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Horner Syndrome (HS) is a rare but benign complication with epidural analgesia in parturients. It is caused by the cephalad spread of local anesthetic with an overflow to the superior cervical sympathetic chain. We present 2 patients, a 28-year old woman and a 23-year old woman, both without any major medical comorbidity. Each patient received a lumbar epidural catheter with the conventional labor pain treatment of our hospital. The first patient developed HS after the administration of 10 ml of lidocaine 1% when a unilateral block occurred. At this time, the patient was placed in genupectoral position. The second patient developed HS directly after the first bolus of 10 ml of the standard epidural solution of our center when the patient was in supine position. A spontaneous resolution of HS was observed in both patients. The exact incidence of HS in parturients is not known and probably underreported by patients as well as by caregivers. Clinical vigilance and appropriate teaching of obstetrics caregivers is very important. We demonstrate that an accidental subdural placement of the catheter and the dose of the epidural solution can play a major role in the development of HS.Horner Syndrome (HS) is a rare but benign complication with epidural analgesia in parturients. It is caused by the cephalad spread of local anesthetic with an overflow to the superior cervical sympathetic chain. We present 2 patients, a 28-year old woman and a 23-year old woman, both without any major medical comorbidity. Each patient received a lumbar epidural catheter with the conventional labor pain treatment of our hospital. The first patient developed HS after the administration of 10 ml of lidocaine 1% when a unilateral block occurred. At this time, the patient was placed in genupectoral position. The second patient developed HS directly after the first bolus of 10 ml of the standard epidural solution of our center when the patient was in supine position. A spontaneous resolution of HS was observed in both patients. The exact incidence of HS in parturients is not known and probably underreported by patients as well as by caregivers. Clinical vigilance and appropriate teaching of obstetrics caregivers is very important. We demonstrate that an accidental subdural placement of the catheter and the dose of the epidural solution can play a major role in the development of HS.

Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy is a pain syndrome with an unclear pathophysiology and unpredictable clinical course. The disease is often therapy resistant, the natural course not always favorable. The diagnosis of CRPS is based on signs and symptoms derived from medical history and physical examination. Pharmacological pain management and physical rehabilitation of limb function are the main pillars of therapy and should be started as early as possible. If, however, there is no improvement of limb function and persistent severe pain, interventional pain management techniques may be considered. Intravenous regional blocks with guanethidine did not prove superior to placebo but frequent side effects occurred. Therefore this technique receives a negative recommendation (2 A-). Sympathetic block is the interventional treatment of first choice and has a 2 B+ rating. Ganglion stellatum (stellate ganglion) block with repeated local anesthetic injections or by radiofrequency denervation after positive diagnostic block is documented in prospective and retrospective trials in patients suffering from upper limb CRPS. Lumbar sympathetic blocks can be performed with repeated local anesthetic injections. For a more prolonged lumbar sympathetic block radiofrequency treatment is preferred over phenol neurolysis because effects are comparable whereas the risk for side effects is lower (2 B+). For patients suffering from CRPS refractory to conventional treatment and sympathetic blocks, plexus brachialis block or continuous epidural infusion analgesia coupled with exercise therapy may be tried (2 C+). Spinal cord stimulation is recommended if other treatments fail to improve pain and dysfunction (2 B+). Alternatively peripheral nerve stimulation can be considered, preferentially in study conditions (2 C+).

In the industrialized world, polyneuropathy induced by diabetes mellitus (DM) is one of the most prevalent forms of neuropathy. Diabetic neuropathy can result from a direct toxic effect of glucose on nerve cells. Additionally, the damage of the nerve structures (central and peripheral) is accompanied by a microvascular dysfunction, which damages the vasa nervorum. More than 80% of the patients with DM-induced polyneuropathy have a distal and symmetric presentation. The initial symptoms are: signs of diminished sensation, burning feet, which may occur particularly during the night and worsen when touched, and tingling sensation in the feet. Attacks of shooting pain may also occur. Proper control of DM is mandatory. Based on the recently published National Institute for Health and Clinical Excellence guidelines, treatment of painful diabetic neuropathy should start with duloxetine or amitriptyline if duloxetine is contraindicated. If pain relief is inadequate, monotherapy with amitriptyline or pregabalin, or combination therapy with amitriptyline and pregabalin should be considered. If pain relief is still insufficient, tramadol instead of or in combination with a second-line agent should be considered. In patients who are unable to take oral medication, topical lidocaine can be considered for localized pain. There are currently four studies showing that spinal cord stimulation can potentially provide pain alleviation for the longer term in patients with painful diabetic polyneuropathy. Complications are mainly implant related, though infections also occur. The available evidence (2 C+) justifies spinal cord stimulation to be considered, preferably study related.