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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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PatientswithMSCCmayhaveautonomicdysreflexia.Thistendstooccurintheacute phaseofparalysisorwithhighcordlesions(aboveT6).Signsinclude:
Hypotensionorhypertension Hypoventilation Bradycardia.
Investigations
Bloods
FBC,U&E,LFT,INR Serumglucose/CBGmayberaisedsecondarytosteroiduse Boneprofile(checkforhypercalcaemia) If unknown primary malignancy, perform myeloma screen (protein electrophoresis, immunoglobulins,BenceJonesprotein)andPSA.
Imaging
MRIwholespine:
Mustbeperformedwithin24hoursifneurologicalsymptomsorsignsarepresent,orsoonerif pressingneedforemergencysurgery
Within7daysifmoderateclinicalsuspicionwithoutneurologicalsymptomsorsigns IfMRIiscontraindicated(e.g.sometypesofpacemaker),discussoptionswithMSCCcoordinator IfMRIisurgentlyindicatedbutisunavailable,transferthepatienttoanotherhospitalthathasMRI availability Do not perform plain radiographs of the spine to make or exclude the diagnosis of spinal metastasesorMSCC.
Management
SeeFig.53.1.
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Fig.53.1SummaryofinvestigationandmanagementofsuspectedMSCC.
Acutemanagement
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Analgesia:
Offeranalgesiatitratedtorequirements
Laxativesshouldbegivenwithopiate-basedanalgesia
Ifintractablepain,considerspecialistpainteaminvolvement Corticosteroids:
ConsideronsuspicionofMSCC,pendingMRIresult
Loading dose 16mg dexamethasonePO, followed by 16mgdexamethasonedaily, e.g. 16mg
OD(morning)or8mgBD(morningandlunchtime):
Dexamethasonecanalsohaveananalgesiceffect Oncedefinitive treatmentisstarted(surgery orradiotherapy),taper thedose over 5–7
daystostop.Ifneurologicalfunctiondeteriorates,thedoseshouldbe↑again Maybecontraindicatedinsuspectedlymphoma(impairshistologicaldiagnosismakingbiopsy difficult);discusswithMSCCcoordinatorpriortogiving ConsiderPPIcover,e.g.omeprazole20mgOD Monitorpatientsforhyperglycaemia,epigastricpain(particularlyifonNSAIDs/aspirin),and steroid-inducedpsychosis
Mobilization:
Nurseflatuntilbonyandneurologicalstabilityareensured Turnusingalog-rollingtechniqueevery2–3hours Worseningneurologyorseveremechanicalbackpainsuggestsspinalinstability Liaisewithphysiotherapytoensurecautiousremobilization
Other:
VTEprophylaxis Pressureareamanagement Bladder/bowelfunction:
Ifbladderdysfunction,thepatientwillneedurinarycatheterization
If bowel dysfunction, discuss with the patient their preference for stool softeners,
oral/rectallaxatives,andconstipatingagentsasrequired.
Treatmentafterstabilization
Discusswithasenior clinicianandspecialistteams.Treatmentdecisions forMSCCpain andparalysispreventionshouldinvolvediscussionwithspinalsurgeonsandoncologists, withthepatientfullyinvolvedinthesediscussions.
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Bisphosphonates:
Offer for analgesia and to reduce the risk of vertebral fracture or collapse if the spinal pathologyisduetomyelomaorbreastcancer If spinal metastases are dueto prostate cancer, consider bisphosphonates if the pain is not controlledwithconventionalanalgesia Donotusefortumoursotherthanmyeloma,breast,orprostate
Surgery:
Aimstoachievespinalcorddecompressionandstabilityofthespinalcolumnwheninstability isseenonimaging.Ifthepatienthasbeenparaplegicortetraplegicfor≥24hours,onlyoffer surgerytoprovidepainrelief Consider vertebroplasty orkyphoplastywhenpainis notcontrolled byanalgesiaorthere is vertebralbodycollapse
Radiotherapy:
Should be offered to all patients withMSCCwho are notsuitable for surgery, unless they have had tetra/paraplegia ≥24 hours and their pain is well controlled, or their overall prognosisistoopoor
Rehabilitation:
Consideradmissiontoaspecialistrehabilitationcentreondischarge,dependentonprognosis, activitytolerance,andrehabilitationpotential.
