Mandisa-Maia Jones-Haywood, MD

• Assistant Professor
• Anesthesiology
• Wake Forest University School of Medicine
• Winston Salem, North Carolina

Division of polyneuropathies into either of these pathological categories is somewhat artificial since both processes are usually present, albeit in varying proportions muscle relaxant m 751 discount baclofen. The findings of axonal degeneration, affecting distal parts of the axon, the cell body, or both, the details of segmental demyelination, remyelination, and onion bulb formation, and the pathological reactions of unmyelinated fibers in different neuropathies are described extensively elsewhere (Dyck and work-up of patients with a neuropathy often includes a range of appropriate investigations, including chemical pathology, cerebrospinal fluid analysis, and genetic testing spasms after surgery cheap baclofen 25mg with amex. Clinical Features the cardinal clinical features of a peripheral neuropathy are weakness or wasting of the affected muscles, hypoesthesia, loss of or attenuated tendon reflexes, and impaired autonomic functions muscle relaxant for back pain purchase baclofen 10mg amex. It is often possible to demonstrate this with a careful neurological examination of patients with neuropathic pain bladder spasms 4 year old cheap baclofen american express. There is the theoretical possibility that after tissue or nerve injury, non-nociceptive primary afferent fibers (A mechanoreceptors, sensitive cold receptors) that physiologically have ongoing activity can add to the magnitude of pain when central sensitization is present spasms top of stomach buy cheap baclofen on line. Some problems with morphological studies of standard nerve biopsy specimens are that examination of transverse sections by light microscopy will fail to recognize segmentally demyelinated axons and thus will underestimate the myelinated fiber population back spasms 4 weeks pregnant cheap baclofen 10 mg on line. An increase in the density of small fibers does not necessarily imply a selective loss of large fibers since regeneration will increase the population of small fibers. By relating axonal diameter to myelin sheath thickness by electron microscopic examination and by using certain criteria for differentiating the sprouts of myelinated and unmyelinated fibers, this problem can be overcome to some extent (Ochoa 1970). Unfortunately, not all studies of nerve specimens include electron microscopic examination, and this essentially precludes the analysis of unmyelinated neurons. Very few electrophysiological and pharmacological studies have been performed on isolated human nerves, which have essentially remained research investigations. Lambert and Dyck (1993) took long multifascicular biopsy specimens of the sural nerve and compared compound action potentials with morphological changes in normal volunteers and those with various neuropathies. Conversely, in dominantly inherited amyloidosis, the absent C-fiber potential, the greatly reduced A potential, and the only moderately reduced A potential correlated well with a near absence of C fibers and reduced small myelinated fiber population on electron microscopy. Similar good correlations were found in two types of hereditary sensory neuropathies and in uremic neuropathy, but not in chronic relapsing inflammatory neuropathy. This was thought to be due to extensive segmental demyelination and remyelination and the resultant dispersion of large-fiber action potentials. In aggregate, these observations established that reasonable predictions about fiber population could be made from physiological observations, except when segmental demyelination was a prominent feature. Magnetic Resonance Imaging In the diagnostic work-up of peripheral nerve disease, imaging studies are often used to exclude focal mass lesions or external compression and to visualize muscle atrophy. A, After the application of capsaicin, A-fiber potentials were only slightly reduced, whereas a capsaicin-resistant component of the C-fiber potential remained. B, Tetrodotoxin abolishes A-fiber potentials but blocks only a portion of the C-fiber potential. Axial T1-weighted (A) and corresponding turbo inversion recovery magnitude (B) images of the region of the fibular head with a peroneal nerve lesion. The method of limits is most frequently used, and the subject operates a switch when a particular sensation is reached. It is generally thought that the warm detection threshold requires signaling through unmyelinated fibers whereas cold detection is signaled by thin myelinated afferents, and these two modalities are thus commonly tested. This psychophysical test does not specify the location in the somatosensory pathway where hypoesthesia or hyperalgesia is generated. Because of this non-specificity, the relatively large intraindividual variability, and the obvious potential for change that patients can introduce when they are biased against a particular outcome, the usefulness of this technique is limited (Zaslansky and Yarnitsky 1998). It is therefore perceived as a relatively weak diagnostic tool when compared with other electrodiagnostic procedures. Results of quantitative thermal threshold testing with a Peltier device in patients after unilateral painful traumatic nerve injury. The ends of the bars show the pain thresholds for cold or heat stimuli on the symptomatic and uninjured sides. Studies of the axon reflex (neurogenic flare) by visual inspection, thermography, or laser Doppler recordings in response to a chemical stimulus that activates cutaneous C fibers are commonly used. Though independent of patient cooperation, a major drawback of this technique is the dependence of a host of other factors that affect the effector response (Low 1993). Autonomic tests can be used to study the function of postganglionic sympathetic neurons. This includes various measures of sudomotor function, such as sweat testing, sympathetic skin response, or quantitative sudomotor axon reflex testing (Low 1993). Except for the latter, it is difficult to define the location of the dysfunction with abnormal test results. It is also possible to visualize unmyelinated fibers innervating blood vessels and sweat glands. Skin biopsy can be performed in multiple sites and can be repeated over time so that a spatiotemporal profile of epidermal innervation can be constructed. Smallfiber loss is an important feature in idiopathic small-fiber neuropathy (Singer et al 2004) and in the early stages of diabetes mellitus or in individuals with impaired glucose control subject and a patient with a diabetic small-fiber neuropathy. Furthermore, secondary changes such as joint lesions or tissue injury can be the cause of pain in peripheral neuropathy. What follows is an account of neuropathies that are typically painful and in which the primary source of the pain is thought to be the main consequence of the nerve disease. It is clinically convenient to subdivide neuropathies on the basis of whether they are symmetrical polyneuropathies or asymmetrical neuropathies. Because neurophysiological investigations can positively diagnose large-fiber involvement, this provides a further important differential diagnostic clue to the underlying disease process, even though it may not be an essential pathophysiological mechanism in the generation of pain. Box 65-2 lists neuropathies important to the present discussion, divided on the basis of painfulness, their topographical distribution, and fiber size involvement. Polyneuropathies with Selective Loss of Pain Sensation Congenital Analgesia Congenital analgesia comprises an exceedingly rare heterogeneous group of inherited disorders in which insensitivity to pain is evident from an early age and can be explained on the basis of an abnormality in peripheral sensory neurons. It is important to distinguish these conditions from severe generalized peripheral neuropathy or disorders in which the peripheral and central nervous systems appear to be intact, where the problem appears to be lack of recognition of pain, indifference, or asymbolia (Schilder et al 1931). In the latter group, patients are able to identify noxious stimuli and sensory thresholds are normal, but they do not react behaviorally or physiologically in the expected way, and the peripheral nerves, spinal cord, and thalamus are all thought to be normal (Baxter and Olszewski 1960). Patients lack superficial and deep pain sensitivity, and thermosensation is severely impaired or absent, which frequently leads to massive injuries, particularly of the joints, early in life. The results of routine electrophysiological investigations are usually normal, save for the generally absent sympathetic skin response and absent histamine flare (Shatzky et al 2000). Patients can have a remarkable dissociated sensory loss of pain and temperature sensation