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ABSTRACT: Pain partially responsive to opioids can lead to rapid escalating dosages due to tolerance development. In this report the case of a 58-year-old female with neuropathic pain using increasing transdermal (TTS) fentanyl dosages to a maximum dose of 3400 microg/h resulting in fentanyl plasma levels of 173 ng/ml is described. For pain relief an epidural infusion at the level T1-2 with bupivacaine was started. Immediate pain relief was accompanied by short lasting respiratory depression and drowsiness.
European Journal of Pain 02/2001; 5(3):325-9; discussion 329-31. · 3.94 Impact Factor
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Pain 05/2000; 85(3):526-7. · 5.78 Impact Factor
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ABSTRACT: To investigate the relation between pain provoking cervical segments identified by diagnostic dorsal root blockades and elevation of detection thresholds in patients suffering from chronic cervicobrachialgia (CCB).
Quantitative sensory testing (light touch) of the cervical dermatomes using Semmes-Weinstein monofilaments.
A university pain clinic.
Thirty-nine patients with CCB, with no clinical or diagnostic evidence of radiculopathy or surgically treatable bony lesion and with one main pain-provoking cervical segment identified by diagnostic dorsal root blockades.
Detection thresholds with 95% confidence intervals (95% CI) of pain-provoking segments, compared with surrounding and contralateral segments and with normal values for cervical dermatomes.
Patients' detection thresholds were significantly (p < .001) higher than those for normal subjects: 3.51 (95% CI, 2.71-4.31) and 3.10 (95% CI, 2.34-3.86), respectively. No significant differences existed between the segments. The elevations were systematic. However, thresholds on the painful side were consistently, slightly higher than those on the contralateral side.
Supporting earlier studies, results from CCB patients in the present study showed systematic elevation of detection thresholds (low threshold mechanoreceptors), an adaptation in contrast with, but not contradictory to, central sensitization of high threshold neurons in chronic pain.
Archives of Physical Medicine and Rehabilitation 04/2000; 81(4):430-5. · 2.28 Impact Factor
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ABSTRACT: Substance P is considered to be an important neuropeptide in nociceptive processes. Although substance P was described more than 60 years ago, there is still controversy about its exact role in nociception. This article reviews the current knowledge about the function of substance P in pain. Special emphasis is put on how to use this knowledge in the development of new ways to treat pain.
European Journal of Pain 02/2000; 4(2):121-35. · 3.94 Impact Factor
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ABSTRACT: To determine the difference in intrathecal morphine dose progression between a continuous intrathecal infusion of a morphine/bupivacaine mixture and morphine for pain relief in patients with cancer.
Patients were treated with intrathecal drugs in a randomized study and followed prospectively until death.
Institute for Anesthesiology, Department of Pain Treatment, University Hospital Nijmegen, St Radboud, The Netherlands.
Twenty patients with cancer were selected for intrathecal treatment because of either side effects or inadequate relief during conventional pain treatment.
Intrathecal drug infusion rates and medication were adjusted according to pain relief and side effects.
Progression of intrathecal morphine dose during a phase of adequate analgesia in both groups following regression analysis and analysis of possible treatment related side effects.
The combination of intrathecal morphine and bupivacaine resulted in a diminished progression of the intrathecal morphine dose (slope of regression line = 0.0003 vs. 0.005, p = 0.0001) during a phase of stable analgesia in comparison with the morphine group. No serious side effects presented.
The diminished intrathecal morphine dose increase in the combination group is considered to be due to a synergistic effect of bupivacaine on the intrathecal morphine-induced antinociception. A dose increment during long-term intrathecal infusion in cancer patients appears to be related to both disease progression and tolerance phenomena.
Clinical Journal of Pain 10/1999; 15(3):166-72. · 2.81 Impact Factor
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Anesthesiology 09/1999; 91(2):576-7. · 5.36 Impact Factor
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ABSTRACT: The value of surgical and chemical lumbar sympathectomy was studied in patients with critical lower-limb ischaemia without the option of vascular reconstruction. Clinical success rates, defined as improvement of ischaemia stage, and limb salvage rates were recorded for 76 limbs of 70 consecutive patients. Chemical lumbar sympathectomy patients were older and had more concomitant diseases than surgical lumbar sympathectomy patients. The short-term (6-week) success rate in 36 cases treated with surgical lumbar sympathectomy (44%) was better than in 40 cases treated with chemical lumbar sympathectomy (18%) (P = 0.01). The long-term (1-year) success rate was 47% for surgical lumbar sympathectomy and 45% for chemical lumbar sympathectomy (P = NS). The 1-year limb salvage rates were 61% for surgical lumbar sympathectomy and 58% for chemical lumbar sympathectomy (P = NS). Complications were minor in both groups. Lumbar sympathectomy still has a limited role in the treatment of critical limb ischaemia in patients without the option of vascular reconstruction. Both surgical and chemical lumbar sympathectomy can be performed with very little morbidity and may provide a benefit over the natural course of the arterial insufficiency.
Cardiovascular Surgery 04/1999; 7(2):200-2.
