Info

Turner J, Loeser J Spinal cord stimulation for chronic low back pain, a systemic literature synthesis. Neurosurgery 37 1088-1096, 1995. 47. Nielson KD, Adams JE, Hosubuchi Y Experience with dorsal column stimulation for relief of chronic intractable pain 1968-1973. Surg 48. Devulder J, Vermeulen H, De Colvenaar L, et al Spinal cord stimulation in chronic pain Evaluation of results, complications, and technical considerations in sixty-nine patients. Clin J Pain 7 21-28, 1991. 49. Probst C...

References

Bier A Versuche ueber cocainisirung des rueckenmarkes. Deutsche Zeitschrift fuer Chirurgie 51 361-368, 1899. 2. Marinacci AA Neurological aspects of complications of spinal anesthesia with medicolegal implications. Bull Los Angeles Neurol Soc 25 170-192, 1960. 3. Moore DC, Bridenbaugh LD Spinal (subarachnoid) block. A review of 11,574 cases. JAMA 195 907-912, 1966. 4. Dripps RD, Vandam LD Long term follow-up of patients who received 10,098 spinal anesthetics Failure to discover major...

Intrathecal Phenol

The patient is placed in the lateral position, with the affected extremity downward. The patient should be rolled backward into a 45-degree oblique position. This maintains the posterior roots in the lowermost position. A spinal needle should then be placed into the intrathecal space at the vertebral interspace of the dermatome to be blocked. A volume of up to 0.5 mL of 5 to 10 phenol may be administered at a slow rate. It is recommended that a tuberculin syringe be used and that increments of...

Central Nervous System Monitoring

Conscious state monitoring is necessary to detect the impact of drugs, metabolic response, and or cardiovascular and respiratory changes. Propofol is frequently used to sedate patients, but methohexital, barbiturates, and other drugs, especially benzodiazepines, are also used. Sometimes fentanyl or remifentanil in variable doses is administered as a rescue analgesic during the operation, because often it is not possible to continue with regional anesthesia. Thus, the regional anesthetic...

Lower Limb Peripheral Nerve Blocks

Spinal or epidural anesthesia is usually chosen when regional anesthesia is being considered for lower limb surgery. An alternative to central neural blockade is the combined femoral and sciatic nerve block. The sciatic nerve block component is technically more difficult, and, therefore, it is not widely used. In a study of 40 patients undergoing unilateral total knee replacement, Lau and coworkers1901 (Taiwan) compared spinal anesthesia with combined femoral (3-in-1) and sciatic nerve block....

Lumbar Dorsal Root Ganglia

Dorsal Root Ganglia

If prognostic blockades of the posterior (facets) and anterior (discs) compartments have been negative and the pain is located in the lower limb, then selective radicular blocks can be considered. It is common for a patient also to report lumbar pain, and the determination must be made whether to treat mechanical lumbar pain with referred pain to the limbs, or pain caused by spinal nerve pathology. Once a referred mechanical origin of the pain has been ruled out, diagnostic blockades of spinal...

Table 461 Overview Of The Neuroendocrine Stress Response

Hypermetabolic, catabolic state Catabolic hormones Heart rate blood pressure Serum glucose Protein catabolism Possible potentiation of postoperative hypercoagulability and immunosuppression Inhibition of the stress response Complete (peripheral procedures) Partial (abdominal or thoracic procedures) Attenuation or prevention of postoperative increase in catabolic hormones after surgical insult includes a general increase in catabolic hormones, such as catecholamines, Cortisol, renin,...

Morbid Obesity

Obesity accentuates many of the physiologic and anatomic changes of pregnancy. For example, there is less pulmonary reserve because functional residual capacity is smaller and oxygen consumption is higher than in the nonobese parturient. Similarly, cardiac output and blood volume are increased in obese individuals. There is a higher incidence of comorbidity (e.g., hypertension and diabetes mellitus), and a higher incidence of difficult airway. Obese parturients are more at risk for...

