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Tumours involving the anterior frontal lobe may present with personality changes and a loss of initiative order 2mg diane-35 with mastercard, inhibition and cognitive function buy diane-35 2 mg online. An expressive aphasia occurs if Brocas area in the dominant hemisphere is involved buy diane-35 2mg visa. Parietal lobe Tumours of the parietal lobe result in difculties or inability to recognise sensory and proprioceptive input from the opposite side of the body purchase diane-35 2mg otc. This may show itself as tending to ignore the contralateral side visuospatially (hemineglect) or as difculties recognizing familiar shapes, textures or numbers when placed in the opposite hand. If the dominant hemisphere is involved, there may be difculties particularly with understanding speech, numbers, reading and writing and carrying out motor tasks (apraxia). Patients with non dominant hemisphere involvement may present with or develop hemineglect. Patients may also have a visual feld defect involving the lower quadrant from the opposite side. Temporal lobe Tumours involving the dominant temporal lobe (usually left sided) may result in aphasia which is receptive in type and also memory impairment. Tumours on either side may result in recent onset temporal lobe seizures and visual feld loss in the contralateral upper quadrant. Occipital lobe Tumours involving the occipital lobe present with visual disturbances, hallucinations, and a loss of vision from the opposite side of the body, a contralateral homonymous hemianopia. Brain stem and cerebellum Tumours of the brain stem present with a combination of ipsilateral cranial nerve palsies and cerebellar ataxia, and contralateral long tract signs. Tese are the support cells in the brain and the main ones are astrocytes and oligodendrocytes. Oligodendrogliomas on the whole tend to be lower grade tumours characterized by a capsule and the presence of cysts and calcium with a good prognosis, but after years about one third may evolve into more malignant tumours. Other forms of glioma include ependymomas which are derived from cells which line the ventricles and choroid plexus. Medulloblastomas are gliomas of the cerebellum and the roof of the 4th ventricle occurring mostly in young children aged 4-8 years (Fig. Clinical features Gliomas present clinically with increasing symptoms usually over weeks or months or years depending on the grade of malignancy. It typically shows a unifocal enhancing mass with surrounding oedema and mass efect (Fig. Management Management where there are full resources includes a combination of surgery, chemotherapy and radiotherapy. Surgery is indicated for biopsy to establish a tissue diagnosis and for partial tumour resection to relieve symptoms. Chemotherapy is used in high grade malignant gliomas and usually involves the alkylating drug temozolomide in combination with other drugs. However temozolomide is expensive, used mostly but not exclusively in younger patients and only available in some specialized oncology units. Radiation is indicated for most high grade gliomas but this is only palliative at this stage. Prognosis The prognosis in low grade gliomas is good with a median survival of 8-10 years. However in patients with higher grade malignancy the prognosis even with treatment is poor with survival of usually <12 months. They occur mostly in the middle and older age groups, >50 years and more commonly in females 2:1. They arise from either the dural or arachnoid meninges, overlying the surface of the brain, cranial nerves, falx and tentorium and are nearly always benign. Small meningiomas <2 cm are usually asymptomatic and tumours only become symptomatic when they reach a size sufcient to afect function. Most tumours arise on the convexities of the brain, as these are the largest surface areas. Clinical features Meningiomas tend to present clinically with focal neurological signs that refect the site and size of the tumour in much the same way as malignant tumours but over a much longer time course usually months or years. Parasagittal meningiomas present with spastic paraparesis, olfactory groove meningiomas with anosmia and papilloedema and sphenoid wing and frontal meningiomas with Foster-Kennedy syndrome: unilateral optic atrophy with contralateral papilloedema. The majority of accessible meningiomas can be cured by resection and large symptomatic tumours are an indication for surgery. Convexity lesions are usually completely removed without any residual neurological defcit and the longer term prognosis for these is generally good. However recurrence is likely if surgical removal is incomplete as is frequently the case with very large or relatively inaccessible tumours. Clinical features Tese are benign intracranial tumours occurring outside the brain which present with headache, local pressure and also endocrine efects. Expansion of the adenoma upwards leads to compression of the optic chiasm which results in a visual feld defect, most commonly bitemporal hemianopia, initially involving the upper quadrants. Infrequently, pituitary tumours undergo infarction and patients then present with sudden headache, vomiting and features of acute hypopituitarism. The diferential diagnosis of pituitary tumours includes other mass lesions that may compress the optic chiasm including craniopharyngioma, meningioma and internal carotid aneurysm. Surgery via the transphenoidal route is usually the management of choice, if the tumour is intrasellar except in prolactin secreting adenomas which can often be managed medically with dopamine receptor agonists such as bromocriptine up to 20-40 mg daily.

