀大学医学部附属病院手術部
【症例】症例は63歳男性．直腸内分泌がんの多発肝転移，骨転移の診断で，化学療法・疼痛コントロール目的に当院入院となった．脊柱管浸潤を伴うL1/2腰椎転移による腰痛，左大腿部痛が強く，緩和ケアチーム介入となった．放射線療法・ゾレドロン酸投与とともに強オピオイド鎮痛薬の増量・変更，鎮痛補助薬の併用を行ったがNRS 5～10/10の痛みが持続した．大腿神経支配領域の痛みだったため，試験的に超音波ガイド下左大腿神経ブロック（0.25％ロピバカイン6 ml）を行い即時効果が得られたが，約30分後ベッド移乗の際に左大腿部の激痛が再燃した．より中枢での痛みの遮断が必要と考え，持続腰部硬膜外ブロック（0.1％ロピバカイン3 ml/h）を行い良好な鎮痛が得られた．後日左L2，3神経根に高周波パルス療法を施行したところ，鎮痛薬の減量，歩行訓練が可能となった．いったん後方支援病院へ転院後，化学療法目的に当院再入院の際にも鎮痛効果は持続し治療を再開できた．化学療法の有害事象のため治療継続が困難となり，PRF後約1カ月で後方支援病院へ転院となったが鎮痛効果は持続していた．
【考察】がん性疼痛に対するPRFの有効性が報告されている．脊髄鎮痛法や，メサドンも適応と考えられる症例だったが，後方支援病院では管理が困難であり，このような症例では神経ブロックはきわめて有効で，PRFの効果を実感できた症例であった．
鬼塚一聡 田代章悟 榎畑 京 上村裕一
鹿児島大学病院麻酔科
【はじめに】開胸術後疼痛症候群（PTPS）とは，「開胸術後2カ月以上にわたり繰り返したり持続する創部に沿った疼痛」と定義される．今回，PTPSに対し肋間神経パルス高周波（肋間神経PRF）を施行し，著効した2症例を経験したので報告する．
【症例①】50歳女性，縦隔腫瘍に対し胸腔鏡下腫瘍摘出術を施行した．術後から続く左前胸部痛の改善がなく，術後18日目に当科を紹介となった．初診時のVASは92 mmであった．肋間神経ブロックにより責任高位をTh4レベルと判断し，持続胸部硬膜外ブロックを施行した．施行後はVAS：43 mmと効果を認めたが，残存する疼痛に対し肋間神経PRFを施行した．直後より効果を認め，施行7カ月後もVAS：0～10 mm程度で疼痛の増悪なく経過している．
【症例②】49歳男性，縦隔腫瘍に対し胸腔鏡下腫瘍摘出術を施行した．術後から左前胸部痛があったが，術後20日目から増強したため当科を紹介となった．初診時のVASは92 mmであった．肋間神経ブロックを施行し責任高位をTh5レベルと判断し，肋間神経PRFを施行した．施行直後より効果を認め，施行1カ月後もVAS：0～5 mm程度で疼痛の増悪なく経過している．
【考察・まとめ】PTPSの疼痛が強い症例や持続する症例では，内服に加え早期の神経ブロックの導入を考慮する必要がある．肋間神経ブロック（PRF含む）は，X線透視下に超音波装置を併用することでより安全に施行できる．今回の治療経験から，PTPSへの肋間神経PRFの高い有効性が示唆された．
平井規雅 廣田一紀 柴田志保 戸山恵美子 中原春奈 山浦 健
福岡大学病院麻酔科
【はじめに】脊髄神経後枝内側枝高周波熱凝固療法は脊椎由来の頸部痛，背部痛，腰痛などに対し行われる治療法の一つである．局所麻酔薬と比較し，長期的にわたる除痛効果を得ることができる．今回，高度側弯症，圧迫骨折による難治性疼痛に対し，多椎体の脊髄神経後枝内側枝高周波熱凝固療法が効果的であった症例を経験したので報告する．
【症例】50代の男性．元来側弯症を指摘されていたが手術適応はなかった．5年前より腰痛が徐々に増悪しており，他院整形外科やペインクリニック科で入院加療されたが痛みは改善せず，当科紹介となった．初診時，NRS 8程度の腰痛があり，歩行器が必要なほどADLが低下していた．高度側弯症と第12胸椎の圧迫骨折による多椎間にわたる椎間関節症と診断した．第12胸椎から第4腰椎までの広範囲に及ぶ脊髄神経後枝内側枝高周波熱凝固療法を3回に分けて施行し，徐々に疼痛はNRS 8→7→4と軽減，ADLも向上し独歩での生活に復帰，復職も果たした．
【まとめ】高度側弯症，圧迫骨折による難治性疼痛に対し，多椎体の脊髄神経後枝内側枝高周波熱凝固療法が有効であった．
谷口奈美＊1 前田愛子＊2 荒木建三＊3 塩川浩輝＊3 辛島裕士＊1
＊1九州大学大学院医学研究院麻酔・蘇生学，＊2九州大学病院手術部，＊3九州大学病院麻酔科蘇生科
【はじめに】特発性三叉神経痛（TN）・舌咽神経痛（GPN）は頭蓋内微小血管による脳神経の圧迫が原因であることが多く，通常は高齢発症である．今回，若年でTN・GPNを発症した症例を報告する．
【症例】21歳，男性．
