Percutaneous Vertebroplasty and Procedural Pain

Discussion

In the performance of PV, the use of infiltration anesthesia as the only pain medication is usually not sufficient to make the procedure tolerable from the perspective of the patient: Three-quarters of patients indicated a VAS score of ≥5. Despite this high VAS score, patients did not request additional medication during the procedure. The surgeons who performed the PVs did not have the impression that pain was apparently unbearable; in many cases, they were surprised by the patients' high VAS scores after the procedure. Apparently, there is a discrepancy between pain as perceived by the patient and the impression of pain perception by the surgeon.

There are several aspects of defining pain. It has been shown that pain intensity can be measured by several methods that show high intercorrelation.³ The VAS appears to be a sensitive instrument for assessing pain intensity and is the most frequently used method. There is some difference of opinion as to whether pain should be measured by the subject or by an observer. Some patients find it difficult to express their pain severity within the descriptive limits of a particular scale or exaggerate the severity of their pain. On the other hand, the opinion of others is that the severity of pain is known only to the patient and not to an observer who measures another person's pain. Pain is a psychological experience, and an observer can play no legitimate part in its measurement.^3,4

Pain management during PV is subject to variation among surgeons and varies from local infiltration anesthesia to general anesthesia in the operating room. Until now, 2 authors^2,5 concentrated on this subject. In a study of 20 patients,² a protocol of fentanyl and titrated intravenous propofol allowed a pain-free procedure. No adverse advents were registered. Such a protocol might meet the criteria of a targeted analgosedative procedure that ensures comfort during PV without, as with general anesthesia, the need for longer hospitalization.

There was a remarkable discrepancy between the patients' VAS scores and the expectations of the surgeons, with far more pain experienced by the patients than expected by the surgeons. We believe the patients' relatively high mean VAS scores in this study are a good representative of the experienced pain during PV, and the surgeons' impressions of pain experienced by the patients are of little importance. The results of this study have made us realize that lidocaine infiltration only is, for most patients, not sufficient for pain reduction during the procedure. We adjusted our pain medication protocol and now administer fentanyl in all patients.