Mark J. Lema

Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer

&NA; Twenty‐six patients with extensive gynecologic, colorectal or genitourinary cancer who suffered uncontrolled, incapacitating pelvic pain were enrolled in this study during a 1‐year period. All the patients receiving oral opioids who developed poor pain response due to the progression of disease or untoward side effects necessitating other modes of therapy were eligible to participate. Bilateral percutaneous neurolytic superior hypogastric plexus blocks with 10% phenol were performed in every patient, 1 day after receiving successful diagnostic blocks using 0. 25% bupivacaine (BUP). All patients reported a visual analog pain score (VAPS) of 10 of 10 before the block. Eighteen patients (69%) had satisfactory pain relief (VAPS < 4 of 10): 15 (57%) after 1 block and 3 (12%) after a second block. The remaining 8 patients (31%) had moderate pain control (VAPS 4–7 of 10) after 2 blocks and received epidural bupivacaine‐morphine (BUP‐MS) therapy with good results. Both groups experienced significant reductions in oral opioid therapy after the neurolytic blocks. No additional blocks were required by patients who had a good response during a follow‐up period of 6 months. No complications related to the block were experienced by any patient. In conclusion, neurolytic superior hypogastric plexus block was both effective in relieving pain in 69% of the patients studied (95% confidence interval of 48–85%). Additional neurolytic blocks using higher volumes of the neurolytic agent may be needed in patients with extensive retroperitoneal disease, a group in whom moderate or poor results should be expected.

Postoperative Epidural Bupivacaine-Morphine Therapy Experience with 4,227 Surgical Cancer Patients

BackgroundWe prospectively studied surgical cancer patients who received epidural bupivacaine-morphine to determine perioperative morphine use, side effects, and complications. MethodsAll study patients received general-epidural anesthesia followed by epidural analgesia with 0.05% or 0.1% bupivacaine and 0.01% morphine at a rate of 5–10 ml · h−1 to keep the dynamic pain score at less than 5 (of 10). Patients were evaluated daily for pain relief, side effects, catheter migration, accidental removal, hypotension, respiratory rate, mental status changes, nausea and vomiting, and pruritus. ResultsOver 4 yr, 4,227 patients (61% women, aged 68 ± 24 yr) were studied. Lumbar epidural catheters (n = 2,248 or 53.18%) were used more frequently than thoracic catheters (n = 1,979 or 46.82%) (P < 0.00001). Most of the patients were discharged to the surgical wards after the procedures (n = 3,001, 71%). Those patients (n = 1,226, 29%) admitted to the surgical intensive care unit, spent 1.2 ± 0.8 days. Epidural catheter failure occurred in 283 (6.3%) patients. Length of epidural analgesia therapy was 6.3 ± 2.6 days. There were three cases (0.07%) of respiratory depression which were treated with oxygen, intravenous naloxone, and by stopping the epidural infusion for 6 h. Hypotension occurred in 126 patients (3%). There were no apparent cases of catheter migration to either the subdural or subarachnoid space. Nausea or vomiting occurred in 929 patients (22%). Pruritus occurred in 930 patients (22%). ConclusionsContinuous epidural analgesia with 0.05–0.1% bupivacaine and 0.01% morphine is an effective method of postoperative analgesia with a low incidence of side effects, that can be safely administered on the surgical wards with no special monitoring equipment.

POSTOPERATIVE EPIDURAL OPIOID ANALGESIA: WHAT ARE THE CHOICES?

The administration of hydrophilic opioids via a continuous infusion results in selective spinal analgesia with a low incidence of side effects. Lipophilic opioids may also be associated with spinal effects. However, the doses required to produce postoperative analgesia also produce plasma concentrations within the MEAC. Thus, in clinical practice it may not be possible to limit epidural doses of lipophilic opioids to those associated with spinal analgesia. Regardless of the mechanism of action, epidural administration of lipophilic opioids may offer no clinical advantages over the IV route. Notwithstanding, epidural administration of small doses of lipophilic opioids in combination with local anesthetics may offer significant clinical advantages over systemic administration of opioids alone. Dose-ranging studies will be necessary to determine the ideal concentrations of opioids and local anesthetics, as well as the ratios of the two drugs to obtain optimal analgesia with minimal incidence of side effects.

