The PIL approach is superior to the TF approach for placing contrast into the anterior epidural space with reduction in fluoroscopy times and an improved spread grade. With increasing attention to neurological injury associated with TF, the PIL approach may be more suitable for routine use.

Objective To introduce the basic concepts of blockchain technologies in tackling the opioid epidemic. Design A narrative review. Setting/Background The opioid epidemic is taking a big toll in terms of lives and livelihood in America. Various public and private sector agencies are actively implementing different strategies to contain the epidemic. Development of robust real-time databases that are secure and easily accessible to the stakeholders in the opioid/paincare ecosystem is essential. Blockchain technologies, with their inherent features of decentralization, immutability, and easy access are well suited to achieving these goals. Some practical applications of blockchain technologies include data collection/aggregation/analysis, patient/provider identification, traceability/monitoring of opioids, supply chain provenance, prescription monitoring, licensure and credentialing, interoperability, seamless integration/communication, development of opioid alternatives, and research incentivization. Conclusions Blockchain technologies may help support the efforts of different agencies in curtailing the opioid epidemic.

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Objective. To understand an unusual complication of a common procedure.Design. This article chronicles the side effect of a lumbar sympathetic nerve block (LSNB). Setting. Loyola University Medical Center Outpatient Chronic Pain Clinic. Patients. One.Results. Our patient had several hours of priapism following a LSNB. Conclusions. A bilateral lumbar sympathetic nerve block can lead to unopposed parasympathetic penile stimulation and cause priapism.A 41-year-old presented to the outpatient Chronic Pain Clinic for continued treatment of complex regional pain syndrome type 1 (CRPS 1) in his left foot. The patient had sustained a gunshot wound to the left foot 7 years earlier.He had undergone multiple corrective surgeries to the foot. The patient's ability to walk had improved somewhat over the years, but his pain had continued to worsen. Prior to this encounter, he had received ankle blocks on two occasions with pain relief lasting only 2 days following each injection. Over a 6-week period in 2005, our clinic performed a series of four lumbar sympathetic nerve blocks (LSNBs), with pain relief lasting 2-4 weeks after each procedure. The patient was lost to follow up for the next 5 years.On this most recent encounter, the patient presented with the same pain complaint as he had 5 years earlier.He described his pain as sharp and constant in his entire left foot. His average pain score on a visual analog scale was 7/10. On exam, the patient was 5′9″ and 220 lbs. He had allodynia throughout the entire left foot, with mild swelling of the left ankle. There was decreased dorsiflexion and plantar-flexion at the left ankle. Temperature of the left foot prior to the procedure was 32.8°C compared with 31.4°C in the right foot. He was consented for LSNB.In the fluoroscopy suite, the patient was placed in the prone position and his back was prepared and draped sterilely. The temperatures of his feet were the same as in the exam room. We sedated the patient with a total of 2.5 mg i.v. midazolam. Using A/P and lateral fluoroscopic guidance, we placed a 22-gauge 5-in spinal needle at the anterio-lateral aspect of the L-3 vertebral body (Figure 1). Radiography with contrast injection confirmed correct needle placement (Figure 2), and 15 mL of 0.25 % bupivacaine with epinephrine 1:200,000 was then slowly injected. Vital signs were stable throughout the procedure. The patient was monitored for 30 minutes after the procedure. The temperature of his left foot increased from 32.8 to 33.2°C. In his right foot, the temperature also increased from 31.4 to 33.0°C.Within 10 minutes of the LSNB, the pain score in his left foot decreased from 7/10 to 3/10, and his range of motion improved significantly. The patient was discharged home. Three hours after the procedure, the patient called the clinic complaining of an erection that began on the car ride home, and was starting to become painful. After discussion with the Urology Service, we instructed the patient to present to the Emergency Department for evaluation. Fearing an additional embarrass...