Analgesic and adverse effects of a low dose of intrathecally administered hyperbaric neostigmine alone or combined with morphine in patients submitted to spinal anaesthesia: pilot studies

Use of Intrathecal Neostigmine as an Adjunct to Other Spinal Medications in Perioperative and Peripartum Analgesia: A Meta-analysis

Intrathecal neostigmine has been used as an adjunct to intrathecal local anaesthetic or opioid to prolong regional analgesia and improve haemodynamic stability, with variable results. This meta-analysis aims to evaluate the effectiveness and side-effects of intrathecal neostigmine in the perioperative and peripartum settings. The literature search was based on Cochrane Controlled Trials Register, EMBASE and MEDLINE (from 1966 to 14 November 2003) databases. Volunteer and animal studies were excluded. We identified 26 studies and 19 were considered suitable for detailed data extraction. Intrathecal neostigmine increased the incidence of nausea and vomiting (OR 5.0, 95% CI: 3.4 to 7.3; P<0.00001), bradycardia requiring intravenous atropine (OR 2.7, 95% CI: 1.4 to 5.4; P=0.005), and anxiety, agitation, or restlessness (OR 10.3, 95% CI: 3.7 to 28.9; P=0.00001). It improved the overall 24 hour VAS score (–1.4 VAS pain score, 95% CI: -1.7 to -1.2, P<0.00001), delayed the time of first request for rescue analgesia (168 min, 95% CI: 125 to 211; P<0.00001), and reduced the total number of rescue injections of nonsteroidal anti-inflammatory drug within the first 24 hours (-0.8, 95% CI: -1.1 to -0.4; P=0.00001). It did not affect the duration of motor blockade (3.5 min, 95% CI: -1.5 to 8.6; P=0.17) or the total amount of ephedrine required (-0.4 mg, 95% CI: -1.5 to 0.7; P=0.5). Adding intrathecal neostigmine to other spinal medications improves perioperative and peripartum analgesia marginally when compared with placebo. It is associated with significant side-effects and the disadvantages outweigh the minor improvement in analgesia achieved.

The efficiency of intravenous acetaminophen for pain control following total knee and hip arthroplasty: A systematic review and meta-analysis

BACKGROUND

This meta-analysis aimed to evaluate the efficiency and safety of intravenous acetaminophen as an adjunct to multimodal analgesia for pain control after total joint arthroplasty (TJA).

METHODS

PubMed, Embase, Web of science, Medline, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) and non-RCTs were included. Fixed/random effect model was used according to the heterogeneity tested by I statistic. Meta-analysis was performed using Stata 11.0 software.

RESULTS

Four studies including 865 patients met the inclusion criteria. The present meta-analysis indicated that there were significant differences between groups in terms of pain scores at 24 hours (weighted mean difference [WMD] = -0.926, 95% confidence interval [CI]: -1.171 to -0.681, P = .000), 48 hours (WMD = -0.905, 95% CI: -1.198 to -0.612, P = .000), and 72 hours (WMD = -0.279, 95% CI: -0.538 to -0.021, P = .034). Significant differences were found regarding opioid consumption at 24 hours (WMD = -4.043, 95% CI: -5.041 to -3.046, P = .000), 48 hours (WMD = -5.665, 95% CI: -7.383 to -3.947, P = .000), and 72 hours (WMD = -6.338, 95% CI: -7.477 to -5.199, P = .000).

CONCLUSION

Intravenous acetaminophen was efficacious for reducing postoperative pain and opioid consumption than the placebo following total joint arthroplasty. Due to the limited quality of the evidence currently available, more RCTs are needed.

Intravenous acetaminophen as an adjunct to multimodal analgesia after total knee and hip arthroplasty: A systematic review and meta-analysis

BACKGROUND

This meta-analysis aimed to perform a meta-analysis to investigate the impact of additional intravenous acetaminophen for pain management after total joint arthroplasty (TJA).

METHODS

We conducted electronic searches of Medline (1966-2017.07), PubMed (1966-2017.07), Embase (1980-2017.07), ScienceDirect (1985-2017.07) and the Cochrane Library. Randomized controlled trials (RCTs) and non-RCTs were included. The quality assessments were performed according to the Cochrane systematic review method. The primary outcomes were postoperative pain scores and opioid consumption. Meta-analysis was performed using Stata 11.0 software.

