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Lumbar facet joints have been identified as a potential source of chronic low back pain (LBP) in 15% to 45% of patients, with the prevalence of such pain varying based on specific populations and settings examined. Lumbar facet joint interventions are useful in the diagnosis as well as the therapeutic management of chronic LBP. Radiofrequency ablation (RFA) of medial branch nerves is recognized as a safe and effective therapy for chronic facet joint pain in the lumbosacral spine, and its efficacy has already been established. The use of RFA is currently widespread in the management of spinal pain, but it is noteworthy that there have been works in the literature reporting complications, albeit at a very low frequency. We present a case of third-degree skin burns following radiofrequency ablation (RFA) for the management of facet joint syndrome. Postoperatively, the patient's skin encircling the needle displayed a pallor and exhibited deterioration in conjunction with the anatomical anomaly. The affected area required approximately 5 months to heal completely. During RFA, heat can induce burns not only at the point of contact with the RF electrode but also along the length of the needle. Vigilant attention is necessary to ensure patient safety and to address any potential complications that may arise during the procedure, including the possibility of minor technical errors. [ABSTRACT FROM AUTHOR]

The recently introduced pectoral nerve (Pecs) block is a simple alterative to the conventional thoracic paravertebral block or epidural block for breast surgery. It produces excellent analgesia and can be used to provide balanced anesthesia and as a rescue block in cases where performing a neuraxial blockade is not possible. In the thoracic region, a neuraxial blockade is often used to manage zoster-associated pain. However, this can be challenging for physicians due to the increased risk of hemodynamic instability in the upper thoracic level, and comorbid and contraindicated medical conditions such as coagulopathy. Here, we introduce an ultrasound-guided Pecs block for the management of herpes zoster-associated pain, which could be an effective alternative to other interventional options in the thoracic region., Author(s): Yeon-Dong Kim [sup.1] , Seon-Jeong Park [sup.1] , Junho Shim [sup.2] , Hyungtae Kim [sup.2] Author Affiliations: (Aff1) 0000 0004 0533 4755, grid.410899.d, Department of Anesthesiology and Pain Medicine, [...]

Pudendal neuralgia is characterized by chronic pain or discomfort in the area innervated by the pudendal nerve, with no obvious cause. A successful pudendal nerve block is crucial for the diagnosis of pudendal neuralgia. Blind or fluoroscopy-guided pudendal nerve blocks have been conventionally used for diagnosis and treatment; however, ultrasound-guided pudendal nerve blocks were also reported recently. With regard to the achievement of long-term effects, although pulsed radiofrequency performed under fluoroscopic guidance has been reported, that performed under ultrasound guidance is not well reported. This report describes two cases of pudendal neuralgia that were successfully managed using ultrasound-guided pulsed radiofrequency and presents a literature review of pudendal nerve block techniques. However, in the management of chronic neuropathic pain, physicians should keep in mind that the placebo effect related to invasive approaches must not be neglected., Author(s): Myong-Joo Hong[sup.1] , Yeon-Dong Kim[sup.2] [sup.3] , Jeong-Ki Park[sup.2] , Hyon-Joo Hong[sup.4] Author Affiliations: (1) Department of Rheumatology, Presbyterian Medical Center, Jeonju, Republic of Korea (2) Department of Anesthesiology [...]

Background and Objectives: Although epidural steroid injections are used as an effective treatment, this technique is associated with rare but serious ischemic complications, especially when particulate steroids are used. However, recent studies have reported that even if non-particulate steroids are used, particulates are formed by the interaction with some local anesthetics (LA), causing ischemic complications. This observational study evaluated commonly used combinations of non-particulate steroids and LA with contrast media via microscopic analysis and analyzed the chemical properties of each mixture to identify the correlation of particulate formation. Materials and Methods: Commonly used clinical non-particulate and particulate steroids, contrast media, and LA agent combinations were evaluated macroscopically and microscopically. The pH values were also measured at both room temperature (26 °C) and body temperature (36 °C). Where particulates were observed, the particulate size was measured. Results: Macroscopically, the mixture of non-particulate steroid and ropivacaine had a slightly cloudy appearance at all concentrations, but there was no visible particulate. However, when observed under a microscope, the pH-dependent particulate formation was observed at all concentration combinations tested. (0.1% ropivacaine: from 19 μm to 70 μm, and 0.2% ropivacaine: from 37 μm to 108 μm at room temperature (26 °C)). When contrast media was mixed or the temperature was raised to body temperature (36 °C), the number and size of the particulates decreased or dissolved. Conclusions: The combination of ropivacaine and dexamethasone, a non-particulate steroid, mainly used in epidural injections, forms particulates. However, when mixed with contrast media, particulates are dissolved because of changes in pH and factors affecting particulate formation. In fluoroscopy-guided injections, the use of contrast media could resolve particulate formation. [ABSTRACT FROM AUTHOR]

