Psychological assessment of chronic pain patient is very useful for the pain management as much as physical examination. This paper shows the psychological assessment evaluated by clinical psychologist (CP) of the pain clinic. At first clinical interview is implemented by CP before psychological test is given. CP interviews patients on focusing the points as follows. 1. Processes which patients have been through before visiting the hospital. 2. Their physical symptom. 3. Disturbances of their daily lives. 4. The causes of pain the patients suppose. Then psychologists suggest a treatment model. It is important for patients to consent to undergo both psychological and physical treatment.
After the interview CP conducts the psychological tests such as questionnaire and projective method. Testers should pay attention to the following points. Test battery should be examined considering patient's state of mind and health. Testers have to master to interprete the result of psychological test and tell the result to the patient.
The psychological assessment can evaluate application of neural blockade, medication and consultation to the psychiatrist. Therefore it will be useful to decide the treatment plan.

View full abstract

Hemifacial spasm is a disorder of the facial nerve characterized by involuntary synkinetic movement of facial muscles on the afflicted side. Causative lesions that have been reported include aneurysm of the posterior circulation, tumor, and arteriovenous malformations. However, most cases are due to the compression to the facial nerve by the aberrantly tortuous blood vessel at the base of the brain. It results in ectopic impulse generation in the facial nerve, with propagation of the impulse through ephaptic transmission, causing the involuntary synchronous motion of half the face. Botulinum toxin type A (BTX-A) is clearly the first choice for treatment of hemifacial spasm. It is relatively easy to administer and provides relief in the vast majority of patients. Typically, injections of BTX-A are given into the pretarsal portions of the orbicularis oculi, corrugator, zygomatics major, zygomatics minor, and risorius muscle. At the administration of BTX-A for orbicularis oculi muscle, intracutaneous injection is recommended for the prevention of the blepharoptosis and diplopia. Usually, 2.5-5 units of BTX-A is administrated in each site. The effect of this therapy is maximum at 4 weeks after the injection and maintains for about 3-5 months. The orbicularis oculi muscle is responsible for eyelid closure, excessive weakness of this muscle will result in incomplete eyelids closure and which in turn leads to exposure keratitis and drying of the cornea. If exposure keratitis occurs, application of ocular ointments or artificial tear solutions is recommended.

View full abstract

Of the neuronal GABA receptors of the spinal cord and the supra spinal cord, two subtypes of GABA receptors play important roles in pain regulation. In this experiment, we compared the effects of intrathecal and lateral-ventricular injections of either GABAa or GABAb receptor ligand on secondary nociception induced by formalin using male Wistar rats (300-350g). As specific ligands for each GABA receptor subtype, muscimol (a GABAa agonist), baclofen (a GABAb agonist) and phaclofen (an inhibitor of GABAb receptor) were used. All agents were administered intrathecally (i.t.) or intraventricularly (i.c.v) 10min prior to formalin injection. Flinching was quantified in five minute intervals for 60min. Between zero and 15min, flinching response was defined as the first phase, and the second phase of this response was between 16 and 60min of the observation period. An i.t. injection of muscimol (15nmol) diminished both phases of formalin-induced flinching response with a muscle relaxation, although a low dose (1.5nmol) of muscimol suppressed the second phase of this response with a weak muscle relaxation. Both low and high doses of muscimol i.c.v. treatments did not effect both phases of response. An i.t. injection of baclofen (1.5nmol) significantly inhibited the second phase responses, although a high dose of baclofen did inhibit both phases of flinching response with muscle relaxation. In contrast, an i.c.v. injection of baclofen significantly enhanced the nociceptive response in a dose-dependent manner with clonic convulsions. However this enhancement of nociceptive response was significantly inhibited by phaclofen, although the convulsion induced by a high dose of baclofen was not influenced. In conclusion, the GABAa receptor in the central nervous system may not relate to the pathway of the formalin-induced nociception, but the spinal GABAb receptor appear to influence strongly this nociceptive response. Furthermore the supraspinal GABAb receptor may locate on the presynaptic neurons and stimulate the excitatory transmissions.

