The analgesic efficacy and side effects of oral tramadol were studied on 456 patients with various acute and chronic painful diseases. Their pain intensities were 3 or more on a verbal rating scale of 5. Patients initially received 0.5-2.0 mg/kg/day of tramadol, and the doses were titrated according to their pain. The efficacy and side effects were evaluated 2 to 84 days after administration. The tramadol doses ranged from 20 to 450 mg/day. The pain intensity became less than 2 on VRS in 50% of the patients (the overall efficacy of tramadol was 50%). It was effective in patients with herpetic pain and post-herpetic neuralgia, and less effective in those with complex regional pain syndrome, vascular disease, and cancer pain. The side effects included nausea, vomiting, dizziness, and constipation and occurred in 2-12% of patients. Because tramadol was effective in nociceptive and neuropathic pain, it may be recommended for a variety of pain disorders.

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We report a 79-year-old woman with rheumatoid arthritis on prednisolone and methotrexate who developed herpes zoster followed by central nervous system dysfunctions and sepsis. The patient noticed pain in the left neck and upper limb. Herpes zoster developed on the painful area three days later. The patient was admitted to our hospital 7 days after occurrence of the pain. Acyclovir, 750 mg/day, was started. Sudden muscle weakness of the lower limbs developed on the next day following admission. Acyclovir was increased to 1000 mg/day and continued for 14 days. The patient's clinical course was complicated by pneumonia, pulmonary cryptococcosis, and sepsis. The general condition was improved by intensive care. A rehabilitation program was begun 13 days after admission. The muscle strength of the left upper limb and both lower limbs improved; however, the patient could not regain her usual activity of daily living. She was referred to another rehabilitation hospital.

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The usefulness of nerve block therapy was examined in eight patients with ossification of the posterior longitudinal ligament (OPLL) in the cervical spine. Three patients, ranging in age from 38 to 82 years presented with cervical myelopathy and five with radiculomyelopathy. The nerve block was performed under fluoroscopy, mainly as an epidural or nerve root block. Outcomes were assessed at 6 months after treatment initiation using the Japanese Orthopaedic Association (JOA) scale for the evaluation of cervical myelopathy. The JOA score showed a significant improvement to 14.3±1.3, from 12.4±1.1 (P<0.05). Similarly, the complaint score also showed a significant improvement to 5.4±2.3, from 10.0 (P<0.05). Remarkable improvements were noted in three patients. Five of the eight patients were satisfied with the treatment. The condition was managed by nerve block therapy performed once every two weeks in five of the eight patients or once monthly in the other three. At 2 years after treatment initiation, six patients were rehabilitated and seven of eight patients were satisfied with the treatment. Although nerve block therapy is not a cure for OPLL, we concluded that following up on patients whose conditions can be managed by it is worthwhile when performed on a monthly basis.

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We report a patient whose residual upper limb pain disappeared after treatment with Tokaku-jokitou. An 81-year-old woman developed pain in the left upper limb. Continuous epidural block relieved the pain; however, the patient developed intermittent elevations of body temperature with increased pain after probable infectious colitis, which were characteristic of the Youmeibyouki stage of chonetsu (cycling fever). The patient received Tokaku-jokitou, and the fever and pain subsequently abated.

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We report five patients with recurrent trigeminal neuralgia following microvascular decompression who visited our department during January 2005 to September 2007. In all, we saw 35 patients with trigeminal neuralgia during the period. Radiofrequency thermocoagulation of the trigeminal ganglion was performed in one patient who had had drug induced hypersensitivity syndrome resulting from carbamazepine. The remaining four patients were managed with oral medications. However, because two of these four still received no relief from pain, they also underwent radiofrequency thermocoagulation, and their pain subsequently decreased.

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We report a patient with a painful leg movement disorder that was relieved with pramipexole. A man in his 60 with pain in the right toes (II-V) and involuntary movement after knee surgery was referred to us. The patient suffered from characteristic symptoms of painful legs and moving toes, such as intractable pain, discomfort, and peculiar involuntary movement of the distal lower legs and toes. The pain was present throughout every day and worsened after walking. The movement was characterized by irregular but persistent tremor of 1-2 Hz with dystonia of the right toes. Repeated caudal blocks and oral pramipexole decreased the pain and involuntary toe movement. This movement and the pain almost disappeared after a weekly increase in the dose of pramipexole with weekly caudal blocks, thus allowing the patient to ambulate. Therefore we conclude that pramipexole may be effective in some patients with painful leg movement disorders.

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An 8% lidocaine pump spray (LPS) was prescribed for 12 trigeminal neuralgia outpatients. They applied it on the painful areas in their mouths as a maximum single dose of up to 3 sprays (24 mg of lidocaine)in intervals of at least 4 hrs. We evaluated the analgesic effect by pain score (PS) measured by a visual analogue scale. LPS significantly decreased the PS from 58 ± 17 mm (mean ± SD) just before application to 5 ± 13 mm at 10 min post application (P<0.01). The effect of LPS persisted for a median of 3.0 hrs (range, 0.5 to 6.0 hrs). Three patients reported oral numbness as a result of LPS, which disappeared without medication. The satisfaction score results consisted of 7 "very satisfied" and 4 "satisfied". The oral application of LPS produced prompt analgesia without serious side effects in the patients with trigeminal neuralgia who had experienced the most severe pain.

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We report a patient who developed bacterial meningitis after radiofrequency thermocoagulation of the Gasserian ganglion. A 50-year-old man underwent this procedure for treatment of cancer pain of the mandible. The pain subsequently decreased; however, headache and elevation of the body temperature up to 39°C occurred the first night following the procedure. The patient showed no apparent sign of meningeal irritation. However, a cerebrospinal fluid examination four days after the procedure revealed pleocytosis, elevated protein level, and decreased glucose level, suggesting bacterial meningitis. Antibiotics were changed to panipenem/betamipron 4 g/day and vancomycin 2 g/day. The headache and pyrexia disappeared eight days after the procedure, and there were no apparent neurological deficits.

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We report two patients with pain caused by malignancy mimicking postthoracotomy pain syndrome. [Case 1] A 68-year-old man who had undergone left nephrectomy because of renal cancer was referred to us for treatment of pain in the left flank. There was no pain on percussion and no pressure along the spine. However, a lumbar X-ray showed a decreased height of the 12^th thoracic vertebral body and an unclear pedicle of the 12^th thoracic vertebra. An MRI of the lumbar spine revealed mass of the 12^th thoracic vertebra spreading in the spinal canal with compression of the 12^th thoracic nerve root. [Case 2] A 65-year-old man was referred to us because of right chest pain along the scar caused by trocar insertion for a thoracoscopic lobectomy. An X-ray of the chest showed an unclear rib just beneath the painful area. A CT revealed the partially eroded 3^rd right rib, and a biopsy of it demonstrated an invasion of adenosquamous cell carcinoma. Physicians should always keep the possibility of malignancy in mind when pain is prolonged or recurrent in patients who have a history of malignancy, and even in patients who have no history of malignancy, but whose pain shows an unusual clinical course for postoperative pain.

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