over most of the body, and radial nerve biopsy shows that small myelinated fibers are selectively lost and unmyelinated fibers are virtually absent (Kocen et al 1973). In many instances, such as isoniazid neuropathy, there is also appreciable small-fiber involvement. Many pathological studies in which selective loss of large fibers has been described have not investigated small-fiber function by electron microscopy or skin biopsy, and thus it is difficult to assess the relative proportion of fiber loss in the myelinated or unmyelinated fiber group. Isoniazid Neuropathy In isoniazid neuropathy, the initial symptoms are distal numbness and tingling paresthesias, which are later accompanied by pain that may be felt as a deep ache or burning sensation. The calf muscles are often painful and tender, and exacerbation of the symptoms by walking may prevent the patient from walking. Ochoa (1970) examined sural nerve biopsy specimens from nine patients and reported primary axonal degeneration in myelinated fibers with evidence of degeneration in unmyelinated fibers and regeneration of both types, together with degeneration of regenerated myelinated fibers. By using several ultrastructural criteria it was possible to distinguish as yet unmyelinated sprouts of myelinated fibers from unmyelinated fibers, as well as make an accurate assessment of differential myelinated fiber damage, through which it was found that large fibers were preferentially lost. Pellagra Neuropathy Peripheral neuropathy is one of the many neurological manifestations of pellagra, which is due to a deficiency of niacin (Spillane 1947). These patients are otherwise almost completely normal neurologically, save for anosmia, and in the past, indifference to pain may have been diagnosed in some of these patients. In these patients neurogenic flare is retained following stimulation of cutaneous nociceptors or purinoceptors by capsaicin or histamine, thus suggesting that initiation and peripheral spread of action potentials are intact but that either a deficit in centripetal propagation of action potentials or a defect in synaptic transmission in the dorsal horn of the spinal cord is present. Because there have been reports of several patients with congenital analgesia, including those with the ill-defined congenital autonomic dysfunction with universal pain loss (Axelrod 940 Section Seven Clinical States/Neuropathic Pain rate of progression and the eventual extent of the disability are extremely variable, and painful symptoms are uncommon (Thomas et al 1971), although some studies have mentioned it (Asbury et al 1963). Although demyelination and remyelination are noted in teased fiber preparations, the main pathology is primary axonal degeneration (Thomas et al 1971). There have been no recent pathological studies of this neuropathy and no ultrastructural study, and thus the degree of small-fiber loss is unclear. The early light microscopic investigations showed a decreased density of myelinated fibers, with a preferential loss of larger fibers. In the spinal cord, extensive degeneration was found in the dorsal and lateral tracts and in the posterior columns. Hypothyroid Neuropathy Pollard and colleagues (1982) reported the pathological changes in sural nerve biopsy specimens from two patients with untreated hypothyroidism. One had a long history of pain in the feet and progressive difficulty walking; the other had pain and paresthesias in the hands. The nerve specimens showed mainly axonal degeneration with occasional segmental demyelination. In both patients, myelinated fiber density was decreased with a relative loss of large fibers, but there were regenerating myelinated fibers that may have contributed to the small-fiber bias, though probably not to a significant extent. Unmyelinated fiber densities were increased because of small-diameter regenerating axons. Electrophysiological studies of sural nerve specimens studied in vitro also found reduced myelinated fiber density in two hypothyroid patients associated with reduced A potentials in vitro, together with relatively normal C-fiber potentials (Lambert and Dyck 1993). However, over half of patients with overt hypothyroidism appear to also have a small-fiber neuropathy (Magri et al 2012). Diabetes Mellitus Diabetes mellitus is associated with several types of polyneuropathies, the most common of which is a symmetrical sensory polyneuropathy (Dyck and Thomas 1999). Evidence is emerging that the causes of neuropathy differ in type 1 and type 2 diabetes mellitus (Callaghan et al 2012). In addition, about a quarter to a third of patients complain of a spontaneous deep aching, burning, or lightning pain (Daousi et al 2006, Abbott et al 2011), and it is frequently troublesome, even when the sensory and motor deficits are mild (Dyck and Thomas 1999). Severe sensory neuropathy in diabetes with loss of protective sensitivity may lead to painless perforating foot ulcers, and in such patients the upper limbs may also be involved and there may be an associated autonomic neuropathy. The characteristic slowing demonstrated in routine nerve conduction studies in most cases of diabetic neuropathy suggests that demyelination is present, but it is also clear that at times extensive demyelination may occur as a result of pathological processes primarily affecting axons. Brown and co-authors (1976) reported the clinical and pathological findings in three patients with severe pain secondary to diabetic polyneuropathy and distal sensory impairment but preserved tendon reflexes. Nerve biopsies suggested a predominant axonal degeneration affecting mainly small myelinated and unmyelinated fibers. Britland and colleagues (1992) reported a morphometric study of sural nerve biopsy specimens from six diabetic patients, four with active acute painful neuropathy and two with recent remission from this type of neuropathy. However, these were all differences in severity, and the authors emphasized the similarity of the pathological changes in the two groups. These observations indicate that small fibers are affected early and large fibers later in diabetic polyneuropathy. Painless Polyneuropathies with Prevalent Large-Fiber Loss In contrast to the polyneuropathies described above, two conditions are associated with neuropathies in which the selective loss of large fibers is not generally accompanied by painful symptoms. This may result in an excess of free radicals, which then leads to cellular damage and death (Delatycki et al 2000). Friedreich himself mentioned it, although others with a large experience in patients with the condition do not report pain as an important feature (Dyck and Thomas 2005). It is worth emphasizing that the selective loss of myelinated fibers takes place only in the earlier stages of the disorder and that loss of all fiber sizes eventually occurs (Dyck and Thomas 2005). Chronic Renal Failure Neuropathy Chronic renal failure of any cause may be associated with a neuropathy in which selective loss of large fibers occurs, but it is rarely painful. A complaint of restless legs is an early symptom, followed by distal numbness and paresthesias, with the distal weakness usually being confined to the legs. Several studies have shown small-fiber loss in patients with early diabetes or impaired glucose tolerance. Furthermore, the ability of C fibers to regenerate after an experimental challenge with topical capsaicin is reduced relative to normal subjects (Polydefkis et al 2004). Over and above the common structural and physiological alterations, two other factors may be of importance in diabetic neuropathy. Hyperglycemia in diabetics may itself be an important factor in acute exacerbations of pain (Dyck and Thomas 1999), and changes in blood flow have also been implicated (Archer et al 1984). This was explained by the presence of mechanically responsive nociceptors that had lost their mechanical and heat responsiveness. These finding could explain the loss of heat and pinprick sensitivity in these patients. Afferent fibers with spontaneous activity or mechanical sensitization were found in patients with and without pain, and there was no obvious neurophysiological marker for patients in pain. However, the findings suggested that there was a higher rate of ongoing activity in the subpopulations of mechanically insensitive C fibers in patients with painful neuropathy. Amyloid Neuropathy Another example of a painful small-fiber neuropathy is that caused by amyloid, both the inherited and the sporadic varieties (Dyck and Thomas 2005). Patients typically have distal sensory loss that initially affects pain and thermal sensations, frequently with autonomic involvement. It is common experience that this type of polyneuropathy is often very painful, the pain usually having a deep aching quality, sometimes with superimposed shooting pain.

