Richard B. Patt

Reflex sympathetic imbalance: Response to epidural blockade

Eleven patients (two male, nine female) were treated with epidural sympathetic blockade for reflex sympa thetic imbalance, an incomplete manifestation of reflex sympathetic dystrophy. Each had developed severe pain, sensitivity, and disability disproportionate to as sociated trauma. One patient injured an ankle, and the remaining 10 patients one or both knees (12 knees). Seven patients had undergone previous surgery. All but one had a favorable response to initial blockade. This individual eventually failed treatment despite surgical sympathectomy. Seven have required readministration of a block for clinical relapse. Mean followup was 22 months (range, 10 to 41 months). Five underwent ex tensive psychological testing. All have required adjunc tive forms of therapy including physical therapy, trans cutaneous electrical nerve stimulation (TENS), antiin flammatory or other nonnarcotic agents. Recovery is typically prolonged, particularly if the diagnosis is de layed. Close attention to, and therefore prevention of, situations that trigger its recurrence is essential for successful rehabilitation.

No pain, no gain: Riding in the car together

The University of RochesterPain TreatmentCenteris amultidisciplinary effort of anesthesiology,psychiatry, nursing and physicaltherapyinitially conceivedof to provide quality outpatientcareto patientswithall typesof pain.I wasrecruitedto Rochester with theaimofbroadeningtheCenter’smission to createa distinct focusfor the management of cancerpain.Like most, this community wasin needof such services.lamfortunateto haveworked within a supportiveacademicandclinical environment, and to have met peoplewithin the community like Hugh Cumming and his family who havesupportedand facilitatedour efforts. Altering assumptions, expectationsandultilmately behavior,is challenging though, especiallywithin the political and bureaucraticconstraints thatarecharacteristicof alargeuniversityandteachinghospital.Suchchange occursonly overtimeandwithconsistenteffort from a committedteamlike the onewehaveestablished. Our first speaker,Dr. Levy will addressthese challengesmoredirectly.

Interventional analgesia: Epidural and subarachnoid therapy:

The provisionof analgesiaof any typeis, by definition, interventional.A recommendationof epiduralor spinal opioid therapycan beregardedas occupyingapositionatthefarextremeof the spectrumof interventional analgesictreatment.Spinal opioid therapy can reasonablybe groupedtogether with analgesicmodalitiessuchasnerve blocks andsome neurosurgery.Interventional techniquesof analgesia generallyentailsomeadditionalriskto thepatient,as well assome additional effort from practitioners,the patient andtheir family. The true test of the utility of interventional analgesic therapyis whethera techniquecontiibutes further to patientand family well beingthanwould more conventional treatment. Widespreadclinical experiencewith epidural and spinal opioid therapyindicate thatthe minimal risks and investmentof time required to learnabout and maintain treatmentjustify its use in selected patients.