RESULTS

A total of four studies were retrieved involving 865 participants. The present meta-analysis indicated that there were significant differences between groups in terms of pain scores at POD 1 (WMD = -0.954, 95% CI: -1.204 to -0.703, P = 0.000), POD 2 (WMD = -1.072, 95% CI: -2.072 to -0.073, P = 0.000), and POD 3 (WMD = -0.883, 95% CI: -1.142 to -0.624, P = 0.000). Significant differences were found regarding opioid consumption at POD 1 (WMD = -3.144, 95% CI: -4.142 to -2.146, P = 0.000), POD 2 (WMD = -5.665, 95% CI: -7.383 to -3.947, P = 0.000), and POD 3 (WMD = -3.563, 95% CI: -6.136 to -0.991, P = 0.007).

CONCLUSION

Additional intravenous acetaminophen to multimodal analgesia could significantly reduce pain and opioid consumption after total joint arthroplasty with fewer adverse effects. Higher quality RCTs are required for further research.

Adjuvants to local anesthetics: Current understanding and future trends

Although beneficial in acute and chronic pain management, the use of local anaesthetics is limited by its duration of action and the dose dependent adverse effects on the cardiac and central nervous system. Adjuvants or additives are often used with local anaesthetics for its synergistic effect by prolonging the duration of sensory-motor block and limiting the cumulative dose requirement of local anaesthetics. The armamentarium of local anesthetic adjuvants have evolved over time from classical opioids to a wide array of drugs spanning several groups and varying mechanisms of action. A large array of opioids ranging from morphine, fentanyl and sufentanyl to hydromorphone, buprenorphine and tramadol has been used with varying success. However, their use has been limited by their adverse effect like respiratory depression, nausea, vomiting and pruritus, especially with its neuraxial use. Epinephrine potentiates the local anesthetics by its antinociceptive properties mediated by alpha-2 adrenoreceptor activation along with its vasoconstrictive properties limiting the systemic absorption of local anesthetics. Alpha 2 adrenoreceptor antagonists like clonidine and dexmedetomidine are one of the most widely used class of local anesthetic adjuvants. Other drugs like steroids (dexamethasone), anti-inflammatory agents (parecoxib and lornoxicam), midazolam, ketamine, magnesium sulfate and neostigmine have also been used with mixed success. The concern regarding the safety profile of these adjuvants is due to its potential neurotoxicity and neurological complications which necessitate further research in this direction. Current research is directed towards a search for agents and techniques which would prolong local anaesthetic action without its deleterious effects. This includes novel approaches like use of charged molecules to produce local anaesthetic action (tonicaine and n butyl tetracaine), new age delivery mechanisms for prolonged bioavailability (liposomal, microspheres and cyclodextrin systems) and further studies with other drugs (adenosine, neuromuscular blockers, dextrans).

Epidural Neostigmine versus Fentanyl to Decrease Bupivacaine Use in Patient-controlled Epidural Analgesia during Labor: A Randomized, Double-blind, Controlled Study

BACKGROUND

The addition of opioids to epidural local anesthetic reduces local anesthetic consumption by 20% but at the expense of side effects and time spent for regulatory compliance paperwork. Epidural neostigmine also reduces local anesthetic use. The authors hypothesized that epidural bupivacaine with neostigmine would decrease total hourly bupivacaine use compared with epidural bupivacaine with fentanyl for patient-controlled epidural analgesia.

METHODS

A total of 215 American Society of Anesthesiologists physical status II, laboring parturients requesting labor epidural analgesia consented to the study and were randomized to receive 0.125% bupivacaine with the addition of either fentanyl (2 μg/ml) or neostigmine (2, 4, or 8 μg/ml). The primary outcome was total hourly local anesthetic consumption, defined as total patient-controlled epidural analgesia use and top-ups (expressed as milliliters of 0.125% bupivacaine) divided by the infusion duration. A priori analysis determined a group size of 35 was needed to have 80% power at α = 0.05 to detect a 20% difference in the primary outcome.

RESULTS

Of 215 subjects consented, 151 patients were evaluable. Demographics, maternal and fetal outcomes, and labor characteristics were similar among groups. Total hourly local anesthetic consumption did not differ among groups (P = 0.55). The total median hourly bupivacaine consumption in the fentanyl group was 16.0 ml/h compared with 15.3, 14.6, and 16.2 ml/h in the 2, 4, and 8 μg/ml neostigmine groups, respectively (P = 0.55).