Syndromes

• Does the part of your body with numbness or tingling change colors? Does it feel cold or warm?
• Bleeding of the gums
• Metal workers
• You may be asked to stop taking drugs that make it hard for your blood to clot. Some of these are aspirin, ibuprofen (Advil, Motrin), vitamin E, warfarin (Coumadin), and clopidogrel (Plavix).
• Bleeding
• Encephalitis

Table 55-2 summarizes the pharmacokinetics and pharmacodynamics of the opioids commonly used for labor analgesia spasms on left side of abdomen quality 25 mg baclofen. However, their use is limited by incomplete labor analgesia, as with other opioids muscle relaxer 800 mg order baclofen 25mg amex. It has been reported that placental transfer of the drug may produce a false sinusoidal fetal heart rate pattern complicating the interpretation of a true ominous sinusoid fetal heart rate pattern (Feinstein et al 1986), as well as the potential precipitation of withdrawal syndrome in opioid-dependent parturients and newborns (Weintraub and Naulty 1985) muscle relaxant liquid buy baclofen on line. Peak time and duration of analgesia are based on mean values and refer to the stated equianalgesic doses spasms kidney best 25 mg baclofen. Some studies have reported that patients needed in excess of 300 g/hr of fentanyl for labor analgesia, with 16% of neonates requiring naloxone, though without adverse neonatal outcomes (Morley-Forster et al 2000, Halpern et al 2004) muscle relaxant cream baclofen 10mg lowest price. The implication of the residual effects of a large cumulative amount of opioids received during labor is unclear, especially in the immediate postpartum period when noxious stimulation is absent spasms gallbladder buy baclofen in india. Lumbar sympathetic blockade is rarely used, but it is highly effective in relieving pain of the first stage and may be preferable to a paracervical block, especially with high-risk pregnancies. The two fingers of the left hand are inserted into the vagina to guide the needle point into the sacrospinous ligament. As long as the bevel of the needle is in the ligament, there is some resistance to injection of local anaesthetic, but as soon as the bevel passes through the ligament, a sudden lack of resistance is felt and indicates that the needle point is next to the nerve. Intrapartum pain relief with inhalational analgesia is much less common in the United States than in the United Kingdom and other countries. Nitrous oxide, in a premixed blend of 50% nitrous oxide and 50% oxygen (Entonox), can be self-administered intermittently during contractions or continuously and is the more common form of labor inhalational analgesia used. Special scavenging equipment is needed (as with all inhalational anesthetic agents) to prevent environmental contamination. The parturient is taught to inhale the correct mixture at about 15 seconds before the peak uterine contraction pain to obtain maximum analgesic benefit. Such intermittent application seems to be safe for both the mother and fetus without significant adverse reports, but its efficacy for labor analgesia remains controversial because of inconsistent results from different studies. Careful monitoring of patients is required because maternal hypoxemia can occur, especially with the concomitant use of systemic opioids (Carstoniu et al 1994, Lucas et al 2000, Rooks 2007). The labor analgesia provided by volatile halogenated anesthetic agents is partial but better than that with nitrous oxide/ oxygen and can result in significant dose-dependent maternal sedation and uterine relaxation. Intermittent inhalation of a volatile halogenated anesthetic agent may be useful for labor analgesia in selected patients with contraindications to neuraxial analgesia. Investigations are needed for refinement and to prove the safety of the techniques. Besides safety concerns, the need for specialized equipment, additional monitoring, and added workload with dedicated anesthesia providers is a factor limiting its more common use. Regional Analgesia A variety of regional analgesia techniques can be used individually or in combination to provide optimal and effective labor analgesia with fewer drug-induced maternal and fetal side effects than seen with systemic analgesics. Among the various regional techniques, neuraxial labor analgesia is the most commonly used and is the most effective and complete labor analgesia, whereas lumbar sympathetic block is performed much less frequently and paracervical, pudendal, and local perineal infiltration techniques are performed occasionally by obstetricians, sometimes as a supplement to inadequate neuraxial analgesia or sometimes as sole labor analgesia. About onethird of parturients in the United Kingdom chose neuraxial labor analgesia according to the U. Meta-analyses of impact studies involving the influence of neuraxial labor analgesia on the rate of cesarean section (C/S) delivery. Continuous spinal analgesia is not commonly used because of the lack of appropriate and approved equipment such as small-gauge spinal introducer needles and intrathecal catheters. Not only does continuous (epidural or intrathecal) catheter-based neuraxial analgesia provide excellent labor analgesia, but such catheters also allow rapid conversion of neuraxial analgesia to anesthesia for cesarean delivery and minimize the need for general anesthesia and manipulation of the airway. Even though prospective human data are lacking and the applicability of animal data to clinical practice is uncertain, these current findings remain a theoretical reason to consider regional analgesia/anesthesia over systemic analgesia for relief of labor pain or for general anesthesia for cesarean delivery or maternal surgery during pregnancy (Loepke and Soriano 2008). Findings from a number of randomized controlled studies in recent years have helped clarify and alleviate some of the concerns of the influence of neuraxial analgesia on obstetric outcomes. Influence on Cesarean Delivery the impact of neuraxial analgesia on cesarean delivery rates has been examined from several aspects: (1) change in the neuraxial labor analgesia rate, (2) concentrations of local anesthetic and regimens used for neuraxial analgesia, and (3) timing of neuraxial analgesia administration. Yancey and associates (1999), in a large impact study, showed that the cesarean rate remained unchanged (19% versus 19. A meta-analysis that included nine impact studies with more than 37,000 parturients further confirmed no association between the use of neuraxial labor