Block Injection Research Articles

PATIENT SATISFACTION AND COST ANALYSIS OF ANALGESIA MANAGEMENT FOR POST-OPERATIVE PROCEDURES IN HTAA: PCA VS. CONVENTIONAL METHOD

Acute pain service (APS) offer several techniques to the post-operative patient in controlling and relieving the pain such as intravenous infusion, patient-controlled analgesia, epidural infusion, subcutaneous or intramuscular injection and intrathecal administration. The effectiveness of and satisfaction towards APS is not clearly defined. Therefore, the aim of this study is to conduct the cost analysis and comparison between these techniques and patient satisfaction. The study design for cost analysis was retrospective study. The means of the data were calculated based on Integration Store of Hospital Tengku Ampuan Afzan records. In addition, the evaluation of patient’s satisfaction was conducted by using a cross-sectional study design. The mean of the data was calculated and analysed by using Chi-square test. The total cost required to prepare PCA for post-operative patient was the highest with RM 8810.98. Meanwhile, the cost for subcutaneous morphine injection, epidural infusion and peripheral block injection were RM 2.11, RM 5323.95 and RM 4.95 respectively. However, when taking into the aspect of patient’s satisfaction, PCA has the highest level of excellent performance with 54.6% compare to EDA (33%) and BLOCK (12.4%) with the p-value is less than 0.05. In conclusion, every drug has its own side effects. As the healthcare provider, it is a need to ensure drugs that were given to the patients are at the very minimum risk of having the side effects. Based on the findings of this study, it could be said that both drugs have lower percentage of people experienced the side effect after treated with the drugs. Therefore, the future study should be more focusing on the side effect of the drugs used. In terms of cost spent for the methods, the PCA regimen is more likely expensive compared to the conventional methods. However, based on survey among the patients, PCA-treated patients expressed higher satisfaction compared to the conventional regimen of pain management.

Continuous adductor canal blockade facilitates increased home discharge and decreased opioid consumption after total knee arthroplasty

BackgroundThere is a growing interest in avoiding discharging patients to rehab to maximize outcome and minimize complications after total knee arthroplasty (TKA). In addition, use of postoperative pain pathways that minimize opioid use is critical amidst the current opioid epidemic. However, the ideal pain regimen after TKA has yet to be determined. MethodsFrom July 1, 2013 to October 1, 2014 two perioperative pathways were used to address surgical pain. These included either a single shot femoral nerve block plus liposomal bupivacaine pericapsular injection (FNB + LB-PAI) or adductor canal catheter plus posterior capsule single shot block (ACC + iPACK), each with an oral analgesic protocol. Little modification occurred with regard to surgical technique, postoperative medications, or postoperative physical therapy (PT). ResultsOverall, 264 unilateral, primary TKA patients (146 FNB + LB-PAI, 118 ACC + iPACK) were included. ACC + iPACK patients had a shorter median length of stay (LOS, 2.0 vs 3.0, p < 0.001), more discharges home (79.7% vs 67.8%, p = 0.002), and less median opioid consumption (IV morphine equivalents, IVME, 20.0 vs 44.1, p < 0.001) than the FNB + LB-PAI group. In multivariable analysis, use of ACC + iPACK remained independently associated with shorter LOS, increased discharge home, and less IVME consumed when controlling for confounding variables. ACC + iPACK patients also had fewer opioid related adverse events (0.8 vs 5.5, p = 0.045) and a lower rate of MUA (0.8% vs 6.2%, p = 0.026). ConclusionsWe recommend ACC + iPACK with a multimodal oral analgesic protocol as the primary postoperative analgesia in enhanced recovery TKA protocols. This resulted in an easier recovery with fewer complications. Level of evidenceLevel III.

