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Letter |
Innsbruck Medical University Innsbruck, Austria
WEB—This is a Web exclusive article.
Instead of selecting patients according to their pretreatment visual analog
scale (VAS) score (i.e., set a minimum VAS score as an inclusion criterion),
we selected patients according to their personal dissatisfaction with current
pain treatment and their per ception of unbearable residual pain (which, of
course, may be quite subjective). However, only a few study patients had a low
VAS score: Although the range of VAS scores on patient inclusion was from 2 to
10, only four of 82 patients (6%) had a VAS score of < 5 but 94% of the
patients had a VAS score of 
5.
All patients had undergone amputation at least 1 year before phenol treatment, and a majority of patients had undergone various pain treatment regimens—conservative and surgical (such as resection of neuroma, implantation of neuroma into muscle, and so on). All patients were on oral analgesics; 61% were on opioids or combinations of opioids with other analgesics.
Although all patients gave initial consent to participate in three scheduled injections, if they were satisfied with the achieved amount of pain reduction after one or two instillations, of course, they were free to refrain from further injections.
According to the data presented in our article, patients with certain constellations of VAS score and pain qualities (abiding and paroxysmal pain) proved to be more favorable candidates for neurosclerosis with phenol than others and experienced a more substantial initial drop in their VAS score, including desired changes in pain quality [2]. In these patients, further instillations may not be necessary—always according to the respective personal condition. In other patients with a poor response after a first instillation, however, further injections may result in a satisfying improvement of pain [2]. Our patient group undergoing three injections, for example, experienced an initial VAS score reduction from 8.0 to 6.5 after one instillation and a final VAS score of 3.0 after three instillations, as can be seen in Table 1 of our article [2].
Sonographic echotexture of neuroma was not a predictor of outcome, either initially or during treatment. In fact, there is little change in the echotexture of neuromas during neurosclerosis with phenol; however, this was not statistically evaluated in our study [2].
We agree with Sivan and Stoppard [1] that it is difficult to give a general recommendation on the basis of the results of an uncontrolled study. Perhaps we should narrow our general recommendation to a recommendation for patients with long-standing pain (which better reflects our patient group) who have previously undergone various other treatment regimens with unsatisfactory results. However, we would strongly advise pain physicians to apply sclerosants such as phenol only under sonographic control because of the ease of the procedure linked with a high success rate for true intraneural injection. We agree that a randomized comparison of sonographically guided phenol injection with other treatment regimens is an important follow-up project.
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