【現病歴】17歳より飲み込み時の右舌根部の電撃痛を自覚し，当院脳神経外科で右GPNと診断された．カルバマゼピン内服での疼痛制御が困難となり，19歳時に微小血管減圧術を施行し症状が改善した．21歳時に食事時の右下顎部痛が出現し，当院脳神経外科で画像所見から右TNと診断された．カルバマゼピンを内服したが次第に疼痛制御困難となり当科紹介受診となった．
【現症】右三叉神経第3枝領域の痛みがあり，他の脳神経に異常はなかった．会話や食事時に強い電撃痛が出現したが，夜間は持続的な痛みであると流涙し訴えた．MR画像では右前下小脳動脈が右三叉神経REZを圧排していた．
【経過】パルス高周波法で右下顎神経ブロックを行ったが改善なく，高周波熱凝固法で再度施行したところ，痛みが消失し内服薬中止となった．
【考察】①若年発症のTN・GPNは非常にまれであり，症候性疾患を除外する必要がある．②本症例では痛みに対する恐怖心によると推察されるTNの典型的な症状から乖離した訴えが一部あった．①②の理由から診断に難渋したが結果的にTNと考えられた．
【結語】若年発症のTN・GPNは画像や症状を注意深く評価する必要がある．
横溝泰司＊1 山田信一＊1,2 津田勝哉＊1 福重哲志＊2 平木照之＊1
＊1久留米大学医学部麻酔学講座，＊2久留米大学病院緩和ケアセンター
【はじめに】腕神経叢ブロック斜角筋間法の合併症に横隔神経麻痺がある．多くは全身麻酔下でのブロックであるため，症状は不顕性である．また外来では手術時のブロックと異なり，薬液の量も少なく濃度も低いため本邦における有害事象報告の例はない．今回，われわれはペインクリンック外来で腕神経叢ブロック後に横隔神経麻痺による呼吸困難をきたした症例を経験した．
【症例】54歳，男性．頸椎症性神経根症による肩腕痛のために当科受診．超音波ガイド下右腕神経叢ブロックを2回（0.25％レボブピバカイン7 mL＋ワクシニアウイルス接種家兎炎症皮膚抽出液3 mL，0.5％レボブピバカイン7 mL＋ワクシニアウイルス接種家兎炎症皮膚抽出液3 mL）行った．3回目のブロック（2回目と同）20分後，頭部に大量の発汗を認め，呼吸苦の訴えがあった．呼吸時の胸郭の上下運動に左右差なかったが，聴診にて右肺の呼吸音が減弱していた．SpO2 94％となり気胸を疑い，X線撮影を行ったところ，右横隔膜の挙上を認め，横隔神経麻痺による呼吸困難と判断した．SpO2はさらに低下（87％）したため，酸素投与を行い，経過観察した．90分後呼吸苦は軽減し，270分後の胸部単純写真で右横隔膜の挙上は改善した．
【まとめ】超音波ガイド下腕神経叢ブロック斜角筋間法後に横隔神経麻痺をきたした．ブロック後は呼吸状態の注意深い観察が必要である．
山本裕梨 樋田久美子 吉﨑真依 村田寛明 原 哲也
長崎大学医学部麻酔学教室
【はじめに】三叉神経節ブロック（GGB）の合併症には，施行時の異常高血圧や血管穿刺による出血性合併症などが，施行後早期には髄膜炎や脳神経症状などがある．今回，GGB施行直後に眼症状が出現し，加齢黄斑変性と診断された症例を経験したので報告する．
【症例】71歳男性．当科の初診2年前に右下顎部痛が出現し三叉神経痛と診断された．カルバマゼピンでStevens-Johnson症候群を発症し内服不可能となり，プレガバリンで鎮痛効果不十分のため当科紹介となった．内服治療を継続していたが痛みが増強したため，2年3カ月で透視下GGBを施行した．ブロック操作中，卵円孔へ刺入したところで血管穿刺があり針位置を調整し高周波熱凝固とパルス高周波を施行した．顔面痛は軽減したが，翌朝より左眼の視野異常が出現した．ブロック施行の反対側であり合併症とは考えにくく，眼科受診を勧め，加齢黄斑変性の診断で治療が開始された．数カ月の経過で視野異常は改善傾向にある．
【結語】GGB施行後に眼症状，脳神経症状を適切に観察したため，早期に視野異常に気づき，加齢黄斑変性の治療を開始することができた．GGB施行後に眼症状が出現した場合には，ブロック関連の合併症だけではなく一般的な眼疾患も視野に入れた原因検索を行わなければならない．
鈴木有希＊1 東 美木子＊1 上村裕一＊2
＊1今村総合病院麻酔・ペインクリニック科，＊2鹿児島大学医学部・歯学部付属病院麻酔科
【症例】45歳男性．
【現病歴】半年前より，左前胸部～左側背部～左肩にズキズキ・ビリビリするような痛みを自覚するようになった．とくに誘因になるような出来事はなく，近医整形外科を受診し，単純X線撮影で頸椎の軽度加齢性変化を指摘された．プレガバリン150 mg/日・アセトアミノフェン1,500 mg/日・ジクロフェナクテープを処方され経過をみられていたが，症状改善しないため，当科紹介となった．
【既往歴】高血圧・うつ病．
