Baþ ve boyun bölgesi vucudun kronik aðrýlardan en çok etkilenen bölgesidir. Nöropatik aðrýlar, periferal ya da santral sinir sistemindeki primer bir lezyon, disfonksiyon ya da geçici bir bozukluk sonucu baþlayan kronik aðrýlardan birisidir. Trigeminal nöralji, atipik odontalji (fantom diþ aðrýsý), yanan aðýz sendromu, travmatik nöropatiler, postherpetik nöralji ve kompleks bölgesel aðrý sendromu diþ ve aðrý kliniklerinde karþýlaþýlabilecek nöpatik orofasial aðrýlardandýr. Aðýz içersinde þikayete neden olan aðrýlarýn bir kýsmýnýn nöropatik aðrýlar olabileceði hatýrlanmadýðýnda yanlýþ taný konulmakta ve etkilenen bölgedeki diþlere gereksiz tedaviler yapýlmaktadýr. Makalede, dental iþlemler sonrasý ortaya çýkabilen posttravmatik periferal aðrýlý nöropatiler tartýþýlacaktýr.

Summary
The head and neck region is the most common site of the human body to be involved in a chronic pain condition. Neuropathic pain is one of those and refers to all pain initiated or caused by a primary lesion or dysfunction or transitory perturbation in the peripheral or central nervous system (CNS). Trigeminal neuralgia, atypical odontalgia (phantom tooth pain), burning mouth syndrome, traumatic neuropathies, postherpetic neuralgias and complex regional pain syndrome are the neuropathic pain conditions in orofacial region can be encountered in pain and dental clinics. Most of the time this problem misdiagnosed by the dentist causing unnecessary treatments including endodontic treatment and extraction of the tooth or teeth in the region. In this review, only post-traumatic peripheral painful neuropathies seen after dental treatments will be discussed.

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Amaç: Çalýþmamýzda, Transdermal fentanil ( TDF ) kullanýlan kronik kanser hastalarýnda doz artýmý gerektiðinde TDF dozunda artým yapmadan önce tedaviye Tramadol eklenmesinin kanser aðrýsý kontrolünde avantaj saðlayýp saðlamayacaðýný araþtýrdýk.
Gereç ve Yöntem: Hastalar; Grup Kontrol(GrupK) ve Grup Tramadol(GrupT) olarak iki gruba ayrýldý. Hastalar aðrý polikliniðimize ilk baþvurduklarýnda demografik özellikleri, kanser türü, aðrý çekme süresi ve ilk VAS deðerleri kaydedildi.Hastalara muayene sonrasý ilk tedavi olarak 25µg/saat fentanil içeren TDF verildi.Çalýþma esnasýnda, Grup K’de hastalarýn kullandýðý TDF dozu; doz yükseltilmesine gerek duyulan her muayenede 25µg/saat yükseltildi.Tramadol Grubunda ise ilk doz yükseltilmesi gerektiðinde TDF dozu arttýrýlmadan tedaviye 200mg tramadol eklendi. Grup T’de daha sonra doz artýrýmý gerektiðinde tramadol kesilmeden TDF dozu ardýþýk olarak ihtiyaç halinde 25µg/saat arttýrýldý. Hastalarýn her poliklinik muayenesinde VAS skorlarý, yan etkiler kaydedildi. Ayda bir hastalarýn uyguladýðýmýz aðrý tedavisini Tedavi Deðerlendirme Skalasý(TDS) ile deðerlendirmeleri istendi. Çalýþma sonunda hastalarýn; çalýþmaya katýlým süreleri ve ulaþýlan en üst TDF dozu kaydedildi. Ayrýca hastalarýn 50 µg/saat,75 µg/saat,100 µg/saat,125 µg/saat ve 150 µg/saat TDF dozlarýna kaç gün içerisinde ulaþtýklarý saptandý.
Bulgular: Çalýþma baþlangýcýndan 1ay ve 2ay sonra ölçülen TDS skoru gruplar arasýnda benzer bulundu. Fakat 3.ay ve 4.ay sonunda ölçülen TDS skoru GrupT’de anlamlý ölçüde yüksek saptandý. Çalýþma sonunda ulaþýlan ortalama TDF dozu Grup K’de GrupT’ye göre anlamlý ölçüde yüksek bulundu.Çalýþmaya katýlan hastalarda kaþýntý Grup K’de anlamlý ölçüde daha sýk görüldü.
Sonuç: Çalýþmamýzda TDF ile Tramadol’un birlikte kullanýldýðýnda, TDF ihtiyacýný azalttýðýný buna baðlý olarak kronik aðrý tedavisi protokolümüzün hastalar tarafýndan daha iyi tolere edildiðini saptadýk. Çalýþmamýz verileri ýþýðýnda, kanser aðrýsý tedavisinde güçlü ve zayýf opioid analjeziklerin birlikte kullanýlmasýný önermekteyiz.

