Local Anesthetic Test Research Articles

Mirogabalin as a Therapeutic Option for Neuropathic Pain Emerging Post-endodontic Treatment: A Two-Case Report

IntroductionOcclusal and percussion pain may manifest occasionally following endodontic treatment, influencing retreatment decisions. Two cases of periapical neuropathic pain, classified as post-traumatic trigeminal neuropathic pain according to the International Classification of Orofacial Pain, are presented. Although mirogabalin is effective in managing neuropathic pain, there is a lack of clinical reports on its use for occasional post-traumatic trigeminal neuropathic pain after endodontic treatment. These cases highlight clinical symptoms and successful treatment with mirogabalin for post-traumatic trigeminal neuropathic pain after endodontic treatment, providing clinicians a “take-away” lesson for improving patient condition. MethodsThe patients, referred by their primary dentist due to postendodontic abnormal pain, found no relief with antibiotics or nonsteroidal anti-inflammatory drugs. Although no findings including swelling or periapical radiolucency were observed around the tooth, they experienced occlusal and percussion pain. Local anesthetic testing showed that the pain originated from the peripheral area around the tooth rather than from central sensitization. Dental radiography and cone-beam computed tomography revealed no abnormal findings. Root canal retreatment was performed by a specialist in endodontic treatment. Although endodontic retreatment drastically decreased visual analog scale pain score, pain persisted. Based on the International Classification of Orofacial Pain criteria, diseases other than post-traumatic trigeminal neuropathic pain were excluded. Mirogabalin (10 mg/d) was prescribed once daily before bedtime. ResultsVisual analog scale scores gradually and drastically decreased 2 weeks after mirogabalin therapy. Several months later, no recurrence of postendodontic pain was observed after tapering off and discontinuing mirogabalin. ConclusionsThese findings suggest the possibility of a new treatment method for post-traumatic trigeminal neuropathic pain after endodontic treatment.

Efficiency of 90-Min Extended EMLA-Induced Stimulated Skin-Wrinkling Test in the Diagnosis of Carpal Tunnel Syndrome.

Background:Previous researchers have used a 30-min eutectic mixture of local anesthetic (EMLA) test, which assesses the sympathetically mediated vasomotor function, in diagnosing carpal tunnel syndrome (CTS). However, its specificity was low, limiting its clinical diagnostic utility. In this study, we assessed the efficiency of 90-min extended EMLA-induced stimulated skin-wrinkling (SSW) test in CTS diagnosis.Methods:A cross-sectional study was designed among patients clinically diagnosed with CTS. Hands of healthy volunteers and the asymptomatic hands of selected patients served as control. The Boston symptom severity scale (SSS) and the neuropathic pain severity inventory (NPSI) were used to assess symptom severity, and nerve conduction study (NCS) was used to assess electrophysiological severity. EMLA-induced SSW was visually graded after 90 min of application and correlated with symptom and NCS severities.Results:Forty-two symptomatic hands and 30 asymptomatic hands were enrolled as cases and controls, respectively. The diagnostic efficiency of the extended EMLA test was found to be 83.4% for digit 2 and 87.3% for the lateral 4 digits (mean), whereas the diagnostic efficiency of standard NCS was 88.1%. Boston SSS and NPSI were better correlated with EMLA positivity than NCS positivity. A linear regression analysis showed negative correlation of wrinkling grade with NCS grade.Conclusion:With its improved diagnostic efficiency, the 90-min extended EMLA test can feasibly be used as an alternative to NCS, especially in general practice settings. Its potential clinical utility should be explored in a large population of CTS patients showing varying clinical and electrophysiological severities.

HIV Neuropathy—a Review of Mechanisms, Diagnosis, and Treatment of Pain

This article is a systematic review of data from 2018 to 2020 regarding information from publications on epidemiologic, diagnostic, and therapeutic advancements in human immunodeficiency virus-associated peripheral neuropathy. The epidemiology/pathology of HIV neuropathy is discussed. Diagnostics includes skin wrinkling-eutectic mixture of local anesthetic test and neurologic examinations. Therapeutic interventions include pharmacologic and nonpharmacologic management as well as self-management strategies. Peripheral neuropathy continues to affect the lives of persons living with HIV. First-line treatment with pregabalin or gabapentin for HIV neuropathic pain has limited data on adequate response. Exercise and self-management strategies may provide benefit in pain reduction. Continuing research on risk factors and biomarkers for HIV-related peripheral neuropathy will be critical for future diagnostic and therapeutic agents.