【臨床経過】痛みの性状は神経障害性疼痛様であったが，筋力低下や知覚低下もなく，Jackson，Spurlingなどの神経根刺激テストは陰性であった．血液検査にもとくに異常はなかった．腹診で左右胸脇苦満強く，うつ病既往や便秘傾向認めたため，大柴胡湯5 g/日・アミトリプチリン10 mg/日を処方したところ，痛みは軽快した．しかし，違和感は依然継続していたため，MRIで精査したところTh5–6に脊髄空洞症と軽度の小脳扁桃下垂の所見を認めた．病変部位と痛みの性状から，左胸背部痛の原因として脊髄空洞症が関与している可能性が疑われた．
【結語】胸背部痛を契機に脊髄空洞症と診断された1症例を経験したので，文献的な考察を加え詳細を報告する．
清永夏絵＊1 鬼塚一聡＊1 榎畑 京＊1 大納哲也＊2 田代章悟＊1 上村裕一＊1
＊1鹿児島大学病院麻酔科，＊2鹿児島市立病院麻酔科
【はじめに】12年間肺がん治療を継続している患者の痛みの治療を経験したので報告する．
【症例】60代，男性．12年前に肩の痛みが出現し，左肺がん，頸椎転移，左尺骨転移と診断された．放射線治療，化学療法が行われ，腫瘍は縮小し痛みは軽減した．その後化学療法が継続して施行された．2年後，頸椎転移による不安定性に対して頸椎固定術が施行された．術後，肩・背部の痛みが続き，トリガーポイント注射が施行された．6年後，左上肢痛が出現し，腫瘍に関連する神経障害性痛と考えられ，強オピオイドと，プレガバリン，抗不安薬などの鎮痛補助薬により痛みは軽減した．7年後，左尺骨の病的骨折に対し固定術が施行された．12年後，左上肢痛が増悪し，腫瘍に関連する神経障害性痛と考えられ，抗うつ薬，抗痙攣薬などの鎮痛補助薬を加え，痛みの軽減を図っている．
【考察】本症例では，腫瘍の脊椎転移に伴う痛み，脊椎固定術後の痛み，不安などによる痛みへの影響などがあり，放射線治療，化学療法，外科手術，神経ブロック治療，薬物などがそれぞれ奏功したと思われる．
【結語】悪性疾患の患者の予後はさまざまである．経時的に変化する病態と症状を考慮し，適切な痛み治療を行う必要がある．
高谷純司
明野中央病院麻酔科
【症例】46歳，女性．
【既往歴】内視鏡下椎間板摘出術（L5/S1，2年前）．
【現病歴】職場で米を持ち上げた後に左下肢痛が再出現．MRIでL5/S1ヘルニアの再発を認めた．S1領域の痛みで体動不可，睡眠困難となり，薬物療法の効果は乏しかったため当院整形外科に緊急入院した．仙骨硬膜外ブロックは無効で，S1神経根ブロックでは無痛を得たが1日後に再燃した．整形外科医および本人と協議し，脊椎固定が考慮される再手術を極力回避すべく，コンドリアーゼ投与を計画した．ただし，患者が疲弊していることから，投与後早期に鎮痛されなければ再手術の予定となった．下肢痛は投与の翌日には自制内にまで軽減し，投与8日目に独歩で退院した．復職後も疼痛は再燃することなく，患者の希望とおり社会生活を継続している．
【考察】コンドリアーゼの臨床試験では，プラセボ群と比較し2週目以降の有意な下肢痛低下が示されている．しかし疼痛が高度な場合には，2週間もの待機はしばしば困難である．本症例では翌日から効果を認めたことから，椎間板内圧は早期に低下したと推測された．
【結語】コンドリアーゼが極早期に効果発現した結果，再手術およびそれに伴う長期入院を回避できた症例を経験した．本薬は，社会生活が中断しないよう強く希望する患者に有用な治療と考えられる．
益山隆志 八木由紀子
鹿児島共済会南風病院ペインクリニック内科
【はじめに】薬物療法や神経ブロック療法でも強い痛みが続く帯状疱疹関連痛の患者に，バースト刺激モードによる脊髄刺激療法（以下，SCS）を短期間行い有効だった2例を報告する．
【症例1】66歳男性．左T4領域に帯状疱疹を発症，第24病日当科初診．薬物療法，持続硬膜外ブロック，神経根ブロックを行ったものの治療効果は一時的だった．第66病日に8極リード1本を留置し17日間バースト刺激を行った．開始後早期に効果が発現，自発痛・アロディニアとも軽減，リード抜去の翌日退院となった．退院後やや痛みが増強したが神経根ブロック，薬物療法で対応できた．
【症例2】68歳男性．右T4領域に帯状疱疹を発症，第72病日当科初診．症例1同様治療を行うも改善が乏しく，第106病日に8極リード2本を留置し21日間バースト刺激を行った．開始翌日には退院できるほどの痛みとの言葉が聞かれ，以降病棟を歩き回るなど活動的になった．リード抜去の2日後に退院，薬物療法は続けたが退院後の痛み増悪はなかった．
【結語】亜急性期の帯状疱疹関連痛に対する一時的なSCSが持続効果を呈しうることが報告され当科でも以前トニック刺激によるSCSを行ったことがあるが有効例は少なかった．今回治療に難渋した患者にSCSをバースト刺激のみで行い痛みの軽減とQOLの改善を認めた．症例数が少なく両刺激の比較検討はできないが帯状疱疹関連痛に対するバースト刺激の有用性が示唆された．
深尾麻由 日髙康太郎 川﨑祐子 渡部由美 山賀昌治 恒吉勇男
