Mide, pankreas, karaciðer, safra kesesi gibi üst batýn organlarýnýn çeþitli patolojilerinden kaynaklananan aðrýlarýn tedavisinde bu organlarýn sempatik innervasyonunu saðlayan splanknik sinirler ve çölyak ganglion sempatik blokajlarýnýn sempatik sinir ve ganglion bloklarýnýn önemli yeri bulunmaktadýr. Çalýþmamýzda çeþitli nedenlere baðlý olarak üst batýn aðrýsý olan hastalarda fenol ile perkütan uygulanan splanknik sinir nörolizinin etkinliði, yan etkileri ve komplikasyonlarý irdelenmiþtir. Çalýþmaya Eylül 1999 - Haziran 2000 tarihleri arasýnda Algoloji Bilim Dalý’na çeþitli nedenlere baðlý üst batýn aðrýsý þikayeti olan 34 hasta dahil edilmiþtir. Hastalarýn yazýlý onaylarý alýndýktan sonra giriþim için hazýrlanan hastalara cerrahi koþullar altýnda, skopi eþliðinde, Boas yaklaþýmý ile fenol (% 10) kullanýlarak splanknik sinir blokajý uygulanmýþtýr. Hastalarýn giriþim öncesi ve sonrasý VAS deðerleri, ilaç gereksinimleri, giriþim sonrasý yan etki ve komplikasyonlar deðerlendirilmiþtir. Uygulanan splanknik sinir bloðunun analjezik açýdan etkinliði deðerlendirildiðinde giriþim sonrasý VAS deðerlerinde giriþim öncesine oranla anlamlý derecede azalma (p=0.01) saptanmýþtýr. Komplikasyonlar açýsýndan deðerlendirildiðinde erken dönemde giriþim sýrasýnda hastalarda herhangi bir hemodinamik deðiþiklik (baþlangýç TA deðerinde %30 artma veya azalma) saptanmamýþtýr. Ayný þekilde hastalarda operasyon sonrasý herhangi bir komplikasyona rastlanmamýþtýr. Çeþitli nedenlerden kaynaklanan üst batýn aðrýlarýnda splanknik sinir bloðu uygulamalarýnýn etkin ve güvenilir bir yöntem olduðu, özellikle düþkün hastalarda çölyak pleksus blokojýna emin bir alternatif yaratacaðý kanýsýna varýlmýþtýr.

Abdominal visceral sympathetic pain due to malign or benign pathologies of the upper gastrointestinal organs can be blocked either by celiac plexus blockade or splanchnic nerve blockade or both. We have evaluated the efficacy and safety of application of splanchnic nerve blockade to patients suffering from abdominal pain due to various reasons. After signing the informed consent, patients were hospitalized for splanchnic nerve blockade. We have performed splanchnic nerve blockade to 34 patients, in the operating room, with fluoroscopic guidance using Boas technique with 12 ml of 10 % phenol. The VAS values and complications were evaluated before the procedure, 3 months and 6 months after the procedure. The complications were recorded respectively. The VAS values at the 3rd and 6th months were significantly lower than the preprocedure values. No complications due to the technique or the drug injected were recorded except aspiration of blood during the procedure of which were postponed to a later date.

