220 Acute and Chronic Pain Management
14AP2-10 Discussion: Epidural space is richly parasympathetic innervated region that
Trigeminal neuralgia and perfusion pump of intrathecal
morphine, a case report
Calvo M.A.1, Fauli A.1, Ojeda A.2, Moreno L.A.2, Busquets C.2
Hospital Clinic, Dept of Anaesthesiology, Barcelona, Spain, 2Hospital Clinic
1
Universitari de Barcelona, Dept of Anaesthesiology, Barcelona, Spain
Background: Trigeminal neuralgia ( TN) is a painful disorder characterized
by brief, electric-shock-like pains, is limited to the distribution of one or more
divisions of the trigeminal nerve, sometimes if medical treatment is not suc-
cessful or results in marked deterioration in activities of daily living, surgical
or invasive techniques should be considered[1]. This case is about of TN for
tretament surgical of sphenoid tumor with unsatisfactory analgesia and surgi-
cal or percutaneous techniques[2] in gasserian ganglion not posible for dis-
semination , we decided to place an intrathecal morphine perfusion.
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Case report: AC is a 68-year-old female, she has been operated for reseccion
of sphenoid fibromyxosarcoma in 2010. She was ievaluated for pain manage-
ment in our hospital in 2012, Medications at the time of consult included long-
acting carbamazepina 200 mg 4 times a day, Cymbalta 30 mg day, Rivotril 0.5
mg night, Lyrica varying doses, without success, Interventional treatment for
the TN included multiple nerve blocks in three divisions of which were helpful
only temporarily.
In October 2013, we did two test events (1 ug morphine) with pain relief for 6
hours , with rapid decrease and finally .We placed the pump (20 ml. Morphine
1% (0.1mg/ml.) and catheter were examined under fluoro, the IT catheter tip
at T12 and advance the catheter until C1-C2, confirming with contrast sub-
arachnoid distribution.
Morphine dose and concentration was 100 ug/d and timely dose was 50 ug
during one hour. At the postprocedure follow-up, the patient reported satisfac-
tion with the procedure, without headache after lumbar puncture, althought
with the increase of dose, she has had a vasovagal syncope, no others effects
and today she continues talking notably relief from the TN.
Discussion: This is a case about analgesic response to intrathecal morphine
in perfusion, for chronic trigeminal neuropathic pain without response to medi-
cal treatment and multiple nerve blocks with pain relief for this patient.
References:
1. International association for the study of pain, global year against, orofacial pain,
October 2013.
2. Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation
and treatment of trigeminal neuralgia (an evidence-based review). Neurology.
2008;71:1183-1190.
Learning points: This technical would be applied in those patients whithout
response in conventional treatment or without possibilities of surgical proce-
dures or percutaneous techniques.
14AP2-11
Refractory back pain treated by caudal epidural pulsed
radiofrequency. Case report
Cernavska I.1, Miscuks A.2, Golubovska I.1, Briuks K.3, Zvirgzdina D.4
1
Hospital of Traumatology and Or thopaedics, Dept of Anaesthesiology &
Intensive Care, Riga, Lat via, 2Universit y of Lat via, Facult y of Medicine,
Riga, Lat via, 3Hospital of Traumatology and Or thopaedics, Dept of Ver tebral
Surger y, Riga, Lat via, 4Riga Stradins Universit y, Student, Riga, Lat via
Background: Central sensitization is a chronic clinical condition dif ficult to
diagnose and treat (1). Long lasting, refractory lower back pain is one of the
reasons for the condition. Pulsed radiofrequency (PRF) is successfully used
for treatment of neuropatic and nociceptive pain (2).
Case report: A 77 year old woman with two years long lower back pain due to
spinal spondilosis, spondiloarthrosis and spinal stenosis L4-L5 presented to
pain clinic; pain level 8 NRS; on physical exam she presented central sensiti-
zation syndrome with tenderness over processi spinosi of thoracic and lumbar
vertebras. As conservative medication regimens and epidural steroid injec-
tions showed no significant pain relief was treated with PRF at 42o Celsius,
50V, 5Hz, 5 ms for 7min in caudal epidural space. Before applying the PRF
fluoroscopic conformation of electrode position was performed in AP and LL
projections with an injected 1ml of contrast medium. Pain level was assessed
by NRS; adapted Oswestry disability questionnaire was used to estimate the
level of disability in daily living. Patient reported 50% (from 8 to 4 NRS) pain
relief 2 days af ter PRF treatment that lasted till the one month follow up. The
disability index (DI) was 28 (ma x 60) points before the PRF. Following PFN,
she reported an increased ability to complete activities of daily living pre-
senting the DI of 14/60 points. The highlight of disability evaluation was the
complete ex tinction of previous sleep disturbances.
contacts with vagus nerve. We suggest that the positive ef fect of caudal PRF
could be associated with the activation of parasympathetic nervous system.
