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)

Long-term pain relief during spinal cord stimulation. The effect of patient selection.

We reviewed our experience with spinal cord stimulation (SCS) in treating 116 patients with pain in one or both legs. All these patients were selected for an initial week of trial stimulation by the criteria: pain due to a known benign organic cause, failure of conventional pain control methods and absence of major personality disorders. Selected patients included 78 with the Failed Back Surgery Syndrome (FBSS), in whom proven correlation existed between the clinical picture and the neuroradiological and electromyogram abnormalities. Eighty-four out of 116 selected patients underwent definitive SCS implantation after 1 week of trial stimulation with excellent results (more than 75% pain relief). They were followed clinically every 3 months for a mean follow-up period of 47 months. Forty-five patients (54%) continued to experience at least 50% of pain relief at the latest follow up. Seventy-seven patients (91%) were able to reduce their medication intake and 50 patients (60%) reported an improvement in lifestyle. FBSS patients responded more positively to the trial stimulation than the other patients. However, the later outcome was not affected by patient selection as long-term benefit was similar in all definitive SCS patients irrespective of aetiology.

Palliative radiotherapy of bone metastases: an evaluation of outcome measures.

The objective of this study was to identify and evaluate important patient-based outcomes that are specific to the palliative radiotherapy of bone metastases. We first conducted a literature review to identify and evaluate outcomes that are currently in use. To identify outcomes that are important to patients, in-depth patient interviews were conducted. Finally, issues identified through the interviews were quantified through a prospective survey, in which patients completed a questionnaire prior to commencing radiotherapy and again after 6 weeks. In our literature review, we found that there was no standardized definition of either response to radiotherapy or assessment of pain relief. Pain measurement in many studies was undertaken using very simple measures, which could possibly yield inaccurate results. The vast majority of studies did not include quality of life as an endpoint. The patient interviews and survey showed that chronic pain and associated limitation of movement were the disease symptoms causing the most concern. Having a clear, alert mind and being able in self-care were the aspects of daily living given the highest priority. Sustained pain relief and minimizing the risk of future complications were the main priorities relating to radiotherapy treatment. The practical aspects of treatment (travelling distance, remaining at home and brevity of treatment) were of least importance. This study indicates the complexity of evaluating the outcomes of palliative interventions, and confirms the deficiencies of pain relief as the primary end-point. The patient's quality of life is affected by many factors other than pain (such as limited mobility, reduced performance, side effects and impaired role functioning); hence a wider range of end-points is required. Greater sensitivity is required than in currently used end-points. Concurrent diseases as well as concurrent therapies can make it difficult to attribute effects with precision. Unless such factors are considered in research design, the results may prove unreliable.

Radiosurgical treatment of trigeminal neuralgia: evaluating quality of life and treatment outcomes.

PURPOSE: To assess the safety, efficacy, and quality of life (QOL) associated with radiosurgical treatment for trigeminal neuralgia (TN). METHODS AND MATERIALS: Between June 1996 and June 2001, 112 patients with TN refractory to medical or surgical management were treated with gamma knife radiosurgery (GKRS) at the University of Maryland Medical Center. A median prescription dose of 75 Gy (range: 70-80 Gy) was delivered to the involved trigeminal nerve root entry zone. Treatment outcomes were assessed through patient self-reports of pain control and medication usage during follow-up visits. In addition, patients responded to a standard questionnaire containing the Barrow Neurologic Institute Pain Scale (BNI) and selected sections of the McGill Pain Scale. Treatment outcomes and objective quality of life measures were also addressed. RESULTS: Ninety-six patients (86%) completed questionnaires for a median follow-up of 30 months (range: 8-66 months). Seventy-four patients (77%) reported pain relief occurring after a median of 3 weeks (range: 0-24 weeks) after GKRS. A decrease in medication usage was noted in 66% of patients. Actuarial analysis demonstrated 1-year, 2-year, and 3-year recurrence rates of 23%, 33%, and 39%, respectively. Response to treatment was associated with lack of prior surgical treatment (p = 0.03) and less than 50 months' pain duration before GKRS (p = 0.04). Patients who described their TN pain as more severe than their worst non-TN headache pain (McGill Pain Scale IV-V vs. I-III) were also more likely to respond to treatment (p < 0.001). Seven (7.3%) patients reported new or increased trigeminal dysfunction; however, only 3.1% reported these symptoms as bothersome (BNI III-IV). Patients with sustained pain relief reported an average of 100% improvement in their QOL as a direct result of pain relief after GKRS, and 100% believed that the procedure was successful. Furthermore, among those patients with temporary pain relief and subsequent recurrence, 65% felt their treatment was a success with an average of 80% improvement in their QOL. CONCLUSIONS: GKRS provides significant pain relief and improves QOL in the majority of patients treated for TN, with few bothersome side effects. Patients with both temporary and sustained responses to treatment realized significant improvements in QOL after GKRS, and considered their treatment successful. Longer follow-up of these patients may reveal additional recurrences highlighting the importance of studies evaluating repeat GKRS and optimization of current treatment techniques and patient selection.

