Perceptions of pain relief after surgery.

OBJECTIVE--To assess patients' satisfaction with postoperative pain relief. DESIGN--A descriptive and questionnaire study of patients' experience. SETTING--Two surgical and two gynaecological wards. PATIENTS--50 Patients admitted to hospital for cholecystectomy and 51 admitted for hysterectomy. MAIN OUTCOME MEASURES--Visual analogue scales with no divisions were completed by the patients immediately after each dose of postoperative analgesia was administered throughout their stay in hospital. A questionnaire completed on the fifth postoperative day recorded patients' recollections of their experience. Opinions were also sought from medical and nursing staff. RESULTS--During the first 24 hours after surgery recorded pain levels were 60% of the maximum and were not influenced by age, sex, or the type of operation performed. The median interval between the return of pain and a further injection of analgesic was 2 hours (interquartile range 1 to 3.5 hours). Expectations of pain relief were low, and for 70% of the patients the pain was at least as bad as they had expected. Only half of the medical and nursing staff questioned thought that postoperative analgesia should relieve pain completely; drugs were prescribed and administered with too little attention to the patient's response and too much concern about adverse effects and opioid dependence. CONCLUSIONS--The results suggest that the standard of postoperative pain relief is poor because of inadequate education of patients in what to expect (and demand), and of medical and nursing staff in how to prescribe and administer analgesia with reference to individual drug response.

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.

Efficacy of epidural neurolysis

Forty-one patients were treated with epidural neurolysis using 50 % ethyl alcohol 2 ml. Thirty eight patients were suffering from cancer pain and three patients were complaining of chronic benign pain. Alcohol block was repeated 2.3 times (mean) in the same patient. Thirty patients were followed after the treatment. Forty-seven percent of the patients reported 70 % or greater pain relief and 20 % of the patients reported about 50 % pain relief. Duration of pain relief was from 9 days to 203 days with a mean duration of 54 days. Adverse effects were reported 43 % of the patients. There is no miserable adverse effect. Adverse effect reported most was pain with epidural injection of drugs after the alcohol block had been performed.

Palliative radiotherapy for bone pain in hormone refractory prostate cancer

From 1970 to 1992, 23 patients were treated with irradiation for palliation of pain caused by bone metastases from hormone refractory adenocarcinoma of the prostate at Cancer Institute Hospital. External beam irradiation was delivered to painful bony metastatic sites using linear accelerator. Numbers of irradiated sites were 1, 2, 3 in 6 patients, 4 in 3 patients and 5 or 7 in one patient. To evaluate the pain relief at the irradiated sites, severity and frequency of pain were measured quantitatively before and 1 month after the treatment. Overall efficacy of palliation was evaluated by summing up results of the irradiated sites in each patient. pain relief was obtained in all the irradiated sites. Minimal relief, partial relief and complete relief of pain were achieved in 10%, 15% and 75% of the 60 irradiated sites, respectively. No significant dose-response relationship was observed. Complete pain relief was attained less frequently at the sites with severe and constant pain that those with moderate and intermittent pain. Minimal, partial and complete palliation of pain was attained in 9%, 17% and 74% of 23 patients, respectively. In patients with highly extensive bone metastases, many irradiated sites, or many irradiated bones, complete palliation was difficult to obtain. Recurrence of pain was observed in one site. In other 59 irradiated sites, pain relief lasted until patient's death or throughout the follow-up period (maximum 51 months, median 9 months). We concluded that external beam irradiation is an effective palliation therapy for pain of bone metastases from hormone refractory prostate cancer and will play a considerable role in the management of advanced disease.

Long-term pain relief produced by intrathecal morphine infusion in 53 patients.

