Non-prosthetic management of grade IV osteochondral lesions of the glenohumeral joint.

Osteochondral lesions of the glenohumeral joint in early stages and in younger patients are an important problem and present a challenge during clinical decision making. Although prosthetic arthroplasty remains the gold standard for treatment in later stages of the disease, alternatives are desirable in the early stages and in young patients. The purposes of this study are to evaluate the results of arthroscopic debridement and capsular release in patients with grade IV osteochondral lesions of the glenohumeral joint and to determine the factors associated with their success. Sixty-one patients with grade IV osteochondral lesions of the glenohumeral articular surfaces were treated with arthroscopic debridement, with or without arthroscopic capsular release. Standardized data collection was performed at the initial office visit and at the time of final follow-up. Overall outcome was analyzed with regard to patients' self-assessment of pain, function, improvement, satisfaction, and duration of pain relief. Forty-five of the patients had a minimum follow-up of 2 years. Time-to-event analysis was used to evaluate the duration of pain relief. The mean patient satisfaction score (0 = not satisfied; 10 = completely satisfied) improved from 0.67 preoperatively to 6.28 at final follow-up (P <.0001), with 87% of patients indicating that they would have the surgery again. Although workers' compensation patients obtained inferior results, significant improvement in pain and function was obtained in 88% of all patients (P <.0001). Most patients noted the onset of pain relief within 5 weeks of surgery and obtained a duration of pain relief of 28 months or greater (P <.05). The addition of concomitant procedures, such as acromioplasty, distal clavicle resection, labral debridement, or labral repair, did not have a negative impact on the functional results after arthroscopic debridement and capsular release. In well-selected patients with grade IV osteochondral lesions of the glenohumeral joint, significant improvements in pain relief and function follow arthroscopic debridement of the glenohumeral joint. Arthroscopic capsular release can be added in patients with a loss of passive arcs of shoulder motion. Osteochondral lesions greater than 2 cm(2) appear to be associated with return of pain and failure of this procedure.

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.

Gamma knife surgery with a dose of 75 to 76.8 Gray for trigeminal neuralgia.

OBJECT: The author presents a large series of patients with idiopathic trigeminal neuralgia (TN) who were treated with gamma knife surgery (GKS), at a maximum dose of 75 to 76.8 Gy, and followed up in a nearly uniform manner for up to 4.6 years. METHODS: Two hundred ninety-three patients were treated and followed up for at least 6 months (range 0.4-4.6 years, median 1.9 years). At the final follow-up review, there was complete (100%) pain relief without medicines in 64 patients (21.8%), 90% or greater relief with or without small doses of medicines in 86 (29.4%), between 75 and 89% relief in 31 (10.6%), between 50 and 74% relief in 19 (6.5%), and less than 50% relief in 23 patients (7.8%). Recurrent pain requiring a second procedure occurred in 70 patients (23.9%). Kaplan-Meier analysis showed that 100%, 90% or greater, and 50% or greater pain relief was obtained and maintained for 3.5 to 4.1 years in 5.6, 23.7, and 50.4% patients, respectively. Of 31 patients who described pain relief ranging from 75 to 89%, 80% of patients described it as good and 10% as excellent; of 17 patients who reported between 50 and 74% pain relief, 53% described it as good and none as excellent (p = 0.014). Dysesthesia scores greater than 5 (scale of 0-10, in which a score of 10 represents excruciating pain) occurred in four (3.2%) of 126 patients who had not undergone prior surgery; all these patients obtained either good or excellent relief from TN pain. There were 36 patients in whom the TN had atypical features; these patients were less likely to attain at least 50% or at least 90% pain relief compared with those without atypical TN features (p = 0.001). CONCLUSIONS: Gamma knife surgery is a safe and effective way to relieve TN. Patients who attain between 75 and 89% pain relief are much more likely to describe this outcome as good or excellent than those who attain between 50 and 74% pain relief.

Minimally invasive 360 degrees instrumented lumbar fusion.

