Pain physician
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Comparative Study
Alternative approach to needle placement in spinal cord stimulator trial/implantation.
Neuromodulation with spinal cord stimulation is a proven, cost effective treatment for the management of chronic radicular low back pain from failed low back surgery syndrome and other neuropathic pain conditions. The traditionally instructed method for percutaneous spinal cord stimulator lead placement promotes the use of a "loss of resistance" technique under anteroposterior fluoroscopic guidance to assure midline lead placement and proper entry into the epidural space. Loss of resistance is a reliable method to locate the epidural space in most clinical situations. ⋯ This method allows for multiple lead placement or single lead insertion multiple times in the same interlaminar space. This is an alternative approach to the loss of resistance technique based on the fluoroscopic landmarks. Theoretically, this should be a safer approach for accessing the epidural space; however, further studies are needed to evaluate its safety.
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Several animal and clinical studies have shown that thoracic spinal cord stimulation (SCS) may decrease mean arterial pressure (MAP). A previous study in normotensive participants demonstrated a small reduction in MAP during SCS at the T5-T6 spinal level. It has also been demonstrated that chronic SCS at the subthreshold stimulation level significantly improved angina attacks and 6-minute hall walk distance in drug refractory angina patients. ⋯ Acute SCS at the T5-T6 region did not significantly alter MAP or HR compared to baseline (no SCS) in participants without sedation, supporting our previous findings in sedated patients. Hypertensive participants had a heightened response to transient cold stress, consistent with the literature. The observation of the tendency for a reduction in HRV in both the time and frequency domain in hypertensive participants is also consistent with the literature. In contrast to acute SCS, the hemodynamic effects of chronic SCS should be explored in the future.
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Review Case Reports
Feasibility of combined epicranial temporal and occipital neurostimulation: treatment of a challenging case of headache.
Evidence of a paradigm shift towards epicranial neurostimulation treatment techniques aimed at the site of headache pain is beginning to populate the literature. This is most apparent by 2 recently published reports describing alternative approaches to peripheral nerve stimulation techniques for refractory migraine, including hemiplegic migraine. ⋯ In the single case reported here, the feasibility of a novel neurostimulation technique (occipital nerve stimulation/bilateral subcutaneous temporal region stimulation) to treat headache is presented. At the 24-month follow-up, no complications (such as loss of coverage due to lead displacement or lead fracture or erosion) or adverse side effects were reported. Finally, inclusion of fundamental programming data in reports on neuroaugmentative approaches to headache care will complement initiatives in research from the clinical and biomedical communities involved in this field.
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Editorial
Medicare physician payment systems: impact of 2011 schedule on interventional pain management.
Physicians in the United States have been affected by significant changes in the patterns of medical practice evolving over the last several decades. The recently passed affordable health care law, termed the Patient Protection and Affordable Care Act of 2010 (the ACA, for short) affects physicians more than any other law. Physician services are an integral part of health care. ⋯ This was based on a total cut of 30.8% with 24.9% of the cut attributed to SGR. However, as usual, with patchwork efficiency, Congress passed a one-year extension of the 0% update, effective through December 2011. Consequently, CMS issued an emergency update of the 2011 Medicare fee schedule, with multiple revisions, resulting in a reduction of the conversion factor of $36.8729 from December 2010 to $33.9764 for 2011.
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Case Reports
Spinal cord stimulation for the treatment of chronic renal pain secondary to uretero-pelvic junction obstruction.
Chronic renal pain secondary to uretero-pelvic junction obstruction (UPJO) is common but remains poorly understood. Patients with UPJO experience frequent infections, renal calculi and pain. Management options for patients with this condition are traditionally limited to surgical interventions to eliminate the obstruction. Spinal Cord Stimulation (SCS) has gained widespread popularity for the treatment of numerous conditions from complex regional pain syndrome to failed back syndrome. With continued success, the possible use of SCS has steadily increased. Although a significant number of patients with severe chronic renal pain will transiently respond to analgesics and physical interventions such as autonomic sympathetic blocks, substantial long-term pain relief is usually lacking. SCS therefore might be a welcome addition to the treatment of moderate to severe chronic renal pain. ⋯ Spinal cord stimulation might be an option in the management of chronic renal pain secondary to uretero-pelvic junction obstruction.