The present report details the characteristics of the analgesic effects of morphine administered chronically by infusion pumps implanted in 53 patients suffering from terminal metastatic disease. The median postimplant survival time in these patients was 4 months. Patients (mean age 58 years) were characterized according to the duration of pain before pump implantation (mean 16 months), prior consumption of systemic opioids (mean one to six daily analgesic equivalents of morphine), and their response to a trial intrathecal dose of morphine (1 to 2 mg). The median infusion dose at 2 weeks was 3.8 mg/day. The analgesic index, calculated as (quality of pain relief x duration of pain relief in hours)/morphine dose in mg, that was observed after the trial dose of morphine was determined for each patient. A close correlation was observed between the acute (2-week) infusion dose necessary to produce pain relief and the analgesic index such that the infusion dose = -8.0 x log (analgesic index) + 17.1. By 16 weeks, the mean spinal morphine dose for the group had increased by a factor of about 2.5; however, significant variation in the dose incrementation was documented. The maximum increase was observed in patients with a low analgesic index, and this rapid incrementation was usually correlated with an unsatisfactory overall outcome. Evidence that long-term infusion continues to yield analgesia was evidenced in six cases where there was an unanticipated loss of drug infusion and a corresponding increase in parenteral narcotic consumption. These data indicate the long-term efficacy and safety of spinal opioid infusion in patients with terminal cancer, and emphasize the advantage of assessing the sensitivity of the patient to spinal opioids by a standardized trial injection prior to pump placement as a prognostic indication of outcome.

The effectiveness of 100 and 200 mg etodolac (Ultradol), aspirin, and placebo in patients with pain following oral surgery.

The analgesic efficacy of etodolac (Ultradol) was evaluated in 168 patients experiencing moderate to severe pain following oral surgery. The patients were given either etodolac 100 mg, etodolac 200 mg, aspirin 650 mg, or placebo. There was a minimum of forty patients in each drug group. Patients recorded pain intensity and pain relief at 1/2 hour and then hourly for up to 12 hours after medication. The efficacy variables analyzed were the sum of pain-intensity differences, total pain relief, onset of analgesia, and the patient's opinion of the study drug. Time-effect curves were made from the pain-relief and pain-intensity difference scores. The analgesic potency of both 100 and 200 mg of etodolac was comparable to 650 mg of aspirin and superior to placebo. Like aspirin, both doses of etodolac showed significant analgesia within one hour and a significantly longer duration of action than placebo.

Sensory decision theory and visual analogue scale indices predict status of chronic pain patients six months later.

Thirty-nine outpatients suffering from chronic pain were studied in a multidisciplinary program. Pain intensity on a visual analogue pain scale (VAPS), sensory decision indices of thermal discriminability, P(A), and pain report criterion, B, age and sex obtained before treatment, were used to predict the patients' status, determined by a follow-up questionnaire 6 mo later. The results showed that patients who were high on the VAPS at intake had shorter pain relief and decreased physical activities on follow-up. Patients with better thermal discriminability had greater pain relief, while those with low pain report criterion, that is, less stoical, demonstrated improved physical activity, and more social and hobby activities. Patients who were less stoical to thermal stimuli (lower pain criterion) took fewer centrally active drugs after treatment. Younger patients showed greater improvement at follow-up. The data indicate that the VAPS, thermal discriminability, and pain report criterion all predict the duration of pain relief after treatment. Nevertheless, each of these variables had its individual character. The VAPS was most efficient in predicting physical activities, thermal discriminability related best to pain relief, and pain report criterion to social and hobby activities as well as drug intake.

Switching opioids to transdermal fentanyl in a clinical setting

INTRODUCTION: The use of transdermal fentanyl is gaining in importance in the management of cancer pain. We describe the reasons for switching opioid medication to transdermal fentanyl in a pain management unit. METHODS: Case records of patients treated with transdermal fentanyl in our pain clinic were evaluated retrospectively. Conversion ratios were calculated from the opioid dosage before and after conversion. Pain intensities were assessed on a numeric rating scale (NRS 0: no pain, 10: worst pain imaginable). RESULTS: From October 1995 to December 1997 101 patients received transdermal fentanyl. Thirty-six patients had been treated with transdermal fentanyl before admission to our pain clinic, and relevant information was missing for one patient, so 64 patients were evaluated. Opioid therapy was switched to transdermal fentanyl during in-patient treatment for 53 patients and during out-patient treatment for 11 patients. Before conversion patients were treated with slow-release morphine (48%), immediate-release morphine (17%), buprenorphine (11%), tramadol (11%), levomethadone (5%), tilidine/naloxone (5%) and piritramid (3%). Reasons for opioid rotation were inadequate pain relief ( 33%), the patients' wish to reduce oral medication (20%), gastrointestinal side effects such as nausea (31%), vomiting (13%) and constipation (19%), dysphagia (27%) or others. Reduction of side effects was reported by 10 of 19 patients. In 12 of 21 patients, in whom the medication was switched because of inadequate pain relief, a reduction in pain intensity was reported. DISCUSSION: Conversion to transdermal therapy may readjust the balance between opioid analgesia and side effects. The opioid switch resulted in more pain relief or fewer side effects in half of the patients. A proposed equianalgesic conversion ratio between 70:1 and 100:1 from oral slow-release morphine to transdermal fentanyl can be confirmed by our data. Conversion rates from other opioids to transdermal fentanyl are suggested.

