Pain management
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SUMMARY Low back and leg pain can arise for a variety reasons, including epidural scarring caused by post lumbar surgery syndrome, infection or bleeding. Treatment options for low back and/or leg pain caused by epidural scarring include conservative approaches, such as physical therapy and medication management, and procedures, such as epidural steroid injections. Despite appropriate treatment, pain can persist in these patients. ⋯ While this has been studied as a caudal procedure, thoracic and cervical procedures have also been described, using both transforaminal and interlaminar approaches. With trained practitioners, complications are minimal. The effectiveness of the procedure has been documented by high-quality randomized controlled trials and observational studies for both postlumbar surgery syndrome and spinal stenosis.
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SUMMARY Lumbar spinal stenosis is one of the most common degenerative diseases of the elderly population, and a major cause of debilitating pain and decreased function. Lumbar spinal stenosis is almost always associated with neurogenic claudication characterized as pain worsened by standing or walking and relieved by lumbar flexion or sitting. While initial treatment of lumbar spinal stenosis may involve conservative therapies, as patients become more symptomatic the traditional treatment path has generally led to open laminectomy and other invasive, potentially destabilizing, procedures. ⋯ This article describes a new method of percutaneous lumbar decompression for treatment of neurogenic claudication secondary to lumbar spinal stenosis, the minimally invasive lumbar decompression procedure. We review the steps of successfully decompressing the hypertrophic ligamentum flavum and lamina, thereby alleviating pressure on neural structures. This is a major innovation in patient care and a step to reduce risks while minimizing costs.
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SUMMARY Local anesthetics have a limited duration of action. Adjuvants are used to prolong the duration of action and to augment analgesia allowing lower concentrations of local anesthetic to be used. Adjuvants have been used more extensively with neuraxial blocks, particularly caudal epidural blocks, but more recently to supplement peripheral nerve blocks. ⋯ Morphine is the historical gold-standard with which other adjuvants are compared. Clonidine is most useful and is becoming increasingly popular, while the side-effect profile of other agents reduces their utility. Concerns with regard to the neurotoxicity of ketamine in animal models has led to its withdrawal in some countries.
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SUMMARY This systematic review compares convenience of administration, adverse events and tolerability of buprenorphine patch with fentanyl patch in patients with chronic pain. Methods of quantitative and qualitative research were combined. Seventeen databases were searched up to December 2010. ⋯ There were no differences between buprenorphine patch and fentanyl patch regarding dizziness, somnolence, nausea and treatment discontinuation. Overall, transdermal administration of buprenorphine and fentanyl can be seen as an alternative pathway for delivering these drugs. Use of transdermal buprenorphine might be favorable in certain groups of patients, such as renally impaired, elderly and immunosuppressed patients.
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SUMMARY The buprenorphine implant (Probuphine™, Titan Pharmaceuticals, CA, USA) is a recently developed long-acting formulation of buprenorphine, which is a partial opioid agonist that is widely used in the marketed, sublingual, daily-dose form for managing opioid addiction. The new formulation uses a novel delivery system consisting of subcutaneously implanted solid matrix 'rods' made from a mixture of ethylene vinyl acetate and buprenorphine. ⋯ The implant has not yet been approved by the US FDA. The information in this review has been gleaned from research reports, documentation in the literature, and from the author's experience treating opioid-dependent patients, and involvement in clinical research examining sublingual buprenorphine and the buprenorphine implant.