A retrospective preliminary study was undertaken of combined minimally invasive instrumented lumbar fusion utilizing the BERG (balloon-assisted endoscopic retroperitoneal gasless) approach anteriorly, and a posterior small-incision approach with translaminar screw fixation and posterolateral fusion. The study aimed to quantify the clinical and radiological results using this combined technique. The traditional minimally invasive approach to the anterior lumbar spine involves gas insufflation and provides reliable access only to L5-S1 and in some cases L4-5. A gas-mediated approach yields many technical drawbacks to performing spinal surgery. A minimally invasive posterior approach involving suprafascial pedicle screw instrumentation has been developed, but without wide-spread use. Translaminar facet fixation may be a viable alternative to transpedicular fixation in a 360 degrees instrumented fusion model. Past studies have shown open 360 degrees instrumented lumbar fusion yields high arthrodesis rates. The study examined the cases of 46 patients who underwent successful 360 degrees instrumented lumbar fusion using a combined minimally invasive approach. Anterior lumbar interbody fusion (ALIF) at one or two levels was performed through the BERG approach; a gasless retroperitoneal approach to the lumbar spine allowing the use of standard anterior instrumentation. Posteriorly, all patients underwent successful decompression, translaminar fixation, and posterolateral fusion at one or two levels through one small (2.5-5.0 cm) incision. Results showed mean hospital stay of 2.02 days; mean combined blood loss was 255 cc; and mean pain relief was 56%, with 75.5% of patients reporting good, excellent, or total pain relief. Forty-two of 46 patients (93.2%) achieved a solid fusion 24 months after surgery. A total of 47% of all patients working prior to surgery returned to work following surgery. The study showed that minimally invasive 360 degrees instrumented lumbar fusion, when performed utilizing these approaches, yields a high rate of solid arthrodesis (93.3%), good pain relief, short hospital stays, low blood losses, accelerated rehabilitation, and a quick return to the workforce. The BERG approach offers technical advantages over the traditional gas-mediated laparoscopic approach to the anterior lumbar spine.

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.

Comparisons of pain relief mechanisms between needling to the muscle, static magnetic field, external qigong and needling to the acupuncture point.

pain relief mechanisms of needling to the pain-producing muscle, application of a static magnetic field or external qigong, and needling to the acupuncture point were investigated in an experimentally designed pain producing muscle of animals. Single isometric twitch height in situ was reduced gradually by 10 Hz tetanic stimulation for one hour of the gastrocnemius muscle of guinea pigs. This reduction of twitch height was recovered by injection of 0.3-1 ml saline to the artery of this muscle, or of injection of a vasodilator, isoproterenol dissolved in 0.1 ml saline. Hence, reduction of twitch height could be induced by reduction of circulation in the muscle and recovery of it could be induced be recovery of circulation. Since it is easily considered that a pain substance might be accumulated in a muscle under reduced circulation, and such an accumulated substance might be eliminated by recovery of circulation, the reduction of twitch height after tetanic stimulation could be estimated as the pain-producing muscle and recovery of twitch, as the pain relieving muscle. 1) Needling to the pain muscle, 2) application of a static magnetic field or external qigong to the muscle, and 3) needling to the acupuncture point recovered the reduced twitch height due to tetanic stimulation. Atropine abolished this effect induced by the above 1, 2 and 3 procedures. Hence, the cholinergic vasodilator nerve might be involved in the induction of this effect. A sciatic nerve cut did not influence the effect of 1), but abolished the effect of 3). Denervation and capsaicin abolished the effect of 1). Substance P and a calcitonin gene- related peptide (CGRP) recovered the reduced twitch height, and atropine blocked the effect of CGRP, but did not block that of substance P. The effect of 2) was equivalent to that of anticholinesterase. A rostral lesion of the contralateral anterior hypothalamus did not abolish the effect of 3, but a caudal lesion of this region did. Electrical stimulation of this region produced an effect similar to that of 3). From these results, it was concluded that muscle pain relief by these procedures might be induced by recovery of circulation due to the enhanced release of acetylcholine as a result of activation of the cholinergic vasodilator nerve endings innervated to the muscle artery. However, manners of activation of the cholinergic nerve was different in effects of 1), 2) and 3). 1) might be induced by axon reflex of the CGRP nerve, 2) might be induced by inhibition of cholinesterase and 3) might be induced by a somato-autonomic reflex. The reflex center of this might be in the anterior hypothalamus.

Pilot study on disposition and pain relief after i.m. administration of meperidine during the day or night.

Two groups (four patients each) of sickle cell anemia patients with severe pain were studied. One group comprised patients admitted to emergency unit in the morning (5:40 to 9:15) and the other patients admitted in the evening (18:53 to 22:50). All patients received intramuscular meperidine (1.5 mg/kg). Pain intensity and pain relief were followed for 4 h; blood samples were taken up to 6 h after drug administration. Significant differences in drug disposition were found between the day and night groups, as the elimination half-life was 46% shorter during the night and the total serum clearance was 70% greater during the night. Whereas a positive correlation was found between drug concentration and pain relief for the day group, no such correlation was found for th night group. Even though peak concentrations were higher during the night, analgesia was lower. This pilot study suggests that much higher meperidine doses might be required during the night to achieve equieffective analgesia.

Comparisons between patients' and nurses' assessment of pain and medication efficacy in severe burn injuries.

