Essentials of Pain Medicine

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Decks in this class (80)

Chapter 1 Anatomy and Physiology of Somatosensory and Pain Processing
KEY POINTS 1. The processes resulting in a noxious stimulus-inducing pain are transduction, transmission, modulation, and perception. 2. Nociceptors in the periphery respond to intense heat, cold, mechanical, or chemical stimuli, and encode the intensity, location, and duration of noxious stimuli. 3. The dorsal horn is anatomically organized in laminae. Unmyelinated C fibers terminate in Rexed’s laminae I and II, and large myelinated fibers terminate in the laminae III to V. 4. Two types of
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Chapter 2 Neurochemistry of Somatosensory and Pain Processing
KEY POINTS 1. The excitatory amino acids glutamate and aspartate are the key excitatory neurotransmitters in the somatosensory system. 2. The four types of excitatory amino acid receptors are the NMDA, AMPA, kainite, and metabotropic receptors. 3. GABA and glycine are the key inhibitory neurotransmitters. Substance P is the key excitatory neuropeptide in the somatosensory system. 4. The enkephalins and somatostatin are the key inhibitory neuropeptides in the somatosensory system.
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Chapter 3 Taxonomy: Definition of Pain Terms and and Chronic Pain Syndromes
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Chapter 4 Physical Examination of the Patient with Pain
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Chapter 5 Pain Assessment
KEY POINTS 1. Pain is a subjective, private, internal experience 2. While there is currently no “objective” measure of pain, a number of self-report pain assessment tools have proven to be valid and reliable 3. Specialized pain assessment scales are available for special populations (e.g., children) 4. Psychophysiologic, behavioral, and functional neuroimaging-based assessment methods cannot substitute for an individual’s self-reported pain experience 5. Biases in estimating another person’
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Chapter 6 Psychological Evaluation and Testing
KEY POINTS 1. Psychological evaluations for pain and disability typically include psychological testing and an interview. 2. Key domains for assessment include pain-related disability, negative affect, pain-related cognitions, coping strategies, psychopathology, and substance use. 3. Multidimensional instruments offer the potential of assessing selected key domains as well as social factors. 4. When interventional pain therapy is being considered, it is advisable to obtain a specialized psyc
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Chapter 7 Diagnostic and Statistical Manual of Mental Disorders and Pain Management
KEY POINTS 1. Somatoform disorders involve somatic complaints that cannot be explained by any general medical or neurologic condition, the effects of a substance, or a culturally sanctioned behavior. 2. Somatization disorder is a polysymptomatic entity beginning before 30 years of age, extending over a period of years, and is characterized by a constellation of pain, gastrointestinal, sexual, and pseudoneurologic symptoms. 3. Undifferentiated somatoform disorder involves one or more physical
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Chapter 8 Neurophysiologic Testing for Pain
KEY POINTS 1. Electrophysiologic studies are very sensitive indicators of central and peripheral nervous system involvement but do not indicate underlying disease. 2. EMG/NCV studies can identify the anatomic site of injury, the type of neurons or fibers involved, the nature of the pathologic alteration, and severity of injury. 3. In QST, cold threshold measures Ad fiber function, whereas warmth, heat pain, and cold pain thresholds reflect the function of C-fibers. 4. SSEPs provide a quantit
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Chapter 9 Anatomy, Imaging, and Common Pain-Generating Degenerative Pathologies of the Spine
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Chapter 10 Determination of Disability
KEY POINTS 1. Disability is a vaguely defined term that describes the inability to perform specific tasks or functions. 2. Impairment is an objective loss of function due to an injury or disease process. 3. Pain specialists require an understanding of disability terminology to provide objective ongoing or independent assessments of pain patients with disabilities and impairments
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Chapter 11 Major Opioids in Pain Management
