Cerrahi sonrasý kronik aðrý (CSKA) son zamanlara dek görmezden gelinen bir fenomendi. Ancak son yýllarda sorunun klinik önemi kadar olasý risk faktörleri de (type of surgery, preoperative pain, acute postoperative pain, psychologic and genetic factors) önemle incelenmeye baþlanmýþtýr. CSKA sadece majör cerrahi giriþimlerden sonra deðil ayný zamanda herni ve vazektomi gibi minör cerrahi giriþimlerden sonra da görülebilmektedir. CSKA insidansý ile ilgili kesin verilere henüz ulaþýlamamýþtýr. Çünkü bu zor ve karmaþýk klinik tablonun çözümünde standart yöntemler geliþtirmek güçtür. CSKA tedavisinde multimodal analjezik teknikler kadar birçok farklý ilaç da (gabapentin, ketamine, venlafaksin, lidokain, tramadol, steroidler v.d.) denenmektedir. Bu nedenle, koruyucu analjezi aðrýyla uyarýlan duyarlýlaþmayý kontrol edebilen herhangi bir ameliyat öncesi analjezik rejimi içeren premptif analjezinin daha geniþ bir uygulamasýdýr.

Chronic postsurgical pain (CPSP) has lately become a neglected phenomenon. However, in recent years, investigations of the possible risk factors (type of surgery, preoperative pain, acute postoperative pain, and psychological and genetic factors) have also gained as much importance as the clinical problem. CPSP is not only observed following major surgery, but also following minor surgical procedures, such as hernia and vasectomy. Definitive data regarding the incidence of CPSP have not been obtained yet, since it is difficult to develop standard methods to resolve this difficult and complicated clinical picture. Many different medications, such as gabapentin, ketamine, venlafaxine, lidocaine, tramadol, and steroids have been tested in addition to multimodal analgesic techniques for the management of CPSP. Hence, preventive analgesia is a broader application of preemptive analgesia that includes any preoperative analgesic regimen able to control the sensitivity induced by pain.

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AMAÇ: Bu çalýþmada, baþarýsýz bel cerrahisi sendromlu (BBCS) olgularda sempatik sinir sisteminin etkilenip etkilenmediði araþtýrýldý. GEREÇ-YÖNTEM: Polikliniðimize baþvuran ve BBCS tanýsý konulan 29 hasta çalýþmaya alýndý. Tüm olgularýn bel operasyonu sonrasý bir yýl veya aylar içerisinde baþlayan, bel, bacak veya bel-bacak aðrýsý vardý. Kontrol grubu ise 13 saðlýklý hastane personelinden oluþturuldu. Elektrofizyolojik sinir iletim çalýþmalarý ve sempatik deri yanýtý (SDY) ölçümleri hasta grubun semptomatik olan (29 bacak) ve kontrol grubunun ise her iki bacaðýnda (26 bacak) yapýldý. Hasta grubunun SSR deðerleri cinsiyet ve yaþlarý eþleþtirilmiþ 13 saðlam kontrol grubunun SSR deðerleri ile karþýlaþtýrýldý. Periferik sinir sýkýþmasý, periferik dolaþým yetersizliði, nörolojik veya psikiyatrik hastalýklar, alkol veya kötü ilaç kullanýmý olan hastalar çalýþmaya dahil edilmedi. Hastalarda aðrý þiddeti Visuel Analog Skala (VAS) ile ve depresyon varlýðý Beck Depresyon Ýndeksi (BDÝ) ile araþtýrýldý. BULGULAR: Saðlýklý kontroller ile karþýlaþtýrýldýðýnda, SDY elde edilen latans sürelerinde hasta grubunda istatistiksel olarak anlamlý bir artýþ saptandý (p=0.006). BBCS’li hastalarýn 4’ünde SDY alýnamadý ve BDÝ ile SDY’nin arasýnda pozitif korelasyon belirlendi (r=0.46). SONUÇ: Baþarýsýz bel cerrahisi sendromlu hastalarda sempatik sistemin etkilendiði, SDY deðiþikliklerin olduðu saptandý. Sempatik sinir sistemi tutulumunun BBCS’de görülen kronik aðrý geliþimine katkýda bulunabileceði düþünüldü.