Sensitivitas Dan Spesifitas Tes Provokatif Dan Pengukuran Latensi H Refleks Pada Sindrom Piriformis

&lt;p&gt;&lt;em&gt;Background&lt;/em&gt; Piriformis syndrome (PS) is one causes of buttock and hip pain which is caused by pressure of sciatic nerves on piriformis muscle. PS is sometime misdiagnosed because of similar clinical signs and symptoms with other lower back pain diagnosis such as Hernia Nucleus Pulposus (HNP), Sacroiliac joint pain, facet joint pain. Gold standard diagnosis of PS is diagnostic block injection. However, provocative test and prolonged H reflex on EMG might be also standard diagnostic of PS.&lt;/p&gt;&lt;p&gt;&lt;em&gt;Aim&lt;/em&gt; Understand the sensitivity and specificity of provocative test and prolonged H reflex to diagnose PS.&lt;/p&gt;&lt;p&gt;&lt;em&gt;Method&lt;/em&gt; 72 patients with suspected PS who came to Neurology OPD in period of August- December 2017 were testing with physical examination (provocative test) and Electromyography test of H reflex. PS is diagnosed by positive diagnostic block injection. Data was proceeded with SPSS 20 version.&lt;/p&gt;&lt;p&gt;&lt;em&gt;Result &lt;/em&gt;72 patients with buttock pain which diagnosed with PS were dominated by female gender than male with ratio 1:3 with housewives as majority of work. Most age groups were 48.6% elderly (age more than 60 years old). Provocative tests result of Freiberg, FAIR, Beatty, Pace Sign, Hip Abduction sensitivity were 52.30; 66.15; 53.84; 46.15; 55.32 and specificity were 100; 42.85; 71.42; 71.42; 57.14. While sensitivity and specificity of prolonged H reflex more than 1.86 msec were 69.23 and 28.59. Combination of 3 provocative tests (FAIR, Freiberg and Beatty) resulted highest sensitivity and specificity in this study as 71.42 and 100.&lt;/p&gt;&lt;p&gt;&lt;em&gt;Conclusion &lt;/em&gt;Provocative test and prolong H reflex can be supported diagnosis of PS. However both tests might not be comparable yet than diagnostic block injection as gold standard of PS. Combination of provocative test increased the sensitivity and specificity of provocative test than single test only.&lt;/p&gt;

Subcostal approach to anterior quadratus lumborum block for pain control following open urological procedures.

In the case of open urological surgeries, analgesic coverage at mid thoracic dermatomal levels is required. As shown in cadaveric studies, the site of QL block injection is an important determinant of the extent of dye spread and presumably local anesthetic dermatomal coverage. In this case series, we evaluated dermatomal blockade and analgesic efficacy of a subcostal approach to anterior QL block following open urological surgeries. Twenty-two adult patients undergoing renal transplant surgery (60%) and open nephrectomy (40%) received unilateral ultrasound-guided subcostal anterior QL block with catheter insertion. Sensory level, pain score (numeric rating scale, NRS), local anesthetic consumption, and opioid consumption (morphine equivalent dose, MED) were assessed daily for 3 days. The block achieved sensory blockade between T6-7 and L1-2. The most frequently affected dermatomes were T8 -T12 and the number of blocked segments was 3 (mean 2.8). The median (interquartile range Q1, Q3) of NRS pain score was 3.7 (2.8-5.5), 3.3 (2.4-4.7), 2.9 (1.9-3.6), and 2.3 (1.0-4.2) on POD0, POD1, POD2, and POD3, respectively. Our preliminary data showed that the subcostal approach to anterior QL block provides appropriate thoracic dermatome level needed for analgesia following open urological surgical procedures between T6-7 and L1-2.

Efficacy of suprascapular nerve block compared with subacromial injection: a randomized controlled trial in patients with rotator cuff tears