KEY POINTS 1. With an informed and cautious approach, opioids may be safe and effective for treating moderate to severe pain of both malignant and nonmalignant origin. 2. Clinicians who choose to offer chronic opioid therapies must formulate rational and individualized regimens according to strategies such as those described by the FSMB and the APS/AAPM consensus guidelines. 3 Safe opioid therapy requires a program for continuous and close observation of analgesia and possible adverse effects
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Chapter 12 Opioids Used for Mild to Moderate Pain
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Chapter 13 Risk Stratification and Management of Opioids
1. The risk-benefit profile of long-term opioids should be carefully weighed in regard to risks for misuse or addiction, endocrine deficiencies, medical comorbidities such as sleep-disordered breathing, and the development of heightened pain sensitivity. 2. Every clinician who provides opioids should be familiar with risk factors for opioid misuse or addiction, screen patients accordingly, and set a level of clinical monitoring and reassessment appropriate to the degree of risk, which may cha
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Chapter 14 Legal and Regulatory Issues in Pain Management
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Chapter 15 Psychopharmacology for Pain Medicine
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Chapter 16 Membrane Stabilizers
1. In neuropathic pain, there is altered processing and changes in central modulation. These include pathologic activity in injured nerves (resulting in hyperexcitability, spontaneous and evoked pain), loss of C-fibers, sprouting of the large fibers in the outer laminas of the dorsal horn where the nociceptive-specific neurons are located (resulting in allodynia), and increased activity in the sympathetic nervous system. 2. Some of the molecular changes in neuropathic pain include the accumulat
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Chapter 17 Nonopioid Analgesics: NSAIDs, COX-2 Inhibitors, and Acetaminophen
1. NSAIDs are antihyperalgesic compounds with antiinflammatory activity determined by their ability to decrease prostaglandin formation through inhibition of COX following tissue injury. 2. There are two major isoforms of COX. COX-1 is largely constitutive and is responsible for the production of prostaglandins involved in homeostatic processes in the stomach (gastric protection), lung, and kidney, and in platelet aggregation. COX-2 is an inducible form created in the presence of inflammation,
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Chapter 18 Myofascial Pain
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Chapter 19 Pharmacology for the Interventional Pain Physician
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Chapter 20 Diagnostic Nerve Blocks
1. Pain relief after local anesthetic blockade does not reliably predict successful neurodestructive surgery, that is, long-lasting analgesia without deafferentation pain. 2. Prognostic local anesthetic blocks may be used to evaluate patients for neurolytic block. A negative response to blockade may be extremely valuable in preventing an unnecessary neurodestructive procedure. 3. Relief of neuropathic pain with intravenous lidocaine appears to predict potential responders to oral mexiletine t
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Chapter 21 Neurosurgical Procedures for Treatment of Intractable Pain
1. Ablative techniques have been used for many decades to control intractable pain. While they continue to have some well-defined indications, they have largely been replaced by neurostimulation procedures. 2. The results of ablative procedures for pain tend to be highly variable, with a substantial proportion of patients obtaining relief early and then experiencing recurrence of pain. 3. Ablative procedures such as cordotomy may be useful in treating pain of malignant origin, given the limite
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Chapter 22 Physical Medicine and Rehabilitation Approaches to Pain Management
KEY POINTS 1. Pain management is the first step in restoration of function. Functional improvement is not always synonymous with alleviation of pain. 2. Physical modalities (ultrasound, hot packs, etc.) may be of benefit in acute pain situations. Chronic use of these interventions should be discouraged. 3. Exercise treatment is a helpful adjunct in treating patients with all types of pain disorders. Exercise programs should include flexibility, muscle strengthening, and aerobic exercise. 4.