The aims of this study were to investigate the current clinical practice of ultrasound (US)-guided stellate ganglion block (SGB) using a bi-national survey of Korea and Japan, and to clarify the anatomical relation of the cervical sympathetic trunk with the prevertebral fascia at the level of cervical vertebrae. The current clinical practice of US-guided SGB in Korea and Japan was investigated using an Internet survey, which received 206 (10.2%) replies from Korea and 97 (8.8%) replies from Japan. The survey questionnaire addressed the actual clinical practice for US-guided SGB, including where the tip of the injection needle is placed. Additionally, 16 half necks of 8 embalmed cadavers were used in an anatomical study. An in-plane needle approach technique and administering 5 ml of local anesthetic were preferred in both countries. However, the type of local anesthetic differed, being lidocaine in Korea and mepivacaine in Japan. The final position of the needle tip also clearly differed in an US image, being predominantly positioned above the prevertebral fascia in Korea (39.3%) and under the prevertebral fascia in Japan (59.8%). In all of the anatomic dissections, the cervical sympathetic trunk was over the prevertebral fascia at the level of the sixth vertebra and under the prevertebral fascia at the level of the seventh vertebra. These results are expected to improve the knowledge on the current clinical practice and to suggest future studies. [ABSTRACT FROM AUTHOR]

The aim of this study was to clarify the topographical relationships between the greater occipital nerve and the trapezius muscle and between the greater occipital nerve and the occipital artery in the occiput in order to increase the success rate of greater occipital nerve blockade. Fifty-six halved heads of 28 cadavers were used in this study. The piercing points and the courses of the greater occipital nerve and occipital artery were analyzed by dividing a line connecting between the external occipital protuberance and mastoid process into three equal parts. A circle with a radius of 2 cm drawn at the medial trisection point of this line was divided into four equal sectors. The greater occipital nerve simply passed the lateral border of the trapezius muscle and then pierced the fascia connecting the cranial attachment of the trapezius muscle with the sternocleidomastoid muscle in 62.5% of the specimens, whereas it pierced the muscle itself in the other 37.5%. The greater occipital nerve and occipital artery pierced the fascia within the 2-cm-radius circle in 85.7% and 98.2% of the specimens, respectively. The piercing points of the greater occipital nerve and occipital artery were observed most frequently in the inferomedial (42.9%) and inferolateral (37.5%) sectors of the circle, respectively. The greater occipital nerve and occipital artery pierced the same sector of the circle and accompanied each other in 51.8% of the specimens. These results are expected to improve the understanding of the topographical relationships between the greater occipital nerve and trapezius muscle and between the greater occipital nerve and occipital artery in the occiput, and thus provide helpful information for the management of occipital neuralgia. [ABSTRACT FROM AUTHOR]

Chronic regional pain syndrome (CRPS) is an inflammatory and neuropathic pain disorder characterized by the involvement of the autonomic nervous system with sensory, autonomic, motor, skin, and bone changes. At present, universally accepted consensus criteria for CRPS are not yet established, despite the diagnostic criteria proposed by the International Association for the Study of Pain (IASP). Various hypotheses for the pathophysiology of CRPS have been proposed; as a result, current therapeutic modalities are varied. General epidemiological data on CRPS are necessary for effective management. However, recent data on the epidemiology of CRPS in Korea are scarce. The aim of this study was to evaluate the incidence and other epidemiological features of CRPS in the general population in Korea. In this study on the epidemiology of CRPS in Korea, population-based medical data acquired from 51,448,491 subscribers to the National Health Insurance Service (NHIS) from 2011 to 2015 were analyzed, including the incidence, distribution by the CRPS type, regional distribution, monthly distribution, medical costs, and healthcare resource-utilization. The findings indicated that the incidence of CRPS in Korea was 29.0 per 100,000 person-years in 2015 and was correlated with patient age and sex. CRPS types included type I (63%) and type II (37%); moreover, the number of individuals with CRPS I have shown a growing trend since 2011. There was no monthly distribution, but there was regional variation according to the province. The medical departments managing CRPS I the most were orthopedics, internal medicine, anesthesiology and pain medicine, in order; however, patients with CRPS spent more money per visit in the departments of rehabilitation medicine, and anesthesiology and pain medicine. The incidence rate of CRPS in Korea was 29.0 per 100,000 person-years with an increasing trend, which was correlated with patient age in the 70s and female sex. CRPS type I was more common than CRPS type II; in addition, constant increase in medical expenses, regional imbalance, and differences in medical expense among medical specialties should be considered for early management of patients to reduce the disease burden in Korea. Sharing of knowledge about the diagnostic criteria of CRPS are also needed. [ABSTRACT FROM AUTHOR]