Denervation Of Cervical Facets C26

Although chronic spinal pain often has a complex mechanical or radicular etiology, sympathetic involvement may dominate the pain condition, producing individual clinical profiles in which more than one structure is involved in the pain syndrome. The treatment of cervical pain syndromes poses challenges for the clinician. Effective alleviation of pain, although a difficult task, is achieved in over 80 of cases, in experienced hands. During the last decade, much work has led to new approaches for...

Peripheral Nerve Blocks

In a nonrandomized prospective study of regional anesthetic blocks reported by Arner and associates,112 38 consecutive patients with neuralgias were treated with various local anesthetic peripheral nerve blocks. Etiologies included entrapment syndromes as well as surgical and traumatic nerve damage, and all patients had demonstrable sensory dysfunction. The peripheral nerves blocked included ilioinguinal, iliohypogastric, saphenous, superficial peroneal, intercostal, suprascapular, and lateral...

Denervation Of Lumbar Facets

The dorsal spine compartment is innervated by the medial and lateral branches of the dorsal ramus. The articular facets are innervated by the medial branch of the dorsal ramus of the superior segment and one or more segmental levels. The multisegmental organization of spinal innervation has an effect on spinal pain therapy because, in the absence of a technique for selectively producing a lesion of the sinuvertebral nerve in the treatment of dorsal compartment or articular facet syndromes, the...

Neurolytic Blocks

Catheter-based neuromodulatory techniques revolutionized the treatment of cancer pain, but a neurolytic technique may be a better choice for some children. Patt and colleagues113 performed a subarachnoid neurolytic block under general anesthesia in a 3-year-old child with neuroblastoma and refractory leg pain. This child had suffered severe pain involving the entire left leg, which was unimproved with high-dose opioid and adjuvant therapy and a psoas compartment block. The parents asked if...

Blockade Of The Obturator Nerve

The obturator nerve has both motor and sensory components. The anterior division provides sensory innervation to the medial aspect of the distal thigh. The posterior division provides sensation to the medial aspect of the distal thigh as well as to the hip and knee joints. The obturator nerve also provides motor innervation to the thigh adductors. Clinical applications of obturator block include use as an adjunct with lateral femoral cutaneous, femoral, and sciatic nerve blocks for surgical...

Procedure

The nurse will phone each outpatient the day after his or her surgery or procedure. If unable to contact the patient on the first day postsurgery postprocedure, the nurse will phone the second day postsurgery postprocedure. Patients who have Friday surgery dates will be contacted the following Monday. B. The nurse will chart a postprocedure phone call note based on the information received and any instructions given to the patient, including any referrals made on the patient's chart. C....

Fluoroscopy

Fluoroscopy is an invaluable adjunct in the performance of difficult regional anesthetic procedures in morbidly obese patients with poor anatomic landmarks or during celiac or hypogastric plexus blocks. Fluoroscopy is essential to verify accurate needle placement and spread of opaque contrast material before neurolytic agents are injected. The ideal contrast material should provide opacification of blood vessels and tissue during fluoroscopy, without any accompanying toxicity or alteration in...

Local Anesthetic Allergy

True local anesthetic allergies are very rare. Patients who have a history of local anesthetic allergies may have experienced intravascular injection of local anesthetics with resultant signs of toxicity, systemic responses to vasoconstrictors, allergic reactions to preservatives mixed with local anesthetics, or anxiety reactions. True allergic reactions are much more common with amino-ester local anesthetics than with amino-amide local anesthetics.13 13 13 Amino-ester local anesthetics are...

Gilbert Y Wong Carlos B Mantilla Jack L Wilson David C Mackey Tim J Lamer

Advances in the early detection and treatment of cancer have resulted in improved patient survival.12 Unfortunately, many patients afflicted with cancer continue to suffer from refractory pain related to their tumors. An estimated 75 to 90 of patients with advanced malignant disease experience significant pain.12 12 12 The development of the three-step World Health Organization (WHO) analgesic ladder ( Fig. 51-1 ) has helped clinicians to provide treatment of cancer pain. Despite the...