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Chapter 23 Acupuncture
KEY POINTS 1. AP and related techniques trigger a sequence of events that involves the release of endogenous opioid-like substances, monoamine neurotransmitters (e.g., serotonin and norepinephrine), expression of c-fos in CNS, and potential reversal of neuroplasticity in animal models. 2. EA of 2 Hz accelerates the release of enkephalin, beta-endorphin, and endomorphin, while EA of 100 Hz selectively increases the release of dynorphin. 3. PENS and AP-like TENS may present potential applicati
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Chapter 24 Psychological Interventions for Chronic Pain
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Chapter 25 Substance Use Disorders and Detoxification
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Chapter 26 Pain Management in the Emergency Department
KEY POINTS 1. Pain is the most common complaint seen in the emergency department. The emergency physician must ensure that patients in pain are treated with appropriate analgesics as soon as is feasible. 2. With modern diagnostic modalities, such as CT scanning, there is no reason to withhold pain medications for patients with abdominal pain. The goal is to reduce the pain for patients while they are undergoing diagnostic evaluation. Oversedation should be avoided to enable reliable physical
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Chapter 27 Preemptive Analgesia
1. Postoperative pain results from peripheral and central sensitization. 2. The NMDA receptor responds to glutamate, an excitatory amino acid. 3. The concept of preemptive analgesia is the perception that therapies can be applied prior to a noxious event in order to prevent or reduce the magnitude and duration of postinjury pain and/or the development of chronic pain. 4. The concept of preventive analgesia is using antinociceptive treatment to cover the entire period of highintensity noxiou
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Chapter 28 Perioperative Nonopioid Infusions for Postoperative Pain Management
KEY POINTS 1. Most of the randomized studies on perioperative intravenous (IV) ketamine infusion showed beneficial effects. The surgeries studied included abdominal, gynecologic, or spine surgery. 2. Ketamine IV infusion appears not to be beneficial when total IV anesthesia is the technique of intraoperative anesthesia. 3. The addition of a ketamine infusion in patients who had patient-controlled epidural analgesia resulted in less opioid requirement and probably a lower incidence of chroni
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Chapter 29 Patient-Controlled Analgesia
KEY POINTS 1. Patient-controlled analgesia is a programmable delivery system by which patients self-administer predetermined doses of analgesic medication at the push of a button. PCA can optimize drug delivery and improve satisfaction by enabling patients to titrate analgesia. 2. Safe use of PCA requires the patient to control analgesic delivery. Increasing plasma concentrations of opioid usually cause sedation prior to causing clinically significant respiratory depression. Sedation usually
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Chapter 30 Intrathecal Opioid Injections for Postoperative Pain
KEY POINTS 1. The pharmacologic properties of IT opioids reflect the extent of the hydro- versus lipophilicity of the specific opioid: lipophilic opioids (fentanyl and sufentanil) have a shorter onset and duration of action, whereas hydrophilic duration of action (and certain side effects such as delayed respiratory depression). 2. Like opioids administered by other routes, IT opioids may result in widely recognized opioid-related side effects such as nausea, vomiting, pruritus, sedation, and
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Chapter 31 Epidural Opioids for Postoperative Pain
KEY POINTS 1. As is seen with intrathecal opioids, the pharmacologic properties of epidurally administered opioids reflect the extent of the hydro- versus lipophilicity of the specific opioid: lipophilic opioids (fentanyl and sufentanil) have a shorter onset and duration of action whereas hydrophilic opioids (morphine, hydromorphone) have a delayed onset and prolonged duration of action (and certain side effects such as delayed respiratory depression). 2. Epidural opioids exhibit the same sid
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Chapter 32 Intra-Articular and Intraperitoneal Opioids for Postoperative Pain
KEY POINTS 1. IA morphine, in some studies, has been shown to provide improved analgesia after knee arthroscopy when compared to local anesthetic alone or to saline placebo. 2. IA morphine may be more beneficial for use in “high inflammatory” arthroscopic knee surgery (e.g., anterior cruciate ligament reconstruction, lateral release, patellar shaving, and plicae removal) than for use in “low-inflammatory” surgery (knee arthroscopy for meniscectomy). 3. IA morphine has not shown promising res
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Chapter 33 Continuous Peripheral Nerve Blocks
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Chapter 34 Pediatric Postoperative Pain
KEY POINTS 1. Anatomic and physiologic differences in neonates and young infants necessitate lower doses of epidural local anesthetics and intravenous opioids up to 4 to 6 months of life. 2. Behavioral or physiologic measures of pain intensity are available for infants and children unable to selfreport their pain. 3. Aspirin is not routinely used for postoperative pain control in children because of an association with Reyes syndrome, a potentially fatal hepatoencephalopathy. 4. Epidural ana
