Ganglionic Local Opioid Analgesia at the Superior Cervical Ganglion: MRI-Verified Solution Spread.

INTRODUCTION: Ganglionic local opioid analgesia (GLOA) at the superior cervical ganglion (SCG) is performed for pain control and is known to be an effective procedure. In this study, we evaluated the spread of the injectate in the area of the SCG. Our expectation was that there would be a correlation between the area and volume of the injectate spread and post-procedural outcome measures. METHODS: This was a retrospective blinded review of magnetic resonance imaging (MRI) scans. Assessors evaluated the anatomical area of fluid spread, the furthermost spread from midline, any hampered spread and contact of contrast fluid with other structures. The efficacy of GLOA and complications were estimated. RESULTS: The main solution spread reached from the C1 to C3 vertebrae. The furthest spread in the lateral and sagittal planes was 21.2 and 15.2 mm, respectively. The furthest craniocaudal spread was 63.5 mm. In 53.3% and 33% of interventions, the solution was found in the parapharyngeal space and in its "medial compartment," respectively. A correlation was found between pain relief and both solution spread and volume of solution spread. No hampered spread was recorded. A negative correlation between pain reduction and number of GLOA was observed. Higher pre-procedural pain intensity was correlated with higher pain reduction. We estimated pain relief in 93% of procedures correctly. No correlation between post-procedural Numerical Rating Scale (NRS) scores and different needle approaches was found. CONCLUSION: For the transoral blocking technique, a strict laterodorsal needle direction is recommended to prevent possible block failures. A total volume of 2 ml injected into the parapharyngeal space and its "medial compartment" is recommended. Higher volumes may lead to uncontrolled distribution patterns. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT05257655; date of registration 2022-02-25; patient enrollment date from 2023-01-09 to 2023-08-31.

The injection of low-dose opioids (mainly buprenorphine or sufentanil) to different sympathetic ganglia has been termed "ganglionic local opioid analgesia" (GLOA). This form of therapy has been successfully used for numerous, often protracted diseases that severely impair the patient's quality of life, such as trigeminal neuralgia. For example, as part of a multimodal approach for pain management, GLOA at the superior cervical ganglion should be considered for pain treatment in patients suffering from trigeminal neuralgia with high pre-procedural pain scores.

Pain in Austrian hospitals: evaluation of 1089 in-patients.

BACKGROUND: Despite the existence of internationally consistent guidelines for the management of pain, efficient regional anesthesia techniques, safe pain medications, and organizational structures, e.g., acute pain services, various studies have shown that pain is still common among both surgical and non-surgical in-patients. OBJECTIVE: The primary objective of this study was to evaluate, on a multi-center basis, the point pain prevalence of surgical and non-surgical in-patients. We further analyzed pain intensities, in-hospital pain triggers, pain-related impairments, pain assessments, patient information about pain, and patient satisfaction with pain therapy. This benchmark information should lead to better implementation of pain management strategies and thus improve health care quality. METHODS: We surveyed all adult in-patients in three general hospitals in Austria (general hospital Klagenfurt am Wörthersee, general hospital Villach, general hospital Wolfsberg) on the index day with two standardized questionnaires for both surgical and non-surgical patients. RESULTS: Overall, a pain prevalence of 40.0%, with no statistically significant difference between surgical and non-surgical patients, was shown. Higher pain prevalence in female patients, high pain prevalence in the age group 18-30 years, and highest pain prevalence in the age group over 90 years old was found. Overall pain intensity was relatively low, but unacceptable maximum pain within the preceding 24 h was shown. Different in-hospital pain triggers like patient's care and mobilization were found. Our survey has shown that pain has an impact on personal hygiene, mobilization, mood, sleep, and appetite. However, patients were very satisfied with their pain therapy. CONCLUSION: Medical staff and nurses have to be sensitized to the urgent need to improve pain management strategies.