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Agence devaluation des technologies et des modes dinterventions Medicine buy 2 mg diane-35 amex, 2003 (15) cheap diane-35 2mg amex, 65-82 cheap 2mg diane-35 amex. At my frst appointment buy diane-35 2mg amex, I was astounded as I fnally met a doctor who understood pain, a We must do a lot to help ourselves. I did not know that doctors who understood During my recovery period, I continually asked questions of the doctors pain like this doctor did even existed. Pain was especially not seen at the hospital clinic about new pains that I was feeling, but I rarely got as an illness by doctors other than those who are pain specialists. I started keeping notes as I found that once it was on paper What an eye-opener this was! I had just come through 18 years of I could focus my mind toward positive things, and not drown in the banging my head against walls and doctors doors, on the road to swamp of unanswered negativity. Thats 18 years in a very dark tunnel, losing hope of ever I got on a merry-go-round for the next few years, going from doc fnding help to deal with these pains. Some surgeons said that they could A plan of action was made, and explained to me by the doctor. We only made one my body and while all the actions I took were not necessarily recom change at a time, giving me suffcient time to evaluate the latest change. I created strategies from my imagination, Over time, we went from changes in medications to adding minimally using logic or what was logical to me, and it got me through many years. We maintained the It also took me through many years while I learned that the vast majority medications that were on record at that time, always evaluating for of medical doctors do not know what to do to help patients with chronic the desired benefts. Chronic pain is one area in which occupational education on the condition therapists work. They have the opportunity to work with children, adults and the elderly in the feld of physical and/or mental health. They work to promote health, prevent defciencies, and promote the autonomy and social integration of individuals as they take part in their tasks, activities and signifcant occupations. Occupational therapy came into being particularly after the two world wars (Friedland & al 2000). Soldiers returning from the battlefeld with physical injuries or mental health problems had to learn to live with their new condition. Occupational therapists helped these soldiers regain a certain amount of autonomy and quality of life. It should be noted that, while the suffering from chronic pain maintain or develop their functional capacity occupational therapist accompanies the individual who is suffering from in terms of their daily activities and tasks, such as personal hygiene, chronic pain throughout the rehabilitation process, the occupational leisure activities and productive activities (school, work, volunteer therapist is not the captain of the ship; the patient is. The therapist can give the patient tools, but the individual is responsible for occupational therapist assesses and treats those suffering from chronic using them, and integrating them in his/her life. In order to promote the activity participation of the individual, he/she As needed, the occupational therapist will evaluate the possibility of must understand what chronic pain is in terms of his/her condition, modifying the individuals physical environment so as to facilitate a and what the intervention plan will involve in terms of occupational return to work or the performance of daily activities. Nevertheless, the various administrative and government levels in the health care system are increasingly working on preventing the There are four principles of energy conservation: planning, prioritiza chronicity of pain. One tool that is essential for the frst three condition to occupational therapy or other disciplines before the pain principles is the use of an agenda. The following points will cover certain principles concerning the Planning Planning involves planning the activities of the day, the week and the month. When an activity is planned, it is important to evaluate the various aspects of the plan: who, what, where, when, how and how much. Who are you going to delegate the task to, are you going to do it with How are you going to do this activity Are there parts of this activity someone else, or on your own… that can be eliminated Section 3 | Chapter 37 occupational therapy and chronic pain 303 • Here are some examples of ways in which to save energy. Do you really need to put all of the clothes tom of the stairs, and place objects that have to be carried up or for the family away, or can each member of the family put their own down in it. The clothing can be placed on the bed of each can either carry the basket or a few objects. Prepare all of the ingredients and dishes/ certain objects up or down the stairs, dont hesitate to ask for help. It is also important to balance work and household chores, rest and one day, and then you dont feel as if you have the necessary energy, leisure activities. Often leisure activities and time for yourself are the you can always do a task that requires less energy, such as a load of frst aspects to be neglected. Balancing these three elements enables you laundry, and postpone the grocery shopping to the next day. Otherwise To ensure this balance, it is important that you plan an interesting you will feel overwhelmed by the list of things to do. One aspect to consider is to start by noting appointments and activities that abso Prioritization lutely must take on a give day at a specifc time, before planning the Prioritization can also be done on a daily, weekly and monthly basis. This involves making a list of the tasks to be completed in order of Moreover, clients suffering from chronic pain often report that they importance (prioritize). It is also important to determine whether the have days when they feel that they have more energy than they usually tasks are obligatory, and if they can be reduced, eliminated or delegated do. Moreover, if it is fnancially possible for you to hire people complete their tasks one after another. Finally, the next day or the day to provide certain services, such as housekeeping, snow removal and after that, they feel drained of energy. Then, they experience another burst of energy and the situation Pacing is repeated all over again. In keeping with the principles for conserving In order to conserve your energy, it is preferable to take a break before energy, you have to be able to plan your activities day by day in order you get tired.

