BACKGROUND Rib fractures are a common traumatic injury with significant morbidity and mortality resulting from respiratory compromise. Regional anesthetic techniques have demonstrated efficacy in reducing morbidity and mortality from rib fractures, but there is limited evidence comparing various techniques, and in complex trauma patients various factors may preclude the use of neuraxial and other techniques. CASE REPORT We report the case of a 72-year-old man who presented with left 4th-11th rib fractures. He was initially managed with a continuous erector spinae plane catheter, which resulted in improved pain and incentive spirometry. Unfortunately, he continued to decline and ultimately was rescued from impending respiratory failure by placement of a T6-T7 epidural catheter and epidural infusion of bupivacaine. CONCLUSIONS This case report suggests that a continuous erector spinae plane block may be a useful regional anesthesia technique in the management of rib fractures through its potential to improve pain control and increase incentive spirometry volumes. It also suggests that there may be limitations to its utility given the continued decline of the patient, who was eventually rescued from respiratory failure by placement of a thoracic epidural. Unique to erector spinae plane blocks are the ability to be managed in the outpatient setting, improved safety profile, ease of placement, and potential to be placed in patients with coagulopathy and on anticoagulation therapies.

We present the case of a 38-year-old man undergoing surgical repair of his pectoralis major tendon. An interscalene catheter was placed between the middle and lower trunks of the brachial plexus. Postoperatively, ropivacaine 0.2% was infused through postoperative day 3. The patient had excellent pain control requiring minimal opioid analgesics. A catheter between the middle and lower trunks of the brachial plexus provided excellent postoperative analgesia after pectoralis major tendon reinsertion. Additionally, the block likely protected the surgical repair during emergence from anesthesia and in the early postoperative period by providing a motor block of the pectoralis major muscle.

Pain after limb amputation is frequently challenging to adequately treat with local anesthetic-based regional anesthesia techniques due to its relatively long duration. Furthermore, uncontrolled pain in the immediate postoperative period is associated with persistent postsurgical pain, and frequently phantom limb pain. Cryoneurolysis is an alternative regional analgesic method to local anesthesia-based techniques. We report 3 cases in which ultrasound-guided percutaneous cryoneurolysis was performed in the perioperative period of limb amputation. All reported profound analgesia in the postoperative period without persistent postsurgical residual limb or phantom pain in the following months. No adverse events associated with the cryoneurolysis procedure occurred.

We report 3 different cases in which ultrasound-guided percutaneous cryoneurolysis was performed to treat acute pain: 1 patient with refractory incisional pain after percutaneous nephrolithotomy; 1 patient with burns to the foot; and 1 patient with pain from iliac crest grafting. Acute pain associated with surgery or injury is a challenge to treat with local anesthetic-based regional anesthesia techniques when the anticipated pain duration exceeds a few days. Cryoneurolysis is an alternative analgesic method that utilizes extremely cold temperatures to reversibly ablate peripheral nerves and is potentially a novel method for acute pain management.

BACKGROUND Postamputation phantom and residual limb pain are common and frequently intractable, with few reliably effective treatments. Pulsed nonthermal shortwave (radiofrequency) electromagnetic field therapy is a noninvasive treatment used previously as an adjunct analgesic and wound healing therapy. Its use for postamputation pain remains unexamined. CASE REPORT Twelve patients with an above or below knee amputation with persistent, intractable phantom and/or residual limb pain unresponsive to multiple previous invasive treatments were provided with a noninvasive, wearable, pulsed electromagnetic field device (RecoveryRx, BioElectronics Corporation, Frederick, MD, USA). Patients used the included dressings to self-apply the 12 cm-diameter ringed antenna to their residual limb and then activated the device, which delivered nonthermal radiofrequency energy continuously for up to 30 days. Of the 12 individuals, 4 (33%) experienced minimal/no change, 7 (58%) rated their phantom and/or residual limb pain as "very much improved" at the conclusion of treatment, and 1 (8%) patient reported "moderate" improvement, using the Patient Global Impression of Change scale. Of the 8 responders, worst and average phantom limb pain improved a mean (SD) of 4.0 (2.9) and 4.2 (1.8) points on the 0 to 10 numeric rating scale, respectively. Worst and average residual limb pain improved 5.4 (3.7) and 3.5 (2.4) points, respectively. CONCLUSIONS These cases suggest that pulsed electromagnetic field therapy may be an effective treatment for intractable postamputation pain. Considering the low patient burden of noninvasive, wearable devices, combined with few contraindications and no significant side effects or adverse events, further study with a randomized, controlled trial is warranted.

