Treatment of pain of diffuse metastatic cancer by stereotactic chemical hypophysectomy: long term results and observations on mechanism of action.

Stereotactic instillation of absolute alcohol into the sella turcica for pituitary destruction was carried out in 29 patients divided into two groups. Seventeen with prostatic carcinoma underwent a total of 19 injections with 94% good to excellent results that persisted throughout the remainder of the patient's life-span. The longest survival was 9 months. Brief relapses did occur, but spontaneous remissions were the rule. A second group of mixed cancers contained 12 patients who received a total of 13 injections. Eleven patients had good to excellent results that persisted in all but 1 patient. The longest survival was 7 months. Hormonal levels and prolactin stimulation tests failed to show any correlation between hormonal changes and pain relief. Naloxone reversal of analgesia did not occur. There was no loss of cognitive function shown on psychological testing. Pathological studies showed destruction of the pituitary gland, which was subtotal in some patients despite good pain relief. All examinations showed that the pituitary stalk was destroyed. Patients who survived longer also showed degeneration of the supraoptic and paraventricular nuclei of the hypothalamus and the median eminence. All but 1 patient with pain relief exhibited a lack of antidiuretic hormone (ADH) production. Interpretation of the data indicates that ADH or its associated neurophysins act as central pain transmitters. The production of these transmitters is decreased or abolished by chemical hypophysectomy through the destruction of hypothalamic nuclei.

Outcomes for surgical management of orchalgia in patients with identifiable intrascrotal lesions.

OBJECTIVE: The outcome of surgery for relief of orchalgia in patients with identifiable intrascrotal pathology is not well defined. We evaluated the success of commonly performed surgical procedure indicated for pain relief in patients with specific intrascrotal lesions. METHODS: Surgical cases performed for relief of painful scrotal pathology were reviewed, including ligation of internal spermatic vein, hydrocelectomy, spermatocelectomy, and orchiopexy for suspected intermittent torsion. Relief of pain as reported to the physician and time for return to full activity were determined. pain relief was compared to a 50% placebo rate using Fisher's exact test. RESULTS: Eigthy-five of 151 patients (56%) undergoing surgery for pain relief had complete data and adequate follow-up for analysis. Of 40 patients who had ligation of the internal spermatic vein, 30 (75%) were relieved of pain (p = 0.037). All 19 patients with painful hydroceles and 16 of 17 (94%) with spermatoceles were relieved of pain (p < 0.001). Of 9 patients undergoing scrotal orchiopexy for suspected intermittent torsion, 8 (89%) were pain-free (p < 0.001). CONCLUSION: Surgical management of specific intrascrotal lesions is highly effective.

Pilot study on disposition and pain relief after i.m. administration of meperidine during the day or night.

Two groups (four patients each) of sickle cell anemia patients with severe pain were studied. One group comprised patients admitted to emergency unit in the morning (5:40 to 9:15) and the other patients admitted in the evening (18:53 to 22:50). All patients received intramuscular meperidine (1.5 mg/kg). Pain intensity and pain relief were followed for 4 h; blood samples were taken up to 6 h after drug administration. Significant differences in drug disposition were found between the day and night groups, as the elimination half-life was 46% shorter during the night and the total serum clearance was 70% greater during the night. Whereas a positive correlation was found between drug concentration and pain relief for the day group, no such correlation was found for th night group. Even though peak concentrations were higher during the night, analgesia was lower. This pilot study suggests that much higher meperidine doses might be required during the night to achieve equieffective analgesia.

Treatment of deafferentation pain by chronic stimulation of the motor cortex: report of a series of 20 cases.

Twenty patients with deafferentation pain were treated by chronic stimulation of the motor cortex. The central fissure was localized using stereotactic MRI and the motor cortex was mapped using intra-operative somatosensory evoked potentials. Seven patients with trigeminal neuropathic pain experienced definite pain relief varying between 40 and 100%. Ten patients had central pain secondary to central nervous system lesions. A satisfactory long-lasting pain control (pain relief > 40%) was obtained in five of them (50% of cases). One patient with pain from peripheral nerve injury obtained more than 80% pain relief. Two patients had pain from spinal cord lesions. One did not respond but the other obtained an excellent long-term result. The location of the effective stimulation plots was in agreement with the somatotopic maps of the primary motor cortex. One patient developed a small extradural haematoma which resolved spontaneously. None of the patients developed seizure activity. This study confirms the potential value of motor cortex stimulation in the treatment of certain forms of intractable pain, especially in cases with trigeminal neuropathic pain.

The BIAX total wrist prosthesis as an alternative to arthrodesis in degenerative and posttraumatic arthritis--early results in twenty-one patients

The BIAX total wrist prosthesis was first implanted 1983 by Beckenbaugh in the United States. From a total of twenty-one BIAX-prostheses between March 2001 and February 2002, we have inserted eleven in patients for degenerative arthrosis, eight for posttraumatic arthrosis and two for rheumatoid arthritis of the wrist. The average age of the patients was 53.0 +/- 10.7 years with a follow-up between eleven and fourteen months on an average of one year. The motion of the operated joints was preserved on average. We have taken pain as the main criterion for the success of the operation and distinguished between pain at rest, in motion and under exertion. All patients showed a very good pain relief of 5 1/2 values from 6 1/2 before to one after surgery on a scale from one to ten. pain relief is less under exertion, thus we are reserved with heavy workers of the implantation of the prosthesis. Apart from that, the indication corresponds to the arthrodesis of the wrist. The satisfaction of patients with the prosthesis is very high: 17 patients declared it was much better, three declared it was better and only one patient said it was unchanged. Complications occurred in six patients. The main complication was the postoperative dislocation of the prosthesis in three patients. After repositioning, the joints were long-term stable. The straight secured surgical technique is described in detail. For the majority of patients with posttraumatic or degenerative arthrosis, as well as with rheumatoid arthritis, the BIAX wrist prosthesis is recommended as a first-time operation as an alternative to wrist arthrodesis due to pain relief with preservation of joint motion and good acceptance among patients.

