Intractable Health Dictionary

A neurological operation to relieve intractable PAIN. The thalamic tracts of the SPINAL CORD contain the nerve-?bres that signal pain. They travel from the source of the pain – in an organ or tissue such as skin or bone – via the cord to the brain stem and cortex (see BRAIN) where the individual becomes ‘conscious’ of the pain. The operation aims to sever these tracts within the medulla oblongata of the brain.... tractotomy

This was introduced in 1936 by Egas Moniz, Professor of Medicine in Lisbon University, for the surgical treatment of certain psychoses (see PSYCHOSIS). For his work in this ?eld he shared the Nobel prize in 1949. The original operation, known as leucotomy, consisted of cutting white ?bres in the frontal lobe of the BRAIN. It was accompanied by certain hazards such as persistent EPILEPSY and undesirable changes in personality; pre-frontal leucotomy is now regarded as obsolete. Modern stereotactic surgery may be indicated in certain intractable psychiatric illnesses in which the patient is chronically incapacitated, especially where there is a high suicide risk. Patients are only considered for psychosurgery when they have failed to respond to routine therapies. One contraindication is marked histrionic or antisocial personality. The conditions in which a favour-able response has been obtained are intractable and chronic obsessional neuroses (see NEUROSIS), anxiety states and severe chronic DEPRESSION.

Psychosurgery is now rare in Britain. The Mental Health Act 1983 requires not only consent by the patient – con?rmed by an independent doctor, and two other representatives of the Mental Health Act Commission – but also that the Commission’s appointed medical representative also advise on the likelihood of the treatment alleviating or preventing a deterioration in the patient’s condition.... psychosurgery

Severance of a limb, or part of a limb, from the rest of the body. The leg is the most common site of amputation. It is usually performed as a controlled operation and may be required for a variety of reasons. In the young, severe injury is the most common cause, when damage to the limb is so extensive as to make it non-viable or functionally useless. In the elderly, amputation is more often the result of vascular insu?ciency, resulting in gangrene or intractable pain.

Sarcoma (see CANCER) of bone, muscle or connective tissues in a limb is another reason for amputation.

The aim is to restore the patient to full mobility with a prosthetic (arti?cial) limb, which requires both a well-?tting PROSTHESIS and a well-healed surgical wound. If this is not possible, the aim is to leave the patient with a limb stump that is still useful for balancing, sitting and transferring. Common types of lower-limb amputation are shown in the illustration. The Symes amputation can be walked upon without requiring a prosthesis. The below-knee amputation preserves normal ?exion of the knee, and virtually normal walking can be achieved with a well-?tting arti?cial limb. Learning to walk is more di?cult following an above-knee amputation, but some highly motivated patients can manage well. After any amputation it is not unusual for the patient to experience the sensation that the limb is still present: this is called a ‘PHANTOM LIMB’ and the sensation may persist for a long time.... amputation

These widely used drugs include a range of different preparations which relieve DEPRESSION. All the antidepressants available at the time of writing are more or less equally e?ective. In studies where patients agree to take either antidepressants or identical dummy PLACEBO pills (without knowing which), at least two-thirds of those who receive antidepressants feel much better within three months, while fewer than one-third of those on placebos recover naturally in the same period. In general these drugs are useful for severe and moderate depression including postnatal illness; they are not e?ective in milder forms of depression although they may be tried for a short time if other therapies have failed.

The most widely prescribed type of antidepressants are the tricyclics, so-called because their molecular structure includes three rings. The other commonly used types are named after the actions they have on chemicals in the brain: the SELECTIVE SEROTONIN-REUPTAKE INHIBITORS (SSRIS) and the MONOAMINE OXIDASE INHIBITORS (MAOIS) – see also below. All types of antidepressant work in similar ways. Tricyclic antidepressants have cured depression in millions of people, but they can cause unpleasant side-effects, particularly in the ?rst couple of weeks. These include SEDATION, dry mouth, excessive sweating, CONSTIPATION, urinary problems, and impotence (inability to get an erection). Up to half of all people prescribed tricyclic drugs cannot tolerate the side-effects and stop treatment before their depression is properly treated. More seriously, tricyclics can upset the rhythm of the heart in susceptible people and should never be given in the presence of heart disease.

