Treatment of central post-stroke pain with oral ketamine.

Case report of 68 year old female with central post-stroke pain successfully treated with oral ketamine. The patient's pain was refractory to conventional pain treatments and she had persistent right hemi-body neuropathic pain with allodynia and hyperalgesia. An intravenous ketamine trial, followed by oral ketamine with titration to 50mg three times a day was beneficial in decreasing allodynia and hyperalgesia, as well as improving functional capabilities. Known side effects including dysphoria, hallucinations, and paranoid feelings were attenuated with benzodiazepines.

Treatment of genitofemoral neuralgia after laparoscopic inguinal herniorrhaphy with fluoroscopically guided tack injection.

OBJECTIVE: This report illustrates that genitofemoral neuralgia can result from laparoscopic inguinal herniorrhaphy and offers a management strategy for this pain syndrome. DESIGN: A patient experienced pain in the distribution of the genitofemoral nerve after laparoscopic herniorrhaphy. Under fluoroscopy, the point of maximal tenderness was elicited and was found to be at the site of a surgical tack placed during the hernia repair. A genitofemoral nerve block was performed at the site of the surgical tack. This resulted in complete resolution of pain symptoms. RESULTS: The patient's treatment and recovery are described. CONCLUSIONS: Recognition and proper diagnosis of genitofemoral neuralgia after laparoscopic herniorrhaphy may result in appropriate therapy and hasten recovery.

Lumbar spine pain originating from vertebral osteophytes.

BACKGROUND AND OBJECTIVES: Axial spine pain originates from a number of structures. Putative pain generators include facet joints, intervertebral disks, sacroiliac joints, and myofascial structures. Osteophytes originating from lumbar vertebral bodies in the area of the intervertebral disks may be a source of nociceptive low back pain which may respond to local injection. METHODS: Five patients with axial low back pain unresponsive to traditional treatment modalities were treated with fluoroscopic guided injection of local anesthetic and corticosteroid near large intervertebral osteophytes. RESULTS: All 5 patients experienced relief. CONCLUSION: Vertebral osteophytes may be a source of axial spine pain. Injection of painful osteophytes with a local anesthetic and corticosteroid solution may produce pain relief.

Treatment of cancer-related pain: when orally administered medications fail.

OBJECTIVE: To summarize the available pain-relieving interventions other than oral medications for cancer-related pain. DESIGN: The pertinent literature is reviewed, and the various options for treating pain in patients with cancer are discussed. MATERIAL AND METHODS: The appropriate situations for use of parenteral administration of opioids, spinal analgesia, neural blockade, and neurosurgical treatment are outlined, and the potential problems and complications associated with these techniques are described. RESULTS: The basic approach to the management of pain in patients with cancer is to begin treatment with less potent analgesic agents early and to progress toward use of more potent pharmaceutical agents, adjuvant drugs, and invasive procedures as needed for alleviation of pain. With parenteral administration of opioids, the dosage can be adjusted rapidly, and therapy can be continued even though a patient may have gastrointestinal dysfunction. A portable ambulatory infusion pump can be used in selected patients. The major advantage of spinal opioid analgesia is the intense analgesia provided with minimal side effects. The potential complications and the availability of treatment alternatives have limited the use of neurolytic blocks, which usually provide only temporary relief of pain. In carefully selected patients with pancreatic or other upper gastrointestinal neoplasms, however, neurolytic celiac plexus and splanchnic nerve blocks are effective. Patients who fail to respond to conservative interventions may be candidates for neurosurgical procedures, such as spinal cord, cortical, or brain-stem stimulation or neuroablative operations (most commonly, cordotomy). CONCLUSION: Cancer-related pain continues to be a major problem, and clinicians should be aware of the availability of effective treatment strategies and techniques. When orally administered medications fail to control pain or cause excessive side effects, patients should be referred to an appropriate specialist or medical center for consideration of other pain-relieving techniques.

Interscalene blocks for chronic upper extremity pain.

A study of 25 patients was carried out to determine the efficacy of interscalene block (ISB) for the treatment of chronic upper extremity pain. An RSD score was used to categorize these patients. Seventeen of the 25 patients had less pain after ISB, and 14 also had increased range of motion of the affected limb. Patients with reflex sympathetic dystrophy (RSD)/causalgia, as well as other chronic pain conditions, improved. ISB was compared with stellate ganglion block (SGB) in patients undergoing both treatments. ISB seemed to be at least as effective as SGB for treatment of RSD/causalgia and may have some advantages over SGB. The role of somatic and sympathetic blockade is discussed.

Ear pain due to cervical spine arthritis: treatment with cervical facet injection.

Two patients with cervical spine arthritis and ear pain were recently evaluated at our clinic. Injection of the C1-2 facet joints with local anesthetic plus corticosteroid resulted in relief of the pain. Therapeutic cervical facet injections may be indicated in cases of recalcitrant head and neck pain due to cervical spine arthritis.

Injection of the facetectomy remnant in the evaluation and treatment of postsurgical back pain: case reports.

A pain syndrome encountered in patients who have undergone laminectomy with medial facetectomy is described. The patients share the following features: (a) unilateral pain, made worse by walking and standing; (b) pain in buttock, thigh, or calf; (c) normal neurologic examination; and (d) response to injection of local anesthetic/depot steroid in the area of the resected medial facet. We believe this pain is caused by neural entrapment, and thus is worsened by movement of the spinal elements. It is proposed that these facet-remnant injections might be used to identify patients who are candidates for surgical stabilization, although this supposition will require further clinical work.

Treatment of acute herpetic neuralgia. A case report and review of the literature.

Herpes zoster (shingles) is a viral infection that results from a reactivation of a dormant varicella zoster virus. It has been estimated that more than 300,000 new cases are seen in the United States each year. Several factors influence the incidence of infection, with increasing age being the most consistent. Postherpetic neuralgia is the No. 1 cause of intractable, debilitating pain in the elderly and is the leading cause of suicide in chronic pain patients over the age of 70.

Management of postoperative pain: review of current techniques and methods.

Pain is a common problem in the early postoperative period. Techniques that provide perioperative analgesia to alleviate pain may have a significant effect on postoperative events, such as earlier ambulation and earlier dismissal from the hospital with use of epidural analgesia than with systemic analgesia. Spinal opioids, which can be administered epidurally or intrathecally, provide analgesia that is superior to that achieved with systemically administered narcotics. For procedures on the upper extremities, selective analgesia can be achieved with use of various types of neural blockade--for example, brachial plexus blockade, interscalene blockade, and axillary plexus blockade. Intercostal nerve block, a valuable but underutilized procedure appropriate for unilateral upper abdominal or flank operations or for thoracotomy, has been shown to reduce postoperative narcotic requirements and pulmonary complications. A patient-controlled analgesia device, consisting of an electronically controlled infusion pump with a timing device that can be triggered by the patient for intravenous administration of a narcotic when pain is experienced, avoids the vast fluctuations in analgesia that accompany parenteral administration of drugs. In most patients, postoperative pain can be prevented or diminished, and clinicians should be aware of the available techniques for achieving this goal.