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Primer baþaðrýlarýnda büyük oksipital sinir injeksiyonu hakkýndaki çalýþmalar Michael Anthony ile baþlamýþtýr ve bugün yapýlan çalýþmalarýn hemen hepsi Anthony’nin çalýþmalarýný referans çalýþma olarak kabul ederler. Üzerinden yirmi yýlý aþkýn süre geçmesine karþýn konu hakkýnda, yeterli sayýda çalýþma bulunmamaktadýr. Mevcut verilere göre, steroidlerin özellikle küme baþaðrýsýnda hem koruyucu tedavide hem de akut atak tedavisinde etkili olduðu anlaþýlmaktadýr. Migren’de ise bu etki küme baþaðrýsýndaki kadar belirgin deðildir. Lokal anestetiklerin ise, akut aðrýnýn hafifletilmesinde rolü olmakla beraber, tek injeksiyon profilaktik tedavi için uygun görünmemektedir. Klinikte uygulamada özellikle, küme baþaðrýsýnda ana koruyucu tedavinin etkisi baþlayýncaya kadar; analjezik kötüye kullanýmý nedeniyle kronikleþen migren’in detoksifikasyon sürecinde bu prosedürün kullanýlabileceði konusunda umut vadeden veriler bulunmaktadýr. Acil þartlarýnda akut küme ve migren ataklarýnda kullanýmý hakkýnda bazý vaka bildirileri bulunsa da sistematik klinik çalýþmalara ihtiyaç vardýr.

Studies about greater occipital nerve injection in primary headaches had begun with Michael Anthony and almost all the studies today accept Anthony’s studies as reference work. Although more than twenty years passed, there is not enough study about the subject. According to the present data, steroids are apparently effective in both preventive and acute attack therapy in cluster headache. Efficacy in migraine is not dramatic as in cluster headache. Despite the fact that local anesthetics has a role in releiving acute headache, single injection is not suitable in prophylactic treatment. In clinical practice, there is promising data about the usage of the procedure, until the beginning of the effect of principal preventive therapy in cluster headache and during the detoxification process in analgesic induced chronic migraine. Although there are case reports about the relieving acute pain in cluster headache and migraine, there is need for systematized clinical studies.

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Servikal bölgede miyofasyal aðrýsý bulunan kiþiler çeþitli klinik bulgularla karþýmýza çýkabilirler. Bu çalýþmanýn amacý servikal miyofasyal aðrý sendromlu hastalarda demografik özellikler, klinik bulgular ve fonksiyonel durumu incelemektir. Kliniðimize baþvuran 94 servikal miyofasyal aðrý sendromlu hasta deðerlendirmeye alýndý. Hastalarda kýsa form-36 yaþam kalitesi (SF-36), aðrý, depresyon, demografik ve fiziksel özellikler deðerlendirildi. Son durum ölçütleri; SF-36 yaþam kalitesi, görsel analog skala, Beck Depresyon Ýndeksi, anamnez ve fizik muayeneydi. Toplamda servikal miyofasyal sendrom tanýsý almýþ 82 hasta çalýþmaya dahil edildi. Hastalarýn hepsi genç olup yaþ ortalamalarý 37.4±9 ve %87.8’ I kadýn idi. Hastalarýn %53.1’ i otonomik fenomen benzeri deri kýzarýklýðý, lakrimasyon ve vertigo ile birlikte trapezius kasýnda tetik noktaya sahipti. %58.5’ u önceden geçirilmiþ servikal travmaya, %40.2’ si Fibromiyalji sendromuna ve %18.5’ u Benign eklem hipermobilite sendromuna sahipti. Otonomik fenomenler ve erken baþlangýçlý servikal yaralanmasý bulunan genç, bayan hastalar servikal miyofasyal aðrý sendromu ve bu hastalarda da Fibromiyalji sendromu oraný yüksek olduðu için Fibromiyalji sendromu açýsýndan deðerlendirilmelidirler.