The SSRIs are newer, coming into wide use in the late 1980s. They increase the levels in the brain of the chemical messenger SEROTONIN, which is thought to be depleted in depression. Indeed, the SSRIs are as e?ective as tricyclics and, although they can cause nausea and excessive sweating at ?rst, they generally have fewer side-effects. Their main disadvantage, however, is that they cost much more than the most commonly used tricyclic, amitriptyline. On the other hand, they are more acceptable to many patients and they cause fewer drop-outs from treatment – up to a quarter rather than a half. The money saved by completed, successful treatment may outweigh the prescribing costs. SSRIs have been reported as associated with an increased risk of suicide.

Another group of antidepressants, the MAOIs, have been in use since the late 1950s.

They are stimulants, rather than sedatives, and are particularly helpful for people who are physically and mentally slowed by depression. They work well but have one big disadvantage – a dangerous interaction with certain foods and other drugs, causing a sudden and very dangerous increase in blood pressure. People taking them must carry an information card explaining the risk and listing the things that they should avoid. Because of this risk, MAOIs are not used much now, except when other treatments have failed. A new MAOI, moclobemide, which is less likely to interact and so cause high blood pressure, is now available.

LITHIUM CARBONATE is a powerful antidepressant used for intractable depression. It should be used under specialist supervision as the gap between an e?ective dose and a toxic one is narrow.

St John’s Wort is a popular herbal remedy which may be e?ective, but which is handicapped by di?erences of strength between di?erent preparations or batches. It can interact with a number of conventional drugs and so needs to be used cautiously and with advice.

In general, antidepressants work by restoring the balance of chemicals in the brain. Improved sleep and reduced anxiety are usually the ?rst signs of improvement, particularly among people taking the more sedative tricyclic drugs. Improvement in other symptoms follow, with the mood starting to lift after about two weeks of treatment. Most people feel well by three months, although a few residual symptoms, such as slowness in the mornings, may take longer to clear up. People taking antidepressants usually want to stop them as soon as they feel better; however, the risk of relapse is high for up to a year and most doctors recommend continuing the drugs for around 4–6 months after recovery, with gradual reduction of the dose after that.

Withdrawal reactions may occur including nausea, vomiting, headache, giddiness, panic or anxiety and restlessness. The drugs should be withdrawn gradually over about a month or longer (up to six months in those who have been on maintenance treatment).

A wide range of antidepressant drugs is described in the British National Formulary. Examples include:

Tricyclics: amitryptyline, imipramine, doxepin.

MAOIs: phenelzine, isocarboxazid.

SSRIs: citalopram, ?uoxetine, paraxtene. (Antidepressant drugs not in these three

groups include ?upenthixol, mertazapine and venlafaxine.)... antidepressant drugs

The surgical operation of cutting the anterolateral tracts of the SPINAL CORD to relieve otherwise intractable pain. It is also sometimes known as tractotomy.... cordotomy

One of the butyrophenone group of drugs used to treat patients with psychoses (see PSYCHOSIS). Its action is similar to that of the PHENOTHIAZINES. It is also used in depot form, being administered by deep intramuscular injection for maintenance control of SCHIZOPHRENIA and other psychoses. The drug may help to control tics and intractable hiccups.... haloperidol

Gonorrhoea is an in?ammatory disease caused by Neisseria gonococcous, affecting especially the mucous membrane of the URETHRA in the male and that of the VAGINA in the female, but spreading also to other parts. It is the most common of the SEXUALLY TRANSMITTED DISEASES (STDS). According to the WHO, 200 million new cases are noti?ed annually in the world. In the UK the incidence has been declining since 1991; in 1999 the rate per million of population was 385 for males (599.4 in 1991) and 171.3 for females (216.5 in 1991).

