We report a patient whose condition improved after the concomitant use of Kampo (Japanese herbal medicine) for complex regional pain syndrome (CRPS) associated with herpes zoster infection. A 68-year-old man developed pain in the right lower extremity. Simultaneously, skin eruption occurred in the same area. He endured the pain for two months without treatment until the eruption disappeared. However, severe pain persisted even after the eruption disappeared; therefore, he visited a dermatologist. However, the dermatologist could not diagnose the cause of the pain because of the absence of eruption, and he was referred to our clinic. He was suspected to have herpes zoster-associated pain because of high levels of varicella-zoster virus immunoglobulin G. Along with pain, he presented with redness, swelling, and elevated skin temperature in his right lower leg. In addition to epidural block and oral mirogabalin, Boiogito and Keishibukuryogan relieved the CRPS symptoms. Thus, Kampo medicine was beneficial in treating the CRPS symptoms associated with herpes zoster infection.

A physician and a physical therapist collaborated to analyze the pain in a 20s-year-old man who was diagnosed with thoracic outlet syndrome at another clinic because of his cervical ribs. The physician examined patient's muscles, nerves and vessels and concluded that it was non-specific pain. Exercise therapy and duloxetine were prescribed. After 123 days, the symptoms improved after 10 rehabilitations and oral administration of duloxetine. Multidisciplinary assessments were effective in minimizing invasive treatment for patients.

We reported two cases which we chanced to find malignant tumors. Case 1 was a man in his 80s who developed upper left arm numbness and pain. We diagnosed him as cervical spondylosis with his cervical spine XP. As his symptoms got worse despite intensive treatment, we examined him with chest CT and a cervical spine MRI revealed cervical spine metastasis from prostate cancer. Case 2 was a man in his 80s. He was referred to our clinic for exacerbating low-back pain. We found abnormal bone permeability during fluoroscopic procedure and an emergency lumbosacral spine MRI revealed multiple lumbar vertebrae metastasis due to double cancer of prostate cancer and colon cancer. Although most patients who visit a pain clinic are already diagnosed, we have to keep in mind that patients with pain may potentially have malignant diseases, particularly in patients with pain refractory to a standard treatment and patients with low-back pain and a red flag sign.

A man in his 70s underwent robot-assisted subtotal esophagectomy for thoracic esophageal cancer and was transferred to the intensive care unit (ICU). He developed two gastrointestinal perforations during his stay in the ICU and underwent emergency surgery and daily intraperitoneal lavage with the abdominal midline wound open. On day 20 of the illness, enhanced rehabilitation was planned to prevent Post Intensive Care Syndrome and ICU-acquired weakness. However, this was not possible because of severe patient pain. An erector spinae plane block was administered; a single dose was remarkably effective, with improvement from 8 to 1 on the numerical rating scale for pain. Rehabilitation became possible, and the patient could walk in place. Regional anesthesia maybe necessary to enhance the analgesia in the ICU.

We report a patient with morbid obesity in whom pulse generator reimplantation was necessitated by lead break during spinal cord stimulation (SCS) 1 month after its initiation. The patient was a 49-year-old male. For pain of the right foot due to right tibial fracture, which persisted even after cast immobilization, epidural block and analgesic therapy using opioids, were performed, but the effect was unsatisfactory, and the patient consulted our department 3 years after the injury. Since edema and allodynia were observed in addition to pain of the right foot, SCS was performed with a diagnosis of complex regional pain syndrome. A permanent pulse generator was implanted, but it was suddenly de-energized 1 month after the implantation, and as lead breakage was confirmed, the device was replaced. The patient had morbid obesity, and lead breakage is considered to have been caused by excessive load exerted on the lead, as the electrode had to be inserted at a sharp angle, and as the proximal end of the anchor protruded out of the fascia. By confirming that the proximal end of the anchor was fixed inside the fascia at the time of reimplantation, an uneventful course was obtained thereafter.