A randomized, placebo controlled, trial of preoperative sustained release Betamethasone plus non-controlled intraoperative Ketorolac or Fentanyl on pain after diagnostic laparoscopy or laparoscopic tubal ligation [ISRCTN52633712].

BACKGROUND: Gynecological laparoscopic surgery procedures are often complicated by postoperative pain resulting in an unpleasant experience for the patient, delayed discharge, and increased cost. Glucocorticosteroids have been suggested to reduce the severity and incidence of postoperative pain. METHODS: This study examines the efficacy of a sustained release betamethasone preparation to reduce postoperative pain and the requirement for pain relief drugs after either diagnostic laparoscopy or tubal ligation. Patients were recruited, as presenting, after obtaining informed consent. Prior to surgery, patients were randomly selected by a computer generated table to receive either pharmacy-coded betamethasone (12 mg IM Celestone trade mark ) or an optically identical placebo injection of Intralipid trade mark and isotonic saline mixture. The effect of non-controlled prophylactic intraoperative treatment with either fentanyl or ketorolac per surgeon's orders was also noted in this study. Blood samples taken at recovery and at discharge times were extracted and analyzed for circulating betamethasone. Visual analog scale data on pain was gathered at six post-recovery time points in a triple blind fashion and statistically compared. The postoperative requirement for pain relief drugs was also examined. RESULTS: Although the injection achieved a sustained therapeutic concentration, no beneficial effect of IM betamethasone on postoperative pain or reduction in pain relief drugs was observed during the postoperative period. Indeed, the mean combined pain scores during the 2 hour postoperative period, adjusted for postoperative opioids as the major confounding factor, were higher approaching statistical significance (P = 0.056) in the treatment group. Higher pain scores were also observed for the tubal ligation patients relative to diagnostic laparoscopy. Intraoperative fentanyl treatment did not significantly lower the average pain score during the 2 hour postoperative period. Intraoperative ketorolac treatment significantly lowered (P = 0.027) pain scores and reduced the postoperative requirement for additional pain relief drugs. CONCLUSIONS: There was a lack of efficacy of preoperative sustained release betamethasone in reducing postoperative pain despite maintaining a therapeutic concentration during the postoperative period. Intraoperative Ketorolac did afford some short-term pain relief in the postoperative period and reduced the need for additional pain relief drugs.

Predictive factors in advanced cancer pain treated only by analgesics.

Analgesic response, incidental pain and pain mechanism were evaluated in order to predict the chances of pain relief in advanced cancer patients. In an observation period of about 2 months, 130 patients were followed at home until death using only a pharmacological approach to control pain according to the WHO ladders. Ninety-eight patients were considered. pain relief was considered good if less than moderate. Pain was assessed during the course of examinations (2-3 a week) by independent observers. If other techniques were needed the result was considered negative. The patients were tested with an NSAID (Diclofenac) and assigned to group 1 if the pain became slight in 3 days. If the response was negative, a 4-day trial with opioids was started. If the pain was slight the patient was included in group 3, otherwise in group 5. Every patient belonging to these groups but with incidentical pain was included in groups 2, 4 and 6, respectively. For each group a subdivision was made according to the pain characteristics. There was a progressive worsening in pain relief in groups 4, 5 and 6, suggesting a good correlation between response to the drugs and future chances of pain control in a period of 2 months. This study demonstrates that incidental pain reduces the possibility of pain control (50%) with the exclusive administration of analgesics in patients with a mean life expectation of about 2 months. This negative influence is counterbalanced by the possible individual response to analgesics administered sequentially during a 1-week period (85.8% good pain relief with NSAID, 74% with opioids).(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous stereotactic differential radiofrequency thermal rhizotomy for the treatment of trigeminal neuralgia.

