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Case report: bilateral tunneled epidural catheters to prevent unilateral analgesia for cancer-related pain.

ABSTRACT: Unilateral analgesia often occurs with epidural analgesia. Traditional methods of troubleshooting this problem can be insufficient in obtaining adequate pain relief in a timely manner for terminal cancer patients. This case report demonstrates a safe and effective solution which can be utilized in these circumstances.A 55-year-old female with stage IV pancreatic cancer and life expectancy of a few weeks presented to the interventional pain clinic with intractable sacral pain. The decision to place an epidural catheter and external pump for analgesia was made. An epidural catheter placed at the L5-S1 level showed contrast spread only along the right nerve roots and a test dose produced only right-sided analgesia. Suspecting compartmentalization of the epidural space, a second left-sided epidural catheter was placed and bilateral analgesia was achieved by using both catheters. This dual catheter technique gave the patient effective bilateral analgesia until she passed away several weeks later.The bilateral epidural catheter technique is safe and effective in patients who present with persistent unilateral epidural analgesia despite exhausting traditional solutions.

SUBMITTER: Padalia RB

PROVIDER: S-EPMC5529603 | biostudies-other | 2017

REPOSITORIES: biostudies-other

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Case Report: Five-Level Unilateral Laminectomy Bilateral Decompression (ULBD) by Two-Stage Unilateral Biportal Endoscopy (UBE).

Project description:IntroductionUnilateral biportal endoscopy (UBE) is a relatively new yet common minimally invasive procedure in spine surgery, capable of achieving adequate decompression for lumbar spinal stenosis through unilateral laminectomy bilateral decompression (ULBD). Neither additional fusion nor rigid fixation is required, as UBE-ULBD rarely causes iatrogenic lumbar instability. However, to our knowledge, five-level ULBD via two-stage UBE without lumbar fusion has been yet to be reported in the treatment of multilevel lumbar spinal stenosis.Case descriptionWe present a case of an 80-year-old female patient who developed progressive paralysis of the lower extremities. Radiographic examinations showed multilevel degenerative lumbar spinal stenosis and extensive compression of the dural sac and nerve roots from L1-2 to L5-S1. The patient underwent five-level ULBD through two-stage UBE without lumbar fusion or fixation. One week after the final procedure, the patient could ambulate with walking aids and braces. Moreover, no back pain or limited lumbar motion was observed at the 6-month follow-up.ConclusionMultilevel ULBD through UBE may provide elderly patients with an alternative, minimally invasive procedure for treating spinal stenosis. This procedure could be achieved by staging surgeries. In this case, we reported complaints of little back pain, despite not needing to perform lumbar fusion or fixation.

| S-EPMC9294320 | biostudies-literature

Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery.

Project description:ObjectiveContinuous thoracic epidural analgesia (TEA) is compared with erector spinae plane (ESP) block for the perioperative pain management in patients undergoing cardiac surgery for the quality of analgesia, incentive spirometry, ventilator duration, and intensive care unit (ICU) duration.MethodologyA prospective, randomized comparative clinical study was conducted. A total of 50 patients were enrolled, who were randomized to either Group A: TEA (n = 25) or Group B: ESP block (n = 25). Visual analog scale (VAS) was recorded in both the groups during rest and cough at the various time intervals postextubation. Both the groups were also compared for incentive spirometry, ventilator, and ICU duration. Statistical analysis was performed using the independent Student's t-test. A value of P < 0.05 was considered statistically significant.Results: comparable VAS scores were revealed at 0 h, 3 h, 6 h, and 12 h (P > 0.05) at rest and during cough in both the groups. Group A had a statistically significant VAS score than Group B (P ? 0.05) at 24 h, 36 h, and 48 h but mean VAS in either of the Group was ?4 both at rest and during cough. Incentive spirometry, ventilator, and ICU duration were comparable between the groups.ConclusionESP block is easy to perform and can serve as a promising alternative to TEA in optimal perioperative pain management in cardiac surgery.

| S-EPMC6078032 | biostudies-literature

Epidural analgesia is superior to local infiltration analgesia in children with cerebral palsy undergoing unilateral hip reconstruction.

