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Persistent postmastectomy pain (PPMP) syndrome is characterized by neuropathic pain that develops following surgery in breast cancer patients. The reported incidence of PPMP ranges between 30% and 50% and is estimated to increase as the number of women surviving cancer continues to rise. Though effective, today's drug treatments are poorly tolerated, limiting their use and reducing adherence to therapy. Since neuropathic pain is localized, international guidelines suggest that topical treatment with 5% Lidocaine medicated plaster either alone or combined with systemic drugs can be considered for pain management. In this retrospective study we reviewed the medical records of 11 patients treated with 5% lidocaine medicated plaster for moderate-to-severe PPMP at our institute between November 2013 and October 2014. Analysis showed that treatment with 5% Lidocaine medicated plaster, either alone or in combination with systemic drugs, achieved significant pain control already after the first week of therapy. The effectiveness and tolerability of 5% Lidocaine medicated plaster we observed suggests that it is a viable option in the management of PPMP.

Aim: Cervical radiculopathy is a mixed pain syndrome characterized by neuropathic, skeletal and myofascial pain. This condition is frequently found in developed countries and is a significant source of disability and a reason for frequent medical consultation. In our Pain Therapy Centre, cervical radiculopathy is initially treated with bi-weekly cycles of mesotherapy coupled, at least 15 days later, with physiotherapy to reach the complete mobilization of cervical spine. Cervical radiculopathy is a localized neuro-pathic pain and in agreement with international guidelines, we checked if patients treated topically with 5% lidocaine medicated plaster may benefit in improving pain management and in reducing the time necessary to start physiotherapy., Methods: A retrospective study was carried out on 60 patients, of which 30 were treated with mesotherapy and 30 were treated with 5% lidocaine medicated plaster. Data for a total of 30 days observation were collected from the patient medical records. In particular, besides medical history, intensity of pain, intensity of allodynia and pain were considered., Results and Conclusion: For all analyzed parameters, both treatments were effective, but patients treated with 5% lidocaine medicated plaster showed faster control of the painful symptoms, an essential condition for an earlier rehabilitative treatment.

The treatment of neuropathic pain is a medical challenge. The responsiveness to the different classes of drugs is often unsatisfactory and frequently associated to a wide range of side effects. International guidelines suggest for the "localized" neuropathic pain the topical treatment with 5% lidocaine medicated plaster, alone or associated to systemic drugs, as the first choice since its favorable efficacy and tolerability profile. Many clinical experiences support the rationale for using 5% lidocaine medicated plaster in different kinds of localized neuropathic pain, such as postherpetic and trigeminal neuralgia, compressive syndromes, painful diabetic polyneuropathy and pain secondary to trauma or surgical interventions. This paper reports a series of clinical cases whose heterogeneity suggests the wide burden of applicability of the topical 5% lidocaine, either alone and associated to systemic drugs. All the described conditions were characterized by a highly intense pain, not adequately controlled by actual medications, which improved after the use of topical lidocaine. The good response to lidocaine allowed the reduction, of even the withdrawal, of concurrent drugs and improved the patients' quality of life.

Localized neuropathic pain (LNP) is a type of neuropathic pain characterized by consistent and circumscribed area(s) of maximum pain, which are associated with negative or positive sensory signs and/or spontaneous symptoms typical of neuropathic pain. This description outlines the clinical features of a group of pathologies, in which a LNP can be diagnosed and for whom topical targeted treatment with 5% Lidocaine medicated plaster can be suggested. Indeed both American as well as European guidelines already suggest 5% Lidocaine medicated plaster as a first line treatment in post herpetic neuralgia and in general in the treatment of conditions such as diabetic painful polyneuropathy and post surgical pain where a LNP can be ascertain. In a daily practice of a Pain Unit however the usual case mix encompasses also other causes of LNP, most of them with a scanty pain control in spite of a ongoing polytherapy. Aims of this paper were to focus on 5% Lidocaine medicated plaster as a first line treatment in LNP and to add new insight on its possible use as add-on therapy reporting our data on a consecutive series of 42 patients affected by LNP under unsatisfactory polytherapy in which 5% Lidocaine medicated plaster was able to achieve a satisfactory pain control.

Aim: The aim of this paper is to confirm the efficacy and safety in clinical practice of 5% lidocaine medicated plaster (LMP) in the treatment of localized neuropathic pain., Methods: Retrospective, observational study carried out in the period 2006-2012, in patients with various forms of localized peripheral neuropathic pain treated with LMP. Only patients with at least one follow-up visit after prescription of the drug were assessed., Results: One hundred and one patients were assessable, 60.4% of whom suffered from postherpetic neuralgia (PHN), while the remainder reported mainly post-traumatic/post-surgical neuropathic pain and other superficial localized neuralgias. In baseline conditions, the mean pain intensity measured on the NRS was 6.1. The median treatment time with LMP was 41 days, at the end of which there was a 64% fall in NRS, with no significant differences between the patients with PHN or other localized neuralgias. A better NRS reduction trend was also observed in those patients who, in our study, started treatment with LMP from the first visit, compared with those patients to whom LMP was prescribed later. The tolerability was good, with few adverse events at the application site, which led to suspension of treatment in just three cases., Conclusion: In our experience, LMP proved to be an effective and well-tolerated drug in the treatment of PHN and other superficial localized neuralgias. This observation is in agreement with the international guidelines, which suggest LMP as first line treatment for the management of localized peripheral neuropathic pain.

Aim: In the present study, we investigated effects of a local anesthetic, in the treatment of pathologic scars., Materials and Methods: this retrospective report describes our experience with 97 patients who underwent lidocaine 2% injections in surgical scars of the hand. The results were evaluated using 4 parameters: cutaneous structure, pain, thikness and colour of the scar., Results: The mean outcome was the pain control. 2 out of 97 showed a 100% improvement in all the parameters. In 95 of 97 patients the improvement was between 60-100%., Discussion: Lidocaine controls different pathways of inflammation. Flogosis is the first phase of cicatrization and so lidocaine could be used in the treatment of pathologic scars. A previous study confirms the role of lidocaine, injected to control the pillar pain in the carpal tunnel's surgery in the improvement of scars., Conclusion: Lidocaine, as neuromodulation treatment, acts on inflammation, temperature, perfusion and partial pressure of oxygen.