Postoperatif dönemde þiddetli aðrýya sebep olan anal fissür ve hemoroid gibi ameliyatlarda uygulanan genel ve kaudal anestezi; etkinlikleri, solunum fonksiyon testlerine etkisi, postoperatif analjezi ve anestezi açýsýndan deðerlendirildi. ASA I-II grubu 54 eriþkin hasta rastgele 2 gruba ayrýldý. I. gruba standart genel anestezi, II. gruba kaudal blok uygulandý. Tüm olgularda preoperatif dönemde, operasyon bitiminde, postoperatif 1. saatte, aðrý duyduðunda ve analjezik yapýldýktan 1 saat sonra arteryel kan basýncý (TA), nabýz (N), periferik oksijen saturasyonu (SpO2), solunum frekansý (SF), tidal volüm (TV), dakika volümü (DV) ve Vizüel Analog Skala (VAS) ile ölçülen postoperatif aðrý deðerlendirildi. TA, N, SpO2, SF, TV, DV gruplar arasý anlamlý farklýlýk göstermedi. Genel anestezi grubundaki 27 hastadan 3’ü, kaudal anestezi grubundaki 27 hastadan 22’si postoperatif dönemde aðrý duymadý ve analjezik ihtiyacý olmadý. Kaudal anestezi ile opere olan grupta postoperatif aðrý ve analjezik gereksinimi anlamlý derecede azdý. Hiçbir hastada komplikasyon geliþmedi. Çalýþma sonucunda, kaudal anestezi tekniðinin komplikasyonlarýnýn az olmasý, postoperatif dönem kalitesinin yüksek olmasý nedeniyle perianal cerrahi uygulanacak vakalarda güvenle tercih edilecek yöntem olduðu kanaatine varýldý.

General anesthesia and caudal anesthesia in anal fissure, anal fistula and hemorrhoid surgery, which cause severe pain in the postoperative period, are compared in terms of effects on respiratory function tests, postoperative pain and analgesic effects. 54 patients in ASA I-II group were randomly allocated into two groups. General anesthesia was applied to the first group and caudal blockade was performed to the second group. Blood pressure (BP), heart rate (HR), arterial oxygen saturation (SpO2), respiratory frequency (RF), tidal volume (TV), minute volume (MV) and pain scores by using Visual Analog Scale (VAS) were measured before the operation, at the end of the operation, one hour after the surgery, when they felt pain and one hour after analgesic administration. No significant differences were found between the groups in the terms of BP, HR, SpO2, RF, TV, MV. Three of the twenty-seven patients in general anesthesia group and twenty-two of the twenty-seven patients in caudal anesthesia group had no pain. Postoperative pain scores were significantly low in patients with caudal anesthesia group. No complications were observed in both groups. We concluded that caudal anesthesia technique in perianal surgery is very effective and reliable as it’s performed easily, its complications are rare and quality of postoperative period is high.

Çocuklarda epidural derinlik, yapýlarý nedeniyle farklýdýr. Bu çalýþmada amaç Türk çocuklarýnda vücut yapýsý ve yaþla epidural derinlik arasýndaki iliþkiyi bulmaktýr. Lomber epidural enjeksiyon yapýlan, yaþlarý 6 gün ile 18 yaþ arasýnda deðiþen 300 çocuk çalýþma kapsamýna alýndý. Epidural aralýða ulaþýlan iðne mesafesi (cm), yaþ (yýl), aðýrlýk (kg), boy (cm) ve vücut yüzey alaný (VYA, m2) kaydedildi. Hastalar yaþlarýna göre gruplandý: 0-1 yaþ (n=37), 1-5 yaþ (n=133), 5-10 yaþ (n=75) ve 10-18 yaþ (n=55). Regresyon korelasyon analizi yapýldý. L4-5 aralýðýnda epidural derinlik (cm) için formüller ve korelasyon iliþkileri þu þekildedir:
- 0.15 (yaþ)+1.35, r2=0.63
- 0.004 (boy)+1.7, r2=0.58
- 0.058 (aðýrlýk)+1.04, r2=0.67
- 2.11 (VYA)+0.59, r2=0.71
En iyi korelasyon epidural derinlik ile VYA arasýnda idi. 5-10 yaþ grubunda korelasyonlarýn iyi olduðu görüldü.