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B J Crul
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ABSTRACT: A 67-year-old woman suffered from terminal cancer as a consequence of local recurrence of endometrial carcinoma which had been treated by hysterectomy. She had excruciating pains and was requesting euthanasia. Advanced techniques for pain relief e.g. intrathecal administration and nerve blocks resulted in adequate relief and postponed the request. Besides knowledge and skill, the application of these techniques requires a logistic network in the home situation. An alternative therapeutic approach for this patient would have been continuous intravenous administration of morphine, which would have implied accepting an earlier death. The Dutch National Inquiry on euthanasia and life ending interventions revealed that in 19.1 per cent of the overall mortality in the Netherlands, pain treatment had contributed to death. In 1.4 per cent (1900 cases per year) death was even the main goal of pain treatment. A wider application of advanced pain relieving techniques can diminish requests for euthanasia in the Netherlands and also can curtail mismanagement of pain. An advice from 1991 of the National Health Council for better hospital support for terminal patients in the home situation is still awaiting implementation.
Nederlands tijdschrift voor geneeskunde 11/1997; 141(44):2097-100.
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Anesthesia & Analgesia 06/1997; 84(5):1140-1. · 3.29 Impact Factor
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Nederlands tijdschrift voor geneeskunde 05/1997; 141(16):796.
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ABSTRACT: It is recognised that radiotherapy provides relief for intractable pain in approximately 50% of patients with cancer pain. Unfortunately, traditional explanatory variables, such as age, gender, histology or radiation dose, do not help to predict which individuals will benefit from palliative radiotherapy. A non-randomised prospective clinical trial was conducted on 51 patients to evaluate the value of pain characteristics as new explanatory variables for predicting the efficacy of palliative radiotherapy for providing cancer pain relief. Two new explanatory variables were identified: the presence of radiating pain and the pain score before radiotherapy.
Pain 02/1997; 69(1-2):131-5. · 5.78 Impact Factor
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ABSTRACT: A 25-year-old male with idiopathic chronic pancreatitis suffered from severe pain not reacting to medical therapy. Intractable pain persisted after the following procedures: subtotal resection of the pancreas, interpleural administration of bupivacaine, epidural administration of bupivacaine, and thoracoscopic sympathectomy. Eventually, adequate pain relief was achieved with intrathecal administration of morphine and bupivacaine. An infusion pump, externally controlled by radiotelemetry, was implanted subcutaneously for intrathecal drug administration. With this pump the patient was fully ambulant. Intrathecal administration of morphine and bupivacaine through an implanted pump is a possible new technique for pain management in chronic pancreatitis.
Nederlands tijdschrift voor geneeskunde 08/1996; 140(27):1410-2.
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Anesthesiology 09/1995; 83(2):424-6. · 5.36 Impact Factor
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Anesthesia & Analgesia 10/1994; 79(3):594-7. · 3.29 Impact Factor
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ABSTRACT: Concentrations of morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) were measured by h.p.l.c. in plasma and cerebrospinal fluid (CSF) samples from 16 patients with cancer receiving oral (controlled-release) morphine. There was a close correlation between plasma and CSF morphine concentrations (r = 0.94, P = 0.0001) and both correlated with drug dosage (r = 0.61, P = 0.013 and r = 0.74, P = 0.0001, respectively). M3G and M6G in plasma and CSF were correlated (r = 0.81 and r = 0.82, both P = 0.0001). No relationship was apparent between M plus M6G concentrations in the CSF and pain scores.
British Journal of Clinical Pharmacology 10/1994; 38(3):271-3. · 2.96 Impact Factor
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Pain 06/1994; 57(2):255-6. · 5.78 Impact Factor
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ABSTRACT: This study evaluates whether irradiation inhibits responses to pain in an animal model. We found that irradiation with doses of 10 Gy, 15 Gy and 17.5 Gy of the lumbar enlargement of the spinal cord inhibits the behavioural responses to the stimulus of the hot-plate. These doses were otherwise without effects. This data is discussed in view of the effects of irradiation of living cells, and we propose that a modification of pain signal processing is accomplished. Similar considerations apply to the human condition.
Life Sciences 02/1994; 54(23):1815-23. · 2.53 Impact Factor
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ABSTRACT: A retrospective analysis of 51 patients with cancer pain treated with a continuous i.t. morphine infusion through a tunnelled percutaneous catheter was undertaken. Because of insufficient pain relief with morphine only, 17 of these patients received a morphine/bupivacaine mixture. Pain relief subsequently improved significantly in 10 patients and a moderate improvement was present in 4 patients. An additional analgesic effect of bupivacaine was not shown in 3 patients with clinical signs of severe mental depression. Bupivacaine-induced side effects were absent below a daily dosage of 30 mg by continuous infusion. In all patients a gradual dose increment was observed. No serious complications, neurologic sequelae or meningitis occurred. It is concluded that long-term i.t. infusion of morphine through a tunnelled catheter can provide adequate pain relief in cancer patients with an acceptable risk-benefit ratio. The effects of long-term intrathecal co-administration of local anesthetics, especially bupivacaine, await further prospective evaluation.
Pain 11/1993; 55(1):119-23. · 5.78 Impact Factor
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Nederlands tijdschrift voor geneeskunde 08/1993; 137(31):1537-9.
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ABSTRACT: A case is described in which a coeliac plexus block with alcohol 48%, performed under X ray control, resulted in paraplegia. Ischaemia of the spinal cord, due to damage to the arterial blood supply, was thought to be the cause.
Anaesthesia 11/1991; 46(10):862-3. · 2.96 Impact Factor
