Giriþimsel teknikler nöroablatif ve nöromodülatör iþlemler olarak iki gruba ayrýlýrlar. Nöroablasyon, cerrahi, kimyasal veya ýsý uygulamalarýyla aðrý yolaklarýnda fiziksel iletinin kesilmesidir. Nöromodülasyon, stimülasyon uygulamasýyla veya intraventriküler ya da intraspinal uygulanan opioidler ve diðer ajanlarla aðrý yolaklarýnýn dinamik ve fonksiyonel inhibisyonudur. Nöroablatif teknikler kanser tedavisinde yüzyýldan fazla zamandýr kullanýlmaktadýr. Fluroskopi gibi görüntüleme araçlarýndaki geliþmelerle nöroablatif uygulamalar daha doðru ve etkili bir þekilde gerçekleþtirilmektedir.

Interventional techniques are divided into two categories: neuroablative and neuromodulatory procedures. Neuroablation is the physical interruption of pain pathways either surgically, chemically or thermally. Neuromodulation is the dynamic and functional inhibition of pain pathways either by administration of opioids and other drugs intraspinally or intraventricularly or by stimulation. Neuroablative techniques for cancer pain treatment have been used for more than a century. With the development of imaging facilities such as fluoroscopy, neuroablative techniques can be performed more precisely and efficiently.

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Amaç: Ýntraperitoneal levobupivakain uygulamasýnýn laparoskopik kolesistektomi sonrasý aðrý üzerine etkisinin randomize, çift kör, plasebo-kontrollü çalýþma olarak araþtýrýlmasý amaçlandý.
Gereç ve Yöntem: Tüm hastalara trokar giriþ yerlerine levobupivakain %0.25’lik (toplam 15 mL) infiltrasyonu ile birlikte, pnömoperiton sonrasý, randomizasyon þemasýna göre, intraperitoneal olarak hepatodiyafragmatik alana ve safra kesesi üst lojuna toplam 40 mL %0.25’lik levobupivakain (Grup LB, n=20) veya 40 mL normal salin (Grup NS, n=20) uygulandý. Ýki grubun intraoperatif özellikleri, postoperatif aðrý durumu ve ek analjezik gereksinimi, yan etkiler ve hasta memnuniyeti ilk 24 saatlik dönemde karþýlaþtýrýldý.
Bulgular: Postoperatif aðrý skoru, postoperatif ilk 30. dk’da, Grup LB’de Grup NS’ye göre anlamlý olarak daha düþüktü (p<0.05). Omuz aðrýsý sýklýðý iki grupta benzerdi (Grup LB’de %10 ve Grup NS’de %15). Ek analjezik (meperidin) gerektiren hasta sayýsý ve ortalama dozu Grup LB’de Grup NS’ye göre daha azdý (p<0.05). Levobupivakain grubunda normal salin grubuna göre, postoperatif kusma daha az ve hasta memnuniyeti daha tatmin edici bulundu (p<0.05).
Sonuç: Çalýþmamýzda, laparoskopik kolesistektomilerde operasyonun baþýnda uygulanan intraperitoneal 40 mL %0.25’lik levobupivakainin postoperatif aðrýyý ve ek analjezik ihtiyacýný yan etkileri artýrmadan azalttýðý ve postoperatif hasta memnuniyeti üzerine etkilerinin daha iyi olduðu bulunmuþtur.

Objectives: We aimed to determine the effects of intraperitoneal administration of levobupivacaine on pain after laparoscopic cholecystectomy in a prospective, randomized, double-blinded, placebo-controlled trial.
Methods: In all patients, infiltration of levobupivacaine 0.25% (15 mL) was used prior to skin incisions for trocar insertion. After pneumoperitoneum was achieved, patients were allocated randomly to receive intraperitoneally either 40 mL of 0.25% levobupivacaine (LB group, n=20) or normal saline (NS group, n=20) under direct vision into the hepatodiaphragmatic lodge and above the gallbladder. Data of intraoperative variables, postoperative pain relief, rescue analgesic consumption, side effects, and patient satisfaction were followed in both groups.
Results: The postoperative pain scores were significantly lower in the first half-hour period in the LB group than in the NS group (p<0.05). However, the incidence of right shoulder pain was not significantly different between the LB group (10%) and NS group (15%). The mean dose of meperidine consumption and the number of patients needing rescue meperidine were significantly lower in the LB group than in the NS group (p<0.05). Significantly lower vomiting incidence and increased patient satisfaction were determined in the LB group compared to the NS group (p<0.05).
Conclusion: Intraperitoneal administration of 40 mL levobupivacaine 0.25% given immediately after pneumoperitoneum into the hepatodiaphragmatic lodge and above the gallbladder demonstrated useful effects on postoperative pain relief after laparoscopic cholecystectomy, especially in the early postoperative period, and reduced postoperative rescue analgesic requirement, with excellent patient satisfaction. There were no LB-related complications or side effects.

