Continuous epidural infusion of morphine for treatment of pain after thoracic surgery: a new technique.

We evaluated postoperative pain relief and the incidence of side effects of three methods of thoracic epidural analgesia. Ninety patients, divided into three equal groups, received postoperative analgesia after thoracic surgery either as intermittent epidural injections of bupivacaine (25 mg/5 ml, 0.5% solution) as needed, or, intermittent epidural injections of morphine (5 mg/5 ml of normal saline, 0.1% solution) as needed, or continuous epidural infusion of morphine (0.1 mg, in 1 ml of normal saline) per hour supplemented with intravenous morphine (2 mg) upon request. pain relief was evaluated by each patient on a pain scale visual analogue and by pain relief questionnaire for a period of 72 hr. Postoperative pain relief was achieved equally with these three methods of epidural analgesia in all patients with no significant difference between groups. Intermittent epidural injection of bupivacaine relieved pain for 4.9 +/- 1.9 (SD) hr/injection and was associated with urinary retention in all patients, with numbness and weakness of the hands in 12 patients, and with severe hypotension in 7 patients. Intermittent epidural injection of morphine relieved pain for 5.8 +/- 2.3 hr/injection and was associated with urinary retention in all patients, with pruritus in 12 patients, and with central narcosis and respiratory depression in 8 patients. Continuous epidural infusion of morphine with occasional intravenous morphine (2 mg) supplementation also effectively relieved postoperative pain and was associated with minimal systemic side effects. One patient complained of pruritus, and two patients developed urinary retention.(ABSTRACT TRUNCATED AT 250 WORDS)

Long term effects of oral sustained release morphine on neuropsychological performance in patients with chronic non-cancer pain.

Morphine is increasingly used in patients with chronic non-cancer pain, but a major concern associated with chronic use relates to possible cognitive side-effects. The aim of this long-term prospective study was to evaluate the cognitive impact of oral sustained release morphine in patients with non-cancer pain. A battery of neuropsychological tests to explore attention, psychomotor speed and memory was administered. The effects of morphine on pain, quality of life, mood, subjective memory impairment and side-effects were also investigated. Evaluations were performed at baseline in patients free from opioids and then after 3, 6 and 12 months. Twenty-eight patients were included: 18 received oral sustained morphine (range 40-140 mg/day), ten patients stopped morphine prematurely because of side-effects or insufficient pain relief and were followed as a control group. There was no impairment of any neuropsychological variable over time in the morphine treated patients in comparison with the control group. Two measures of information processing speed - the Stroop interference score and the digit symbol test were improved at 6 and 12 months and there were significant correlations with the pain relief and improvement of mood. Self-reported memory impairment improved notably in responders to morphine. Morphine induced persisting effects on pain, and to a lesser extent on quality of life and mood. The visual analog scale score for side-effects increased at 12 months and essentially consisted of gastrointestinal disorders. This study demonstrates that 12 months treatment with oral morphine does not disrupt cognitive functioning in patients with chronic non-cancer pain and instead results in moderate improvement of some aspects of cognitive functioning, as a consequence of the pain relief and concomitant improvement of well-being and mood.

Radiolunate arthrodesis of the rheumatoid wrist - mid- and long-term results

Late Synovectomy of the rheumatoid wrist combined with ulna head resection and dorsal wrist stabilization will not prevent carpal instability and dislocation. Depending on the radiological destruction pattern and the natural course of the wrist according to Simmen, dorsal wrist synovectomy is combined with soft-tissue or osseus stabilization procedures.This article describes the mid- and long-term results of radio-lunate arthrodesis in patients with rheumatoid arthritis. We present a retrospective study of 69 radiolunate arthrodesis performed from 1988 to 1994. Fifty patients with 57 wrists were available for clinical and radiological follow-up. All patients were suffering from rheumatoid arthritis (dominating female). The average length of R.A. illness was 9.6 years. The mean age at operation was 54.4 years. Postoperative results were reviewed with the Clayton score. The radiographic analysis included measurement of the carpal height index and ulnar translation of the carpus. The follow-up period ranged from 4 to 10.8 years (average: 7 years). The postoperative Clayton score averaged 74.2 points, representing 70% good or excellent results. Twelve wrists achieved satisfactory results and five were judged poor. The most benefit was achieved in pain relief and restoration of wrist function and extensor strength. Complete pain relief was achieved in 36 wrists, while 16 reported slight pain from loads. Five patients still complained about pain with daily wrist activity. We noticed a moderate decrease for extension-flexion (-39 degrees ) and for combined ulnar-radial deviation (-10 degrees ). The radiographic analysis proved stabilization of ulnar translocation in most cases. We routinely noticed a moderate radiographic progression according to the Larsen classification (+0.7) with reduction of the carpal height ratio. In conclusion radioulnate arthrodesis proved satisfactory pain relief and maintenance of functional wrist motion. Despite radiographic deterioration, partial wrist arthrodesis restrains ulnar translocation, while stabilization of the rheumatoid wrist is achieved.

