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Nerve blocks, indwelling catheters and infiltration

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ARE EPIDURAL STEROID INJECTIONS SAFE?

G. Bonetti*, M. Barbien, R. Bettaglio*, L. Demartini*. D. Miotti, L. Paulin* and C. Bonezzi, Pain Management Unit, IRCCS Fon-dazione Maugeri, via Ferrata 8, 27100 Pavia, Italy

Aim of Investigation: To evaluate the presence and the incidence of side effects due to epidural steroid injections in patients suffering with radicular pain.

Methods: 25 consecutive patients with radicular pain candidate for a epidural steroid injection treatment (methylprednisolone SOmg) were enrolled. Patients were divided into two groups: Group A received oral misoprostol 200mcg twice a day as gastroprotection against steroid and Group B received oral placebo twice a day during all the observation period. For every patient we measured glucose serum level and symptoms ofgastropathy (anamnesis and physical examination of the abdomen) before and after every epi-dural steroid injection (one week interval) in order to evaluate the presence of eventual hyperglicemia or gastric damage due to the treatment. ANOVA for repeated measures was applied to the glucose serum levels.

Results: We observed an increment between basal glucose serum levels and after the first (p=0.018) and the second (p=0.036) epidural injections, with a linear growth (p=0.056). No patients showed evidence of gastric symptoms.

Conclusions: Even though from a strictly statistical point of view the difference between the value ofglycemia before and after the treatment are significative, it is important to note that the values remained always in a safe range of values. In fact the maximum value was 1 lOmg/dl which is borderline between normo- and hy-pcr-glycemic status. We conclude that epidural steroid injections are safe as regard glucose serum levels and symptoms ofgastropathy.

TREATMENT OF THE GREATER OCCIPITAL NEURALGIA AFTER WHIPLASH INJURY

Alessandro Cesaroni. PierVittorio Nardi*, Umberto Agnllo*. Neu-rosurgical Division "S. Pertini" Hospital 00157 Rome. Italy

Aim of Investigation: The most common cause for the persistence ofalgesic symptomatology after whiplash injury is Arnold's greater occipital nerve neuralgia. We have studied a new conservative treatment for this pathology that seriously affecting working activity and relationships of patients.

Methods: From June 1996 to June 1998 we have treated 58 patients (46F-12M) suffering from greater occipital neuralgia arising after a whiplash injury and persisting for over 6 months (range 8-24). XR examination of the cervical spine was earned out on every patient as to exclude osteo-ligamcntal lesions. In all of the cases an anesthetic block of the nerve was practised using mepivacaina 2% repeating it 7 days later and established a specific pharmacologic treatment with gabapentin from initial 300 mg dose to 900 mg/day.

Results: By using this treatment we have had an improvement in 50 patients (86%) in a period ranging from 2 to 6 weeks. In 8 cases (14%) the painful symtomatology not being solved, alcoholization (4 cases) or radiofrequency (4 cases) was performed with satisfaction in 7 cases; in all of them pharmacology therapy was maintained. Surgical treatment was never necessary in this cases.

Conclusions: Anesthetic bloc discontinued the painful stimulation and permitted the restoration of the endogenous analgesia. The gabapentin's usage appears to be, as for other neuropathic pain, the best treatment leading to the resolution of painful in 80% of the patients. Whenever neuralgia persist, good results can be achieved by the nerve alcoholization or radiofrequency lesion along with the gabapentin treatment.

INFLUENCES OF STELLATE GANGLION BLOCK ON THE CELLULAR IMMUNEFUNCTION

Fu Zhijian*. (SPON: Y-X Yuan) Dept of Pain Management, Shan-dong Provincial Hospital, 324 Jingwulu Weiqilu, 250021, Jinan, Shandong Province, P.R.China

Aim of Investigation: To study the influences of stellate ganglion block (SGB) on the cellular immune function.

Methods: 35 patients suffered from headache were selected to receive SGB once a day for 7 days by the route ofparatrachea. The solution contained lidocaine 2% 4ml, VitB^OO u.g and VitB;, lOOmg. T lymphocytes including CD,, CD.i, and CDg.RBC-CsbR, RBC-1C and plasma level ofcortisol were observed respectively before and after SGB.

Results: CD4 (%) was significantly ascended after SGB (P<0.05), there was no difference before and after SGB with CD3 (%) and CDg (%). RBC-CjbR was markedly elevated after SGB and maintained at a high level for the seven days (P<0.05); there were no differences of RBC-1C before and after SGB. And the plasma level ofcortisol declined markedly after SGB and kept at a low level for the seven days. There was no correlation between the RBC-C3bR and the plasma level ofcortisol (r =- 0.126, P>0.05).

Conclusions: SGB is used widely in the pain clinic for several kinds of headache, but the mechanism is unknown. CD4 (%) is one of the most important factors in the immune reaction since it is an initiating factor that regulates the immune balance of body and has an activating effect. C^R is a main part of the red cell immune that plays an important role in the immune system of body. The results indicate that SGB can improve the immune function including T lymphosytes and red blood cell. Probably these changes are regulated partially by complex immunologic homeostasis.

Acknowledgments: Supported by a MONSANTO Co.

EVALUATION OF CERVICAL EPIDURAL BLOCKADES IN VARIOUS PAIN SYNDROMES.

Gryncewicz*. Wojcicch Bozyk, W. Kryda*, M. Suchorzewski*, (SPON: M. Hilgicr), Multidisciplinary Pain Clinic, Nicholas Copernicus Hospital, ul. Nowe Ogrody 1-6, 80-803 Gdansk, Poland.

Aim of Investigation: Our investigation focused on efficiency of the cervical epidural blocks in various pain syndromes.

Methods: We analysed 90 patients. 102 cervical epidural blockades were done and we used for that, 1% Lignocaine solution with addition of methylprednisolone or betamethasone. These blockades were done, because of various pain syndromes - mostly cervical and cervico-brachial pain syndromes (52 patients). Blocks efficiency was estimated in: VAS and verbal pain scores.

Results: In majority of patients we achieved clear improvement. Before the blockade the mean estimation of the pain intensity was 7,8 points in VAS scale, but after blockade it decreased to the mean value - 4,8 points in VAS scale. The obtained results were statistically significant. We did not find any complications due to the blocks which we had done so far.

Conclusions: Cervical epidural blockade with steroids application is an effective method of pain treatment in various chronic pain syndromes.

EFFICACY OF THERAPEUTIC REGIONAL ANESTHESIA AS PART OF A MULTIMODAL TREATMENT PROGRAM IN A MULTIDISCIPLINARY PAIN CENTER: INFLUENCE OF THE DEGREE OF CHRONICITY ON THE EFFICACY OF REGIONAL ANESTHESIA.

