[Ten years of therapy resistant intercostal neuralgia-suspected postherpetic neuralgia following herpes zoster sine herpete.]. / Zehn Jahre therapieresistente Interkostalneuralgie-Verdacht auf Postzosterneuralgie nach Herpes zoster sine herpete : Ein Fallbericht.

We report the case of a 65 year old man who has been suffering from segmental back pain for 10 years. The diagnosis postherpetic neuralgia following herpes zoster sine herpete was fixed 9 years after the beginning of pain. All treatments prior to ours were ineffective. Acupuncture and the use of homeopathic drugs led to success at last.

Coeliac plexus block with bupivacaine reduces intestinal dysfunction in neurosurgical ICU patients.

Coeliac plexus block, an established method of treatment for pain associated with pancreatitis and cancer, was used in neurosurgical patients with gastrointestinal dysfunction. The study was performed in 16 patients whose gastric reflux volume exceeded 600 ml per day for 3 consecutive days. Patients were allocated to a block group (n = 8) or a control group (n = 8). Coeliac plexus block was accomplished with a modified Moore technique using 50 ml bupivacaine 0.25%. In the block group, gastric reflux volumes for 3 days preceding coeliac plexus block and 3 consecutive days following coeliac plexus block were analysed. In the control group, gastric reflux volumes were observed over a period of 6 days. Mean (SEM) gastric reflux volume decreased significantly following coeliac plexus block from 770 (50) ml to 60 (30) ml (p < 0.01). In the control group, gastric reflux remained unchanged over the corresponding periods (730 (60) ml c.f. 670 (50) ml). The response of gastric reflux volume to coeliac plexus block suggests that the mechanism is related to inhibition of sympathetic activity in patients whose sympathetic drive is increased due to the underlying neurological disease, and possibly due to sedation withdrawal symptoms.

[Restricted adenohyphophyseal function after neuroadenolysis for severe pain due to bony metastases.]. / Funktionseinschränkungen der adenohypophyse bei der neuroadenolyse zur behandlung schwerster schmerzzustände bei multiplen Knochenmetastasen.

Neuroadenolysis of the pituitary (NALP) is an efficient measure for treatment of severe pain in patients with bony metastases. It is especially recommended for primary carcinomas of the breast or prostate. The procedure, transsphenoidal puncture of the pituitary under radiographic control and instillation of up to 2 ml 95% alcohol, is simple. The pathomechanism of the analgesic effect is still unknown. Extensive determinations of the anterior pituitary hormones LH, FSH, HPRL, ACTH, and HGH were done before and up to 14 days after NALP in six consecutive patients receiving this treatment. The pituitary was stimulated with releasing hormones LHRH (100 mug) and TRH (200 mug) before and 3 days after NALP. Determinations of hormone parameters were done 25 and 60 min after injection. The results showed that hormone production by the adenohypophysis becomes unevenly suppressed. The following results are significant (P<0.05): (1) LH: poststimulation values are extremely suppressed; (2) FSH: basal values decrease; (3) ACTH: basal values decrease after the 6th day. The antalgic effect of NALP is independent of its hormonal consequences. NALP produces hormonal suppressions of various degrees, and is not a "chemical hypophysectomy".

[Cancer pain.]. / Der karzinomschmerz.

There is no uniform etiology of cancer pain. It is essential to understand the pathogenesis of pain as far as possible before a therapeutic modality can be conceived. The anatomical relation of the painproducing lesion to the site of pain perception should be clear (local, projected and referred pain). The origin of cancer-induced pain is classified as follows: malignant, mostly metastatic bone lesions, compression and infiltration of peripheral nerval structures, expansion in limited spaces, distension of liver, obstruction of blood vessels, obstruction and distension of the intestine, other abdominal or thoracic processes that produce visceral pain, infiltration and ulceration of soft tissue in sensitive areas. There are also pain syndromes caused by cancer therapy: post-operative, post-radiation and post-chemotherapy pain. Attention is drawn to the difficulties of pain recording and pain measurement. Psychological and social aspects of cancer patients emphasize the importance of a sufficient pain therapy which is divided into non-drug therapy and drug therapy. Various specialities can contribute therapeutic modalities for the treatment of cancer pain. Surgery, orthopedics, neurosurgery, radiotherapy and others have their specific methods. Anesthesiological methods are mentioned in more detail. The celiac plexus block with alcohol as a simple, safe and efficious procedure should become available to any patient with upper abdominal visceral tumor pain. Attention is drawn to the hospice movement, which is more or less unknown in central Europe. Psychological aspects of cancer patient care are considered. Drug therapy is of greater importance than all other methods. That is the domain of the general practitioner. Commonly used analgesic antipyretics and NSAIDs are listed in Table 1. The principles of opioid therapy follow. Due consideration is given to neuroleptics and antidepressive drugs. Information about hormones (corticosteroids, calcitonin a. o.) in cancer pain therapy conclude this survey. Enormous differences of morphine use (Austria: 0.66 kg vs Denmark 16.59 kg per million people per year) indicate that there is a great demand for further professional education in this field.

