Current pain and headache reports
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Curr Pain Headache Rep · Apr 2021
ReviewManagement of Refractory Pain After Total Joint Replacement.
Chronic pain after total joint replacement (TJA), specifically total knee replacement (TKA), is becoming more of a burden on patients, physicians, and the healthcare system as the number of joint replacements performed increases year after year. The management of this type of pain is critical, and therefore, understanding the various modalities physicians can use to help patients with refractory pain after TJA is essential. ⋯ The modalities by which chronic pain can be successfully managed include genicular nerve radioablation therapy (GN-RFA), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and peripheral subcutaneous field stimulation (PSFS). Meta-analyses and case reports have demonstrated the effectiveness of these treatment options in improving pain and functional outcomes in patients with chronic pain after TKA. The purpose of this paper is to review and synthesize the current literature investigating the different ways that refractory pain is managed after TJA, with the goal being to provide treatment recommendations for providers treating these patients.
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While traditionally encountered in ambulatory settings, bruxism occurs in patients with a variety of acute neurologic illnesses including encephalitis, intracerebral hemorrhage, traumatic brain injury, hypoxic-ischemic encephalopathy, and acute ischemic stroke. Untreated bruxism in acute neurologic illness can lead to tooth loss, difficulty in mouth care resulting in recurrent aspiration pneumonia, endotracheal tube dislodgement, and even tongue laceration or amputation. Inpatient clinicians should be aware of the etiologies and management strategies for bruxism secondary to acute neurologic illness. ⋯ Management strategies for bruxism are varied and include pharmacologic and non-pharmacologic therapies in addition to onabotulinumtoxinA (BoNT-A). Bruxism impacts patients with a variety of acute neurologic illnesses, and emerging evidence suggests successful and safe treatment strategies.
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Curr Pain Headache Rep · Apr 2021
ReviewNeurology of Preeclampsia and Related Disorders: an Update in Neuro-obstetrics.
Preeclampsia and related hypertensive disorders of pregnancy affect up to 10% of pregnancies. Neurological complications are common and neurologists often become involved in the care of obstetric patients with preeclampsia. Here, we review the definition(s), epidemiology, clinical features, and pathophysiology of preeclampsia, focusing on maternal neurological complications and headache as a common presenting symptom of preeclampsia. ⋯ Neurological symptoms are early and disease-defining features of preeclampsia. Neurological complications of preeclampsia may include headaches, visual symptoms, cerebral edema, seizures, or acute cerebrovascular disorders such as intracerebral hemorrhage or reversible cerebral vasoconstriction syndrome. A history of migraine is an independent risk factor for vascular diseases during pregnancy, including preeclampsia and maternal stroke. The pathophysiology of both preeclampsia and migraine is complex, and the mechanisms linking the two are not fully understood. Overlapping clinical and pathophysiological features of migraine and preeclampsia include inflammation, vascular endothelial dysfunction, and changes in vasoreactivity. Neurological complications are recognized as a major contributor to maternal morbidity and mortality. Pregnant and postpartum women commonly present with headache, and red flags in the clinical history and examination should prompt urgent neuroimaging and laboratory evaluation. A focused headache history should be elicited from patients as part of routine obstetrical care to identify patients at an increased risk of preeclampsia and related hypertensive disorders of pregnancy. Collaborative models of care and scientific investigation in the emerging field of neuro-obstetrics have the common goal of reducing the risk of maternal neurological morbidity and mortality from preeclampsia.
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Pain management in dermatologic conditions can be complicated by the primary disease burden and associated decreased quality of life, disability, and psychosocial issues. This review focuses on pain management strategies in some of the more painful dermatologic conditions. ⋯ Pain management in painful dermatologic conditions such as pyoderma gangrenosum, postherpetic neuralgia, lower limb ulcers, and hidradenitis suppurativa revolves around treatment of the underlying disease process. Topical agents such as topical steroids and systemic immunosuppressants with over-the-counter analgesics usually suffice in mild to moderate pain. Severe pain may need neuropathic agents and referral to interventional pain physicians for consideration of advanced techniques such as epidural steroid injections and sympathetic nerve blocks. Part of the treatment process is for dermatologists to establish patient expectations and to treat pain within their scope of practice. More research is needed towards pain control in painful dermatologic conditions with elucidation of treatment algorithms unique to each condition.
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This review explores the workings of the legal process in posttraumatic headache (PTH) claims by discussing representative court cases, the approaches taken by both plaintiff and defense attorneys in evaluating a client with PTH, and the role of the expert witness. This discussion also examines the question of whether or not litigation prolongs the symptoms of PTH and concussion, looking at the issues of malingering and the psychological effect of litigation. ⋯ Litigation prolongs recovery of PTH, primarily not from malingering but rather due to the psychological mindset of the plaintiff as created by the litigation process. Just as the medical community struggles with PTH diagnosis, mechanism, and treatment, the legal system grapples with identifying valid claims for PTH. Psychological support is an important component for PTH recovery to more effectively deal with the psychological impact of litigation and the concept of perceived injustice.