We aimed to compare the clinical efficacy of a suprascapular nerve block (SSNB) versus subacromial injection (SA) for outpatient treatment of patients with symptomatic rotator cuff tears in a double-blinded, randomized controlled trial using sealed-envelope randomization. A total of 42 participants with symptomatic partial- and full-thickness rotator cuff tears quantified by ultrasound or magnetic resonance imaging received either an ultrasound-guided SSNB or SA. The primary outcome measure was shoulder function measured by the modified Constant-Murley (CM) score and the secondary outcome was the pain score measured by a visual analog scale at 2, 6, and 12 weeks after injection. We analyzed 43 shoulders (27 in male patients, 62.2%). The mean age was 65.2 years (standard deviation [SD], 11.9 years). Of the shoulders, 22 (51.2%) underwent SAs and 21 (48.8%) underwent SSNBs. Continuous variables were analyzed by an independent t test (2 tailed), and nominal data were analyzed by the Fisher exact test (1 sided). At 6 weeks, the mean change from the baseline CM score was significantly higher in the SSNB group than in the SA group (14.3 [SD, 18.1] vs 3.0 [SD, 12.8]; P = .048). At 12 weeks' follow-up, the SSNB group had a significantly higher CM score than the SA group (57.6 [SD, 10] vs 44.6 [SD, 16]; P = .023) and greater improvement from the baseline CM score (23.4 [SD, 17.5] vs 7.8 [SD, 16.5]; P = .014). At 12 weeks, the visual analog scale score was significantly better in the SSNB group than in the SA cohort (9.9 [SD, 3.3] vs 7.3 [SD, 4.3]; P = .03). This study demonstrates that an SSNB resulted in better pain and functional results than an SA at 6 and 12 weeks for symptomatic rotator cuff tears.

Clinician's experiences and views on the use of suprascapular nerve block injections in the management of shoulder pain

Purpose: Suprascapular nerve block (SSNB) injections are used in the management of chronic shoulder pain, including degenerative glenohumeral joint disease, subacromial pain, frozen shoulder and non-specific shoulder pain, however little is known about its use and application in clinical practice in the United Kingdom. This preliminary study explored the experiences and views of clinicians who use SSNB injections for the non-surgical management of shoulder pain. The main objectives were to gain an in-depth understanding regarding the current use and application of SSNB injections in clinical practice and identify where future research is needed to inform clinical practice in the future.

Ultrasound-guided suprascapular nerve block versus intra-articular steroid injection in adhesive capsulitis of shoulder: Comments on treatment options

Ultrasound-guided suprascapular nerve block versus intra-articular steroid injection in adhesive capsulitis of shoulder: Comments on treatment options

Comparison of the Effects of an Adductor Canal Block and Periarticular Multimodal Drug Local Injection on Pain after a Medial Opening High Tibial Osteotomy

Comparison of the Effects of an Adductor Canal Block and Periarticular Multimodal Drug Local Injection on Pain after a Medial Opening High Tibial Osteotomy

Prevalence of Failed Inferior Alveolar Nerve Block (IANB) in Achieving Pulpal Anaesthesia in Mandibular Molars with Symptomatic Irreversible Pulpitis

Introduction: Patient comfort during root canal treatment is immense for patient cooperation and endodontist efficiency. Establishing the high prevalence of failure of IANB injections in providing pulpal anaesthesia, will most likely support the investigation of supplemental techniques to ensure patient comfort. Objectives: The study aimed to evaluate the prevalence of failed Inferior Alveolar Nerve Block (IANB) injections in achieving pulpal anaesthesia in mandibular molars diagnosed with symptomatic irreversible pulpitis when administered alone. Methods: This study involved fifty patients, diagnosed with symptomatic irreversible pulpitis in their mandibular first and second molars. IANB injection using 2% lidocaine with 1:100,000 epinephrine was administered to anesthetize the acutely inflamed teeth before commencing root canal treatment. Lip and tongue numbness was checked subjectively after injection to ensure successful IANB injection. Objectively, cold test was performed after 15 minutes and pain level was recorded using Visual Analogue Scale (VAS). Success was defined as no pain response by (VAS) during cavity preparation, endodontic access, or initial instrumentation. Results: Although, majority of patient (96%) expressed surrounding soft tissue numbness, only 73% did not feel any pain during initiating root canal treatment. Conclusions: IANB injection alone is not enough to provide profound pulpal anaesthesia in acutely inflamed mandibular molars; therefore, supplemental injections are required to achieve patients comfort during treatment.

