Reduction mammaplasty: a way helping females with neck,shoulder and back pain symptoms

Summary This study documents that the excessive weight of the female breast can lead to, or increase, existing pain symptoms of the neck, shoulder and upper trunk. Consequently, a reduction mammaplasty has to be considered as a mainly medical indication in women with permanent musculoskeletal pain symptoms in their medical history since surgery reduces the pain symptoms, increases the capacity to work, improves self-confidence and life conditions. The various technical procedures for reduction mammaplasty with a low postoperative complication rate give excellent results in correctly selected patients.     

Past,Present, and Future of Minimally Invasive Abdominal Surgery

Laparoscopic surgery has generated a revolution in operative medicine during the past few decades. Although strongly criticized during its early years, minimization of surgical trauma and the benefits of minimization to the patient have been brought to our attention through the efforts and vision of a few pioneers in the recent history of medicine. The German gynecologist Kurt Semm (1927–2003) transformed the use of laparoscopy for diagnostic purposes into a modern therapeutic surgical concept, having performed the first laparoscopic appendectomy, inspiring Erich Mühe and many other surgeons around the world to perform a wide spectrum of procedures by minimally invasive means. Laparoscopic cholecystectomy soon became the gold standard, and various laparoscopic procedures are now preferred over open approaches, in the light of emerging evidence that demonstrates less operative stress, reduced pain, and shorter convalescence. Natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS) may be considered further steps toward minimization of surgical trauma, although these methods have not yet been standardized. Laparoscopic surgery with the use of a robotic platform constitutes a promising field of investigation. New technologies are to be considered under the prism of the history of surgery; they seem to be a step toward further minimization of surgical trauma, but not definite therapeutic modalities. Patient safety and medical ethics must be the cornerstone of future investigation and implementation of new techniques.     

Compliance with clinical practice guidelines in family physicians managing worker''s compensation board patients with acute lower back pain

BACKGROUND CONTEXT: Family physician compliance with acute lower back pain clinical practice guidelines remains uncertain. PURPOSE: To determine the degree of guideline compliance of family physicians managing patients with workers' compensation claims and acute mechanical lower back pain. STUDY DESIGN: Observational study. PATIENT SAMPLE: One hundred thirty-nine family physicians in British Columbia. OUTCOME MEASURES: Compliance with guideline recommendations for history, examination procedures, diagnostic testing and treatments. METHODS: Physician workers' compensation board patient reports for acute lower back pain without leg symptoms and not greater than 2 to 3 weeks duration were scored for guideline adherence up until 12 weeks after onset. RESULTS: Physicians demonstrated a high degree of compliance with the guideline-recommended history, examination procedures and medications, but low compliance with recommended imaging and many treatment recommendations. CONCLUSIONS: Recently published clinical practice guidelines regarding the management of patients with acute mechanical lower back pain have not been fully implemented into the patterns of practice of the family physicians.     

Destructive procedures for the treatment of nonmalignant pain: a structured literature review

OBJECT: Nonmalignant pain has been treated in the past century with ablative, or more appropriately, destructive procedures. Although individual outcomes for these procedures have previously been described in the literature, to the authors' knowledge this is the first comprehensive and systematic review on this topic. METHODS: A US National Library of Medicine PubMed search was conducted for the following ablative procedures: cingulotomy, cordotomy, DREZ (also input as dorsal root entry zone), ganglionectomy, mesencephalotomy, myelotomy, neurotomy, rhizotomy, sympathectomy, thalamotomy, and tractotomy. Articles related to pain resulting from malignancy and those not in peer-reviewed journals were excluded. In reviewing pertinent articles, focus was placed on patient number, outcome, and follow-up. RESULTS: A total of 146 articles was included in the review. The large majority of studies (131) constituted Class III evidence. Eleven Class I and 4 Class II studies were found, of which nearly all (13 of 15) evaluated radiofrequency rhizotomies for different pain origins, including lumbar facet syndrome, cervical facet pain, and Type I or typical trigeminal neuralgia. Overall, support for ablative procedures for nonmalignant pain is derived almost entirely from Class III evidence; despite a long history of use in neurosurgery, the evidence supporting destructive procedures for benign pain conditions remains limited. CONCLUSIONS: Newly designed prospective standardized studies are required to define surgical indications and outcomes for these procedures, to provide more systematic review, and to advance the field.     

