Acupuncture: an evaluation in the painful crises of sickle cell anaemia.

An evaluation of acupuncture for pain relief was made in 10 patients with sickle cell anaemia during 16 pain crises. A model was developed in which the patient served as his own control and in which both patient and examiner were unaware of whether an acupuncture point or a sham site was treated. The results show (1) that pain relief was obtained in 15 of the 16 painful episodes regardless of whether an acupuncture point or a sham site was treated, demonstrating considerable overlap between the effects of needling acupuncture points and sham sites; (2) that needling at acupuncture points for pain relief is not significantly superior to treatment at sham sites; (3) that needling, per se, whether at acupuncture points of at sham sites can be useful for alleviating pain in sickle cell crises. The model could be useful for evaluation of pain relief by needling in other diseases.

Diagnostic epidural opioid technique.

Diagnostic epidural blocks were performed on 27 chronic pain patients sequentially using saline, fentanyl, and lidocaine solution. The patients were divided into one of four groups based on their response to the epidural solutions: placebo response group--pain relief with placebo solutions; fentanyl response group--pain relief with epidural fentanyl; lidocaine response group (LRG)--pain relief with lidocaine but not fentanyl; and no response group--no pain relief with any of the solutions used. The four groups were compared on the basis of age, sex, site of pain, duration of pain, narcotic use, pain assessment index, and workmen's compensation claims. The comparisons resulted in the conclusion that LRG patients had a much longer average duration of pain than the other groups. On the basis of the information gathered, it was theorized that, despite their response to epidural lidocaine, LRG patients may actually be a group of operant pain patients. Their failure to receive analgesia from epidural fentanyl may be a learned response such that they associate any sensory input from the affected area as painful. If follow-up studies support these findings, then the diagnostic opioid technique may be a more sensitive tool in diagnosing chronic pain.

Linear accelerator radiosurgery using 90 gray for essential trigeminal neuralgia: results and dose volume histogram analysis.

OBJECTIVE: To evaluate treatment of essential trigeminal neuralgia with 90 Gy delivered by a linear accelerator dedicated to radiosurgery. METHODS: This is a retrospective case series of 25 patients with essential trigeminal neuralgia treated from March 1999 to March 2001. All were treated with 90 Gy by means of a 5-mm collimator directed to the nerve root entry zone. Patient follow-up (range, 8-52 mo; median, 18 mo) was completed by an uninvolved party. Dose volume histograms of the brainstem were developed for the 20, 30, and 50% isodose lines by means of radiosurgery planning software. RESULTS: All patients obtained good to excellent pain relief with treatment. Nineteen (76%) of 25 patients achieved excellent pain relief (pain-free without medication). Six patients (24%) achieved good pain relief (50-90% reduction of pain with or without medication). Median time to pain relief was 2 months. Eight patients (32%) experienced relapse 4 to 13 months after treatment. Eight patients (32%) developed facial numbness, but none developed painful numbness. Mean brainstem volume within the 50% isodose line and occurrence of numbness was statistically significant (P = 0.03). There was no correlation between brainstem volume treated and outcome. CONCLUSION: Dedicated linear accelerator-based stereotactic radiosurgery that uses a 5-mm collimator to deliver 90 Gy to the nerve root entry zone is a safe and effective method for the treatment of essential trigeminal neuralgia. Care should be taken to limit brainstem volume included in the 50% isodose line in the treatment plan to avoid facial numbness.

Continuous intracisternal and high cervical intrathecal bupivacaine analgesia in refractory head and neck pain.

BACKGROUND: The upper cervical component of the spinomesencephalic tract and cranial nerves V, VII (nervus intermedius), IX, and X are involved in mechanisms of acute and chronic pain from head and neck structures. To date there is no reliable method for relief of refractory pain (i.e., pain that cannot be relieved by conventional pharmacologic therapies) from these structures. Therefore, we explored continuous intracisternal infusion of bupivacaine for the treatment of refractory pain of the head and neck. METHODS: Intracisternal catheters were inserted in 13 adults with refractory nonmalignant (n = 4) and malignant (n = 9) pain from the head, face, mouth, neck, and upper extremities; 0.5% plain bupivacaine was infused continuously at rates of 1-7 (median 1.5) mg/h with optional bolus doses of 0.5-2.0 mg 4-2 times/h. The efficacy was assessed from pain relief (daily VAS(max), VAS(min), and VAS(mean) scores 0-10), daily doses of intracisternal bupivacaine and total opioid (expressed as mg parenteral morphine-eq), amount of nocturnal sleep, and rates of adverse effects. RESULTS: The 13 patients were treated for 3-182 days (median 37, total 712 days), 3 patients being treated at home for 10-112 days (median 88, total 210 days). In one patient, the efficacy of the treatment could not be estimated because of advanced senility. Eleven of the remaining 12 patients obtained acceptable pain relief with daily doses of intracisternal bupivacaine ranging from 20 to 118 mg (median 37 mg): VAS(mean) scores decreased from 7 to 2, mean pain relief increased for 30% to 80%, total opioid daily dose decreased from 53 to 36 mg parenteral morphine-eq, and nocturnal sleep increased from 2 to >6h (all figures are median values). Speech, eating, walking, and natural functions were generally not affected. Side effects such as tiredness and malaise, somnolence and sleep, feeling of coldness in the neck and skull base, transient post-spinal puncture headache, paresthesias, hoarseness, dysphagia, transient paresis of the upper/lower extremities, episodic miosis and conjunctival hyperemia, and transient orthostatic arterial hypotension were each observed in one or two patients. No patient presented clinical evidence of phrenic nerve paralysis. There was no nausea or vomiting. No persistent neurologic deficit or death could be attributed to the intracisternal pain treatment. CONCLUSIONS: Continuous intracisternal infusion of bupivacaine may be a useful method in exceptional, well selected patients with refractory pain from the head and neck structures. Further studies are necessary to establish the indications and the safety of the method.

