Instructional course lectures
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Review
Radiculopathy and the herniated lumbar disk: controversies regarding pathophysiology and management.
Lumbar disk herniation is one of the most common problems encountered in orthopaedic practice. Despite the frequency of its occurrence, however, much about lumbar disk herniation is poorly understood. It is important to review the basic and clinical science underlying the pathophysiology and treatment, surgical and nonsurgical, of this disorder.
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A significant proportion of patients will experience moderate to severe pain after hip or knee replacement surgery. Multimodal pain control regimens have been developed to address this issue. ⋯ Cyclooxygenase-2 inhibitors, a class of NSAIDs, are not believed to increase the risk of bleeding and may be useful in this population of patients. However, recent research shows increased cardiovascular and renal risks with cyclooxygenase-2 inhibitors and has limited their use for postoperative pain control in joint arthroplasty patients.
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The decision to use regional or general anesthesia for patients undergoing total joint arthroplasty continues to be controversial. Recent reviews of the literature support the growing trend for the use of regional anesthesia with a multifaceted approach, spanning nuances in block placement as well as pharmacologic agents and delivery systems. Innovative developments offer appealing options and encouraging results for the management of pain after major orthopaedic procedures. The ultimate decision, although varied, requires careful preoperative planning and protocols to ensure adequate pain control and patient satisfaction.
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Theoretically, an appropriately designed and implemented multimodal pain protocol should reduce postoperative pain levels, need for narcotic medication, and adverse events while improving functional recovery including ambulation, discharge from hospital, range of motion, and return to work. A complete, perioperative multimodal pain protocol for total hip replacement and total knee replacement, including use of a novel periarticular injection, has been described and early clinical results are reported.
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Pain control following total joint arthroplasty is critical for optimizing patient outcome. Both the real and perceived success of joint arthroplasty surgery depends on the patient's level of pain in the postoperative period. ⋯ Optimal pain control must be balanced against the adverse effects of narcotics, including alteration of sensorium (especially in older patients) as well as respiratory depression. Modern strategies to control postoperative pain involve a multimodal approach that includes the use of intravenous patient-controlled analgesia.