Background: Dexmedetomidine is a highly selective a2 adrenergic agonist that has been shown to decrease the intensity of opioid-induced hyperalgesia (OIH). We aimed to investigate the antihyperalgesic effects of dexmedetomidine on high-dose remifentanil-induced hyperalgesia. Methods: Ninety American Society of Anesthesiologists physical status I-II patients undergoing laparoscopically assisted vaginal hysterectomy (LAVH) were randomly assigned to one of the following three groups, each of which received either dexmedetomidine (an initial dose of 1.0 µg/kg for 10 min, followed by a continuous infusion of 0.7 µg/kg/hr) or placebo saline 15 min before the induction of anesthesia and intraoperative remifentanil infusion: group C received a placebo and 0.05 µg/kg/min remifentanil; group RH received a placebo and 0.3 µg/kg/min remifentanil; and group DRH received dexmedetomidine and 0.3 µg/kg/min remifentanil. Results: The mechanical hyperalgesia threshold 24 hr after surgery was significantly lower in group RH than in the other two groups. Postoperative pain intensity using visual analog scale (VAS) and cumulative volume of a patient-controlled analgesia (PCA) containing morphine over 24 hr were significantly greater in group RH than in group DRH. The time to the first postoperative analgesic requirement was significantly shorter in group RH than in the other two groups. The desflurane requirement was significantly greater in group C than in the other groups. The frequency of hypotension and bradycardia was significantly higher, but shivering and postoperative nausea and vomiting were significantly lower in group DRH than in the other two groups. Conclusions: High-doses of remifentanil induced hyperalgesia, which presented a decreased mechanical hyperalgesia threshold, enhanced pain intensity, a shorter time to first postoperative analgesic requirement, and greater morphine consumption, but dexmedetomidine efficiently alleviated those symptoms. Dexmedetomidine may be a novel and effective treatment option for preventing or attenuating OIH. [ABSTRACT FROM AUTHOR]

Background: Dexmedetomidine is a highly selective α2 adrenergic agonist that has been shown to decrease the intensity of opioid-induced hyperalgesia (OIH). We aimed to investigate the antihyperalgesic effects of dexmedetomidine on high-dose remifentanil-induced hyperalgesia. Methods: Ninety American Society of Anesthesiologists physical status I-II patients undergoing laparoscopically assisted vaginal hysterectomy (LAVH) were randomly assigned to one of the following three groups, each of which received either dexmedetomidine (an initial dose of 1.0 μg/kg for 10 min, followed by a continuous infusion of 0.7 μg/kg/hr) or placebo saline 15 min before the induction of anesthesia and intraoperative remifentanil infusion: group C received a placebo and 0.05 μg/kg/min remifentanil; group RH received a placebo and 0.3 μg/kg/min remifentanil; and group DRH received dexmedetomidine and 0.3 μg/kg/min remifentanil. Results: The mechanical hyperalgesia threshold 24 hr after surgery was significantly lower in group RH than in the other two groups. Postoperative pain intensity using visual analog scale (VAS) and cumulative volume of a patient-controlled analgesia (PCA) containing morphine over 24 hr were significantly greater in group RH than in group DRH. The time to the first postoperative analgesic requirement was significantly shorter in group RH than in the other two groups. The desflurane requirement was significantly greater in group C than in the other groups. The frequency of hypotension and bradycardia was significantly higher, but shivering and postoperative nausea and vomiting were significantly lower in group DRH than in the other two groups. Conclusions: High-doses of remifentanil induced hyperalgesia, which presented a decreased mechanical hyperalgesia threshold, enhanced pain intensity, a shorter time to first postoperative analgesic requirement, and greater morphine consumption, but dexmedetomidine efficiently alleviated those symptoms. Dexmedetomidine may be a novel and effective treatment option for preventing or attenuating OIH. [ABSTRACT FROM AUTHOR]

Cervical facet joint (CFJ) syndrome is a common cause of neck pain. For its diagnosis and treatment, CFJ injection with arthrogram is generally performed. This study aimed to investigate the frequency of extra-CFJ flow on CFJ arthrograms during injections and its differences according to age, sex, and cervical vertebral level. We analyzed 760 CFJ arthrograms administrated to 208 patients diagnosed with CFJ syndrome. Arthrograms at each vertebral level were collected to evaluate the normal CFJ and extra-CFJ flow. The primary and secondary outcomes were frequency of extra-CFJ flow according to cervical vertebral level, age, and sex and according to pairwise cervical levels, respectively. Extra-CFJ flow at the cervical spine occurred during 179 injections, and the overall incidence was 3.3–36.2% at different cervical levels. The incidence of extra-CFJ flow at each cervical vertebral level according to age and sex was not significant. Extra-CFJ flow was the highest at C6 and C7, but there was no statistical significance. Extra-CFJ flow was higher at lower vertebral levels (C5–C7) than at upper levels (C3 and C4). Additional clinical studies and anatomical evaluations are needed to support its clinical value and enable the development of new injection techniques. [ABSTRACT FROM AUTHOR]