Remnants of a 35-year-old ventriculo-atrial shunt presenting as orofacial pain

A 36-year-old man presented to his general dental practitioner with pain in the right jaw and neck. This was initially treated as a dento-alveolar abscess. Three days later, he presented to the oral and maxillofacial unit with neck swelling to the right side. An ultrasound confirmed the swelling was due to thrombosis associated with remnants of a ventriculo-atrial (VA) shunt in the right internal jugular vein. This had been placed during the patient’s infancy and apparently removed at the age of 8 years. The patient was treated conservatively with warfarin and Coamoxyclav. The patient made a full recovery and was placed on long-term anticoagulant therapy. The introduction of cerebral spinal fluid shunt procedures for the treatment of hydrocephalus has resulted in a reduction in the mortality rate from 80% to 15–20%. Various thrombo-embolic complications have been described with VA shunts. A thorough medical history is absolutely essential in order to identify uncommon causes of common presentations.     

用多感官型分心装置缓解患儿伤口处理时疼痛的研究

目的 设计多感官型分心装置(MMD),观察其在烧伤换药和其他医疗过程中减轻患儿焦虑和疼痛的效果.方法 设计3项前瞻性、随机对照临床试验.选择澳大利亚布里斯班皇家儿童医院烧伤中心和骨折整形外科患儿182例,共计354个医疗过程,分别应用标准分心法、手握电子游戏机和MMD(前MMD-D型、MMD-D型及MMD-PP型).采用改良面部表情评分法、面部疼痛评分法、视觉模拟评分法及Wong-Baker面部表情疼痛评分法,记录患儿报告的疼痛分数、父母和护理人员报告的患儿焦虑和疼痛分数以及换药时间.结果 与标准分心法组和电子游戏机组[(3.60±0.25)、(3.83±1.49)分]比较,MMD-D组与MMD-PP组患儿首次换药时的疼痛分数[(2.13±0.23)、(2.15±0.17)分]显著降低(P<0.01),换药时间明显缩短(P<0.01),且MMD在连续3次换药过程中均能发挥缓解疼痛的作用.此外,MMD-PP组患儿在换药前由焦虑引起的疼痛分数也较其他组显著降低(P<0.01).结论 MMD较标准分心法和手握电子游戏机更能有效减轻患儿伤口处理过程中的焦虑和疼痛.该装置仍在临床试验中,且继续显示其有效性.     

Clinical diagnosis of vertebrobasilar insufficiency: resident's case problem

STUDY DESIGN: Resident's case problem. BACKGROUND: Vertigo and visual disturbances are common symptoms associated with vertebrobasilar insufficiency (VBI), but the physical examination procedures to verify the existence of VBI have not been validated in the literature. The objective of this resident's case problem is to demonstrate how a patient's complaint of vertigo and visual disturbances, combined with positive clinical examination findings, can be a potential medical screening tool for VBI. DIAGNOSIS: The patient in this report was initially referred to physical therapy for neck pain. However, the patient's chief concerns identified during the history were (1) vertigo, (2) visual disturbances, (3) headache, and (4) right shoulder region pain. Clinical VBI tests were performed, whereby the patient's vertigo and visual disturbances were reproduced with cervical spine extension. The patient was sent back to the referring physician to be evaluated for possible VBI. Diagnostic imaging tests were ordered. Carotid ultrasound revealed 80% to 90% stenosis in the proximal left internal carotid artery, and magnetic resonance angiography of the extracerebral vessels showed greater than 90% stenosis of the left internal carotid artery. DISCUSSION: VBI may be present in patients with subjective reports of vertigo and visual disturbances that are reproduced with VBI physical examination procedures.     

Legal and social aspects of pain medicine

Pain is the most common reason for patients to see a doctor. Socio-economic issues including unemployment and difficulty accessing education are common in such patients. Pain is the third leading cause for absence from work. Patients frequently seek support from their multidisciplinary pain team for welfare support and staying in or returning to employment or education. Pain physicians perform a range of intervention procedures and need to have a clear grasp of the law of consent. They are also called on to give expert evidence in personal injury and medical negligence claims where claimants have been left with chronic pain. This paper explores the legal and social infrastructure, and useful knowledge that should be at the fingertips of all those practising in the field of pain medicine.     