Michael Hahn* (Spon: Paul Nilges), Bemd Nagel, H. U. Gerber-shagen, DRK-Schmerz-Zentnim, Aufder Steigl4-16, D-55131 Mainz, Germany

Aim of Investigation: Therapeutic regional anesthesia (RA) is a frequently used method in the treatment of chronic pain. In our multidisciplinary pain center RA is mainly used to facilitate physiotherapy (as a part of a standardized therapeutic program). We evaluated retrospectively pain relief and its duration with different methods ofRA, pain relief and possible relations between efficacy and the degree ofchronicity of pain.

Methods: Details of the techniques, e.g. dose and type of local anesthetic, are routinely documented in our EDP system, just as the data about severity of pain (VAS), pain relief (VAS) and the degree ofchronicity measured using the Mainz Pain Staging System (MPSS). Data from 1993 to 1998 were analysed using programs of SPSS.

Results: In total 14221 blocks were performed, including 6750 (47,5%) infiltration anesthetics, 3994 (28,1%) nerve- or plexus-blocks, 815 (5,7%) spinal or epidural blocks, 987 (6,9%) sympathetic blocks and 1675 (11,0%) others. The mean pain relief was 52,3%, the mean duration of pain relief was 7,8 h. 3285 patients were treated with an average of 4,33 blocks. The resulting mean pain relief ranged from 36,9% for skin-wheel-raising to up to 78,2% for spinal anesthesia. Only for the group of infiltration techniques (muscles, tendons, ligaments, joints) the relationship between pain relief and the degree ofchronicity was statistically significant.

Conclusions: Relief of pain by RA decreases with increasing degree ofchronicity. This can be proven for infiltration anesthesia, but not for more invasive techniques like nerve blocks, spinal and epidural anesthesia or sympathetic blocks. The most marked pain relief was obtained by the most invasive techniques. Considering the degree ofchronicity the use of infiltration anesthesia is to be seen critically.

A CERVICAL FACET JOINT BLOCK FOR FACIAL PAIN.

Hiromi Hajiri*. Tomoko Otake*, Kazuhiro Toriumi*, Yoshikiyo Amaki, Dept ofAnesthesiology Jikei Univ School of Medicine, Nishi-shinbashi, Minatoku, Tokyo 105-8461, Japan

Aim of Investigation: Trigeminal nerve block is generally effective for a mandibular pain due to trigeminal neuralgia. However, some patients don't response to that block. The aim of this study is to demonstrate the cervical facet joint block is useful to mandibular pain in patients whom trigeminal nerve block were not effective.

Methods: The position of patient is lateral position (diseased side up and pillow below the head). Under fluoroscopic guidance, a 23G, 6cm sharp needle was directed towards upper facet joints. One ml iotrolan (51%) was injected and patient's response was reported, then one ml mixture of 1 % mepivacaine and betameth-azone 0.5mg was injected. This study was approved by our hospital ethical committee and a written informed consent was taken. Ten patients with mandibular pain were studied. These patients were asked to report any pain or other sensations during the procedure, for one week later and whenever they have pain following the procedure.

Results: Nine patients reported the same pain after contrast medium injection. They also reported no pain after local anesthetics injection. Only one patient reported no pain or any other sensation during both contrast medium and local anesthetics injections. One week after the all nine patients didn't report any mandibular pain. One month later one patient complained mild pain. Another patient started to complain at 2 months, and the third one started to complain at 4 months after injection.

Conclusions: In this study, a cervical facet joint block was effective in 60% of patients with mandibular pain and was improved in 30% of them. We concluded that cervical facet joint block is an effective method in diagnosis and treatment of cases with mandibular pain.

THE PAIN CYCLE CANNOT BE BROKEN IN PERIPHERAL NEUROPATHIC PAIN

Wolfgang Hamann. Farid Salam, Teo Goroszniuk, Pierluigi di Vadi8, GKT Dept of Anaesthetics, Guy's Hospital, London SE1 9RT, UK and ^Dept of Anaesthetics, Univ Hospital Lewisham, London SE13 7HL, UK

Aim of Investigation: To test the hypothesis whether epidural anal-gesia with lignocaine can "break the pain cycle" in patients suffering from neuropathic pain.

Methods: 24 patients suffering from neuropathic pain following damage to peripheral nerves or spinal roots (23 cases) or posther-petic neuralgia (1 case) received epidural injections of 2% lignocaine (2 ml) preceded by an injection of saline as part of the loss of resistant technique. Severity of ongoing pain was recorded on the visual analogue scale (VAS 0-100 mm) every 5 minutes. Results: Mean pain score before the epidural injection with lignocaine was 59.25 (SD 13.3). Following delays between 10 and 30 minutes the mean pain score had dropped to 7.25 (SD 11.63) returning to 58 (SD 12.60) after a total duration between 30 and 300 min following injection. Return to pre-injection levels was complete or almost complete in all patients.

Conclusions: In none of the 24 patients investigated was there any evidence of an analgesic effect beyond the expected duration of direct pharmacological action of lignocaine. In the present setting of neuropathic pain there was no evidence that the pain cycle had been "broken" by the action of the local anaesthetic lignocaine alone. It is also interesting to note that in 4 patients of this group tested in this way there was hardly any placebo effect when saline was infused in a double blind controlled situation for a duration of 3 hours.

THE LUMBAR ROOT BLOCK BY THE OBLIQUE VIEW, A NEW APPROACH

Makoto Hashimoto*. Yutaka Masuda, Kenichirou Okamoto*, Hi-roshi Takemura*, Hitomi Higuchi*, Yasumasa Yuda*, Dept of Anesthesiology, Showa Univ School of Medicine, 1-5-8 Hatano-dai, Shinagawa-ku Tokyo, 142-8666, Japan

Aim of Investigation: We will present the lumbar root block by the oblique approach.

Methods: The patient lies in a prone position with a pillow under the stomach of surgical side. We adjust the fluoroscopy to align the body of target vertebra. Under fluoroscopy, the point of needling is between the tip ofdiapophysis and the bottom of vertebra. This point is about 5cm outside from the spinous process. Supposing a right-angled triangle to do in the pedicle of arch of vertebra, the processus articularis superior and the lower edge of vertebra, the needle is inserted toward the oblique line of this triangle. Radio-paque medium is infused if it can get lancinating pain to the nerve area of the purpose. We can confirm the target nerve under fluoroscopy, and infuse 2 to 3ml of 1% mepivacaine and 2mg ofdexa-methasone. The lancinating pain disappears according to infuse a local anesthetic. We can finish it within 5 minutes.

Results: We applied it by the oblique view to about 300 patients in a year. It could get lancinating pain with all the patients. We could confirm the target nerve with 80.3% of them under fluoroscopy. Few complications were recognized.

Conclusions: Usually, a root block is carried out under fluoroscopy in 2 direction. But we can perform the root block by our method only 1 direction, and certainly confirm the target nerve. We can carry out the root block by the oblique view safer, easier and earlier than a usual root block by the prone position.