Background: Cervical epidural block (CEB) is an effective intervention for managing cervical radicular pain. This study aimed to investigate the current status of performing CEB in South Korea., Methods: Pain physicians affiliated with the Korean Pain Society were asked to complete anonymous questionnaires regarding CEB between September and October 2022. The questionnaire consisted of 24 questions assessing the current status and methods of CEB in detail., Results: Of the 198 surveys collected, 171 physicians (86.4%) reported performing CEB. Among those, the majority (94.7%) used fluoroscopy during the procedure. The paramedian interlaminar (IL) approach was the most preferred method (50.3%). Respondents performing fluoroscopic-guided IL CEB were categorized into two groups based on clinical experience: those with ≤10 years of experience (≤10-year group, n = 91) and those with >10 years of experience (>10-year group, n = 71). The proportion of physicians obtaining informed consent in the ≤10-year group and >10-year group was 50.5% and 56.3%, respectively. When entering the epidural space during IL CEB, the contralateral oblique view was the second most frequently used in both groups (≤10-year group, 42.9%; >10-year group, 29.6%). In targeting the upper cervical lesions (C3-4), the proportion of respondents who used an IL space higher than C6-7 was 17.6% in the ≤10-year group and 29.5% in the >10-year experience group., Conclusions: This study demonstrated variability in the CEB technique used by pain physicians in South Korea. The findings highlight the need for education on informed consent and techniques to enhance safety.

Introduction: Stenotic thoracic ligamentum flavum hypertrophy can cause leg and/or low back pain similar to that caused by lumbar spinal stenosis. However, the thoracic spine may occasionally be overlooked in patients with leg and/or low back pain. An accurate understanding of the prevalence of stenotic thoracic ligamentum flavum hypertrophy and its associated factors is necessary., Methods: In this prevalence study, we reviewed whole-spine MRI scans of patients who visited the pain clinic complaining of leg and/or low back pain between 2010 and 2019. We analyzed the overall prevalence and prevalence according to the age group, sex, grade of lumbar disc degeneration, and thoracic level. In addition, we identified factors independently associated with stenotic thoracic ligamentum flavum hypertrophy occurrence., Results: Among 1896 patients, the overall prevalence of stenotic thoracic ligamentum flavum hypertrophy was 9.8% (185/1896), with the highest prevalence observed in the ≥80-year-old age group among all age groups (15.9%, 14/88). The region with the highest prevalence was the T10/11 level (3.0%, 57/1896). Multivariable logistic regression analysis revealed that when compared with the <50-year-old age group, all other age groups were significantly associated with stenotic thoracic ligamentum flavum hypertrophy (p<0.01). In addition, grade 5 of lumbar disc degeneration was significantly associated with stenotic thoracic ligamentum flavum hypertrophy (p=0.03)., Conclusions: Given the possibility for missed stenotic thoracic ligamentum flavum hypertrophy to potentially result in neurological complications, extending lumbar spine MRI covering the lower thoracic region may be considered for patients over 50 years of age with suspected severe lumbar disc degeneration., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: : This study aimed to identify exact anatomical landmarks and ideal injection volumes for safe adductor canal blocks (ACB)., Methods: : Fifty thighs from 25 embalmed adult Korean cadavers were used. The measurement baseline was the line connecting the anterior superior iliac spine (ASIS) to the midpoint of the patellar base. All target points were measured perpendicular to the baseline. The relevant cadaveric structures were observed using ultrasound (US) and confirmed in living individuals. US-guided dye injection was performed to determine the ideal volume., Results: : The apex of the femoral triangle was 25.3 ± 2.2 cm distal to the ASIS on the baseline and 5.3 ± 1.0 cm perpendicular to that point. The midpoint of the superior border of the vasto-adductor membrane (VAM) was 27.4 ± 2.0 cm distal to the ASIS on the baseline and 5.0 ± 1.1 cm perpendicular to that point. The VAM had a trapezoidal shape and was connected as an aponeurosis between the medial edge of the vastus medialis muscle and lateral edge of the adductor magnus muscle. The nerve to the vastus medialis penetrated the muscle proximal to the superior border of the VAM in 70% of specimens. The VAM appeared on US as a hyperechoic area connecting the vastus medialis and adductor magnus muscles between the sartorius muscle and femoral artery., Conclusions: : Confirming the crucial landmark, the VAM, is beneficial when performing ACB. It is advisable to insert the needle obliquely below the superior VAM border, and a 5 mL injection is considered sufficient.

Background: The rise in national health care costs has emerged as a global problem given the ever-aging population and rapid development of medical technology. The utilization of interventional pain management has, similarly, shown a continued rise worldwide. This study evaluates the differences in the medical costs in the field of interventional pain treatment (IPT) between two countries: Korea and Japan., Methods: Korean medical insurance costs for 2019 related to pain management focused on IPT were compared to those of Japan. Purchasing power parity (PPP) was used to adjust the exchange rate differences and to compare prices in consideration of the respective societies' economic power., Results: The cost of trigger point injections in Japan was 1.06 times higher than that of Korea, whereas the perineural and intraarticular injection prices were lower in Japan. The cost of epidural blocks was higher in Japan compared to Korea in both cervical/thoracic and lumbar regions. As for blocks of peripheral branches of spinal nerves, the cost of scapular nerve blocks in Japan was lower than that in Korea, given a PPP ratio 0.09. For nerve blocks in which fluoroscopy guidance is mandatory, the costs of epidurography in Japan were greater than those in Korea, given a PPP ratio 1.04., Conclusions: This is the first comparative study focusing on the medical costs related to IPT between Korea and Japan, which reveals that the costs differed along various categories. Further comparisons reflecting more diverse countries and socio-economic aspects will be required.

