The author discusses selected problems of ethical character developing in connection with medical management of neurological and psychiatric patients. (Ed.)
The underlying cause of neuropathic pain associated with other sensory disturbances such as hyperalgesia or allodynia frequently is peripheral nerve damage which can be documented. The study of its pathological mechanism is based on animal models of neuropathy in which changes are studied in the responses to sensory stimuli following severing, ligation or freezing of nerves. The changes of sensory reactivity can be due to a number of structural, physiological and neurochemical changes observed in these animal experiments. Acute changes (stimulation of neurons in sensory pathways, release of neuropeptides: substance P, CGRP and other neurotransmitters, neurogenic inflammation, vascular lesions) produce physiological processes of chronic character (inflammation of nerve and tissues, degeneration, regeneration) leading to functional, neurochemical (increase of receptor number, release of mediators of inflammatory process: bradykinin, histamine, serotonin, prostaglandins, cytokines, nerve growth factors), structural anatomic (loss of myelinated fibres, growth of axonal processes in sensory and sympathetic neurons). All these factors should be considered in the principles of neuropathic pain therapy.
After presentation of the definition of pain, the authors discuss the pathways of nociceptive impulses and their stages: peripheral neurons, spinal neurons, and ascending pathways to thalamic nuclei. The nociceptive information undergoes modulation at various levels of pain pathways. The mechanisms modifying the sensation of pain or exerting antinociceptive action are various, and it is known presently, that a major role is played in it, apart from spinal factors, also descending pathways in the central nervous system. (Ed.)
Pain may be the cause of depression but it may develop also during depression. In the former case the development of depression can be influenced, apart from pain, by a number of other factors, such as personality features and pharmacological treatment. In the latter situation pain can be a manifestation of endogenous depression. The author describes the complex patterns of various forms calling particular attention to pain as their element which can be foremost in the clinical picture. The principles of recognition of masked depression are discussed.
The introduction of WHO principles for the treatment of pain caused by malignant neoplasms in the network of palliative care centres and hospice developed also in Poland, with the cooperation of pain treatment clinics and leading oncology centres has brought an improvement in the care of patients with advanced malignant neoplasms. An important role in this was the introduction for therapy of the most effective analgesic – morphine in oral form (or subcutaneously in case of vomiting or dysphagia). Its introduction was associated with tearing off of the myths about the dependence, euphorising and respiratory depression causing effects of that opiate. The advances in the knowledge of the pathological mechanisms of pain in malignant neoplasms, in pharmacokinetics and pharmacodynamics of analgesics have led to synthesis of new safe drugs (inhibitors of COX-2), tramadol has replaced codeine known to produce constipation, and oral preparations of tramadol and morphine with long-acting controlled effects, as well as percutaneous fentanyl have been evolved for dealing with pain resistant to morphine in about 5% of patients, such as opioid rotation, subarachnoid or extrathecal analgesia, addition of ketamine (an antagonist of NMDA receptor) in subanaesthetic doses, or in exceptional situations – controlled sedation in place of invasive method of pain treatment, often with low effectiveness and fraught with complication risk.
Postzoster neuralgia is pain in the area affected previously by zoster which persists after 3-4 weeks from the beginning of the disease. The present views on the pathogenesis of this very troublesome pain are discussed in this paper. In the early stage of this neuralgia pain originates in a peripheral nerve. Blockades are the best method of treatment in that stage. Later on, the central component prevails in the development of pain, and this requires pharmacological treatment with psychotropic and neurotropic agents. An important condition in the prevention of chronic postzoster neuralgia is early beginning of blockades. The effectiveness of this treatment is documented with the results obtained in the patients of the Pain Treatment Clinic. (Ed.)
In pain treatment a considerable role is played by the skill in making use of its pathophysiology in its therapy. The article lays stress on various methods of pain treatment based on the knowledge on its mediators and pathways.
Atypical headaches differing from migraine and .tension headache in their course and clinical symptoms can be due to disturbances in sympathetic system. The author describes the criteria of the diagnosis of these headaches and suggests blockades of sympathetic ganglia as possible treatment the technique of these interventions is described. (Ed.)
The diagnosis on cases of lumbosacral pains is based on the demonstration of nosological connection between clinical semiotics and imaging of this spinal segment. The author discusses various mechanisms of lumbosacral pain development and surgical methods of their direct and indirect treatment. The necessity of delayed treatment in some cases, and secondary treatment is discussed. Always the possibility of various reactions of patients to surgical treatment, also in late period of convalescence, should be kept in mind. (Ed.)
Various causes and mechanisms of the "spinoradicular conflict" are described in this paper. Depending on the character of the process causing vertebral canal and intervertebral foramina stenosis various methods are applied for their decompression, or spondylodesis in cases of spinal instability. The author describes the most frequently used techniques of operations for intervertebral disc prolapse and spinal instability, including endoscopic stabilization. Attention is called to the decrease of good therapeutic results with time passing from the operation. (Ed.)
Trigeminal neuralgia is usually a major troublesome disease poorly tolerated. Its aetiology can be different. Recently attention has been called to the compression of the nerve by the superior cerebellar artery or, less often, by another blood vessel. The author describes the criteria of the diagnostic method used. The principles of the presently used surgical techniques are briefly presented. (Ed.)
The clinical symptoms are presented which sometimes are associated with the formation of calcifications in the area of basal ganglia and cerebellum. Attention is called to the frequent connection of these calcium deposits with blood vessels. The intravital detection of these deposits has become more frequent since the introduction of computerized tomography which is presently the best method for their visualization.
Metabolic disturbances in diabetes are the cause of multiorgan lesions including also the peripheral and central nervous systems. Diabetic polyneuropathy and acute manifestations of cerebral origin caused by diabetes are generally known. Chronic mild diabetic encephalopathy is rarely diagnosed, on the other hand, although its incidence is much higher than it is thought generally. It seems to be connected with abnormal metabolism of neurotransmitters, breakdown of autoregulatory mechanisms during acute episodes of metabolic disturbances and reduced cerebral blood flow due to changed vascular reactivity.
Inflammatory demyelinating polyradiculoneuropathy, especially its acute form (Guillain-Barré syndrome) is a frequent cause of flaccid paresis. It is an immunological disease and its aetiology is often unknown. In severe forms good therapeutic effects are obtained with plasmapheresis or intravenous administration of human immunoglobulins. Very important is monitoring of respiratory efficacy and circulatory functions, as well as symptomatic treatment. Immunosuppresion is applied in justified cases.