NERVE ROOT BLOCK THERAPY: TREATMENT OF ACUTE HERPETIC PAIN AND POSTHERPETIC NEURALGIA

Seiyu Higa. Ruriko Ozawa, Tuneo Tatara*, Takehiko lijima*, Ya-suhide Iwao* Dept ofAnesthesiology, Kyonn Univ, 6-20-2 Shinkawa, Mitaka City, Tokyo 181 -8611, Japan

Aim of Investigation: Established postherpetic neuralgia (PHN) is often resistent to conventional therapy such as nerve block, acyclo-vir, antidepressants and NSAIDs. Nerve root block may be an effective treatment for PHN. We evaluated the therapeutic effects of nerve root block for acute herpetic pain (AHP) and postherpetic pain.

Methods: Forty-six patients were treated by nerve root block using 4 mg ofdexamethasone and 1% mepivacaine in a volume of 2 ml. Five patients had cervical herpes zoster (HZ) (AHP 2, PHN 3), 33 had thoracic HZ, (APH 16, PHN 17), and 8 had lumbar HZ (AHP 5, PHN 3). AHP is defined as its onset was less than three months, (24 patients; average 37 days. The other 22 patients were PHN; more than three months after onset, average 23 months. Its effect was evaluated using a visual analog scale (VAS) ofOto 10 (0-2 markedly effective, 3-5 effective, 6-8 slightly effective, 9-10 ineffective) at one month or more after nerve root block, or at the end point of treatment.

Results: The VAS score for APH was 2.6 on average (markedly effective in 13 patients, effective in 8, and slightly effective in 3), and that for PHN was 5.9 on average (significantly higher than APH; markedly effective in 3 patients, effective in 6, slightly effective in 9, and ineffective in 4).

Conclusions: Nerve root block for AHP is more effective than for PHN. It is possible that nerve root block may be used as a treatment for AHP and PHN.

ULTRASONOGRAPHY-GUIDED INFRACLAVICULAR BRACHIAL PLEXUS BLOCK IN THE SITTING POSITION AND THE EVALUATION OF CURRENT PERCEPTION THRESHOLDS.

S. Honjo, Pain Relief Unit, Jinwakai Hosp, Tokyo, Japan

Aim of Investigation: To estimate the effects of the color Doppler ultrasonography (CDUS)-guided modified infraclavicular brachial plexus block (m-IcBPB) in the sitting position for persistent upper extremity pain. Sitting position is preferred by obese and in the patients who may find the supine position intolerable.

Methods: Ultrasonographic examinations of the infraclavicular vessels and coracoid process were done using the linear probe (PLF-805 ST, PLF-703 ST/ NT, 7.5 MHz. TOS1BA, Japan). Pulmonary function was evaluated by FVC. Current perception thresholds (CPT) were measured on the 2nd finger tip with neu-rometer (Neurometer-CPT, Neurotron). 17 patients with persistent upper extremity pain participated in the study of the 56 m-IcBPBs. After visualization of the anatomy and the cold saline thermic stimulation induced paresthesia in forearm was elicited, 1% mepivacaine (0.3ml/kg) was injected.

Results: 11 of the 17 patients had complete resolution of the persistent pain (CRPS) and 6/17 patients had a VAS of 5-3/10 following a series ofm-IcBPBs. The mean CPTs with 5-Hz and 250-Hz stimulation were increased to greater than baseline after a series of the m-IcBPBs. There were no significant differences between pre and post block respiratory function in FVC. None of the patients showed hematoma, clinical symptoms ofpneumothorax or needle induced neurological sequelae after the blocks.

Conclusions: This clinical study suggests that the CDUS-guided m-IcBPB in sitting is easier than the method using B-mode ultrasonography and is a useful method for pain control of persistent upper extremity pain without phrenic nerve paralysis in obese patients.

PERIPHERAL NERVE BLOCKS WITH LOCAL ANESTHETICS ARE EFFECTIVE FOR TRIGEMINAL NEURALGIA THAT IS NOT ALLEVIATED WITH CARBAMAZEPINE.

Masako Iseki. Yutaka Tanabe, Hiromasa Mitsuhata, Toyo Miya-zaki, Dept ofAnesthesiology, Juntendo Univ School of Medicine, 3-1-3 Hongo, Tokyo, 113-0033 Japan

Aim of Investigation: To investigate the effectiveness of peripheral nerve blocks with local anesthetics on trigeminal neuralgia that was not alleviated with carbamazepine.

Methods: Patients suffering from trigeminal neuralgia on various branches of the nerve that was not alleviated with oral carbamazepine were treated with peripheral nerve blocks using local anesthetics including 2% mepivacaine, 0.5% bupivacaine or 0.1% dibucaine. A patient has experienced several occurrences of neuralgia on same or different branches of the trigeminal nerve, and each occurrence was counted as one episode. Effectiveness of the blocks was evaluated based on the criteria for Complete Response (no pain for >2 months; carbamazepine not necessary). Partial Response (able to conduct daily life with carbamazepine intake for >2 months), Minor Response (some difficulty in daily life), and Null (no effect).

Results: Seventy-three episodes occurred in 30 patients examined, Complete Response and Partial Response were 33% and 18%, respectively.

Conclusions: Peripheral nerve blocks with neurolytic agents are often selected despite their potentially detrimental side effects when trigeminal neuralgia is not alleviated with oral analgesics. Our present study demonstrated that nerve blocks using local anesthetics can effectively control many episodes of trigeminal neuralgia (51% of the total episodes) and should be considered not merely as a temporary relief but as a long-term pain control measure.

CONTINUOUS MAXILLARY NERVE BLOCK USING INDWELLING CATHETER

Hikaru Kohase*. Shigeru Ideguchi * Masahiro Umino*(SPON: M. Kawashima), Dept. of Dental Anesthesiology, Tokyo Medical Dental Univ, Tokyo, Japan, 113-8549

Aim of Investigation: To investigate the efficacy of the continues maxillary nerve block for perioperative pain control of radical maxillary sinosotomy.

Methods: The written informed consent was obtained from 8 patients undergoing elective radical maxillary sinusotomy. The clinical research board of the Tokyo Med. and Dent. Univ. approved this study. After sterilizing the skin of lateral portion of patients' face, the 22G block needle was inserted at the mandibular notch and advanced to the pterygopalatine fossa. Using catheter introdu-cer, 24G catheter were in-dwelled through the needle. Then General anesthesia was performed. During the operation, 2-5 ml of 1% lidocaine were administered through the catheter every 40min. For post operative pain control, 1% lidocaine or 0.25% bupivacaine were administered continuously or intermittently. We evaluated post-operative pain relief by visual analogue scale (VAS). Results: General anesthesia was performed on nearly 1-MAC of Sevoflurane in all patients. 7 of 8 patients was achieved the analgesia for 5 postoperative days. Evaluated VAS at the each time was less than 1.0 cm, except the removal of the gauze in nasal cavity. In one patient, the analgesia was effective during only 2 days due to displacement of catheter by face swelling. No other complication was found.

Conclusions: A new method of catheter indwelling continuous trigeminal nerve block were useful for penoperative pain management in oral surgery.

Acknowledgments: Supported by Grant for Sci.Res. Edu.Min. of Japan 08672291.