Gabapentin for idiopathic trigeminal neuralgia: Report of two cases

Several case reports have suggested that the new anticonvulsant gabapentin is effective in the treatment of neuropathic pain condition~.l-~ We report our experience with two cases of trigeminal neuralgia treated with gabapentin after conventional treatment failed. Patient 1. This 88-year-old woman presented to her physician complaining of pain in the right maxilla above the lip. She described the pain as sharp and shooting, lasting 30 seconds or less. Her pain was triggered by lightly touching the cheek and by eating. The neurologic examination was within normal limits. Anterior rhinoscopy was unremarkable. Palpation of the right maxillary canine and premolar teeth elicited the maxillary pain. Consequently, the patient was referred to a dentist for evaluation. The dental examination and subsequent paranasal radiographs were negative. The patient was then referred to the pain clinic for further evaluation. The patient described her painful paroxysms as 10/10 on a pain intensity scale numbered 0 to 10 and labeled “no pain” a t 0 and “worst pain imaginable” at Physical examination confirmed allodynia at one discrete spot above the upper lip on the right side. Touching the trigger point produced paroxysmal pain of several seconds duration in the distribution of the infraorbital nerve. An anesthetic block of the nerve with 2% lidocaine was performed using an intraoral approach. The patient was unable to elicit her pain for the duration of the nerve block. A diagnosis of idiopathic trigeminal neuralgia was made and the patient was placed on baclofen 10 mg orally qid. She returned to the clinic 1 week later and reported that her painful paroxysms occurred with less frequency and were never more than 1/10 on the pain intensity scale. She was subsequently lost to follow-up until she returned to the pain clinic approximately 8 months later with 8/10 paroxysmal pain in the same location. She explained that she had discontinued taking baclofen after 2 months because of increasing dizziness. Although her dizziness subsided, her neuralgia gradually returned over a period of several weeks after she stopped taking her medication. Nevertheless, she was unwilling to restart baclofen and requested an alternative therapy. A course of gabapentin, 300 mg tid, was initiated. One week later, the patient returned to the pain clinic, reporting very few paroxysms, which never exceeded a pain intensity of 1/10 on the pain intensity scale. A follow-up telephone call to the patient 6 months later revealed that she had been pain-free since a few days after her last clinic visit and had not experienced any side effects. Patient 2. An 84-year-old woman presented to the pain clinic with a history of idiopathic second division trigeminal neuralgia of approximately 20 years duration. She reported that carbamazepine, 600 mg daily, had effectively controlled her pain until recently. Her neurologst prescribed baclofen, 40 mg daily, as a replacement, but the patient complained of confusion and anxiety while on the medication, so it was discontinued. Phenytoin was tried, but the patient developed a skin rash. She was referred to the pain clinic for evaluation of treatment alternatives. The patient rated the intensity of her paroxysmal pain a t 8/10 on the pain intensity scale. Physical examination revealed allodynia restricted to a small area of skin overlying the right zygomatic arch. Stimulation of the trigger resulted in pain in the distribution of the maxillary branch of the trigeminal nerve. Neurosurgical treatment alternatives were discussed, but the patient rejected those options. She did agree to try neurontin, 300 mg tid, on a trial basis. After 1 week, she returned to the pain clinic to report that the medication had abated her paroxysmal pain but for no more than 3 to 4 hours per dose. Her dosage was adjusted to 300 mg every 3 hours over the next several days, after which she no longer experienced paroxysms. Approximately 4 months later, the patient was still pain-free and had no side effects associated with a neurontin dosage of 2,400 mg daily. Discussion. We believe ours is the first reported use of gabapentin for trigeminal neuralgia. The apparent effectiveness of the drug in our patients is encouraging, but randomized studies comparing gabapentin to other medications such as carbamazepine is essential before causal inference regarding the relationship between gabapentin activity and symptom relief can be justified. Both patients could have experienced remission coincident with gabapentin therapy, although this is unlikely, especially for the second patient, whose pain relief appeared to be dose-dependent. The striking response of these patients to gabapentin is matched by the absence of side effects. Both patients had problems with side effects while on other medications. Side effects associated with gabapentin are dose-related for levels at 1,800 to 3,600 mg and are not as marked as with carbamezapine and phenytoin. Furthermore, idiosyncratic effects, such as hypersensitivity reactions, are ra1-e.5.~