Efficacy of serotonin receptor blocker for symptomatic lumbar disc herniation.

Serotonin is one of the chemical mediators associated with nerve root inflammation and sciatic symptoms in lumbar disc herniation. The efficacy of serotonin 5-HT(2A) receptor blocker was examined in 44 patients with symptomatic lumbar disc herniation. A selective 5-HT(2A) receptor blocker (sarpogrelate hydroxychloride) was administered orally at a dose of 300 mg per day for 2 weeks. Visual analog scales of low back pain, sciatic pain, and numbness were significantly improved after the administration of the serotonin 5-HT(2A) receptor blocker. Clinical results were good (> 50% pain relief) in 23 patients, fair (25%-50% pain relief) in five patients, and poor (< 25% of pain relief) in 16 patients. Nineteen patients eventually required surgery because of muscle weakness or cauda equina symptoms. The effect of 5-HT(2A) blocker was good in 64% of patients who had uncontained disc herniation, whereas all patients with contained disc herniation had fair or poor results. Patients with uncontained disc herniation responded more favorably to the 5-HT(2A) blocker treatment than patients with contained disc herniation. A 5-HT(2A) blocker has the potential to block the cascade of acute nerve root inflammation and to alleviate symptoms in lumbar disc herniation.

Who gives pain relief to children?

OBJECTIVE: To compare pre-hospital parental administration of pain relief for children with that of the accident and emergency (A&E) department staff and to ascertain the reason why pre-hospital analgesia is not being given. DESIGN/METHODS: An anonymous prospective questionnaire was given to parents/guardians of children < 17 years. The children were all self referred with head injuries or limb problems including burns. The first part asked for details of pain relief before attendance in the A&E department. The second part of the questionnaire contained a section for the examining doctor and triage nurse to fill in. The duration of the survey was 28 days. RESULTS: Altogether 203 of 276 (74%) of children did not receive pain relief before attendance at the A&E department. Reasons for parents not giving pain relief included 57/203 (28%) who thought that giving painkillers would be harmful; 43/203 (21%) who did not give painkillers because the accident did not happen at home; and 15/203 (7%) who thought analgesia was the responsibility of the hospital. Eighty eight of the 276 (32%) did not have any painkillers, suitable for children, at home. A&E staff administered pain relief in 189/276 (68%). CONCLUSIONS: Parents often do not give their children pain relief before attending the A&E department. Parents think that giving painkillers may be harmful and often do not have simple analgesics at home. Some parents do not perceive that their child is in pain. Parents require education about appropriate pre-hospital pain relief for their children.

NSAID use and efficacy in the emergency department: single doses of oral Ibuprofen ( Motrin ) versus intramuscular ketorolac.

OBJECTIVE: To compare the clinical efficacy of single doses of intramuscular ketorolac and oral Ibuprofen ( Motrin ) in the emergency department (ED) treatment of acute pain. DESIGN: A retrospective analysis of data collected during a prospective survey of pain management efficacy. The design was noninterventional, and therapy was selected by the treating physician independent of the trial. SETTING: Urban teaching hospital adult patient emergency department. PARTICIPANTS: A convenience sample of ED patients in acute pain. INTERVENTIONS: Patients received Ibuprofen ( Motrin ) 800 mg po (n = 95), or ketorolac 60 mg im (n = 30) as a single dose. Therapy was selected by the treating physician and was not influenced by the study. RESULTS: Data collected were a 100-mm visual analog pain scale at patient arrival and discharge, verbal description of pain relief, patient demographics, pain management data, and discharge diagnosis. Baseline pain intensity was higher in patients receiving ketorolac (77 mm median) than in those receiving Ibuprofen ( Motrin ) (65 mm, p = 0.02). pain relief was similar (p = 0.29) with either treatment when assessed by visual analog scale or patient definition of pain relief. CONCLUSIONS: A single dose of either nonsteroidal antiinflammatory drug produced similar pain relief in the general ED population during clinical treatment of pain. Ketorolac should not necessarily be considered a more effective analgesic than Ibuprofen ( Motrin ) in these commonly used doses.

Contradictory correlations between derived scales.

In a clinical trial one scale of pain relief is scored backwards relative to another (high on one corresponding to low on the other), with a consequent large negative correlation. But two derived scales of total pain, obtained by multiplying average pain relief on each scale by duration of pain (common to both pain relief measurements) gave an almost zero correlation. This apparent contradiction is explained by the inverse relationship between the pain relief scales and the large differences in duration of pain experienced by the patients.

The Chiropractic Outcome Study: pain, functional ability and satisfaction with care.