Medicolegal and social implications of practising in pain medicine

Pain is the most common reason for patients to see a doctor. Low social support and unemployment are common in such patients. Pain is the third leading cause for absence from work. Patients frequently seek support from their multidisciplinary pain team for welfare support and staying in or returning to employment or education. Pain physicians perform a range of intervention procedures and need to have a clear grasp of the law of consent. They are also called on to give expert evidence in personal injury and medical negligence claims where claimants have been left with chronic pain. This paper explores the legal and social infrastructure, and knowledge that should be at the fingertips of all practising in the field of pain medicine.     

Phimosis in antiquity

The medical term phimosis has been in use since antiquity, but in contrast to the imprecise definition of the term that is characteristic of nineteenth-century and some controversial modern medical writing, Greek and Roman medical writers imbued it with a clinically precise definition. Using the tools of the history of medicine, an analysis of the medical writings of antiquity reveals that phimosis was defined exclusively as a rare, inflammatory or cicatricial stricture of the preputial orifice consequent to a true pathological condition rather than a disease process in itself. Putative associations between phimosis and diseases such as urinary tract infections or cancer were not made in antiquity and are reflections of modern, geographically isolated social anxieties. The modern European scientific conceptualisation of phimosis, however, represents a return to the precise terminology and conservative therapeutic approach characteristic of Greek and Roman medicine.     

Spinal cord stimulation in chronic pain management

As a general rule, even though it is always difficult to predict the efficacy of a method ina single patient, we consider SCS in every non-malignant chronic pain patient when other conservative treatments have failed. After three decades of clinical experience with SCS, we have learned a lot about its efficacy indifferent pain conditions and have made great technical progress with the materials and surgical procedures. Acceptance of the technique was slow at the beginning; however, we must be aware of the problems related to the application of a therapy that cannot be shamed, and thus the necessity of performing studies that include large numbers of patients. This is even more complicated when dealing with pain patients because of the well-known multifactoriality of pain. Nowadays, every algorithm for the treatment of different pain conditions includes SCS; consequently, every pain center should be able to offer this therapy in its treatment program. This article discusses what has been learned so far with regard to SCS, but there is a lot more to learn about this technique as well as about other types of neuromodulation procedures. As mentioned in the introduction of this article and discussed in the section on the effects of SCS, particularly in clinical applications like peripheral vascular disease and angina, the results of the interaction with the function of the nervous system can be observed in other systems in the body affecting pathologic conditions that are of interest to different specialists. Only the strict cooperation of different medical disciplines can provide substantial help in acquiring knowledge about the mechanisms put into play by SCS and the possible extension of its clinical applications. The complexity of the procedures of neuromodulation and the theoretic background needed for safe and proficient clinical use and for progress raise the issue for medical schools of offering courses in this new discipline.     

Surgical therapy of femoral artery pseudoaneurysm after angiography

Seventy patients requiring surgical treatment for femoral artery pseudoaneurysm after angiographic procedures have been presented. The 10 year study period encompassed 38,822 catheter procedures (31,951 cardiology procedures and 6,871 radiology procedures) performed through the femoral artery. Presenting complaints included pain (51 percent) and neuropathy (19 percent). Additional morbidity has been discussed. The present study differs from previous ones in that many of the patients had femoral artery pseudoaneurysm formation in the common femoral artery without a history of smoking, diabetes, or hypertension. There was no demonstrable association with anticoagulation or antiplatelet therapy. The incidence of femoral artery pseudoaneurysm did increase with the use of a catheter sheath from 0.06 to 0.3 percent (p less than 0.005). This has not been reported previously. Direct arterial repair was utilized in 63 patients, whereas arterial reconstruction was required in 7 patients (saphenous vein graft in 4 and prosthetic graft in 3). There was one wound complication but no mortality associated with the surgical repair. Acceptable reasons for repair of femoral artery pseudoaneurysms are persisting or enlarging femoral artery pseudoaneurysms, associated pain or neuropathy, and rupture of femoral artery pseudoaneurysms.     

