Nerve Blocks of Cancer Pain in Palliative Care

More than 80% of cancer-related pain is pharmacologically controllable, whereas 10~20% of patients require interventional treatments. Neurolytic nerve block can play a major role in cancer pain treatment, and it has been proposed to prevent the development of pain and improve the quality of life of patients with cancer. If the pain is well localized and restricted to certain peripheral parts of the body, spinal peripheral or sympathetic nerve blocks may result in excellent therapeutic effects. Neurolytic sympathetic block, especially Celiac plexsus block (CPB) performed in earlier stages, is effective with successful long term results. However, selection of patients is critical for succeful outcomes. Neurolytic plexus block significantly improves the quality of life of patients and reduces abdominal and pelvic cancer pain, analgesic consumption and adverse opioids-related side effects. Interventional pain management should be considered at earlier stages to provide patients with the best quality of life possibleope

Analgesic therapy according to disease specific pathophysiology

This article reviews the pharmacologic management of osteoarthritis, low back pain, and neuropathic pain. In order to manage chronic pain appropriately, pharmacologic management, such as adequate drug selection, is the most important in clinical situations. Pain is classified as nociceptive, neuropathic, or mixed pain according to its mechanism. For effective pain control, we choose analgesics depending on adequate evaluation and understanding of the pathophysiology of pain. Nociceptive pain like osteoarthritis is controlled by acetaminophen, nonsteroidal antiinflammatory drugs, and opioids according to the pain intensity. However, our recommendation for neuropathic pain is antidepressants and anticonvulsants as first line treatments. Low back pain arises from nociceptive and neuropathic mechanisms, classified as mixed pain syndrome. Therefore, the rational management of low back pain targets the different mechanisms of pain by combining agents with different mechanisms of action.ope

Safety and Efficacy of Gabapentin in Neuropathic Pain

Background: The newer generation of anticonvulsant, gabapentin is probably the most useful agent for neuropathic pain. This report reviews prospective safety and efficacy data collected in actual clinical situations for various neuropathic pains. Methods: This was an open label, prospective, non-comparative, clinical study of gabapentin for the treatment of various neuropathic pain syndromes. 392 patients were enrolled between June, 2002 and August, 2003, and 42 pain specialists from 40 private pain clinics were participated in the study. Safety and efficacy were assessed in 177 patients after a minimum of 6 weeks of gabapentin treatment, with starting and final doses determined by the prescribing physician. The primary efficacy measure was a change in the average daily pain score (DPS) based on an 11-point Likert scale (0, no pain; 10, worst possible pain) and change in sleep interference (SI) from baseline to the final week of therapy. Results: In 157 (88.7%) of the 177 patient gabapentin was assessed as effective, as follows; 72 patients (40.7%) were markedly improved; 85 patients (48.0%) moderately improved; 16 patients (9.0%) slightly improved; and 4 patients were unchanged. Patients that rated baseline pain as severe improved in 86.2 % (50/58 patients) of cases and 90% of patients that rated their baseline pain as mild to moderate showed improvement. Various neuropathic pains except other polyneuropathies, were clinically improved by more than 80%. Most patients were started at 300 mg/day of gabapentin, and were maintained within 600 900 mg/day at the end of the study. There was a significant reduction in the average daily pain score from 7.3 to 2.8 (P < 0.0001). Sleep Interference was also significantly improved from 5.0 to 1.6 points after gabapentin administration (P <0.0001). Of the 392 patients, 58 patients (14.8%) experienced 67 adverse events (17.1%). Most events were mild but 6.0% were severe. Conclusions: Gabapentin is effective and safe drug for the treatment of neuropathic pain.ope

The Effect of the Continuous Intravenous Infusion of Magnesium for the Treatment of Postherpetic Neuralgia

Postherpetic neuralgia (PHN) is a chronic pain syndrome associated with the reactivation of a primary varicella zoster virus infection and is one of the most serious complication of herpetic zoster. The clinical features of PHN are ongoing pain accompanied by allodynia, hyperalgesia, and paresthesia. Current treatment options aimed at relieving the symptoms of PHN include oral agents, such as, opioid, NSAIDs, antidepressants, anticonvulsants. And local anesthetics with steroids are used for subcutaneous infiltration, somatic nerve block, sympathetic nerve block and epidural nerve block. However, in some cases, the pain does not respond to this treatment. We report a case in which a patient suffering from PHN did not respond to conventional therapy, but in whom continuous intravenous infusion of magnesium and physiologic N-methyl-D-aspartate (NMDA) receptor antagonist, reduced severe pain.ope

Wound Infiltration in Patients with Chronic Pain after Forehead Lift Surgery: A case report.

Local infiltration in surgical wounds can reduce postoperative pain with very few side effects. We experienced two cases of chronic pain after forehead lift surgery. A 41-year-old male patient was suffering from a headache at the crown of the head and pain from the posterior neck. A 54-year-old female patient had pain around the forehead, worsened by psychological stress. They underwent forehead lift surgery 10 years and 8 months ago, respectively. Conservative treatments such as medication and physical therapy were not effective. After wound infiltration with 1% lidocaine more than ten times, pain significantly resolved in both patients.ope

