The effect of patient age, gender, and tibial component fixation on pain relief after cementless total knee arthroplasty.

Cementless total knee arthroplasties (TKAs) were prospectively evaluated for pain relief in 1110 knees. The effect of screws in the tibial component, the age of the patients, and the gender of the patients were studied to determine the effect of these parameters on pain relief one and two years postsurgery. The group with screws in the tibial component (Ortholoc II) had a significantly higher percentage of pain-free knees at one year than at two years postsurgery, and the older patients had a significantly higher rate of pain-free knees at one- and two years postsurgery than the younger patients. Older female patients with Ortholoc I TKAs had a significantly higher percentage of pain-free knees than did older male patients at one-year postsurgery, but not at two years. The group with screws in the tibial components (Ortholoc II) had a higher percentage of pain-free knees at one-year postsurgery than did the Ortholoc I knees, but there was no difference between Ortholoc I and II at two-years postsurgery. In the Ortholoc II group, there was also no difference in results among sexes or between patients older and younger than 65 years old. The correlation coefficient was calculated to evaluate the relationship between body weight and the degree of pain after TKA. No significant correlation could be found at one and two years after surgery.

Spinal cord stimulation in the treatment of paraplegic pain.

Twenty-five patients suffering from intractable pain due to a chronic spinal cord lesion underwent a percutaneous test of spinal cord stimulation. At the end of the test period, 40.9% of the patients reported a mean of 65% pain relief and these patients were selected for ongoing stimulation. At a mean follow-up time of 37.2 months the success rate, based on the number of patients with more than 50% pain relief, had fallen to 18.2%. pain relief rates were analyzed in relation to quality of pain, neurological status, level and extent of the lesion, and electrode level to identify prognostic factors that could improve the clinical usefulness of spinal cord stimulation. Patients experiencing painful spasms or a constrictive type of pain and with incomplete thoracic lesions were found to be the best candidates for spinal cord stimulation.

Continuous epidural infusion of morphine for pain relief after cardiac operations.

Postoperative pain relief and stress hormones were examined during the use of continuous epidural infusion of morphine at a rate of 0.1 mg/hr in 30 patients (Group B) after coronary artery bypass grafting. This was compared to our routine method of postoperative analgesia of intravenous morphine 2 mg/2 hr and as needed in another 30 patients (Group A). Continuous epidural morphine infusion required occasional supplementation with intravenous morphine and achieved effective analgesia in 80% of the patients. pain relief was adequate in 50% of the patients in Group A. The mean dose of morphine used in Group B during the first 3 postoperative days was 5 mg per patient per day and was significantly lower than that used in Group A (mean 18 mg per patient per day). Serum morphine was undetectable (below 2.5 ng/ml) in Group B and was significantly lower than that in Group A (17 ng/ml). Epidural analgesia was associated with adequate postoperative pulmonary and cardiovascular functions; nausea and vomiting occurred in two patients. Levels of postoperative stress, serum cortisol, and beta-endorphin were significantly lower in Group B than in Group A. This study shows that continuous epidural infusion of morphine at a rate of 0.1 mg/hr provides selective and effective pain relief and reduces postoperative stress after cardiac operations. This method of analgesia was also associated with minimal side effects and provides an alternate approach for treatment of pain after cardiac operations.

The effectiveness of microvascular decompression in various types of vascular compression in patients with trigeminal neuralgia

The aim of the work was to evaluate the efficacy of microvascular decompression (MVD) in different types of vascular compression (VC) in 20 patients with the idiopathic form of trigeminal neuralgia (TN). The typical VC was found in 17 cases. An arterial vessel was the cause of VC in 6 cases, a venous vessel in 5. The mixed type of VC was present in 6 cases. In every case of the mixed VC one of the vessels compressing the 5th nerve predominated: arterial in 5 and venous in 1. In 3 cases of TN no VC was found. Observation time after MVD was from 6 to 61 months (median 26.7 months). In the TN patients with the arterial VC (including the mixed VC with the arterial predominance) pain relief was complete in 7 cases, satisfactory in 2 and none in 1 case. In patients with venous VC (including mixed VC with venous predominance) pain relief was complete in 4 cases and satisfactory in 2. In the TN patients without VC pain relief was satisfactory in 1, unsatisfactory in 1 and none in 1 case. Long term results of MVD in the analyzed series of the TN patients confirm the efficacy of MVD when vascular compression of the 5th nerve--either arterial or venous--is found intraoperatively.

The effect of wound perfusion on the relief of postoperative pain

The efficacy of wound perfusion (WP) with lidocaine for postoperative pain relief was studied in patients with median incision for cholecystectomy. Twenty four patients were divided into 3 groups according to the method of postoperative pain relief; group C, n = 8: intramuscular injections of penta-zocine 30 mg administered on demand, group WP, n = 8: WP with continuous lidocaine perfusion for 24 hours (plus pentazocine on demand); group EPI, n = 8: buprenorphine administered epidurally for 24 hours (plus pentazocine on demand). Pain scores at 0, 6, 12, 24, 48, hours after operation were examined. Arterial blood gas analysis, FVC and FEV1 were measured preoperatively and on the first postoperative day. Pain scores at 0 and 24 hours in group WP and EPI were significantly lower than those in group C. There were no significant differences in the scores between group WP and EPI at all the points. Analgesic requirement was significantly reduced in group WP and EPI compared with group C. FVC, FEV1 and PaO2 were significantly reduced postoperatively in every group but there were no differences among three groups. PaCO2 significantly increased postoperatively in group C and EPI. We conclude that the technique of wound perfusion with lidocaine is effective and safe for postoperative pain relief.

