The Committee on Safety of the Japan Society of Pain Clinicians (JSPC) investigated the adverse events (AEs) in pain management in 2018 to all Japanese board-certified training facilities. Method: Web questionnaires were requested from the facilities. The contents of AEs were 3 or more serious events complying with the rule of impact classification of the National University Hospital Council of Japan. Results: Most reported AEs were side effects of analgesics or analgesic adjuvants or complications of invasive treatments, such as nerve blocks or surgeries. Analgesic-related AEs were reported in 25 cases, and some of these were serious. Side effects of antidepressants and opioids were most frequently reported. Invasive treatment-related AEs were reported in 145 cases, 57 of which were serious. Serious AEs related to surgical treatments were reported more in comparison with average years. Conclusion: It is necessary to share the information of these AEs with the members of the JSPC and enhance the consideration of risk management in pain-treatment settings.
This study aimed to evaluate the analgesic effect of perineural dexamethasone administration for arthroscopic shoulder surgery under interscalene brachial plexus block. Fifty-two patients scheduled for arthroscopic rotator cuff repair (ARCR) were enrolled in this study. We used 10 ml of 1％ mepivacaine and 10 ml of 0.75％ ropivacaine for all patients. The patients were divided into two groups: C group, 26 patients without dexamethasone administration, and D group, 26 patients with 6.6 mg of perineurally administered dexamethasone. The median age, operation time, and number of suture anchors were not significantly different between the two groups. Induction time (IT), effectiveness of the nerve block, anesthesia effect time (AET), and adverse events were compared. The median IT, effectiveness of the nerve block, and AET in the C and D groups were 11 vs. 12 min, 100％ vs. 100％，and 494 min vs. 746 min, respectively. AET was significantly longer in the D group. Adverse events were absent in both groups. Perineural dexamethasone administration as an anesthetic agent was effective for postoperative pain management in arthroscopic shoulder surgery.
Objectives: In order to examine the effect of mirogabalin on tingling or pins & needles, a post hoc subgroup analysis of the phase 3 study (J303) was performed on patients with only those symptoms. Methods: Patients received placebo, mirogabalin 15 mg, 20 mg or 30 mg/day for 14 weeks. The main endpoints were the change in average daily pain score (ADPS), ADPS responder rate, the change in average daily sleep interference score (ADSIS), patient global impression of change (PGIC) and impressions of subjective symptom for tingling or pins & needles at week 14. Results: The subgroup analysis was made in 168 patients only with tingling or pins & needles. ADPS, ADSIS, PGIC and the impression for tingling or pins & needles showed improvement in 30 mg/day group. Adverse events were mostly mild and the incidence was low. These results were similar to that of J303. Conclusions: Mirogabalin can be effective on tingling or pins & needles in diabetic peripheral neuropathy.
Somatic symptom disorder is characterized by physical symptoms, abnormal thoughts, feelings, and behaviors that affect the patient's daily living. In general, pharmacotherapy alone is insufficient; various types of psychotherapy are often required. Herein, we report a case in which supportive psychotherapy was effective for somatic symptom disorder with burning sensation in the feet. A 74-year-old woman with gastric cancer and metastatic liver cancer was admitted to a hospital because of worsening burning sensation in bilateral legs 10 days after chemotherapy. A series of laboratory tests showed no abnormal results. We diagnosed the patient's physical symptoms based on the diagnostic criteria in DSM-V. We delivered supportive psychotherapy, which consisted of reassurance and emotional support from the palliative care team. After she felt accepted, the symptoms ameliorated. Her symptoms were a relatively rare phenotype of somatic symptom disorder, and supportive psychotherapy seemed to be effective. Supportive psychotherapy may be useful in building good relationships with patients and reducing their pain.
Although psychological interventions are well established in the treatment of chronic pain, their importance in acute pain is not documented. We report a pediatric case of acute pain in the bilateral legs, which was later diagnosed as somatic symptom and related disorders. A 10-year-old girl presented with acute bilateral leg pain; she could not ambulate without physical support. She visited our hospital on a wheelchair with extended knees and was admitted. Despite examination by expert doctors, the cause of her acute pain could not be identified. Her class teacher visited her on the fifth day of hospital stay; subsequently, her pain disappeared and she began to walk. She was diagnosed with brief somatic symptom disorder, which belongs to the group of somatic symptom and related disorders. Resolution of socio-psychological concerns can occasionally ameliorate severe acute pain. Psychological approach can be effective in the management of pediatric cases of acute pain.
Herein, we report a case in which radiofrequency thermocoagulation (RFTC) as a nerve root block was extremely effective for leg spasticity caused by thoracic spinal cord injury. The patient was a 13-year-old girl who developed involuntary movement of her lower limbs, accompanied by intractable pain around her knees. She previously underwent bilateral Achilles tendon and hamstring tendon surgeries several times to treat these symptoms, but without any resolution; moreover, her activity of daily living (ADL) progressively deteriorated. After providing sufficient explanations about the risks and benefits of RFTC, and obtaining consent from both the patient and her family, we performed bilateral RFTC (90℃ for 180 seconds each) of the lumbar 2–4 nerve roots under general anesthesia. Fortunately, the technique was extremely effective, and her involuntary movement and pain disappeared completely. Presently, the patient's ADL has remarkably improved, and she can go to school.
