Pain physician
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Discogenic low back pain resulting from internal disc disruption can be severely disabling, clinically challenging, and expensive to treat. Previously, when conservative care had been exhausted, open surgical intervention such as spinal fusion or artificial disc replacement was the only treatment option for these patients. Intradiscal electrothermal therapy (IDET), a minimally-invasive technique performed in the outpatient setting, offers an intermediate intervention between conservative care and surgery. ⋯ Final indications for use consist of clinical and imaging criteria. There are 5 compulsory indications for use: 1) persistent axial low back pain +/- leg pain and non-responsive to > or = 6 weeks of conservative care; 2) history consistent with discogenic low back pain without marked lower extremity neurological deficit; 3) one to 3 desiccated discs with or without small, contained herniated nucleus pulposus by T2-weighted magnetic resonance imaging, with at least 50% remaining disc height; 4) concordant pain provocation by low pressure (< 50 psi above opening pressure) discography; and, 5) posterior annular disruption by post-discography computed tomography. Using these patient selection characteristics, approximately 3 of 4 IDET-treated patients should achieve a minimal clinically important improvement in pain and disability.
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Even though the prevalence of thoracic pain has been reported to be 15% of the general population and up to 22% of the population in interventional pain management settings, the role of thoracic discs as a cause of chronic thoracic and extrathoracic pain has not been well researched. The intervertebral discs, zygapophysial or facet joints, and other structures including the costovertebral and costotransverse joints have been identified as a source of thoracic pain. ⋯ Based on the available evidence for this systematic review, thoracic provocation discography is provided with a weak recommendation for the diagnosis of discogenic pain in the thoracic spine, if conservative management has failed. This is qualified by the need to appropriately evaluate and diagnose other causes of chronic thoracic pain including pain originating from thoracic facet joints.
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Chronic mid back and upper back pain caused by thoracic facet joints has been reported in 34% to 48% of the patients based on the responses to controlled diagnostic blocks. Systematic reviews have established moderate evidence for controlled comparative local anesthetic blocks of thoracic facet joints in the diagnosis of mid back and upper back pain, moderate evidence for therapeutic thoracic medial branch blocks, and limited evidence for radiofrequency neurotomy of therapeutic facet joint nerves. ⋯ The evidence for the diagnosis of thoracic facet joint pain with controlled comparative local anesthetic blocks is Level I or II-1. The evidence for therapeutic facet joint interventions is Level I or II-1 for medial branch blocks. Recommendation is 1A or 1B/strong for diagnostic and therapeutic medial branch blocks.
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This article examines the association between smoking and pain intensity and functional interference in a heterogeneous group of patients evaluated at a tertiary outpatient pain clinic. Current smoking is associated with less favorable clinical presentations. ⋯ In patients who completed evaluation in an outpatient pain clinic, current cigarette smokers reported significantly greater pain intensity and pain interference with functioning. Symptoms were more pronounced in smokers with more severe nicotine dependence.
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Subdural migration of epidural catheters is well known and documented. Subdural placement of intrathecal catheters has not been recognized. Two cases of sudural placement of intrathecal catheters are presented. ⋯ These cases differ from others in the literature because the catheter was apparently subdural at the time of initial implantation. As these 2 cases demonstrate, this placement may manifest immediately, but it may remain undetected for a prolonged period. Initial subdural placement should be considered along with catheter migration into the subdural space in the differential of a malfunctioning pump.