Trigeminal neuralgia

Trigeminal neuralgia (TN) is the most common facial neuralgia, and is considered to be one of the most painful conditions to affect patients. The rate of occurrence of TN in men and women is 2.5 and 5.7 per 100,000 per year respectively. TN is generally characterized by lancinating, unilateral, paroxysmal pain occurring in the distribution of the fifth cranial nerve. The diagnosis of TN is made clinically by excluding other possible causes of facial pain and is based on signs and symptoms from the patient history such as a trigger zone, typical unilateral lancinating paroxysms following neural disturbance, and a refractory period. Generally, TN can be diagnosed by the typical patient history, a negative neurologic exam, and response to a trial of carbamazepine. Imaging studies should be considered if the diagnosis is uncertain or neurologic abnormalities are noted. Most cases are caused by compression of the trigeminal nerve root, usually within a few millimeters of entry into the pons. In a few cases, TN is caused by a primary demyelinating disorder. The treatment modalities for the management of TN may be divided into medical, surgical, and gamma-knife radiosurgery. Generally, response to drug therapy is good, with over 80% of patients responding to some of the anticonvulsants. Percutaneous approaches to trigeminal gangliolysis are considered to have less associated risk and less cost than open surgical procedures. Three different techniques may be used to perform percutaneous destruction of the ganglion: percutaneous radiofrequency trigeminal gangliolysis (PRTG), percutaneous balloon microcompression (PBM), and percutaneous retrogasserian glycerol rhizotomy (PRGR). Open surgical procedures used in the treatment of TN include microvascular decompression of the trigeminal root and retrogasserian rhizotomy. Additionally, because both of these procedures have greater associated risks, morbidity, and mortality, they are customarily applied only to younger patients in good health. Stereotactic radiosurgery has been established as an alternative treatment for patients who do not respond to optimal medical management.     

Management of pain in small duct chronic pancreatitis

Small duct chronic pancreatitis (CP) is defined by a nondilated main pancreatic duct, and the morphological and clinical features of chronic pancreatitis with pain are the most prominent symptoms. Current treatment strategies are based on pain history and the location and extent of disease. Traditionally, radical pancreatic resectional procedures have been carried out for small duct CP, especially with an associated head mass of uncertain aetiology. Based on the information from five randomized trials, the duodenum-preserving pancreatic head resection and its modifications have proven to provide excellent long-term pain relief and to be superior to more radical operations. Therefore, these procedures can be considered the standard for small duct CP with head dominant disease. The longitudinal V-shaped excision of the ventral pancreas combines extensive drainage and a limited resection and offers good pain relief in diffuse small duct CP. However, long-term results and larger series are awaited for definite conclusions. Thoracoscopic splanchnicectomy and endosonography-guided celiac plexus blocks require controlled trials before their routine use. This article provides an overview about the current and evidence-based pain management in small duct CP. Presented at the 2005 American Hepato-Pancreato-Biliary Association Congress, Hollywood, Florida, April 14–17, 2005.     

Pain relief for the pediatric surgical patient

Modern techniques available for the relief of pain following major surgical procedures or trauma in childhood receive scant attention in pediatric surgical textbooks. A range of options for pain relief have been offered to children in our hospital, which include: regional analgesia; appropriate use of intermittent intramuscular narcotic injections; and variable-rate intravenous narcotic infusions. Since 1982 regional analgesia has been used in more than 2,000 patients following operations on the penis and in the inguinoscrotal region. Two hundred forty five children with fractured femora have been managed using femoral nerve blocks. Intermittent intramuscular narcotic injections are the most common method of pain relief. However, the variable nature of children's pain frequently results in an unsatisfactory outcome. Variable-rate intravenous narcotic infusions were introduced in 1982 and the first 155 infusions in 144 patients have been analyzed. The protocol and method of administration are described along with the dosage and problems encountered during the introduction of the technique. It has now been employed postoperatively in 242 more patients and many infusions have been commenced in the emergency department, intensive care, and neonatal units bringing the total number of infusions to more than 600. Assessment of effective pain relief has been made on the basis of observation and comment by parents and patients and by medical and nursing staff. The steady increase in demand for the use of this technique is an index of its value. It is concluded that there is a real need to improve pain relief for children by better education of medical and nursing staff and inclusion of this important subject in pediatric surgical text books.     

Chronic pain after surgery

Chronic pain after surgery is an area of considerable interest. Sufferers of chronic pain experience a poor quality of life, and the economic costs of treatment of the condition and resulting disability are high. Factors such as severe preoperative pain, psychosocial factors and particular surgical procedures have been identified as risk factors. Neuropathic mechanisms are involved in the pathophysiology of chronic post surgical pain and our understanding of this continues to grow. Much interest has focused on perioperative analgesic interventions to reduce the incidence and severity; however, as yet the evidence is neither compelling nor consistent. At present there remains a need for education of the medical profession and the public of the risks of chronic post surgical pain, so that unnecessary or inappropriate operations are minimized.     

