Considerable Pain Relief Research Articles

Subtalar arthroscopy for persistent subfibular pain after calcaneal fractures.

This is a report of 10 consecutive patients who had subtalar arthroscopy for persistent pain in the subfibular area after open reduction and internal fixation for intra-articular calcaneal fractures. The average period between the injury and the subtalar arthroscopy was 14.3 months (range, 6-36 months). The average follow-up period after subtalar arthroscopy for the patients who did not require further treatment was 16.7 months (average, 11-35 months). All the patients except two had chondromalacia. Three had grade II, three had grade III, and two had grade IV. Five patients had intra-articular adhesion. Two patients had a loose body. The power shaver has been used for debridement of the damaged cartilage and excision of the adhesion. Eight patients (80%) had considerable pain relief and did not require further local injection or surgical management. The two patients who required subtalar fusion had grade IV chondromalacic lesions. Only four patients had improvement in the range of motion of the subtalar joint. The preoperative American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score for the whole group was 69.9 points (range, 68-74 points), which was improved postoperatively to 77.2 points (range, 48-90 points). Subtalar arthroscopy for persistent pain after calcaneal fractures should be considered, especially if the radiological examination shows mild degenerative changes in the subtalar joint.

Supraorbital Neuralgia. On the Clinical Manifestations and a Possible Therapeutic Approach

The clinical manifestations of supraorbital neuralgia are apparently only incompletely known. The lack of awareness of this head pain may possibly be due to its rarity and problems with making the diagnosis. In the present work, the long-term result of minor, decompressive surgery of the supraorbital nerve in five patients is reported. The immediate improvement was good and, after a mean observation time of more than 6 years, an improvement of 50% to 100% was observed (mean, circa 85%). In the two patients with the longest postoperative observation time, approximately 8 years, pain has not recurred. The pain was severe, leading to suicidal thoughts in several patients. The long-term course was intermittent or continuous. The pain was generally unilateral, but was bilateral in one patient. Generally, there was lack of, or only minor benefit from drug treatment, including carbamazepine and indomethacin. There was clearly tenderness over the supraorbital nerve, especially at its outlet, and in some subjects occasionally, a slight local loss of sensation. Definite trigger zones were not present. Supraorbital nerve blockade generally provided instant and considerable pain relief. The persistence of protracted unilateral forehead/ocular pain, tenderness over the nerve, and repeated blockade effect strongly suggests the diagnosis.

The multimodal interdisciplinary therapeutic program in chronic back pain. A new treatment strategy

The epidemic-like rise in chronic low back pain in western industrial nations is less an expression of a medical than a psychosocial phenomenon. Differentiation between acute, chronic or chronifying pain is of crucial importance for therapeutic procedures. Pain syndromes in the muscular-skeletal system tend to become chronic to a far larger extent than expected. More than 80 % of low back pain represents a functional pain syndrome and does not show any pathoanatomical correlate. Pain existing independently seems to be predestined by a somatic and psychosocial deconditioning syndrome. Those at risk of chronifying pain or those whose pain is already chronic should be given an interdisciplinary, multimodal therapeutic program. A pilot study was carried out in our clinic: multidisciplinary treatment was given to our patients (of which over 90 % belonged to stages II and III on the Gerbershagen scale) and the result was significant improvement in the measurements of pain intensity, sensoric and affective pain perception, their list of complaints, the common scale of depression and the pain disability index. Taking previously published studies into consideration, it is safe to say that a multidisciplinary, multimodal program of therapy even after stay in hospital results in considerable relief of pain and improvement in the ability to cope with the pain for patients with chronified pain syndromes in the muscular-skeletal system which are resistant to treatment on an outpatient basis.

Interposition of the split flexor hallucis longus tendon after resection of a coalition of the middle facet of the talocalcaneal joint.

