Pain physician
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Failed back surgery syndrome is common in the United States. Management of post lumbar surgery syndrome with multiple modalities includes interventional techniques, resulting in moderate improvement, leaving a proportion of patients in intractable pain. The systematic reviews of long-term benefits and risks of spinal cord stimulation (SCS) for patients with failed back surgery syndrome showed limited to moderate evidence and cost effectiveness. However, with the exponential increase in surgery in the United States, spinal cord implants are also increasing. Thus, the discussion continues with claims of lack of evidence on one hand and escalating increases in utilization on the other hand. ⋯ This systematic review evaluating the effectiveness of SCS in relieving chronic intractable pain of failed back surgery syndrome indicated the evidence to be Level II-1 or II-2 for clinical use on a long-term basis.
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Post lumbar surgery syndrome or failed back surgery syndrome with persistent pain continues to increase over the years. The speculated causes of post lumbar laminectomy syndrome include acquired stenosis, epidural fibrosis, arachnoiditis, radiculopathy, and recurrent disc herniation. Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome. Percutaneous epidural adhesiolysis has been employed in interventional pain management in the treatment of chronic, refractory low back and lower extremity pain after back surgery. ⋯ The indicated level of evidence for percutaneous adhesiolysis is Level I or II-1 based on the US Preventative Services Task Force (USPSTF) criteria.
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Chronic neck pain represents a significant public health problem. Despite high prevalence rates, there is a lack of consensus regarding the causes or treatments for this condition. Based on controlled evaluations, the cervical intervertebral discs, facet joints, and atlantoaxial joints have all been implicated as pain generators. Cervical provocation discography, which includes disc stimulation and morphological evaluation, is often used to distinguish a painful disc from other potential sources of pain. Yet in the absence of validation and controlled outcome studies, the procedure remains mired in controversy. ⋯ Cervical discography performed according to the IASP criteria may be a useful tool for evaluating chronic cervical pain, without disc herniation or radiculitis. Based on a modified AHRQ accuracy evaluation and USPSTF level of evidence criteria, this systematic review indicates the strength of evidence as Level II-2 for diagnostic accuracy of cervical discography.
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Post lumbar surgery syndrome with persistent chronic low back and lower extremity pain is common in the United States. Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome (FBSS). Percutaneous adhesiolysis with a catheter or direct visualization of the spinal canal and the contents with an endoscope are techniques employed in resistant cases when patients fail to respond to conservative modalities of treatment, including fluoroscopically directed epidural injections. Some patients failing to respond to percutaneous adhesiolysis are candidates for spinal endoscopic adhesiolysis. However, literature evaluating the effectiveness of spinal endoscopic adhesiolysis is sparse and discussions continue about its effectiveness, utility, and complications. ⋯ Spinal endoscopic adhesiolysis may be used as an effective treatment modality for chronic refractory low back pain and radiculopathy that is related to epidural adhesions.
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The sacroiliac joint has been implicated as a source of low back and lower extremity pain. There are no definite historical, physical, or radiological features that can definitively establish a diagnosis of sacroiliac joint pain. Based on the present knowledge, an accurate diagnosis is made only by controlled sacroiliac joint diagnostic blocks. The sacroiliac joint has been shown to be a source of pain in 10% to 27% of suspected patients with chronic low back pain utilizing controlled comparative local anesthetic blocks. ⋯ The indicated evidence for the validity of diagnostic sacroiliac joint injections is Level II-2. The evidence for the accuracy of provocative maneuvers in the diagnosing of sacroiliac joint pain is limited (Level II-3). The evidence for radiofrequency neurotomy is also limited (Level II-3).