Causes The disease is directly contagious from another person already suffering from it – usually by sexual intercourse, but occasionally conveyed by the discharge on sponges, towels or clothing as well as by actual contact. The gonococcus is found in the discharge expressed from the urethra, which may be spread as a ?lm on a glass slide, suitably stained, and examined under the microscope; or a culture from the discharge may be made on certain bacteriological media and ?lms from this, similarly examined under the microscope. Since discharges resembling that of gonorrhoea accompany other forms of in?ammation, the identi?cation of the organism is of great importance. A gram-stained smear of urethral discharge enables rapid identi?cation of the gonococcus in around 90 per cent of men.

Symptoms These di?er considerably, according to whether the disease is in an acute or a chronic stage.

MEN After an incubation period of 2–10 days, irritation in the urethra, scalding pain on passing water, and a viscid yellowish-white discharge appear; the glands in the groin often enlarge and may suppurate. The urine when passed is hazy and is often found to contain yellowish threads of pus visible to the eye. After some weeks, if the condition has become chronic, the discharge is clear and viscid, there may be irritation in passing urine, and various forms of in?ammation in neighbouring organs may appear – the TESTICLE, PROSTATE GLAND and URINARY BLADDER becoming affected. At a still later stage the in?ammation of the urethra is apt to lead to gradual formation of ?brous tissue around this channel. This contracts and produces narrowing, so that urination becomes di?cult or may be stopped for a time altogether (the condition known as stricture). In?ammation of some of the joints is a common complication in the early stage – the knee, ankle, wrist, and elbow being the joints most frequently affected – and this form of ‘rheumatism’ is very intractable and liable to lead to permanent sti?ness. The ?brous tissues elsewhere may also develop in?ammatory changes, causing pain in the back, foot, etc. In occasional cases, during the acute stage, SEPTICAEMIA may develop, with in?ammation of the heart-valves (ENDOCARDITIS) and abscesses in various parts of the body. The infective matter occasionally is inoculated accidentally into the eye, producing a very severe form of conjunctivitis: in the newly born child this is known as ophthalmia neonatorum and, although now rare in the UK. has in the past been a major cause of blindness (see EYE, DISORDERS OF). WOMEN The course and complications of the disease are somewhat di?erent in women. It begins with a yellow vaginal discharge, pain on urination, and very often in?ammation or abscess of the Bartholin’s glands, situated close to the vulva or opening of the vagina. The chief seriousness, however, of the disease is due to the spread of in?ammation to neighbouring organs, the UTERUS, FALLOPIAN TUBES, and OVARIES, causing permanent destructive changes in these, and leading occasionally to PERITONITIS through the Fallopian tube with a fatal result. Many cases of prolonged ill-health and sterility or recurring miscarriages are due to these changes.

Treatment The chances of cure are better the earlier treatment is instituted. PENICILLIN is the antibiotic of choice but unfortunately the gonococcus is liable to become resistant to this. In patients who are infected with penicillin-resistant organisms, one of the other antibiotics (e.g. cefotaxime, cipro?oxacin or spectinomycin) is used. In all cases it is essential that bacteriological investigation should be carried out at weekly intervals for three or four weeks, to make sure that the patient is cured. Patients attending with gonorrhoea are asked if they will agree to tests for other sexually transmitted infections, such as HIV (see AIDS/HIV) and for assistance in contact tracing.... gonorrhoea

A term applied to a condition in which two things are ?rmly lodged together. For example, when one piece of bone is driven within another following a fracture, this is known as an impacted fracture; when a tooth is ?rmly lodged in its socket so that its eruption is prevented, this is known as dental impaction. Intractable constipation is termed faecal impaction.... impaction