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Certain rehabilitation processes can have mitigated results when the patient perceives more inconveniences than advantages in taking action for change cheap diane-35 2mg online, or when he/she continues to expect an exterior solution or a new medical treatment diane-35 2 mg without prescription. Thus cheap diane-35 2mg free shipping, the objectives buy discount diane-35 2 mg online, the progress and the results are different for each individual. But the key to success still depends on the cooperation and team work of the user and the rehabilitation professionals, as well as on joint efforts with the various partners involved in the rehabilitation process. Agence devaluation des technologies et des modes dintervention interdisciplinaire de premiere ligne 2006. Document sur la prise en charge de la douleur ete fait en collaboration avec 5 organismes representant les chronique (non cancereuse), Organisation des services de sante, professionnels de la sante de premiere ligne. Multidisciplinary bio-psycho-social rehabilitation • Chown, Marjorie, Lynne Whittamore, Mark Rush, Sally Allan, David for chronic low-back pain. Prediction of Success from a Multidisciplinary Treatment Program for • Core Curriculum for Professional Education in Pain, edited by Edmond Chronic Low Back Pain. La douleur et lexpression du vecu dou for Low-back-pain in occupational health on sick-leave, functional loureux vers une approche globale. Lorientation Professionnelle, status and pain: 12 months result of a randomised controlled trial. Manipulative Physiol Ther, 2009 of Management of Mechanical Neck Disorders: A Systematic Review. Does patient-physiotherapist Paradigm for the Management of Occupational Back Pain. Avoidance behaviour and its role in sustaining chronic reinsertion socioprofessionnelle. From evidence to community practice in sful vocational rehabilitation for clients with back pain problems. Maceachen, from work due to low back pain: how well do interventions strategies M. Spine J, 2004; 4(4) : leur chronique, implications pour la prise en charge en reeducation. Congres annuel de la Societe quebecoise de la douleur, Montreal, dysfunction in patients with chronic back pain. As a result of their acute phase (0 to 4 weeks) molecular effects, physical agents can complement or sub-acute phase (4 to 12 weeks) replace anti-infammatory or analgesic medication. Partial tissue re-modelling and functional gain phases or complete relief of pain by means of these invasive forms Chronic phase of energy will, in most cases, improve quality of life, but will also enable the individual to undertake functional 4. In the feld of physiotherapy, we know that one of the major indications and one of the most frequent reasons for consulting is to treat pain, at all stages in the pathological process, from the post-trauma to the chronic phase. In all stages, physiotherapists must adapt their treatment to those of the care team, since certain treatment means could work against the medication or objectives. The treatment and relief of pain serve to start a functional re-edu Several published articles and books document the scientifc aspect cation programme and treat physical defcits and incapacities. Certain pain clinics offer relatively complete treatments including an approach in For the physiotherapist, pain relief should be used as part of a physiotherapy and psychology. The patient must participate in the global approach including, as the case may be, manual techniques, entire approach offered, from the use of medication to relieve pain ergonomic advice, general or specifc exercises, and a return to to re-education of the body and mind. This chapter will not discuss the physiological or molecular served to explain the therapeutic applications of the various physical effects of physical agents in detail. Physiotherapy and the physical agents can act on pain by means most often in literature. This this reason, we are presenting the most conclusive therapeutic effects hyperalgesia is the consequence of a tissue lesion, a haemorrhage, or for the relief of pain, obtained from therapies using physical agents, in an infammatory reaction. The earlier the ice desired are the reduction of the haemorrhage, the restriction of the deve is applied, the more benefcial the slowing of the metabolism will be. For optimum effectiveness, it is recommended that a maximum of this alteration is a process that is necessary for the activation of the 30 minutes be allowed between applications, for the frst 4 hours mastocytes responsible for chemical infammation mediators. For common cryotherapy, the treatment can