宮崎大学医学部附属病院麻酔科
【背景】オピオイド鎮痛薬の使用において，副作用である便秘に対する耐性形成はほとんどないため，下剤の継続投与などの対策が必要である．オピオイド誘発性便秘症（opioid induced constipation：OIC）は，腸管壁内神経叢のオピオイド受容体作用によって腸管蠕動が低下することで起こり，ナルデメジンは末梢性μオピオイド受容体拮抗作用でOICを改善するとされる．便秘に対して使用される他の薬剤で代表的な酸化マグネシウムやセンノシドと比較し，ナルデメジンでは副作用である下痢の発生頻度が非常に高く，ナルデメジンによる下痢にはオピオイド鎮痛薬の退薬症状の成立が関与している可能性があると考えた．
【目的】オピオイド鎮痛薬の開始早期からナルデメジンを併用することで下痢の発症が減少しないかどうかを検討する．
【方法】当院入院中にOICに対してナルデメジンを開始された患者を対象とし，下痢の発症について後ろ向きに調査する．
【結果】当院においては，オピオイド鎮痛薬の開始から7日以内にナルテメジンを開始した患者で有意に下痢の発症が少なかった．
【結論】オピオイド鎮痛薬を使用する際には，可能な限り早期にナルデメジンを開始することで副作用としての下痢の発症を予防できることが示唆された．
Sang Yoong Park＊1 Chan Jong Chung＊1 Hae-Kyu Kim＊2 Rushin Maria Dass＊3
＊1 Department of Anesthesiology and Pain Medicine, School of Medicine, Dong-A University, Busan, Republic of Korea, ＊2 Department of Anesthesiology and Pain Medicine, School of Medicine, Pusan National University, Busan, Republic of Korea, ＊3 Department of Anesthesiology and Critical Care, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
Background: BPC-157 is a stable gastric pentadecapeptide that effective in trials for wound healing capability, increased collagen and new blood vessels formation, decreased myeloperoxidase activity and inflammatory cell influx, including healing of muscle and tendon. BPC-157 also has undoubtedly a positive effect on muscle healing that may be provided partly by the regeneration of the damaged intramuscular nerve branches. There are no studies about the effect of BPC-157 on the pain transmission to the high level like central sensitization. This study was aimed to investigate the effect of BPC-157 on the central sensitization of pain from formalin test.
Methods: Male Sprague-Dawley rats (250–300 g) were included in this study. All the experimental animals were randomly divided into Control (n＝6), Morphine 7 mg/kg (n＝6) and BPC 3 groups (n＝6). BPC group was randomly subdivided according to dosage of BPC-157 (n＝6 in each groups). Formalin test was done as follows. For induction of pain, 50 µL of 5％ formalin solution was applied to the hind paw. Pain behavior was quantified