Pain physician
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Diagnosis is a critical component of health care. The world of diagnostic tests is highly dynamic. New tests are developed at a fast pace and technology of existing tests is continuously being improved. ⋯ Interventional techniques as a diagnostic tool in painful conditions is important due to multiple challenging clinical situations, which include the purely subjective nature of pain and underdetermined and uncertain pathophysiology in most painful spinal conditions. Precision diagnostic blocks are used to clarify these challenging clinical situations in order to determine the pathophysiology of clinical pain, the site of nociception, and the pathway of afferent neural signals. Part 5 of evidence-based medicine (EBM) in interventional pain management describes the various aspects of diagnostic accuracy studies.
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Since the descriptions by Mixter and Barr of open surgical treatment for rupture of the intervertebral disc in 1934, open surgical procedures have become a common practice. Disc herniations have been reported as being contained and non-contained. The results of open surgical discectomy for contained disc herniation have been poor. Consequently, several alternative techniques have been developed which are minimally invasive including percutaneous laser disc decompression. ⋯ This systematic review illustrates Level II-2 evidence for percutaneous laser disc decompression which is equivalent to automated percutaneous lumbar disc decompression.
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Review
Systematic review of percutaneous lumbar mechanical disc decompression utilizing Dekompressor.
In recent years, a number of minimally invasive nuclear decompression techniques for lumbar disc prolapse, protrusion, and/or herniation have been introduced, including the Dekompressor a device utilizing an Archimedes screw. The primary goal of the surgical treatment of nerve root compression from a disc protrusion continues to be the relief of compression by removing the herniated nuclear material with open discectomy. However, poor results have been reported for contained disc herniations with open surgical interventions. The results with several alternative techniques including the Dekompressor, automated percutaneous discectomy, and laser discectomy have been described, but are not convincing. There is a paucity of evidence for all decompression techniques. ⋯ This systematic review illustrates Level III evidence for mechanical percutaneous disc decompression procedures with the high RPM device or Dekompressor.
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The intervertebral disc has been implicated as an etiology of chronic lumbar spine pain based on clinical, basic science, and epidemiological research. However, there is lack of consensus regarding the diagnosis and treatment of intervertebral disc disorders. Based on controlled evaluations, the lumbar intervertebral discs have been shown to be sources of chronic back pain without disc herniation in 26% to 39%. Lumbar provocation discography, which includes disc stimulation and morphological evaluation, is often used to distinguish a painful disc from other potential sources of pain. Despite the extensive literature, controversy continues about provocation lumbar discography. ⋯ Based on the current systematic review, lumbar provocation discography performed according to the IASP criteria with control disc (s) with minimum pain intensity of 7 of 10, or at least 70% reproduction of worst pain (i.e. worst spontaneous pain of 7 = 7 x 70% = 5) may be a useful tool for evaluating chronic lumbar discogenic pain. Discography is an important imaging and pain evaluation tool in identifying a subset of patients with chronic low back pain secondary to intervertebral disc disorders.
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Physician impairment is a serious public health issue affecting not only physicians, but also their families, colleagues, and patients. Physician impairment is used most often to refer to substance use disorders, which involve both substance abuse and substance dependence and/or addiction. ⋯ Physician impairment is a real and significant public health concern; however, recovery is feasible and the data support favorable odds of recovery and a return to clinical practice among those seeking appropriate treatment, counseling, and relapse prevention strategies.