We encountered 3 cases of lumbar facet joint cyst, which were successfully treated by facet joint arthrography and subsequent steroid injection. On magnetic resonance imaging (MRI), we observed nerve root compression due to the cysts. The area of the pain and the nerve root compression findings on MRI were neurologically consistent. Arthrography confirmed the inflow of contrast medium from the facet joint to the cyst. In all the cases, lower limb pain was induced at the time of pressure injection into the facet joint. In 2 cases, the cyst ruptured on contrast medium injection, following which, steroid was injected; in 1 case, the cysts did not rupture following contrast medium injection. However, the pain improved dramatically in all patients. No patient presented with cyst recurrence even after 6 months. Facet joint arthrography followed by steroid injection appears to be an effective alternative to surgery in the treatment of facet joint cysts.
Background: Peripheral nerve injury is a significant perioperative complication. We report a case of a patient with intraoperative position-related brachial plexus injury, whose symptoms were improved by brachial plexus block. Case: A 23-year-old man underwent thoracoscopic resection for an anterior mediastinal tumor. The surgery lasted 8 hours under the right prone position with his left arm fixed at the shoulder height, and his neck-slightly extended. Immediately after the surgery, the patient complained of severe pain, with paralysis and numbness of the left upper extremity. Magnetic resonance neurography revealed a swollen brachial plexus. He was referred to our pain clinic because his symptoms did not improve with conservative treatment. We decided to perform ultrasound-guided branchial plexus block (1％ mepivacaine＋dexamethasone [3.3 mg]) to control pain and inflammation. After five blocks, although numbness remained, his pain improved considerably. Conclusion: The brachial plexus block could ameliorate acute neuropathic pain with inflammation.
A housewife in her 30s referred to our multidisciplinary pain center with a 10-year history of right chest pain. Initial consultation by a nurse revealed the following: 1) she was a perfectionist and had a serious disposition; 2) she took care so that she was not deserted by her mother and husband; 3) she had experienced several emotionally traumatic episodes and 4) she believed that she would die because of the pain. Nurses interviewed her mother to investigate the relationship between them and to get further information about her daughter's previous negative experiences. The investigation revealed that she was highly anxious in nature and was extremely fearful following an experience of encountering the dead body of her friend on the way to school and being bullied in school age. The nurse's consultation at the multidisciplinary pain center might have facilitated the identification of the psychosocial element of her pain.
A woman in her 20s underwent a radical surgery for peritoneal metastasis of appendix cancer; there was no apparent sign of recurrence at postoperative 28-month follow-up. She was prescribed oral fentanyl (OF), but the frequency of its administration eventually increased to eight or more times a day. Since an excessive demand for the drug and suicidal tendencies were observed in the patient, the drug dosage was reduced to 1,800 µg/day. However, her demand for OF made it difficult to further reduce the dosage, and she was referred to our hospital. After admission to the psychiatric ward, the OF was replaced with 10 mg/day of methadone. Although she continued to demand OF initially, the demand decreased gradually. Thereafter, methadone was replaced with buprenorphine patches on the 15th day of hospitalization, and opioid use was completely discontinued on the 25th day. No physical withdrawal symptoms were observed. To achieve discontinuation of OF, the switch to methadone and buprenorphine was effective.
We encountered a case involving a 69-year-old man with stage IV small cell lung cancer suffering from severe epigastralgia and systemic fatigue, who was later diagnosed with esophageal candidiasis. His epigastralgia was initially thought to be derived from mediastinum lymph node metastasis. However, the use of opioid or analgesic adjuvant did not reduce his complaints, and antipsychotics were needed for unbearable pain. The pain was accompanied by heartburn and nausea that worsened when the patient was on an empty stomach. We suspected upper gastrointestinal disease. Therefore, an endoscopic examination was performed, which led to the diagnosis of esophageal candidiasis. Antifungal therapy relieved the patient's pain and improved his general condition, leading to a reduction in his opioid dose and termination of antipsychotics. The cause of painful symptoms in cancer patients may not necessarily be associated with their cancer, and thus, the actual cause of the pain should be thoroughly assessed. Early detection of any treatable cause may benefit patients with cancer even in the terminal phase.
Abdominal angina is a postprandial abdominal pain that is often difficult to control. The conventional therapy for its treatment is pharmacotherapy or revascularization by surgery. However, these are not often effective. Spinal cord stimulation therapy (SCS) is effective for pain control of ischemic limbs, such as Buerger's disease. The authors report a case of a patient with severe abdominal angina whose abdominal symptoms were improved by implantation of an SCS. SCS may be an effective treatment for ischemic pain caused by peripheral blood flow disorders not only in the extremities but also in the torso of a patient.
We report a patient who underwent stellate ganglion block (SGB) for refractory dialysis access-associated steal syndrome (DASS). A 50s-year-old man who had an internal shunt placed in his left forearm 10 years ago due to chronic kidney failure. Two months ago, he noticed a color change in his left hand fingers that worsened during dialysis, as well as cold and painful sensations. He was diagnosed with DASS, and vasodilators and analgesics were prescribed for these symptoms, and arteriovenous fistula removal was performed, but they did not provide relief. Then, we changed analgesics and performed SGB, which resulted in symptom relief at the first attempt. DASS is caused by a peripheral circulatory disturbance due to steal phenomenon in radiocephalic arteriovenous fistula. Therefore, the effect of additional SGB on blood flow may be efficacious in treating ischemic symptoms in refractory DASS.