Lee HJ, et al. Korean J Pain. 2018 Apr;31(2):116-124. https://doi.org/10.3344/kjp.2018.31.2.116

A lumbar sympathetic ganglion block (LSB) is a therapeutic method for complex regional pain syndrome (CRPS) affecting the lower limbs. Recently, LSB with botulinum toxin type A and B was introduced as a novel method to achieve longer duration of analgesia. In this study, we compared the botulinum toxin type A (BTA) with botulinum toxin type B (BTB) in performing LSB on patients with CRPS. LSB was performed with either BTA or BTB on patients with CRPS in their lower extremities. The length of time taken for patients to return to the pre-LSB pain score and the adverse effect of LSB with BTA/BTB were investigated. The median length of time taken for the patients to return to the pre-LSB pain score was 15 days for the BTA group and 69 days for the BTB group (P = 0.002). Scores on a visual analogue scale decreased in the patients of both groups, and no significant adverse effects were experienced. In conclusion, the administration of either BTA or BTB for LSB is a safe method to prolong the sympathetic blocking effect in patients with CRPS. BTB is more effective than BTA to prolong the sympathetic blocking effect in CRPS patients.

Pudendal nerve block (PNB) is an effective diagnostic and/or treatment method for perineal pain. Various approach techniques, such as transperineal, transvaginal, computerised tomography (CT)- or sono-guided approach, have been suggested for this block. However, they have some limitations, such as high cost, difficulty to perform in practice, inaccurate and unreliable results and inconvenience. To overcome these limitations, we first tried C-arm-guided approach for accomplishing PNB in the prone position. Under the optimal ischial spine view of C-arm fluoroscopy, the block needle was placed on the tip of the ischial spine. Then a mixed solution for the block was administered. All of the 25 patients enrolled in this study were blocked successfully using this method. No side-effects or complications were observed in relation to the block. We concluded that the C-arm-guided approach for PNB is an effective alternative to the existing techniques, which can overcome their limitations.

For over a thousand years, various substances have been applied to the skin to treat pain. Some of these substances have active ingredients that we still use today. However, some have been discontinued due to their harmful effect, while others have been long forgotten. Recent concerns regarding the cardiovascular and renal risk from nonsteroidal anti-inflammatory drugs, and issues with opioids, have resulted in increasing demand and attention to non-systemic topical alternatives. There is increasing evidence of the efficacy and safety of topical agents in pain control. Topical analgesics are great alternatives for pain management and are an essential part of multimodal analgesia. This review aims to describe essential aspects of topical drugs that physicians should consider in their practice as part of multimodal analgesia. This review describes the mechanism of popular topical analgesics and also introduces the most recently released and experimental topical medications.

The different methods of cervical epidural injection include the median or paramedian interlaminar (PI) approach and the transforaminal (TF) approach. We hypothesized that the modified PI (mPI) approach could deliver drugs suitably and safely into the anterior epidural space compared with the TF approach. A total of 62 patients were randomized into either the mPI group (n=31) or the TF group (n=31). Contrast to the anterior epidural space (primary outcome, grade 1–3), vascular uptake and discomfort were assessed. Furthermore, pain intensity in the arm and neck [numeric rating scale (NRS)] and the degree of symptoms (5-point Likert scale) before the procedure and 2 weeks, 1 and 3 months following the procedure were compared between two groups. Effectiveness (a secondary outcome) was defined as a ≥50% reduction on the NRS for arm and neck pain and a result of 3 or 4 on the Likert scale at 3 months following the procedure. Contrast to the anterior epidural space in the mPI group was significantly greater than that in the TF group (P=0.036). Vascular uptake and discomfort in the mPI group were significantly lower than those in the TF group (P<0.001, respectively). Of the patients in whom the procedure was effective, 24 (77.4%) were from the mPI group and 20 (64.5%) were from the TF group (P=0.263). This result suggests that the mPI approach allows for suitable and safe delivery of drugs into the anterior epidural space. Institutional Review Board of Seoul National University Bundang Hospital (B-1206/159-004) and Clinical Research Information Service (KCT0000626).

Objective: This study investigated psychological characteristics of patients with chronic complex regional pain syndrome (CRPS) and examined relationships between psychosocial factors and pain severity. Methods: In total, 76 patients with CRPS, 95 patients with other types of chronic pain, 171 healthy controls, and 66 patients with major depressive disorder (MDD) were included. Minnesota Multiphasic Personality Inventory (MMPI-2) profiles and scores on the Beck Depression Inventory and State–Trait Anxiety Inventory were calculated. Pain intensity was measured using a visual analog scale (VAS). Results: Patients with CRPS scored higher on the Hypochondriasis (Hs), Depression (D), Hysteria (Hy), Paranoia (Pa), and Psychasthenia (Pt) scales of the MMPI-2 compared to healthy controls. The CRPS group scored lower on the D, Psychopathic deviate (Pd), Pa, Pt, Schizophrenia (Sc), and Social introversion (Si) scales compared to the MDD group. Although CRPS patients reported higher levels of pain than patients with other types of pain, the MMPI profiles of the two pain groups did not differ significantly. Linear regression analyses revealed that pain severity was significantly associated with depression and scores on the Masculinity–Femininity (Mf) scale. Conclusion: This is the first comparative study of the psychological characteristics of chronic CRPS patients, healthy controls, and patients with MDD. The neurotic profiles of CRPS patients were more psychologically adaptable than were those of patients with MDD; however, this profile was shared by both pain groups. The present findings further showed that, although pain severity was not a major contributor to depression, patients with CRPS should be evaluated for depressive symptoms.