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Treatment of pain with botulinum neurotoxins is now entering a new era due to the emergence of newly engineered compounds which by targeting the sensory neurons can offer a more effective means of pain control. The preliminary data from cell culture and animal experiments suggest a significant potential for these toxins/toxin chimeras and toxin/antibody compounds in relieving human pain.

Labor pain is a critical point during child birth, and labor regional analgesia (LRA) is a very common, satisfactory method to control labor pain. Today, this anesthetic procedure is crucial in obstetric care, and anesthesiologists must be in disposal to give information and work with pregnant women in multi-professional environment, both for high- and low-risk pregnancy. There are many innovations in LRA, and studies proved the best performance of this technique in parturient satisfaction and pain alleviation, when compared with other methods of pain control. Regional labor analgesia currently reflects obstetric analgesia guidelines that focus on the quality of the parturition process and its outcomes. Nowadays, cesarean section rates are high because of multiple factors, with local variable frequencies. Anesthetic protocols were developed to enhance security, control pain, and increase satisfaction among women that gave birth under the cesarean section.

Bone marrow lesions (BMLs) include a variety of pathologies characterized by a specific MRI signal. The underlying aetiology sustaining BMLs should be firstly identified and removed, if possible, in order to provide an effective treatment. Pharmacological therapy currently represents the gold standard, aiming to both pain control and modulation of the osteoclastic-osteoblastic response. Physical therapies such as hyperbaric oxygen therapy, extracorporeal shockwaves, and pulsed electromagnetic fields represent feasible alternatives in patients not suitable for pharmacological treatment or could be used to provide an additional healing stimulus. In BMLs not responding to the overmentioned therapies, or in highly demanding patients, surgical treatment should be considered to provide a structural support to the subchondral bone while promoting bone self-healing response.

Ambulatory surgery centers (ASCs) are prevalent throughout the United States and provide benefits to both patients and healthcare systems. Accordingly, ASCs have anesthetic challenges that are unique from hospitals in providing optimal patient care. Success of these centers is predicated on same-day patient discharge while maintaining patient safety and comfort. Adequate control of analgesia and postoperative nausea and vomiting remain two fundamental challenges of achieving this goal. Regional anesthetic techniques in combination with multimodal analgesia and enhanced recovery protocols aid in this process. Failure to meet these objectives may result in delayed discharge or escalation of care resulting in hospital admission. We present an overview of the causes of inadequate analgesia in ASCs, major postoperative concerns, regional anesthetic techniques to aid in recovery and discharge, and fundamentals of appropriate discharge analgesia.

Regional anesthesia in the pediatric population has grown in popularity over the past several years. Use of neuraxial techniques and peripheral nerve blocks are considered safe adjuncts to general anesthesia. As part of a multimodal plan, regional anesthesia promotes analgesia without the added side effects of nausea, vomiting, or respiratory depression associated with opioids. Patients who receive regional anesthesia breathe more effectively due to adequate pain control especially after thoracic and abdominal surgeries. Implementation of regional anesthesia leads to faster functional and bowel recovery and shorter hospitalizations. In this chapter, we focus on regional anesthesia suitable for general surgery procedures.

The overwhelming majority of skin cancer surgery is accomplished with local anesthesia, which accounts for some of the safety and cost-effectiveness benefits of clinic-based dermatologic surgery vs. procedures conducted in hospital operating rooms. Pain control is one of the most important components of skin cancer surgery. When done well, it makes the surgical experience much more pleasant for both the patient and the surgeon. Pain control for outpatient procedures requires a holistic approach focusing on more than simply the injection of an anesthetic. These considerations include addressing patient pre- and intraoperative anxiety, knowledge of local anesthetics and their additives, skill with appropriate injection techniques to reduce patient discomfort, and the ability to anticipate and address analgesia following the procedure and will be covered in this chapter.

Gynecologic surgery is performed by many different approaches and for a variety of indications. One of the most common operations, hysterectomy, is performed in over 500,000 women annually in the United States. Prior methods of postoperative pain control relied heavily on the use of opioid pain medications, but modern applications of postoperative analgesia have shifted to focus on multimodal approaches in pain control. To facilitate early postoperative convalescence and reduce reliance on opioid pain medications, gynecologic surgeons must be able to apply these modern approaches to postoperative pain control. This chapter explores multimodal pharmacologic, nonpharmacologic, and intraoperative techniques for postoperative pain control with a focus on opioid-sparing modalities to help aid gynecologic surgeons in treating and preventing postoperative pain with a focus on the patient undergoing hysterectomy.

Conventional treatment of complex regional pain syndrome (CRPS) involves a pharmacologic regimen that supplements intensive physical and cognitive-behavioral therapy. Pharmacotherapies available for CRPS are at times insufficient for pain control or carry with them intolerable side effects. Frequently, patients and practitioners then turn to adjuvant therapies to facilitate treatment and symptom relief and reduce prescription pain medication use. This chapter offers an overview of adjuvant treatments, their proposed mechanisms of action, and a review of existing literature. Overall, there was a paucity of literature investigating the use of nonconventional therapies for CRPS, suggesting the need for further evidence-based research in this area.

For robotic thoracic surgical patients, minimizing pulmonary complications is the key to decreasing morbidity. Once the pain is controlled, the morbidity associated with thoracic surgery is decreased. Consequently, control of pain is the core requirement in robotic thoracic surgical patients.

Vertebroplasty and Kyphoplasty are mini-invasive surgical procedures that, since their introduction about 30 years ago, have gained an increased popularity for the treatment of symptomatic vertebral compression fractures. Due to the reported positive results in terms of increased pain control, quality of life, and spinal stability, the surgical indications have progressively expanded encompassing vertebral angiomas, osteoporotic, traumatic and pathologic vertebral lesions. In this chapter, the history and development of such techniques have been briefly reviewed, as well as the main results, guidelines, controversial topics, and recent developments that emerged from the literature.

The inclusion of pain management services would be an organic expansion of perioperative care at ambulatory surgery centers. Clinical evidence and research have promoted the need for acute perioperative pain control. The current trajectory within the United States healthcare system also increasingly supports the addition of perioperative pain services through regulatory agencies and economic factors. If well designed and implemented, pain management services may provide multifaceted benefits to all stakeholders – patients, local community, physicians, clinical providers, administrators, owners, and investors.

Proper analgesia should be part of an integrated care plan for patients who undergo surgery or sustain trauma. Satisfactory analgesia is not only compassionate care but also necessary for optimal end-organ function and recovery. Establishing expectations regarding pain management, assessing pain, and limiting variability in practice by developing and implementing protocols will allow for appropriate pain control in postsurgical and trauma patients. While opioids are effective in managing pain, side effects may limit their utility. A multimodal pharmacologic approach is often employed as part of a comprehensive plan for pain management in an effort to optimize but also limit opioid administration. This chapter presents not only specific opioids commonly utilized in contemporary practice, but also non-opioid analgesics and adjuncts useful in opioid sparing. Specific metabolism factors in the setting of end-organ dysfunction are reviewed. Case specific scenarios as well as transitioning of care during recovery are also discussed.

Lower limb nerve blocks may be extremely beneficial in an austere or combat environment. Nerve blocks can be useful as pain control after trauma, as an adjunct to sedation or general anesthesia, or to facilitate surgical interventions of their own.