by periodically counting the number of flinches of the injected paw after injection. The number of flinches was counted for 1 min periods at 1 and 10 min and at 10 min intervals from 10 to 60 min. Morphine 7 mg/kg, BPC-157 10, 20, 40 µg/kg in BPC group and normal saline (all same volume) in Control group were administered intraperitoneally 60 minutes before the formalin injection.
Results: Intraperitoneal administration of BPC 157 decreased dose-dependently the sum of the number of flinches during phase1, but not during phase 2 in the formalin test.
Conclusions: These findings indicated that BPC-157 was effective against a facilitated pain evoked by formalin injection at the peripheral level but not at the central level. Thus, the BPC-157 may be useful in the management of acute peripheral pain.
Hak-Moo Cho Kun-Moo Lee Young-Jae Kim
Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, College of Medicine, Inje University, Busan, Korea
Background: Anterior cutaneous nerve entrapment syndrome (ACNES) is an important cause of chronic abdominal wall pain and a nerve entrapped condition in the rectus abdominal muscle characterized by a severe localized neuropathic pain at the front of the abdomen. Diagnostic confirmation of ACNES has Carnett's sign and is proven by using the infiltration of local anesthetics on the anterior sheath of the rectus abdominal muscle. And the local anesthetic infiltration is one of the most common interventional treatment of ACNES.
Case presentation: A 81 years old female patient presented with right upper abdominal pain for 2 months. She underwent surgery for cholecystectomy two years ago, but had normal laboratory and imaging. Physical examination revealed the abdominal pain by palpation with the pain occurring during Carnett's sign testing. We injected subcutaneously the solution of 5％ dextrose instead of local anesthetics at 4 tender points in accordance with the anterior subcutaneous nerve of Th7, Th8, Th9, and Th10 intercostal nerves. And the abdominal pain was resolved about 10 second later.
