Editor-in-Chief: Kenneth D. Candido, MD

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  1. IPM 2018; 197-203 Quadratus Lumborum Block for Back Pain Related to Pancreatic Cancer – A Report of Two Cases
    Case Reports
    Uri Hochberg, MD, Amir Minerbi, MD, PhD, Rodrigo Diez Tafur, MD, and Jordi Perez, MD, PhD.

Pancreatic cancer is often accompanied by severe pain. Patients typically experience upper abdominal and/or thoracolumbar back pain. For those cases failing to respond to standard medical management, as suggested by the World Health Organization, interventions designated at interruption of the sympathetic axis (such as neurolysis of the celiac plexus or splanchnic nerves) have been shown to be efficacious. Other than axial drug delivery, there are few interventional alternatives in patients with pancreatic cancer-related pain.
There is little knowledge regarding the therapeutic effects of treating peripheral somatic soft tissue among oncological patients. Here we report on 2 such patients, whose back pain improved following a quadratus lumborum block.
Two patients diagnosed with pancreatic cancer presented with severe back pain. The pain pattern and patients’ physical exams were compatible with myofascial pain arising from the quadratus lumborum muscle, possibly irritated by the abdominal tumor. Advanced pain management, including long- and short-acting opioids and adjuvants, as well as celiac plexus neurolytic block, failed to provide satisfactory pain relief. Given the apparent muscular origin of the pain, a bilateral ultrasound-guided quadratus lumborum block was performed. Four weeks post procedure, the 2 patients reported substantial pain relief supported by reduced consumption of pain medication and improved functional status. No adverse events or complications were observed in either case.
In the patients described here, quadratus lumborum block proved to be safe and efficacious in alleviating back pain related to pancreatic cancer. In our opinion, clinicians should be aware of the possible contribution of a myofascial component to pain in pancreatic cancer and in cancer-related pain in general.

Key words: Quadratus lumborum block, cancer pain, pancreatic cancer, pain control, myofascial pain syndrome, interventional pain management

Cervicothoracic Epidural Blood Patch Provides Pain Relief after Failed Lumbar Epidural Blood Patch: A Case Report
Owais Qureshi, DO, Phillip Suwan, MD, Sachin Bahadur, MD, and Anterpreet Dua, MD
Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta University, Georgia
Background: Spontaneous intracranial hypotension is an increasingly relevant cause of headaches as the breadth and depth of its diagnosis and management improves.
Objectives: The objective of this case report is to describe a novel treatment for headaches caused by spontaneous intracranial hypotension without locating the cerebrospinal fluid (CSF) leak and to review the diagnostic and therapeutic options for spontaneous intracranial hypotension.
Study Design: This is a report of a single case.
Setting: The setting for this case report is a major academic center.
Methods: After a review of the treatments and interventions that our patient had previously undergone, we decided to trial epidural blood patches for her chronic headaches.
Results: Although the exact site of a CSF leak could not be identified despite exhaustive diagnostic interventions, cervicothoracic epidural blood patches provided excellent pain control for our patient’s severe headaches. The patient was completely free of headaches for 15 hours and reported well-controlled pain for approximately a month after her procedure as well as after 5 subsequent monthly procedures.
Limitations: As this is a report of a single case, more rigorous study in a larger patient population is needed to provide guidance.
Conclusions: This case demonstrates that a nontargeted cervicothoracic epidural blood patch can be a treatment option for patients with spontaneous intracranial hypotension in which clinical suspicion is high despite nondiagnostic imaging.
Key words: Spontaneous intracranial hypotension, cervicothoracic epidural blood patch, headache