Electrical Stimulation Test for Epidural Catheter Placement After Receiving Intrathecal Local Anesthetic During a Combined Spinal-epidural Technique for Cesarean Delivery: Confirmation of the Spinal Nerve Root as Epidural Site of Action

(Can J Anesth/J Can Anesth. 2020;67:498–499) For the prediction of adequate epidural analgesia following abdominal surgery, the epidural stimulation test (EST) has been shown to have a higher sensitivity than the local anesthetic test dose. This test could confirm proper epidural catheter placement for combined spinal epidurals (CSEs) in either laboring women or women having a cesarean delivery. As epidural failure is a known complication of the CSE procedure, confirmation of the epidural catheter placement is a crucial step following a full spinal dose CSE for cesarean delivery. This case describes using EST to confirm CSE placement in a woman having cesarean delivery.

Epidural test dose in obstetric patients: should we still use it?

As the application of a test dose after epidural catheter insertion in obstetrics has recurrently been associated with serious adverse events affecting both maternal and foetal outcomes, the question whether to test or not remains a controversial issue. Present guidelines do not provide clear recommendations in this regard and several recent surveys indicate a heterogeneity in clinical routine. Physiological alterations during pregnancy and labour restrict the use and also the validity of traditional test agents. Epinephrine is not appropriate to detect a vascular insertion in labour and the application of a local anaesthetic test dose may lead to dose-dependent fatal consequences should the catheter be intrathecal, due to an increased sensitivity in parturients. Given the current practice of opioid-amended-low-concentration epidurals, the waiving of a test dose results at worst in a failed epidural, a stark contrast to the potentially severe to fatal complications of a 'traditional' test dose. Hence, an originally preventive measure providing potentially more harm than the consequences of the situation aimed to prevent, should not be recommended. A simple fractionated administration of the initial analgesic dose seems reasonable though.

Early detection of peripheral neuropathy using stimulated skin wrinkling test in human immunodeficiency virus infected patients: A cross-sectional study.

Peripheral neuropathy is a common condition of human immunodeficiency virus (HIV)-infected patients, which often remains undetected. We assessed the performance of stimulated skin wrinkling-eutectic mixture of local anesthetic (SSW-EMLA) test compared with brief peripheral neuropathy screening (BPNS) to detect HIV neuropathy.This is a cross-sectional study conducted in HIV-positive patients. A modified skin wrinkling grading was used to assess SSW-EMLA effect. BPNS-detectable neuropathy was assessed by a combination of neuropathy severity scoring scale (subjective) and objective method of sensory and tendon reflex examination. The SSW-EMLA test accuracy with reference to BPNS was assessed using sensitivity and specificity and predictive values.In a total of 99 HIV patients, 61.6% were males and the majority age group were between 30 and 40 years (52%). The neuropathy detection was SSW-EMLA test 36.4% versus BPNS 15.2% (P = .04). The sensitivity of SSW-EMLA test was 60.0% [95% confidence interval (95% CI) 34.5–81.7], specificity 67% (95% CI 63.3–3–71.7), and overall accuracy of 66.7% (95% CI 58.9–73.2).The SSW-EMLA test detected many more peripheral neuropathy cases than BPNS in HIV patients and has potential as an alternative test for screening for HIV neuropathy in resource-constraint hospitals in Indonesia.

Digital subtraction angiography does not reliably prevent paraplegia associated with lumbar transforaminal epidural steroid injection

Digital subtraction angiography (DSA) has been touted as a radiologic adjunct to minimize complications during interventional neuraxial procedures where it is imperative to identify vascular compromise. We present a case of instantaneous paraplegia following lumbar TFESI wherein a local anesthetic test dose, as well as DSA was used as adjuncts to fluoroscopy. An 80 year-old male with chronic L5 radiculopathic pain was evaluated at a University Pain Management Center. Two previous lumbar interlaminar epidural steroid injections provided transient pain relief, and decision was made to perform right-sided L5-S1 TFESI with a 5 inch, 22-gauge Quincke type spinal needle with a curved tip.

