The Clinical journal of pain
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The objective was to examine the evidence to determine the optimal management of phantom limb pain in the preoperative and postoperative phase of amputations. ⋯ Although up to 70% of patients have phantom limb pain after amputation, there is little evidence from randomized trials to guide clinicians with treatment. Evidence on preemptive epidurals, early regional nerve blocks, and mechanical vibratory stimulation provides inconsistent support for these treatments. There is currently a gap between research and practice in the area of phantom limb pain.
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The case here presented adequately reflects the difficulties involved in the treatment of pain in patients where the neuropathic component of pain predominates, and shows the different therapeutic steps that may be taken-from surgery and radiotherapy, to the administration of different drugs via the spinal route, to, finally, the presently little-used option of a direct intraventricular access. ⋯ Spinal tumors are infrequent, but pose great difficulties for the management and control of the pain they cause. The utility of the spinal route as an early approach for the provision of adequate analgesia seems clear. However, it also appears to lose efficacy with time, and dose incrementing and/or the addition of drugs that enhance the analgesic action of morphine are not always effective. In such selected cases, the intraventricular route may constitute a useful alternative, allowing improved symptoms control with lower morphine doses, and the use of the system previously implanted for intrathecal spinal infusion.
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Clinical Trial
Painful polyneuropathy in patients with and without diabetes: clinical, neurophysiologic, and quantitative sensory characteristics.
To study pain characteristics and peripheral nerve involvement in patients with painful diabetic and nondiabetic polyneuropathy in comparison with patients with non-painful polyneuropathy. ⋯ Neuropathy pain was always located in the feet and more severe in diabetic patients compared with patients with neuropathy pain of other etiologies. The authors also found evidence for a greater tactile sensibility involvement in patients with neuropathy pain, irrespective of etiology, whereas other quantitative sensibility and neurography parameters were equally affected in all patient groups.
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The objective was to present new visual sensorimotor findings in a patient with complex regional pain syndrome type I, formerly known as reflex sympathetic dystrophy. ⋯ The patient manifested signs and symptoms of complex regional pain syndrome type I per the prior neurologic diagnosis, as well as the newly diagnosed accommodative infacility, accommodative insufficiency, convergence insufficiency, and deficits of saccades and pursuits, which were severely debilitating. The findings neither support nor refute the conventional notion of abnormal sympathetic mediation as a mechanism of fatigue and pain. However, the diagnoses of accommodative infacility and insufficiency suggest abnormal parasympathetic activation. Further investigation is needed to characterize the array of visual dysfunctions in a large sample of such patients, which may help elucidate the precise underlying neurologic causes of the sensorimotor deficits in these patients.