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Anesth Analg 2003 Jan;96(1):201-6
University of Sydney, Pain Management & Research Centre, Royal North Shore Hospital, St. Leonards, Australia.
[Medline record in process]
IMPLICATIONS: This case history describes the treatment of a patient suffering with persistent pain. He was treated surgically with implantation of a spinal cord stimulator. After surgery, a partial paralysis that could not be explained medically and that was probably related to emotional factors occurred, and cognitive behavioral treatment was begun. This paper discusses the importance of considering social and psychological factors when medical treatment options are considered.
PMID: 12505953, UI: 22392427
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Anesth Analg 2003 Jan;96(1):179-85
Departments of Nursing and Anesthesiology, University Hospital Center of Charleroi, Charleroi, Belgium.
This study, conducted before and after the implementation of an acute pain service (APS) in a 1000-bed hospital, describes the process of the implementation of an APS. The nursing, anesthesia, and surgery departments were involved. In this study we sought to evaluate the results of a continuous quality improvement program by defining quality indicators and using quality tools. A quality program in accordance with current standards of acute pain treatment (multimodal) was worked out to enhance pain relief for all surgical inpatients. A survey of nurses' knowledge with regard to postoperative pain was conducted, and a visual analog scale (VAS) was introduced to assess pain intensity. Both nurses and physicians became familiar with evidence-based guidelines concerning postoperative pain. The entire process was monitored in three consecutive surveys and enrolled 2383 surgical inpatients. Pain indicators based on VAS and analgesic consumption were recorded during the first 72 postoperative hours. After a baseline survey about current practices of pain treatment, a nurse-based, anesthesiologist-supervised APS was implemented. The improvement in pain relief, expressed as VAS scores, was assessed in two further surveys. A quality manual was written and implemented. A major improvement in pain scores was observed after the APS inception (P < 0.001). IMPLICATIONS: The implementation of an acute pain service, including pain assessment by a visual analog scale, standard multimodal pain treatment, and continuous quality evaluation, improved postoperative pain relief. Establishing teams of surgeons, anesthesiologists, and nurses is the prerequisite for this improvement.
PMID: 12505949, UI: 22392423
Anesth Analg 2003 Jan;96(1):78-81
Departments of Anesthesiology and Critical Care Medicine, and Oncology, Children's Hospital of Philadelphia and the University of Pennsylvania, School of Medicine.
IMPLICATIONS: This open-label, multicenter trial was designed to determine the safety profile and analgesic efficacy of tramadol for the treatment of painful conditions lasting 7-30 days in 7-16-yr-old children. We found that tramadol 1-2 mg/kg per os every 4-6 h (maximal dose = 8 mg. kg(-1). d(-1), not to exceed 400 mg/d) is a safe and effective analgesic in this patient population.
PMID: 12505927, UI: 22392401
Anesth Analg 2002 Dec;95(6):1793-805
Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, 75390, USA. babatunde.ogunnaike@utsouthwestern.edu
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PMID: 12456461, UI: 22344064
Anesth Analg 2002 Dec;95(6):1767-9, table of contents
Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Germany. sandra.kampe@medizin.uni-koeln.de
We surveyed current German practice in postoperative epidural analgesia (EA). Of 300 questionnaires sent anonymously, 147 (49%) were returned fully completed. A 24-h acute pain service (APS) was offered in 41% of German hospitals. Seventy percent of the large teaching hospitals (>1000 beds) offered an APS, whereas just 9% of the hospitals of <500 beds provided an APS. Small-size hospitals (<200 beds) preferred ropivacaine as the local anesthetic (LA) in contrast to large teaching hospitals using more bupivacaine than ropivacaine. In the general ward setting, 36% of the respondents used plain LA, and 64% combined the LA with an opioid. If ropivacaine was used, 0.2% was the most popular concentration (78%), combined with morphine (17%), fentanyl (14%), or sufentanil (75%). If bupivacaine was used, 0.25% was the preferred concentration (30%), combined with morphine (40%), fentanyl (8%), or sufentanil (60%). On wards, 58% of German anesthetic departments used continuous epidural infusion, 57% bolus doses, and 20% patient-controlled EA mode. We conclude that the availability of a 24-h APS (41%) in German hospitals corresponds favorably to international data. EA with the combination of LAs and opioids was the most common modality in the ward setting. IMPLICATIONS: We surveyed current German practice in postoperative epidural analgesia. We found that the availability of a 24-h acute pain service (41%) in German hospitals corresponds favorably to international practice. Epidural analgesia with the combination of local anesthetics and opioids was the most common modality in the ward setting.
PMID: 12456455, UI: 22344058
Anesth Analg 2002 Dec;95(6):1698-701, table of contents
Teaching Hospital, Department of Biomechanics, Medicine, and Rehabilitation of Locomotor Members, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, Brazil.
In this study, we examined the side effects and analgesia of the combination of epidural neostigmine and morphine in patients undergoing orthopedic surgery. Sixty patients undergoing knee surgery were divided into four groups. The intrathecal anesthetic was 15 mg of bupivacaine. The epidural test drug was diluted in saline to a final volume of 10 mL. The control group received saline as the epidural test drug. The morphine group received 0.6 mg of epidural morphine. The neostigmine group (NG) received 60 micro g of epidural neostigmine. The morphine/neostigmine group received 0.6 mg of epidural morphine combined with 60 micro g of epidural neostigmine. The groups were demographically the same and did not differ in intraoperative characteristics. The visual analog scale score at first rescue analgesic and the incidence of adverse effects were similar among groups (P > 0.05). One patient from the NG complained of intraoperative nausea, closely related to spinal hypotension. Postoperatively, two patients from the NG had vomited once. The time (min) to first rescue analgesic was longer in the morphine/neostigmine group ( approximately 11 h) compared with the other groups (P < 0.05). The analgesic consumption (number of analgesic administrations in 24 h) was larger in the control group compared with the other groups (P < 0.05). IMPLICATIONS: The combination of epidural morphine and epidural neostigmine resulted in postoperative analgesia (11 h) devoid of side effects, being an alternative analgesic technique in the population studied.
PMID: 12456442, UI: 22344045
Anesth Analg 2002 Dec;95(6):1590-5, table of contents
Department of Anesthesiology and Critical Care, University Clinic, School of Medicine, University of Navarra, Pamplona, Spain.