Neurolytic celiac plexus block for pancreatic cancer pain.

Neurolytic celiac plexus block (NCPB) is an effective method for relief of the pain of pancreatic cancer, but many physicians are reluctant to use the technique because of the perception that the incidence of complications is high. We analyzed the incidence of complications and the quality of pain relief obtained during the use of NCPB in 136 patients with pancreatic cancer. Eighty-five percent of the patients had good pain relief that, in 75% of cases, lasted through the patients' remaining life. No permanent neurologic complications resulted, although two patients had a pneumothorax. Radiographically guided needle placement did not affect quality of pain relief or the incidence of complications. This neurolytic pain block is effective, has a low incidence of neurologic complications, and deserves more widespread use in patients with pancreatic cancer.

Localization of specific joint causing hindfoot pain: value of injecting local anesthetics into individual joints during arthrography.

OBJECTIVE. The purpose of this study was to evaluate the utility of selective injection of local anesthetic into hindfoot articulations for localizing the source of posttraumatic pain and to compare clinical response with the severity of degenerative change in the various articulations evident on plain radiographs or CT scans. SUBJECTS AND METHODS. Anesthetic arthrography was performed in 18 patients with posttraumatic hindfoot pain. In all, 32 joints were assessed: 15 talocalcaneonavicular, 11 subtalar, five ankle, and one calcaneocuboid. Following intraarticular injection of a mixture of equal amounts of meglumine diatrizoate 60%, lidocaine 1%, and bupivacaine 0.25%, patients were asked to grade the degree of pain relief they experienced on a scale from 0% to 100%. The degree of degenerative changes seen on preliminary radiographs and CT scans was graded blindly and retrospectively by an experienced musculoskeletal radiologist using a 3-point scale (grade 0 indicated a normal joint, grade 1 indicated mild to moderate degenerative change, and grade 2 indicated severe degenerative change). The value of findings on both routine radiographs and CT scans as predictors of the degree of symptomatic relief obtained from specific joint injections was determined. Arthrodesis was performed in nine patients on the basis of the results of anesthetic injections. RESULTS. The degree of pain relief experienced after intraarticular injection of anesthetic correlated with the severity of degenerative change as assessed by routine radiography in 15 of 32 joints and as assessed by CT in eight of 18 joints. In 14 of 32 joints assessed by routine radiography and in seven of 18 joints assessed by CT, the amount of pain relief achieved by anesthetic arthrography was less than that predicted by imaging evidence of degenerative disease. In five of 32 joints judged normal on plain film radiographs, significant pain relief was experienced following anesthetic injection, resulting in a change in the proposed surgical procedure. Long-term follow-up indicated satisfactory results in eight of the nine patients in whom arthrodesis was performed. CONCLUSION. Selective intraarticular anesthetic injections afford a direct method of confirming the site of hindfoot pain and may aid in surgical planning, because plain film radiography or CT may underestimate or poorly indicate the most symptomatic articulations.

Deriving dichotomous outcome measures from continuous data in randomised controlled trials of analgesics.

Reports of RCTs of analgesics frequently describe results of studies in the form of mean derived indices, rather than using discontinuous events--such as number or proportion of patients with 50% pain relief. Because mean data inadequately describe information with a non-normal distribution, combining mean data in systematic reviews may compromise the results. Showing that dichotomous data can reliably be derived from mean data, at least in acute pain models, indicates that more meaningful overviews or meta-analysis may be possible. This study investigated the relationship between continuous and dichotomous analgesic measures in a set of individual patient data, and then used that relationship to derive dichotomous from continuous information in randomised controlled trials (RCTs) of analgesics. Individual patient information from 13 RCTs of parallel-group and crossover design in acute postoperative pain was used to calculate the percentage of the maximum possible pain relief score (%maxTOTPAR) and the proportion of patients with greater than 50% pain relief (> 50%maxTOTPAR) for the different treatments. The relationship between the measures was investigated in 45 actual treatments and 10,000 treatments simulated using the underlying actual distribution; 1283 patients had 45 separate treatments. Mean %maxTOTPAR correlated with the proportion of patients with > 50%maxTOTPAR (r2 = 0.90). The relationship calculated from all the 45 treatments predicted to within three patients the number of patients with more than 50% pain relief in 42 of 45 treatments, and 98.8% of 10,000 simulated treatments. For seven effective treatments, actual numbers-needed-to-treat (NNT) to achieve > 50%maxTOTPAR compared with placebo were very similar to those derived from calculated data.

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.

Lamotrigine in the treatment of chronic refractory neuropathic pain.

Many patients suffer from chronic, intractable neuropathic pain. Despite similar diagnoses and presumed pathophysiologies, symptoms and response to treatment can differ. Monotherapy is only occasionally successful. In this prospective survey, 20 patients with chronic, neuropathic pain not responding to interventional therapy received lamotrigine, sometimes as monotherapy and sometimes combined with oral morphine. The latter occurred in patients who lost pain relief from morphine after time. Ten patients did not respond to the drug; 4 were temporary responders and 6 patients obtained sustained pain relief. It is interesting that 5 patients regained opioid responsiveness and that the drug combination produced excellent pain relief for more than 5 months. We hypothesize an additive effect between morphine and lamotrigine.