Ultrasound-guided suprascapular nerve block versus intra-articular steroid injection in adhesive capsulitis of shoulder: Comments on treatment options

Ultrasound-guided suprascapular nerve block versus intra-articular steroid injection in adhesive capsulitis of shoulder: Comments on treatment options

Comparison of outcome of ultrasound-guided suprascapular nerve block versus intra-articular steroid injection in adhesive capsulitis of shoulder: A randomized control trial

Background: Adhesive capsulitis (AC) is the most common cause of shoulder pain in India. There is little consensus regarding the optimal course of treatment for AC. The aim of the present study was to compare the effectiveness of ultrasound-guided suprascapular nerve block (USNB) with intra-articular steroid injection (IASI) in AC of shoulder in providing pain relief, functional improvement, and reduction of disabilities. Settings and Design: A prospective randomized control trial at a tertiary care hospital compared a single dose of IASI with USNB in patients having shoulder pain and stiffness secondary to AC of ≥12 weeks' duration, visiting Outpatient Department of Physical Medicine and Rehabilitation. Materials and Methods: Patients in the first group were given IASI (2 ml of 40 mg/ml triamcinolone) while in the other group received USNB (4 ml of 0.5% injection bupivacaine). Home-based therapeutic exercise program for AC was advised for both the groups. The outcome measures were the Shoulder Pain and Disability Index (SPADI) and passive range of motion (ROM) (flexion, abduction, and external rotation) of the affected shoulder. Follow-up was done at 1-week, 3-week, and 6-week time-points. Results: Both domains of SPADI (pain score and disability score) and passive shoulder ROM significantly improved (P 0.05). Conclusion: Suprascapular nerve block is comparable in efficacy to IASI in patient with AC.

Student-to-Student Dental Local Anesthetic Preclinical Training: Impact on Students' Confidence and Anxiety in Clinical Practice.

Effective dental local anesthetic administration forms the basis of pain-free dentistry; therefore, the application of theoretical knowledge and the ability to deliver injections safely and competently are vital aspects of student learning. Student- to-student administration of the first local anesthetic injection has been a traditional method for preclinical training. The aim of this study was to evaluate oral health students' perceived value of such practice and the impact on their level of anxiety and confidence in giving their first injections to patients. A sequential mixed-methods cohort study design was used. After their local anesthesia training, all 42 second-year students in the oral health program at the Sydney Dental School, University of Sydney, Australia, in 2016-17 were asked to complete five short questionnaires. All 42 students completed each questionnaire, after which seven of them participated in a voluntary focus group. The students reported that they valued the one-on-one feedback from the educators during student-to-student preclinical training. The students' primary concern was the possible pain and discomfort that may arise when they perform the first infiltration or inferior alveolar nerve block injections on patients. Most students reported they felt "a little nervous" and experienced a similar level of confidence in administering the two types of injections. The oral health students valued the experiential learning of student-to-student preclinical dental local anaesthetic training. Students' level of anxiety and confidence was affected by the age of patients and type of local anesthetic injections. The level of anxiety students experienced was negatively correlated with their confidence in giving first local anesthetic injections to patients. Further investigation is needed to determine if this level changes with more clinical experience.

Pain perception and efficacy of local analgesia using 2% lignocaine, buffered lignocaine, and 4% articaine in pediatric dental procedures.

BackgroundThe purpose of this study was to compare the pain perception and anesthetic efficacy of 2% lignocaine with 1:200,000 epinephrine, buffered lignocaine, and 4% articaine with 1:200,000 epinephrine for the inferior alveolar nerve block.MethodsThis was a double-blind crossover study involving 48 children aged 5–10 years, who received three inferior alveolar nerve block injections in three appointments scheduled one week apart from the next. Pain on injection was assessed using the Wong-Baker Faces pain scale and the sound eye motor scale (SEM). Efficacy of anesthesia was assessed by subjective (tingling or numbness of the lip, tongue, and corner of mouth) and objective signs (pain on probing).ResultsPain perception on injection assessed with Wong-Baker scale was significantly different between buffered lignocaine and lignocaine (P < 0.001) and between buffered lignocaine and articaine (P = 0.041). The onset of anesthesia was lowest for buffered lignocaine, with a statistically significant difference between buffered lignocaine and lignocaine (P < 0.001). Moreover, the efficacy of local analgesia assessed using objective signs was significantly different between buffered lignocaine and lignocaine (P < 0.001) and between lignocaine and articaine.ConclusionBuffered lignocaine was the least painful and the most efficacious anesthetic agent during the inferior alveolar nerve block injection in 5–10-year-old patients.