Goehler LE et.al. (3) have described vagal immunosensory communication to
brain. Previous successful epidural caudal PRF has been described by Atim
for coccygodynia patients in 2011.
References:
1. Clif ford J Woolf, Central sensitization: Implications for the diagnosis and treatment of
pain. Pain,2011,V152,S2-S15
2. Rohof OJ, Radiofrequency treatment of peripheral nerves, Pain Pract.2002
Sep;2(3):257-60.
3. Goehler LE et.al. Vagal immune-to-brain communication: a visceral chemosensory
pathway. Autonomic Neuroscience,2000,85,49-59
Learning points: Caudal epidural PRF may be alternative minimally invasive
and safe treatment for refractory back pain. Further studies should be made
to ascertain the role of parasympathetic nervous system in chronic pain with
central sensitization syndrome.
14AP3-1
Catechol-O-methyltransferase (COMT) and opioid µ-1 receptor
(OPRM1) gene single nucleotide polymorphisms (SNP) and
postoperative opioid analgesia
Potapov O., Boiarkina G., Babanin A.
State Institution ‚Crimea State Medical Universit y named af ter S.I.
Georgievsk y’, Emergency and Anaesthesiology, Simferopol, Ukraine
Background and Goal of Study: COMT 1947G>A (rs4680) and OPRM1
118A>G (rs1799971) gene SNPs are actively investigated in various popu-
lations and diseases; but the results remain controversial1. Objective of this
study is to evaluate the prevalence of SNPs in Crimean (Ukrainian) population
and their possible association with postoperative opioid analgesia.
Materials and methods: 81 consecutive patients scheduled for a major
urologic surgery were enrolled in this study. COMT 1947G>A and OPRM1
118A>G gene SNPs were detected via real-time PCR. For basic analgesia
all patients received 100 mg of µ-agonist trimeperidine on the first postopera-
tive day (POD1), additional analgesia was provided using dexketoprofen. The
severity of postoperative pain and side ef fects of opioids have been analyzed
on POD1. Statistical analysis was performed using median and Pearson’s χ2
tests with data presented as Me (QI-QIII).
Results and Discussion: Possible variations of COMT SNP 1947G>A were
identified: A A - 15 (18.5%) patients, AG - 44 (54.3%) patients, GG - 22 (27.2%)
patients. Ma ximum pain level on POD1 for A A group was 5 (5-6) points, 7 (5-8)
points in AG group and 8 (5-9) points in GG group (p=0.024). The incidence
of pruritus was lower in group A A+AG than in GG group - 3.3% vs. 22.7%,
respectively (p=0.021). Data for OPRM1 SNP 118A>G genotypes were as
follows: A A - 57 (70.3%) patients, AG - 16 (19.7%) patients, GG - 8 (9.9%)
patients. There were no statistically significant dif ferences in ma ximum pain
level between groups on POD1: A A patients - 7 (5-8) points, AG patients - 6.5
(5-9) points, GG patients - 6 (4-9) points (p=0.97). Nevertheless, patients from
A A group more rarely reported about additional analgesic requirements than
patients in AG+GG group - 17.5% vs. 41.7%, respectively (p=0.044). There
were no dif ferences in the incidence of nausea, vomiting and respiratory de-
pression between groups of both SNPs. Thus, SNPs COMT 1947G>A and
OPRM1 118A>G might be associated with ef ficacy of postoperative analgesia
and the incidence of pruritus.
Conclusion(s): COMT 1947G>A and OPRM1 118A>G gene SNPs might af-
fect the postoperative opioid analgesia. For the clinical implication of this data
further research is required.
References:
1. Mura E., Govony S., Racchi M. et al. Consequences of the 118A>G polymorphism in
the OPRM1 gene: translation from bench to bedside? J Pain Research 2013; 6:331-53.
14AP3-2
Choice of anesthesia af fects post-operative pain af ter
anklefracture surgery
Christensen K.P., Sort R., Nielsen J.K., Moeller A.M.
Herlev Universit y Hospital, Dept of Anaesthesiology, Herlev, Copenhagen,
Denmark
Background and Goal of Study: Multiple anaesthesia techniques are used
for ankle fracture surgery. The post-operative ef fects of anaesthesia choice
have not been described suf ficiently in the literature.
With this study we aimed to investigate the impact of anaesthetic teqhnique on
postoperative pain and related parameters in ankle fracture patients.