In order to provide burn patients with adequate pain relief, the nurses must be able to accurately evaluate the patients' pain levels and to assess whether sufficient analgesia is achieved or not. The present study examined this issue by comparing the pain ratings in 42 patients hospitalized for burn injuries and 42 nurses. The patient and the attending nurse were asked to rate, independently of each other, the intensity of the pain felt by the patient during a therapeutic procedure and at rest. When analgesic medication was given prior to the procedure, both the patients and the nurses were asked to estimate the degree of pain relief. All ratings were obtained using visual analogue and verbal scales. The results revealed significant but small correlations between the nurses' and patients' ratings. Frequently, the nurses underestimated or overestimated the patients' pain. Discrepancies were also observed in the evaluation of pain medication efficacy, the nurses showing a tendency to overestimate the degree of pain relief. The accuracy of the nurses' perception did not vary as a function of the patients' age, socioeconomic status or burn severity. However, the number of years of experience in burn-nursing had a significant influence on the nurses' estimation of the patients' pain during therapeutic procedures. Theoretical and clinical implications of these results are discussed with a particular emphasis on the need to implement systematic procedures to assess pain and success of analgesia. Additional recommendations to optimize pain management in burn patients are also made.

Dose-dependent epidural leakage of polymethylmethacrylate after percutaneous vertebroplasty in patients with osteoporotic vertebral compression fractures.

OBJECT: The use of polymethylmethacrylate (PMMA) cement by percutaneous injection in cases requiring vertebroplasty provides pain relief in the treatment of osteoporotic vertebral compression fractures. A retrospective study was performed to assess what caused PMMA cement to leak into the epidural space and to determine if this leakage caused any changes in its therapeutic benefits. METHODS: Polymethylmethacrylate was injected into 347 vertebral compression fractures in 159 patients. The cement leaked into the epidural space in 92 (26.5%) of 347 treated vertebrae in 64 (40.3%) of the 159 patients, as demonstrated on postoperative computerized tomography scanning. Epidural leakage of PMMA cement occurred more often when injected above the level of T-7 (p = 0.001) than below. The larger the volume of PMMA injected the higher the incidence of epidural leakage (p = 0.03). Using an injector also increased epidural leakage (p = 0.045). The position of the needle tip within the vertebral body and the pattern of venous drainage did not affect epidural leakage of the cement. Leakage of PMMA into the epidural space reduced the pain relief expected after vertebroplasty. The immediate postoperative visual analog scale scores were higher (and therefore reflective of less pain relief) in patients in whom epidural PMMA leakage occurred (p = 0.009). Three months postoperatively, the authors found the highest number of patients presenting with pain relief, including those in the group with epidural leakage, and at this follow-up stage there were no significant differences between the two groups. CONCLUSIONS: The authors found that epidural leakage of PMMA after percutaneous vertebroplasty was dose dependent. The larger amount of injected PMMA, the higher the incidence of leakage. Injecting vertebral levels above T-7 also increased the incidence of epidural leakage. Epidural leakage of PMMA may attenuate only the immediate therapeutic effects of vertebroplasty.

Oral ibuprofen and diclofenac in post-operative pain: a quantitative systematic review.

Surveys show consistently that pain is not treated well. Improvement depends on knowing which treatments are the most effective. We used systematic review to compare the relative efficacy of two common analgesics, ibuprofen and diclofenac, in post-operative pain. Studies were identified by searching MEDLINE (1966 to Dec 1996), EMBASE (1980 to Jan 1997), the Cochrane Library (Aug 1996), Biological Abstracts (Jan 1985 to Dec 1996) and the Oxford pain relief Database (1950 to 1994). We sought randomised, controlled, single-dose comparisons of oral ibuprofen or diclofenac against placebo. Summed pain relief or pain intensity difference over 4-6 h was extracted and converted into dichotomous information yielding the number of patients with at least 50% pain relief. This was then used to calculate the relative benefit and the number-needed-to-treat for one patient to achieve at least 50% pain relief. Thirty-four reports compared ibuprofen and placebo (3591 patients), six compared diclofenac with placebo (840 patients), and there were two direct comparisons of diclofenac 50 mg and Ibuprofen ( Motrin ) 400 mg (130 patients). In post-operative pain, the numbers-needed-to-treat for Ibuprofen ( Motrin ) 200 mg were 3.3 (95% confidence interval 2.8-4.0) compared with placebo, for Ibuprofen ( Motrin ) 400 mg 2.7 (2.5-3.0), for Ibuprofen ( Motrin ) 600 mg 2.4 (1.9-3.3), for diclofenac 50 mg 2.3 (2.0-2.7) and for diclofenac 100 mg 1.8 (1.5-2.1). Direct comparisons of diclofenac 50 mg with Ibuprofen ( Motrin ) 400 mg showed no significant difference between the two. Both drugs worked well. Choosing between them is an issue of dose, safety and cost. Copyright 1998 European Federation of Chapters of the International Association for the Study of Pain.