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Schellhas KP solian 100mg otc, Garvey TA quality 100 mg solian, Johnson BA cheap solian 100 mg otc, et al: Cervical diskography: analy- sis of provoked responses at C2-C3 order 50 mg solian with visa, C3-C4 quality solian 50mg, and C4-C5. Interobserver reliability of de- tecting lumbar intervertebral disc high-intensity zone on magnetic reso- References 119 nance imaging and association of high-intensity zone with pain and an- nular disruption. Painful lumbar disc derangement: relevance of endplate abnormalities at MR imaging. Cervical discogenic syndrome: results of op- erative intervention in patients with positive discography. Thoracic discography in healthy individuals: a controlled prospective study of magnetic resonance imag- ing and discography in asymptomatic and symptomatic individuals. Painful adult thoracic Scheuermann’s disease: di- agnosis by discography and treatment by combined arthrodesis. The ability of pressure-controlled discography to predict surgical and nonsurgical outcomes. Position statement from the North American Spine Society Diagnostic and Therapeutic Committee. Reported pain during lumbar discography as a function of annular ruptures and disc degeneration: a re- analysis of 833 discograms. The association between pain drawings and computed tomographic/discographic pain responses. Relation between pain location and disc pathology: a study of pain drawings and CT/discography. Effects on the vertebral end-plate of un- complicated lumbar discography: an MRI study. The prevalence and clinical fea- tures of internal disc disruption in patients with chronic low back pain. Dallas discogram description: a new classification of CT/discography in low back disorders. Four-year follow-up results of lumbar spine arthrodesis using the Bagby and Kuslich lumbar fusion cage. Eckel Back pain is the most common pain complaint resulting in physician of- fice visits. Most back pain resolves spontaneously with conservative treatment, although in some patients, pain persists, and the condition is termed chronic. Internal disc disruption is now thought to be causative in a large number, if not the majority, of instances of chronic low back pain. Surgical treatment for these patients, including interbody fu- sion techniques, has yielded mixed results in management of chronic pain and carries the risk of morbidity at surgery. The phenomenon of subsequent degeneration of adjacent spinal levels after interbody fusion is also well recognized. Given the mixed results and significant morbidity associated with surgery, there has been increased interest in developing minimally invasive therapies for the treatment of the painful disc. Chymopapain infusion,11 percutaneous disc decom- pression,12 percutaneous laser disc decompression,13 nucleoplasty, and other techniques have been developed for percutaneous disc decom- pression with dissolution or removal of portions of the nucleus pulpo- sus. Intradiscal electrothermal annuloplasty (IDEA), or intradiscal elec- trothermal therapy (IDET),3 is the first technique developed with the intent of directing minimally invasive therapy primarily to the posterior annulus of the disc to treat painful internal disc disruption. Anatomy The intervertebral disc is anatomically composed of a central nucleus pulposus with a peripheral and circumferential annulus fibrosus (Fig- ure 7. The soft inner nucleus pulposus is encircled by the fibrous bands of the annulus which are thinner posteriorly. The annulus itself is composed of two layers, an inner layer that at- taches to the cartilaginous endplates, and an outer ligamentous layer that attaches directly to bone of the vertebral bodies. The annulus is loosely attached to the anterior longitudinal ligament but densely ad- herent to the posterior longitudinal ligament. The nucleus is a notochordal remnant that is relatively avas- cular in the adult and is not significantly innervated. The role of the nucleus in back pain is believed to be primarily a consequence of me- chanical mass effect or chemical effects on local innervated structures. The annulus fibrosus, however, is innervated, most densely along the posterior aspect, and substance P and unmyelinated C fibers have been demonstrated in the annulus, supplied by way of the sinovertebral nerve (Figure 7. The function of the intervertebral disc is a combination of stress ab- sorption (primarily nucleus), and motion restriction (annulus). There is no significant innervation of the nucleus, while the annulus is innervated with un- myelinated fibers, primarily by way of the sinovertebral nerve. Pain fibers are present throughout the disc but most densely in the posterior annulus.