Louis Appia (1818-98): military surgeon and member of the International Committee of the Red Cross

From Appia's writings we compose a view on his contribution to international medical relief in warfare, to the establishment of the Red Cross and the Geneva Convention, and to surgical procedures on the battlefield. Much information comes from his work on the Battle of San Martino e Solferino in June 1859 on the subject of which he wrote seven letters. We report also on his role during the Garibaldinian Campaign in 1866 and his work in Europe as a member of the International Committee of the Red Cross (ICRC).     

Is the self-reported history accurate in patients with persistent axial pain after a motor vehicle accident?

Background contextA patient's self-reported history has, in general, assumed to be accurate. Clinical management of individuals with persistent axial pain after a motor vehicle accident (MVA) and measures to prevent future MVA, spinal cord injury, and traffic deaths often depend on a presumed accurate report of preexisting axial pain, drug, alcohol, and psychological problems to initiate intervention. In addition, research efforts to determine the effects of MVA on subsequent health are often predicated on a presumed accurate history from the patient of past medical and psychosocial problems. Despite so many clinical, public health, and research efforts being dependent on an accurate assessment of pre-injury health, the validity of the self-reported history after MVA has not been systematically investigated.PurposeTo determine the validity of self-reported history in subjects with axial neck or back pain attributed to a recent MVA.Study designA prospective, multiclinic validation study examining the critical elements of a patient's self-reported history after an MVA judged against an audit of his or her medical records.Patient sampleA cohort of consecutive patients with persistent axial pain after an MVA was prospectively identified from five spine-specialist's outpatient clinics. Of 702 patients, 335 subjects were randomly selected for auditing of their medical records.Outcome measuresSelf-reported demographic and clinical features were recorded by standardized questionnaires and clinical interviews. Audits compared these responses to an extensive medical record search.MethodsThe self-reported prevalence of preexisting axial pain, at-risk comorbidities (psychological distress, alcohol, and drug abuse), and control conditions (hypertension and diabetes) was recorded. The medical records of a random sample of 50% of the enrolled cohort underwent auditing of their medical records in a wide search of network paper and electronic and archived records, and compared with the self-reported history of pre-accident health.ResultsOverall, approximately 50% of the subjects were found to have previous axial pain problems at audit when none was reported to the spine-specialist after an MVA. Similarly, approximately 75% of the subjects were found to have one or more preexisting comorbid conditions at audit that were not reported during the evaluation after the MVA (alcohol abuse, illicit drug use, and psychological diagnosis). For those who perceived that the accident was the fault of another, as opposed to their own or no one's fault, the documented previous back and neck pain troubles in the medical records was more than twice the self-reported rate of these problems (p<.01). The rate of previously documented psychological problems was more than seven times that of the self-reported rate (p = 0.001). In those subjects who perceived that the accident was their own or no one's fault, a lesser degree of under-reporting of axial pain and comorbid conditions was found.ConclusionThe validity of the patient's self-reported history when presenting with persistent axial pain after an MVA appears poor in this large multiclinic random sample.The self-reported rates of alcohol abuse, illicit drug use, and psychological diagnosis, as well as prior axial pain were significantly lower than that seen in the medical records, especially in thosewho perceive that the MVA was another's fault. The failure to recognize this under-reporting may seriously compromise clinical care, public health efforts at injury prevention, and research protocols dependent on accurate pre-accident morbidity assessments.     

Methodologies for the treatment of acute and chronic nononcologic pain in children

Pain represents the most feared symptom of illness but for many years it has been underestimated in children. Only recently has analgesic treatment become an integral part in the assistance of ill children with acute pain, such as postoperative pain, and with chronic pain. Postoperative pain is a complication of surgery: postoperative pain prevention should replace the current theory and practice of postoperative treatment through the creation of 'pain services' and adequate pain prevention planning. Pain prevention begins in the preoperative period, continues in the operating theaters and in the postoperative phase. A multimodal approach should employ techniques of loco-regional anesthesia using a variety of agents from opioids to nonsteroidal anti-inflammatory drugs or paracetamol. The techniques we currently use to control procedural pain are both medical and nonmedical. Nonmedical interventions such as distraction, muscular relaxation, and guided imagination for pain control are psychological techniques showing very good results in those children who must undergo various procedures. The medical treatment must guarantee both sedation and effective analgesia. Our medical approach includes local anaesthesia, conscious sedation, deep sedation, and general anaesthesia.