Our patient, a 52-year-old male (165 cm, 90 kg), was a known case of chronic lymphocytic leukemia (CLL, Rai Stage II). He had received two cycles of bendamustine and rituximab-based chemotherapy in two consecutive months. He developed herpes zoster infection in the following month and was started on oral acyclovir after consultation with a dermatologist. One week later, he visited our pain clinic and complained of severe pain on the right side of his lower back []. The pain was burning in nature and was associated with allodynia and restricted mobility. A diagnosis of PNH was made, and he was started on gabapentin in view of neuropathic nature of pain. The dermatomal distribution of the pain was from T11 to S1. The pain was affecting the quality of life of the patient and the pharmacological therapy was inadequate.\nWe decided to perform a right-sided ESPB in prone position for acute pain relief of the patient. A high-frequency linear ultrasound probe was placed in longitudinal orientation, about 3 cm lateral to the spinous process of the third lumbar vertebra. The interfacial plane below the erector spinae muscle was identified, and 0.25% bupivacaine and triamcinolone 40 mg (total volume 30 ml) were injected []. Patient's NRS score was decreased from 8/10 to 3/10 30 min after the block procedure. Later on, the ESPB was performed two times for 2 weeks and provided effective analgesia for the PHN. The patient reported a decline in pain score and analgesics consumption in follow-up clinics.
Case 1: A 38-year-old male (weight 75 kg, ASA status III) was scheduled for right total hip arthroplasty (THA) due to severe bilateral rigid and sore hip joints. He had a history of ankylosing spondylitis for more than 18 years. Despite a long term usage of sulfasalazine and “painkiller”, the patient developed a rigid kyphotic and scoliotic deformity. An overall physical examination revealed rheumatoid arthritis involved most articles in the body resulting in limited movement and swelling of interphalangeal joints, metacarpophalangeal joints, elbow joints, shoulder joints, and ankle joints, with rigid bilateral hip and knee joints preventing any walk. The airway assessment revealed a Mallampati class III, interincisor distance of 3 cm, and rigid neck incapable of any movement. X-ray of his cervical, thoracic and lumbar vertebrae and pelvis revealed a loss of physiological curvature of the vertebral column, kyphosis, hyperplasia at the edge of the vertebrae, “bamboo” like bony bridge, blurred facet joints, and calcification of ligament, a fusion of both sacroiliac joints, rough articular face and narrowed articular cavity and hyperplasia of both hip joints (Fig. ). After administration, he received immunosuppressive therapy, with prednisone 20 mg per day, and methotrexate 10 mg once per week, and anti-TNF therapy with etanercept (TNF receptor fusion protein) 25 mg i.h. twice per week, and anticoagulation therapy with low-molecular-weight heparin 4000 U per day.