Aim: Subarachnoid anaesthesia has been demonstrated to be safe and effective in elderly patients. Isobaric Ropivacaine 0.5% has been recently introduced for subarachnoid anaesthesia: aim of our trial is to compare this drug with 0.5 Levobupivacaine in elderly patients scheduled for endoscopic urological surgery., Methods: Premedication: Atropine 0.5 mg + Fenotiazine 50 mg im. Lumbar intrathecal anaesthesia, Group L (n=25) receiving Levobupivacaine 15 mg, Group R (n=25) receiving Ropivacaine 18.05 mg (relative motor blocking potency ratio Ropivacaine / Levobupivacaine = 0.83). Statistical analisys: Bonferroni test and variance analisys., Results: No statistically relevant differences between the 2 groups in terms of antropometric characteristics, onset time and duration of sensitive and motor block, perioperative complications, postoperative analgesic consumption and customer satisfaction. Large presence of comorbidities in the studied population., Discussion: The presence of cases of subtotal anaesthetic coverage (with necessity to recur to general anaesthesia), and others with good anaesthetic coverage, but difficultly treatable hypotensions show that the best dosage of these local anaesthetics is to be found yet. The indications to use a standard dosage for every patient have to be re-evalutated. As positive point, very important the postoperative fast recovery from under limb motor block. A longer recovery time (typical with hyperbaric local anaesthetics) was frequently cause of cognitive alterations in a population of elderly patients.

In the past, general and spinal anesthesia were used for hernia surgery, but nowadays local anesthesia has become the method of choice for hernia repair, especially in outpatient patients. The one-day surgery is sufficient in the management of this pathology. The advantages of local anesthesia are simplicity, safety, extended postoperative analgesia, early mobilization, lack post-anesthesia effects, and low costs. From January 2004 to December 2008 we observed 297 male patients with inguinal hernia. These patients were divided, with rigorous chronological order of hospital admission, in two study groups, different for anesthetic techniques used. Our controlled randomized clinical trial examines the effectiveness of local anesthesia to reduce the time of hospitalization, without alteration of results, and particularly the degree of satisfaction of patients surgical treated for inguinal hernia.

Mesotherapy is a treatment method devised for controlling several diseases by means of subcutaneous microinjections given at or around the affected areas at short time intervals. It is used to treat a variety of medical conditions, amongst which all orthopaedic diseases and rheumatic pain. Mesotherapy is especially indicated for neck pain. The mechanism of action is twofold: a pharmacological effect due to the drug administered, and a reflexogenic effect, the skin containing many nerve endings that are sensitive to the mechanical action of the needle. Although this therapy is safe, like any other medical intervention it cannot be considered free of complications that may occur, such as allergies, haematomas, bruising, wheals, granulomas and telangiectasias. Infective complications are also possible, due to pathogenic bacteria that are inoculated through contamination of products, of the materials used for the procedure or even from germs on the skin. We present the case of a patient who had cervical lymphadenopathy due to Pseudomonas aeruginosa after mesotherapy treatment for neck pain.

The Authors report the results of the tumescent anesthesia in 187 patients submitted to various outpatient surgical procedures comparing with those in patients submitted to local anesthesia by direct infiltration.

Objectives: To refer a possible resolving treatment of chronic benign pain by injecting local anaesthetics into scars., Materials and Methods: This original article consists of 7 interesting cases who have been extracted by a group of 2145 patients treated with local anaesthetic (lidocaine 0.5-1%), of one or more than one scar., Results: The clinical and therapeutical data of a 2 years follow up show that in these 7 cases of chronic benign pain, treated by injecting local anaesthetic (lidocaine 0.5-1%) into one or more scars, the algic symptomatology stably disappeared., Conclusions: This record of cases confirms the hypothesis of a possible aetiological role of scars in causing benign chronic painful syndromes, as stated by Brothers Huneke in the 40's and validated by a recent review on the topic.

Aim: The aim of this study was to determine the effectiveness of an incisional infusion of local anesthetics through a continuous-infusion elastomeric pump for the management of postoperative pain after thoracotomy., Methods: A comparative analysis of 40 patients undergoing thoracotomies was carried out. Postoperative pain management with a continuous-infusion elastomeric pump providing local anesthetic into the incisional area was compared with traditional values. Data sources were reviewed for mean narcotic use, pain score, and complications., Results: After thoracotomy procedures, 20 patients received the ON-Q Pain Relief System (I-Flow Corp, Lake Forest, CA, USA). Narcotic use and pain scores were significantly reduced in the ON-Q group. There were no wound healing complications or infections associated with the use of the pump., Conclusion: A continuous infusion of ropivacaine at 4 mL/h through the ON-Q elastomeric infusion pump is a safe and effective adjunct in postoperative pain management after thoracotomy. The use of the ON-Q Pain Relief System results in decreased narcotic use and lower pain scores.

Background: Hypospadias is one of the most common congenital anomalies occurring in approximately (1/300) male births. If it is not surgically corrected the consequences may negatively impact on quality of life in adolescents. The surgery is very invasive and the post-operative phase very painful. To improve the control of post-operative pain, continuous analgesia via epidural catheter was implemented., Aims: To compare the effectiveness in controlling pain of two different regimens: continuous epidural catheter infusion vs oral and rectal non-steroidal pain-killers., Materials and Methods: Comparative study on children undergoing hypospadias surgery. Group A (catheter) was treated with continuous postoperative analgesia via epidural catheter and Group B (scheduled times) with rectal and oral analgesics at scheduled times and on demand, after caudal block. In both groups nurses measured pain with VAS and FLACC scales (score from 0 to 10) for 72 hours after surgery., Results: 41 children were studied (average age 64.1 months, SD 47.3), with 332 post-operative pain recordings (Group A n = 161, Group B n = 171). Mean pain score of Group A was 0.13 (SD 0.3) and 0.45 (SD 0.8) in group B, p = 0.006. The median duration of the epidural catheter was 65 hours, mean 51.8 hours (SD 24.3). During the 1st post-operative medication, the mean pain score in Group A was 1.2 (SD 1.4), and 3.2 (SD 1.8) in group B, p = 0.003. In group A the number of pain scores indicating pain (> 0) where 3.1% while in group B were 10.5%, p = 0.0007., Conclusions: In children undergoing hypospadias surgery, post-operative analgesia with continuous epidural catheter infusion seems to offer a better analgesic coverage than the traditional oral/rectal analgesic treatment at scheduled times and on demand.

