Long-term outcome of spinal cord stimulation and hardware complications.

Spinal cord stimulation (SCS) is a treatment modality for medically intractable chronic pain. This study reports an 11-year experience with SCS assessing long-term pain relief and specifically evaluating complications and revisions. It took the form of a retrospective review of medical/surgical records with a postal questionnaire. The subjects were 102 patients with medically intractable chronic pain who underwent SCS implantation between 1989 and 2000. There were 64 revision operations carried out on 35 patients. These comprised electrode replacement/repositioning (29), generator replacement (23), cable failure (3) and implant removal (5). Five (4.9%) implants became infected and 2 required removal. Clinician-reported pain relief was substantial in 69 (68%) patients. This study adds to the weight of evidence that patients undergoing SCS derive significant benefits in terms of pain relief. However, revision rates remain high due to technical and biological factors. Copyright 2003 S. Karger AG, Basel

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.

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.

Continuous epidural analgesia for painless labor does not increase the incidence of cesarean delivery.

BACKGROUND: Continuous epidural analgesia is a popular technique provided for labor pain relief. However, the possible association between epidural analgesia and increased rate of cesarean delivery is always a concern. The purpose of this study was to explore if epidural analgesia would affect the rate of cesarean delivery in healthy term parturient women. METHODS: A retrospective review of obstetric records of 822 parturients was done to compute the proportions and odds ratio of cesarean delivery between parturients receiving epidural analgesia for labor pain relief and those not receiving. RESULTS: Results indicated that the overall proportion of cesarean delivery was 11.1% in the epidural group as against 16.2% in the control group and the odds ratio was 0.65 (95% confidence interval: 0.37 to 1.08). The difference between groups was not statistically significant. However, for nulliparous women alone, the proportions of cesarean delivery were 11.6% and 25.1% in exposure group and control group respectively. The odds ratio was 0.39 (95% CI: 0.20 to 0.71). This difference was statistically significant. CONCLUSIONS: The findings may support the conclusion that continuous epidural analgesia for pain relief during labor would not increase the rate of cesarean delivery. In contrast, it may reduce this risk in nulliparas.

Palliative radiotherapy for symptomatic adrenal metastases.

To evaluate the role of palliative radiotherapy for adrenal metastases, a retrospective review was performed on 16 patients treated between 1972 and 1988 for palliation of symptomatic adrenal metastases. The median patient age was 56 years. In 15 cases lung cancer was the primary site (7 adenocarcinomas, 3 squamous cell carcinomas, 3 large cell carcinomas, and 2 small cell carcinomas) and in 1 case there was an unknown primary (squamous cell carcinoma). Ten of 16 patients were treated with 3000 cGy to opposed anterior and posterior fields (300-cGy fractions [four patients] and 250-cGy fractions [six patients]). The remaining six patients were treated with a variety of techniques, with total doses ranging from 2925 cGy to 4500 cGy. The patients were analyzed for response at their first follow-up visit (2 to 4 weeks after treatment). The overall response rate was 75% (12 of 16 patients). Six patients (38%) had complete pain relief without medication that lasted until death. Two patients had marked pain relief, but still required analgesics. Four patients had marked or moderate pain relief that did not continue through follow-up. Four patients had minimal to no response. All patients were observed until death, with a median survival time after irradiation of 3 months (range, 0.5 to 11 months). Although the prognosis for patients with adrenal metastases is poor, radiotherapy to symptomatic adrenal metastases can be administered with a high probability of achieving effective palliation.

Evaluation of radiation therapy for bone metastases: pain relief and quality of life.

The records of 158 patients irradiated for bone metastases were reviewed to evaluate the effectiveness of pain relief and to judge the effect of treatment on overall quality of life. Within 3 months 73% of the sites treated had pain relief, with 55%-65% having sustained relief up to 1 year or death. Of patients surviving more than 3 months, 63% maintained a satisfactory quality of life and were able to take care of most personal needs. The median survival of all patients was 1 year from initial treatment for bone metastasis. Radiation dose and the primary tumor site do not seem to be significant prognostic factors for initial pain relief or quality of life.

Problems related to dorsal root entry zone lesions.

