Lumbar epidural fentanyl: segmental spread and effect on temporal summation and muscle pain

Background. Despite extensive use, different aspects of the pharmacological action of epidural fentanyl have not been clarified. We applied a multi‐modal sensory test procedure to investigate the effect of epidural fentanyl on segmental spread, temporal summation (as a measure for short‐lasting central hyperexcitability) and muscle pain. Methods. Thirty patients received either placebo, 50 or 100 µg single dose of fentanyl epidurally (L2-3), in a randomized, double‐blind fashion. Heat pain tolerance thresholds at eight dermatomes from S1 to fifth cranial nerve (assessment of segmental spread), pain threshold to transcutaneous repeated electrical stimulation of the sural nerve (assessment of temporal summation) and pain intensity after injection of hypertonic saline into the tibialis anterior muscle (assessment of muscle pain) were recorded. Results. Fentanyl 100 µg, but not 50 µg, produced analgesia to heat stimulation only at L2. Surprisingly, no effect at S1 was detected. Both fentanyl doses significantly increased temporal summation threshold and decreased muscle pain intensity. Conclusions. The findings suggest that a single lumbar epidural dose of fentanyl should be injected at the spinal interspace corresponding to the dermatomal site of pain. Increased effect on L2 compared with S1 suggests that drug effect on spinal nerve roots and binding to opioid receptors on the dorsal root ganglia may be more important than traditionally believed for the segmental effect of epidurally injected fentanyl. Epidural fentanyl increases temporal summation threshold and could therefore contribute to prevention and treatment of central hypersensitivity states. I.M. injection of hypertonic saline is a sensitive technique for detecting the analgesic action of epidural opioids. Br J Anaesth 2003; 90: 467-7

Muscle pain induced by hypertonic saline in the knee extensors decreases single-limb isometric time to task failure

Purpose: Increased nociceptive activity and the experience of exercise-induced pain (EIP) may contribute to fatigue during endurance exercise. To investigate this, a pain model that produces pain similar to EIP and decouples its’ relationship to exercise intensity is required. This study 1) compared the quality of pain caused by a hypertonic saline injection into the vastus lateralis in resting and exercise conditions, and 2) investigated whether this pain contributes to changes in time to task failure. Methods: On separate days, eighteen participants completed a time to task failure at 20% maximal voluntary torque (MVT), a resting hypertonic saline intramuscular injection, and in a further three visits a time to task failure at 10% MVT following injection of isotonic saline, hypertonic saline or a control (no injection). Results: In a subset of eligible participants (n = 12), the hypertonic saline combined with 10% MVT produced a qualitative experience of pain (assessed by the McGill Pain Questionnaire) that felt similar to EIP. 10% MVT with hypertonic saline significantly elevated pain intensity in the first 20% of the time to task failure and caused a significantly (P < 0.05) shorter time to task failure (448 ± 240 s) compared with the isotonic saline (605 ± 285 s) and control (514 ± 197 s) conditions. Conclusion: These findings demonstrate that hypertonic saline increases the intensity of pain during exercise, which results in a faster occurrence of exercise-induced fatigue. These results provide important evidence supporting pain as a limiting factor in endurance performance