Joint fluid aspiration, or arthrocentesis, is one of the most useful and commonly performed procedures for the diagnosis and treatment of rheumatic diseases, but to date no definite guidelines have been published. For this reason, a group of experts of the Italian Society of Rheumatology (SIR) produced evidence based recommendations for performing arthrocentesis. Among them, the most relevant are: a) arthrocentesis is necessary when synovial effusion of unknown origin is present, especially if septic or crystal arthritis is suspected; b) the patient should be clearly informed of the benefits and risks of the procedure in order to give an informed consent; c) ultrasonography should be used to facilitate arthrocentesis in difficult joints; d) fluid evacuation often has a therapeutic effect and facilitates the success of the following intraarticular injection; e) careful skin disinfection and the use of sterile, disposable material is mandatory for avoiding septic complications. Disposable, non sterile gloves should always be used by the operator, mainly for his own protection; f) contraindications are the presence of skin lesions or infections in the area of the puncture; g) the patient's anticoagulant treatment is not a contraindication, providing the therapeutic range is not exceeded; h) joint rest after arthrocentesis is not indicated. Several of these recommendations were based on experts' opinion rather than on published evidence which is scanty.

Aim: The aim of this study was to report our results on the treatment of chronic constipation associated with pain during defecation., Methods: From January 1999 to January 2004, 60 patients (25 females, 35 males; age range, 6 months to 12 years) who met the ROMA II diagnostic criteria for chronic functional constipation associated with pain on defecation were enrolled in the study. All subjects underwent anorectal manometry to determine rectosphincter inhibitory reflex function. A retraining program for daily defecation, a diet high in fiber and lactulose, and local administration of prilocaine/lidocaine were instituted. At rectal anal endosonography, 7 drug-treatment-resistant patients presented with increased thickness of the internal anal sphincter and received botulin toxin A injection at the sphincter. Because symptoms persisted in 2 of these patients, they received a sphincterectomy., Results: At the end of treatment, 40 (71.4%) of the 56 patients who completed the study had a daily bowel movement without pain; 9 experienced a relapse; in the 2 surgical patients the alveus returned to normal function at 2 and 6 weeks, respectively., Conclusions: Our treatment strategy breaks the vicious circle of spasm-pain-spasm with use of prolonged analgesic treatment and feces softener over the course of the day. In treatment-resistant patients with functioning rectosphincter reflexes and thickened internal anal sphincter, administration of botulin toxin A may be a valuable aid in place of standard sphincterectomy.

Carpal tunnel syndrome, the most common peripheral neuropathy, results from compression of the median nerve at the wrist, and is a cause of pain, numbness and tingling in the upper extremities and an increasingly recognized cause of work disability. If carpal tunnel syndrome seems likely, conservative management with splinting should be initiated. Moreover, it has suggested that patients reduce activities at home and work that exacerbate symptoms. Pyridoxine and diuretics, since are largely utilised, are no more effective than placebo in relieving the symptoms. Non steroidal anti-inflammatory drugs and orally administered corticosteroids can be effective for short-term management (two to four weeks), but local corticosteroid injection may improve symptoms for a longer period. Injection is especially effective if there is no loss of sensibility or thenar-muscle atrophy and weakness, and if symptoms are intermittent rather than constant. If symptoms are refractory to conservative measures, the option of surgical therapy may be considered.

It is common knowledge that therapeutical approach of temporomandibular disorders (TMD) is multidisciplinary and directed to remove the cause of disorder, to eliminate symptomatology and to make an improvement to patient's life. Most of the subjects observed have pain, often caused by muscular component (90-95%) and rarely by the intercapsule. Generally, it deals with chronic-ache, bound by a layer of stress and by considerable emotionalism. A correct diagnosis is the indispensable requirement for the drugs prescription, not only, but remarkable is: to attach importance to the knowledge of workings action, the side effects and active principals contraindications took into account. This article will be a question of medicines which are the basis of medical therapy for temporal-jaw excess with: analgesic, antinflammatory, short-relaxing and tranquillizer, tricyclical antidepressant and local anesthetic. As regards to TMD, notice that pharmacological therapy must not be over protracted for too much time, especially for use of benzodiazepine and tricyclic antidepressants, dosage demanded are decisively less if we compare, usually main therapeutical indications. The pharmacological therapy can be an agent for competent method for symptomatology treatment of temporal-jaw disorder but, patient must be acquainted about a fact, trouble often could not disappear only with a drug. To conclude, we can assert that the right use of medicines, in addition with physiotherapeutical therapy and an occlusal splint, represent the most efficient means to deal with the majority of temporal-jaw diseases.

Aim: The aim of the study was to determine whether intrathecal sufentanil alone provides an adequate analgesia for patients undergoing transurethral resection of the bladder (TURB) and to compare it to standard spinal bupivacaine anesthesia in terms of motor and sensory blockade, discharge time and side effects., Methods: Sixty-two patients were blindly and randomly assigned to receive either intrathecal bupivacaine (10 mg of 0.5% hyperbaric bupivacaine) or intrathecal sufentanil (15 microg). Motor and sensory blockade was evaluated using a modified Bromage scale as well as cold and pinprick tests. Severity of pain was assessed by means of a 10-point verbal analog scale., Results: We found that the mean duration of sensory blockade was similar for both sufentanil and bupivacaine patients but the quality of analgesia induced by sufentanil alone was poor as compared with spinal bupivacaine anesthesia., Conclusion: The subarachnoid administration of sufentanil 15 mg seems to be inadequate for TURB surgery. In addition, the advantage of a faster recovery we observed in sufentanil patients is minimized by the occurrence of a troublesome symptom such as pruritus. On the other hand, spinal bupivacaine produces an undesirable motor blockade exceeding, in our opinion, the requirement for TURB procedure.

Most cases of total spinal block have been reported in the literature. The displacement of the catheter and the consequent dural perforation are the causes in large percentage of the patients (75%). The Authors describe this case for the importance of the causes and outcome of the patient. A 48 years old woman presented for hysterectomy for uterine fibromas. After having individualized the L3-L4 interspace, a test dose of 3 ml carbocaine 2% was injected. After that, the spinal block was obtained using ropivacaine 0.75% (total dose = 10 ml) injecting slowly, in following times, 5+5 ml of anaesthetic solution. The patient, perfectly conscious at first, presented a gradual increase of the difficulty in talking and breathing. Subsequently she showed a complete paralysis with loss of the consciousness, respiratory arrest, bilateral and symmetrical midriasis, as well as total areflexia. Endotracheal tube was placed. After eighty minutes from the end of the administration of the local anesthetic, spontaneous thoracic excursions appeared, even though of moderate ampleness, midriasis reduced. The patient recovered consciousness and sufficiently ventilated; therefore the endotracheal tube was removed.