The esophageal tracheal combitube: preliminary results with a new airway for CPR.

We developed the esophageal tracheal combitube (ETC), a plastic twin-lumen tube, one lumen resembling an esophageal obturator airway (EOA), the other resembling an endotracheal airway (ETA). Ventilation is possible after either esophageal or tracheal placement of the ETC. A specially designed pharyngeal balloon replaces the mask of the EOA and provides sufficient seal, preventing the escape of air through the mouth and nose. The effectiveness of ventilation with the ETC in esophageal position was tested in a crossover study comparing ETC and ETA during routine operations in 31 patients. Blood gas measurements showed a significantly higher (P less than .001) mean arterial oxygen tension during ventilation with the ETC. The reason for this is not yet clear. Preliminary investigations during CPR in 21 arrest patients indicate that the ETC is as effective as the ETA.

[Intrathecal alcohol neurolysis of the lower sacral roots in inoperable rectal cancer]. / Die intrathekale Alkoholneurolyse der unteren sakralen Wurzeln beim inoperablen Rektumkarzinom.

Intrathecal neurolytic blocks are performed with either 95% alcohol or with 6-8% phenol in glycerin. Alcohol is hypobaric and phenol hyperbaric compared with the cerebrospinal fluid; positioning of the patient must therefore be done accordingly. This is a report about 67 consecutive neurolytic alcohol blocks of the lower sacral roots. Although lumbar puncture is done at the lowest possible level at L5-S1, the block only affects the roots from S3 or S4 downwards. The detailed anatomy of the caudal dural sack reveals why S1 and S2 are not affected. S1 and S2 contribute to the lumbosacral plexus and are important for the innervation of the lower extremities. However in patients with very low CSF pressure, S2 and S1 might become damaged. This is the most important result of this series. To avoid an unexpected extension of the block in patients with very low CSF pressure, we now recommend that synthetic CSF be instilled prior to alcohol. The results were unsatisfactory in patients with perineal pain and pain in the lower extremities as well. In these cases S2 or S2 + S1 are already affected by the tumor. One should employ other therapeutic procedures (e.g., epidural morphine) for these patients. After careful selection of patients, alcohol neurolysis of the lower sacral roots is a useful procedure.

Local anesthetics in the treatment of cancer pain.

Local anesthetics are in general not suitable for the treatment of patients with severe cancer pain. Local blocks are useful for diagnostic and prognostic purposes. As their action is instantaneous and reliable, they can be used to relieve pain for a limited period of time. The use of local anesthetics may yield long-lasting relief in some specific pain syndromes, such as tumor-related reflex dystrophies, in painful muscle spasms, and trigger points due to tumor-affected vertebrae. In addition, local anesthetics may have a generally beneficial effect in the restless, cachectic, and aged patient.

[Endobronchial ventilation in transthoracic endoscopic sympathectomy]. / Endobronchiale Beatmung bei der transthorakalen endoskopischen Sympathektomie.

Thoracic endoscopic sympathectomy (TES) is a short surgical procedure used for the treatment of axillary and palmar hyperhydrosis. It involves creation of tension pneumothorax, lateral and head-up position and necessitates minimal lung excursions during breathing, so that a special anaesthetic technique is required. In six otherwise healthy patients an endobronchial double lumen tube was used for one-lung ventilation with intravenous anaesthesia and muscular relaxation, and circulatory response, FE CO2 and blood gases were monitored in order to compare this anaesthetic technique to conventional endotracheal intubation in previous patients. Some difficulties with inserting and securing the double lumen tube were encountered, but were far outweighed by the advantages of stable circulation, physiological blood gas values and easy access to a calm surgical field.

[Choice of anaesthesia technique in thoracic endoscopic sympathectomy (author's transl)]. / Zur Wahl des Anaesthesieverfahrens bei der transthorakalen endoskopischen Sympathektomie.

Thoracic endoscopic sympathectomy (TES) is a short surgical procedure used for the treatment of palmar and axillary hyperhidrosis. It involves pneumothorax, the lateral and head up position, and necessitates minimal chest excursions during breathing, so that a special type of anaesthesia is required. In 13 patients two different methods were compared and blood gas analysis as well as circulatory parameters were studied. We therefore propose an anaesthetic method using controlled mechanical ventilation; relaxation; intravenous anaesthesia; at least 1 1 fluid replacement; and careful monitoring.

[A case of pneumoperitoneum during induction of anaesthesia (author's transl)]. / Massiver Pneumaskos nach versehentlicher Druckerhöhung im Beatmungssystem.

A patient with a large sliding hiatus hernia developed left side pneumothorax and pneumoperitoneum following high inspiratory pressure.