The effectiveness of endoscopic epidurolysis in treatment of degenerative chronic low back pain: a prospective analysis and follow-up at 48 months.

The aim of this prospective study was to evaluate the efficacy of endoscopic epidurolysis in the treatment of degenerative chronic low back pain.Two hundred and thirty four patients affected by chronic low back pain, with VAS ≥ 5 and Oswestry Low Back Pain Disability Index (ODI) from 0 to 60% (0-20%, group A; 20-40%, group B; 40-60%, group C) were enrolled and treated prospectively with endoscopic epidurolysis by means of a flexible fiberoptic endoscope introduced into the caudal epidural space and by the intermittent instillation of saline solution added with 150 UI hyaluronidase. Targeted application of ozone (8 ml; 38 γ/ml) and 50 mg ciprofloxacin close to the abnormal areas was also performed. Short and long term efficacy (1 week, 3 months, 6, 12, 24, 36 and 48 months) was prospectively evaluated. VAS score <5 and ODI <40% were considered as a positive outcome.The treatment significantly reduced VAS score in all three groups of patients starting from the first week and throughout the entire follow-up period (P < 0.001). Disability Index (ODI) too showed encouraging results (P < 0.001) that was particularly evident at 3 months and maintained up to long-term follow-up intervals.Epiduroscopy by mechanical adhesiolysis and administration on targeted areas of ciprofloxacin and ozone seems to be, in this prospective study, an effective technique to provide a sensible and persisting pain relief and act of improving ODI in chronic low back pain.

[The benefit of combining spinal morphine and intravenous buprenorphine for perioperative pain].

Concurrent administration of opioids with different affinity produces synergistic antinociceptive effect in rats. We tested the perioperative antinociceptive effects of the simultaneous double blind administration of morphine, a pure agonist and buprenorphine, a partial agonist, in 30 patients undergoing hysterectomy under general anesthesia. Pre- and post-operatively regimens consisted of random patient assignment to intrathecal 0.3 mg morphine plus intravenous saline (group 1), intravenous 0.09 mg buprenorphine plus intrathecal saline (group 2) or intrathecal morphine 0.3 mg plus intravenous buprenorphine 0.09 mg (group 3). Postoperative pain relief for group 3 consisted of supplementation of intravenous buprenorphine plus intrathecal saline. The immediate postoperative pain, sedation and anxiety levels (by numerical or categorical scores) were similar among all groups. The 12-hour pain and sedation scores were significantly (P < 0.05) lower in group 3 than in the other two groups. Buprenorphine-induced analgesia in group 3 lasted significantly (P < 0.05) longer than in group 2. Side effects in groups 2 and 3 were by 44% and 42% fewer than in group 1, respectively, with no withdrawal symptoms. Thus, concomitant administration of intrathecal morphine and low dose intravenous buprenorphine produces better and longer pain relief than intravenous buprenorphine alone in women after hysterectomy.

The epidural and intrathecal administration of somatotrophin-release inhibiting factor: native and synthetic analogues.

It is well-known that morphine is the king of analgesics. It is widely used, and administered in various ways for the control of acute and chronic pain states. There are, however, certain types of pain and certain clinical conditions in which morphine cannot be used due to the risk of possible complications. These are usually pain states associated with intracranial hypertension, the presence of serious respiratory problems, the onset of major opioid tolerance, persistent vomiting, and so on. The search for "alternative analgesics" has been in progress for a decade, alternatives that could be used alone or in combination for spinal administration in the treatment of complex chronic pain states and with a low incidence of secondary effects. Today, research is carefully assessing the clinical effectiveness and the side effects of a series of drugs for spinal administration, that is, epidural or intrathecal, such as the new narcotics, alpha-2 agonists, central muscle relaxants, calcitonin, and local anesthetics. In this alternative analgesic category we have to mention the somatotrophin-release inhibiting factor (SRIF), which is an ubiquitous native hormone with widespread, predominantly inhibitory actions, and octreotide, its synthetic analogue. In this article we review the literature on the natural drug and its synthetic analogue, paying particular attention to the problems connected with intraspinal administration and analgesic properties.

Complications of super-selective subarachnoid anesthesia (SSA) with hyperbaric bupivacaine: experiences with 355 patients in general and orthopaedic surgery.

The results obtained from 355 patients of both sexes subjected to general and orthopaedic surgery with super-selective subarachnoid anesthesia (SSA) by means of small (26-27 gauge) needles with a modified Whitacre needle with ogival point are described. The use of thin spinal needles with "pencil-point" type ends together with microdoses of local anesthetics has meant a reduction in the complications typical of this technique such as hypotension, post-dural puncture, headache (PDPH) and urinary retention. Super-selective subarachnoid anesthesia realised through an infusion of 0.8-1 ml of hyperbaric bupivacaine is a safe effective technique with a low percentage of side-effects.

