Long-term results of cervical epidural steroid injections.

Fifty-eight patients undergoing cervical epidural injection of corticosteroids were followed for a 6-month period. Patients with 90% pain relief lasting 6 months were considered to have excellent results, those with greater than 50% pain relief lasting at least 6 weeks were considered to have good results, and all others were considered to have poor results. Six months after the injection, 41.4% of patients had excellent pain relief by our criteria. Twenty-nine percent of patients reported good results and 29.3% had poor results. Those patients with the diagnosis of cervical spondylosis and those with subacute cervical strain had statistically significantly (p less than 0.001, difference of proportions test) better results than patients with other diagnoses. The procedure of cervical epidural steroid injection may be most effective in patients with cervical degenerative joint disease as the etiology of their cervical pain.

Differences in midwives' approaches to pain relief in labour.

OBJECTIVE: To examine the influence of midwives' approaches on the care given to women for pain relief during labour. DESIGN: Non-participant observation was used to collect data on midwives' behaviours during interactions with women in labour. SETTING: A large teaching hospital in Northern Ireland. PARTICIPANTS: Observations focused on interactions that were related to pain relief and involved 11 midwives caring for 15 women throughout the first stage of labour. KEY FINDINGS: Midwives' approaches to pain relief differed; at one extreme the midwife acted as 'a cold professional' whilst at the other extreme she was observed to be 'a disorganised carer'. In the middle of these two extremes was the 'warm professional'; her approach had a positive influence on the women's experience of labour pain. IMPLICATION FOR RESEARCH: Further research is needed to develop a profile of the factors that 'make' for a warm professional. The information gained could be used to teach midwives the skills of being 'a warm professional', in particular, the value of effective communication for sensitive care such as pain relief in labour.

Relief of cancer pain in man: alcohol-induced neuroadenolysis vs. electrical stimulation of the pituitary gland.

To explore new methods for the control of intractable pain caused by advanced cancer, the analgesic effect of electrical stimulation of the pituitary gland was investigated in 25 patients. The results were compared with a control study and with the effects of alcohol-induced pituitary neuroadenolysis (NALP) in the same patients. The pain score (0: no pain at all, 4: extreme pain) in the control study was 3.88 +/- 0.33. After electrical stimulation of the pituitary gland it was 1.24 +/- 1.61; and after NALP it was 1.0 +/- 1.60. The pain scores after electrical stimulation and NALP were significantly lower (P less than 0.01) than those in the control study; but there was no significant difference when the two were compared with each other. The duration of pain relief following NALP (59.65 +/- 68.72 days) was significantly longer compared with that recorded following electrical stimulation (2.97 +/- 2.58 days). Autopsy examinations of 3 patients who expired from their malignancies revealed that the pain relief was unrelated to the degree of necrosis induced in the pituitary by alcohol. Naloxone administration did not inhibit the analgesic effect of either NALP or electrical stimulation. The advantages and disadvantages of electrical stimulation, the pain relief mechanism activated by this method, and potential clinical applications are also discussed.

Orthotic therapy in the management of osteoarthritis.

The authors evaluate the use of orthoses as a primary therapeutic means in the long-term management of patients with osteoarthritis of the foot and ankle. A comparison of the amount of pain relief experienced by 64 subjects (mean age 63 years) with different treatment regimens for osteoarthritis was made to determine the role orthoses played in helping to reduce or eliminate pain. One hundred percent of the subjects wearing orthoses only for relief of pain had a statistically significant longer period of pain relief than those on nonsteroidal anti-inflammatory drugs. Fifty-five percent of the subjects using orthoses and nonsteroidal anti-inflammatory drug therapy also had a statistically significant longer period of pain relief than those receiving nonsteroidal anti-inflammatory drug therapy only.

Pain intensity and pain relief after surgery. A comparison between patients' reported assessments and nurses' and physicians' observations.