OBJECTIVES: The aim of this study was to investigate whether sympathetic skin response (SSR) was affected in cases with failed back surgery syndrome (FBSS). METHODS: Twenty-nine cases admitted to our department and diagnosed as FBSS were recruited for the study. All the cases had back, leg or back and leg pain in the months or in one year following spinal surgery. The control group consisted of 13 healthy hospital personnel. Electrophysiologic nerve conduction studies and SSR recordings were applied on the symptomatic side (29 legs) in study cases and both sides (26 legs) in the control group. SSRs of the study group were compared with those of the sex-, body mass index- and age-matched control group of 13 people. Patients having peripheral nerve entrapment syndromes, peripheral vascular disease, neurologic or psychiatric disease, alcoholism, or drug abuse were excluded from the study. Pain intensity was recorded by visual analog scale (VAS) and depression was recorded by Beck Depression Inventory (BDI). RESULTS: Latency duration in SSR in the study group was significantly higher (p=0.006) when compared with the healthy controls. There was no SSR in 4 patients and there was a positive correlation between BDI and SSR (r=0.46). CONCLUSION: It was concluded that the sympathetic nervous system is affected in FBSS patients with changes in SSR, and that the dysfunction of the sympathetic nervous system may contribute to the intensity and chronicity of pain states in this group of patients.

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AMAÇ: Supraskapular sinir bloðunun akut, postoperatif ve kronik omuz aðrýsýnda etkili olduðu bildirilmiþtir. Analjezinin nöral dokuda destrüksiyon oluþturmaksýzýn saðlanmasý anlayýþý non-nörodekstrüktif bir yöntem olan pulsed radyofrekans (PRF) uygulamalarýný cazip kýlmaktadýr. Bu çalýþmada, subakromiyal sýkýþma sendromuna baðlý kronik omuz aðrýsýnda supraskapular sinire uygulanan PRF’nin etkinliðini sýnanarak uzun dönem sonuçlarý deðerlendirildi. GEREÇ-YÖNTEM: Omuz aðrýsý þikayeti iki aydan fazla süren, manyetik rezonans görüntüleme ile subakromiyal sýkýþma sendromu tanýsý alan 40 hasta çalýþmaya dahil edildi. Hastalara önce diyagnostik supraskapular sinir bloðu yapýldý. Diyagnostik supraskapular sinir bloðu ile kullanýlan lokal anesteziðin etki süresi boyunca aðrý kontrolü saðlanan hastalara daha sonra pulse modunda radyofrekans lezyonu uygulandý. Aðrý deðerlendirilmesi Likert ölçütü, omuz eklem fonksiyonunun deðerlendirilmesi Oxford Omuz Ölçütü ile yapýldý. Çalýþmanýn deðerlendirmeleri erken dönem olarak üçüncü haftada, uzun dönem olarak da altýncý ayda gerçekleþtirildi.
BULGULAR: Çalýþmayý 32 hasta tamamladý; 8 hasta oturur pozisyonda yapýlan giriþim sýrasýnda vagotoni geliþmesi nedeniyle dýþlandý (%20). Hastalarýn baþlangýç kronik omuz aðrýlarý üçüncü haftadaki ve altýncý aydaki kronik omuz aðrýlarý ile karþýlaþtýrýldýðýnda her iki deðerlendirmede kronik omuz aðrýlarýnýn Likert ölçütü (6.73±0.78; 6.50±1.07) çok iyi olarak bulundu (her ikisi için p=0.000). Hastalarýn baþlangýç OOS puaný üçüncü haftadaki ve altýncý aydaki OOS puaný ile karþýlaþtýrýldýðýnda her iki deðerlendirmede ortalama OOS puaný (16.28±3.15; 13.81±2.23) düþük olarak bulundu (her ikisi için p<0.001).
SONUÇ: Supraskapular sinir PRF uygulamasý subakromiyal sýkýþma sendromuna baðlý kronik omuz aðrýsýnda etkindir ve bu etki uzun süre korunmaktadýr. Omuzun fonksiyonel kapasitesinin kronik omuz aðrýsýnýn giderilmesine paralel olarak düzelmesi ayrýca dikkat çekicidir.

