Cervical epidural morphine and buprenorphine for postoperative pain relief after thoracic surgery--a comparative study in the same patients

The effects of cervical epidural morphine and buprenorphine on postoperative pain were studied in 12 patients who received thoracic surgery twice. The patients who had received morphine 3 mg on the first operation were given buprenorphine 0.15 mg on the second operation, and the others received them vice versa. Morphine or buprenorphine was administered with 6 ml of 0.25% bupivacaine before skin incision. The duration of pain relief with morphine was longer (21.5 +/- 4.0 h) than with buprenorphine (13.9 +/- 7.8 h). The result of the questionnaires to the patients after operation shows that 10 patients (84%) were satisfied with morphine whereas only 6 patients (50%) were satisfied with buprenorphine. Seven patients preferred morphine to buprenorphine for postoperative analgesia, and the rest of the patients stated that analgesic effects were similar between the two. It seems that epidural morphine 3 mg may give more excellent postoperative pain relief after the thoracic surgery than epidural buprenorphine 0.15 mg.

Percutaneous stereotactic differential radiofrequency thermal rhizotomy for the treatment of trigeminal neuralgia.

PURPOSE: The purpose of this study was to evaluate the effectiveness of radiofrequency thermal rhizotomy (RTR) for trigeminal neuralgia, after failure of pharmacological management. PATIENTS AND METHODS: Two hundred fifteen patients underwent RTR from 1991 to 1996 and were prospectively evaluated. These patients were characterized by age, sex, side of the face, and division(s) involved. Patients were evaluated for pain relief, recurrence requiring or not requiring reoperation, and the type and rate of complications. They were followed-up by serial clinical evaluation and telephone interview. Patients were categorized into groups: 1) Successful result: excellent, good pain relief; and 2) Unsuccessful result: fair, poor, or no pain relief. The RTR group was compared with historical controls. Follow-up ranged from 9 to 68 months (mean, 32 months) and results were evaluated at early and long-term follow-up. RESULTS: At early follow-up (defined as immediately postoperatively to 6 months), pain relief of excellent or good quality (successful result) occurred in 198 of 215 patients (92%). Fair or poor or no pain relief (unsuccessful result) occurred in 17 (8%) patients. At long-term follow-up (>6 months to 68 months), recurrence of pain that required reoperation occurred in 24 patients (11%) and recurrence of pain that did not require reoperation (medically managed) occurred in 34 patients (16%). Dysesthesia developed in 18 patients (8%); seven patients (3%) had dysesthesia alone (medically managed) and 11 patients (5%) had dysesthesia with recurrence of pain (medically or surgically managed). "Anesthesia/analgesia dolorosa" developed in four patients (1.8%) and was medically managed. At long-term follow-up, 83% of patients had good to excellent pain relief (successful result). There were no mortalities, no significant morbidity, and a low rate of minor complications. CONCLUSION: With the use of this specific diagnostic approach and management algorithm, patients with trigeminal neuralgia can be successfully managed.

Clonazepam open clinical treatment trial for myofascial syndrome associated chronic pain.