be of ice and a means of compression affect the vascular state. Controlling applied 20 to 30 minutes for deep structures and 10 to 15 minutes for the vascular state at this stage is necessary to limit both the haemorrhage superfcial structures. In addition, there is the need to effectively control During the acute phase, superficial thermotherapy, particularly pain and muscular spasms, ensure that the cleaning of the injured area heatwraps, is used a lot less than cryotherapy. After the frst four hours that certain forms of inexpensive superfcial thermotherapy can be following the injury, it is recommended that the patient continue to used to effectively treat pain, spasms and the sensation of stiffness11, apply cold every hour or every second hour, for the frst 24 to 48 hours. The same applies to certain and even facilitate contraction8 of the inhibited muscle, and accelerate recent injuries, such as rib fractures. Moreover, in order to accelerate the return to functionality as long as the contraction does not exert any excessive pressure on the injured structures – the electrical stimulation of the muscles adjacent to the injured structure can be used as of the acute phase or following surgery, such as knee replacement. Warming up the deep structures before stretching them, tissue healing, prevent atrophy and muscular imbalances, fght against sometimes followed by cooling of the tissues in the extended position, painful inhibition, prevent the formation of adherences or retractions will probably result in lasting gains in joint amplitude, as compared to of soft tissues and, fnally, prevent chronic pain. For this purpose, the techniques used during the dual oedema that tend to produce a fbrosis of the connective tissue. Thus, the Although it is still controversial, depending on what a few well physical agents will fght tissue degeneration, the absence of complete controlled studies have demonstrated, extra-corporal shock therapy healing, or the elimination of tissue calcifcation. At the same time, it can be useful in cases of chronic tendinopathies23, and several types of is a good idea to use all means possible to fght chronic pain, to enable devices have been approved in the United States by the Food and Drug the patient to once again be autonomous in controlling his/her pain Administration for the treatment of epicondylitis and plantar fasciitis.

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The switch rate of patients in depressive episodes undergoing antidepressant treatment was 35% discount diane-35 2mg with mastercard. Cycle acceleration was likely to be associated with antidepressant treatment in 26% of the patients generic diane-35 2mg amex. Another naturalistic study described an increase of the frequency of episodes up to the rapid cycling phenomenon (more than four episodes per year) under antidepressant treatment (Ghaemi et al generic 2mg diane-35. This tendency to an increased frequency of episodes was also found in some other studies (Reginaldi et al order 2 mg diane-35 free shipping. The rapid cyclers were more frequent in those patients of female gender, with a depressive hypomanic index episode or with a fast cycling from depression to hypomania during the index episode. A causal relationship between the use of antidepressants and rapid cycling could not be demonstrated in this sample. To explain the results of other authors concerning the risk of antidepressants for inducing rapid cycling, the authors state that rapid cycling is significantly more often preceded by depression, which leads to treatment with an antidepressant, which leads in the end to the wrong causal attribution between antidepres sant treatment and rapid cycling. Altogether there seems to be a special risk of rapid cycling under antide pressant treatment (Grunze et al. Due to the open and naturalistic manner of the studies the results are not totally clear, and leave some questions unanswered. If the induction of switch into mania and the induc tion of rapid cycling are related phenomena, it could be supposed that Antidepressant treatment of bipolar depression 395 drugs with a higher risk rate of inducing switch into mania also have a higher risk rate concerning rapid cycling. Empirical findings which support this hypothesis sufficiently are not yet available. Several experts and guidelines recommend mood stabilizers as the treat ment of first choice in acute bipolar depression (Frances et al. This recommendation has to be questioned as long as there is no definite proof that mood stabilizers have antidepressive efficacy in unipolar and/or bipolar depres sion, and that this efficacy is comparable to the