[Electrical muscle stimulation in combination with heat for patients with chronic, nonspecific low back pain : A randomized, double-blind, stratified, placebo-controlled clinical trial]. / Elektrische Muskelstimulation in Kombination mit Wärme bei Patienten mit chronischen unspezifischen Rückenschmerzen : Eine randomisierte, stratifizierte, doppelblinde, placebokontrollierte klinische Studie.

BACKGROUND: Chronic non-specific low back pain (LBP) causes more disability than any other medical condition worldwide. Electrical muscle stimulation in combination with heat (EMS/H) for management of LBP has yet not been properly studied. Our hypothesis was that EMS/H provides better pain relief and improves subjective and objective data compared to standard treatment. METHODS: Between 2015 and 2017, we conducted a 6 week randomized, double-blind, stratified, placebo controlled clinical trial, comparing two different forms of EMS/H with placebo treatment with a follow-up 12 weeks after randomization. Patients >18 years with LBP for >6 months and a pain intensity of numerical rating scale (NRS) ≥4/10 were enrolled. RESULTS: A total of 100 patients were recruited. Patients were representative of a LBP population with moderate to severe pain (NRS 5.7/10). After 18 treatments, we found a statistically significant pain reduction, which was also observed at the 12 week follow-up. CONCLUSION: EMS/H is an effective and safe method for managing LBP. A clinically relevant and persisting pain reduction, a stable decrease in self-perceived disability, an improvement in both mood and affective characterization as well as sensory characterization of pain, muscle strength and endurance may have a significant impact on the management of LBP.

Prevalence of palliative care patients in emergency departments.

BACKGROUND: Emergency departments (ED) serve as a contact point for critically ill patients. According to experience, a fraction of patients visiting ED present with palliative symptoms and require palliative care; however, the prevalence of these patients has not been determined in Austria so far. METHODS: In the ED of a tertiary care medical centre in Carinthia all adult patients presenting between 8 January 2018 and 17 January 2018 were classified on arrival with the Manchester triage system (MTS) and were afterwards assessed with a validated 2­tier screening tool for palliative care. Patient records were screened in April 2018 to find out whether they received palliative care. RESULTS: In total 1277 patients visited the ED during the investigation period. Of these patients 1096 were screened and 145 of these patients (13.2%) showed palliative symptoms and needed a goal-oriented therapy. Of these 145 patients 10.9% were assessed by MTS as emergency, 2.7% as very urgent, 34.7% as urgent, 51% as normal, and 0.7% as not urgent. Only 8 (5.5%) of the patients with palliative medical symptoms actually received palliative care consultation. CONCLUSIONS: More than 1 in 10 patients attending an ED suffered from palliative symptoms. Hence it is to be expected that healthcare providers in an ED in Austria will frequently encounter patients with palliative symptoms in emergency admissions. Therefore, it is necessary to develop suitable structures to provide these patients with the best possible care.

[Long-term experience with Collagenase Clostridium Histolyticum (CCH, Xiapex®) for the treatment of Dupuytren's contracture: lessons learned]. / Langzeiterfahrung mit Collagenase Clostridium Histolyticum (CCH, Xiapex®) zur Behandlung der Dupuytrenschen Kontraktur: Lessons learned.

INTRODUCTION: CCH (Collagenase Clostridium Histolyticum; Xiapex®) has become established as a simple and reliable alternative to traditional treatments for Dupuytren's contracture. This study aims to analyse our results and discuss our modifications of this therapy. PATIENTS AND METHODS: The study included 312 fingers treated with CCH between 2011 and 2018 (256 patients; 225 men and 31 women). There were 157 fingers (50.3 %) with an isolated joint contracture, while multiple joints were affected in 155 fingers (49.7 %). The average age at surgery was 65.8 years. The follow-up period averaged 41.2 weeks. A retrospective data analysis evaluated our results and the effect of our technical modifications on treatment success. RESULTS: The average presurgical degree of contracture was 63.3 degrees. The average contracture reduction compared to the initial value was 94 % immediately after surgery and 81 % at the last follow-up. There were skin cracks in 22.1 %. The postsurgical course was uneventful in 99.4 %, with minor complications in 0.6 %. The recurrence rate was 14.4 % Extension of the time interval until stretching (24 vs. 48 hours) had no significant effect on the immediate success rate or the rate of skin lesions. CONCLUSIONS: If the indication is chosen correctly and the treatment is performed by an experienced surgeon, the success rate with CCH is comparable to other current treatment options.

