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.

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.

A prospective analysis of predictive factors on the results of laparoscopic adhesiolysis in patients with chronic abdominal pain.

Laparoscopic adhesiolysis for chronic abdominal pain is subject for criticism. In this prospective study, we analyze factors that encourage or discourage the indication for therapeutic laparoscopic adhesiolysis. Two hundred twenty-four consecutive patients with chronic abdominal pain underwent diagnostic laparoscopy, and in case of adhesions, they underwent adhesiolysis. pain relief was assessed, and the individual impact of variables on pain relief was determined. Laparoscopy was performed in 224 patients. Two hundred patients had only adhesions and underwent primary laparoscopic adhesiolysis. Three months after adhesiolysis, 74% of patients were pain-free or had less pain. The remaining 26% of the patients felt no change (22%) or had more pain (4%). Gender, age, and bowel perforation leading to a laparotomy appear to be individual factors significantly influencing pain relief. Laparoscopic adhesiolysis can be done (almost) completely in 92% of patients with adhesions. After laparoscopic adhesiolysis, 74% of patients had good results and 4% had more pain. The complication rate is high.

Effectiveness of hypofractionated radiotherapy in painful bone metastases. Two prospective studies with 1 x 4 Gy and 4 x 4 Gy.

BACKGROUND: Although effectiveness of fractionated radiotherapy for painful bone metastases is well documented, there are unanswered questions regarding the adequacy of low-dose short radiation schedules for long-term pain control which give maximum benefit in patients with a short life expectancy. PATIENTS AND METHODS: Two consecutive non-randomized prospective follow-up studies were performed at a single institution to analyze pain response and duration of response in patients with a variety of primary tumors. Included were only patients with symptomatic nonvertebral bone metastases and without impending pathologic fracture. Forty-five patients received 1 x 4 Gy to 50 different sites (group I) while 86 patients received 4 x 4 Gy to 96 sites (group II). pain relief to irradiation was evaluated according to patient interviews using a 4-point categorical scale. Follow-up was performed 7 and 90 days after radiotherapy. RESULTS: pain relief after 4 x 4 Gy was significantly superior to 1 x 4 Gy with pain control rates being 86.5% vs 48% at day 7 (after end of treatment) and 80% vs 55% at day 90, respectively. A subgroup analysis of patients treated with 4 x 4 Gy demonstrated a more favorable outcome for breast cancer patients in comparison to patients with other primaries concerning pain relief (96% vs 81%), pain control after 90 days (93% vs 72%), median time to pain progression (9 vs 3 months), and median overall survival (14 vs 5.5 months). CONCLUSIONS: In this study 4 x 4 Gy proved to be clearly superior to 1 x 4 Gy in relieving pain from symptomatic nonvertebral bone metastases without impending pathologic fracture. Even if radiotherapy with 1 single fraction seems to be applicable in specific cases doses higher than 4 Gy should be chosen. In breast cancer patients pain control seems to be better compared to other primaries.

Epidural morphine for postoperative pain relief: a dose-response curve.

Different doses of epidural morphine were studied in order to determine their effectiveness in providing postoperative pain relief after surgery of the lower extremities and their relationship to the incidence of untoward reactions. The study was carried out in a double-blind fashion using five dosages of epidural morphine (0.5, 1.0, 2.0, 4.0, and 8.0 mg) and included 60 patients. The higher doses of morphine (2.0, 4.0, and 8.0 mg) were equally effective and more effective than the lower doses (0.5 and 1.0 mg) in providing postoperative analgesia. Nausea and vomiting were encountered more frequently with the highest dose (8.0 mg) and this finding was statistically significant (P less than 0.03). No statistically significant difference was found between the doses studied with regard to itching, urinary retention, and respiratory depression; the latter was evaluated in a subgroup of 20 patients. These data suggest that effective postoperative pain relief after surgery of the lower extremities can be achieved with relatively low doses of morphine sulfate and with minimal side effects. For the type of surgery studied, 2 mg morphine sulfate appeared to be the optimum dose.

Ventilatory response to intractable pain.

