Articles: chronic-pain.
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Epidural fibrosis is seen as a common phenomenon among postlumbar laminectomy syndrome patients, contributing to approximately 60% of symptom recurrence. Percutaneous epidural lysis of adhesions has been described as a modality to effectively manage chronic low back pain secondary to epidural fibrosis. Forty-five patients were randomly assigned, with fifteen patients in the control group, or Group I, who were treated with conservative modalities of treatments, including medication, physical therapy, and an exercise program; and, thirty patients in Group II, who were treated with percutaneous epidural adhesiolysis and hypertonic saline neurolysis. ⋯ The study also showed that overall health status improved significantly in the treatment group in all parameters with average pain, physical health, mental health, functional status, psychological status and narcotic intake. Analysis also showed that this is a cost-effective treatment, with cost for 1-year improvement of quality of life at $2693. In conclusion, epidural adhesiolysis with hypertonic saline neurolysis performed on a 1-day basis is an effective modality of treatment in managing chronic low back pain in patients who failed to respond to fluoroscopically directed epidural steroid injections and also were demonstrated not to have facet joint mediated pain.
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Postlumbar laminectomy syndrome, or pain following operative procedures of the lumbar spine, is increasingly a common entity in modern medicine. Multiple causes proposed for recurrence of pain after lumbar laminectomy are: epidural fibrosis, recurrent disc herniation, instability, and facet joints. Even though the prevalence of persistent low back pain secondary to the involvement of lumbosacral facet joints has been described in controlled studies from 15% to 45%, the prevalence of facet joint mediated pain in postlumbar laminectomy syndrome has not been studied. ⋯ Results showed that the prevalence of facet joint mediated pain in non-surgical patients was 44% compared to 32% in post surgical patients determined by comparative controlled local anesthetic blocks utilizing lidocaine and bupivacaine. This study also showed a false positive rate of 36% in non-surgical group and 24% in post-surgical group. In conclusion, this study shows that facet joint mediated symptomatology in chronic low back pain is prevalent, both in non-surgical as well as post-surgical patients even though prevalence was somewhat higher in the non-surgical group compared to post-surgical group.
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Elan Pharmaceuticals (formerly Neurex) is developing ziconotide, a neuron-specific N-type calcium channel blocker, for the potential treatment of severe pain and ischemia. A US NDA for the use of the compound in intractable pain is under review [351606,357600] and phase III trials for ischemia are ongoing [261455,292579]. Elan received an approvable letter from the FDA for pain in June 2000, and by October 2000, was responding to questions raised by the FDA in the letter [372580,386279]. In December 2000, DRAXIS filed an NDS for ziconotide with the Therapeutic Products Programme of Health Canada [393773]. The drug has Priority Review status in Canada [387218]. PAIN: In pivotal studies, ziconotide showed a significant reduction in pain compared to placebo. In the two trials, completed by December 1999, more than 700 patients received the drug for the treatment of intractable pain intrathecally. This included patients who had failed morphine therapy, or who had become intolerant of therapy due to side-effects. The drug was safe and well tolerated over periods as long as 3 years [351606]. ⋯ Elan and Pfizer (formerly Warner-Lambert) are also developing ziconotide for the treatment of ischemia associated with head trauma and stroke [292579]. In September 1997, Neurex and Warner-Lambert restarted a pivotal phase III head trauma study with no changes in the study design. In July 1997, patient enrollment had been halted pending analysis of clinical data from earlier studies to determine the relative risk/benefits of administering ziconotide with the current protocol [261455]. By April 1999, Parke-Davis (now Pfizer) was also working on the development of nonpeptide analogs of ziconotide, with the aim of developing an orally available agent for the treatment of chronic pain [325613,324954]. In July 2000, Merrill Lynch predicted FDA approval and launch in the third or fourth quarter of 2000 [375966], but in January 2001, the prediction of approval was revised to be in 2001 [395423].
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The practice guidelines for interventional techniques in the management of chronic pain are systematically developed statements to assist physician and patient decisions about appropriate health care related to chronic pain. These guidelines are professionally derived recommendations for practices in the diagnosis and treatment of chronic or persistent pain. They were developed utilizing a combination of evidence and consensus based techniques, to increase patient access to treatment, improve outcomes and appropriateness of care, and optimize cost-effectiveness. ⋯ These guidelines do not constitute inflexible treatment recommendations. It is expected that a provider will establish a plan of care on a case-by-case basis, taking into account an individual patient's medical condition, personal needs, and preferences, and the physician's experience. Based on an individual patient's needs, treatment different from that outlined here could be warranted.
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During the last 25 years, there have been substantial advances in our understanding of the physiology and pathophysiology of pain. The development of animal models that more closely mimic clinical pain in humans has helped elucidate the putative mechanisms by which chronic pain develops and is maintained. However, our increased understanding of the neurobiology of pain has not translated into breakthrough treatments for pain management. ⋯ This retrospective validation of "novel" analgesics in animal models of pain raises a question of the predictive validity of these models. This article reviews the use of several adjuvant and standard analgesics currently used to treat difficult-to-manage pain. What can these drugs teach us about the development of novel pain medicines? Within this context, the use of animal models of pain to predict analgesic efficacy in clinical pain conditions is considered.