The Long-Term Effects of Plasma Disc Coagulation Therapy for Cervical Disc Hernia.

OBJECTIVES: Recently, plasma disc coagulation therapy (PDCT) has been used in the treatment of lumbar and cervical disc hernia (CDH), but the long-term effects of PDCT have not been well documented. The aim of this study was to assess the long-term effects of PDCT on pain score, disc volume and patient satisfaction in patients with CDH. METHODS: Eighty patients with CDH, who underwent PDCT treatment, were included in the study. The patients demographics and pain scores (visual analog scale-VAS) were recorded on the baseline and in the 1st, 3rd, 6th and 12th month after PDCT treatment. We evaluated patient satisfaction and disc volume on the 12th month after PDCT. RESULTS: A statistically significant and time-dependent decrease was determined in VAS score. The initial mean VAS score was 6.5 ± 0.9, and it decreased to 3.4 ± 0.2 on the final follow-up (p<0.01). According to magnetic resonance imaging pathology, VAS score after PDCT was higher in patients with an extruded disc when compared to patients with bulging and protruded discs at all times (p<0.05). After 12 months, 50 % of the patients were reported as excellent and 8.7 % of the patients reported as poor based on the Odoms' criteria. Disc volume decreased after PDCT treatment in the patients who reported that they were excellent based on the Odoms' criteria (p<0.01). CONCLUSIONS: This study demonstrated that PDCT is a safe, effective and minimally invasive treatment technique for adequately selected patients with CDH.

[Effective pain therapy can improve the survival of patients with pancreatic cancer]. / Etkin agri tedavisi pankreas kanserli hastalarda sagkalimi artirabilir.

OBJECTIVES: In this study, characteristics and analgesic treatment of patients with pancreatic cancer who applied to the algology clinic were evaluated. METHODS: Demographic characteristics, pathologic diagnosis, metastasis, cancer treatment, and analgesic interventions in 60 patients with pancreatic cancer, referred to the algology clinic, were examined. RESULTS: The application time of the patients to the clinic was 3.9+-0.92 months after the diagnosis, and the visual analog scale (VAS) was 6.96+-0.11 at the initial assessment. According to the analgesic step ladder protocol, a nonopiod + weak opioid + strong opioid (transdermal) were applied in 58.33%, a nonopioid + weak opioid + strong opiod (oral) in 5%, and nonopiod + weak opioid in 36.66% of the patients. Adjuvant pain medications were used in 68.33% of the patients (benzodiazepine, 80.48%; antidepressant, 19.51%), while no adjuvant was used in 31.66% of the patients. While the mean survival time for patients with pancreatic cancer changed from 3 to 6 months, it was 8.48+-7.46 months for patients who applied to the pain clinic. CONCLUSION: Abdominal pain in pancreatic cancer is the most common symptom that negatively affects the quality of life. A good analgesia improves the survival, while pain decreases the survival. The results of the present study demonstrated that the survival of the patients with metastatic pancreatic cancer who received effective pain therapy in the algology clinic may be longer.

Intradiscal ozone therapy for lumbar disc herniation.

The rationale behind intradiscal O2-O3 therapy is the pain elicited by the mechanical compression of the nerve root, which is associated with periganglionic and periradicular inflammation. This study aimed to determine the effect of intradiscal ozone injection on pain score and satisfaction of patients with low back pain (LBP) secondary to disc herniation. Patients with LBP diagnosed with disc herniation were enrolled in this clinical trial. After prepping and draping the area, intradiscal injection of ozone/oxygen mixture (10 ml, 25µg/ml) was performed under fluoroscopy guide (c-arm). Pain score and patient satisfaction were assessed prior to the injection (baseline) and 1, 3, 6, 12 and 24 months after the injection. Sixty three patients (24 males, 39 females) with mean age of 53.3 ±2.0 y enrolled in the study. The mean±standard deviation (SD) of pain score before intervention was 6.968 ±0.11. Pain score was reduced to 4.25±0.19 at 1 month, 4.33±0.20 at 3 months, 4.87 ±0.21 at 6 months and 5.22 ±0.20 at 24 months. According to the modified MacNab scale success of pain relief was as follows: excellent: 4 (6.3%), good: 17 (26.98 %), sufficient: 13 (20.63 %), poor: 13 (20.63 %), no result: 11 (17.46%), negative: 4 (6.3 %). Intradiscal ozone therapy was determined to provide improved outcomes in patients with single level of bulging and protrusion.

