Pain physician
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Microglial cells appear to play a vital role in the initiation of certain neuropathic pain states. In order to initiate neuropathic pain, microglia need to be activated. Microglia activation in the spinal cord involves both hypertrophy as well as hyperplasia, progressing through a hypertrophic morphology, with thickened and retracted processes (observed within the first 24 hours after nerve injury), and an increase in cell number (observed around 2-3 days after nerve injury). ⋯ These 5 pathways will be discussed and are identified by their main signaling mediator and/or receptor which include fractalkine, interferon-gamma, monocyte chemoattractant protein-1, TLR4, and P2X4. Thus, one or more of these mediators/pathways which lead to microglial activation might contribute to neuropathic pain. A greater appreciation of the roles of various mediators/paths which activate microglia might help lead to future novel therapeutic targets in efforts to ameliorate severe symptoms of neuropathic pain.
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Randomized Controlled Trial Multicenter Study
Efficacy of intrathecal midazolam with or without epidural methylprednisolone for management of post-herpetic neuralgia involving lumbosacral dermatomes.
Post herpetic neuralgia is a chronic neuropathic pain syndrome which remains one of the most difficult pain disorders to treat. Epidural injection of methylprednisolone with or without local anesthetic provides relief for neuralgia for a short duration only. Recent studies have shown a promising anti nociceptive effect for intrathecal midazolam, a water soluble benzodiazepine, due to its interaction with benzodiazepine-GABA-A receptor complex within the spinal cord. ⋯ The dose-response relationship of intrathecal midazolam was not evaluated in our study, so further study should be conducted with different doses of intrathecal midazolam for management of PHN.
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Review Case Reports
Root cause analysis of paraplegia following transforaminal epidural steroid injections: the 'unsafe' triangle.
The utilization rate of transforaminal epidural steroid injections (TFESIs), an elective diagnostic and therapeutic spinal procedure, has risen dramatically over the past decade. In 2006 alone, greater than 300,000 thoracolumbar TFESIs were performed on Medicare beneficiaries. Despite the purported superiority of the transforaminal route, compared to other modes of epidural injection, TFESIs are associated with potential hazards. ⋯ Injury to the ARM can lead to paraplegia, independent of operator skill or adjuvant safety initiatives (digital subtraction angiography, local anesthetic test dose). Injury to the ARM is a "black swan" event. The authors believe that catastrophic injury may be averted when performing TFESIs by avoiding the "un-safe," superoanterior triangle in the foramen and that transforaminal injections should be performed at the inferior aspect of the foramen, known as Kambin's triangle.
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Randomized Controlled Trial
Multi-day low dose ketamine infusion as adjuvant to oral gabapentin in spinal cord injury related chronic pain: a prospective, randomized, double blind trial.
Severe, intractable, chronic pain is a significant management problem for those involved in the long-term care of spinal cord injury (SCI) patients . Gabapentin, an anticonvulsant, is widely used for treating chronic pain. Ketamine, an NMDA receptor antagonist, has been available in clinical practice for 35 years. Its usefulness in pathological pain states is known. Despite this, no formal research on its effectiveness in treating neuropathic SCI pain exists. ⋯ Study size limited to 40 patients.
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Comparative Study
An evaluation of the diagnostic accuracy of liquid chromatography-tandem mass spectrometry versus immunoassay drug testing in pain patients.
Immunoassay screening is used by pain physicians to determine compliance with controlled substances. Because clinical use of pain medications is different from illicit drug use, there is a need to evaluate the level of diagnostic accuracy of this procedure for the pain patient. ⋯ We show that in general, immunoassay screening results are accurate, although as shown in this study there are many false negative observations. The use of LC-MS/MS technology significantly decreases the number of false negative results.