Staphylococcus spp., which are nonmotile, are the most frequently isolated pathogens from the catheter of epidural abscesses. The movement mechanisms of Staphylococci remain unclear. We hypothesized that increased bacterial concentration and catheter reciprocal movements correlated with deeper penetration of Staphylococci into the catheterized site. We investigated the correlations among bacterial concentrations on the needle puncture surface and epidural catheter insertion sites, catheter movement, and Staphylococcus aureus growth in deeper layers of the agar. Staphylococci grew in the deeper layers of the agar when bacterial concentrations on the needle puncture surface and catheter insertion sites were increased. When 5-mm reciprocal movements of the catheter were repeated every 12 h over a 72-h period, Staphylococci penetrated the 5-cm-thick agar, the average distance from the skin to epidural space in adults. This resulted in increased Staphylococci concentrations and minor repeated catheter-movements because of physical movements of patients, which may result in the migration of Staphylococci into deeper tissues from the skin surface.

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A-68-year old woman, who has been suffering from pain, hyponatremia, and confusion by psychogenic polydipsia, restless legs syndrome, irritable bowel syndrome, and insomnia for several years, came to our institution. We carefully heard her detailed story and provided her substantial relief. Subsequently, we diagnosed her central sensitivity syndrome (CSS), including fibromyalgia and treated it with pharmacological and cognitive behavioral therapy. Complains in patients with CSS or fibromyalgia are multifactorial and not fully explained medically. However, pain clinicians have roles to diagnose and manage those disorders. We described the effects of narrative therapy and pharmacological and cognitive behavioral therapy.

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The patient was a 73-year-old female with a chief complaint of right oral pain during eating. The pain could not be closely evaluated because of difficulty in communication due to her past medical history of subarachnoid hemorrhage. The cause could not be identified by computed tomography or magnetic resonance imaging, but neuralgia of the third branch of the right trigeminal nerve was suspected based on the course. Oral drugs and a nerve block were administered, but evaluation of the effect of each treatment was difficult. Because the pain was intractable, craniotomy was performed on a trial basis. Two arteries contacted the trigeminal nerve, for which microvascular decompression was applied, and it was markedly effective. Reflecting on this case, we should evaluate pain by formalizing physical expressions, such as facial expressions, for patients with communication difficulty. Even though no cause may be observed on imaging, it is suggested to perform a craniotomy on a trial basis for patients with intractable trigeminal neuralgia.

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Nerve blocks in the cervical region may result in some complications due to an unexpected spread of injected local anesthetics. We report a case of transient severe hypertension after a deep cervical plexus block (DCPB) for degenerative cervical spondylosis. A 70-year-old female presented with pain and numbness radiating from the back of the head to the left upper arm. After a series of cervical nerve blocks, an occipital nerve block, a superficial cervical plexus block, and a brachial plexus block were normally provided, and DCPBs were scheduled for the remaining neck pain. Though each DCPB progressed normally with ultrasound guidance, all three consecutive DCPBs led to transient hypertension for more than a half-hour. This is the first report concerning transient hypertension after DCPB. A careful observation of vital signs after cervical nerve block is important to detect some adverse events such as hypertension, caused by the spread of local anesthetics.

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The patient was a 49-year-old male undergoing artificial dialysis and treatment with anticoagulant and antiplatelet agents. The blood flow of his right forearm was reduced as a result of peripheral arterial disease. Although he had undergone brachial-radial artery bypass and ulnar artery dilation surgery, the ischemia of the 4th and 5th right fingers was progressing to necrosis. The ischemic pain was very severe, especially during dialysis. We implemented right ulnar nerve block with single bolus doses just before dialysis, and the patient achieved a pain-free state for several hours. We inserted a catheter near the ulnar nerve at the patient's forearm under ultrasound guidance. When we initiated continuous injection of local anesthetic, the finger pain was reduced immediately. We managed to achieve pain control with ropivacaine administration via the catheter during amputation of the fingers. We managed the postoperative pain and the pain accompanying wound treatment after surgery. The duration of catheterization was fifty-two days.

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Postoperative pain management for chronically opioid-consuming patients is challenging because of opioid tolerance and the requirements of opioid route conversion and/or switching. We report a case of a patient who was successfully treated with oxycodone by route conversion in the perioperative period. A 49-year-old man with severe pain resulting from a recurrence of clivus chordoma was scheduled for cervical spinal tumor resection. Before surgery, his daily oral oxycodone consumption was approximately 50 mg/day. Opioid route conversion of oral to intravenous oxycodone was performed using an intravenous patient-controlled analgesia device in the postoperative period. Cumulative oxycodone consumption in the 24 h after surgery was equivalent to the preoperative oxycodone daily dose. Satisfactory analgesia was achieved without opioid-related adverse effects throughout the perioperative period. Intravenous oxycodone may be a useful option for perioperative pain management of patients using preoperative oral oxycodone.