analgesia and cesarean delivery (Segal et al 2000). Furthermore, both a Cochrane review including 20 randomized clinical trials and a meta-analysis of 17 studies that included more than 6700 women showed no difference in the cesarean delivery rate between laboring parturients receiving systemic or epidural analgesia (Anim-Somuah et al 2005, Halpern and Leighton 2005). In one randomized trial with 1300 parturients at Parkland Hospital, Dallas, Texas, the authors reported a cesarean rate of 9% in parturients who received epidural analgesia versus 3. However, this study did not use an intent-to-treat analysis and had a high crossover rate such that about one-third of women did not receive their assigned treatment. The impact of the timing of neuraxial analgesia on obstetric outcomes was evaluated earlier by Chestnut (1994a, 1994b) and more recently by Wong and colleagues (2005, 2009), Ohel and colleagues (2006), and Wang and Neuraxial Analgesia Effect of Neuraxial Analgesia on Obstetric Outcomes Although observational studies often conclude that parturients receiving neuraxial labor analgesia have a higher incidence of cesarean and instrument delivery and a longer duration of labor, a cause-and-effect relationship has not been proved. However, completely effective second-stage analgesia often requires a denser blockade with a higher concentration or larger amount of local anesthetic. As a result, current evidence seems to support a potentially increased risk for instrumental vaginal delivery with completely effective second-stage neuraxial analgesia when a higher concentration and/or amount of local anesthetic is used. Influence on Duration of the First and Second Stages of Labor Evidence of the impact of neuraxial analgesia on the duration of the first stage of labor is obtained mostly as a secondary outcome in studies evaluating its effects on cesarean and/or instrumental vaginal delivery. The definition of the onset of first-stage labor often varies among studies, and assessment of when the first stage begins and ends in many studies may be inaccurate because of the imprecise timing and long interval between cervical assessment. Although the definition of the duration of second-stage labor is usually consistent, the accuracy and frequency of assessment and the application of early or delayed pushing can greatly influence results when measuring the duration of the second stage of labor. Evidence from meta-analyses suggests that parturients receiving neuraxial analgesia (especially with effective second-stage analgesia) (Sharma et al 2004, Halpern and Leighton 2005) have a longer second stage of labor by about 15 minutes than do those receiving opioid systemically. As Chestnut points out in his series of three studies (Chestnut 1987a, 1987b, 1990), lower concentrations of local anesthetic, even with opioid, may provide second-stage labor analgesia that is only marginally better than that with saline placebo. Chestnut and colleagues (1994a) randomized nulliparous women in early spontaneous labor (median cervical dilation of 3. The authors performed a similar study in women under oxytocin induction (Chestnut et al 1994b). Both studies showed that early administration of epidural analgesia did not prolong labor or increase the frequency of operative deliveries. The authors found no difference in the cesarean delivery rate between the early neuraxial and the systemic analgesia groups in both studies. These results were further confirmed by findings from a 2007 meta-analysis that included 3320 subjects (Marucci et al 2007) and a randomized trial in 2009 involving more than 12,000 nulliparous women over a 5-year period (Wang et al 2009), both showing no increase in the cesarean delivery rate with neuraxial analgesia administered early (latent phase) in labor as compared with late (active phase) in labor. Influence on Instrument Delivery Besides the risk for cesarean delivery, instrumental vaginal delivery is another concerning obstetric outcome related to neuraxial analgesia. Several meta-analyses, including ones by Halpern and Leighton (2005), Liu and Sia (2004), and Sharma and colleagues (2004), compared the effects of labor epidural versus systemic analgesia on the risk for instrumental vaginal delivery and reported a statistically significantly higher odds ratio ranging from 1. Chestnut and coworkers in a series of three studies (1987a, 1987b, 1990), as well as a study by Vertommen and colleagues (1991), reported that effective second-stage analgesia with a relatively higher concentration and amount of local anesthetic administered neuraxially may result in an increased incidence of instrumental delivery when compared with neuraxial administration of a lower dose of local anesthetic or systemic analgesia. Over the past 2 decades, modification of techniques and new drugs and adjuvants have provided effective analgesia with minimal motor block and minimal maternal and fetal/neonatal side effects. Typically, labor lumbar epidural analgesia is administered sterilely with a 17- or 18-gauge Tuohy epidural needle, through which a 19- or 20-gauge flexible single- or multi-orifice catheter is inserted epidurally for continuous or intermittent bolus administration of epidural drugs. After an appropriate test dose or doses to exclude inadvertent intrathecal or intravenous catheter insertion, an initial loading dose of epidural drug is administered to initiate analgesia and confirm that the epidural catheter is functioning appropriately to provide a bilateral sensory block as intended. Other studies have explored which mode of delivery would be best to provide continual delivery of epidural drugs for optimal analgesia with the least need for clinician intervention, least motor block, and lowest total drug consumption. Technique of continuous epidural analgesia and the extent and intensity of analgesia during the first and second stages of labor and for delivery. B, If after 5 minutes there is no sign of accidental intravenous or subarachnoid injection, a bolus of 5 mL of local anesthetic is injected while the patient is in the lateral position. F, After internal rotation has occurred, injection of a bolus of 10 mL of local anesthetic solution, such as 1% lidocaine (lignocaine), produces an increase in the intensity of analgesia as indicated by the more heavily shaded area involving the lower sacral segments. Note the wedge under the right hip and lower region to help displace the uterus to the left. During the second stage of labor, forceps delivery or