Epidural Bupivacaine/Sufentanil Therapy for Postoperative Pain Control in Patients Tolerant to Opioid and Unresponsive to Epidural Bupivacaine/Morphine

BackgroundOpioids are thought to have equal analgesic effects when equivalent doses are used. However, sufentanil may achieve maximum effect while occupying fewer spinal opioid receptors (higher intrinsic efficacy). Therefore, sufentanil may be more effective than morphine when administered intraspinally in opioid-tolerant patients. MethodsThis study evaluated 20 chronic cancer pain patients who underwent abdominal surgery for tumor resection. All patients used large doses of morphine (> 250 mg/day-1) preoperatively for 3 months or longer. Intraoperatively, patients received combined general-epidural anesthesia with 0.5% bupivacaine and 0.02% morphine at 8 ml/h-1. Postoperative continuous epidural analgesia with 0.1% bupivacaine and 0.02% morphine at 5 ml/h-1 plus intravenous patient-controlled analgesia morphine (3 mg every 6 min) was given. Epidural infusions were increased every 30 min by 1 ml/h-1 to achieve a dynamic (during coughing) visual analog pain score (VAPS) of less than 5/10. If the desired VAPS was not achieved after 6 h or the epidural morphine infusion was increased to 2 mg/h-1, 50 μg of sufentanil in 10 ml of normal saline was given as an epidural bolus dose. The epidural infusion then was switched to 0.0002% sufentanil (2 μg/ml-1) and 0.1% bupivacaine (1 mg/ml-1) at 7 ml/h-1. Further titration to maintain a dynamic VAPS of less than 5/10 occurred every 4 h. ResultsMean preoperative daily oral morphine use was 380 ± 97 mg (range 290–490) for 4 ± 1 months. Before the switch to sufentanil, patients had received a mean maximum morphine dose of 8.8 ± 0.2 mg intraoperatively plus 9.0 ± 1.2 mg during 4.2 ± 0.3 h postoperatively (1.8 ± 0.4 mg/h-1), at which point VAPS ranged between 7–10/10. All patients experienced adequate analgesia within 1 h of starting sufentanil therapy. The mean sufentanil dose during the first 4 h of treatment was 17 ± 0.2 μg/h-1. At this time, VAPS ranged from 0–3/10. Satisfactory analgesia was achieved with sufentanil at a lower than a calculated equally potent dose of morphine (23 μg/h-1 vs. 17 μg/h-1, P < 0.01). Intravenous patient-controlled analgesia morphine requirements were also lower (7.8 mg/h-1 vs. 2.0 mg/h-1, P < 0.01). Length of morphine and sufentanil therapies were 5 ± 3 h and 10 ± 2 days, respectively. No patient experienced signs or symptoms of opioid withdrawal. ConclusionsThese results suggest that sufentanil can be used successfully in opioid-tolerant patients who do not experience adequate pain control in the early postoperative period despite a large dose of epidural morphine. Moreover, sufentanil should be considered an effective alternative therapy for postoperative pain control in chronic opioid users using high doses of oral opioids before surgical intervention.

Bowel function recovery after radical hysterectomies: thoracic epidural bupivacaine-morphine versus intravenous patient-controlled analgesia with morphine: a pilot study.

STUDY OBJECTIVE To determine if the use of continuous epidural bupivacaine-morphine in the perioperative period is associated with a significant decrease in the recovery time of postoperative ileus when compared with parenteral morphine administration. DESIGN Prospective (quality of analgesia) and retrospective (bowel function recovery), nonrandomized study. SETTING Inpatient gynecology-oncology patients at a university-affiliated tertiary cancer center hospital. PATIENTS 68 women who experienced uncomplicated radical hysterectomies for cancer. INTERVENTIONS Intraoperative epidural-general anesthesia or general anesthesia only was administered. Postoperative continuous epidural analgesia with bupivacaine-morphine and intravenous (IV) morphine via patient-controlled analgesia (PCA). Both forms of therapy were titrated to provide patients with a dynamic visual analog pain score of 5 or less on a 10-point scale throughout the study period. Patients were weaned from infusions when pain scores remained at less than 5 for 12 hours and no breakthrough medication was used. MEASUREMENTS AND MAIN RESULTS Rest and dynamic pain scores, time of first flatus, length of nasogastric therapy, time to solid food intake, daily and total morphine requirements and length of hospitalization were recorded. The epidural group required fewer days of nasogastric therapy (4 +/- 3 versus 8 +/- 2 days, p = 0,0001), tolerated solid foods sooner (6 +/- 2 versus 11 +/- 3 days, p < 0.0001), and had a shorter hospitalization time (10 +/- 3 versus 14 +/- 4 days, p = 0.0001) when compared with the PCA group. CONCLUSIONS The use of thoracic epidural bupivacaine-morphine results in a decrease in the duration of postoperative ileus, which was associated with earlier hospital discharge.

