Neurologic clinics
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The reasonable clinical approach to the patient who has low back pain includes a search for any of the red flags that would prompt consideration of additional diagnostic testing for serious underlying disease. The common patterns of back pain would be explored in an effort to categorize the patient's symptoms and to begin formulation of a diagnostic impression. Re-evaluation of the patient in light of his response (or lack of response) to these measures is an essential component of the clinical assessment. Finally, some consideration must be given to the various biopsychosocial factors that may affect prognosis, particularly in patients who have more chronic pain and disability-related issues.
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Complex regional pain syndromes (CPRS) may develop as a disproportionate consequence of a trauma affecting the limbs without (CRPS I, reflex sympathetic dystrophy) or with (CRPS II, causalgia) obvious nerve lesions. The clinical picture of CRPS consists of asymmetrical distal extremity pain, swelling, and autonomic (sympathetic) and motor symptoms. Changes in the peripheral and central somatosensory, autonomic and motor processing, and a pathologic interaction of sympathetic and afferent systems are discussed as underlying pathophysiologic mechanisms. Therapeutic strategies include pharmacologic pain relief, sympatholytic interventions, and rehabilitation.
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Moderate to severe pain is a common feature of central and peripheral demyelinating disorders. Pain in multiple sclerosis tends to occur when the disease is well-established and usually lingers infinitely. ⋯ Pain syndromes are well-defined in each disorder based on the underlying pathophysiology. Treatment involves a variety of pharmacologic and nonpharmacologic approaches individualized for each specific pain syndrome.
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Although most acute conditions of the spine are benign and self-limited, the economic costs and disability resulting from these disorders have reached epidemic proportions in industrialized society. Recent scientific research to determine the causes of common spinal disorders, long attributed to structural abnormalities, have now implicated complex biochemical and neurophysiologic processes which may offer insights for future therapy interventions. This article reviews the functional and pathologic anatomy and correlates with current diagnostic and nonoperative management strategies for common mechanical spinal and radicular pain syndromes.
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Postherpetic neuralgia (PHN) is a neuropathic pain disorder that occurs most often in the elderly. This painful condition is uniquely suited for clinical research, resulting in an emerging understanding of the pathophysiology of the persistent pain. Until recently, only the tricyclic antidepressants proved effective for PHN. Controlled trials of a wide variety of therapeutic strategies are in progress or have been recently completed.