Karina Gritsenko

Multimodal therapy in perioperative analgesia

This article reviews the current evidence for multimodal analgesic options for common surgical procedures. As perioperative physicians, we have come a long way from using only opioids for postoperative pain to combinations of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), selective Cyclo-oxygenase (COX-2) inhibitors, local anesthetics, N-methyl-d-aspartate (NMDA) receptor antagonists, and regional anesthetics. As discussed in this article, many of these agents have decreased narcotic requirements, improved patient satisfaction, and decreased postanesthesia care unit (PACU) times, as well as morbidity in the perioperative period.

Fibromyalgia Pathogenesis and Treatment Options Update

This review article presents and summarizes up-to-date literature on the clinical manifestations, diagnosis, pathophysiological mechanisms, and treatment options for fibromyalgia patients. First, the most recent diagnostic criteria for fibromyalgia, as put forth by the American College of Rheumatology will be summarized. Clinical features, including chronic widespread pain, hyperalgesia, mood disorders, anxiety, and disturbed sleep patterns will be explored in-depth. The pathogenesis and pathophysiology of fibromyalgia involves alterations in multiple ascending and descending central nervous system pathways, as well as peripheral pathways, leading to heightened pain sensitivity. Risk factors have been studied extensively, and the most recent research focuses on various genetic influences and the contributions of stress and poor sleep. Lastly, the discussion in this article focuses on treatment options for fibromyalgia; some have been mainstay options for many years. Pharmacological agents include tricyclic antidepressants, anti-epileptic drugs, selective serotonin reuptake inhibitors, norepinephrine/serotonin reuptake inhibitors, as well as some investigational agents. The evidence behind non-pharmacologic treatments, including massage therapy, exercise, and acupuncture, are discussed.

Peripheral neuromodulation for the treatment of refractory trigeminal neuralgia

Trigeminal neuralgia is an extremely painful condition. Treatment options for trigeminal neuralgia include anticonvulsants, opioids and surgical methods; however, some cases may be refractory to these therapies. In this article, the authors report a case involving a patient for whom conventional treatments failed; she underwent a successful trial of peripheral nerve stimulation and subsequently opted for a permanent implantation of an internal pulse generator, leading to long-term relief of her pain.

Placebo and Pain

Placebos and their effects have been described in medical literature for at least two centuries, but the complex neurological mechanisms responsible for it are still unknown.

Anticoagulation and Neuraxial/Peripheral Anesthesia

Novel anticoagulants (NAGs) have emerged as the preferred alternatives to vitamin K antagonists. In patients being considered for regional anesthesia, these drugs present a layer of complexity in the preprocedure evaluation. There are no established tests to monitor anticoagulant activity and our experience is short with these drugs. These authors believe it is important to review the relevant hematology, orthopedics, and anesthesiology literature to provide a valuable reference for the clinician who is met with these challenges. In addition to discussing NAGs, we also review the existing American Society of Regional Anesthesia guidelines for heparin, low-molecular-weight heparin, and antiplatelet agents.

Review of perioperative pain management of opioid-dependent patients

Opioid dependence can occur due to prescription opioid use, recreational opioid use, or as a result of opioid use for the treatment of drug addiction. Pain control in these patients is truly a challenge. It is important to understand the patients condition such as the phenomenon of drug dependence, drug addiction, and pseudoaddiction to provide effective analgesia. This may be accomplished using appropriate multimodal therapies and by treatment of coexisting diseases such as anxiety. The goal is to provide effective analgesia, prevent cognitive and emotional problems, and produce a positive postoperative rehabilitation process. Multimodal options include pharmacological and nonpharmacological approaches, psychological support, and interventional pain procedures, all focused toward providing optimal pain control while preventing undertreatment, withdrawal symptoms, and other complications.

Complications of Intrathecal Drug Delivery

Intrathecal pumps are an option that allows patients who suffer from moderate-to-severe pain to have an improvement in quality of life, reduction in pain, improvement in systemic side effects, and change in function. They also are an option for patients who are at the end of life to improve alertness, reduce fatigue and nausea, and improve survival in the cancer population. This has been noted to be both clinically beneficial and cost effective, especially in those patients who are expected to survive longer than 6 months. Unfortunately, despite the many positive attributes of these devices, they are not without risks. The complications can be classified as surgical, device related, or drug related. This chapter focuses on the complications of intrathecal drug delivery and options to assess and reduce risks.

Botulinum Toxin Injections for Chronic Pain

This chapter discusses the recent developments in using botulinum toxin in treating various chronic pain conditions. As it is a relative newcomer in the array of therapeutics available to clinicians, the chapter briefly reviews its history, pharmacology, and initially the very limited clinical uses for botulinum toxin. It then summarizes some of the new studies and anecdotal evidence toward finding different applications for its use, including migraine, arthritis, and trigeminal neuralgia. Furthermore, the latest studies regarding botulinum toxin are explored and summarized. Because of its potential as a therapeutic agent and because of a lack of data regarding its clinical applications, further evidence will be needed to fully explore botulinum toxin’s role in the treatment of chronic pain.

Cervical and Thoracic Sympathetic Blocks

The sympathetic nervous system plays a role in creating vascular, visceral, and neuropathic pain. Thus, interventional pain techniques aimed at blocking sympathetic ganglia can offer diagnostic, prognostic, and therapeutic value in various disease states. The cervical sympathetic ganglia and the upper thoracic sympathetic chain are examples of such targets. Thus, sympatholysis of the cervical sympathetic (stellate ganglion) and thoracic sympathetic ganglion has proven to be a useful means for managing sympathetically mediated pain. The understanding of relevant anatomy of the sympathetic nervous system, specifically in the cervicothoracic region, the pathophysiology of sympathetic mediated pain, the diagnosis of pain syndromes associated with the aforementioned ganglia, and intricacies of the technical aspects are crucial for interventional pain management physicians.

Ganglion Impar Blockade

The ganglion impar, also known as the ganglion of Walther or sacrococcygeal ganglion, is a structure found in the pelvic retroperitoneum anterior to the sacrococcygeal junction. Given its supply of nociceptive and sympathetic innervation to a number of pelvic and perineal structures, it is a central point for relaying pain information in this region. As such, the ganglion impar is an excellent candidate for neuronal block or ablation in order to greatly reduce or eliminate pain symptoms to these aforementioned structures. The literature provides adequate evidence suggesting that ganglion impar blocks provide both immediate and long-term amelioration of pelvic and perineal pain states. These blocks have also been found beneficial for malignant and nonmalignant pain sources alike. In this chapter, we review the indications for a ganglion impar block, as well as relevant anatomy, complications, and precautions for the procedure. A myriad of techniques are used for this block in the field of interventional pain. We review the most common and safest approaches to this block, including appropriate strategies for the use of fluoroscopic and/or ultrasound image guidance.