Project description:Treatment of postoperative pain in children with cerebral palsy (CP) is a major challenge. We investigated the effect of epidural analgesia, high-volume local infiltration analgesia (LIA), and an approximated placebo control on early postoperative pain in children with CP who were undergoing unilateral hip reconstruction.Between 2009 and 2014, we included 18 children with CP. The first part of the study was a randomized double-blind trial with allocation to either LIA or placebo for postoperative pain management, in addition to intravenous or oral analgesia. In the second part of the study, the children were consecutively included for postoperative pain management with epidural analgesia in addition to intravenous or oral analgesia. The primary outcome was postoperative pain 4 h postoperatively using 2 pain assessment tools (r-FLACC and VAS-OBS) ranging from 0 to 10. The secondary outcome was opioid consumption over the 21-h study period.The mean level of pain 4 h postoperatively was lower in the epidural group (r-FLACC: 0.7; VAS-OBS: 0.6) than in both the LIA group (r-FLACC: 4.8, p?=?0.01; VAS-OBS: 5.2, p?=?0.02) and the placebo group (r-FLACC: 5.2, p?=?0.01; VAS-OBS: 6.5, p?<?0.001). Corrected for body weight, the mean opioid consumption was lower in the epidural group than in the LIA group and the placebo group (both p?<?0.001).Epidural analgesia is superior to local infiltration analgesia for early postoperative pain management in children with cerebral palsy who undergo unilateral hip reconstruction.

| S-EPMC4812081 | biostudies-literature

Preventive Epidural Analgesia in Bilateral Single-Stage Knee Arthroplasty: A Randomized Controlled Trial.

Project description:INTRODUCTION:Although controversial, pre-emptive analgesia has shown some promise in preventing altered pain perception and reducing pain amplification after surgery. Hence, it has the potential to be more effective than a similar analgesic regimen started after surgery with an appropriate combination of patient category and analgesic modality. Hence, the present study was undertaken to evaluate the effect of preventive epidural analgesia in reducing pain severity and duration after bilateral single-stage knee arthroplasty. METHODS:Fifty patients, 18-70 years, with American Society of Anesthesiologists physical status class I & II posted for bilateral single-stage knee replacement under regional anesthesia were randomly allocated into preventive versus postoperative epidural analgesia group to compare severity of post-operative pain, analgesic consumption, day of mobilization, C-reactive protein (CRP) levels, and hospital stay. RESULTS:The pain score after surgery [2.0 (1.5, 2.0); 3.0 (1.5, 3.0), p?=?0.005] and day of mobilization [(2. 92 ± 0. 28; 3. 31 ± 0. 48; p value 0.02)] were significantly lesser in the preventive epidural group. However, there was no difference in the hospital stay (9.92 ± 3.71 and 9.00 ± 2.12, p?=?0.95) and analgesic consumption (65.38 ± 37.55 and 73.08 ± 43.85, p?=?0.30). The preventive group had a larger drop in CRP and experienced a lesser number of days with pain after surgery as compared to the controls [(64.29 ± 21.29); (142.37 ± 80.04), p?=?0.0001]. Six patients in the preemptive group (24%) and 13 of the control group (24 vs. 56.5%; p?=?0.02) had chronic postsurgical pain. CONCLUSIONS:Preventive epidural analgesia reduces the severity and number of chronic pain days after bilateral single-stage knee replacement. TRIAL REGISTRATION:The study was registered in the Indian national registry (CTRI/2017/03/008240 on 28/03/2017).

| S-EPMC7203305 | biostudies-literature

Subdural Hematoma Associated With Labor Epidural Analgesia: A Case Series.