Ten consecutive patients (fourteen feet) who had a painful coalition of the middle facet of the talocalcaneal joint with restricted motion of that joint were managed with a resection of the coalition and interposition of a split flexor hallucis longus tendon in 1992, 1993, or 1994. Initial nonoperative treatment of all of the feet had failed. According to the ankle-hindfoot clinical rating system of the American Orthopaedic Foot and Ankle Society, there were eleven excellent results and one good, one fair, and one poor result at a mean of fifty-one months (range, thirty-two to sixty months) after the procedure. Thirteen of the fourteen procedures resulted in considerable relief of pain, an improved range of motion of the talocalcaneal joint, and improved function of the foot. No patient had symptoms or functional impairment of the great toe secondary to the interposition of the split flexor hallucis longus tendon. On the basis of these early results, tendon interposition appears to be an excellent procedure for the treatment of a symptomatic coalition of the middle facet of the talocalcaneal joint after initial nonoperative treatment has failed. The presence of degenerative osteoarthritis in the other facets of the talocalcaneal joint is a contraindication to this procedure. The long-term results have yet to be determined. However, the standardized rating system used in the present study will allow accurate comparison of our results with those of subsequent studies.

Percutaneous lumbar sympathetic plexus catheter placement for short- and long-term pain relief: CT technique and results.

The purpose of this work was to evaluate the use of percutaneously placed lumbar sympathetic plexus catheter placement under CT guidance in patients with complex regional pain syndrome (CRPS) or nonspecified neuropathic pain (NP) of the lower extremity. Sixteen lumbar sympathetic plexus catheter placements were performed in seven patients with CRPS and seven patients with NP. A 19 gauge epidural catheter was placed anterior to the psoas muscle at the L2-3 level. Twenty-five to 840 mg of bupivacaine hydrochloride per day was administered for a 1 to 8 day duration. In CRPS patients, there was complete short-term pain relief in one patient, considerable in four, mild in one, and none in one. There was total long-term pain relief in one patient and considerable long-term pain relief in three. In three patients, there was enduring pain relief at last follow-up. In NP patients, the procedure yielded considerable short-term pain relief in four, mild in two, and none in one. There was no enduring long-term in any of these patients. A retroperitoneal abscess developed in one patient and resolved on intravenous antibiotics without sequelae. Percutaneous lumbar sympathetic plexus catheter placement is easily performed, achieves short-term pain relief in the majority of patients, and may prove effective in long-term pain relief of CRPS patients.

Rectovaginal septum adenomyotic nodules: a series of 500 cases.

Laparoscopic procedure with excision of deep fibrotic endometriotic nodules of the rectovaginal septum and histological study of the lesions. An academic teaching hospital. A series of 500 women undergoing laparoscopy for pelvic pain or infertility. Laparoscopic (n = 497) and laparotomic (n = 3) excision of endometriotic nodules resulted in considerable pain relief. Histologically the rectovaginal nodule was similar to an adenomyoma as it was a circumscribed nodular aggregate of smooth muscle and endometrial glands and stroma. The variations in oestrogen receptor and progesterone receptor content suggested a regulatory mechanism different from that of eutopic endometrium. This form of disease should be considered as an entity distinct from peritoneal and ovarian endometriosis, and originating from the Müllerian rests present in the rectovaginal septum.

Wrist arthrodesis using a dynamic compression plate

In order to determine the effectiveness of wrist arthrodesis using dynamic compression plating and bone grafting, we reviewed 18 consecutive procedures in 17 patients performed using a standardized technique over a 6-year period. Fourteen patients had previously undergone an average of 2.1 operations prior to arthrodesis. Mean follow-up was 48 months. All but one patient reported considerable pain relief and were satisfied with their results. Grip strength remained limited compared to the contralateral wrist. Complications were limited to one case of reflex sympathetic dystrophy and metacarpophalangeal joint contracture, and minor problems related to the bone graft donor site.

