Low dose single fraction radiotherapy in the treatment of metastatic bone pain: a pilot study.

Single fraction radiotherapy can be used effectively to palliate painful bone metastases. The optimal single dose of radiotherapy required for pain relief is unknown. Twenty-six patients have been treated with a single fraction of 4 Gy to the site of the bone pain. Partial pain relief was seen in 9/21 (5%). Response occurred within 3 weeks of radiotherapy. These results question the mechanism of pain relief following radiotherapy and suggest a method of pain control using single repeatable low dose treatments.

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.

Management and relief of pain in an emergency department from the adult patients' perspective.

To estimate the prevalence of pain in adult patients attending an emergency department (ED) and to identify risk markers for insufficient pain relief, a cross-sectional survey was conducted for 16 days, 24 hours each day, in the ED of a Paris university hospital. A structured questionnaire was used to collect characteristics of pain and its management from patients. Pain intensity was evaluated both on arrival and before discharge using two scales (a numerical descriptor scale or a verbal pain intensity scale). On arrival, 78% of the patients complained of pain; among them, 54% complained of intense pain and 47% suffered procedural pain. Insufficient pain relief was assessed in 289 (77%) patients. We identified the following risk markers for insufficient pain relief: moderate or low pain intensity, no intervention in the ED before the medical examination, and no use of medication before arrival.

Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia.

OBJECTIVE: To compare responses to trigger point (TrP) injection between patients having both myofascial pain syndrome (MPS) caused by active TrPs and fibromyalgia syndrome (FMS) and patients with MPS due to TrPs but without FMS. DESIGN: Prospective design blinded measurement, before- after trial. SETTING: A pain control medical clinic. PATIENTS: Group 1: MPS + FMS; Group 2: MPS only. All patients (9 in each group) had active TrPs in the upper trapezius muscle. INTERVENTION: Myofascial TrP injection with 0.5% xylocaine. MAIN OUTCOME MEASURES: Subjective pain intensity (PI), pain threshold (PT), and range of motion (ROM) were assessed before, immediately after, and 2 weeks after TrP injection. RESULTS: In a comparison of preinjection measures to immediate postinjection measures, only ROM was significantly improved (p < .05) in Group 1 patients; all three parameters were significantly improved (p < .05) in the Group 2 patients who had only MPS. Two weeks after injection, both groups showed significant improvement (p < .05) in all three measured parameters as compared to preinjection measurements. In a comparison of the two groups, the immediate effectiveness of TrP injection was significantly less (p < .05) in Group 1 than in Group 2 for all three parameters. Two weeks after injection, the degree of improvement in PT or ROM (but not PI) was not significantly different between two groups. Postinjection soreness (different from myofascial pain) was more severe, developed sooner, and lasted longer in Group 1 than in Group 2. CONCLUSION: Trigger point injection is a valuable procedure for pain relief for patients in both group. Patients with FMS are likely to experience significant but delayed and attenuated pain relief following injection of their active TrPs compared to myofascial pain patients with similar TrPs but without FMS. Also, FMS patients are likely to experience significantly more postinjection soreness for a longer period of time.

Effect of repeated irradiation of low-power He-Ne laser in pain relief from postherpetic neuralgia.

In order to investigate the efficacy of repeated irradiation of low-power helium-neon laser in pain relief, we irradiated 36 outpatients suffering from postherpetic neuralgia. Each patient underwent 20 trials of irradiation on several points around the painful area at a frequency of 2 or 3 times a week. The efficacy of the laser at the end of 20 trials was noticed on 88.9%, and the degree of pain relief was 55.3%, which correlated with the number of trials. These results suggest that the irradiation of He-Ne laser is an effective and safe treatment for postherpetic neuralgia.

Efficacy of serotonin receptor blocker for symptomatic lumbar disc herniation.

Serotonin is one of the chemical mediators associated with nerve root inflammation and sciatic symptoms in lumbar disc herniation. The efficacy of serotonin 5-HT(2A) receptor blocker was examined in 44 patients with symptomatic lumbar disc herniation. A selective 5-HT(2A) receptor blocker (sarpogrelate hydroxychloride) was administered orally at a dose of 300 mg per day for 2 weeks. Visual analog scales of low back pain, sciatic pain, and numbness were significantly improved after the administration of the serotonin 5-HT(2A) receptor blocker. Clinical results were good (> 50% pain relief) in 23 patients, fair (25%-50% pain relief) in five patients, and poor (< 25% of pain relief) in 16 patients. Nineteen patients eventually required surgery because of muscle weakness or cauda equina symptoms. The effect of 5-HT(2A) blocker was good in 64% of patients who had uncontained disc herniation, whereas all patients with contained disc herniation had fair or poor results. Patients with uncontained disc herniation responded more favorably to the 5-HT(2A) blocker treatment than patients with contained disc herniation. A 5-HT(2A) blocker has the potential to block the cascade of acute nerve root inflammation and to alleviate symptoms in lumbar disc herniation.

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.

Analgesia in cancer: beliefs and an update

Cancer pain relief is not yet adequate, but there are resources for this. Professional's misconception and the tabu about that pain in cancer is inevitable have been contributing to this problem. Important nurses' knowledge lacuna about pain relief in cancer was found by this study. The WHO program about pain relief in cancer is presented too.

Spinal cord stimulation for chronic pain in peripheral neuropathy.

BACKGROUND: Spinal cord stimulation (SCS) has been used for the relief of chronic, intractable pain for over 2 decades. Recent technologic improvements in hardware have resulted in improved clinical outcome. We report our experience with epidural spinal cord stimulation for pain control of peripheral neuropathy for the past 15 years. METHODS: An analysis of our series of 276 patients revealed 30 patients diagnosed with peripheral neuropathy. The mean age of the 16 men and 14 women in the study was 62.4 years. The anatomic sources of pain included thorax, as well as upper and lower limbs. Causes of intractable pain included postherpetic neuralgia, intercostal neuralgia, causalgic pain, diabetic neuropathy, and idiopathic neuropathy. RESULTS: Nineteen patients reported relief of pain on trial stimulation and had their systems permanently implanted. At an average of 87 months' follow-up, 14 of these patients achieved long-term success in control of chronic pain (47% of all patients included in this study). Six patients reported excellent pain relief (> 75% pain relief), eight described good results (> 50% pain relief), and six had poor pain relief (< 50% pain relief). CONCLUSION: SCS is an effective therapy for pain syndromes associated with peripheral neuropathy. Causalgic and diabetic neuropathic pain seem to respond relatively well. whereas postherpetic pain and intercostal neuralgia syndromes seem to respond less favorably to the long-term beneficial effects of SCS. This information will be useful in the selection of patients with peripheral neuropathic pain who could be helped by SCS.

Spinal cord stimulation in the treatment of paraplegic pain.

Twenty-five patients suffering from intractable pain due to a chronic spinal cord lesion underwent a percutaneous test of spinal cord stimulation. At the end of the test period, 40.9% of the patients reported a mean of 65% pain relief and these patients were selected for ongoing stimulation. At a mean follow-up time of 37.2 months the success rate, based on the number of patients with more than 50% pain relief, had fallen to 18.2%. pain relief rates were analyzed in relation to quality of pain, neurological status, level and extent of the lesion, and electrode level to identify prognostic factors that could improve the clinical usefulness of spinal cord stimulation. Patients experiencing painful spasms or a constrictive type of pain and with incomplete thoracic lesions were found to be the best candidates for spinal cord stimulation.