Geçtiðimiz son on yýl içinde aðrý kavramý ve tedavisinde hatýrý sayýlýr geliþmeler olmuþtur. Özellikle, kronik aðrý geliþimini önlemek için aðrýnýn ciddi ve etkin bir biçimde tedavi edilmesi gerektiðinin farkýna varýlmýþtýr. Yaralanmanýn veya hastalýðýn baþlattýðý fizyolojik mekanizmalar periferdeki olaydan baðýmsýz bir biçimde santral olarak ilerleme gösterir. Bu santral olaylar genellikle sinir bloklarýyla veya afferent sinir yollarýnýn kesilmesiyle iyileþtirilemez. Aðrý tedavisindeki son geliþmeler yeni ilaçlarý, elektrostimulasyonu, psikoterapi ve aðrý tedavi programlarýný ortaya çýkarmýþtýr. Radyofrekans uygulamalarý kontrollü ve kesin bir sinir bloðu metodu olarak giderek kabul görmektedir Bu yazýda radyofrekans termokoagülasyonun avantaj ve dezavantajlarý var olan diðer aðrý tedavi yöntemleri ile karþýlaþtýrýlarak tartýþýlmýþtýr. Ayrýca endikasyonlar ve bu yöntemle tedavi edilebilecek durumlarýn kýsa açýklamalarý da bu yazýda yer almaktadýr. Tekniðin zorluklarý ilk baþta göründüðü kadar büyük deðildir ve rejyonel anestezi pratiðine sahip bir kiþi gerekli deneyimi edinebilir. Týbbýn her dalýnda olduðu gibi baþarý için sabýr, gayret ve çalýþma gereklidir. Son olarak, geliþmeler heyecan vericidir ve radyofrekans uygulamalarý gelecekte þimdikinden daha fazla aðrý probleminde kullanýlabilecektir.

During the last decade there have been considerable advances in the understanding and treatment of pain. In particular we have learnt that pain must be treated swiftly and effectively to prevent the development of chronic pain. The physiological mechanisms created by the original injury or disease progress centrally, irrespective of what happens at the periphery. This central state is often not ameliorated by nerve block or severance of the afferent nervous pathways. Recent developments in pain therapy have consisted of new drugs, electrostimulation, psychotherapy and Pain Management Programmes. Radiofrequency procedures are being increasingly recognized as an accurate and controlled form of nerve block. Its advantages and disadvantages, in comparison with other pain treatments available are discussed. Indications for use and brief descriptions of the conditions, which can be treated in this way, are also included in this treatise. The complexities of technique are not as great, as might appear on first acquaintance, and the expertise required can be acquired by anyone familiar with the practice of regional analgesia. Patience, diligence and study are necessary for success, just as in any other branch of medicine. Finally there are exciting prospects for future developments, which could make radiofrequency procedures available for a wider range of pain problems than that at present.

Bu çalýþmanýn amacý; diz artroskopisi sonrasýnda intraartiküler uygulanan ve bupivakaine oranla daha az toksik etkisi olduðu ileri sürülen ropivakainin analjezik etkinliðinin bupivakain ile karþýlaþtýrýlmasýdýr. Elektif diz artroskopisi yapýlacak, 20-60 yaþ arasýnda ve ASA I-II grubunda 30 hasta çalýþmaya dahil edilmiþtir. Tüm hastalara indüksiyonda 5 mg/kg tiyopental-sodyum ve 0.1 mg/kg veküronyum-bromid i.v. ve idamede 1 MAC sevofluran ve % 66 N2O - % 33 O2 olacak þekilde standart genel anestezi uygulanmýþtýr. Operasyon sonunda hastalar 2 gruba ayrýlarak I. gruba 20 cc % 0.75 ropivakain ve II. gruba 20 cc % 0.5 bupivakain intraartiküler uygulanmýþtýr. Postoperatif 1., 2., 4., 6., 12., 24. saatlerde Vizüel Analog Skala ile aðrý skorlarý, ilk ek analjezik gereksinim zamanlarý ve yan etkiler kaydedilmiþtir. Postoperatif aðrý skorlarý iki grup arasýnda farklýlýk göstermemiþtir. Ýlk analjezik gereksinim zamaný I. Grupta 391.66 ± 81.7 ve II. grupta 444.16 ± 64.8 dakikadýr (p>0.05). Grup I’de 10 hasta (% 66) ve grup II’de 5 hasta (% 33) 24 saat süresince ek analjezik kullanmamýþtýr (p>0.05). Hiçbir hastada yan etki gözlenmemiþtir. Sonuç olarak; diz artroskopisi sonrasýnda intraartiküler 20 cc % 0.75 ropivakainin, 20 cc % 0.5 bupivakaine eþdeðer analjezi saðladýðý sonucuna varýlmýþtýr.