BACKGROUND: Postoperative pain remains a problem for many patients. One of the reasons could lie in the insufficient evaluation of pain and analgesia. This study was designed to obtain more insight in the performance of nurses and physicians in evaluating patients' postoperative pain and pain relief. METHODS: Forty patients hospitalised in one surgical unit and the 8 nurses and the 2 surgical residents in charge of this unit were investigated. Patients were asked to assess on a visual analogue scale the intensity of their pain and their pain relief at rest, on coughing and globally since the operation, on the first and second postoperative days and the day before hospital discharge. Separately, the nurses and the physicians were asked to evaluate the pain intensity and the pain relief for each patient involved. A MANOVA and a multiple comparisons test with Bonferroni adjustment were used. RESULTS: At rest, only nurses underestimated pain intensity on the day before hospital discharge. On coughing, physicians underestimated pain intensity in all 3 assessments, whereas nurses only in the 3rd assessment (on the day before hospital discharge). Globally, physicians underestimated pain intensity in all 3 assessments, nurses in the 2nd and the 3rd assessment. Only physicians overestimated pain relief on coughing on the day before hospital discharge and globally in all 3 assessments. Surprisingly, the pain scores rated by the patients before hospital discharge were high. CONCLUSION: The results of this survey suggest that assessment of pain and pain relief is inadequately done by both physicians and nurses. This emphasises the importance of a better training, and a systematic assessment of pain intensity and pain relief.

Laparoscopic adhesiolysis and relief of chronic pelvic pain.

OBJECTIVE: To evaluate the short- and long-term results of laparoscopic enterolysis in patients with chronic pelvic pain following hysterectomy. METHODS: Forty-eight patients were evaluated at time intervals from 2 weeks to 5 years after laparoscopic enterolysis. Patients were asked to rate postoperative relief of their pelvic pain as complete/near complete relief (80-100% pain relief), significant relief (50-80% pain relief), or less than 50% or no pain relief. RESULTS: We found that after 2 to 8 weeks, 39% of patients reported complete/near complete pain relief, 33% reported significant pain relief, and 28% reported less than 50% or no pain relief. Six months to one year postlaparoscopy, 49% of patients reported complete/near complete pain relief, 15% reported significant pain relief, and 36% reported less than 50% or no pain relief. Two to five years after laparoscopic enterolysis, 37% of patients reported complete/near complete pain relief, 30% reported significant pain relief, and 33% reported less than 50% or no pain relief. Some patients required between 1 and 3 subsequent laparoscopic adhesiolysis. A total of 3 enterotomies and 2 cystotomies occurred, all of which were repaired laparoscopically. CONCLUSION: We conclude that laparoscopic enterolysis may offer significant long-term relief of chronic pelvic pain in some patients.

Neurosurgical therapy of facial neuralgias

INTRODUCTION: Neuralgias of the face, especially trigeminal neuralgia and glossopharyngeal neuralgia are indications for surgical interventions after failed medical therapy. In contrast to other forms of headache or atypical facial pain, where surgical measures are considered to be contraindicated, percutaneous procedures or microvascular decompression are able to produce immediate and longstanding pain relief. Careful preoperative evaluation is essential to confirm the clinical diagnosis and to rule out other causes as multiple sclerosis or tumors afflicting the cranial nerves. The following study will summarize the common surgical techniques and their role considering a mechanism-based therapy as well as document long-term results of these measures. METHODS: Between 1977 and 1997 316 thermo-controlled radiofrequency trigeminal rhizotomies (TK) and 379 microvascular decompressions (MVD) were performed in our hospital to treat trigeminal neuralgia; additional 6 MVDs for glossopharyngeal neuralgia and one MVD of the intermediate facial nerve were carried out. Questionnaires were sent out to all patients still living in 1981, 1982, 1992 and 1998. For all other patients, interviews with relatives or the general practitioners were conducted. A retrospective analysis of postoperative pain relief was performed using Kaplan-Meier curves at the latest follow-up. Additionally 80 patients underwent careful quantitative sensory testing with Von-Frey-hairs. RESULTS: 225 patients who underwent microvascular decompression and 206 with radiofrequency trigeminal rhizotomies were further analyzed. There was a 50% risk for pain recurrence two years after radiofrequency rhizotomy. On the other hand 64% of patients who underwent microvascular decompression remained painfree 20 years postoperatively. Patients with microvascular decompression without sensory deficit were painfree significantly longer than patients with postoperative hypesthesia. DISCUSSION: Etiology and pathogenesis of facial neuralgias are far from understood despite several hypotheses. Based on current models there is no explanation for the immediate pain relief especially after microvascular decompression. Some authors even discuss surgical trauma as the only cause for postoperative pain relief.

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.

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.

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.