In this study we compared the efficacy and safety of three antiemetic combinations in the prevention of postoperative nausea and vomiting (PONV). Ninety ASA status I-II women, aged 18-65 yr, undergoing general anesthesia for major gynecological surgery, were included in a prospective, randomized, double-blinded study. A standardized anesthetic technique and postoperative analgesia (intrathecal morphine plus IV patient-controlled analgesia (PCA) with morphine) were used in all patients. Patients were randomly assigned to receive ondansetron 4 mg plus droperidol 1.25 mg after the induction of anesthesia and droperidol 1.25 mg 12 h later (Group 1, n = 30), dexamethasone 8 mg plus droperidol 1.25 mg after the induction of anesthesia and droperidol 1.25 mg 12 h later (Group 2, n = 30), or ondansetron 4 mg plus dexamethasone 8 mg after the induction of anesthesia and placebo 12 h later (Group 3, n = 30). A complete response, defined as no PONV in 48 h, occurred in 80% of patients in Group 1, 70% in Group 3, and 40% in Group 2 (P = 0.004 versus Groups 1 and 3). The incidences of side effects and other variables that could modify the incidence of PONV were similar among groups. In conclusion, ondansetron, in combination with droperidol or dexamethasone, is more effective than dexamethasone in combination with droperidol in women undergoing general anesthesia for major gynecological surgery with intrathecal morphine plus IV PCA with morphine for postoperative analgesia. IMPLICATIONS: The combination of ondansetron plus dexamethasone or droperidol was significantly better than the combination of dexamethasone plus droperidol in the prophylaxis of postoperative nausea and vomiting in women undergoing general anesthesia for major gynecological surgery, with intrathecal and IV morphine (patient-controlled analgesia) for management of postoperative pain.
PMID: 12456422, UI: 22344025
Anesthesiology 2003 Jan;98(1):209-16
Department of Anesthesiology, Medical College of Wisconsin, Wisconsi 53226, USA. mccallum@mcw.edu
BACKGROUND: Pathophysiology in the primary sensory neuron may contribute to chronic neuropathic pain. Ca channels play a central role in neuronal processes, and sensory neurons are rich in low-voltage-activated calcium channels (LVACCs). However, the physiologic function of these channels is unknown. Their possible role in rebound burst firing makes them a candidate for increased excitability after neuropathic injury. METHODS: This study uses pharmacological methods to isolate LVACC in cells from the dorsal root ganglia of neuropathic and sham-operated rats, including the blockade of high-voltage-activated Ca channels with fluoride and selective toxins. LVACCs were examined with conventional whole cell patch clamp electrophysiology techniques. RESULTS: After chronic constriction injury of the peripheral axon, LVACC was significantly reduced compared to sham rats as shown by a 60% reduction in peak current density and an 80% reduction in total calcium influx. A depolarizing shift in the voltage dependence of activation and an increase in the rate of deactivation and inactivation appear to cause this reduction of LVACC. Either Ni2+ or mibefradil, blockers of LVACC, applied in the bath to normal dorsal root ganglion cells during current clamp significantly and reversibly increased excitability. CONCLUSIONS: These results suggest that loss of LVACC may contribute to decreased spike frequency adaptation and increased excitability after injury to sensory neurons. Through decreased Ca2+ influx, the cell becomes less stable and more likely to initiate or transmit bursts of action potentials. Consequently, modulation of Ca2+ currents at the dorsal root ganglion may be a potential method of therapeutic intervention.
PMID: 12502999, UI: 22390620
Anesthesiology 2003 Jan;98(1):151-5
Department of Anesthesiology, Research Institute, Department of Gynecology, Rabin Medical Center, Golda-Hasharon Campus, Petah Tiqva, Israel. beilinb@inter.net.il
BACKGROUND: The postoperative period is associated with increased production of proinflammatory cytokines, which are known to augment pain sensitivity, among other effects. In a previous study, the authors found that patients treated with patient-controlled epidural analgesia (PCEA) exhibited attenuated proinflammatory cytokine response in the postoperative period. In the present study, the authors examined whether preemptive analgesia continued with PCEA may further attenuate the proinflammatory cytokine response and reduce pain sensitivity in the postoperative period. They compared cytokine production in two groups of patients, one receiving PCEA, the other receiving preemptive epidural analgesia continued by PCEA. METHODS: Female patients hospitalized for transabdominal hysterectomy were randomly assigned to one of two pain management techniques: PCEA or preemptive epidural analgesia followed by PCEA (PA + PCEA). Postoperative pain was assessed using the visual analog scale. Blood samples were collected before, 24, 48, and 72 h following surgery. Production of the following cytokines was assessed in stimulated peripheral blood mononuclear cells: interleukin (IL)-1beta, tumor necrosis factor alpha, IL-6, IL-1ra, IL-10, and IL-2. RESULTS: Patients of the PA + PCEA group exhibited lower pain scores throughout the 72 h postoperatively, compared with patients of the PCEA group. In patients of the PA + PCEA group in the postoperative period, production of IL-1beta, IL-6, IL-1ra, and IL-10 was significantly less elevated, while IL-2 production was significantly less suppressed. CONCLUSIONS: Proinflammatory cytokines are key mediators of illness symptoms, including hyperalgesia. The present results suggest that preemptive epidural analgesia is associated with reduced postoperative pain and attenuated production of proinflammatory cytokines.
PMID: 12502991, UI: 22390612
Anesthesiology 2002 Dec;97(6):1597-601
Department of Anesthesiology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109-0615, USA.
BACKGROUND: Both pain and the pharmacologic management of pain can cause the undesirable effect of sleep disruption. One goal of basic and clinical neuroscience is to facilitate rational drug development by identifying the brain regions and neurochemical modulators of sleep and pain. Adenosine is thought to be an endogenous sleep promoting substance and adenosinergic compounds can contribute to pain management. In the pontine brain stem adenosine promotes sleep but the effects of pontine adenosine on pain have not been studied. This study tested the hypothesis that an adenosine agonist would cause antinociception when microinjected into pontine reticular formation regions that regulate sleep. METHODS: The tail flick latency (TFL) test quantified the time in seconds for an animal to move its tail away from a thermal stimulus created by a beam of light. TFL measures were used to evaluate the antinociceptive effects of the adenosine A1 receptor agonist N6-p-sulfophenyladenosine (SPA). Pontine microinjection of SPA (0.1 microg/0.25 microl, 0.88 mm) was followed by TFL measures as a function of time after drug delivery and across the sleep-wake cycle. RESULTS: Compared with saline (control), pontine administration of the adenosine agonist significantly increased latency to tail withdrawal (P < 0.0001). The increase in antinociceptive behavior evoked by the adenosine agonist SPA was blocked by pretreatment with the adenosine A1 receptor antagonist 8-cyclopentyl-1, 3-dipropylxanthine (DPCPX, 0.75 ng/0.25 microl, 10 microm). CONCLUSIONS: These preclinical data encourage additional research on the cellular mechanisms by which adenosine in the pontine reticular formation contributes to the supraspinal modulation of pain.