Background: Fibromyalgia (FM) is a complex disorder characterized by widespread chronic pain and tenderness in the muscles, ligaments, and soft tissues. It is a chronic pain condition often accompanied by other symptoms and comorbidities. To effectively manage FM, it is crucial to obtain fundamental epidemiological data pertaining to the target population. Therefore, this study was conducted to elucidate the epidemiological characteristics of FM in the Korean population., Methods: Population-based medical data of 51,276,314 subscribers to the National Health Insurance Service of Korea from 2014 to 2018 were used in this study., Results: The overall incidence of FM ranged from 441 (2014) to 541 (2018) cases per 100,000 person-years, with a higher prevalence observed among female patients compared to male patients. The incidence gradually increased until middle age, followed by a decrease. The highest incidence rates were observed in the fifth decade of life for females and the sixth decade of life for males. When categorizing the affected parts of the body, the shoulder region was observed to be the most frequently affected. A comparison of the drug prescriptions based on medical specialty showed that antidepressants were the most commonly prescribed medications. The management of FM leads to consistent increases in medical expenses, regional disparities, and variations in prescription patterns across different medical specialties., Conclusions: The findings of this study will not only contribute to the understanding of FM characteristics but also provide a vital foundation for efficient management of FM in Korea.

Background: Percutaneous radiofrequency thermocoagulation (RFTC) has been widely utilized in the management of trigeminal neuralgia. Despite using image guidance, accurate needle positioning into the target area still remains a critical element for achieving a successful outcome. This study was performed to precisely clarify the anatomical information required to ensure that the electrode tip is placed on the sensory component of the mandibular nerve (MN) at the foramen ovale (FO) level., Methods: The study used 50 hemi-half heads from 26 South Korean adult cadavers., Results: The cross-sectioned anterior and posterior divisions of the MN at the FO level could be distinguished based on an irregular boundary and color difference. The anterior division was clearly brighter than the posterior one. The anterior division of the MN at the FO level was located at the whole anterior (38.0%), anteromedial (6.0%), anterior center (8.0%), and anterolateral (22.0%) parts. The posterior division was often located at the whole posterior or posterolateral parts of the MN at the FO level. The anterior divisions covered the whole MN except for the medial half of the posterolateral part in the overwrapped images of the cross-sectional areas of the MN at the FO level. The cross-sectional areas of the anterior divisions were similar in males and females, whereas those of the posterior divisions were significantly larger in males ( P = 0.004)., Conclusions: The obtained anatomical information is expected to help physicians reduce unwanted side effects after percutaneous RFTC within the FO for the MN.

Coccydynia is a debilitating pain disorder. However, its pathophysiology is not well understood. When approaching coccydynia, the exact underlying cause of pain must be identified to develop an appropriate treatment plan. The specific approach to coccydynia can vary depending on an individual's condition and the underlying cause. Thorough evaluation by a pain physician is essential to determine the most appropriate course of treatment. The purpose of this review is to examine the various causes contributing to coccygeal pain and specifically focus on the exact anatomical neurostructures, such as the anococcygeal nerve, perforating cutaneous nerve, and ganglion impar. We also reviewed the relevant clinical outcomes and suggested recommendations for each anatomical structure.

Background: Trigeminal neuralgia (TN) is one of the most painful disorder in the orofacial region, and many patients have suffered from this disease. For the effective management of TN, fundamental epidemiologic data related to the target population group are essential. Thus, this study was performed to clarify the epidemiological characteristics of TN in the Korean population. This is the first national study to investigate the prevalence of TN in Korean patients., Methods: From 2014 to 2018, population-based medical data for 51,276,314 subscribers to the National Health Insurance Service of Korea were used for this study., Results: The incidence of TN was 100.21 per 100,000 person-years in the year of 2018 in Korea, and the male to female ratio was 1:2.14. The age group of 51-59 years had the highest prevalence of TN. Constant increases in medical cost, regional imbalance, and differences in prescription patterns by the medical specialties were showed in the management of TN., Conclusions: The results in this study will not only help to study the characteristics of TN, but also serve as an important basis for the effective management of TN in Korea.

Lumbar facet joints have been implicated in chronic low back pain in up to 45% of patients with low back pain (LBP). Facet joint pain diagnosis and management are always challenging for pain physicians. Facet joint pain is not diagnosed by specific demographic features, pain characteristics, or physical findings, even though electrodiagnostic studies and imaging modalities are available. Although comparative local anesthetics or placebo saline injections can be used, diagnostic blocks are the only reliable diagnostic measures according to the current literature. Treatment of chronic LBP arising due to facet joint includes intraarticular injections, medial branch blocks, and radiofrequency neurotomy. However, the evidence of their clinical efficacy is continuously under scrutiny. Pain physicians must have a detailed understanding of the spinal anatomy in order to perform safe and effective interventional procedures. This review outlines the important aspects of spinal anatomy as they relate to interventional pain management related to facet joint injections. Additionally, we provide a comprehensive review of the procedure and clinical evidence., Competing Interests: CONFLICTS OF INTEREST No potential conflict of interest relevant to this article was reported., (Copyright © the Korean Society of Anesthesiologists, 2019.)

