Microsurgical DREZotomy for pain due to brachial plexus avulsion: long-term results in a series of 37 patients.

The authors analyzed the postoperative and long-term results of the microsurgical DREZotomy procedure performed in 37 patients suffering from chronic pain due to brachial plexus avulsion. The evaluation was based on clinical parameters. The immediate results consisted of good pain relief (pain relief > 75%) in 79% of the patients. A long-lasting good pain relief has been achieved in 66.5% of the patients with a mean follow-up of 60 months (range 12-120). The morbidity rate was 5%.

Long-term intrathecal infusion of morphine and morphine/bupivacaine mixtures in the treatment of cancer pain: a retrospective analysis of 51 cases.

A retrospective analysis of 51 patients with cancer pain treated with a continuous i.t. morphine infusion through a tunnelled percutaneous catheter was undertaken. Because of insufficient pain relief with morphine only, 17 of these patients received a morphine/bupivacaine mixture. pain relief subsequently improved significantly in 10 patients and a moderate improvement was present in 4 patients. An additional analgesic effect of bupivacaine was not shown in 3 patients with clinical signs of severe mental depression. Bupivacaine-induced side effects were absent below a daily dosage of 30 mg by continuous infusion. In all patients a gradual dose increment was observed. No serious complications, neurologic sequelae or meningitis occurred. It is concluded that long-term i.t. infusion of morphine through a tunnelled catheter can provide adequate pain relief in cancer patients with an acceptable risk-benefit ratio. The effects of long-term intrathecal co-administration of local anesthetics, especially bupivacaine, await further prospective evaluation.

Electrical stimulation in chronic low-back pain.

Since 1972, 367 patients with chronic low-back pain have been treated by electrical stimulation (e.s.). Patients with herniated disc lesions and spondylitis and allied conditions were included. Following e.s. 75-100% pain relief was obtained by 53% of the patients 50% pain relief by 27% and there was no improvement in 20% of patients. In a follow-up of 208 patients, 6-36 months later, approximately 70% stated that pain relief was similar to that obtained at the end of treatment.

Postoperative pain relief by continuous epidural infusion of bupivacaine and buprenorphine

Continuous postoperative pain relief produced by epidural block with bupivacaine and buprenorphine was evaluated in 12 patients after thoracotomy, 19 patients after upper abdominal surgery, and 14 patients after lower abdominal surgery. Patients initially received 8 ml of 0.25% bupivacaine and 0.1 mg of buprenorphine at recovery room in operating theater and continuously received the mixture of 0.25% bupivacaine and 5 micrograms.ml-1 buprenorphine at a rate of 1 ml.h-1 using a portable pump. About fifty percent of the patients did not need additional narcotics during 48 postoperative hours. About ninety percent of the patients needed one additional narcotics during 48 postoperative hours. The authors conclude that epidural analgesia with the mixture of bupivacaine and buprenorphine produces satisfactory postoperative pain relief.

Effects of topical capsaicin on normal skin and affected dermatomes in herpes zoster.

Hyperalgesia and allodynia, lasting for months or even years, occurs in the form of post-herpetic neuralgia in approximately 70% of adults previously infected with the varicella herpes zoster virus. The present study aimed at testing the analgesic desensitising actions and reversibility of repeated application of topical capsaicin on disordered polymodal nociceptors and peptidergic sensory fibres mediating warm and pain sensation. Cutaneous nociceptor desensitisation was measured using the Glasgow automated thermal threshold test (Medelec TTT). For normal subjects (n = 69) the mean forearm warm threshold was 0.15 +/- 0.07 degrees C and the cold threshold was 0.14 +/- 0.10 degrees C. A variable degree of partial desensitisation of herpes-affected skin was found in 15 patients with post-herpetic neuralgia before capsaicin treatment where the mean threshold elevation for warm detection was 1.19 degrees C and 0.7 degrees C for cold detection, compared with the corresponding normal skin. In preliminary studies of 15 patients with post-herpetic neuralgia, good pain relief averaging 30% or 77% occurred in the affected dermatome(s) after 3 to 4 weeks of 0.01% or 0.05% capsaicin cream respectively, applied 3-4 times daily. The warm thresholds, after chronic capsaicin treatment, increased between 0.1 and 7.60 degrees C, the average elevation being 3.69 degrees C. By contrast cold thresholds after capsaicin altered inconsistently and by only an average of 0.08 degrees C. The results suggest that elevation of the warm threshold may indicate the desensitisation achieved by capsaicin treatment of skin polymodal nociceptors. Cold detection, being dependent upon A-delta cold fibre function, is unaffected by capsaicin treatment. There was a poor correlation between pain relief and elevation of warm detection in response to capsaicin treatment. Generally, it was found that those patients with less initial desensitisation to warm detection as a consequence of post-herpetic neuralgia experienced better pain relief after capsaicin was applied. The method used permits determination of the minimum effective desensitising dose of capsaicin, enables patient compliance and progress to be monitored and should allow the prediction of patients likely to achieve the best response to treatment.

Neonatal circumcision and pain relief: current training practices.