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Chapter 35 Chronic Pain after Surgery
KEY POINTS 1. Chronic pain after surgery is common. 2. Risk factors include patients with preexisting pain, psychosocial factors, age, gender, and possibly genetic susceptibility. 3. CPSP can be prevented using good surgical technique (avoiding nerve damage and using minimally invasive techniques) and aggressive multimodal analgesia starting immediately prior to surgery. 4. Future strategies should include more consistent use of multimodal analgesia across surgical populations and screenin
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Chapter 36 Pain Management during Pregnancy and Lactation
KEY POINTS 1. Pain is frequent during pregnancy and lactation. Many women suffer from pelvic girdle pain and back pain. 2. Physiologic changes during pregnancy may alter drug pharmacokinetics and pharmacodynamics. 3. Most drugs cross the placenta and cross into breast milk. 4. Drug effects on the fetus may be direct or indirect (effect on the mother). 5. Efforts should be made to minimize maternal exposure to drugs during pregnancy and lactation. 6. Possible adverse effects of in utero dr
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Chapter 37 Pain Control in the Critically Ill Patient
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Chapter 38 Migraine Headache and Cluster
KEY POINTS 1. The incidence of migraines in females increases into the early forties. 2. Consuming more than about 400 mg of caffeine per day can predispose to chronic migraines. 3. Basilar migraine can present with mental status changes. 4. Vasoconstrictor drugs, such as triptans, are contraindicated in basilar migraine. 5. Analgesic overuse (use of analgesics 10 or more days per month) can lead to chronic daily migraine. 6. The trigeminal autonomic cephalalgias include cluster, hemicr
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Chapter 39 Tension-Type Headache, Chronic Tension-Type Headache, and Other Headache
KEY POINTS 1. Chronic tension-type headaches are frequently caused by analgesic overuse, that is, using analgesic medication 10 or more times per month. 2. Prophylactic medication usually does not work in the setting of analgesic overuse headache. 3. “Sinus headaches” are rarely that; they usually represent analgesic overuse or parasympathetic symptoms of a milder migraine. 4. Sleep-disordered breathing can cause headaches, particularly in patients whose sleep architecture is disrupted or s
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Chapter 40 Postmeningeal Puncture Headache and Spontaneous Intracranial Hypotension
KEY POINTS POSTDURAL PUNCTURE HEADACHE 1. The crucial components of PDPH are a history of dural/ arachnoid puncture and a postural bilateral headache on examination. 2. The occurrence of headache after dural/arachnoid puncture is not directly related to the amount of CSF leaked or the subarachnoid pressure. The headache may be secondary to a sudden alteration in CSF volume and subsequent cerebral vasodilatation. 3. Concomitant intracranial pathology may be present in patients with PDPH. The
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Chapter 41 Cervicogenic Headache
KEY POINTS 1. Cervicogenic headache is referred pain from cervical structures innervated by the upper three cervical nerves. 2. The diagnostic criteria of cervicogenic headache, according to the International Headache Society, include the following: (1) pain referred from a source in the neck, (2) evidence of a disorder within the cervical spine or soft tissues of the neck as a cause of the headache, (3) abolition of the headache following a diagnostic block, and (4) resolution of the pain
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Chapter 42 Orofacial Pain
KEY POINTS 1. Diagnosis guides management; an algorithmic approach is necessary to treat patients with headache and facial pain. Accurate diagnosis requires knowledge of the ICHD-2 criteria, and stepwise elimination of primary and secondary headaches. 2. Red flags in the history and physical examination require further investigation. 3. Treatment centers on preventive and abortive strategies. The appropriate timing for interventional treatment needs to be measured against the severity of th
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Chapter 43 Overview of Low Back Pain Disorders
KEY POINTS 1. Spinal pain is prevalent in general population, and it is considered the most common reason for lost work time, workers’ compensation claims, and early social security disability. 2. Acute spinal pain is typically self-limiting, whereas chronic spinal pain could often be persistent, recurring, and frequently associated with psychosocial, behavioral, and substance abuse– and disability-related issues. 3. Intervertebral disc cells function in a precarious anaerobic environment
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Chapter 44 Interlaminar Epidural Steroid Injections for Lumbosacral Radicular Pain
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Chapter 45 Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections
KEY POINTS 1. Epidural steroid injections are indicated in patients with lumbosacral radiculopathy. The beneficial effect of the steroids is secondary to its anti-inflammatory effect and specific antinociceptive effect. The antiinflammatory effect is probably related to inhibition of phospholipase A2. Local application of methylprednisolone inhibits the transmission of impulses through the C-fibers but not in the Ab fibers. 2. Epidural steroids are more effective in patients with acute lumb
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Chapter 46 Facet Syndrome: Facet Joint Injections, Medial Branch Blocks, and Radiofrequency Denervation
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Chapter 47 Pain Originating from the Buttock: Sacroiliac Joint Syndrome and Piriformis Syndrome
KEY POINTS 1. Sacroiliac joint pain can be caused by intra- and extraarticular causes. 2. Several tests confirm the diagnosis of SI joint syndrome. An analgesic response to an SI joint injection is the most accurate means to diagnose a painful SI joint complex. 3. Corticosteroid injections may provide short or intermediate-term relief in well-selected patients but evidence for long-term benefit is mainly anecdotal. 4. There is moderate evidence supporting RF denervation to treat pain arising
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Chapter 48 Myofascial Pain Syndrome
KEY POINTS 1. Myofascial pain syndrome is a type of regional soft tissue pain syndrome involving muscles of the trunk and extremities. 2. Although myofascial pain may generalize, it remains distinct from fibromyalgia. 3. Hyperirritable loci of trigger points have been found to contain vasoactive mediators, algogenic neurotransmitters, and inflammatory mediators. 4. Excessive acetylcholine leakage has been hypothesized to contribute to dysfunctional motor end plates, creating the sustained
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Chapter 49 Fibromyalgia
KEY POINTS 1. Fibromyalgia can be considered a discrete condition as well as a construct to help explain how/why individuals have multifocal pain and other somatic symptoms in spite of the lack of nociceptive input (i.e., peripheral damage/inflammation) that adequately accounts for the pain. 2. The primary abnormality identified to date in FM and related pain syndromes is an increased gain or volume control in CNS pain processing (i.e., secondary hyperalgesia/allodynia). 3. It is likely that
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Chapter 50 Complex Regional Pain Syndrome
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Chapter 51 Herpes Zoster and Postherpetic Neuralgia
KEY POINTS 1. Herpes zoster (shingles) is caused by reactivation of the varicella-zoster virus (VZV), which establishes latency in sensory ganglia after primary infection (chicken pox). 2. The characteristic unilateral dermatomal vesicular rash of herpes zoster heals within 2 to 4 weeks and is accompanied by pain in the majority of patients. 3. Older age is associated with an increased risk of herpes zoster because of an age-associated decline in VZVspecific cell-mediated immunity. 4. Antivi
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Chapter 52 Postamputation Pain
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Chapter 53 Central Pain States
KEY POINTS 1. Central pain states are common sequelae of SCI and stroke. 2. Pathophysiology of central pain is not understood. 3. Alterations in several neurotransmitters occur, including glutamate, GABA, norepinephrine. 4. Involvement of the spinothalamocortical pathway is strongly supported by animal models, but the precise pathway in humans is unknown. 5. The three components of central pain (steady dysesthetic, intermittent neuralgic, and evoked) must all be treated. In central pain o
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Chapter 54 Pelvic Pain
KEY POINTS 1. Chronic pelvic pain (CPP) usually persists for more than 6 months. Even after a thorough evaluation, the etiology of the pain may remain obscure, and inconsistency remains in the pathology of various disorders and pain. 2. The prevalence of female pelvic pain is estimated to be one in seven women of reproductive age. Internationally, the prevalence of CPP is equivalent to that of asthma, back pain, or migraine. 3. Both diagnosis and management of these patients require good in
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Chapter 55 Painful Peripheral Neuropathies
KEY POINTS 1. Neuropathic pain arises from disorders of the peripheral nervous system. Although there are many etiologies of peripheral neuropathy, not all of which always produce pain, the most prominent and common is diabetic neuropathy. 2. Many mechanisms have been proposed for the pain that occurs in peripheral neuropathic states. They can be categorized into peripheral and central. Peripheral mechanisms proposed include: formation of ectopic foci, formation of ephapses (unlikely), rele
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Chapter 56 Entrapment Neuropathies
KEY POINTS 1. When an entrapment neuropathy is clinically suspected, electrodiagnostic testing should be performed to confirm the diagnosis and exclude other neurologic diseases including “double crushes.” 2. Pressure in the carpal tunnel increases with flexion and extension of the wrist, often provoking symptoms. 3. The ulnar nerve is most vulnerable to impingement at the humeroulnar aponeurotic arcade, also called the cubital tunnel, or just a few centimeters proximally across the ulnar g
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Chapter 57 Chronic Pain Management in Children and Adolescents
