Techniques in regional anesthesia & pain management最新文献

Contrast agents (CAs) are one of the medications most used by interventional pain practitioners. They are used to confirm target, to distinguish different surrounding tissues, and to deliver adequate medication to specific areas of pathology. The high tolerance of modern CAs has been achieved through successive developments in chemical pharmacologic technology. Different CAs vary greatly in their chemical properties and toxic effects. Adverse reactions can occur while administering these substances and can be classified into acute and delayed. Acute reactions range from mild symptoms, such as urticaria and itching, to more severe reactions, such as cardiopulmonary arrest and death. Pain practitioners should be familiar with the clinical pharmacology of CAs, be aware of their potentially life-threatening reactions, and know how to prevent and treat them. All staff members should be able to recognize a potentially serious adverse reaction, as rapid response is critical.

Radiofrequency (RF) is a minimally invasive, target-selective technique that has demonstrated success in reducing pain in several chronic pain conditions. The lack of standard continuous RF ablation protocols for specific targets makes it difficult to compare the percentage of complications of RF between different studies addressing the same pain syndrome. The present article reviews the most frequent complications associated with the most widely used percutaneous continuous RF techniques in pain treatment, and the strategies used to minimize such complications.

Chronic pain related to headache disorders causes significant burden of disease not only for the patients having these conditions, but also on society as a whole and often is associated with high utilization of health care systems. Despite advances in treatment, however, most patients with chronic headache continue to be undertreated or misdiagnosed. Appropriate evaluation using an in-depth history and physical examination, with imaging or laboratory studies as indicated by the findings of the examination, is paramount in selecting appropriate therapeutic options for treatment. Several studies on the effect of interdisciplinary care in patients with headache have shown improved outcomes for pain intensity, medication use, overall disability and work absence, and general mental health. Thus, it is recommended that care for patients with chronic headache disorders be interdisciplinary. Interdisciplinary care should include neurologic care and pharmacotherapy, physical therapies, complementary and alternative medicine, and psychological therapies. Consideration for interventional pain procedures or surgical procedures is recommended for patients with appropriate diagnoses or for those with pain refractory to conservative management.

Chronic pain in children is overwhelmingly prevalent and is recognized as a major health concern in this population. A biopsychosocial model has been essential for understanding and treating chronic pain in children for decades through interdisciplinary or multidisciplinary pain programs, with results showing a trend for favorable outcomes. However, despite this trend, there remains a subset of patients who continue to have pain issues and disability that prevents full recovery to an optimally functional life. With our increased understanding of central sensitization, the underlying mechanism that promotes chronic pain, we need to target interventions that will calm and balance the nervous system. With expanded use of nutritional therapies that can reduce inflammation and complementary and alternative medicine modalities that have “centrally acting” nonspecific actions, many of these children may have resolution of symptoms and an improved quality of life. An integrative approach to pain management is particularly applicable in children as it seeks to have a full understanding of the underlying problem, promotes partnership with the patient and the family, and uses evidence-based medicine to employ all appropriate therapeutic approaches, both conventional and alternative.

For most patients, the most feared effect of cancer is the pain associated with the disease and its treatments. Poorly controlled pain in patients with cancer leads to suffering, poor nutrition, decreased compliance with treatment regimens, and increased mortality. Obviously, effective pain control is one of the pillars of effective global treatment of cancer in general. Historically, the treatment of pain in the cancer population was the responsibility of the medical oncologist, with escalating doses of opioids being the main form of therapy. Breakthroughs in diagnosis and treatment of cancer have led to patients living longer and potentially surviving this disease. Simple single-modal therapy with oral opioids fails to achieve adequate pain control in a significant percentage of patients. The interdisciplinary model for the management of cancer has long been a standard of practice, with collaboration among medical, radiation, and surgical oncologists. In this article, we describe an analogous approach to the management of cancer pain with collaboration among different specialties involved in the management of these patients.

In the United States, back pain has become a medical epidemic whose prevalence is increasing. The prevalence of neck and back pain is estimated to be 54%-80%. All types of neck pain have an estimated yearly prevalence of 12.1%-71.5%, and that of back pain is 15%-45%. Such a widespread prevalence, with lack of evidence-based recommendations for treatment, has fueled the development of novel pain treatments. Currently, the field of pain management has introduced the concept of interdisciplinary care in the biopsychosocial model.

Complex regional pain syndrome is an ill-defined disorder typified by disproportional pain to the inciting insult in a variable setting of vasomotor and autonomic changes. The exact etiology remains unclear but likely involves augmented cytokine release affecting both peripheral and central nervous systems with concomitant psychosocial intricacies. Management of complex regional pain syndrome should encompass a systematic, interdisciplinary approach including physical and occupational therapy, psychological interventions, and oral analgesics. A thorough diagnostic evaluation should be completed before pursuing invasive treatment options, and these should be considered only in patients experiencing difficulty in progressing through a multimodal program. Collaborative therapy among a multitude of specialties should aim to facilitate reanimation and functional restoration of the affected limb.

To accomplish successful ultrasound-guided interventions for the management of pain in the hip region, a thorough understanding of the essential anatomy of the hip joint and adjacent structures is required. This is also the basis for the acquisition of high-quality dynamic real-time sonoanatomical images. This review article addresses the anatomy, sonoanatomy, and ultrasound-guided interventional approach to 3 key structures in this region—the intra-articular hip, the femoral nerve, and the obturator nerve—using important anatomical landmarks.

The possibility of performing the majority of the pain-control interventions in the lumbar spine without using fluoroscopy is a very promising alternative. A clear description of the most relevant sonoanatomy of the lumbar spine and the proposal for a systematic approach to perform principal lumbar spine blocks may help those that are beginning to use ultrasound and increase the interest of professionals that normally perform these blocks with x-rays. Therefore, the structures that are easily identifiable by ultrasound from the muscular blocks and the facet joints are first described.

Portable and affordable high-resolution ultrasound (US) machines have accelerated the interest in the use of US guidance for interventional pain procedures. The advantages of ultrasonography over fluoroscopy are as follows: (1) no radiation exposure to both the patient (especially with repeated procedures) and the practitioner; (2) real-time visualization of soft tissues (nerves, muscles, tendons, and vessels); and (3) needle-tip advancement relevant to surrounding structures and local anesthetic spread. Even though the target structure is identified correctly, there is still the challenge of placing the needle tip in the optimum site. To encourage pain physicians to use US for interventional procedures, this article aims to review some basic aspects of scanning and imaging techniques.