Strategies in Pain Management: New and Potential Indications for COX-2 Specific Inhibitors

The role of the coxibs in the management of osteoarthritis and rheumatoid arthritis has been widely discussed, but there are other potential applications for the coxibs that have received less attention. Here we consider the use of the coxibs in acute pain syndromes such as primary dysmenorrhea and the pain associated with dental extraction, as well as considering their application in chronic low back pain and cancer pain. Another area where the coxibs may prove particularly beneficial is in the management of post-surgical pain. Traditional post-surgical analgesia has involved the use of non-selective NSAIDs and opioids, but these agents can be associated with side effects such as post-operative bleeding, gastrointestinal problems, nausea, and constipation. Because the coxibs do not inhibit COX-1 dependent platelet aggregation like traditional NSAIDs, the risk of post-surgical bleeding is reduced. The careful application of coxibs as part of a multi-modal approach to pain management in the perioperative period can reduce the requirement for opioid medications and thus reduce the risk of post-operative complications such as ileus. In the future, coxibs are likely to play an important role in multi-modal perioperative analgesic regimens with the aim of reducing post-operative periods of convalescence.

Experience with gabapentin for neuropathic pain in the head and neck: report of ten cases.

Background and Objectives. Gabapentin is an oral antiepileptic agent with an unknown mechanism of action. Recent case reports have suggested that gabapentin may be effective in the treatment of a variety of neuropathic pain states. This report presents baseline and follow‐up data on ten patients who were treated with gabapentin when other pharmacologic interventions failed to relieve their neuropathic pain. Methods. Ten patients referred for treatment of unrelieved neuropathic pain in the head and neck region were included in this study. Baseline and follow‐up information included measures of pain intensity and pain quality. All of the patients were started on 300 mg gabapentin three times per day, though daily doses of up to 2400 mg were required for pain relief. Results. Eight of the ten patients had no neuropathic pain on follow‐up, whereas the remaining 2 patients reported only partial relief at follow‐up. None of the patients complained of side effects. Gabapentin was effective in alleviating steady burning pain as well as lancinating pain and allodynia. Conclusions. The results suggest that gabapentin may be effective in the management of some cases of neuropathic pain in the head and neck. However, controlled, double‐blind longitudinal studies are needed to evaluate this possibility.

Types and Epidemiology of Cancer-Related Neuropathic Pain: The Intersection of Cancer Pain and Neuropathic Pain

Neuropathic pain--pain resulting from a lesion, damage, or dysfunction of the somatosensory nervous system--can arise through several distinct etiologies ranging from toxicity, surgery, radiation, and trauma to congenital disorders. Neuropathic pain is widely recognized as a common consequence of cancer and results from administration of several common oncology drugs. It not only impacts quality of life, but it also impacts patient outcomes because of resulting treatment delays, dose reductions, and discontinuations. We estimate that the cost of the problem in the U.S. alone is approximately

Characteristics of Postradical Neck Pain Syndrome: A Report of 25 Cases

2.3 billion. Despite its widely recognized importance, there is a paucity of reliable information available regarding the incidence, prevalence of patient-and physician-reported severity, and time course of cancer-related neuropathic pain. To address this severe knowledge gap, we need new, high-quality, population-based studies of individual cancer pain syndromes and conditions. However, in order to gather this information, we also need substantial improvements in the specific classification of cancer-related neuropathic syndromes and better validated diagnostic tools that can help to elucidate the incidence, prevalence, severity, and potential economic impact of cancer-associated neuropathies.