10 Advanced laparoscopic surgery for the removal of rectovaginal septum endometriotic or adenomyotic nodules

In the pelvis, three different forms of endometriosis (Donnez et al, 1992) must be considered: (1) peritoneal, (2) ovarian, (3) rectovaginal septum. By evaluation of the mitotic activity and the stromal vascularization, we have recently suggested (Nisolle et al, 1993) that peritoneal red lesions were the most aggressive form of the disease and progress to the so-called typical or black lesion, which must be considered as an enclosed implant surrounded by fibrosis. This type of infiltration must be clearly differentiated from the rectovaginal endometriotic nodule. Koninckx (1993) recently described three types of deep-infiltrating endometriosis: deep-infiltrating endometriosis of type I is a rather large lesion in the peritoneal cavity, infiltrating conically with the deeper parts becoming progressively smaller. It has been suggested that this type of endometriosis is caused by infiltration. In type II lesions, the main feature is that bowel is retracted over the lesion which thus becomes deeply situated in the rectovaginal septum although not actually infiltrating it. Type III lesions are the deepest and most severe. They are spherically shaped, situated deep in the rectovaginal septum, often only visible as a small typical lesion at laparoscopy or often not visible at all. This lesion is often more palpable than visible and is acutely tender if the patient is examined at the time of menstruation, and gives rise to severe dyspareunia. In our experience there are two different types of 'deep-infiltrating endometriosis': 1. True deep-infiltrating endometriosis caused by the invasion of a very active peritoneal lesion deep in the retroperitoneal space. In cases of lateral peritoneal invasion, uterosacral ligaments can be involved as well as the anterior wall of the rectosigmoid bowel junction resulting in a retraction, adhesions and secondary obliteration of the cul-de-sac. 2. Pseudo deep-infiltrating endometriosis or adenomyosis of the rectovaginal septum. This lesion originates from the rectovaginal septum tissue and consists essentially of smooth muscle with active glandular epithelium and scanty stroma. In our study, the rectovaginal nodule was histologically similar to an adenomyoma (Zaloudek and Norris, 1987). It was a circumscribed, nodular aggregate of smooth muscle, endometrial glands and endometrial stroma. As in the 'adenomyoma', secretory changes were frequently absent in 'endometriotic' rectovaginal nodules. The invasion of the muscle by a very active glandular epithelium, without stroma, proved that the stroma is not necessary for invasion in this particular type of pathology called adenomyosis. In some instances, it can be seen that the vaginal pluristratified epithelium was replaced by a glandular epithelium. The fact that ciliated cells were present and the co-expression of both vimentin and cytokeratin (Donnez and Nisolle, personal communication) proved the Mullerian origin of the nodule, where certain histological characteristics are completely different to those observed in peritoneal lesions (Nisolle et al, 1990). In our series, deep fibrotic tissue assumed to contain endometriosis was excised or vaporized from the anterior rectum with the aid of multiple rectovaginal examinations. Cul-de-sac dissection was followed by excision of deep fibrotic endometriosis, without cul-de-sac reconstruction. In three cases, the bowel lumen was entered. A comprehensive laparoscopic procedure, while not eradicating all the endometriosis, may result in considerable pain relief or a desired pregnancy.(ABSTRACT TRUNCATED AT 400 WORDS)

Superior hypogastric plexus block for chronic pelvic pain in the presence of endometriosis: CT techniques and results.

To evaluate the use of superior hypogastric plexus block with computed tomographic (CT) guidance in patients with endometriosis and chronic pelvic pain. Seven blocks were performed on an outpatient basis in five women with endometriosis and pelvic pain. In the first four patients, one or two 20-gauge, 15-cm needles were placed anterior to the spine at the common iliac bifurcation from a posterior approach. In the fifth patient, the block was performed from an anterior approach with a single needle. One procedure resulted in mild pain relief, three in considerable pain relief, one in complete midline pain relief with no change in the lateral pain, and one in complete pain relief. One procedure was terminated because anesthetic was injected into the peritoneal cavity. There were no other complications. CT-guided superior hypogastric plexus block is easily performed and can be used to assess whether chronic pelvic pain can be attenuated by blocking the superior hypogastric plexus.

Celiac plexus block: efficacy and safety of the anterior approach.