Sphenopalatine Ganglion Block

Hemispheric Ganglion Block For Headaches

Block of the sphenopalatine ganglion may be used to provide regional anesthesia for nasal and dental surgery or for fiberoptic airway management. It may also be used in the management of acute migraine, acute cluster headache, and facial neuralgia. For the transnasal approach, the patient is placed supine. With a cotton tip soaked in 4 lidocaine or 10 cocaine, the first applicator is passed along the upper border of the first turbinate until contact is made Figure 20-18 Approaches for the...

Thoracic And Abdominal Wall

The causes of pain originating in the chest and abdominal wall vary, but they are usually secondary to neoplastic invasion of the vertebral bodies and rib cage (prostate, breast), spinal cord and peripheral nerves, or parietal peritoneum (lung). Various therapies for patients with thoracic or abdominal wall pain syndromes are derived in part from regional anesthetic procedures such as treatment with intercostal or paravertebral blocks, and the quest continues for a longer duration of pain...

Supracla Vicular Region

The supraclavicular region has well-defined limits, with the collarbone located at the base, the posterior margin of the sternocleidomastoid muscle located anteriorly, and the trapezius muscle located posteriorly. This triangle is identified by the skin depression found within its limits the supraclavicular fossa. The supraclavicular fossa is covered by the skin, the subcutaneous lax tissue, and the cutaneous supra-acromial and supraclavicular branches of the superficial cervical plexus. The...

Continuous Sciatic Nerve Infusion

Posterior Approach Sacrum

Patients with CRPS I and II, vascular insufficiency, and unilateral leg edema from many causes are frequently managed with lumbar epidural catheters. There are, however, inherent risks with long-term placement of an epidural catheter. The sciatic catheter can be an alternative in such patients. It can eliminate the risk of epidural abscesses, hematoma formation, or catheter erosion of the dura. The unilateral affected limb can be specifically treated without numbing or weakening the opposite...

Herpes Simplex Virus

Herpes simplex virus infection is epidemic in the adult population. Its clinical spectrum is wide. Herpes simplex virus type 2 is a recurrent disease characterized by painful vesicular genital lesions. Viremia occurs with primary infection. Symptoms are varied but can include fever, headache, and, rarely, aseptic meningitis. Secondary infections occur sporadically, and little is known about what events may precipitate a recurrence. Secondary infections are not associated with viremia. Cesarean...

Elliot S Krames Francis S Pecoraro

The costs of unrelieved pain and disability arising from chronic pain in the United States is, and will continue to be, a major problem until appropriate, cost-effective algorithms for the management of chronic pain are created and implemented. Chronic, unrelieved pain is not only a major drain on scarce healthcare resources but also the cause of untold suffering for millions of people worldwide. The direct, hard costs of unrelieved pain for patients and their families are loss of job, income...

Pcra In Neurosurgery

London, Lippincott Williams & Wilkins, 1999. 2. Caplan RA, Ward RJ, Posner K, Cheney FW Unexpected cardiac arrest during spinal anesthesia A closed claims analysis of predisposing factors. Anesthesiology 68 5-11, 1988. 3. Knill RL Cardiac arrests during spinal anesthesia Unexpected Anesthesiology 69 629, 1988. 4. Shen CL, Ho YY, Hung YC, Chen PL Arrhythmias during spinal anesthesia for Caesarean section. Can J Anaesth 47 393-397, 2000. 5. Rosenfeld SI,...

Invasive Therapies For The Control Of Chronic Pain

When more conservative, less invasive therapies fail to provide pain relief, the treating physician should offer more invasive therapies which, if performed correctly by well-trained physicians, may provide pain relief for the patient suffering from intractable, chronic pain. Interventional strategies used when less invasive therapies fail include anesthetic blocking techniques, continuous intraspinal analgesia, continuous plexus analgesia, implantable neuromodulatory techniques, and...

Neuropathic Pain

Neuropathic Pain and the Sympathetic Nervous System The sympathetic nervous system has been shown to contribute to the evolution and maintenance of certain chronic pain states through a variety of mechanisms. Numerous studies document sympathetic involvement in protective reflexes during acute and impending pain as well as reorganization and sensitization of spinal cord neuronal connections in response to persistent noxious stimulation, through inflammatory induction of hyperalgesia and in...