Background: Various developments in imaging techniques, interventional procedures, and medications for pain management have beneficial consequences. However, the nature of pain management often results in physicians becoming involved in medico-legal disputes with patients who purposely or accidentally bring litigation., Methods: Data on medical disputes cases related to pain management were collected and analyzed through the Korea Medical Dispute Mediation and Arbitration Agency from 2012 to 2016., Results: In total, we identified 210 public-disclosed cases; of these, we identified 36 cases related to pain management. The department of orthopedics (n = 9, 25%) was the most related to these pain management cases. Pain management was most commonly offered for pain in the lumbar region (n = 13, 37%), lower extremities (n = 12, 34%), and for infection (n = 7, 19%). The time spent resolving disputes ranged from 8.0 to 17.5 months and the final settlement amount ranged from 1,800,000 to 15,000,000 Korean won. Causal relationships and medical malpractice were the most common controversial subjects of legal debate., Conclusions: Various characteristics of medical disputes related to pain management in Korea were identified. Information regarding medical disputes in pain management should be available to help prevent further disputes and litigation, which is also useful to both patients and pain physicians. Guidelines and recommendations for pain management are needed, especially those focused on medico-legal cases., Competing Interests: CONFLICTS OF INTEREST No potential conflict of interest relevant to this article was reported., (Copyright © the Korean Society of Anesthesiologists, 2020.)

Background: The aim of this study was to clarify the topographical relationship between the accessory nerve (AN) and transverse cervical artery (TCA) to provide safe and convenient injection points for AN blockade., Methods: This study included 21 and 30 shoulders of 14 embalmed Korean adult cadavers and 15 patients, respectively, for dissection and ultrasound (US) examination., Results: The courses of the TCA and AN in the scapular region were classified into four types based on their positional relationships. Type A indicated the nerve that was medial to the artery and ran parallel without changing its location (38%). In type B (38%), the nerve was lateral to the artery and ran parallel without changing its location. In type C (19%), the nerve or artery traversed each other only once during the whole course. In type D (5%), the nerve or artery traversed each other more than twice forming a twist. At the levels of lines I-IV, the nerve was relatively close to the artery (approximately 10 mm). TCAs were observed in all specimens around the superior angle of the scapula at the level of line II, whereas they were not found below line VI. In US images of the patients, the TCA was commonly observed at the level of line II (93.3%) where all ANs and TCAs were observed in cadaveric dissection., Conclusions: The results expand the current knowledge of the relation between the AN and TCA, and provide helpful information for selective diagnostic nerve blocks in the scapular region.

Background: The aim of this study was to clarify the topographical relationships between the dorsal scapular nerve (DSN) and the dorsal scapular artery (DSA) in the interscapular region to identify safe and convenient injection points related to DSN blockade., Methods: Thirty shoulders of embalmed Korean cadavers and 50 live subjects were used for dissection and ultrasound (US) analysis., Results: The running patterns of the DSA and DSN in the interscapular region were classified into 3 types. Type I was defined as nerves that were medial to the artery and parallel without changing location (80.0% of specimens). In type II (13.3%), the nerve and artery traversed one another only one time over their entire length. In type III (6.7%), the nerve and artery traversed one another, resembling a twist. Above the level of the scapular spine, the nerve was always medial to the artery. Below the scapular spine, the number of arteries was obviously decreased. Most of the arteries were lateral to the medial border of the scapula, except at the level of the superior angle of the scapula artery (SA). The positional tendency of the DSN toward the medial or lateral sides from the medial border of the scapula was similar. In US imaging of live subjects, the DSA was most observed at the level of the SA (94.0%)., Conclusions: Results of this study enhance the current knowledge regarding the pathway of the DSN and DSA and provide helpful information for selective diagnostic nerve blocks in the interscapular region.

Background: Recently, the use of ultrasound (US) techniques in regional anesthesia and pain medicine has increased significantly. However, the current extent of training in the use of US-guided pain management procedures in Korea remains unknown. The purpose of the present study was to assess the current state of US training provided during Korean Pain Society (KPS) pain fellowship programs through the comparative analysis between training hospitals., Methods: We conducted an anonymous survey of 51 pain physicians who had completed KPS fellowships in 2017. Items pertained to current US practices and education, as well as the types of techniques and amount of experience with US-guided pain management procedures. Responses were compared based on the tier of the training hospital., Results: Among the 51 respondents, 14 received training at first- and second-tier hospitals (Group A), while 37 received training at third-tier hospitals (Group B). The mean total duration of pain training during the 1-year fellowship was 7.4 months in Group A and 8.4 months in Group B. Our analysis revealed that 36% and 40% of respondents in Groups A and B received dedicated US training, respectively. Most respondents underwent US training in patient-care settings under the supervision of attending physicians. Cervical root, stellate ganglion, piriformis, and lumbar plexus blocks were more commonly performed by Group B than by Group A ( P < 0.05)., Conclusions: Instruction regarding US-guided pain management interventions varied among fellowship training hospitals, highlighting the need for the development of educational standards that mandate a minimum number of US-guided nerve blocks or injections during fellowships in interventional pain management.