EFFECTS OF CONTINUOUS EPIDURAL INFUSION OF LOCAL ANESTHETICS ON ACUTE ZOSTER PAIN - A PROSPECTIVE, RANDOMIZED, DOUBLE-BLIND, MULTICENTER STUDY

Haruhiko Manabe. Kenjiro Dan*, Kazuhiko Hirata*, Kohichi Hori*, Kazuo Higa*, Yutaka Masuda** and Hitomi Higuchi**, Dept ofAnesthesiology, Kitakyushu Municipal Hosp, Fukuoka Univ Hosp*, Showa Univ Hosp**, Fukuoka JAPAN.

Aim of Investigation: To assess the influence of continuous epidu-ral infusion block (CEIB) techniques on the duration of acute zoster pain (AZP) compared with intermittent epidural block (IMEB) techniques.

Methods: After institutional approval and informed consent, 61 patients, 50 years of age or older, within 10 days after onset were included. Patients were admitted and randomly allocated into 2 groups, either CEIB or IMEB group. Patients in CEIB received continuous infusion of 0.5% bupivacaine through the epidural catheter, 0.5-1.0 ml/hr. for 7-20 days and patients in IMEB received placebo. All the patients also received intermittent epidural injection of local anesthetics, 3-5 times daily until AZP decreased to 0-2 on VAS of 10 and oral acyclovir 4.000mg/day for 5-7 successive days. Patients were treated until resolution of the pain.

Results: The duration of treatment was significantly shorter with CEIB group than IMEB group (p<0.05). Allodynia persisted on 3 patients in IMEB and none in CEIB.

Severity of the disease Moderate lesion IMEB(17)CEIB(17) Severe lesion 1MEB(13)CEIB(15)
Mean age (years) VAS at baseline Mean duration of treatment (days) 59.4 6.7 38.0 66.0 6.7 25.9* 69.8
6.7 43.8
68.1 6.7 32.4*

*P < 0.05 compared with IMEB

Conclusions: The continuous pain relief with CEIB has a role of preventing neural sensitization of dorsal root ganglion and shortening the duration of AZP.

DOES STELLATE GANGLION BLOCK INDUCE "BORROWING-LENDING" HEMODYNAMIC PHENOMENON CLINICALLY?

K. Murakawa. S. Maeda*, M. Matsuda*, K. Fu*, H. Kakiuchi*, C. Tashiro* and R. Izumi*, Dept. ofAnesthesiology, Hyogo College of Medicine, Nishinomiya, Hyogo, 663-8501, Japan

Aim of Investigation: The therapeutic effect of stellate ganglion block (SGB) is partly brought about by vasodilation and improvement in blood flow to the affected region, but unilateral sympa-thectomy might increase blood flow ipsilaterally and simultaneously decrease flow on the contralateral side. The compensatory distribution of blood flow is called "borrowing-lending" phenomenon, about which few reports concerning SGB were elucidated. In this study, the effects of unilateral SGB on blood flow in bilateral facial and palmar cutaneous tissues were determined clinically.

Methods: Thirty patients with informed consent underwent SGB with 8 ml of 1% mepivacaine. The cutaneous tissue blood flow was measured using a laser Doppler tissue blood flowmeter. Facial blood flow was examined in 15 cases, and palmar blood flow was determined in another 15 cases before and after SGB for 120 mm. on both sides.

Results: The facial cutaneous tissue blood flow in the ipsilateral sides increased significantly 20 min. after SGB and reached its highest value of 142.67.9%. This high level was maintained 90 min. after SGB. No significant changes were observed on the con-tralateral side. Palmar blood flow ipsilateral to SGB also showed marked increase 10 min after SGB and reached a peak of 135.76.2%. This increase persisted 75 min. after SGB. There was no significant change in palmar blood flow contralateral to SGB.

Conclusion: From the present study, unilateral SGB does not cause significant decrease of cutaneous tissue blood flow in the contralateral face and palm. It is suggested that "borrowing-lending" hemo-dynamic phenomenon might not be induced by SGB clinically.

NOVEL TECHNIQUE FOR CONTINUOUS SUPERIOR HYPOGASTRIC PLEXUS BLOCK IN THE TREATMENT OF CHRONIC ORCHALGIA

Sunil J. Panchal, M.D., Dept ofAnesthesiology/CCM, Johns Hop-kins Univ School of Medicine, Baltimore, MD

Introduction: Superior hypogastric plexus (SHP) blockade and neurolysis have been used in the treatment of pelvic cancer pain.' Patients with chronic non-malignant testicular pain have not been well studied for therapeutic response to superior hypogastric plexus block. A novel technique is described to achieve continuous blockade of the superior hypogastric plexus for analgesia in a patient with chronic benign orchalgia.

Patient History: A 28 year old male with an eight year history of left testicular and groin pain secondary to epididymitis had an increase of pain after surgical epididectomy. Excellent short-term relief was achieved with single-shot superior hypogastric plexus blockade. Therefore a novel continuous technique was attempted. Technique: Using aseptic technique and fluoroscopic guidance a 20 gauge 8" Tuohy needle was placed at the level of the cephalad margin of the L4 vertebral body approximately 9 cm lateral to the midline. The needle was advanced to a point 1 cm anterior to the L5-S1 intervertebral disc. A 24 gauge pediatric epidural catheter was inserted 5 cm beyond the needle tip, and appropriate spread of contrast confirmed good catheter placement. Injection of 10 ml 0.25% bupivacaine resulted in complete relief of testicular pain.

Patient Course and Results: Preoperatively the patient complained of left testicular pain with an 8-9/10 intensity, with interference with work, sleep, and had inadequate symptom management with opiate and TCA therapy. The patient returned to the pain center daily for repeat injections with 0.25% bupivacaine for one week. Pain intensity after catheter discontinuation was 1-2/10 with improved activity, and no further requirements for opiates. Follow-up at three months, six months, and one year revealed that the patient had maintained an active lifestyle, returned to full employment involving physical labor and with continued pain relief at 1-2/10.

Conclusion: Patients with chronic non-malignant visceral pelvic pain may benefit from a continuous neural blockade technique as an additional tool to systemic pharmacotherapy. Continued study to evaluate potential advantages of this novel technique in a prospective manner is warranted.

Reference: 1) Plancarte R, et al. Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Reg Anesth 22:562-8, 1997.

COMPARISON OF THE LUMBAR AND EPIDURAL APPROACHES TO THE EPIDURAL SPACE USING FLUOROSCOPY

Cathy Price. Alison Prosser*, Peter Rogers, Pain Clinic, Portsmouth, P03 SLY

Aim of Investigation: To determine the accuracy of two methods of approaching the epidural space.