The depth of epidural space is variable in children because of their sizes. The purpose of this study is to find out relation between epidural depth and age and the constitute in Turkish children. Three hundred patients who had lumbar epidural injections as a part of their anesthetic management, ages ranging from 6 days to 18 years included in this study. Length of epidural needle when reached to epidural space, age, weight, height and body surface area (BSA) of the patients were recorded. Patients are stratified according to age groups, 0-1 years (n=37), 1-5 years (n=133), 5-10 years (n=75) and 10-18 years (n=55). Regression correlation analysis was performed. The formulas and level of correlations for epidural depth (cm) at L4-L5 were as follows:
- 0.15 (age in years)+1.35, r2=0.63
- 0.004 (height in cm)+1.7, r2=0.58
- 0.058 (weight in kg)+1.04, r2=0.67
- 2.11 (BSA in m2)+0.59, r2=0.71
The best correlation coefficient achieved by epdidural depth and BSA. Best corelation observed, in 5-10 years old group.

Bu çalýþmada, klasik yöntemle patellofemoral (PF) aralýktan yapýlan Na-hyaluronat (HA) enjeksiyonlarýnýn etkisi, manuel týp yardýmý ile deðiþik diz eklemi kompartmanlarýna yapýlan HA enjeksiyonlarýnýn etkinliði ile karþýlaþtýrýldý. Bu arada kýsa dönemde intraartiküler hyalürinat enjeksiyonlarýnýn etkisi deðerlendirildi ve farklý uygulama teknikleri birbiri ile kýyaslandý. Çalýþmaya Osteoarthritis Research Society (OARS) önerilerine göre klinik ve radyolojik olarak evre 2 ve 3 diz osteoartrit tanýsý konan 100 hasta alýndý ve randomize olarak 2 gruba ayrýldý. Çalýþma sonunda 16 hasta çalýþmadan ayrýldý ve 84 hasta deðerlendirilebildi. Birinci gruba birer hafta arayla, üç kez, skopi altýnda, sadece patellofemoral eklem aralýðýna, ikinci gruba birer hafta ara ile, önce her iki tibiofemoral kompartman, sonra patellofemoral eklem aralýðýna olmak üzere, traksiyon yardýmýyla her üç kompartmana 2 cc Orthovisc (HA derivesi) enjeksiyonu yapýldý. Hastalar çalýþma öncesi ve her üç enjeksiyondan bir hafta sonra enjeksiyon ekibi dýþýndan bir araþtýrmacý tarafýndan deðerlendirildi. Tedavi öncesinde her iki grup arasýnda istirahat, yürüme ve ayaða kalkarken deðerlendirilen Vizüel Analog Skala (VAS), günlük analjezik kullanýmý, sabah tutukluðu süresi (dk), aðrýsýz yürüyebildikleri mesafe (m) ve süre (dk), aktif ve pasif fleksiyon ve ekstansiyon ölçümü açýsýndan bir fark yoktu (p>0.05). Her iki grupta da tedavi öncesi ile tedavi sonrasý arasýnda, bu parametrelerde iyileþme yönünde anlamlý fark olduðu bulundu (p<0.0001). Tedavi sonuçlarý açýsýndan kýyaslandýðýnda iki grup arasýnda fark bulunmadý (p>0.05). Bu sonuçlar, uygulamasý daha kolay olan ve daha az travmatize ettiði düþünülen patellofemoral eklem aralýðý injeksiyonlarýnýn, diz osteoartriti olan hastalarýn tedavisinde rahatlýkla tercih edilebileceðini düþündürmektedir.