Objectives: Our aim was to search addition of Tramadol to the treatment, when a dose increase is needed; before increasing transdermal fentanyl(TDF) dose in cancer patients using TDF would have any advantages.
Methods: Patients were divided in two groups as ControlGroup(GroupK) and TramadolGroup(GroupT).When patients were first came to polyclinic, demographic data,duration of pain and first VAS values were recorded.Following the first examination, all patients were given TDF containing 25µg/hfentanyl as initial treatment. During study period, TDF dose of patients in GroupK was increased in step of 25µg/h whenever needed. In GroupT, 200mgTramadol was added to treatment whitout increasing TDF dose when a dose increase is needed.In subsequent dose increase requirements in GroupT, TDF dose was sequentially increased 25µg/h when needed without stoping tramadol.Patients VAS score,advers effects were recorded in each polyclinic examination. Patients were asked to asses pain treatment with Treatment Assesment Scale(TAS).Each patient’s participation to the study and highest TDF dose reached were recorded.
Results: The TDS scores measured 1month and 2months after start of study were found similar.However, TAS scores measured at the end of 3rd and 4th months were found significantly higher in GroupT. Mean TDF dose reached at end of the study was found significantly higher in GroupK compared to GroupT.Itching was observed significantly more frequent among patients of GroupK.
Conclusion: We found out in our study, when TDF and Tramadol are use together,TDF need is reduced and pain managment protocol is beter tolerated by patients.Based on results of our study;we suggest concomitant use of strong and weak opioids.

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Objective: Propofol causes considerable pain on injection, although different methods and propofol formulations have been used to decrease it. We aimed to investigate the effect of i.v esmolol pretreatment on the propofol injection pain.
Methods: Ninety ASA I-II patients undergoing elective surgery under general anesthesia were randomly assigned into three groups, tirthy each. A 20 G cannula was inserted into the dorsum of the nondependent hand. After venous occlusion for one minute, groups E, L and S were pretreated with 5 mg/cc (total 2cc) esmolol, 40 mg lidocaine and 2cc saline i.v respectively. After release of venous occlusion, one fourth of total propofol dose was administered at a rate of 0.5 ml/sec. During the injection of both pretreatment solution and propofol, patient pain was assessed by using 4 point scale. Heart rate and noninvasive arterial blood pressure values were recorded before induction, just after entubation and five minutes after entubation.
Results: Demographic values were similar among groups. Incidence of pain on injection of propofol in control, esmolol and lidocaine groups was 90%, 33.3%, 50% respectively.(p<0.05) Heart rate, systolic arterial pressure, diastolic arterial pressure values were not different between the groups.
Conclusions: Pretreatment with low dose esmolol i.v seems to be effective in attenuating pain during propofol injection.