Background: Recently, ultrasound has been commonly used. Ultrasound-guided interscalene brachial plexus block (IBPB) by posterior approach is more commonly used because anterior approach has been reported to have the risk of phrenic nerve injury. However, posterior approach also has the risk of causing nerve injury because there are risks of encountering dorsal scapular nerve (DSN) and long thoracic nerve (LTN). Therefore, the aim of this study was to evaluate the risk of encountering DSN and LTN during ultrasound-guided IBPB by posterior approach., Methods: A total of 70 patients who were scheduled for shoulder surgery were enrolled in this study. After deciding insertion site with ultrasound, awake ultrasound-guided IBPB with nerve stimulator by posterior approach was performed. Incidence of muscle twitches (rhomboids, levator scapulae, and serratus anterior muscles) and current intensity immediately before muscle twitches disappeared were recorded., Results: Of the total 70 cases, DSN was encountered in 44 cases (62.8%) and LTN was encountered in 15 cases (21.4%). Both nerves were encountered in 10 cases (14.3%). Neither was encountered in 21 cases (30.4%). The average current measured immediately before the disappearance of muscle twitches was 0.44 mA and 0.50 mA at DSN and LTN, respectively., Conclusions: Physicians should be cautious on the risk of injury related to the anatomical structures of nerves, including DSN and LTN, during ultrasound-guided IBPB by posterior approach. Nerve stimulator could be another option for a safer intervention. Moreover, if there is a motor response, it is recommended to select another way to secure better safety.

Postherpetic neuralgia (PHN) is a disease entity defined as persistent pain after the acute pain of herpes zoster gradually resolves. It is associated with impaired daily activities, resulting in reduced quality of life. General epidemiological data on PHN is necessary for the effective management. However, data on the epidemiology of PHN in Korea is lacking. The aim of this study was to evaluate the epidemiological features of PHN in the general population.We used population-based medical data for 51,448,491 subscribers to the Health Insurance Service in the year of 2013 to analyze of PHN epidemiology in Korea, such as the incidence, regional distribution, seasonal variation, and healthcare resource utilization. Total number of patients and medical cost on PHN were analyzed from 2009 to 2013.Findings indicate that the incidence of PHN in Korea was 2.5 per 1000 person-years, which was strongly correlated with age and sex. There were no differences in seasonal variation or regional distribution. The medical cost increased steadily over the study period. When admitted to general hospitals, patients with PHN were mainly managed in the dermatology and anesthesiology departments.The incidence and prevalence rates of PHN in Koreans appear to be considerably higher compared to those in western populations, while the sex and age predisposition was similar. Considering that the pain associated with PHN can have a marked impact on a patient's quality of life resulting in a medicosocial economic burden, anesthesiology physicians have an important role in primary care in Korea. Future research on the cost-effectiveness of the management of PHN is needed., Competing Interests: The authors have no conflicts of interest to disclose.

Background: Pain medicine often requires medico-legal involvement, even though diagnosis and treatments have improved considerably. Multiple guidelines for pain physicians contain many recommendations regarding interventional treatment. Unfortunately, no definite treatment guidelines exist because there is no complete consensus among individual guidelines. Pain intervention procedures are widely practiced and highly associated with adverse events and complications. However, a comprehensive, systemic review of medical-dispute cases (MDCs) in Korea has not yet been reported. The purpose of this article is to analyze the frequency and type of medical dispute activity undertaken by pain specialists in Korea., Methods: Data on medical disputes cases were collected through the Korea Medical Association mutual aid and through a private medical malpractice liability insurance company. Data regarding the frequency and type of MDCs, along with brief case descriptions, were obtained., Results: Pain in the lumbar region made up a major proportion of MDCs and compensation costs. Infection, nerve injury, and diagnosis related cases were the most major contents of MDCs. Only a small proportion of cases involved patient death or unconsciousness, but compensation costs were the highest., Conclusions: More systemic guidelines and recommendations on interventional pain management are needed, especially those focused on medico-legal cases. Complications arising from pain management procedures and treatments may be avoided by physicians who have the required knowledge and expertise regarding anatomy and pain intervention procedures and know how to recognize procedural aberrations as soon as they occur.

