Ultrasound-guided supraclavicular or interscalene brachial plexus block carries the risk of puncturing vascular structures because of vascularity of the posterior triangle of the neck. Although the subclavian artery can be used in identification of the brachial plexus during supraclavicular brachial plexus block, this artery or its branches (transverse cervical artery, dorsal scapular artery, suprascapular artery) can be inadvertently punctured. In this review we describe the anatomy of the vasculature relevant to ultrasound-guided brachial plexus block at the posterior triangle of the neck. Color Doppler is suggested to help detect the arterial branches of the subclavian artery, a step that may be useful in reducing the risk for vascular puncture during ultrasound-guided supraclavicular or interscalene brachial plexus blocks.

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Our palliative care team (PCT) used continuous injection of low-dose ketamine combined with opioids for opioid-resistant cancer pain. But there are no guidelines for the use of ketamine. Our PCT administers lower-dose ketamine to decrease the risk of adverse effects. In this research we retrospectively surveyed daily dose and duration of ketamine-opioid usage on our cancer patients. We found considerable changes of cancer-pain management in our PCT. The daily doses of ketamine and opioids thus became lower and the durations of ketamine usage became shorter year by year. Recent availability of injectable oxycodone and analgesic adjuvants, such as gabapentin or pregabalin, may result in these clinical changes. It is acceptable that lower-dose ketamine contributes to the development of cancer pain management. It is expected that this research will be useful for improving the quality of life of cancer-pain patients.

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Plungers of disposable syringes can contact internal surfaces of the syringes with movement of the plungers. We studied bacterial contamination of those syringes after repeated movements of plungers applied with bacteria (methicillin-resistant Staphylococcus aureus: MRSA). Twenty-five ml of brain-heart-infusion broth were aspirated into 20 ml disposable syringes; thereafter, the protruded sites of the plungers were evenly applied with fluid containing MRSA. The plungers were pushed to empty the media. These procedures were repeated 10 times with each syringe, and each aspiration-emptying procedure was comprised of five syringes. Bacteria grew in the first emptying procedure of the emptied media from one syringe, none in the second procedure, two in the third, and four in the fourth. All syringes were contaminated after five or more aspiration-emptying procedures. In a controlled study, five syringes were applied with bacteria-free fluid in a similar procedure, and almost no syringes were contaminated. We conclude that repeated aspiration-emptying procedures should be avoided when the plungers are contaminated with bacteria in a clinical setting.

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A 64-year-old woman was referred to our department because of pain over a wide area of her body, including the neck, a shoulder, the anterior chest, and the back, that persisted after fracture dislocation of the shoulder joint. No skin symptom was noted at the initial examination, and autoantibody was negative, suggesting that the possibility of rheumatic disease was low. Because her condition fulfilled the classification criteria for fibromyalgia issued by the American College of Rheumatology, oral administration of amitriptyline and codeine was initiated. A detailed physical examination revealed the presence of anterior chest and back pain from before injury of the shoulder and a thickening of the right sternoclavicular joint. A diagnosis of SAPHO syndrome was made on the basis of bone thickening on MRI and a bull's head sign on bone scintigraphy. Rash later appeared on a foot and was diagnosed as palmoplantar pustulosis. Pain was markedly alleviated by oral bisphosphonate, and the condition ceased to fulfill the classification criteria for fibromyalgia.

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We report a case of pneumocephalus caused by a lumbar epidural block. The patient was a 75-year-old woman who had lumbar canal stenosis. After undergoing a lumbar epidural block using loss of resistance with saline, she suddenly complained of an intense headache as she got up from the bed. We evaluated by using an urgent head computed tomography scan and found pneumocephalus with an air image around the brain stem. Although an epidural block using loss of resistance with saline rather than air is recommended to prevent pneumocephalus, it is necessary to realize that this complication cannot be completely prevented.

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We report a case of an infected subcutaneous port for intrathecal analgesia treated by conservative antibiotic therapy. The port was not removed. The patient was a female in her 50s with intractable pelvic cancer pain of rectal cancer recurrence. Pain was not relieved with irradiation, phenol saddle block, or high-dose opioids. Because intravenous morphine provoked delirium, intrathecal analgesia with subcutaneous port was installed, which enabled her supine position. On the 27th day after installation, bacterial meningitis occurred via this port. The authors respected the patient's wish to avoid morphine-induced delirium, and intravenous and intrathecal antibiotics infusion preceded without port removal. Meningitis was completely improved on the 75th day after installation, and six months later, the patient died at home with complete pain relief (morphine 8 mg/day; bupivacaine 50 mg/day). Although it is common to remove the infected port, nonremoval is also suggested.

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A 71-year-old male developed acute herpes zoster (AHZ) of the left Th10-11 dermatomes. After 3 days the same rash occurred on the right Th5-6 dermatomes, and he was admitted to our clinic. Acyclovir administration, and continuous epidural analgesia and nerve root blocks (Th10-11) were performed. He obtained pain relief of the left Th10-11 dermatomes with nerve blocks after approximately 1 month, but the pain affecting the right Th5-6 dermatomes without nerve blocks progressed to postherpetic neuralgia (PHN). We speculate that early treatment of AHZ with nerve blocks may prevent progression of PHN.

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After epiduroscopy, one case was seen to have an epidural hematoma. It involved a 78-year-old woman who received an epiduroscopy for her degenerative spondylolisthesis. Obvious bleeding was not seen during the epiduroscopy. After the epiduroscopy, pain in the lower limbs increased, and paralysis of the lower limbs and dysuria appeared. Because extensive epidural hematoma was observed with an MRI, an emergency laminectomy was performed, and paralysis of the lower limbs was reduced. When pain appears in the lower back or lower limbs after epiduroscopy, the nerves must be attentively observed and close attention given to the epidural hematoma. Early examination and treatment are also necessary in cases of paralysis.

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