OBJECTIVE: To examine changes in pain experienced, changes in functional ability and degree of patient satisfaction with chiropractic care. Patient characteristics influencing these parameters were also explored. DESIGN: A follow-up study consisting of a questionnaire to be completed at the beginning of treatment and a mailed questionnaire 6 wk later. SETTING: Non-random sample of 13 chiropractic practices in Calgary and Red Deer, Alberta, Canada. PATIENTS: Three hundred sixty-nine patients presenting with neck and/or back pain who saw a chiropractor for the first time or who had not seen a chiropractor for a period for 6 months before the first visit. RESULTS: pain relief and changes in functional ability were greatest among patients whose initial pain or disability level was moderate or severe. No significant improvement was found among those whose initial level of pain or disability was mild. pain relief and improved functional ability was greatest among those with an acute condition and those who saw no one other than the chiropractor during treatment. In addition, pain relief was highest among men, those who perceived themselves to be in good or excellent health and those who had completed treatment in 6 wk. Patients positively endorsed all items on the satisfaction questionnaire, indicating a high level of satisfaction with the care they received. Patients were most satisfied with access to chiropractic care and least satisfied with financial aspects. Improvement in pain and in back and neck disability were significantly related to general satisfaction. CONCLUSION: Based on these results, it seems that patients suffering from back and/or neck complaints experience chiropractic care as an effective means of resolving or ameliorating pain and functional impairments, thus reinforcing previous results showing the benefits of chiropractic treatment for back and neck pain.

Postoperative analgesia after total hip arthroplasty: i.v. PCA with morphine, patient-controlled epidural analgesia, or continuous "3-in-1" block?: a prospective evaluation by our acute pain service in more than 1,300 patients.

STUDY OBJECTIVE: To assess the most appropriate postoperative analgesic technique after hip surgery. DESIGN: Prospective, nonrandomized study. SETTING: University hospital. PATIENTS: 1,338 ASA physical status I, II, and III patients scheduled for elective unilateral total hip arthroplasty (THA). INTERVENTIONS: During the first 48 postoperative hours, pain relief was provided by intravenous (i.v.) patient-controlled analgesia (PCA) with morphine (Group 1), continuous "3-in-1" block (Group 2), or patient-controlled epidural analgesia (PCEA) (Group 3). MEASUREMENTS AND MAIN RESULTS: During a 7.5-year period, pain scores, supplemental analgesia, satisfaction score, technical problems, and side effects were collected by our acute pain service. Postoperative pain relief was comparable in the three groups. More paracetamol was required in Group 2 (1.0 +/- 1.2 g/48 h) and Group 3 (0.9 +/- 1.3 g/48 h) than in Group 1 (0.5 +/- 1.1 g/48 h) (p < 0.01). However, only 8% of patients in Group 2 and 12% of patients in Group 3 needed an opioid. A higher incidence of technical problems was noted in Group 3 (23.4%) than in Group 1 (2.3%) or Group 2 (5.5%) (p < 0.001). A lower incidence of side effects was observed in Group 2 (23.5%) when compared with Group 1 (58.8%) and Group 3 (71.9%) (p < 0.001). Satisfaction score was significantly higher in Group 2 than in the other two groups [80 +/- 16 vs. 87 +/- 14 vs. 81 +/- 14 in Groups 1, 2, and 3 respectively (p = 0.003)]. CONCLUSION: After THA, i.v. PCA with morphine, continuous "3-in-1" block, and PCEA provided comparable pain relief. Because it induces the fewest technical problems and side effects, continuous "3-in-1" block is the preferred technique.

Palliative radiotherapy for bone pain in hormone refractory prostate cancer

From 1970 to 1992, 23 patients were treated with irradiation for palliation of pain caused by bone metastases from hormone refractory adenocarcinoma of the prostate at Cancer Institute Hospital. External beam irradiation was delivered to painful bony metastatic sites using linear accelerator. Numbers of irradiated sites were 1, 2, 3 in 6 patients, 4 in 3 patients and 5 or 7 in one patient. To evaluate the pain relief at the irradiated sites, severity and frequency of pain were measured quantitatively before and 1 month after the treatment. Overall efficacy of palliation was evaluated by summing up results of the irradiated sites in each patient. pain relief was obtained in all the irradiated sites. Minimal relief, partial relief and complete relief of pain were achieved in 10%, 15% and 75% of the 60 irradiated sites, respectively. No significant dose-response relationship was observed. Complete pain relief was attained less frequently at the sites with severe and constant pain that those with moderate and intermittent pain. Minimal, partial and complete palliation of pain was attained in 9%, 17% and 74% of 23 patients, respectively. In patients with highly extensive bone metastases, many irradiated sites, or many irradiated bones, complete palliation was difficult to obtain. Recurrence of pain was observed in one site. In other 59 irradiated sites, pain relief lasted until patient's death or throughout the follow-up period (maximum 51 months, median 9 months). We concluded that external beam irradiation is an effective palliation therapy for pain of bone metastases from hormone refractory prostate cancer and will play a considerable role in the management of advanced disease.