Gamma Knife radiosurgery for treatment of trigeminal neuralgia: idiopathic and tumor related.

Sixty patients with trigeminal neuralgia who did not have a response to pharmacologic treatment (including 22 who had no response to conventional surgical treatment) underwent stereotactic radiosurgical treatment with the Leksell Gamma Knife. A radiosurgical maximum dose of 70 Gy was delivered to the trigeminal nerve root adjacent to the pons via a 4-mm collimator helmet in 51 patients who presented with trigeminal neuralgia unrelated to tumors. In these patients, the root was localized by stereotactic MRI. Follow-up assessment of pain relief was accomplished by a third party not involved in the patients' clinical care. Within a latency period of 1 day to 4 months following the treatment, 38 of 51 patients (74.5%) were completely free of pain and eventually all medications were tapered off. An additional seven patients (13.7%) experienced reductions in pain from 50 to 90% and utilized little or no medications. Patients who had no prior surgical intervention fared much better than those who had previous surgery to relieve their facial pains. At last follow-up, a mean of 16.3 months (range 6-36 months) after treatment, 41 patients (80.4%) remained pain-free or had marked pain reduction. There were four patients with recurrent pain. All 26 patients with classical symptoms of trigeminal neuralgia with no atypical features who had no prior surgery, had complete or nearly complete pain relief, and none of these patients had recurrent pain. Nine patients with trigeminal neuralgia due to tumors received standard radiosurgical treatment directed at their tumors, and eight of nine (88.8%) had pain relief. Of the total of 60 patients treated for trigeminal neuralgia, 49 (81.7%) experienced complete or nearly complete relief of pain at last follow-up. Only one patient with pre-existing facial sensory loss due to a tumor had a mild increase in facial numbness. No other patient experienced either loss of facial sensation or any other complication. Gamma Knife radiosurgery appears to be a minimally invasive, safe, and effective therapy of trigeminal neuralgia.

pain relief through transcutaneous electrical nerve stimulation (TENS). Results on painful neurological disorders in 180 cases (author's transl)

A series of 180 patients with painful neurological disorders were treated with TENS. The findings most frequently encountered when the treatment was successful are analyzed. Depending upon the etiology of the primary disorder, good results (i.e. pain relief of 20% or higher) were obtained as follows : -- Peripheral Nerve Involvement : Amputation - 35 cases; Traumatism - 13 cases ; Miscellaneous - 7 cases. (87 %). -- Radicular Syndromes : Epidural scar and/or Arachnoiditis - 19 cases; Miscellaneous - 9 cases. (60 %). -- Post Herpetic Pain : 34 cases. (67 %). -- Brachial Plexus Lesions (Avulsions) : 12 cases. (25 %). -- Spinal Cord Disorders : 17 cases. (11 %). --Thalamic Pain : 5 cases. (0 %). -- Post-Radiation Pain or Carcinomatous Pain : 16 cases. (30 %). Satisfactory long-term results (over 3 years) were maintained in 80 % of cases of peripheral nerve involvement. In all other cases the percentage of pain relief decreased with follow-up. In this series the likelyhood of good results was associated with the following objective data : 1) Pain is generally secondary to deafferentation. 2) Pain is localized. 3) TENS application in close contact with the nervous structure innervating the painful area is more productive. 4) A relative preservation of lemniscal fibers to superior centers must be present so that stimulation can be transmitted.