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Treatment of cancer pain is generally based on the three-step World Health Organization (WHO) pain relief ladder, which utilizes a sequential approach with drugs of increasing potency. Goals of pain management include optimization of analgesia, optimization of activities of daily living, minimization of adverse effects, and avoidance of aberrant drug taking. In addition, it is recommended that analgesic regimens are individualized and simplified to help ensure patient compliance and should provide the least invasive, easiest, and safest route of opioid administration to ensure adequate analgesia. Buprenorphine and fentanyl are two opioids available for the relief of moderate-to-severe cancer pain. Available clinical data regarding the transdermal (TD) formulations of these opioids and the extent to which they fulfill the recommendations mentioned earlier are systematically reviewed, with the aim of providing additional information for oncologists and pain specialists regarding their comparative use. Due to lack of studies directly comparing TD buprenorphine with TD fentanyl, data comparing these with other step-3 opioids are also evaluated in a network fashion., Video abstract

Except for neurotrophin, no drug had an indication for postherpetic neuralgia (PHN) in Japan prior to pregabalin approval. This approval might have changed PHN treatment patterns. This study aimed to compare PHN treatment patterns and medical costs between patients who started treatment before and after pregabalin approval. Japanese claims data were used to identify patients aged 18 years or more with PHN, postherpetic trigeminal neuralgia or postherpetic polyneuropathy who were initiated on their first PHN-associated prescription through May 2010 (before approval) or from June 2010 (after approval). From these claims, 6-month treatment patterns from first prescription were compared for the periods before and after approval. These patterns included pain-related medications and the frequency of pain-relief procedures. All-cause and pain-related medical costs were also compared for these periods. The number of PHN patients who were initiated on treatment before and after approval were 107 (mean age, 47.4 ± 13.0 years) and 505 (45.9 ± 13.0), respectively. Post-approval, significant reductions were observed for prescription of non-steroidal anti-inflammatory drugs, tricyclic antidepressants and neurotrophin relative to before approval. Excluding pregabalin acquisition costs, mean costs per patient for medications associated with PHN for 6 months from the first prescription were significantly lower after approval, ¥2882 vs ¥4185. Total medical costs were similar in both periods. Approval of pregabalin appeared to result in a treatment paradigm toward use of an approved therapy with demonstrated efficacy.

Limited research exists to support the extrapolation of the analgesic efficacy of pregabalin from one neuropathic pain condition to another. This retrospective analysis evaluated similarities in the efficacy of pregabalin for treating neuropathic pain associated with post-herpetic neuralgia (PHN), diabetic peripheral neuropathy (DPN), and spinal cord injury (SCI) in a Japanese population, as a basis for considering the extrapolation of these data to other neuropathic pain conditions.Data were analysed across pregabalin doses within each pain condition, from three comparable 13- to 16-week, randomized, double-blind, placebo-controlled trials (RCTs) and the corresponding 52-week, open-label extension trials of pregabalin in Japanese patients with PHN, DPN or SCI. Efficacy outcomes in the RCTs included endpoint and weekly mean pain and sleep interference scores; endpoint proportions of responders in pain; Patient Global Impression of Change scores; and 36-Item Short Form Health Survey (SF-36) scores or Hospital Anxiety and Depression Scale (HADS) assessments. Study discontinuation rates were compared between treatment groups. The extension trials assessed pain intensity, using the Short-Form McGill Pain Questionnaire.In the RCTs for all pain conditions, significant improvements in comparison with placebo in mean pain and sleep interference scores were evident after 1 week with pregabalin and were sustained throughout the treatment periods (p0.05). At the study endpoint, in comparison with placebo, a significantly greater percentage of pregabalin-treated patients experienced a ≥30 % reduction in pain across the RCTs (p0.05), and pregabalin significantly improved six of 16 SF-36 subscale scores in the PHN and DPN trials (p0.05). In the SCI trial, pregabalin-treated patients had numerically better outcomes of HADS scores. In the extension trials, improvements in pain intensity were maintained over a 52-week period.Similarities in the pregabalin efficacy profiles, including time to onset and magnitude of response, were confirmed regardless of the neuropathic pain condition. These data support the potential for extrapolating analgesic efficacy to other neuropathic pain conditions. CLINICALTRIALS.NCT00394901, NCT00553475, NCT00407745, NCT00424372, NCT00553280, NCT01202227.

