Neurolytic superior hypogastric plexus block under CT-guidance [BILGISAYARLI TOMOGRAFI ESLIGINDE NOROLITIK SUPERIOR HIPOGASTRIK PLEKSUS BLOGU (BIR TEKNIK)]

In this study, the method, efficacy and results of superior hypogastric plexus blockade (SHPB) under guidance of computed tomography in the treatment of malignancy-caused pelvic pain is reported. SHPB was performed in 12 selected patients who has intractable pelvic pain due to malignancy. Bilateral neurolytic SHPB was performed in prone position under CT-guidance. The puncture sites are both 7-8 cm lateral from the midline at the level of L4 spinous processus. Visual analog scale (VAS) was used for pain measurement just before and after the block, at 24 hours, 1 week and 3 months post-block. All patients had complete pain relief according to VAS scale (<4) just after the block. Oral morphine consumption decreased significantly after the block when compared to pre-block values (p<0.05). As for the complications, vascular puncture was done in 1 patients and another patient had transient leg paralysis and neuralgia. Neurolytic SHPB under CT-guidance is a specific and useful technique for malignancy-caused pelvic pain when pharmacologic treatment is inadequate

Implanted drug delivery systems for spinal administration of morphine in cancer pain relief

The results of long term epidural and intrathecal use of opioids by drug delivery systems are compared in this study. Epidural ports (Periplant® or Cordis®) were implanted to 147 patients whereas intrathecal implant systems (PAR®, Secor, Cordis®) were implanted to 58 patients. The dose and concentration of morphine were adjusted according to the patients' report of pain intensity. Pain severity, pump or port function, spinal morphine requirements, adverse side effects were evaluated. Initial daily dose of morphine was 8.9±2.9 mg for epidural ports and 2.6±0.5 mg for intrathecal drug delivery systems. Mean duration of analgesia was 6.5±3.2 h in epidural ports whereas 12.8±4.1 h in intrathecal systems. Mean duration of epidural morphine treatment was 130.8±70.1 days. The drug delivery system remained with an average of 3.2 months in the intrathecal group. Most of the patients (80% of epidural ports and 90% of intrathecal pumps) had significant pain relief. Device-related complications in the epidural group were catheter occlusion (2.0%), disconnection (2.7%), infection (7.5%), skin necrosis (3.4 %), port damage (2.0%). Drug-related complications in the epidural group were nausea-vomiting (25.9%), constipation (25.9%), urinary retention (11.6%), pruritis (8.8%), burning pain on injection (12.2%), and headache (3%). Device-related complications in the intrathecal group were seroma (6.9%), infection (3.4%), skin necrosis (1.7%). Drug-related complications in the intrathecal group were nausea-vomiting (17.2%), constipation (10.3%), urinary retention (8.6%), pruritis (6.9%), burning pain on injection (1.7%), headache (10.3%), and respiratory depression (3.4%). Implantable opioid delivery systems are useful adjuncts for cancer pain management. Proper selection of patients and delivery systems, good patient education and communication, good surgical and sterility techniques, and knowledge of risks and complications will increase the success of these systems

Use of long-term opioids: A case discussion of addiction and dependence

Cancer pain is often undertreated in patients with cancer due to fears of iatrogenic addiction when opioids are used for pain control. Physicians and patients and their families fear that patients will use their medicines in aberrant fashion, become 'addicted' or use up their tolerance so that medicines will not be helpful to them when the disease advances and they 'really need the pain medicine'. Doctors and patients alike mislabel physiological dependence for addiction, misunderstand the phenomenon of tolerance, and are informed about the exceedingly low risk of addiction among medical patients. Z.S. 75 years old woman diagnosed inoperable cervix carcinoma, had been put on oral opioids due to severe pain. Our patient lived longer than expected and used oral opioids for three years, and applied to algology department when she was not able find any more opioids. No evidence of physical disease for a long time she used oral opioids only not to 'feel bad' longer than 2 years. We discussed important principles of opioid use in cancer pain and the difference between addiction and dependence. With the right indication, carefully planned pain control program patients could be treated by opioids with decreasing the risk of addiction and dependence to minimum