Intraoperative Results and Postoperative Clinical Outcomes of Lumbar Microdiscectomy in Patients who Previously Received a Transforaminal Anterior Epidural Steroid Injection for Lumbar Radiculopathy.

AIM: To describe the intra- and postoperative results of patients who received a transforaminal anterior epidural steroid injection (TAESI) prior to lumbar microdiscectomy. MATERIAL AND METHODS: Sixty-four patients who did not improve after minimally invasive techniques (MIT) for lumbar radiculopathy were evaluated. Thirty-two of them treated with techniques other than TAESI and those receiving thrombolytic or anticoagulant drugs before microdiscectomy were excluded. We recorded the type of MIT, numbers of levels and injections, time interval between the last MIT and microdiscectomy, duration of surgery, amount of intraoperative blood loss, rate of incidental durotomy, postoperative infection, and visual analogue scale (VAS) scores for leg pain before and after microdiscectomy at 24 hours, and the 1st and 3rd months (Group 1). A total of 35 patients with no history of MIT or lumbar surgery who had undergone unilateral, single-level lumbar microdiscectomy at our clinic were randomly selected to be included in the control group (Group 2) and same parameters were recorded for the comparison of both groups. RESULTS: The mean duration of lumbar discectomy was 140 minutes, and the amount of average intraoperative blood loss was 227 cc in the study group (Group 1), and 65 minutes and 73 cc, respectively in the control group (Group 2)(p > 0.05). The comparison of VAS scores revealed that lumbar discectomy was still effective after TAESI (p=0.00). CONCLUSION: Although epidural steroid injection is an effective modality for the management of chronic pain, these patients should be informed preoperatively about the relatively long duration of surgery and the possible requirement for blood transfusion.

[Analgesic step ladder treatment in cancer patients with pain]. / Agrili kanser hastalarinin tedavisinde analjezik basamak tedavisinin yeri.

OBJECTIVES: In this study, we retrospectively evaluated the characteristics of 1736 patients presenting to our clinic, including analgesic step treatments and method of treatments. METHODS: A total of 1467 patients, excluding 269 out of 1736, with pain due to malignancy were included in this study. Patients presented to the Algology Division of the Department of Anesthesiology and Reanimation of Firat University School of Medicine. Among the patients included in the study, 85.5% were treated according to the analgesic step ladder protocol of the WHO. Minimally invasive analgesic interventions were applied in 14.5% of the cases in which adequate pain control could not be achieved with step ladder treatment. RESULTS: The adjuvant pain medications used were antidepressants, corticosteroids, anticonvulsants, neuroleptics, benzodiazepines, local anesthetics, bisphosphonates, and calcitonin and their rate of usage were 61.0%, 7.1%, 4.0%, 4.0%, 1.6%,12.3%,1.2%, and 2.8%, respectively. CONCLUSION: Because pain in the cancer patients is mostly severe, pain management can be difficult in these patients. The patients who cannot be treated with the analgesic step ladder method have been treated with minimally invasive analgesic intervention methods. A multidisciplinary medical expert group evaluation of the cases and a treatment planned by this team are cornerstones of achieving success in pain management. We believe in this way, no patient with cancer will live with uncontrolled pain. Access to adjuvant drugs should be easy in order to achieve success in pain management. We believe that expert algology physicians who treat pain should easily prescribe adjuvant drugs.