CONCLUSIONS

The data do not support any difference in bupivacaine requirements for labor patient-controlled epidural analgesia whether patients receive epidural bupivacaine with 2 to 8 μg/ml neostigmine or epidural bupivacaine with 2 μg/ml fentanyl.

A systematic review of the effects of adding neostigmine to local anesthetics for neuraxial administration in obstetric anesthesia and analgesia

BACKGROUND

Drugs used in obstetric patients must accomplish two goals: efficacy and safety for both mother and fetus. Neostigmine has been co-administered epidurally and intrathecally with local anesthetics and other adjuncts in the obstetric setting. The aim of this meta-analysis was to assess the efficacy and incidence of adverse events related to the use of neostigmine in obstetric anesthesia.

METHODS

A meta-analysis of randomized-controlled human trials was conducted using the data sources Google Scholar and PubMed (updated 1 November 2014). Inclusion criteria were: random allocation to treatment; comparison of neostigmine or neostigmine with local anesthetics and/or other adjuvants versus placebo or placebo with local anesthetics and/or other adjuvants; and approval by an ethics committee.

RESULTS

The use of neostigmine as an adjuvant in neuraxial anesthesia is associated with a reduction in the dose of local anesthetic during labor analgesia and postoperative analgesia following cesarean section: mean reduction of local anesthetic (ropivacaine or bupivacaine) vs. control -4.08 (95% CI -6.7 to -1.5) mg/h (P=0.002). The risk of nausea was increased vs. control with intrathecal neostigmine (OR 8.99 [95% CI 4.74 to 17.05], P <0.001) but not with epidural neostigmine (OR 0.97 [95% CI 0.46 to 2.05], P=0.94). Use of neuraxial neostigmine was associated with a decrease in the risk of pruritus but there was no increase in the incidence of hypotension, dizziness or sedation and no effect on the incidence of abnormal fetal heart rate patterns or Apgar scores.

CONCLUSIONS

Neuraxial administration of neostigmine significantly reduces local anesthetic consumption without serious adverse side effects to the mother or fetus. However, neostigmine is only recommended for epidural administration as intrathecal use significantly increases the incidence of maternal nausea and vomiting.

A comparative study between intrathecal clonidine and neostigmine with intrathecal bupivacaine for lower abdominal surgeries

Background and Aims:

Spinal anaesthesia requires a small volume of drug to produce profound reproducible sensory analgesia and motor blockade, but has limited duration of action. A properly chosen adjuvant to local anaesthetic agent produces the best way to achieve a better quality regional block. Hence, a study was conducted to compare the effect of intrathecal clonidine 75 μg or neostigmine 50 μg added to intrathecal hyperbaric bupivacaine, with regards to sensory characteristics, motor characteristics, haemodynamic stability and side effects.

Methods:

This was a prospective randomized experimental study in 50 patients posted for lower abdominal surgery belonging to ASA I and II status and aged between18 and 60 years. One group received intrathecal clonidine 75 μg and 2.5 ml (12.5 mg) of intrathecal 0.5% hyperbaric bupivacaine (group BC) and second group received neostigmine 50 μg with 2.5 ml (12.5mg) of intrathecal 0.5% hyperbaric bupivacaine (group BN) and they were compared with regards to sensory characteristics, motor characteristics, haemodynamic stability and side effects.

Results:

Addition of 50 μg neostigmine significantly enhanced the onset of sensory block (BN - 90 ± 15 secs, BC-160 ± 20 secs, P value as <0.05) and motor block (BN-110 ± 15 secs, BC-210 ± 20 secs, P value as <0.05) compared to clonidine. Haemodynamics were well maintained in the neostigmine group. Group BC had prolonged analgesia (362 ± 36 mins) compared to BN group (300 ± 25 mins)(P < 0.05) with no serious adverse effects noted perioperatively in either groups.

Conclusion:

Intrathecal clonidine with hyperbaric bupivacaine produces prolonged postoperative analgesia and intrathecal neostigmine with bupivacaine produces a good sensory and motor for the surgical procedure.