Both the peripheral and central mech- anisms of sensitization following injury or noxious Behavioural stimulation appear to be developmentally regulated generic 100 mg solian, as Observation for pain-related behaviour is an option do many modulating influences purchase solian 50 mg on-line, such as descending for children who cannot self-report generic 100mg solian free shipping. It is important inhibitory controls (which develop later than afferent that behavioural tools are appropriate for age and excitatory pathways) generic solian 100 mg visa. Nevertheless solian 50mg cheap, sensitization after setting, as behaviour is highly modified by develop- injury (causing pain and tenderness) has been demon- mental, affective and other factors. Facial expression strated in both animal models and human neonates and and cry have been found to be the most reliable is amenable to treatment with local anaesthetics and behaviours in the very young, followed by body opioids. Due to the plasticity of the infant nervous 186 PAIN IN THE CLINICAL SETTING system there is a concern that the response to pain, Peripheral nerve blocks injury or analgesia at this age may initiate changes with A number of simple to learn and perform local blocks important effects on subsequent development. In Block Procedure Evidence level addition, the immaturity of the respiratory system and Ilio-inguinal nerve Inguinal hernia ** of respiratory control mechanisms at birth predispose Orchidopexy ** to acute respiratory failure in response to physiologic- Penile dorsal nerve Circumcision ** ally adverse or stressful circumstances for some time. Infra-orbital nerve Cleft lip: Child ** The need for adequate analgesia in the neonatal period Infant ** has been heightened by studies showing that infants Neonate * who undergo painful procedures without analgesia Axillary plexus Hand surgery * subsequently display relatively greater behavioural Fascia Iliaca Surgery to * responses to pain than control subjects. Neonatal pain thigh/femur management depends on careful attention to anal- ***Systematic review. Analgesics Central nerve blocks Local anaesthetics (LA) Single dose and infusion epidural analgesia are fre- LA techniques are versatile and have many advan- quently used in paediatrics for post-operative pain tages when used alone, or as part of a multi-modal and other indications. The efficacy and safety of LA has been empirically and experimentally established over many • There is little interference with other body sys- years. Suitable equipment is readily available commercially for even the smallest infant. Recent experience of augmenting Topical LA central local anaesthetic blocks with opioids, cloni- EMLA and amethocaine gel have revolutionized the dine or ketamine has been encouraging, but their place management of procedural pain in children of all is not fully established. They are effective for venepuncture, arterial puncture, lumbar puncture and other brief procedures. They also have been used to reduce pain of chest Paracetamol, NSAIDs and weak opioids drain removal and for operative and post-operative Paracetamol is a weak analgesic and anti-pyretic at all pain of neonatal circumcision. NSAIDs are often used in combination with paracetamol and/or opioids (see Table 27. NSAIDs are avoided in neonates and in the presence of renal Infiltration LA dysfunction. Aspirin-induced asthma is a contra- Wound infiltration, a simple and safe technique during indication. Codeine is popular but of low efficacy and surgery, has been shown to reduce post-operative may be unreliable in certain patients who cannot pro- analgesic requirements after many procedures including duce the active metabolite morphine. It allows rapid popular, although absorption is known to be slow and and sensitive titration of analgesia within pre-defined erratic requiring adjustments to both dosing and dos- limits. Excessive sedation and hypotension have Concentration 20mcg/kg/ml been reported, but appear to be rare complications in Initial dose 0. Patient controlled analgesia Key points With adequate support children are able to under- Infants and children of any age can feel pain. There Developmental age profoundly influences pain • is evidence that a small background infusion is bene- assessment and treatment. Novel analgesics (not in routine use) • Chronic pain is also prevalent in children. Analgesics for the treat- toxic effect of intrathecal ketamine and poor availability ment of pain in children. Pain The 2 adrenoceptor agonist clonidine has a wide assessment in infants and children. Guidelines for the Recognition and Assessment of Acute Pain in Pain in children (1998). Jaggar Demographics Key physiological changes with ageing The term ‘elderly’ refers to the oldest age group of the population. The age-range represented by this • Ageing, or senescence, may be defined as the grad- group has varied with the changing morbidity and ual reduction of organ and tissue function by rea- mortality of both time and circumstances. Modern son of genetic (DNA and RNA) malfunction in terminology also sometimes refers to the elderly, the cell metabolism, occurring over time. Key points on life disease, such as atherosclerosis, hypertension and expectancy at birth include: osteoarthritis.

