Cases reported "Pain, Postoperative"

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1/10. Neuropathic complications of mandibular implant surgery: review and case presentations.

    Injuries to trigeminal nerves during endosseous implant placement in the posterior mandible appear to occur acutely in approximately 5-15 of cases, with permanent neurosensory disorder resulting in approximately 8%. Nerve lateralization holds even higher risks from epineurial damage or ischaemic stretching. Neuropathy from implant compression and drill punctures can result in neuroma formation of all types, and in some cases precipitate centralized pain syndrome. Two patterns of clinical neuropathy are seen to result; hypoaesthesias with impaired sensory function, often seen with phantom pain, and hyperaesthesias with minimal sensory impairment but presence of much-evoked pain phenomena. The clinician must differentiate, through careful patient questioning and stimulus-response testing, those patients who are undergoing satisfactory spontaneous nerve recovery from those who are developing dysfunctional or dysaesthetic syndromes. Acute nerve injuries are treated with fixture and nerve decompression and combined with supportive anti-inflammatory, narcotic and anti-convulsant therapy. Surgical exploration, neuroma resection and microsurgical repair, with or without nerve grafting, are indicated when unsatisfactory spontaneous sensory return has been demonstrated, and in the presence of function impairment and intractable pain.
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2/10. acupuncture treatment of phantom limb pain and phantom limb sensation in amputees.

    Three case histories are presented in which amputees with acute or chronic phantom limb pain and phantom limb sensation were treated with Western medical acupuncture, needling the asymptomatic intact limb. Two out of the three cases reported complete relief of their phantom limb pain and phantom limb sensation. acupuncture was successful in treating phantom phenomena in two of these cases, but a larger cohort study would be needed to provide more evidence for the success rate of this treatment technique for this indication.
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3/10. A paraspinal abscess following spinal anaesthesia for caesarean section and patient-controlled epidural analgesia for postoperative pain.

    We present a rare case in which a healthy parturient developed a paraspinal abscess after spinal anaesthesia for caesarean section and epidural analgesia for postoperative pain management. The catheter was in situ for 58 h. Backache was the initial and major symptom. A concealed course with no neurological deficit resulted in a delayed diagnosis and treatment in this case. The infection was not diagnosed until 20 days after the removal of the epidural catheter when there was a purulent discharge from the epidural puncture site. Surgical drainage was required. Anaesthesiologists should be aware that serious epidural analgesia-related infections can happen in extra spinal-epidural spaces. Vigilance for these infections, especially in postpartum patients with backache, is needed.
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4/10. acupuncture for acute postoperative pain relief in a patient with pregnancy-induced thrombocytopenia--a case report.

    A 39 year old woman, scheduled for elective caesarean section in her second pregnancy, developed thrombocytopenia. Therefore, at the time of surgery, spinal anaesthesia and non-steroidal analgesic drugs were avoided and she was given a standard general anaesthetic procedure including fentanyl 100 microg and morphine 10 mg. In the early postoperative period she received tramadol 100 mg and a further 10 mg of morphine. These drugs did not control her pain, but caused side effects--in particular nausea and retching. acupuncture to LI4 and PC6 on the right side produced dramatic pain relief within minutes.
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5/10. Post-dural headache associated with thoracic paravertebral blocks.

    The thoracic paravertebral block is effective in providing anesthesia and postoperative analgesia for thoracic and abdominal surgeries. This case report describes a suspected post-dural puncture headache following bilateral thoracic paravertebral blocks for postoperative analgesia after an umbilical hernia repair.
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6/10. Continuous intrathecal fentanyl infusion for postoperative analgesia.

    Following inadvertent dural puncture during epidural catheter placement, a 20 gauge polyethylene catheter was placed in the intrathecal space, and continuous spinal anesthesia with hyperbaric bupivacaine was administered intraoperatively to supplement general anesthesia. Following surgery, a continuous intrathecal fentanyl infusion (0.2 mcg/kg/hr) was administered to provide postoperative analgesia. The child was awake and comfortable throughout this time and required no supplemental analgesic agents. Although epidural catheters are still our preferred method of analgesia, intrathecal fentanyl infusion is one alternative when inadvertent dural puncture occurs.
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7/10. Respiratory depression complicating epidural diamorphine. Two case reports of administration after dural puncture.

    Two cases of severe respiratory depression complicating epidural diamorphine administration are reported. In both cases, the dura had been punctured. The risk of epidural opiate administration in association with a breach in the dura is reiterated.
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8/10. The time course of a sixth nerve paresis following epidural anesthesia.

    An isolated sixth nerve palsy is seldom seen following epidural anesthesia. An unintentional puncture through the dura may cause a leak of cerebrospinal fluid resulting in a shift of the cerebral content. This may cause a stretching of the sixth cranial nerve giving an abduction palsy. The palsy is benign and resolves completely within two months. The time course of a case will be described.
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9/10. Epidural morphine for postoperative pain relief in children.

    Epidural morphine for postoperative pain relief is in general use, and has proved to be very efficient in adults. The epidural technique and the use of epidural morphine are much less frequent in children. For 2 years we have prospectively followed 76 children who had epidural morphine for postoperative pain relief after major abdominal surgery. The age distribution was from newborn to 13 years, with a median age of 12 months. It was estimated that 94% of the patients had good analgesia for the first 24 postoperative hours and no other opioids were given. The side effects were few, but one case of respiratory depression was seen and 20% of the children had pruritus. There were four dural punctures and three catheters slipped out accidentally, but otherwise the treatment was continued as long as it was considered necessary (1-11 days). The use of postoperative ventilatory support decreased during the investigation. We observed a change in the sleeping pattern with an increased number of sleep-induced myoclonia during the administration of epidural morphine. In conclusion, the use of epidural morphine in children for postoperative pain relief is very efficient. The minimal effective dose has not been established as yet, but 50 micrograms/kg every 8 h, supplemented with small doses of bupivacaine, provides excellent analgesia in the immediate postoperative period after major abdominal surgery. The side effects are few, but the risk of respiratory depression is always present and observation in the intensive care unit or recovery for the first 24 h is strongly recommended.
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10/10. Postdural puncture symptoms in a child.

    An 11-year-old boy suffered an inadvertent dural puncture during placement of an epidural catheter for postoperative analgesia. He developed symptoms of mild headache only, but severe and protracted orthostatic nausea and dizziness, which eventually resolved completely following epidural blood patch. His symptoms were atypical and could have been misinterpreted in the context of dural puncture for diagnosis, or for administration of intrathecal chemotherapy. The reported incidence of headache following dural puncture in children is low. It may be that the manifestations are different from those of adults and that the true incidence of symptoms related to leakage of cerebrospinal fluid is higher in children than currently recognised.
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