Subjects with myofascial pain of muscles of the neck region may present with various clinical symptoms. The aim of this study was to explore the demographics features, clinical findings and functional status in a group of patients presenting with myofascial pain of the cervical muscles. 94 cervical myofascial pain syndrome patients were recruited from the out-patient clinic. Evaluated of patient short form health survey (SF-36), pain, depression, patient demographics and physical examinations. Outcome measures; SF-36 Health Survey, visual analog scale, Beck Depression Inventory, history, physical examination. A total of 82 patients with a diagnosis of cervical myofascial syndrome were included in the study. All patients were in the young age group 37.4±9, and 87.8% were females. 53.1% had trigger points in the trapezius muscle with high percentage of autonomic phenomena like skin reddening, lacrimation, tinnitus and vertigo. 58.5% of the series had suffered from former cervical trauma and 40.2% also had Fibromyalgia syndrome and 18.5% had Benign Joint Hypermobility syndrome. Younger female patients presenting with autonomic phenomena and early onset cervical injury should be examined for cervical myofascial pain syndrome and also for Fibromyalgia syndrome since this study demonstrated a high percentage of Fibromyalgia syndrome in these patients.

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Akciðer Kanserli Hastalarýn Aðrýlarýnýn Tedavisinde Transdermal Fentanil ve Yavaþ Salýnýmlý Morfinin Karþýlaþtýrýlmasý

AMAÇ: Randomize ve kontrollü olan bu çalýþmanýn birincil amacý, akciðer kanserine baðlý kronik aðrýlý olgularda, TDF ile YSM’ in erken dönem analjezik etkinliklerinin ve ikincil amacý ise yan etkilerinin deðerlendirilmesidir.
GEREÇ-YÖNTEM: Dünya Saðlýk Örgütü’ nün önerdiði basamak tedavisine göre 3. basamak tedaviyi gerektiren 50 kronik akciðer kanserli hasta, 15 günlük çalýþma süreci için ya transdermal fentanil (Grup F, n=25) ya da yavaþ salýnýmlý oral morfin (Grup M, n=25) aldý. Olgular sayýsal sýralamalý aðrý skorlarý ve performans durumlarýnýn yanýsýra, konstipasyon, bulantý-kusma, hipoventilasyon, idrar retansiyonu ve ürtiker gibi ilaç yan etkileri açýsýndan da günlük olarak deðerlendirildi.
BULGULAR: Gruplar arasýndaki baþlangýç aðrý skorlarý benzerdi (p>0.05) Yedinci ve 15. günlerdeki aðrý skorlarý, baþlangýç deðerleri ile karþýlaþtýrýldýðýnda Grup F ve Grup M olgularýnda anlamlý olarak daha düþük olmasýna raðmen (p>0.001), gruplar arasýnda farklýlýk göstermedi (p>0.05). Grup M ile karþýlaþtýrýldýðýnda, konstipasyon sýklýðý Grup F’ de anlamlý olarak daha düþük (sýrasýyla, 14 olgu, %64 ve 6 olgu, %27) idi (p=0.03). Bulantý-kusma, idrar retansiyonu ve ürtiker görülme sýklýklarý guplar arasýnda anlamlý farklýlýk göstermedi (sýrasýyla p>0.05). Hiç bir olguda hipoventilasyon geliþmedi.
SONUÇ: Akciðer kanserine baðlý kronik aðrýlarýn giderilmesinde, hem transdermal fentanil hem de yavaþ salýnýmlý morfin güvenli ve etkili analjezi saðlamaktadýr. Ancak TDF, anlamlý olarak daha az konstipasyona neden olmaktadýr.

Comparison of TD-fentanyl with Sustained-Release Morphine in the Pain Treatment of Patients with Lung Cancer
AIM: The aim of this randomized and controlled trial was to evaluate the analgesic efficacy of trans-dermal fentanyl (TDF) and sustained-release oral morphine (SRM) primarily and their side effects secondarily, in patients with chronic lung cancer-related pain.