A celiac plexus block performed via an anterior approach offers several potential advantages over a posterior approach, including shorter procedure time, less discomfort to the patient, and less risk of neurologic complications. We evaluated the use of an anterior approach to determine its efficacy and safety. The procedure was performed in 17 consecutive patients referred for treatment of chronic abdominal pain thought clinically to be of celiac ganglion origin. A subjective evaluation of the degree of pain relief was obtained by retrospectively reviewing the notes of physicians and nurses. The degree of pain relief was graded from 1+ (no change) to 4+ (complete relief). An objective evaluation was also obtained by comparing average daily in-hospital analgesic usage before and after the procedure. Ethanol injection was performed successfully in 13 of 14 patients with pancreatic carcinoma and in two of three patients with other causes of pain. Eleven (79%) of the 14 patients with pancreatic carcinoma had some (2+ or greater) relief of pain, and eight of these patients had considerable or complete (3+ or 4+) relief of pain. Of the 10 patients with pancreatic carcinoma for whom complete data on the use of pain medication were available, the mean daily analgesic usage declined from 17% to 100% (mean, 58%) relative to preprocedure doses. Complications, all relatively mild, were encountered in only three of 17 patients, and no patient had neurologic symptoms or long-term sequelae. The anterior approach to a celiac plexus block is a safe and effective means of pain control in patients with pancreatic carcinoma. It offers several potential advantages to the posterior approach, and should be considered for all patients with pain caused by pancreatic carcinoma that is refractory to pain medication.

Finnish Orthopedic Association: Tampere, Finland, November 5-6, 1992

(1993). Finnish Orthopedic Association: Tampere, Finland, November 5-6, 1992. Acta Orthopaedica Scandinavica: Vol. 64, No. sup253, pp. 80-84.

Extracorporeal lithotripsy of pancreatic stones in patients with chronic pancreatitis and pain: a prospective follow up study.

Extracorporeal shock wave lithotripsy of pancreatic duct stones (largest stone 12 (SD) 6 mm) was performed in 24 patients with abdominal pain and a dilated duct system (main pancreatic duct 10 (3) mm). The procedure was well tolerated in all but two patients, who had a mild pancreatitic attack immediately after lithotripsy. Disintegration of the stones was achieved in 21 patients. This allowed complete clearance of the duct system by an endoscopic approach in 10 (42%) patients and partial clearance in 7 (29%) patients. Within a mean follow up period of 24 (14) months half of the patients showed complete or considerable relief of pain and alleviation of symptoms was achieved in seven patients. Relief of pain occurred more often after complete ductal clearance. There were no fatalities within the follow up period. These findings underline the value of a combined non-surgical approach, using endoscopy and adjuvant shock wave lithotripsy to patients with large pancreatic calculi and pain attacks.

Calcitonin: analgesic effects.

Animal experiments demonstrate that the intracerebro-ventricular administration of calcitonin induces analgesia. During the treatment of such diseases as osteitis deformans Paget and acute pancreatitis with calcitonin no spectacular pain-relieving effect was evident, but the application of calcitonin in hypercalcemic patients with bone tumors led to considerable pain relief. Recent double-blind studies document the analgesic effectiveness of calcitonin in malignant diseases, but also against postoperative pains in nontumor patients. Calcitonin as an analgesic drug deserves further investigation.

Whole-body hyperthermia in cancer therapy: a report of a phase I–II study

Twenty-seven patients were treated with whole-body hyperthermia alone or in combination with either chemotherapy or radiotherapy. Whole-body hyperthermia was performed in the Pomp-Siemens cabin with hot air and a warm water mattress, the patient being covered with plastic film to avoid cooling by perspiration. The heat treatment lasted for 2 hr at 41.8–42.0°C. Toxicity, such as liver damage and respiratory problems, was considerable. There were two fatalities. Hyperthermia gave an improved therapeutic effect in 6 of the patients. Considerable pain relief was observed in 8 of 10 patients. Whole-body hyperthermia at 42°C can be effective but the potential toxicity limits its use to those patients with severe complaints for whom no other palliative treatment is available.

The role of metal and bone cement fixation in the management of malignant lesions of the vertebral column.