PMID: 12459690, UI: 22346950
Anesthesiology 2002 Dec;97(6):1458-65
Department of Anaesthetics and Intensive Care, Imperial College of Science, Technology and Medicine, University of London, 369 Fulham Road, London SW10 9NH, UK.
BACKGROUND: In a previous study, the authors found that nitrous oxide (N2O) exposure induces c-Fos (an immunohistochemical marker of neuronal activation) in spinal cord gamma-aminobutyric acid-mediated (GABAergic) neurons in Fischer rats. In this study, the authors sought evidence for the involvement of alpha1 adrenoceptors in the antinociceptive effect of N2O and in activation of GABAergic neurons in the spinal cord. METHODS: Adult male Fischer rats were injected intraperitoneally with alpha1 adrenoceptor antagonist, alpha2 adrenoceptor antagonist, opioid receptor antagonist, or serotonin receptor antagonist and, 15 min later, were exposed to either air (control) or 75% N2O. In some animals, nociception was investigated with the plantar test after 30 min of exposure, while in other animals, gas exposure was continued for 90 min and the spinal cord was examined for c-Fos immunostaining. In a separate experiment, animals were exposed to the above gases alone, after which the spinal cords were examined immunohistochemically for c-Fos and alpha1 adrenoceptor by double-staining methods. RESULTS: The antinociceptive effect of N2O was attenuated by prazosin (an alpha1 adrenoceptor antagonist), yohimbine (an alpha2 adrenoceptor antagonist), and naloxone (an opioid receptor antagonist) but not by methysergide and tropisetron (serotonin receptor antagonists). N2O exposure induced c-Fos expression in the spinal cord, which was blocked by prazosin and naloxone but not by other drugs. N2O-induced c-Fos expression was colocalized with alpha1 adrenoceptor immunoreactivity in laminae III-IV. CONCLUSIONS: These findings support the hypothesis that N2O activates GABAergic interneurons through alpha1 adrenoceptors to produce its antinociceptive effect.
PMID: 12459672, UI: 22346932
Eur J Pharmacol 2003 Jan 5;458(3):275-82
Department of Pharmacology, NeuroSearch A/S, 93 Pederstrupvej, DK-2750, Ballerup, Denmark
The pain-relieving effects of various voltage-activated Na(+) channel blockers have been evaluated in two rat models of neuropathic pain; the photochemically induced nerve injury model (Gazelius) and spared nerve injury model. Lidocaine (up to 40 mg/kg, i.p.) and lamotrigine (up to 60 mg/kg, i.p.) had no effect on mechanical or cold allodynia in either model. However, lamotrigine (10, 30 and 60 mg/kg) significantly attenuated mechanical hyperalgesia in the spared nerve injury model, while mexiletine (25 and 37.5 mg/kg, i.p.) attenuated mechanical allodynia in the Gazelius model. Tocainide (50, 75 and 100 mg/kg, i.p.) significantly reduced all types of pain behaviour measured. The present results show that these voltage-activated Na(+) channel blockers have broadly similar antinociceptive effects in these two models of neuropathic pain. They also show that these drugs can have markedly different effects on distinct neuropathic pain-related behaviours within models.
PMID: 12504783, UI: 22393062
Geriatrics 2002 Dec;57(12):22-6
University of Miami Medical School, Miami, FL, USA.
Pain is a common complaint and its perception is a complex issue. The older person with neck and shoulder pain may have contributions to that pain from multiple and diverse sources. These can range from nociceptive stimulation, neurologic sensitization, emotional issues, socio-cultural biases, cognitive interpretation and meanings of the pain to that person, concurrent medical and psychiatric illnesses, and memory (both pain and non-pain related memories). The affective dimension of pain can be more influential on a person's ultimate pain experience than the sensory-discriminative component, and both must be understood for each patient, in terms of it's relative weight in each pain. Neck and shoulder pain can represent eudynia and maldynia, or concurrent existence of both. To properly treat patients with this complaint, physicians must understand what comprises each individual's pain hologram and direct treatment at as many component parts as possible.
PMID: 12494730, UI: 22382967
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J Pain Symptom Manage 2002 Oct;24(4):437-46
UCLA Pediatric Pain Program, Department of Pediatrics, UCLA School of Medicine, Los Angeles, CA, USA
The purpose of the present study was to conduct a Phase I investigation examining the feasibility and acceptability of a complementary and alternative medicine (CAM) package combining acupuncture and hypnosis for chronic pediatric pain. Thirty-three sequentially referred children (21 girls) aged 6-18 years were offered 6 weekly sessions consisting of individually tailored acupuncture treatment together with a 20-minute hypnosis session (conducted while the needles were in place). Parent and child ratings of pain and pain-related interferences in functioning, as well as child ratings of anxiety and depression, were obtained at pre- and post-treatment. The treatment was highly acceptable (only 2 patients refused; >/= 90% completed treatment) and there were no adverse effects. Both parents and children reported significant improvements in children's pain and interference following treatment. Children's anticipatory anxiety declined significantly across treatment sessions. Our results support the feasibility and acceptability of a combined acupuncture/hypnosis intervention for chronic pediatric pain.
PMID: 12505213, UI: 22393742
J Pain Symptom Manage 2002 Oct;24(4):429-36
Department of Rehabilitation, University Hospital Groningen, Groningen, The Netherlands
Amputation of a limb may affect quality of life. However, little is known concerning health-related quality of life in amputees. The purposes of this study were to describe health-related quality of life in a population of lower limb amputees and to investigate potential determinants, including phantom pain. Data from 437 patients with a lower limb amputation were analyzed in this cross-sectional study. Amputation-related problems were investigated using a questionnaire. Health-related quality of life was investigated using the RAND-36 DLV. Amputees with phantom pain had a poorer health-related quality of life than amputees without phantom pain. In general, the most important amputation-specific determinants of health-related quality of life were 'walking distance' and 'stump pain.'
