We retrospectively analyzed 5 patients (group P) who had residual intermittent pain and 5 without residual pain (group N) after radiofrequency thermocoagulation of the trigeminal ganglion for trigeminal neuralgia. The electrode of radiofrequency thermocoagulation was placed in the trigeminal ganglion where burst stimuli with 50 Hz gave paresthesia in the affected region. There were statistically no significant differences between the groups in the angles formed by the sagittal plane and the needle on the basal x-ray view, the ratios of the distances from the anterior edge of the oval foramen to the needle tip and the lengths of the short axis of the oval foramen, or the angles between the clivus and the needle on lateral x-ray view. The ratios of the distances from the infratemporal surface of the sphenoid to the needle tip and the distances to the clivus ranged at 0.50-0.79 for group N on lateral x-ray view. whereas, they were<0.50 or>0.80 for group P. Tactile sensation significantly decreased after thermocoagulation in group P versus in group N (1.8±4.7 vs. 6.2±2.7; P<0.05), as compared with the contralateral side. We conclude that patients who developed more intense impaired tactile sensation after thermocoagulation of the trigeminal ganglion for trigeminal neuralgia had residual intermittent pain. The position of the needle tip in relation to the oval foramen on lateral x-ray view and tactile sensation after thermocoagulation would indicate effective pain relief of trigeminal neuralgia after radiofrequency thermocoagulation of the trigeminal ganglion.

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Problems and side effects during patient-controlled epidural analgesia (PCEA) with 0.2% ropivacaine and fentanyl in patients who underwent surgery of the thorax (thoracic group, n=132) and abdomen (abdominal group, n=295) were retrospectively analyzed. More epidural catheters were spontaneously withdrawn in the thoracic group than in the abdominal group(18% vs. 5%; P=0.001). Whereas, dysuria occurred more frequently in the abdominal group than in the thoracic group (25% vs 8%; P=0.03). Nausea (n=7) and somnolence (n=4) were the most frequent causes to change the programs of PCEA in the thoracic group; dysuria (n=13) and hypotension (n=8) were the main causes to re-adjust PCEA in the abdominal group. We conclude that it is important to prevent spontaneous withdrawal of epidural catheters in patients who undergo thoracic surgery and to manage dysuria and hypotension in patients who undergo abdominal surgery, during PCEA.

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We analyzed results of treatment for severe trigeminal herpes zoster pain. Nine patients received mandibular nerve block with local anesthetic and steroid at the exit of oval foramen (group B) and 9 did not receive mandibular nerve block (group C).
Mandibular nerve block was performed with 1% lidocaine and dexamethazone 2 mg. There were statistically no significant differences of age, sex, duration of symptoms before treatment, and pain intensity before and at the end of treatment between the groups. The median duration of treatment, by which the pain intensity became 20 on a visual analog scale, was significantly shorter in group B than in group C (14 days vs. 88 days, respectively; P=0.008). Group B needed significantly less nerve blocks than group C (8 vs. 23; P=0.017). Duration of whole treatment was significantly less in group B than in group C (66 days vs. 365 days; P=0.015). We conclude that mandibular nerve block with a local anesthetic and steroid at the exit of oval foramen is effective in the treatment of severe herpes zoster pain involving the trigeminal regions.

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Intraspinal-canal cysts are known to cause pain in the leg. A juxta-facet cyst often shows radiculopathy. We report a patient with juxta-facet cyst associated with arachnoid cyst at the same vertebral level. A 61-year-old woman presented with pain in the left leg. She had radiculopathy of the left L5 and S1. Lumbar MRI showed a juxta-facet cyst at L5/S1 on the left. Pulsed radiofrequency on the L5 and S1 roots, and aspiration of the cyst contents reduced the pain for only 2 weeks. Myelography revealed an arachnoid cyst at the same vertebral level with the juxta-facet cyst. The left S1 root was compressed. Partial laminectomy and resection of the facet cyst were performed and the pain in the leg completely resolved after the surgery.

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We report a patient who developed probable serotonin syndrome after taking amitriptyline and paroxetine. A 78-year-old man suffered from post-herpetic neuralgia since 3 years before. He had been treated with repeated stellate ganglion blocks and amitriptyline 30mg/day. He subsequently developed disorientation and tremor 14 days after taking amitriptyline. The tremor spontaneously resolved 3 days after cessation of amitriptyline. Paroxetine 20mg/day was begun 7 days after cessation of amitriptyline. Upper respiratory symptoms occurred 3 days before this medication. Thereafter, he developed tremors of the upper limbs and torso, myoclonus, and exaggerated deep tendon reflexes. These symptoms disappeared 6 days after withdrawal of paroxetine. There was no abnormal finding in the cerebrospinal fluid. Clinical symptoms and signs strongly suggested that the patient developed serotonin syndrome. Physicians should be alert that amitriptyline and paroxetine may cause serotonin syndrome.

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We report re-insertion of an electrode lead for spinal epidural electrical stimulation with Seldinger method. A patient had received spinal epidural electrical stimulation. The electrical stimuli covered the painful area; however, the threshold for electrical stimulation increased, suggesting damage of the electrodes. Since adhesion of the epidural space was expected and a new one should be placed at the previous position, it was inserted into the epidural space at the previous position with Seldinger method guided by a Tuohy needle under fluoroscopy. Electrical stimuli via the newly inserted electrode lead covered the painful area. The pain was well controlled. We conclude that re-insertion of an electrode lead for spinal epidural electrical stimulation with Seldinger method can minimize the incision for re-insertion and displacement of the electrode lead.

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Questionnaires on the second revision of the guidelines for the treatment of pain published by the Japanese Society of Pain Clinicians (JSPC) were sent to all 4,002 members of the JSPC to clarify its impact on daily clinical practice. Two hundred forty-three members (6.1%) responded. Based on the age distribution, duration of providing pain treatment, and the proportion of specialists among the respondents, the results could reflect the general opinions of pain clinicians who play active roles in pain treatment. Among the 243 respondents, 161 (66.3%) treated patients mainly with nerve blocks. The second revision, which focused on nerve blocks, was used by 114 respondents (46.9%). One hundred seventy-one respondents(70.4%) evaluated the second revision useful. Analyses of the questionnaires revealed that publishing the guidelines for pain treatment was essential for the Japanese Society of Pain Clinicians. The respondents suggested that the third revision be user-friendly, describe more nerve blocks, diseases, anatomy for and physiology of nerve blocks, and pharmacotherapy. They also recommended more high-quality references be mentioned in the highly ranked 20 diseases and pain syndromes and delete lesser ranked ones to improve the overall quality of the next guidelines published by the JSPC.

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