Specialconsiderations
Patients with cancer, bone metastasis, or at risk of developing bone metastasis mustbe informedaboutthesymptomsofMSCC.
Furtherreading
1.Al-QurainyR,CollisE(2016).Metastaticspinalcordcompression:diagnosisandmanagement.BMJ. 353:i2539.
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Chapter54
Neuropathicpain
Guideline: NICE CG173 (Neuropathic pain in adults: pharmacological
management in non-specialist settings):
https://www.nice.org.uk/guidance/cg173
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Neuropathicpainiscausedbyalesionordiseaseoftheneuraltissue.
Causesofneuropathicpaininclude:
Diabeticneuropathy Post-herpeticneuralgia Trigeminalneuralgia Radicularpain Post-surgicalchronicneuropathicpain Spinalcordinjury Multiplesclerosis.
Diagnosis
Neuropathicpaincanbeintermittentorconstant,andspontaneousorprovoked Patientsdescribethepainasshooting,stabbing,electricshock-like,burning,tingling,tight,numb, prickling,itching,orasasensationofpinsandneedles. SeeTable54.1
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Table54.1Keycharacteristicsforcommoncausesofneuropathicpain
Diagnosis Characteristic
Diabetic neuropathy
Patientswithdiabetesmellitus,tendstoaffectlowerlimbsbeforeupper
Post­herpetic neuralgia
Painthatcontinuesformonths-yearsaftertheresolutionofaVZVrash.Usuallyinvolvesaspecific nerveandlocalizestoonedermatomeunilaterally
Trigeminal neuralgia
Oftenparoxysmalbutcanalsobetriggeredbylighttouch.Lastsforsecondsratherthanminutesin thedistributionofthetrigeminalnerve.Usuallyunilateral.Oftenassociatedwithautonomic symptomssuchaslacrimationandrhinorrhea
Radicular pain
Duetoinflammationofaspinalnerverootcausingadermatomaldistributionofpain
Management
Wherepossible,treatthecauseofthepain Whenagreeingatreatmentplanwithapatient,considerthefollowing:
Theeffectthepainhasonthepatient’slifestyleandactivitiesofdailyliving,e.g.difficulties sleepingduetothepain Whethertheunderlyingconditionthatcausesthepainhasdeteriorated Theimportanceoftitrating medicationdosetoachieve adequatecontrolbutconsideringthe benefitsandadverseeffectsofpharmacologicaltreatments
Non-pharmacologicaltreatmentssuchaspsychologicalandphysicaltherapies When introducing a new treatment, consider overlap with old treatments initially to avoid deteriorationofpaincontrol.
Pharmacologicaltreatment
Trigeminalneuralgia
Offer carbamazepine 100mg 1–2 times a day. Usual dose 200mg 3–4 times a day—titrate as needed.Maximumdailydose1.6gdaily.
Othercausesofneuropathicpain
Options:
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Amitriptyline10–25mgatnight.Escalateiftoleratedevery3–7days.Usualdailydose25–75mg
OR
Duloxetine60mgOD(particularlyhelpfulindiabeticneuropathy)OR Gabapentin300mgODonday1,300mgBDonday2,300mgTDSonday3,withfurthertitration asrequired(maximum3.6mg/day,inthreedivideddoses)OR Pregabalin 50mg TDS. Dose maybe ↑ if needed after 3–7 days. Maximum 600mg OD in 2–3 divideddoses.
Consider:
Switchingdrugifthefirstisineffective—allfourcanbetrialledifnecessary Tramadol50–100mgQDSasashort-termrescuemedication Capsaicincreamifthepatientwishestoavoidoralanalgesiaandthepainislocalized.