Technique

Epidural Anterior Spread Contrast

Consent must always be obtained before the procedure is begun. In the consent form, all possible complications related to the procedure must be included, such as bruising, transient hypotension, transient difficulty breathing, numbness of the extremities, bowel or bladder dysfunction, paralysis, infection, sexual dysfunction, and the possibility that the catheter may shear. Additionally, laboratory studies that must be performed are a complete blood cell count, urinalysis, prothrombin time,...

Lower Extremity Blocks

Injury to the lateral femoral cutaneous nerve can result in a neuropathic pain syndrome known as meralgia paresthetica. Multiple etiologies have been reported, including surgical trauma, sports-related injuries, compressive tumors,- limb length discrepancy, - degeneration of the symphysis pubis,- and nerve entrapment by the inguinal ligament. In most cases, no underlying cause can be determined. Characteristic features are pain, sensory loss, allodynia, and paresthesias in the anterolateral...

Selective Cervical Nerve Root Block

Pain originating from the posterior cervical vertebral body and posterior spinal segments is innervated by each segmental cervical nerve. Depending on the extent of the metastatic disease, at least one segment above and below the lesion are required for pain control. This block is performed under fluoroscopic guidance, with the patient in the supine position. To block both the sinuvertebral nerve innervating the posterior cervical vertebral body and the dorsal rami innervating the posterior...

Table 261 Neurohumoral And Physiologic Responses To Trauma

Activation of the cytokine and complement cascades Activation of the coagulation cascade, hypercoagulable state Activation of neutrophils and stimulation of lymphocytes Increased catecholamines and sympathetic activity Increased cortisol, growth hormone, ACTH, and prolactin Increased renin, angiotensin, aldosterone, and vasopressin Adapted from Patel N, Smith CE Pain management in trauma. Anesthe siol Clin North Am 17 295 1999. Hedderich R, Ness TJ Analgesia for trauma and burns. Crit Care Clin...

Lumbar Sympatholysis

Chemical sympathectomy of the lumbar chain must be one of the more common procedures performed in pain medicine centers worldwide. Indeed, percutaneous techniques of sympatholysis in this region have probably supplanted open surgery.53 RF techniques have also been devised for the lumbar chain in an attempt to reduce complications such as genitofemoral neuralgia and the retroperitoneal scarring that can accompany the use of neurolytic agents. The spread of phenol, even with use of the...

Abdominal Wall Surgery

The abdominal wall is supplied by the lower seven intercostal nerves and the upper two lumbar somatic nerves. When selecting the block to be performed, one must remember that at least two segments above and two segments below the operative site must be anesthetized. Abdominal wall anesthesia is readily provided by spinal or epidural anesthesia in a manner similar to that used for intra-abdominal surgery. However, if the viscera are not to be stimulated, the higher level of anesthesia required...

217 Gaj Pilot Ka Naksha

In Bartlett J, Kaplan J (eds) Familiar Quotations, 16th ed. Boston, Little, Brown, 1992, p 71. 2. World Health Organization Cancer Pain Relief, 2nd ed. Geneva, World Health Organization, 1996. 3. Leape LL Error in medicine. JAMA 272 1851-1857, 1994. 4. Committee on Quality Health Care in America, Institute of Medicine Creating safety systems in health care organizations. In Kohn LT, Corrigan J, Donaldson MS (eds) To Err is Human Building a Safer Health System....

Abdominal And Pelvic Surgery

Abdominal procedures constitute the bulk of general surgery. These procedures include operations on the abdominal wall for hernias, infections, tumors, and trauma, as well as intra-abdominal operations including gastric, intestinal, liver, pancreas, spleen, and adrenal gland surgery. General surgical procedures involving the perineum include operations for fissure, hemorrhoidectomy, anal fistula, abdominoperineal proctectomy, ischiorectal abscess, and pilonidal sinus and abscess drainage. The...

