Pain physician
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Ziconotide is commonly used for intrathecal (IT) therapy of chronic pain, and has been recently indicated as a first-line IT drug. It is also extremely useful for patients intolerant or refractory to the common IT drugs (such as morphine). The literature, excluding registration studies, mostly includes small samples, and gives only fragmentary evidence on the long-term risks and benefits of ziconotide. ⋯ Ziconotide IT therapy is a treatment option commonly used for clinical practice in 17 Italian pain therapy and neurosurgery units. It might give relief to patients with refractory chronic pain, and it seems to have a safe profile. Long-term studies and controlled trials are required.
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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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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.
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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.