OBJECTIVES: Suprascapular nerve block has been shown to be effective in acute, postoperative and chronic shoulder pain. The understanding of providing analgesia without destruction of neural tissue makes pulsed radiofrequency (PRF) lesioning attractive as a non-destructive method. In this study, the effectiveness of suprascapular PRF in chronic shoulder pain in both the short- and long-term was assessed. METHODS: Forty patients suffering from shoulder pain of at least two months’ duration, diagnosed with rotator cuff rupture by MRI scanning and with no response to systemic or physical therapy, were enrolled. After a favorable response to a diagnostic suprascapular nerve block, PRF application was done. Pain assessment was done using a standardized 7-point Likert scale and shoulder joint function assessment by Oxford Shoulder Score (OSS). The outcome measures were assessed in the third week as short-term and in six months as long-term. RESULTS: Thirty-two patients completed the study. Eight patients were excluded from the study because of vagotony due to sitting position (20%). In comparison with baseline, Likert score of chronic shoulder pain was good (6.73±0.78; 6.50±1.07) (for both, p=0.000) and mean OSS was 16.28±3.15; 13.81±2.23 (for both, p<0.001) in the two assessment periods. CONCLUSION: Suprascapular nerve PRF lesioning was effective in chronic shoulder pain of rotator cuff lesion, and this effect was maintained in the long-term period. The improvement in shoulder joint function in parallel with decreased chronic shoulder pain was also notable.

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AMAÇ: Ýntravenöz rejyonal anestezide (ÝVRA), tek baþýna lidokain ile lidokainin morfin ve tramadol ile kombinasyonlarýnýn turnike aðrýsýna, duyusal, motor blok baþlama ve geri dönüþ zamanlarýna, analjezi süresi ve düzeyi ile analjezik tüketimine etkileri karþýlaþtýrýldý. GEREÇ-YÖNTEM: Etik kurulu izni ve hasta olurlarý alýndýktan sonra, el ve ön kol cerrahisi uygulanacak 90 olgu çalýþmaya dahil edildi ve rastgele yöntemle üç eþit gruba ayrýldý. Grup L’ye 40 ml %0.5’lik lidokain, Grup LT’ye 40 ml %0.5’lik lidokain + 1.5 mg.kg-1 tramadol, Grup LM’ye 40 ml %0.5’lik lidokain + 0.1 mg.kg-1 morfin uygulandý. Duyusal ve motor blok baþlama ve dönüþ zamanlarý, analjezi süresi, proksimal ve distal turnike süresi, ilk analjezik alma zamaný, vizüel analog skala (VAS), 24 saatlik analjezik tüketimi, vital bulgular ve yan etkiler kaydedildi. BULGULAR: Duyusal blok baþlama süreleri Grup LM’de diðer iki gruba göre, Grup LT’de ise Grup L’ye göre anlamlý kýsa; duyusal blok dönme süresi ise Grup L’de Grup LM’ye göre anlamlý olarak daha kýsa olarak saptandý (p<0.05). Ameliyat sonrasý dönemde 4. ve 5. saatlerde Grup L’de diðer iki gruba göre VAS anlamlý olarak yüksekti (p<0.05). Grup LM’de turnike iniminde ortalama arteriyel basýnç deðerleri diðer iki gruba göre anlamlý olarak azaldý (p<0.05). SONUÇ: Ýntravenöz rejyonal anestezide lidokaine morfin veya tramadol eklenmesinin, duyusal blok ve ameliyat sonrasý analjezi düzeyini artýrdýðý, ancak turnike aðrýsýna, motor blok kalitesine, analjezi süresine ve analjezik tüketimine etkilerinin olmadýðý belirlendi.

