A randomized, placebo controlled, trial of preoperative sustained release Betamethasone plus non-controlled intraoperative Ketorolac or Fentanyl on pain after diagnostic laparoscopy or laparoscopic tubal ligation [ISRCTN52633712].

BACKGROUND: Gynecological laparoscopic surgery procedures are often complicated by postoperative pain resulting in an unpleasant experience for the patient, delayed discharge, and increased cost. Glucocorticosteroids have been suggested to reduce the severity and incidence of postoperative pain. METHODS: This study examines the efficacy of a sustained release betamethasone preparation to reduce postoperative pain and the requirement for pain relief drugs after either diagnostic laparoscopy or tubal ligation. Patients were recruited, as presenting, after obtaining informed consent. Prior to surgery, patients were randomly selected by a computer generated table to receive either pharmacy-coded betamethasone (12 mg IM Celestone trade mark ) or an optically identical placebo injection of Intralipid trade mark and isotonic saline mixture. The effect of non-controlled prophylactic intraoperative treatment with either fentanyl or ketorolac per surgeon's orders was also noted in this study. Blood samples taken at recovery and at discharge times were extracted and analyzed for circulating betamethasone. Visual analog scale data on pain was gathered at six post-recovery time points in a triple blind fashion and statistically compared. The postoperative requirement for pain relief drugs was also examined. RESULTS: Although the injection achieved a sustained therapeutic concentration, no beneficial effect of IM betamethasone on postoperative pain or reduction in pain relief drugs was observed during the postoperative period. Indeed, the mean combined pain scores during the 2 hour postoperative period, adjusted for postoperative opioids as the major confounding factor, were higher approaching statistical significance (P = 0.056) in the treatment group. Higher pain scores were also observed for the tubal ligation patients relative to diagnostic laparoscopy. Intraoperative fentanyl treatment did not significantly lower the average pain score during the 2 hour postoperative period. Intraoperative ketorolac treatment significantly lowered (P = 0.027) pain scores and reduced the postoperative requirement for additional pain relief drugs. CONCLUSIONS: There was a lack of efficacy of preoperative sustained release betamethasone in reducing postoperative pain despite maintaining a therapeutic concentration during the postoperative period. Intraoperative Ketorolac did afford some short-term pain relief in the postoperative period and reduced the need for additional pain relief drugs.

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

Caudal epidural blocks for elderly patients with lumbar canal stenosis.

OBJECTIVE: To determine the efficacy of caudal epidural blocks (CEB) in relieving pain and the duration of pain relief with CEB in elderly patients suffering from degenerative lumbar canal stenosis (LCS). DESIGN: This study was a descriptive, prospective study with a 10-month follow-up. PARTICIPANTS AND SETTING: Thirty patients, 76 +/- 6.7 years of age, with leg discomfort with or without back pain and with LCS documented by magnetic resonance imaging (MRI) within 1 year of the study, were recruited from the outpatient clinic of the Cleveland Clinic Florida. None of the subjects had received CEB or surgery for their leg discomfort and none had relief of pain by analgesics alone. MEASUREMENTS AND INTERVENTIONS: Subjects received a total of three doses of 0.5% Xylocaine with 80 mg Depo-Medrol into the caudal epidural space through the sacral hiatus at weekly intervals. The Roland 5-point pain rating scale was utilized before and at 2-month intervals up to 10 months after the CEB was administered. MRI was used to identify the degree of LCS. RESULTS: The degree of LCS on admission was moderate in 66.7% (n = 20) of the patients, mild in 23.3% (n = 7), and severe in the remaining 10% (n = 3). Patients had LCS involving 2.4 +/- 0.49 lumbar vertebrae. The degree of LCS is directly correlated with the pain level before CEB. After CEB, the pain level changed from 3.43 +/- 0.82 to 1.5 +/- 0.86 (P < 0.0000), with a significant relief of pain up to 10 months (the end of observation). The duration of pain relief ranged from 4 to 10 months (P < 0.0001). CONCLUSION: CEB offers significant pain relief and appears to be a reasonable therapeutic option among elderly patients with LCS. This alternative seems particularly important among patients with poor response to drug therapy and who are either poor surgical risks or who have refused surgery.

pain relief by electrical stimulation of the central gray matter in humans and its reversal by naloxone.