episiotomy and supplement epidural doses with a higher concentration of local anesthetic. Opioid (fentanyl or sufentanil), with its local anesthetic-sparing effect, is commonly added to the epidural local anesthetic solution to provide synergistic analgesia, to reduce the concentration and total amount of local anesthetic needed for analgesia, and to decrease the amount of motor block. Other less commonly used adjuvants, such as neostigmine, clonidine, and epinephrine, have been attempted. After removal of the spinal needle, the epidural catheter is inserted and used in the standard manner. The lower volume/rate within the range is for the higher-concentration solution, whereas the upper volume/rate is for the lower-concentration solution. Lidocaine is not commonly used for maintenance because of its short duration of action. However, it is reasonable to consider its use even in nulliparous women not in an advanced stage of labor if the patient is already in severe labor pain and/or prefers more control of motor function or ambulation. The symptoms are usually worse during the initial 30 minutes, but the need for treatment is relatively low and the symptoms can be treated effectively with nalbuphine (2. A systematic review conducted by Mardirosoff and colleagues (2002) showed that the use of intrathecal opioid analgesia may result in an increased risk for fetal bradycardia when compared with non-opioid intrathecal analgesia. Van de Velde and co-authors (2004) reported a dose-dependent increase in the incidence of fetal bradycardia with intrathecal sufentanil, but no difference in operative delivery. However, Nielsen and colleagues (1996) did not report any difference in fetal heart rate abnormalities (including bradycardia) when comparing parturients receiving intrathecal sufentanil versus epidural bupivacaine. Fortunately, these episodes of fetal bradycardia are usually transient and self-limited and do not alter overall obstetric and neonate outcomes, such as the cesarean delivery rate. Treatment consists of exclusion of other causes and supportive treatment, such as discontinuing any exogenous uterotonic agents, maintaining normal hemodynamics, uterine displacement, administration of supplemental oxygen, and administration of a short-acting uterine muscle relaxant such as nitroglycerin or terbutaline if the uterine hypertonus and fetal bradycardia persist. D, Lateral deviation of the epidural needle causing the spinal needle to miss the dural sac. E, Similar to D except that the dura is punctured laterally, which may result in an inability to aspirate cerebrospinal fluid. Further advancement of the epidural needle may result in the dura rebounding over both the spinal and epidural needle tips and cause an accidental "wet tap" with the epidural needle. However, the authors reported a higher incidence of technical difficulty and catheter failure in the continuous spinal group and also indicated that safe use of the spinal catheter needed to be confirmed with larger studies. Because of the lack of an appropriate small spinal introducer needle and spinal catheter, continuous spinal labor analgesia is usually performed by puncturing the dura with the standard epidural needle and inserting the standard epidural catheter as a spinal catheter. When these complications develop in the relatively uncontrolled setting of the labor and delivery suite, there is a further increase in risk for lethal catastrophic outcomes. Therefore, continuous spinal labor analgesia is uncommonly performed and should be reserved only for selected cases with extra special precautions. Examples of such cases are intentional or unintentional dural puncture with the epidural needle in patients in whom epidural catheter placement has proved difficult or not possible. Maintenance of continuous spinal analgesia can be provided by the continuous infusion or intermittent bolus method (Table 55-4). If operative delivery is needed, analgesia can be converted to surgical anesthesia quickly. However, even with the conventional epidural technique, the epidural catheter may still have the potential to fail at any time during labor or operative delivery. In a retrospective review of more than 12,000 neuraxial labor analgesia procedures, Pan and co-authors (2004) reported a 6. A commonly cited reason for failure is deviation of needle placement from the midline resulting in no return of spinal fluid when the spinal needle is inserted through the epidural needle after the epidural space is identified. Continuous Spinal Labor Analgesia Continuous spinal analgesia requires the insertion of a catheter into the low lumbar subarachnoid space, through which spinal medication can be administered intermittently or continuously. In the early 1990s, a series of cases of cauda equina syndrome in non-pregnant patients was reported in association with the administration of continuous spinal anesthesia via 32-gauge spinal microcatheters (Rigler et al 1991). The reason for neurological injury is not fully understood but is thought to be due to subarachnoid maldistribution of a relatively high concentration of agents (local anesthetic and/or dextrose) (Rigler and Drasner 1991). Nausea and vomiting are common with labor and delivery itself but can often be a result of hypotension from the sympathetic block of neuraxial analgesia or from aortocaval compression. For hypotension, vasopressor treatment, such as with ephedrine and phenylephrine, should be administered promptly together with left lateral tilt positioning to relieve aortocaval compression. Most current evidence suggests an association between epidural analgesia and maternal fever during labor (Camann et al 1991, Lieberman et al 1997). The significance of a low-grade maternal fever on the mother or the fetus is not clear, but it may lead to an increase in evaluation for neonatal sepsis even though the actual neonatal sepsis rate does not appear to be increased (Lieberman et al 1997). The mechanism is also unclear and usually only a small percentage of these patients are symptomatic with diaphoresis and feeling hot (instead of feeling cold and shivering). Active warming seems to be ineffective, whereas lorazepam has been used successfully to treat the hypothermia and associated symptoms, with rapid cessation of symptoms and restoration of temperature (Hess et al 2005). Intrapartum and postpartum urinary retention in patients receiving neuraxial analgesia is observed to be increased over those with systemic or no labor analgesia (Weiniger et al 2006).