Fifty-two patients, admitted to a pain relief unit, had a cannula placed in the radial artery to measure the paO2, paCO2 and pH of arterial blood every 2 h, for periods ranging from 12 to 24 h. The patients were divided into 3 groups: 14 had low back pain, 21 patients had pain from cancer, and 17 had pain from other causes. Twenty were male and 32 were female with a mean age of 53 years (range 16-82 years). The mean paO2 of these groups was within normal limits. The mean paCO2 and pH for the 3 groups were, low back pain paCO2 4.1 kpa, pH 7.42, others, paCO2 4.2 kpa, pH 7.42. The finding of a normal pH associated with a low paCO2 suggests that patients were "reset" to a low paCO2. Treatment, which was most commonly nerve blocks, resulted in marked pain relief in 30 patients. Ten of these patients were available for follow-up at least 1 week later (4 from the low back pain group, 6 from the cancer group), and in every patient, after pain relief, there was a rise in paCO2 which was statistically significant (P less than 0.001) and was not accompanied by a fall in pH. This suggests that intractable pain is accompanied by chronic hyperventilation and that the relief of pain is accompanied by a decrease in ventilation.

Personal control in pain relief during labour.

Personal control is a central feature of women's involvement in their childbirth experiences. To achieve this control tacit rules and guidelines are applied to define how women and the professionals who care for them should behave. This study investigated the extent to which women exercised control in pain relief during the first stage of labour by comparing (a) the rules which they held prior to childbirth (2-3 cm cervical dilatation) with those which they afterwards felt applied to their labour and (b) the rules held by the women before and after childbirth with those held by the midwives. In a quantitative study using a repeated measures design, a questionnaire was administered to 35 midwives and to 100 women prior to and within 24 hours following their delivery. Consistency of the women's scores before and after childbirth, indicated by few statistically significant differences, tended to confirm their rules on control of pain relief. Some of the rules were held even more strongly following childbirth. A surprising finding was the even stronger agreement by midwives with some of the rules. There was a definite trend for many of the rules held by the women prior to childbirth to increase following birth towards those of the midwives. This could be the result of the experience of childbirth per se but the possibility that it was contributed to by the influence of the midwives cannot be ruled out and warrants further research. An interesting hierarchy in the rules for compliance with professional care has been highlighted.

Postoperative pain relief in primigravida caesarean section patients--combination of intrathecal morphine and epinephrine.

BACKGROUND: Uterine contraction is less severe in primigravida patients. Intrathecal coadministration of morphine and epinephrine may provide an easy way of postcaesarean pain control. METHODS: Twenty-eight primigravida patients who requested postcaesarean pain control were studied for the effectiveness of coadministration of intrathecal morphine and epinephrine. The solution for spinal anesthesia which contained 0.2 mg morphine, 0.1 mg epinephrine and 10 mg hyperbaric bupivacaine was injected intrathecally. Another 30 primigravida patients were collected randomly as control. In the control group, normal saline and 0.1 mg epinephrine were used with bupivacaine. Side effects from intrathecal morphine and the need of analgesia were recorded within 48 h. RESULTS: In the study group, 89.3% (25/28) of patients did not need further narcotics for pain relief during their hospitalization after caesarean section. 96.4% (27/28) of patients needed only one dose of 50 mg intramuscular meperidine (Demerol) or no narcotic at all for pain relief within 48 h. No respiratory depression occurred. In the control group, each patient received in the average 6-7 doses of 50 mg Demerol for pain control within 48 h. CONCLUSIONS: Our results showed that 0.2 mg morphine and 0.1 mg epinephrine in combination with 10 mg hyperbaric bupivacaine given intrathecally could provide a simple way of pain control in primigravida patients undergoing caesarean section.

Microsurgical DREZotomy for pain due to brachial plexus avulsion: long-term results in a series of 37 patients.

The authors analyzed the postoperative and long-term results of the microsurgical DREZotomy procedure performed in 37 patients suffering from chronic pain due to brachial plexus avulsion. The evaluation was based on clinical parameters. The immediate results consisted of good pain relief (pain relief > 75%) in 79% of the patients. A long-lasting good pain relief has been achieved in 66.5% of the patients with a mean follow-up of 60 months (range 12-120). The morbidity rate was 5%.

Attitudes to pain and pain relief in adult surgical patients.

pain relief after surgery is frequently inadequate. In the last few years much research has been devoted to improving the situation. Unfortunately, very little work has been undertaken to explore the patients' contribution to pain management. The beliefs and attitudes held by patients when they enter the hospital environment may be responsible in some instances for their not achieving optimal pain relief from the available techniques. We have studied some of these attitudes with a survey of 180 adult patients admitted for elective surgery. We found that most patients still expect pain following surgery. However, they are not afraid to ask for analgesics when in pain and do not attribute pain to their own wrong doing. There are, however, some patients who appear to have 'deviant' pain beliefs that could hinder their appropriate use of analgesics. Sadly, it is impossible to identify these patients according to age, gender, socio-economic group or previous experience of pain or surgery.