W. W. A. Zuurmond

The treatment of complex regional pain syndrome type I with free radical scavengers: a randomized controlled study

&NA; To compare the effects of two free radical scavengers, dimethylsulfoxide 50% (DMSO) and N‐acetylcysteine (NAC), for treatment of complex regional pain syndrome I (CRPS I), a randomized, double‐dummy controlled, double‐blind trial was conducted. Two outpatient clinics of two university hospitals in The Netherlands participated in the study and 146 patients, were included over a period of 24 months. Patients were randomized into two treatment groups, one was instructed to apply DMSO 50% five times daily to the affected extremity, the second was treated with NAC 600 mg effervescent tablets three times daily, both combined with placebo. Interventions were accompanied by pain medication, occupational therapy for upper extremity CRPS I and physical therapy for lower extremity CRPS I in specific circumstances. Treatment was given for 17 weeks, with a possibility to continue or switch medication after this period, up to 1 year following the onset of treatment. An impairment level sum score was the primary outcome measure. Upper and lower extremity skills and functions, and general health status were also evaluated. Overall, no significant differences were found between NAC and DMSO after 17 and 52 weeks on impairment level and general health status. Significant differences were found for subscores of lower extremity function, in favor of DMSO‐treatment. Subgroup analysis showed more favorable results for DMSO for warm CRPS I and significantly better performance of NAC for patients with a cold CRPS I. Results tended to be negatively influenced if the duration of the complaint was longer. Treatment with DMSO and NAC are generally equally effective in treatment of CRPS I. Strong indications exist for differences in effects for subgroups of patients with warm or cold CRPS I: for warm CRPS I, DMSO‐treatment appears more favorable, while for cold CRPS I, NAC‐treatment appears to be more effective.

Treatment of acute reflex sympathetic dystrophy with DMSO 50% in a fatty cream

Acute Reflex Sympathetic Dystrophy (acute RSD) was defined using a reproducible classification. Elevated temperature of the affected extremity (“calor”), measured by the dorsal side of the observers hand and mentioned by the patient, pain (“dolor”) measured by the Visual Analogue Scale (VAS), redness (“rubor”), edema (“tumor”) and limited active range of motion (“functio laesa”), all contributed to the classification system. Patients scoring 4 or 5 positive symptoms were considered to have acute RSD.

A comparison of the incidence of the oculocardiac and oculorespiratory reflexes during sevoflurane or halothane anesthesia for strabismus surgery in children.

UNLABELLEDnWe examined changes in the cardiorespiratory system of small children during surgical correction of strabismus with a laryngeal mask airway and spontaneous respiration with sevoflurane or halothane inhaled anesthesia. Fifty-one children, 1-7 yr old, having outpatient strabismus correction were randomized to sevoflurane (S) or halothane (H) in 66% nitrous oxide at 1.3 minimum alveolar concentration. Children breathed spontaneously through a laryngeal mask airway and were not pretreated with anticholinergics. The oculocardiac reflex (OCR), defined as a 20% decrease in heart rate (HR) from baseline, dysrhythmias, or sinoatrial arrest concomitant with ocular muscle traction occurred less frequently with sevoflurane than with halothane (S 38%, H79%, P = 0.009). The baseline HR was higher with sevoflurane (S 114 +/- 13 bpm, H 101 +/- 15 bpm, P = 0.002). The lowest HR occurred with halothane (S 95 +/- 22 bpm, H 73 +/- 19 bpm, P = 0.001). The incidence of dysrhythmias was higher in the halothane group (S 4%, H 42%, P = 0.004). Reductions in minute ventilation and PETCO(2) accompanied OCRs. Airway irritability was present with halothane only (S 0, H 3). Eleven children, of whom the majority had received halothane, required measures to correct SpO(2) < 95% or PETCO(2) > 60 mm Hg during maintenance anesthesia (S 11%, H 32%). Sevoflurane may be a more suitable anesthetic than halothane for operations involving traction on the ocular muscles with spontaneous respiration in children because of reduced incidence of OCR, airway irritability, and ventilatory disturbances.nnnIMPLICATIONSnSome children experience a sudden slowing of the heart and impaired breathing when the surgeon pulls on the eye muscles during squint operations under anesthesia. Sevoflurane, a recently developed anesthetic vapor, may reduce this problem when compared with the established vapor halothane.

Neurohistopathological findings after continuous intrathecal administration of morphine or a morphine/ bupivacaine mixture in cancer pain patients

Background: As the number of terminal cancer patients receiving continuous intrathecalinfusion of opioids and local anesthetics for relief of pain increases, we decided to investigate the post‐mortem findings of the spinal cord, meninges and nerve roots of patients after continuous intrathecal administration of morphine and combined with bupivacaine.

Interrater reliability of diagnosing complex regional pain syndrome type I

Background:u2003 Diagnosis of complex regional pain syndrome type I (CRPS I) is based on clinical observation of symptoms. As little information is available on the reliability of CRPS I diagnosis, we evaluated the agreement between therapists with regard to the presence and severity of CRPS I and its symptoms.