[Analgesic effects of natural growth hormone release inhibitors and their synthetic analogs. Intraspinal administration]. / Effetti analgesici degli inibitori della liberazione degli ormoni della crescita (GHRIH) nativi ed analoghi sintetici. Luci ed ombre sulla somministrazione intraspinale.

The authors examine the pharmacological characteristics, distribution and clinical effects of natural (somatostatin) and synthetic (octreotide) growth hormone release inhibitors (GHRIH). They mainly discuss the analgesic effect of these substances using intraspinal, epidural and subarachnoid administration. The intraspinal use of somatostatin and its synthetic analog, octreotide, are not without risks: among these, it is worth recalling the neurotoxic and vasomotor effects. Further studies may more clearly define these and other secondary effects and also the real indications for these drugs in the context of analgesics for intraspinal use. It is hypothesised that somatostatin and octreotide, owing to their analgesic capacities, may replace the intraspinal administration of opioids in a number of clearly defined clinical conditions, such as severe pain in which opioids are contraindicated.

Some remarks on the current morphine consumption in Italy.

AIM: To analyse therapeutic morphine consumption in Italy and explain the current trend. ENVIRONMENT: Morphine consumption was examined at Santa Croce Hospital, Cuneo, a general provincial hospital. METHOD: The overall annual consumption of morphine was used as a starting point from which to evaluate the "average daily consumption of set doses", both in general and using a number of methods of administration. From these figures it was possible to calculate the average number of patients receiving full doses of the drug daily; this finding was compared every 10,000 days of hospitalisation. RESULTS: The analysis of consumption over the two-year period 1991-92 shows a 98.41% increase in mean morphine consumption compared to the period 1988-89. Over the five-year period the average number of patients receiving full doses of morphine daily through a variety of methods of administration was 9.89, equivalent to 3.79 patients every 10,000 days of hospitalisation. CONCLUSIONS: Useful information can be derived regarding the trend of morphine consumption from the "mean daily consumption of set doses" of morphine and, above all, from monitoring consumption per 10,000 days of hospitalisation. At present we are not aware of similar data relating to other hospitals. We hope that this lacuna will soon be filled so as to evaluate and monitor morphine consumption trends in Italy.

A "pitiful death": is it the response to a "painful life"?

The problem of pain and suffering in the terminal phase of illness such as cancer or Aids has not received adequate attention and has not been given valid solutions. The author tries to offer a new interpretation key for the problem starting from the Good Samaritan Novel that is considered a clear example of the capability of bringing help and assistance in concrete terms. The request for euthanasia will never be considered a superfluous problem unless a patient can receive concrete answers to his physical and emotional suffering and to the problem of his personal "quality of life".

Cutaneous, musculoskeletal and bone flow scintiscan by intravenous infusion of 99mTc-MDP (Diphosphonate) in the evaluation and control of patients treated with spinal cord stimulation for ischaemic pain.

In patients affected by unbearable pain secondary to peripheral vascular disorders beyond surgical repair such as thromboangitis obliterans, diabetic microangiopathy, arteriosclerosis obliterans, there is a need to establish the degree of micro-circulation functionality before proceeding with invasive pain therapy, such as Spinal Cord Stimulation (SCS). From our series some cases of refractory ischaemic pain subjected to nuclear medicine techniques assessment before and after SCS implant will be presented; these data suggest that the use of radionuclides for quantifying regional perfusion, in view of the information it offers us both in the dynamic angiographic phase and in the later static phase, constitutes a very valid aid in the diagnosis and treatment of chronic pain conditions of ischaemic origin. Cutaneous, musculoskeletal and bone flow scintiscan is a non-invasive procedure which allowed us to make an objective selection of patients who are candidates for prolonged conservative treatment thus limiting the incidence of ineffective permanent SCS implants.

[Compliance problems in chronic pain]. / Problemi di "compliance" nel dolore cronico.

The aim of this paper is to focus on a medical issue which is not held in due consideration in Italy. In chronic pain control and management, specialists may advise at various times drugs, physical therapies, behavioral modification techniques, and not demolitive antinociceptive procedures. Quite often patients do not follow medical prescriptions as one should expect, especially if they are not inpatients. The Authors examine this clinical problem known as compliance and try to explain the reasons for this behaviour from different points of view.

Chronic low back pain patients around the world: cross-cultural similarities and differences.