A blunt needle (Epimed®) does not eliminate the risk of vascular penetration during transforaminal epidural injection

Background:Transforaminal epidural injection of local anesthetics and corticosteroids is a common practice in patients with radicular pain. However, serious morbidity has also been reported, which can be attributed to an arterial or venous injection of the medication especially particulate glucocorticoid preparations. Using a blunt needle in contrast to sharp needle has been suggested to reduce this risk in a study on animals.Case Description:We present a 59-year-old female with L5 lumbar radicular symptoms and left L5-S1 foraminal narrowing who underwent transforaminal epidural injection with fluoroscopic guidance using a 22-gauge blunt curved needle (Epimed®, Johnstown, NY). Intravascular needle placement was detected during real-time contrast injection under live fluoroscopy after a negative aspiration and local anesthetic test dose. The needle was slightly withdrawn and correct distribution of the contrast was confirmed along the target nerve root and into the epidural space.Conclusion:This case report discusses vascular penetration utilizing an Epimed® blunt needle to perform transforaminal injections in a clinical setting. This topic was previously discussed in earlier animal studies. We also reemphasize that neither negative aspiration or local anesthetic test doses are reliable techniques to ensure the safety of transforaminal epidural injections.

Digital Subtraction Angiography Does Not Reliably Prevent Paraplegia Associated with Lumbar Transforaminal Epidural Steroid Injection

Digital subtraction angiography (DSA) has been touted as a radiologic adjunct to interventional neuraxial procedures where it is imperative to identify vascular compromise during the injection. Transforaminal epidural steroid injections (TFESI) are commonly performed interventions for treating acute and chronic radicular spine pain. We present a case of instantaneous and irreversible paraplegia following lumbar TFESI wherein a local anesthetic test dose, as well as DSA, were used as adjuncts to fluoroscopy. An 80-year-old man with severe lumbar spinal stenosis and chronic L5 radiculopathic pain was evaluated at a university pain management center seeking symptomatic pain relief. Two prior lumbar interlaminar epidural steroid injections (LESI) provided only transient pain relief, and a decision was made to perform right-sided L5-S1 TFESI. A 5-inch, 22-gauge Quincke-type spinal needle with a curved tip was used. Foraminal placement of the needle tip was confirmed with anteroposterior, oblique, and lateral views on fluoroscopy. Aspiration did not reveal any blood or cerebrospinal fluid. Digital subtraction angiography was performed twice to confirm the absence of intravascular contrast medium spread. Subsequently, a 0.5mL of 1% lidocaine test dose was performed without any changes in neurological status. Two minutes later, a mixture of one mL of 1% lidocaine with 80 mg triamcinolone acetonide was injected. Immediately following the completion of the injection, the patient reported extreme bilateral lower extremity pain. He became diaphoretic, followed by marked weakness in his bilateral lower extremities and numbness up to his lower abdomen. The patient was transferred to the emergency department for evaluation. Magnetic resonance imaging (MRI) of the lumbar and thoracic spine was completed 5 hours postinjection. It showed a small high T2 signal focus in the thoracic spinal cord at the T7-T8 level. The patient was admitted to the critical care unit for neurological observation and treatment with intravenous methylprednisolone. Follow-up MRI revealed a hyper-intense T2 and short-tau inversion recovery signal in the central portion of the spinal cord beginning at the level of the T6 superior endplate and extending caudally to the T9-T10 level with accompanying development of mild spinal cord expansion. The patient was diagnosed with paraplegia from acute spinal cord infarction. At discharge to an acute inpatient rehabilitation program, the patient had persistent bilateral lower extremity paralysis, and incontinence of bowel and bladder functions. In the present patient, DSA performed twice and an anesthetic test dose did not prevent a catastrophic spinal cord infarction and resulting paraplegia. DSA use is clearly not foolproof and may not be sufficient to identify potentially life-or-limb threatening consequences of lumbar TFESI. We believe that this report should open further discussion regarding adding the possibility of these catastrophic events in the informed consent process for lumbar TFESIs, as it has for cervical TFESI. Utilizing blunt needles or larger bevel needles in place of sharp, cutting needles may minimize the chances of this event occurring. Considering eliminating use of particulate steroids for TFESI should be evaluated, although the use of nonparticulate agents remains controversial due to the perception that their respective duration of action is less than that of particulate steroids. Key words: Digital subtraction angiography, transforaminal epidural steroid injections, paraplegia, chronic low back pain.