Effects of Metastasis on Pain Treatment in Patients with Cancer-Related Pain: A Retrospective Study.

OBJECTIVE: The goal of this study was to investigate the effect of the presence of metastases on pain treatment in patients with cancer-related pain. METHODS: Of the 1736 patients who were treated in Firat University, Faculty of Medicine, Department of Anaesthesiology and Reanimation, Algology Section, for cancer-related pain between January 1997 and December 2010, 1467 with complete medical records were evaluated. Patients were grouped as having no metastasis (Group I), a single organ metastasis (Group II), or multiple organ metastasis (Group III). RESULTS: There was no difference between the groups with regard to age. Visual Analog Pain (VAS) scores at admission were higher in Group III compared to the other groups, and significantly higher in Group I than in Group II. Analgesic ladder treatment was given to 85.5% of patients, and 14.5% were treated using additional minimally invasive analgesic intervention (MIAI) methods. In Group II and Group III, the rates of treatment in Step I and II were lower compared to Group I, while the rates of treatment in Step III were higher. Implementation of MIAI was higher in Group III than in the other groups, and higher in Group II than in Group I. CONCLUSION: The presence of metastases causes more severe pain, which becomes more difficult to treat, and increases the analgesia step and the consumption of opioids in patients with cancer-related pain.

[Comparison of non-invasive and invasive techniques in the treatment of patients with myofascial pain syndrome]. / Miyofasiyal agri sendromlu hastalarin tedavisinde non-invazif ve invazif tekniklerin karsilastirilmasi.

OBJECTIVES: We compared in this study the efficiency of non-invasive techniques including transcutaneous electrical nerve stimulation (TENS) and laser treatments with invasive techniques including lidocaine and botulinum toxin-A injection in patients with myofascial pain syndrome (MPS). METHODS: One hundred patients who admitted to Firat University Hospital Pain Department and who were diagnosed as MPS were included in the study. Patients were randomized into four groups of 25 patients each. Sixty sessions of TENS and 20 sessions of laser treatments were performed in the first and second groups, respectively. Lidocaine and botulinum toxin-A were injected in the third and fourth groups, respectively. 2 ml (20 mg) 1% lidocaine was injected in each patient twice a week for one month in Group III. 25 U (0.5 ml) of botulinum toxin-A was injected in each patient only once in Group IV. Pain was evaluated with visual analogue scale (VAS), palpable muscle spasm scoring (PMSS) and anesthesiometer at baseline, 15, 30 and 45 days. RESULTS: There were no statistically significant differences between the groups with respect to age, sex and education level. Pain control was statistically better in Group IV compared with the other groups with respect to VAS, PMSS and anesthesiometer scores. CONCLUSION: Botulinum toxin-A injection provided better pain control when compared to trigger point injection with lidocaine and non-invasive techniques including TENS and laser treatments.

Effects of ondansetron and granisetron on postoperative nausea and vomiting in adult patients undergoing laparoscopic cholecystectomy: a randomized, double-blind, placebo-controlled clinical trial.

