Anesthesiology clinics of North America
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Anesthesiol Clin North America · Dec 2003
ReviewSpinal cord stimulation for angina pectoris and peripheral vascular disease.
SCS is a viable option for treating angina pectoris and inoperable PVD. Its mechanism of action remains controversial, but successful pain relief has been consistently reported in various studies. Many clinicians are foregoing a formal trial, choosing instead to obtain an adequate area of paresthesia and implant in one session. ⋯ No convincing data have been published on the cost-effectiveness of SCS in this patient population. SCS is a safe procedure that is minimally invasive, reversible, and associated with only infrequent side effects, the most common of which include lead migration and infection. SCS is clearly an option for the improvement of pain and the quality of life in this carefully selected subset of patients.
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The important issues to be emphasized when considering the intrathecal administration of novel analgesics are their proven antinociceptive effect, safety (short- and long-term effects on the spinal cord and potential toxicities), stability in shelf solution and at body temperature by itself, or in combination with other drugs in spinal fluid, compatibility with a long-term spinal infusion pump, whether they are of sufficiently high potency and solubility to be used in the finite volume of an implanted infusion pump, and if a pharmaceutical company is willing to invest the immense resources needed for US Food and Drug Administration approval and subsequent commercial development.
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As suggested by this article, considerable advances in clinical management and research have taken place during the past 20 years. Although mechanisms underlying the pain syndrome CRPS I and CRPS II remain far from one's understanding, glimpses of the pathophysiology are beginning to take shape. There is now strong evidence that these syndromes exemplify a complex neurologic disease involving the brain at several integrated levels. ⋯ For this to be successful, as described in the foregoing pages, different non-interventional and interventional modalities are applied in a time-restricted manner to facilitate those modalities that favor progress in the treatment algorithm. As has been described, it is important when using physiotherapeutic maneuvers to minimize joint movement in the affected region to reduce the mechanorecpetor barrage and its increase in perceived pain to encourage and maintain a patient's compliance with their rehabilitation. Finally, of greater significance is the understanding that sympatholysis per se is not a "diagnostic" test for CRPS, but rather a useful procedure that may facilitate treatment for pain that is sympathetically maintained.
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Anesthesiol Clin North America · Dec 2003
ReviewSpecial techniques in pain management: lysis of adhesions.
Low back pain, with or without radicular symptoms, is a common medical condition. It can cause mild to severe suffering, high health costs, and disability. ⋯ The less fortunate group of patients who do not improve despite conservative and mildly interventional therapy, find themselves in search of a more effective treatment. To enhance treatment outcome, an understanding of the pathophysiology of the underlying pain and the design of target-specific treatment modalities is important.
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Anesthesiol Clin North America · Dec 2003
Case ReportsSacral neuromodulation for chronic pain conditions.
Some of the pelvic pain syndromes seem to have features of neurogenic inflammation and neuropathic pain in common. As opposed to being separate disease entities, they may represent a spectrum of clinical presentations of CRPS I of the pelvis. ⋯ The techniques of retrograde root stimulation may offer superior results with fewer complications and lead migrations when compared with other methods. Perhaps neuromodulation should be used earlier in the treatment paradigm for these disorders, before the potentially injurious procedures of hydrodistention, bladder installations, and cystectomies.