Aim: Combining an opioid with peridural local analgesia is an excellent technique to control post-operative pain. Sufentanil is a widely used opioid agent, but its optimal dosage has not yet been defined. In this study we wanted to determine the best dose of epidural sufentanil in major surgery., Methods: Before the operation, 45 major abdominal surgery patients received blended anesthesia through an epidural chest catheter. The patients were randomized into 3 groups of 15 subjects according to different sufentanil doses [0.2% ropivacaine combined with sufentanil at a dose of 0.5 microg/ml(-1), 0.75 microg/ml(-1), or 1 microg/ml(-1) (groups A, B and C, respectively)] administered through an epidural chest catheter connected to an elastometric pump (5 ml/h) for the first 36 postoperative hours. The level of postoperative analgesia in motion and at rest was measured using an analog visual scale (VAS-R, VAS-I)., Results: Analgesia was best in group A, and similar in groups B and C; 2 cases of pruritus were noted in group C. The VAS-I scores were <3 across all 3 patient groups., Conclusion: Epidural analgesia is an efficacious and reliable technique. The combination of 0.2% ropivacaine and 0.75 microg/ml(-1) sufentanil was found to be the optimum choice between analgesic efficacy and minor side effects, which correlated with the higher dose of sufentanil given to group C.

Objective: We have developed a standardized technique for intra-articular injection of the hip joint with the purpose of extending routine intra-articular injection of hyaluronans and steroids to the hip, as commonly used in the knee. The purpose of this study was to examine the safety of this technique in an extended series of patients., Methods: A 7 MHz linear or 3.5 MHz convex transducer was used with a sterilized biopsy guide attached. Intra-articular (IA) injection was performed by inserting into the biopsy guide a 20 gauge needle with the anterosuperior approach. Then, using biopsy real-time guidance software, the needle was advanced into the anterior capsular recess, at the level of the femoral head., Results: The standardised technique was used to inject 97 patients (114 hips) with 185 injections of either steroid/local anaesthetic (10) or hyaluronan (175) over a three-year period. The treatment was well tolerated with few, and exclusively local, side effects. No systemic side effects or joint infections were observed in our study. The colour Doppler vision allowed us to avoid injecting blood vessels. In all cases direct visualization of needle introduction and progression into the articular space was shown by on-screen guidance. Ultrasound guidance is more economic and faster in comparison to the TC or fluoroscopic guidance. Contrary to TC or fluoroscopic techniques ultrasound does not require use of radiations or iodized contrast., Conclusion: Our data suggest that the administration of hyaluronans or steroids with ultrasound-guided intra-articular injection is a safe technique for treatment of rheumatic diseases of the hip.

Aim: This study examines 10.112 cases in 10 years of bilateral block anaesthesia to Spix's spine. The aim of this study is therefore to eliminate any doubt about executing a bilateral anaesthesia to Spix's spine for the extraction, in inclusion and impacted of the inferior wisdom teeth., Methods: A retrospective study was carried out on 10,112 operations (59% females, 41% males,) regarding the removal of the lower 3 molar teeth undertaken in the past 10 years. Locoregional anaesthesia and standard instruments and protocol were applied to all operations. The anaesthetic used was mepicavina at 2% with epinefrine 1:100,000 with a 4 x 25 mm, 27 Gauge needle. In order to completely anaesthetize the areas subject to surgery a quantity of approximately 3-ml on each side was injected. Local anaesthetics used were the same throughout the study; all the patients were in good health and not undergoing any pharmaceutical treatment., Results: The onset of complications was 3 times less when using local anaesthesia (LA) compared to general anaesthesia (GA). It was also proven that local anaesthesia was advantageous, as the operation time was considerably less (24 min for LA and 46 min for GA)., Conclusions: The paper shows that LA offers a significant reduction in complications, psychological advantages for the patients and facilitation of the operational position too, so that GA is to be preferred only for non-cooperative patients.

Aim: To evaluate the effectiveness and safety of epidural ropivacaine anesthesia in association with light general anesthesia during renal transplantation and compare epidural and endovenous analgesia techniques for postoperative pain control., Experimental Design: prospective randomized study., Setting: Organ Transplantation Center, Department of Surgery, "Tor Vergata" University of Rome, St. Eugenio Hospital, Rome., Patients: 25 patients affected by chronic renal failure were enrolled in this study. Thirteen constituted the combined epidural-general anesthesia group (EPI-GEN), mean age 40.15+/-9.81 years; while the others constituted the general anesthesia group (GEN), mean age 46.75+/-7.45 years. Operation: cadaveric renal transplantation. Group EPI-GEN: epidural anesthesia performed with 12-15 ml of a ropivacaine 0.75% and fentanyl 5 microg/ml solution followed by light intravenous or inhalatory general anesthesia and postoperative epidural analgesia with ropivacaine 0.2% and fentanyl 2 mg/ml. Group GEN: inhalatory or intravenous general anesthesia and intravenous tramadol postoperative analgesia., Measurements: hemo-dynamics, renal function, arterial blood gases analysis, acid-base balance and postoperative pain data was collected and examined., Results: Postoperative epidural analgesia resulted significantly more effective than intravenous tramadol. PaO(2)/FiO(2) ratio was significantly higher in group EPI-GEN patients both on awakening and throughout postoperative observation. Hemodynamics and renal function did not appear to differ significantly., Conclusion: Combined epidural-general anesthesia is as valid a technique as any for renal transplantation; however postoperative epidural ropivacaine analgesia resulted more effective than intravenous tramadol. Respiratory function appeared less affected, facilitating a fast and uncomplicated postoperative recovery.

Aim: Subjects in spinal anaesthesia have been reported to show a decrease in the level of alertness, even when they have not received any sedative drugs., The Aim: of this study is to verify, in caesarean delivery if the bupivacaine subarachnoid anaesthesia, with or without intrathecal fentanyl dose, produces a sedative effect, to define the entity and to identify the mechanism that most likely causes it., Methods: The clinical investigation is divided into Part I (non-randomized trial) and Part II (randomized trial) and is set in the University hospital's delivery-unit. Part I: 45 pregnant women were recruited and enrolled in 3 groups: women having natural delivery (n=15), women receiving caesarean delivery with subarachnoid anaesthesia (n=15) and with general anaesthesia (n=15). Self-rating depression scale (SDS), self-rating anxiety scale (SAS), state anxiety inventory (SAI) and trait anxiety inventory (TAI) psychometric tests were patient-completed for pre-delivery anxiety evaluation. Part II: 23 pregnant women undergoing caesarean delivery were single-blind randomized to receive subarachnoid anaesthesia with single 12.75 mg 0.5% hyperbaric bupivacaine (n=10) or with 12.75 microg 0.5% hyperbaric bupivacaine and 15 mg fentanyl (n=13). Bispectral index (BIS), observer's assessment of alertness/sedation (OAA/S) scale, self-sedation visual analogic scale (VAS) and mean arterial pressure (MAP) were perioperatively monitored., Results: Part I: it was found, using SAI, a higher level of state anxiety in the pregnant women undergoing caesarean delivery than those having natural delivery (p<0.05). Part II: pregnant women receiving subarachnoid anaesthesia for caesarean delivery had a decrease of the level of alertness from 10 to 70 min after the execution of lumbar puncture (p<0.05), with a sedative peak from 35 to 45 min (p<0.01), as measured by OAA/S scale and self-sedation VAS but not by BIS. Women who received bupivacaine-fentanyl spinal anaesthesia had a more consistent sedative effect from 35 to 70 min (p<0.05)., Conclusions: Pregnant women undergoing caesarean delivery had a more elevated level of state anxiety, assessed by SAI, as seen in Part I. Subarachnoid anaesthesia in caesarean delivery is associated with a reduction of alertness level. A double mechanism might cause a clinically valuable sedative effect, observed by OAA/S scale and self-sedation VAS: decrease of the afferent spinal inputs and an anxiolytic psychophysiologic effect, induced by good outcome of the birth and mother-baby contact. Intrathecal bupivacaine-fentanyl dose produces a larger alertness decrease than single bupivacaine, because the anaesthetic block density increases. BIS was not a sensitive measure to detect the light sedation occurring in Part II of this study.

