Recognizing and managing pain in s...

Recognizing and managing pain in somewhat advanced in life patients can be a challenge to perioperative feeds because these patients take multiple medications for their illnesses. Pain is a everyday complaint among elderly patients, and somewhat old patients generally are undermedicated or given medications with significant side effects(1) Perioperative nurses' lack of knowledge regarding effective pain management can lead to ineffective nursing care for somewhat advanced in life patients with pain.(2)

Lumbar canal stenosis (LCS) is a habitual disorder in the elderly that usually is manifested on recurring leg or back pain.(3) The use of caudal epidural stiffens (CEBs) to relieve pain in somewhat old patients with LCS is a promising treatment. Perioperative nurses' awareness of this, along with their astute clinical nursing skills, makes them important members of the treatment team.

A CAUSE OF LEG AND BACK PAIN

Degenerative LC is a usual cause of back and leg pain in patients older than 50 years of age.(4) Leg discomfort with or without back pain also can be be caused through other conditions (Table 1).(5)

Table 1

COMMON CAUSES OF LEG AND BACK PAIN

* bitter herniated disc

* Lumbar canal stenosis

* strict spondylolisthesis

* Osteoporotic spinal fracture

* Metastatic spinal disease

* Degenerative disc disease

* Lumbar disc disease with prior laminectomy

* Fasciatis (ie, fascia lata)

* Depression with somatization

* Scoliosis with or without osteoporosis

* Fibromyalgia with or without degenerative disc disorder

* Incidental ovarian or pelvic tumors

* Peripheral vascular disease

* Abdominal aortic aneurysm

* Ureterolithiasis

* Pancreatitis or pancreatic tumors

* Appendicitis (ie, retrovert appendix)

* Sickle small room crisis

* Thrombophlebitis

Abnormalities of the lumbar spine or disc may cause dural and courage root irritation from nerve radix compression, creating leg discomfort or back pain. Increased squeezing around the nerve roots can trigger spasms and lead to radicular pain in the legs(6)

DIAGNOSTIC TESTS

Lumbar canal stenosis in somewhat old patients classically is aggravated through standing and walking and is relieved by way of sitting or lying down with the spine flex as in a fetal position.(7) The plain and degree of LCS can be ascertained easily by magnetic resonance imaging scans.(8) Magnetic resonance imaging scans also may disclose other lesions (eg spinal tumors, slipped discs, herniated disc disease, vertebral fractures). A manhood conduction velocity test and electromyography can demonstrate further evidence of energize root irritation.

THERAPEUTIC OPTIONS

Intractable and chronic leg pain in somewhat old patients may lead to limited ambulation, decreased independence, and psychosocial point in disputes All these problems eventually may require more hospital nursing services and assistance in activities of daily living at place of abode The spastic cycle of pain created by means of nerve root irritation needs to be treated locally. Local treatment, as in the introduction of anesthetic, will break the round of years and lead to longer pain relief.(9) Pain from LC is controll with

* analgesics,

* heat,

* massage,

* bed rest

* back braces, and

* surgery

Caudal epidural stops are administered to relieve pain that does not suit to traditional therapies and for situations in which surgery is not considered a therapeutic option.(10) The courses usually are performed in outpatient clinics because it is more cost-effective than performing the courses in ORs.

The equipment penuryed for CEB consists of a 10-mL syringe, a 22-G 4-inch spinal needle; and a local anesthetic agent (eg 1 mL to 2 mL of 005% lidocaine with 80 mg of methylprednisolone acetate), which can be prepackaged in a standard epidural tray. The anesthesia care provider injects the anesthetic in consequence of the patient's sacral hiatus, in such a manner the patient must be placed in a sloping (Figure 1) or side-lying position.

The incidence of technical failure and complications is subdued when the CEB procedure is performed at a properly trained anesthesia care provider. Technical failure usually is secondary to anatomical variations in the dorsal wall of the patient's sacrum or sacral hiatus. The incidence of technical failure (eg dural pierce unintentional subarachnoid injection, postspinal headache) is small (ie, 01% to 12%) because the patient's dura completions at the level of the secondary sacral foramen, and the CEB is administered between the L4 and L5 vertebrae.(11) Systemic local anesthetic toxic reactions, hematomas, and injection site infections are additional possible complications that decrease with the expertise of the anesthesia care provider. There are a not many contraindications for CEBs; they are shown in Table 2

Table 2

CONTRAINDICATIONS FOR CAUDAL EPIDURAL BLOCKS(1)

* Ongoing anticoagulant therapy

* Infection at caudal epidural mould injection site

* Acute spinal cord compression

* Allergy to lidocaine

* Adverse reaction to steroids (eg mental confusion, psychosis, hallucinations)

NOTE

(1) J O Ciocon, D Galindo-Ciocon, L Amaranath, "Caudal epidural moulds for elderly patients with lumbar canal stenosis," Journal of the American Geriatrics Society 42 (June 1994) 593-596