KEY POINTS 1. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) group recently recommended outcome domains and measurement tools for research on pediatric acute and chronic pain. 2. The management of complex regional pain syndrome includes physical therapy, regional blocks, pharmacological management, and psychological interventions. 3. Several characteristics of headache suggest a pathological or more serious etiology. 4. The management of headache in
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Chapter 58 Geriatric Pain
KEY POINTS 1. As the number of older adults living with chronic conditions continues to increase physicians in all disciplines will need to be adept at the management and treatment of the older patient in persistent pain. 2. Pain may present subtly in older adults as changes in mobility or activity level, mood, sleep, and/or appetite. These symptoms constitute the older adult’s pain signature and represent pain treatment outcomes. 3. Effective pain treatment requires differentiating the weak
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Chapter 59 Interventional Techniques for Pain Management
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Chapter 60 Pulsed Radiofrequency, Water-Cooled Radiofrequency, and Cryoneurolysis
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Chapter 61 Spinal Cord Stimulation
KEY POINTS 1. Neurostimulation mechanisms of analgesia are poorly understood, but it appears to interrupt transmission of nociceptive signaling via interneural inhibition at the substantia gelatinosa and modulation of spinal cord neurotransmitters. Neurostimulation is effective for many neuropathic pain conditions but careful patient selection with a multidisciplinary perspective is valuable to ensure higher rates of successful implantation. 2. There are multiple choices for leads and power g
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Chapter 62 Peripheral Nerve Stimulation
KEY POINTS 1. Peripheral nerve stimulation systems can be trialed prior to permanent implantation with an ultrasoundguided placement. 2. The long-term safety of permanent implants of percutaneous electrodes is not yet known with certainty. 3. Although percutaneous ultrasound-guided PNS is similar to peripheral nerve catheter placement for perioperative nerve blockade, the larger size of the needle and potential areas of placement are quite different. These differences mandate a very strict an
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Chapter 63 Implanted Drug Delivery Systems for the Control of Chronic Pain
KEY POINTS 1. Intraspinal therapy restricts drug effects to regions associated with the source of the nociceptive input. 2. Morphine and hydromorphone are well suited for intrathecal use in view of their hydrophilicity and slow absorption from the cerebrospinal fluid. Morphine, hydromorphone, and ziconotide are the first-line agents in intrathecal drug therapy. The inclusion of ziconotide as a first line drug is secondary to the randomized, double-blind placebo-controlled studies showing its
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Chapter 64 Discography
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Chapter 65 Intradiscal Techniques: Intradiscal Electrothermal Therapy, Biacuplasty, Percutaneous Decompression Techniques
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Chapter 66 Osteoporosis, Vertebroplasty, and Kyphoplasty
KEY POINTS 1. Osteoporosis and VCFs are a significant public health concern with high morbidity. 2. Vertebral augmentation is a safe and efficacious procedure for treatment of painful VCFs that fail conservative therapy. 3. Proper technique and vigilance can help avoid serious complications and the procedure should only be performed by those trained and experienced with the procedure. 4. Both kyphoplasty and vertebroplasty are efficacious for pain relief, but recent double-blind, placebo-
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Chapter 67 Ultrasound-Guided Sympathetic Blocks: Stellate Ganglion and Celiac Plexus Block
KEY POINTS 1. Celiac plexus is supplied by the greater, lesser, and least splanchnic nerves originating from the T5–T12. 2. Celiac plexus is made up of a few ganglia and interconnecting nerves and is located adjacent to the junction of the celiac artery and the aorta. 3. Ultrasound guidance for the performance of neurolytic celiac plexus block permits an anterior approach with relative safety and without radiation. 4. Ultrasound guidance is real time and may avoid accidental neurolytic in
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Chapter 68 Fluoroscopy and Radiation Safety
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Chapter 69 Approach to the Management of Cancer Pain
KEY POINTS 1. Successful treatment of cancer pain is possible most of the time. 2. The cancer pain syndrome should be determined: nociceptive, neuropathic, or mixed. 3. Cancer pain should be assessed and managed within the dimensions of suffering that a patient and his or her family experience: physical, psychological, social, and spiritual. 4. Daily evaluation includes an assessment of the location, type, temporal profile, and severity of each significant pain. 5. The World Health Organiza
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Chapter 70 Management of Pain at End of Life
KEY POINTS 1. All physicians, regardless of specialty, are responsible for care of patients with life-threatening illnesses. 2. Assessment of pain and other symptoms at end of life requires knowledge of common syndromes, as well as skill to conduct a thorough history and physical examination, with particular attention to the neurologic evaluation. 3. Complex pain syndromes require novel drug therapies, in addition to standard nonopioid, opioid, and adjuvant analgesics. 4. Adequate pain contr