PMID: 12505212, UI: 22393741
J Pain Symptom Manage 2002 Oct;24(4):415-23
College of Nursing, Taipei Medical University, Taipei, Taiwan
This pilot cross-sectional study aimed to 1) explore pain beliefs and adherence to prescribed analgesics in Taiwanese cancer patients, and 2) examine how selected pain beliefs, pain sensory characteristics, and demographic factors predict analgesic adherence. Pain beliefs were measured by the Chinese version of Pain and Opioid Analgesic Beliefs Scale-Cancer (POABS-CA) and the Survey of Pain Attitudes (SOPA). Analgesic adherence was measured by patient self-report of all prescribed pain medicine taken during the previous 7 days. Only 66.5% of hospitalized cancer patients with pain (n = 194) adhered to their analgesic regimen. Overall, patients had relatively high mean scores in beliefs about disability, medications, negative effects, and pain endurance, and low scores in control and emotion beliefs. Medication and control beliefs significantly predicted analgesic adherence. Patients with higher medication beliefs and lower control beliefs were more likely to be adherent. Findings support the importance of selected pain beliefs in patients' adherence to analgesics, suggesting that pain beliefs be assessed and integrated into pain management and patient education to enhance adherence.
PMID: 12505210, UI: 22393739
J Pain Symptom Manage 2002 Oct;24(4):398-403
Marie Curie Center, Liverpool, United Kingdom
The introduction of fentanyl transdermal patches has led to concern and confusion regarding the management of pain control in the dying phase. Data were collected retrospectively from 94 dying patients. Two groups were identified-patients treated with fentanyl transdermal patch who remained on the patch in the dying phase and patients on oral morphine who converted to a 24-hour subcutaneous infusion of diamorphine via a syringe driver in the dying phase. Both the fentanyl group and the diamorphine group had good pain control in the last 48 hours of life. During the last 48 hours of life, the proportion of patients with controlled pain was statistically significant in favor of the fentanyl group in 2 of the 12 observations undertaken, in particular whether the fentanyl transdermal patch should be continued or discontinued. Patients in the fentanyl group received fewer 'as required' opioid doses compared to patients in the diamorphine group, although the difference was statistically significant only for the last day of life. This study showed that pain control was not compromised in the dying phase with continued use of the fentanyl patch.
PMID: 12505208, UI: 22393737
J Pain Symptom Manage 2002 Oct;24(4):379-87
Pain Relief and Palliative Care Unit, Department of Radiology, University of Athens, Athens, Greece
In 1968, Melzack and Casey suggested that there are three major psychological dimensions of pain: sensory, affect, evaluative. These categories interact with one another to provide quantitative and qualitative information on the components of pain. In 1975, Melzack developed the McGill Pain Questionnaire, which is composed of four major parts and evaluates the qualities of pain. The aim of this study was to assess the applicability, reliability, and validity of the McGill Pain Questionnaire on a sample of Greek cancer patients receiving palliative treatment. It was administered to 114 cancer patients before the initiation of the palliative treatment, and then to 80 cancer patients during the treatment 7 days later. The results indicated that scale reliability was very good (0.95-0.97). During the pretreatment period, correlations between Present Rating Index (PRI), Present Pain Intensity (PPI), and Number of Words Chosen (NWC) ranged between 0.42 and 0.92. During the post-treatment time, the correlations ranged between 0.28 and 0.91. Only 21.8% of the words met a criterion of 30% for representativeness on the first administration of the questionnaire, and 9% met this criterion on the second. Validity was satisfactory (P < 0.005) according to 'responsiveness to changes in time', as there was a statistical difference between the pretreatment and post-treatment time. Patients presented a desirable level of convergent construct validity (P < 0.05) concerning their performance status. Exploratory factor analysis was examined and two factors with eigenvalue over 1 were extracted, and they accounted for 95.2% of the variance. These results support the Greek-MPQ as a reliable and valid measure for evaluating the qualities of cancer pain in patients receiving palliative care.
PMID: 12505206, UI: 22393735
J Pain Symptom Manage 2002 Oct;24(4):366-78
Section of Hematology/Oncology, VA New Jersey Health Care System, East Orange, NJ, USA
The purpose of this study was to develop a Cancer Pain Prognostic Scale (CPPS) which could predict the likelihood of pain relief within 2 weeks for cancer patients with moderate to severe pain. Seventy-four (74) consecutive patients who presented with cancer-related pain were managed in accordance with the guidelines for pain management developed by the United States Agency for Health Care Policy and Research (AHCPR). Patients were followed weekly using the Brief Pain Inventory (BPI), and medications were recorded weekly for 3 weeks. Baseline scores from the Functional Assessment of Cancer Therapy (FACT-G), Mental Health Inventory (MHI), Karnofsky Performance Status (KPS), and Memorial Symptom Assessment Scale Short Form (MSAS-SF) at initial interview served as explanatory variables in a logistic regression model. Pain relief >/= 80% at the end of weeks 1 and 2 were used as outcomes in this model. From this analysis, we developed a predictive formula, the CPPS, which includes the worst pain severity, FACT-G emotional well being, daily opioid dose, and pain characteristics. The rule yields a numerical score that ranges from 0-17. Higher scores correspond to a higher probability of good pain relief. The CPPS has the potential to rapidly identify patients with poor pain prognosis. It can be used as a research tool to characterize pain in cancer patients.
PMID: 12505205, UI: 22393734
J Pain Symptom Manage 2002 Oct;24(4):361-3
Markey Cancer Center University of Kentucky, Lexington, KY, USA
PMID: 12505203, UI: 22393732
Pain 2003 Jan;101(1-2):199-208
Department of Neurology and Neurosurgery, Montreal Neurological Institute, 3801 University Street, Quebec, H3A 2B4, Montreal, Canada
Pharmacological and physiological evidence supports a role for delta (delta) opioid receptors in the nociceptive mechanisms of inflammation. However, few data exist regarding delta opioid receptor expression and localization in such conditions. In this study, we have assessed the distribution and function of delta opioid receptors in the rat spinal cord following induction of chronic inflammation by intraplantar injection of complete Freund's adjuvant (CFA). Intrathecal administration of the selective delta opioid receptor agonist, D-[Ala(2), Glu(4)] deltorphin, dose-dependently reversed thermal hyperalgesia induced by CFA. In situ hybridization and Western blotting experiments revealed an increase in delta opioid receptor mRNA and protein levels, respectively, in the dorsal lumbar spinal cord ipsilateral to the CFA injection site compared to the contralateral side and sham-injected controls. By electron microscopy, immunopositive delta opioid receptors were evident in neuronal perikarya, dendrites, unmyelinated axons and axon terminals. Quantification of immunopositive signal in dendrites revealed a twofold increase in the number of immunogold particles in the ipsilateral dorsal spinal cord of CFA-injected rats compared to the contralateral side and to sham-injected rats. Moreover, the relative frequency of immunogold particles associated with or in close proximity to the plasma membrane was increased in the ipsilateral dorsal spinal cord, indicating a more efficient targeting of delta opioid receptors to neuronal plasma membranes. These data demonstrate that CFA induces an up-regulation and increased membrane targeting of delta opioid receptors in the dorsal spinal cord which may account for the enhanced antinociceptive effects of delta opioid receptor agonists in chronic inflammatory pain models.
