For the development and maintenance of chronic pain, neuroplasticity in the central nervous system is the main cause. However, the role of the innate immune system in blood is also drawing attention. Therefore researches to fi nd a novel blood marker for chronic pain are being carried out, and the brain-derived neurotrophic factor (BDNF) is one of the possibilities. Peripheral nerve injury very likely increases BDNF in the central nervous system under pro-infl ammatory signals, and decreases under anti-infl ammatory signals. Although some researchers consider that such changes in BNDF in the central nervous system refl ect serum concentrations of BNDF, our clinical investigation showed that epigenetic changes in BDNF genes in the peripheral blood cells cause the decrease in the serum concentrations of BDNF with an anti-infl ammatory state in patients suffering from chronic back pain and that the decrease of serum BDNF correlates with the increase in number of pain symptoms. Blood BDNF expressions in considering immune status could be a biomarker for chronic pain.

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An epidural nerve block is widely and often effectively used for treating pains. However, it has risks of severe complications, such as epidural hematoma and nerve injuries. Because a blind puncture is generally employed, it is impossible to grasp the relative arrangement of the needle tip, blood vessels, and nerves. However, use of a dull-ended Tuohy needle (dull needle) can reduce tissue damage caused by a sharp needle point. Moreover, puncture resistance increases, which may relay the sensation much more clearly when the ligament is pierced. Therefore we used conventional Tuohy needles and dull needles for epidural block cases to compare the presence of piercing sensation, puncture frequency, level of bleeding, and presence of pain at the insertion. As a result, in the dull needle group significantly many cases were recognized to have the piercing sensation, and significantly few cases of bleeding needed compression at the puncture site. It is suggested that use of the dull needle may reduce the risk of complications.

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Purpose: To compare the efficacy of ultrasound-guided stellate ganglion block (US-SGB) with that of landmark SGB, we studied changes in skin temperature of the face and palm after SGB. We also investigated a difference in efficacy between C6-SGB and C7-SGB among the US-SGB group. Methods: Twenty-eight patients who underwent SGB were assigned to either US-SGB 13 patients (52 implementations) or landmark SGB 15 patients (60 implementations). Further, the US-SGB group was classified as a subgroup of either the C6 group (patients who underwent SGB at the sixth cervical vertebra) or the C7 group. Results: The US-SGB group showed a more significant increase of skin temperature compared to the landmark SGB group. The difference between the C6 and C7 groups was insignificant. The US-SGB group has no adverse effects. The landmark SGB group has a case of chest numbness. Conclusion: It is suggested that US-SGB was a more effective and safer procedure than landmark SGB. From a study of the US group, C6-SGB is recommended because the vertebral artery damage can be avoided.

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A 77-year-old man underwent transurethral surgery in the lithotomy position under spinal anesthesia. Although bed rest ended the day after surgery, on postoperative day 2 (2POD) he experienced pain in the left leg while walking, which later spread to both legs. Anesthesia had originally proven difficult, and examination by an orthopedic surgeon on 4POD showed no abnormal neurological findings or image findings; on 5POD, he was referred to a pain clinic. The symptom of pain was pain on motion, and trigger points were noted in both legs. He had a history of osteoarthritis of the hip, and his daily living activities had declined. He showed no complications associated with the anesthesia, surgery, or body position on examination at our department; therefore, myofascial pain syndrome was suspected. After starting drug therapy and physical therapy as diagnostic therapy, his symptoms improved, and he was discharged on 10POD.

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For the diagnosis of cerebrospinal fluid leak, CT myelography (CTM) images of the epidural retention of contrast medium are accurate and useful, but it is impossible to identify the leak point. In this study, we performed CTM with dynamic myelography (DM) to detect the leak point. In four patients in whom cerebrospinal fluid leak was strongly suspected, CTM with DM was conducted five times. In three of five sessions of DM, the efflux of contrast medium from the subarachnoid cavity into the epidural space could be confirmed, suggesting the point of leak. In the other two sessions, it could not be confirmed, but it was possible to clarify the extent of the leak point based on the serial changes in contrast-enhanced epidural images. In conclusion, dynamic myelography may be useful for detecting the leak point of cerebrospinal fluid.

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Primary erythromelalgia (PE) is a refractory pain disorder characterized by the triads of pain, redness, and heat in the extremities induced by local exposure to warmth. Here we report a successful treatment for a 54-year-old woman who suffered from triads of PE for ten years. Originally, she underwent intermittent severe pain attacks twenty times per day and had sleep disorder. The symptoms showed remarkable improvements by stellate ganglion block of 14 times. Subsequently, sustaining oral administration of alpha-1 adrenergic antagonist keeps the symptoms in stable condition. Previous studies showed that PE patients have mutations in the gene encoding the sodium channel Nav1.7 expressed within the dorsal root ganglion and sympathetic ganglion neurons. These observations suggested that this increases the excitability in neurons and causes low pain thresholds and peripheral ischemia. Meanwhile this generates neuropeptide and chemical mediator releases and causes peripheral redness. Consistent with prior reports, our experience suggests that PE has excessive activities in a sympathetic nervous system.

