Sacral magnetic stimulation for pain relief from pudendal neuralgia and sciatica.

INTRODUCTION: Magnetic stimulation of the sacral nerve roots is used for neurologic examination. However, no one has reported therapeutic efficacy of pain relief from pudendal neuralgia with sacral magnetic stimulation. METHODS: Five patients with pudendal neuralgia or sciatica received 30 to 50 pulsed magnetic stimuli of the sacral nerve roots. The median age of the patients was 59 (range, 28-69) years; there were 3 females. RESULTS: Sacral magnetic stimulation immediately eliminated the pain. The pain relief lasted between 30 minutes and 56 days (median, 24 hours). Adverse effects were not observed. CONCLUSIONS: This pilot study indicates that magnetic stimulation of the sacral nerve roots may be a promising therapeutic modality for pain relief from pudendal neuralgia and sciatica. Further studies should be performed to determine the appropriate intensity and frequency, as well as the utility of a second course, of magnetic stimulation treatment.

Palliative care education and training during residency: a survey among residents at a tertiary care hospital.

BACKGROUND: Palliative care is the active total care of patients in advanced and incurable stages of cancer. More than 70% of all cancer patients in India require palliative care for relief of pain, other symptoms and psychosocial distress. The need for education and training in palliative care has been emphasized by the World Health Organization (WHO) during the past 15 years. This survey aimed to assess the awareness, clinical knowledge, and education and training aspects of palliative care among the clinical residents of a tertiary care hospital. METHODS: During January and February 1999, a total of 100 residents were asked to respond to a questionnaire on palliative care education and training during residency. The questionnaire consisted of 10 questions (each question with 3 different responses). Awareness regarding palliative care was assessed by 3 questions; clinical knowledge by 4 questions; and education and training obtained during residency by 3 questions. Comparisons were made using the Chi-square test between the oncology and non-oncology resident groups. RESULTS: Forty-nine residents (23 oncology and 26 non-oncology) responded to the survey. Awareness that palliative care involves active total care was lacking in 8 (16%) residents. The cost of palliative care in India was considered high by 17 (65%) non-oncology residents and 21 (43%) of the whole group. Hospice, as the right place for palliative care, was chosen by 14 (61%) oncology and 3 (11.5%) non-oncology residents (p = 0.0003). In the whole group, 21 (43%) believed that palliative care could be provided on an outpatient basis. Pain, depression and cachexia were identified as the most distressing symptoms of patients with incurable cancer. Seventeen (83%) oncology and 4 (15%) non-oncology residents (p = 0.000) knew how to use the WHO step-ladder for cancer pain relief. All oncology residents and 10 (38%) non-oncology residents preferred the oral route for providing medications for pain relief (p = 0.0001). The didactic education and training imparted during residency was considered as 'not enough' by 39% of oncology and 62% of non-oncology residents (51% overall). The confidence to deliver quality palliative care was lacking in 43% and 58% of oncology and non-oncology residents, respectively. CONCLUSION: Clinicians in India need to be provided focused skills and training for them to be able deliver quality palliative care to the large number of patients with incurable cancer. The cost of palliative care and the optimum place to deliver it, the symptoms of advanced cancer, pain relief and symptom control methods and quality of life in end-stage cancer patients are some aspects that should be an integral part of clinical residency programmes.

Transcutaneous oxygen tension (TcPO2) in the testing period of spinal cord stimulation (SCS) in critical limb ischemia of the lower extremities.

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 transcutaneous oxygen tension (TcPO2) measurements as a specific prognostic parameter in the prediction for permanent device implantation in a prospective controlled study in patients with lower limb ischemia. METHODS: 45 patients (35 men, 10 women; mean age 65 years, range: 46-70 years) were submitted to implantation of a spinal cord electrical generator for rest pain, trophic lesions dry gangrene in severe lower limb ischemia, after failed conservative or surgical treatment. The clinical status was classified as Fontaine's stages III and IV and the main pathology was essentially due to atherosclerosis and diabetic vascular disease. Pedal transcutaneous oxygen tension (TcPO2), ankle and toe pressure Doppler measurements were performed before, 2 weeks and 4 weeks after implantation. RESULTS: After 18 months follow-up, pain relief was > 75% and limb salvage was achieved in 26 patients. In 9 patients, a partial success with pain relief > 50% and limb salvage was obtained for at least 6 months. In 10 patients, the method failed, and the patients' limbs were amputated. TcPO2 was assessed on the dorsum of the foot. Clinical improvement and SCS success was associated with an increase of TcPO2, within the first 2 weeks after implantation (temporary period). Limb salvage was achieved in those patients who presented significant TcPO2 increase within the first 2 weeks of the testing period (from 21.6 mmHg to 29.5 mmHg in the patients with rest pain, P = 0.035, from 15.2 mmHg to 21.1 mmHg, P = 0.035 in those with trophic lesions < 3 cm2, and in those with trophic lesions > 3 cm2, from 12.4 mmHg to 17.3 mmHg) independently of the stage of the disease and of the initial TcPO2 value. TcPO2 changes were related to the presence of adequate paresthesias and warmth 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 prove an excellent alternative therapy that improves the quality of life. We also demonstrate that TcPO2 increase within a test period of 2 weeks, is a predictive index of SCS therapy success and should be considered in terms of cost effect before the final decision for permanent implantation.

Segmental epidural analgesia for labor and delivery.

A study to evaluate segmental epidural analgesia in labor is described. Bupivacaine (0.25 per cent) was used during the first stage of labor and for the second stage, either 3 per cent - Chloroprocaine delivered through the catheter (Group I) or 1 per cent Lidocaine as a perineal infiltrate (Group II) was used. There were 124 full term patients of whom, 36 were nulliparous and 88 were multiparous. The effects of segmental epidural analgesia on maternal blood pressure, pain relief, preservation of lower limb motor power, duration and progress of labor, and fetal outcome were evaluated. pain relief during the first stage of labor was satisfactory in 114 (92 per cent) of the patients. There were no significant changes in maternal blood pressure, motor power in lower limbs, efficiency of uterine contractions and internal rotation of the presenting part when analgesia was effective. The use of 2-Chloroprocaine for second stage pain relief required low forceps delivery in 84 (91 per cent) patients, as compared to 14 (44 per cent) patients that had 1 per cent Lidocaine local infiltration. Fetal outcome, was excellent in all cases in that the one minute Apgar score was never lower than 7.