The first aim of this study is to compare the efficacy of sodium hyaluronate (HA) injection which is done by classical method from the patellofemoral (PF) joint and the efficacy of HA injection which is done to different knee joint compartments in conjuction with manual medicine. The second aim of the study is to establish the short term efficacy and to compare the results of different techniques. One hundred patients admitted to the outpatient clinic of the Department of Physical Medicine and Rehabilitation, Istanbul Medical Faculty, and who had grade 2 and 3 osteoarthritis (OA) according to the clinical and radiological data of Osteoarthritis Research Society (OARS), were included in the study. Two groups have been constructed by the randomisation tables, however 16 patients were drooped from the study and 84 patients had completed the study. 2 ml Orthovisc injection which is a derivative of HA, was done by fluoroscopy to the first group only to the PF joint space 3 times, every consecutive week. For the second group, 3 injections were done in the similar pattern, but first to the two tibiofemoral compartments then to the PF compartment with the aid of traction. Patients were evaluated by a blind investigator, before and 1 week after the three injections. Before the treatment no difference has been found between the two groups according to the parameters; namely pain severity at rest, pain in walking and standing scored by Visual Analog Scale (VAS), daily analgesic consumption, duration of morning stiffness in minutes (min), painless walking distance in meters(m) and duration (min), Range of Motion (ROM) of passive and active knee flexion and extension (p>0.05). All of the above parameters improved in both groups after the treatment, the difference being statistically significant (p<0.0001). There was no difference between the two groups when the results of the treatments were compared (p>0.05). Therefore, PF joint space can be chosen for routine application since it is easier to perform and may be less traumatic.

Bu çalýþmada, Ocak 1995 - Aralýk 1998 tarihleri arasýnda, Ç. Ü. T. F. Algoloji Bilim Dalý’na baþvuran 663 hasta, karþýlaþtýðýmýz sorunlarý, ilaç ve yöntemden kaynaklanan komplikasyonlarý deðerlendirmek amacýyla retrospektif olarak deðerlendirildi. Hastalarýn yaþ ve cinsiyetleri, kanserin kaynaklandýðý organlar aðrýnýn nedeni, yoðunluðu ve bölgesel daðýlýmý, baþvuru öncesi aldýðý antineoplastik ve analjezik tedavi, bilim dalýmýz tarafýndan verilen medikal tedavi, uygulama yolu ve takip süresi, tedaviye baðlý saptanan komplikasyonlar tespit edilerek kaydedildi. Hastalarýn ortama yaþý 50 ± 16 idi. Neoplazmlarýn kaynaklandýðý bölgeler en sýk gastrointestinal sistem (% 33.6), solunum sistemi (% 19.0) ve genitoüriner sistem (% 18.1) idi. Hastalarýn % 78.3’ünde metastaz bulunmaktaydý. Bize baþvurmadan önce hastalarýn % 29.4’ü sadece cerrahi giriþim, % 9.5’i kemoterapi, % 4.8’i radyoterapi ve % 0.3’ü hormonal tedavi görmüþtü. Aðrý lokalizasyonunun en belirgin olduðu bölge abdominal bölge (% 21.1) idi. Hastalarýn % 24.9’unun üçten fazla bölgede aðrýsý vardý. % 92.2 hastada aðrý nedeni tümör invazyonuydu. Hastalarýn % 93.2’si analjezik tedavinin yanýnda ko-analjezik ilaçlar da kullanmýþtý. Baþlýca analjezik uygulama yolu oral yol (% 89.7) idi. Hastalarýn kontrol sayýlarý 1-5 arasýnda (% 84.0) yoðunluk gösteriyordu. Hastalarda ilaçlara baðlý olarak bulantý, kusma, kaþýntý, kabýzlýk, idrar retansiyonu; uygulamalara baðlý olarak kontaminasyon, dural giriþte zorlanma, kataterde týkanma, baþaðrýsý, porta baðlý allerji, subaraknoido-kuteneal fistül komplikasyon olarak saptandý. Sonuç olarak daha etkin tedavi protokollerinin hazýrlanabilmesi ve komplikasyon sýklýðýný azaltabilmek için uzun izlem süreli, detaylý prospektif çalýþmalara gereksinim olduðunu düþünmekteyiz.