A preliminary list to identify attitudes toward different conditions for discussing possible termination or refusal of medical treatment except for pain relief.

Effective communication about decisions concerning termination or refusal of medical treatment except for pain relief necessitates clarifying the attitudes of those in the decision-making process. Effective communication increases the likelihood that a patient's advance directives are implemented and decreases the likelihood of litigation. Psychotherapists, counselors, chaplains, etc. can be facilitators of effective communication. This study generated a list for use in discussion by asking persons who cared for individuals with terminal illnesses, critical injuries or elderly people what conditions seemed appropriate for termination or refusal of medical treatment except for pain relief. The 182 out of 204 individuals who contributed conditions showed clear agreement on terminal illnesses, brain disorders, dependence on machines for life, and other irreversible deterioration or severe loss of quality of life, lack of suitable treatment, patient's wish, and concern about the effect of the patient's condition on others. Some specified further qualifications, such as at what point during a terminal illness termination or refusal was appropriate. The list with notes could be appended to a Living Will or a Durable Power of Attorney for Health Care. The notes should be updated periodically. Through use and research, the list also can be refined further.

Percutaneous vertebroplasty for osteoporotic compression fractures: quantitative prospective evaluation of long-term outcomes.

PURPOSE: Osteoporotic vertebral compression fractures may cause debilitating pain that lasts for weeks or months, and which is often neither quickly nor completely relieved by conventional conservative therapy. Previous retrospective studies have suggested significant and nearly immediate pain relief, as well as rapid and sustained functional recovery, after percutaneous polymethylmethacrylate vertebroplasty (PPV). This prospective, quantitative study with long-term follow-up was designed to evaluate the safety and efficacy of PPV as a new treatment for patients with osteoporotic vertebral body compression fractures of the lumbar and thoracic spine. MATERIALS AND METHODS: PPV was performed in 30 patients with 54 symptomatic osteoporotic vertebral compression fractures who had a less-than-satisfactory response to conventional therapy. All procedures were performed by a single operator with significant experience in performing PPV. The Musculoskeletal Outcomes Data Evaluation and Management Scale (MODEMS) spinal intervention questionnaire, which includes the SF-36, was administered to all patients before intervention and exactly 2 weeks after the final PPV procedure. Pain and disability, treatment expectations and satisfaction, mental function, and quality of life were evaluated by four specialized modules, and responses to questionnaires preceding treatment were compared to those obtained at follow-up. Results of a long-term follow-up questionnaire were collected 15-18 months after the final vertebroplasty treatment. RESULTS: Our population consisted of three men and 27 women, with a mean age of 79 years. Fifty-four PPV procedures were performed for compression fractures in these 30 patients. Significant postprocedural improvement in all four MODEMS modules was demonstrated at 2 weeks (treatment score, P <.0001; pain and disability, P <.0001; physical function, P =.0004; and mental function, P =.0009). A small epidural leak of polymethylmethacrylate in one patient was asymptomatic and did not require intervention. At long-term follow-up (15-18 mo), 22 of 23 patients responding remained satisfied with the outcome of therapy and believed that the procedure had provided durable pain relief. Verbal pain scores documented significantly diminished back pain at 2 weeks (P <.0001) and again at long-term follow-up when compared to baseline (P <.0001). CONCLUSIONS: PPV is a safe and efficacious procedure for the relief of pain and disability after osteoporotic vertebral compression fractures. Patient satisfaction is high and persists when compared to preprocedural expectations; durable pain relief is provided.

Sensory decision theory and visual analogue scale indices predict status of chronic pain patients six months later.