Poster 379 Paraplegia Following Lumbar Transforaminal Epidural Steroid Injection with Digital Subtraction Angiography and Local Anesthetic Test Dose: A Case Report

Poster 379 Paraplegia Following Lumbar Transforaminal Epidural Steroid Injection with Digital Subtraction Angiography and Local Anesthetic Test Dose: A Case Report

Electrocardiographic and haemodynamic alterations caused by three different test solutions of local anaesthetics to detect accidental intravascular injection in children

The aim of this study was to investigate ECG and haemodynamic alterations provoked by a test dose of bupivacaine, epinephrine, and their combination. Paediatric patients undergoing general anaesthesia were randomized into three groups. After anaesthesia induction and tracheal intubation, 0.2 ml kg(-1) (max. 3 ml) of the corresponding test solution was i.v. injected: bupivacaine 0.125% (Group B), bupivacaine 0.125% plus epinephrine 1:200 000 (Group BE), or epinephrine 1:200 000 (Group E). ECG was printed and analysed post hoc. Non-invasive arterial pressure (AP) was measured at 1 and 2 min after test dose injection. Increases in T-wave of ≥ 25%, in heart rate (HR) of ≥ 10 beats min(-1), and in systolic AP of ≥ 15 mm Hg above baseline value were considered a positive result. A total of 105 children aged 0.2-16 (median 6.8) yr were enrolled. Test dose injection provoked T-wave elevation in 0%, 85%, and 89% of patients in Groups B, BE, and E, respectively. A positive increase in HR was found in 0%, 68%, and 76%. A positive increase in AP at 1 min was found in 0%, 88%, and 94% and at 2 min in 0%, 42%, and 59%. A decrease in HR of ≥ 10 beats min(-1) was observed in 6%, 76%, and 69%. Alterations in T-wave and HR were significantly influenced by age. ECG and haemodynamic alterations after i.v. injection of a local anaesthetic test dose were significantly influenced by epinephrine. T-wave elevation, increase in AP, and changes in HR are highly reliable variables, particularly when age is taken into account.

Role of nasal middle turbinectomy in nasal headache

Objective: To analyse the results of total resection of middle turbinate and partial resection of middle turbinate on nasal headache Design: Prospective study of chronic rhinogenic headache in 40 patients between January 2011 and December 2011, 25females and 15males,their age range was 18-55years,with a mean age of 32.4 years and their range of duration of headache was 1-20 years, with a mean duration of headache 6.125 years.The operation of total resection of middle turbinate has been performed in 40 ethmoidectomies & a control group of partial resection of middle turbinate has been performed by the same author in 40 ethmoidectomies. All the patients underwent pre-operative & post-operative assessment with a questionnaire of headache, using the visual analogue scale (VAS). Results: Total resection of middle turbinate showed complete cure of headache in 40 ethmoidectomies (100 percent) by questionnaire (subjective analysis). A control group of partial resection of middle turbinate showed complete cure in 20 ethmoidectomies (50 percent ), improvement (by 70%) in 4 ethmoidectomies (10 percent) & unchanged or worsened headache in 16 ethmoidectomies (40 percent) by subjective analysis at the last follow- up.The difference was statistically highly significant(P<0.01). Conclusion: Total resection of nasal middle turbinate in ESS is a good choice in chronic rhinogenic headache, not responding to usual medical anti-headache treatment & not septic. I. Introduction Each patient completed a questionnaire to elicit information on medications, medical history and the patient's subjective assessment of pre-operative & post-operative rhinogenic headache using standarized symptoms questionnaire quality of life score by Lund and Macky, the visual analogue scale (VAS). The scoring is range from 0 to 10 in which 0 represents no symptom & 10 represents greatest severity . 1 Local anesthetic test is done during the attack of headache. The nose is decongested then a piece of cotton soaked in xylocaine 2%, adrenaline 1:200.000 is put in the nose at any suspected contact area in the nose. The cotton is left for 5 minutes. Positive test is considered if the patient shows improvement of headache severity more than 50%. The simple presence of an intranasal pathology does not prove its role in headache causation.The etiologic role of this pathology should be confirmed by diagnostic local anesthetic testing as the source of pain. 2 The appropriate management of the middle turbinate remains controversial and arguments for its resection and for its preservation have been proposed. 3-5 Davis et al. reported that middle turbinectomy was the most important variable in predicting patency of the middle meatus antrostomy .6 A standard ESS Technique is done, the uncinate process is incised and removed & the middle turbinate is medialized with a freer elevator, the ethmoid bulla is entered & removed. A posterior ethmoidectomy is performed. The frontal sinus ostium is identified with a blunt curved suction .The natural ostium of the maxillary sinus is identified .The sphenoid sinus is entered medially and inferiorly as indicated. At this point, the procedure is essentially completed except for planning in regard to prevention of post-operative complications . 7 the present author has performed these procedures, as previously described, 7 on 40 patients with chronic rhinogenic headache. At a mean follow-up of 6 months. The patients were seen in the office 1 week post-operatively, any crusts are suctioned from the middle meatus & ethmoid, saline nasal irrigations were administrated. All the patients were followed up by endoscope and questionnaire of headache. The aim of this report was to review the cases of total resection of middle turbinate performed on nasal headache and compare the results with those of partial resection of middle turbinate performed by the same author at the same institution & period.