Introduction The mechanism of complex regional pain syndrome (CRPS) was reported as being related to both the central and peripheral nervous systems. Recurrence of CRPS was, reportedly, induced by hand surgery in a patient with upper limb CRPS. However, there is no documentation of mechanical allodynia and burning abdominal pain induced by Cesarean section under spinal anesthesia in patients with upper limb CRPS. Case We report the case of a patient who suffered from burning abdominal pain during Cesarean section under spinal anesthesia 13 years after the occurrence of venipuncture-induced CRPS of the upper arm. The patient's pain characteristics were similar to the pain characteristics of her right arm during her previous CRPS episode 13 years earlier. In addition, mechanical allodynia around the incision area was confirmed after surgery. We provided ultrasound-guided rectus sheath block using 20 mL of 0.4% ropivacaine under ultrasound guidance twice, which resulted in the disappearance of the spontaneous pain and allodynia. Discussion The pain relief was probably related to blockade of the peripheral input by this block, which in turn would have improved her central sensitization. Conclusion Our report shows that attention should be paid to the appearance of neuropathic pain of the abdomen during Cesarean section under spinal anesthesia in patients with a history of CRPS.

腰下肢痛を訴えてペインクリニックを訪れる患者は増加しており，報道から情報を得て，エピドラスコピ－を希望する高齢者も多い．今回，85歳以上の2症例に本手術を施行した．いずれも，主訴は両側腰痛，両足のしびれが主であり，腰椎MRIで腰部脊柱管狭窄症が認められた．手術所見では，両者とも癒着が強く，強力な癒着剥離が必要であった．術後，1症例は痛みとしびれのため，他の1症例は下肢脱力のため，回復に時間を要したが，腰痛は改善し，両者とも満足度は高かった．85歳以上の高齢者にエピドラスコピーを施行する際には，十分な説明のもと，病態，患者の置かれた環境などを鑑みて適応を決めること，また手術を丁寧に施行することが重要である．

To describe a case of complete neurological recovery from cauda equina syndrome lasting ten months following spinal anesthesia with 0.5% hyperbaric bupivacaine and epidural anesthesia with ropivacaine, and to discuss the possible mechanisms involved.A 79-yr-old man with Paget's disease was scheduled for surgery to remove a skin tumour below his scrotum. He had no history of radicular pain or back pain and no pre-existing neurologic disorder. Surgery was performed with the patient in the supine position. He received 0.5% hyperbaric bupivacaine intrathecally for the procedure and ropivacaine through an epidural catheter for postoperative pain management. After catheter removal, the patient developed urinary retention, fecal incontinence, and perianal hypoesthesia. A lumbosacral magnetic resonance imaging (MRI) revealed no tumour, infarction, degeneration, spinal stenosis, or compression on the cauda equina nerve roots. A diagnosis of cauda equina syndrome was made, and the etiology was thought to be toxicity of bupivacaine either alone or in combination with ropivacaine. After three months, the patient reported some return of sensation at the perianal area, with complete resolution at four months. At the ten-month follow-up visit, the patient had recovered from his urinary retention and fecal incontinence.This case suggests that spinal anesthesia, even with an ordinary dose of hyperbaric 0.5% bupivacaine, might induce cauda equina syndrome in older patients.

国際疼痛学会が痛みを，「実際に組織損傷が起こったか，あるいは組織損傷の可能性のあるとき，またはそのような損傷を表す言葉によって述べられる不快な感覚と情動体験」と定義しているように，痛みという感覚はあくまで主観的なものであることから，これを客観的に評価，定量化することが困難である．しかし，臨床の場面では患者の訴える痛みにつき少しでも適切に評価する必要がある．そのために行う方法として，痛みを適正に評価するための条件，痛みのスケール，機器を用いる方法，脳画像診断，薬理学的疼痛機序判別試験について解説した．今後，より客観的な評価法の開発が求められる．