The pain is often exacerbated by sitting or lying and is relieved by standing or walking (Payer 2003) spasms of the diaphragm baclofen 25 mg fast delivery. Data from the largest prospective survey of cancer pain syndromes revealed that almost one-quarter of patients experienced two or more pains zerodol muscle relaxant 25mg baclofen with amex. Over 90% of patients had one or more tumor-related pains and 21% had one or more pains caused by cancer therapies muscle relaxant 500 mg order generic baclofen canada. Somatic pain (71%) was more common than neuropathic (39%) or visceral (34%) pain (Caraceni and Portenoy 1999) muscle relaxant zolpidem discount 25mg baclofen overnight delivery. Bone pain and compression of neural structures are the two most common causes (Daut and Cleeland 1982, Foley 1987, Banning et al 1991, Grond et al 1996, Twycross et al 1996) spasms 1983 download order baclofen american express. Bone Pain Bone metastases are the most common cause of chronic pain in cancer patients muscle relaxant with least side effects cheap baclofen 10 mg on-line. Cancers of the lung, breast, and prostate most often metastasize to bone, but any tumor type may be complicated by painful bony lesions. Although bone pain is usually associated with direct tumor invasion of bony structures, more than 25% of patients with bony metastases are pain free (Wagner 1984), and patients with multiple bony metastases typically report pain in only a few sites. Differential Diagnosis Bone pain secondary to metastatic tumor needs to be differentiated from less common causes. Non-neoplastic causes in this population include osteoporotic fractures, including those associated with multiple myeloma; focal osteonecrosis, which may be idiopathic or related to chemotherapy, corticosteroids, or radiotherapy (see below); and osteomalacia (Shane et al 1997). Rarely, paraneoplastic osteomalacia, which is associated with elevated levels of fibroblast growth factor 23, can mimic multiple metastases (Jan de Beur 2005). Multifocal or Generalized Bone Pain Bone pain may be focal, multifocal, or generalized. Multifocal bone pain is most commonly experienced by patients with multiple bony metastases. A generalized pain syndrome is occasionally produced by replacement of bone marrow (Hesselmann et al 2002, Lin et al 2002). This bone marrow replacement syndrome has been observed in patients with hematogenous malignancies (Beckers et al 2002) and, less commonly, with solid tumors (Cohen et al 1982, Wong et al 1993) and brain tumors (Rajagopalan et al 2005). Weakness may begin segmentally if related to nerve root damage or in a multisegmental or pyramidal distribution if the cauda equina or spinal cord, respectively, is injured. The rate of progression of weakness is variable; in the absence of treatment, paralysis will develop within 7 days of the onset of weakness in one-third of patients (Barron et al 1959). Without effective treatment, sensory abnormalities, which may also begin segmentally, may ultimately evolve to a sensory level, with complete loss of all sensory modalities below the site of injury. The upper level of sensory findings may correspond to the location of the epidural tumor or be below it by many segments (Helweg-Larsen and Sorensen 1994). Bladder and bowel dysfunction occurs late, except in patients with a conus medullaris lesion, who may have acute urinary retention and constipation without preceding motor or sensory symptoms (Helweg-Larsen and Sorensen 1994). When available, it is generally the preferred mode of evaluation (Loblaw et al 2005). Whenever possible, total spine imaging should be performed since multiple-level involvement is common and other sites may be clinically occult. In a study of 65 patients with cord compression, 32 (49%) had involvement of multiple levels, and of these, 28 (66%) were clinically occult (Heldmann et al 1997). This is particularly true for bacterial abscesses, leptomeningeal carcinomatosis, intradural extramedullary or, rarely, intramedullary metastases or primary tumors, and infectious or inflammatory myelitis. It can usually define the extent of the cord compression (Boesen et al 1991) and may help in distinguishing between cord compression caused by displaced bony fragments and soft tissue extension and in identifying paraspinal tumors with extension through the intervertebral foramina (Helweg-Larsen et al 1992). Besides immediate patient discomfort, myelography is often complicated by post-procedure side effects that include back pain, headache, vomiting, seizures, and adverse neurobehavioral reactions. Risk for adverse effects is related to the gauge and type of needle used (Wilkinson and Sellar "pyriformis syndrome" characterized by buttock or posterior leg pain that is exacerbated by internal rotation of the hip. The most important determinant of the efficacy of treatment is the degree of neurological impairment at the time that therapy is initiated. Back pain, however, is a non-specific symptom that can result from bony or paraspinal metastases without epidural encroachment, from retroperitoneal or leptomeningeal tumor, from epidural lipomatosis secondary to steroid administration, or from a large variety of other benign conditions. Clinical Features of Epidural Extension Some pain characteristics are particularly suggestive of epidural extension (Helweg-Larsen and Sorensen 1994). Rapid progression of back pain in a crescendo pattern is an ominous occurrence (Rosenthal et al 1992). Radicular pain, which can be constant or lancinating, has similar implications (HelwegLarsen and Sorensen 1994). It is generally unilateral in the cervical and lumbosacral regions and bilateral in the thorax, where it is often experienced as a tight, belt-like band across the chest or abdomen (Helweg-Larsen and Sorensen 1994). The improved resolution observed with contemporary spiral techniques facilitates very clear imaging of the spinal canal contents. Pain Syndromes of the Bony Pelvis and Hip the pelvis and hip are common sites of metastatic involvement. Lesions may involve any of the three anatomical regions of the pelvis (ischiopubic, iliosacral, or periacetabular), the hip joint itself, or the proximal end of the femur (Papagelopoulos et al 2007). The weight-bearing function of these structures, essential for normal ambulation, contributes to the propensity of disease at these sites to cause incident pain with walking and weight bearing. Hip Joint Syndrome Tumor involvement of the acetabulum or head of the femur typically produces localized hip pain that is aggravated by weight bearing and movement of the hip (Singh et al 2006). The pain may radiate to the knee or medial aspect of the thigh, and occasionally, pain is limited to these structures (Sim 1992). Medial extension of an acetabular tumor can involve the lumbosacral plexus as it traverses the pelvic sidewall. Important differential diagnoses include avascular necrosis, radicular pain (usually L1), or occasionally, occult infections. Acrometastasis Acrometastasis, or metastasis in the hands and feet, is rare and often misdiagnosed or overlooked. In the feet, the larger bones containing higher amounts of red marrow, such as the os calcis or talus, are usually involved (Kouvaris et al 2005, Bahk et al 2006). Effective antitumor therapy is sometimes associated with regression of symptoms (Hung et al 2000, Kishi et al 2002); bisphosphonate therapy may help relieve the symptoms (Suzuma et al 2001, Amital et al 2004), and there are case reports of resolution after vagotomy (Treasure 2006, Ooi et al 2007). Other Polyarthritides Rarely, rheumatoid arthritis, systemic lupus erythematosus, and an asymmetrical polyarthritis may occur as paraneoplastic phenomena that resolve with effective treatment of the underlying disease (Racanelli et al 2008). Muscle Pain Muscle Cramps Persistent muscle cramps in cancer