Postoperative intramuscular dextromethorphan injection provides postoperative pain relief and decreases opioid requirement after hemorrhoidectomy.

BACKGROUND: Previous studies have shown that dextromethorphan (DM) produces an analgesic/antihyperalgesic effect. This study was designed to examine whether postoperative DM intramuscular (i.m.) injection could reduce post-hemorrhoidectomy pain. METHODS: At the end of the surgery, patients in the study group (n = 30) were given an intramuscular injection of 40 mg DM and 20 mg chlorpheniramine (CPM) while in the study group (n = 30), the patients were given intramuscular 20 mg CPM only. Pethidine (1 mg/kg, i.m.) was prescribed for postoperative pain relief if required. The time to first pethidine injection, total pethidine consumption, worst pain score, and pethidine-related side effects were recorded for 48 h postoperatively. RESULTS: The time from the end of operation to the first pethidine injection was 5.4 +/- 1.6 h and 17.8 +/- 3.7 h (P = 0.006) in the control group and the study group, respectively. Total pethidine consumption was 139.5 +/- 11.5 mg and 77.5 +/- 12.2 mg (P < 0.001) in the control group and the study group, respectively. The worst VAS score was 7.5 +/- 0.2 and 7.1 +/- 0.2 (P = 0.09) in the control and the study groups, respectively. The number of patients who required pethidine injection was 29 and 21 (P < 0.005) in the control and the study groups, respectively. The number of patients who suffered pethidine-related side effects was 7 and 1 (P < 0.025) in the control and the study groups, respectively. CONCLUSIONS: We found that intramuscular DM given at the end of operation could provide good postoperative pain relief and decrease the pethidine requirement after hemorrhoidectomy.

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.

Subarachnoid and epidural calcitonin in patients with pain due to metastatic cancer.

Nine patients with metastatic cancer who had pain refractory to traditional treatments received a subarachnoid injection of salmon calcitonin. Eight of the nine patients reported pain relief after subarachnoid injection varying from 1 hr to 5 days. Four of the responding patients subsequently received an epidural injection of salmon calcitonin, and two of these patients reported pain relief. Although many patients experienced pain relief, nausea and vomiting appeared to be a significant side effect, occurring in seven out of nine patients.

Palliative radiotherapy of bone metastases: an evaluation of outcome measures.

The objective of this study was to identify and evaluate important patient-based outcomes that are specific to the palliative radiotherapy of bone metastases. We first conducted a literature review to identify and evaluate outcomes that are currently in use. To identify outcomes that are important to patients, in-depth patient interviews were conducted. Finally, issues identified through the interviews were quantified through a prospective survey, in which patients completed a questionnaire prior to commencing radiotherapy and again after 6 weeks. In our literature review, we found that there was no standardized definition of either response to radiotherapy or assessment of pain relief. Pain measurement in many studies was undertaken using very simple measures, which could possibly yield inaccurate results. The vast majority of studies did not include quality of life as an endpoint. The patient interviews and survey showed that chronic pain and associated limitation of movement were the disease symptoms causing the most concern. Having a clear, alert mind and being able in self-care were the aspects of daily living given the highest priority. Sustained pain relief and minimizing the risk of future complications were the main priorities relating to radiotherapy treatment. The practical aspects of treatment (travelling distance, remaining at home and brevity of treatment) were of least importance. This study indicates the complexity of evaluating the outcomes of palliative interventions, and confirms the deficiencies of pain relief as the primary end-point. The patient's quality of life is affected by many factors other than pain (such as limited mobility, reduced performance, side effects and impaired role functioning); hence a wider range of end-points is required. Greater sensitivity is required than in currently used end-points. Concurrent diseases as well as concurrent therapies can make it difficult to attribute effects with precision. Unless such factors are considered in research design, the results may prove unreliable.

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.

Cervical nerve root blocks: indications and role of MR imaging.

PURPOSE: To examine whether magnetic resonance (MR) imaging findings of the cervical spine can predict pain relief after selective computed tomography (CT)-guided nerve root block and thus assist in the appropriate selection of patients who are suitable for this procedure. MATERIALS AND METHODS: Sixty consecutive patients with cervical radicular pain were examined with MR imaging and then treated with CT-guided cervical nerve root blocks (CNRBs). Various MR imaging findings were assessed and compared in terms of associated pain relief after CNRB. pain relief was graded (0%-100%) by using a visual analogue scale (VAS). The relationship between MR imaging findings and level of pain relief was tested by using Mann-Whitney U and Kruskal-Wallis tests. RESULTS: The mean percentage of pain reduction at VAS grading was 46%. There was a significant relationship between pain relief level and both location of disk herniation (mean pain reductions of 41% at median or mediolateral locations and 64% at foraminal locations, P =.034) and location of nerve root compromise (mean pain reductions of 19% at intraspinal, 45% at foraminal entrance, and 58% at foraminal locations; P =.019). There was an inverse relationship between pain relief level and absence or presence of spinal canal stenosis (mean pain reductions of 29% when stenosis present and 53% when stenosis absent, P =.013). Other parameters were not significantly related to pain relief. CONCLUSION: MR imaging of the cervical spine assists in the appropriate selection of patients suitable for CNRB. Patients with foraminal disk herniation, foraminal nerve root compromise, and no spinal canal stenosis appear to have the greatest pain relief after this procedure. Copyright RSNA, 2004

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.