BACKGROUND: Postoperative nausea and vomiting (PONV) are common and potentially distressing adverse events (AEs) associated with surgery and anesthesia. In patients undergoing laparoscopic cholecystectomy (LC) without antiemetic prophylaxis, the incidence of PONV can be as high as 72%. OBJECTIVE: The aim of this study was to investigate the prophylactic antiemetic effects of ondansetron and granisetron in patients undergoing LC when these agents are administered before the end of surgery. METHODS: Patients classified by the American Society of Anesthesiologist's physical status as I or II who were scheduled for elective LC were included in this randomized, double-blind, placebo-controlled study. Anesthesia was induced with thiopental 5 mg/kg and fentanyl 2 µg/kg, and was maintained with isoflurane 1% to 3% in 50% oxygen and 50% nitrous oxide and fentanyl as needed. Approximately 20 to 30 minutes before the end of the surgery, the patients randomly received either IV ondansetron 100 µg/kg (group O), IV granisetron 40 µg/kg (group G), or normal saline (group P). Plasma levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were determined preoperatively and 24 hours postoperatively. The patients were observed for 24 hours for PONV and other possible AEs. Postoperative pain intensity was determined using a 10-cm visual analogue scale. Four-point satisfaction scores were determined at 24 hours. RESULTS: Ninety patients (69 women, 21 men) participated in the study. Demographic characteristics and operative data (duration of surgery and anesthesia and amount of intraoperative fentanyl) were similar in the 3 groups. The only AE reported by patients during the 24-hour observation period was nonsevere headache. The number of patients experiencing headache was similar in group P, group O, and group G (10 [33%] patients, 6 [20%], and 10 [33%], respectively). No significant changes were found in presurgical and postsurgical plasma levels of ALT and AST in any group. The mean (SD) satisfaction scores in group O and group G (3.0 [0.4] and 3.0 [0.6], respectively) were significantly higher than those in group P (2.5 [0.5]; both, P < 0.01). Immediately after surgery (period 0), significantly more patients in the placebo group (21 [70%]) experienced PONV compared with those in the ondansetron group (9 [30%]; P < 0.05) and the granisetron group (7 [23%]; P < 0.01). During the 24-hour observation period, a significantly greater number of patients in group P (18 [60%]) required a single dose of a rescue antiemetic drug compared with those in groups O and G (9 [30%] and 6 [20%], respectively; both, P < 0.01). CONCLUSIONS: Patients administered ondansetron 100 µg/kg or granisetron 40 µg/kg 20 to 30 minutes before the end of LC had significantly higher PONV control during the 24-hour postoperative observation period than patients receiving placebo. However, there were no significant differences between the active treatment groups in the incidence of PONV, patient satisfaction, or AEs.

Preliminary findings for preemptive analgesia with inhaled morphine: efficacy in septoplasty and septorhinoplasty cases.

OBJECTIVE: The aim of this study was to assess the efficacy of inhaled morphine for preemptive analgesia in patients who undergo septoplasty or septorhinoplasty. STUDY PLAN AND METHODS: Eighty ASA I-II patients scheduled for septoplasty or septorhinoplasty were recruited and randomly divided into 2 groups that received different treatments 10 minutes prior to induction. The preemptive analgesia group (Group P, n = 40) received 65 mug kg(-1) morphine sulphate (a 3-mL volume) via an oral nebulizer, and the control group (Group C, n = 40) received 3 mL 0.9% sodium chloride (physiological saline) via the same type of nebulizer. Blood pressure, oxygen saturation, heart rate, time to first requirement for analgesia, and occurrence of nausea/vomiting were recorded. RESULTS: There were no significant differences between Groups P and C with respect to age, body weight, sex distribution, or duration of surgery. There was also no significant difference between the group frequencies of postoperative nausea/vomiting. The time to first requirement for analgesia was significantly longer in Group P than Group C. CONCLUSION: The results of this preliminary study suggest that a single dose of inhaled morphine administered preemptively prior to septoplasty or septorhinoplasty provides effective postoperative analgesia. EBM RATING: B-3b.

[Adjuvant analgesics in pain management]. / Analjezik adjuvanlar.

The term adjuvant analgesics describes any drug with a primary indication other than pain, but with analgesic properties in some painful conditions. Adjuvant analgesics often are administered as first-line drugs in the treatment of chronic non-malignant pain. The group includes numerous drugs in diverse classes. Some adjuvant analgesics possess analgesic properties in several types of pain, whereas others are specific for neuropathic pain, or nociceptive pain. Antidepressants, anticonvulsants, neuroleptics, antiarrythmics, antihistaminics, NMDA receptor-antagonists, steroids, muscle relaxants, bisphosphonates, and radiopharmaceuticals are adjuvant agents. This article reviews the evidence supporting the use of adjuvant analgesics for the treatment of pain and emphasizes medical dosages, side effects, and drug interactions.