PURPOSE: The purpose of this study was to evaluate the effectiveness of radiofrequency thermal rhizotomy (RTR) for trigeminal neuralgia, after failure of pharmacological management. PATIENTS AND METHODS: Two hundred fifteen patients underwent RTR from 1991 to 1996 and were prospectively evaluated. These patients were characterized by age, sex, side of the face, and division(s) involved. Patients were evaluated for pain relief, recurrence requiring or not requiring reoperation, and the type and rate of complications. They were followed-up by serial clinical evaluation and telephone interview. Patients were categorized into groups: 1) Successful result: excellent, good pain relief; and 2) Unsuccessful result: fair, poor, or no pain relief. The RTR group was compared with historical controls. Follow-up ranged from 9 to 68 months (mean, 32 months) and results were evaluated at early and long-term follow-up. RESULTS: At early follow-up (defined as immediately postoperatively to 6 months), pain relief of excellent or good quality (successful result) occurred in 198 of 215 patients (92%). Fair or poor or no pain relief (unsuccessful result) occurred in 17 (8%) patients. At long-term follow-up (>6 months to 68 months), recurrence of pain that required reoperation occurred in 24 patients (11%) and recurrence of pain that did not require reoperation (medically managed) occurred in 34 patients (16%). Dysesthesia developed in 18 patients (8%); seven patients (3%) had dysesthesia alone (medically managed) and 11 patients (5%) had dysesthesia with recurrence of pain (medically or surgically managed). "Anesthesia/analgesia dolorosa" developed in four patients (1.8%) and was medically managed. At long-term follow-up, 83% of patients had good to excellent pain relief (successful result). There were no mortalities, no significant morbidity, and a low rate of minor complications. CONCLUSION: With the use of this specific diagnostic approach and management algorithm, patients with trigeminal neuralgia can be successfully managed.

Sacral magnetic stimulation for pain relief from pudendal neuralgia and sciatica.

INTRODUCTION: Magnetic stimulation of the sacral nerve roots is used for neurologic examination. However, no one has reported therapeutic efficacy of pain relief from pudendal neuralgia with sacral magnetic stimulation. METHODS: Five patients with pudendal neuralgia or sciatica received 30 to 50 pulsed magnetic stimuli of the sacral nerve roots. The median age of the patients was 59 (range, 28-69) years; there were 3 females. RESULTS: Sacral magnetic stimulation immediately eliminated the pain. The pain relief lasted between 30 minutes and 56 days (median, 24 hours). Adverse effects were not observed. CONCLUSIONS: This pilot study indicates that magnetic stimulation of the sacral nerve roots may be a promising therapeutic modality for pain relief from pudendal neuralgia and sciatica. Further studies should be performed to determine the appropriate intensity and frequency, as well as the utility of a second course, of magnetic stimulation treatment.

The natural history of pain in alcoholic chronic pancreatitis.

BACKGROUND & AIMS: The pain pattern of chronic pancreatitis (CP) and its surgical implications are discussed. The aim of this study was to (1) define typical pain patterns, (2) correlate pain patterns with the presumptive causes of the pain, and (3) compare the natural history of patients treated conservatively or surgically with respect to pain relief, pancreatic dysfunction, and clinical outcome. METHODS: A cohort in this prospective long-term study included 207 patients with alcoholic CP (91 without and 116 with surgery for pain relief). A clinically based staging system was applied to characterize pain in the evolution from onset to end-stage CP. RESULTS: Average duration of CP was 17 years. In early-stage CP, episodes of recurrent (acute) pancreatitis predominated. Chronic pain was typically associated with local complications (mainly pseudocysts, 84 of 155; 54%), relieved definitely by a single (drainage) procedure in approximately two thirds of patients. Additional surgery was required for late pain recurrence in 39 patients (34%), primarily symptomatic cholestasis (18 of 39; 46%). All patients achieved complete pain relief in advanced CP. CONCLUSIONS: In our experience, relief of chronic pain regularly follows selective surgery tailored to the presumptive pain cause or occurs spontaneously in uncomplicated advanced CP.

What decline in pain intensity is meaningful to patients with acute pain?

Despite widespread use of the 0-10 numeric rating scale (NRS) of pain intensity, relatively little is known about the meaning of decreases in pain intensity assessed by means of this scale to patients. We aimed to establish the meaning to patients of declines in pain intensity and percent pain reduction. Upon arrival to the postanesthesia care unit, postsurgical patients rated their baseline pain intensity on both a 0-10 NRS and on a 4-point verbal scale. Patients whose NRS was higher than 4/10 received intravenous opioids until their pain intensity declined to 4/10 or lower. During opioid titration, patients were asked every 10 min to rate pain intensity on a NRS and to indicate the degree of pain improvement on a 5-point Likert scale from 'no improvement' to 'complete pain relief'. Seven hundred adult patients were enrolled. For patients with moderate pain, a decrease of 1.3 units (20% reduction) corresponded to 'minimal' improvement, a decrease of 2.4 (35% reduction) to 'much' improvement, a decrease of 3.5 units (45% reduction) corresponded to 'very much' improvement. For patients with severe pain, the decrease in NRS pain score and the percentage of pain relief had to be larger to obtain similar degrees of pain relief. The change in pain intensity that is meaningful to patients increases as the severity of their baseline pain increases. The present findings are applicable in the clinical setting and research arena to assess treatment efficacy.

