Ben J. P. Crul

Diagnostic lumbosacral segmental nerve blocks with local anesthetics: a prospective double-blind study on the variability and interpretation of segmental effects.

Background and Objectives Selective spinal nerve infiltration blocks are used diagnostically in patients with chronic low back pain radiating into the leg. Generally, a segmental nerve block is considered successful if the pain is reduced substantially. Hypesthesia and elicited paresthesias coinciding with the presumed segmental level are used as controls. The interpretation depends on a standard dermatomal map. However, it is not clear if this interpretation is reliable enough, because standard dermatomal maps do not show the overlap of neighboring dermatomes. The goal of the present study is to establish if dissimilarities exist between areas of hypesthesia, spontaneous pain reported by the patient, pain reduction by local anesthetics, and paresthesias elicited by sensory electrostimulation. A secondary goal is to determine to what extent the interpretation is improved when the overlaps of neighboring dermatomes are taken into account. Methods Patients suffering from chronic low back pain with pain radiating into the leg underwent lumbosacral segmental nerve root blocks at subsequent levels on separate days. Lidocaine (2%, 0.5 mL) mixed with radiopaque fluid (0.25 mL) was injected after verifying the target location using sensory and motor electrostimulation. Sensory changes (pinprick method), paresthesias (reported by the patient), and pain reduction (Numeric Rating Scale) were reported. Hypesthesia and paresthesias were registered in a standard dermatomal map and in an adapted map which included overlap of neighboring dermatomes. The relationships between spinal level of injection, extent of hypesthesia, location of paresthesias, and corresponding dermatome were assessed quantitatively. Comparison of the results between both dermatomal maps was done by paired t-tests. Results After inclusion, data were processed for 40 segmental nerve blocks (L2-S1) performed in 29 patients. Pain reduction was achieved in 43%. Hypesthetic areas showed a large variability in size and location, and also in comparison to paresthesias. Mean hypesthetic area amounted 2.7 ± 1.4 (± SD: range, 0 to 6; standard map) and 3.6 ± 1.8 (0 to 6; adapted map; P < .001) dermatomes. In these cases, hypesthesia in the corresponding dermatome was found in 80% (standard map) and 88% of the cases (adapted map, not significant). Paresthesias occurring in the corresponding dermatome were found in 80% (standard map) compared with 98% (adapted map, P < .001). In 85% (standard map) and 88% (adapted map), spontaneous pain was present in the dermatome corresponding to the level of local anesthetic injection. In 55% (standard map) versus 75% (adapted map, P < .005), a combination of spontaneous pain, hypesthesia, and paresthesias was found in the corresponding dermatome. Conclusions Hypesthetic areas determined after lumbosacral segmental nerve blocks show a large variability in size and location compared with elicited paresthesias. Confirmation of an adequately performed segmental nerve block, determined by coexistence of hypesthesia, elicited paresthesias and pain in the presumed dermatome, is more reliable when the overlap of neighboring dermatomes is taken into account.

Changed patterns in Dutch palliative sedation practices after the introduction of a national guideline.

BACKGROUND Continuous sedation, contrary to euthanasia, has been increasingly accepted among medical professionals worldwide. In the Netherlands, a national guideline for continuous palliative sedation has been developed to contribute to the quality of palliative sedation practice. The present follow-up study investigated whether the practice of continuous sedation has changed after the introduction of this guideline. METHODS This study compared the practice of continuous sedation before and after the introduction of the guideline on December 7, 2005. A baseline measurement was performed between February 1, 2003, and May 1, 2005, with an enrollment of 492 physicians (medical specialists, general practitioners, and nursing home physicians). From January 1 to June 30, 2007, after the introduction of a national guideline for palliative sedation, a follow-up study was performed with the respondents of the baseline study. Physicians were asked to report on their last case of deep and continuous sedation in the past 12 months. RESULTS This study reports the results of the follow-up study and compares them to the results of the baseline study. The response rate was 69.3% (n = 341). Of these physicians, 160 reported a last case of continuous sedation in both the baseline and the follow-up studies. Physicians reported a significant increase in patient involvement in decision making, from 72.3% to 82.2%. Pain remained the most often reported reason to start sedation, whereas exhaustion as a reason for sedation increased. The use of benzodiazepines increased from 69.9% to 90.4%. In the first and second measurements, symptom-directed treatment during sedation was applied in 56% to 58% of the cases. In the second period, there was more often an explicit decision to not give artificial hydration during sedation (78.8% vs 56.3%). Of the physicians, 34.2% were convinced that sedation shortened the life of the patient because of dehydration. CONCLUSIONS After the introduction of the guideline, physicians reported that changes in palliative sedation practice conform to the recommendations of this guideline. For example, benzodiazepines were used for sedation more frequently than before and patient involvement in the decision-making process improved. Possible effects of dehydration and the large variation in symptom-directed treatment during sedation deserve careful attention.