Patients with burning mouth syndrome (BMS) report burning sensation and pain involving the tongue and oral mucosa without any apparent medical or dental cause. The pathogenesis of this syndrome remains unclear and there is currently no standard treatment. BMS is, therefore, often misdiagnosed and its management is complex. This lack of clinical expertise may result in decreased health-related quality of life and increased psychological distress among patients with BMS. The present case report involves a 77-year-old female patient with BMS refractory to conventional treatment with nerve block and medication, who was successfully treated with duloxetine. Duloxetine may become a new therapeutic option in the management of BMS., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: Epidural steroid injection (ESI) is one of the most common procedures for patients presenting low back pain and radiculopathy. However, there is no clear consensus on what constitutes appropriate steroid use for ESIs. To investigate optimal steroid injection methods for ESIs, surveys were sent to all academic pain centers and selected private practices in Korea via e-mail., Methods: Among 173 pain centers which requested the public health insurance reimbursements for their ESIs and were enrolled in the Korean Pain Society, 122 completed questionnaires were returned, for a rate of 70.5%; also returned were surveys from 39 academic programs and 85 private practices with response rates of 83.0% and 65.9%, respectively., Results: More than half (55%) of Korean pain physicians used dexamethasone for ESIs. The minimum interval of subsequent ESIs at the academic institutions (3.1 weeks) and the private practices (2.1 weeks) were statistically different (P = 0.01)., Conclusions: Although there was a wide range of variation, there were no significant differences between the academic institutions and the private practices in terms of the types and single doses of steroids for ESIs, the annual dose of steroids, or the limitations of doses in the event of diabetes, with the exception of the minimum interval before the subsequent ESI.

Background: Although one lung ventilation (OLV) is frequently used for facilitating thoracic surgical procedures, arterial hypoxemia can occur while using one lung anesthesia. Continuous positive airway pressure (CPAP) in 5 or 10 cmH(2)O to the non-ventilating lung is commonly recommended to prevent hypoxemia. We evaluated the effects of incremental CPAP to the non-ventilating lung on arterial oxygenation and pulmonary shunt without obstruction of the surgical field during OLV., Methods: Twenty patients that were scheduled for one lung anesthesia were included in this study. Systemic and pulmonary hemodynamic data and blood gas analysis was recorded every fifteen minutes according to the patient's positions and CPAP levels. CPAP was applied from 0 cmH(2)O by 3 cmH(2)O increments until a surgeon notifies that the surgical field was obstructed by the expanded lung. Following that, pulmonary shunt fraction (Q(S)/Q(T)) was calculated., Results: There were no significant differences of Q(S)/Q(T) between supine and lateral positions with two lung ventilation (TLV). OLV significantly decreased arterial oxygen partial pressure (PaO(2)) and increased Q(S)/Q(T) compared to TLV. PaO(2) and Q(S)/Q(T) significantly improved at 6 and 9 cmH(2)O of CPAP compared to 0 cmH(2)O. However, there were no significant differences of PaO(2) and Q(S)/Q(T) between 6 and 9 cmH(2)O CPAP. In 18 patients (90%), surgical fields were obstructed at 9 cmH(2)O CPAP., Conclusions: This study suggests that 6 cmH(2)O CPAP effectively improved arterial oxygenation without interference of the surgical field during OLV when CPAP was applied from 0 cmH(2)O in 3 cmH(2)O increments.

Breast surgery is a common procedure performed in women. Many women who undergo breast surgery suffer from ill-defined pain syndromes. A nerve block is used in the treatment of the acute and chronic pain, but the effectiveness of the treatment has been limited because of its short duration. Recently, the advent of pulsed radiofrequency lesioning (PRF) has proved a successful treatment for chronic refractory pain involving the peripheral nerves. We experienced a case of a 52-year-old female patient complaining of chronic breast neuropathic pain after breast reduction, which was relieved after PRF lesioning of the 4th thoracic spinal nerve and its root.

Background: When applying pulsed radiofrequency on dorsal root ganglia for treating chronic lower back pain, maximum efficiency can be expected when a needle is placed 1-2 cm peripheral to the dorsal root ganglion. The object of this study is to analyze images taken after adding contrast to transforaminal epidural injection, categorize root ganglia according to anatomical position, and provide a reference for efficient needle positioning in applying pulsed radiofrequency on dorsal root ganglia., Methods: From January 2008 to January 2009, 457 patients who visited our hospital for root pain or radiculopathy were treated with transforaminal epidural injection on the nerve roots based on the dermatome of the painful area. Anteroposterior views were taken after injection of contrast. A virtual line was made by connecting the internal and external parts of the spinal pedicle from the contrast images. Then the dorsal root ganglia were categorized as intraspinal (IS), intraforaminal (IF), or extraforaminal (EF)., Results: In the fourth lumbar spine, dorsal root ganglia positions were 48% IF, 41% IS, and 6% EF. In the fifth lumbar spine, dorsal root ganglia positions were 75% IF, 10% IS, and 6% EF. In the first sacral spine, dorsal root ganglia locations were 8% IF and 83% IS., Conclusions: Positional categorization of dorsal root ganglia according to contrast images was proven to be good anatomical references for effective radiofrequency or blocking of dorsal root ganglia.