OBJECTIVE: The current study sought to determine whether there were any significant cross-cultural differences in medical-physical findings, or in psychosocial, behavioral, vocational, and avocational functioning, for chronic low back pain patients. DESIGN: Partially double-blind controlled comparison of six different culture groups. SETTING: Subjects were selected from primarily ambulatory care facilities specializing in treating chronic pain patients. PATIENTS-SUBJECTS: Subjects consisted of 63 chronic low back pain patients and 63 healthy controls. Low back pain patients were randomly selected from six different culture groups (American, Japanese, Mexican, Colombian, Italian, and New Zealander). Ten to 11 were gathered per culture from a pool of patients treated at various pain treatment programs. Likewise, 10 or 11 control group subjects were obtained from each culture from a pool of healthy support staff. MAIN OUTCOME MEASURES: The Sickness Impact Profile and the Medical Examination and Diagnostic Information Coding System were used as primary outcome measures. RESULTS: Findings showed that (a) low back pain subjects across all cultures had significantly more medical-physical findings and more impairment on psychosocial, behavioral, vocational, and avocational measures than controls did; (b) Mexican and New Zealander low back pain subjects had significantly fewer physical findings than other low back pain groups did; (c) the American, New Zealander, and Italian low back pain patients reported significantly more impairment in psychosocial, recreational, and/or work areas, with the Americans the most dysfunctional; and (d) findings were not a function of working class, age, sex, pain intensity, pain duration, previous surgeries, or differences in medical-physical findings. CONCLUSIONS: It was concluded that there were important cross-cultural differences in chronic low back pain patients' self-perceived level of dysfunction, with the American patients clearly the most dysfunctional. Possible explanations included cross-cultural differences in social expectation; attention; legal-administrative requirements; financial gains; attitudes-expectations about usage, type, and availability of health care; and self-perceived ability and willingness to cope.

Persistent pain and personality evaluation. A report of seven multi-operated patients for chronic pain complaints of non malignant origin.

The MMPI scores, the PPI and the MPQ of seven multi-operated patients for chronic pain complaints of non malignant origin were studied. The results of the analysis performed in this group of surgically treated patients point out that there is a strong evidence of relationship between personality traits and the persistence of pain.

Continuous spinal analgesia by means of micropumps[correction of micropumpus]: a report of 163 chronic pain patients.

Chronic pain in patients suffering from advanced cancer as well as unbearable chronic pain states depending on non-malignant pathology have always represented a test bench to verify results of advanced therapeutical programs as to more traditional approaches. The Authors present their experience resulting from longterm spinal infusion with peridural catheters connected to portable micropumps for the continuous administration of analgesic solutions. The availability of portable micropumps, a better understanding of spinal opioid receptors and advances in pharmacokinetics of opiate analgesics led in these years to a tremendous improvement of pain control possibilities and of the quality of life of patients.

Total parenteral nutrition (TPN) in the critically ill patient.

A study has been carried out on the effectiveness of a total parenteral nutrition (TPN) program on 12 patients in intensive care units (ICU). Conclusions have been drawn from biohumoral parameters during the first fornight's stay in the ICU. Results, relating to the re-equilibrium of the glycid and protydic sectors, varied in respect of their temporal distribution. There was in fact a stabilisation, if only temporary, in the glycemy, in the very first days, while the proteic metabolism figures showed a recovery leading to stabilisation only in the second week.

Trigeminal neuralgia: evaluation of percutaneous neurodestructive procedures.

The treatment of trigeminal neuralgia (TN), which is resistant to medical therapy, has benefited from many surgical techniques. It is not possible, in light of the present level of knowledge, to establish exactly which method is the most suitable. It does, however, seem significant that certain side effects appear, in varying percentages, in all kinds of operations. In 13 years, 2,094 patients suffering from TN have been treated by the authors with percutaneous Gasserian neurolysis, 128 patients with radiofrequency trigeminal neurolysis, and 1,966 with selective ethanolic trigeminal neurolysis (SETN). Our experience treating TN with controlled increments of ethanol by means of a needle introduced through the oval foramen in the Gasserian ganglion is related here. The tip of the needle is accurately placed among the roots desired under fluoroscopic control. The clinical effects on the conscious patient of a prognostic block with local anesthetics are evaluated before producing the neurolysis. Follow-up has been long enough to show that SETN is a highly selective procedure, which shouldn't be underrated in the centers that use it routinely.

[The use of althesin in endoscopy]. / Utilizzazione dell'Althesin nelle pratiche endoscopiche.

Althesin was used on account of its pharmacokinetic and pharmacodynamic properties and its high therapeutic index in a search for a narcotic drug displaying minimal interference with metabolic and functional parameters in the aged. Continuous perfusion of the anaesthetic proved an extremely flexible method bearing in mind the varying length of the operations concerned. Stress is laid on the need for clinical control, especially at the moment of induction to ensure that timely action can be taken in the event of complications.