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.

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.

Analgesic effects of epidurally administered fentanyl for postoperative pain relief--comparison with buprenorphine

We did a retrospective study on 177 patients after upper and lower abdominal surgery, and compared the efficacy of epidural administration of fentanyl and that of buprenorphine for postoperative pain relief. In fentanyl (F) group, 73 patients received fentanyl 0.1 mg with saline 8 ml epidurally after operation, followed by a constant rate infusion of 0.025 mg.hr-1 for 18-24 hrs. In buprenorphine (B) group, 104 patients, received buprenorphine 0.2 mg with saline 9 ml epidurally. After upper abdominal surgery, 33 patients (76.7%) in F group and 27 patients (52.9%) in B group obtained satisfactory analgesia (P < 0.05). The difference of the degree of analgesia after lower abdominal surgery was not significantly different in both groups. Respiratory depression occurred in 19 patients in B group and 5 patients in F group (P < 0.05). It is concluded that epidural fentanyl delivered by continuous infusion offers a significant advantage compared with epidural buprenorphine for postoperative pain relief following upper abdominal surgery.

Treatment of lumbar spinal stenosis with epidural steroid injections: a retrospective outcome study.

OBJECTIVE: To determine patient satisfaction, relief of pain, frequency of injections, change of function, and subsequent surgical rate in patients who received epidural steroid injections (ESIs) for the diagnosis of lumbar spinal stenosis (LSS). DESIGN: Retrospective review conducted using a standard set of questions asked over the telephone, 6 to 36 months after the patient received an ESI. SETTING: An outpatient spine center. PARTICIPANTS: One hundred forty patients at or over the age of 55 years diagnosed with LSS who received ESI(s). INTERVENTION: Transforaminal or caudal fluoroscopically guided ESIs with 60 to 100mg of triamcinalone in combination with local anesthetic or normal saline.Main outcome measures Duration and amount of pain relief, change in functional status, patient satisfaction, and surgical rate, assessed by a 5-item questionnaire. RESULTS: Of the 140 participants, 32% reported more than 2 months of pain relief, 39% reported less than 2 months of pain relief, and 29% reported no relief from the injection(s). Twenty percent subsequently had surgery. Fifty-three percent reported improvement in their functional abilities. Seventy-four percent where at least somewhat satisfied with ESI as a form of treatment. CONCLUSIONS: ESI is a reasonable treatment for LSS, providing one third of our patient population with sustained relief and more than half with sustained improvement in function.

Treatment of deafferentation pain by chronic stimulation of the motor cortex: report of a series of 20 cases.

Twenty patients with deafferentation pain were treated by chronic stimulation of the motor cortex. The central fissure was localized using stereotactic MRI and the motor cortex was mapped using intra-operative somatosensory evoked potentials. Seven patients with trigeminal neuropathic pain experienced definite pain relief varying between 40 and 100%. Ten patients had central pain secondary to central nervous system lesions. A satisfactory long-lasting pain control (pain relief > 40%) was obtained in five of them (50% of cases). One patient with pain from peripheral nerve injury obtained more than 80% pain relief. Two patients had pain from spinal cord lesions. One did not respond but the other obtained an excellent long-term result. The location of the effective stimulation plots was in agreement with the somatotopic maps of the primary motor cortex. One patient developed a small extradural haematoma which resolved spontaneously. None of the patients developed seizure activity. This study confirms the potential value of motor cortex stimulation in the treatment of certain forms of intractable pain, especially in cases with trigeminal neuropathic pain.

An investigation into the use of aromatherapy in intrapartum midwifery practice.

