Epidural Steroid and Clonidine for Chronic Intractable Post‐thoracotomy Pain: A Pilot Study

Background: Chronic post‐thoracotomy pain is relatively common after major thoracic surgery. The primary results of a pilot study using thoracic epidural steroid and clonidine injection to treat chronic intractable post‐thoracotomy pain are presented. Methods: Twenty‐one patients with intractable post‐thoracotomy pain participated in the study. Thirteen patients received thoracic epidural injection of a mixture of 150 μg clonidine and 80 mg of methylprednisolone acetate diluted in 8 mL 0.5% lidocaine. Eight patients continued with comprehensive medical management and served as a control group. A visual analog scale (VAS) for pain was recorded before treatment, 30 minutes after the epidural injection and before discharge, at 3 weeks and 6 months. Pain, sleep disturbances, appetite changes and daily activity, as well as the incidence of complications were recorded. The need for opioid rescue medications was recorded. Results: Twelve of 13 patients in the injection group reported improvement (> 50% reduction of pain) at 3 weeks and 6 months following the injection. Allodynia improved in all injection group patients compared to four of eight in the control group. Sleep disturbance, appetite changes and daily activity were improved in the injection group. The number of patients requiring opioid rescue medications was reduced from 61.5% to 15.3% during the 6‐month duration of study. Injection caused transient hypotension in 46.2% of patients. Mild sedation was noted in 30.7% of patients receiving injection; 15.3% of the patients had localized back pain at the site of injection. Discussion: Our preliminary data suggest possible efficacy of thoracic epidural steroid and clonidine mixture in the treatment of chronic post‐thoracotomy pain. No serious adverse effects were noted in this pilot study. ?     

Pulsed Radiofrequency of Suprascapular Nerve for Chronic Shoulder Pain: A Randomized Double‐Blind Active Placebo‐Controlled Study

Background: The suprascapular nerve block is frequently implemented to treat chronic shoulder pain. Although effective the nerve blockade provides only a short‐term relief, and more compelling apaproaches have been investigated. Pulsed radiofrequency (pRF) has been anecdotally reported as safe and reliable method. However, formal efficacy study has not been published. Ostensibly evidence‐based validation of a new method is necessary for both scholastic and practical purposes. Methods: This study was designed as a randomized active placebo‐control double‐blind trial. Because of encountered difficulties in recruitment and high rate of dropout, the study was redesigned as to allow a smaller sample size and statistical analyses were performed utilizing the last observation carry forward method. Lidocaine injections alone or with combination of the pRF were performed. Participants were followed up during 6 months, and multiple subjective and objective outcome variables were recorded. Results: Thirteen of 22 participants completed 6 months follow‐up. Dropout rate was higher in the lidocaine group. A significant linear trend (P < 0.05) for improvement on the numeric rating scale, Shoulder Pain and Disability Index and Constant‐Murley score was observed in the pRF group, but not in the lidocaine group. Patients in the pRF group were on average more satisfied than the lidocaine group at 1 month (P = 0.041) and at 3 months (P = 0.035). Discussion: Considering limitations of the study design and statistics, it seems plausible to attribute better results in the pRF group to unique properties of this physical modality.     

A Multicenter,Randomized, Double‐Blind,Placebo‐Controlled Trial of Intravenous Ibuprofen (IV‐Ibuprofen) in the Management of Postoperative Pain Following Abdominal Hysterectomy

