Pain physician
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A number of variables have contributed to the current crisis in chronic pain care and are affected by, and affect, the philosophies and politics that influence the socio-economic climate of the American healthcare system. Thus, we posit that managing the crisis in chronic pain care in the United States is contingent upon the development of a multi-focal healthcare paradigm that more thoroughly enables and fortifies research, its translation (in education and practice), and the implementation of, and support for, both the curative and healing approaches in medicine in general, and pain care specifically. These steps necessitate re-examination, if not revision of the health care system and its economics. ⋯ But establishing such a system does not guarantee access, and distribution of these services and resources requires economic support to ensure that capabilities are more broadly available (i.e., supplied), and afforded as needed and wanted (i.e., demanded). Toward this end, we posit the need to focus upon, and more fully integrate 1) education, 2) multi-disciplinary care (including re-vivification of MPCs), 3) policies that allow financial subsidies that afford patients the latitude to access and utilize such expanded resources appropriately to meet identified medical needs, and 4) medico-legal initiatives and statutes that protect and enable patients and physicians. The proposed changes comport with a number of ethical systems in that they support the basic deontic structure of the profession and allow for a richer, more finely grained articulation of clinical and ethical responsibilities within the scope of particular general, specialty, and sub-specialty practices.
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Randomized Controlled Trial
Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 2--Disc herniation and radiculitis.
The pathophysiology of lumbar radicular pain is a subject of ongoing research. The prevalence of sciatica or radiculitis ranges from 1.2% to 43%. Epidural injections are one of the most commonly performed interventions in the United States in managing chronic low back and lower extremity pain secondary to disc herniation and radiculitis. There is a paucity of evidence with contemporary methodology used in performing epidural injections under fluoroscopy and based on pain relief and functional status improvement. ⋯ Caudal epidural injections with or without steroids may be effective in patients with disc herniation or radiculitis with between 79% to 91% of patients showing significant pain relief and improvement in functional status.
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Randomized Controlled Trial
Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 4--Spinal stenosis.
Spinal stenosis is one of the 3 most common diagnoses of low back and leg symptoms which also include disc herniation and degenerative spondylolisthesis. Spinal stenosis is a narrowing of the spinal canal with encroachment on the neural structures by surrounding the bone and soft tissue. In the United States, one of the most commonly performed interventions for managing chronic low back pain are epidural injections, including their use for spinal stenosis. However, there have not been any randomized trials and evidence is limited with regards to the effectiveness of epidural injections in managing chronic function-limiting low back and lower extremity pain secondary to lumbar spinal stenosis. ⋯ Caudal epidural injections with or without steroids may be effective in patients with chronic function-limiting low back and lower extremity pain with spinal stenosis in approximately 60% of the patients.
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Cervicogenic headache descriptors include its unilateral nature, "signs and symptoms linking it to the neck," and trauma of the neck. Since the pain often occurs over the C2 or C3 nerve root, we used a modification of the deep cervical block technique for treatment of this refractory type headache. ⋯ These results showed that for some patients this series of blocks provided effective pain relief for 3 months post treatment but by 6 months the pain had returned to pre-treatment levels. This block technique significantly diminished pain after the initial as well as the last treatment. These clinically significant changes in pain relief suggest that more aggressive selective therapy targeting these nerve routes might provide longer lasting relief.
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Radiofrequency neurolysis is a common technique used in the treatment of chronic pain, particularly facet (zygapophyseal joint) arthralgia. A needle-like cannula is insulated except for the exposed active tip, which is positioned as parallel and adjacent as possible to the targeted nerve branch. Via an inserted probe connected to a radiofrequency generator, energy flowing from the tip of the cannula creates a heat lesion in the 80 - 85 degree Celsius range mostly about the length of the exposed active tip and in proportion to the diameter of the probe. The common active tip lengths used for neurolysis are 5mm or 10mm. The cannulae are FDA approved. The manufacturer advises physicians not to bend or otherwise modify a cannula prior to use. The cannulae are available straight or bent, sharp and blunt. The technique is guided under C-arm fluoroscopy. X-rays passing through the patient demonstrate in 2 dimensions the projected relative radio-opaque bony landmarks and the metallic cannula. Most currently available cannulae are uniform in their radio-opacity from tip to hub. The physician must make an educated guess as to the portion of the cannula that will be making the lesion in relationship to the bony landmark. ⋯ The ROC did represent an improvement over standard cannulae to optimize visualization of cannula and thus lesion placement using a phantom model. The applications described were only for conventional or "hot" RF.