Postherpetic neuralgia: clinical experience with a conservative treatment.

Ninety-seven consecutive cases of postherpetic neuralgia (PHN) were retrospectively reviewed. Patients comprised 49 women and 48 men with a mean age of 71.6 years. The most common painful locations were the chest and upper back (34%), abdomen and lower back (25.2%), and face (20.2%). Burning pain was the most common type of pain (61.3%). Lancinating pain was reported by 40% and throbbing pain by 22.6%. Treatments included drugs (mainly tricyclic antidepressant, anticonvulsant, and neuroleptic drugs), transcutaneous electrical nerve stimulation (TENS), and dry needling of muscles in the affected dermatomes. Positive response to treatment occurred in 18.5% of the patients after one visit. In 9.3% of the patients, the pain still could not be controlled after 10 visits of 2-week intervals. TENS proved to be effective in patients whose skin sensation was preserved. It was concluded that in most PHN cases, pain can be effectively controlled by conservative noninvasive therapy.

Mechanisms of syncope in glossopharyngeal neuralgia.

Syncope is a rare presentation of glossopharyngeal neuralgia (GN). The mechanisms of the syncope were studied in a patient with recurrent episodes comprising prolonged cardiac standstill and arterial hypotension. During attacks, no supraventricular or ventricular potentials were recorded in the ECG. Atropine prevented the cardiac arrest without affecting the pain, indicating the vagus as the efferent limb of the reflex asystole. Following atropine blood pressure continued to fall during GN attacks, suggesting abolition of sympathetic tone. Indeed, serum norepinephrine levels fell during these attacks. Infiltration of either vagus above the clavicle with local anesthetics did not abolish the cardiac asystole. Carbamazepine and a dual chamber pacemaker were effective in controlling the symptoms of the patient. The results suggest that, during a neuralgic attack, the stimulation excites both vagi, causing asystole and simultaneously abolishes sympathetic tone.

Augmentation of bupivacaine analgesia in labor by epidural morphine.

The analgesic properties and motor effect of epidural 0.25% bupivacaine (8 mL) were compared with those of epidural morphine (2 mg in 10 mL saline) followed by 8 mL of 0.25% bupivacaine. The study was performed on two groups of parturients (30 in each group) in active labor. Pain relief in the morphine-bupivacaine group lasted for a mean of 131.1 minutes (SD +/- 49.8) as opposed to the plain bupivacaine group -57 minutes (SD +/- 15.28). Satisfaction from analgesia in the morphine-bupivacaine group was higher as well. Motor involvement was not seen in either group. Perineal pain relief in the postpartum period lasted for a mean of 16 hours and 40 minutes in the morphine-bupivacaine group. It was concluded that the concomitant use of epidural morphine augmented the analgesic effect of 0.25% bupivacaine without motor effect.

Variations in the effect of epidural morphine in gynecological and obstetric patients.

A prospective study was performed on the effect of epidural morphine (2 mg in 10 ml of saline) in three groups of patients: (1) following gynecological operations, 60; (2) following cesarean section, 120; (3) patients in active labor, 30. Pain relief in the first group was uniformly and almost invariably complete for up to 24 hours. In the second group spasmodic visceral pain was felt after about 10 hours, relieved by light analgesics. The wound was not painful. In the third group only hypoalgesia was obtained during labor, but if an episiotomy was done, the pain in the perineum was relieved. Few side effects were observed: urinary retention, vomiting, and non-segmental itching. Neither motor nor sympathetic block were noted. The somatic effect of epidural morphine was reliable and uniform, whereas visceral pain was poorly affected. The side effects cause relatively little disturbance at the dose used.