In January 2014, the Committee on Safety of the Japan Society of Pain Clinicians sent a questionnaire on pain-management-related adverse events (AEs) in 2013 to all 310 board-certified training facilities in Japan. Responses were received from 199 facilities (response rate 64 %). Similar to the results of the 2012 survey, most reported AEs were classified as side effects of analgesics/analgesic adjuvants or as complications of nerve blocks/interventional therapy. The following severe drug-associated side effects were reported: Stevens-Johnson syndrome induced by tramadol/acetaminophen; anaphylactic shock induced by antibiotics or muscle relaxants; and serotonin syndrome induced by tramadol or antidepressants. The specific AEs of nerve blocks/interventional therapy were as follows: pneumothorax after intercostal nerve block, celiac plexus block or suprascapular nerve block; subarachnoid injection or respiratory-circulatory failure induced by epidural block; and infection induced by nerve block. It is necessary to recognize the significance of these side effects and complications and to implement additional security measures for safer pain management.

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We report here a case of acute epidural hematoma after epidural anesthesia for a patient taking ticlopidine hydrochloride. An 80-year-old woman with a history of atrial fibrillation and cerebral infarction was referred to our hospital for postherpetic neuralgia. Neither the patient nor the former physician was aware of the ticlopidine hydrochloride intake. Epidural anesthesia at level Th4/5 was therefore performed without a proper withdrawal period. Eight hours after puncture, leg movement disorder developed with loss of thermal nociception and tactile sensation, further followed by paraplegia. Because the symptoms did not resolve, an MRI scan was taken 3 days later, which revealed an epidural hematoma from level Th2 to Th11. No surgical treatment was performed. Epidural hematoma is a rare but severe complication of epidural anesthesia; thus appropriate withdrawal of anticoagulant and antiplatelet drugs is crucial before a procedure. A thorough interview is also necessary in elderly patients or patients with a history of cerebral infarction and atrial fibrillation.

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A 51-year-old male undergoing conservative treatment for spontaneous intracranial hypotension developed disturbance of consciousness. Computed tomography (CT) of the head showed subdural hematoma, and a radionuclide cisternogram showed cerebrospinal fluid leakage from the lumbar. Neurological deterioration worsened, and an epidural blood patch was performed following drainage of the intracranial hemorrhage under general anesthesia. After this operation, his consciousness had restored and the headache was cured. A CT of the head after this operation revealed a high-density area similar to a subarachnoid hemorrhage appeared; however, it disappeared on the next day. Conservative treatment was continued until day 8 postoperatively. He was discharged on day 20 postoperatively and had no recurrence. A simultaneous operation, epidural blood patch following drainage of intracranial hemorrhage, was effective for a patient of spontaneous intracranial hypotension with subdural hematoma. However, it was necessary to examine the dose of autologous blood because of the expanse of epidural blood patch in this simultaneous case.

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A 65-year-old woman underwent hernioplasty for an abdominal wall hernia by general anesthesia accompanied with epidural anesthesia. A few hours after removal of the epidural catheter, she complained of wound pain. We immediately started epidural anesthesia, and incisional pain became well controlled. We removed the catheter on postoperative day 9, but severe pain in the region of the right lateral femoral cutaneous nerve appeared. Concerning surgical procedures and the pain character of symptoms, we diagnosed meralgia paresthetica. We tried a lateral femoral cutaneous nerve block, and the symptoms improved dramatically. This confirmed the diagnosis. We repeated the nerve block twice a week, and pain intensity decreased day by day.

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International Association for the Study of Pain defines burning mouth syndrome as“a distinctive nosological entity characterized by unremitting oral burning or similar pain in the absence of detectable mucosal changes.” This syndrome develops on women, particularly after menopause. It also often develops after a dental treatment; however, unidentified causes can be found. Psychogenic problems may greatly contribute to the development of this syndrome. A sharp pain on the tip of and/or part of the margin of the tongue appears most commonly. Nevertheless, this pain lessens during sleep and during the consumption of food. Four patients with burning mouth syndrome who were not effectively treated with Western medicine were effectively treated with Kampo (Japanese herbal medicine). According to the diagnosis based on Kampo, four patients with an abnormality of “Qi”were respectively prescribed four formulae, Shigyakusan+ Kososan, Keishininjinto, Kamishoyosan, Shigyakusan. The pains of these patients were attenuated to 0-3 on numerical rating scale, respectively. Kampo, especially the Qi formula, may be effective to burning mouth syndrome when Western medicine is not.

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A patient with recurred rectal cancer at the stoma site had an enterocutaneous fistula. Because the cutaneous infection was expanded and a wide range of subcutaneous abscess was formed at the anus and gluteal region, daily continuous irrigation and drainage were required. However, none of the analgesics reduced the pain, and it was impossible to perform irrigation to treat the severe infection. Intrathecal analgesia/anesthesia enabled daily irrigation and drainage possible in a favorable analgesic condition, and consequently it improved systemically. We reported the intrathecal analgesia in the patient with severe enterocutaneous fistula. We successfully controlled the pain and infection.

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Pregabalin is the first line of treatment for fibromyalgia in adults. However, its use for pediatric patients has yet to be established. We report here two adolescents who were successfully treated for juvenile fibromyalgia (JFM) within a year by the use of pregabalin. A ten-year-old boy complained of pain in the extremities, which had started at seven years of age and continued to worsen to the point of disrupting daily behavior, such as attending school. Six months of pregabalin administration and multimodal treatments restored normalcy. A thirteen-year-old girl complained of pain in the extremities. She had begun to experience such pain at eleven years of age. She received pregabalin and physical therapy. After seven months, the symptoms remitted and she returned to normal life. Pregabalin was effective in treating these JFM patients when used in combination with supplementary physical and psychological therapy. However, the use of pregabalin has yet to be firmly established, and multicenter studies are required to corroborate its efficacy in treating the disease.

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