OBJECTIVES: The aim of this study was to compare the effects of lidocaine alone and those of morphine or tramadol when added to lidocaine for intravenous regional anesthesia (IVRA) on tourniquet pain, the onset and regression time of motor and sensory block, the level and duration of analgesia, and analgesic consumption. METHODS: After institutional approval and informed consent, 90 patients scheduled for forearm or hand surgery were enrolled and randomly assigned to one of three groups for administration of either 0.5% lidocaine (Group L), 0.5% lidocaine with 1.5 mg.kg-1 tramadol (Group LT), or 0.5% lidocaine with 0.1 mg.kg-1 morphine (Group LM) in a volume of 40 ml. The onset and duration of sensory and motor blocks, duration of analgesia and proximal and distal tourniquet, time to first pain medication, visual analog scale (VAS) scores, analgesic requirements in 24 hours, vital signs, and side effects were recorded. RESULTS: Sensory block onset time was significantly shorter in Group LM compared with the other groups and also in Group LT compared to Group L. In addition, sensory block regression time was significantly shorter in Group L than in Group LM (p<0.05). There was a significant increase in VAS scores at the postoperative 4th and 5th hr in Group L (p<0.05). Mean arterial blood pressure was significantly reduced in Group LM at the time of tourniquet deflation (p<0.05). CONCLUSION: IVRA with lidocaine and morphine or tramadol improves postoperative analgesia and sensory block. However, these combinations provide no advantage on tourniquet pain, motor block quality, analgesia duration or analgesic consumption.

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AMAÇ: Sportif aktivitenin, menstrüasyon sýrasýndaki aðrý algýsýný deðiþtirmesi konusu tartýþmalýdýr. Bu çalýþmada, kadýn sporcularda menstrüel döngünün farklý fazlarýnda dinlenim ve maksimal kardiyovasküler streslerin aðrý eþiði ve toleransýna etkisi deðerlendirildi. GEREÇ-YÖNTEM: Celal Bayar Üniversitesi Voleybol Takýmý’nýn profesyonel 13 oyuncusu gönüllü olarak çalýþmaya katýldý. Dinlenim anýnda antropometrik ölçümleri ve sistolik-diyastolik kan basýnçlarý ölçüldü; kollarýnýn üst kýsmýna yerleþtirilen manuel tansiyon manþonu yardýmýyla yaratýlan iskemik aðrý Vizüel Analog Skalasý (VAS) ile deðerlendirildi. Olgularýn menstrüel döngülerinin 2. (menstrüel faz) ve 14. günlerinde (ovulasyon fazý) aþamalý artan maksimal egzersiz testlerinde maksimal oksijen tüketimi (VO2), kan laktatý (KL), kalp atým hýzý (KAH), algýlanan yorgunluk miktarý (RPE) ölçümleri yapýlýrken her aþamada aðrý VAS ile derecelendirildi.
BULGULAR: Ýstatistiksel analiz sonuçlarýna göre dinlenim aðrý eþiði ve toleransý ovulasyon safhasýnda istatistiksel olarak daha düþük bulundu. Maksimal egzersiz sýrasýnda VO2 ve KL deðerleri menstrüel safhada ovulasyon safhasýndan daha fazla idi (p<0.05). Egzersizde aðrý algýsý, menstrüasyon safhasýnda ovulasyon safhasýna göre daha düþük bulundu (p<0.05). Lineer regresyon analizi sonuçlarýna göre iki farklý dönemde yapýlan aþamalý egzersiz testlemeleri süresince aðrý algýlanýmýnda olan deðiþikliklerin menstrüel fazda %74’ü, ovulasyon fazýnda ise %86’sý RPE ve KL deðerleri ile açýklanabilmektedir.
SONUÇ: Çalýþmamýzýn bulgularý menstrüel fazda sporcularýn egzersiz sýrasýnda aðrý duyumlarýnýn azaldýðýný göstermekte ve buna baðlý olarak antrenman yüklerini artýrýlabileceklerini düþündürmektedir.