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Amaç: Karpal tünel sendromu (KTS) olan hastalarýn, Washington Nöropatik Aðrý Ölçeði (NAÖ) ile deðerlendirdiðimiz klinik semptomlarý ile elektrodiyagnostik sýnýflamalarý arasýndaki iliþki olup olmadýðýný saptamayý amaçladýk.
Gereç ve Yöntem: Tek taraflý KTS’si olan seksen hasta çalýþmaya alýndý. Elektromiyografik olarak KTS tanýsý konduktan sonra, hastalar 10 soru içeren NAÖ’yü yanýtladýlar.
Bulgular: NAÖ’nün toplam deðeriyle KTS’nin þiddeti arasýnda istatiksel olarak anlamlý bir korelasyon bulundu (p=0.013, r=0.276).
Sonuç: Çalýþmamýzda, NAÖ’nün KTS’li hastalarýn klinik gidiþini deðerlendirmede yararlý olduðu sonucuna varýldý.

Objectives: We undertook this study to examine the relationships between clinical symptoms as evaluated by Washington Neuropathic Pain Scale (NPS) and electrodiagnostic classification in patients with carpal tunnel syndrome (CTS).
Methods: Eighty patients with unilateral CTS were included in this study. After diagnosis of CTS by electromyography, all patients completed a 10-item questionnaire (NPS).
Results: A statistically significant correlation between total NPS score and severity of CTS was found (p=0.013, r=0.276).
Conclusion: The present study indicates that using NPS might be useful in evaluating the clinical outcome of patients with CTS.

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Amaç: Hasta pozisyonunun popliteal bölgede siyatik sinirin ultrason (US) incelemesi sýrasýnda görünürlüðü üzerine etkisi araþtýrýldý.
Gereç ve Yöntem: Popliteal katlantý (PK) ile PK’nýn 4 ve 8 cm yukarýsýnda pron pozisyonda 7-12 MHz geniþ band linear US probu kullanarak kör bir uygulayýcý tarafýndan mümkün olan en iyi görüntü hedeflenerek 24 siyatik sinir incelemesi yapýldý. Ýncelemeler nötral pron pozisyonda (Grup N), ayak altýna silikon rulo konularak (Grup R) ve “dört pozisyonunda” (Grup D). “Dört pozisyonu” incelenen bacak diðer ayaðýn üstünde olacak þeklide fleksiyon ve addüksiyon pozisyonu olarak tarif edildi. Siyatik sinir için aþaðýdaki gibi bir görünürlük skoru tariflendi: Skor I: Sinir tanýnabilir ancak sýnýrlarý net deðildir. Skor II: Sinir tanýnabilir. Sinirin sýnýrlarý diðer yapýlardan kolaylýkla ayýrt edilebilir. Üç ya da daha az fasikül görülebilir. Skor III: Sinir tanýnabilir. Sinirin sýnýrlarý diðer yapýlardan kolaylýkla ayýrt edilebilir. Dört ya da daha fazla fasikül görülebilir.
Bulgular: Sinirlerin PK’dan ayrýlma mesafesi 6.9±1.6 cm idi. Grup D’de elde edilen görüntü skoru (2.6±0.6 ve 1.7±0.8) PK’da, PK’dan 4 cm (2.3±0.5 ve 1.6±0.8) ve 8 cm (2.3±0.7 ve 1.4±0.7) yukarýsýnda Grup N’den daha iyiydi (p<0.001).
Sonuç: “Dört pozisyonu” siyatik sinirin görünürlüðünü iyileþtirmektedir ve klinik öneme sahip olabilir.