The Treatment of a Droopy Shoulder Syndrome Patient - A case report -

Droopy shoulder syndrome (DSS) is a rare disease, characterized by drooping shoulders, which stretches the brachial plexus, and causes pain, but without any signs of neurological impairment. These patients suffer from pain in the neck, shoulders, arms and hands, which result in long, graceful, swan necks, low-set shoulders, and horizontal or down sloping clavicles. No abnormalities in the vascular, neurological or electrical findings have also been known. The T1 and/or T2 bodies can be seen in the lateral view in a radiological study of the cervical spine. In the majority of cases, conservative treatments, such as postural correction and shoulder girdle strengthening exercise, are commonly recommended. However, DSS may be misdiagnosed as severe thoracic outlet syndrome or herniated cervical disc disease, leading to unnecessary and hazardous invasive treatments. The presented case was consistent with DSS, and was treated with stellate ganglion block, trigger point injection, and shoulder girdle strengthening exercise.ope

The effect of stellate ganglion block on the treatment of idiopathic sudden sensorineural hearing loss

BACKGROUND: Idiopathic sudden sensorineural hearing loss (ISSNHL) is defined as a sensorineural hearing loss which develops abruptly without definitive causes. Stellate ganglion block (SGB) has been used as one of the treatment modalities in ISSNHL. However, published data establishing the effect of SGB has been slim. We conducted this study to evaluate the effect of SGB according to the factors that may influence the prognosis of the disease. METHODS: We reviewed the records of 343 patients. The control group was managed with medications, and the SGB group was managed with SGB and the same medications. SGB was performed with 5 ml of 1.0% mepivacaine. The pure-tone audiogram was performed after the therapy and Siegel's criteria was used to define the recovery of hearing. RESULTS: The recovery rate of the SGB group was higher than that of the control group (58.1% vs. 42.1%, P < 0.05). The SGB group had a higher recovery rate than the control group in patients treated within 7 days from the onset of symptoms (66.9% vs. 44.1%, P < 0.05), without diabetes mellitus (58.5% vs. 44.9%, P < 0.05), without dizziness (61.6% vs. 44.6%, P < 0.05), or whose initial hearing loss was between 71 and 90 dB (69.4% vs. 38.9%, P < 0.05). CONCLUSIONS: SGB is thought to be a useful therapy for ISSNHL, especially in the patients treated within 7 days, without diabetes mellitus, dizziness, or whose initial hearing loss was severe.ope

Chronic Mandibular Osteomyelitis with Normal Value of C-reactive Protein

A 58-year-old male was referred to our pain clinic with right lower facial pain of visual analogue scale 8/10 cm. One week ago, his right lower 3rd molar was extracted for vesicles at the buccal mucosal membrane and right lower facial hypoesthesia. Immunoserologic tests revealed negative varicella-zoster virus immunoglobulin-M, positive immunoglobulin-G and normal value of C-reactive protein. Buccal mucosa biopsy revealed squamous epithelial hyperplasia. Medications for pain control was pregabalin 150 mg PO bid, amitriptyline 10 mg PO hs, fentanyl patch 12.5 Ռg/h, carbamazepine 200 mg PO hs. C-arm guided block and pulsed radiofrequency lesionning was performed at mandibular branch of the right trigeminal nerve. And then VAS score was reduced to 4/10 cm. On facial bone CT, facial MRI and 3-phase bone scan, chronic osteomyelitis was suspected on the right mandible. Herpes zoster by atypical clinical manifestations was excluded. After additional biopsy and culture on lesion, antibiotics were used to treat the osteomyelitis and surgical follow-up was planned for surgical removal of necrotic tissue.ope

The Analgesic Interaction between Ketorolac and Morphine in Radiant Thermal Stimulation Rat

Background: Previous studies have suggested synergistic analgesic drug interactions between NSAIDs and opioids in neuropathic and inflammatory pain models. The aim of this study was to investigate the analgesic drug interaction between intraperitoneal (IP) ketorolac and morphine in radiant thermal stimulation rat. Methods: Initially, we assessed the withdrawal latency time of the hindpaw to radiant thermal stimulation every 15 min for 1 hour and every 30 min for next 1 hour after IP normal saline 5 ml (control group). The latency time was changed into percent maximal possible effect (%MPE). Next, IP dose response curves were established for the %MPE of morphine (0.3, 1, 3, 10 mg/kg) and ketorolac (3, 10, 30 mg/kg) to obtain the ED50 for each agent. And we confirmed that the IP morphine effect was induced by opioid receptor through IP morphine followed by IP naloxone. At last, we injected three doses of IP ketorolac (3, 10, 30 mg/kg) mixed with one dose of morphine (2 mg/kg) for fixed dose analysis. Results: IP morphine delayed the paw withdrawal latency time dose dependently, but not ketorolac. ED50 of IP morphine was 2.1 mg/kg. And the IP morphine effect was reversed to control level by IP naloxone. IP ketorolac + morphine combination showed no further additional effects on paw withdrawal latency time over morphine only group. Conclusions: IP ketorolac did not produce antinociceptive effect during radiant thermal stimulation. There was neither additional nor synergistic analgesic interaction between IP morphine and ketorolac in thermal stimulation rat.ope

Spontaneous Intracranial Hypotension and Epidural Blood Patch

Spontaneous intracranial hypotension (SIH), a syndrome of low CSF pressure, occurs without preceeding events such as lumbar puncture, back trauma, an operative procedure, or medical illness. Postural headache, the most characteristic symptom, usually resolves spontaneously or with bed rest, hydration, and medication. Autologous epidural blood patch is an effective management of headache in SIH patients, and here we describe a one case successfully treated 5 times with an epidural blood patch. The patient had a cardinal feature of a postural headache, low CSF pressure, and showed CSF leakages on RI cisternography. The first three epidural blood patches improved the patient's headache markedly, but the headache recurred in one month. On her second RI cisternography, we found other CSF leakage sites. After a fifth epidural blood patch the patient became asymptomatic and remained so throughout 4 months of follow up. Epidural blood patches are considered the treatment of choice in SIH patients.ope