PMID: 12507715, UI: 22396435
Pain 2003 Jan;101(1-2):187-92
Departments of Neurology, Odense University, Odense Universitetshospital, Neurologisk afdeling, Sdr.Boulevard 29, DK-5000, Odense C, Denmark
Painful polyneuropathy is a common neuropathic pain condition characterized by different typical pain phenomena and symptoms. The present study determined the frequency of pain phenomena and signs in painful polyneuropathy, and compared the symptomatology in patients with signs of increased small fiber response with that in patients with signs of deafferentation. Eighty-one consecutive patients with painful polyneuropathy were studied. The most common pain phenomena were deep aching pain (88%) and pain on pressure (69%), followed by pain paroxysms (59%) and less frequently pain on light touch (31%). Patients with increased cold and heat detection thresholds were more likely to have pain paroxysms (odds ratio (OR) 2.5 and 5.2) and patients with pain summation on repetitive mechanical stimulation more often had touch-evoked pain (OR=4.0) than patients without these phenomena. Findings compatible with increased small fiber response were found in six patients (7.4%), in 41 (50.6%) unequivocal signs of deafferentation were found, and 34 patients (42%) could not be classified. There was no significant difference in presenting symptoms between these groups. In conclusion, in painful polyneuropathy, (1) deep aching pain is the most frequently reported pain symptom; (2) the association between pain paroxysms with decreased small fiber function and touch-evoked pain with abnormal pain summation on mechanical stimulation indicate that central nervous system mechanisms are responsible for these symptoms; (3) sensitized small fibers as the single mechanism of pain is rare; and (4) pain symptomatology cannot predict pain mechanisms as being mainly deafferentation or sensitized small fibers.
PMID: 12507713, UI: 22396433
Pain 2003 Jan;101(1-2):167-74
Department of Medicine, University of Florida, P.O. Box 100221, 32610-0221, Gainesville, FL, USA
Diffuse noxious inhibitory control (DNIC) is part of a central pain modulatory system that relies on spinal and supraspinal mechanisms. Previous studies have shown that fibromyalgia (FMS) patients are lacking DNIC effects on experimental pain, compared to normal control (NC) subjects. Because DNIC has a greater effect on second pain than on first pain, we hypothesized that wind-up (WU) of second pain should be attenuated by a strong conditioning stimulus. Thus, we compared DNIC's effect on WU in three groups of subjects: 11 NC males, 22 NC females, and 11 FMS females. To separately assess the contributions of distraction related mechanisms to inhibition of second pain, we designed the experiment in such a way that directed the subjects' attention to either the test or conditioning stimulus. Repeated heat taps to the thenar surface of the right hand were used as test stimuli to generate WU of second pain. Immersion of the left hand into a hot water bath was the conditioning stimulus. As previous experiments have shown, DNIC requires a strong conditioning stimulus for pain attenuation, which may be at least partly dependent on a distraction effect. DNIC significantly inhibited thermal WU pain in normal male subjects, but adding distraction to the DNIC effect did not increase the extent of this inhibition. In contrast, neither DNIC nor DNIC plus distraction attenuated thermal WU pain in female NCs. DNIC plus distraction but not DNIC alone produced significant inhibition of thermal WU pain in female FMS patients. Our results indicate that DNIC effects on experimental WU of second pain are gender specific, with women generally lacking this pain-inhibitory mechanism.
PMID: 12507711, UI: 22396431
Pain 2003 Jan;101(1-2):155-65
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 218, 21287, Baltimore, MD, USA
Despite decades of research, hundreds of studies, and a number of recent reviews, the effects of aging on the experience of pain remain poorly understood. Many prior investigators have reported increases in persistent pain conditions and diminished tolerance for certain types of laboratory-induced pain among the elderly. While explanations for these effects often propose senescent decrements in endogenous analgesic systems as a possible contributory mechanism, almost no direct empirical evidence for this hypothesis has yet emerged in human studies. The present investigation was designed to evaluate the existence and nature of these putative age-related differences in endogenous pain inhibition. Groups of healthy younger (n=45, mean age=21.6 years, range=18-25) and older (n=48, mean age=63.1 years, range=55-67) adults participated in a controlled, two-session laboratory assessment of diffuse noxious inhibitory controls (DNIC), a measure of endogenous pain inhibition. In this study, we examined age differences in the effects of concurrent cold pain on ratings of heterotopically presented repetitive noxious thermal stimuli. Interestingly, older adults demonstrated facilitation rather than inhibition of thermal pain during concurrent noxious cold stimulation while younger adults demonstrated some expected DNIC effects (i.e. a reduction in thermal pain ratings during heterotopic stimulation with noxious cold). Collectively, the findings of the present study suggest age-associated decrements in at least one form of endogenous analgesic response. If replicated, such findings of reduced pain-modulatory capacity in the elderly may partially explain age-related differences in the prevalence, severity, and impact of chronic pain.