Treatment for patient with chronic postherpetic neuralgia

Fifty postherpetic neuralgia (PHN) patients with a course ≥3 years and the Pain Numeric Rating scale (NRS)≥5 were included in the analysis. All patients were treated with nerve block and subcutaneous injection in the affected area. The paravertebral nerve blocks were performed by injecting 5 ml lidocaine in the concentrations of 0.3%; the concentration of lidocaine for branch blockage and peripheral nerves was 1.0%, and that for subcutaneous injection was 0.3%, respectively; 2 mg dexamethasone and 0.5 mg vitamin B12 were added in the injections. The NRS scores and quality of life scores were documented before and after the treatment. The NRS score was significantly decreased at different time points of treatment (F=279.6, P<0.01). At the end of the treatment and at 1 month, 3months, 6months of follow-up, the scores were significantly lower than those before the treatment. All patients showed enormous improvement in the quality of life at 1, 3 and 6 months after treatment. The pain relief was excellent or good in 38 cases. The efficacy of treatment is associated with skin scar and allodynia. The study indicates that nerve block and subcutaneous injection has a satisfactory efficacy in treatment of chronic postherpetic neuralgia. Key words: Neuralgia, postherpetic; Nerve block; Injections, subcutaneous

Clinical study on primary frozen shoulder treated by warm acupuncture, manipulation combined with western medicine

Objective To evaluate the clinical effect of warm acupuncture,manipulation combined with western medicine in the treatment of primary frozen shoulder. Methods A total of 90 patients with primary frozen shoulder, from October 2015 to February 2017, were randomly divided into three groups (n=30): the western medicine group, the traditional Chinese medicine(TCM) group and the integrated TCM and western medicine group. The western medicine group was treated with local block and intra-articular injection. The TCM group was treated with acupuncture combined with manipulation. The integrated TCM and western medicine group were treated with western medicine and TCM. The three groups were treated for four weeks. The shoulder function (Constant-Murley shoulder scores) and shoulder pain (VAS scores) were evaluated in the three groups after treatment. Results The effective rate in TCM and western medicine group was 100% versus TCM group 83.3%,and Western medicine group 76.7%, which showed significantly higher differnce among three groups (P<0.05). The Constant-Murley shoulder scores in TCM and western medicine group were (72.4 ± 3.8 vs. 67.5 ± 4.5, 58.9 ± 5.4), which were significantly higher than those in TCM group and western medicine group (P<0.05). The VAS scores in TCM and western medicine group were (1.6 ± 0.7 vs. 2.5 ± 0.8, 2.7 ± 0.7) which were lower than those in TCM group and western medicine group (P<0.05). Conclusions The combination of warm acupuncture, manipulation and western medicine could improve shoulder function and reduce shoulder pain in patients with primary frozen shoulder.. Key words: Frozen shoulder; Needle warming therapy; Manipulation; Point TE14(Jianliao); Point LI15(Jianyu); Point SI9(Jianzhen)

Fascia-iliaca compartment block vs intra-articular hip injection for preoperative pain management in intracapsular hip fractures: A blind, randomized, controlled trial