Purpose: Pain on capsule distension in painful joints may affect feasibility of the MR Arthrography. We tried to overcome this limitation by adding a local anesthetic (lidocaine) to the paramagnetic contrast agent solution. We aimed at: a) investigating which contrast agent dilution provides the best signal-to-noise ratio in the SE T1 sequences; b) evaluating the effects of lidocaine on the signal intensity and on the viscosity of the solutions; assessing the viscosity of solutions containing iodinated contrast agent., Materials and Methods: The paramagnetic contrast agent was diluted with saline and lidocaine at various concentrations. Signal intensity was measured with a 1.5 Tesla superconductive MR unit with a dedicated head coil; we used T1-weighted spin-echo sequence. The viscosity coefficient of the solutions was analyzed and compared with that of solutions containing iodinated contrast agents (but not lidocaine)., Results: Signal intensity is also unaffected by variations in the concentration of lidocaine, which does not interfere with the biphasic behavior of Gadolinium. Viscosity is scarcely affected by changes in lidocaine concentration when the paramagnetic contrast agent concentration is not changed., Conclusions: The optimal signal-to-noise ratio in T1-weighted sequences is provided by 0.4%, contrast agent dilution but contrast agent-saline solutions, with(out) lidocaine, cannot be considered steady and signal intensity values change over time. The addition of lidocaine does not significantly influence the signal-to-noise ratio and the viscosity of the solutions. The low viscosity of the paramagnetic contrast agent appears to favor quicker spread of the solution, even in tiny defects; thanks to its anesthetic effect, lidocaine could facilitates execution of the examination in painful joints without affecting the diagnostic result.

Aim: A retrospective study of benign low back pain, comparing the early and long-term results obtained by means of acupuncture and Huneke's neural-therapy is presented., Methods: Two groups, (dry needling group and neural-therapy group) consisting of 104 and 152 patients respectively, were compared for age, pain duration, treatment length, number of sessions and initial intensity of the pain., Results: The age and pain duration resulted significantly higher in the neural-therapy group; the percentage of subjective improvement proved to be greater for neural-therapy, even if not in a statistically significant manner, both immediately after therapy (70.4% and 74.8%) and at all the time intervals studied (every 3 months until 4 years, when possible). Similar results have been obtained both in acute cases (pain duration shorter than 6 weeks) and in chronic ones (pain lasting at least 6 months)., Conclusion: In conclusion, this study shows a slight, but not statistically significant, preference for neural-therapy, subjectively considered by the patient more effective than acupuncture in 49 out of 51 comparisons carried out.

The authors report the case of a female patient (41 years old) affected by mucopolysaccharidosis type III or Sanfilippo syndrome submitted to a gynecologic surgical procedure and describe the main anesthesiologic problems. A sub-arachnoid anesthesia with hyperbaric Bupivacain 0.5% was used. This technique proved to be safe and convenient without peri- and postoperative complications.

Purpose: To assess the efficacy of intraarterial lidocaine on peri- and post-procedural pain and on length of hospital stay in hepatocellular carcinoma (HCC) patients undergoing chemoembolization., Materials and Methods: Twenty-eight patients (19M, 9F, age range 49-76) who underwent hepatic chemoembolization at our Institution between March 2000 and February 2002 were included in the study. Group A consisted of 14 patients who received intraarterial lidocaine immediately before and during chemoembolization, while in the 14 patients of group B lidocaine was substituted with saline solution. The doses of centrally acting narcotics (tramadol) administered periprocedurally and in the three days following the procedure were compared, as were the hospitalization times. Subjective pain was measured using the visual analogue scale. Chemoembolizations were performed with an emulsion of lipiodol, cisplatin and epirubicin followed by embolizing material (gelfoam of Contour particles) in order to achieve complete blood flow stop in the proper hepatic artery., Results: No side effects were noted that could be due to systemic administration of lidocaine. All patients experienced some degree of post-embolization syndrome. Periprocedural, day 1 and day 2 post chemoembolization dosages of tramadol were significantly lower in group A with respect to group B patients. No group A patient required analgesia on day 3. No statistical difference was observed in time persistence of nausea and vomiting, fever and hospitalization time between the two patient groups., Conclusions: Intraarterial administration of lidocaine before and during chemoembolization is a safe and effective method for preventing or reducing peri- and post-procedural pain and dosage of narcotic analgesics in patients with HCC. Hospitalization times did not differ significantly between the two groups, probably because of the other components of post-embolization syndrome, such as fever, nausea and vomiting.

Background: The aim of the study was to compare efficacy and side effects produced by two techniques of epidural analgesia during labor: intermittent bolus and patient-controlled epidural analgesia., Methods: Eighty parturients were enrolled in this study: forty received intermittent bolus analgesia (first bolus: 20 mg of ropivacaine 0.1% + 10 gamma of sufentanil, next bolus: 10 mg of ropivacaine 0.1% during the first 4 hours, and then 10 mg of ropivacaine 0.1% + 2.5 gamma of sufentanil each time they complained of pain), and forty parturients received PCEA (starting with a bolus of 20 mg ropivacaine 0.1% + 10 gamma sufentanil, followed by administration with a pump programmed to deliver a continuous background infusion of ropivacaine 0,1% + 0.25 gamma/ml of sufentanil at 5 ml/h and 5 ml patient-triggered boluses with a 15 min lock-out interval; insufficient analgesia was treated by extra boluses of the same ropivacaine solution). In each group the efficacy of the analgesia (verbal numerical pain scores, amount of local anesthetics consumption), labor duration, side effects and patient satisfaction have been studied., Results: There were no differences between the two different epidural techniques., Conclusions: This regimen of PCEA proves a viable and safe alternative for epidural analgesia during labor.

