Efficacy of paraspinal anesthetic block in patients with chronic pelvic pain refractory to drug therapy: a randomized clinical trial / Eficácia do bloqueio anestésico paraespinhal em pacientes com dor pélvica crônica refratária a terapia medicamentosa: um ensaio clínico randomizado

PURPOSE: To determine whether paraspinal block reduces pain scores compared to placebo in women with chronic pelvic pain refractory to drug therapy. METHODS: Subjects with chronic pelvic pain due to benign conditions and refractory to drug therapy were invited to participate in a randomized, double blind, superiority trial at a tertiary reference center. Subjects were randomly allocated to receive paraspinal anesthetic block with 1% lidocaine without epinephrine or placebo (control). Lidocaine was injected along the spinal process of the painful segment in the supra- and interspinal ligaments using a 25G X 2" needle. Placebo consisted of introduction of the needle in the same segment without injecting any substance. The main outcome measured was the pain score based on a visual analog scale at T0 (baseline), T1 (within 15 min after the procedure) and T2 (one week after the procedure). Data were statistically analyzed by ANOVA and the 95% confidence interval (95%CI). RESULTS: Mean age was similar for both groups, i.e., 51.2 (paraspinal anesthetic block) and 51.8 years (control). A blind examiner measured the degree of pain according to the visual analog scale from 0 (no pain) to 10 (worst pain imaginable). Based on the visual analog scale, the mean pain scores of the paraspinal anesthetic block group at T0, T1 and T2 were 5.50 (SD=2.92; 95%CI 3.84-7.15), 2.72 (SD=2.10; 95%CI 1.53-3.90), and 4.36 (SD=2.37; 95%CI 1.89-6.82), respectively. The difference between T0 and T1 was statistically significant, with p=0.03. CONCLUSIONS: Paraspinal anesthetic block had a small effect on visual analog scale pain score immediately after the injections, but no sustained benefit after one week. Further studies are needed to determine the efficacy of paraspinal anesthetic block with different lidocaine doses for the treatment of visceral pain of other causes. .

OBJETIVO: Avaliar se o bloqueio paraespinhal reduz os escores de dor quando comparado com placebo em mulheres com dor pélvica crônica refratária a terapia medicamentosa. MÉTODOS: As pacientes com dor pélvica crônica de origem benigna que eram refratárias a terapia medicamentosa foram convidadas a participar nesse estudo de superioridade, randomizado, duplo-cego, em um centro de referência terciário. As pacientes foram alocadas randomicamente para receber o bloqueio anestésico paraespinhal com lidocaína 1% sem epinefrina ou placebo (controle). A lidocaína foi injetada ao longo do processo espinhal do segmento doloroso, nos ligamentos supra e interespinhal, usando uma agulha de 25G X 2". O placebo consistia na introdução da agulha no mesmo segmento sem injetar qualquer substância. O desfecho principal foi a medida dos escores de dor, baseado numa escala análogo visual nos tempos T0 (basal), T1 (dentro de 15 minutos depois do procedimento) e T2 (uma semana depois do procedimento). A análise estatística realizada utilizou ANOVA e o intervalo de confiança de 95% (IC95%). RESULTADOS: A média de idade das pacientes foi similar: 51,2 (bloqueio anestésico paraespinhal) e 51,8 anos (controle). Um examinador, cegado quando ao tratamento, mediu o grau de dor de acordo com a escala análogo visual de 0 (sem dor) a 10 (pior dor imaginável). De acordo com a escala análogo visual, a média dos escores para o grupo bloqueio anestésico paraespinhal em T0, T1 e T2 foi 5,50 (DP=2,92; IC95% 3,84-7,90), 2,72 (DP=2,10; IC95% 1,53-3,90) e 4,36 (DP=2,37; IC95% 1,89-6,82), respectivamente. A diferença entre T0 e T1 foi estatisticamente significativano grupo bloqueio anestésico paraespinhal, com p=0,03. CONCLUSÕES: O bloqueio anestésico paraespinhal tem um pequeno efeito na redução da dor(escala análogo visual) imediatamente após a injeção, mas esse benefício não permanece após uma semana. Outros estudos são necessário para avaliar a eficácia do bloqueio anestésico ...