Relief of intractable pain was produced in six human patients by stimulation of electrodes permanently implanted in the periventricular and periaqueductal gray matter. The level of stimulation sufficient to induce pain relief seems not to alter the acute pain threshold. Indiscriminate repetitive stimulation produced tolerance to both stimulation-produced pain relief and the analgesic action of narcotic medication; this process could be reversed by abstinence from stimulation. Stimulation-produced relief of pain was reversed by naloxone in five out of six patients. These results suggest that satisfactory alleviation of persistent pain in humans may be obtained by electronic stimulation.

Triple arthrodesis in rheumatoid arthritis.

Fifty-five patients with rheumatoid arthritis were treated with 65 triple arthrodeses of the hindfoot from March 1975 through July 1985. Twelve patients (12 procedures) have died, and follow-up evaluation could not be completed on three patients (four procedures), leaving 40 patients (49 procedures) available for clinical and roentgenographic evaluation. There were 32 women and eight men, with an average age at the time of surgery of 50 years. The follow-up period averaged five years. Standard operative technique involved medial and lateral incisions with staple fixation and local bone grafting. Correction of deformity was performed with closing wedge osteotomies. All patients had moderate to severe pain preoperatively and difficulty with ambulation. Postoperatively, 94% of the patients had significant pain relief and 83% had complete pain relief. Ambulatory status was improved in 80% of the patients. Ninety percent were at least community ambulators at the time of review, whereas more than half the patients were limited to household ambulation preoperatively. Complications included four superficial wound infections, all of which responded to local care. One patient required revision surgery for pseudarthrosis, and three patients had progression of ankle disease and required pantalar arthrodeses. There was no significant progression of fore-foot or knee symptoms, however, and there was no progression of ankle symptoms in patients whose hindfeet were corrected to 0 degrees-10 degrees valgus. Triple arthrodesis in the rheumatoid population has a high union rate. pain relief and ambulation improvement can be expected.

Treatment of lumbar spinal stenosis with epidural steroid injections: a retrospective outcome study.

OBJECTIVE: To determine patient satisfaction, relief of pain, frequency of injections, change of function, and subsequent surgical rate in patients who received epidural steroid injections (ESIs) for the diagnosis of lumbar spinal stenosis (LSS). DESIGN: Retrospective review conducted using a standard set of questions asked over the telephone, 6 to 36 months after the patient received an ESI. SETTING: An outpatient spine center. PARTICIPANTS: One hundred forty patients at or over the age of 55 years diagnosed with LSS who received ESI(s). INTERVENTION: Transforaminal or caudal fluoroscopically guided ESIs with 60 to 100mg of triamcinalone in combination with local anesthetic or normal saline.Main outcome measures Duration and amount of pain relief, change in functional status, patient satisfaction, and surgical rate, assessed by a 5-item questionnaire. RESULTS: Of the 140 participants, 32% reported more than 2 months of pain relief, 39% reported less than 2 months of pain relief, and 29% reported no relief from the injection(s). Twenty percent subsequently had surgery. Fifty-three percent reported improvement in their functional abilities. Seventy-four percent where at least somewhat satisfied with ESI as a form of treatment. CONCLUSIONS: ESI is a reasonable treatment for LSS, providing one third of our patient population with sustained relief and more than half with sustained improvement in function.

Intrathecal morphine for postoperative pain relief after transvaginal hysterectomy

We studied the effect of a low-dose intrathecal morphine (0.1 or 0.2 mg) in postoperative pain relief and the incidence of side effects. Two hundred and fifteen patients scheduled for transvaginal hysterectomy were divided into 3 groups according to intrathecal morphine doses: M1 (morphine 0.1 mg N = 75), M2 (morphine 0.2 mg N = 69) and C (control N = 71). A standard mid-line lumbar puncture was performed using a 25-gauze needle in the L3/4 interspace. Preservative-free morphine hydrochloride mixed in hyperbaric tetracaine solution was administered intrathecally. pain relief was significantly greater for the first 24 hrs in groups M1 and M2 compared with group C. Respiratory depression was not seen in any groups. The incidence of vomiting was about 40% in all groups. We conclude that intrathecal morphine 0.1-0.2 mg is useful for pain relief after transvaginal hysterectomy and accompanies no major side effects.

Lumbar microdiscectomy in the elderly patient.