Methods: 200 patients attending for epidural steroid injection in an outpatient based pain clinic were randomised into 2 groups - the lumbar approach (L) and caudal approach (C) - to the epidural space. Exclusions included requests for X-ray screening or a specific approach. The epidural space was clinically identified. An epidurogram was then performed by an experienced anaesthesiolo-gist (>50 epidurals). Accuracy of needle placement and potential patient and operator factors influencing the result were recorded. Results: The groups were matched for age, sex and diagnosis. Group L had a success rate of 94%. The false positive rate was 3% -2 were in the paravertebral space and 1 in the interspinous ligament. Accidental dural puncture rate was 1%. Group C had a success rate of64%(p<0.001 between groups). The false positive rate was 17%. There were 5 accidental intravenous injections, 3 of which were not identified before screening. Obesity was the only predictor of failure in this group (odds ratio for BMI>30 =3.92 (95%C.I. 1.48,10.47)).

Conclusions: Lumbar epidurals can be accurately placed without x-ray screening. Caudal epidurals require x-ray screening to be accurately placed. In addition, intravascular needle placement cannot be excluded on clinical grounds alone. The weight of the patient needs to be considered when planning a caudal epidural.

GASSERIAN GANGLION BLOCK TREATMENT ON OPHTHALMIC HERPES ZOSTER IN RASH STAGE (PRELIMINARY REPORT)

Juan Jose Rios-Girard. Hospital Comunitano Regional de Coatza-coalcos, Veracruz, Mexico. C.P.: 96500.

Aim of Investigation: Ophthalmic Herpes Zoster can be so devastating and associated with a poor and/or late treatment the severe acute ophthalmic lesions may turns into chronicity, supervening and lingering for up to ten years and may appears at any time in Rash stage, or weeks or months later. We have blocked the Gasse-rian Ganglion affected with steroids and local anesthetic with the principal goal to evaluate their effects on ophthalmic lesions evolution.

Methods: 60 patients were treated with Gasserian Ganglion block on affected side using Hartel's anterior approach technique injecting Bupivacaine and Betametasone. This 60 patients were classified into two groups: Older than 50 years (18 cases, 30 %) and younger than 50 years (42 cases, 70 %) with Ophthalmic Herpes Zoster in Rash stage diagnosis, with several ophthalmic lesions ranging from trivial to devastating.

Results: We noted in all patients the day after performed Gasserian Ganglion block, a marked diminution on the seventy of the ophthalmic lesions, with drastic changes on skin lesions going from Rash to Resolution stage. The most important and significant finding was that the patients did not present any ophthalmic SEQUELAE when this was performed within the first seven days of Rash onset. Patients blocked after this time they do developed one or more ophthalmic SEQUELAE.

Conclusions: The early performance of this procedure produced in hours a very significant clinical improvement on ophthalmic and skin lesions, preventing from any chronic ophthalmic lesions.

NEUROLOGICAL SEQUELAE AFTER SPINAL BLOCK FOR CAESAREAN SECTION

M. Rorarius'. M. Haanpaa2, P. Suominen'*, P. Pajunen3*, R. Tui-mala3', G. Baer'', 'Dept Anaesthesiol & Clin. ^Neurology & Clin. ^Obstet Gynaecol, Univ Hospital, Tampere, Finland

Aim of Investigation: To evaluate prospectively the incidence and type of transient neurological symptoms (TNS) and other neurological sequelae after spinal block with heavy bupivacaine for cae-sarean section (CS).

Methods: In 200 patients scheduled for elective or emergency CS performed under spinal block with heavy bupivacaine (5mg/ml, mean 12.5 mg) we recorded all complications during anaesthesia and postop until leaving home (usually 6th postop day). The patients filled out a questionnaire on the first and fifth postoperative day. In case of complaints typical for neurological symptoms they were checked first by the anaesthesiologist and, in case of persistent symptoms, thereafter by a neurologist.

Results: 15 of 197 (7.6%) mothers complained of TNS in the lower back, buttocks and/or legs during the 1-3 post-op days, lasting 1-2 days. In one mother (emergency CS, partus protractus) and another mother (elective CS, sectio antea) sensory abnormalities compatible ofneurotoxic sequelae were found. Both mother had no signs ofparaesthesia during lumbar puncture. Their symptoms have persisted now for now 2 years. One mother (emergency CS, partus protractus) had signs of a slight sacral plexus lesion. The only common risk factor identified was the use of heavy bupivacaine.

Conclusion: In contrary to non-pregnant patients, where the incidence of TNS after spinal bupivacaine is negligible', pregnant women seem to be more sensitive to the neurotoxic action of bupivacaine. 1. Freedman JM et al Anesthesiology 1998;89:633-41

A NATIONAL SURVEY ON THE CURRENT USE OF FLUOROSCOPY IN U.S. ACADEMIC PAIN CENTERS

Ashok K. Saha, Jean-Louis Horn, Vanderbilt Univ Medical Center, Dept of Anesthesiology, Nashville, TN 37232, USA

Aims of Investigation: To investigate current use offluoroscopy in academic pain centers in the U.S.A.

Methods: We sent a standardized questionnaire to each Pain Fellowship program in the U.S.A. listed in 1998 ASRA directory.

Results: Among 93 programs 19 responses were received. The results show (meanSd): for each center 4.22.2 persons are performing the blocks, among them 2.62.8 (62%) received formal training in fluoroscopy, 2.48 (56%) received a radiation safety course and 3.52.6 (82%) wear radiation badges. Numbers of centers where fluoroscopy units are situated in pain clinics: 10. Preferred location offluoroscopy: pain clinics: 12 centers, operating rooms: 3 and radiology: 1. Monthly, each center sees 6035.1 new patients, 318233.7 return visits, and performs 126.569.7 blocks, 68.548.5 (54%) under fluoroscopy. Four centers perform all blocks except stellate ganglion under fluoroscopy. All centers perform sacroiliac, lumbar sympathetic, hypogastric and facet blocks under fluoroscopy. Two centers perform celiac plexus block under CT, all others under fluoroscopy. Other procedures performed under fluoroscopy are as follows: stellate ganglion blocks: 2 centers, lumbar epidurals: 4 centers, caudal 7, cervical 5, and thoracic 4. Ten directors want to expand the use offluoroscopy, 2 believe it increases safety, and 1 avoids fluoroscopy in epidurals because of expense. Radiation safety course is not offered in one institution.

Conclusions: Large discrepancies exist between centers. More training in fluoroscopy, radiation safety, and regular use of badges are deemed necessary. More study will establish guidelines for fluoroscopy use for each procedure.

NERVE BLOCKS FOR CANCER PAIN.

Dr. Sushila Shah* (SPON: S. Sanghvi) Jagjivanram Hospital, Mumbai 400008, India

Aim: To evaluate the results of nerve blocks done for cancer pain.

Method: This is retrospective analysis of nerve blocks done for cancer pain during 7yr period 1987 to 1993 at Tata Memorial Hospital. Pain relief was evaluated as good (> 50%), fair (30-50%), poor (< 30%).