Recent studies do Clinical cor pulmonale indicate that elderly postoperative patients in the ICU Established right ventricular hypertrophy who need intubation and mechanical ventilation (MV) Pulmonary hypertension under any circumstances do as well as younger patients Optimal medical management established in terms of outcome buy generic solian 50mg on line, although if they have been nutri- P O buy cheap solian 100 mg online, partial pressure of arterial oxygen buy cheap solian 50mg line. Colchicine has been symptoms of gastroesophageal reflux discount 100 mg solian visa,51 classic rheumato- recommended and is safer than steroids or immunosup- logic symptoms (which would suggest rheumatoid arthri- pression purchase 50mg solian free shipping, but long-term results show no difference from tis or vasculitis), and environmental exposures during untreated patients. Portable oxygen can improve exercise abnormal liver function tests suggest the possibility of capacity and quality of life in these patients. The chest radiograph usually shows an increase in interstitial markings and on serial films an associated progressive decrease in lung volume. Diag- Sleep complaints increase in the elderly, partly because nostic inferences may be made by correlating pleural of changes in central nervous system control of breath- changes or adenopathy. The sensitivity of brainstem receptors to relating to radiographic findings are beyond the scope of carbon dioxide and oxygen levels decreases with aging to this text; contemporary review articles are available. The resultant High-resolution computerized tomography (CT) of the reduction in ventilation can combine with an increase lung is of considerable value in determining the extent in upper airway resistance and lead to rises in the blood and severity of these interstitial disorders, although, like levels of carbon dioxide (PaCO2) and decreases in roentgenograms, it does not give an etiologic diagnosis— oxygen (PaO2) during sleep. Gallium scans are explain the increase in sleep disordered breathing that nonspecific, have serious problems of interobserver occurs with aging, with increasingly frequent apneic or variability, and are totally useless in evaluating these enti- hypopneic events being more common in older men than ties. If diagnosis cannot be achieved on the basis of a careful Pulmonary complications in the postoperative period history, physical examination, and consideration of the occur with increased frequency in older as compared to patient’s overall medical diagnoses, and if it appears younger patients, especially in those undergoing thoracic that lung biopsy will likely be useful in terms of manage- or upper abdominal procedures. Trans- evaluation, patient education, and postoperative man- bronchial biopsy with a fiberoptic bronchoscope (FOB) agement will decrease the risk of pulmonary complica- may be helpful and is safe in older patients, although the tions such as atelectasis, impaired gas exchange, and tissue sample size is usually quite limited and the ability infection. The elderly are at higher risk of complications, to achieve a firm diagnosis is disappointingly small in not because of age, but as a result of decreased pul- most series. Open lung biopsy with sampling of several monary and cardiovascular reserves associated with sites gives a higher probability of a definitive diagnosis, aging and an increased number of accompanying comor- although it carries a small (approximately 1%) risk of bidities. Congestive atelectasis is the predominant mortality and a 5% to 10% incidence of complications. Following thoracic or upper abdominal pulmonary fibrosis (IPF), leaving both the patient and procedures, it may take to 2 to 3 weeks for pulmonary physician unsatisfied. IPF, which occurs on average at age 61, has an dures cause impaired diaphragmatic and intercostal especially poor prognosis, with a 50% mortality in 2 years. Corticosteroids or cytotoxic agent associated increase in residual volume (RV) and a closing treatments have significant side effects, and if they are capacity (CC), which rises into the tidal volume (TV). Dermatologic Diseases and Problems 873 risk for the adverse side effects of systemic therapy, and therefore it is important to carefully evaluate the risks and benefits in this age group. The various systemic agents are psoralen with long-wave ultraviolet light (PUVA), methotrexate, and etretinate (an oral retinoid), recently replaced by its metabolite acitretin. Cyclosporin is effective, but its use in the elderly is limited by the adverse effects of nephrotoxicity and hypertension. The retinoids have numerous side effects, but myalgias, arthralgias, xerosis, and headache are particularly common in older people. Bullous pemphigoid on the upper aspect of the Contact dermatitis is an inflammatory reaction to either arm. The typical acute lesions are ery- thematous macules, papules, and vesicles with exudation 10 decades. Elderly people may present with milder may contain clear or hemorrhagic fluid (Fig. They clinical disease because of depressed inflammatory occur on normal or urticarial skin over flexural surfaces of responses. Approximately one-third severe itching, associated with mild erythema, scaling, of patients may have oral involvement. Diagnosis is made or early hyperpigmentation, and lichenification rather 10 by skin biopsy. Common causa- deposits of immunoglobulin G and C3 along the base- tive agents in older persons include neomycin, parabens 19 ment membrane. Typically, the disease subsides after (a common preservative in medications), lanolin, ethyl- months to years, but relapses do occur. Debilitated enediamines, nitrofurazone, and acrylate adhesives in patients with widespread blistering have died of this transdermal medications. Steroids should be tapered The key to treatment is removal of the offending agent.