antidepressive efficacy of traditional or modern antidepressants. Traditionally, lithium is the most intensively evaluated mood stabilizer with respect to antidepressive efficacy (Adli et al. In most studies no differentiation is made between unipolar and bipolar depression. Several of the controlled studies are not randomized, parallel-group studies, but followed cross-over designs with all their known problems and limitations, including the problem of hang over and withdrawal phenomena. Most of the randomized, parallel-group studies compare lithium with a standard antidepressant, without a placebo arm. The sample size is extremely small in each of these studies, in general less than 20 patients per treatment group. The conclusion of equal efficacy is completely misleading under these conditions, given the fact of an enor mous problem. Furthermore, in most of the studies the daily dose of the standard comparator was inadequate,. Without mentioning the other methodological problems from a modern perspective, the essence of these studies with respect to efficacy is extremely weak, a critical position which cannot even be softened by posi tive-sounding meta-analytical approaches or review papers. Lithium seems to have some antidepressive efficacy – for example as shown in the very small placebo-controlled study by Khan et al. In a head-to head comparison of lithium with imipramine under controlled treatment conditions, lithium was inferior to imipramine (Fieve et al. Many patients require lithium treatment for 6–8 weeks before a "full" antidepres sive response becomes evident (Zornberg and Pope 1993). A recent study published by Nemeroff (1997), in which the combination of lithium with placebo, with paroxetine and with imipramine in the treatment of bipolar depression were compared under double-blind conditions, demonstrated 396 H-J. Grunze that co-medication with an antidepressant led to a significantly higher responder rate compared with monotherapy with lithium. To avoid misun derstandings these statements are related only to the question of acute antidepressive effects of lithium and not to the efficacy of lithium augmentation. The respective database giving hints of an antidepressive property of carbamazepine is even worse. A meta-analysis of several open and con trolled studies, all of which had a small sample size and often made no differentiation between unipolar and bipolar depressives, found a response rate of 56% for depressed patients in open trials and 44% for patients in the controlled studies (moderate and good response) (Post et al. Apparently, the responder rates between unipolar and bipolar depressive patients are not different, as demonstrated in the studies of Svestka et al. In an open study Calabrese and Delucchi (1990) found a marked improvement in 57% of the patients. In the study with the largest sample of 103 patients, however, a moderate improvement was found in only 22% of the patients (Lambert 1984). With respect to the current methodological standards in the field of the evaluation of antidepressive efficacy of mood stabilizers, the placebo-con trolled study on lamotrigine, involving 195 patients, seems paradigmatic (Calabrese et al. The study was based on positive findings of some open clinical studies and observations giving a hint of an antidepressive property of lamotrigine. In this study 200 mg lamotrigine per day was compared to 50 mg lamotrigine per day and to placebo. Lamotrigine 50 mg/day demonstrated some efficacy compared to placebo but was inferior to the higher dosage of lamotrigine. From the tactical viewpoint it should be mentioned that lamotrigine must be increased very slowly, due to its known risk of severe dermatosis, not reaching the final dose of 200 mg/day before 6 weeks. This might limit the possibility of inducing an antidepressive response as soon as possible. Antidepressant treatment of bipolar depression 397 To prove the antidepressive efficacy of lithium or other mood stabilizers, at least two adequately designed, positive, double-blind, randomized, paral lel group studies in comparison to placebo are necessary. In trials comparing a mood stabilizer to standard antidepressants the problem has to be considered very carefully before the conclusion of equal efficacy can be made. The antidepressive property of mood stabilizers has to be proven in severe depression before a final judgement on antidepressive efficacy can be made (Laakman et al. To summarize, overall the antidepressive efficacy of mood stabilizers is not well proven, at least not following the same methodological standards as are commonly used for establishing the efficacy of antidepressants.

