Epidermolysis bullosa hereditaria is an inherited, intractable disease in which blisters and erosions form on the skin in response to small external forces. This case report describes pain management for painful procedures in a 60-year-old man with dominant dystrophic epidermolysis bullosa who fell down a flight of stairs and developed extensive erosions. Although analgesia with opioid analgesics or ketamine were considered options, complications such as nausea and respiratory depression were feared to be potentially unmanageable due to lack of time for anesthesiologists to respond appropriately. Therefore, a pain management plan was implemented in which the epidural block was managed by a dermatologist using an epidural tube placed by an anesthesiologist. This approach successfully reduced the pain during treatment while ensuring patient safety. Notably, meticulous securing of the epidural catheter allowed for management without inciting additional skin lesions.

The decision to continue or discontinue apixaban, an oral inhibitor of blood coagulation factor Xa, before peripheral nerve block should be individualized. We encountered a case of extensive hematoma after adductor canal block (ACB) in a patient on oral apixaban. The patient was a 70-year-old woman who had persistent pain after left knee arthroplasty. She was taking apixaban for atrial fibrillation. The dose of apixaban was increased because she had venous thrombosis of the lower extremities after surgery. We performed an ultrasound-guided continuous ACB. Because of thrombosis, apixaban was continued before administering ACB. After ACB, we observed continuous bleeding from the insertion site and removed the catheter. However, the hematoma expanded from the adductor canal to her hip and knee. The bleeding was controlled within a week. In this case, the increased dose of apixaban for venous thrombosis and renal dysfunction increased the bleeding risk. ACB should be carefully considered for patients taking anticoagulants.

Micturition pain after intravesical bacillus Calmette-Guerin (BCG) therapy is the most common side effect. The use of opioids for refractory pain, such as micturition pain, may lead to inappropriate use. In this report, we describe a case of refractory micturition pain after intravesical bacillus Calmette-Guerin (BCG) therapy that resulted in inappropriate use of prescribed opioids. By taking steroids and transurethral resection of bladder tumor (TURBT), the patient's dependence on oxycodone gradually improved, and he was eventually able to discontinue oxycodone through education about opioid use and treatment of coexistent pain other than micturition pain.

A 71-year-old male patient who underwent surgery for cancer in the right lung complained four months after the surgery of left hypochondrium pain that he described as persisting for one month. After being diagnosed with a compression fracture of the 8th thoracic vertebra due to metastatic bone tumor, he was referred to our pain clinic for the purpose of controlling the pain and intolerable side effects of opioids but the benefit of thoracic epidural block we provided was only temporary. His left hypochondrium pain was similar to electric shock suggesting the pain was of neuropathic nature. The next course of treatment composed of pulsed radiofrequency to the left 8th and 9th thoracic nerve roots proved effective in alleviating the pain allowing the patient to be discharged from our hospital. This experience suggests us that pulse radiofrequency therapy may be effective for pain relief and improving quality of life of patients with cancer pain localized in the thoracic nerve area.

Case 1: A man in his 50s. He had been treated for lung adenocarcinoma and skull base metastasis. The dose of oxycodone was increased and naldemedine was started in combination. He continued to experience pain, and nausea and vomiting appeared. Naldemedine was suspected to have an antagonistic effect and was discontinued. From the next day, his nausea and vomiting disappeared. Case 2: A female in her 40s. She had multiple mass lesions due to multiple schwannomas in the dural sac and epidural mater. She had severe pain in the abdomen and both limbs. After controlling her pain with a fentanyl patch, her constipation worsened, and she was administered naldemedine. Within hours of taking naldemedine, she had nausea and terrible diarrhea. Two years later, she was diagnosed with a right cerebellar pontine angle tumor. Conclusion: When reduced analgesic effect and withdrawal symptoms are suspected after administration of naldemedine with an opioid, the patient should be evaluated for the possible presence of brain tumor.