Effectiveness and complications of [153]Sm-EDTMP in palliative treatment of diffuse skeletal metastases

The aim of the present study was to evaluate the efficacy and safety profile of bone palliative therapy following administration of [153]Sm-EDTMP in patients with intractable metastatic bone pain. Sixteen patients [9 male, 7 female] aged 29-80 years [57.3 +/- 16.7 years] with severe metastasis-related bone pain resistant to analgesic medications were enrolled in the study. All patients having multiple bone metastases, positive bone scans, and estimated life expectancy of more than 2-3 months were entered the study. All patients received intravenous injection of 1.5 mCi [56 MBq]/kg of [153]Sm-EDTMP. Four subscales for the intensity of pain were recorded: one as the present pain score [PPS] and the other three as maximum pain score [Max PS], minimum pain score [Min PS] and average pain score [APS] over the last 24 hours. Also the mean value of these 4 subscales was calculated as the mean total pain score [MTPS]. The pain mental interference [PMI] was also assessed in 9 separate. Seven patients with breast cancer [43.75%], seven with prostate cancer [43.75%], one with papillary thyroid carcinoma [6.25%] and one with malignant paraganglioma [6.25%] were included in the study. A significant response to therapy, i.e. 2-point reduction in pain score and/or remarkable reduction [>/=25%] in the equivalent narcotic dose, was observed in 11 out of 16 patients [68.7%] by the 2nd week and in 12 patients [75%] by the 8[th] week. Regarding the palliative response to treatment and equivalent narcotic dose reduction, no significant difference between two major types of underlying malignancies [breast and prostate cancer] was found. There was no significant difference regarding response to therapy between two genders and among different age groups. The severity of bone marrow suppression was graded

Os efeitos da estimulação magnética transcraniana repetitiva (EMTr) aplicada sobre o córtex motor de pacientes com síndrome complexa de dor regional / The effects of repetitive transcranial magnetic stimulation (r-TMS) over the motor cortex on complex regional pain syndrome patients

Introdução e objetivos: Estudos recentes sugerem que a estimulação magnética transcraniana repetitiva (EMTr) aplicada sobre o córtex motor é eficaz no tratamento analgésico de doentes com dor crônica. O objetivo deste estudo foi avaliar os efeitos da aplicação da EMTr sobre o córtex motor, utilizada como co-intervenção terapêutica no tratamento de pacientes com síndrome complexa de dor regional (SCDR) refratária aos tratamentos convencionais. Métodos: Vinte e três doentes com SCDR na mão foram distribuídos aleatoriamente em dois grupos de tratamentos para receberem o tratamento padrão (analgésicos, medicações adjuvantes e terapia física) associado a dez sessões diárias e consecutivas de EMTr rápida ou estimulação magnética placebo (EMTp), aplicadas sobre a região correspondente ao córtex motor da mão acometida. Os grupos foram comparados em relação aos aspectos epidemiológicos, apresentação clínica da doença, intensidade da dor, alterações do humor, qualidade de vida e função do membro acometido até noventa dias após a conclusão do tratamento, utilizando-se de entrevistas estruturadas, da escala visual analógicas de dor (EVA), do questionário de dor de McGuill (QM), do questionário PIQ-6 (Pain Inpact Questionnaire), do questionário DASH (Disabilities of Arm, Shoulder and Hand), do questionário SF-36 e dos questionários Hamilton para ansiedade e depressão. Resultados: Ocorreu redução significativa dos escores da EVA no grupo tratado com EMTr durante o tratamento, que durou até o sétimo dia após o encerramento das aplicações (p<0.05). A redução média da EVA no grupo tratado com EMTr foi de 4.65 cm (redução de 50.9% dos escores de dor), estatisticamente superior ao grupo tratado com placebo, no qual a redução foi de 2.18 cm (redução de 24.7%). A diminuição dos escores de dor na EVA foi independente de outras variáveis em estudo, exceto pela melhora no domínio sete do questionário SF-36 (aspectos emocionais). Conclusões: A aplicação de EMTr rápida sobre a...

