Articles: neuralgia.
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A case of bilateral fenestration of the vertebral artery at the level of the atlas in a patient who had occipital neuralgia and cervical myelopathy is presented. MRI and vertebral angiogram demonstrated the fenestrated vertebral artery compressing the upper cervical cord. Surgical decompression for the C-1 and C-2 sensory roots and the upper cervical cord was performed. ⋯ However, considering the pathway of the fenestrated vertebral artery, it is quite possible that the fenestrated vertebral artery might compress the neural structures, resulting in some clinical problems. Although occipital neuralgia may result from a variety of causes, this case was caused by the fenestrated vertebral artery compressing the C-1 and C-2 sensory roots. The authors wish to emphasize that microsurgical vascular decompression may be the only effective treatment in such cases as well as in facial spasm and trigeminal neuralgia.
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Neurogenic pain (encompassing all types of neuropathic and central pain) is discussed. Experimental work is presented in a model in which the rat sciatic nerve is loosely ligatured. In painful human neuropathies, tricyclic antidepressants have been found to be effective in proportion to the degree they facilitate monoaminergic activity. ⋯ In nociceptive pain, recent findings in humans emphasize the importance of both the retroinsular (SII) and the anterior cingulate cortices in the conscious appreciation of pain. Opioid studies have revealed individual differences in the metabolism of morphine to its 3- and 6-glucuronosides; patients with nociceptive pain who respond poorly to morphine or diamorphine probably have a high 3:6 ratio. It has been pointed out that methadone may be useful in such cases, as it is not broken down to glucuronosides.
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Postherpetic neuralgia (PHN) is the most common and feared complication of herpes zoster. The more severe and painful the initial zoster outbreak, the more likely that PHN will develop, with elderly patients being at greatest risk. ⋯ Tricyclic antidepressants are the mainstay of treatment for established PHN, aided by transcutaneous electrical nerve stimulation, physical therapy techniques, and cautious use of other medications. Topical agents, such as capsaicin, aspirin, and lidocaine, may soon become one of the mainstays of therapy for PHN.
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Several pathophysiologic mechanisms are known which induce neuropathic pain in presence of peripheral nerve damage. They help to explain the clinical features of neuropathic pain syndromes and why causal and symptomatic treatments can be effective. However, careful analysis of every pain syndrome is necessary in order to select the type of pain management required.