Thirty-nine outpatients suffering from chronic pain were studied in a multidisciplinary program. Pain intensity on a visual analogue pain scale (VAPS), sensory decision indices of thermal discriminability, P(A), and pain report criterion, B, age and sex obtained before treatment, were used to predict the patients' status, determined by a follow-up questionnaire 6 mo later. The results showed that patients who were high on the VAPS at intake had shorter pain relief and decreased physical activities on follow-up. Patients with better thermal discriminability had greater pain relief, while those with low pain report criterion, that is, less stoical, demonstrated improved physical activity, and more social and hobby activities. Patients who were less stoical to thermal stimuli (lower pain criterion) took fewer centrally active drugs after treatment. Younger patients showed greater improvement at follow-up. The data indicate that the VAPS, thermal discriminability, and pain report criterion all predict the duration of pain relief after treatment. Nevertheless, each of these variables had its individual character. The VAPS was most efficient in predicting physical activities, thermal discriminability related best to pain relief, and pain report criterion to social and hobby activities as well as drug intake.

Why do patients feel positive about patient-controlled analgesia?

We studied 200 patients to identify the aspects of their experience of patient-controlled analgesia (PCA) that made them feel 'extremely positive' about this technique. After PCA had been withdrawn, patients completed a questionnaire which included the following topics: pre-operative information, pain relief, the degree of control that PCA afforded the patient, side-effects and safety. Multiple regression analysis identified three factors of their experience which were associated uniquely with feeling 'extremely positive' about PCA: having better pain relief, not worrying about 'giving oneself too much drug' and not experiencing feeling 'peculiar in the head'. Control over pain relief, although highly correlated with feeling 'extremely positive' about PCA, was unimportant when these variables were controlled. Because of the well-recognised difficulties in measuring satisfaction with analgesic regimens, we suggest that a satisfaction score based on these variables would be a significant advance on existing methods.

Cerebrospinal fluid nitric oxide metabolites are novel predictors of pain relief in degenerative lumbar diseases.

This study was undertaken to determine whether or not nitric oxide metabolites (NO(2)(-) plus NO(3)(-): NOx levels) in cerebrospinal fluid (CSF) would be predictors of treatment outcome in patients with degenerative lumbar diseases (DLD) including lumbar disc herniation (LDH) and lumbar spinal canal stenosis (LCS). The NOx levels in CSF were measured using an NO analyzer based on the Griess method. Six healthy volunteers and 18 patients with painless diseases were included in the control group. The pre- and postoperative NOx levels in 25 DLD patients, who underwent herniotomy for LDH (17 patients) or selective decompression for LCS (eight patients), were analyzed. The postoperative follow-up periods were approximately 8 months. Nineteen of 25 DLD patients, whose preoperative NOx levels were two standard deviations higher than the mean NOx levels of an age-matched control group, were included in an NO elevated (NOE) group. Among the 25 DLD patients, the preoperative NOx levels in six patients (young LDH group) were within the normal range. The pain-related Japanese Orthopaedic Association score and the Hirabayashi recovery rate were respectively used to evaluate the pain severity and the degree of pain relief. The preoperative and changes of postoperative NOx levels in the NOE group were negatively correlated with the Hirabayashi recovery rate. Normal postoperative NOx levels and excellent pain relief were achieved in young DLD patients. In conclusion, the preoperative and changes in postoperative NOx levels are quantitative predictors of postoperative pain relief in DLD patients.

Pain management in a rheumatology department: a satisfaction survey.

OBJECTIVES: To evaluate the quality of pain management in a teaching hospital rheumatology department. METHODS: We conducted a satisfaction survey among all the patients admitted to the conventional rheumatology department of our teaching hospital over a 1-month period (88 patients with a mean length of stay of 5 d). The patients were asked to complete a questionnaire on the day of discharge. The professional staff was not informed of the survey. RESULTS: The mean pain severity score at admission (visual analog scale, VAS) was 7.76 +/- 1.76 and the mean score decrease with treatment was 7.27 +/- 2.81. Expected pain relief and actual pain relief were correlated (R = 0.39; P = 0.001). Nearly all the patients (96.1%) reported have been encouraged to communicate about their pain. Information on the treatment was given to 89.3% of the patients; no significant differences in pain severity or pain relief were found between the patients who did and did not receive this information. The patients were satisfied with their management by the physicians (VAS: 8.83 +/- 2.07) and nurses (VAS: 8.68 +/- 1.72). CONCLUSION: Satisfaction with pain management (a subjective criterion) was good in our patients. However, no validated tools for measuring satisfaction are available, and measurements should be repeated to look for improvements over time. Limitations to these results include the placebo effect, the influence of memory, and the effects of the behavior of hospitalized patients. A repeat survey is needed.