Seminars in Pain Medicine最新文献

A child is not a “little adult” and many developmental and individual factors affect headaches; these pertain to the clinical expression, diagnosis, and therapy of the primary headache. Accordingly, several aspects must be clarified by: considering the child as a whole in his or her development; taking into account neurobiologic and psychologic maturational processes and familial, social, and environmental factors; and avoiding an adult-focused approach to the disease. Key information in the etiology, pathogenesis, diagnosis, treatment, and outcome of childhood headache must be obtained. Both diagnosis and therapy need to take into account age-related factors.

Interspinal drug delivery via pump for chronic pain and spasticity is only part of a more comprehensive patient management program for the long-term success of therapy. This therapy should not be relied upon solely, but rather used in conjunction with other rehabilitative modalities during long-term patient management. Physicians who manage these devices should be able to answer questions that arise from patients or other health-care providers regarding activity restrictions or other limitations imposed by this therapy. They should be able to recognize and treat side effects that arise from drugs used in the pump and complications related to the pump system. Physicians should also have a clear plan of action for patients whose symptoms are not well controlled. This review assesses the long-term management of patients who receive this therapy.

There is a growing need and concern to identify appropriate therapeutic approaches to the pain patient demonstrating behaviors suggestive of “addiction.” A proper and common understanding of terms, definitions, and how these behaviors influence pain perception and therapy is gradually evolving. Intraspinal therapy may have a unique role in the treatment algorithm as it often eliminates the cues, ie, access to pain pills, that may trigger addictive behavior. Although possible, it is also much more difficult to abuse or divert opioids delivered by a drug administration system. Whether or not infusing opioids into the spine is likely to activate the “addictive process” and what patients are best suited for this therapy remain unclear. This paper presents some considerations and suggestions along with one possible approach to pre-implant trialing.

Spasticity is a frequent symptom of central nervous system disorders, and in many patients has a significant subjective and objective impact. Intrathecal baclofen (ITB) therapy is increasingly utilized to treat severe spasticity refractory to oral antispasticity medications, based on a growing body of evidence demonstrating its efficacy in various conditions. Because ITB involves significant risks, careful patient selection, thorough multidisciplinary patient evaluation and education, treatment planning, standardized surgical techniques, and aggressive management are required to maximize treatment benefits. Further research is needed to explore the long-term effects of ITB on function and subjective health status.

Economic considerations for intrathecal morphine pump versus alternative therapy (medical management) in chronic and cancer pain can be assessed with different economic models such as cost-minimization, cost-effectiveness, and cost-benefit analyses. The objective of each model is to estimate the direct cost of an intrathecal morphine pump as compared with other systemic treatments. The purpose of this study is to determine cost factors for various routes of delivery, particularly with regard to hospital stay, charges relating to the operation, staff salaries, postoperative care including pump replacement, routine hospital check-ups, and other possible complications that require medical care.

Despite advances in understanding the pathophysiology of pain associated with cancer and the implementation of aggressive therapies with oral/transdermal medications, many patients do not achieve adequate analgesia. Intraspinal drug-delivery techniques have been successful in providing adequate pain control for these patients. However, there are several caveats in attaining this goal. The site of the tip of the catheter is of paramount importance. It must be placed close to the spinal segment corresponding to the site of nociception. Moreover, the use of bupivacaine and/or clonidine will not only enhance the quality of analgesia but will also decrease the incidence of opiate-induced side effects. Implementing protocols for the management of these patients with intraspinal techniques will not only yield better analgesia in patients unresponsive to oral pharmacologic therapy, but may also be associated with improved survival. This study examines the implementation of intraspinal therapy in patients with oncologic pain unresponsive to oral pharmacologic therapy.