Continuous intrathecal analgesia in terminal cancer patients within transmural health care

OBJECTIVE. To record the daily morphine doses, the influence of the treatment on quality of life and the incidence of side-effects and complications of continuous intrathecal morphine administration. SETTING. Academic Hospital, Free University, Amsterdam. DESIGN. Prospective. METHODS. Forty terminal patients with intractable cancer pain, who had either insufficient pain relief or severe side effects from systemic analgesics were selected for continuous intrathecal administration of morphine. An intrathecal catheter was implanted, tunnelled and connected with a portable infusion pump delivering morphine constantly and if needed on demand. In a pain diary the patients recorded: the number of daily doses of morphine, concomitant medication, pain scores on a visual analogue scale (VAS), extra doses and activities. RESULTS. The total number of catheter days was 1486. Patients were treated for a mean of 37.2 (range 2-183) days. The mean dose of daily administered morphine was in 30 patients (75%) less than 20 mg. Sufficient pain relief (VAS score < 5) was achieved in 37 patients (92.5%). Three patients had pain due to spinal cord compression, hardly responding to intrathecal morphine. Withdrawal symptoms, post-puncture headache and leakage of fluid could been treated conservatively. The catheter was removed inadvertently 6 times and could be replaced on outpatient basis. Meningitis occurred in 2 patients, who were adequately treated with antibiotics. The catheter could be re-inserted within 10 days. CONCLUSION. In terminally ill cancer patients, the continuous intrathecal administration of morphine may be recommended if conventional pain relief fails.

Defining patient-based minimal clinically important effect sizes: a study in palliative radiotherapy for painful unresectable pelvic recurrences from rectal cancer.

PURPOSE: To measure patient-based minimal clinically important effect sizes (minimal incremental benefit that an individual would require to accept one treatment option over another) for pain relief between two contrasting palliative radiotherapy regimens for painful pelvic recurrences from rectal cancer. METHODS AND MATERIALS: Forty-three patients with a history of cancer pain without prior pelvic radiotherapy participated in decision aid-facilitated trade-off exercises. The clinical scenario and treatment options of a 5-day vs. a 20-day course of radiotherapy were described. The duration of pain relief for the 20-day regimen was increased until the respondents' preferences switched to the 20-day regimen. The exercises were repeated for different probabilities of benefit and pain intensity at the time of decision making. RESULTS: When the probability of pain relief was unchanged, the median switch point for the duration of pain relief was 6.7 and 7.2 months for severe and mild pain, respectively. The cumulative percentage frequency curve for the switch points approximated a sigmoid distribution. CONCLUSION: Determining the minimal clinically important effect sizes for symptom relief for palliative therapies is feasible. This type of information can be used to incorporate patient values into clinical trial designs. Modification of this method can be used to improve our understanding of shared (physician and patient) decision making.

Response of intractable pain to continuous intrathecal morphine: a retrospective study.

We have treated 37 patients with intractable pain (35 with cancer-related pain) by continuous intrathecal morphine infusion via implanted pump. These patients were carefully selected according to specific criteria, and each demonstrated a significant reduction in pain following a test dose of intrathecal morphine. All patients had good pain relief from intrathecal morphine infusion, even with pain located in cervical dermatomes. Systemic narcotics could be withdrawn from most patients. Significant side effects were rare and typically self-limited. Many patients required gradually increasing doses, seemingly related to disease progression. Two patients with non-malignant pain have had variable dose requirements over 28 and 44 months without clear tolerance. In these patients we observed a reduction in side effects associated with systemic opioids when continuous intrathecal opioid infusion was instituted. Intrathecal opioid administration may have fewer complications than ablative pain relief procedures. In properly selected patients, this method offers an effective alternative for pain relief.

Spinal cord stimulation--a long-term evaluation in patients with chronic pain.

Spinal cord stimulation (SCS) is an established treatment modality for chronic pain, angina pectoris, and peripheral vascular disease. This study evaluates experience with SCS over a 13-year period with emphasis on surgical complications, revisions and pain relief. It took the form of a retrospective study of medical/surgical records coupled with a postal/telephone questionnaire. The subjects consisted of seventy patients, aged from 21 to 76 years (mean 47; median 46), with severe, chronic pain refractory to conventional treatment, who underwent SCS implantation between 1984 and 1997. It investigated surgical revisions, complications and pain relief. There were 72 surgical revisions comprising electrode replacement/repositioning (32), generator replacement (22), cable failure (6) and implant removal (12). Half the devices were revised within 3 years (95% confidence interval: 2-5 years) of implantation. Six (8.6%) implants became infected. Sixty per cent of patients reported substantial relief of pain. This study shows that the majority of patients undergoing SCS derive significant benefit in terms of pain relief, but commonly require surgical revisions due to both technical and biological factors. These devices require systematic evaluation to determine optimal usage, clinical effectiveness and cost-benefit analysis.

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.

