ACUTE PAIN
MANAGEMENT
- Pain is the fifth vital sign.
- Good pain control may decrease postoperative complications.
- Adjuvant drugs can be helpful.
- Continuous femoral infusions are as good as epidural infusions for postoperative pain control after knee procedures.
- Doses of morphine differ by a factor of 10 between intravenous, epidural, and intrathecal routes.
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CHRONIC PAIN
MANAGEMENT
- Chronic pain is best treated using multiple therapeutic modalities. These include physical therapy, psychological support, pharmacological management, and the rational use of more invasive procedures such as nerve blocks and implantable technologies.
- Patients suffering from cancer pain often exhibit complex symptomatology that includes various forms of nociceptive and neuropathic pain.
- In patients suffering from chronic pain underlying psychological/psychiatric conditions should be addressed if any meaningful recovery is to be achieved.
- Neuropathic pain is usually less responsive to opioids than pain originating from nociceptors.
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CRPS stands for
complex regional pain syndrome. It is a painful condition usually
centered in an extremity in which different degrees of sympathetic dysfunction
can be identified. CRPS usually presents with spontaneous pain, hyperalgesia, hyperpathia, and allodynia that is not restricted to the territory of a single
nerve. Sympathetic dysfunction presents as variations in regional blood flow
that can cause edema and cyanosis. Localized sweating and trophic
changes in the skin and nails of the affected part of the body can be seen as
the disease progresses. CRPS I (formerly
known as RSD) can follow minor trauma, venipuncture,
or carpal tunnel surgery; sometimes no identifiable cause can be found. CRPS II (formerly causalgia)
follows damage to a peripheral nerve. Sympathetic blocks are very useful since
they can facilitate physical therapy and help the patient regain some function
in the affected extremity. Upper extremity sympathetic denervation
is accomplished by blocking the stellate ganglion;
for lower extremity sympathetic block a lumbar sympathetic block is performed.
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Myofascial pain syndrome is a group of muscle disorders
characterized by hypersensitive areas called trigger points that can occur in
more than one muscle group. Trigger points when mechanically stimulated will be
painful and will refer pain to an area called the reference zone. This
reference zone does not correlate with any dermatome or peripheral nerve innervation area.
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Fibromyalgia
is a chronic pain condition characterized by widespread musculoskeletal pain,
aches, and stiffness, soft tissue tenderness, general fatigue, and sleep
disturbances. The most common sites of pain include the neck, back, shoulders,
pelvic girdle, and hands, but any body part can be involved. Fibromyalgia
patients experience a range of symptoms of varying intensities that wax and
wane over time.
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Melzack and Wall in 1965 proposed that the substantia gelatinosa in the spinal cord
was the primary gate in the transmission of noxious and non noxious stimulus to
the central nervous system. The pain gate is opened by information coming from
slow unmyelinated C fibers and closed by the impulses
from faster myelinated fibers such as A-ß. Since pain
is transmitted by slow A-d and C fibers they reason that by activating faster
fibers such as the ones that transmit proprioception
the gate will be closed and the pain symptoms will improve. A practical application is the use of TENS
units as well as spinal and peripheral nerve stimulators for the treatment of
pain.
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The most common indication for use of spinal cord stimulation in the United
States is in the treatment of postlaminectomy
pain syndromes. In Europe the most common indication is in the treatment of
peripheral vascular disease. Among other uses are CRPS I and II, arachnoiditis, and intractable angina pectoris.
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