patients are usually caused by an identifiable neural, muscular, or biochemical abnormality (Siegal 1991). In one series of 50 patients, 22 had peripheral neuropathy, 17 had root or plexus pathology (including 6 with leptomeningeal metastases), 2 had polymyositis, and 1 had hypomagnesemia. In this series, muscle cramps were the initial symptom of recognizable and previously unsuspected neurological dysfunction in 64% (27 of 42) of the identified causes (Steiner and Siegal 1989). Cramps have been reported as an adverse effect of imatinib (Breccia et al 2005), goserelin (Ernst et al 2004), and vincristine (Haim et al 1994). Skeletal Muscle Tumors Soft tissue sarcomas arising from fat, fibrous tissue, or skeletal muscle are the most common tumors involving the skeletal muscles. Skeletal muscle is one of the most unusual sites of metastasis from any malignancy (Cekinmez et al 2009). They occur disproportionally at sites of previous muscle trauma (Magee and Rosenthal 2002). Periosteitis and arthritis can produce pain, tenderness, and swelling in the knees, wrists, and ankles. The onset of symptoms is usually subacute, and it may precede discovery of the underlying neoplasm by several months. Less commonly it may be associated with benign mesothelioma, pulmonary metastases from other sites, smooth muscle tumors of the esophagus, breast cancer, and metastatic nasopharyngeal cancer. Therapeutic approaches have recently been subjected Headache in cancer patients results from traction, inflammation, or infiltration of pain-sensitive structures in the head or neck. Early evaluation with appropriate imaging techniques may identify the lesion and allow prompt treatment, which may reduce pain and prevent the development of neurological deficits (Vecht et al 1992). Among 183 patients with new-onset chronic headache as an isolated symptom, investigation revealed underlying tumor in 15 (Vazquez-Barquero et al 1994). The headache is presumably produced by traction on pain-sensitive vascular and dural 1050 Section Eight Clinical States/Cancer Pain enhancement of the basilar cisterns, parenchymal metastases, hydrocephalus without a mass lesion, or spinal subarachnoid masses or enhancement may all have therapeutic implications (Grossman and Krabak 1999). Ninety percent of patients ultimately show positive cytology, but multiple evaluations may be required. Tumor markers such as lactate dehydrogenase isoenzymes (Wasserstrom et al 1982), carcinoembryonic antigen (Liu et al 2009), 2-microglobulin (Twijnstra et al 1987), and tissue polypeptide antigen (Soletormos and Bach 2001) may help delineate the diagnosis. Current treatment strategies, which include radiation therapy delivered to the area of symptomatic involvement, corticosteroids, and intraventricular or intrathecal chemotherapy or systemic chemotherapy, are of limited efficacy, and in general patient outlook remains poor (Clarke et al 2010). Base of Skull Metastases Base of skull metastases are associated with well-described clinical syndromes (Greenberg et al 1981, Laigle-Donadey et al 2005) that are named according to the site of metastatic involvement: orbital, parasellar, middle fossa, jugular foramen, occipital condyle, clivus, and sphenoid sinus. Cancers of the breast, lung, and prostate are most commonly associated with this complication (Greenberg et al 1981, LaigleDonadey et al 2005), but any tumor type that metastasizes to bone may be responsible. Orbital Syndrome Orbital metastases usually cause progressive pain in the retro- and supraorbital area of the affected eye (Ahmad and Esmaeli 2007). Signs may include proptosis, chemosis of the involved eye, external ophthalmoparesis, ipsilateral papilledema, and decreased sensation in the ophthalmic division of the trigeminal nerve. Parasellar Syndrome Parasellar syndrome is typically manifested as unilateral supraorbital and frontal headache, which may be associated tissue. Patients with multiple metastases and those with posterior fossa metastases are more likely to report this symptom (Kirby and Purdy 2007). Headache has lateralizing value, especially in patients with supratentorial lesions (Suwanwela et al 1994, Argyriou et al 2006b, Kirby and Purdy 2007). The quality of the headache is usually throbbing or steady, and the intensity is generally mild to moderate (Suwanwela et al 1994, Argyriou et al 2006b). In children headache is the most common initial symptom of brain tumors (Wilne et al 2006). The headache is frequently worse in the morning and is exacerbated by stooping, sudden head movement, or Valsalva maneuvers (cough, sneeze, or strain) (Suwanwela et al 1994). Of solid tumors, adenocarcinomas of the breast and small cell lung cancer predominate (Bruno and Raizer 2005). Leptomeningeal metastases are associated with focal or multifocal neurological symptoms or signs that may involve any level of the neuraxis. The most common initial symptoms are headache, cranial nerve palsies (Yamanaka et al 2011), and radicular pain in the low back region and buttocks (van Oostenbrugge and Twijnstra 1999). More than one-third of patients have evidence of cranial nerve damage, including double vision, hearing loss, facial numbness, and decreased vision (Wasserstrom et al 1982, Yamanaka et al 2011). Less common features include seizures, papilledema, hemiparesis, ataxic gait, and confusion (Balm and Hammack 1996). Pain that resembles cluster headache (DeAngelis and Payne 1987) or glossopharyngeal neuralgia with syncope (Sozzi et al 1987) has also been reported. Ophthalmoparesis (Besada et al 2007) or papilledema may be present, and formal visual field testing may demonstrate hemianopia or quadrantanopia. Middle Cranial Fossa Syndrome Middle cranial fossa syndrome is characterized by facial numbness, paresthesias, or pain, which is usually referred to the cheek or jaw (in the distribution of the second or third divisions of the trigeminal nerve) (Lossos and Siegal 1992). The pain is typically described as a dull continual ache, but it may also be paroxysmal or lancinating. On examination, patients may exhibit hypoesthesia in the trigeminal nerve distribution and signs of weakness in the ipsilateral muscles of mastication. Occasional patients have other neurological signs, such as abducens palsy (Greenberg et al 1981). Jugular Foramen Syndrome Jugular foramen syndrome is usually associated with hoarseness or dysphagia. Pain is generally referred to the ipsilateral ear or mastoid region and may occasionally be manifested as glossopharyngeal neuralgia, with or without syncope (Greenberg et al 1981, Laigle-Donadey et al 2005). Ipsilateral paresis of the tongue may also occur if the tumor extends to the region of the hypoglossal canal. Occipital Condyle Syndrome Occipital condyle syndrome is typified by unilateral occipital pain that is worsened with neck flexion (Martinez Salamanca et al 2006). Examination may reveal head tilt, limited movement of the neck, and tenderness on palpation over the occipitonuchal junction. Neurological findings may include ipsilateral hypoglossal nerve paralysis and sternocleidomastoid weakness (Capobianco et al 2002). Clivus Syndrome Clivus syndrome is characterized by vertex headache, which is often exacerbated by neck flexion. Sphenoid Sinus Syndrome Sphenoid sinus metastasis often causes bifrontal and/or retro-orbital pain, which may radiate to the temporal regions (Lawson and Reino 1997). Associated features of nasal congestion and diplopia may be present (Mickel and Zimmerman 1990). Physical examination is often unremarkable, although unilateral or bilateral sixth nerve paresis may be observed. Painful Cranial Neuralgias As noted, specific cranial neuralgias can result from metastases in the base of the skull or leptomeninges. They are most commonly observed in patients with prostate and lung cancer (Gupta et al 1990, McDermott et al 2004).

