Myasthenia gravis is a chronic autoimmune disorder affecting post-synaptic neuromuscular junction. It is characterized by skeletal muscle weakness and fatigability which improves with rest. The anesthesiologists may encounter these patients for thymectomy or sometimes for incidental surgeries. However, it is a real challenge for anesthesiologists because of the unpredictable response with muscle relaxants and analgesics and the possibility of ventilatory complications. In the present case report, we report the management of a 52-year-old female patient with myasthenia gravis who is posted for schwannoma surgery.
Urinary bladder paraganglioma is an extra-adrenal pheochromocytoma. As it lacks specific symptoms and because of its rare occurrence, it presents incidentally while tumour handling. A forty-eight-year-old female who presented with nausea, vomiting, weight loss, pain abdomen and hematuria was diagnosed with a bladder mass. She was scheduled for transurethral resection of the bladder tumour. On tumour manipulation, it showed numerous fluctuations in heart rate and blood pressure, from where a differential diagnosis of urinary bladder paraganglioma was made. Histopathology revealed a zellbellan pattern of paraganglioma. This case was discharged successfully postoperatively. But if undiagnosed preoperatively, it can be a real challenge because of the fatal hypertensive crisis and life-threatening cardiopulmonary complications.
Introduction
Low back pain behaves as a “silent epidemic,” ranking first among complications related to work. Often there is a large gap between a patient's desired pain reduction and the minimum percentage of improvement that would make a treatment worthwhile. Consequently, debate continues as to the value of epidural steroid injections, supremacy of one adjuvant over others, various doses, and concentrations in optimizing pain management.
Objective
To compare the efficacy of ketamine vs normal saline as an adjuvant to epidural steroids in chronic low back pain.
Study design
Randomized prospective placebo-controlled study.
Materials and methods
The study was conducted on 60 patients of age group 18 to 70 years having chronic lower backache with or without radiculitis of minimum 3 months duration and having no relief with conventional treatment. The patients selected were randomly allocated into two groups of 30 patients each: Group I (n = 30) given triamcinolone 40 mg, preservative-free ketamine 30 mg (0.6 mL) made up to 6 mL solution with 0.25% bupivacaine and group II (n = 30) given 0.6 mL normal saline instead of ketamine.
Outcome measures
The primary outcome measured was number of patients requiring repeat blocks and number of repeat blocks administered in 3 months. Other outcome measures were functional improvement quantified by visual analog scale (VAS) and Oswestry disability index (ODI) as well as improvement in psychological status by depression scoring, all taken at 2 weeks interval for 3 months. The periprocedural complications were also noted at the end of the study.
Results
In managing lumbar radicular pain with lumbar epidural steroid injection (LESI), ketamine's role as an adjuvant proved to be advantageous for long-term relief by its inhibition of dorsal horn “wind up” phenomenon through N-methyl-D-aspartate (NMDA) receptor antagonism, thus reducing frequency of repeat blocks in group II (ketamine).
Conclusion
Thus to conclude, ketamine's advantage as a drug that prolongs pain relief from LESI is an avenue for further research and promises a bright future in the field of interventional pain medicine.
How to cite this article
Gupta R, Bawa C, Singh S, Mahajan L, Kaur B, Kaur T. Prospective Placebo-controlled Randomized Trial to compare the Efficacy of Ketamine as an Adjuvant to Epidural Steroids in preventing Repeat Blocks in Chronic Low Back Pain. Curr Trends Diagn Treat 2017;1(1):15-21.
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