Pain practice : the official journal of World Institute of Pain
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Intrathecal drug delivery (IDD) is a proven and effective treatment alternative in carefully selected patients with chronic pain that cannot be controlled by a well-tailored drug regime and/or spinal cord stimulation (SCS), and may be specifically trialed in patients who fail to respond to SCS. While the lack of randomized controlled trials is often perceived as a limitation of IDD, many studies attest to the efficacy of this therapy, and a number are large-scale and with follow-up periods of up to five years. Good to excellent pain relief is achieved in many patients who have failed more conservative therapies, and there is often a reduced need for analgesia. ⋯ Some patients are able to return to work. The benefits of IDD (including a potent analgesic response with a more stable therapeutic drug level, decreased latency, increased duration of action, and decreased pharmacological complications) mean that side effects such as nausea, vomiting, sedation, and constipation are reduced. In addition, IDD demonstrates long-term cost-effectiveness when compared to conventional pain therapies, addressing a concern that affects many physicians in clinical practice today.
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Faced with rapidly escalating costs, healthcare policy makers are increasingly turning to research evidence to serve as a basis for their population-based decisions on access and funding of new and existing therapies-health technology assessment. A two-stage approach is often used to arrive at a policy recommendation for a given treatment. First, following a systematic review of literature, the "level of evidence" for the treatment is assessed according to epidemiological principles. ⋯ By including randomized controlled trials, a number of these systematic reviews indicate a high grade of evidence. Nevertheless, more pragmatic clinical trials are needed to address the evidence needs of healthcare policy makers. These trials should address a direct comparison of the relative effectiveness of neuropathic pain therapies, particularly in combination with other therapies and at different points in the disease course.
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To pilot the efficacy of mirtazapine for relief of phantom limb pain (PLP); to correlate the putative drug mechanism with theoretical PLP mechanisms; and to develop a rationale for further study of mirtazapine in this population. ⋯ Mirtazapine may be an effective treatment for PLP that can also potentially enhance sleep and mood. This information provides preliminary reinforcement for more formal, controlled studies concerning mirtazapine use in PLP.
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Postherpetic neuralgia (PHN) is defined as pain that persists 1 to 3 months following the rash of herpes zoster (HZ). PHN affects about 50% of patients over 60 years of age and 15% of all HZ patients. Patients with PHN may experience two types of pain: a steady, aching, boring pain and a paroxysmal lancinating pain, usually exacerbated by contact with the involved skin. ⋯ Although antiviral agents are appropriate for acute HZ, and the use of neural blockade and sympathetic blockade may be helpful in reducing pain in selected patients with HZ, there is little evidence that these interventions will reduce the likelihood of developing PHN. Postherpetic neuralgia remains a difficult pain problem. This review describes the epidemiology and pathophysiology of PHN and discusses proposed mechanisms of pain generation with emphasis on the various pharmacological treatments and invasive modalities currently available.
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Superior cluneal nerve (SCN) entrapment is one of the infrequent etiologies of low back pain (LBP), which is rarely diagnosed. Few clinical reports have been published in the literature. We present a case of severe LBP radiating to the ipsilateral buttock after decubitus surgery. ⋯ SCN entrapment should be considered in patients who suffer from LBP radiating to the iliac crest and buttock after other causes of LBP have been excluded.