Pain is a sensory experience and distinct from nociception, which refers to the neural mechanisms involved in detecting tissue damage. This article reviews nociceptive mechanisms and how these relate to pain sensation. The emphasis is on recent advances in our understanding of nociceptive mechanisms, including transduction at the peripheral nociceptor terminal, ascending pathways, and the cortical role in pain. Plasticity in nociceptive systems and a new role for descending systems in pain facilitation are also discussed.
{"title":"Anatomy and Physiology of Pain","authors":"Mary Heinricher1","doi":"10.1055/s-2004-830010","DOIUrl":"https://doi.org/10.1055/s-2004-830010","url":null,"abstract":"Pain is a sensory experience and distinct from nociception, which refers to the neural mechanisms involved in detecting tissue damage. This article reviews nociceptive mechanisms and how these relate to pain sensation. The emphasis is on recent advances in our understanding of nociceptive mechanisms, including transduction at the peripheral nociceptor terminal, ascending pathways, and the cortical role in pain. Plasticity in nociceptive systems and a new role for descending systems in pain facilitation are also discussed.","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"35 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123183273","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Glossopharyngeal neuralgia (GPN) is a pain syndrome characterized by attacks of severe pain in the sensory distribution of the glossopharyngeal nerve. Most cases of GPN respond to treatment with carbamazepine and other anticonvulsants. The causative element of essential GPN appears to be a vascular compression of the glossopharyngeal nerve root and the upper rootlets of the vagus nerve; therefore, the most definitive surgical treatment consists of microvascular decompression of the ninth (and tenth) nerve in the posterior cranial fossa. In cases of secondary GPN and when microvascular decompression is not possible, intracranial rhizotomy of the glossopharyngeal and upper portion of the vagal nerve roots may be the next logical step in surgical management. Extracranial neurotomy and percutaneous radiofrequency rhizotomy are useful for patients with GPN who have failed medical treatment but for some reason cannot undergo intracranial intervention.
{"title":"Glossopharyngeal Neuralgia","authors":"Konstantin Slavin1","doi":"10.1055/s-2004-830015","DOIUrl":"https://doi.org/10.1055/s-2004-830015","url":null,"abstract":"Glossopharyngeal neuralgia (GPN) is a pain syndrome characterized by attacks of severe pain in the sensory distribution of the glossopharyngeal nerve. Most cases of GPN respond to treatment with carbamazepine and other anticonvulsants. The causative element of essential GPN appears to be a vascular compression of the glossopharyngeal nerve root and the upper rootlets of the vagus nerve; therefore, the most definitive surgical treatment consists of microvascular decompression of the ninth (and tenth) nerve in the posterior cranial fossa. In cases of secondary GPN and when microvascular decompression is not possible, intracranial rhizotomy of the glossopharyngeal and upper portion of the vagal nerve roots may be the next logical step in surgical management. Extracranial neurotomy and percutaneous radiofrequency rhizotomy are useful for patients with GPN who have failed medical treatment but for some reason cannot undergo intracranial intervention.","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"23 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124171284","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Pain Management for the Neurosurgeon: Part 1","authors":"Kim Burchiel1","doi":"10.1055/s-2004-830009","DOIUrl":"https://doi.org/10.1055/s-2004-830009","url":null,"abstract":"","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"63 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124583186","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Postherpetic neuralgia (PHN) is a chronic neuropathic pain syndrome defined as pain persisting more than 3 months after the resolution of herpes zoster–associated rash. It is often characterized as spontaneous aching or burning with paroxysmal shooting pains in the affected dermatome and may be accompanied by allodynia or hyperalgesia. There is an increased incidence of PHN in elderly patients, patients with ophthalmic herpes zoster, and immunocompromised patients. PHN may result from dorsal horn destruction, although pathophysiologic changes in more proximal central structures and distal peripheral structures have been described. Based on randomized, controlled studies, the most effective medical therapies include gabapentin, topical lidocaine, tricyclic antidepressants, and oral opioid analgesics. Surgical interventions for refractory cases including intrathecal drug administration, central ablative procedures, and central electrical stimulation continue to meet with limited success.
{"title":"Postherpetic Neuralgia","authors":"Kenneth Little1, Allan Friedman1","doi":"10.1055/s-2004-830017","DOIUrl":"https://doi.org/10.1055/s-2004-830017","url":null,"abstract":"Postherpetic neuralgia (PHN) is a chronic neuropathic pain syndrome defined as pain persisting more than 3 months after the resolution of herpes zoster–associated rash. It is often characterized as spontaneous aching or burning with paroxysmal shooting pains in the affected dermatome and may be accompanied by allodynia or hyperalgesia. There is an increased incidence of PHN in elderly patients, patients with ophthalmic herpes zoster, and immunocompromised patients. PHN may result from dorsal horn destruction, although pathophysiologic changes in more proximal central structures and distal peripheral structures have been described. Based on randomized, controlled studies, the most effective medical therapies include gabapentin, topical lidocaine, tricyclic antidepressants, and oral opioid analgesics. Surgical interventions for refractory cases including intrathecal drug administration, central ablative procedures, and central electrical stimulation continue to meet with limited success.","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"140 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127490424","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Michael Wang1, Brian O'Shaughnessy2, Iftikharul Haq2, Barth Green2
Pain following spinal cord trauma is common and frequently perplexing as multiple etiologies can confuse the diagnosis. Neuropathic pain from spinal cord damage is frequent, occurring in up to 40% of patients. However, autonomic and musculoskeletal pain generators are also common.