The effects of 2 µg and 4 µg doses of dexmedetomidine in combination with intrathecal hyperbaric bupivacaine on spinal anesthesia and its postoperative analgesic characteristics

OBJECTIVE

To compare the postoperative analgesic characteristics and side effects of two different doses of intrathecal dexmedetomidine in combination with hyperbaric bupivacaine, and to evaluate the effects of these combinations on spinal anesthesia.

METHODS

After obtaining approval from the local ethics committee, 60 male patients who were undergoing inguinal surgery and were classified as American Society of Anesthesiologists physical status class I were included in the study. The present study was conducted in 2003 in a military hospital with a capacity of 100 beds. The patients were randomly assigned to three groups of 20 patients: group 1, 0.5 mL saline added to 3 mL (15 mg) hyperbaric bupivacaine; and groups 2 and 3, 2 µg dexmedetomidine and 4 µg dexmedetomidine added to 3 mL (15 mg) hyperbaric bupivacaine, respectively. Medications were administered by intrathecal injection in a total volume of 3.5 mL. The postoperative analgesic characteristics, effects on spinal anesthesia and side effects were recorded.

RESULTS

Demographic characteristics were similar among the groups. The mean (±SD) time to onset of pain was 220.75±112.7 min in group 1, 371.5±223.5 min in group 2 and 1042.50±366.78 min in group 3. Time to first pain sensation in group 3 was significantly longer than that in groups 1 and 2 (P<0.001).

CONCLUSION

Two different doses of dexmedetomidine, an α2-adrenoceptor agonist with analgesic effects, resulted in an increased duration of analgesia and efficacy, decreased postoperative analgesic use and was associated with no notable adverse effects.

Postoperative analgesic effects of epidural administration of neostigmine alone or in combination with morphine in ovariohysterectomized dogs

OBJECTIVE

To evaluate analgesic effects of epidurally administered neostigmine alone or in combination with morphine in dogs after ovariohysterectomy. Animals-40 healthy bitches.

PROCEDURES

After acepromazine premedication, anesthesia was induced. Dogs randomly received 1 of the following 4 epidural treatments 30 minutes before ovariohysterectomy (n = 10/group): saline (0.9% NaCl) solution (control), morphine (0.1 mg/kg), neostigmine (10 microg/kg), or morphine-neostigmine (0.1 mg/kg and 10 microg/kg, respectively). Analgesia was assessed for 24 hours after surgery by use of a visual analogue scale (VAS; scale of 0 to 10) or numeric descriptive scale (NDS; scale of 0 to 24) and by the need for supplemental analgesia (morphine [0.5 mg/kg, IM] administered when VAS was > or = 4 or NDS was > or = 8).

RESULTS

Significantly more control dogs (n = 8) received supplemental analgesia, compared with the number of neostigmine-treated dogs (1); no dogs in the remaining groups received supplemental analgesia. Compared with values for the control dogs, the NDS scores were lower for morphine-neostigmine-treated dogs (from 2 to 6 hours and at 12 hours) and for morphine-treated dogs (all time points). The NDS scores were lower for morphine-treated dogs at 3, 12, and 24 hours, compared with values for neostigmine-treated dogs. The VAS was less sensitive than the NDS for detecting differences among groups.

CONCLUSIONS AND CLINICAL RELEVANCE

Epidurally administered neostigmine reduced the use of supplemental analgesia after ovariohysterectomy in dogs. However, analgesic effects were less pronounced than for epidurally administered morphine or morphine-neostigmine. Adding neostigmine to epidurally administered morphine did not potentiate opioid-induced analgesia.

A prospective randomized double-blind study to determine the effect of thoracic epidural neostigmine on postoperative ileus after abdominal aortic surgery

BACKGROUND

Postoperative ileus is a major gastrointestinal complication of abdominal aortic surgery leading to increased rates of morbidity and mortality, longer lengths of hospital stay, and higher costs. In this study, we evaluated the effect of epidurally administered neostigmine on postoperative ileus after abdominal aortic surgery.

METHODS

We enrolled 45 patients who were scheduled for elective abdominal aortic surgery at our institution. All patients received identical general and epidural anesthesia. Before the induction of general anesthesia, an epidural catheter was placed at the T7-T8 intervertebral space, and 20 mL bupivacaine (0.5%) was injected over 15 min. Patients were randomized into two groups. Patients received a 5 mL bolus of neostigmine (1 microg/kg) diluted with normal saline (Group 1) or a 5 mL bolus of normal saline (Group 2) via an epidural catheter at the end of surgery and 8 h postoperatively. Times of bowel sounds were recorded postoperatively in the intensive care unit. Times of daily passage of flatus and defecation also were recorded.