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Chapter 71 Neurolytic Visceral Sympathetic Blocks
KEY POINTS 1. Neurolytic blocks of the sympathetic axis are an important adjunct to pharmacologic therapy for the relief of severe visceral pain experienced by cancer patients. The goal of performing these blocks is to maximize the analgesic effect of opioid and nonopioid analgesics while reducing their dosage to alleviate untoward side effects. 2. Neurolytic celiac plexus block for patients with pancreatic cancer pain results in excellent analgesia, reduced opioid utilization, and decreased
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Chapter 72 Central and Peripheral Neurolysis
KEY POINTS 1. Neurolytic therapy should only be considered after other pain modalities have been exhausted. These therapies are usually reserved for patients with terminal disease. Very clear therapeutic goals and limitations need to be communicated between patient and practitioner. 2. Neurolytics can offer patients the ability to decrease their systemic pain medications that can improve their quality of life and allow them the opportunity to clearly communicate with loved ones during diffi
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Chapter 73 Head and Neck Blocks
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Chapter 74 Brachial Plexus Blocks: Techniques Above the Clavicle
KEY POINTS 1. The C4 nerve root contributes to about two-thirds of brachial plexuses and shifts the plexus cephalad (prefixed plexus). The T2 nerve root contributes to about one-third of plexuses and shifts the plexus caudad (postfixed plexus). 2. The minimum distances from the skin to the C6 vertebral foramen and to the spinal cord are 23 mm and 35 mm, respectively, implying that inserting a needle for interscalene brachial block to a depth of less than 25 mm may result in nerve root contact
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Chapter 75 Brachial Plexus Blocks: Techniques Below the Clavicle
KEY POINTS 1. There were no currently described techniques of brachial plexus block that rely upon blockade at the level of the divisions of the plexus until the advent of US guidance. 2. It has been demonstrated that the capacity of the axillary perivascular sheath is 42 ml. 3. Axillary and infraclavicular blocks of the brachial plexus are appropriate for surgeries of the upper extremity from the elbow to the fingers. 4. Paresthesias occur in up to 40% of cases of axillary perivascular
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Chapter 76 Truncal Blocks: Intercostal, Paravertebral, Interpleural, Suprascapular, Ilioinguinal, and Iliohypogastric Nerve Blocks
KEY POINTS 1. When compared to epidural analgesia for thoracotomy, paravertebral blocks with catheters provide equipotent analgesia with a lower incidence of pulmonary complications, hypotension, urinary retention, nausea and vomiting, and failure rate. 2. A single injection of 15 ml in a thoracic paravertebral space can be expected to provide analgesia over 3 to 4.6 dermatomes, with a preferential caudad spread of injectate. 3. Ultrasound imaging usually underestimates the distance to the tr
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Chapter 77 Blocks of the Lumbar Plexus and its Branches
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Chapter 78 Sciatic Nerve Block and Ankle Block
KEY POINTS 1. The sciatic nerve is the largest nerve in the body and innervates the entire leg below the knee and the foot, except for its medial aspect, which is innervated by the saphenous nerve. Its two divisions, the tibial nerve and the peroneal nerve, while separate entities, are covered by a continuous connective tissue sheath. 2. The sciatic nerve can be blocked at different levels along its entire length as it exits the pelvis at the greater sciatic foramen to its termination in the p
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Chapter 79 Peripheral Sympathetic Blocks
KEY POINTS 1. The stellate ganglion is located just anterior or lateral to the longus colli muscle between the base of the seventh cervical transverse process and the neck of the first rib. 2. The appearance of Horner’s syndrome does not signify sympathetic blockade of the upper extremity. 3. The evidence for the efficacy of stellate ganglion blocks is based mostly on case reports. 4. The risks of potential complications with stellate ganglion blocks are rare, but real, and may be decreased
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Chapter 80 Anticoagulants and Neuraxial and Peripheral Nerve Blocks
KEY POINTS 1. Some 50% of DVTs after total joint surgery begin intraoperatively; the highest incidence occurs during surgery and the first postoperative day. Almost 75% of DVTs develop within the first 48 hr after surgery. 2. Case reports of intraspinal hematoma after aspirin and NSAIDs had complicating factors such as concomitant administration of other anticoagulant, epidural vascular abnormalities, and technical difficulties. The intake of different antiplatelet medications has been identif
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otc medicine mod 4 - pain and analgesia
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Decks: Nsaids, Opioid Analgesics, Musculoskeletal Injuries, And more!
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