Pain physician
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Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain are systematically developed and professionally derived statements and recommendations that assist both physicians and patients in making decisions about appropriate health care in the diagnosis and treatment of chronic or persistent pain. The guidelines were developed utilizing an evidence-based approach to increase patient access to treatment, to improve outcomes and appropriateness of care, and to optimize cost-effectiveness. All types of relevant and published evidence and consensus were utilized. ⋯ It is expected that a provider will establish a plan of care on a case-by-case basis, taking into account an individual patient's medical condition, personal needs, and preferences, and the physician's experience. Based on an individual patient's needs, treatment different from that outlined here could be warranted. These guidelines do not represent "standard of care."
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Healthcare decisions are increasingly being made on research-based evidence, rather than on expert opinion or clinical experience alone. Consequently, the process by which the strength of scientific evidence is evaluated and developed by means of evidence-based medicine recommendations and guidelines has become crucial resulting in the past decade in unprecedented interest in evidence-based medicine and clinical practice guidelines. Systematic reviews, also known as evidence-based technology assessments, attempt to minimize bias by the comprehensiveness and reproducibility of the search for and selection of articles for review. ⋯ The complex processes of guideline development depend on integration of a number of activities, from collection and processing of scientific literature to evaluation of the evidence, development of evidence-based recommendations or guidelines and implementation and dissemination of the guidelines to relevant professionals and consumers. Guidelines are being designed to improve the quality of healthcare and decrease the use of unnecessary, ineffective or harmful interventions. This review describes various aspects of evidence-based medicine, systematic reviews in interventional pain management, evaluation of the strength of scientific evidence, differences between systematic and narrative reviews, rating the quality of individual articles, grading the strength of the body of evidence and appropriate methods for searching for the evidence.
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It is the responsibility of clinician investigators to advance clinical knowledge and specifically its application to patient care. Randomized controlled trials remain near the top of the hierarchy of evidence based medicine. The acquisition of evidence based medicine by means of randomized controlled trials presents general difficulties and additional pitfalls specific to interventional treatments. ⋯ To generate clinically useful research results requires an understanding of the mechanics of performing studies and the reporting of methodologies to ensure appropriate interpretation. Placebo arms and sham interventions present serious ethical issues, which must be analyzed on a case by case basis. The conscientious researcher must always abide by the principles of ethical research and the tenets of human subject protection.
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This is a preliminary report of a new concept of lumbar medial branch neurotomy by measurement of minimal sensory threshold. This technique is not recommended for routine clinical use until further controlled data are available. The lumbar zygapophysial joints (Z-joint) or facet joints, are a potential source of low back pain. ⋯ The other is that the Z-joint is innervated by the sensory fibers of the medial branches. As a result, the multifidus may be successfully denervated as demonstrated by electromyography but the Z-joints may be inadequately denervated. As a result, this technique describes measurement of minimal sensory threshold prior to lesioning and seeking to double that threshold as an additional, intra-operative measure of successful sensory denervation of the Z-joint.