Project description:OBJECTIVE:This report aimed to describe the characteristics and impact of subdural hematoma (SDH) after labor epidural analgesia. CASE REPORTS:Eleven obstetric patients had SDHs associated with the use of labor epidural analgesia over 7 years at a tertiary care hospital. Ten of 11 patients had signs consistent with postdural puncture headache before the diagnosis of SDH. Five patients (45%) had a recognized unintentional dural puncture, 1 (9%) had a combined spinal-epidural with a 24-gauge needle, and 5 (45%) had no recognized dural puncture. For 10 of the 11 cases, SDH was diagnosed at a mean of 4.1 days (range, 1-7 days) after performance of labor epidural analgesia; one case was diagnosed at 25 days. Ten (91%) of 11 cases had a second hospital stay for a mean of 2.8 days (range, 2-4 days) for observation, without further requirement for neurosurgical intervention. One case (9%) had decompressive hemicraniectomy after becoming unresponsive. The observed rate of labor epidural analgesia-associated SDH was 0.026% (11 in 42,969, approximately 1:3900), and the rate of SDH was 1.1% (5 in 437, approximately 1:87) if a recognized dural puncture occurred during epidural catheter placement. CONCLUSIONS:Subdural hematoma after labor epidural anesthesia is rare but potentially more common than historically estimated. Cases of postdural puncture headache after labor epidural anesthesia should be monitored closely for severe neurologic signs and symptoms that could herald SDH.

| S-EPMC4993647 | biostudies-literature

A randomized trial of breakthrough pain during combined spinal-epidural versus epidural labor analgesia in parous women.

Project description:There is controversy regarding the benefits and risks of combined spinal-epidural compared with epidural analgesia (CSE, EPID) for labor analgesia. We hypothesized that CSE would result in fewer patient requests for top-up doses compared to EPID.One-hundred ASA physical status I or II parous women at term in early labor (<5 cm cervical dilation) requesting analgesia were randomized in double-blind fashion to the EPID group (epidural bupivacaine 2.5 mg/mL, 3 mL, followed by bupivacaine 1.25 mg/mL, 10 mL with fentanyl 50 microg) or the CSE group (intrathecal bupivacaine 2.5 mg with fentanyl 25 microg). Both groups received identical infusions of bupivacaine 0.625 mg/mL with fentanyl 2 microg/mL at 12 mL/h. The primary outcome variable was the number of top-up doses requested to treat breakthrough pain.There was no significant difference between the two groups in the percentage of patients requesting top-up doses (44% CSE vs 51% EPID; 95% confidence interval of the difference -28% to +14%) nor in the need for multiple top-up doses (14% CSE vs 15% EPID). Visual analog scale scores were lower in the CSE group compared to the EPID group at 10 min after initiation of analgesia [median 0 cm (0, 0) vs 4 cm (1, 6) respectively, P < 0.001] and at 30 min [0 cm (0, 0) vs 0 cm (0, 1), respectively, P = 0.03].We did not find a difference in the need for top-up doses in parous patients; however, CSE provided better analgesia in the first 30 min compared to EPID.

| S-EPMC2670780 | biostudies-literature

Observing the initial onset of retinal vasculitis as unilateral Birdshot Retinochoroiditis becomes bilateral: A case report.

Project description:PurposeBirdshot Retinochoroiditis (BRC) is an uncommon but distinct form of bilateral posterior uveitis. It is generally of indolent onset, making early natural history difficult to study. Our report seeks to expand knowledge on the natural history of the onset of BRC.ObservationsOur patient presented with clinical features that were consistent with unilateral BRC, despite it being defined as a bilateral condition. Over the course of one year he developed retinal vasculitis, vitritis and fundus features of BRC in the second eye.Conclusions and importanceAlthough BRC is a bilateral disease, our case demonstrates that the onset may sometimes be sequential instead of simultaneous. Unilateral disease that is characteristic of BRC should be monitored for second-eye involvement with multi-modal imaging including fundus photography, angiography, perimetry, electroretinography, and optical coherence tomography of the macula with emphasis on the choroidal thickness.

| S-EPMC9160671 | biostudies-literature

Traumatic bilateral knee dislocations, unilateral hip dislocation, and contralateral humeral amputation: a case report.

