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Because of the poorer car- diac profile of bupivacaine buy 300mg ranitidine otc, third-generation amide anesthetics were developed cheap ranitidine 150mg otc. Ropivacaine is a member of this group that produces long- 32 Chapter 2 Materials Used in Image-Guided Spine Interventions term local anesthesia like bupivacaine but with a better cardiac profile buy discount ranitidine 150mg on line. Injections of local anesthetic are small enough that one should gener- ally never approach the maximum allowable dosages. The lower dosages are useful for pain relief in epidural and nerve blockage injections. The more concentrated dosages will produce motor blockade, which is not wanted with these procedures. Antibiotics Antibiotics are needed for only selected procedures in spine interven- tion. These include discography, intradiscal electrothermal therapy, percutaneous discectomy, vertebroplasty and kyphoplasty, and the im- plantation of pumps and stimulators. The purpose of antibiotic coverage in most of these procedures is to decrease the chance of seeding bacteria in poorly vas- cularized sites such as the disc or around foreign bodies (implantables). Since penicillin allergy is not uncommon, a broad-spectrum antibiotic with minimal or no penicillin cross-reactivity is generally chosen. Though some penicillin cross-reactivity with the cephalosporins exists, it is minimal and therefore a reasonable choice is cefazolin (Ancef). This is the most common antibiotic used for this purpose and is given in a 1 g dosage intravenously or intramuscularly (IV or IM) 30 minutes prior to the procedure. Additionally, it can be put into the contract for discographic procedures (usually 20–100 mg, with the upper range used when no IV antibiotics are given). It must be borne in mind that this antibiotic will cause grand mal seizure activity if given intra- thecally. In some patients, allergy or lack of access to an IV hookup may make alternate choices better. Another commonly utilized antibiotic in the interventional lab is ciprofloxacin (Cipro). This is a fluoroquinolone with a broad spectrum of coverage and without cross-reactivity to peni- cillin. It can be given intravenously (400 mg) but must be given slowly over a 60- minute period to avoid pain and IV site reaction. Another good alternative is levofloxacin (Levaquin), a fluorinated carboxyquinolone. It may be given orally or intravenously and has sim- ilar plasma and time profiles for both, making it a good choice for ei- ther route (again slow administration is required for IV use). Analgesics Conscious sedation, sometimes needed with a few procedures in the realm of image-guided spine pain management (e. If persistent pain occurs, one may need to prescribe analgesics appropriate for the patient’s pain level and sus- pected duration. This will not usually take the form of long-term or chronic analgesic administration. The two mainstays for postproce- dural pain management are opioids, nonsteroidal anti-inflammatory (NSAID) drugs, or combination agents that contain drugs of both types. Mild to intermediate pain may be handled by the use of NSAIDs alone or in combination with a weak opioid (codeine, hydrocodone, dihydrocodeine, oxycondone). Controlled trials show little difference in efficacy of the NSAID category, and therefore finding one that works will usually be sufficient. There is potential toxicity from the NSAIDs to the gastrointestinal, genitourinary, central nervous, and hematolog- ical systems.

Kidney infections are particularly worrying in MS: they may be asso- ciated with both abdominal pain and a high fever order 150 mg ranitidine with amex, and require a tougher drug approach buy generic ranitidine 300 mg on-line, perhaps with intravenous antibiotics cheap ranitidine 150mg with amex. The problem is that, once infections get a hold in the kidneys, there is a substantial risk that they pass unchecked into the bloodstream, and cause major, even on occasions life-threatening, difficulties. On the other hand some urinary infections in MS can be almost symptomless, and thus periodically – and especially if you feel that you suffer from some prob- lems of urine retention – ask your doctor if you could have a urine test for infections just to make sure. For people who seem particularly liable to urinary tract infections, a long-term low-dose antibiotic might be given occasionally to eliminate or suppress bacteria. It is also a wise precaution to empty your bladder both before and after sexual intercourse. Indwelling catheterization When urinary difficulties become a real problem, a permanent catheter can be fitted. Although some may think this is more convenient, it is not an easy step to take for many others; some actually think of it as the hidden equivalent of being in a wheelchair. Furthermore, medically, it is best if some other way can be found to manage urinary problems. An indwelling catheter opens up the inside of the body to the continual possibility of infections from which it is normally protected, even during ISC, and it can be particularly dangerous if you have a weakened immune system. Therefore, in principle, the less time that people with MS use an indwelling catheter, the better. If the MS becomes more severe, there may be no option, particularly when you cannot undertake ISC, or when drugs or other strategies do not appear to deal with the problem. An indwelling catheter can be inserted through the urethra (like ISC), or through a specially constructed surgical opening in the lower abdomen, above the pubic bones (‘suprapubic catheterization’). Through the other end, on the outside of the body, urine is continuously drained into a collection bag. Increasingly, the medical preference is to insert the catheter through the special opening in the lower abdomen. This is because a permanent catheter through the urethra may enlarge, change or disrupt the urethral opening, and make it difficult to maintain control of the urine. An indwelling catheter like this can cause problems with sexual activity and we deal with this elsewhere in Chapter 5. Even if a catheter is inserted through the lower abdomen, there are still likely to be some problems: PROBLEMS WITH URINATION AND BOWELS 53 • Infection can occur around the site of the insertion. An indwelling catheter can be used on a temporary basis, or for particular occasions when other means of urinary control are difficult, but you need to discuss all this with your doctor or continence nurse. Each insertion runs a risk of introducing infection and it has to be undertaken as meticulously as possible. Surgery and urinary problems in MS Surgery is very rarely performed to ensure urinary control in MS – indeed it seems to offer no major improvement in such control. Several procedures are possible, but are only undertaken on rare occasions when almost all else has failed, and a more or less intractable problem remains. There is another factor here: MS, over time, is a progressive disease, and it is possible that once you have undergone some surgery, other surgical procedures may then be needed later, to manage further problems that might arise. Other management techniques In addition to trials of further drugs that may be of value to people with MS, some other procedures or techniques may help. Research has suggested that bladder training – involving working out a schedule of regular urination on the basis of ultrasound assessments – together with ISC, may be helpful. Because of the association between CNS control of leg function and urinary function, an appropriate exercise regime may help the urinary function indirectly. Bladder training generally involves a series of educational and training exercises.