The aim of this study was to investigate whether monitoring neuromuscular block at the masseter muscle (MM) would allow faster tracheal intubation when compared with that at the adductor pollicis muscle (APM).Twenty female patients undergoing gynecological surgery were enrolled into this study. Immediately after inducing anesthesia with fentanyl and propofol, both the left masseter and ulnar nerves were stimulated in a 2 Hz train-of-four (TOF) mode using peripheral nerve stimulators. Contractions of the MM were felt with the anesthesiologist's left hand lifting the patient's jaw and holding an anesthesia facemask, while those of the APM were visually observed. Immediately after the contracting responses of the muscles were confirmed, all of the patients received an iv bolus of vecuronium 0.1 mg kg(-1). Onset times after vecuronium were defined as the duration until the contractions became impalpable at the MM or invisible at the APM. When the contraction of the MM could no longer be felt, the conditions for laryngoscopy and tracheal intubation were assessed.Onset time evaluated tactually at the MM (mean +/- SD, 108.4 +/- 27.7 s) was significantly shorter than that evaluated visually at the APM (181.2 +/- 32.1 s, P0.0001). The intubating conditions for all patients were graded as either excellent or good.Tactual evaluation of muscle paralysis of the MM during induction of anesthesia is clinically useful since it leads to faster tracheal intubation.

Classification of pain and their mechanisms are described in this chapter. Pain is classified into three categories according to the mechanisms; these are nociceptive pain, neuropathic pain and psychological pain. Nociceptive pain is caused by tissue damage and accompanies inflammation. Neuropathic pain is defined as pain arising as a direct consequence of a lesion or disease affecting the somatosensory system. Psychological pain is pain that is particularly attributable to the thought process, emotional state, or personality of the patient in the absence of an organic or delusional cause or tension. The characteristics of these different types of pain and methods of pain assessment are also described.

痛みは主観的な感覚であり, その測定・評価は難しい. 痛みの強さの測定についても, visual analogue scale (VAS) など, これまでにいくつかの評価法が提示されているが, いずれも主観的な測定法であった. この度, 患者がもつ痛みを, 痛みを伴わない異種感覚に置き換えて定量評価する知覚・痛覚定量分析装置が考案された. これにより, より客観的に痛みの強さを測定することができ, 患者間の痛みの強さや, ある患者の長期にわたる痛みの強さの比較・検討が可能になると考える. VASと比較した臨床データの一部を提示する.

Objectives: Several studies have demonstrated the advantages of epiduroscopy versus conservative therapies for low back pain with few studies evaluating the results in operated and non-operated back patients. We compared the effects and complications of epiduroscopy between these patients. Patients and methods: A multi-institutional, prospective, clinical study was performed in 183 patients whose low back and leg pain had failed to respond to conservative therapies. Patients were divided into an operated back (Op) group and a non-operated (Non-op) group. Japanese Orthopedic Association (JOA) score, the Japanese version of the Roland-Morris Disability Questionnaire (JRMDQ) scores, and 100-mm visual analogue scales (VAS) for leg pain, leg numbness, low back pain and dissatisfaction with ADL were recorded before and at 1 month and 3 months after epiduroscopy. Results: All scores significantly improved at 1 month and 3 months after epiduroscopy in both groups. JOA scores in the Non-op group were sign...

A S b ORONARY ARTERY FISTULA (CAF) is an infrequent vascular anomaly that establishes a direct link between a arge subepicardial coronary artery and a cardiac chamber, ajor vessels, or other vascular structures. Although coronary rteriography remains the gold standard for the diagnosis of AF, it is not always possible to reveal the complete delineaion of CAF including its origin, course, and drainage. A case f left main CAF originating directly from the aorta is reported n which preoperative coronary arteriography failed to identify he site of drainage and intraoperative transesophageal echoardiography (TEE) was used to identify the precise location of rainage. Scheduled surgical repairs included closure of the rigin of the CAF (the left main coronary orifice from the aorta) nd closure of the drainage of the CAF combined with coronary rtery bypass graft (CABG) surgery to the left anterior decending artery and the circumflex artery. In this particular ase, the left anterior descending artery and the circumflex rtery were not scheduled for closure at their origins from the eft main CAF to keep the circulation available for the other eeding arteries to the left ventricle (LV) that might originate rom the CAF. Therefore, intraoperative TEE was also essential or confirmation of absence of fistulous flow and regional wall otion abnormalities of the LV.

平成元年1月から平成6年5月までに,静脈注射や採血時などに注射針による神経損傷が原因で発生したと考えられる疼痛および知覚障害を主訴として当院ペインクリニック科を受診した患者6例について調査,検討した.穿刺部位では手関節橈側,肘関節屈側,示指部であった.症状としては火傷様疼痛,しびれ,冷感などを訴えhypesthesia, allodyniaなどの知覚障害が認められた.神経損傷によるinjury dischargeや炎症による侵害刺激伝播を抑制するため,損傷部への局所麻酔薬浸潤や抗炎症薬が有用であった.医療従事者へ対する患者の不満も痛みを長引かせる重要な因子であり,発生直後からの適切な対処が必要であると思われた.