MATERIAL-METHODS: According to three step analgesic guidelines recommended by the World Health Organization, 50 chronic lung cancer patients requiring third line therapy were enrolled and received either TDF patch (Grup F, n=25) or SRM per orally (Grup M, n=25) for 15 days. Patients were assessed in view to numeric rating scale of their pain, as well as the drugs’ side effects like constipation, nausea-vomiting, urinary retention and urticaria, hypoventilation.

RESULTS: Pain scores were similar for both groups at the beginning (p>0.05). While significantly lower pain scores were achieved on the 7th and 15th days compared to those of initial values in Group F and Group M patients (p<0.001); these decreases did not reach statistical significance between the groups (p>0.05). Compared to Group M, constipation was significantly lower in Group F (14 patients and 64% vs. 6 patients and 27%, respectively) (p=0.03). However, the frequencies of nausea-vomiting, urinary retention and urticaria were different between the groups (p>0.5). None of the patients developed hypoventilation.

CONCLUSION: Both TDF and SRM are safe and effective analgesics for the management of chronic cancer pain. However, TDF is associated with significantly less constipation rate than that of with SRM.

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Araþtýrma Gaziantep Üniversitesi Þahinbey Araþtýrma ve Uygulama Hastanesi’nde hastaya bakým veren saðlýk çalýþanlarýnýn aðrý kontrolünde uyguladýklarý giriþimleri belirlemek amacýyla tanýmlayýcý olarak yapýldý. Þubat – Nisan 2007 tarihleri arasýnda hastanede hastaya bakým veren saðlýk çalýþanlarý örnekleme alýndý. Veri toplama aracý olarak araþtýrmacýlar tarafýndan hazýrlanan anket formu ve aðrý azaltma yöntemleri anketi kullanýldý.
Aðrýyý azaltma yöntemleri anketi toplam puaný deðerlendirildiðinde, hastaya bakým veren saðlýk çalýþanlarýnýn % 34.7’si aðrý azaltma yöntemlerini çok iyi biliyor; % 57.8’i iyi biliyor ve % 7.5’i ise biliyor þeklinde tespit edildi.
Aðrýyý azaltma yöntemleri anketi alt gruplarýný kapsayan sorular ve bu sorulardan aldýklarý ortalama puanlara göre; bilgi yönetimi puanýnýn en yüksek bulunduðu, bunu aðrýyý deðerlendirmenin takip ettiði; en düþük puana sahip alt grubun ise fiziksel rahatlýðýn saðlanmasý puaný olduðu belirlendi. Araþtýrmada elde edilen sonuçlar doðrultusunda, eðitim durumundan kaynaklanan farklýlýklarýn azaltýlmasý için eðitim durumu standartlaþtýrýlmasý, saðlýk eðitimi veren okullarda aðrý ve aðrý kontrolü konularýna daha çok önem verilmesi önerilerinde bulunulmuþtur.

The study was conducted at Sahinbey Research and Intervention Hospital in order to define the interventions of health staff who were in charge of patient pain care. Those who had been an employee already between February- April 2007 were enrolled in the study. As data collecting tools, a questionnaire prepared by the authors and a scale on pain management methods were used.
As far as the total scores obtained from the scale are concerned, 34.7% knows the methods to deal with acute pain very well, 57.8% is good, and 7.5% is fair. In addition, the bullet-in questions of the scale revealed that the participants scored highest for knowledge management, followed by pain evaluation, and the least for the maintenance of physical comfort. The results of the study imply that standardization of education is mandatory to decrease individual differences due to educational status, and that more consideration should be given to pain and pain relief topics in schools providing health education.

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Hiperhidrozisli hastalar sýklýkla fiziksel, sosyal ve mental rahatsýzlýklar yaþarlar ve sýklýkla bu rahatsýzlýklar konservatif yöntemlerle yeteri kadar tedavi edilemezler. Yeni bir perkutan sempatektomi yaklaþýmý olan radyofrekans ile denervasyonun daha uzun etki süresi oluþturduðu ve daha az sýklýkla postsempatik nöraljiye neden olduðu düþünülmektedir. Bu yazý sað tek taraflý lomber hiperhidrozisli, 35 yaþýnda erkek hastada sempatik radyofrekans (RF) nöroliz deneyimimizi bildirmektedir.

