Lumbosacral plexus entrapment syndrome (LPES) is a little-known but common cause of chronic lumbopelvic and lower extremity pain. The lumbar plexus, including the lumbosacral tunks emerge through the fibers of the psoas major, and the proximal sciatic nerve beneath the piriformis muscles. Severe weakness of these muscles may lead to entrapment plexopathy, resulting in diffuse and non-specific pain patterns throughout the lumbopelvic complex and lower extremities (LPLE), easily mimicking other diagnoses and is therefore likely to mislead the interpreting clinician. It is a pathology very similar to that of thoracic outlet syndrome, but for the lower body. This two-part manuscript series was written in an attempt to demonstrate the existence, pathophysiology, diagnostic protocol as well as interventional strategy for LPES, and its efficacy.

Multiple organ dysfunction syndrome (MODS) is observed in 40% of adult patients and 56% of pediatric patients admitted to the intensive care unit (ICU). Mortality in case of MODS can reach 50% and more. Pain management in this population of patients is always a big challenge due to systemic derangements. We give a narrative review of this problem and the recommended lines of action here. We performed a literature search for a period from 1984 to 2018 in Google Scholar, PubMed, Medline, Embase, and Cochrane. Data from 45 articles devoted to the problems of MODS, severe sepsis, heart, liver and renal failures, coagulation disorders and pain management were accumulated and presented here. First step in the management of any pathology is diagnosis and assessment. Organ dysfunction in adults can be assessed according to Sequential Organ Failure Assessment (SOFA) score, and other Systems in pediatric patients. Acetaminophen, tramadol and fentanyl is a safe option for analgesia in MODS after dose adjusting according to liver failure or eGFR. Other methods of analgesia can be used in specific types of organ failure, but have limitations or are not well studied, so they are best avoided or used with caution in patients with MODS. In this article pain management strategies in each particular failure are presented and an algorithm for pain management has been suggested by the authors. Further investigations are required in order to determine the best modalities for pain management in this group of patients.

A 68-year-old man underwent abdominoperineal resection to treat anal fistula carcinoma three years previously, following which he developed perineal pain and dysuria and was prescribed sustained-release and immediate-release oxycodone by his primary physician to treat the cancer pain. The patient subsequently received dose increases and rescue doses of opioids in accordance with the WHO method for cancer pain relief. However, since pain management became difficult, he was referred to our pain clinic. At the time of referral, the tumor had completely disappeared, and the pain was due to chronic postoperative pain and not cancer pain. First, the rescue agent was switched from immediate-release oxycodone and oral fentanyl tablet to acetaminophen 500 mg/dose. Ganglion impar block was performed and the prescribed fixed opioid dose was reduced at this point. In this case, the pain was due to postoperative wound pain, and its treatment by the WHO method for cancer pain relief was not indicated due to the risk of opioid-dependency. Treatment and management conforming to opioid analgesic indications for non-cancer pain were necessary.

Background and Aims: Pain on injection is common in non-premedicated patients receiving propofol for colonoscopy. Multiple studies have examined strategies to prevent propofol injection pain in surgical patients. However, many of these studies were not blinded or randomized and many of the studied patients received premedication prior to propofol injection. This study was designed to test the hypothesis that injecting a premixed solution of propofol/lidocaine will be associated with less pain than when lidocaine is injected separately before propofol. The study’s propofol induction protocols closely mirrored those used routinely at our institution.Methodology: This was a randomized, double-blinded, comparative study performed with IRB approval and patients’ informed consent. One 150 patients scheduled for screening colonoscopy were randomly assigned into two groups of 75 patients in each group. In Group-LB, patients received 40 mg lidocaine IV followed by propofol from a syringe containing 19 ml propofol and 1 ml saline. In Group-ML, patients received 2 ml saline IV followed by propofol from a syringe containing 19 ml propofol and 1 ml 2% (20 mg) lidocaine. Following the initial IV injection of the 2 ml clear solution the patients were asked about symptoms of systemic lidocaine (light headedness, ringing in the ears, or metallic taste in the mouth). Disregarding the minor dilution of the 19 ml propofol with the added 1 ml clear solution, propofol 0.75 mg/kg was then injected at a constant rate over 15 seconds. The patients were asked to grade any associated pain or discomfort at the injection site on a 4 point scale: (0) no pain, (1) mild pain, (2) moderate pain, (3) severe pain and/or grimacing or withdrawal of limb. Thirty second later a second dose of 0.75 mg/kg propofol was injected. The patients continued to be questioned about pain on injection until they lost consciousness. Fisher’s exact test was used to compare the proportion of patients who experienced pain and the incidence of experiencing systemic lidocaine symptoms between the 2 groups. Wilcox rank sum test was used to compare the severity of pain for patients who experienced pain in the two groups.Results: There was no difference in pain rates between the two groups (p=1). If they did experience pain, patients in Group-ML experienced less pain compared to patients in the Group-LB (p < 0.001). The incidence of experiencing lidocaine symptoms was significantly higher in the Group-LB (p < 0.001).