RESULTS

Times to the first bowel sounds and the first flatus were significantly shorter in Group 1 than they were in Group 2 (11.6 +/- 11.2 h vs 22.6 +/- 12.8 h and 21.8 +/- 15.6 h vs 36.6 +/- 19.1 h, respectively, P < 0.05). The times to first defecation were similar in both groups (P > 0.05). Nausea was more frequent in patients in Group 2 than in Group 1 (P < 0.05). The incidence of postoperative complications was similar between the groups (P > 0.05).

CONCLUSIONS

Thoracic epidural neostigmine enables faster restoration of bowel sounds and shortens duration of postoperative ileus after abdominal aortic surgery.

Use of neostigmine in the management of acute postoperative pain and labour pain: a review

Neostigmine is a parasympathomimetic agent that has been recently investigated for use as an adjunct analgesic agent in the perioperative and peripartum period. A number of studies have investigated the intrathecal, epidural, caudal and intra-articular routes of administration of this agent, as well as the addition of neostigmine to local anaesthetics used for brachial plexus block and intravenous regional anaesthesia. While the intrathecal administration of neostigmine produced useful analgesic effects in the postoperative period in some studies, the high incidence of adverse events, mainly nausea and vomiting, limit the clinical usefulness of this route of administration. Several studies investigated the postoperative analgesic effects of epidural neostigmine using a number of different regimens. Overall, this route of administration appeared to improve postoperative analgesia in most studies without increasing the incidence of adverse events, and merits further research. Neuraxial administration of neostigmine appears to be safe in the obstetric population, with no reported adverse effects in the mother or fetus. While intrathecal administration is limited by a high incidence of nausea and vomiting in this patient population, the epidural route appears more promising and requires further investigation. The addition of neostigmine to caudal local anaesthetics was associated with improved postoperative analgesia in a number of studies. A dose of 2 microg/kg proved to be effective in several studies but was associated with an increased incidence of vomiting in some studies. Intra-articular administration of neostigmine 500microg produced a useful analgesic effect in the postoperative period in several studies and was not associated with an increase in the incidence of adverse effects. Studies investigating the efficacy of adding neostigmine to the local anaesthetics used for brachial plexus block and intravenous regional anaesthesia reported conflicting results. Further studies are required to determine the place of the administration of neostigmine by these routes.

The efficacy of thoracic epidural neostigmine infusion after thoracotomy

Few anesthesia studies have explored perioperative continuous epidural infusion of neostigmine. We examined such a regimen in thoracotomy patients. Ninety patients were randomized to one of three groups in this double-blind trial. Before anesthesia induction, an epidural catheter was inserted in all patients at T5-8 levels under local anesthesia. Pre-neo patients received bolus 500-microg epidural neostigmine before anesthesia induction followed by infusion of 125 microg/h until the end of surgery. Post-neo patients received epidural saline during the same time periods plus bolus 500-microg epidural neostigmine at end of surgery. Patients in the control group received saline placebo during all three periods. Patients in the neostigmine groups postoperatively received patient-controlled epidural analgesia with morphine 0.02 mg/mL, bupivacaine 0.08 mg/mL, and neostigmine 7 microg/mL. Control patient-controlled epidural analgesia excluded neostigmine. Data were recorded for 6 postoperative days. Daily patient-controlled epidural analgesia consumption (mL) for Pre-neo patients was significantly less than that of post-neo and control group patients for postoperative days 1-6 (at least 10% and 16% less, respectively; P < 0.05). There was a modest decrease in pain intensity on postoperative days 3-6 for pre-neo patients versus other groups (P < 0.05). These results suggest that continuous thoracic epidural neostigmine started before anesthesia provided preemptive, preventive analgesia and an analgesic-sparing effect that improved postoperative analgesia for these patients without increasing the incidence of adverse effects.

Role of Analgesic Adjuncts in Postoperative Pain Management

Postoperative pain remains a major problem. A multi-modal analgesic approach is recommended to optimize pain management and reduce opiate-related adverse effects. Several analgesic adjuncts have been investigated, and many have proved to have a useful analgesic effect. This article reviews the literature regarding use of analgesic adjuncts in the perioperative period.

