The Clinical journal of pain
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There continues a significant debate over the best contemporary method for treating trigeminal neuralgia. Glycerol injection into the trigeminal cistern has been used in a consecutive series of 200 patients. A total of 80% of the patients have had good or excellent pain relief. ⋯ A recurrence rate of 24% has been the single largest disadvantage of the procedure. Reinjection is usually successful in treatment of recurrence. The combination of efficacy, minimal and temporary neurologic dysfunction, and low complication rate make this procedure, in our opinion, the procedure of choice for the first step, when surgical treatment is required.
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Over a 3 1/2-year period, a series of 20 chronic pain patients with back pain and with documented organic difficulties were treated by means of implanted spinal cord stimulation. Short-term treatment outcome was found to be significantly related to diagnosis, with single nerve root injury and mononeuropathy patients having better treatment outcomes than arachnoiditis patients with multiply injured nerve roots. Outcome was not related to the psychological evaluation, or age, sex, number of previous pain surgeries, pain location, the Minnesota Multiphasic Personality Inventory, or the Pain Assessment Index. Implications for patient selection are discussed.
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Fifty-eight patients undergoing cervical epidural injection of corticosteroids were followed for a 6-month period. Patients with 90% pain relief lasting 6 months were considered to have excellent results, those with greater than 50% pain relief lasting at least 6 weeks were considered to have good results, and all others were considered to have poor results. ⋯ Those patients with the diagnosis of cervical spondylosis and those with subacute cervical strain had statistically significantly (p less than 0.001, difference of proportions test) better results than patients with other diagnoses. The procedure of cervical epidural steroid injection may be most effective in patients with cervical degenerative joint disease as the etiology of their cervical pain.
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Surgical indications do not forecast outcomes as well as they should. A review of the literature demonstrates a significant rate of overutilization of coronary angiography, coronary artery surgery, cardiac pacemaker insertion, upper gastrointestinal endoscopies, carotid endarterectomies, back surgery, and pain-relieving procedures. ⋯ Arguments against this approach and a plea for the development of tighter focused indications are presented. Implications for cost saving and reduction in suffering are discussed.
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Case Reports Comparative Study
Hypnosis and chronic pain. Two contrasting case studies.
Some of the theoretical and technical problems associated with the use of hypnosis for chronic pain are discussed in the context of two similar case studies, one of which had an unsuccessful outcome. Different hypnotic strategies are discussed which depend on a careful, direct evaluation of the role of secondary gain and depression in maintaining the pain in the two patients. ⋯ Self-hypnotic procedures are described stressing the development of mastery and self-control over pain. Differences in the kinds of hypnotic intervention that are appropriate when secondary gain or depression are central to the pain problem, compared to the more direct techniques available when they are not, are discussed.