Compliance in administration of prescribed analgesics

In this noninterventional study, the implementation of ‘modern’ pain management in clinical practice was investigated by recording the regular prescription, administration and efficacy of analgesic drugs. This resulted in a reproducible and superficial quality control design for hospitals. One hundred and fifty surgical patients were followed during 5 days postoperatively. For every patient, pain, mood and sedation were measured using visual analogue and verbal descriptive scores; the prescription of analgesics at set times and administered doses of analgesics were also recorded. Only paracodeine and naproxen were administered regularly as prescribed, unlike paracetamol and morphine. The prescribed daily dose of morphine was only received by 4.2% of all patients. Although the postoperative pain treatment pathway was considered to be improved after better education and communication, in fact the opposite was found. This is probably caused by traditional thinking, lack of control and time pressure on the hospital staff and the subservient attitude of the patient.

Effects of epidural and spinal anesthesia on blood rheology

This study was designed to compare the influence of epidural and spinal anesthesia on blood viscosity. We studied 22 patients, ASA classification I, who underwent elective knee or ankle arthroscopy and received epidural (n = 11) or spinal (n = 11) anesthesia with plain bupivacaine, and 10 control volunteers, who did not undergo surgery or receive anesthesia. There were significant decreases in hematocrit, plasma viscosity, and whole-blood viscosity at high (70 s-1), medium (0.5 s-1), and low (0.05 s-1) shear rates. The magnitude of changes was similar in all groups but occurred earlier in the control group (between 10 and 30 min) and after spinal administration (between 10 and 30 min) rather than after epidural administration (between 30 and 60 min) of bupivacaine. Only spinal anesthesia was associated with a decrease in erythrocyte deformability. The observed rheologic changes are attributed to hemodilution from the intravenous administration of fluids and the redistribution of fluid in the intravascular and extravascular compartments after sympathetic blockade and to postural changes rather than the effect of bupivacaine on blood elements.

Comprehensive distribution of substance P and calcitonin gene-related peptide in human sacroiliac joint: 14AP12-3

Background and Goal of Study: Primary sacroiliac (SI) joint pain can be confirmed by complete pain-relief after an intra-articular infiltration with local anaesthetics [1]. However, the efficacy of this intervention is difficult to explain, due to insufficient knowledge regarding the presence of nociceptive nerves in the SI joint. Employing immunohistochemistry for detection of nociceptors, such as antigen labelling of Substance P and Calcitonin Gene-Related Peptide (CGRP), should give a new insight in the distribution of nociceptors in the SI joint, and could provide a better understanding of the efficacy of invasive treatments for SI joint. Materials and Methods: The SI joint ventral capsular and interosseous ligament, bone and cartilage tissue samples of nine human cadavers (6 male and 3 female, aged 60-91), were used to trace nerve fibres with primary antisera against CGRP (Chemicon) and substance P (Chemicon). Free-floating sections were stained with the avidin-biotin method. Positive and negative control sections of a human spinal cord and SI joint tissue respectively, have been stained simultaneously. Results and Discussion: Microscopic analysis of ligaments, and cartilage’s sections showed CGRP and Substance P-immunoreactivity. Wavy formed thick bundles, classified as myelinated fibres (Aδ-type), were seen in the dense and loose ligamentous tissue. Single, beads shaped and occasionally ramified nerve fibres, classified as unmyelinated (C-type) were more frequently seen in the dense connective tissue of ligaments. Cartilage showed immunoreactivity for both antisera in the peripheral parts. Although bone tissue was hardly immunopositive, in a few sections, well-stained unmyelinated fibres were seen. The posterior column of spinal cord stained positive, and negative control sections showed no staining. Currently, the diagnostic infiltration of the SI joint involves a careful analgesia of the SI joint synovial cavity, avoiding peri-synovial ligaments. However, besides the synovial part of the SI joint, consisting of the ventral capsular ligament and cartilage, the peri-synovial, interosseous ligament contains nociceptive fibres. Consequently, both intraand peri-synovial structures could be involved in pain sensations stemming from the SI joint. Conclusion(s): Based on the presence of nociceptors in the SI joint, diagnostic infiltrations of the SI joint should target the synovial cavity and also well innervated ligaments adjacent to the SI joint cavity. References: 1 Schwarzer AC, et al. Spine 1995; 20(1): 31–37. 14AP12-4 Subanaesthetic concentrations of propofol decrease amplitudes of contact heat evoked potentials (CHEPs)

Wat is de behandeling van perineurale fibrose na een HNP-operatie?

Na HNP(hernia nuclei pulposi)-operaties wordt het beoogde resultaat - het verdwijnen van de pijn zonder functieverlies - niet altijd bereikt.

Achtergronden bij het voorschrijven van opioïden bij chronische pijn

Zowel het medisch als niet-medisch gebruik van opium is al duizenden jaren bekend. Reeds 4000 jaar voor Christus waren er in Mesopotamie voorschriften voor de bereiding en het veilig gebruik ervan, hoewel de kwaliteit wisselend was. Het woord ‘opium’ is afgeleid van het Griekse woord όπος dat sap betekent; het sap afkomstig uit de onrijpe bol van de papaver somniferum, de slaapdragende papaver.