Results: There were 628 patients, 381 (60.7%) males, 247 (39.3%) females in whom 830 total blocks were done. The common nerve blocks done were, head & neck blocks 296 (35.7%), coeliac plexus blocks 158 (19%), Epidural Phenolization 95 (11.4%) Epidural Narcotics 90 (10.8%), Intercostal nerve blocks 69 (8.3%), Sub-arachnoid blocks 59 (7.1%). Epidural phenolization was done at thoracic (72 cases) or lumbar (31 cases) level. For pain due to pelvic malignancies lumbar phenolization was utilised, where as for pain of cancer lung or esophagus thoracic phenolization was done. In head & neck cancer pain, nerve blocks are sometimes very useful in relieving lancinating pain. Initially LA is used & then neurolytics, namely absolute alcohol or 5% aqueous phenol are used for blocks. The overall pain relief was good in 64%, fair in 26% & poor in 10%.

Conclusion: Nerve blocks are useful in relief of intractable pain in advanced cancer. The coeliac plexus blocks for upper abdominal malignancies were the most effective with good pain relief in 81.6%, fair in 15.2%, & poor in 3.2%. Nerve blocks give long lasting pain relief & reduce the dose of narcotics.

PREDICTING THE DIFFICULT NEURAXIAL BLOCK (NAB): A PROSPECTIVE STUDY

Juraj Sprung*. Denis L. Bourke* (SPON: Jeffrey Grass) Dept of General Anesthesiology, The Cleveland Clinic Foundation, Cleveland, Ohio, 44195 USA

Aim of Investigation: Anticipated technical difficulty is one of the many factors that can influence the anesthesiologist's decision to perform neuraxialspinal or epiduralblockade. This study was designed to determine if any patient characteristics would be useful in predicting a difficult NAB.

Methods: We studied prospectively 595 patients over 1 year (1997) receiving NAB. Before the procedure, the following data were noted: subjective assessment of body habitus (normal, thin, muscular, obese), spinal landmarks (goodeasily palpable spinous landmarks; poordifficult to palpate landmarks; noneunable to positively identify landmarks), and apparent spinal anatomy (assessed as normal or deformed). We also recorded whether the measures of difficulty i.e., if the procedure was completed at the first level (first-level success, FLS) or another spinal level attempt was required, and the total number of new skin punctures (spinal attempts, SA) necessary to successfully complete the NAB.

Results: The quality of landmarks best correlated with technical difficulty in achieving NAB, by both criteria, achieving FLS (P< 0.02) and by number ofSA (P<0.001). The presence of abnormal spinal anatomy correlated with difficulty only as measured by number ofSA (P<0.001). Body habitus, in the progression normal (1 spinal attempt)-thin (1.4 spinal attempt)-muscular 2.2 (spinal attempts)-obese (2.9 spinal attempts), also correlated with difficulty but only measured by number ofSA (PO.001) and there was no significant difference between adjacent habitus classifications.

Conclusions: An examination of the patient's back for the quality of landmarks is the best predictor of the ease or difficulty in achieving NAB.

CHANGES IN ANXIETY AND PAIN ANXIETY IN PATIENTS UNDERGOING DIAGNOSTIC PROCEDURES.

Peter S. Staats. Cheryl Bernstein, Fred Luthardt*, Hamid Hekmat*, Johns Hopkins Pain Treatment Center, Johns Hopkins Univ, Baltimore, MD, 21205, USA

Aim of Investigation: To evaluate overall anxiety and pain anxiety in patients receiving diagnostic neural blockade procedures.

Methods: Patients receiving nerve blocks were asked to rate their pain and anxiety on a scale (0- 10) before, during, and 20 minutes after a diagnostic block procedure. Pain anxiety was measured with the Pain Anxiety Symptoms Scale (PASS)' prior to and 20 minutes after the procedure.

Results: There was a significant reduction in pain scores after the diagnostic block (7.0 pre-procedure vs. 2.4 post-procedure, p<0.05). Subjective overall anxiety responses were also significantly decreased after the neuro-blockade procedure (5.2 pre- procedure vs 1.8 post-procedure, p>0.05). Additionally, mean pain anxiety as measured with the PASS decreased significantly (93.5 pre-procedure to 82.0 post-procedure. p<0.05). We observed that patients with the highest reported subjective anxiety demonstrated the greatest reduction in PASS scores after their blocks.

Conclusions: Chronic pain is a multdimensional disease contributed to by both nociceptive input and emotional state(s)2. The relief of anxiety may result in pain reduction especially in those with high anxiety for pain3. Physicians frequently attribute relief of pain following diagnostic blocks only to a modification of afferent input. Our results show that the reduction in patient reported pain after diagnostic nerve block is associated with a decrease in nociceptive input as well as a reduction in anxiety. An understanding of this complex relationship will help to interpret accurately diagnostic blocks.

References: 'McCracken, L.M., Zayfert, C., Gross, R.T., The pain anxiety symptoms scale (PASS): A Multimodal measure of pain specific anxiety symptoms, Behavior Therapist, 16 (1993) 183-184. Staats, P.S., Hekmat, H., Staats, A.W., The psychological behaviorism theory of pain: A basis for unity. Pain Forum, 5 (1996), 194-207. Staats, P.S., Hekmat, H., Staats, A.W., Suggestion/Placebo Effects on Pain: Negative as Well as Positive, Journal of Pain and Symptom Management, 15 (1998) 235-243.

THE DISTRIBUTION OF THE ANESTHETIC SOLUTION FOLLOWING A CAUDAL EPIDURAL BLOCK

Vranken J*. Zuurmond W.W.A.*, Giezeman M.M. Brink H., De Lange J.J., Dept. ofAnaesthesiology Academic Hospital, Vrije Universiteit, Amsterdam, The Netherlands.

Introduction: Caudal epidural block is used for diagnosis and to treat a variety of largely unspecified low back pain syndromes, especially by non-anesthesiologists with varying claims of success. The cephalad spread of the anesthetic solution may be limited by minor bony obstruction in the sacral canal, with unpredictable dermatomal distribution of anesthesia.

Aim of the study: We investigated in 20 adult patients, the spread of a mixture of local anesthetic with contrast fluid following a caudal epidural block

Methods: After approval of the local ethic committee, 20 patients with varying chronic pain syndromes where treated with a single shot caudal epidural block. In prone position, with the aid of fluoroscopy, the sacral hiatus was identified. A TOP-XE 100mm needle was introduced in the epidural space The correct position of the needle was confirmed by 1 ml contrast fluid (iotrolan, Schenng). Subsequently, 20 ml mixture of local anesthetic (lido-caine 1%, 5ml), methylprednisolon 40mg, iotrolan (Isovist, Scher-ing) 5ml and saline 10 ml was injected in the epidural space. With fluoroscopy, images in anterior-posterior way were made.

Results: In all cases, the solution leaked out of the sacral foramina with complete visualisation of the sacral roots. Moreover, there was no contrast, or almost none, in the lumbal region.

Conclusion: Inpredictability ofanalgesia following a caudal epidural block in patients with low back pain syndromes can be subscribed to absent or insufficient spread of solution in the lumbal region. Possible explanations are the presence of minor bony obstruction in the sacral canal or a anatomical narrowing of the epidural space in the lumbosacral region with subsequently more resistance compared to the sacral foramina for the spread of solution. In this view we recommend the caudal approach for the treatment of pain in dermatomes supplied by the sacra! roots.