BackgroundThe aim of this study was to compare the fascia-iliaca compartment block and the intra-articular hip injection in terms of pain management and the need for additional systemic analgesia in the preoperative phase of intracapsular hip fractures. MethodsPatients >65 years old with an intracapsular hip fracture were randomized in this prospective, blind, controlled, parallel trial in a Level-I trauma center. Patients were randomly assigned to receive either the fascia-iliaca compartment block (cohort FICB) or the intra-articular hip injection (cohort IAHI) upon admission to the emergency department. The primary outcome was pain relief at 20 min, 12 h, 24 h and 48 h after the regional anesthesia, both at rest and during internal rotation of the fractured limb. The Numeric Rating Scale was used. Residual pain was managed with the same protocol in all patients. Additional analgesic drug administration during the 48 h from admission was recorded. ResultsA total of 120 patients with comparable baseline characteristics were analyzed in this study: the FICB group consisted of 70 subjects, while the IAHI group consisted of 50 subjects.Pain was significantly lower in the IAHI group during movement of the fractured limb at 20 min (p < 0.05), 12 h (p < 0.05), 24 h (p < 0.05) and 48 h (p < 0.05).In the FICB cohort 72.9% of patients needed to take oxycodone, in contrast to 28.6% of the IAHI cohort (p < 0.05). In the FICB cohort 14.09 ± 11.57 mg of oxycodone was administered, while in the IAHI cohort 4.38 ± 7.63 mg (p < 0.05). No adverse events related to either technique were recorded. ConclusionsIntra-articular hip injection provides better pre-operatory pain management in elder patients with intracapsular hip fractures compared to the fascia-iliaca compartment block. It also reduced the need for supplementary systemic analgesia. Level of EvidenceTherapeutic Level I.

Using Gagne's Theory and Peyton's Four-Step Approach to Teach Inferior Alveolar Nerve Block Injection

Developing skills in performing inferior alveolar nerve block injection is an essential element of the dentistry undergraduate curriculum. As a dental faculty staff member working in the conservative dentistry department, I provide preclinical and clinical teaching for dental students. This study presents a lesson plan for this injection technique using a combination of Gagne's nine events of instruction and Peyton's four-step approach. Gagne's nine events of instruction identified the mental conditions of learning that are necessary for effective learning when adult students are presented with various stimuli. This model is based on the nine instructional events used during a teaching session. These are gaining attention, defining learning objectives, stimulating recall of prerequisite learning, presenting the stimulus material, providing learning guidance, practice, providing feedback, assessing the performance, and enhancing retention and transfer. Peyton's four-step approach is a model for teaching practical skills. These are demonstration, deconstruction, explanation, and performance. Each step in this lesson plan is carefully arranged with relevant activities to suit learners with various learning styles using Gagne's theory, while Peyton's approach is incorporated to teach the actual skill. This lesson plan is particularly relevant for tutors designing injection techniques teaching for undergraduate dental and medical students and fresh graduates. In all, this lesson plan also serves as a template on which many other practical skill teachings can be subsequently modeled. The flexible adoption of Gagne's nine events of instruction in combination with other instructional models such as Peyton's approach facilitates the planning of effective clinical teaching sessions.

WIRELESS HIGH FREQUENCY SPINAL CORD STIMULATION FOR THE TREATMENT OF POST-HERPETIC OCULAR NEURALGIA: A CASE REPORT

Background: High frequency wireless Spinal Cord Stimulation (SCS) at the C1-C2 vertebral levels provides analgesia for the treatment of refractory ocular pain on the left side secondary to post-herpetic neuralgia. Objective: To assess analgesic effects of minimally invasive wireless neuromodulation in the treatment of chronic pain due to post-herpetic neuralgia. Study Design: This observational, prospective case report was designed to illustrate the effectiveness of relieving chronic, intractable pain utilizing wireless spinal cord stimulation at multiple frequencies for the treatment of post-herpetic neuralgia. Setting: Private Practice Interventional Pain Clinic. Methods: This is a single case study of a 62-yearold patient who experienced an episode of shingles with rash over the left frontal and lateral ocular margin. After the rash subsided, the patient began suffering from severe pain in the left eye. The patient was placed on a 10-day course of valacyclovir, gabapentin, which was discontinued secondary to sedation intolerance, pregabalin titrated to 300 mg/day and oxycodone, all of which were ineffective in relieving the pain. The patient received a stellate ganglion block injection on 6 occasions, experiencing pain relief of only up to one-day after each injection. Stellate ganglion radiofrequency ablation was also unsuccessful. With original Visual Analog Scale (VAS) score of 9/10, inability to sleep and incapacity to perform activities of daily living (ADLs), the patient had Stimwave Freedom wireless stimulators placed sequentially at the C1-C2 vertebral levels. Results: Programming at low frequencies from 40-120 Hz was unsuccessful in reducing left eye pain. Stimulation was increased to high frequency on the Stimwave SurgeTM adjustable waveform, and within 12 hours, the patient noted significant decrease in pain. At 3 days post-procedure, the patient’s VAS score was 1/10. The patient had permanent placement of the devices, and at 8-month follow-up, VAS scores were 0-2/10, and the patient’s mood, sleep and ability to perform ADLs all improved substantially. Limitations: The study was limited by the novelty of the device. Although the doctor who implanted the device is very experienced, more cases of the use of the wireless Stimwave Freedom apparatus are necessary to establish its long-term effectiveness and safety. More clinical trials investigating the utilization of multiple frequencies are also required. Conclusions: Epidural placement of 2, wireless sequentially placed octopolar stimulators with a minimally invasive technique at high frequency stimulation was safe and effective. Key words: post-herpetic neuralgia, ocular, spinal cord stimulation, wireless, shingles, trigeminal nerve, high frequency

