Neuromodulation : journal of the International Neuromodulation Society
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Background. Expert panels of physicians and nonphysicians in the field of intrathecal therapies convened in 2000 and 2003 to make recommendations for the rational use of intrathecal analgesics based on the preclinical and clinical literature known up to those times. An expert panel of physicians convened in 2007 to update previous recommendations and to form guidelines for the rational use of intrathecal opioid and nonopioid agents. ⋯ Results. The panelists, after review of the literature from 2000 to 2006 and discussion, created an updated algorithm for the rational use of intrathecal opioid and nonopioid agents in patients with nonmalignant and end-of-life pain. Of note is that the panelists felt that ziconotide, based on new and relevant literature and experience, should be updated to a line one intrathecal drug.
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Central cord pain is very difficult to relieve, even with the many kinds of medical and surgical treatments available. Following spinal cord infarctions, central cord pain can develop. The problems that may arise could include limb pain, pelvic pain, difficulties voiding, and difficulties defecating. ⋯ Limb pain was reduced by spinal cord stimulation. Voiding and defecation difficulties and pelvic pain were reduced by sacral nerve stimulation. Thus, in a case involving both intractable limb and pelvic pain, a combination therapy of these two stimulations might be an effective treatment modality.
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Objective. We studied long-term clinical efficacy of sacral neuromodulation (SNM) therapy in patients with refractory urgency incontinence (UI), urgency/frequency (UF) and voiding difficulty (VD), together with urodynamic data at baseline and six months postimplant. Materials and Methods. Twenty-two patients were implanted with a neurostimulator after a positive response to a percutaneous nerve evaluation test defined as a greater than 50% improvement in symptoms. Results. At five-year follow-up, the number of incontinent episodes and pad usage per day decreased significantly in 10 out of 15 UI patients. ⋯ Mean first sensation of filling at the six-month urodynamic investigation for the UI and UF patients increased from 78 to 241 mL and 141 to 232 mL, respectively, and the maximum bladder capacity increased from 292 to 352 mL and 223 to 318 mL, respectively. Five of 22 patients underwent device explant and one patient still has an inactive stimulator implanted. Conclusion. SNM is an effective treatment modality that offers sustained clinical benefit in the majority of patients with refractory UI, UF, and VD that do not respond to other, more conservative therapies.
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Objective. This case report presents an application of peripheral nerve stimulation to a patient with intractable postherpetic neuralgia that conventional treatment failed to ameliorate. Methods. The patient underwent an uneventful peripheral nerve stimulator trial with placement of two temporal eight-electrode percutaneous leads (Octrode leads, Advanced Neuromodulation Systems, Plano, TX, USA) into the right subscapular and right paraspinal area of the upper thoracic region. ⋯ Peripheral nerve stimulation offers an alternative treatment option for intractable pain associated with postherpetic neuralgia, especially for elderly patients where treatment options are limited due to existing comorbidities. Further studies are warranted.
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Objective. To determine the stability of ziconotide-clonidine hydrochloride admixtures with and without morphine sulfate during simulated intrathecal infusion under laboratory conditions at 37°. Materials and Methods. Admixtures of ziconotide (25 µg/mL) and clonidine hydrochloride (2 mg/mL) with and without morphine sulfate (35 mg/mL) were stored in Medtronic SynchroMed® II pumps at 37°. Pumps were sampled immediately after filling and at four additional time points over the course of 28 (ziconotide-clonidine hydrochloride admixture) or 20 (ziconotide-clonidine hydrochloride-morphine sulfate admixture) days. ⋯ When compounded with both clonidine and morphine, ziconotide and clonidine concentrations declined; statistical evaluation indicated that the ziconotide concentration was 70% of initial after 20 days, and that clonidine would remain 90% stable for 42 days. Morphine was stable in the presence of ziconotide and clonidine. Conclusions. A ziconotide-clonidine admixture was 90% stable for 60 days (extrapolated), and a ziconotide-clonidine-morphine admixture was 70% stable for 20 days.