Background

There are few effective pain treatments following trauma on the battlefield other than opioids, which are limited by respiratory depression. Ultrasound-guided percutaneous peripheral nerve stimulation ("neuromodulation") has been proposed as an analgesic, but requires physician-level skills, advanced equipment, and an hour to administer. In contrast, percutaneous auricular neuromodulation may be placed by a medic in the field under nonsterile conditions in a few minutes, theoretically provides analgesia for any anatomic location, has no side effects, and no significant risks. It therefore offers the potential to be applied quickly on the battlefield without any of the limitations of opioids. We propose total joint replacement as a surrogate for battlefield trauma and here present a case report to demonstrate proof of concept.

Methods

Following open total knee or hip arthroplasty under spinal anesthesia, two patients had an auricular neuromodulation device applied within the recovery room. Patients were discharged with the unit and contacted daily for 7 days.

Results

The devices were each applied in under 3 minutes without difficulty, were well tolerated during use, and removed without complication at home on Day 5. During use, neither patient experienced pain while lying, sitting, or ambulating. Neither required analgesics other than scheduled celecoxib; and a single tablet (50 mg) of tramadol for one patient on postoperative Days 3 and 4 for pain while lowering herself to a seated position. On Days 6 and 7, both patients experienced an increase in pain, one of whom required around-the-clock tramadol.

Conclusion

Ambulatory postoperative percutaneous auricular neuromodulation is feasible. In these two cases, it appears to have markedly reduced pain scores and opioid requirements free of systemic side effects during the week following major orthopedic surgery. Considering the potential of this modality to treat trauma on the battlefield without systemic side effects, additional investigation appears warranted.

Level of evidence

Therapeutic/care management; Level V.

Background

Following outpatient surgery, it is often difficult to provide adequate analgesia while concurrently minimizing opioid requirements. Ultrasound-guided percutaneous peripheral nerve stimulation has been proposed as an analgesic, but requires physician-level skills, advanced equipment, up to an hour to administer, and is frequently cost prohibitive. In contrast, percutaneous auricular neuromodulation may be placed by nursing staff in a few minutes without additional equipment, theoretically provides analgesia for nearly any anatomic location, lacks systemic side effects, and has no significant risks. We now present a case report to demonstrate proof of concept for the off-label use of an auricular neuromodulation device-originally developed to treat symptoms associated with opioid withdrawal-to instead provide analgesia following outpatient surgery.

Case presentation

Following moderately painful ambulatory orthopedic and breast surgery, seven patients had an auricular neuromodulation device (NSS-2 Bridge, Masimo, Irvine, California, USA) affixed within the recovery room in approximately 5 min and discharged home. Average resting and dynamic pain scores measured on the 0-10 Numeric Rating Scale were a median of 1 over the first 2 days, subsequently falling to 0. Five patients avoided opioid use entirely, while the remaining two each consumed 5 mg of oxycodone during the first 1-2 postoperative days. After 5 days, the devices were removed at home and discarded.

Conclusions

These cases demonstrate that ambulatory percutaneous auricular neuromodulation is feasible and may be an effective analgesic and decreasing or even negating opioid requirements following outpatient surgery. Considering the lack of systemic side effects, serious adverse events, and misuse/dependence/diversion potential, further study with a randomized, controlled trial appears warranted.