In this study, 663 patients admitted to the Algology Department of our university were evaluated in order to define the patient characteristics, our treatment modalities and complications related to the medications and interventions. The age and sex of the patient, the origin of the neoplasm, the reason, intensity and distribution of pain, the antineoplastic and analgesic therapy taken before inclusion to the study, the treatment modalities performed in our clinic, the routes of administriation, the follow-up duration, the comlications related to the treatment are defined and recorded. The avarage age of the patients were 50 ± 16 years. The origins of the neoplasms were gastrointestinal tract (33.6 %), respiratory system (19.0 %), genitourinary tract (18.1 %). There was metastasis in 78.3 % of the patients. 29.4 % of the patients had only surgical intervention, 9.5 % had chemotherapy, 4.8 % had radiotherapy and 0.3 % had hormonal therapy before coming to our clinic. 38.2 % had two or more antineoplastic therapy. 13.6 % of the patients didn’t have analgesic therapy before us. The most dominant painful region was abdomen (21.1 %). 24.9 % of the patients had pain at more than three regions. In 92.2 % of the patients, the reason of the pain was tumor invasion. 93.2 % had recieved co-analgesics with the analgesic therapy. Main route of analgesic administration was oral route (89.7 %). Most of the patients (84.0 %) came to the clinic 1-5 times for the follow-up. For the medications; nausea, vomitting, pruritus, constipation, urinary retention, for the interventions; contamination, difficulty of dural penetration, obstruction of the catheter, headache, allergy to the port, subarachnoido-cutaneal fistula were the complications we have seen. As a result we believe that in order to have more effective treatment procols and reduce the complication rates, detailed prospective studies with long follow-up times are needed.

Nonsteroid antienflamatuar ajanlarýn preemptif analjezi saðlamak için kullanýlabileceði bildirilmiþtir. Bu çalýþmada, sezaryen olgularýnda postoperatif analjezi yönetiminde preemptif veya perioperatif dönemde uygulanan tek doz tenoksikamýn, epidural analjezi üzerine etkilerinin araþtýrýlmasý amaçlanmýþtýr. Epidural anestezi ile elektif sezaryen endikasyonu olan 67 olgu randomize olarak üç gruba ayrýlarak; Grup P’ye operasyondan 3 saat önce tenoksikam 20 mg intramüsküler (i.m.), Grup T’ye intraoperatif bebek çýkýmýndan hemen sonra tenoksikam 20 mg i.m., Grup K’ya ise yine bebek çýkýmýndan hemen sonra serum fizyolojik 2 ml. i.m. yapýldý. Tüm olgularda postoperatif analjezi epidural meperidin ile saðlandý. Olgularýn postoperatif ilk 24 saat içinde meperidin tüketimi kaydedildi ve VRS (verbal aðrý skalasý) istirahatte epidural meperidin uygulanmasýndan hemen önce ve 1’er saat sonra deðerlendirildi. Gruplar arasýnda demografik deðerler açýsýndan fark yoktu (p>0.05). Ýlk 24 saat içerisinde tüketilen toplam meperidin miktarý; Grup K’da diðer iki gruptan daha yüksekti (p<0.05). Her üç grupta da epidural meperidin uygulanmasýndan hemen önce saptanan VRS skorlarý 1 saat sonraki deðerlendirmede anlamlý olarak azalmýþtý (p<0.01), bu deðerler gruplararasý karþýlaþtýrýldýðýnda ise anlamlý fark saptanmadý (p>0.05). Çalýþmamýz sonucunda tek doz tenoksikamýn sezaryen ameliyatlarýndan sonra epidural opioid gereksinimini azalttýðý fakat preemptif uygulanmasýnýn perioperatif uygulanmasýna bir üstünlüðü olmadýðý kanýsýna varýlmýþtýr.