The main aim of this study was to compare the onset times of rocuronium evaluated subjectively and by acceleromyography at the masseter muscle (MM). Forty female patients were sequentially enrolled in this study. In the first 20 patients, neuromuscular block was evaluated subjectively. After induction of anesthesia with fentanyl and propofol, both the left masseter and ulnar nerves were stimulated in 2-Hz train-of-four (TOF) mode using peripheral nerve stimulators. Contractions of the MM were felt with an anesthesiologist’s left hand holding an anesthesia facemask; those of the adductor pollicis (APM) were visually observed. All the patients received a bolus of rocuronium, 0.6 mg/kg. Onset times after rocuronium were defined as the duration until the contractions became impalpable at the MM or invisible at the APM. At the time contraction of the MM had not been felt, intubating conditions were assessed. In the next 20 patients, contractions of the MM and the APM were concurrently quantified using acceleromyography after induction of anesthesia and laryngeal mask insertion. Following 0.6 mg/kg rocuronium, onset of the action was recorded. Onset of the action of rocuronium at the MM evaluated subjectively [mean (SD), 70.3 (17.7) s] was similar to that monitored acceleromyographically [73.3 (27.6) s, P > 0.05], and significantly shorter than that at the APM acceleromyographically [111.0 (34.8) s, P = 0.016]. Intubating conditions of 20 patients were graded either excellent or good. Subjective evaluation of contractions of the MM by an anesthesiologist’s hand may be reliable to determine faster timing for safe tracheal intubation.

The main purpose of this study was to examine the effectiveness of the timing principle with 1 mg kg(-1) rocuronium for rapid sequence intubation. As secondary outcomes, propofol and lidocaine with or without remifentanil were examined to note their effects on the cardiovascular responses to laryngoscopy and intubation.Thirty patients were randomly allocated to one of two groups of 15 patients each: a lidocaine-treated group (L) and a lidocaine/remifentanil-treated group (LR). Thirty seconds after lidocaine 1 mg kg(-1) with or without infusion of remifentanil 1 microg kg(-1) min(-1), all patients received a bolus of rocuronium 1 mg kg(-1). Shortly afterwards, patients were given propofol 2-2.5 mg kg(-1). Intubating conditions and cardiovascular responses were observed 60 s after rocuronium. The time to spontaneous recovery of visible train-of-four (TOF) counts of 4 was observed at the thumb during 1.0-1.5% end-tidal sevoflurane and remifentanil anesthesia.All patients had excellent or good intubating conditions. Hypertension and tachycardia during laryngoscopy were well prevented in group LR, whereas they were significantly observed in group L. The times to reappearance of TOF counts of 4 were comparable in all groups [mean (SD); 63.6 (8.6) min in group L and 63.5 (11.6) min in group LR].Application of the timing principle with 1 mg kg(-1) rocuronium is beneficial for rapid tracheal intubation. Co-administered lidocaine, remifentanil and propofol can definitely suppress cardiovascular responses during laryngoscopy and intubation.

Two patients with spinocerebellar ataxia received epidural analgesia with no exacerbation of their symptoms. The patients developed transient, but extremely severe, low back pain as a result of the epidural analgesia.

A surgical patient with ventricular septal rupture after acute myocardial infarction is presented. The primary concern of general anesthesia was in the maintenance of systemic arterial pressure and reduction of afterload. General anesthesia was induced with a combination of fentanyl, ketamine, and propofol, which successfully suppressed fluctuations of hemodynamic variables associated with induction of anesthesia and tracheal intubation. Intravenous milrinone was used for inotropic support and reduction of systemic vascular resistance. The ventricular septal rupture was successfully repaired.

IT is well known that phantom limb pain can reappear or be exacerbated transiently during spinal anesthesia in amputees. 1 However, to the best of our knowledge, the reappearance of phantom limb pain immediately after nonamputation surgery in an amputee has not been reported. We herein present a patient with chief complaint of reactivation of phantom limb pain the day immediately after cervical myelopathy surgery.