Patient expectations for pain relief in the ED.

The objective of the study was to assess patient expectations for pain relief in the ED. A convenience sample of 522 patients with pain and 144 patients without pain were enrolled in a prospective observational study at a university ED. Patients reported a mean expectation for pain relief of 72 % (95% CI 70-74). Eighteen percent expected complete (100%) pain relief in the ED. Patient expectations for pain relief were poorly correlated (r = 0.150) with initial pain intensity. Patients without pain reported a mean expectation for pain relief of 74% (95% CI 71-77) if they had presented with pain. There were no differences in patient expectations for pain relief based on age or gender. Patients expect a large percentage of their pain to be relieved in the ED, and many expect complete analgesia. Patient expectations for pain relief do not vary based on age, gender or pain intensity.

Percutaneous stereotactic differential radiofrequency thermal rhizotomy for the treatment of trigeminal neuralgia.

PURPOSE: The purpose of this study was to evaluate the effectiveness of radiofrequency thermal rhizotomy (RTR) for trigeminal neuralgia, after failure of pharmacological management. PATIENTS AND METHODS: Two hundred fifteen patients underwent RTR from 1991 to 1996 and were prospectively evaluated. These patients were characterized by age, sex, side of the face, and division(s) involved. Patients were evaluated for pain relief, recurrence requiring or not requiring reoperation, and the type and rate of complications. They were followed-up by serial clinical evaluation and telephone interview. Patients were categorized into groups: 1) Successful result: excellent, good pain relief; and 2) Unsuccessful result: fair, poor, or no pain relief. The RTR group was compared with historical controls. Follow-up ranged from 9 to 68 months (mean, 32 months) and results were evaluated at early and long-term follow-up. RESULTS: At early follow-up (defined as immediately postoperatively to 6 months), pain relief of excellent or good quality (successful result) occurred in 198 of 215 patients (92%). Fair or poor or no pain relief (unsuccessful result) occurred in 17 (8%) patients. At long-term follow-up (>6 months to 68 months), recurrence of pain that required reoperation occurred in 24 patients (11%) and recurrence of pain that did not require reoperation (medically managed) occurred in 34 patients (16%). Dysesthesia developed in 18 patients (8%); seven patients (3%) had dysesthesia alone (medically managed) and 11 patients (5%) had dysesthesia with recurrence of pain (medically or surgically managed). "Anesthesia/analgesia dolorosa" developed in four patients (1.8%) and was medically managed. At long-term follow-up, 83% of patients had good to excellent pain relief (successful result). There were no mortalities, no significant morbidity, and a low rate of minor complications. CONCLUSION: With the use of this specific diagnostic approach and management algorithm, patients with trigeminal neuralgia can be successfully managed.

Intracranial stimulation for the control of chronic pain.

Long-term stimulation of deep brain structures for pain relief has been efficacious in a significant number of patients who have been total failures at every other means of pain control. Two primary sites are used at this time--the periventricular grey area, which is related to the endogenous opiate system, and the internal capsule system, which is related to the dorsal column projection system. Periventricular sites are more efficacious for externally generated pain, that is, pain with input through the dorsal horn. Internal capsule stimulation is more efficacious for central nervous system-generated pain. While the preoperative preparation and intraoperative testing as well as postoperative testing of these patients requires a great deal of time and tedious attention to detail, our long-term results have been excellent using a combined comprehensive pain unit approach to pain and stress management, plus the stimulation techniques in carefully selected patients. Our results would indicate that initially 80-85% of patients get good pain relief, and then that range decreases to between 50 and 60% over a long period of time. Deep brain stimulation for pain relief is not a technique that should be used on a large number of patients with simple pain problems, but is highly efficacious in a selected group of patients with very specific pain problems that do not respond to usual pain treatment techniques. In patients with pain generated by benign etiologies, it is far superior to destructive procedures and does not have the secondary side effects of sensory loss, postchordotomy dysesthesias, or secondary neurological deficits.(ABSTRACT TRUNCATED AT 250 WORDS)