Background: Ibuprofen and other nonsteroidal anti‐inflammatory drugs are widely used to block pain and inflammation in a variety of settings. Contrarily, opioid analgesia does not block the inflammatory component of pain and the use of these agents can be accompanied by serious side effects. We conducted a multicenter, randomized, double‐blind, placebo‐controlled trial to evaluate the safety and efficacy of intravenous ibuprofen (IV‐ibuprofen) as a postoperative analgesic. Methods: A total of 319 patients were randomly assigned in a 1:1 ratio to receive 800 IV‐ibuprofen or placebo every 6 hours; in addition patients had access to morphine at a dose of 1–2 mg every 5 minutes. The primary outcome measure was median morphine consumption within the first 24 hours following surgery. Results: During the first 24 hours of treatment, the median morphine requirement was reduced by 19% (P ≤ 0.001) and resulted in a significant reduction in pain at rest (AUC, 6 to 24 hours and 12 to 24 hours, P < 0.001) and pain with movement (AUC, 6 to 24 hours, P = 0.010 and 12 to 24 hours, P ≤ 0.001) as measured by the visual analog scale (VAS) in patients receiving 800 mg IV‐ibuprofen compared to placebo. Time to ambulation was significantly faster (P = 0.018) in the IV‐ibuprofen treated group, as well. Similar treatment‐emergent adverse events occurred across both study groups and there was no difference in the overall incidence of these events. Conclusion: This study demonstrated that IV‐ibuprofen is an effective analgesic medication that is safe and well tolerated when administered as an 800 mg dose every 6 hours in patients undergoing total abdominal hysterectomy surgery.     

Analgesic Effectiveness of Dipyrone (Metamizol) for Postoperative Pain after Herniorrhaphy: A Randomized,Double‐Blind,Dose–Response Study

Background: The efficacy of non‐narcotic analgesics is mostly supported by randomized, placebo‐controlled trials with no comparison with ordinary practice. Additionally, systematic reviews of these placebo‐controlled trials have failed to determine clinically meaningful dose–response effect. Methods: In this double‐blind, randomized trial, patients undergoing elective inguinal, umbilical or epigastric herniorrhaphy under general anesthesia were assigned to receive 15 mg/kg (D15 group) vs. 40 mg/kg (D40 group) of dipyrone intravenously during surgery. The primary outcome was the incidence of moderate to severe pain with movement during the recovery room phase. The secondary outcomes were morphine consumption, incidence of vomiting, and Ramsay score (sedation scale). Results: One hundred sixty‐two patients were enrolled and analyzed for the primary and secondary outcomes. Relative to the D15 group, the D40 group showed a lower incidence of moderate to severe pain in the first 30 minutes (61% and 40%; P value < 0.05); lower cumulative morphine consumption during the recovery period (3.85 vs. 2.55 mg, P value < 0.006) as well as a lower incidence of vomiting (15.8% vs. 2.5%, P value < 0.005). In addition, more cases of sedation were recorded in the D15 group than in the D40 group (17 vs. 10 cases). There were no serious adverse effects attributed to dipyrone in either group. Conclusion: This trial shows a dose–response effect of 40 mg/kg over 15 mg/kg of intravenous dipyrone based on better movement‐induced pain control, lower morphine consumption and fewer opioid‐related side effects.     

Comparison of epidural analgesia and intercostal nerve cryoanalgesia for post‐thoracotomy pain control

Epidural analgesia is regarded as the gold method for controlling post‐thoracotomy pain. Intercostal nerve cryoanalgesia can also produce satisfactory analgesic effects, but is suspected to increase the incidence of chronic pain. However, randomized controlled trials comparing these two methods for post‐thoracotomy acute pain analgesic effects and chronic pain incidents have not been conducted previously. We studied 107 adult patients, allocated randomly to thoracic epidural bupivacaine and morphine or intercostal nerve cryoanalgesia. Acute pain scores and opioid‐related side effects were evaluated for three postoperative days. Chronic pain information, including the incidence, severity, and allodynia‐like pain, was acquired on the first, third, sixth and twelfth months postoperatively. There was no significant difference on numeral rating scales (NRS) at rest or on motion between the two groups during the three postoperative days. The patient satisfaction results were also similar between the groups. The side effects, especially mild pruritus, were reported more often in the epidural group. Both groups showed high incidence of chronic pain (42.1–72.1%), and no significance between the groups. The incidence of allodynia‐like pain reported in cryo group was higher than that in Epidural group on any postoperative month, with significance on the sixth and the twelfth months postoperatively (P<0.05). More patients rated their chronic pain intensity on moderate and severe in cryo group and interfered with daily life (P<0.05). Both thoracic epidural analgesia and intercostal nerve cryoanalgesia showed satisfactory analgesia for post‐thoracotomy acute pain. The incidence of post‐thoracotomy chronic pain is high. Cryoanalgesia may be a factor that increases the incidence of neuropathic pain.