PMID: 12507710, UI: 22396430
Pain 2003 Jan;101(1-2):97-107
University Laboratory of Physiology, Oxford University, Parks Road, OX1 3PT, Oxford, UK
Chronic deep brain stimulation (DBS) of the periventricular gray (PVG) has been used for the treatment of chronic central pain for decades. In recent years motor cortex stimulation (MCS) has largely supplanted DBS in the surgical management of intractable neuropathic pain of central origin. However, MCS provides satisfactory pain relief in about 50-75% of cases, a range comparable to that reported for DBS (none of the reports are in placebo-controlled studies and hence the further need for caution in evaluating and comparing these results). Our experience also suggests that there is still a role for DBS in the control of central pain. Here we present a series of eight consecutive cases of intractable chronic pain of central origin treated with PVG DBS with an average follow-up of 9 months.In each case, two electrodes were implanted in the PVG and the ventroposterolateral thalamic nucleus, respectively, under guidance of corneal topography/magnetic resonance imaging image fusion. The PVG was stimulated in the frequency range of 2-100Hz in alert patients while pain was assessed using the McGill-Melzack visual analogue scale. In addition, local field potentials (FPs) were recorded from the sensory thalamus during PVG stimulation.Maximum pain relief was obtained with 5-35Hz stimulation while 50-100Hz made the pain worse. This suggests that pain suppression was frequency dependent. Interestingly, we detected low frequency thalamic FPs at 0.2-0.4Hz closely associated with the pain. During 5-35Hz PVG stimulation the amplitude of this potential was significantly reduced and this was associated with marked pain relief. At the higher frequencies (50-100Hz), however, there was no reduction in the FPs and no pain suppression.We have found an interesting and consistent correlation between thalamic electrical activity and chronic pain. This low frequency potential may provide an objective index for quantifying chronic pain, and may hold further clues to the mechanism of action of PVG stimulation. It may be possible to use the presence of these slow FPs and the effect of trial PVG DBS on both the clinical status and the FPs to predict the probable success of future pain control in individual patients.
PMID: 12507704, UI: 22396424
Pain 2003 Jan;101(1-2):79-88
Department of Rehabilitation Medicine, Erasmus MC, University Medical Center Rotterdam, P.O. Box 1738, 300 DR Rotterdam, Rotterdam, The Netherlands
Complex regional pain syndrome type 1 (CRPS1) often leads to serious activity limitations in everyday life. To date, however, limitations in patients with CRPS1 of an upper limb have not been objectively measured.Therefore, the aim of this study was to determine the long-term impact of upper limb CRPS1 on general mobility and upper limb usage during everyday life, as measured with a novel upper limb-activity monitor (ULAM). In ten female chronic CRPS1 patients and ten healthy control subjects, 24-h activity patterns were measured with the ULAM. This ULAM consists of body-fixed acceleration sensors, connected to a recorder worn around the waist. The ULAM automatically detects upper limb activity during mobility-related activities. Several outcome measures related to general mobility and upper limb usage were compared between patients and controls. The results showed that CRPSI in the dominant upper limb had modest impact on general mobility; i.e. on the percentages spent in body positions and body motions and on mean intensity of body activity. For upper limb usage outcome measures during sitting, there was a marked difference between CRPS1 patients and controls. Especially patients with dominant side involvement clearly showed less activity of their involved limb during sitting, indicated by significant differences for the mean intensity (P=0.014), percentage (P=0.004), and proportion (P=0.032) of upper limb activity. It is concluded that these ten chronic CRPS1 patients still had limitations in upper limb usage during everyday life, 3.7 years (average) after the causative event.
PMID: 12507702, UI: 22396422
Pain 2003 Jan;101(1-2):65-77
Department of Anatomy and Neuroscience, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, 663-8501, Hyogo, Japan
Neuropathic pain models, such as the chronic constriction injury (CCI) model, are partial nerve injury models where there exist both intact and injured peripheral axons. Recent studies suggested that dorsal root ganglion (DRG) neurons with intact axons also show the alteration of excitability and gene expression and might have some role in the pathophysiological mechanisms of neuropathic pain. The incidence of pain-related behavior after the CCI is unstable and variable. In the present study, we used activating transcription factor 3 (ATF3) expression as a neuronal injury marker, and analyzed a relationship between the number of axotomized neurons and the incidence of pain-related behavior. We divided all rats into three groups according to the percentage of ATF3-immunoreactive (IR) neurons, group 1 (<12.5%), group 2 (12.5-25%), and group 3 (>25%). We found that rats in groups 2 and 3 showed thermal hyperalgesia, whereas only the rats in group 2 developed tactile allodynia from the third day to the fourteenth day after surgery. Rats in group 1 did not show thermal hyperalgesia or tactile allodynia. The DRG neurons in group 2 contained ATF3-IR neurons mainly in medium- and large-sized neurons.In order to investigate brain-derived neurotrophic factor (BDNF) and gamma-aminobutyric acid(A)-receptor (GABA(A)-R) regulation in both intact and injured primary afferent neurons after the CCI, we used a double-labeling method with immunohistochemistry and in situ hybridization, as well as double immunofluorescent staining. The CCI induced an increased number of BDNF-labeled neurons in the ipsilateral DRG and the increase in BDNF expression was observed mainly in small- and medium-sized neurons that were mainly ATF3-negative. On the other hand, the number of GABA(A)-Rgamma2 subunit mRNA-positive neurons decreased in the ipsilateral DRG and GABA(A)-R- and ATF3-labeled neurons rarely overlapped. These changes in molecular phenotype in intact and injured primary afferents may be involved in the pathophysiological mechanisms of neuropathic pain produced by partial nerve injury.
PMID: 12507701, UI: 22396421
Pain 2003 Jan;101(1-2):55-64
Section of Hematology/Oncology, VA New Jersey Health Care System, 385 Tremont Avenue, 07018, East Orange, NJ, USA
The purpose of this study is to analyze cancer breakthrough pain (BP) characteristics and how BP responds to conventional cancer pain management. Seventy-four cancer pain patients with worst pain severity >/=4 out of 10 completed the Brief Pain Inventory (BPI), Memorial Symptom Assessment Scale-Short Form, Functional Assessment Cancer Therapy and Breakthrough Pain Questionnaires (BPQ) at an initial interview. Agency for Health Care Policy and Research (AHCPR) cancer pain management guidelines were followed. Pain syndromes and morphine equivalent daily dose (MEDD) orally were determined. One-week follow-up assessments were obtained in 66 patients with BPI and BPQ. The BP characteristics were similar at both time points. On day 1, 52 patients (70%) had BP, and the BP was unpredictable in 30 patients (58%). The median time to worst BP severity was 3min. Patients with BP had significantly higher worst pain (P<0.001). At week 1, the median MEDD doubled from 60 to 120mg orally, and the number of patients who received adjuvant analgesics doubled from 31.1% (23 patients) on day 1 to 62.2% (41 patients). At week 1, 21 patients (32%) remained without BP, 21 patients (32%) were classified as BP responders and 24 patients (36%) were BP non-responders. The mean pain relief was similar for all three subgroups, i.e. around 80%. Compared to BP responders, BP non-responders had significantly higher worst pain (P<0.0001), average pain (P<0.004), and higher BPI interference parameters and shorter time to worst pain severity. The study confirmed the applicability of the BPQ to an US veteran population, and that pain management following the AHCPR guidelines is effective for a group of patients with cancer related BP. Underlying pain syndromes and the BP location may influence the response of BP to treatment. Patients with bone pain located in the spine, back, and pelvis may be at risk for resistant BP.
