The role of bupivicaine in post-tonsillectomy pain

The peritonsillar tissues on one side of 45 consecutive patients undergoing tonsillectomy were infiltrated with bupivicaine and adrenaline, the opposite side serving as a control. Although a significant difference was noted between the two sides this was not a substantial difference in terms of pain relief.     

Convergence of occipital nerve and superior sagittal sinus input in the cervical spinal cord of the cat

Co-existence of facial and occipital pain may occur in occipital neuralgia, migraine and cluster headache; suggesting convergence of trigeminal and cervical afferents. Such convergence has been shown in humans and other animals, but the site and extent of this are uncertain. In anaesthetized adult cats, the superior sagittal sinus and occipital nerve were stimulated electrically, and extracellular recordings made in the dorsolateral area of the upper cervical cord using glass-coated tungsten electrodes. Of 49 units in 10 cats, 33 (67%) had input from the superior sagittal sinus and the occipital nerve. Thirteen (27%) had superior sagittal sinus input and 3 (6%) had occipital nerve input. Convergent receptive fields were identified mechanically in 7 units. These experiments in cats show convergent input from occipital nerve and superior sagittal sinus on dorsolateral area units in two-thirds of cases studied. This experimental site of trigeminocervical convergence may relate to referral of pain in occipital neuralgia and other headaches.     

Role of group II and group III metabotropic glutamate receptors in spinal cord injury.

Spinal cord injury (SCI) produces an increase in extracellular excitatory amino acid (EAA) concentrations that results in glutamate receptor-mediated excitotoxic events. An important class of these receptors is the metabotropic glutamate receptors (mGluRs). mGluRs can activate a number of intracellular pathways that increase neuronal excitability and modulate neurotransmission. Group I mGluRs are known to modulate EAA release and the development of chronic central pain (CCP) following SCI; however, the role of group II and III mGluRs remains unclear. To begin evaluating group II and III mGluRs in SCI, we administered the specific agonists for group II, APDC, or group III, L-AP4, by interspinal injection immediately following SCI. Contusion injury was produced at spinal segment T10 with a New York University impactor (12.5-mm drop, 10-g rod 2 mm in diameter) in 30 adult male Sprague-Dawley rats (175-200 g). Evoked and spontaneous behavioral measures of CCP, locomotor recovery, changes in mGluR expression, and amount of spared tissue were examined. Neither APDC nor L-AP4 affected locomotor recovery or the development of thermal hyperalgesia; however, L-AP4 and APDC attenuated changes in mechanical thresholds and changes in exploratory behavior indicative of CCP. APDC- and L-AP4-treated groups had higher expression levels of mGluR2/3 at the epicenter of injury on post contusion day 28; however, there was no difference in the amount of spared tissue between treatment groups. These results demonstrate that treatment with agonists to group II and III mGluRs following SCI affects mechanical responses, exploratory behavior, and mGluR2/3 expression without affecting the amount of tissue spared, suggesting that the level of mGluR expression after SCI may modulate nociceptive responses.     

VALUE OF COMPUTED TOMOGRAPHY FOR EVALUATING THE INJECTION SITE IN ENDOSONOGRAPHY‐GUIDED CELIAC PLEXUS NEUROLYSIS

Endosonography‐guided celiac plexus neurolysis (EUS‐CPN) safely and effectively relieves pain associated with intra‐abdominal malignancies when the neurolytic is accurately injected. We applied contrast medium to evaluate the ethanol injection sites in patients who received EUS‐CPN due to abdominal pain caused by malignancies. We injected, under the guidance of endoscopic ultrasonography (EUS), ethanol containing 10% contrast medium into the celiac plexus of patients with intra‐abdominal pain due to malignancies. Immediately after the endoscopic therapy, patients underwent computed tomography (CT) to confirm the injection site. Images of distribution of injected solutions were classified into three groups. Injected solution dispersed in unilateral and bilateral anterocrural space was defined as ‘unilateral injection’ or ‘bilateral injection’, respectively. Injected solution located out of the anterocrural space was defined as ‘inappropriate injection’. Pre‐ and postprocedure pain was assessed using a standard analog scale. Before and 2, 4, 8, 12, and 16 weeks after the procedure, pain scores were evaluated. From April 2003 to May 2005, 13 patients were enrolled in this study. Improvement of pain score in the ‘bilateral injection’ and ‘unilateral injection’ groups was significantly superior to the change in the ‘inappropriate injection’ group. Although EUS‐CPN was effective in eight of 13 patients (61.5%), additional EUS‐CPN to the ‘inappropriate injection group’ increased the response rate to 84.6%. Injection of ethanol to the anterocrural space by EUS‐CPN produced adequate pain relief. Immediate examination by CT for confirmation of injection sites after EUS‐CPN would increase the likelihood of induction of pain relief.     

