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.

The interpretation of pain relief and sensory changes following sympathetic blockade.

A comparative study of the effects of sympathetic blockade by stellate ganglion block (SGB) and intravenous phentolamine infusion (PhI) was carried out in 24 patients with presumed sympathetically maintained pain of an upper extremity. A total of 15 SGBs and 16 PhIs were performed, with seven patients undergoing both procedures. All patients developed a Horner's syndrome with SGB and nasal stuffiness and cardiovascular changes with PhI. Similar pain relief was obtained with SGB and PhI in six of the seven who underwent both procedures. Pre-procedure patient characteristics including age, sex, duration of pain, historical and physical examination features suggestive of the reflex sympathetic dystrophy syndrome, and sensory disturbances such as allodynia and hyperpathia did not predict pain relief from either procedure. Changes in skin temperature following the sympatholytic procedure did not correlate with pain relief. For PhI, pain relief correlated with the magnitude of decrease in systolic blood pressure. After SGB, changes in quantitative thermal sensory testing (QST) suggestive of a partial deficit in thermal sensation correlated with pain relief. In 20 normal controls, water bath immersion to cool the hand passively by 7 degrees C and warm the hand passively by 4 degrees C had small and selective effects on thermal QST thresholds, but did not produce a general impairment in thermal sensation. In conclusion, the diagnosis of sympathetically maintained pain based on the history and physical examination alone cannot be made with confidence and therefore a sympatholytic procedure is necessary. When SGB produces pain relief but PhI does not, systemic absorption of local anaesthetic and/or sensory blockade by spread to somatic nerves may be the reason. Thus, PhI appears to be a less sensitive but more specific test than SGB. These two procedures provide complementary information and both may be needed to establish the diagnosis of sympathetically maintained pain.

Dose-dependent epidural leakage of polymethylmethacrylate after percutaneous vertebroplasty in patients with osteoporotic vertebral compression fractures.

OBJECT: The use of polymethylmethacrylate (PMMA) cement by percutaneous injection in cases requiring vertebroplasty provides pain relief in the treatment of osteoporotic vertebral compression fractures. A retrospective study was performed to assess what caused PMMA cement to leak into the epidural space and to determine if this leakage caused any changes in its therapeutic benefits. METHODS: Polymethylmethacrylate was injected into 347 vertebral compression fractures in 159 patients. The cement leaked into the epidural space in 92 (26.5%) of 347 treated vertebrae in 64 (40.3%) of the 159 patients, as demonstrated on postoperative computerized tomography scanning. Epidural leakage of PMMA cement occurred more often when injected above the level of T-7 (p = 0.001) than below. The larger the volume of PMMA injected the higher the incidence of epidural leakage (p = 0.03). Using an injector also increased epidural leakage (p = 0.045). The position of the needle tip within the vertebral body and the pattern of venous drainage did not affect epidural leakage of the cement. Leakage of PMMA into the epidural space reduced the pain relief expected after vertebroplasty. The immediate postoperative visual analog scale scores were higher (and therefore reflective of less pain relief) in patients in whom epidural PMMA leakage occurred (p = 0.009). Three months postoperatively, the authors found the highest number of patients presenting with pain relief, including those in the group with epidural leakage, and at this follow-up stage there were no significant differences between the two groups. CONCLUSIONS: The authors found that epidural leakage of PMMA after percutaneous vertebroplasty was dose dependent. The larger amount of injected PMMA, the higher the incidence of leakage. Injecting vertebral levels above T-7 also increased the incidence of epidural leakage. Epidural leakage of PMMA may attenuate only the immediate therapeutic effects of vertebroplasty.

What decline in pain intensity is meaningful to patients with acute pain?

Despite widespread use of the 0-10 numeric rating scale (NRS) of pain intensity, relatively little is known about the meaning of decreases in pain intensity assessed by means of this scale to patients. We aimed to establish the meaning to patients of declines in pain intensity and percent pain reduction. Upon arrival to the postanesthesia care unit, postsurgical patients rated their baseline pain intensity on both a 0-10 NRS and on a 4-point verbal scale. Patients whose NRS was higher than 4/10 received intravenous opioids until their pain intensity declined to 4/10 or lower. During opioid titration, patients were asked every 10 min to rate pain intensity on a NRS and to indicate the degree of pain improvement on a 5-point Likert scale from 'no improvement' to 'complete pain relief'. Seven hundred adult patients were enrolled. For patients with moderate pain, a decrease of 1.3 units (20% reduction) corresponded to 'minimal' improvement, a decrease of 2.4 (35% reduction) to 'much' improvement, a decrease of 3.5 units (45% reduction) corresponded to 'very much' improvement. For patients with severe pain, the decrease in NRS pain score and the percentage of pain relief had to be larger to obtain similar degrees of pain relief. The change in pain intensity that is meaningful to patients increases as the severity of their baseline pain increases. The present findings are applicable in the clinical setting and research arena to assess treatment efficacy.

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.