Pain 33:87–107 Bennett GJ generic ranitidine 150mg fast delivery, Kajander KC buy 300mg ranitidine mastercard, Sahara Y discount 150 mg ranitidine free shipping, Iadarola MJ, Sugimoto T (1989) Neurochemical and anatomical changes in the dorsal horn of rats with an experimental painful periph- eral neuropathy. In: Cervero F, Bennett GJ, Headley PM (eds) Processing of sensory information in the superficial dorsal horn of the spinal cord. Plenum Press, New York, pp 463–471 Berkley KJ, Hubscher CH (1995) Are there separate central nervous system pathways for touch and pain? Nature Med 1:766–773 Berkley KJ, Blomqvist A, Pelt A, Flink R (1980) Differences in the collateralization of neuronal projections from the dorsal column nucleus and lateral cervical nucleus to the thalamus and the tectum in the cat: an anatomical study using two different double labelling techniques. Brain Res 202:273–290 Berkley KJ, Budell RJ, Blomqvist A, Bull M (1986) Output systems of the dorsal column nuclei in the cat. Brain Res Rev 11:199–225 Berkley KJ, Hubscher CH, Wall PD (1993) Neuronal responses to stimulation of the cervix, uterus, colon, and skin in the rat spinal cord. J Neurophysiol 69:545–556 BernardJF,BessonJM(1990)Thespino(trigemino)pontoamygdaloidpathway:electrophys- iological evidence for an involvement in pain processes. J Neurophysiol 63:473–490 Bernard JF, Villanueva L, Carroue J, Le Bars D (1990) Efferent projections from the subnu- cleus reticularis dorsalis (SRD): a Phaseolus vulgaris leucoagglutinin study in the rat. Neurosci Lett 116:257–262 Bernard JF, Dallel R, Raboisson P, Villanueva L, Le Bars D (1995) Organization of the efferent projections from the spinal cervical enlargement to the parabrachial area and the periaqueductal gray: a PHA-L study in the rat. J Comp Neurol 353:480–505 74 References Bernard JF, Bester H, Besson JM (1996) Involvement of the spino-parabrachio-amygdaloid and hypothalamic pathways in the autonomic and affective emotional aspects of pain. Prog Brain Res 107:243–255 Bernardi PS, Valtschanoff JG, Weinberg RJ, Schmidt HHHW, Rustioni A (1995) Synaptic in- teractions between primary afferent terminals and GABA and nitric oxide-synthesizing neurons in superficial laminae of the rat spinal cord. J Neurosci 15:1363–1371 Berthier M, Starkstein S, Leiguarda R (1988) Asymbolia for pain: a sensory-limbic discon- nection syndrome. Lancet 353:1610–1615 Besson JM, Chaouch A (1987) Peripheral and spinal mechanisms of nociception. Physiol Rev 67:67–186 Bester H, Besson JM, Bernard JF (1997a) Organization of efferent projections from the parabrachial area to the hypothalamus: a Phaseolus vulgaris-leucoagglutinin study in the rat. J Comp Neurol 383:245–281 BesterH,MatsumotoN,BessonJM,BernardJF(1997b)Furtherevidencefortheinvolvement of the spinoparabrachial pathway in nociceptive processes: a c-Fos study in the rat. J Comp Neurol 383:439–458 Bester H, Beggs S, Woolf CJ (2000) Changes in tactile stimuli-induced behavior and c-Fos expression in the superficial dorsal horn and in parabrachial nuclei after sciatic nerve crush. J Comp Neurol 428:45–61 Bester H, De Felipe C, Hunt SP (2001) The NK1 receptor is essential for the full expression of noxious inhibitory controls in the mouse. J Neurosci 21:1039–1046 Bevan S (1999) Nociceptive peripheral neurons: cellular properties. Churchill-Livingstone, New York, pp 85–103 BirbaumerN,LutzenbergerW,MontoyaP,LarbigW,UnerlK,TopfnerS,GroddW,Taub E, Flor H (1997) Effects of regional anesthesia on phantom limb pain are mirrored in changes in cortical reorganization. J Neurosci 17:5503–5508 Blakeman KH, Hao JX, Xu XJ, Jakoby AS, Shine J, Crawley JN, Iismaa T, Wiesenfeld-Hallin Z (2003) Hyperalgesia and increased neuropathic pain-like response in mice lacking galanin receptor 1 receptors. Neuroscience 117:221–227 Blomqvist A, Berkley KJ (1992) A re-examination of the spino-reticulo-diencephalic path- way in the cat. Brain Res 579:17–31 Blomqvist A, Craig AD (1991) Organization of spinal and trigeminal input to the PAG. Plenum Press, New York, pp 345–363 Blomqvist A, Craig AD (2000) Is neuropathic pain caused by the activation of nociceptive- specific neurons due to anatomic sprouting in the dorsal horn? J Comp Neurol 428:1–4 Blomqvist A, Ma W, Berkley KJ (1989) Spinal input to the parabrachial nucleus in the cat. Brain Res 480:29–36 Blomqvist A, Ericson AC, Craig AD, Broman J (1996) Evidence for glutamate as a neuro- transmitter in spinothalamic tract terminals in the posterior region of owl monkeys. Exp Brain Res 108:33–44 Blomqvist A, Zhang ET, Craig AD (2000) Cytoarchitectonic and immunohistochemical characterization of a specific pain and temperature relay, the posterior portion of the ventral medial nucleus, in the human thalamus. Eur J Pharmacol 429:115–119 Bogousslavsky J, Regli F, Uske A (1988) Thalamic infarcts: clinical syndromes, etiology, and prognosis.

