Current pain and headache reports
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Curr Pain Headache Rep · Jun 2001
ReviewNeuraxial infusion in patients with chronic intractable cancer and noncancer pain.
Ever since the application in 1980 of morphine for spinal analgesia in patients with refractory cancer pain, spinal infusion therapy has become one of the cornerstones for the management of chronic, medically intractable pain. Initially, spinal infusion therapy was indicated only for patients with cancer pain that could not be adequately controlled with systemic narcotics. However, over the past decade, there has been a significant increase in the number of pumps implanted for the treatment of nonmalignant pain. ⋯ Because of the difficulties associated with long-term intrathecal opiate therapy, much of the research, both basic and clinical, has focused on developing alternative nonopioid agents to be used either alone or in combination with opiates. Clinical trials have been and continue to be conducted to evaluate drugs such as clonidine, SNX-111, local anesthetics, baclofen, and many other less common agents to determine their efficacy and potential toxicity for intrathecal therapy. This article reviews the agents developed as alternatives to intrathecal opiates.
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Curr Pain Headache Rep · Jun 2001
ReviewModern management of cancer-related intestinal obstruction.
Malignant-associated bowel obstruction remains a common and perplexing problem for patients with advanced gynecologic and gastrointestinal malignancies. The ability to locate and define its cause preoperatively has improved with the advent of computed tomography. Initial clinical experience with half-Fourier acquisition single-shot turbo spin-echo magnetic resonance imaging (HASTE MRI) and virtual colonoscopy is exciting. ⋯ Stent placement for upper and lower bowel obstructions is an option in nonoperable patients. Pharmacologic symptom management for intestinal obstructions consists of an opioid, an anticholinergic, and an antiemetic. Octreotide, either alone or added to the original regimen, will palliate symptoms that are resistant to the three-drug combination.
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Curr Pain Headache Rep · Jun 2001
ReviewPostdural puncture headache: the role of prophylactic epidural blood patch.
Prophylactic epidural blood patch may prevent postdural puncture headache that develops after intentional or inadvertent dural puncture. However, despite earlier reports that this procedure was of value, subsequent studies have failed to show it has significant advantages over delayed blood patch. ⋯ At the present time, most centers do not routinely offer prophylactic blood patches, and those that do report a variable success rate. A recent case study of permanent neurologic deficit after prophylactic epidural blood patch has also raised some concern about the safety of this prophylactic technique.
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Spontaneous intracranial hypotension (SIH) is typically manifested by orthostatic headaches that may be associated with one or more of several other symptoms, including pain or stiffness of the neck, nausea, emesis, horizontal diplopia, dizziness, change in hearing, visual blurring or visual field cuts, photophobia, interscapular pain, and occasionally face numbness or weakness or radicular upper-limb symptoms. Cerebrospinal fluid (CSF) pressures, by definition, are quite low. SIH almost invariably results from a spontaneous CSF leak. ⋯ Although various treatment modalities have been implemented, epidural blood patch is probably the treatment of choice in patients who have failed an initial trial of conservative management. When adequate trials of epidural blood patches fail, surgery can offer encouraging results in selected cases in which the site of the leak has been identified. Some of the spontaneous CSF leaks are related to weakness of the meningeal sac, likely in connection with a connective tissue abnormality.
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Constipation is an expected side effect of opioid use and as such should be treated prophylactically. However, because it is often overlooked and under-appreciated it is one of the most common reasons patients avoid or abandon opioid use and, as a result, suffer pain needlessly. Thorough assessment, ongoing evaluation, and patient teaching are key factors in establishing an effective bowel regimen. ⋯ Once any impactions have been eliminated, a regular regimen of senna and docusate is recommended. Dietary modifications, fluids, and exercise are important but usually not sufficient to overcome opioid-induced constipation. Although many of the medicines that are used to treat pain and related symptoms come with a significant potential for distressing side effects, it is important to understand that most side effects, especially constipation, can be managed and quality of life can be preserved without sacrificing needed analgesia.