Project description:Bilateral traumatic knee dislocations are a rarity. We report a case of bilateral traumatic knee dislocations with concomitant right hip dislocation and complete traumatic amputation of the left, nondominant upper extremity at the level of the proximal one-third of the humerus. Angiograms revealed no evidence of popliteal artery injury. Orthopedic treatment consisted of immediate reduction of the dislocations and urgent revision amputation of the upper extremity. Staged, bilateral knee ligamentous reconstructions were performed on hospital days 24 and 29, respectively. Despite this constellation of devastating injuries, the patient had a satisfactory outcome. In patients with high-energy hip or knee dislocations, the bilateral hips and knees should be carefully examined to check for associated fractures and/or dislocations.

| S-EPMC2642548 | biostudies-other

Pain management after pneumothorax surgery: intercostal nerve block or thoracic epidural analgesia.

Project description:ObjectivesIn patients undergoing video-assisted thoracoscopic surgery for pneumothorax, the benefits and risks of single-shot intercostal nerve block as loco-regional analgesia are not well known. We retrospectively compared the effectiveness of intercostal nerve blocks as a viable alternative to thoracic epidural analgesia regarding pain control and enhanced recovery.MethodsA retrospective multicentre analysis with single-center propensity score matching was performed in patients undergoing video-assisted thoracoscopic surgery for pneumothorax receiving either thoracic epidural analgesia or intercostal nerve block. The primary outcome was proportion of pain scores ≥4 (scale 0-10) until postoperative day 3. Secondary outcomes included variation in pain over time, additional opioid use, length of stay, mobility, complications and recurrence rate.ResultsIn 218 patients, thoracic epidural analgesia was compared to intercostal nerve block and showed no difference in proportion of pain scores ≥4 (14.3% [IQR 0.0-33.3] versus 11.1% [IQR 0.0-27.3] respectively, p = 0.24, more frequently needed additional opioids on the day of surgery (18% versus 48%) and first postoperative day (20% versus 42%), had a shorter length of stay (4.0 days [IQR 3.0-7.0] versus 3.0 days [IQR 2.8-4.0]), and were significantly more mobile until postoperative day 3, while having similar recurrences. Intercostal nerve block had higher pain scores early in course whereas thoracic epidural analgesia had higher late (rebound) pain scores.ConclusionsIn a multimodal analgesic setting with additional opioids, intercostal nerve block shows comparable moments of unacceptable pain from POD 0-3 compared to thoracic epidural analgesia and is linked to improved mobility. Results require randomized confirmation.

| S-EPMC10645434 | biostudies-literature

Continuous Epidural Hydromorphone Infusion for Post-Cesarean Delivery Analgesia in a Patient on Methadone Maintenance Therapy: A Case Report.

Project description:The prevalence of opioid use disorder (OUD) in the United States has more than quadrupled over the past two decades. This patient population presents a number of challenges to clinicians, including difficult pain management after surgical procedures due to the development of opioid tolerance. Significantly greater opioid consumption and pain scores after cesarean delivery have been reported in patients with OUD compared to other obstetric patients. A multi-modal analgesic regimen is generally recommended, but there are few well-established pain management strategies after cesarean delivery specific to patients with OUD. We present the case of a patient with OUD maintained on daily methadone that received a continuous epidural hydromorphone infusion for post-cesarean analgesia, a technique not previously reported in obstetric patients and only rarely described for patients undergoing other surgical procedures. The patient received epidural anesthesia for cesarean delivery, and after surgery, the epidural catheter was left in place for the epidural hydromorphone infusion, initiated at 140 mcg/hr and continued for approximately 40 hrs. This strategy reduced her average daily oral opioid consumption by 97%, reduced self-reported pain scores, shortened the length of hospitalization and improved ability to ambulate compared to her previous cesarean delivery. The use of continuous epidural hydromorphone infusion was effective in this case, and this analgesic technique may also be applicable to other types of surgical procedures with the potential for significant post-operative pain, particularly in patients with OUD.

| S-EPMC7196209 | biostudies-literature

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