OBJECTIVE: A number of case reports and nonplacebo controlled studies have documented the efficacy of clonazepam (Klonopin) in the treatment of a number of chronic pain syndromes including lancinating and neuropathic/deafferentation pain. There are, however, no data on the efficacy of clonazepam for chronic pain (CP) associated with myofascial pain syndrome (MFPS). Therefore, we wish to report the results of an open clinical treatment trial of clonazepam for CP associated with MFPS. DESIGN: Forty-six patients with chronic pain (PWCP) and a diagnosis of MFPS were recruited into a clonazepam pain treatment open clinical trial. At entrance and completion of the study the patients completed a 10-cm visual analog scale (VAS) requesting them to rate their pain over the last 24 hours. Clonazepam was titrated upwards from 0.5 mg per day, at 0.5 mg increments, every 2 days. These patients rated their perceived pain relief daily on a 3-point rating scale: none, partial, total. Once a patient claimed partial pain relief clonazepam increases were stopped. Patients who complained of intolerable side effects before partial pain relief were withdrawn from the study. For a subgroup of patients claiming partial pain relief, clonazepam serum levels were determined. Because of the reported efficacy of clonazepam for neuropathic/deafferentation type of pain, patients with this diagnosis were withdrawn from the partial response group. Statistical analyses were performed on this remaining patient group with myofascial pain syndrome without a secondary diagnosis of neuropathic/deafferentation pain and partially responsive to clonazepam. Descriptive statistics were calculated for this group. Drop in pain level from entrance to partial response was tested for statistical significance via t test. In addition, 17 independent variables such as presence of trigger points, presence of burning pain etc, were utilized in a regression analysis, with drop in pain level as the dependent variable. A Pearson correlation analysis was first performed in order to determine which of the independent variables significantly correlated with decrease in pain level. Independent variables having a Pearson r of.3687 or greater were selected for the regression procedure. SETTING: Multidisciplinary pain facility. PATIENTS: Patients with chronic pain with a diagnosis of MFPS and without neuropathic/deafferentation pain. RESULTS: Of the 46 patients entered into the study, 9 were not titrated to partial pain relief because of intolerable sedation and 9 had a diagnosis of neuropathic/deafferentation pain. For the remaining group (n = 28), mean drop in VAS pain level from beginning of the study to partial response was 2.78 (SD = 1.94). This was statistically significant (t = 5.49, P <.001). Mean clonazepam dosage to reach partial response was 2.41 (SD = 1.62) mg/day and the mean dosage per kilogram body weight per day was 0.04 (SD = 0.03) mg. Mean clonazepam serum level was 30.58 (SD = 24.53) microg/L. Decrease in pain level was associated with the presence of the following independent variables: trigger points (r =.451); range of motion restriction (r =.653); non anatomical sensory abnormalities (r =.370); chronic low back pain (r =.451); and burning pain (r =.482). In the regression analysis, restricted range of motion and presence of burning pain accounted for 42% and 16% of the variance respectfully. CONCLUSION: Clonazepam may have an antinociceptive effect for pain associated with myofascial pain syndrome.

Continuous epidural infusion of morphine for treatment of pain after thoracic surgery: a new technique.

We evaluated postoperative pain relief and the incidence of side effects of three methods of thoracic epidural analgesia. Ninety patients, divided into three equal groups, received postoperative analgesia after thoracic surgery either as intermittent epidural injections of bupivacaine (25 mg/5 ml, 0.5% solution) as needed, or, intermittent epidural injections of morphine (5 mg/5 ml of normal saline, 0.1% solution) as needed, or continuous epidural infusion of morphine (0.1 mg, in 1 ml of normal saline) per hour supplemented with intravenous morphine (2 mg) upon request. pain relief was evaluated by each patient on a pain scale visual analogue and by pain relief questionnaire for a period of 72 hr. Postoperative pain relief was achieved equally with these three methods of epidural analgesia in all patients with no significant difference between groups. Intermittent epidural injection of bupivacaine relieved pain for 4.9 +/- 1.9 (SD) hr/injection and was associated with urinary retention in all patients, with numbness and weakness of the hands in 12 patients, and with severe hypotension in 7 patients. Intermittent epidural injection of morphine relieved pain for 5.8 +/- 2.3 hr/injection and was associated with urinary retention in all patients, with pruritus in 12 patients, and with central narcosis and respiratory depression in 8 patients. Continuous epidural infusion of morphine with occasional intravenous morphine (2 mg) supplementation also effectively relieved postoperative pain and was associated with minimal systemic side effects. One patient complained of pruritus, and two patients developed urinary retention.(ABSTRACT TRUNCATED AT 250 WORDS)

Pain characterization in cancer patients and the analgetic response to epidural morphine.

In 48 patients with pain related to malignancy, a pain characterization was performed during oral opioid therapy. After an optimal epidural morphine regimen had been established, the alteration in pain relief was evaluated by means of a visual analogue scale. The CSF and plasma morphine concentrations at minimum steady state were then analysed in 28 patients and related to the degree of pain relief. The efficacy of the spinal treatment ranked in the following order: somatic greater than visceral greater than radiating = 0, but the difference was only significant between the somatic and radiating pain groups. There was a tendency for continuous pain to be better relieved than intermittent pain. No correlations were found between the CSF or plasma morphine concentrations and the degree of pain relief, suggesting that not all pain impulses are modulated in a dose-dependent manner by morphine at the spinal level. Pain characterization may be instrumental in providing an optimal spinal opioid analgesia in malignancy. Moreover, there is a need for better defined diagnostic criteria for clinical pain characterization.

Carcinoma of the superior pulmonary sulcus. Results of irradiation and radical resection.