Background and aims: There are many evidences that repetitive transcranial magnetic stimulation (r-TMS) of the motor cortex is effective in relief of chronic pain. The aim of this study was to evaluate the analgesic effects of r-TMS in patients with refractory CRPS. Methods: Twenty-three patients presenting with complex regional pain syndrome (CRPS) of the hand were randomly selected and treated with conventional treatment (analgesics, adjuvant medications and physical therapy) plus sham-TMS or r-TMS to the motor cortex opposite the affected limb: 100% MT, 10 hz, 10 s trains, 25 trains daily, 10 daily sessions. The Visual Analogical Scale of Pain (VAS), McGill Questionnaire, Pain Impact Questionnaire (PIQ-6), Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH), Hamilton Depression and Anxiety Rating Scales and SF-36 Questionnaire were the instruments used for the evaluation. The groups were comparable with regards to socio-demographics, mood and pain intensity. Evaluations were performed before, during TMS treatment and up to three months the end of the treatment. Results: There was a significant reduction in VAS scores favoring the r-TMS group up to the seventh follow-up day (p <0.05). The mean reduction in the rTMS group was of 4.65 cm (fall of 50.9%) against 2.18 cm (fall of 24.7%) in sham group during treatment. Improvement in VAS scores was independent of other variables, except for improvement in emotional aspects in the SF-36. Conclusions: During r-TMS sessions there was significant and positive improvement in pain experience of CRPS patients regardless of mood, function or quality of life effects.

Estratégias terapêuticas no tratamento da dor crônica: uma genealogia da clínica da dor / Therapeutic strategies in the treatment of chronic pain: a genealogy of the pain clinic

O objetivo desse trabalho é analisar a singularidade das estratégias terapêuticas introduzidas pelo modelo das Clínicas da Dor, através de um estudo genealógico desse projetoterapêutico e sua contextualização no âmbito da racionalidade científica moderna. Mais especificamente, pretende-se analisar as transformações na racionalidade médica que permitiram, sucessivamente, a apreensão da dor pelo discurso médico, a concepção da dorcomo uma doença e a construção e a consolidação do modelo terapêutico das Clínicas da Dor. Para tal, inicialmente, analisamos o modelo terapêutico desenvolvido pelo médico anestesista John Bonica, idealizador do modelo das Clínicas da Dor, destacando as ferramentas conceituais que possibilitaram a compreensão da dor crônica como doença e como fenômenobiopsicossocial. Num segundo momento, realizamos uma descrição e análise dos principais eventos que permitiram a consolidação da medicina da dor como uma prática específica e multidisciplinar, dando destaque à inserção deste modelo no contexto do Sistema Único de Saúde Brasileiro. Finalmente, a partir de uma experiência clínico-institucional buscamos refletir sobre os limites e possibilidades da aplicação prática deste modelo, lançando luz sobre os impasses da clínica e tensões oriundas da problematização do dualismo mente e corpo e das práticas terapêuticas interdisciplinares.

Medicina paliativa: una respuesta para el paciente con cáncer avanzado / Palliative medicine: an answer for patients with advanced stage cancer

El cáncer avanzado representa un desafío para los equipos de salud, considerando que epidemiológicamente el problema del cáncer muestra un crecimineto sostenido en el mundo. Esto crea una necesidad creciente de manejo de los problemas biofísicos y psicosociales asociados, bajo una forma integral e interdisciplinaria característica de la Medicina Paliativa. El control del dolor es el primer objetivo de este cuidado. Las recomendaciones de la OMS desde hace 20 años promueve el uso de una terapia en escalera de 3 peldaños combinando AINEs, opioides débiles o potentes y coadyuvantes. El uso de los opioides siempre ha estado obstaculizado por confusiones entre los conceptos de tolerancia, dependencia y adicción. Otros métodos intervencionales han aportado algunas alternativas para el control del dolor de los pacientes. Además del dolor los pacientes con cáncer avanzado experimentan muchos otros síntomas que requieren el enfoque integral de la Medicina Paliativa para intentar mejorar la calidad de vida. Actualmente existe suficiente evidencia científica y experiencia clínica para validar la Medicina paliativa en los programas de Cáncer de distintos países del mundo.

Advanced stage cancer represents a challenge for medical teams if we consider that from an epidemiologic perspective, the number of cancer patients has been increasing steadily all over the world. This lead to a greater need to manage the associated biophysical and psychosocial issues using the integral and multidisciplinary approach of Palliative Medicine. Pain control is the primary objective in the field of care. The HWO has been promoting for the last 20 yearsthe use of a three step therapy using a combination of AINEs, weak or strong opiates and soothing agents. The use of opiates has always encountered difficulties because the meaning of words such as tolerance, dependency and adiction has always been confused. Other intervention methods have provided some alternatives to pain control. In addition to pain cancer patients at an advanced stage have many other symptoms that require the integral approach of Palliative Medicine to improve the quality of their lives. There is at present enough scientific evidence and clinical experience to validate Palliative Medicine in Cancer programs in many countries of the world.