Convulsion Caused by a Lidocaine Test in Cervical Transforaminal Epidural Steroid Injection

Cervical transforaminal epidural steroid injections (CTFESI) have been used to treat cervical radicular pain with the rationale of suppressing spinal nerve root inflammation. However, potential serious procedure-related complications demand several protective measures, such as careful placement of a needle tip at the posterior wall of the neural foramen; real-time fluoroscopic surveillance of contrast flow, preferably with digital subtraction; and a local anesthetic test just before injection of the steroid [1,2]. The purpose of a local nesthetic test is to detect any temporary and reversible neurologic signs of intravascular nstillation of a short-duration local anesthetic agent so that subsequent steroid injection hat may potentially result in permanent neurologic complications can be withheld [1,3]. ince the test dose was advocated, only 2 reports [1,2] have described the value of the test y presenting cases of temporary neurologic deficits. More cases or research is needed to etermine whether and how the test should be done [1]. The present case report discusses onvulsion caused by a local anesthetic test because of inadvertent vertebral artery injection.

The outcomes for nasal contact point surgeries in patients with unsatisfactory response to chronic daily headache medications

The nasal contact point may act as a trigger point or peripheral enhancer in patients with chronic daily headaches. A total of 42 patients had unsatisfactory response to medical treatment for chronic daily headache with radiologic evidence of nasal contact point. Of them, 12 (28.5%) patients were positive for the local anesthetic test. Those patients were operated upon to separate this contact by either septoplasties or submucous resections with or without partial turbinectomies. The mean headache frequency was reduced from 22 to 7days/month. The mean headache severity was reduced from 5.6 to 2.4. Eight (19%) patients became completely free from headache and its medications, six (75%) of them were positive for local anesthetic test. The patients were satisfied with postoperative monotherapy, or headache severity and frequency could be tolerated without medications in 26 (62%) patients. There was no improvement in seven (16.6%) patients and only one patient (2%) became worse. The overall satisfaction was 83 and 81% for positive and negative anesthetic tests, respectively. The average monthly medication cost was reduced from $85 to 32. Nasal contact point surgery for chronic daily headache patients can satisfy them compared to previously unsatisfactory medications. Nasal contact point may contribute to potentiating or triggering chronic daily headache.