View full abstract

Percutaneous radiofrequency thermocoagulation, has gained popularity in recent years as a method for treatment of trigeminal neuralgia. We have performed this treatment using propofol anesthesia in a series of 22 patients suffering from trigeminal neuralgia. With this technique, we could minimize pain which had been unavoidable in previous methods. We present the outcome and side-effects of our technique.

View full abstract

Aim: Relief of acute herpetic pain and prevention of postherpetic neuralgia are important in the treatment of herpes zoster. Guidelines on the treatment of herpes zoster are published in France and England. However, sympathetic nerve blocks that can relieve even severe acute herpetic pain are adopted in neither country. Guidelines on the treatment of herpes zoster are needed in the country where sympathetic nerve blocks are performed to relieve severe acute herpetic pain. Methods: We reviewed non-steroidal anti-inflammatory drugs, antiviral drugs, sympathetic nerve blocks, adrenocorticosteroid hormones, and adjuvant analgesics for the treatment of acute herpetic pain. Guidelines for each patient were sought. Results and Conclusions: Oral antiviral and non-steroidal anti-inflammatory drugs should be taken by patients whose onset of herpes zoster is less than 72 hours and who are older than 50 years old. Sympathetic nerve blocks are recommended for patients with severe acute herpetic pain. Guidelines on the treatment of herpes zoster for other patients are also presented.

View full abstract

Purpose of Study: The role of continuous intravenous infusion of morphine (CIVI-Morphine) was evaluated in terminal lung cancer patients with pain.
Methods: In the 10-year period from 1988 to 1998, 33 patients with progressive lung cancer were given CIVI-Morphine until their deaths. Clinical staging, symptoms, duration of CIVI-Morphine and the daily amount of morphine were investigated.
Results: Of these 33 patients, 6 (18%) were in Stage III (regional metastases), and 26 (79%) in Stage IV (remote metastases). Besides pain relief, alleviation of dyspnea was also requested in 11 Cases (33%). As the primary symptom of lung cancer, pain (14 cases, 42%) followed coughing (20 cases, 61%) in frequency of occurrence. Twenty-six patients (79%) were found to have metastases to bone at the time of referral to our Pain Clinic. The duration of CIVI-Morphine ranged from 1 to 161 days (mean 22 days, median 18 days). Forty-five percent of the patients died within two weeks of CIVI-Morphine and 90% within one month. Daily amounts of morphine given were 10 to 1, 500mg/day (mean 136mg/day, median 80mg/day). For the control of pain, 45% of patients required less than 50mg/day, and 80% of patients required less than 200mg/day.
Conclusion: Progression of lung cancer and advent of pain are rapid. It is imperative to start pain relief therapy in the early stages. Relief of pain is best accomplished by early institution of CIVI-Morphine, especially in patients for whom difficulty in breathing and swallowing develops.

View full abstract

We present a patient with long-standing painful scars whose pain completely disappeared after injection of local anesthetic and steroid. The patient was a 61-year-old female who had had her left arm wounded by broken glass shards at age 36 years. She had been operated on for removal of the glass shards two times. Pain gradually developed in the scars at age 56 years. She received anti-inflammatory agents, anti-depressants and psychotropic drugs in the ensuing 5 years. These medications did not lessen her pain, which was continuous. Allodynia and hyperalgesia were noted over the painful scars. The pain was completely relieved one month after local injections twice of dexamethasone and lidocaine. Local injections of steroid with local anesthetic may be beneficial in some patients with the pain associated with long-standing scars.