Conclusion: It is sometimes hard to diagnose ACNES. We report perineural injection therapy with the solution of 5％ dextrose as an available alternative treatment of ACNES with Carnett's sign.
Kyung-Hoon Kim
Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University
Background: It is not uncommon for patients who have received a permanent implant to remove the spinal cord stimulator (SCS) after discontinuation of medication in complex regional pain syndrome (CRPS) due to their completely painless state. This study evaluated CRPS patients who successfully removed their SCS.
Methods: This 10-year retrospective study was performed on patients who had received the permanent implantation of an SCS and had removed it 6 months after discontinuation of stimulation, while halting all medications for neuropathic pain. Age, sex, duration of implantation, site and type of CRPS, and their return to work were compared between the removal and non-removal groups.
Results: Five (12.5％，M/F＝4/1) of 40 patients (M/F＝33/7) successfully removed the permanent implant. The mean age was younger in the removal group than the non-removal group (27.2±6.4 vs. 43.5±10.7 years). The mean duration of implantation in the removal group was 34.4±18.2 months. Two of 15 patients (13.3％) and 3 of 25 patients (12％) who had upper and lower extremity pain, respectively, had removed the implant. The implants could be removed in 5 of 27 patients (18.5％) with CRPS type 1 (vs. 0 of 14 patients with CRPS type 2). All 5 patients (100％) who removed their SCS returned to work, while only 5 of 35 (14.3％) in the non-removal group did.
Conclusions: Even though this study had limited data, younger patients with CRPS type 1 had a better prognosis for complete pain relief after SCS implantation and could remove the SCS within a 5-year period and return to work.
Eunsoo Kim＊1 Hae-Kyu Kim＊1 Seong-Ho Lee＊2
＊1 Department of Anesthesiology and Pain medicine, School of Medicine, Pusan National University, Busan, Korea, ＊2 Department of Anesthesiology and Pain medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
Genicular nerve block is a popular technique to alleviate knee pain particularly in patients with knee osteoarthritis, chronic post-operative pain of the knee after arthroplasty or arthroscopic surgeries. Radiofrequency ablation of these nerve has been widely reported in small scale studies and in multiple case reports and in general this procedure has a 25％ failure rate. However, we would like to report another technique of neurolysis using chemical technique either with alcohol.
We report two cases of genicular nerve neurolysis using with use of alcohol. The first patient had mixed neuropathic and nociceptive after multiple arthroscopic knee surgeries and was not responsive to conservative treatments. The second case is a patient with chronic knee osteoarthritis with mainly nociceptive like pain and effusion of the knee. She also has functional limitation effusion of the knee and was not responding to conservative treatment. In both these cases we performed diagnostic genicular nerve block with 2 ml of 1％ lidocaine under ultrasonography. After checking the reduction of pain, we performed genicular nerve neurolysis with 1 ml of 99％ alcohol under both ultrasonography and fluoroscopy guidance with excellent outcome after six weeks review. No complications were noted immediately or after six weeks.
In conclusion, chemical neurolysis of the genicular nerve is safe and effective alternative techniques for both chronic knee osteoarthritis and post-surgical pain syndrome. Apart from that, the comparatively low cost, ease of use and early clinical outcomes when compared to radiofrequency ablation makes it an attractive alternative.
Sang Eun Lee
Department of Anesthesiology and Pain Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
Complex regional pain syndrome (CRPS) is a chronic neuropathic pain conditions, usually affecting a limb which manifests as extreme pain, swelling, limited range of motion, and changes to the skin and bones. Lumbar degenerative spine disease is a common cause of disability and can lead to an aggravation in the symptoms of CRPS, and a reduction in the quality of life.
A 59-year old man presented with right ankle with a visual analogue scale (VAS) of 70 (0＝no pain, 100＝worst imaginable pain) lasting longer than 1 year, after he received an ankle surgery three times because of right ankle fractures. He was diagnosed with CRPS and complained of persistent chronic pain, differential skin temperature, edema, and joint disability. After 1 month, he complained of pain in both legs. In addition to medications, this patient often underwent caudal blocks, lumbar epidural blocks, lumbar sympathetic blocks, and peripheral nerve blocks. At 9 months after starting the treatment at the pain clinic, it was difficult to walk due to severe radiating pain in the left lower limb and worsening of the right foot pain. The lumbar MRI showed a protruded disc at L4/5 with inferior migration into the left subarticular zone. After sacral epiduroscopic laser decompression (SELD), the pain in the lower back and left lower extremity completely disappeared. Although the neuropathic pain in the right ankle had little improvement, the discomfort and pain of the right ankle during walking were significantly reduced.
