Long-acting local anesthetics, such as ropivacaine, bupivacaine, and levobupivacaine, are frequently used for brachial plexus block. Plasma concentration of local anesthetics is highest 15-30 min after injection, and it increases more rapidly after the interscalene approach than after the axillary or subclavicular approach. Adding adrenaline suppresses the increase of plasma concentrations of local anesthetics. An increase of its plasma concentration induces systemic toxicity characterized by a dual-phase response, i.e., excitement and depression in the central nervous and cardiovascular systems, depending on levels of the protein-unbound fraction. Cumulative doses of ropivacaine, bupivacaine, and levobupivacaine for inducing central nervous system toxicity are comparable. It is often manifested by visual, hearing, and speech disturbances with an increase of blood pressure and heart rate. Cardiovascular toxicity characterized by refractory arrhythmia, hypotension, and asystole is often resistant to conventional treatment with adrenaline and antiarrhythmic agents. Because intravenous lipid emulsion is effective for treating local anesthetic-induced systemic toxicity, it should be administered during treatment of such toxicity.

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Staphylococcus aureus was applied to wounds on the backs of mice to prepare models of wound infections for examining changes in the wounds over time. Every 3 hours for up to 24 hours after the application of bacteria, and then at 48 and 120 hours, seven mice were sacrificed. Five were frozen and stored, followed by the quantification and culture of the wounded areas. The wounded areas of 2 mice were fixed in 5% formalin for observation. At 6 hours after the application of bacteria, no inflammatory cells infiltrated the wounded areas. At 9 hours, the bacteria proliferated around the wound, and many neutrophils that engulfed the bacteria infiltrated. At 12-21 hours, the number of bacteria on the surface layer increased. At 21-120 hours, the number of bacteria decreased. These relationships were significant. Our models revealed the course of wound and puncture infections, providing a potentially useful tool for investigating their prevention and treatment.

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Hypertrophic pachymeningitis (HP) is a chronic progressive diffuse inflammatory fibrosis of the dura mater, leading to its enlargement and subsequent nervous system sequelae. We report a case of a 71-year-old man who was diagnosed as hypertrophic cranial pachymeningitis. His initial symptoms were double vision and headache, which were followed by various cranial nerve symptoms such as ptosis, dysphagia, and hoarseness, as well as the headache. In the early stages, the headache was severe and resembled a cluster headache. However, it became continuous and dull at later stages. T1-weighted magnetic resonance imaging using gadolinium contrast was useful for diagnosis of the thickening of dura mater. Steroid therapy was started, and the cranial nerve symptoms improved immediately.

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We report a patient with intractable painful toe ulcer whose pain and wound healing were improved by continuous sciatic nerve block (CSNB). An 80-year-old man who was on anticoagulant therapy had gradually developed ulcer and pain in the toe during 2 months. We suspected that this condition was caused by vasospastic ischemia. Because caudal block provided temporary analgesia, we performed CSNB. We inserted a catheter on the right sciatic nerve and administered a continuous infusion of 0.2% levobupivacaine at a rate of 4 ml/h. Although pain disappeared after the block, a motor block on an ankle appeared. Therefore we gradually decreased the concentration of local anesthetic. When concentration was reduced to 0.03%, plantar flexion and dorsiflexion appeared, but no pain recurred. The ulcers turned to scabs, and the wound healing was good. CSNB may become one of the effective treatments for patients with painful ischemic ulcers of the leg.

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Opioids have been regarded as the most effective analgesics for treating cancer pain, whereas their administration is still controversial in chronic noncancer pain. We report a 73-year-old male with persistent cervical pain after cervical spine surgery. The administration of fentanyl patches of 6.3 mg and gabapentin of 1,200 mg failed to relieve the pain. His excruciation resulted in insomnia, depression, and body weight loss of 6 kg. A continuous brachial plexus block with 0.2% ropivacaine was conducted with the method known as patient-controlled analgesia (PCA); thus it proved the effectiveness of an ultrasound-guided brachial plexus block. With decreasing pain, the dosage of opioid administration was tapered without withdrawal phenomenon. Lastly, he could manage his cervical pain without opioid use. Moreover, rehabilitation and social support by medical social workers were virtually useful and helpful for the patient and his family.

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We report a patient with left-occipital pain diagnosed as left vertebral artery dissection. A 38-year-old woman was suffering from migraine for 3 years and had left-occipital pain. During an evening meal, she had experienced this acute pain. Headache treatment drugs provided no relief, so she entered ER. She was revealed by computed tomography to have no subarachnoid hemorrhage, but magnetic resonance angiography revealed left vertebral artery dissection, which may be a much more common disease than we think. Therefore in a case of acute occipital pain, we should suspect it and obtain magnetic resonance angiography or computed tomography angiography.