View full abstract

Reported are 4 patients with deep pain of the orbital region with regard to the potential mechanisms and treatment strategies. Case 1 was a 72-y-o female with left eye pain and mild chemosis. Magnetic resonance angiogram revealed abnormal vasculature at the intracranial cavernous portion, which was confirmed by DSA as the carotid cavernous sinus fistula. In this case, orbital pain may be caused by increased cavernous sinus pressure, resulting in mechanical stretching of the trigeminal branches or nerve plexus around the internal carotid artery. Case 2 was a 34-y-o female who had had continuous type of cluster headache for the last 2 years. None but lithium ever relieved her from the right eye pain. Radiofrequency thermocoagulation at the pterygopalatine ganglion (PPG) made her almost pain free for two months. In this case the cause of her eye pain may have been derived from some kind of neuronal irritation at the PPG. Case 3 was a 51-y-o depressed man who complained of bilateral occipital pain and left deep eye pain. Great occipital trigeminal syndrome was suspected, and bilateral C₂ ganglion thermocoagulation was performed. His eye pain did not improve, but stellate ganglion blockade, which had had no effect before the procedure, became effective for his eye pain, suggesting that a potential irritation of the trigeminal nerve region could be sympathetic-mediated, and thus relieved by stellate ganglion blockade. Case 4 was a 67-y-o male who had been treated for the cluster headache for 2 years. Stabbing deep pain of the right eye was diagnosed as the trigeminal neuralgia. After a successful Gasselian ganglion blockade, routine microvascular decompression was performed uneventfully, and his stabbing eye pain disappeared. Four patients with deep pain of orbital regions described may indicate that the irritation of the trigeminal nerve (V2) involving the automatic nervous activity seems to induce the pain around the PPG.

View full abstract

Werner syndrome is an autosomal recessive syndrome characterized by premature aging. A 54-year-old man was diagnosed with Werner syndrome. He had received treatment for cataract, hyperopia, and lower limb skin ulcer for a period of over 10 years. In the last few years, the patient complained of a pain and numbness of the lower limbs, on effort, which could not be controlled by Non Steroidal Anti-Inflammatory Drugs (NSAIDs). Lumbar or sacral epidural block and lumbar sympathetic ganglion block were extremely effective for the pain and numbness. The pain and numbness associated with Werner syndrome are considered to be induced by atrophy of congenital cutaneous and subcutaneous tissue and arteriosclerotic disorders.

View full abstract

A case of chylothorax following a neurolytic celiac block is presented with review and discussion of the possible pathophysiology.
A 51-year-old man with a history of chronic pancreatitis was referred to our Pain Clinic for celiac plexus block. Under image intensifier direction, in the prone position, 12-cm 22-gauge needles were placed 7cm lateral to the midline at the L-1 level and directed beneath the 12th ribs in a medial cephalad direction to rest anterior to the L-1 vertebral body; 10ml of 100% alcohol were injected on each side after negative aspiration tests. The patient had no pain relief in the right side, so four days later, the same directive technique was employed with addition of anatomic demarcation using 1ml of 10% lidocaine with 4ml iotrolan. Aspiration test was positive of milky fluid, hence we suspected the thoracic duct was penetrated. After changing needle position and injecting contrast solution, 10ml of 100% alcohol injected. X-ray films of the chest taken the day after the block revealed normal aeration of the lung field. The patient did well to had no immediate problems, obtained pain relief and was discharged from the hospital 7 days later. Thirty-two days after the last celiac block, he presented to the emergency room with chest pain, dyspnea, and a right pleural effusion on radiographic examination of the chest. Chest tube drainage was necessary to relieve symptoms, and 4, 500ml of chylous fluid was withdrawn during the next nine days. Chest tube drainage diminished daily.
Our case report reinforces the need for follow-up of patients having such neurolytic celiac block and the need to include the relationships of the major lymphatic structures in anatomic descriptions of this particular procedure.

View full abstract

Presented is a 48-year-old man who had complex regional pain syndrome (CRPS) Type I in the left upper extremity after a car accident. There were no abnormal MRI images associated with the traffic accident. Two years later he was admitted to a local hospital and diagnosed as having whiplash injury. He received medication and physical therapy, but his symptoms did not improve. He was referred to our clinic 2 years ago. He complained of burning pain in his left upper extremity which was evaluated at 80-mm of visual analogue scale (VAS). He also had edema, hyperpathia, allodynia, coldness, and cyanosis in his left hand. However, there was no headache, vertigo, tinnitus nausea, or memory loss. Therefore, the diagnosis of CRPS Type I was made. The patient received left stellate ganglion block 20 times, which reduced his VAS from 80-mm to 40-mm, and he resumed working thereafter. The cause of CRPS type I may be due to the left sympathetic efferent fibers being incompletely torn or stretched because of flexion, extension, or axial rotation of the lower cervical vertebrae that occurred at the traffic accident.

View full abstract