Objective and subjective response in stage D2 prostate cancer patients with cancer pain

Fourty-eight patients with stage D2 prostate cancer, initially treated with endocrine therapy at the University of Tokyo between 1981 and 1990, were followed up and analysed. For the assessment of a subjective response, pain score, narcotic score, and performance stages (PS) were used. Of the fourty-eight patients, twenty-one suffered from cancer pain due to bone metastases. These patients showed significantly (p < 0.01) more lesions of bone metastases and higher PS, compared with patients without cancer pain. The progression free survival of these patients was significantly (p < 0.01) lower than that of patients without cancer pain, although the actuarial survival was not significant. In twenty-one patients with cancer pain, the objective and subjective response rates to endocrine therapy were 75% and 86%, respectively. The duration of pain relief was 1.25-54 (median 19) months. Those rates to anti-cancer chemotherapy in refractory patients (8 patients) previously treated with endocrine therapy were both 25% and those to additional administration of flutamide (FUL) or diethylstilbestrol (DES) in refractory patients (6 patients) were 33% and 100%, respectively. Although the duration of pain relief was 0.78-8 (median 2) months, the additional administration of DES or FLU led to pain relief and improved quality of life (QOL) in all 6 patients. Endocrine therapy such as LH-RH agonist and non-steroidal pure anti-androgen, which has no severe side effects, would be of great usefulness in stage D2 prostatic cancer patients with pain on the basis of efficacy and safety.(ABSTRACT TRUNCATED AT 250 WORDS)

Test instrument for predicting the effect of rigid braces in cases with low back pain.

The difficulty of predicting the acceptance and the result of wearing rigid braces has been identified before and is reported in the literature. Therefore a test instrument has been developed and tested. The intention is that the test instrument can imitate a rigid brace. Furthermore, different attributes of the rigid brace can be altered. Thus the range of the lordosis, the level of maximal dorsal support and the amount of abdominal support can be altered. By changing these parameters the maximal pain relief is sought. A good correlation between the result in the test instrument and the rigid brace manufactured according to the information from the former was seen (93%). No false negative results were seen. Thus, if no acceptance or pain relief was seen in the test instrument no pain relief could be expected in a rigid brace. Another purpose of this test instrument is to simplify the manufacture of the brace and to transfer easily the information gained from the test instrument to the brace with the aid of a so called measuring device.

Sensory decision theory and visual analogue scale indices predict status of chronic pain patients six months later.

Thirty-nine outpatients suffering from chronic pain were studied in a multidisciplinary program. Pain intensity on a visual analogue pain scale (VAPS), sensory decision indices of thermal discriminability, P(A), and pain report criterion, B, age and sex obtained before treatment, were used to predict the patients' status, determined by a follow-up questionnaire 6 mo later. The results showed that patients who were high on the VAPS at intake had shorter pain relief and decreased physical activities on follow-up. Patients with better thermal discriminability had greater pain relief, while those with low pain report criterion, that is, less stoical, demonstrated improved physical activity, and more social and hobby activities. Patients who were less stoical to thermal stimuli (lower pain criterion) took fewer centrally active drugs after treatment. Younger patients showed greater improvement at follow-up. The data indicate that the VAPS, thermal discriminability, and pain report criterion all predict the duration of pain relief after treatment. Nevertheless, each of these variables had its individual character. The VAPS was most efficient in predicting physical activities, thermal discriminability related best to pain relief, and pain report criterion to social and hobby activities as well as drug intake.

Symposium on Surface Replacement Arthroplasty of the Hip. Socket and cup surface replacement.

pain relief is the most striking feature following this procedure. In Group I, in which the metal acetabular socket and the metal femoral cup were used, 60 per cent of the patients gained satisfactory pain relief at five to nine years of follow-up. In Group II, in which the metal-polyethylene socket and the metal cup were used, 84 per cent of the patients gained satisfactory pain relief, with 1 to 5 years of follow-up. There have been 12 revision cases in the 130 hips operated on, with the average time to revision being 3 years and 10 months. Revision procedures consisted of the conventional total hip replacement (seven cases), replacement of the socket and/or the cup (four cases), and arthrodesis (one case). The secondary operations could be performed without difficulties, probably because no bone cement was used in our surface replacement. No cases of pulmonary embolism, thrombophlebitis, deep infection, heterotopic ossification, or femoral neck fracture were encountered after the procedure.

Postoperative pain relief and hospital stay after total esophagectomy.

Intraoperative and postsurgical epidurally administered pain relief is associated with reduced morbidity. We reviewed the charts of 19 patients who had total esophagectomy to see whether the method of postoperative pain relief influenced the length of hospital stay and cost of the procedure. The patients received either intravenous (group M) or epidural (group E) morphine for postoperative pain. The length of stay in the intensive care unit was reduced by 2 1/2 days and total hospital stay by 7 days in the epidural group. This resulted in a saving of Canadian $12,770 per patient.