Objective: The frequencies of sacroiliac joint (SIJ) pain over low back pain (LBP) experienced by pain clinic outpatients in Japan are rarely reported. Patients and methods: We were retrospectively evaluating by use of medical records of our outpatients who had chief complaints with LBP during 2013. Patients suspected of suffering SIJ pain with present histories of, such physical fi ndings received diagnostic SIJ blocks. Patients were diagnosed as SIJ pain when the pain alleviated more than 50%. Results: In 459 patients who had chief complaints with LBP, we suspected that 100 patients who had responsibility focus at SIJ with clinical diagnosis and diagnostic block. Of these 100 patients, 90 could retrospectively be evaluated through clinical courses in the medical records. Fifty-five were diagnosed as SIJ pain; consequently the frequency of SIJ pain in LBP patients was at least 12.0% (55/459). Conclusion: The frequency of SIJ pain in LBP patients visiting our pain clinic was at least 12.0%.

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Aim: The purpose of this study is to know the current status of interventional treatment (IT) for cancer pain in Japan. Methods: Questionnaires were posted to 583 directors of hospices or palliative care and pain clinics in Japan. Results: Answers were obtained from 209 directors (35.8%). IT was performed in 65.2% of facilities but not in 34.8%, and the rate of performance was higher in the facilities whose director was an anesthesiologist rather than a palliative care physician (76.5% vs. 40.8%). The main reasons for no performance was the achievement of pain control with medication (28.1%), no doctors to perform IT (25.9%), labor shortage of anesthesiologists (17.8%), fear of complications (9.6%), no knowledge of indications (5.9%). Conclusion: Increase in doctors who can perform IT and education of the usefulness of IT are necessary for the spread of IT.

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We recently performed the ultrasound-guided stellate ganglion block (US SGB). However, there has been no study for a comparison of the expert landmark SGB and US SGB. We prospectively studied the effect of each SGB method. We performed each with local anesthesia mixed with contrast medium. After the blocks, we evaluated contrast images with CT-like imaging and measured bilateral forefingers' blood flow with radical pulse oximeters and effects and side effects. In total, 17 patients are satisfied with the inclusion criteria for this study. We divided the patients into two groups, 9 in the landmark group and 8 in the US group. We confirmed every SGB procedure accurately from contrast images. And there is no significant difference in the blood flow of forefingers or in clinical effects and side effects after SGB between the two groups. In this study, we suggested no significant difference between the expert landmark SGB and the US SGB.

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We report the case of a 42-year-old man who suffered from trauma-induced complex regional pain syndrome (CRPS) in the right upper limb, four years after improvement of left lower limb CRPS that was controlled by spinal cord stimulation. The spontaneous burning pain on his right forearm increased with movement, and it degraded the range of motion and was severe enough to interfere with his work. After diagnosis with traumainduced right forearm CRPS, he was treated with the ultrasound-guided interscalene approach brachial plexus blockade and medication. Mechanical-allodynia impeded early rehabilitation; however, following peripheral nerve block, the rehabilitation could be intervened. Two months after the initial visit to our pain clinic, his spontaneous pain and allodynia were diminished, and the range of motion was improved; therefore he was able to carry on daily life and resume work. The peripheral nerve blockade of somatic afferent inputs from the forearm probably debased his central hypersensitivity relating to pain.

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We report 3 patients who had restricted activities of daily living (ADL) because of chronic low back pain and sciatica who were successfully treated with wheelchair exercise. Their back pain and sciatica were caused by lumbar disc herniation or lumbar spinal canal stenosis. We considered that the pedaling motion by wheelchair exercise enables patients to participate in the exercise and is effective treatment that improves walking ability and ADL. We suggest that pedaling a wheelchair induces treatment not only of disuse syndrome factor, but also of fear avoidance. This report may indicate that wheelchair exercise is expected to be an introduction to a walking exercise for lumbago and sciatic pain patients.

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Pregabalin is often prescribed to patients with neuropathic pain, including painful diabetic neuropathy. Here we have reported a case in which incidence of hypoglycemia increased after prescription of pregabalin in a patient with painful diabetic neuropathy. A 50-year-old woman with type 1 diabetes mellitus complained of bilateral leg pain and numbness. After diagnosing painful diabetic neuropathy, 50 mg of pregabalin was administered one day and 75 mg the next. Although no complications of pregabalin, including sleepiness and dizziness, were observed, hypoglycemic symptoms were frequently observed following the start of pregabalin administration. During hospitalization this patient had hypoglycemic attacks 11 times, and 9 of them occurred in the morning. Because of frequent hypoglycemia, insulin dose was reduced during hospitalization. We considered that this hypoglycemia might have resulted from an improvement of impaired glucose tolerance and insulin overdose. However, we could not find the exact mechanism of these hypoglycemia attacks after a prescription of pregabalin in this patient with painful diabetic neuropathy.