{"title":"Pain Following Spinal Cord Injury","authors":"Michael Wang1, Brian O'Shaughnessy2, Iftikharul Haq2, Barth Green2","doi":"10.1055/s-2004-830018","DOIUrl":"https://doi.org/10.1055/s-2004-830018","url":null,"abstract":"Pain following spinal cord trauma is common and frequently perplexing as multiple etiologies can confuse the diagnosis. Neuropathic pain from spinal cord damage is frequent, occurring in up to 40% of patients. However, autonomic and musculoskeletal pain generators are also common.","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"21 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122929363","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Complex regional pain syndrome (CRPS; reflex sympathetic dystrophy and causalgia) is a heterogeneous chronic pain condition that usually develops following a traumatic injury, usually to an extremity. Although there has been considerable research regarding the mechanisms responsible for pain in CRPS, its pathophysiology remains unclear. The hallmark of CRPS is spontaneous and/or evoked pain. Although signs and symptoms of sympathetic nervous system dysfunction are commonly present, not all patients demonstrate a significant component of sympathetically maintained pain. There is no specific test or finding that is diagnostic of CRPS, and the diagnosis is largely clinical. Treatment of CRPS can be challenging. Management of the patient with CRPS should involve a multidisciplinary approach, and early intervention is important in this regard. The goals of treatment include reduction in pain but, just as important, functional restoration of the affected body part. Management of CRPS includes any combination of pharmacotherapy, physical and occupational therapy, regional anesthetic blocks, behavioral therapies, and surgery. The primary surgical procedures that have been effective for CRPS include spinal cord stimulation, intrathecal drug infusion, and sympathectomy. Surgical intervention is usually most effective earlier rather than later, when patients have developed end-stage CRPS.
{"title":"Complex Regional Pain Syndromes","authors":"Richard Osenbach1","doi":"10.1055/s-2004-830016","DOIUrl":"https://doi.org/10.1055/s-2004-830016","url":null,"abstract":"Complex regional pain syndrome (CRPS; reflex sympathetic dystrophy and causalgia) is a heterogeneous chronic pain condition that usually develops following a traumatic injury, usually to an extremity. Although there has been considerable research regarding the mechanisms responsible for pain in CRPS, its pathophysiology remains unclear. The hallmark of CRPS is spontaneous and/or evoked pain. Although signs and symptoms of sympathetic nervous system dysfunction are commonly present, not all patients demonstrate a significant component of sympathetically maintained pain. There is no specific test or finding that is diagnostic of CRPS, and the diagnosis is largely clinical. Treatment of CRPS can be challenging. Management of the patient with CRPS should involve a multidisciplinary approach, and early intervention is important in this regard. The goals of treatment include reduction in pain but, just as important, functional restoration of the affected body part. Management of CRPS includes any combination of pharmacotherapy, physical and occupational therapy, regional anesthetic blocks, behavioral therapies, and surgery. The primary surgical procedures that have been effective for CRPS include spinal cord stimulation, intrathecal drug infusion, and sympathectomy. Surgical intervention is usually most effective earlier rather than later, when patients have developed end-stage CRPS.","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"27 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123725440","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The realization that chronic pain and acute pain might have different mechanisms has led to important developments in both research and patients’ care. Basic research paradigms that focus upon long-term changes in tissues and the nervous system have led to useful models for chronic pain. Clinical research has shown that strategies effective for acute pain often fail in patients with chronic pain and that there is utility in the cognitive-behavioral approach to the management of patients with chronic pain. We discuss the history and implementation of comprehensive multidisciplinary pain diagnosis and treat-ment. We conclude with a review of the data on outcomes and cost-effectiveness for multidisciplinary pain management.