Cost Of Chronic Unrelieved Pain

In the United States, the costs of unrelieved pain and disability arising from chronic pain are and will continue to be a major problem until appropriate, cost-effective algorithms for the management of chronic pain are created and implemented. Chronic unrelieved pain is not only a major drain on scarce healthcare resources but is the cause of untold suffering of millions of people worldwide. The direct, hard costs of unrelieved pain to patients and their families are loss of job, income,...

Athina N Vadalouca

The use of adjuvant drugs for spinal and epidural anesthesia is intended to improve the success of regional anesthesia by prolonging the analgesia of local anesthetics and preventing the deleterious clinical effects of their toxic doses. The nerve blockade produced must be complete and reproducible and must also produce the desired duration of action. In the past, this goal was attained by means of new local anesthetic drugs with better spread and good separation of motor and sensory effects....

Efficacy Of Clinically Used Peripheral Nerve Stimulators

Accurate delivery of current is important in the use of nerve stimulators for nerve location. A nerve stimulator that overestimates the current output is likely to lead the operator to assume the needle is further away from the nerve than it is. This could lead to penetration of the nerve by the needle and intraneural injection. Conversely, a stimulator that underestimates the current output is likely to mislead the operator by indicating that the needle is nearer the nerve than it is. This...

Table 246 Complications With Regional Anesthesia In The Renal Patient

The complications arising from regional blockade in patients with renal failure are similar to those that can occur in other patients. These complications include hemorrhage, hypotension, infection, failure of technique, intravascular injection, headache, local anesthetic toxicity, and pneumothorax in patients with supraclavicular brachial plexus block ( Table 24-6 ). The possibility of neurologic sequelae of spinal anesthesia in the transplantation recipient is a complex consideration. In...

Sacroiliac Injections

The sacroiliac (SI) joint is a synovial (diarthrodial) joint that is formed from the union of the sacrum with the iliac bones in the pelvis. The pathologic state of this joint is becoming a more common source of discussion among specialists after years of being virtually ignored as a cause of low back pain. When Mixter and Barr published their article in the New England Journal of Medicine in 1934, describing the intervertebral disc as a source of back pain, the SI joint was suddenly relegated...

Central Neural Blockade

Dura Cutting And Dura Separating Needle

The first description of the administration of a central neural axis blockade is attributed to James Leonard Corning in 1885.a Nearly another decade passed before Heinrich Irenaeus Quincke described a technique for safely performing lumbar punctures.141 It was only in 1899 that August Bier published the technique of lumbar puncture for the administration of spinal anesthesia with cocaine.13 The use of spinal anesthesia did not become popular until the introduction of neurologically safer local...

Electrical Characteristics Of Peripheral Nerve Stimulators Currently Available In Clinical Practice

Peripheral Nerve Stimulator Diagram

To determine which electrical characteristics of the PNS contributed to the localization of a peripheral nerve, the electrical properties of eight commercially available peripheral nerve stimulators and a Grass S-88 stimulator were measured. The PNS was then used in the laboratory to locate a peripheral nerve in an anesthetized cat. The controlled environment in the laboratory allowed each PNS to be used under nearly identical conditions. Experiment I Determination of Output Characteristics of...

Surgery Of The Nose And Nasal Septum

Surgery of the nose requires blocking the sensory nerves derived from the frontal, nasociliary, and infraorbital Figure 24-16 The technique for the extraoral block of the mandibular nerve is essentially the same as that for the maxillary block, except that the needle is directed upward and posteriorly, so that the mandibular nerve is contacted as it exits the foramen ovale. (Redrawn from Bononi SR The trigeminal nerve. In Bennett CR ed Monheim's Local Anesthesia and Pain Control in Dental...

Neuraxial Blocks In Infected Or Febrile Patients

Single-shot spinal techniques and short-term epidural catheterization appear to pose little risk to patients who may become transiently bacteremic during surgery. Conversely neuraxial blocks in infected or febrile patients may increase the risk of neuraxial infection, and these blocks remain controversial. Most authorities believe that neuraxial blocks should not be performed in patients who are bacteremic and have not commenced antibiotic therapy. If antibiotics have been started and there has...