Thus the facts that MS is found largely in temperate regions of the world and more amongst women cheap solian 50mg overnight delivery, and that there appear to be geographical ‘hotspots’ of the disease buy 100mg solian mastercard, all seem to explain something about MS purchase 50mg solian with mastercard. The problem with epidemiological research is that there are many generic solian 100 mg with visa, many reasons why such patterns could occur buy discount solian 50mg online. Most patterns are misleading in that they either disappear when subjected to detailed investigation, or are explained by RESEARCH 189 another factor not related to MS. Quite a number of people with MS have found several others with the condition in their area, or have had some job or other life experience in common. It is tempting to jump immediately to the conclusion that there must be some link that has caused the MS. Usually such patterns occur just by chance – even when very odd things happen, such as two or three unrelated people with MS living in the same street. In such cases the findings of epidemiological research are primarily suggestive, and must be supported by other kinds of research. At present two of the most interesting, although very time-consuming, types of epidemiological research, are those trying to detect and assess all people with MS in a particular area, and those measuring the distribution in the population of certain genetic ‘markers’ linked with MS. In the former studies, findings are indicating that there are more people with MS than we had previously thought, and the latter findings are suggesting increasingly firm associations between particular genetic markers and types of MS. Laboratory research There is a very wide spectrum of research in this area; it is usually undertaken on individual cells or cellular processes, often in animals. Much of this research is linked to understanding how the body’s immune system in MS seems to attack itself. Many scientists believe that the body’s failure to distinguish between ‘foreign invaders’ in the form of bacteria, viruses and so on (which it should attack), and its own tissue (which it should not attack), is the root explanation of why MS occurs. This kind of research has identified many of the different types of cell in the immune system, how they work, and what happens when they fail or become disrupted. Studying how immune systems work both in animals and in people with MS, who also have other diseases thought to be immune related (such as rheumatoid arthritis), gives a clearer idea of what is happening in people with MS. For example, in the late 1980s, research on a disease model in animals (called EAE – experimental allergic encephalomyelitis), thought to be similar to MS in humans, revealed promising clues to therapies that might prevent EAE in animals, and thus possibly prevent MS in humans. However, it turned out that the human immune system was far more complicated than that of laboratory animals. As a parallel development a number of fierce immunosuppressant therapies were devised, in the hope that, by suppression of the activities of the immune system, then at least no 190 MANAGING YOUR MULTIPLE SCLEROSIS further ‘autoimmune’ attacks would occur on the body’s own tissue. However, many of these therapies suppressed all immune system activity, and so led to major infections and complications, in which often the intended ‘cures’ produced worse symptoms than those of the disease they were supposed to help. Nevertheless, from these studies have come some interesting develop- ments – and one of these developments is work on what are called ‘cytokines’. These are chemical messengers associated with the regula- tion of immune system activity; understanding these cytokines has already proved rewarding. For example ‘interferons’ are one kind of cytokine and, of course, ‘beta-interferons’ have proved to give consider- able therapeutic benefit in MS. However, the position is still complicated, for some cytokines seem to make MS worse and some seem to help con- trol it; whilst beta-interferons seem to help MS, other types of interferon do not. The lesson from this particular kind of research, just as in much scientific research, is that there are many disappointments as well as new developments, and often the disappointments lead to new approaches to MS. Clinical research Clinical research directly involves studying people with MS and their symptoms on an individual basis. Although it may sound strange after many years of research on MS, what is called the ‘natural history’ of the disease is still not entirely clear, although major studies in Canada have revealed much about the long-term outcome of MS. As we discussed in Chapter 1, it is still not really possible to give anyone a clear idea of how their disease will develop over time, so much clinical research is still devoted to assessing people with MS over long periods of time – several decades – to chart as carefully as possible how their disease develops, especially in relation to early symptoms and signs. Such information is very important, in order to judge, for example, whether early inter- vention will affect the later course of the disease. As people with the condition know, the effects of MS appear to be very fickle on a day-to-day basis, let alone a longer term one, so it is one of the most difficult research tasks to determine the specific effects of MS, as against those occurring from other, perhaps unrelated, conditions, and the effects of natural ageing processes. Other clinical research is focused on improving and developing diagnostic techniques to try and ensure that such techniques are both accurate and available as early as possible.

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