Payer M: Neurological manifestation of sacral tumors, Neurosurgical Focus 15(2):E1, 2003 muscle relaxant name brands cheap generic baclofen uk. Stillman M: Perineal pain: diagnosis and management, with particular attention to perineal pain of cancer muscle relaxant definition buy baclofen mastercard. Scully C, Epstein J, Sonis S: Oral mucositis: a challenging complication of radiotherapy, chemotherapy, and radiochemotherapy spasms near elbow generic 10mg baclofen overnight delivery. Skriapas K, Konstandinidis C, Samarinas M, et al: Pain level and anal discomfort during transrectal ultrasound for guided prostate biopsy muscle relaxant robaxin order discount baclofen on line. Zhu Z, Friess H, diMola F, et al: Nerve growth factor expression correlates with perineural invasion and pain in human pancreatic cancer, Journal of Clinical Oncology 17:2419, 1999 muscle relaxant anticholinergic discount baclofen 25 mg with amex. Much of the literature on palliative care in adults and children concerns cancer; we focus in large measure on cancer in this chapter but also address a range of other life-threatening conditions, including neurodegenerative disorders, acquired immunodeficiency syndrome, and more rapidly progressive cases of cystic fibrosis spasms with spinal cord injury discount baclofen 25 mg otc. Each of the latter conditions differs from cancer in its natural history, clinical course, patterns of symptoms, and prognosis; these differences are important for instituting individualized approaches to palliative care. Aspects of a supportive care approach should be incorporated into the care of all children with life-threatening illnesses, even while curative or life-prolonging therapies continue. Pediatric analgesic pharmacology has received extensive study in the past 20 years, and there is now a basis for safe and effective prescription of opioids and other classes of analgesics for infants and children. The majority of children with cancer can be made comfortable by using the World Health Organization analgesic "ladder" approach, with weight-based adjustments in dosing. Much less information is available regarding the prescription of adjuvant medications, anticonvulsants, and antidepressants for neuropathic pain in children; most prescribing is currently based on extrapolation from adult studies. Although pain is a prominent symptom in many cases, it should be emphasized that palliative care efforts must address the full spectrum of non-painful symptoms, as well as the emotional and spiritual suffering of patients at the end of life (Himelstein et al 2004). Acute lymphoblastic leukemia, the most common childhood cancer, was uniformly fatal in the early 1950s; now, disease-free long-term survival rates exceed 70%. The prognosis is less optimistic with some of the primary central nervous system neoplasms, although recent advances have improved survival. When compared with adults, multimodal treatment consisting of chemotherapy, radiation therapy, and surgery is performed more commonly with curative intent. Cancer therapy in children can be arduous and require a year or longer of repetitive cycles of chemotherapy and frequent diagnostic and therapeutic procedures, along with associated medical complications, pain, nausea, and other symptoms. Many children with widely advanced cancer participate in experimental protocols of chemotherapeutic agents and other novel treatment approaches. They and their families are often willing to undertake treatments with low a priori probability of cure. Many developing countries lack the resources to provide the medications, blood products, radiation therapy, surgical expertise, and intensive medical support required to deliver curative therapy. It was with recognition of these economic realities that the World Health Organization Cancer Unit emphasized straightforward, cost-effective, non-technological methods of palliative care. Regulatory barriers continue to limit access to effective analgesics (Joranson and Gilson 1998). Leukemias and other malignancies that proliferate in bone marrow can cause pain as a result of filling and compression of the bone marrow spaces. Leukemias, lymphomas, and neuroblastomas proliferate in the abdominal viscera, especially in the liver and spleen, and cause pain because of capsular stretch. Headache is common in children with brain tumors, although others initially have neurological deficits. The majority of children with spinal cord tumors have back or neck pain at diagnosis (Hahn and McClone 1984). Back pain as a sign of spinal cord compression in children usually occurs before abnormal neurological signs or symptoms become apparent (Lewis et al 1986). More than 60% of children in whom malignancy is diagnosed in developed countries and who have access to state-of-the-art 1062 Section Eight Clinical States/Cancer Pain transmucosal fentanyl citrate-with placebo for the pain of lumbar puncture and bone marrow aspiration (Schechter et al 1995). The group that received the active agent for the first procedure showed less distress and pain at subsequent procedures, thus implying a persistent carryover effect of inadequately treated pain (Weisman et al 1998). Some aspects of the non-pharmacological approach are commonsense, as outlined in Box 74-1. In addition to these commonsense measures, there are a number of specific psychological techniques for managing the pain and distress associated with procedures, including hypnosis, relaxation training, and guided imagery (Kuttner 1989, Steggles et al 1997). There are many variations of these methods, and the optimal techniques depend on the experience of the practitioners and the developmental level and personal style of the child. Evidence supports the efficacy of psychological techniques for managing painful procedures in children with cancer (Jay et al 1987, 1995). In our opinion, these techniques should be taught to children with cancer whenever possible. They are exceedingly safe, and the child can develop a sense of mastery and confidence that can be generalized to new situations. Conversely, hypnosis should not be used as an excuse to withhold adequate analgesics for moderate to severe pain. Some children may be too traumatized to use these techniques or may have developmental or cognitive limitations that prevent their use. Initiation of cancer therapy brings relief of pain in the majority of cases, typically within 2 weeks. Resolution of bone marrow and visceral pain is particularly rapid with hematological malignancies and somewhat slower with solid tumors. Headache from brain tumors may improve with corticosteroid therapy or with relief of increased intracranial pressure, either from surgical resection or from shunting of cerebrospinal fluid. Children and their families experience an array of emotions at diagnosis, including among others, fear, anxiety, anger, denial, and panic. Child life programs have taken a lead in advocating the emotional support of children and families facing illness (Brazelton and Thompson 1988, Anonymous 1993). Painful Diagnostic and Therapeutic Procedures Needle procedures are a major source of distress for children with cancer (Zeltzer et al 1989). Common procedures include venipuncture, venous cannulation, lumbar puncture, bone marrow aspirate and biopsy, and removal of central venous lines. Radiation therapy is not painful per se but often requires sedation or general anesthesia to facilitate cooperation and immobility. It is crucial to treat the pain and distress associated with the initial diagnostic procedures very effectively.

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