High-Volume Anesthetic Suboccipital Nerve Blocks for Treatment Refractory Chronic Cluster Headache With Long-Term Efficacy Data: An Observational Case Series Study.

To determine the efficacy of high-volume anesthetic suboccipital nerve blocks (HVSON) for chronic cluster headache (CCH) and to define consistency of response over long-term use. There are studies showing efficacy of greater occipital and suboccipital nerve block injections for CCH and also their possible use as a preventive treatment modality. There are scant data about the long-term efficacy of repetitive greater occipital and suboccipital nerve injections in CCH. HVSON has not been studied for CH. This was an open label, observational, case series study. Patients with CCH seen at a dedicated headache clinic over a 7-year time period and injected on at least 2 separate occasions were used for analysis. All were deemed medicinal treatment refractory. HVSON consisted of 9 mL 1% lidocaine and 1 mL triamcinolone 40mg/mL injected on the side of CH. Ten CCH patients were retrospectively studied. Range of mean average response to HVSON (all patients had complete pain freedom) was 1.5-31 weeks (longest: 44 weeks in 2 patients). Only one patient did not respond; 2 patients had 1.5-2 weeks of response; the remainder had at least 4 weeks of response. The mean average duration of effect was 10.3 weeks in the responders. Five patients were injected serially for 2-4 years (30x, 17x, 15x, 10x and 3x, respectively) with a consistent response of 6 weeks, 4 weeks, 12 weeks, 4 weeks, and 31 weeks, respectively, after each injection. Response duration was very reliable per individual patient. All 5 patients felt HVSON was effective as a preventive treatment. Smoking history did not appear to alter treatment response (8/10 were chronic current smokers and 7/8 responded to HVSON). The one patient who received the most injections developed avascular necrosis of the hip; the remainder of the subjects had no adverse events. HVSON from this open label study appears to be effective in the preventive treatment of medicinal refractory CCH and shows consistent response over long-term use with high rates of pain freedom.

An innovative educational approach in using instructional videos to teach dental local anaesthetic skills.

Good clinical skills are crucial for all dental practitioners. The transfer of knowledge from didactic lectures to daily clinical application can be challenging for current millennial learners. This study aimed to evaluate the effectiveness of using instructional videos to teach dental local anaesthesia in an undergraduate oral health programme in 2017. The philosophical basis of this study relies on the Advanced Trauma Life Support (ATLS) course which has been proven effective in practical education. Video clips were made in 3 different formats, with the addition of a quiz-embedded version to reinforce learning and revision for practical assessments. All the students agreed that their motivation to watch the videos was to refresh their memories before assessments. 90% of students agreed the videos helped them to learn psychomotor skills that required accuracy. There was a statistically significant correlation between the number of views of the videos on the administration of block injections and the marks received for practical assessment (r=0.36, P=0.05), and correlation between participating in online quizzes and theory assessment (r=0.371, P=0.044). Videos with narration and background music were found to be popular amongst oral health students. The use of instructional videos has been found effective in complementing the ATLS approach for teaching psychomotor skills in the administration of local anaesthetics by oral health students. Further studies are required to measure the students' retention of knowledge and application of skills on a patient in clinical settings.