We report a case of recurrent ST-segment elevations totaling 7 times over 3 hours during subtotal gastrectomy and the early postoperative period in a patient with no history of coronary artery disease. Possible contributing factors include cold stimulus, epidural anesthesia, and inadequate depth of anesthesia. The first episode almost resulted in cardiac arrest and was treated with intravenous epinephrine. The second episode was associated with ventricular fibrillation, which was treated with defibrillation and intravenous verapamil. The third to the seventh episodes were successfully treated with intravenous nitrate. The electrocardiographic changes and postoperative coronary angiography were consistent with a clinical diagnosis of coronary artery spasm. This case suggests that coronary artery spasm is capable of occurring repeatedly in a cyclic pattern during perioperative periods.

A patient with severe right chest pain and mechanical allodynia induced by an intercostal drainage tube to his chest is presented. It was not relieved by treatment with diclofenac sodium and was worsened by movement and touch to the right chest wall. Mechanical allodynia was also present. The patient's wrenching pain disappeared immediately after stitch removal, but the dull pain and mechanical allodynia persisted, gradually decreasing to zero in 7 days.

A randomized, double-blind, controlled study was designed to evaluate the effect of presurgical local infiltration of bupivacaine in the surgical field on postsurgical wound pain relief and analgesic requirements in 28 healthy patients scheduled for laparoscopic gynecologic examinations.After induction of general anesthesia by routine methods, the patients were randomly divided into two groups. In the bupivacaine (B) group (n = 15), patients were injected with 5 ml of 0.25% bupivacaine at each incisional area (four sites, total of 20 ml) approximately 15 minutes before skin incision. In the control (C) group (n = 13), the surgical field was injected with an equal volume of physiologic saline solution (four sites, total of 20 ml).Postsurgical wound pain at rest was evaluated by a 10-cm visual analog pain scale at 1, 10, 24, and 72 hours and 1 month after surgery. The patients were interviewed via telephone 1 month after hospital discharge for re-evaluation of resting pain.The results indicated that the incidence of postsurgical wound pain for up to 10 hours after surgery in group B was significantly lower (p0.05) than in group C. Pain intensity ranged from mild to moderate (2-5 cm). In addition, the mean visual analog pain scale pain intensity was significantly less for group B (0.31 +/- 0.85 cm) than for group C (2.62 +/- 2.06 cm) for up to 10 hours after surgery (p0.05). The number of patients who requested analgesics and complained of sleep disturbances was significantly higher in group C (p0.05). The mean cumulative dose of diclofenac sodium at 24 hours was significantly (p0.05) lower in group B (6.67 +/- 17.6 mg) than in group C (30.8 +/- 25.3 mg). Prolonged postsurgical wound pain persisting 1 month after surgery was observed in one patient in group C.It is concluded that presurgical infiltration of 0.25% bupivacaine in the surgical field is a useful method for decreasing postsurgical wound pain for up to 10 hours and analgesic consumption for up to 24 hours after laparoscopic gynecologic examination.

Dear Editor, A 14-year-old girl reported severe pain of the left first toe after a sprain of the left ankle joint when she was 9 years old. She complained of continuous pain in her chest, back, abdomen, and left first toe. The pain at all the sites was of a burning type with intensity of 6 on the numerical rating pain scale. She was unable to walk due to pain. Mechanical allodynia was present. Redness and swelling were recognized over the left first toe. …

A hundred and twenty-four patients of herpes zoster who were treated by nerve blocks within one month after beginning of the disease were analyzed with the questionnaire and from their clinical charts.The results showed that (1). Slight to moderate pain remained in 21% of the 124 patients. (2). Pain recured in 16 cases who relieved their pain completely. (3). it is emphasized that nerve blocks have to be started quiclky as soon as possible after finding the disease, and the block should be continued till two weeks later than their pain relief. Some problems related the prognosis such as affected areas, character of pain and age of the patients were also discussed.

Fourteen patients whose post-herpetic neuralgia could not be alleviated by conventional methods were treated with cryocautery using a stick of solid carbon dioxide (dry ice) applied directly to the hyperesthetic skin areas of the cutaneous scars. Follow-up evaluation revealed that 5 of 14 subjects maintained excellent pain relief and another 5 subjects showed good relief. Ten subjects discontinued further therapeutic procedures after cryocautery even though some low grade pain persisted. We believe that cryocautery of localized skin areas is a valuable method for treating patients with post-herpetic neuralgia who have not been improved by conventional methods. Disadvantages of this procedure are discussed.