Pain physician
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Today, with the growing interest of the medical community and others in practice guidelines, there is greater emphasis on formal procedures and methods for arriving at a widely scrutinized and endorsed consensus than ever before. Conflicts in terminology and technique are notable for the confusion that guidelines create and for what they reflect about differences in values, experiences, and interests among different parties. While public and private development activities continue to multiply, the means for coordinating these efforts to resolve inconsistencies, fill in gaps, track applications and results, and assess the soundness of particular guidelines continue to be limited. In this era of widespread guideline development by private organizations, the American College of Occupational and Environment Medicine (ACOEM) has developed guidelines that evaluate areas of clinical practice well beyond the scope of occupational medicine and yet fail to properly involve physicians expert in these, especially those in the field of interventional pain management. As the field of guidelines suffers from imperfect and incomplete scientific knowledge as well as imperfect and uneven means of applying that knowledge without a single or correct way to develop guidelines, ACOEM guidelines have been alleged to hinder patient care, reduce access to interventional pain management procedures, and transfer patients into a system of disability, Medicare, and Medicaid. ⋯ Both the low back pain and chronic pain chapters of the ACOEM guidelines may not be ideal for clinical use based on the assessment by the AGREE instrument, AMA attributes, and criteria established by Shaneyfelt et al. They also scored low on IOM criteria (37.5%). These guidelines may not be applicable for clinical use.
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Intrathecal granuloma formation has commonly been described with morphine therapy. It has been suggested that a high concentration of intrathecal morphine may be responsible for this complication. Much less commonly, intrathecal hydromorphone has been associated with intrathecal granuloma formation. ⋯ In the current study, rapidly declining neurologic function with a confirmed inflammatory mass adherent to the spinal canal necessitated urgent surgical intervention. Though use of intrathecal hydromorphone still represents an off label application, this opiate is commonly employed as an alternative first line analgesic agent. This case report highlights the potential of high-dose and high infusate concentration intrathecal hydromorphone to form an inflammatory granuloma.
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Previous studies have compared MRI parameters to the results from discography. However, none have evaluated the overall diagnostic performance of MRI, taking into account that many MRI characteristics may be correlated. ⋯ MRI parameters are correlated with each other and with discography findings, influencing the diagnostic performance of MRI. Combining MRI parameters improves the diagnostic performance of MRI, but only in the presence of moderate loss of nuclear signal. When there is either normal nuclear signal or severe loss of nuclear signal the other MRI parameters have no influence on test performance. The practical implication for physicians that use discography is that the most important single MRI parameter to consider is nuclear signal. If nuclear signal is normal the disc is very likely to be negative on discography, while if there is severe loss of nuclear signal it is very likely to be positive. Discography will be most useful in discs with moderate loss of nuclear signal, particularly if there are no other MRI abnormalities present.
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In the modern day environment, workers' compensation costs continue to be a challenge, with a need to balance costs, benefits, and quality of medical care. The cost of workers' compensation care affects all stakeholders including workers, employers, providers, regulators, legislators, and insurers. Consequently, a continued commitment to quality, accessibility to care, and cost containment will help ensure that workers are afforded accessible, high quality, and cost-effective care. ⋯ The evidence ratings for intradiscal electrothermal therapy (IDET), an automated percutaneous disc decompression and also deserve further scrutiny and analysis. In conclusion, these ACOEM guidelines for interventional pain management have no applicability in modern patient care due to lack of expertise by the developing organization (ACOEM), lack of utilization of appropriate and current EBM principles, and lack of significant involvement of experts in these techniques resulting in a lack of clinical relevance. Thus, they may result in reduced medical quality of care; may severely hinder access to appropriate, medically needed and essential medical care; and finally, they may increase costs for injured workers, third party payors, and the government by transferring the injured worker into a non-productive disability system.
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Review Case Reports
Tension pseudomeningocele associated with retained intrathecal catheter: a case report with a review of literature.
Catheter related complications are not uncommon with permanently implanted intrathecal drug delivery systems. Pericatheter leak of cerebrospinal fluid usually responds to conservative treatment. We report a case of tension pseudomeningocele due to retained lumbar intrathecal catheter. ⋯ If a patient with IDDS develops a complete fracture of the catheter at the spinal end, all attempts should be made to define the 2 ends of the catheter and establish the continuity with a titanium connector. If the spinal end of the catheter is retracted deep into the interspinous ligaments and not recoverable, avoid entering the intrethecal space at the same level. If a patient develops pseudomeningocele in the postoperative period of IDDS and conservative methods including autologous epidural blood patch fail, we recommend an MRI of the spine for a detailed study along with prompt neurosurgical consultation.