The NERVE which chie?y supplies the DIAPHRAGM. A phrenic nerve arises on each side of the SPINAL CORD from the third, fourth and ?fth cervical spinal nerves; both follow a long course down the neck, and through the chest to the diaphragm. They play a key part in RESPIRATION through control of the diaphragm. Injury to one nerve paralyses one half of the diaphragm. Occasionally the phrenic nerve may be surgically crushed as part of the treatment to repair a HIATUS HERNIA or, rarely, to stop intractable hiccups.... phrenic nerve

n. surgical excision of a joint. It is usually performed on a painful joint that has ceased to function, as may result from intractable infection, or after a failed joint replacement. See also arthroplasty.... arthrectomy

n. calcific uraemic arteriolopathy: a rare and often fatal complication of end-stage renal failure associated with small vessel calcification, intractable skin ulceration, and a high risk of septic complications.... calciphylaxis

n. surgical excision of the *cingulum, the part of the brain concerned with anger and depression. The procedure has occasionally been carried out as *psychosurgery for intractable mental illness, usually bilaterally. It is very rare in current psychiatric treatment.... cingulectomy

An infectious skin disease caused usually by Staphylococcus aureus and less often by Streptococcus pyogenes. The itching rash is seen especially on the face but may spread widely. Vesicles and pustules erupt and dry to form yellow-brown scabs. Untreated, the condition may last for weeks. In very young infants, large blisters may form (bullous impetigo).

Treatment Crusts should be gently removed with SALINE. Mild cases respond to frequent application of mupiricin or NEOMYCIN/BACITRACIN ointment; more severe cases should be treated orally or, sometimes, intravenously with FLUCLOXACILLIN or one of the CEPHALOSPORINS. If the patient is allergic to penicillin, ERYTHROMYCIN can be used.

For severe, intractable cases, an oral retinoid drug called isotretinoin (commercially produced as Roaccutane®) can be used. It is given systemically but treatment must be supervised by a consultant dermatologist as serious side-effects, including possible psychiatric disturbance, can occur. The drug is also teratogenic (see TERATOGENESIS), so women who are, or who may become, pregnant must not take isotretinoin. It acts mainly by suppressing SEBUM production in the sebaceous glands and can be very e?ective. Recurrent bouts of impetigo should raise suspicion of underlying SCABIES or head lice. Bactericidal soaps and instilling an antibiotic into the nostrils may also help.... impetigo

A disorder of the intestinal tract that affects its motility and causes abdominal distension and irregular defaecation. Traditional, but now discarded, names have been spastic or irritable colon. The disease affects around 20 per cent of the general population but in most it is no more than a minor nuisance. The causes are not fully understood, but it is generally believed that symptoms develop in response to psychological factors, changed gastrointestinal motility, or altered visceral sensation. About 50 per cent of patients meet criteria for a psychiatric diagnosis. Anxiety, depression, neurosis, panic attacks, acute disease are among possible triggering factors. Some patients have diarrhoea, others are constipated, and some alternate between the two. Many have increased sensitivity to distension of the intestine. Dietary factors such as intolerance to dairy products and wheat are apparent in certain patients.

Common features of IBS include:

abdominal distension.

altered bowel habit.

colicky lower abdominal pain, eased by defaecation.

mucous discharge from rectum.

feelings of incomplete defaecation.

Investigations usually produce normal results. Positive diagnosis in people under 40 is usually straightforward. In older patients, however, barium ENEMA, X-rays and COLONOSCOPY should be done to exclude colorectal cancer.

Reassurance is the initial and often e?ective treatment. If this fails, treatment should be directed at the major symptoms. Several months of the antidepressant amitriptyline (see ANTIDEPRESSANT DRUGS) may bene?t patients with intractable symptoms, given at a dose lower than that used to treat depression. The majority of patients follow a relapsing/remitting course, with episodes provoked by stressful events in their daily lives. (See also INTESTINE, DISEASES OF.)... irritable bowel syndrome (ibs)