Nerve Blocks

Panlilio Prabhav Tella Srinivasa N. Raja Pain is primarily a subjective phenomenon. Often, it is a complex perceptual experience of an individual that defies easy description and quantification. Tissue injury and inflammation lead to increased excitability in both the peripheral and central nervous systems. These reversible sensory changes serve a protective role against further injury during the healing process. Neuropathic pain, in contrast to inflammatory pain, is characterized by...

Local Anesthetic Neural Blockade

Although it is a temporary measure, local anesthetic neural blockade (LANB) is a valuable tool in the management of cancer pain. 112 Because the effects are temporary, the role of LANB must be clearly outlined to the patient, family, and healthcare providers. Tt can be very distressing to the patient to experience significant pain relief after LANB only to have the severe pain return after a few hours. LANB is useful for the purposes of diagnosis, prognosis, and therapy. For diagnostic...

Table 282 Dtagnosttc Blocks Tn Cancer Patn Management

Differentiates thoracoabdominal wall pain from thoracic and abdominal visceral pain Differentiates abdominal visceral pain from abdominal wall pain Differentiates pelvic visceral pain from pelvic wall pain Cervicothoracic ganglion (stellate T4) block Differentiates thoracic visceral pain from thoracic wall pain Sympathetic versus somatic pain Stellate ganglion block Differentiates sympathetically mediated pain from somatic pain of the head, neck, and upper extremity Lumbar sympathetic block...

Dural Lesions Induced By Quincke And Whitacretype Beveled Needles

Wuincke Needle Type

The studies published in the literature on postdural puncture headache (PDPH) have analyzed the use of needles with different tip designs and different external diameters. Most authors agree that needles with small external diameters pencil point designs1 cause fewer cases of PDPH because such needles (e.g., Sprotte, Whitacre types) produce less damage by separating rather than sectioning the dura mater fibers.1 However, when the morphology is examined in detail concerning the damage produced...

Midhumeral Block

The midhumeral block was developed as a method of isolating and blocking each peripheral nerve individually. This block is performed at the junction of the upper and middle third of the arm. The relationship of the peripheral nerves relative to the brachial artery for midhumeral block is similar to the relationship for axillary block in that the median nerve is anterior to the artery, the radial nerve is posterior, the ulnar nerve is medial, and the musculocutaneous nerve is lateral. The...

Nerve Block Anesthesia

Injection of a solution of a local anesthetic into or about individual peripheral nerves or nerve plexuses produces even greater areas of anesthesia than the techniques described earlier. Blockade of mixed peripheral nerves and nerve plexuses also usually anesthetizes somatic motor nerves, producing skeletal muscle relaxation, which is useful for some surgical procedures. The areas of sensory and motor block usually start several centimeters distal to the site of injection. Brachial plexus...

Susan R Anderson

Prolonged interruption of painful pathways may be accomplished by injection of neurolytic agents. This form of chemical neurolysis has been performed for many years. Perineural injections have been used therapeutically since the discovery of cocaine by Koller in 1884.11 The application of neurolytic substances to provide relief for patients with cancer has been practiced since 1930. The first reported injection of a neurolytic solution in the treatment of pain was probably by Luton, 1 who, in...

Table 175 Summary Of Differences Between Insulated And Uninsulated Needles

Both insulated and uninsulated needles have been used with nerve stimulators for peripheral nerve blockade. Pither and colleagues113 have developed an in vivo cat model to compare nerve stimulators and to assess the electrical behaviour of both types of needles. Two sets of experiments were performed. In the first, the needle was advanced toward the sciatic nerve in the thigh, and stimulation of the nerve was assessed by twitches of the tibialis muscle attached to a force transducer. In the...

Reason Of Pain In Lower Anterior Teeth And Lip After Rftc And Mental Block

Sphenopalatine Ganglion Block

Blockade of the SPG is used in the treatment of many painful medical syndromes involving the face and head. Sluder was the first to describe in the literature a unilateral facial pain at the root of the nose, which sometimes spread retro-orbitally toward the zygoma and extended back to the mastoid and occiput.13 The pain was commonly associated with parasympathetic features such as lacrimation and rhinorrhea, with or without mucosal congestion.13 Sluder called this pain syndrome sphenopalatine...