The aim of this study was to compare the analgesic effect of intraarticular ropivacaine with bupivacaine following knee arthroscopy. 30 patients, aged between 20-60 years and undergoing elective knee arthroscopy were enrolled into the study protocol. A standardized general anesthesia including 5 mg/kg thiopental-sodium, 0.1 mg/kg vecuronium-bromide i.v. and 1 MAC sevoflurane with 66 % N2O in oxygen was administered to all patients. At the end of surgery the patients were randomly assigned into two groups (n=15). Group I received 20 ml 0.75 % ropivacaine and group II received 20 ml 0.5 % bupivacaine intraarticularly. Pain scores with Visual Analogue Scale at 1., 2., 4., 6., 12., 24. hours postoperatively, time to the first analgesic requirement and side effects were recorded. There were no significant difference in the postoperative pain scores of the patients between groups. The first analgesic requirement times were not statistically different (391.66 ± 81.7 min in group I and 444.16 ± 64.8 min in group II). 10 patients in group I (66 %) and 5 patients in group II (33 %) needed no additional analgesic during 24 hours (p>0.05). No side effect was observed in any patient. We concluded that intraarticular 20 ml 0.75 % ropivacaine provides effective analgesia comparable to that provided by 20 ml 0.5 % bupivacaine.

Lomber vertebral diskler bel aðrýlarýnýn en önemli kaynaklarýndandýr. Disk kaynaklý aðrýlarda medikal tedavi, disk içi enjeksiyonlar, cerrahi, radyofrekans termokoagulasyon uygulanabilmektedir. Çalýþmamýzda disk kaynaklý bel aðrýlarýnda radyofrekans termokoagulasyon uygulanýmýnýn etkinliði ve yan etkileri deðerlendirilmiþtir. Bilim dalý polikliniðine baþvuran; deðerlendirmeler sonucu diskojenik bel aðrýsý tanýsý alan 25 hasta, aðrý uyarýmý (provokatif test) ardýndan olumlu yanýt alýndýðý taktirde radyofrekans termokoagulasyon uygulanýmý için hospitalize edilmiþlerdir. Cerrahi koþullar altýnda ve skopi yardýmý ile hastalara 2 ml (iohexol + % 1 aritmal) solüsyon ile provokatif diskografi uygulanmýþtýr. Olumlu yanýt alýnan hastalarda 80 derecede 6 dakika lezyon oluþturulmuþtur. Hastalarýn VAS deðerleri giriþimden önce (VAS0), giriþimden 24 saat sonra (VAS1), ve 8 hafta sonra (VAS2) deðerlendirilmiþtir. Hastalarda deðerlendirme dönemi sonunda % 52 iyilik saptanmýþtýr. Herhangi bir komplikasyona rastlanmamýþtýr. Diskojenik bel aðrýlarýnda radyofrekans termokoagulasyon uygulanýmýnýn diðer tedavi yöntemlerinin yetersiz kaldýðý durumlarda etkili ve güvenilir bir yöntem olduðu sonucuna varýlmýþtýr.

The lumbar intervertebral discs are one of the major origins of low back pain. Medical therapy, intradiscal procedures and surgery are the treatment modalities in discogenic low back pain. Recently radiofrequency denervation therapy has been used in discogenic pain. We have evaluated the efficacy and complications of application of radiofrequency in discogenic pain. 25 patients who were admitted to the outpatient clinic of Algology Department, diagnosed as discogenic pain were hospitalized for provacative test and if responded positively application of radiofrequency. Under surgical conditions and fluoroscopic guidance provocative test was applied by injection of 2ml of (iohexol and 1 % lidocaine) solution into the related disc. When the response was positive, a 80 degrees 6 minutes lesion was made. The VAS values were recorded before the procedure (VAS0), 24 h after the procedure (VAS1), 8 weeks after the procedure (VAS2). At the end of the 2nd month the patients were found to be 52 % well. No complications were observed due to the technique. We have concluded that application of RFTC in discogenic pain is an effective and safe method when conservative treatment modalities fail.