Long-term improvement of the bio-psycho-social state of cancer patients after 3 weeks of inpatient oncological rehabilitation : A long-term study at the Humanomed Zentrum Althofen.

A 3-week cancer rehabilitation program was conducted at the Humanomed Zentrum Althofen, comprising therapy of organic defects, lifestyle modification, and psycho-social support. Therapeutic efficacy was assessed in comprehensive surveys before and after the therapy, and after 6 and 12 months. The study covers a 5-year period with data from 3233 patients. Parameters of subjective health assessed according to the European Quality of Life - 5 Dimensions (EuroQol EQ-5D) standard and signifying quality of life showed significant improvement both immediately after the therapy, and after 6 and 12 months. Anxiety and depression, assessed according to the Hospital Anxiety and Depression Scale, were significantly and persistently diminished, and the sense of coherence elevated. Therapeutic success was somewhat dependent on socio-economic parameters, but was largely independent of income and cancer type. This study thus clearly documents the significant efficacy of a rehabilitation treatment based on bio-psycho-social concepts, which may be further improved by additional ambulant or stationary care.

Treatment of localized neuropathic pain of different etiologies with the 5% lidocaine medicated plaster - a case series.

OBJECTIVE: To assess the efficacy and safety of the topical 5% lidocaine medicated plaster in the treatment of localized neuropathic pain. STUDY DESIGN: This was a case series at an Austrian pain clinic, using retrospective analysis. PATIENTS AND METHODS: Data of 27 patients treated for localized neuropathic pain with the 5% lidocaine medicated plaster were retrospectively analyzed. Assessment included changes in overall pain intensity, in intensity of different pain qualities, and of hyperalgesia and allodynia, and changes in sleep quality. RESULTS: Patients (17 female, ten male; mean age 53.4±11.4 years) presented mainly with dorsalgia (16 patients) or postoperative/posttraumatic pain (seven patients); one patient suffered from both. The mean overall pain intensity prior to treatment with lidocaine medicated plaster was 8.4±1.2 on the 11-point Likert scale. In the majority of cases, the lidocaine plaster was applied concomitantly with preexisting pain medication (81.5% of the patients). During the 6-month observation period, overall mean pain intensity was reduced by almost 5 points (4.98) to 3.5±2.6. Substantial reductions were also observed for neuralgiform pain (5 points from 7.9±2.6 at baseline) and burning pain (3 points from 5.2±4.1). Sleep quality improved from 4.6±2.6 at baseline to 5.5±1.8. Stratification by pain diagnosis showed marked improvements in overall pain intensity for patients with dorsalgia or postoperative/posttraumatic pain. The lidocaine plaster was well tolerated. CONCLUSION: Overall, topical treatment with the 5% lidocaine medicated plaster was associated with effective pain relief and was well tolerated.

Treatment of localized neuropathic pain after disk herniation with 5% lidocaine medicated plaster.