Intrathecal opioids for combined spinal-epidural analgesia during labour

In <25 years, intrathecal administration of opioids (i.e. spinal analgesia) has evolved from an experimental model into an important therapy for obstetric analgesia and anaesthesia. A small dose of opioid delivered into the CSF provides almost immediate relief from labour pain with minimal risks to the mother and fetus. Careful attention, and prompt treatment when needed, can ameliorate the adverse effects of fetal bradycardia, respiratory depression and pruritus. The major limitation of intrathecal opioids for labour analgesia is the short duration of effect: 90-180 minutes under ideal circumstances. To address this problem, and to increase flexibility for anaesthesia as well as analgesia, the combined spinal-epidural (CSE) technique was developed. The CSE technique involves injection of drugs into the CSF and placement of an epidural catheter. An intrathecally administered opioid provides a rapid onset of labour analgesia without motor block or significant haemodynamic perturbation. The epidural catheter allows ongoing administration of medications to maintain labour analgesia and provides a means of delivering anaesthesia for operative delivery. This review will focus on intrathecally administered opioids as used as part of CSE analgesia. Considerable research has focused on the optimum dose of opioids when delivered intrathecally, with or without adjuncts, in the CSE technique. Fentanyl and sufentanil, two of the lipophilic synthetic opioids, have emerged as the most useful. Bupivacaine, a long-acting local anaesthetic, is often added to prolong the duration of analgesia, although this tends to increase the likelihood of motor blockade of the lower extremities. Comparisons of the CSE technique with standard epidural practices have shown that both are effective means of providing analgesia during labour. Controversy revolves around the incidence of fetal bradycardia following CSE and whether this phenomenon increases the rate of operative deliveries. The rapid onset of analgesia with intrathecally administered opioids must be balanced against the added risks of dural puncture and considered in the context of the whole duration of labour. Ultimately, the decision to choose a CSE technique depends on the experience of the anaesthesia provider and the local availability of drugs, equipment and monitoring capabilities.

Epidural morphine and neostigmine for postoperative analgesia after orthopedic surgery

In this study, we examined the side effects and analgesia of the combination of epidural neostigmine and morphine in patients undergoing orthopedic surgery. Sixty patients undergoing knee surgery were divided into four groups. The intrathecal anesthetic was 15 mg of bupivacaine. The epidural test drug was diluted in saline to a final volume of 10 mL. The control group received saline as the epidural test drug. The morphine group received 0.6 mg of epidural morphine. The neostigmine group (NG) received 60 micro g of epidural neostigmine. The morphine/neostigmine group received 0.6 mg of epidural morphine combined with 60 micro g of epidural neostigmine. The groups were demographically the same and did not differ in intraoperative characteristics. The visual analog scale score at first rescue analgesic and the incidence of adverse effects were similar among groups (P > 0.05). One patient from the NG complained of intraoperative nausea, closely related to spinal hypotension. Postoperatively, two patients from the NG had vomited once. The time (min) to first rescue analgesic was longer in the morphine/neostigmine group ( approximately 11 h) compared with the other groups (P < 0.05). The analgesic consumption (number of analgesic administrations in 24 h) was larger in the control group compared with the other groups (P < 0.05).

IMPLICATIONS

The combination of epidural morphine and epidural neostigmine resulted in postoperative analgesia (11 h) devoid of side effects, being an alternative analgesic technique in the population studied.

Spinal drug delivery

Clinicians currently base decisions regarding the use of intrathecal drug therapy for chronic pain on reports from uncontrolled and retrospective studies that fail to rely on standardized outcome measures. In this article, we summarize what is known about currently administered intrathecal therapies, including opioids, gamma-aminobutyric acid agonists, alpha-2 adrenoreceptor agonists, local anesthetics (sodium channel antagonists), calcium channel antagonists, miscellaneous agents, and drug combination therapy. In addition, we offer a brief look at novel approaches that may revolutionize intrathecal drug delivery.

What is the best way to provide postoperative pain therapy after caesarean section?

In the following text recently published data on postoperative pain therapy after caesarean section will be summarized. As most papers discuss epidural and intrathecal strategies of pain relief, these aspects of pain therapy for the often underestimated pain after caesarean section will be emphasized.