Comparison of buprenorphine and fentanyl for postoperative pain relief by continuous epidural infusion

This study examined analgesic efficacy and adverse effects of buprenorphine and fentanyl for the postoperative pain relief by continuous epidural infusion. Fifty patients after upper or lower abdominal surgeries were assigned to two groups and buprenorphine and fentanyl were epidurally administered postoperatively. Buprenorphine (B) group received bolus injection of B 0.1mg + saline 8 ml and continuous infusion of B 0.8 mg+saline 92 ml (2 ml.h-1). Fentanyl group received bolus injection of F 0.1 mg+saline 6 ml and continuous infusion of F 0.6 mg+saline 84 ml (2 ml.h-1). There was no significant difference between the two groups in the analgesic efficacy, which became lower from 2 to 12 hours postoperatively. However, compared with buprenorphine group, the incidence of nausea or vomiting and dizziness was significantly less in the fentanyl group (11 vs. 4 cases and 7 vs. 1 cases). These results imply that the major site of action of epidurally administered fentanyl is the spinal cord. In contrast, analgesic effect of epidural buprenorphine appears to be enhanced by the supraspinal action. We conclude that fentanyl is superior to buprenorphine for postoperative pain relief by continuous epidural infusion.

Patient-controlled analgesia (PCA) with codeine for postoperative pain relief in ten extensive metabolisers and one poor metaboliser of dextromethorphan.

Postoperative pain relief with codeine was evaluated in 11 women undergoing hysterectomy. Patient-controlled analgesia (PCA) was used to administer codeine. After the study the patients were phenotyped with respect to the O-demethylation of dextromethorphan (cytochrome P4502D6 polymorphism). Ten were extensive metabolisers and one a poor metaboliser. There was a nine-fold variation in the minimum plasma concentration of codeine consistent with pain relief (40-350 ng ml-1). Two patients did not experience any effect of codeine, one of whom was a poor metaboliser of dextromethorphan, confirmed by genotyping. In the other nine patients the effective dose of codeine varied from 4.8-25.3 mg h-1.

Lumbar facet joint synovial cyst: percutaneous treatment with steroid injections and distention--clinical and imaging follow-up in 12 patients.

PURPOSE: To determine the imaging characteristics of lumbar facet joint synovial cysts after percutaneous treatment with steroid injections and distention of the cyst and to correlate these findings with the clinical outcome. MATERIALS AND METHODS: Clinical outcome and imaging findings were retrospectively studied in 12 patients (four men, eight women) aged 45-79 years (mean, 60 years) with a symptomatic lumbar facet joint synovial cyst treated with percutaneous steroid injections. At varying times after the procedure, patients were contacted for clinical follow-up, and repeat imaging was performed to verify the status of the cyst. RESULTS: Excellent pain relief was achieved in nine (75%) of 12 patients. At follow-up imaging, the cyst completely regressed in six (67%) of these nine patients, partially regressed in two (22%) patients, and was unchanged in one (11%) patient. One (8%) of the 12 patients had transient pain relief, with recurrence of symptoms at short intervals after each of three injections. No pain relief was achieved in two (17%) of 12 patients. CONCLUSION: Image-guided percutaneous steroid injections are often effective in the treatment of lumbar facet joint synovial cysts and may result in complete regression of the cyst.

Radiographic clinical and functional diagnosis and treatment of low back pain associated with pelvic malposition

Low back pain ist frequently associated with malposition of the pelvis due to an imbalance of the postural muscles. In these patients functional malposition of both the sacrum and the ileum can be observed, resulting in differences in the length of the legs. We investigated whether the return to a normal position correlated with pain relief. METHODS: A total of 40 control patients and 65 patients with low back pain were included in this retrospective study. Prior to the start and at the end of the treatment period the differences in the length of the legs were determined manually and radiographically at the ankles with the patient in the supine and sitting position. Furthermore, somatic dysfunctions at C0/C1 or C2/C3 were determined in all patients. In the low back pain group, 39 patients were treated with manual therapy at the cervico-occipital joints and/or infiltration of the iliosacral joint with local anaesthetics and 26 patients were treated with parenteral non-steroidal anti-inflammatory drugs (NSAIDs). The success of the treatment was determined after 6 months and correlated with a return to the normal pelvic position. RESULTS: Somatic dysfunction at C0/C1 or C2/C3 and differences in the length of the legs were observed in 32 control patients and in all patients with low back pain. Manual therapy/lidocaine infiltration resulted in complete long-term pain relief in 23 patients (59 %), while in the NSAID group only 4 patients (15 %) became pain free (P < 0.05). Long-term pain relief significantly correlated with normalization of the pelvic position. CONCLUSION: Differences in the length of the legs can be successfully treated by manual therapy at C0/C1 or C2/C3 in the majority of patients with pelvic malposition. However, infiltration of the iliosacral joints is often required as additional therapy for short-term and long-term pain relief. Treatment with NSAIDs alone is only seldom effective in cases of pelvic malposition and rarely affords long-term pain relief.

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.