Pain physician
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Review
Evidence-based interventional pain management: principles, problems, potential and applications.
The past decade has been marked by unprecedented interest in evidence-based medicine (EBM) and a focus upon the use of innovative methods and protocols to provide valid and reliable information for and about healthcare. Thus (it is at least purported that), healthcare decisions are increasingly being based upon research-derived evidence, rather than on expert opinion or clinical experience alone. But this quest for evidence to support clinical practice also compels the question of whether the methods employed to acquire information, the ranking of information that is acquired, and the prudent use of this information are sound enough to actually sustain the validity of an evidence-based paradigm in practice. Moreover, it is becoming apparent that the scope, depth, and applicability of available evidence to effectively and ethically guide the myriad of situational decisions in clinical practice is not uniform across all medical fields or disciplines. In particular, comprehensive evidence synthesis or complete guidelines for clinical decision-making in interventional pain management remain relatively scarce. EBM is defined as the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients. Thus, the practice of EBM requires the integration of individual clinical expertise with the best available external evidence from systematic research. To arrive at evidence-based medical decisions all valid and relevant evidence should be considered alongside randomized controlled trials, patient preferences, and resources. ⋯ Interpreting and understanding evidence synthesis, systematic reviews and other analytic literature is a difficult task. It is crucial for pain physicians to understand the goals, principles, and process(es) of EBM so as to meaningfully improve its application(s). This knowledge affords better insight into not only the analytic reviews in interventional pain management provided herein, but ultimately allows future information to be selected, evaluated, and used with prudence in technically competent, ethically sound medical practice.
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Review Case Reports
Neuromodulation of the cervical spinal cord in the treatment of chronic intractable neck and upper extremity pain: a case series and review of the literature.
Electrical spinal neuromodulation in the form of spinal cord stimulation is currently used for treating chronic painful conditions such as complex regional pain syndrome, diabetic neuropathy, postherpetic neuralgia, peripheral ischemia, low back pain, and other conditions refractory to more conservative treatments. To date, there are very few published reports documenting the use of spinal cord stimulation in the treatment of head/neck and upper limb pain. This paper reports a case series of 5 consecutive patients outlining the use of spinal cord stimulation to treat upper extremity pain. ⋯ Patients continue to report excellent pain relief up to 9 months following implantation. This case series documents the successful treatment of neck and upper extremity pain following unsuccessful cervical spine fusion surgery. Given this initial success, prospective, controlled studies are warranted to more adequately assess the long term utility and cost effectiveness of electrical neuromodulation treatment of chronic neck and upper extremity pain.
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The introduction of intrathecal opioid administration for intractable chronic non-malignant pain and cancer pain is considered as one of the most important breakthroughs in pain management. Morphine, the only opioid approved by FDA for intrathecal administration, has been increasingly utilized for this purpose. For over 3 decades, there have been numerous reports on the non-nociceptive side effects associated with ever increasing long-term intrathecal morphine usage. ⋯ The utilization of intrathecal morphine administration for cancer and intractable non-malignant chronic pain represents an important leap forward in pain management. Yet, a wide variety of non-nociceptive side effects may also occur in susceptible patients. The side effects due to intrathecal morphine administration are mostly mediated by opioid receptors. Treatment usually involves the utilization of opioid receptor antagonist, such as naloxone. Patients considering intrathecal opioid pump therapy should be informed and advised about the possible side effects associated with long-term intrathecal morphine administration prior to placement of a permanent morphine infusion pump.
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Clinical Trial
Radiofrequency denervation of the lumbar zygapophysial joints: 10-year prospective clinical audit.
Evidence for the efficacy of zygapophysial joint nerve radiofrequency neurotomy has remained controversial. Two randomized controlled trials showed positive results, but two others demonstrated no benefit. One carefully performed prospective trial confirmed high efficacy and lasting pain relief after the procedure; however, selection criteria for this study were superfluous, which resulted in a small number of patients available for follow up. ⋯ This large, prospective clinical audit indicates that proper patient selection and anatomically correct radiofrequency denervation of the lumbar zygapophysial joints provide long-term pain relief in a routine clinical setting.