Clinical trials.gov (NCT00615342).

Clinical trials.gov (NCT00615342).

SummaryThis randomised, double-blind, placebo-controlled study compared the effect of perineural with intravenous dexamethasone, both administered concomitantly with interscalene brachial plexus block for shoulder surgery. Patients received 8 mg dexamethasone mixed with ropivacaine in the block injection (n = 42), 8 mg dexamethasone intravenously at the time of the block (n = 37), or intravenous saline (n = 41) at the time of the block. Perineural and intravenous dexamethasone resulted in prolonged mean (SD) duration of block to 16.9 (5.2) h and 18.2 (6.4) h, respectively, compared with 13.8 (3.8) h for saline (p = 0.001). Mean (SD) opioid consumption (morphine equivalents) during the first 24 h after postanaesthesia recovery arrival was 12.2 (9.3) mg in the perineural dexamethasone, 17.1 (15.9) mg in the intravenous dexamethasone and 24.1 (14.3) mg in the saline groups (p = 0.001). Dexamethasone via either route reduced anti-emetic use (p = 0.046). There was no effect on patient satisfaction. These results suggest that both perineural and intravenous dexamethasone are useful adjuncts to ropivacaine interscalene block, with the intravenous route preferred as this avoids the possibility of neural toxicity of dexamethasone.

The enhanced organizational emphasis on the management of pain in hospitalized patients mandated by the Joint Commission for Accreditation of Health Care Organizations (JCAHO) pain initiative precipitated a number of changes by the perioperative services at our facility. In October 2002, a numeric pain scale became mandatory in our postanesthesia care unit (PACU). Response to analgesia in the PACU was recorded using this scale. In addition, an acceptable pain score was required for discharge from the PACU. We evaluated the effects of these changes in the pain management of 1082 patients undergoing general, orthopedic, neurosurgical, urologic, and gynecologic surgeries. We detected an overall increase in the average consumption of opiates (morphine equivalents) in 2002 compared with 2000 (46.6 +/- 20.4 mg versus 40.4 +/- 13.2 mg, P <0.001). This increase was most significant in the PACU (10.5 +/- 10.4 mg versus 6.5 +/- 7.3 mg, P <0.001 between the 2 periods, respectively). This increase in opiate use was not associated with an increased length of stay, an increase in the requirement for naloxone, or an increase in treatment for postoperative nausea and vomiting. We conclude that the increase in opiate use, which could be explained by compliance with the JCAHO pain initiative, was not associated with additional opiate-induced morbidity in the immediate postoperative period.

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The objective of this article is to review the surgical aspects of occipital stimulation. Since 1999 there has been a growing interest in neuromodulation of the distal branches of C2-3 in an effort to treat refractory headache disorders. This is accomplished via implantation of subcutaneous electrodes to stimulate peripheral nerves in the occipital region. "Occipital nerve stimulation" is a term generically used to describe the technique. Mechanisms and outcome of this modality are beyond the scope of this review, which will focus on the technical aspects of the procedure with its associated complications such as lead migration, localized pain, and infection. The history of peripheral nerve and spinal cord stimulation as pain treatment modalities will be briefly reviewed. The equipment and surgical technique for both trial and permanent implantation of occipital nerve stimulators will be described, in addition to patient selection considerations. The available literature will be summarized and a discussion of future directions will be provided. Occipital nerve stimulation may be an effective minimally invasive treatment modality for refractory headache disorders; clearly, further studies are needed.

Examination of naloxone use can assist in the identification and stratification of patients at risk for opioid-induced respiratory depression and oversedation and can serve as a driver for improvements in hospital patient safety. This information can also guide other institutions interested in similar improvements.

Digital subtraction myelography is a valuable diagnostic tool for the localization of rapid spinal CSF leaks and should be considered in patients who are clinically suspected to have a dural tear that is accompanied by a longitudinally extensive extradural fluid collection on spinal MRI.