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Chemotherapy-induced peripheral neuropathy (CIPN) can lead to neuropathic pain, which is usually drug-resistant and difficult to manage. Painful CIPN could sustain after chemotherapy and profoundly impair patients' quality of life. Novel treatment strategies are needed. Duloxetine, which is an antidepressant and the first-line drug for diabetic neuropathy, is expected to have efficacy for painful CIPN. In Japan, the maximum daily dose of duloxetine is 60 mg. However, in the United States a dose of 120 mg per day is approved as an antidepressant, and its safety is established. In this clinical study, we applied high-dose duloxetine (120 mg/day) to a CIPN patient. Her pain was improved prominently, and few adverse events were observed. The degree of pain-related functional interference was improved completely. Further, after cessation of duloxetine, pain again became worse, but the completely improved pain-related functional interference continued. Although further studies are needed, high-dose duloxetine would be promising for a novel treatment of painful CIPN.

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An 83-year-old female patient suffered from herpes zoster in the left arm and developed complex regional pain syndrome-like symptoms, including drug-resistant pain and immobilization of the arm. A dramatic relief of the symptoms was achieved by limited-duration spinal cord stimulation for 1 week combined with physical therapy 40 days after onset, and the patient completely recovered. This clinical course suggests that intensive spinal cord stimulation treatment during the acute phase not only brought about a rapid palliation of pain, but it was also useful to enhance the effects of aggressive physical therapy without blocking any motor nerves.

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Arthroscopic shoulder surgeries cause severe postoperative pain. The interscalene block technique is a gold standard and more effective in controlling postoperative pain. However, it may eventually be associated with some critical complications. We reported a regional anesthesia that combines ultrasound-guided continuous suprascapular nerve catheter (SNC) and axillary nerve block (ANB) in arthroscopic shoulder surgery in a patient who had chronic spinal cord injury at C5-C6. Before surgery, ultrasound-guided SNC and ANB were performed using a high-frequency linear ultrasound probe. 15 ml of 0.5% ropivacaine was injected in each. During surgery, patients were intubated, and general anesthesia was performed with sevoflurane, fentanyl, and remifentanil (0.05-0.1 µg/kg/min). The patients did not require an increase of infusion rate of remifentanil during the surgical procedure. No serious complications occurred, and postoperative pain control was effective during the observation time. In conclusion, combining SNC and ANB is an effective and safe technique with intraoperative anesthesia and postoperative analgesia for certain procedures of arthroscopic shoulder surgery.

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Abdominal migraine is classified as childhood periodic syndromes in the International Classification of Headache Disorders (ICHD). This disease often develops in children. Adult cases have been reported, but very few; therefore it is difficult to make diagnosis and treatment. We experienced a case of abdominal migraine using the diagnostic criteria of ICHD and successfully treated it by indomethacin or triptan for attack pain and by valproic acid for stroke prevention. Adult abdominal migraine is a rare case, but it can be diagnosed by using the diagnostic criteria of childhood abdominal migraine, carefully asking about the attack and excluding the other disease. The treatment is according to migraine.

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A 62-year-old man who had been treated for lumbar canal stenosis developed right buttock pain after he was injured by falling off a bicycle. Findings on radiography, computed tomography, magnetic resonance imaging, and bone scintigraphy were normal except for slight narrowing of the right L4/5 intervertebral foramen. The Freiberg and Pace tests were both positive. Right sciatic nerve block (parasacral) and right L4 nerve root block resulted in marked alleviation of the right buttock pain, but no obstruction of the contrast medium was noted in the L4/5 intervertebral foramen. Piriformis muscle resection was performed with a diagnosis of piriformis syndrome, resulting in immediate relief of the right buttock pain, and the patient was discharged without recurrence. Piriformis syndrome requires differentiation from conditions including lumbar spinal disorders and tumoral diseases of the pelvic region. The disorder in this patient was diagnosed based on physical findings and the results of multiple nerve blocks, and pain was relieved by surgery.

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A 28-year-old man underwent surgery for cubital tunnel syndrome 10 months ago. His attending orthopedist introduced him to our clinic because he still had sharp pain on motion accompanied with numbness dysesthesia and allodynia around the scar area, which he could not touch. Irradiation of linearly polarized near-infrared ray and oral administration of pregabalin provided no effect. Oral administration of mexiletine was then begun, and it relieved dysesthesia to some extent. Therefore we began topical application of 9% lidocaine ointment to the affected area and brachial plexus block. This resulted in twenty-four hours of complete pain relief. Furthermore, prolonged complete pain relief in the scar area was obtained by brachial plexus block followed by local infiltration of levobupivacaine to the scar area. By these therapies, he was able to touch the ulnar area of his forearm, even after the effect of brachial plexus block had disappeared, and his daily life was remarkably improved.

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