Is nitric oxide involved in the antinociceptive activity of tramadol? Findings in a rat model of neuropathic pain.

The aim of this investigation was to assess the role that NO plays in the antinociceptive activity of tramadol using a rat model of neuropathic pain. Thirty male Wistar rats weighing 200-250 g were randomly divided into five equal groups. The neuropathic pain model used for the study was chronic constrictive injury (CCI) model. Three weeks after the surgical procedure, each rat was tested to assess mechanical threshold in grams using an electronic algometer. After CCI was induced, tramadol hydrochloride was administered by intraperitoneal (i.p.) injection in all groups, and Nomega-nitro-L-arginine (L-NA) and L-arginine were administered i.p. or intrathecally (i.t.) depending on the group. Tramadol was administered in 10 mg/kg doses i.p., L-NA was given in 10 mg/kg doses i.p. and in 30 microg/kg doses i.t.. L-arginine was given in 10 mg/kg doses i. p. and in 50 microg/kg doses i.t.. The multiple agents were given 30 minutes apart from each administration. Intraperitoneal administration of tramadol (Group 1) only increased mechanical threshold in the rats' left hind paw, whereas in i.p. L-NA group (10 mg/kg) (Group 2) produced a significant reduction of the mean mechanical antinociceptive threshold (p<0.05). Like this, in i.t. L-NA group (30 microg/kg) (Group 4) a significant reduction of the mean mechanical antinociceptive threshold (p<0.05) was also observed. The mean threshold values in Group 2 (i.p. tramadol+i.p. L-NA) and Group 4 (i.p. tramadol+i.t. L-NA) were not significantly different. The mean threshold values in Groups 3 (i.p. tramadol+i.p. L-NA+i.p. L-arginine) and 5 (i.p. tramadol+i.t. L-NA+i.t. L-arginine) were also similar. The mean mechanical antinociceptive threshold was significantly increased in Group 3 (i.p. L-NA+L-arginine) and Group 5 (i.t. L-NA+L-arginine) when compared to Group 1 (i.p. tramadol only) (p<0.05 for both). The results of this study support the involvement of the L-arginine/nitric oxide pathway in the antinociceptive effect of tramadol in a rat model of neuropathic pain.

Intrathecal melatonin increases the mechanical nociceptive threshold in the rat.

The aim of this investigation was to determine whether intrathecal (i.t.) administration of monodose melatonin provides an increase in mechanical nociceptive threshold in the rat. Twenty-four male Wistar rats were randomly assigned to four groups. Each animal was anesthetized, and a catheter was placed intrathecally via the cisterna magna. The study groups were: untreated controls (n=6); melatonin only (MEL, n=6); melatonin + luzindole (MEL+LZN, n=6); and melatonin + naloxone (MEL+NLX, n=6). Measurements of mechanical nociceptive threshold were made using an electronic algometer. Each animal was tested prior to injection and at 10, 20, 30 and 40 min after injection. In the MEL group, the mean nociceptive thresholds at all post-injection time points were significantly higher than the baseline value (p<0.05 for all). In the control and MEL+LZN groups, none of the four mean nociceptive thresholds recorded after i.t. injection was significantly different from the baseline value (p>0.05 for all). In the MEL+NLX group, the mean nociceptive thresholds at 20, 30 and 40 min post-injection were all significantly lower than the baseline value (p<0.05 for all). Comparison among the group nociceptive thresholds at baseline revealed no significant differences, and the same was true at 10 min after i.t. injection. At the 20, 30 and 40 min stages, the threshold in the MEL group was significantly higher than the threshold in the control group. The results indicate that i.t. injection of melatonin produces a time-dependent increase in mechanical nociceptive threshold in the rat and that the mechanism that underlies these effects involves both melatonin and opioid receptors.