Pathological fracture complicating epidural local anaesthetic opioid infusion for cancer pain.

Two cases of severe bone pains from metastatic cancer, without clinical or radiological evidence of fractures on admission, are presented. Pain control and mobilization were achieved initially with local anaesthetic-opioid epidural infusion. Subsequent loss of analgesia prompted a re-examination, which revealed pathological fractures of the femur. Internal fixation of the fractures resulted in good control such that strong opioids were no longer required.

Premedication with slow release morphine (MST) and adjuvants.

Sixty-one women undergoing major gynaecological surgery received slow release morphine (MST) 60 mg, with placebo, hyoscine 0.6 mg or diazepam 10 mg, by mouth 2 h before surgery. Plasma morphine concentrations reached a steady level usually within 3 h after administration of MST, and did not increase after surgery unless supplementary opioid was given. Hyoscine delayed morphine absorption. Before operation no fewer than 50% of patients were sedated after MST alone, but this increased to 85% after MST and diazepam. Similarly, only the combination MST and diazepam produced anxiolysis. Postoperative mood was unhappier after MST and hyoscine. Emesis occurred in 40-57% of patients, and was not reduced by hyoscine. Therefore premedication with MST alone did not produce reliable sedation or anxiolysis. A combination of hyoscine and MST premedication cannot be recommended, as it did not produce sedation, anxiolysis or antiemesis and hyoscine may have delayed morphine absorption.

Long-term efficacy of surgical cordotomy in intractable non-malignant pain.

Our results show that about 40% of patients who have cordotomies for non-malignant pain gain a prolonged and worthwhile period of relief, allowing a return to work and normal living. The available evidence, though scanty, suggests that the decline in the analgesic efficacy of cordotomy tends to 'plateau' with the passage of time, though the exact pattern of this change remains undefined. We conclude that, while the complication rate of cordotomy is undoubtedly high, and its effectiveness far from ideal, it may nevertheless have a place in the treatment of carefully selected patients with intractable pain due to non-malignant causes.

Cryoanalgesia for intractable perineal pain.

Cryoanalgesia, the local application of extreme cold to nerves to produce analgesia, has been used to treat patients with intractable perineal pain. The cryoprobe was inserted percutaneously through the sacral hiatus into the sacral canal to produce anaesthesia of the lower sacral nerve roots. Forty patients received a total of 70 treatments: 31 patients (78%) were helped by the procedure and the median duration of improvement was 30 days. The treatment was more successful in relieving symptoms in patients suffering from pelvic cancer and coccydynia. The best results were obtained in those patients who received numerous freeze applications or prolonged freezing.

Post-partum intracranial subdural haematoma. A possible complication of epidural analgesia.

A case is reported of bilateral chronic subdural haematomas in a 29-year-old woman 1 month after childbirth under attempted epidural analgesia. The possible link between leakage of cerebrospinal fluid through a hole in the lumbar theca and the later development of an intracranial chronic subdural haematoma is discussed, with a review of eleven previous reported cases.