Radiation therapy in bone metastases from lung cancer

The record of 73 patients with 153 sites of bone metastases from a lung cancer treated by radiation have been reviewed to evaluate the effectiveness of pain relief. Radiation therapy for bone metastases was found to be very effective. Sufficient symptomatic improvement was achieved in 94% of all patients, while 63% obtained almost complete pain relief that was sustained until death. Onset of a symptomatic response to radiotherapy was within less than 20 Gy in total dose in more than 80% of all patients. There were no significant differences in the frequency of pain relief among the various histological types of primary lung tumors.

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.

Spinal cord stimulation in critical limb ischemia of the lower extremities: our experience.

BACKGROUND: Spinal cord stimulation (SCS) improves microcirculatory blood flow, relieves ischemic pain and reduces amputation rate in patients with severe peripheral arterial occlusive disease. Aim: To evaluate the specific prognostic parameters in the prediction of successful SCS and to perform a retrospective data analysis obtained during our patient follow-up. METHODS: 150 patients (97 men, 53 women; mean age: 68 years; range: 46-81) were submitted to implantation of a spinal cord electrical generator for rest pain, and trophic lesions with dry gangrene in severe lower limb ischemia, after failed conservative or surgical treatment. The clinical status was classified as Fontaine's stage III and IV and the main pathology was essentially due to atherosclerosis and diabetic vascular disease. In clinical controls, pedal transcutaneous oxygen tension (TcPO2), ankle and toe pressure Doppler measurements were utilised to select and follow-up the patients. RESULTS: After a mean follow-up of 71 months (range 24-138), pain relief >75% and limb salvage was achieved in 85 patients. In 28 patients was obtained a partial success with pain relief >50% and limb salvage for at least 6 months, while in 37 patients the method failed or for technical problems the device was removed, and the patients were amputated. TcPO2 was assessed on the dorsum of the foot. Clinical improvement and SCS success was associated with the increasing of TcPO2, before and after implantation (temporary period). Limb salvage was achieved in the patients that presented significant TcPO2 changes within the first 2 weeks of the testing period, indifferent from the stage of the disease, and from the initial TcPO2 value. After long-term patient follow-up TcPO2 changes, from 22.6 to 43.1 mm Hg in these with rest pain (p<0.01), from 16.2 to 36.1 mmHg (p<0.02) in those with trophic lesions <3 cm2, and from 12.4 to 28.1 in the patients with trophic lesions >3 cm2. A TcPO2 increase of more than 50% in the first 2 months after implantation was predictive of success, and was related with the presence of adequate paresthesias in the painful area during the trial period. The systolic ankle/brachial blood pressure index did not change under stimulation. CONCLUSIONS: In patients with failed conservative and surgical treatment for severe critical lower limb ischemia, the SCS increases the skin blood flow, is associated with a significant pain relief and could be proven an excellent alternative therapy that improves the quality of life. TcPO2 changes, within a test period of 2 weeks, is a predictive index of therapy success and should be considered before the final decision in terms of cost effect, for the permanent implantation.

Intravenous infusion of fosphenytoin produces prolonged pain relief: a case report.

The objective of this case report is to emphasize the analgesic effect of antiepileptic drugs in those with neuropathic pain, confirm that fosphenytoin possesses these analgesic properties, and to highlight that intravenous administration of fosphenytoin for 24 hours can produce good quality pain relief that lasts for many weeks. A 37-year-old woman with a neuroma (caused by surgical intervention for an endometrial sarcoma) producing neuropathic pain unresponsive to opiates was successfully treated with intravenous infusion of 1,500 phenytoin equivalent units fosphenytoin for 24 hours. The pain relief after this and subsequent infusions persisted for between 3 and 14 weeks and was associated with a reduced opiate requirement and an increase in activities of daily living. Fosphenytoin infusion can give good quality pain relief in the patient with neuropathic pain.

Bilateral chronic proximal plantar fasciopathy: treatment with electrohydraulic orthotripsy.