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Facial pain as a symptom frequently observed in routine clinical services is caused by headache; oral, ophthalmologic, nasal, and oral abnormalities; facial impairment; and cranial nerve disorders. However, some patients have long-lasting facial pain with no organic changes or nonmeeting criteria of trigeminal neuralgia or migraine. These cases are usually diagnosed as persistent idiopathic facial pain (PIFP). Here we report 3 PIFP cases with intractable pain for 2-20 years that were successfully treated with nerve blocks and 10-25 mg/day tricyclic antidepressants (TCAs). Pain relief was subsequently maintained with low-dose (10 mg/day) TCAs. Although its therapeutic mechanism has not yet been fully clarifi ed, this approach is suggested to be effective for patients with nonretractable facial pain.

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We report the case of a 66-year-old woman with involuntary movement and muscle pain in the back as a sequel to thoracotomy. The patient had previously undergone upper lobe resection of the right lung for bronchiectasis. Two months later, the muscle next to the operation scar in her back began to twitch intermittently. The involuntary movement was accompanied with severe local pain extending from the operation scar to the anterior chest. Her symptoms remained refractory to drug therapy and nerve blocking. Botulinum toxin A (BTXA) was injected into the muscle surrounding the scar to treat the involuntary movement. This movement and pain around the scar completely disappeared. BTX-A was also injected into the anterior chest muscle, and the pain in the anterior chest was relieved. BTX-A not only decreased the involuntary movement, but also relieved the pain. Moreover, it can be used for the treatment of refractory neuropathic pain after thoracotomy even if its mechanism is not yet fully understood.

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We report of two male patients with RS3PE syndrome which began with an acute onset of polyarthralgia and pitting edema during the course of treatment for spine-related pain symptoms of the upper and lower extremities. RS3PE syndrome was diagnosed from the patients' physical and laboratory fi ndings. In both patients, therapy with low doses of oral steroids resulted in prompt remission of joint pain and edema. Increased awareness of RS3PE syndrome as a collagen disease-like clinical entity resembling rheumatic arthritis may be warranted.

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Intravenous lidocaine has been used to provide analgesia in patients with neuropathic pain; however, no guidelines exist regarding this procedure as the fi rst choice. This study was performed to evaluate the effect of lidocaine infusion, especially on neuropathic pain, using the quantitative immediate pain-relieving measurement system Pain Vision^®, which indicates the degree of pain in addition to the visual analogue scale (VAS) method. Using VAS and Pain Vision^®, we evaluated pain intensity pre- and postintravenous administration of lidocaine in four postherpetic neuralgia patients and four other neuropathic patients. Intravenous lidocaine resulted in a decrease in both VAS and pain intensity measured by Pain Vision^® to some extent. We demonstrated the analgesic effect of intravenous lidocaine on neuropathic pain using Pain Vision^® in addition to VAS. Although we showed signifi cant immediate pain-relieving effect, we need further study to test the long-term pain-relieving effect of intravenous lidocaine.

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Attacks of menstrual migraine (MRM) are more resistant to treatment, longer, and recur more frequently than other migraine types. Although naratriptan, with the longest half-life, seems suitable for MRM, few studies show its efficacy. We analyzed data from 16 patients with MRM who met the diagnostic criteria of the international classifi cation of headache disorders, 2nd edition (ICHD-II), and evaluated the adherence, efficacy, and adverse effects of naratriptan 2.5 mg as an acute treatment for MRM. The adherence and efficacy rates were both 14/16 (87.5%). No patients experienced serious adverse effects. However, two patients could not continue treatment, one because of nausea and vomiting, and the other from a slower action of naratriptan in comparison to other triptans. These two patients used other triptans properly in different situations. Naratriptan may be effective and well-tolerated for the acute treatment of MRM, although further evaluation in larger controlled trials is needed. Educating patients in the appropriate use of different types of triptans is important.

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We report two cases of pneumothorax following nerve block detected by ultrasonography in an outpatient setting. Case 1 was a 59-year-old woman who reported chest pain after thoracic paravertebral block. Case 2 was a 68-year-old woman who reported chest pain after acupuncture. In both cases, we suspected pneumothorax and performed diagnostic ultrasonography. There was no sign of pleural sliding, and air reverberation artifacts were apparent in both. Pneumothorax was diagnosed, and the patients were admitted to our hospital. Although chest X-ray and computed tomography are typically used to assess the severity of pneumothorax, ultrasonography allowed for a rapid diagnosis and an effective follow-up.

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Malignant psoas syndrome (MPS) causes severe pain that is difficult to manage. We report a case of refractory cancer pain from malignant psoas syndrome successfully treated with radiation therapy in combination with analgesic agents. The patient was a 31-year-old female who had left-back pain 5 months before admission. She felt paresthesia in her left thigh and could not walk. CT detected enlargement of her cervix and a cyst on her left psoas muscle, and the pathology detected squamous cell carcinoma in her cervix and cyst. She was diagnosed with metastatic cervical cancer and malignant psoas syndrome, and treatment for refractory pain by a combination of analgesic agents and radiation therapy was successful. This case suggests that a combination of analgesic agents and radiation therapy may be effective for symptom relief of malignant psoas syndrome.

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