Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Dec 2002
ReviewSteroid injections: effect on pain of spinal origin.
Pain originating from the spine is a common clinical problem that is often difficult to manage. This chapter considers the evidence supporting the use of corticosteroid injections for pain of spinal origin. Clinical problems considered in this review are radicular pain, zygapophyseal joint pain, discogenic pain and non-specific pain from the cervical, lumbar and thoracic spine. ⋯ Intradiscal and intra-articular injections in both lumbar and cervical spines have not been shown to be effective. Sacroiliitis responds well to intra-articular corticosteroids. There is insufficient evidence to support the use of atlanto-axial or atlanto-occipital joint injections.
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Best Pract Res Clin Anaesthesiol · Dec 2002
ReviewCellular mechanisms of opioid tolerance and the clinical approach to the opioid tolerant patient in the post-operative period.
The high prevalence of opioid use for recreational purposes in the USA and the European Union, as well as the use of opioids for the treatment of chronic non-malignant pain, has resulted in an increase in the number of patients with opioid tolerance who undergo surgery and require post-operative pain management. The approach to post-operative pain control in these patients is significantly different to the strategies used in opioid naïve patients. Fortunately, better understanding of the cellular mechanisms of opioid tolerance in animals has resulted in the transfer of concepts from the 'bench' to the clinical arena. This chapter describes the new developments in opioid tolerance and how this knowledge can be applied to clinical practice.
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Best Pract Res Clin Anaesthesiol · Dec 2002
ReviewEpidural and intrathecal analgesia for cancer pain.
The three-step analgesic ladder approach developed by the World Health Organization works well in treating the vast majority (70-90%) of patients suffering from pain related to cancer. In those patients who do not get pain relief by this three-step approach, intraspinal agents can be a fourth step in managing pain of malignant origin. ⋯ Many non-opioid agents have also been used intraspinally either alone or in combination with opioids in the treatment of intractable cancer pain. This chapter summarizes the clinical use of these agents with some practical points.
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Systemic administration of analgesic drugs is still the most widely used method for providing pain relief in acute painful situations. Opioids may be selected on the basis of their physicochemical characteristics and their diffusion index to the brain. But in clinical practice, their very steep concentration-analgesic effect relationship remains a critical aspect of opioid therapy. ⋯ CSIs may be beneficial in patients in whom post-operative bleeding is a major surgical risk as the effects of NSAIDs on coagulation may last for days. Finally, low-dose ketamine infusions remain a worthwhile addition to opioid therapy. Analgesic concentrations of ketamine are 1/5th to 1/10th the anaesthetic concentration and exert significant inhibition on N-methyl-d-aspartate (NMDA) receptor activation.
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Radiofrequency current is simply a tool used for creating discrete thermal lesions in neural pathways in order to interrupt transmission. In pain medicine, radiofrequency lesions have been used to interrupt nociceptive pathways at various sites. ⋯ Nevertheless, there is evidence that radiofrequency neurotomy has an important role in the management of trigeminal neuralgia, nerve root avulsion and spinal pain. In this chapter the evidence for efficacy and safety is reviewed and interrogated with special emphasis on the available randomized controlled trails and systematic review.