OBJECTIVE: To assess treatment with the 5% lidocaine medicated plaster for peripheral neuropathic pain after disk herniation. STUDY DESIGN: Case series, single center, retrospective data. PATIENTS AND METHODS: Data of 23 patients treated for neuropathic pain with the lidocaine plaster for up to 24 months after a protrusion or prolapse of the cervical, thoracic, or lumbar vertebral disks were retrospectively analyzed. Changes in overall pain intensity, in intensity of different pain qualities and of allodynia and hyperalgesia were evaluated. RESULTS: Patients (14 female/nine male, mean age 53.5 ± 10.4 years) presented with radiating pain into the abdomen, back, neck, shoulder, or legs and feet with a mean pain intensity of 8.3 ± 1.5 on the 11-point Likert scale. Mean treatment duration was 7.6 months; 52% of the patients received lidocaine plaster as monotherapy. At the end of the observation, mean overall pain intensity had been reduced to 3.1 ± 1.8. All other parameters also improved. The treatment was well tolerated. CONCLUSION: These results point to a safe and effective treatment approach with 5% lidocaine medicated plaster for localized neuropathic pain related to disk herniation. However, owing to the small sample size, further investigation in a larger-scale controlled trial is warranted.

[Dementia and pain]. / Demenz und Schmerz.

Dementia has been associated with disturbed pain processing and an impaired ability to provide self-reported ratings on pain. Patients with cognitive impairment have been shown to receive pain treatment less frequently than cognitively unimpaired individuals. Comorbidity is common in patients with dementia and a major factor contributing to pain. This demonstrates that a structured evaluation and categorisation of pain is mandatory for the treatment of older patients and that care should be taken to note indirect signs of pain. The appropriate scales are available and we propagate their application. Multimodal pain therapy is superior to one-dimensional approaches. A discussion of the effects and interactions of the analgesics presently available for geriatric care forms an integral part of this review.

[Cancer pain from the nurses' perspective--findings from Austria]. / Tumorschmerz aus Sicht der Pflege--Befunde aus Osterreich.

The present study addresses the issue of cancer pain from the perspective of Austrian nurses. By the means of a standardised questionnaire 332 nurses (79 percent female, 63 percent with age < 40) were asked about causes and triggers of cancer pain, patients' burden of pain, used analgesics and their side effects, and the authority by whom they want to be informed about an own malignant disease. The respondents mentioned a wide range of causes, triggers and multipliers of cancer pain. According to the respondents, most cancer patients experience pain that exceeds the degree of pain a person can bear. Many side effects of use of analgesics are observed. In case of an own malignant disease the majority of the interviewees would like to be informed by a physician. The results point out that nursing personnel is aware of the patients' burden of pain, but at the same time they show the need for improvement at clinical pain management and in the area of vocational training and advanced nursing education.

Modified lateral block of the suprascapular nerve: a safe approach and how much to inject? A morphological study.

BACKGROUND AND OBJECTIVES: This paper presents an evaluation of a modified lateral suprascapular nerve block with easy orientation, low risk of displacement of the needle, and with an assessment of 2 different volumes to propose an ideal volume for a successful block. METHODS: Both shoulders of 34 cadavers were investigated. Insertion point of the needle was determined in the angle of the lateral end of the clavicle, acromion, and the spine of the scapula. The needle was directed toward the medial, dorsal, and caudad direction. Ten mL of diluted contrast agent for computerized tomography was injected in the 34 right sides (group A) and 5 mL in the 34 left sides (group B). Immediately after injection, all shoulders were investigated by computerized tomography scans and 3-dimensional reconstruction to document the constrast dissemination. Five sides of each group were injected with colored contrast and dissected after computerized tomography investigation. RESULTS: Group A showed a distribution to the entire supraspinous fossa in all cases and the contrast was pressed out of the suprascapular notch in 4 cases with a maximal extension into the axillary fossa in 3 cases. In group B, the supraspinous fossa was filled in 24 cases, with a maximal extension to the axillary fossa in 2 cases. In 9 cases, the contrast agent stayed in the lateral half of the supraspinous fossa. In 1 case we had a medial spread only which still surrounded the suprascapular notch, in another case a superficial spread with misplacement of the needle. CONCLUSION: Based on this cadaver study, the lateral modified approach appears to be a safe technique for a suprascapular nerve block, which might be preferred as a single shot technique. A 5 mL volume appears sufficient to fill the supraspinous fossa and to reach the suprascapular nerve, which branches in this anatomical compartment.