Osteoporosis and Back Pain among the Elderly

Questionnaire responses from 120 men and 337 women over the age of 50 years were studied to determine the prevalence of back pain among the elderly. In order to gain a rough indication of the back pain among elderly women which might be due to osteoporosis, the prevalence was compared in the two sexes. The prevalence of back pain without radiation to the legs and concomitant morbidity was found to be similar among men and women up to the 70–79-year age-group. After this age the prevalence was higher in women. Those with exceptional loss of body height or kyphosis had a high prevalence of back pain, while those who had sustained previous hip or radius fractures did not. There was increasing prevalence of back pain among women with increasing number of previous fractures. The study gives little indication of serious morbidity of osteoporosis in the form of back pain before very old age.     

A blinded,controlled evaluation of anxiety and depressive symptoms in patients with fibromyalgia,as measured by standardized psychometric interview scales

The objective of the study was to evaluate the presence of psychopathology in fibromyalgia patients compared with a control group of other rheumatologic patients with pain. Forty-nine fibromyalgia patients and 33 control patients were interviewed blinded, using standardized psychometric scales. Pain was scored on a visual analogue scale. Fibromyalgia patients scored significantly higher than the controls on the Bech-Rafaelsen Melancholia Scale, the Atypical Depression Scale and the Hamilton Anxiety Rating Scale. On the Newcastle Depression Scale there was no difference. In both groups a correlation was found between pain score and psychometric scoring. The fibromyalgia patients scored significantly higher on pain than the controls. After correcting for this difference, the fibromyalgia patients still scored higher on anxiety and depression.     

Development of the Diploma in Clinical Dentistry (Conscious Sedation and Pain Control) Faculty of Dentistry, University of Sydney

The Diploma in Clinical Dentistry (Conscious Sedation and Pain Control) of the Faculty of Dentistry, University of Sydney, is the first dedicated programme devoted to this field in Australia. Its development followed a decision by the Dental Board of New South Wales to require a formal qualification from the University of Sydney before dental practitioners could offer sedation and pain management in practice.
The programme is conducted at Westmead Hospital in conjunction with the Department of Anaesthetics, and satisfies the guidelines developed by the Royal Australasian College of Dental Surgeons and the Royal Australasian College of Surgeons.
The course is conducted either over one or two years, with block sessions requiring attendance at Westmead Hospital, together with assignments which are completed outside the block sessions. In this way, a dental practitioner enrolled in the programme is able to continue practice.
The block sessions need not be completed over one year, but must be completed within two years.     

Role of technetium-99m planar bone scanning in the evaluation of low back pain

The records of 1018 patients with low back pain in a tertiary spine referral practice were reviewed. One hundred thirty-nine out of 1018 (13.6%) underwent technetium-99m planar bone scanning as part of their investigation. Seventy-three out of 139 scans (52%) showed increased uptake in some area, but only 27 out of 139 (19.4%) showed increased uptake specifically in the low back. Scans consistently yielded no findings with reference to the back when the prescan diagnosis was spinal stenosis, lumbar pain syndrome, herniated nucleus pulposus, or postlaminectomy syndrome. Some scans gave positive findings in patients with a diagnosis of degenerative disc disease, pseudarthrosis, spondylolisthesis, fracture, infection, metabolic disorder, or tumor. Positive scans were generally obtained early after presentation (within 3 months) and negative scans obtained later (after 6 months), suggesting that clinical suspicion is still the main indication for early scanning. Planar bone scanning was helpful in both diagnosis and therapeutic decisionmaking in many conditions.