THE EFFECT OF CLONIDINE ON UPPER EXTREMITY TOURNIQUET PAIN

SD Lurie*. SS Reuben, RB Steinberg, P. DeLuca*, H. Macioiek*, Baystate Medical Center and the Tufts Univ School of Medicine, Dept of Anesthesia, Springfield, MA 01199, USA

Aim of Investigation: Tourniquet pain is considered a limiting factor during intravenous regional anesthesia (IVRA). Clonidine added to spinal bupivacaine has been shown to decrease tourniquet pain (1). The aim of this study is to determine whether the addition ofclonidine (C) to IVRA lidocaine (L) decreases tourniquet pain. Methods: After institutional review board approval, informed consent was obtained from 15 healthy volunteers. Each volunteer had two upper extremity IVRAs at least one week apart; with either 40cc 0.5% L or 40cc 0.5% L and 1 ug/kg C, in a blinded manner. No premedication was given. BP cuff and ECG monitor were placed, and baseline vital signs were obtained. A 22g IV was placed in the hand being studied. The arm was exsanguinated and a double cuff was placed on the upper arm. The proximal cuff was inflated to 250 mmHg and L (IVRA-L) or L with C (IVRA-C) was injected. Verbal pain scores (VbAS) from 0-10 were recorded every 5 minutes. When VbAS reached 6, defined as first tourniquet time (Ti), the distal cuff was inflated and the proximal cuff was deflated. The study was terminated at a VbAS of 10 or at 60 minutes, whichever occurred first. The time from distal cuff inflation to VbAS 10 was defined as second tourniquet time (T;). Total tourniquet time (TT) was the sum ofT, and T:.

Results: The onset of tourniquet pain at t[ was not significantly different between the two groups. Tourniquet times (in mins) were significantly longer (p<0.01) for IVRA-C at both T; (34.1 3.9) and TT (56.8 5.0) compared to IVRA-L (24.9 5.9) and (46.5 6.1) respectively.

Conclusions: The addition ofclonidine 1 ug/kg to IVRA L delays the onset time of significant tourniquet pain. References: 1. Br J Anaesth 1989;63:93-96.

GREATER OCCIPITAL NEURALGIA - A CASE STUDY AND STATE OF THE ART REVIEW

Toni J. Hanson, M.D. Peter R. Wilson, M.D., Mayo Clinic, Physical Medicine, Rochester, Minnesota 55905 USA

Aim of Investigation: The purpose of the study was to delineate "state of the art" as regards diagnosis and management ofGON (greater occipital neuralgia) via case study and comprehensive review of the literature, including anatomy and proposed patho-physiologic mechanisms.

Method: A case study of a medically complex 52-year-old female juvenile diabetic with diabetic complications including retinopathy (legally blind), nephropathy, and neuropathy is presented. She developed persisting occipital symptoms including burning with intermittent cephalad radiation following supine positioning for a six-hour pancreatic transplant. She presented for evaluation 40 months following onset of symptoms, having experienced an exacerbation after falling down the stairs. Pressure over the greater occipital nerve reproduced her symptoms.

Result: The region of the left greater occipital nerve was injected with 5 cc of 0.25 percent bupivacaine and 10 mg oftriamcinolone which produced prompt relief of her symptoms. Relief continued after the effects of the local anesthetic dissipated. Proposed mechanisms in the case include: 1) Prolonged occipital pressure due to positioning for surgery, 2) Underlying diabetic neuropathy, 3) Paucity of subcutaneous tissue in the affected region (noted on clinical exam and MRI).

Conclusion: A unique case study is presented which confirms that greater occipital neuralgia remains an overlooked diagnosis. We present a comprehensive review of the literature, anatomy, and proposed pathologic mechanisms of greater occipital neuralgia.

CERVICAL EPIDURAL STEROID INJECTIONS: A SURVEY OF PRACTICE IN THE UNITED KINGDOM

Madhu Hemraiani. Hafeez ur Rehman*, Roger Packham*, Pain Control Unit, Dept of Anaesthesia, Poole Hospital NHS Trust, Poole, Dorset, BH15 UB, United Kingdom.

Aim of Survey: To conduct a postal survey of pain clinics in the UK in an attempt to establish current practice regarding cervical epidural steroid injections (CESI), prompted by a local increase in referrals, principally from neurosurgeons and rheumatologists, for this procedure.

Methods: Questionnaires were sent to all 235 pain clinics listed with The Pain Society, UK, asking whether they performed CESI, and if so, referral sources, indications, contraindications, investigations, technique and complications.

Results: 160 pain clinics responded, giving a return rate of 68%. Of those who responded, 61% indicated that they perform cervical cpidurals regularly, and a detailed analysis was performed on these questionnaires. There were considerable differences in terms of indications, technique used (especially use of image intensifier) and reported complications.

Conclusions: It is clear that a significant number of pain clinics are regularly undertaking cervical epidural steroid injections. However the diversity in the current practice suggests that it would be appropriate to undertake a prospective multicentre trial or possibly a well designed audit project in an attempt to identify those groups of patients most likely to benefit from this procedure and the risks involved.

DISTANCE FROM SKIN TO VERTEBRAL LAMINA AS A PRINCIPAL LANDMARK TO PREDICT THE EPIDURAL DEPTH FOR PARAMEDIAN APPROACH

Akira Ogura. Tetsuo Inoue*, Ritsuko Masuda, Kazuyuki Imanaga, Tatsusuke Yoshikawa*, Dept. of Anaesthesia, Chiba-Hokusoh Hosp., Nippon Medical School, 1715 Kamakari, Inba, Chiba270-1694, JAPAN

Aim of Investigation: To predict the epidural depth (ED) for para-median approach (PA), the distance from skin to vertebral lamina (DSVL) was measured as a primary landmark. And the relationships between ED and physical parameters were studied.

Methods: After institutional review board approval and informed consent, patients undergoing operation under epidural block with or without general anesthesia were divided into three groups according to the site of epidural puncture; i.e. groupU: upper thoracic (T3-4, n=102), groupM: middle thoracic (T8-9, n=138), groupL:

lumbar (L3-4, n=l 56). Epidural puncture was performed by PA, using loss of resistance technique. DSVL and ED were measured. To study the relationships between ED and physical parameters (weight, height, age, sex, and DSVL), simple linear regression, multiple regression and stepwise regression were performed.

Results: Measured DSVL from groupU, groupM and groupL was 4.U0.8, 3.70.7and 3.90.6, ED was 5.71.0, 5.2:fc0.9 and 4.70.6 (meanSD cm) respectively. Significant correlation with ED was found for DSVL (groupU: R=0.783, groiipM: R=0.692, groupL: R=0.735). Practical formulae to estimate ED were obtained from multiple linear regression and stepwise regression analyses for ED and five physical parameters.