The present role of percutaneous cervical cordotomy for the treatment of cancer pain

The results obtained by percutaneous cervical cordotomy (PCC) were analysed in 43 terminally ill cancer patients treated in our institution from 1998 to 2001. We wished to determine whether there is still a place for PCC in the actual clinical situation with its wide choice of pain therapies. All patients had severe unilateral pain due to cancer, resistant to opioids and co–analgesics. Following PCC, mean pain intensity was reduced from Numeric Rating Scale (NRS) 7.2 to 1.1. At the end of life, pain had increased to NRS 2.9. Initially following PCC a good result (NRS<3) was obtained in 95% of patients. At the end of life, a good result was still present in 69% of patients. Mean duration of survival after the intervention was 118 days (2–1460). In general, complications were mild and mostly subsided within 3–4 days. There was one case of partial paresis of the ipsilateral leg. PCC remains a valuable treatment in patients with treatment–resistant cancer pain and still deserves a place in the treatment of terminal cancer patients with severe unilateral neuropathic or incidence pain.

Obstacles to the delivery of primary palliative care as perceived by GPs

Introduction: In order to facilitate GPs in their work and increase the possibilities for patients to remain at home, it is important to identify the obstacles which hinder the delivery of primary palliative care. From previous research we learned about some of the problems experienced by GPs. In this survey we aimed to identify the prevalence of such problems in providing palliative care and its determinants. Methods: The prevalence of obstacles and its determinants were identified by a questionnaire to 320 GPs in three regions of the Netherlands. Obstacles were grouped as follows: communication, organisation & co-ordination of care, knowledge & expertise, integrated care, time for relatives. The potential determinants were GP characteristics and expertise development activities. Results: The response rate was 62.3%. GPs experienced considerable obstacles in all aspects of palliative care. The most prevalent were: problems with bureaucratic procedures (83.9%), the time necessary to arrange home care technology (61.1%) and the difficulties accompanied with the wish or necessity to obtain extra care (56.3%). In general, more years of GP experience and the participation in (multidisciplinary) case discussions were associated with less perceived obstacles. Discussion: Based on the results of our survey policymakers and practitioners can plan and set priorities in handling the obstacles. There is a high necessity of firstly overcoming the barriers within organisation and coordination of care. Furthermore, our study can help in choosing the (additional) expertise needed in the future and in the realisation of the preferred expertise advancement activities. Palliative Medicine 2007; 21 : 697—703

Dealing With Delicate Issues in Continuous Deep Sedation Varying Practices Among Dutch Medical Specialists, General Practitioners, and Nursing Home Physicians

BACKGROUND This article examines delicate issues in continuous deep sedation (CDS) from the perspectives of different types of physicians. The following sensitive issues involved in CDS were investigated: artificial hydration, sedation for nonphysical discomfort, the relationship between CDS and euthanasia, and patient involvement in decision making for CDS. METHODS A structured retrospective questionnaire concerning the most recent case of CDS during the past 12 months was sent to a sample of medical specialists (n = 727), general practitioners (n = 626), and nursing home physicians (n = 111). RESULTS Response rates were 26.4% for medical specialists, 37.4% for general practitioners, and 59.5% for nursing home physicians. Indications for CDS differed among the types of physicians. General practitioners (25.0%) were most often confronted with a patient request for euthanasia before starting CDS compared with medical specialists (8.9%) and nursing home physicians (6.5%). A decision to forgo artificial hydration in CDS was more often made by nursing home physicians (91.3%) compared with medical specialists (53.7%) and general practitioners (51.2%). Shorter survival was found for patients sedated for nonphysical discomfort (vs other patients) by general practitioners. Among all patients, 74.5% were involved in decision making before the start of CDS. CONCLUSIONS The present study demonstrates notable differences in CDS practice among various types of physicians. To what extent this is related to different patient populations or to different expertise requires further investigation. The use of CDS for nonphysical discomfort calls for critical examination to avoid ambiguous practice.

Normal values for sensory thresholds in the cervical dermatomes: a critical note on the use of Semmes-Weinstein monofilaments.