(EECP) an experimental treatment for patients with intractable angina. Specially designed inflatable trousers are inflated rhythmically in time with ventricular *diastole. Theoretically this imparts additional energy to the circulating blood volume when the heart is relaxed, and this may improve blood flow down severely narrowed coronary arteries. It is also claimed to have beneficial effects on blood flow to other organs. Despite promising clinical trials, this technique has not been widely adopted.... enhanced external counterpulsation

an autosomal *dominant disorder due to a mutation in the gene for the *prion protein (PrP): it is an example of a *spongiform encephalopathy. Patients present with intractable progressive insomnia, disturbances of the autonomic nervous system, and eventually dementia.... fatal familial insomnia

n. a rare tumour that secretes the hormone gastrin, which stimulates excessive gastric acid production. Such tumours most frequently occur in the pancreas; about half of them are malignant. Patients present with intractable gastroduodenal ulceration, abdominal pain, and diarrhoea (the *Zollinger–Ellison syndrome). Gastrinomas may be a feature of *MENS type 1.... gastrinoma

n. a surgical procedure in which selected nerve roots are cut at the point where they emerge from the spinal cord. In posterior rhizotomy the posterior (sensory) nerve roots are cut for the relief of intractable pain in the organs served by these nerves. An anterior rhizotomy – the cutting of the anterior (motor) nerve roots – is sometimes done for the relief of severe muscle spasm or *dystonia.... rhizotomy

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain, 1979). Pain is perceived in the cerebral cortex (see BRAIN) and is always subjective. Sometimes sensations that would usually be benign can be perceived as painful – for example, allodynia (extreme tenderness of the skin) or dysaesthesia (unpleasant skin sensations resulting from partial damage to sensory nerve ?bres, as in herpes zoster, or shingles).

Acute pain is caused by internal or external injury or disease. It warns the individual that harm or damage is occurring and stimulates them to take avoiding or protective action. With e?ective treatment of disease or injury and/or the natural healing process, the pain resolves – although some acute pain syndromes may develop into chronic pain (see below). Stimuli which are su?ciently intense potentially to damage tissue will cause the stimulation of speci?c receptors known as NOCICEPTORS. Damage to tissues releases substances which stimulate the nociceptors. On the surface of the body there is a high density of nociceptors, and each area of the body is supplied by nerves from a particular spinal segment or level: this allows the brain to localise the source of the pain accurately. Pain from internal structures and organs is more di?cult to localise and is often felt in some more super?cial structure. For example, irritation of the DIAPHRAGM is often felt as pain in the shoulder, as the nerves from both structures enter the SPINAL CORD at the same level (often the structures have developed from the same parts of the embryo). This is known as referred pain.

The impulses from nociceptors travel along nerves to the spinal cord. Within this there is modulation of the pain ‘messages’ by other incoming sensory modalities, as well as descending input from the brain (Melzack and Walls’ gate-control theory). This involves morphine-like molecules (the ENDORPHINS and ENKEPHALINS) amongst many other pain-transmitting and pain-modulating substances. The modi?ed input then passes up the spinal cord through the thalamus to the cerebral cortex. Thus the amount of pain ‘felt’ may be altered by the emotional state of the individual and by other incoming sensations. Once pain is perceived, then ‘action’ is taken; this involves withdrawal of the area being damaged, vocalisation, AUTONOMIC NERVOUS SYSTEM response and examination of the painful area. Analysis of the event using memory will occur and appropriate action be taken to reduce pain and treat the damage.

Chronic pain may be de?ned in several ways: for example, pain resistant to one month’s treatment, or pain persisting one month beyond the usual course of an acute illness or injury. Some doctors may also arbitrarily choose the ?gure of six months. Chronic pain di?ers from acute pain: the physiological response is di?erent and pain may either be caused by stimuli which do not usually cause the perception of pain, or may arise within nerves or the central nervous system with no apparent external stimulation. It seldom has a physiological protective function in the way acute pain has. Also, chronic pain may be self-perpetuating: if individuals gain a psychological advantage from having pain, they may continue to do so (e.g. gaining attention from family or health professionals, etc.). The nervous system itself alters when pain is long-standing in such a way that it becomes more sensitive to painful inputs and tends to perpetuate the pain.