Several clinical problems related to the dorsal root entry zone lesions (DREZLs) in 15 patients with chronic pain are presented and discussed in terms of ratings of pain relief following surgery, development of sensory or motor weakness and postmortem histologies. Subjective pain relief exceeding 70% was achieved at around 2 weeks after the operations in most patients (13/15), and then decreased in some to 30 from 70% in the follow-up observations. Our new "objective" pain relief score was tested in these patients. A significant positive correlation between subjective pain relief and our objective pain relief scale was found, but some discrepancies between them were also found during the follow-up. Sensory loss, motor weakness, paraesthesia and a new pain were found as complications in 12, 7, 4 and 6 patients, respectively. Postmortem histological findings of the spinal cord in two patients with systemic lupus erythematosus and uterine cancer, who received bilateral DREZLs twice and bilateral DREZLs plus commissural myelotomy, respectively, indicate that care should be taken to avoid extension of the coagulation beyond the dorsal horn.

Pain management in a rheumatology department: a satisfaction survey.

OBJECTIVES: To evaluate the quality of pain management in a teaching hospital rheumatology department. METHODS: We conducted a satisfaction survey among all the patients admitted to the conventional rheumatology department of our teaching hospital over a 1-month period (88 patients with a mean length of stay of 5 d). The patients were asked to complete a questionnaire on the day of discharge. The professional staff was not informed of the survey. RESULTS: The mean pain severity score at admission (visual analog scale, VAS) was 7.76 +/- 1.76 and the mean score decrease with treatment was 7.27 +/- 2.81. Expected pain relief and actual pain relief were correlated (R = 0.39; P = 0.001). Nearly all the patients (96.1%) reported have been encouraged to communicate about their pain. Information on the treatment was given to 89.3% of the patients; no significant differences in pain severity or pain relief were found between the patients who did and did not receive this information. The patients were satisfied with their management by the physicians (VAS: 8.83 +/- 2.07) and nurses (VAS: 8.68 +/- 1.72). CONCLUSION: Satisfaction with pain management (a subjective criterion) was good in our patients. However, no validated tools for measuring satisfaction are available, and measurements should be repeated to look for improvements over time. Limitations to these results include the placebo effect, the influence of memory, and the effects of the behavior of hospitalized patients. A repeat survey is needed.

Intravenous infusion of fosphenytoin produces prolonged pain relief: a case report.

The objective of this case report is to emphasize the analgesic effect of antiepileptic drugs in those with neuropathic pain, confirm that fosphenytoin possesses these analgesic properties, and to highlight that intravenous administration of fosphenytoin for 24 hours can produce good quality pain relief that lasts for many weeks. A 37-year-old woman with a neuroma (caused by surgical intervention for an endometrial sarcoma) producing neuropathic pain unresponsive to opiates was successfully treated with intravenous infusion of 1,500 phenytoin equivalent units fosphenytoin for 24 hours. The pain relief after this and subsequent infusions persisted for between 3 and 14 weeks and was associated with a reduced opiate requirement and an increase in activities of daily living. Fosphenytoin infusion can give good quality pain relief in the patient with neuropathic pain.

Temporary external pedicular fixation versus definitive bony fusion: a prospective comparative study on pain relief and function.

Temporary external pedicular fixation is used as a prognostic instrument when treating degenerative conditions with spinal fusion. We studied the validity of the method and whether a functional test could improve the prognostic value of such fixation. Twenty-six patients with long-standing lumbar pain had an external temporary fixation. Pain levels were registered before fixation on a visual analogue scale at rest, as a mean for the previous week, and at seven different standardized activities. Walking capacity and walking speed for a standardized distance were also measured. Identical evaluations were then repeated during the external fixation and 1 year after definitive fusion. Based on the outcome of the temporary fixation, 20 patients were recommended for definitive surgical fusion. In six cases, the option of fusion surgery was rejected due to an unfavourable pain response or insufficient pain relief during the test fixation period, and this group was not further followed within the study. One year after surgery, 14 of 20 patients reported a good outcome. Solid bony fusion assessed by conventional radiography was seen in 19 patients. One patient with a poor clinical outcome had a pseudarthrosis. The mean values for pain level at rest, during last week and at the seven different activities in the functional test tended to decrease after fusion compared to the situation with temporary external fixation. In no activity did the external fixator overestimate the mean positive pain-relieving effect after definitive fusion. The walking capacity significantly increased, while the walking speed did not alter at the three different measurements. We conclude that with a good outcome ratio of 14 patients out of 19 having a solid fusion, the external frame improved patient selection and can be used as a valid prognostic instrument. The pain relief and function after definitive fusion can not be quantified by the external fixation, probably due to the fact that the stabilisation with an external frame is partial. The value of the functional test design presented is moderate, and an outcome evaluation comprising pain relief at rest and mean pain level during a week in fixation seems adequate.