Fighting cancer is half the battle... living life is the other half.

PURPOSE: The purpose of this study was to explore the psychological and social problems the terminally ill are facing in India. Another objective of this study was to explore the Locus of Control and Depression. AIMS: The study was conducted on an incidentally available sample of fifteen terminally ill patients at the Pain Clinic, I.R.C.H., AIIMS, ranging from young adults (30-35 years), to middle aged (40-50 years), to the elderly (55-65 years). MATERIALS AND METHODS: A thematic and narrative analysis was done using semi-structured interview. After the semi-structured interview, two standardized inventories were administered. The two inventories used were Multidimensional Health Locus of Control, and Beck's Depression Inventory. The statements from the two inventories were translated into Hindi and then asked. The inventories were not given as a questionnaire to be filled; rather they were asked orally and marked by the investigator. RESULTS: The co-relation between Internal Health Locus of Control and Depression was found to be significant below the 0.05 level. Statistics also revealed that a large number of participants were either severely depressed (33.33%) or extremely depressed (20%). The seven common themes running through all the narratives were identified; Concern for physical pain; Anxiety and Depression; Body-image problems; Social withdrawal; Disease viewed as bad 'karma'; Desire for hastened death; and lastly Hope. CONCLUSION: This article would create greater awareness among all the concerned people working with cancer patients on what intervention strategies should be utilized to help the patients, as well as, how the belief in karma can help gain a more positivistic outlook towards death and the core role spirituality and the belief in karma can play in the counseling of the patients and their families.

CT-guided celiac plexus block for intractable abdominal pain

Treatment of intractable abdominal pain due to inoperable intraabdominal malignancy is important, and the ineffectiveness of pharmacological agents has led many investigators to recommend chemical neurolysis of the celiac ganglions as a treatment. The author describes the technique and results of celiac plexus neurolysis under CT-guidance with various approach routes, including anterior, posterior and transaortic routes. Twenty-eight patients, ranging in age from 36 to 82 years, have been treated with this procedure. All had inoperable or recurred intraabdominal malignancies and suffered from intractable upper abdominal pain and/or back pain. The author performed the procedure using absolute alcohol by an anterior approach (n=18), posterior approach (n=6) and transaortic approach (n=4). Pain was rated according to a visual analog scale before and after the procedure to gauge treatment success. No major complications occurred. Mild hypotension occurred in five patients (18%) and transient diarrhea in six patients (21%). Twenty-one (75%) of the 28 patients had some relief of pain and 17 of these patients (61%) had good relief of pain after the procedure. The results support that CT-guided celiac plexus block with alcohol is a safe and effective means of pain control in patients with intraabdominal malignancy.

Aracnoiditis / Arachnoiditis

La aracnoiditis es un proceso inflamatorio proliferativo no específico que produce un espectro de cambios patológicos que comprometen principalmente los elementos intratecales y conduce a un proceso de enfermedad permanente capaz de causar dolor intratable y deficit neurológico. Puede estar causada por la introducción de la sustancia irritativa de un cuerpo extraño en el espacio subaracnoideo, como: agentes terapéuticos (metrotraxato, antibióticos, etc.), contaminantes químicos (antisépticos), trauma con desgarro dural (sangrado subaracnoideo), tumores que invaden la aracnoides, infecciones en la columna espinal, sangre en el espacio subaracnoideo, sangrado en el momento de la cirugía, parches de sangre epidurales, mielitis aséptica transversal, tinturas solubles en aceite utilizadas para los mielogramas (por ej., iofendilato), algunas tinturas solubles en agua (metrizamida) y trauma quirúrgico (lesión directa a las estructuras neurales). Cuando se utilizan epiduralmente, son seguros los esteroides sin preservativos. La confirmación del diagnóstico de aracnoiditis puede obtenerse mediante RMN (que es el mejor método) de diagnóstico; en ciertos casos pueden ser útiles las radiografías planas de la columna, la exploración por TC, los potenciales somatosensoriales evocados selectivos, EMG y mieloscopía. El estilo de vida de los pacientes con aracnoiditis adhesiva se ve gravemente afectado con el progreso de los síntomas y las discapacidades. Un diagnóstico precoz en este grupo de pacientes le permite al médico tratante establecer cuánta aracnoiditis adhesiva es responsable de los síntomas, porque a menudo otras causas coexistentes deterioran la evolución y el pronóstico de dicha enfermedad. Son necesarios los programas específicos para la rehabilitación psico-social de los pacientes. Las medidas para tratar estos pacientes permitirán al menos una recuperación parcial de sus actividades sociales. Se requiere un esfuerzo multidisciplinario para resolver la complejidad de las manifestaciones de la aracnoiditis adhesiva, así como otras condiciones patológicas frecuentemente asociadas con ésta. Actualmente, la prevención es el objetivo primordial.

