Pain physician
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Review Comparative Study
The impact of comparative effectiveness research on interventional pain management: evolution from Medicare Modernization Act to Patient Protection and Affordable Care Act and the Patient-Centered Outcomes Research Institute.
The Patient-Centered Outcomes Research Institute (PCORI) was established by the Affordable Care Act of 2010 to promote comparative effectiveness research (CER) to assist patients, clinicians, purchasers, and policy-makers in making informed health decisions by advancing the quality and relevance of evidence concerning the manner in which diseases, disorders, and other health conditions can effectively and appropriately be prevented, diagnosed, treated, monitored, and managed through research and evidence synthesis. The development of PCORI is vested in the Medicare Modernization Act (MMA) and the American Recovery and Reinvestment Act (ARRA). The framework of CER and PCORI describes multiple elements which are vested in all 3 regulations including stakeholder involvement, public participation, and open transparent decision-making process. ⋯ Further, stakeholders in PCORI are not scientists, are not balanced, and will set an agenda with an ultimate problem of comparative effectiveness and PCORI that it is not based on medical science, but rather on political science and not even under congressional authority, leading to unprecedented negative changes to health care. Thus, PCORI is operating in an ad hoc manner that is incompatible with the principles of evidence-based practice. This manuscript describes the framework of PCORI, and the role of CER and its impact on interventional pain management.
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Post-dural puncture headache (PDPH) is the most common complication of procedures in which the dura mater is penetrated. ⋯ The use of fine gauge pencil-point needles may reduce the incidence of PDPH. The technique of repeated caudal saline injections is easy, rapid, and effective in providing the patient with almost immediate headache relief. In cases where this treatment fails, a blood patch should be considered. Observations from this study suggest that randomized, controlled, double-blind studies may be warranted.
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Case Reports
Peripheral nerve stimulation of the thoracic paravertebral plexus for chronic neuropathic pain.
Persistent post surgical pain is reported in 70% of patients following thoracotomy and mastectomy. This pain is often neuropathic in nature and occasionally it is refractory to traditional medical and interventional management. Neurostimulation of peripheral nerves can be a highly effective clinical modality for the management of neuropathic pain. ⋯ The limitations include only 2 case reports, considered as the lowest level of evidence available in the era of evidence-based medicine, and lack of utilization of multiple other modalities of treatments utilized in managing neuropathic pain. In conclusion, these cases demonstrate the effectiveness of peripheral nerve stimulation of the thoracic paravertebral plexus in the long-term management of refractory neuropathic pain. They also serve to underline the importance of clinical awareness in order to improve patient safety.
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The application of radiofrequency (RF) has been successfully used in the treatment of chronic pain conditions, including facet arthropathy, sacroiliac joint pain, groin pain, radicular pain, cervicogenic headaches, and phantom limb pain. Due to the neurodestructive effect of continuous RF ablation and possible deafferentation sequelae, only pulsed radiofrequency (PRF) has been applied to peripheral sensory nerves. There are no previous reports of successful PRF application to the sural nerve. ⋯ It is conceivable that PRF may provide long-term pain relief in cases of sural nerve injury. The exact mechanism of the antinociceptive effect is still unknown. Possible mechanisms include changes in molecular structure by the electric field, early gene expression, stimulation of descending inhibitory pathways, and transient inhibition of excitatory transmission.
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Case Reports
The use of lumbar sympathetic blockade at L4 for management of malignancy-related bladder spasms.
Cancer-related bladder spasms may be a rare but severe symptom of bladder or metastatic cancer or its related treatments. Various treatments described in the literature include systemic medications, intravesical or epidural medications, or even sacral neurolectomies. ⋯ Lumbar sympathetic blockade could be a useful treatment for recurrent bladder spasm in the oncologic population. Based on these findings, we feel that the branches of the sympathetic nerve set at L4 may be a good target for neurolytic procedures, such as radiofrequency ablation, for long term treatment of bladder spasms. Further research is necessary to determine the efficacy of this technique for the treatment of bladder spasms in the oncologic population.