Stefano Ischia

Three Posterior Percutaneous Celiac Plexus Block Techniques A Prospective, Randomized Study in 61 Patients with Pancreatic Cancer Pain

Variations and refinements of the classic retrocrural technique of neurolytic celiac plexus block (NCPB) for pancreatic cancer pain (PCP) have been proposed over the last 30 yr to improve success rates, avoid complications and enhance diagnostic accuracy. The aim of this prospective, randomized study was to assess the efficacy and morbidity of three posterior percutaneous NCPB techniques in 61 patients with PCP. The 61 patients were randomly allocated to three NCPB treatment groups: group 1 (20 patients, transaortic plexus block); group 2 (20 patients, classic retrocrural block); and group 3 (21 patients, bilateral chemical splanchnicectomy). The quality and quantity of pain were analyzed before and after NCPB. No statistically significant differences (P greater than 0.05) were found among the three techniques in terms of either immediate or up-to-death results. Operative mortality was nil with the three techniques and morbidity negligible. NCPB abolished celiac PCP in 70-80% of patients immediately after the block and in 60-75% until death. Because celiac pain was only a component of PCP in all patients, especially in those with a longer time course until death: 1) abolition of such pain did not ensure high percentages of complete pain relief (immediate pain relief in 40-52%; pain relief until death in 10-24%); 2) NCPB was effective in controlling PCP in a higher percentage of cases if performed early after pain onset, when the pain was still only or mainly of celiac type and responded well to nonsteroidal antiinflammatory drug therapy; and 3) the probability of patients remaining completely pain-free diminished with increased survival time.(ABSTRACT TRUNCATED AT 250 WORDS)

A new approach to the neurolytic block of the coeliac plexus : the transaortic technique

Abstract The present study critically examines the coeliac plexus block techniques hitherto adopted, pointing out the complications involved and stressing the seriousness of the neurological complications due to spread of the neurolytic agent to the sympathetic chain and the lumbar plexus. Contrast enhanced CT scans demonstrate the difficulties involved in confining the neurolytic agent to the anterior, peri‐aortic and precrural regions. The authors report their recent experience with coeliac plexus block by means of a single transaortic needle in 28 patients. In 12 of the patients, the GT scan revealed a spread of the neurolytic agent anterior and lateral to the aorta; on all occasions this spread was anterior to the medial crura of the diaphragm, sometimes extending laterally towards the costovertebral gutter along the ventral surface of the diaphragm. Pain relief was obtained in 93% of the cases and no complications were observed. The transaortic technique is simple, and a control lateral scan provides a characteristic image.

A double-blinded evaluation of propacetamol versus ketorolac in combination with patient-controlled analgesia morphine: analgesic efficacy and tolerability after gynecologic surgery.

We assessed the relative morphine consumption in a combined analgesic regimen (on-demand morphine plus the nonopioids propacetamol or ketorolac) after gynecologic surgery. Two hundred women randomly received two IV doses of propacetamol 2 g or ketorolac 30 mg in a double-blinded, double-dummy trial.

Ondansetron versus metoclopramide in the treatment of postoperative nausea and vomiting

In this prospective, randomized, double-blind study, we compared the efficacy and safety of ondansetron and metoclopramide in the treatment of postoperative nausea and vomiting (PONV). One hundred seventyfive patients with PONV during recovery from anesthesia for gynecological laparoscopy were treated intravenously with either ondansetron 4 mg (58 patients), metoclopramide 10 mg (57 patients), or placebo (60 patients). Early antiemetic efficacy (abolition of vomiting within 10 min and of nausea within 30 min from the administration of the study drugs with no further vomiting or nausea episodes during the first hour) was obtained in 54 of 58 patients (93.1%) in the ondansetron group, in 38 of 57 patients (66.7%) in the metoclopramide group, and in 21 of 60 patients (35%) in the placebo group (P < 0.001). This difference was still significant when controlling for age, body weight, history of motion sickness, previous PONV episodes, duration of anesthesia, and intraoperative fentanyl consumption using a logistic model. Early antiemetic efficacy was inversely related to the amount of fentanyl administered during anesthesia, regardless of treatment. According to the Kaplan-Meier method, the probability of remaining PONV-free for 48 h after a successful treatment was 0.59 (95% confidence interval 0.45-0.71) in the ondansetron group, 0.45 (0.29-0.60) in the metoclopramide group, and 0.33 (0.15-0.53) in the placebo group (P = 0.003). In conclusion, ondansetron 4 mg is more effective than metoclopramide 10 mg and placebo in the treatment of established PONV. (Anesth Analg 1997;85:395-9)

Results up to death in the treatment of persistent cervico-thoracic (Pancoast) and thoracic malignant pain by unilateral percutaneous cervical cordotomy

&NA; The authors analyse the results up to death in 103 followed‐up patients undergoing unilateral percutaneous cervical cordotomy for persistent cervico‐thoracic malignant pain (45 cases of Pancoast syndrome and 58 cases of thoracic pain associated with lung cancer or metastases). On the basis of epidemiological data, relationships emerge between onset of pain, stage of cancer, patient survival and lasting efficacy of pain relief. Twenty (44%) of 45 patients with Pancoast syndrome were pain‐free up to death as a result of cordotomy alone, while only 13/58 patients (22%) with thoracic pain were pain‐free as a result of cordotomy alone owing to the very high incidence of mirror pain in this group of patients (42/58 patients, 72%) compared to those with Pancoast syndrome (14/45 patients, 31%). The type and intensity of mirror pain, however, were of such a nature in both groups as to be amenable to control with analgesic drugs. In both groups of patients, there was a low incidence of the causes of post‐cordotomy pain recurrence contralateral to the lesion, i.e., deafferentation pain, fading of analgesia and pain above the levels up to which deep pin‐prick analgesia had been obtained. Cordotomy alone or, as necessary, in conjunction with analgesic drugs afforded complete pain control in 34/45 patients (75%) with Pancoast syndrome and in 50/58 patients (86%) with thoracic pain. These data provide evidence of the unique usefulness of the procedure in controlling otherwise intractable persistent cervicothoracic malignant pain, when the technique is correctly performed.

