Neurosurgery clinics of North America
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The generation of neuropathic pain is a complex phenomenon involving a process of peripheral and central sensitization producing enhanced transmission of nociceptive inputs to the brain associated with the loss of discriminatory processing of noxious and innocuous stimuli. This increased flow of abnormally processed nociceptive inputs to the brain may overcome the ability of descending modulatory pathways to produce analgesia, causing further worsening of the pain. Several crucial locations involved in the physiologic generation of pain inputs (eg, peripheral nociceptors, dorsal horns, thalamus, cortex) show evidence of functional reorganization and altered nociceptive processing in association with chronic pain. These locations present the best targets for therapeutic intervention, including systemic administration of drugs able to counteract the chemical storm induced by neural injuries in the nociceptive afferents and dorsal horns, or for more focused intervention, such as neuroablative procedures; intrathecal drug delivery; and spinal cord, deep brain, or motor cortex stimulation.
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As a general rule, even though it is always difficult to predict the efficacy of a method ina single patient, we consider SCS in every non-malignant chronic pain patient when other conservative treatments have failed. After three decades of clinical experience with SCS, we have learned a lot about its efficacy indifferent pain conditions and have made great technical progress with the materials and surgical procedures. Acceptance of the technique was slow at the beginning; however, we must be aware of the problems related to the application of a therapy that cannot be shamed, and thus the necessity of performing studies that include large numbers of patients. ⋯ As mentioned in the introduction of this article and discussed in the section on the effects of SCS, particularly in clinical applications like peripheral vascular disease and angina, the results of the interaction with the function of the nervous system can be observed in other systems in the body affecting pathologic conditions that are of interest to different specialists. Only the strict cooperation of different medical disciplines can provide substantial help in acquiring knowledge about the mechanisms put into play by SCS and the possible extension of its clinical applications. The complexity of the procedures of neuromodulation and the theoretic background needed for safe and proficient clinical use and for progress raise the issue for medical schools of offering courses in this new discipline.
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Although the definitive treatment for neuropathic pain remains elusive, scientific investigation continues to provide the field with better and better therapies. As our understanding of the neurophysiologic mechanisms of pain improves, pharmaceutic therapies have become more effective even as side effects are minimized. ⋯ Advances in neurophysiology have given rise to new advances in the field of neuro-modulation. As this therapy continues to emerge, ablative procedures recede as therapies offering minimal invasiveness, reversible mechanisms, and long-standing relief emerge to the forefront of treatment for neuropathic pain.
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Since the beginnings of medicine, physicians have sought minimally invasive ways to peer into body cavities. It is only in the last several decades that the promises of endoscopy have begun to be answered. What follows is a brief outline of the development of endoscopic technology and its application to the nervous system both for diagnostic and therapeutic procedures.
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Neurosurg. Clin. N. Am. · Jul 2003
ReviewSpinal cord stimulation: patient selection, technique, and outcomes.
Spinal cord stimulation, as with neuromodulation procedures in general, is a nondestructive, screenable, and reversible treatment option. Because there are no long-term side effects that have been reported; spinal cord stimulation is generally preferable as a first step when other less invasive treatments have failed to produce acceptable control of the pain.