The woman whose case was described under “Current Therapeutic Concepts” did just that and experienced an immediate cessation of pain cheap ranitidine 300mg fast delivery. Resume Physical Activity Perhaps the most important (but most difficult) thing that patients must do is to resume all physical activity purchase ranitidine 150mg, including the most vigorous discount ranitidine 300 mg visa. This means overcoming the fear of bending, lifting, jogging, playing tennis or any other sport, and a hundred other common physical things. It means unlearning all the nonsense about the correct way you are supposed to bend, lift, sit, stand, lie in bed, which swimming strokes are good and bad, what kind of chair or mattress you must use, shoes or corset or brace you must wear, and many other bits of medical mythology. The various health disciplines interested in the back have succeeded in creating an army of the partially disabled in this country with their medieval concepts of structural damage and injury as the basis of back pain. Though it is often difficult, every patient has to work through his or her fear and return to full normal physical activity. One must do this not simply for the sake of becoming a normal human being again (though that is a good enough reason physically and psychologically by itself) but to liberate oneself from the fear of physical activity, which is often more effective than pain in keeping one’s mind focused on the body. As Snoopy, that great contemporary philosopher, once said, “There’s nothing like a little physical pain to keep your mind off your emotional problems. I now believe that the physical restrictions imposed by TMS are much more important than the pain, thus making it imperative that the patient gradually overcome them. If patients cannot do 80 Healing Back Pain this they are doomed to have recurrences of pain. The pervasive, universal fear of physical activity in people with these pain syndromes, especially of the low back, has prompted me to suggest a new word— physicophobia. It should be noted, parenthetically, that the advice to resume normal physical activity, including the most vigorous, has been given to a very large number of patients over the past seventeen years. I cannot recall one person who has subsequently said that this advice caused him or her to have further back trouble. I suggest to patients that they begin the process of resuming physical activity when they experience a significant reduction in pain and when they are feeling confident about the diagnosis. To start prematurely only means that they will probably induce pain, frighten themselves and retard the recovery process. Patients are usually conditioned to expect pain with physical activity and so must not challenge the established programmed patterns until they have developed a fair degree of confidence in the diagnosis. One of my patients, an attorney in his midthirties, had an interesting experience in this regard. He went through the program uneventfully and in a few weeks was free of pain and doing everything—except one thing. He explained to me later that it had been drummed into his head for so many years that running was bad for your back that he simply couldn’t get up the courage to try, though he could do many things more strenuous than running. He called for my advice but unfortunately I was on vacation and he had to make his own decision. Then one night he was awakened from sleep with a very sharp pain in the upper back, but his low back pain was gone. Knowing that TMS The Treatment of TMS 81 often moves to different places during the process of recovery, he decided that he had probably won, and he had. Within a couple of days the upper back pain was gone too and he has not had a recurrence of either upper or lower back pain since that time. Losing one’s fear and resuming normal physical activity is possibly the most important part of the therapeutic process. Discontinue All Physical Treatment Another essential for full recovery is that all forms of physical treatment or therapy must be abandoned. It is instructive to consider that I did not stop prescribing physical therapy until twelve or thirteen years after I began to make the diagnosis. It took that long for me to fully break with all the old traditions in which I had been schooled.

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