No abstract

Lower limb amputation is a frequent surgical intervention. It is well known to be associated with postoperative pain. Optimisation of perioperative pain has been shown to reduce the risk of chronic pain. There are no national guidelines for the perioperative pain management of lower limb amputations. Following a baseline audit, we devised a multimodal perioperative pain management guideline, which included the insertion of a local anaesthetic perineural catheter. All patients undergoing an elective or emergency above, through and below knee amputation were reviewed prior and following the implementation of this guideline. Patient postoperative pain scores and opiate usage were analysed. One hundred and twenty-four patients were reviewed (68 patients prior to the implementation of the guideline and 56 patients following the guideline introduction). Following the implementation of the guideline, a greater proportion of patient's pain scores were reported as 0 (i.e. no pain) compared to patients prior to its implementation (78% vs 61%). Pain scores were lower at all time intervals 6 days postoperatively following the guideline introduction. Statistically significant (Kendall's tau-b analysis) (p < 0.05) reduction in pain scores was found upon admission to the ward, 6, 12, 24 hours and 2 days postoperatively. Fewer patients required the use of opioid patient controlled of analgesia after the guideline was introduced (26% vs 4%). The implementation of a perioperative pain management guideline improved pain scores and reduced opioid consumption in patients undergoing lower limb amputations. We suggest a holistic and collaborative, multimodal pathway towards the perioperative pain management of lower limb amputations.

An acute whiplash injury follows sudden or excessive hyperextension, hyperflexion, or rotation of the neck affecting the soft tissues. It typically results from rear-end or side-impact motor vehicle collisions. Patients commonly present with pain and stiffness in the neck, headache, and upper backache with or without paraesthesia of the upper limbs. Chronic whiplash syndrome is characterized by symptoms that persist for more than 3 months. 1 With over half a million people making whiplash injury claims per annum in the UK, it has a major impact on the healthcare and legal systems and also the economy.

This chapter provides an overview of the role of interventional pain management to reduce patients’ pain levels, and improve their mobility, activity levels, sleep, and quality of life. The key principles to be considered before, during, and after a pain intervention are described. The role of fluoroscopy, ultrasound, and computed tomography guidance to perform interventions is outlined. The factors that play a role in increasing the likelihood of complications from pain interventions (radiation safety/health care professionals/equipment/patient-related) and considerations to implement in daily practice to prevent patient harm are discussed. Furthermore, the role of chemical neurolysis, radiofrequency denervation, and pulsed radiofrequency treatment in interventional pain medicine is described.

This chapter provides an overview of commonly performed thoracic and abdominal interventions for the management of acute, chronic, and cancer pain. It includes thoracic medial branch blocks and their radiofrequency denervation, intercostal and thoracic paravertebral blocks, and abdominal plane blocks. This chapter also includes the analgesic management of patients with rib fractures. For each procedure, the relevant anatomy, indications, contraindications, patient positioning, technique, and possible complications are outlined.