Objectives: We studied the influence of patient positioning on the visibility of the sciatic nerve during ultrasound (US) examination in the popliteal region.
Methods: Using a linear broad band 7-12 MHz frequency probe, US examination of 24 sciatic nerves was performed by a blinded operator to obtain the best possible image at the level of the popliteal crease (PC) and at 4 and 8 cm above the PC in the prone position. Examinations were performed in neutral prone (Group N), with a silicone roller under the foot (Group R) and in “figure of four” (Group FOF) positions. “Figure of four” position was described as: the leg to be examined is flexed and abducted to allow the foot to rest on the ankle of the contralateral leg. A visibility score for the sciatic nerve was established as follows: Score I: Nerve is identified, but borders are not clear. Score II: Nerve is identified. Borders of the nerve are clearly distinguished from the surrounding structures. Three or less fascicles are visible. Score III: Nerve is identified. Borders of the nerve are clearly distinguished from the surrounding structures. Four or more fascicles are visible.
Results: The distance of nerve division from the PC was 6.9±1.6 cm. A higher visibility score was obtained in Group FOF (2.6±0.6 vs 1.7±0.8) at the PC and at 4 cm (2.3±0.5 vs 1.6±0.8) and 8 cm (2.3±0.7 vs 1.4±0.7) above the PC, compared to Group N (p<0.001).
Conclusion: “Figure of four” position improves the visibility of the sciatic nerve and may have clinical impact.

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Amaç: Cerrahi giriþim sonrasý uygulanacak postoperatif analjezi yöntemi, uygulanan cerrahiye, hastaya, anesteziste ve koþullara göre deðiþmektedir. Hasta kontrollü analjezi (HKA) özellikle postoperatif aðrýnýn giderilmesinde kullanýlan etkili yöntemlerden birisidir. Bu çalýþmada, HKA uygulamasýnda gereksinim, tercih ve karar verme konularýnda hasta profilinin ve uyguladýðýmýz postoperatif HKA tedavisinin güvenilirlik ve etkinliðinin ortaya konulmasý amaçlandý.
Gereç ve Yöntem: Çalýþmada, kliniðimizde iki yýlda uygulanan HKA protokolleri, HKA uygulanan giriþimlerin genel daðýlýmý ve aðrý timinin çalýþma prensipleri sunuldu.
Bulgular: HKA uygulanan operasyonlar, diz protezi, sezaryen, kalça protezi, alt ekstremite travmasý cerrahisi, aðrýsýz doðum, gastrointestinal sistem cerrahisi, çoklu travma cerrahisi, torakotomi, histerektomi, laminektomi ve ürogenital cerrahi olarak tespit edilmiþtir. Postoperatif HKA’nýn hastalarýn %89’unda tek baþýna baþarý ile uygulandýðý, %6’sýnda ise kurtarýcý analjezik ajan ilavesi ile baþarýlý olunduðu saptanmýþtýr, baþarýlý HKA uygulamamýzýn %95 düzeyinde olduðu bulunmuþtur.
Sonuç: Kliniðimizde postoperatif analjezi amacýyla uygulanan epidural ve intravenöz HKA protokollerinin güvenilir ve etkin olduðu kanýsýndayýz.

Objectives: Postoperative analgesia technique varies depending on the operation, patient, anesthetist, and circumstances. PCA (patient controlled analgesia) is an effective way of supporting postoperative analgesia. In this study, we aimed to present the efficacy and safety of our postoperative PCA treatment and the patient profile along with the requirements, preferences and decision-making process.
Methods: We discuss herein the PCA protocols of our clinic, the overall distribution of operations for which PCA was applied and the principles by which a pain team works.
Results: The operations for which PCA was applied included knee prosthesis, cesarean section, hip prosthesis, lower extremity trauma surgery, painless delivery, gastrointestinal surgery, multiple trauma surgery, thoracotomy, hysterectomy, laminectomy, and urogenital surgery. Postoperative PCA alone was successful in 89% of the patients, and with the supplemental analgesic agent, it was successful in an additional 6% of the patients, thus achieving a total success rate of 95%.
Conclusion: We believe the epidural and intravenous PCA protocols applied in our clinic for postoperative analgesia are effective and safe.

