Neurosurgery clinics of North America
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Neurosurg. Clin. N. Am. · Jul 2003
Review Historical ArticleMechanisms of action of intrathecal medications.
Intrathecal delivery of medications for the management of chronic pain syndromes reflects a modern targeted delivery system with the potential for even greater efficacy than is outlined in Tables 1 and 2. The twentieth century ushered in the development of parenteral approaches of medical therapy for chronic pain and other diseases that were superior to the traditional oral delivery methods known in the preceding century. ⋯ This method of delivery is best represented by current drug delivery systems, such as the intrathecal drug pump. Traditional pharmacologic agents will still be used in the twenty-first century; however, the development of novel compounds, transplanted tissues, and genetic engineering will likely usher in a new era of pain management, including their use as analgesics for intraspinal infusion.
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Neuroaugmentation, the use of chronic stimulation of the brain and spinal cord for pain management, developed during the past 30 years. It evolved, however, from concepts of pain treatment that were based on observations and clinical experience dating back an additional two decades or more. ⋯ The concept proposed in that theory, that pain perception could be lessened by increasing activity in neural structures not associated with pain, led to chronic stimulation of deep brain and spinal cord as a modality for the management of chronic pain. Both brain and spinal structures emerged as targets for neuroaugmentation.
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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.
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This brief review of intrathecal pain medication delivery has emphasized the unusual but useful pharmacology of CSF drug delivery, the new study definitely showing that the method is helpful in cancer pain, and the rare complication of mass formation at the catheter tip. As new medications are developed for intrathecal delivery, this field is likely to expand, especially if a wider range of dorsal horn receptor mechanisms underlying pain processing can be modified. The changes in spinal cord signaling that are induced by chronic pain states are being investigated, and new possibilities for intervention are likely. the availability of a reliable well-understood way of delivering such new therapies by implanted drug pumps will speed the process. Intrathecal morphine for chronic pain has an important role in helping many patients with a wide variety of pain conditions and, as with all pain treatment, is woefully underused.
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Neurosurg. Clin. N. Am. · Apr 2003
ReviewNeurosurgery for intractable obsessive-compulsive disorder and depression: critical issues.
Intractable OCD and depression cause tremendous suffering in those affected and in their families. The impaired ability to function of those affected imposes a heavy burden on society as a whole. Existing data suggest that lesion procedures offer benefit to a large proportion (ranging from about 35%-70%) of patients with intractable OCD and depression. ⋯ The rationale for those standards is found throughout this issue and is especially developed in the article by Fins. The need for safe and effective therapeutic options for people suffering with these severe illnesses is just as clear. The experience over the last several decades provides grounds for careful optimism that refined lesion procedures or reversible deep brain stimulation may relieve suffering and improve the lives of people with these devastating disorders.