Skopi yardýmý ile lomber omurun lokalize edilmesinden sonra, L2-5 vertebralar seviyesine lokal anestezik ile, tanýsal amaçlý sempatik blok uygulandý. Uygulamanýn etkinliði bilateral ayak cildi ýsýsýnýn ölçümü ile monitörize edildi. Ýlk sempatik ganglion bloðu ile elde edilen klinik etki 1 hafta boyunca devam etti ve sonrasýnda ayný seviyeden lomber sempatik gangliona, RF nöroliz, daha uzun bir etki süresi için, uygulandý. Ýþlem 30 dakikada tamamlandý ve hasta iþlemden sonra 2 saat içinde taburcu edildi. Hiperhidrozis iþlemden sonra geriledi ve postsempatektomik nöralji veya seksüel disfonksiyon geliþmedi. Takiplerde birinci ayda hasta lomber hiperhidrozisinde gerileme elde etti ve sonuçtan memnundu.

Sonuç olarak lokalize hiperhidrozisli hastalarda aþýrý terlemeyi rahatlatmak için, lomber sempatik ganglionlarýn RF nörolizinin, minimal invaziv özelliðe sahip, güvenli ve etkin bir paliatif giriþim olduðunu düþünmekteyiz.

Patients with hyperhidrosis suffer from physical, social and mental discomfort which often cannot be treated sufficiently using conservative measures. A new percutaneous approach to sympathectomy using radiofrequency denervation has seemed to offer longer duration of action and less incidence of post sympathetic neuralgia. This article reports the authors' experience with sympathetic RF neurolysis in a 35 year old male with right unilateral lumbar hyperhidrosis.

Under scopy guided localization of the lumbar spine sympathetic blockade with local anesthetics to L2-5 vertebral levels were performed as a diagnostic block. Lesion effectiveness is monitored by bilateral feet skin temperature measurement. Clinical effects produced by the first sympathetic ganglion block were sustained for 1 week and then RF neurolysis of lumbar sympathetic ganglion was performed to the same levels for a longer effect. The procedure was accomplished within 30 minutes and the patient was discharged within 2 hours after the procedure. Hyperhidrosis was relieved after the procedure and there were no postsympathectomy neuralgia and sexual dysfunction. The patient obtained improvement of lumbar hyperhidrosis at his first month of follow-up and was satisfied with the outcome.
In conclusion, RF neurolysis of lumbar sympathetic ganglions is a safe and effective palliative procedure with minimal invasiveness for relieving excessive sweat secretion in patients with localized hyperhidrosis.

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Yakýn zamanda deðerlendirdiðimiz 54 yaþýnda kadýn, hikayesinde aurasýz migren baþaðrýsý dýþýnda tipik hipnik baþaðrýsý (HH) mevcut. Büyük ihtimalle primer baþaðrýsý olmayan ergotamin aþýrý kullanýmý ile iliþkili baþaðrýsý vardý. Hasta, hiçbir analjezik kullanmamaya cesaretlendirilerek ve metoklopramide günlük 75 mgr amitriptilin eklenerek oluþturulan washout protokolü ile rahatlatýldý. Amacýmýz tek hastada bu nadir iliþkiyi ve olasý patofizyolojik etkileri vurgulamaktýr.

We have recently evaluated a 54-year-old woman who had migraine without aura in her history but presenting with a typical hypnic headache (HH) which is presumably not a primary headache but associated with an ergotamine overuse headache. Her HH was relieved with a washout protocol which includes 75 mg amitriptyline daily with the addition of metoclopramide and encouraging her not to use any analgesics. Our aim was to report this unique patient to emphasize this rare association and to discuss the possible pathophysiological implications for both of these entities.

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