Management of renal colic
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5499 (Published 29 August 2012) Cite this as: BMJ 2012;345:e5499
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Dear Editors,
Dear Michel R ODENT,
The dorsal horns are not merely passive transmission stations but sites at which dynamic activities (inhibition, excitation and modulation) occur. [18]
Via a series of filters and amplifiers, the nociceptive message is integrated and analysed in the cerebral cortex, with interconnections with various areas. [1]
The processing of pain takes place in an integrated matrix throughout the neuroaxis and occurs on at least three levels, at peripheral, spinal, and supraspinal sites. [9]
Knowledge of the modalities of pain control is essential to correctly adapt treatment strategies (drugs, neurostimulation, psycho-behavioural therapy, etc.).
Dysfunction of pain control systems causes neuropathic pain. [1]
Spinal Cord Stimulation modalities evolved from the gate-control theory postulating a spinal modulation of noxious inflow. [16] [2] [7] [11] [12] [15] [17] [20] [22] [23] [24] [25] [26]
It has been demonstrated in multiple studies that dorsal horn neuronal activity caused by peripheral noxious stimuli could be inhibited by concomitant stimulation of the dorsal columns. [8]
Pain relief was more prominent at pain ascending through C fibers than pain ascending through Adelta fibers. [21]
Many theories on the mechanism of action of Spinal Cord Stimulation have been suggested, including activation of gate control mechanisms, conductance blockade of the spinothalamic tracts, activation of supraspinal mechanisms, blockade of supraspinal sympathetic mechanisms, and activation or release of putative neuromodulators. [14]
At present, Spinal Cord Stimulation is a well established form of treatment for failed back surgery syndrome, complex regional pain syndromes (CRPS), low back pain with radiculopathy and refractory pain due to ischemia. [4] [3] [8] [13]
Stimulation produced analgesia can provide a level of analgesia and efficacy that is unattainable by other treatment modalities. [19]
Spinal Cord Stimulation for the treatment of chronic pain is cost-effective when used in the context of a pain treatment continuum. [14]
Precise subcutaneous field stimulation is targeted to specific areas of neuropathic pain. [6]
We aim at attenuation or blockade of pain through intervention at the periphery, by activation of inhibitory processes that gate pain at the spinal cord and brain. [9]
Segmental noxious stimulation produces a stronger analgesic effect than segmental innocuous stimulation. [10]
That is exactly what intradermal sterile water or subcutaneous saline injections do!
Chloride, used in subcutaneous injections, independently regulates the pain pathway. [5]
We can use sterile water injections to relieve pain in patients, avoiding pharmaceutical compounds.
References
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Defrin R, Ariel E, Peretz C.
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Competing interests: No competing interests
Dear Sir/Madame
This very comprehensive review encompassess several important aspects of the management of renal colic. We would like to emphasise three points which we feel may require further discussion.
Firstly, an acute hospital admission, we feel, is necessary for all patients with type 2 diabetes. Such patients may be predisposed to infection and colonisation. Complications such as Emphysematous Pyelonephritis are associated with high morbidity and mortality rates in this category of patient (1,2).
Secondly, we believe that ureteric colic represents a radiological diagnosis. Despite radiation safety concerns of both CT (NCCT) and Invtravenous Pyelography (IVP), it is now accepted that NCCT is the principle investigation in suspected colic (3). Some hospitals however do not offer this as an out-of-hours service.
Lastly, there is no system within the NHS framework for ‘acute’ out patient urology review, except for patients with a suspected malignancy under the ‘2 week’ rule. Consequently, unless patients are admitted to a hospital, very few patients could be seen promptly within an out-patient setting. Clinical Decision Units are one means by which Accident and Emergency Departments provide for the care of such patients for the purpose of clinical stabilisation, analgesia and diagnosis where radiological imaging is available throughout the 24 hours.
Yours Sincerely,
Karol M Rogawski
karol.rogawski@blueyonder.co.uk
Consultant Urologist
Calderdale & Huddersfield NHS Foundation Trust
Richard Khafagy
rkhafagy@doctors.net.uk
Consultant Urologist
Scarborough & NE Yorkshire NHS Trust
References
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Emphysematous pyelonephritis in type II diabetes: A case report of an undiagnosed ureteric colic.
Vollans SR, Sehjal R, Forster JA, Rogawski KM.
2. BJU Int. 2011 May;107(9):1474-8. doi: 10.1111/j.1464-410X.2010.09660.x. Epub 2010 Sep 14.
Emphysematous pyelonephritis.
Ubee SS, McGlynn L, Fordham M.
3.European Association of Urology Guidelines on urolithiasis - 2012.
http://www.uroweb.org/gls/pdf/20_Urolithiasis_LR%20March%2013%202012.pdf
Accessed September 2nd 2012.
Competing interests: No competing interests
In 1975, I reported in a French medical journal my fifteen-year experience of the use of intracutaneous injections of sterile water in the costo-muscular angle to treat renal colic and also acute lumbar pain during labour.(1) Through word of mouth this method drew attention among midwifery circles and its use in obstetrics was evaluated through randomised controlled trials. A systematic review of non-pharmacological methods of pain relief during labour led to the conclusion that such injections of sterile water are effective.(2)
It is difficult, on the other hand, to find in the medical literature and among practitioners references to what I have called “lumbar reflexotherapy” to treat renal colic. However two randomised controlled trials - one Danish (3) and one Iranian (4) - have confirmed its effectiveness, although in both studies the place of injection was imprecise. Through trials and mistakes, I had come to the conclusion that the ideal place for these intracutaneous injections was the muscular depression just below the last rib, an area of skin served by the posterior branch of the 12th dorsal nerve: theoretically, painful stimulations of this cutaneous zone can compete at the level of the spinal posterior horn with painful messages coming from ureter/kidney. I found out by chance that the sterile water we use for hand washing in an operating theatre had more spectacular effects than distilled water. “Lumbar reflexotherapy” might have a diagnostic interest: it is inefficient in the case of biliary colics, retrocoecal appendicitis and other abdominal painful syndromes.
1 - Odent M. La reflexotherapie lombaire. Efficacité dans le traitement de la colique néphrétique et en analgésie obstétricale. La Nouvelle Presse Medicale 1975 ; 4 (3) :188
2 - Huntley AL, Coon JT, Ernst E Complementary and alternative medicine for labor pain: a systematic review. Am J Obstet Gynecol 2004 Jul;191(1):36-44
3 – Bengtsson J, Worming AM, Gertz J, et al. Urolithiasissmetter behandlet med intrakutane sterilvanspapler. Ugeskr. Laeger 1981;43:3463-3465
4 – Ahmadnia H, Younesi Rostami M. Treatment of renal colic using intracutaneous injections of sterile water. Urol J 2004;1(3):200-203
Competing interests: No competing interests
Re: Management of renal colic
We must be grateful to Savros Saripanidis for this updated review of our current understanding of the transmission of nociceptive messages. I take this opportunity to mention that I have been waiting until 1975 to dare to publish my observations about the effects of “lumbar reflexotherapy”: before Melzack and Wall had introduced the gate control theory of pain it was impossible to offer plausible interpretations to the effects of painful skin stimuli on visceral pains.
Competing interests: No competing interests