Articles: neuropathic-pain.
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Intrathecal drug delivery improves pain relief, reduces suffering, and enhances quality of life in the small proportion of patients who do not respond well to oral analgesics, including oral morphine. Although morphine is the "gold standard," and the only drug approved for intrathecal pain therapy in the United States, off-label use of alternative agents appears promising, particularly in patients with neuropathic pain. Careful patient selection and management are significant determinants of successful treatment outcomes. ⋯ In addition, all patients (those with cancer or nonmalignant pain) must exhibit a positive response to an epidural or intrathecal screening test. A multidisciplinary team approach, involving psychologists, nurses, physical therapists, social workers, and spiritual leaders should be used to manage patients. Current practices for patient selection and management, screening tests, and dosing guidelines for intrathecal drug delivery systems are discussed.
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Objective. Over the past two decades, with the increasing use of spinal instrumentation to treat deformity, surgical restoration has become more frequent. A complication of surgical reconstruction for adult scoliosis, the iatrogenic flat back syndrome, has been described. ⋯ Given the unpredictability of spinal osteotomy to address this pain, a possible alternative treatment strategy is presented. This involves the use of selective pharmaceutical therapy and spinal cord stimulation. Based on the response of this patient to spinal cord stimulation, it is a possible that a component of this persistent pain is neuropathic, despite the fact that preoperative imaging studies failed to disclose a significant compressive lesion.
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Neuropathic pain syndromes may be treated by intervention at the sympathetic nervous system. The pain in these syndromes is therefore called sympathetically maintained pain (SMP). Typical disorders with a SMP component are complex regional pain syndromes (reflex sympathetic dystrophy and causalgia), traumatic neuralgias and herpes zoster. ⋯ Open questions are how the efferent sympathetic nervous system is capable of influencing pain sensation and which mechanisms underly the autonomic dysregulation often observed in these syndromes.(1) Somatic afferents that project through the sympathetic trunk do not exist. Therefore, a pure sympathetic block does not block afferent information arising from the affected extremity. What alternatives are possible? Under pathophysiological conditions a functional interaction of efferent sympathetic fibers and afferent nociceptive fibers could be demonstrated in patients and animal studies. The intensity of this coupling varies considerably between individual patients and is not necessary for the diagnosis of the disorder. (2) Sympathetically maintained pain and signs of autonomic dysfunction are independent clinical and pathophysiological phenomena without any causal relation. However, it is possible to treat both the SMP and the autonomic dysfunction with sympathetic blocks.
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Objective and Importance. The subarachnoid infusion of narcotics by programmable devices in patients with chronic non-malignant pain can be a useful therapeutic method. However, certain side-effects, opioid tolerance or changes in the nature of the pain can lead to failure of the therapy. ⋯ The patient therefore needed alternative infusions of both drugs with changes of infusional parameters. Conclusion. The possibility of varying the infusion method of mixed drugs or alternating the drugs is fundamental for successful therapy since neuropathic pain must be considered a dynamic state.
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Objective. This study examines, in a retrospective fashion, the effects of intraspinal infusion therapy in 36 patients with pain of non-cancer origin. In those cases where pain was recalcitrant to the infused opiate and/or had a neuropathic component, a local anesthetic, tetracaine, was added. ⋯ Conclusion. The results support the potential utility of infusion therapy in the treatment of non-cancer pain. This treatment, however, is not without problems and should be applied judiciously and in the context of evolving guidelines.