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      Infecciones de repetición en un paciente portador de un sistema de neuromodulación tras la picadura de insecto Translated title: Recurrent infection following an insect bite. In a patient with a neuromodulation system

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          Abstract

          El desarrollo de la tecnología en las últimas décadas del siglo XX ha conllevado disponer de dispositivos, como los neuroestimuladores espinales, que han permitido un salto cualitativo muy importante en el tratamiento de pacientes con dolor severo y de difícil control. En general, las complicaciones que pueden surgir tras la colocación de un electrodo de estimulación de cordones posteriores son mínimas, pero se han descrito algunas de ellas, como son: el desplazamiento del electrodo, la infección y la rotura del electrodo. Presentamos el caso de un paciente joven, ingeniero técnico agrícola, con antecedente de alergia a ácaros del polvo, que presentó tras la picadura de un insecto (Simulium Dam-nosum) en miembro superior derecho, un cuadro de shock séptico, con ingreso durante 48 horas en Reanimación. Durante la hospitalización presentó dolor neuropático severo con escasa respuesta a tratamiento convencional. Tres años y medio después de la picadura del insecto, fue remitido a la Unidad del Dolor de nuestro centro, donde se procedió a primer tiempo de implante de electrodo de estimulación de cordones posteriores, que hubo de ser retirado a los seis días por una infección del electrodo por Estafilococo Aureus. El paciente fue sometido a las pruebas epicutáneas con las sustancias habituales y con las sustancias procedentes de los componentes del neuroestimulador. Se descartó la posibilidad de alergia a alguno de los componentes del sistema implantable que fuera el responsable de una reacción inflamatoria y posterior sobreinfección del catéter. Es necesario destacar que la mejor manera de evitar las infecciones es extremar las medidas de asepsia y debemos valorar la realización de las pruebas de alergia en pacientes con historia de reacciones alérgicas o atopia que aseguren no causarán rechazo del sistema.

          Translated abstract

          Technological developments in the last decade of the 20th century have led to the design of devices such as spinal cord stimulators for the management of severe and intractable pain. Complications after the implantation of the electrodes are infrequent, but some as breakage, infection and displacement have been reported. The case of a young technical agricultural engineer with a medical history of allergy to acarus is described. He developed a septic shock following the sting of an insect (Simu-lium Damnasum) on the top right limb, being admitted to intensive care for 48 hours. During his hospital stay, he had severe neuropathic pain with a poor response to conventional treatment. Three and a half years after this event, the patient was sent to the Pain Management Unit, where the first stage of an electrode implantation for a spinal cord stimulator was carried out. The system was withdrawn after six days due to a Staphylococcus Aureus infection. A series of epicutaneous test for regular substances and for those from the spinal cord stimulator components were made. The likelihood of an allergy to some component of the implantable device, responsible for an inflammatory reaction and subsequent infection of the catheter, was ruled out. It is important to point out that careful asepsis is still the best means to avoid infections. In patients with a medical history of atopia or allergic reactions, allergic tests should be considered as a measure to prevent rejections of devices.

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          Most cited references15

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          Prospective, multicenter study of spinal cord stimulation for relief of chronic back and extremity pain.