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AMAÇ: Çalýþmamýzda vaginal doðumda epidural katater takýlarak düþük doz levobupivakain ve fentanil kombinasyonu ile yapýlan sürekli infüzyon ve hasta kontrollü bolus uygulamanýn anne, bebek ve doðum süreci üzerine etkisini karþýlaþtýrmayý amaçladýk. GEREÇ-YÖNTEM: Çalýþmaya katýlan 45 gebe randomizasyon yöntemine göre Grup HKEB (hasta kontrollü epidural bolus) ve Grup SEÝ (sürekli epidural infüzyon) olarak iki gruba ayrýldý. Gebelerin hemodinamik parametreleri ve VAS deðerleri, fetal kalp tepe atýmý, bebek APGAR skorlarý, doðum evrelerinin süreleri, doðum þekilleri ve yan etkiler kaydedildi. T10 dermatoma ulaþma süreleri belirlendi. Motor blokaj düzeyleri modifiye Bromage skalasý ile deðerlendirildi. Ek analjezik ihtiyaçlarý takip edildi, toplam ilaç tüketimleri karþýlaþtýrýldý. BULGULAR: Hasta kontrollü epidural bolus uygulamada toplam ilaç tüketiminin anlamlý olarak daha az olduðunu görüldü (p<0,01). SONUÇ: Analjezi seviyesini sürekli koruyacak bazal bir ilaç dozunun bolus verilmesinin ve hasta talep ettiðinde ek ilaç yapmasýnýn hem gebelerin gereksiz dozda ilaç kullanýmýndan kaçýnarak aðrýlý bir dönem geçirmesini önleyeceði, hem de gebenin kendi aðrý karakterine göre istediði zaman ilaç talep etmesi konforunu ve güvenini saðlayacaðý kanýsýndayýz.

OBJECTIVES: We aimed to compare the efficacies of patient controlled bolus administration and continuous infusion of low dose Fentanyl and Levobupivacaine combination by epidural catheter during vaginal labor on mother, baby and the duration of labor. METHODS: The 45 pregnants involved in the study were divided randomly into two groups, Group HKEB (patient controlled epidural bolus) and Group SEI (continuous epidural infusion). Hemodynamic parameters and VAS values of the pregnants, fetal heart rate, Apgar scores, duration of labor stages, types of delivery and side effects were recorded. Time to reach T10 dermatome was determined. Motor block was evaluated with modified Bromage scale. Additional analgesic needs were followed up and total drug consumptions were compared. RESULTS: Drug consumption was found to be significantly lower in HKEB admiistration(p<0,01). CONCLISION: Bolus administration of a basal dose that will keep analgesia level constant and additional drug administred upon patient requests both will prevent pregnants to experience a painful period and will give confidence and comfort to patient to ask for drug when she needs according to her pain character.

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Amaç: Malatya il merkezinde yaþayan 18-69 yaþ arasý bireylerde boyun, sýrt ve bel aðrýsý prevalanslarýný ve iliþkili faktörleri saptamaktýr.
Materyal ve Metod: Bu araþtýrma kesitsel tipte bir araþtýrmadýr. Otuz küme örnekleme yöntemi ile Malatya il merkezindeki saðlýk ocaklarýna baðlý otuz saðlýk evi bölgesi sistematik örnekleme ile seçilmiþ ve her bir kümeden 20 birey alýnarak araþtýrmaya 600 birey dahil edilmiþtir. Veriler 1 Haziran-1 Eylül 2006 tarihleri arasýnda toplanmýþtýr. Analizlerde ki-kare, ve lojistik regresyon analizi kullanýlmýþtýr.
Bulgular: Araþtýrma kapsamýna girenlerin %56.2’si kadýn, %43.8’i ise erkektir, yaþ ortalamasý 38.5±0.5 yýldýr. Araþtýrma kapsamýna giren kadýnlarýn %13.6’sý, erkeklerin ise %2.3’ü ilkokul bitirmemiþlerdir. Araþtýrma kapsamýna girenlerde hayat boyu bel, boyun ve sýrt aðrýsý prevalanslarý sýrasýyla %86.3, %79.3, %59.5’dir. Bel, boyun ve sýrt aðrýsý nokta prevalanslarý sýrasýyla %18.3, %12.0, %3.0 saptanmýþtýr. Cinsiyet, yaþ ve psikolojik sorunlarýn hayat boyu aðrý prevalanslarý ile primer iliþkili faktörler olduðu; cinsiyet, psikolojik sorunlar ve beden kitle indeksinin nokta aðrý prevalanslarý ile primer iliþkili faktörler olduðu görülmüþtür.
Sonuç: Araþtýrma sonuçlarýna göre kas-iskelet sistemi hastalýklarýnýn göstergesi olan boyun, sýrt ve bel aðrýlarý Malatya il merkezinde yaygýndýr. Konu ile ilgili olarak saðlýk personeline hizmet içi eðitim verilmelidir. Aðrýlarýn tanýnmasý, önlenmesi ve bildirimi ile ilgili yöntemler geliþtirilmelidir.