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We planned to perform a splanchnic nerve block with the guidance of fluoroscopy to a patient in his 80s who complained of postoperative recurrent abdominal pain after surgical treatment of gallbladder cancer. We assessed that his spinal deformity was severe and his range of posture was restrictive because of the pain. Under biplane fluoroscopy, we rapidly identified the target spot on both his ventral and lateral sides where the needle needed to be placed. When the osteophyte interrupted the manipulative procedure, cone beam CT helped it verify the needle tip placement adequately. Cone beam CT and biplane fluoroscopy may be helpful for block therapy with patients who require the treatment for a short time, who limit their range of posture, and who have a high degree of difficulty for treatment in anatomically.

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A 55-year-old woman, who was diagnosed with breast cancer, complained of severe pain due to skin metastasis, even though she took morphine 720 mg/day, fentanyl patch 200 mg/h, and some adjuvants. To improve pain relief, opioid switch with methadone was performed. Because she took high-dose opioids, an increase of methadone and a decrease of morphine and fentanyl were done gradually. Six months later after start of methadone, satisfied pain relief was obtained with methadone 120 mg/day and fentanyl 100 µg/h with no severe adverse events. Furthermore, the cost of opioids decreased from approximately 620,000 to 240,000 yen per month. With patients who need high-dose opioids, methadone may be useful because it offers both good pain relief and opioid cost reduction.

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A 68-year-old woman underwent living-donor liver transplantation and received immunosuppressive therapy. She developed severe herpes zoster in the left fifth thoracic nerve region and visited the department of dermatology. The severe pain persisted despite antiviral treatment; therefore, she was referred to our department for relief from herpetic pain and was administered tramadol (75 mg/day) on the ninth day after the onset of symptoms. The patient had received lidocaine and nortriptyline concurrently for pain suppression in the acute phase. Her pain reduced gradually, and no prolongation or recurrence of pain was observed after discontinuation of tramadol. Immunocompromised patients who undergo organ transplantation often develop herpes zoster infection and subsequent postherpetic neuralgia. Although such patients require intensive therapy, the available treatment options are limited. Tramadol administration could thus be beneficial in patients contraindicated for neuraxial block therapy and those experiencing acute herpetic pain that shows a poor response to nonsteroidal antiinflammatory drugs.

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Postthoracotomy pain syndrome (PTPS) was defined as the pain that recurs or persists along a thoracotomy scar at least two months following the surgical procedure. We report a serious PTPS patient who was ameliorated by intravenous drip infusion of lidocaine. A 79-year-old woman, who was diagnosed as right lung carcinoma, underwent a right lung lobectomy and was cut off the sixth rib and intercostal nerve at the operation. She complained of a serious pain (numerical rating scale 8), and the pain was not improved by intercostal nerve block or oral intake of nonsteroidal antiinflammatory drugs and pregabalin. An intravenous drip infusion of 100 mg lidocaine improved the pain and this effect was maintained for three days. An epidural block further relieved the pain, and it completely disappeared 90 days after the operation. We recommend the intravenous drip infusion of lidocaine for the treatment of refractory PTPS.

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We report three cases of postdural puncture headache (PDPH) that were successfully treated with 150 mg/day of pregabalin. They were women in their 40s and 50s, and epidural anesthesia was performed for their anesthetic managements. On postoperative day 1 (POD1), they developed a headache in the upright position. They received pregabalin 75 mg/day from POD3. After the dose was increased to 150 mg/day, the headache improved. The results reported here indicate that pregabalin might become a new option for the treatment for PDPH.

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The patient was a 77-year-old male. His lumbosacral pain was so severe that the scheduled radiation therapy for lung cancer was postponed because of the difficulties in keeping a supine position. Pregabaline (75 mg/day) and combination tablets of tramadol hydrochloride (75 mg/day) and acetaminophen (650 mg/day) were prescribed, but his pain was not relieved. He was referred to our clinic. On the basis of his symptoms and MRI findings, his pain was assumed to in the left 3rd lumbar radiculopathy of lumbar spinal canal stenosis. We started oral administration of steroid followed by lumbar plexus block, which relieved his pain and the difficulty of keeping supine position, and then the scheduled radiation therapy was completed.

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