Is there a connection between the clinical response after an external fixation test or a subsequent lumbar fusion and the pre-test intervertebral kinematics?

STUDY DESIGN: Evaluation of a possible correlation of clinical symptoms of chronic low back pain (LBP) patients before and after application of external spinal fixation (ESF) with three-dimensional motion patterns. OBJECTIVE: To determine whether the intervertebral kinematics in chronic LBP patients correlate with pain relief after stabilization of the suspected painful segments. SUMMARY OF BACKGROUND DATA: Chronic LBP is a complex clinical entity with mechanical, biochemical, and psychosocial components. Although clinically controversial, ESF has been shown to reduce intervertebral motion, and thus, it provides a mechanism to investigate the mechanical aspect of LBP. METHODS: Thirty-four chronic LBP patients were tested with ESF of the suspected painful segments. The subjective pain relief experienced by the patients during the test and 2 years after spinal fusion surgery was determined, along with the Oswestry Disability Index. Before removal of ESF, the three-dimensional intervertebral kinematics of the painful segments (specifically range of motion, coupling patterns, and motion asymmetries) were analyzed with a precision optoelectronic camera system during active trunk motions. A series of linear correlations were performed between the clinical measures and the motion parameters. RESULTS: The subjective pain relief during the ESF test was nominally, but not significantly, associated with lateral bending asymmetry ( = 0.22) and "abnormal" axial rotation-lateral bending coupling ( = 0.13). The improvement in the Oswestry Disability Index both post-test and at 2 years after lumbar fusion surgery was significantly correlated with the extension range of motion ( = 0.049 and = 0.036, respectively) and the extension-to-flexion range of motion ratio ( = 0.035 and = 0.044, respectively). CONCLUSIONS: The "abnormal" motion patterns of chronic LBP patients did not correlate with subjective pain relief after ESF of the suspected symptomatic levels or with the midterm outcome of subsequent lumbar fusion surgery. The results suggest that preserved motion of the symptomatic segments before surgery is positively correlated with the clinical result of the subsequent spinal fusion in case of a positive ESF test result.

Heel spur: radiation therapy for refractory pain--results with three treatment concepts.

PURPOSE: To evaluate radiation therapy (RT) to treat refractory pain in plantar heel spur. MATERIALS AND METHODS: From 1984 to 1994, 141 patients with refractory painful plantar heel spur (170 heels, because of bilateral disease) underwent RT. Quantitative criteria were used to evaluate heel pain and ankle function prior to RT, 6-12 weeks after RT, and at last follow-up (median, 4 years). Patients were divided into three treatment groups: group A (n = 72 heels [two courses, 1.0-Gy fractions, 12-Gy total RT dose]), group B1 (n = 50 heels [one course, 0.3-Gy fractions, 3-Gy total dose]), and group B2 (n = 48 heels [one course, 0.5-Gy fractions, 5-Gy total dose]). RESULTS: At last follow-up, complete pain relief was achieved in 48 (67%) of 72 group A heels and in 71 (72%) of 98 group B heels. Statistically significant (P < .05) differences between groups were found for insufficient pain relief (< 80%) in patients in whom the response time after RT was longer than 4 weeks or in whom pain recurred during follow-up. The best results were achieved with the 5-Gy total RT dose (P < .05). Prognostic factors for complete pain relief were acute pain and short duration of pain prior to RT. The prognostic factor for insufficient pain relief was total RT dose. CONCLUSION: Refractory heel pain is effectively treated with RT, which should be considered a primary treatment approach rather than a last resort.