In patient with CRPS with lumbar disc disease, SELD may not only reduce primary pain in the lower back and the lower limb caused by lumbar disc lesions, but also reduce secondary pain during walking, thus improving quality of life.
Yusom Shin Changwoo Lim Doo Sik Kim Sie Jeong Ryu
Department of Anesthesiology and Pain Medicine, Kosin University College of Medicine, Republic of Korea
Introduction: It is already known that chronic pain and depression are related and can have a bad influence on each other. It is reported that the probability of depression in patients with pain is almost 3 to 5 times higher than in patients without pain. In Korea, the prevalence of depression in chronic patients is 35.1％，which is higher than the prevalence in general population. According to the American Association of Suicidology, depression is most commonly associated with suicide among psychiatric diagnoses. 15％ of patients will eventually die of suicide even if they are being treated with depression. Ketamine is an anesthetic, but it is also used to treat pain. The usefulness of ketamine treatment in the acute phase of suicide has been reported.
Case presentation: A 32-year-old 164-cm, 51-kg female patient has undergone pain treatment with atypical facial pain after mandibular surgery. Outpatient follow-up was discontinued and only one visit was made about four months later. Again, she returned to our pain clinic with severe pain after eight months. She refused a psychiatrist's recommendation for voluntary hospitalization due to high risk of suicide. After about 6 weeks she showed red flags for suicide. Immediately, she was provided ketamine infusion therapy with the dose of ketamine 60 mg for one hour. There was a clear improvement in suicidal ideation and pain after an additional four ketamine therapies.
Conclusions: Depression is accompanied by pain and exacerbates each other, so both require active intervention. Ketamine should be a good choice in the acute phase, especially in chronic pain-associated depression with a risk of extreme action of suicide.
Makito Oji Natsuko Oji Maki Ohno Yusuke Kasai Yoshiaki Terao Makoto Fukusaki
Department of Anesthesia, Nagasaki Rosai Hospital, Nagasaki, Japan
Introduction: Previously, we reported a case in which a caudal epidural pulsed radiofrequency for sacroiliac joint pain on single side was performed. In this study, we report efficacy of caudal epidural pulsed radiofrequency (hereinafter CE-PRF) in single procedure for bilateral sacroiliac joint pain.
Case: The case is 71 years old, male. His chief complaint is bilateral lower back and leg pain. He had medical history of lumbar laminectomy 3 years ago and 2 months ago. He visited to our department because his pain had persisted for 6 months. At the first visit, He seemed to have pain derived from S1 area. We performed a caudal block but it had no effects. Bilateral sacroiliac joint block was performed at the follow up, and it was effective for a short time and he was diagnosed as bilateral sacroiliac joint pain. The sacroiliac joint block was repeatedly performed, but his pain did not perfectly relieve. CE-PRF was performed for 600 seconds with the electrode pad in the center on his back. The degree of pain decreased from 5 to 3 on the numerical rating scale after 2 weeks.
Consideration: Sacroiliac joint block is performed in the treatment of sacroiliac joint pain as necessary. In addition to local anesthetics, we can apply thermocoagulation for a long-term analgesic effect. The patient's physical burden is not small because the thermocoagulation for sacroiliac joint pain requires several nerve branches blocks even when performed on single side. It would be still more for bilateral performance. We would like to recommend CE-PRF which can be applied as a convenient substitute therapy with minimally pain during treatment. The implementation conditions of the almost PRF method and the extent and range of the effect are not sufficiently verified. Also, the effect range of PRF would vary depending on the application site of the electrode pad. Since the sacroiliac joint is dominated by the 1–3 sacral nerve roots, CE-PRF was performed so as to the effect range is aimed to bilateral S1–3. We were able to obtain a certain extent of effectiveness with only single puncture.
Conclusion: CE-PRF showed a both side efficacy for bilateral sacroiliac joint pain.