Radiation therapy for painful bone metastases; aiming at optimal treatment schedules

PURPOSE: To evaluate the pain relief obtained by radiation therapy for painful bone metastases, with a special regard to general condition. MATERIALS AND METHODS: Between June 1998 and May 2000, 54 patients with 86 painful bone metastases were treated with radiation therapy whose effects could be evaluated for a minimum period of 6 months or until death. Treatment schedules were 3 Gy/fraction/day (30-36 Gy/10-12 fractions) in usual cases (61 lesions), 4-8 Gy/fraction/day (8-20 Gy/1-5 fractions) in patients with a poor general condition (9 lesions), and 2 Gy/fraction/day (40-50 Gy/20-25 fractions) in lesions with a large radiation field (16 lesions). RESULTS: Complete pain relief without medication (CR) was achieved in 40 lesions (47%). Significant predictors for CR were primary site (p = 0.0003), performance status (p = 0.0060), pain score (p = 0.0190), narcotic score (p < 0.0001), and prognosis (p < 0.0001), but no difference was found in CR among treatment schedules. No evidence of severe radiation-induced complication was seen. CONCLUSION: General condition (performance status and prognosis) has an influence on pain relief. Compared with the daily 2 Gy protocol, the daily 3 Gy protocol has the advantage of shorter treatment time. The treatment schedule should be assessed in patients with a large radiation field and/or poor general condition. Especially for the patients with poor general condition, combined pain medication should be considered.

Gamma knife surgery with a dose of 75 to 76.8 Gray for trigeminal neuralgia.

OBJECT: The author presents a large series of patients with idiopathic trigeminal neuralgia (TN) who were treated with gamma knife surgery (GKS), at a maximum dose of 75 to 76.8 Gy, and followed up in a nearly uniform manner for up to 4.6 years. METHODS: Two hundred ninety-three patients were treated and followed up for at least 6 months (range 0.4-4.6 years, median 1.9 years). At the final follow-up review, there was complete (100%) pain relief without medicines in 64 patients (21.8%), 90% or greater relief with or without small doses of medicines in 86 (29.4%), between 75 and 89% relief in 31 (10.6%), between 50 and 74% relief in 19 (6.5%), and less than 50% relief in 23 patients (7.8%). Recurrent pain requiring a second procedure occurred in 70 patients (23.9%). Kaplan-Meier analysis showed that 100%, 90% or greater, and 50% or greater pain relief was obtained and maintained for 3.5 to 4.1 years in 5.6, 23.7, and 50.4% patients, respectively. Of 31 patients who described pain relief ranging from 75 to 89%, 80% of patients described it as good and 10% as excellent; of 17 patients who reported between 50 and 74% pain relief, 53% described it as good and none as excellent (p = 0.014). Dysesthesia scores greater than 5 (scale of 0-10, in which a score of 10 represents excruciating pain) occurred in four (3.2%) of 126 patients who had not undergone prior surgery; all these patients obtained either good or excellent relief from TN pain. There were 36 patients in whom the TN had atypical features; these patients were less likely to attain at least 50% or at least 90% pain relief compared with those without atypical TN features (p = 0.001). CONCLUSIONS: Gamma knife surgery is a safe and effective way to relieve TN. Patients who attain between 75 and 89% pain relief are much more likely to describe this outcome as good or excellent than those who attain between 50 and 74% pain relief.

pain relief in Thailand.

Pain is a complex problem, for both those who are enduring it and those trying to relieve it. Most people in the developed world have access to adequate treatment and management of pain, the availability of trained and educated doctors and nurses, feasible opioid prescribing policies, as well as ready access to appropriate medication. Often, this is not the case in developing countries such as Thailand. This paper is based on recent experience in the southeast of Thailand providing pain relief for persons with HIV and AIDS in Rayong Province at the Camillian Social Centre. The severity and frequency of pain endured by this group of individuals presented a daily challenge. Problems encountered in providing pain relief for these patients and some potential solutions are described. There is a lack of literature on pain relief in Thailand.

Postoperative pain relief and hospital stay after total esophagectomy.

Intraoperative and postsurgical epidurally administered pain relief is associated with reduced morbidity. We reviewed the charts of 19 patients who had total esophagectomy to see whether the method of postoperative pain relief influenced the length of hospital stay and cost of the procedure. The patients received either intravenous (group M) or epidural (group E) morphine for postoperative pain. The length of stay in the intensive care unit was reduced by 2 1/2 days and total hospital stay by 7 days in the epidural group. This resulted in a saving of Canadian $12,770 per patient.