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The latter study specifically focused on patients with so-called « painful iliac crest syndrome » order diane-35 2mg online. Reported side effects are far from being negligible and include major complications such as infection discount diane-35 2mg otc, anaphylaxis and nerve/nerve root damages buy 2 mg diane-35 mastercard. According to the promoters of this technique buy cheap diane-35 2 mg on-line, insertion of needles in so-called « trigger points » allows alleviation of myofascial pain and dysfunction. The effectiveness of acupuncture might be slightly improved if combined with other treatments Evidence 252 In a recent meta-analysis by Manheimer et al. However they also conclude that there is no evidence available suggesting that acupuncture could be superior to any other treatment. The conclusion is that For chronic low back pain, there is evidence of pain relief and functional improvement for acupuncture, compared to no treatment or sham therapy. These effects were only observed immediately after the end of the sessions, and at short-term follow-up. When no significant difference between acupuncture and sham acupuncture (minimal acupuncture) was noted at week 8, acupuncture was significantly more effective than no treatment at week 8. There is limited evidence in each case that acupuncture is similar to self-care education and better than training of proper posture and motion in accordance with Bruegger concepts (level C). The same conclusions apply for acupuncture combined to more extensive conventional treatment (physiotherapy, diclofenac, varied physical therapy modalities, exercise, back school ). No evidence exists that allows defining the most effective type of acupuncture Safety No study was found about the safety of acupuncture techniques 2. Levels of evidence were respectively low, limited for a short-term effect 267 and insufficient for Washington States Departement of Labor and Industries. However, major adverse effects have been reported including burning sensations in the legs during several weeks, disc prolapse and development of 269 radicular pain, numbness and paresis resolving after several weeks ; and septic discitis 270 61. A radiofrequency cannula is placed under radiographic guidance in the center of the disc that is heated at temperatures up to 80°C. The device is heated up to 40-70°C, ablating the centre part of the disc and creating a channel. After stopping at a pre-determined depth, the probe is withdrawn, coagulating the tissue as it is removed. Such procedures are generally performed after a positive preliminary facet injection test. Evidence about the effectiveness of radiofrequency facet-denervation is conflicting. Evidence 2 Cost B13 evaluated the effectiveness of the procedure on the basis of one Cochrane 274 275 review and one systematic review. Proper selection of patients and optimal techniques are probably determinant factors to obtain better results. Finally, a comparison between two denervations comes to the following conclusion: there is limited evidence that intra articular denervation of the facet joints is more effective than extra-articular denervation (level 279 C, based on one low quality study ). Boswell et al describe adverse effects such as painful dysesthesias, increased pain due to neuritis or neurogenic inflammation, anesthesia dolorosa, cutaneous hyperesthesia and 61 deafferentation pain. No sensory-motor deficits and no infection in a series of 616 lumbar facet joint radiofrequency lesions performed in 92 patients. Radiofrequency lesioning of dorsal root ganglia Radiofrequency lesioning of dorsal root ganglia is an invasive procedure consisting in partial lesioning of one or several dorsal root ganglia. The rationale for this procedure is that partial lesion of the dorsal root ganglion may reduce nociceptive input at the level of the primary sensory neuron without causing any sensory deficit. This procedure may thus be considered as an alternative to surgical rhizotomy for chronic refractory radicular pain. Radiofrequency lesioning of dorsal root ganglia seems not effective: one good-quality study demonstrated that it was not superior to sham procedure. Radiofrequency neurotomy of sacroiliac joints Radiofrequency neurotomy of sacro-iliac joints is a procedure consisting in denervating the sacro-iliac joint through radiofrequency. Such a hypothesis is evoked when pain relief has been obtained through preliminary sacro-iliac diagnostic blocks with anesthetics or corticoids as described above. Effectiveness of radiofrequency neurotomy of sacro-iliac joints has not been established and its safety is unknown. Evidence 61 Only the guideline of the American Society of Interventional Pain Physicians addresses this procedure. The rationale for this procedure is to inhibit neurons assumed to be involved in the persistence of pain, neurogenic inflammation, muscle 282-285 dysfunction and contracture. This therapy is administered without anesthesia and can be performed on an outpatient basis. However, more good-quality studies should be conducted to reproduce the encouraging results obtained by this team. The safety of the procedure seems good as only minor side effects have been reported. However, these results are limited to three trials conducted by a small number of specially trained and experienced clinicians, in a limited geographical location. Unfortunately, the frequency of such complications is unknown as no study has specifically addressed this issue. This procedure is performed percutaneously or using a spinal endoscope (myeloscope). The rationale for epidural adhesiolysis is to eliminate scar formation, which can prevent direct epidural application of drugs to nerves and other tissues. Hence, instillation of anesthetic drugs, corticosteroids or other substances (hyaluronidase ) is often included in the procedure. Epidural adhesiolysis is generally considered as a technique that should be applied to patients with chronic intractable radicular pain such as the so-called « failed back surgery syndromes ».