Nociceptive pain Well-localized Sharp Aching Throbbing Pressurelike Visceral pain
When associated with obstruction of a hollow viscus: Gnawing Cramping
Spontaneous pain (suggesting tissue damage or impending damage; may be steady or intermittent) Sharp Aching Crampy Stabbing Knifelike Crushing Evoked pain
Can occur as hyperesthesia from stimulation of receptors, often associated with areas of somatosensory malfunction Allodynia (painful perception of normal stimulation) Hyperpathia (heightened pain of a normally painful stimulus) Burning Stinging Radiating Electric shock-like autonomic nervous system. Although the pain responds to opioid analgesics in high concentrations, it is less responsive than nociceptive pain at the usual levels.17,20,21
Assessing the pain type and characteristics requires an adequate history and physical examination. In addition, any medical risk factors should be well understood. Table 15.2 gives general inclusion and exclusion criteria for intraspinal opioid therapy. The patient should have progressed to level 3 of the World Health Organization (WHO) pain ladder (Table 15.3) and should have demonstrated opiate responsivity.19 Psychological assessment has become an important part of ongoing management for chronic pain patients as well as an integral part of selection for implantable therapies. The question asked of the neuropsy-chologist or psychiatrist is whether any untreated psychosocial problems exist that might lead to a bad outcome from the therapy. The question of whether a patient is a candidate for implantable therapy is answered by the implanter, generally not by the psychologist. However, certain psychiatric diagnoses such as psychosis or conflicting motives and expectations may lead to nonselection. Olson has identified several risk factors for chronic pain and poor outcomes with treatment, including major psychopathology, mood disorder, potential for self-harm, dementia, anxiety, catastrophizing, high magnitude of distress, addictive issues, and sleep disturbances.22 Socioeconomic problems and family and social support mechanisms should be identified and problems dealt with before and concurrently with implantation.23
If there has been a failure of standard pain management techniques to obtain long-term control of the pain, implantable therapies including spinal cord stimulation (SCS) and intraspinal drugs should be conTable 15.2. Exclusion and inclusion criteria for intraspinal opioids Exclusion criteria Absolute exclusion Aplastic anemia Systemic infection
Known allergies to the materials in the implant Known allergies to the intended medication(s) Active intravenous drug abusers Psychosis or dementia Relative exclusion Emaciated patients Ongoing anticoagulation therapy Children whose epiphyses have not fused Occult infection possible Recovering drug addicts
Opioid nonresponsivity (other drugs may be considered) Lack of social or family support Socioeconomic problems Lack of access to medical care Inclusion criteria
Pain type and generator appropriate Demonstrated opioid responsivity
No untreated psychopathology that might predispose to an unsuccessful outcome Successful completion of a screening trial_
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