This study retrospectively analysed 60 patients who had undergone microsurgical lumbar discectomy at an age of > or = 60 years. The results were compared with those obtained in 44 discectomy patients who were operated on during the same study period, but not selected for age. Sixty-five operations were performed on the elderly group and 49 on the age comparison group. Patients were scored for pain relief in a short-term follow-up (2 months) using office visit records. Long-term follow-ups [mean 6.5 years (elderly) vs 8.8 (comparison) years], obtained by a mailed questionnaire, quantified leg and back pain and scored success in return to normal activities (RTA) and satisfaction with the results of surgery. In the short-term, overall pain relief was highly successful and not significantly different in both group [94% (elderly), 98% (comparison)]. Long-term follow-up yielded the following successful outcomes (elderly, comparison groups): leg pain relief (91%, 86%), back pain relief (76%, 76%), RTA (68%, 87%), and satisfaction (81%, 91%). As with other pre- and postoperative parameters, these differences were not statistically significant. As the proportion of older individuals continues to rise in developed countries, physicians are increasingly faced with geriatric patients whose symptoms are caused by herniated lumbar discs. The present study indicates that microsurgical discectomy for relief of this condition can be performed safely and effectively on these older patients.

Transcatheter embolization of expansive masses of the sacrum

The authors report their 4-year (1984-1988) experience with TCE in the treatment of primary sacral benign/malignant and vascular bone tumors, after similar preliminary studies on aneurysmal bone cysts. Eleven patients were treated, for a total of 21 procedures: in 85% of the eight cases of palliative embolization, multiple instrumental approaches were needed for late revascularization, up to four consecutive embolizations in the same patients. Severe complications were observed in 19% of the procedures, due to arterial catheterization and/or instrumental maneuvers, but in none of them was surgery required. Technical results--i.e. devascularization of the mass--were optimal/suboptimal in all cases at the end of multiple procedures in the same patient: in 7/8 patients treated for palliation, however, the treatment was repeated, the late venous DSA angiographic control showing recanalization of the great vessels surrounding the lesion and/or revascularization through collateral channels. The analysis of morphological and clinical results (with reference to pain relief, dimension of the mass, and calcification at CT follow up) showed a complete pain relief in 100% of the patients treated preoperatively for palliation. The dimension of the mass was reduced in 12.5% of the cases treated for palliation, and recalcification was demonstrated on CT in 12.5% of cases. In 25.5% the mass had increased in size and in 62.5% its dimensions were unchanged. Effective pain relief was always obtained in the cases treated preoperatively. Thus, in our experience TCE of expansive lesions of the sacral bone can be considered as an effective therapeutical choice, with special reference to pain relief, for use in all inoperable cases, and as a preoperative treatment to minimize blood loss at surgery. Still, embolization materials are not completely satisfying: many of them are expensive, difficult to use and cannot be trusted to permanently occlude the vessels, which forces to intervene more than once to obtain optimal clinicomorphological results. As for malignant lesions, chemo-embolization with cytostatic substances should be used to improve the efficacy of the method. However, even through such negative judgements can be expressed on TCE, both technical and clinical results have been, in our experience, quite satisfactory, which calls for optimization of the methodology.

Comparison of buprenorphine and fentanyl for postoperative pain relief by continuous epidural infusion

This study examined analgesic efficacy and adverse effects of buprenorphine and fentanyl for the postoperative pain relief by continuous epidural infusion. Fifty patients after upper or lower abdominal surgeries were assigned to two groups and buprenorphine and fentanyl were epidurally administered postoperatively. Buprenorphine (B) group received bolus injection of B 0.1mg + saline 8 ml and continuous infusion of B 0.8 mg+saline 92 ml (2 ml.h-1). Fentanyl group received bolus injection of F 0.1 mg+saline 6 ml and continuous infusion of F 0.6 mg+saline 84 ml (2 ml.h-1). There was no significant difference between the two groups in the analgesic efficacy, which became lower from 2 to 12 hours postoperatively. However, compared with buprenorphine group, the incidence of nausea or vomiting and dizziness was significantly less in the fentanyl group (11 vs. 4 cases and 7 vs. 1 cases). These results imply that the major site of action of epidurally administered fentanyl is the spinal cord. In contrast, analgesic effect of epidural buprenorphine appears to be enhanced by the supraspinal action. We conclude that fentanyl is superior to buprenorphine for postoperative pain relief by continuous epidural infusion.