Articles: chronic-pain.
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After the initial clinical reports of Shealy 1967 dorsal column stimulation (DCS) was first introduced in Germany by Krainick (Freiburg) and Winkelmüller (Hannover) in 1972. At first, the success rate in unselected patients was unsatisfactory. The results improved with careful patient selection and better technical equipment allowing preliminary testing procedures before definitive implantation. ⋯ The best indications and target group are cases with radicular low-back pain after failed back surgery, stump and phantom pain, pain states following partial lesions of brachial/lumbar plexus and peripheral nerves, sympathetic dystrophy and rest pain in peripheral vascular disease (PVD). Possible indications for SCS are pain after incomplete lesions of spinal cord or cauda equina, postherpetic neuralgia, sclerodermia and PVD. Failures must be expected in pain states related to progressive malignant disease and complete deafferentation after spinal lesions or root avulsion.
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The rationale for the use of spinal cord stimulation (SCS) in the treatment of chronic pain arose from Melzack and Wall's gate theory of the control of pain (1965). Originally electrodes were placed directly on the spinal cord via open operation, while now they are placed by means of direct puncture the epidural space. ⋯ The implantation of an SCS system is a surgical procedure, which requires the highest standards in asepsis. The operation and its complications and ways of avoiding them are described.
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The chronic headache patients in our neurological outpatient department treated between 1985 and 1987 were retrospectively studied. One-third (n=44) were examined and questioned about the efficacy of treatment. Initial treatment in the outpatient department had been at least 2 years before the study, thus allowing evaluation of the long-term course of the illness. ⋯ Adequate consideration of the non-medical therapeutic elements should be ensured in such structures headache therapy. A uniform classification of headache and records of the course in the form of headache diaries are essential for comparing the results. A sufficiantly long post-therapy observation period should be allowed in order to facilitate evaluation of the therapeutic response.
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A consecutive series of 98 patients presenting at an orthopedic outpatient clinic with chronic low back pain of at least 6 months' duration and with no organic findings (ruled out by clinical and radiological examination) were evaluated by means of a questionnaire which included the constructs "patient history," "pain-related restrictions," and "depression." Pain perception was evaluated with an adjective list revealing four main factors: two affective factors, i.e., "suffering from pain" and "anxiety," and two sensory factors, i.e., "acuteness" and "rhythmics of pain." The two affective factors (as against the sensory factors) subsequently influence the degree of pain intensity (measured with a visual analog scale), the patient's history and the patient's perceived impairment of daily life. Depression (von Zerssen scale) correlated with pain factors only when the whole range of pain factors was considered. The implications for treatment in patients with a high score for affective factors in the adjective list (indicator for a low success rate with traditional therapy) are discussed.
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Dextropropoxyphene is a mild opioid analgesic whose analgesic potency corresponds to that of acetylsalicylic acid and paracetamol. It has a similar analgesic effect to codeine but also a considerably lower addiction and dependence potential. Dextropropoxyphene is a therapeutic alternative to other weak opioids such as codeine or dihydrocodeine. ⋯ Repeated administration of the sustained-release form at the therapeutically recommended intervals does not lead to cumulation, and the risk of accidental overdosage is extremely low. Intoxication can only occur after simultaneous ingestion of alcohol or other centrally depressant substances or in the presence of hepatic and/or renal failure. Sustained-release dextropropoxyphene is a sensible and undeniable alternative for the second stage in the analgesic ladder of chronic pain therapy.