Objectives: To determine the lifetime and point prevalences of neck, upper back and low back pain of the people living in the central Malatya with the influencing factors.
Methods: This research is a cross-sectional interview survey. Thirty health house spots tied to the health clinics in the city center were chosen as thirty sets with the method of sampling and 600 people by taking 20 people from each set were included in the research. The data were collected between the 1st of June and the 1 st of September. Association between pain prevalences and socio-demographic, health and behavior related characteristics were evaluated. Chi-square and backward stepwise logistic regression tests were used in the analyses.
Results: Of the participants, 56.2% were women, 46.8% were men, and the mean age was 38.5±0.5 years. The lifetime neck, upper back and low back prevalences were 79.3%, 59.5% and 86.3%, respectively. The point prevalences of neck, upper back and low back were, 12.0%, 3.0% and 18.3%, in order. Gender, age, and psychological problems were determined to be the main predictors of life time pain prevalences. For point pain prevalences, the main predictors were gender, psychological problems and body mass index.
Conclusion: Both lifetime and point pain prevalences showed that musculoskeletal disorders symptoms were common in the central Malatya. In-service training of health personnel on the subject, and assessment, notification and prevention methods should be developed.

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Giriþ ve amaçlar: Hiperhidrozun sempatik sinir sisteminin fonksiyonel bozukluðu sonucu oluþtuðu düþünülmektedir. Bu çalýþmada, konservatif tedaviye yanýt vermeyen palmar hiperhidrozun tedavisinde perkütan T4 sempatik radyofrekans (RF) termokoagülasyon, güvenlik, verimlilik ve hasta memnuniyeti açýsýndan deðerlendirildi.
Yöntem: Bu çalýþma, 16-48 yaþ arasý 15 hastanýn düzenli kayýtlarýndan elde edilen veriler geriye dönük olarak incelenerek yapýldý. Hasta memnuniyeti skoru (memnun deðil, memnun, çok memnun), tedavi sonrasý elin durumu (kuru, hafif kuru, hiçbir iyileþme yok) ve en sýk rastlanan komplikasyon olan kompansatuvar hiperhidroz (KH) derecesi (hiç yok,hafif, orta,þiddetli) incelendi.
Sonuçlar: Bir hastada 2 saat süren öksürük krizi, 1 hasta geçici bradikardi ve tüm vakalarda geçici enjeksiyon yerinde aðrý dýþýnda herhangi bir komplikasyon gözlenmemiþtir. Ýki hastada 1. Haftada, üç hastada da 1, 2 ve 6. aylarda nüks geliþti.
Sonuç: Perkutan sempatik T4 RF termokoagülasyon ile ablasyon uzun vadeli (6 ay) hasta memnuniyeti (% 80) saðlamýþtýr. Ayrýca el terlemesinde (kuru veya hafif kuru % 80) etkili azaltma gözlendi. KH oraný % 27 idi. Bu sonuçlarýna göre, Perkutan sempatik T4 RF termokoagülasyonun yüksek hasta memnuniyeti ile güvenli ve etkili bir tedavi yöntemi olduðu düþüncesindeyiz.

Background and aims: Hyperhidrosis is thought to result from functional impairment of sympathic nervous system. In this study, percutaneous T4 sympathic radiofrequency (RF) thermocoagulation was used to treat palmar hyperhidrosis which do not respond to conservative treatment and the results were evaluated in terms of safety, efficiency and patient satisfaction.
Methods: In this study, 15 patients aged 16-48 regularly performed retrospectively on data obtained from records kept. Patient satisfaction scores (very satisfied, satisfied, not satisfied), after treatment of the hand condition (dry, mild dry, no improvement), and whether the most common complication and most patients expressed by the compensatory hyperhidrosis (CH) degree (none, mild, moderate, severe) were analyzed.
Results: No complications were observed except a coughing crisis lasting in 2 hours in one patient, transient bradycardia in 1 patient and transient injection site pain in all cases. Two patients 1 per week and three patients 1, 2 and 6 months developed recurrence.
Conclusions: Sympathic T4 ablation with RF thermocoagulation was found to have a long term (6 months) patient satisfaction (80 %). It was also effective in reducing the sweating of hand (80 % dry or mild dry). The CH rate was 27 %. According to our results, sympathic T4 ablation with RF thermocoagulation is a safe and effective treatment with high patient satisfaction.

