Current opinion in anaesthesiology
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The purpose of this review is to provide an update on the diagnosis, treatment, and prevention of neuropathic pain. ⋯ The literature reveals that neuropathic pain is underdiagnosed and often undertreated or treated with ineffective or untested modalities. Evolving definitions of neuropathic pain has broadened the range of therapeutic approaches and brought current treatment paradigms under increased scrutiny. The lack of a mechanism-based approach to treatment may be responsible for the lackluster responses seen in most neuropathic pain conditions.
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A major challenge in the treatment of brain-injured patients is the decision on indication and timing of prophylactic anticoagulation. In addition, an increasing number of patients suffering from traumatic brain injury (TBI) are on preinjury anticoagulation therapy. Despite clear evidence for an increased risk of venous thromboembolic events and pulmonary embolism in traumatized patients without prophylactic anticoagulation, there is a lack of distinct recommendations and standardized clinical practice guidelines. This review summarizes current research evidence regarding post-traumatic prophylactic anticoagulation and management of patients with prehospital use of anticoagulants. ⋯ Stratification scores for identification of TBI patients with low, moderate, or high risk for spontaneous cerebral bleeding may help to allow early thromboprophylaxis while maintaining a good risk-benefit ratio. So far, these scores require validation by prospective trials. Therefore, current evidence requires control computed tomography scans prior to early pharmacological thromboprophylaxis.
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In this review, we present an update on the relationship between anesthesia and intraoperative hemodynamic complications, early postanesthesia recovery, postoperative pain and postoperative nausea and vomiting after craniotomy. We also review latest advances in education and research in neuroanesthesia for brain surgery. ⋯ Neuroanesthesia for craniotomy should be aimed to ensure intraoperative loss of consciousness (unless awake craniotomy is the selected anesthesiological approach), pain control and an uneventful postoperative recovery, but should also be addressed to manipulate physiological variables including cerebral blood flow and to obtain optimal surgical exposure.
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Curr Opin Anaesthesiol · Oct 2013
ReviewMinimally invasive lumbar decompression: a treatment for lumbar spinal stenosis.
Percutaneous lumbar decompression is a minimally invasive procedure for the treatment of symptomatic lumbar spinal stenosis (LSS). The purpose of this article is to review the current literature on percutaneous lumbar decompression as well as review the safety and outcomes associated with the procedure. ⋯ This minimally invasive procedure is an option for patients with central canal LSS who have continued pain-following conservative treatment such as physical therapy, oral medications, and lumbar spine injections. Percutaneous lumbar decompression is a procedure that bridges the gap between invasive surgery and more conservative treatment for LSS. This percutaneous technique provides increasing options to those patients with central canal lumbar stenosis who may not be candidates for an invasive decompression procedure. Overall, this procedure has been found to be well tolerated and effective in reducing pain while generally improving function.
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Curr Opin Anaesthesiol · Oct 2013
ReviewEpidural steroids for spinal pain and radiculopathy: a narrative, evidence-based review.
Epidural steroid injections (ESIs) are the most commonly performed intervention in pain clinics across the USA and worldwide. In light of the growing use of ESIs, a recent spate of highly publicized infectious complications, and increasing emphasis on cost-effectiveness, the utility of ESI has recently come under intense scrutiny. This article provides an evidence-based review of ESIs, including the most up-to-date information on patient selection, comparison of techniques, efficacy, and complications. ⋯ The cost-effectiveness of ESI is the subject of great debate, and similar to efficacy, the conclusions one draws appear to be influenced by specialty. Because of the wide disparities regarding indications and utilization, it is likely that indiscriminate use is cost-ineffective, but that judicious use in well-selected patients can decrease healthcare utilization. More research is needed to better refine selection criteria for ESI, and to determine which approach, what dose, and how many injections are optimal.