The main purpose of this study was to investigate pain perception of the professional volleyball players at rest and maximal cardiovascular stresses during different phases of menstruation. Thirteen volleyball players from Celal Bayar University were used as the participants of the study. At rest, anthropometric measurements, systolic and diastolic blood pressures were determined. Then, pain tolerance and pain threshold were measured by sphygmomanometer that placed upper part of the arm. Visual Analog Scales (VAS) was used to grade the pain. At the 2nd (menstrual phase) and 14th (ovulation phase) days of menstruation, oxygen consumption (VO2), heart rate (KA), blood lactate (KL) pain perception and rate of perceived exertion (RPE) were taken during two incremental maximal exercises testing. Statistical analysis of this study indicated that at rest pain tolerance and threshold values of the volleyball players were significantly higher during menstruation phase compare to ovulation phase. Also, VO2 and KL measurements taken at the high intensities during 2nd day of mensturation were statistically higher than that of measurements were done at 14th day of mensturation. Moreover, pain perception of the participants that was measured during 2nd day of menstruation was significantly lower than that of measurements during the 14th days of menstruation (p<0.05). According to results of regression analysis, RPE and KL were two dependent variables that were statistically related to pain perception during two different phases of menstruation. As a conclusion due to the decrease in pain perception, the intensity of the training could be increase during menstruation period.

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Dýþ kulak yolundaki yabancý cisimler kulak aðrýsýna (otalji) neden olabilir. Böcekler de bu yabancý cisimlerden olabilir ki; onlarý etkisiz hale getirmek için birçok yöntem kullanýlmýþtýr. Bu yazýda, dýþ kulak yolundaki bir böceðin, EMLA krem kullanýlarak etkisiz hale getirilmesi ve saðladýðýmýz analjezi deneyimimizi sunduk.

Foreign bodies in the external auditory canal may cause otalgia, and live insects have been reported among the causes. A number of methods have been used to immobilize the live insects. In our manuscript, we describe immobilization of an insect and provision of analgesia using EMLA cream.

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Ultrason farklý nedenlerle sinir stimülasyonunun uygun olmadýðý durumlarda sinir bloklarýnda etkili bir rehber olabilir. Bu yazýda lateral sajital infraklaviküler blokla pektoral flep ayrýlmasý ameliyatý geçiren 28 yaþýnda, ASA I, erkek hasta sunuldu. Ultrason rehberliðinde toplam 30 ml lokal anestezik karýþýmý (15 ml levobupivacaine 5 mg/ml ile 5 µg/ml adrenalin içeren 15 ml lidokain 20 mg/ml) aksiller arterin dorsal bölgesine uygulandý. Vasküler ponksiyon ya da farklý bir komplikasyon geliþmedi. Blok baþarýlý oldu ve hasta uygulamadan 20 dakika sonra cerrahiye hazýr oldu. Bu olgu, emniyetli bir þekilde rejyonal anestezi uygulamasýnda tek yolun ultrason rehberliði olduðu ve infraklaviküler blok uygulamasýnda sadece ultrason rehberliðinin etkinliðini gösteren bir örnektir.

Ultrasound may provide effective guidance during nerve blocks in cases where nerve stimulation is not feasible for various reasons. We describe a 28-year-old, ASA physical status I, male patient who was operated for pectoral flap release under lateral sagittal infraclavicular block. Using ultrasound guidance alone, total volume of 30 ml of local anesthetic mixture (15 ml of levobupivacaine 5 mg/ml and 15 ml of lidocaine 20 mg/ml with 5 µg/ml epinephrine) was injected dorsal to the axillary artery. There was no vascular puncture or any other complication. The block was successful and the patient was ready for surgery 20 minutes after block performance. This case report is one of the examples that ultrasound guidance may be the only way to perform safe regional anesthesia; ultrasound guidance alone is an effective way of performing infraclavicular block.

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