Fantom ekstremite aðrýsý (FEA)'nýn oluþ mekanizmasý ve tedavi metodlarý üzerine pek çok araþtýrma yapýlmýþtýr. Ancak bazý sorular henüz aydýnlatýlamamýþ, standart bir tedavi metodu ortaya konulamamýþtýr. Gülhane Askeri Týp Akademisi (GATA) Ortopedi ve Travmatoloji Anabilim Dalý'nda yeni travmatik amputasyonlu ve FEA'lý 24 hasta üzerinde yapýlan çift kör çalýþmamýzda, vanilil alkaloidi kapsaisinin (CPS) etkileri incelenmiþtir. Sonuçlar CPS'nin FEA'nýn tedavisinde alternatif bir tedavi seçeneði olabileceðini gösterir niteliktedir

The mechanism of phantom limb pain and treatment modalities have been well-documented, but some problems have not been clarified yet. No single modality has had universal success. 24 patients who have recent traumatic amputation were treated at Department of Orthopaedics and Traumatology of Gülhane Military Medical Academy. The study was done in a double-blind fashion. In this study the effect of capsaicin, a topically applied vanillyl alkaloid, was investigated. According to the statistical results, capsaicin may be used as an alternative treatment for the phantom limb pain.

Diz ve kalça protezi uygulanan hastalarda iki farklý i.v. PCA doz rejiminin etkinliðini irdelediðimiz çalýþmada ASA I-III grubundan 47 hasta randomize olarak ikiye ayrýldý. Postoperatif dönemde bolus grubundaki (Grup 1) 23 hastaya 1 mg bolus morfin HCI 5 dk kilitli kalma süresiyle. Ýnfüzyon grubundaki (Grup 2) 24 hastaya 1 mg bolus + 0.3-0.5 mg/st. bazal infüzyon 5 dk kilitli kalma süresiyle uygulandý. Tüm hastalar yükleme sonrasý ve postoperatif 6., 12. ve 24. saatlerde hemodinamik ve solunumsal parametreler. aðrý skorlarý. Total morfin HCI tüketimi ve yan etkiler açýsýndan deðerlendirildi.
Grup 2'de 18. ve 24. saatlerdeki VAS skorlarý Grup 1'e göre göre anlamlý olarak düþüktü (p<0.001 ve p<0.005). Gruplardaki arteriel basýnçlar ve solunum sayýlarýnda. PCA uygulamalarý baþladýktan sonra yükleme sonrasýna göre anlamlý düþüþler oldu (p<0.01 ve p<0.001) ancak hipotansiyon ve solunum depresyonu gözlenmedi. Yan etkiler gruplar arasýnda anlamlý derecede farklý deðildi. Grup 2'deki diz protezlerinde aðrý skorlarý Grup 1'deki diz protezlerine göre 18. ve 24. saatlerde anlamlý olarak düþüktð (p<0.005 ve p<0.05).
Kalça protezinde i.v. PCA bolus uygulamasý postoperatif aðrý kontrolünde yeterli analjezi saðlayabilirken. Diz protezlerinde bolus+bazal infüzyon uygulamasýnýn daha etkili ve güvenilir bir analjezi saðlayabileceði sonucuna varýldý.