Fifteen patients with malignant spinal metastases underwent fixation of the spine using metallic implants and bone cement. The operation provided considerable relief of pain in all 15 cases and a significant improvement in mobility in 12 cases. These results compared favourably with 77 patients with fatal metastatic cancer of the spine who were treated without spinal surgery. The technique seems to be best indicated for use in patients with breast and thyroid cancer with a relatively prolonged terminal course.

First results wih extralemniscal myelotomy.

In the past thalamic lesions have been practised in our clinic to treat deep medial pain in cancer patients in the advances stages. Such lesions centred on the CM-Pf complex resulted in considerable pain relief without any objective sensory loss. However the frequent recurrence of pain and the accompanying psychic disturbances called for a critical analysis of their indications 2.

The results of the pseudarthrosis after removal of an infected total hip prosthesis.

Twenty-nine patients with thirty pseudarthroses after removal of infected total hip prostheses have been reviewed one to six years later. Six hips still had a discharging sinus. Complete removal of all cement was found to be essential for healing, and various points in the technique of its clearance have been made. In this respect radio-opaque cement was a great advantage, and lateral guttering of the femur was most effective. Compared with the situation before replacement considerable relief of pain was obtained in most patients but there was much less improvement in function.

A FOLLOW-UP STUDY OF MOORE'S ARTHROPLASTY IN THE TREATMENT OF OSTEOARTHRITIS OF THE HIP

1. A total of 120 Moore's arthroplasties in 111 patients were reviewed one to nine years after operation. 2. There was striking reduction in the severity of pain in 105 out of the 120 hips reviewed. Range of movement was improved in most patients but the degree of independence was improved less often. The reasons for this are discussed. 3. We draw the following conclusions regarding the place of Moore's arthroplasty. Firstly, it was a natural step in the evolution towards total hip replacement, an operation which promises to give more complete relief of symptoms and which seems likely to replace Moore's arthroplasty as the treatment of choice in osteoarthritis of the hip in the elderly. Secondly, Moore's arthroplasty is still a rational procedure for the treatment of degeneration if the acetabulum is not involved—for instance, in idiopathic avascular necrosis of the femoral head. Thirdly, it is certainly a valuable operation for some cases of recent fracture of the femoral neck. Avascular necrosis of the femoral head after trifin nailing can be satisfactorily treated by Moore's arthroplasty, particularly in the early stages before the acetabulum becomes involved. Finally, Moore's arthroplasty gave many fairly elderly patients considerable relief of pain at a time when nothing better was available. Much of the relief afforded has proved to be lasting, but deterioration sometimes occurred with time. In the few patients whose deterioration amounted to failure a definite cause for the failure was found. In the majority the deterioration was slight, and it seems likely that the operation will last most of these elderly patients for the rest of their lives.

A review of 350 cases of paracervical nerve block.

SummaryThree hundred and fifty cases of para‐cervical block are reviewed showing the procedure to be safe, technically simple, and giving considerable relief of pain in the first stage of labour.

EFFECT OF SODIUM FLUORIDE ON CALCIUM, PHOSPHORUS, AND NITROGEN BALANCE IN PATIENTS WITH PAGET'S DISEASE.

Prolonged exposure to increased quantities of fluoride, either in industry or in drinking-water, is likely to cause sclerotic changes in bones (Roholm, 1937). It has been suggested that this action could be of great benefit in the treatment of certain metabolic bone diseases. Accordingly Rich and Ensinck (1961) studied the effects of sodium fluoride 60 mg./day on the calcium balance of seven patients with osteoporosis and one with Paget's disease, and found a more positive balance in every case. A later report from these authors stated that the drug also produced a positive phosphorus balance (Rich and Ensinck, 1962). Purves (1962) treated 14 patients with Paget's disease with sodium fluoride 60 mg./day and reported considerable relief of pain in four to six weeks. Calcium balance studies were made before and during treatment on eight patients, and in six of them the balance became more positive. Bernstein, Guri, Cohen, Collins, and Tamvakopoulos (1963) studied an unspecified number of patients with various types of osteoporosis and Paget's disease before and after fluoride therapy (NaF 50-200 mg./day). They state that fluoride initiates a grossly positive calcium balance mainly through increased gastric * intestinal absorption of calcium.