The effects of an education video on patients' requests for postoperative pain relief.

A patient education videotape called if it hurts, tell us was used to provide one of three groups of 20 preoperative patients with information about pain control and to encourage them to be assertive in their requests for postoperative pain relief. There were no significant differences in the levels of pain or requests for analgesia between the group which had been specifically encouraged by the education video to seek pain relief and the groups which had not seen the video. Patients in all three groups generally experienced a good deal of pain following surgery, but they were not dissatisfied with this experience and did not take available action to eliminate all their pain. While the literature suggests that improvements in postoperative pain management might be achieved by better staff education, patients' reluctance to eliminate their pain should also be considered.

pain relief following tennis elbow release.

We studied the outcome of tennis elbow release in 27 patients at an average of 29.6 months after surgery. We found that 44% of patients had obtained complete pain relief, 37% of patients experienced occasional pain and 19% of patients still experienced moderate pain. pain relief was significantly better in those patients with the shorter duration of preoperative symptoms. We therefore conclude that surgery for tennis elbow should be employed at an earlier stage than is currently practised.

Postoperative pain relief by demand analgesia.

Postoperative pain relief is only apparently an easy task. A brief survey of literature investigating the discomfort experienced in the postoperative phase is all but encouraging. One can identify four basic problems in obtaining adequate results by delivery of analgesic drugs: a) the biological variability among individual patients, b) the unpredictable uptake of the drug administered intramuscularly, c) the time lag involved between request by the patient and the subsequent administration of a single dose and d) the lack of knowledge about the nature of the discomfort and its remedies. An alternative strategy introducing "On-Demand" analgesia administering prescribed doses at the right moment is presented and analysed a) as an operant conditioning process implementing a particular reinforcement schedule (behavioural sciences), as well as b) a negative feedback control loop that entrust the central judgement to the patient (system theory). Both approaches give insight into the results: the technique copes with biological variability; anticipating pain induced by fear disappears; the feedback strategy works well and patients adapt to a wide range in prescriptions; intermittent administration makes more efficient use of the analgesic; an optimal result is demonstrated in studies comparing on-demand analgesia with the normal IM-regime and epidural analgesia; continuity in pain relief can be obtained in routine clinical practice.

Long term effects of oral sustained release morphine on neuropsychological performance in patients with chronic non-cancer pain.

Morphine is increasingly used in patients with chronic non-cancer pain, but a major concern associated with chronic use relates to possible cognitive side-effects. The aim of this long-term prospective study was to evaluate the cognitive impact of oral sustained release morphine in patients with non-cancer pain. A battery of neuropsychological tests to explore attention, psychomotor speed and memory was administered. The effects of morphine on pain, quality of life, mood, subjective memory impairment and side-effects were also investigated. Evaluations were performed at baseline in patients free from opioids and then after 3, 6 and 12 months. Twenty-eight patients were included: 18 received oral sustained morphine (range 40-140 mg/day), ten patients stopped morphine prematurely because of side-effects or insufficient pain relief and were followed as a control group. There was no impairment of any neuropsychological variable over time in the morphine treated patients in comparison with the control group. Two measures of information processing speed - the Stroop interference score and the digit symbol test were improved at 6 and 12 months and there were significant correlations with the pain relief and improvement of mood. Self-reported memory impairment improved notably in responders to morphine. Morphine induced persisting effects on pain, and to a lesser extent on quality of life and mood. The visual analog scale score for side-effects increased at 12 months and essentially consisted of gastrointestinal disorders. This study demonstrates that 12 months treatment with oral morphine does not disrupt cognitive functioning in patients with chronic non-cancer pain and instead results in moderate improvement of some aspects of cognitive functioning, as a consequence of the pain relief and concomitant improvement of well-being and mood.