The authors describe their experience with local tumescent anaesthesia with lidocaine and bupivacaine in 80 cases of saphenous stripping. The method is discussed thoroughly and provides: 1) good anaesthesia throughout surgery, requiring only brief propofol sedation in 55 patients with large-volume legs; 2) less bleeding during and after surgery in all patients, with visual evaluation of ecchymoses at 3 and 7 days; 3) good postsurgical analgesia without functional impairment in all patients. These are real advantages in the ambulatory and day-hospital surgery settings, inasmuch as the scheduled discharge time is not modified. Local tumescent anaesthesia proves to be a simple, easy technique, with good patient compliance; it is appreciated by the surgeon on account of its technical advantages and is helpful in the organization of modern surgical departments.

Background: The purpose of this study was to assess the value of intra-articular fluid injection under pressure, as a technique suggested for temporo-mandibular joint (TMJ) closed-lock treatment, and to determine if there is a persisting lock resolution in time., Methods: Twelve patients were studied at our centre, with a diagnosis of TMJ closed-lock, not amenable with conventional therapies. All patients underwent a MRI scan, confirming the presence of anteriorly displaced disk. This technique is based on intra-articular injection of anaesthetic (mepivacaine cloridrate) under pressure, using the so called pumping technique, that allows an inferior distraction of the condyle. The study has a six months follow-up. After closed-lock resolution all patients underwent physiotherapy with guided mouth opening, for one month., Results: Mandibular function (maximal mouth opening) increased on average of 20.2 mm after treatment, and of 21.1 mm six months later (p=0.00000; with p<0.005). Pain decreased on average from VAS=6.75 to VAS=0.3 (p=0.00001; with p<0.005). The masticatory efficiency improved from VAS=5.25 to VAS=8.75 (p=0.002; p<0.005). Functional TMJ limitation level is significantly increased (p=0.002; p<0.005). Also, patient's efficacy judgement (mean value 3.58= good) and tolerability judgement (mean value 2.92=good) indicate that this therapy is well accepted., Conclusions: This technique is easy to perform, well tolerated and does not need specific instruments: it permits the resolution of TMJ closed-lock, decreases the pain and improves masticatory efficiency. All these effects persist in time. Subjects with recent closed-lock have an immediate and complete functional recovery while patients with chronic closed-lock do not.

Background: Epidural analgesia effectively alleviates labor pain. However controversy exists about the effect of epidural analgesia on labor outcome. The aim of this study is to assess the effect of a low concentration local anesthetic (ropivacaine 0.08%) in labor epidural analgesia (LEA) on labor pain relief, on the incidence of cesarean sections and instrumental vaginal deliveries, and on neonatal outcome., Methods: In the period April 1998 - July 2000, 323 women in active labor with live, singleton and in vertex presentation fetuses at term of gestation were included in this prospective study. Women with pre-gestational and/or obstetric diseases or previous caesarean deliveries were excluded. One-hundred and five patients requiring - by written informed consent - LEA were allocated to receive standardised protocol of a low concentration local anesthetic (ropivacaine 0.08%) coadministered with opioid (sufentanil): ropivacaine group. The remaining 239 parturients who didn't require LEA were included in the control group., Results: The demographic characteristics of the two groups were similar; 12 (10.4%) patients receiving LEA delivered by cesarean section, 17 (14.8%) by vacuum extractor whereas 86 (74.8%) had a spontaneous delivery. The risk of cesarean section (adjusted for age, BMI, parity, neonatal weight and gynecologist) resulted lower, even if not significantly, in the ropivacaine group (OR 0.9; 95% IC: 0.6-1.3), while a significant increased instrumental vaginal delivery rate has been reported, although little numbers reduce statistical significance. Neonatal outcome was unaffected by the use of LEA., Conclusions: The conclusion is drawn that a lower concentration of ropivacaine (0.08%) in LEA produces good labor pain relief with no detectable adverse effects on mother and neonate, and without significantly increasing cesarean section rate.

The analgesic effect of EMLA anesthetic cream is evaluated during contact turbinoplasty with a Neodymium: yttrium-aluminum-garnet (Nd: Yag) laser. A total of 48 patients were selected and randomized in two groups. EMLA was applied on the nasal mucosa, respectively, for 15 and 30 minutes after using vasoconstrictor cottonoids. Both groups underwent turbinate reduction by contact with Nd: Yag laser using three discharge incisions traced parallel on the medial surface of the lower turbinate working from the tail to the head. The pain induced by the surgical procedure was evaluated with a visual analogic scale. The score obtained was significantly lower in the 1st group than in the 2nd group and this difference was statistically significant (p < 0.01). The EMLA anesthetic cream applied on the mucosa for 15 minutes allows to obtain a good analgesia during the functional contact turbinate surgery with a Nd: Yag laser and thus can be considered a valid alternative to anesthesia by local infiltration.

Caudal block is the single most popular regional anesthetic technique used in infants and children. A review of the literature concerning complications related to this technique reveals that it is safe and it has a low failure rate. Probably the incidence of complications of caudal block is 7/10.000, the lowest of all the central blocks. High success rates in performing caudals in children are achieved after a lower caseload than for other regional anesthetic procedures. The success rate in children under 7 years of age is 99%, but most failures occur in the oldest. Caudal anaesthesia can be used for anything surgical under the umbilicus and is an acceptable alternative to general or spinal anaesthesia in premature and high-risk infants, where a regional anaesthesia alone may be preferable. Caudal morphine has been used successfully for postoperative analgesia in children of all ages, including neonates after open-heart surgery. Possible complications of this technique are: local anesthetics overdose, vascular penetration and intravascular injection of local anesthetics, dural puncture and total spinal anaesthesia, intraosseous injection, infections, meningitis, respiratory depression (when morphine is used). Authors analyze all these complications and the safety rules for their prevention.

Background: The aim of this study was to determine the ED50 for the dose of levobupivacaine 0,5% that, if given intrathecally will not cause total spinal anesthesia but will give a reliable and reproducible clinical sign to differentiate intrathecal from epidural injection., Methods: Thirty women at term undergoing elective cesarean section under a combined spinal-epidural technique (CSE) were enrolled into this sequential allocation study. The dose in each test dose was determined by the response of the previous patient to the higher or lower dose in her test syringe, according to up-down sequential allocation. The exception to this was the first woman in each group, for whom the starting dose was chosen to be 4 mg. The end point was the occurrence of any motor block, in any side, within 5 minutes from intrathecal injection of the test dose. Test dose efficacy was assessed using a modified Bromage scale every minute for 5 minutes. The median effective dose of levobupivacaine was estimated from the up-down sequences using the formula of Dixon and Massey., Results: The MAD of the test dose for levobupivacaine was of 4,8 mg (4,4 to 5,2; 95% C.I.)., Discussions: This study may help to determine the appropriate dose for a test dose for inadvertent spinal levobupivacaine.