PMID: 12507700, UI: 22396420
Pain 2003 Jan;101(1-2):45-53
Emory University School of Nursing, 1520 Clifton Rd., NE, 30322, Atlanta, GA, USA
Chronic stable angina pectoris, the chest pain associated with reversible myocardial ischemia has detrimental effects on health-related quality of life, particularly in women. The limited research on gender differences in chronic stable angina suggests that angina may be experienced differently in women and that women report greater functional disability related to angina symptoms. No studies have examined gender differences in chronic stable angina from a multidimensional pain perspective or have included reliable and valid measures of pain that would facilitate comparing chronic angina patients with other chronic pain populations. The purpose of this descriptive study was to examine gender differences in characteristics of chronic stable angina using the short-form McGill pain questionnaire (SF-MPQ) and to explore relationships among these pain characteristics and perceived limitation in performing physical activities in patients with coronary artery disease (CAD) (physical limitation subscale of the Seattle angina questionnaire). One hundred and twenty-eight subjects (30.5% women) with stable CAD and angina pectoris documented by a cardiologist completed study questionnaires in an outpatient cardiology clinic. Results of the study suggest that men and women with chronic stable angina had more similarities than differences in chest pain characteristics. No significant gender differences were demonstrated in total sensory or affective intensity scores, the present pain intensity index, or the number of pain words chosen. However, women did report significantly greater pain intensity on the SF-MPQ visual analogue scale. Women were also significantly more likely to describe their chronic angina as 'hot-burning' and 'tender' and to have greater intensity of pain for these two descriptors. Despite the similarities in pain characteristics, women reported greater physical limitation related to anginal pain. The variables of social status and years diagnosed with CAD significantly interacted with gender in predicting physical limitation suggesting that gender-specific models of physical limitation in angina patients need to be explored. To our knowledge, this is one of the first studies that has assessed chronic anginal pain using a reliable and valid generic pain instrument. More research is needed to better understand the nature of gender differences in functional limitation secondary to anginal pain and the physiologic, cognitive-perceptual and psychosocial mechanisms that lead to angina-related functional disability.
PMID: 12507699, UI: 22396419
Pain 2003 Jan;101(1-2):33-43
Department of Medical Psychology and Psychotherapy, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands
A number of psychosocial factors have been associated with the onset, exacerbation and/or maintenance of chronic pain in adolescents. The present study was conducted to evaluate the relative importance of vulnerability, reinforcement, and modeling. We compared 222 adolescents with chronic pain and no documented physiological etiology (headache, back, limb and abdominal pain) with 148 controls and their (respectively 183 vs. 127) parents. Analyses showed that adolescents with chronic pain are more vulnerable in terms of neuroticism, negative fear of failure, and (less) experienced social acceptance. Contrary to our expectations, the chronic pain group experienced less reinforcement for their pain behavior by both parents and peers than the control group. While the number of pain models was higher in the chronic pain group, no differences were found between their parents and those of the adolescents without chronic pain in pain experience, pain parameters, and pain coping. Regression analyses on the contribution of psychosocial factors to chronic pain and its parameters sustained the positive relation between vulnerability, (less) pain reinforcement, pain models and coping with pain. Furthermore, we also found evidence that gender differences have to be taken into account.
PMID: 12507698, UI: 22396418
Pain 2003 Jan;101(1-2):25-32
Department of Psychiatric and Neurological Sciences, University of Bari, Bari, Italy
Syndromes with chronic daily headache include chronic migraine (CM). The reason for the transformation of migraine into chronic daily headache is still unknown. In this study, we aimed to evaluate heat pain thresholds and event-related potentials following CO(2)-laser thermal stimulation (LEPS) in hand and facial regions in patients with CM, to show changes in nociceptive brain responses related to dysfunction of pain elaboration at the cortical level. The results were compared with findings from normal control subjects and from subjects who suffer from migraine without aura. The effects of stimulus intensity, subjective pain perception and attention were monitored and compared with features of the LEPS. Twenty-five CM patients, 15 subjects suffering from migraine without aura and 15 normal control subjects were enrolled in the study.LEPS amplitude variation was reduced in CM patients with respect to the perceived stimulus intensity, in comparison with migraine without aura patients and control subjects. In both headache groups, the distraction from the painful laser stimulus induced by an arithmetic task failed to suppress the LEPS amplitude, in comparison with control subjects. These results suggest an abnormal cortical processing of nociceptive input in CM patients, which could lead to the chronic state of pain. In both headache groups, an inability to reduce pain elaboration during an alternative cognitive task emerged as an abnormal behaviour probably predisposing to migraine.
PMID: 12507697, UI: 22396417
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Pediatrics 2003 Jan;111(1):e1-11
Department of Pediatrics, University of Arizona Health Sciences Center, Tucson, Arizona 85724-5073, USA.
OBJECTIVE: To conduct a systematic review of evaluated treatments for recurrent abdominal pain (RAP) in children. METHODS: Online bibliographic databases were searched for the terms "recurrent abdominal pain," "functional abdominal pain," "children," or "alternative therapies" in articles classified as randomized controlled trials. The abstracts or full text of 57 relevant articles were examined; 10 of these met inclusion criteria. Inclusion criteria required that the study involve children aged 5 to 18 years, subjects have a diagnosis of RAP, and that subjects were allocated randomly to treatment or control groups. The methodology and findings of these articles were evaluated critically, and data were extracted from each article regarding study methods, specific interventions, outcomes measured, and results. RESULTS: Studies that evaluated famotidine, pizotifen, cognitive-behavioral therapy, biofeedback, and peppermint oil enteric-coated capsules showed a decrease in measured pain outcomes for those who received the interventions when compared with others in control groups. The studies that evaluated dietary interventions had conflicting results, in the case of fiber, or showed no efficacy, in the case of lactose avoidance. CONCLUSIONS: Evidence for efficacy of treatment of RAP in children was found for therapies that used famotidine, pizotifen, cognitive-behavioral therapy, biofeedback, and peppermint oil enteric-coated capsules. The effects of dietary fiber were less conclusive, and the use of a lactose-free diet showed no improvement. There seemed to be greater improvement when therapy (famotidine, pizotifen, peppermint oil) was targeted to the specific functional gastrointestinal disorder (dyspepsia, abdominal migraine, irritable bowel syndrome). The behavioral interventions seemed to have a general positive effect on children with nonspecific RAP. Many of these therapies have not been used widely as standard treatment for children with RAP. Although the mechanism of action for each effective therapy is not fully understood, each is believed to be safe for use in RAP.