Root Cause Analysis of Paraplegia Following Transforaminal Epidural Steroid Injections: The ‘Unsafe’ Triangle

The utilization rate of transforaminal epidural steroid injections (TFESIs), an elective diagnostic and therapeutic spinal procedure, has risen dramatically over the past decade. In 2006 alone, greater than 300,000 thoracolumbar TFESIs were performed on Medicare beneficiaries. Despite the purported superiority of the transforaminal route, compared to other modes of epidural injection, TFESIs are associated with potential hazards. The artery of Adamkiewicz (ARM) might enter any mid thoracic, lower thoracic, or lumbar foramen; the exact level, in a specific patient, will be unknown to the proceduralist· The authors propose that the “safe triangle” approach to transforaminal epidural injections is not safe (TFESIs). Injury to the ARM can lead to paraplegia, independent of operator skill or adjuvant safety initiatives (digital subtraction angiography, local anesthetic test dose). Injury to the ARM is a “black swan” event. The authors believe that catastrophic injury may be averted when performing TFESIs by avoiding the “un-safe,” superoanterior triangle in the foramen and that transforaminal injections should be performed at the inferior aspect of the foramen, known as Kambin’s triangle. Key words: transforaminal, spinal cord, artery of Adamkiewicz, paraplegia, foramen, radiculomedullary, root cause analysis, patient safety, medico-legal, black swan

Positive Intravascular Test Dose Criteria in Children During Total Intravenous Anesthesia with Propofol and Remifentanil Are Different than During Inhaled Anesthesia

The use of local anesthetic test doses is standard practice when performing regional anesthesia. When an intravascular test dose is administered during inhaled anesthesia, the heart rate does not increase in about 25% of children; altered T-wave amplitude is a better indicator. No studies have examined the criteria for a positive result during total i.v. anesthesia (TIVA) in children. We studied the effect of a simulated positive test dose on heart rate, arterial blood pressure, and T-wave amplitude in 17 ASA physical status I or II children receiving TIVA with propofol and remifentanil. Bupivacaine 0.25% 0.1 mL/kg with epinephrine 1:200,000 was injected i.v., and vital signs and electrocardiogram were continuously monitored. Increases of heart rate and arterial blood pressure >10% and T-wave amplitude >25% of baseline were considered clinically significant changes. All subjects had increased systolic and diastolic blood pressure (30.3% +/- 11.7% and 49.3% +/- 16.7%), which peaked within 120 s. Heart rate increases >10% of baseline occurred in 73% of subjects. T-wave amplitude increased in 33.3%, was unchanged in 25%, and decreased in 41.7% of subjects. A positive test dose during TIVA is best detected by increased arterial blood pressure. Twenty-seven percent of intravascular injections were missed using heart rate criteria. T-wave amplitude is not a reliable indicator of intravascular injection during TIVA. This is in marked distinction to what is seen during inhaled anesthesia.

795. Local Anaesthetic Allergy Testing in Pregnancy

795. Local Anaesthetic Allergy Testing in Pregnancy

Local Anaesthetic Allergy Testing in Pregnancy

Local Anaesthetic Allergy Testing in Pregnancy

795: Local Anaesthetic Allergy Testing in Pregnancy

795: Local Anaesthetic Allergy Testing in Pregnancy

Delayed-type hypersensitivity (type IV) reactions in dental anesthesia

The recommended methodology of evaluating patients who have presented with reactions to local anesthetics consists of epicutaneous skin testing and serial subcutaneous challenge. However, the role of type IV reactions in this group has been poorly documented. Epicutaneous routine testing and subcutaneous challenge to local anesthetic was performed, as well as patch testing and subcutaneous rechallenge of both at 24 and 48 hours with evaluation up to 72 hours was performed. Three patients presented with a history of localized edema after dental anesthesia. All had negative lidocaine and mepivacaine testing as well as negative lidocaine challenge on evaluation at 1 hour. The first patient, who had previously reacted to EMLA, reacted to both lidocaine and mepivacaine patch testing and challenge, with delayed swelling at 24 and 48 hours after challenge. This patient subsequently tolerated the ester anesthetic chloroprocaine. Two other patients had strong histories of contact dermatitis. Patch testing and challenge with lidocaine was negative, but strong reactions were found to benzocaine on patch testing. Patients undergoing local anesthetic testing should be screened historically for features and risk factors associated with type IV reactions. This should be considered in patients who react to multiple amide anesthetics, who have delayed swelling, or who have a history of severe contact dermatitis. We confirm previous data showing that patients reacting to benzocaine can tolerate lidocaine and that lidocaine-allergic individuals can tolerate ester anesthetics.