Background and Aims: Some authors have shown that increased blood levels of adrenaline do not have any effect on cardiovascular function. Others have documented major changes in arterial blood pressure and heart rate even following non-maximal doses of adrenalin in association with anesthetics. The aim of this study was to evaluate the toxicity of local anesthetics when used with/without associated vasoconstrictors., Methods: The authors studied the hemodynamic, cardiac and respiratory changes in two groups of patients respectively undergoing general and local anesthesia for a variety of pathologies of the oro-maxillo-facial district. At a preoperative stage, 4 ml of mepivacaine (carbocaine) 2% with 1:100,000 adrenaline was administered to patients in the first group. Data were compared to changes in the same parameters recorded in the second control group undergoing local anesthesia for day-hospital surgery who received the same quantities of local anesthetic (2 tubes of mepivacaine 2% with 1: 100,000 adrenaline or 3% without adrenaline)., Results: The comparison between the two groups of data showed no significant change in cardiorespiratory parameters, except in patients with an abnormal response to dentistry stress., Conclusions: No elements were found to support the systemic toxicity of local anesthetic or its association with adrenaline.

Introduction: Personal experience in the treatment of postoperative pain using intrapleural analgesia applied on 50 patients chosen at random in a group of 90 after thoracotomy is reported., Methods: At the end of operation a peridural catheter for continuative infusion was applied in the paravertebral socket by direct transfixion of chest wall. A local anaesthetic has been given (75 mg of bupivacaine 0.50%) through the catheter at 8 hours interval for three times at the most. The degree of analgesia has been valued immediately before and after medicine administration and during the 8 hours interval by recording the cardiocirculatory and haemogasanalytical parameters. The measurement of pain intensity has been achieved by visual analogous just an hour after operation and subsequently every 4 hours during the first post operative day and every 8 hours during the following days., Results: Most of the examined patients (90%), reported a remarkable attenuation of pain, valued by achromatic grey test after 4 hours since the first giving. The catheter has always been removed during the 8th postoperative day and it did not cause intrapleural complications. The method used warrants a good level of analgesia, improving the respiratory per-formance and giving a rapid mobilization, essential items in the reduction of immediate post operative complications., Conclusions: The results confirm the validity of this treatment in the pain control of thoracothomized patients with a positive answer in 45 out of 50 examined patients without remarkable complications.

The use of a new technique in spermatic cord block in surgical treatment of large hydroceles is reported. Identification of the cord in these cases is often difficult due to the presence of the hydrocele. The reported technique consists in the percutaneous drainage of the hydrocele prior to the block, in order to allow an easier identification of the cord. The block is then performed by the usual method. 108 patients with large hydroceles (above 250 mls) underwent surgical repair employing this approach. In only one case the cord was not identified even after drainage due to the effects of a previous hernioplasty. In the remaining 107 patients the cord was easily identified and blocked. The excellent results obtained with this approach, show that cord block is possible in all patients, even when a large hydrocele is present.

Purpose: To assess the suitability of EMDA local anaesthesia for invasive procedures on lower urinary tract in one day surgery treatment., Patients and Methods: The deep penetration of lignocaine into the bladder wall was attained by catheters, electrodes and electric current generators using revised electrochemical principles. Since 1994 203 patients with transitional cell carcinoma of the bladder underwent TURBT and 70 patients with bladder neck or prostatic obstruction underwent TURP, TUIP, TULAP; 20 patients underwent miscellaneous procedures: in 34 patients the procedures were combined. The patients' age was within 20 and 90 years (mean age 67.3). The procedures were performed in a single small endoscopic theatre annexed to the Urology Ward. A standard rigid resectoscope was used as well as a standard electrocautery (360 kHz) or a mega frequency low temperature Vesalius generator (4 MHz). Most patients received a premedication and some of them a light sedation when necessary, but all of them were fully conscious and able to complete an assessment using a simple pain scale., Results: 8 out of 273 patients (3%) considered pain intolerable and other 11 (4%) reported painful but tolerable sensation, and the remaining 254 patients referred absent or minimal discomfort. Most of the patients were able to walk back to their room and go home in the evening. Those who had no chance of going back home were admitted for the night as well as those who had no assistance at all at home or those who had high probability of haemorrhage. Side effects were minimal and not related to local anesthesia: the serum lignocaine levels measured in 4 patients were innocuous. All patients experienced some tingling and reddening at the skin site of the dispersive electrode fading in a few hours., Conclusions: Local anaesthesia by using EMDA proved to be effective for most invasive endoscopic procedures in the lower urinary tract and suitable for patients undergoing day hospital surgery.

Objective: Assessment of the outcomes on the articular and periarticular pain of the knee, by a reflexotherapy with local anesthetics, denominated also neuraltherapy., Experimental Design: Retrospective observational study with 3 years' follow-up., Environment: An Ambulatory Center for Pain Management., Patients: All the patients (N = 115) with knee pain treated with neuraltherapy in the period 1982-31 August 1996 (retired patients 2, mean age 68 +/- 15.2 years in the remaining)., Interventions: The employed reflexotherapy, denominated also neuraltherapy by Huneke, uses a local anesthetic (prevalently lidocaine) in 0.5-1% concentration and small quantity (0.5-1 ml for point) on tender/trigger and/or acupuncture points, as well as in anatomical structures like articulations, nerves, arteries or veins. The number of sessions has been of 7.03 +/- 3.3., Outcome Measures: Outcomes are evaluated in terms of percentage subjective improvement of the pain at the end of the therapy and at 1-3-6 months, 1-2-3 years, and then divided in 5 groups (no improvement-fair-good-very good-excellent)., Results: At the end of the therapy the improven cases were the 91.2%, the 83.7% at 1 month, the 64.6% at 3 months, the 41.3% at 6 months, the 22.5% at 1 year, the 12.1% at 2 years and the 7.9% at 3 years., Conclusions: These outcomes suggest a good effectiveness of this treatment in the painful diseases of the knee, but further randomised double-blind trials are necessary.