BACKGROUND: Patients presenting for treatment of chronic plantar fasciopathy often have bilateral involvement. When various nonoperative treatments fail, subsequent intervention may be problematic, especially since bilateral surgery (bilateral fascial release) may not be realistic because of variable, frequently restrictive postoperative weightbearing limitations. METHODS: Twenty-three patients (46 heels) were treated with electrohydraulic high-energy orthotripsy to the plantar entheses of both feet while under the same anesthesia (conscious sedation). Following orthotripsy, all patients immediately were fully weightbearing and resumed normal activities of daily living and work, usually within 24 hours. Progressive return to athletic activities was allowed. Patients were assessed by three outcome parameters: (1) pain measured objectively by a dolorimeter combined with the patient's subjective evaluation of the level of pain; (2) pain after 5 minutes of walking upon arising; and (3) pain with daily activities. All pain measurements were done by the visual analog scale. RESULTS: Patients initially experienced varied pain relief responses. This included earlier pain relief in one heel compared to the other, as well as better pain relief in one heel than the other at the 6- and 12-week evaluations, but with much less variance at the 1-year evaluation. By 3 months following orthotripsy, 28 heels (61%) had good or excellent results. These results were maintained or improved at 1 year. In 18 heels (39%), the outcome was fair or poor. Nineteen heels received a second orthotripsy application; one patient requested a second orthotripsy treatment of only one heel, while nine patients requested a second treatment of both heels. The outcome showed further improvement following the second application of orthotripsy. At 1 year after one or two orthotripsy applications, 19 patients (38 heels) were satisfied with the results in both heels (83%), while four patients (eight heels) still had an unsatisfactory outcome (17%). CONCLUSION: Electrohydraulic high-energy orthotripsy is a reasonable nonincisional method for treating patients with bilateral chronic proximal plantar fasciopathy under a single anesthetic without the prolonged nonweightbearing status often recommended for patients following unilateral open or endoscopic fascial release.

Comparison of percutaneous radiofrequency gangliolysis and microvascular decompression for the surgical management of tic douloureux.

Forty-two patients with tic douloureux underwent posterior fossa craniectomy and microvascular decompression (MVD) or partial rhizotomy of the trigeminal nerve and were followed an average of 25 months after operation. Thirty-six patients were found to have anatomical distortions of the nerve by an artery, vein, bony prominence, or a combination of factors, and 30 patients (83%) of this groups hav remained pain-free postoperatively. Six patients had no discernible pathological condition at the time of operation and underwent partial trigeminal rhizotomy. No patient underwent repeated MVD or rhizotomy, although 4 patients whose pain recurred after MVD underwent rhizotomy at a second operation. Eight of the 10 patients treated by rhizotomy are currently pain-free. The overall success rate of the entire group is 90%; 2% experienced a complication, and there was 1 perioperative death. Seventy-eight patients with tic douloureux who underwent 92 percutaneous radiofrequency trigeminal gangliolysis (PRTG) procedures were evaluated on average of 56 months postoperatively. Sixty-eight per cent of these patients when evaluated 1 year postoperatively were pain-free. However, only 35% of the PRTG procedures resulted in continued pain relief 5 years after operation. Twelve of the 78 patients (15%) required repeat gangliolysis because of recurrent tic pain. Considering all 78 patients treated with 92 PRTG procedures, 64% were pain-free at follow-up examination. PRTG was associated wtih an 8% risk of complications, which included anesthesia dolorosa, corneal anesthesia with keratitis, and significant facial paresthesias. Both PRTG and MVD have advantages. MVD should be considered because: (a) it attacks what is believed to be the primary etiology of tic douloureux, (b) the trigeminal nerve is preserved, (c) postoperative pain relief dose not depend upon the production of sensory deficit, and (d) it may have a greater potential for producing long-lasting pain relief. However, PRTG has other advantages: (a) it avoids the risks of craniectomy, (b) it is repeated easily if tic pain recurs, (c) morbidity is minimal and there is essentially no risk of mortality, and (d) it is much less expensive.

Effective pain relief with continuous intrapleural bupivacaine after thoracotomy in infants and children.

The effect of continuous intrapleural bupivacaine on pain relief after lateral thoracotomy was studied in nine infants (< or = 15 kg body weight) and 11 children (> 15 kg body weight). An intrapleural catheter was inserted under direct vision during surgery. After extubation, the patients were transferred to the ICU where vital signs and pain scores were monitored. An intrapleural infusion of bupivacaine 0.25% with adrenaline was given at a loading dose of 0.625 mg.kg-1 body weight followed by a continuous infusion with a starting rate of 1.25 mg.kg-1.h-1. Haemodynamic and respiratory parameters did not differ significantly from control values throughout the study period in either group. The mean infusion rate could be reduced stepwise in both groups to 0.75 +/- 0.32 mg.kg-1.h-1 and 0.73 +/- 0.38 mg.kg-1.h-1 respectively. The pain score indicated a rapid onset of analgesia in both groups and remained low during the study period. The degree of analgesia amongst other factors was position dependent. The lack of any recognizable side effects or complications related to this method has been most encouraging. Only one child required a supplementary dose of an opioid. We conclude that continuous intrapleural access has proved to be a safe and suitable route for pain relief in infants and children following thoracotomy.