{"title":"Multidisciplinary Pain Management","authors":"John Loeser1 , 2, Dennis Turk2","doi":"10.1055/s-2004-830011","DOIUrl":"https://doi.org/10.1055/s-2004-830011","url":null,"abstract":"The realization that chronic pain and acute pain might have different mechanisms has led to important developments in both research and patients’ care. Basic research paradigms that focus upon long-term changes in tissues and the nervous system have led to useful models for chronic pain. Clinical research has shown that strategies effective for acute pain often fail in patients with chronic pain and that there is utility in the cognitive-behavioral approach to the management of patients with chronic pain. We discuss the history and implementation of comprehensive multidisciplinary pain diagnosis and treat-ment. We conclude with a review of the data on outcomes and cost-effectiveness for multidisciplinary pain management.","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"20 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115262400","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Classic, idiopathic trigeminal neuralgia is an easily recognizable condition of excruciating, lancinating pain in one or more of the trigeminal distributions. Atypical features may exist (i.e., constant burning pains of a background nature) and we propose this condition represents the natural progression of trigeminal neuralgia type 1 to type 2. The etiology of trigeminal neuralgia is accepted as occurring from microvascular compression at the root entry zone, but other trigeminal facial pain syndromes exist and occur from iatrogenic (trigeminal deafferentation pain) or traumatic (trigeminal neuropathic pain) injuries. It is important to recognize when facial pain occurs in cranial nerve distributions other than the trigeminal nerve, as the treatments are different for geniculate, glossopharyngeal, and occipital neuralgia. Lastly, atypical facial pain occurs in a nonanatomic distribution and may be attributed to nonorganic or psychological causes. Pain from the facial sinuses, odontologic pain, and temporal mandibular joint pain are discussed.
{"title":"Trigeminal Neuralgia and Other Craniofacial Pain Syndromes: An Overview","authors":"W. Elias1, Kim Burchiel2","doi":"10.1055/s-2004-830014","DOIUrl":"https://doi.org/10.1055/s-2004-830014","url":null,"abstract":"Classic, idiopathic trigeminal neuralgia is an easily recognizable condition of excruciating, lancinating pain in one or more of the trigeminal distributions. Atypical features may exist (i.e., constant burning pains of a background nature) and we propose this condition represents the natural progression of trigeminal neuralgia type 1 to type 2. The etiology of trigeminal neuralgia is accepted as occurring from microvascular compression at the root entry zone, but other trigeminal facial pain syndromes exist and occur from iatrogenic (trigeminal deafferentation pain) or traumatic (trigeminal neuropathic pain) injuries. It is important to recognize when facial pain occurs in cranial nerve distributions other than the trigeminal nerve, as the treatments are different for geniculate, glossopharyngeal, and occipital neuralgia. Lastly, atypical facial pain occurs in a nonanatomic distribution and may be attributed to nonorganic or psychological causes. Pain from the facial sinuses, odontologic pain, and temporal mandibular joint pain are discussed.","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"99 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116407028","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Pain Management for the Neurosurgeon: Part 1","authors":"Winfield Fisher1","doi":"10.1055/s-2004-830008","DOIUrl":"https://doi.org/10.1055/s-2004-830008","url":null,"abstract":"","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"101 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124824744","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Successful management of chronic pain disorders and diseases starts with an appreciation of the many biological and psychosocial factors, including pain generators and comorbidities, that may affect outcome. Choosing the appropriate treatment for any one patient hinges on a careful assessment of these factors and a reasoned and feasible outcomes-oriented treatment plan that controls as much of the variance as possible. Chronic pain, a coping challenge for everyone, causes some psychosocial problems for everyone and clinically significant psychiatric disorder in many. Or, chronic pain onset can worsen preexisting psychosocial problems and psychiatric disorders. Simple screening questions are highly sensitive, missing few cases. Specific diagnosis requires a more detailed interview. Suicide is the most common mortal complication of chronic pain, particularly with comorbid depression, and should be asked about routinely. Depression, anxiety disorders, and substance abuse are the most common complicating psychiatric comorbidities. These should be identified and managed to achieve optimal surgical outcomes. A plethora of effective medications, some for specific depression and anxiety disorder diagnoses, are available. Substance abuse and addiction are more difficult and may require special treatments. Skillfully treating both pain and psychiatric comorbidity leads to the best functional outcomes for the person in pain.
{"title":"Biopsychosocial Pain Medicine: Integrating Psychiatric and Behavioral Therapies into Medical Treatment","authors":"Rollin Gallagher1, Sunil Verma2","doi":"10.1055/s-2004-830012","DOIUrl":"https://doi.org/10.1055/s-2004-830012","url":null,"abstract":"Successful management of chronic pain disorders and diseases starts with an appreciation of the many biological and psychosocial factors, including pain generators and comorbidities, that may affect outcome. Choosing the appropriate treatment for any one patient hinges on a careful assessment of these factors and a reasoned and feasible outcomes-oriented treatment plan that controls as much of the variance as possible. Chronic pain, a coping challenge for everyone, causes some psychosocial problems for everyone and clinically significant psychiatric disorder in many. Or, chronic pain onset can worsen preexisting psychosocial problems and psychiatric disorders. Simple screening questions are highly sensitive, missing few cases. Specific diagnosis requires a more detailed interview. Suicide is the most common mortal complication of chronic pain, particularly with comorbid depression, and should be asked about routinely. Depression, anxiety disorders, and substance abuse are the most common complicating psychiatric comorbidities. These should be identified and managed to achieve optimal surgical outcomes. A plethora of effective medications, some for specific depression and anxiety disorder diagnoses, are available. Substance abuse and addiction are more difficult and may require special treatments. Skillfully treating both pain and psychiatric comorbidity leads to the best functional outcomes for the person in pain.","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"14 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123930898","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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