The aim of the study was to evaluate the efficiency and safety of ropivacaine, in comparison with bupivacaine, in axillary brachial plexus block. 24 patients, undergoing upper limb surgery, was divided into 2 homogeneous groups and the local anaesthetics was administered: A (ropivacaine 0.75%, 25 ml; total dose 187.5 mg) and B (bupivacaine 0.5%, 25 ml; total dose 125 mg). The axillary plexus block was executed with the help of an electrostimulator. The results show that using ropivacaine the onset-time is lower and the duration of sensory and motor block is higher than using bupivacaine. In conclusion we can affirm that ropivacaine is a new step in local anaesthetic field.

The review of 50 cases of urologic diseases has allowed us to show the utility of EMLA; even if it has been limited by some practical factors, it has permitted alone or as a first step in local and loco-regional anesthesia, to carry out surgical urologic procedures, with good surgical conditions, both for the surgeon and for the patient.

Background: High concentrations of intrathecal local anaesthetics may be neurotoxic. The purpose of this study was to compare the features of superselective spinal anaesthesia (ASS) obtained with an equivalent dose (5 mg) of 0.5% (available now also in Italy) and 1% hyperbaric bupivacaine., Methods: A prospective study was carried out on 100 patients undergoing saphenectomy, who were randomized into two groups to receive either 0.5% bupivacaine 1 ml (group A) or 1% bupivacaine 0.5 ml (group B). The anaesthetic solution was injected 1 ml/min at L2-L3 with an atraumatic needle. During dural puncture and following 20 minutes patients were held with the operative side down. In every patient were recorded: quality and level of analgesia on dependent (operative) and non dependent sides; motor-block at the 20th minute and 2nd, 3rd and 4th hours on both sides; reduction per cent of systolic artery pressure (SAP) and heart rate (HR), incidence of hypotension (SAP < 90 mmHg) and bradycardia (HR < 50 bts/min); recovery of deambulation and micturition and side effects., Results: Significant differences between the two groups have been found in: 1) number of thoracic segments blocked (3.22 vs 2.02); 2) motor block at the 2nd hour; 3) number of patients able to walk (19 vs 3) and to micturate (11 vs 3) at the 2nd hour., Conclusions: 0.5% hyperbaric bupivacaine can be successfully use in ASS; early regression of motor block is especially suitable for the requirements of day surgery.

Taking the starting point of a trial conducted on female patients who had undergone laparoscopic gynaecologic operations, which shows a good control of the postoperative pain through intraperitoneal infusion of local anaesthetic during the operation, the authors have proposed to reproduce the study on patients undergoing a laparoscopic cholecystectomy. The trial was conducted on two groups, a 50 patients each, undergoing an intraperitoneal infusion of local anaesthetic (bupivacaine) and placebo (physiologic solution) respectively. The results regarding the rate of patients who had felt postoperative pain (88% in the first group, 96% in the second group) and the different places of it, the pain in the right shoulder particularly (28% in the first group, 22% in the second), the intensity in the time and the different requests of analgesics new recorded. The results don't show statistically significant differences and they are different from the gynaecologic ones. The authors suggest, as reasons for these differences, the various moments of the liquid inoculation (at the beginning of the operation in gynaecology, at the end of it in cholecystectomy) and the Trendelemburg position of patients during the gynaecologic operation, on the contrary of cholecystectomy operations. They suggest, in the end, that the trials esecutions on numerically larger groups could bring more significant results.

The authors compare the efficacy of epidural morphine analgesia with continuous intercostal extrapleural block using bupivacaine 0.5% after thoracotomy. They affirm that antalgic treatment in thoracotomised patients is the most important factor in preventing the onset of major complications that may negatively influence the results of surgery. The efficacy of the analgesic techniques examined was evaluated using El-Baz's visual analogic scale of pain, through the analysis of spirometric values and on the incidence of postoperative complications. The authors demonstrate that the extrapleural continuous nerve block is a reliable method of post-thoracotomic analgesia.

The term "pre-emptive analgesia" implies the hypothesis that an analgesic treatment, given before nociceptive stimuli reach the Central Nervous System, could prevent or reduce the subsequent pain. The rational basis of this phenomenon, giving rise to much interest in the last years, comes from the finding that noxious stimuli cause wind-up and receptive fields expansion phenomena in the dorsal horn neurons of the spinal cord leading to hyperalgesia. Recently, many clinical trials to verify the existence of a pre-emptive effect regarding the management of postoperative pain by the administration of non steroidal antiinflammatory drugs (NSAIDs), local anesthetics and opioids have been conducted. As regards NSAIDs to date no study demonstrated a pre-emptive effect. Conflicting results emerged from trials employing local anesthetics, opioids or associations of the three classes of drugs. Thus, the "pre-emptive analgesia" represents a very important phenomenon for the basic research, but further trials must investigate its clinical impact.

Postoperative pain relief has the aim to provide patient subjective comfort, to inhibit neuroendocrine and metabolic responses to surgical injury and to enhance restoration of function by allowing the patient to breathe, cough, move more easily and to begin enteral nutrition. Opioid analgesics, independently from the route of administration, are unable to provide all this. In addition to spinal opioids other drugs, such as local anesthetics, alpha 2-agonists and cholinergic drugs, may produce an antinociceptive effect when administered by spinal route. All these drugs may be administered in combination between them, realising the so called "balanced spinal analgesia". The aim of this study is to analyse the available methods for the evaluation of pharmacological interactions, the types of interaction among different spinal antinociceptive drugs and the role of balanced spinal analgesia in the treatment of postoperative pain. Analysis of the presented data shows that the spinal synergism between opioids-local anesthetics and opioids-alpha 2-agonists can be useful in the treatment of postoperative pain, because these drug combinations are able to provide a satisfactory pain control at low doses with a reduction of the adverse effects. Furthermore, the combined use of opioids-local anesthetics proved to be effective also in abolishing postoperative incident pain and in inhibiting neuroendocrine and metabolic responses to surgical injury. Especially in high risk patients this is related to a better outcome. Finally, even if the synergism between cholinergic drugs with opioids or a2-agonists have been proved, at the moment their use in man by spinal route in the treatment of postoperative pain is not advisable.

Surgery is an unpleasant experience which is always related to a period of pain. In the pediatric patient this results in an important effective and metabolic-neuroendocrine manifestation. After a short review of the methods recently used to evaluate pain-qualitatively as well as quantitatively, we focused on the different techniques and drugs which can be used by the anesthesiologist to achieve an adequate control of the pain symptoms. The aim is to provide devices which can be used for different groups of age in order to guarantee the maximum efficacy in pain control with the least side effect and invasiveness.

The technique and advantages of caudal peridural anesthesia for proctology surgery are reported. The scarce invasivity of this methodology, the scarce or lack of interference with respiratory and cardiocirculatory functionality, the good analgesic effect postoperatively in our patients operated for proctology pathology, established the reason why we consider caudal analgesia particularly indicated for proctology surgery.