PMID: 12509588, UI: 22397934
Pediatrics 2003 Jan;111(1):129-35
Department of Pediatric Surgery, Erasmus MC-Sophia, Rotterdam, The Netherlands. peters@anes.azr.nl
OBJECTIVES: Pain exposure during early infancy affects the pain perception beyond infancy into childhood. The objective of this study was to examine whether major surgery within the first 3 months of life in combination with preemptive analgesia alters pain responses to immunization at 14 or 45 months and to assess whether these alterations are greater in toddlers with a larger number of negative hospital experiences. METHODS: Two groups of 50 toddlers each were compared: index group and control group. All index toddlers had participated within the first 3 months of their life in a randomized, clinical trial that evaluated the efficacy of preemptive morphine administration for postoperative analgesia. The controls were matched by type of immunization and community health care pediatrician. Pain reactions were recorded at routine immunization at either 14 (measles-mumps-rubella immunization) or 45 months (diphtheria-tetanus-trivalent polio immunization) of age. Outcome measures were facial reaction, coded by the Maximum Discriminative Facial Movement Coding System; heart rate (HR); and cortisol saliva concentration. Negative hospital experiences included number of operations requiring postoperative morphine administration, cumulative Therapeutic Intervention Scoring System scores, and length of stay in the intensive care unit or total hospitalization days. RESULTS: No differences were found between the index and control groups in the facial display of pain, anger, or sadness or in physiologic parameters such as HR and cortisol concentrations. Intragroup analyses of the index group showed that after measles-mumps-rubella vaccination, the number of negative hospital experiences correlated positively with the facial responsiveness and negatively with HR responses. No effect was seen after diphtheria-tetanus-trivalent polio immunization. CONCLUSIONS: Major surgery in combination with preemptive analgesia within the first months of life does not alter pain response to subsequent pain exposure in childhood. Greater exposure to early hospitalization influences the pain responses after prolonged time. These responses, however, diminish after a prolonged period of nonexposure.
PMID: 12509565, UI: 22397911
Pediatrics 2002 Oct;110(4):758-61
Department of Nursing, Children's Hospital of Iowa with University of Iowa Health Care, Iowa City, Iowa 52242-1083, USA. charmaine-kleiber@uiowa.edu
OBJECTIVES: Children view needle sticks as the worst source of pain and fear in the hospital setting. In an effort to minimize the pain of needle sticks, the use of eutectic mixture of lidocaine and prilocaine (EMLA) has become standard practice in many children's hospitals. Unfortunately, EMLA requires at least 60 minutes to be fully effective and reportedly may cause vasoconstriction, leading to difficult vein cannulation. A newly available local anesthetic (ELA-Max) may require less time and cause less vasoconstriction. The purpose of this randomized crossover study was to investigate the anesthetic equivalence of EMLA and ELA-Max. METHODS: Thirty well children (14 girls and 16 boys) who were between the ages of 7 and 13 years volunteered to have EMLA applied to the dorsal aspect of 1 hand for 60 minutes and ELA-Max applied to the other hand for 30 minutes. Right and left hands were randomized to treatment type and order of intravenous (IV) insertion. Clinical Research Center nurses, blind to the anesthetic randomization, attempted to insert a 22-gauge Teflon IV catheter into a vein in each hand. The children rated pain during IV insertion on the Oucher scale, and the nurse rated the difficulty of the insertion. RESULTS: There was no significant difference in pain ratings for hands that were treated with EMLA (mean: 20.5) or with ELA-Max (mean: 24), and there was no difference for the difficulty of vein cannulation. Children's preprocedure state anxiety was positively associated with pain ratings. CONCLUSIONS: ELA-Max, applied for 30 minutes before IV cannulation, has an anesthetic effectiveness similar to EMLA applied for 60 minutes. Some children rated IV insertion pain fairly high for both hands (eg, 60 on a 0- to 100-point scale) despite anesthetic treatment. Preprocedural anxiety may affect the perception and/or rating of pain. There were no differences between hands that were treated with EMLA or with ELA-Max for success of IV insertion.
PMID: 12359791, UI: 22247524
Reg Anesth Pain Med 2002 Sep-Oct;27(5):535; author reply 535-6
PMID: 12373711, UI: 22260867
Reg Anesth Pain Med 2002 Sep-Oct;27(5):476-80
Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA. klein006@mc.duke.edu
BACKGROUND: Inguinal herniorrhaphy (IH) is a common outpatient procedure, yet postoperative pain and anesthetic side effects remain a problem. Paravertebral somatic nerve blocks (PVB) have the potential to offer unilateral abdominal wall anesthesia and long-lasting pain relief with minimal side effects. We compared PVB with peripheral neural blocks for outpatient IH. METHODS: Forty-six patients scheduled for IH were entered into this prospective, single-blind study. All patients underwent a standardized general anesthetic. Patients were randomly assigned to receive a PVB (levels T10-L2) preoperatively (n = 24) or an intraoperative peripheral block (PB) by the surgeon (n = 22), using 0.5% ropivacaine (40 mL). Opioid use, verbal analog pain scores, and side effects were documented for 72 hours. RESULTS: The use of opioids during surgery was less for the PVB group 162 +/- 70 mg than the PB group, 210 +/- 60 (P =.02). Need for opioids in PACU was less for the PVB group (39%) than the PB group (61%) (P =.002). Time until first pain after discharge was not different between groups, 312 +/- 446 minutes (PB) and 425 +/- 384 minutes (PVB) (P =.12). Of the PVB patients, 29% used no opioids at all compared with 18% of PB patients (P =.12). Mean time until first oxycodone use was similar between groups, 303 +/- 469 minutes (PB) and 295 +/- 225 minutes (PVB) (P =.18). Oxycodone use was also similar; 35 +/- 34 mg (PVB) versus 49 +/- 42 mg (PB) (P =.30). More patients in the PB group (50%) required antiemetic treatment in the postanesthesia care unit than the PVB group (21%) (P <.001). Side effects were similar at all other measurements. CONCLUSIONS: This study shows that PVB provides analgesia equivalent to extensive peripheral nerve block for inguinal herniorrhaphy, offering an alternative method of postoperative pain management and perhaps fewer side effects.
PMID: 12373694, UI: 22260850