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The management of cancer pain developed in ground by World Health Organization (WHO) is an analgesic ladder in cancer pain primarily in a region of palliative medicine. After being diagnosed with cancer, however, the number of patients who were followed up in outpatient care or treated for long terms gradually increased, and importance of the management of pain these people experienced also increased. We consider the pain management of long-term cancer survivors by showing 3 cases that produced various kinds of cancer pain. It was a neuropathic pain associated with the chemotherapy, prolonged postoperative pain, contribution of the psychological factor such as anxiety of the recurrence, and use of opioids that became a problem especially for these patients. The pain of a long-term cancer survivor includes a severe element of chronic pain and needs different correspondence, unlike a cancer pain because of the cancer's advanced progression, and it is thought to be the region where the pain clinician should positively intervene.

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We report a case of refractory back pain successfully treated with transdermal fentanyl patch. A 44-year-old woman with low back pain resulting from L3/4 disc degeneration was treated with 1 mg of transdermal fentanyl patch, which decreased pain from 9 to 3 on the numerical rating scale. The patient underwent spinal surgery of L3/4 fixation 3 months later, and the transdermal fentanyl patch was stopped. A transdermal fentanyl patch may be useful for patients suffering from chronic back pain by disc degeneration.

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Although recent studies show that thoracic paravertebral block (TPVB) provides similar pain relief with lesser adverse effects compared with epidural analgesia after thoracic surgery, there are few reports of TPVB for cancer pain relief. We present a case of successful pain management with the combination of opioid, ultrasound-guided TPVB, and radiation therapy in a woman suffering from intractable chest pain with lung cancer. In this case, a tumor extended to the middle thoracic area and dissemination of the lower pleura. TPVB was performed twice. During ultrasound-guided TPVB, fluoroscopy was used to confirm the spread of injected solution after the ultrasound-guided needling and to determine the dose of 100% alcohol. Her pain was reduced, and she had spent 6 months at home after the block. In conclusion, ultrasound-guided TPVB can be applied to thoracic cancer pain, and we recommend the use of fluoroscopy to provide adequate analgesia and to minimize adverse effects.

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We report a case of successful pulsed radiofrequency stimulation of the pudendal nerve for pudendal neuralgia. A 70-year-old woman suffered from perineal pain for 3 months. The pain was predominantly experienced only in the sitting position. She experienced tenderness by palpation of the bilateral ischial spine. After diagnosis with pudendal neuralgia according to Nantes Criteria, she was treated with the pulsed radio frequency of the pudendal nerve, and the pain was well controlled.

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A 76-year-old female developed left superior cluneal nerve disorder (SCN-D). She could not sit for even a short time because of a sharp low-back pain. Trigger-point injection around the left iliac crest was effective in the short term. Ultrasonography findings revealed an enlarged SCN and edematous thoracolumbar fascia where SCN penetrated. Pulsed radiofrequency therapy was tried with ultrasound peripheral nerve block technique. She got the pain relief and was able to sit comfortably when desired for more than one month.

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We tend to prescribe pregabalin (PGB) for patients for a long time without checking its effectiveness. In the present study, the authors investigated whether PGB administration could be stopped without any harm in 11 patients who had had PGB for 6 months or more. The experimental protocol was as follows. When we judged that a further analgesic effect of the patient would not be expected and if the patient suffered no recurring severe pain, we gradually reduced the doses of PGB. If the dose could be reduced to 25 mg, we stopped PGB administration to the patient. The results showed that PGB administration was successfully stopped for 7 patients, but could not be stopped for 4 patients. We suggested that we possibly continue unnecessary PGB administration to patients without checking its effectiveness.

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Treatment of phantom limb pain and stump pain remains difficult. This case report describes successful management of phantom limb pain and stump pain using radiofrequency thermocoagulation. A woman in her 70s lost her left arm at the forearm while at work 1 year ago. When we first saw her, she felt a phantom limb tightly clenched and lightning pain in its fingers. She also felt allodynia on the stump. We diagnosed phantom limb pain and stump pain. After Kampo medicine treatment for 1 year and 6 months, the phantom hand was unclenched, but the lightning pain on the phantom fingers and the stump pain remained. The patient underwent ultrasound-guided radiofrequency thermalcoagulation at 80℃ for 180 s to the median nerve. Six months later, frequency of the lightning pain was significantly decreased, and the stump pain disappeared.

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