Followup
Afterinitialtreatment,reviewafter1–2weeks Onceestablishedontreatment,reviewregularlytomonitoreffectivenessoftreatment Ateachreview,assess:
Paincontrol
Impactonlifestyleanddailyactivities
Physicalandpsychologicalwell-being
Adverseeffectsoftherapy,e.g.prolongedQTcandarrhythmiaswithamitriptylineuse
Whethercontinuedtreatmentisneeded After6monthsoftreatmentconsidergradualdosereduction When withdrawing or switching treatment, taper the drugs to reduce the risk of interval pain symptoms.
Specialconsiderations
Specialistpainclinicreferral
Refertoaspecialistpainclinicif:
ThepatienthasseverepainOR ThepainsignificantlyimpairsactivitiesofdailylivingOR Theunderlyinghealthconditionthatiscausingthepainhasdeteriorated.
Elderly
Becautiouswiththestartingdoseofamitriptylinedueto↑riskofpsychiatricandcardiac sideeffects.
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Chapter55
Parkinson’sdisease
Guideline: NICE NG71 (Parkinson’s disease in adults):
https://www.nice.org.uk/guidance/ng71
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Parkinson’sdisease(PD)isadegenerative,incurablemovementdisorderresultingfrom thelossofdopamine-containingcellsinthesubstantianigraparscompacta.
Diagnosis
Historyandexamination
TheUKParkinson’sDiseaseSocietyBrainBankClinicalDiagnosticCriteriamustbemet1:
Bradykinesiaandatleastoneof:
Muscularrigidity 4–6Hzrestingtremor Postural instability not caused by primary visual, vestibular, cerebellar, or proprioceptive dysfunction.
Exclusioncriteria
Symptoms suggestive of alternative neurological diagnoses that might also explain the presentingclinicalsymptoms,e.g.recurrentheadinjuryorpreviousstroke.
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Supportivecriteria
≥3mustbepresent:
Unilateralonset Restingtremor Progressivesymptoms Persistentasymmetryaffectingsideofonsetmost Excellentresponsetolevodopa Severelevodopa-inducedchorea Levodoparesponsefor≥5years Clinicalcourse≥10years.
IfPDissuspected,referwithoutstartingmedicationforpromptspecialistreview.
Investigations
Diagnosisisbasedonclinicalfindings MRIisonlyhelpfulinthedifferentialdiagnosisofothercausesofparkinsonism ConsiderSPECTifunabletoruleoutessentialtremor.
Management
Lifestyleandsimpleinterventions
Involvephysiotherapistsandoccupationaltherapistsforbalance,motor,andfunctionalproblems Liaisewithadieticianas:
SomefoodsmayinteractwithPDmedications
Tremor,stiffness,andimpairedswallowmaymeanpatientsneedtochangetheirdiet Speech and language therapists can improve speech and swallow, aiding communication and reducingtheriskofaspiration.
Pharmacologicalmanagement
Mainaimofdrugtherapy
Improvement in motor symptoms and activities of daily living: levodopa, MAO-B inhibitors, COMTinhibitors.SeeFig.55.1 Improving off time (when symptoms worsen in between doses due to ‘wearing off’ of the medication):dopamineagonists.
Possibleadverseeffects
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Greaterriskofmotorcomplications:levodopa Greaterriskofsleepiness,hallucinations,andimpulsecontroldisorders:dopamineagonists PDpatientsarepronetomissingtheirmedicationswhenadmittedtohospital,orreceivingthemat the wrong times, potentiallyleading toacuteakinesia or neuroleptic malignantsyndrome dueto suddenwithdrawaloftherapy. Bevigilantforcausesofpoortreatmentadherencee.g.gastroenteritis,missedprescriptions,being keptnilbymouth—andbeproactiveinremovingbarrierstotreatment,e.g.usenasogastrictubes, self-administration Changesofformulationmaybenecessary,e.g.toatopicalpatch,withseniorclinicianassistance. A helpful resource for drug formulation conversion is available online (the OPTIMAL
calculator2).
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