Why is the pain relief of dying patients often unsuccessful? The relatives' perspectives.

In order to determine relatives' opinions of the pain relief of dying patients a postal questionnaire was sent to close relatives (n = 371) of aged patients (mean age 80.1 years) who had died one to two years earlier. In the relatives' opinions, 57% of the patients (n = 211) had suffered from moderate to severe pain and in 22% (n = 46) of these the pain relief was unsuccessful. Inadequate pain relief was associated with a feeling of helplessness in the patients (odds ratio 2.6), insufficient self-determination of analgesic use (9.4), unsatisfactory care of daily needs such as nutrition (8.3), and insufficient care of concomitant symptoms such as dry mouth (6.2). The pain relief was also evaluated as having been unsuccessful when the relatives received limited information about the forthcoming death (5.7), when it was difficult to discuss with the clinical staff (5.7), and when the relatives were not supported by, for example, comforting and heartening (7.9) or encouraging to participate in the care (7.2). In the multivariate analysis, the self-determination of the patients about their pain medication (5.7), difficulties of the relatives to discuss issues with the nursing staff (3.7) and poor atmosphere of the treatment environment (2.8) emerged as the most significant associates of unsuccessful pain relief. The results show that dissatisfaction with the pain management is associated with low appreciation of the treatment of other discomforts and complaints. Successful pain management therefore requires a holistic approach to the wider spectrum of problems in dying patients.

The efficiency and tolerance of half-body irradiation (HBI) in patients with multiple metastases. The Krakow experience.

AIM: To present our experience regarding the efficiency and tolerance of half-body irradiation in patients with multiple cancer metastases. PATIENTS AND METHODS: Between January 1986 and December 1997, 102 patients with multiple cancer metastases received half-body irradiation (HBI) at the Center of Oncology--Maria Sklodowska-Curie Memorial Institute in Krakow. Most of the patients (93/102) had bone metastases (Table 1). The HBI was performed with 9 MV photon beam from linear accelerator. In 88 patients only one region (upper, mid or lower) was treated, and 14 patients received upper and lower HBI (13 patients), or upper and mid HBI (one patient) (Table 2). The mean doses were: 6 Gy in upper HBI, 8 Gy in mid HBI, and 9 Gy in lower HBI (Table 3). RESULTS: The positive palliative effect (complete or partial pain relief) was observed in 77 (75.5%) patients (Table 4). Complete pain relief was higher in patients with prostate cancer, and in patients who received mid or lower HBI. During follow-up 47 (46.1%) patients developed pain progression after treatment (Table 5). The probability of survival without pain progression was higher in patients who developed complete pain relief (86.7% at 6 months, 69.3% at 12 and 24 months) than in patients with partial response (52.9% at 6 months, 32.8% at 12 months, and 5.5% at 24 months) (Figure 1). In most of the patients (74/102, 72.5%) the tolerance was good. CONCLUSIONS: HBI is an efficient method for palliation in patients with multiple painful metastases.

Pain and the ethics of pain management.

KIE: After clarifying the concepts of "pain", "suffering", "pain of body", and "pain of soul", the author presents a humanistic ethic of pain management based on the premise that the patient has a strong "prima facie" right to freedom from unnecessary pain. This premise imposes two moral obligations upon medical professionals: (1) the duty not to inflict unnecessary pain and suffering upon the patient, and (2) the duty to do whatever is possible to alleviate pain and suffering. Both the questions of informed consent to treatment of pain and the right to refuse pain relief are addressed.

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.

Oral ibuprofen and diclofenac in post-operative pain: a quantitative systematic review.

Surveys show consistently that pain is not treated well. Improvement depends on knowing which treatments are the most effective. We used systematic review to compare the relative efficacy of two common analgesics, ibuprofen and diclofenac, in post-operative pain. Studies were identified by searching MEDLINE (1966 to Dec 1996), EMBASE (1980 to Jan 1997), the Cochrane Library (Aug 1996), Biological Abstracts (Jan 1985 to Dec 1996) and the Oxford pain relief Database (1950 to 1994). We sought randomised, controlled, single-dose comparisons of oral ibuprofen or diclofenac against placebo. Summed pain relief or pain intensity difference over 4-6 h was extracted and converted into dichotomous information yielding the number of patients with at least 50% pain relief. This was then used to calculate the relative benefit and the number-needed-to-treat for one patient to achieve at least 50% pain relief. Thirty-four reports compared ibuprofen and placebo (3591 patients), six compared diclofenac with placebo (840 patients), and there were two direct comparisons of diclofenac 50 mg and Ibuprofen ( Motrin ) 400 mg (130 patients). In post-operative pain, the numbers-needed-to-treat for Ibuprofen ( Motrin ) 200 mg were 3.3 (95% confidence interval 2.8-4.0) compared with placebo, for Ibuprofen ( Motrin ) 400 mg 2.7 (2.5-3.0), for Ibuprofen ( Motrin ) 600 mg 2.4 (1.9-3.3), for diclofenac 50 mg 2.3 (2.0-2.7) and for diclofenac 100 mg 1.8 (1.5-2.1). Direct comparisons of diclofenac 50 mg with Ibuprofen ( Motrin ) 400 mg showed no significant difference between the two. Both drugs worked well. Choosing between them is an issue of dose, safety and cost. Copyright 1998 European Federation of Chapters of the International Association for the Study of Pain.