          This prospective, multicenter study was designed to investigate the efficacy and outcome of spinal cord stimulation using a variety of clinical and psychosocial outcome measures. Data were collected before implantation and at regular intervals after implantation. This report focuses on 70 patients who had undergone 1 year of follow-up treatment at the time of data analysis. To provide a more generalizable assessment of long-term spinal cord stimulation outcome by comparing a variety of pain and functional/quality-of-life measures before and after management. This report details results after 1 year of stimulation. The historically diverse methods, patient selection criteria, and outcome measures reported in the spinal cord stimulation literature have made interpretation and comparison of results difficult. Although short-term outcomes are generally consistent, long-term outcomes of spinal cord stimulation, as determined by prospective studies that assess multidimensional aspects of the pain complaint among a relatively homogeneous population, are not well established. Two hundred nineteen patients were entered at six centers throughout the United States. All patients underwent a trial of stimulation before implant of the permanent system. Most were psychologically screened. One hundred eighty-two patients were implanted with a permanent stimulating system. At the time of this report, complete 1-year follow-up data were available on 70 patients, 88% of whom reported pain in the back or lower extremities. Patient evaluation of pain and functional levels was completed before implantation and 3, 6, 12, and 24 months after implantation. Complications, medication usage, and work status also were monitored. All pain and quality-of-life measures showed statistically significant improvement during the treatment year. These included the average pain visual analogue scale, the McGill Pain Questionnaire, the Oswestry Disability Questionnaire, the Sickness Impact Profile, and the Back Depression Inventory. Overall success of the therapy was defined as at least 50% pain relief and patient assessment of the procedure as fully or partially beneficial and worthwhile. Using this definition, spinal cord stimulation successfully managed pain in 55% of patients on whom 1-year follow-up is available. Complications requiring surgical intervention were reported by 17% (12 of 70) of patients. Medication usage and work status were not changed significantly. This prospective, multicenter study confirms that spinal cord stimulation can be an effective therapy for management of chronic low back and extremity pain. Significant improvements in many aspects of the pain condition were measured, and complications were minimal.
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            New trends in neuromodulation for the management of neuropathic pain.

            Since its first application in 1967, the methodology and technology of spinal cord stimulation for the management of chronic, intractable pain have evolved continuously. Despite these developments and improved knowledge of the effects of spinal anatomy and epidural contact configuration on paresthesia coverage, the clinical results of spinal cord stimulation-particularly the long-term effects-are still unsatisfactory in many patients. This dissatisfaction has come primarily from the failure of single-electrode configurations to provide consistent paresthesia coverage of the entire painful area. Therefore, new approaches were developed during the late 1990s that attempted to selectively cover one or more dermatomes with paresthesia as well as to provide sequential stimulation of different anatomic sites. These approaches have been applied both intraspinally and extraspinally by stimulating either the spinal nerves or the dorsal columns. To target parts of the latter, different methods have been developed and tested using either two-dimensional contact configurations or electronic field steering. These developments hold promise for improving long-term outcomes as well as increasing the number of pain conditions that can be treated with neuromodulation therapy. In this review, the history, theoretical basis, and evolution of these methodologies, as well as the ways in which they represent new trends in neuromodulation, are discussed.
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              The cost effectiveness of spinal cord stimulation in the treatment of pain: a systematic review of the literature.

              In this systematic review, we identified and evaluated studies of the cost effectiveness of spinal cord stimulation (SCS) for the treatment of chronic pain. Published reports were identified from a systematic search of a number of general medical electronic databases (Medline, CINAHL, and EMBASE), and specialist economic databases (NHS Centre for Reviews and Dissemination Economic Evaluation Database, and Health Economics Evaluation Database). Reference lists of retrieved reports were also searched, and contact was made with experts in the field. Of the 99 abstracts identified, 14 studies were considered to meet the inclusion criteria of the review. We found that across a range of medical indications, the initial healthcare acquisition costs of SCS implantation are consistently offset by a reduction in post-implant healthcare resource demand and costs. Further research is required to formally examine the cost effectiveness of SCS.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Journal
                dolor
                Revista de la Sociedad Española del Dolor
                Rev. Soc. Esp. Dolor
                Sociedad Española del Dolor (Madrid )
                1134-8046
                June 2006
                : 13
                : 5
                : 294-299
                Affiliations
                [1 ] Consorcio Hospital General Universitario de Valencia Spain
                [2 ] Consorcio Hospital General Universitario de Valencia Spain
                Article
                S1134-80462006000500003
                a37c008d-5d98-4534-a435-27cb1386d689

                http://creativecommons.org/licenses/by/4.0/

                History
                Categories
                CRITICAL CARE MEDICINE

                Emergency medicine & Trauma
                Spinal cord stimulation,infection,allergy,Estimulación medular,infección,alergia

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