Articles: neuralgia.
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Several pathophysiologic mechanisms are known which induce neuropathic pain in presence of peripheral nerve damage. They help to explain the clinical features of neuropathic pain syndromes and why causal and symptomatic treatments can be effective. However, careful analysis of every pain syndrome is necessary in order to select the type of pain management required.
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The anticonvulsants, carbamazepine, clonazepam, phenytoin, and valproic acid are capable of depressing attacks of shooting pain in neuralgia. Shooting pain is perceived in trigeminal, intercostal, and other neuralgias, as a consequence of infectious diseases such as herpes zoster, and in the course of polyneuropathies of various causes. It is due to injury of nociceptive afferents, which generate bursts of activity in response to appropriate environmental changes. ⋯ Both carbamazepine and phenytoin block synaptic transmission of neuronal hyperactivity by a direct depressant action that includes reduction of sodium conductance and by activation of inhibitory control. Clonazepam and valproic acid act by enhancing GABA-mediated inhibition of synaptic transmission. Carbamazepine is by far the most widely used compound; phenytoin, clonazepam, and valproic acid are not so popular because of their side effects.
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Treatment of chronic pain disease is a scientific and clinical challenge encountered in all branches of medicine. Essential trigeminal neuralgia and chronic pain situations are noted for their exceptionally marked severity and also for their psychic and social consequences. It is not rare for a primarily somatic pain syndrome to develop into a painful disease in its own right, which is highly refractory to treatment. ⋯ Vincristine iontophoresis was applied in 33 patients hitherto unsuccessfully treated with various other methods. In 78% of the cases, attenuation of the pain was achieved. This noninvasive therapy proved to be free of side effects.
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A case history of therapy resistent trigeminal neuralgia was presented by Wechsung and Müller. This patient was previously treated without any succes with glycerol injections, "electrocauterisation", a Janetta operation and 2 reexplorations of the posterior fossa. Attempts with oral carbamazepine and baclofen were unsuccesful too. ⋯ The most succesful surgical procedure is the radiofrequency thermal lesion of the Gasserian ganglion (Sweet). Data from the literature from 8500 patients and own data (from over 600 patients) show that therapy resistance is very infrequent (0.5%). The costs of clinical implantation of a pump with intrathecally administered baclofen are 10-15 times higher than ambulant radiofrequency lesioning.