Objective To describe rates and risk factors for prolonged postoperative use of opioids in patients who had not previously used opioids and undergoing major elective surgery.

Exposure to opioids is largely unavoidable after major surgery because they are routinely used to treat postoperative pain. Nonetheless, continued long-term opioid use has negative health consequences including opioid dependence. 1 Patients and health care professionals are therefore concerned about long-term postoperative opioid use. 2 There are limited data on the risk of previously opioid-naive individuals developing persistent postoperative opioid use. In a 2014 population-based cohort study, we found that 3% of previously opioid-naive patients continued to use opioids 3 months after major elective surgery in Ontario, Canada. 3 Importantly, the risk of persistent opioid use over longer periods after surgery remains unclear. We therefore conducted a follow-up study to measure rates of ongoing opioid use up to 1 year after major surgery.

Ultrasound has emerged to become a commonly used modality in the performance of chronic pain interventions. It allows direct visualization of tissue structure while allowing real time guidance of needle placement and medication administration. Ultrasound is a relatively affordable imaging tool and does not subject the practitioner or patient to radiation exposure. This review focuses on the anatomy and sonoanatomy of peripheral non-axial structures commonly involved in chronic pain conditions including the stellate ganglion, suprascapular, ilioinguinal, iliohypogastric, genitofemoral and lateral femoral cutaneous nerves. Additionally, the review discusses ultrasound guided intervention techniques applicable to these structures.

Background and objectivesTwo ultrasound (US)-guided techniques for greater occipital nerve (GON) block have been described for the management of headache disorders: a “proximal or central” technique targeting the GON at the level of the second cervical vertebra and a “distal or peripheral” technique targeting the GON at the level of the superior nuchal line. In this multicenter, prospective, randomized control trial, we compared accuracy, effectiveness, and safety of these two techniques in patients with chronic migraines (CMs).MethodsForty patients with refractory CMs were randomized to receive either a proximal or distal US-guided GON block with bupivacaine and methylprednisolone acetate. The primary outcome was the difference in Numerical Rating Score (NRS) for headache intensity at 1 month. Secondary outcomes were effectiveness, performance, and safety-related. Effectiveness-related outcomes included NRS for headache intensity, number of headache days per week, patient satisfaction, quality of life, assessment of sleep quality, and sleep interruption. Performance-related outcomes included procedure time, accuracy of block, and patient discomfort. Safety-related outcomes included an assessment for adverse effects.ResultsNRS pain scores were significantly reduced at 24 hours and at 1 week postprocedure in both cohorts and at 1 and 3 months in the proximal group as compared with the baseline. There was no significant difference in NRS pain scores between the two cohorts at any of the follow-up time points. There was a significant reduction in number of headache days per week at 1 month in both groups, and a significant improvement in sleep interruption at 1 week in both groups. There were no significant adverse effects.ConclusionsThis study was designed to compare two different US-guided approaches for blocking the GON. Our results demonstrate that both distal and proximal techniques can provide a short-term improvement in headache intensity, reduction in number of headache days per week, and an improvement in sleep interruption. The proximal GON technique may confer more sustained analgesic benefit compared with the distal approach in patients with CM headaches.Trial registration number NCT02031822.

Ultrasound-guided SIJ injection with fluoroscopic confirmation has similar accuracy and efficacy to fluoroscopy alone for SIJ injections in patients with chronic low back pain secondary to SIJ arthritis.

Ultrasound-guided injections in pain medicine are emerging as a popular technique for pain interventions. Ultrasound can be applied for procedures of the ankle joint and surrounding structures. This review describes the anatomy and sonoanatomy of the ankle joint, subtalar joint, and surrounding extra-articular structures relevant for intra-articular injection. Second, it reviews injection techniques and the accuracy and efficacy of these intra-articular ankle injections.

Accidental intraventricular placement of a pericardiocentesis catheter is a rare but well-recognized complication. Failure to achieve adequate hemostasis in the ventricular wall on removal of the catheter can potentially result in fatal consequences. Here we describe a case in which a chest drain (10.2F) accidentally entered into the right ventricle while attempting to drain pleural fluid, and the entry site was sealed using an Amplatzer VSD occluder device (St. Jude Medical, St. Paul, MN).

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