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Amaç: Ýntraoperatif remifentanil kullanýmýnda akut opioid toleransýna baðlý olarak postoperatif aðrý, opioid tüketimi ve insizyon çevresinde hiperaljezi artmaktadýr. Bu çalýþmada amacýmýz, remifentanile baðlý geliþen postoperatif hiperaljezinin önlenmesinde lornoksikamýn etkiliðini deðerlendirmektir.
Gereç ve Yöntem: Olgular randomize olarak iki gruba ayrýldý. Cerrahi baþlamadan 15 dk önce Grup I’e (n=22, kontrol) serum fizyolojik, Grup II’ye (n=20, lornoksikam) 16 mg lornoksikam i.v uygulandý. Anestezi indüksiyonu 1 µg/kg remifentanil, 1.5-2 mg/kg propofol, idamesi 0.5 minimum alveolar konsantrasyon (MAC) desfluran ve 0.4 µg/kg/dk remifentanil ile saðlandý. Desfluran konsantrasyonu otonomik cevaplara göre titre edildi. Bütün olgulara cerrahi sonlanmadan 30 dk önce 0.15 mg/kg morfin i.v verildi. Cerrahinin sonunda olgulara i.v hasta kontrollü analjezi cihazý ile morfin uygulandý. Aðrý skoru, morfin isteði ve sunumu postoperatif 2., 4., 6., 12. ve 24. saatlerde deðerlendirildi. Total morfin tüketimi 24. ve 48. saatte kaydedildi. Periinsizyonel hiperaljezi operasyon öncesi ve postoperatif 24. ve 48. saat algometre ile aðrý eþiði ölçülerek deðerlendirildi.
Bulgular: Aðrý skorlarý ve toplam morfin tüketimi lornoksikam grubunda kontrol grubuna göre daha düþük bulundu (p<0.05). Aðrý eþiði 24. ve 48. saatlerde kontrol grubunda daha yüksekti (p<0.05). Yan etkiler açýsýndan gruplar arasýnda fark bulunmadý (p>0.05).
Sonuç: Preemtif olarak uygulanan lornoksikam remifentanile baðlý geliþen hiperaljeziyi önlemektedir.

Objectives: Intraoperative remifentanil administration results in acute opioid tolerance that is manifested by increased postoperative pain, opioid requirement and specifically peri-incisional hyperalgesia. The aim of this study was to investigate the effect of lornoxicam in preventing remifentanil-induced hyperalgesia.
Methods: Patients were randomly divided into two groups. Fifteen minutes before surgery, saline solution was given to the patients in group I and 16 mg i.v. lornoxicam in group II. Anesthesia was induced with 1 µg/kg remifentanil combined with 1.5-2 mg/kg propofol and maintained with 0.5 MAC desflurane and 0.4 µg/kg/dk remifentanil in both groups. Desflurane concentration was titrated according to autonomic responses. All patients were given i.v. 0.15 mg/kg morphine 30 min before the end of surgery. At the end of surgery, patients received morphine i.v. via a PCA (Patient Controlled Analgesia) device. Pain score, morphine demand and delivery were assessed at 2, 4, 6, 12 and 24 h after surgery. Total morphine consumption was recorded for 24-48 h. Peri-incisional hyperalgesia was assessed by measuring pain threshold to pressure using an algometer before operation and at 24-48 h postoperatively.
Results: The pain scores and cumulative morphine consumption were significantly lower in the lornoxicam group when compared with the control group (p<0.05). Pain thresholds were significantly less at 24-48 h postoperatively in the control group than in the lornoxicam group. No significant difference was observed in side effects (p>0.05).
Conclusion: Lornoxicam administered preemptively prevented remifentanil-induced hyperalgesia.