Conclusions: This study has shown that measuring DSVL prior to identify the epidural space offers a simple and valuable information for ED, when punctured by PA. To estimate ED more accurately, the distinctive formula obtained from stepwise regression for ED and physical measurements should be useful.

AN UNUSUAL COMPLICATION OF GANGLION IMPAR BLOCK

Mingi Chan-Liao, Wang-Hin Yip, Seng Jin Ooi, Chin-San Liew, Chi-Lin Chuang*, Dept. of Anesthesia and Radiology*, Jen-Ai Hospital, Tali, Taichiing, Taiwan

Blockade of the ganglion impar (ganglion ofWalther) was first described in abstract form by Plancarte in 1990. It is a suggested treatment for intractable neoplastic perineal pain of viscera] origin. Theoretic complications associated with ganglion impar block include rectal perforation, infection, incontinence and local anesthetic toxicity due to accidental intravascular injection. Although the above complications may occur, specific data on their incidence are lacking. We report a case of localized tumor in the pre-sacral space following an image-guided neurolytic ganglion impar block in a 65-year-old male patient with pudendal neuralgia of non-malignant neuropathic nature. Based on its appearance, this focal lesion was most conistent with a hematoma. We believe this is a very rare occurrence and unique case because with CT-guidance an aberrant needle puncture in the relatively avascular pre-sacral space is unlikely and the hematoma was only accidentally identified during a MRI study 10 days post-block in this already incontinent patient. Our search of the contemporary literature failed to unearth a previous case of large hematoma arising from this interventional procedure.

SYMPATHETIC NERVE BLOCKS WITH 0.25% ROPIVACAINE IN ACUTE HERPES ZOSTER PAIN.

Susana Carrada-Perez*, Victor Whizar-Lugo. Roberto Cis-neros-Corral*, (SPON: Carlos Cortes-Gomez). Servicios Profe-sionales de Anestesiologia y Clinica de Dolor. Centro Medico del Noroeste. Tijuana BC, Mexico. 22,320.

Aim of Investigation: To investigate the role of sympathetic nerve blocks (SNB) done with 0.25% ropivacaine in the treatment of severe pain during the acute phase of herpes zoster.

Methods: Nine consecutive patients, both sexes, 52 to 76 years old, suffering severe pain due to acute zoster (1 to six weeks) were treated. Six patients with a thoracic or lumbar acute herpes zoster, were injected through an epidural catheter repeatedly with 8 to 10 ml of 0.25% ropivacaine 2 to 4 times daily during 10 to 15 days. Two cases with trigeminal affection were treated every other day with stellate ganglion block done with 12 ml of 0.25% ropivacaine, and one case with V; involvement was treated with sphenopalatine ganglion block done every 6 h/10 days. Complete analgesia was achieved immediately after each block, and after we finished the series of SNB a reduction of the median pain intensity from 9.40.7 to 0.851.2 (p 0.05) was obtained. This analgesic effect lasted during the follow-up period up to seven months. There were no significant side effects. One patient needed to take 50 mg of tramadol one or two times a day for breakthrough pain.

Conclusions: Fear of cardiovascular arrest and convulsions after inadvertent intravascular injection ofbupivacaine has spurred the search for a safer alternative resulting in the introduction of ropivacaine, a long acting local anesthetic that is formulated as the pure S-enantiomer. It is a HCI amino-amide, with a profile quite similar to bupivacaine, but with less potential of cardiovascular and neu-rotoxic effects. Although the number of patients in this study is small, the analgesic effect last long enough to propose 0.25% ropivacaine as an alternative to bupivacaine to perform SNB in patients suffering severe pain secondary to acute herpes zoster. Studies with a bigger number of cases are needed to properly place the role of ropivacaine in the treatment of these patients.

COMPLEX REGIONAL PAIN SYNDROME (CRPS I): AN INNOVATIVE TREATMENT APPROACH USING CONTINUOUS SYMPATHETIC BLOCKS.

Dureja. P.P.. Jayalakshmi, T.S. Pain Clinic, Dept ofAnaesthesiol-ogy. All India Inst of Medical Sciences, New Delhi - 110029 India

Aim of Investigation: To investigate whether continuous cervico-thoracic sympathetic chain and stellate ganglion blocks are feasible in the management of CRPS type I involving the upper extremity and their evaluation in comparison to intermittent stellate ganglion blocks in a randomized trial.

Methods: 103 consecutive patients with CRPS I of upper extremity referred to our Pain Clinic over a period of 2 years (1996-1998) were randomly administered either daily cervical sympathetic ganglion blocks (n=62) with 10 ml. of 0.25% bupivacaine or a continuous sympathetic block (n=41) by an innovative approach. A PTFE cannula was placed at the sympathetic chain under fluoro-scopic control. The details of the method will be discussed. An infusion of 0.125% bupivacaine was initiated using an infusion pump. Patients were sent for active physiotherapy as soon as they had relief in pain and joint stiffness.

Results: Relief in pain, dysesthesia and associated symptoms was achieved faster with continuous block (mean 2.3 days) as compared to intermittent approach (mean 7.8 days). A total of 12-15 sympathetic blocks were administered in the intermittent group as compared to 5-7 days of continuous block with bupivacaine infusion. Full recovery was achieved in a period of 23.1 6.3 days in continuous group as compared to 47.0 7.9 days in patients who received intermittent blocks.

Conclusions: Management of CRPS I pose a real challenge to the Pain Clinician. Continuous stellate ganglion blocks were administered by an innovative approach using a PTFE cannula placed under fluoroscopic control. Continuous sympathetic block (cervico-thoracic chain) result in a faster relief in pain, dysesthesia and trophic changes associated with CRPS I. Full recovery was also achieved faster with a continuous block regime.

BLOCKADE OF GANGLION STELLATE IN TREATMENT OF HERPES ZOSTER OF FACE, NECK AND SHOULDER.

Lubomir Hakl. Olga Haklova, Marek Haki, Pain Relief Unit, Univ Hospital Bmo, Czech Republic

Aim of Investigation: To show our experiences with treatment of herpes zoster and postherp. neuralgia using complex therapy.

Methods: Our standard of treatment consisted of: 1) antivirotic drugs, 2) blockade of. gang. stellate with bupivicain or lidocain together with clonidin, 3) local blockade with methyl prednisolon, 4) TENS and 5) vitamins, antidepressive drugs, carbamazepin, analgesics painless p.o.

Results: 8 of the 26 patients during 1 month's complex therapy were painless. After two months therapy, which means 6-8 visit of our Dept average decrease. After three months therapy only two patients had pain (VAS 3-4). Both patients visited pain unit when they had pain for more than 6-8 weeks.

Conclusions: The results show that the best prevention ofposther-petic neuralgia is early complex therapy. The results are better, when the therapy starts at the beginning of the disease. Average patients who visited our Dept were 7,8 days after the beginning of herpes zoster.

9th WORLD CONGRESS ON PAIN, 1999, Vienna, Austria, p.314 - 322

   

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