Treatment The treatment of pain depends upon its nature and cause. Acute pain is generally treated by curing the underlying complaint and prescribing ANALGESICS or using local anaesthetic techniques (see ANAESTHESIA – Local anaesthetics). Many hospitals now have acute pain teams for the management of postoperative and other types of acute pain; chronic pain is often treated in pain clinics. Those involved may include doctors (in Britain, usually anaesthetists), nurses, psychologists and psychiatrists, physiotherapists and complementary therapists. Patients are usually referred from other hospital specialists (although some may be referred by GPs). They will usually have been given a diagnosis and exhausted the medical and surgical treatment of their underlying condition.

All the usual analgesics may be employed, and opioids are often used in the terminal treatment of cancer pain.

ANTICONVULSANTS and ANTIDEPRESSANT DRUGS are also used because they alter the transmission of pain within the central nervous system and may actually treat the chronic pain syndrome.

Many local anaesthetic techniques are used. Myofascial pain – pain affecting muscles and connective tissues – is treated by the injection of local anaesthetic into tender spots, and nerves may be blocked either as a diagnostic procedure or by way of treatment. Epidural anaesthetic injections are also used in the same way, and all these treatments may be repeated at intervals over many months in an attempt to cure or at least reduce the pain. For intractable pain, nerves are sometimes destroyed using injections of alcohol or PHENOL or by applying CRYOTHERAPY or radiofrequency waves. Intractable or terminal pain may be treated by destroying nerves surgically, and, rarely, the pain pathways within the spinal cord are severed by cordotomy (though this is generally only used in terminal care).

ACUPUNCTURE and TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) are used for a variety of pain syndromes, particularly myofascial or musculoskeletal pain. It is thought that they work by increasing the release of endorphins and enkephalins (see above). It is possible to implant electrodes within the epidural space to stimulate directly the nerves as they traverse this space before passing into the spinal cord.

Physiotherapy is often used, particularly in the treatment of chronic backache, where pain may be reduced by improving posture and strengthening muscles with careful exercises. Relaxation techniques and psychotherapy are also used both to treat chronic pain and to help patients cope better with their disability.

Some types of chronic pain are caused by injury to sympathetic nerves or may be relieved by interrupting conduction in sympathetic nerves. This may be done in several ways. The nerves may be blocked using local anaesthetic or permanently destroyed using alcohol, phenol or by surgery.

Many of these techniques may be used in the management of cancer pain. Opioid drugs are often used by a variety of routes and methods, and management of these patients concentrates on the control of symptoms and on providing a good quality of life.... pain

a condition resulting from damage to the thalamus, often by a stroke, that is characterized by severe intractable pain and hypersensitivity in the area of the body served by the damaged brain region. It is extremely resistant to treatment.... thalamic syndrome

the fusion of endoscopy with ultrasonography. An ultrasound probe is incorporated into the endoscope in order to deliver highly detailed images from within the body. Endoscopic ultrasound is used predominantly by gastroenterologists, to assess internal structures or organs within the upper gastrointestinal tract, or by respiratory physicians in the assessment of bronchial disease. It may be used for diagnostic purposes, to accurately stage a confirmed diagnosis of cancer or to obtain tissue samples using fine-needle aspiration. Therapeutic indications include drainage of a pancreatic *pseudocyst, the common bile duct, or the pancreatic duct, and coeliac plexus neurolysis, a technique used to deliver pain relief in cases of intractable abdominal pain, usually resulting from chronic pancreatitis.... endoscopic ultrasound

n. the surgical operation of interrupting the pathways of white nerve fibres within the brain: it was formerly the most common procedure in *psychosurgery. In the original form, prefrontal leucotomy (lobotomy), the operation involved cutting through the nerve fibres connecting the *frontal lobe with the *thalamus and the association fibres of the frontal lobe. This was often successful in reducing severe emotional tension. However, prefrontal leucotomy had serious side-effects and the procedure has now been abandoned.

Modern procedures use *stereotaxy and make selective lesions in smaller areas of the brain. Side-effects are uncommon and the operation is very occasionally (only a few each year in the UK) used for intractable pain, severe depression, obsessive–compulsive disorder, and chronic anxiety, where very severe emotional tension has not been relieved by other treatments.... leucotomy