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Amaç: Migren ataklar halinde giden baþ aðrýlarý ve deðiþik organ sistemlerine ait belirtilerle kendini gösterir. Akut migren ataklarýnýn tedavisinde kullanýlacak uygun ilacýn reçete edilmesi için baþ aðrýsýnýn zamansal özellikleri bilinmelidir. Bu çalýþmamýzda, üçüncü basamak bir saðlýk kuruluþuna baþvuran migrenlilerde baþ aðrýlarýnýn zamansal özelliklerini ortaya koymayý ve bu özelliklerin hasta alt gruplarýnda deðiþkenlik gösterip göstermediðini araþtýrmayý hedefledik.
Gereç ve Yöntem: Kocaeli Üniversitesi Týp Fakültesi Eðitim ve Araþtýrma Hastanesi, Baþ aðrýsý Polikliniði’ne ardý sýra baþvuran eriþkin migrenliler çalýþmaya alýndý. Demografik bilgileri, týbbi öyküleri ve baþ aðrýlarýnýn zamansal özellikleri sorgulandý.
Bulgular: Çalýþmaya alýnan 153 eriþkin migren hastasýnýn 30’u (%19.6) kronik günlük baþ aðrýsýna sahipti. Hastalarýn 34’ünde (%22.2) aðrý ilk 2 saatte zirve þiddetine ulaþýyordu ve 87 (%56.9) hastada aðrý 24 saatten uzun sürüyordu. Baþ aðrýlarý 24 saatten uzun süren hastalarýn yaþ ortalamasý kýsa olanlara kýyasla daha yüksekti (sýrasýyla 40.8±12.4 ve 36.2±11.4; p=0.019). Baþ aðrýlarý 24 saatten uzun süren migrenlilerin hastalýk yaþlarý da diðerlerine kýyasla daha büyüktü.
Sonuç: Bizim çalýþmamýz eriþkin migrenlilerde baþ aðrýlarýnýn zamansal özelliklerinin hasta alt gruplarýnda deðiþkenlik gösterebildiðini ortaya koymaktadýr. Bu bulgularýn doðrulanmasý ve hangi alt gruplarda hangi zamansal özelliklerin ön planda olduðunun saptanabilmesi için daha geniþ hasta sayýsýný içeren ileri çalýþmalara ihtiyaç olduðunu düþünmekteyiz.

Objectives: Migraine is characterized by headache attacks, and symptoms belong to various organ systems. Temporal characteristics of headache must be known to prescribe the appropriate drug for the treatment of migraine attacks. In this study, we aimed to reveal the temporal characteristics of headache and to search whether or not these characteristics differ in patient subgroups in migraineurs admitted to a tertiary health center.
Methods: Consecutive adult migraineurs who admitted to the Headache Section of Kocaeli University Faculty of Medicine Research Hospital involved the study. Their demographical data, medical history and temporal caharacteristics of headaches were questioned.
Results: Thirty (19.6%) patients among the 153 migraineurs involved had chronic daily headache. Headaches were detected to reach the maximum pain intensity within 2 hours in 34 patients (22.2%) and to continue over 24 hours in 87 (56.9%) patients. Patients with headaches lasting over 24 hours had a greater mean age than of those with headaches ending within 24 hours (40.8±12.4 and 36.2±11.4, respectively; p=0.019). The mean disease age of the patients with headaches lasting over 24 hours was also greater than of the group with headaches ending within 24 hours.
Conclusion: Our study revealed that temporal characteristics of headache may differ in patient subgroups in adult migraineurs. Further studies with large populations are warranted to verify these results and determine which temporal characteristics are common in which patient subgroups.

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Herpes zoster, esas olarak posterior kök ganglionlarýný ve duysal sinir liflerini tutar, deride veziküler döküntüler, radiküler aðrý, etkilenen ganglionun daðýlýmýnda duysal bozukluklara yol açar. Bununla beraber motor tutulum da gözlenir. Klasik kütanöz lezyonlar olduðunda herpes zostere baðlý motor parezi kolaylýkla tanýmlanýr. Fakat, güçsüzlüðün deri lezyonlarý ve duysal yakýnmalardan önce olduðu durumlarda taný zorlaþýr. Bu yazýda, herpes zostere baðlý servikal segment radikülopatide motor güçsüzlüðün majör klinik semptom ve bulgu aldýðý olgu sunuldu.

Herpes zoster primarily affects the posterior root ganglions and sensorial nerve fibers, and causes vesicular skin eruptions, radicular pain and loss of sensorial function along the distribution of the affected ganglion. Motor involvement can also be observed. When classical cutaneous lesions are present, the motor paresis consequent to herpes zoster is easily diagnosed. However, diagnosis becomes complicated when the motor weakness is the earlier sign and precedes the cutaneous lesions and sensory symptoms. We present a case in whom the major clinical symptom and sign was the motor weakness in cervical radiculopathy consequent to herpes zoster.

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