Acupuncture and subtypes of chronic pain: assessment of long-term results.

OBJECTIVE: To determine patients' opinions of pain relief for a longer time after one treatment period of acupuncture for chronic pain. PATIENTS AND SETTING: Two hundred and eleven patients had acupuncture treatment for chronic pain at the Pain Clinic of Malmo University Hospital during 1983-5. Their mean duration of pain was 10.4 years prior to treatment. INTERVENTION: The patients were treated with needle acupuncture with a combination of local and distal points every 1-2 weeks. Both manual and electrical stimulation was utilized. The mean number of treatments was 7.8. DESIGN: In 1988, all patient documents were screened, and the pain conditions were classified as nociceptive, neurogenic, or psychogenic. Of the 211 treated patients, initial results could be evaluated from the clinic records in 202 cases. Eighty-five of these patients (42.1%) experienced pain relief immediately after the treatment period. These patients were sent a 1-page questionnaire by mail in 1988. OUTCOME MEASURES: pain relief over defined time periods (yes/no); do more work at home or at workplace (yes/no); analgesic consumption. RESULTS: Only 35 patients (17.3% of all patients) still experienced pain relief 6 months after treatment. Among those with nociceptive pain, 70 of 142 (49%) had experienced initial pain relief, while those with neurogenic or psychogenic pain experienced relief in only 11 of 34 and four of 26 of the cases, respectively. pain relief for > 6 months was experienced by 33 of 142 of the cases with nociceptive pain, but by only two of 34 of those with neurogenic pain, and by none of those with psychogenic pain. CONCLUSION: Only patients with nociceptive pain can be expected to get pain relief for > 6 months after one treatment period of acupuncture, and of these only a small proportion will be helped.

Treatment of pain of diffuse metastatic cancer by stereotactic chemical hypophysectomy: long term results and observations on mechanism of action.

Stereotactic instillation of absolute alcohol into the sella turcica for pituitary destruction was carried out in 29 patients divided into two groups. Seventeen with prostatic carcinoma underwent a total of 19 injections with 94% good to excellent results that persisted throughout the remainder of the patient's life-span. The longest survival was 9 months. Brief relapses did occur, but spontaneous remissions were the rule. A second group of mixed cancers contained 12 patients who received a total of 13 injections. Eleven patients had good to excellent results that persisted in all but 1 patient. The longest survival was 7 months. Hormonal levels and prolactin stimulation tests failed to show any correlation between hormonal changes and pain relief. Naloxone reversal of analgesia did not occur. There was no loss of cognitive function shown on psychological testing. Pathological studies showed destruction of the pituitary gland, which was subtotal in some patients despite good pain relief. All examinations showed that the pituitary stalk was destroyed. Patients who survived longer also showed degeneration of the supraoptic and paraventricular nuclei of the hypothalamus and the median eminence. All but 1 patient with pain relief exhibited a lack of antidiuretic hormone (ADH) production. Interpretation of the data indicates that ADH or its associated neurophysins act as central pain transmitters. The production of these transmitters is decreased or abolished by chemical hypophysectomy through the destruction of hypothalamic nuclei.

Do quantitative changes in pain intensity correlate with pain relief and satisfaction?

OBJECTIVE: To correlate measured pain intensity (PI) changes with pain relief and satisfaction with pain management. METHODS: A prospective single-group repeated-measures design study. A heterogeneous group of patients were asked to record their levels of PI at initial presentation and at ED release using a numerical descriptor scale (NDS) and a visual analog scale (VAS). At release, a 5-point pain relief scale and a pain management satisfaction survey were also completed. RESULTS: A convenience sample of 81 patients were enrolled over the study period. The average reduction in PI for all patients was 33%. A 5%, 30%, and 57% reduction in PI correlated with "no," "some/partial," and "significant/complete" relief, respectively (p < 0.001). However, when patients were divided into 2 groups based on their initial PI scores, patients with moderate/severe pain (NDS > 5) required a reduction of 35% and 84% in PI to achieve "some/partial" and "significant/complete" relief, respectively. Patients in less pain (NDS < or = 5) needed 25% and 29% reductions in PI for the same categories (p=0.8). Patients were generally satisfied with their pain management. There was a positive association between pain relief and satisfaction with pain management. CONCLUSION: There is a significant association between changes in PI and pain relief. Greater reductions in PI are required for patients presenting with more severe initial pain to achieve relief compared with those who have lesser initial PI. While there is a linear relationship between increasing pain relief and satisfaction, relief of pain appears to only partially contribute to overall satisfaction with pain management.