Los bloqueos neuroliticos en el dolor oncologico / Neurolytic block in oncologic pain

Exponemos la tematica tan compleja y discutida en la actualidad sobre el empleo de los agentes neuroliticos por medio de los bloqueos nerviosos, sobre todo en los enfermos con dolor y cancer. Hemos abarcado una breve descripcion del concepto de dolor, de las causas fundamentales del dolor oncologico, la clasificacion de los bloqueos nerviosos y de los neuroliticos; tambien se mencionan sus agentes, las indicaciones, dosificacion, sus ventajas y complicaciones

Risk factors for unpleasant paresthesiae induced by paresthesiae-producing deep brain stimulation

Paresthesiae-producing deep brain stimulation (stimulation of ventrocaudal nucleus - VC, medial lemniscus - ML or internal capsule - IC) is one of the few procedures to treat the steady element of neural injury pain (NIP) currently available. Reviewing the first 60 patients with NIP submitted to deep brain stimulation (DBS) from 1978 to 1991 at the Division of Neurosurgery, Toronto Hospital, University of Toronto, we observed that 6 patients complained of unpleasant paresthesiae with paresthesiae-producing DBS, preventing permanent electrode implantation in all of them. Such patients accounted for 15 per cent of the failures (6 out of 40 failures) in our series. In an attempt to improve patient selection, we reviewed our patients considering a number of parameters in order to determine risk factors for unpleasant paresthesiae elicited by paresthesiae-producing DBS. The results showed that this response happenned only in patients with brain central pain complaining of evoked pain, secondary to a supratentorial lesion. Age, sex, duration of pain, quality of the steady pain, size of the causative lesion and site (VC,ML,IC) and type (micro or macroelectrode) of surgical exploration were not important factors. Unpleasant paresthesiae in response to dorsal column stimulation, restricted thalamic lesion on computed tomography and the occurrence of associated intermittent pain were considered major risk factors in this subset of patients and the presence of cold allodynia or hyperpathia in isolation and the absence of sensory loss were considered minor risk factors. It is our hope that the criteria here established will improve patient selection and so, the overall results of DBS.

Vertebroplastia acrílica percutánea: técnica, indicaciones y resultados / Vertebroplasty with acrylic cement: indication and results

Ciertas afecciones raquídeas son responsables de dolores y/o de complicaciones neurológicas secundarias al aplastamiento vertebral que ellas producen. Con el fin de consolidar la vértebra y aliviar el dolor surge la Vertebroplastia Acrílica Percutánea, que consiste en la inyección de cemento acrílico por vía percutánea, propuesta inicialmente en el tratamiento de los angiomas vertebrales agresivos. Luego de realizar una punción biopsia de la vértebra, se inserta una aguja de 10 G en el cuerpo vertebral y se inyectan una mezcla de polvo de tantalio y de metil-metacrilato (3 a 5 ml). Fueron tratados exitosamente con este método 31 pacientes portadores de hemangiomas vertebrales y 10 pacientes con dolores severos debidos al aplastamiento vertebral de origen osteoporótico. Siendo el resultado clínico y radiológico estable con un seguimiento de 6 años para los angiomas vertebrales y de 30 meses en 7 pacientes tratados con osteoporosis. Un efecto analgésico significativo permitió desarrollar una actividad normal a 12 pacientes de los 20 tratados con tumores vertebrales. El efecto analgésico fue durable en 10 de ellos con un seguimiento de 6 meses