In many healthy subjects, sensory thresholds for touch using Semmes-Weinstein monofilaments appear to be higher than the 2.83 filament, which some authors have suggested as a screening instrument. The currently proposed normal values, the interpretation of results, as well as the calibration of the filaments are questioned. A normative study of 20 normal subjects using Semmes-Weinstein monofilaments was undertaken at a pain clinic in a university hospital. The main outcome measures were sensory thresholds (touch) in dermatomes C3 to C8. Per subject, 24 sites were tested and 50 sites in dermatome C5 left of one subject. The threshold distribution patterns were analyzed. The mean threshold expressed in log (10 x F; with F = force in milligrams) of all sites (n = 480) in normal subjects was 3.10 (95% confidence interval, 2.34-3.86). The mean threshold per subject was 3.10 (range, 2.70-3.50). The mean threshold of 50 sites in dermatome C5 left of one healthy subject was 3.22 (range, 2.42-4.02). In the study contained herein, sensory thresholds in the cervical dermatomes have been shown to be higher than the generally proposed normal values. The cervical dermatomes show thresholds from 0.13 to 8.47 mN. This concurs with other authors. Results depend on the testing method, which in this study was different from previous studies. The testing method must be described accurately. The distribution of thresholds within all tested sites, dermatomes, subjects, or even within one dermatome in one subject are comparable. Individual results have to be related to the mean of the subject to determine abnormality. Calibration of the monofilaments is important. When these terms are met, testing with Semmes-Weinstein monofilaments is an easy, reliable, and relatively inexpensive method of quantitative sensory testing and can be a useful tool in the process of rehabilitation.

Methadone for Phantom Limb Pain

ObjectiveThe objective of this case series was to determine if severe phantom limb pain could be reduced with oral methadone. DesignFour cases of phantom limb pain refractory to multiple treatment modalities were treated with oral methadone. SettingPain clinic at a major university medical center. PatientsFour patients with severe, intractable phantom limb pain. InterventionOral methadone was administered, starting with a low dose of 2 to 5 mg twice a day or three times a day and slowly titrated upward to achieve pain relief. Outcome MeasuresRepeated administration of a visual analog scale for pain. Results and ConclusionsAdministration of oral methadone may be of value in the treatment of phantom limb pain; controlled clinical trials would be appropriate to verify this observation.

Psychological predictors of the effectiveness of radiofrequency lesioning of the cervical spinal dorsal ganglion (RF-DRG)

In this study, 54 patients suffering from chronic cervicobrachialgia (mean pain duration 7 years) were treated with radiofrequency lesioning of the cervical spinal dorsal root ganglion (RF‐DRG). The aim of the study was to investigate whether psychological variables would be predictive for the changes in pain intensity after medical treatment. The following psychological aspects were measured: pain cognitions, negative self‐efficacy and catastrophizing, physical and psychosocial dysfunction, and overall distress. The level of catastrophizing before treatment appeared to predict 10% of the changes in pain intensity after treatment. Changes in pain intensity after RF‐DRG were positively correlated with changes in psychosocial dysfunction and negative self‐efficacy.

Inefficacy of high‐dose transdermal fentanyl in a patient with neuropathic pain a case report

Pain partially responsive to opioids can lead to rapid escalating dosages due to tolerance development. In this report the case of a 58‐year‐old female with neuropathic pain using increasing transdermal (TTS) fentanyl dosages to a maximum dose of 3400 μg/h resulting in fentanyl plasma levels of 173 ng/ml is described. For pain relief an epidural infusion at the level T1–2 with bupivacaine was started. Immediate pain relief was accompanied by short lasting respiratory depression and drowsiness.

Multidisciplinary allocation of chronic pain treatment: Effects and cognitive-behavioural predictors of outcome

OBJECTIVES Multidisciplinary treatment approaches have been found to be effective for chronic pain patients although there are large individual differences in outcomes. To increase overall treatment effects, tools are needed to identify patients most likely to benefit from tailored, comprehensive modular treatment schemes. DESIGN The present study evaluates the effects of a multidisciplinary pain treatment allocation protocol in chronic pain patients and seeks to identify cognitive-behavioural predictors of outcome. Pain intensity, functional disability, depression, and use of medication in an intervention group of 110 chronic pain patients were compared to the outcomes of a 110 strong control group. RESULTS Paired pre- and post-treatment t tests showed that all primary outcomes had significantly decreased in the intervention group with ANCOVAs revealing a main group effect for post-treatment pain intensity levels and functional disability. Paired t tests demonstrated both variables to have significantly reduced after treatment relative to the levels reported by the control group. Predictor analyses further showed higher levels of acceptance to significantly predict larger reductions in pain intensity in the intervention but not in the control group. CONCLUSION The tested multidisciplinary allocation scheme for out-patient treatment of chronic pain complaints was effective in reducing pain intensity and functional disability. Findings also showed that especially those patients that are able to accept their condition are likely to profit most from the treatment in terms of pain reduction.