Background: Sevoflurane is widely used to anesthetize children because of its rapid action with minimal irritation of the airways. However, there is a high risk of agitation after emergence from anesthesia. Strabismus surgery, in particular, can trigger agitation because patients have their eyes covered in the postoperative period. The aim of this study was to determine whether or not esmolol and lidocaine could decrease emergence agitation in children. Methods: Eighty-four patients aged 3 to 9 years undergoing strabismus surgery were randomly assigned to a control group (saline only), a group that received intravenous lidocaine 1.5 mg/kg, and a group that received intravenous esmolol 0.5 mg/kg and lidocaine 1.5 mg/kg. Agitation was measured using the objective pain score, Cole 5-point score, and Richmond Agitation Sedation Scale score at the end of surgery, on arrival in the recovery room, and 10 and 30 min after arrival. Results: The group that received the combination of esmolol and lidocaine showed lower OPS and RASS scores than the other two groups when patients awoke from anesthesia (OPS = 0 (0–4), RASS = –4 [(–5)–1]) and were transferred to the recovery room (OPS = 0 (0–8), RASS = –1 [(–5)–3]) ( P < 0.05). There was no significant difference in the severity of agitation among the three groups at other time points ( P > 0.05). Conclusions: When pediatric strabismus surgery is accompanied by sevoflurane anesthesia, an intravenous injection of esmolol and lidocaine could alleviate agitation until arrival in the recovery room. Trial registration: Clinical Research Information Service, No. KCT0002925; https://cris.nih.go.kr/cris/en/search/search_result_st01.jsp?seq=11532

Rationale: Reversible cerebral vasoconstriction syndrome (RCVS) is often accompanied by thunderclap headaches. Although symptoms usually resolve spontaneously within 2 months, it can cause fatal complications, such as cerebral hemorrhage, and is difficult to differentiate from a migraine and other headaches on the basis of symptoms and Imaging study. In this case report, we explore clinical findings and appropriate treatment methods for RCVS through the case study of a female patient who experienced severe headache upon defecation Patient concerns: A 42-year-old female patient complained of a severe throbbing headache with a Numeric Rating Scale (NRS) score of 10 after defecation. The pain subsided temporarily after treatment with diclofenac 75 mg and Tridol 50 mg propacetamol 1 g, but the headache returned upon defecation; soon after, the patient complained again of regular headaches at 4 to 6-hour intervals irrespective of defecation. Diagnosis: Brain computed tomography (CT) and head and neck magnetic resonance angiography, performed during a headache episode, revealed no specific neurological findings. Blood analysis was also normal. Head and neck CT angiography, performed one month after the start of the headaches, revealed RCVS. Interventions: Treatment commenced with pregabalin (150 mg), oxycodone HCl/naloxone (10/5 mg), Alpram (0.5 mg), milnacipran (25 mg), and frovatriptan 25 mg, but there was no improvement in the headaches. The patient received bilateral trigger point injections (TPI) in the temporal muscles on four occasions at the pain clinic. Outcomes: Medication showed no effect, but after the patient received four sessions of bilateral TPI in the temporal muscles her NRS score eventually decreased from 10 to 2. The patient is currently continuing medication while still experiencing headaches at reduced intensities. Lessons: RCVS is difficult to diagnose; moreover, it is difficult differentiate RCVS from other headaches. However, as it can cause fatal complications, it should not be overlooked. It is essential to consider diagnostic treatment for all types of headaches because RCVS can be accompanied by headaches originating from other causes.

Herpes zoster is a disease that involves reactivation of the varicella-zoster virus and induces pain by injuring the nerve ganglia. We present the case of a 52-year-old woman without a notable medical history. She complained of painful itches that were causatively associated with infiltration to the ophthalmic nerve of the trigeminal nerve. Furthermore, the patient did not positively respond to antiviral agents, analgesics, and anticonvulsants. However, after inducing a stellate ganglion block, her Visual Analog Scale for pain and itching reduced from a scale of 8 to 2.

Navicular stress fractures (NSFs) are relatively uncommon, and predominantly affect athletes. Patients complain of vague pain, bruising, and swelling in the dorsal aspect of the midfoot. Os supranaviculare (OSSN) is an accessory ossicle located above the dorsal aspect of the talonavicular joint. There have been few previous reports of NSFs accompanied by OSSN. Herein we report the case of a patient with OSSN who was successfully treated for an NSF. A 34-year-old Asian man presented with a 6-month history of insidious-onset dorsal foot pain that occasionally radiated medially toward the arch. The pain worsened while sprinting and kicking a soccer ball with the instep, whereas it was temporarily relieved by rest for a week and analgesics. Plain radiographs of the weight-bearing foot and ankle joints revealed a bilateral, well-corticated OSSN. Computed tomography (CT) revealed a sagittally oriented incomplete fracture that extended from the dorsoproximal cortex to the center of the body of the navicular. The OSSN was excised and the joint was immobilized with a non-weight-bearing cast for 6 weeks, followed by gradual weight bearing using a boot. The 5-month follow-up CT scan demonstrated definite fracture healing. At the 1-year follow-up, the patient’s symptoms had resolved, the American Orthopedic Foot and Ankle Society midfoot score had improved from 61 to 95 points, and the visual analog scale pain score had improved from 6 to 0. We describe a rare case of NSF accompanied by OSSN. Because of the fracture gap and biomechanical properties of OSSN, OSSN was excised and the joint was immobilized, leading to a successful outcome. Further research is required to evaluate the relationship between NSFs and OSSN, and determine the optimal management of NSFs in patients with OSSN.