Pain physician
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Vertebral compression fractures are a common pathology affecting primarily the elderly, postmenopausal women, and those with metastatic vertebral disease. Vertebral augmentation procedures are popular treatment options for stability and pain relief. Preliminary studies have suggested that such procedures are adequately efficacious. However, the first randomized controlled trials (RCTs) published in the New England Journal of Medicine in 2009 showed that these procedures were not significantly different than placebo with regards to pain relief and quality of life. These studies were met with considerable criticism. The matter was further complicated when The Lancet published an RCT of its own that demonstrated the superiority of vertebroplasty over conservative management. The conflicting evidence has sparked ongoing debate in the medical community. All sides have provided arguments supported by evidence of varying strength and validity. ⋯ The arguments presented by proponents of both sides of the debate appear to have validity. All of the major studies cited as evidence for or against vertebral augmentation procedures have limitations in their quality. Consequently, the debate cannot be concluded, convincingly, until more elaborate studies are conducted involving larger numbers of patients with clear procedure methods agreed upon by the major authorities in the field.
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Meta Analysis Comparative Study
Comparing pain reduction following vertebroplasty and conservative treatment for osteoporotic vertebral compression fractures: a meta-analysis of randomized controlled trials.
Osteoporotic vertebral compression fractures (OVCFs) are the most common osteoporotic fractures. Pain is the main symptom. Percutaneous vertebroplasty (PVP) is a therapeutic procedure performed to reduce pain in vertebral compression fractures. Numerous case series and several small, non-blinded, non-randomized controlled studies have suggested that vertebroplasty is an effective means of relieving pain from osteoporotic fractures. However, a recent pooled analysis from 2 multicenter randomized controlled trials concluded that the improvement in pain afforded by PVP was similar to placebo. ⋯ PVP has some value for relieving pain; however, the possibility of a placebo effect should be considered. PVP has gained acceptance as a complementary treatment when conservative management has failed before its benefits have been fully understood. More large scale, double blinded, controlled trials are necessary in order to quantify the pain relief afforded by PVP more precisely.
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Randomized Controlled Trial
Concordant pressure paresthesia during interlaminar lumbar epidural steroid injections correlates with pain relief in patients with unilateral radicular pain.
Transforaminal and interlaminar epidural steroid injections are commonly used interventional pain management procedures in the treatment of radicular low back pain. Even though several studies have shown that transforaminal injections provide enhanced short-term outcomes in patients with radicular and low back pain, they have also been associated with a higher incidence of unintentional intravascular injection and often dire consequences than have interlaminar injections. ⋯ This study showed that the lateral parasagittal interlaminar approach was more effective than the midline interlaminar approach in targeting low back pain with unilateral radicular pain secondary to degenerative lumbar disc disease. It also showed that pressure paresthesia occurring ipsilaterally during an LESI correlates with pain relief and may therefore be used as a prognostic factor.
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Randomized Controlled Trial
A randomized, double-blind, active-controlled trial of fluoroscopic lumbar interlaminar epidural injections in chronic axial or discogenic low back pain: results of 2-year follow-up.
Chronic low back with or without lower extremity pain is extremely common, expensive, and disabling. However, all modalities of treatments are directed towards disc herniation which is responsible for a very small proportion of the patients. Thus, chronic low back pain without disc herniation is common. Multiple modalities of treatments are utilized in managing axial or discogenic pain including surgery and epidural injections including surgery, intradiscal therapies, and epidural injections. However, there is continued debate on the effectiveness, indications, and medical necessity of all modalities treatments in managing axial or discogenic pain in the lumbar spine. ⋯ Lumbar interlaminar epidural injections of local anesthetic with or without steroids are effective in patients with chronic axial low back pain of discogenic origin without facet joint pain, disc herniation, and/or radiculitis.