OBJECTIVE: We conducted a national survey of pediatric, family practice, and obstetrics and gynecology residency program directors to determine the curriculum content and predominant practices in US training programs with regard to neonatal circumcision and anesthesia/analgesia for the procedure. METHODS: Residency directors of accredited programs were surveyed in two mailings of a forced response and short answer survey (response rate: 680/914, 74%; pediatrics 83%; family practice 72%; obstetrics 71%). RESULTS: Pediatric residents were less likely than family practice [odds ratio (OR), 0.04; 95% confidence interval (CI), 0.02-0.08] or obstetrical (OR, 0.14; 95% CI, 0.08-0.23) residents to be taught circumcision. Training and local custom were rated as important determinants of medical responsibility for neonatal circumcision. Pediatric residents training in programs in which community pediatricians perform circumcisions were more likely to learn circumcision (OR, 39.0; 95% CI, 14.3-110.6) as were obstetric residents (OR, 79.0; 95% CI, 22.4-306.4) training in programs in which community obstetricians perform circumcision. In programs that teach circumcision, pediatric (84%; OR, 3.4; 95% CI, 1.7-7.1) and family practice (80%; OR, 2.7; 95% CI, 1.7-4.2) programs were more likely than obstetric programs (60%) to teach analgesia/anesthesia techniques to relieve procedural pain. Overall, 26% of programs that taught circumcision failed to provide instruction in anesthesia/analgesia for the procedure. Significant regional variations in training in circumcision and analgesia/anesthesia techniques were noted within and across medical specialties. CONCLUSIONS: Residency training standards are not consistent for pediatric, family practice, and obstetrical residents with regard to neonatal circumcision or instruction in analgesia/anesthesia for the procedure. Training with regard to pain relief is clearly inadequate for what remains a common surgical procedure in the United States. Given the overwhelming evidence that neonatal circumcision is painful and the existence of safe and effective anesthesia/analgesia methods, residency training in neonatal circumcision should include instruction in pain relief techniques.

Low dose single fraction radiotherapy in the treatment of metastatic bone pain: a pilot study.

Single fraction radiotherapy can be used effectively to palliate painful bone metastases. The optimal single dose of radiotherapy required for pain relief is unknown. Twenty-six patients have been treated with a single fraction of 4 Gy to the site of the bone pain. Partial pain relief was seen in 9/21 (5%). Response occurred within 3 weeks of radiotherapy. These results question the mechanism of pain relief following radiotherapy and suggest a method of pain control using single repeatable low dose treatments.

Thalamic relay nucleus stimulation for relief of intractable pain. Clinical results and beta-endorphin immunoreactivity in cerebrospinal fluid

Chronic implantation of a stimulating electrode in the thalamic relay nucleus (11 cases), in the periaqueductal gray (1 case) and in the internal capsule (2 cases) was performed in fourteen cases which suffered from intractable pain. All these cases could get pain relief at least initial two months. Ventricular fluids were collected before and after stimulation with optimal combination of parameters, and measurements of beta-endorphin were performed by radio-immunoassay. Intrathecal morphine (1mg) injection was performed in eight cases. Cerebrospinal fluids were collected by lumbar tap before and 24 hours after morphine injection. beta-endorphin immunoreactivity was measured by the same method. pain relief was judged to be excellent if the patient so claimed, and if he discontinued analgesics. pain relief was thought to be good when it was not completely controllable by stimulation but was sufficiently improved that the patient could do without analgesics. It was thought to be fair when patient could not discontinue analgesics, and poor when patient could not get pain relief. We usually attempt to prevent the stimulation-tolerance by administration of the monoamine precursors , i.e., 1-dopa and 1-tryptophan, on the basis of the experimental observation reported previously. In somatogenic pain patients, the thalamic relay nucleus stimulation was performed in 7 cases (excellent; 3, good; 1, fair; 3) and the periaqueductal gray stimulation in one case (good).(ABSTRACT TRUNCATED AT 250 WORDS)

Orthotic therapy in the management of osteoarthritis.

The authors evaluate the use of orthoses as a primary therapeutic means in the long-term management of patients with osteoarthritis of the foot and ankle. A comparison of the amount of pain relief experienced by 64 subjects (mean age 63 years) with different treatment regimens for osteoarthritis was made to determine the role orthoses played in helping to reduce or eliminate pain. One hundred percent of the subjects wearing orthoses only for relief of pain had a statistically significant longer period of pain relief than those on nonsteroidal anti-inflammatory drugs. Fifty-five percent of the subjects using orthoses and nonsteroidal anti-inflammatory drug therapy also had a statistically significant longer period of pain relief than those receiving nonsteroidal anti-inflammatory drug therapy only.

Effect of high-dose medroxyprogesterone acetate on plasma hormone levels and pain relief in patients with advanced prostatic cancer.

High-dose medroxyprogesterone acetate (MPA) was given orally to 7 patients with advanced prostatic cancer and severe pain due to bone metastases; 5 patients had stable and 2 had progressive disease. pain relief was obtained in 6 patients. Two patients who reported complete relief of pain showed suppressed levels of gonadotrophins after MPA treatment. In the other patients, suppression of plasma gonadotrophin levels was observed before treatment. The plasma levels of prolactin, growth hormone and thyroid stimulating hormone were not affected by MPA. Only 1 patient showed suppression of plasma adrenocortical trophic hormone. The plasma levels of cortisol and dihydroepiandrosterone sulphate were suppressed in 6 patients, but there was no correlation between the suppression and the occurrence of pain relief. These findings suggest that the mechanism of pain relief by high-dose MPA may be very complicated.