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Atipik belirtilerle bir arada bulunan migren baþ aðrýlarý “migren varyantlarý” olarak sýnýflandýrýlabilir. Migren varyantlarýnýn çoðu 2004 yýlýnda yayýnlanan baþ aðrýlarýnýn uluslararasý sýnýflamasýnda yeniden tanýmlanmýþtýr. Hemiplejik migren, baziler-tip migren, çocukluk çaðý periyodik sendromlarý, retinal migren, komplike migren, oftalmoplejik migren ve vertijinöz migren “migren varyantlarý” olarak sýnýflandýrýlabilir. Bu yazýda uzun süren atipik aura belirtileriyle migren varyantlarýndan biri olan baziler-tip migrene benzeyen farklý yaþ grubunda iki olgu sunulmuþtur. Migren Varyantlarý’nýn klinik pratikte bilinmesi, çoðunun antimigren profilaksi tedavisine iyi cevaplý olmalarý açýsýndan ayýrýcý tanýda çok önemlidir. Doðru taný ile tedaviye alýnan cevap tatmin edeci olur.

If migraine does not manifest itself in the form of headache but in some other atypical symptoms with a headache, it is labelled a Migraine Variant. Many migraine variants have been redefined and included in the International Classification of Headache Disorders 2004 classification. These include hemiplegic migraine, basilar-type migraine, childhood periodic syndromes, retinal migraine, complicated migraine, ophthalmoplegic migraine and vertiginous migraine. In this study, we report two patients in different age group who resemble basilar-type migraine with symptoms of prolonged atypical aura. Migraine Variants are important to recognise in clinical practice. Most variants respond well to treatment with antimigraine prophylaxis. If diagnosed correctly, treatment response is always satisfying.

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Kronik baþ aðrýsýnýn açlýk ile kötüleþtiði bilinmektedir ve açlýk kronik baþ aðrýsý yaþamayan insanlarda dahi baþ aðrýsýna neden olabilir. Baþ aðrýsý, Müslümanlarýn yýlda bir ay boyunca güneþin doðuþundan batýþýna kadar yemek yemediði, su ve sigara içmediði Ramazan ayý boyunca da kötüleþmektedir. Fakat bu ayda da özellikle migrenliler gibi baþ aðrýsýna yatkýn olan kiþilerde baþ aðrýsý ortaya çýkmaktadýr. Bildiðimiz kadarýyla açlýk ile tetiklenen baþ aðrýsý sendromlarýna iþaret eden bildiri bulunmamaktadýr. Burada, spontan intrakraniyal hipotansiyon tanýsý konan, konservatif yöntemler ile tedavi edilen ve Ramazan sýrasýndaki açlýk ile tetiklenen baþ aðrýsý olan 32 yaþýnda bir olgu sunulacak ve açlýk nedeniyle tetiklenen ortostatik baþ aðrýsýnýn olasý mekanizmalarý tartýþýlacaktýr.

Chronic headache is known to be aggravated by fasting and fasting even triggers headache among those not suffering from chronic headache. Headache is also aggravated during Ramadan in which The Moslem do not eat and drink anything or smoke from dawn to sunset for about a month in a year. But it mainly increases in people who are prone to headaches like migraine sufferrers. As far as we know there are no reports in specific headache syndromes pointing to precipitating factor of fasting. In this report, we present a 32 years-old man diagnosed as spontaneous intracranial hypotension, treated by conservative means and relapsed after fasting during Ramadan and we aim to discuss the possible underlying mechanisms of precipitation of orthostatic headache during fasting.

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