Fifty-six patients with superior sulcus syndrome were evaluated at the First Surgical Department of the University of Padua between 1981 and 1990. Forty-two patients with the characteristic of Pancoast's tumor received preoperative irradiation and then en bloc resection of the tumor, chest wall, and adjacent structures. Seven lobectomies and 35 segmentectomies or wedge resections were performed. There was one early postoperative death. Median survival was 14 months, and actuarial survival was 25% at 5 years. Patients with pain relief had better 5-year survival (36.4%) than patients without pain relief (9%). We have no patients with vertebral invasion who survived more than 1 year. Of the five patients with subclavian artery invasion, only one survived more than 1 year. Of five patients with N2 disease, only one survived more than 1 year. Our results suggest that pain relief after irradiation is a good prognostic factor, whereas N2 involvement and vertebral body and great vessel invasion are ominous factors. Another ominous prognostic factor is the Claude Bernard-Horner syndrome even if it is not a contraindication to resection.

Outcome of patients with chronic abdominal pain referred to chronic pain clinic.

OBJECTIVE: We determined the outcome of patients with chronic abdominal pain of unknown etiology referred by gastroenterologists to a chronic pain clinic. METHODS: A retrospective chart review of 43 consecutive patients seen by a university-based gastroenterology group was referred to our Chronic Pain Clinic for evaluation and treatment. Pain character and location, the referring diagnosis, and initial Chronic Pain Clinic diagnosis was compared between responders and nonresponders. Early and long-term pain relief was scored by standard questionnaire. RESULTS: Of the 43 patients with chronic abdominal pain of undetermined etiology, 70% reported complete or substantial pain relief by the end of chronic pain management. Pain character and location and the referring diagnosis were not predictors of pain relief. Long-term pain relief was reported by 35% of patients. CONCLUSION: A substantial group of patients with chronic abdominal pain of unknown etiology benefited from Chronic Pain Clinic services.

Extradural analgesia during labour using alfentanil.

Sixteen primiparous patients requesting pain relief during labour received a continuous infusion of alfentanil 30 micrograms kg-1 h-1 via an extradural catheter. Supplementary (extradural) bolus doses (30 micrograms kg-1) were administered when deemed necessary. Excellent pain relief was rapidly obtained early in labour in all patients. However, analgesia was inadequate in the latter part of stage I and during the second stage in five of the 16 patients--notwithstanding several additional doses of alfentanil, and bupivacaine had to be administered. No serious maternal side-effects, except nausea, were encountered. Although all neonatal Apgar scores were between 7 and 10, the Amiel-Tison test clearly indicated the existence of neonatal hypotonia. The continuous extradural administration of alfentanil proved to be unsatisfactory for pain relief in labour.

Development of a cancer pain prognostic scale.

The purpose of this study was to develop a Cancer Pain Prognostic Scale (CPPS) which could predict the likelihood of pain relief within 2 weeks for cancer patients with moderate to severe pain. Seventy-four (74) consecutive patients who presented with cancer-related pain were managed in accordance with the guidelines for pain management developed by the United States Agency for Health Care Policy and Research (AHCPR). Patients were followed weekly using the Brief Pain Inventory (BPI), and medications were recorded weekly for 3 weeks. Baseline scores from the Functional Assessment of Cancer Therapy (FACT-G), Mental Health Inventory (MHI), Karnofsky Performance Status (KPS), and Memorial Symptom Assessment Scale Short Form (MSAS-SF) at initial interview served as explanatory variables in a logistic regression model. pain relief > or = 80% at the end of weeks 1 and 2 were used as outcomes in this model. From this analysis, we developed a predictive formula, the CPPS, which includes the worst pain severity, FACT-G emotional well being, daily opioid dose, and pain characteristics. The rule yields a numerical score that ranges from 0-17. Higher scores correspond to a higher probability of good pain relief. The CPPS has the potential to rapidly identify patients with poor pain prognosis. It can be used as a research tool to characterize pain in cancer patients.

Long-term follow-up study of rostral mesencephalic reticulotomy for pain relief--report of 34 cases.

A long-term follow-up study of rostral mesencephalic reticulotomy (RMR) for pain relief is presented. 34 patients (24 males and 10 females) were operated. Ages ranged from 18 to 65 years. The follow-up period was 1-70 months. The overall effectiveness of RMR showed good relief of pain in 23 patients (67%). The study of effectiveness of RMR according to type of pain showed good relief of pain in 5 out of 6 patients (83%) with nondenervation pain, whereas satisfactory pain relief was obtained in 18 out of 28 patients (64%) with denervation pain.