We compared the efficacy of two different i.v. PCA dose regimens in 47 patient from ASA I-III who underwent total knee and hip replacement. The patient were randomly allocated into two groups. In the postoperative period 23 patients in the bolus group (Group 1) were received 1 mg bolus morphine HCI with 5 min. lock-out interval. 24 patients in bolus + 0.3-0.5 mg. hr.-1 basal infusion group (Group 2) were received 1 mg bolus + 0.3-0.5 mg. hr.4 basal infusion with 5 min lock-out interval. Hemodynamic and respiratory parameters. pain scores. total morphine consumption and side effect were evaluated after loading doses and at 6th. 12th. 18th and 24th hours.
The pain scores in Group 2 were significantly lower than Group 1 at 18th and 24th hour (p<0.001. p<0.005). The arterial blood pressure and respiratory rates were decreased significantly after PCA (p<0.01, p<0.001) but hypotension or respiratory depression were not observed in groups. No significant differences were observed between the groups according to side effects. Knee replacement patients who were in Group 2 had significantly lower pain scores than the patients in Group 1 at 18th and 24th hours postoperatively (p<0.005, p<0.05).
As a result in hip replacement patients. PCA bolus is sufficient in pain relief but adding a basal infusion to i.v. PCA when compared with PCA bolus alone is more effective and reliable in knee replacement patients without any side effect.

Abstract | Full Text PDF

Propofol popüler bir intravenöz indüksiyon ajanýdýr ve propofol enjeksiyon aðrýsý yaygýn bir problemdir. Bu çalýþmanýn amacý propofolün i.v. injeksiyonu ile maydana gelen aðrýnýn insidansý ve þiddeti üzerine iki farklý doz tramadol ön uygulamasýnýn, propofole lidokain ilave edilmesi ile karþýlaþtýrmaktýr. Biz elektif cerrahi geçiren 80 olguda plasebo kontrollü, prospektif, randomize, çift kör bir çalýþma planladýk. Grup L’de 180 mg propofol’e 20 mg lidokain ilave edildi. Propofol enjeksiyonundan 10 dk. önce Grup T50’ye 50 mg, Grup T100’e 100 mg Tramadol i.v. yapýldý; Grup P ise plasebo grubu idi (normal salin). Grup P’deki aðrý insidansý % 75 idi. Grup T100 ve Grup L’deki aðrý insidansý anlamlý olarak Grup P’dekinden daha düþüktü (p<0.05). Grup P ve Grup T50 arasýnda aðrý insidansý yönünden anlamlý bir farklýlýk yoktu (sýrasýyla % 75, % 50). Ýndüksiyon esnasýnda aðrý hisseden olgularýn % 49’u (18/37) uyanma odasýnda da aðrýyý hatýrladýlar (Grup P’de 10 olgu, Grup T50’de 5 olgu ve Grup T100’de 3 olgu). Grup L’deki olgularýn hiçbiri uyanma odasýnda aðrýyý hatýrlamadý. Uyanma odasýnda aðrýyý hatýrlamada Grup P ile diðer gruplar arasýnda anlamlý bir farklýlýk vardý (p<0.0001). Sonuç olarak, propofol enjeksiyon aðrýsýnýn insidansýný ve þiddetini azaltmada 100 mg tramadol ön uygulamasýnýn, propofole lidokain ilavesi kadar etkili olduðu, fakat 50 mg tramadol ön uygulamasýnýn ise diðer tedavi metodlarýndan daha az etkili olduðu kanaatine varýldý.

Propofol is a popular intravenous anesthetic induction agent, and pain on injection of propofol is a common problem. The purpose of this study was to compare the effects of pretreatment with two different dozes of tramadol and lidocaine mixed with propofol on incidence and severity of the pain produced by intravenous injection of propofol. We conducted a prospective, randomized, double-blind trial on eighty patients undergoing elective surgery. Group L, lidocaine 20 mg added to 180 mg propofol; Group T50, tramadol 50 mg 10 minutes prior to propofol; Group T100, tramadol 100 mg 10 minutes prior to propofol; Group P, plecebo (normal saline). The indicence of pain in Group P was 75 %. Group T100 and Group L had a significantly lower incidence of pain than Group P (p<0.05). There was no significant difference in the incidence of pain between the Group P and T50 (75 % and 50 %, respectively). Fourty-nine percent of the patients (18/37) who experienced pain at induction had recall of that pain in the recovery room (10 patients in Group P, 5 patients in Group T50 and 3 patients in Group T100). In Group L, none of the patients had recall of that pain in the recovery room. There was significant difference in the recall of that pain in the recovery room among Group P and other groups (p<0.0001). In conclusion, we have shown that pretreatment with tramadol 100 mg is as effective as lidocaine mixed with propofol in reducing the incidence and severity of pain during injection of propofol. But pretreatment with tramadol 50 mg is less effective than other treatments methods.