Non-steroidal anti-inflammatory drugs are proposed for pre-emptive analgesia. In this study we aimed to investigate the additive effect of single dose systemic tenoxicam when applied preoperatively or peroperatively to patients who had undergone caesarean section (C/S) and were given epidural meperidine for postoperative analgesia. Sixty-seven ASA I patients scheduled to undergo lower segment C/S were divided into three groups randomly. Patients in Group P were given 20 mg tenoxicam intramusculary (i.m.) 3 hours before the operation; patients in Group T were given 20 mg tenoxicam i.m. intraoperatively just after the delivery of the baby and patients in Group K were given saline solution 2 ml. i.m. intraoperatively just after the delivery of the baby. Meperidine was administered for postoperative analgesia at the dose of 25 mg with the volume of 10 ml via epidural catheters in all patients. Meperidine consumptions were noted in the postoperative first 24 hours. Pain was evaluated with Verbal Rating Scale (VRS; 0=no pain, 4=unbearable pain) just before the injection and one hour after the injection of epidural meperidine. Groups were comparable on demografhic variables (p>0.05). Mean meperidine consumption in the first 24 hours was significantly lower in Group P (71.25 ± 23.18 mg) and in Group T (72.61 ± 18.74 mg) than Group K (96.87 ± 24.27 mg), but no difference was observed between Group P and Group T. Change in VRS values that were evaluated before the administration of epidural meperidine and one hour after the intervention was statistically significant within all three groups (p<0.01). However there was no statistically significant difference between all three groups in pain scores at each evaluating time and during 24 hrs as well, (p>0.05). We concluded that single dose tenoxicam does lower the need for opioid use after caesarean operations but pre-emptive administration of the drug was not shown to be superior to perioperative application.

Meralgia parestetika çeþitli cerrahi giriþimlerin bir komplikasyonu olarak, diyabetik nöropati, bazý neoplaziler ya da geniþ ve aðýr kemer kullanma gibi nedenlerle lateral femoral kutanöz sinirin basýsýna baðlý geliþen bir tuzak nöropatisidir. Bazen bel aðrýlarý þeklinde yakýnmalara da yol açtýðýndan bel aðrýlarýnýn diðer nedenleri ile ayýrýcý tanýya gitmek gerekebilir. Bel ve bacak aðrýsý yakýnmalarý ile gelen ve daha önce lumbalji tanýsýyla tedavi gören bir hastada bel aðrýsýna ve siyataljiye yönelik incelememizde fizik baký ve radyolojik görüntülemelerde bir patoloji bulunamadý. Belde sýký, geniþ ve üzerinde aðýrlýk taþýnan kemer kullanmaya baðlý geliþen meralgia parestetika düþünüldü. Lateral femoral kutanöz sinir bloðu ile yakýnmalarý geçen hastanýn kemeri kaldýrýldý ve istirahate alýndý. Birbuçuk ay sonraki kontrolünde yakýnmalarýnýn tümüyle ortadan kalktýðý gözlendi. Meralgia parestetika çeþitli nedenlerden kaynaklanabileceðinden etiyolojisinin iyi araþtýrýlmasý, bel aðrýlarýnýn ayýrýcý tanýsýnda düþünülmesi ve öncelikle konservatif tedavi yöntemlerinin denenmesi gerektiði kanýsýna varýldý.

Meralgia paresthetica is an entrapment neuropathy arising from compression of lateral femoral cutaneous nerve as a surgical complication or diabetic neuropathy, some neoplasms or wide and heavy belt usage. It may cause complaints like low back pain and this requires differential diagnosis with other causes of low back pain. A 21 year old male patient was admitted to our hospital with low back and thigh pain. He also had a history of lumbalgia. Physical examination and radiologic studies for low back pain and siatalgia revealed no pathologic finding. Thight, wide and heavy belt usage was thought to be the most probable cause of meralgia paresthetica. His complaints disappeared by lateral femoral cutaneous blockage, removal of the belt and bed rest. He was completely symptom- free in his 45th day control. In this report, we aimed to emphasize this rare entity, meralgia paresthetica, from the point of its wide spectrum of etiology, need for a meticulous investigation of symptoms, and conservative therapy as the treatment of choice.