Subarachnoid neurolytic block (L5-S1) and unilateral percutaneous cervical cordotomy in the treatment of pain secondary to pelvic malignant disease.

&NA; The present study deals with the immediate and long‐term results of subarachnoid neurolytic block (L5−S1) with 7.5%, 10% and 15% concentrations of phenol in glycerine and/or unilateral percutaneous cervical cordotomy in 73 patients (follow‐up in 56 patients) suffering from perineal, perineopelvisacral or pelvisacral pain secondary to malignant diseases of the pelvic cavity. Subarachnoid neurolytic block (L5−S1) produced satisfactory, long‐lasting relief of perineal pain when the higher concentrations of phenol (10 and 15%) were used. The only sequela reported was urinary retention. Percutaneous cervical cordotomy used for the treatment of pelvisacral or predominantly unilateral perineal pain gave complete pain relief until death in 76.7% of patients, either alone (36.7%) or in conjunction with pharmacological therapy (40%). Analysis of the data enabled us to establish the respective indications for the two procedures and to identify those cases in which their use may be complementary.

Retrogasserian glycerol injection: a retrospective study of 112 patients.

From 1984 to 1989. 112 patients with typical drug-refractory trigeminal neuralgia were treated by retrogasserian glycerol injection. The present study assesses results and complications after a mean follow-up period of 3.5 years (range 0.1–5.5 years). One hundred and three of 112 patients (91.9%) showed complete pain relief 1 month postoperatively, and at the end of follow-up 80 patients (71.4%) were still enjoying complete pain relief (recurrence rate 20.5%). Abnormal facial sensations were noted in 49 patients, the most common complication being mild hypoesthesia (32% of patients), while paresthesia occurred in 19% of cases and dysesthesia in 3%. The corneal reflex was absent in 3% of patients and reduced in 5%. None of the patients developed anesthesia dolorosa, permanent masseter weakness, neuroparalytic keratitis, or diplopia.

Percutaneous controlled thermocoagulation in the treatment of trigeminal neuralgia.

This study reviews the results and complications of 162 percutaneous thermocoagulations of the gasserian ganglion in 124 patients with typical idiopathic trigeminal neuralgia. The mean duration of follow-up observation was 3.7 years (range. 1–6 years). One hundred eighteen of 124 patients continued to show complete pain relief I month after the operation. and at the end of follow-up observation, 83 of 124 patients (67%) continued to enjoy complete pain relief (recurrence rate, 28.2%). Anesthesia dolorosa occurred in 3% of cases, dysesthesia in, and paresthesia in l7%; neuroparalytic keratitis with permanent reduction of visual acuity was observed in 2% of cases, permanent diplopia in l%, permanent hearing deficit in 3%, and permanent impairment of mastication in 3%. We compare thermocoagulation with other surgical procedures (microvascular decompression, glycerol injection, and percutaneous decompression) used in the treatment of trigeminal neuralgia.

Functional plasticity in the human primary somatosensory cortex following acute lesion of the anterior lateral spinal cord: neurophysiological evidence of short-term cross-modal plasticity.

&NA; The primary somatosensory cortex (S1) in adult animals and humans is capable of rapid modification after deafferentation. These plastic changes may account for a loss of tonic control by nociceptive inputs over inhibitory mechanisms within structures of the dorsal column‐medial lemniscal system. Most studies, however, have been performed under conditions where deafferentation of C and A&dgr; fibres coexists with large‐diameter fibres deafferentation. In this study the effect of the acute lesion of one ascending anterior lateral column on neuronal activity within the dorsal column‐medial lemniscal system was assessed by recording somatosensory evoked potentials (SEPs) in seven patients who underwent unilateral percutaneous cervical cordotomy (PCC) as treatment for drug‐resistant malignant pain. Spinal, brainstem and cortical SEPs were recorded 2 h before and 3 h after PCC by stimulating the posterior tibial nerve at both ankles. Amplitudes of cortical potentials obtained by stimulation of the leg contralateral to PCC were significantly increased after PCC. No significant changes in spinal or brainstem potentials were observed. PCC did not affect SEP components obtained by stimulation of the leg ipsilateral to PCC. Our results suggest that nociceptive deafferentation may induce a rapid modulation of cortical neuronal activity along the lemniscal pathway, thus providing the first evidence in humans of short‐term cortical plasticity across the spinothalamic and lemniscal systems.

Radiofrequency treatment of cancer pain.

An accurate analysis of the pain experienced by the patient is now the sine qua non for an accurate pain therapy. The type of pain (somatic, visceral, neurogenic), the temporal pattern (continuous or incident pain), the intensity and the site of pain, and the site and the evolution of the painful lesions constitute the basis of the therapeutic analgesic approach in cancer patients. Moreover, aspects which should always be borne in mind are the patient survival curves, the time from onset of pain, the point at which pain fails to respond to nonsteroidal anti-inflammatory drugs and requires opioid treatment, and the likely duration of the efficacy of the treatment. In the light of these very basic considerations, it is clear that the mainstay of cancer pain treatment is the pharmacological therapy. 1 Cancer related pain can be adequately treated in most patients using relatively simple methods such as the regular administration of non opioid or opioid analgesics. 2 The remaining patients, especially those with neurogenic or incident-type pain, are less responsive to these methods and may require more aggressive approaches, such as neuroinvasive or neuroablative procedures. 3