OBJECTIVE: The principal aim of the study was to examine the contribution of aromatherapy to the promotion of maternal comfort during labor and as a tool to improve the quality of midwifery care. DESIGN: Evaluative study. SETTING: Delivery suite in a large British teaching hospital with approximately 6,500 deliveries per annum. SUBJECTS: A total of 8,058 mothers were evaluated between 1990 and 1998. INTERVENTIONS: Women were offered aromatherapy to relieve anxiety, pain, nausea and/or vomiting or to strengthen contractions. Routine data collected on the use of aromatherapy over the period were analyzed. Data from the unit audit were used to provide a comparison group of mothers not given aromatherapy (n = 15,799) from the study center. OUTCOME MEASURES: Outcome measures include mothers' ratings of effectiveness, outcomes of labor, use of pharmacologic pain relief, uptake of intravenous oxytocin, reported associated symptoms, and annual costs. RESULTS: The use of aromatherapy during childbirth was an increasingly popular care option with mothers and midwives. More than 50% of mothers rated it as helpful, and only 14% found it unhelpful. The use of aromatherapy was not confined to low-risk mothers. Sixty percent of the sample were primigravidae, and 32% overall had had their labor induced. The administration of aromatherapy in childbirth did appear to reduce the need for additional pain relief in a proportion of mothers. More than 8% of primigravidae and 18% of multigravidae used no conventional pain relief during labor after using essential oils. During the years of the study, the use of pethidine in the study center declined from 6% to 0.2% of women. The study also showed that aromatherapy may have the potential to augment labor contractions for women in dysfunctional labour. A very low number of associated adverse symptoms were reported (1%). CONCLUSION: This study represents a successful example of the integration of a complementary therapy into mainstream midwifery practice and forms a basis for future research.

Carcinoma of the superior pulmonary sulcus. Results of irradiation and radical resection.

Fifty-six patients with superior sulcus syndrome were evaluated at the First Surgical Department of the University of Padua between 1981 and 1990. Forty-two patients with the characteristic of Pancoast's tumor received preoperative irradiation and then en bloc resection of the tumor, chest wall, and adjacent structures. Seven lobectomies and 35 segmentectomies or wedge resections were performed. There was one early postoperative death. Median survival was 14 months, and actuarial survival was 25% at 5 years. Patients with pain relief had better 5-year survival (36.4%) than patients without pain relief (9%). We have no patients with vertebral invasion who survived more than 1 year. Of the five patients with subclavian artery invasion, only one survived more than 1 year. Of five patients with N2 disease, only one survived more than 1 year. Our results suggest that pain relief after irradiation is a good prognostic factor, whereas N2 involvement and vertebral body and great vessel invasion are ominous factors. Another ominous prognostic factor is the Claude Bernard-Horner syndrome even if it is not a contraindication to resection.

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.

Radiotherapy for pain relief in locally recurrent colorectal cancer.

Eighteen patients with local recurrence of colorectal cancer have been treated by external beam radiotherapy for pain relief. Seven received a fractionated course of 4500cGy and the remainder received single fractions of 1000cGy, a number being treated more than once. The median survival for all patients once recurrence had produced pain was 7 months. Treatment benefit was recorded in 71% treated by fractionated courses and in 66% by single fractions. The duration of pain relief was 3 months for each method. The repeatability of single fraction treatment indicates that this is a worthwhile alternative technique, particularly for those in poor general condition.

Patient-controlled analgesia with piritramid for the treatment of postoperative pain.

Patient-controlled analgesia (PCA, intravenous self-application of narcotics) was studied during the early postoperative period. Subjects were 40 ASA I-III patients recovering from elective major and minor surgery (20 each having undergone abdominal or orthopedic operations). Whenever the patients required pain relief, piritramid demand doses of 2.0 mg were given via the hand-button of a microprocessor-controlled injection pump (On-Demand Analgesia Computer, ODAC). Hourly maximum dose was set to 15 mg with a pump refractory time of 1 minute between valid demands. A continuous low-dose piritramid infusion (0.24 mg/h) was additionally administered in order to prevent catheter obstruction. Duration of the PCA period was 19.7 +/- 6.5 hours (mean +/- SD). During this time, 17.1 +/- 13.8 demands per patient were recorded resulting in mean individual piritramid consumptions of 30.4 +/- 28.1 micrograms/kg/h. Self-administration was characterized by considerable intra- and interindividual variability. Following abdominal surgery, slightly more piritramid was needed compared with orthopedic patients, although less pain relief was achieved in the former group. The same proved to be true for a comparison between the sexes, males requiring significantly more piritramide for less pain relief than females (p = 0.05). Over-all efficacy and patient acceptance proved to be excellent. Effectiveness of PCA was judged superior by about 73% of patients when compared with previously experienced conventional postoperative analgesia. Side effects (sweating, nausea, emesis) occurred in about 20% but were usually of minor intensity. No serious circulatory or respiratory problems were observed during the PCA period. Patient-controlled analgesia is discussed as a promising concept for the treatment of acute pain and for clinical pain research.