Pain physician
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Therapy with glucocorticoids often results in bone loss and glucocorticoid-induced osteoporosis. However, the relationship between epidural steroid injection (ESI), bone mineral density (BMD), and vertebral fracture remains to be determined. ⋯ Older age and lower BMD were associated with osteoporotic fracture in postmenopausal women treated for low back pain with ESI. The ESIs were not associated with low BMD or fracture.
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Epidural corticosteroid injection is a commonly used approach for managing back pain of several etiologies. The risk of clinical complications from systemic absorption is felt to be rare. Ritonavir is a protease inhibitor whose potent cytochrome P450 3A4 inhibition is exploited for pharmacologic boosting in human immunodeficiency virus (HIV) infection. ⋯ The preponderance of reported cases of iatrogenic hypercortisolism following injectable corticosteroids has involved triamcinolone acetonide, which may be due to the relatively rapid absorption characteristics and high serum levels of this compound compared with other preparations. For individuals on ritonavir-containing HIV therapy, we recommend close coordination with the involved HIV clinicians prior to use of injectable corticosteroids, and avoidance of injections with triamcinolone acetonide whenever possible. Choosing an alternative corticosteroid preparation to triamcinolone acetonide may reduce the risk of systemic absorption, though more research is needed to confirm this hypothesis.
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Pain is one of the most common symptoms in patients suffering from advanced cancer and receiving palliative care and is often responsible for a poor quality of life. To date, there exists no published correlation between biological, measurable biomarkers and pain intensity. ⋯ Our results provide preliminary evidence of a significant correlation of pain relief in patients with cancer and at least 5 cytokines. These biomarkers may serve as the basis for development of diagnostic tools for pain assessment and could serve as potential new targets for pain control.
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Digital subtraction angiography (DSA) has been touted as a radiologic adjunct to interventional neuraxial procedures where it is imperative to identify vascular compromise during the injection. Transforaminal epidural steroid injections (TFESI) are commonly performed interventions for treating acute and chronic radicular spine pain. We present a case of instantaneous and irreversible paraplegia following lumbar TFESI wherein a local anesthetic test dose, as well as DSA, were used as adjuncts to fluoroscopy. ⋯ We believe that this report should open further discussion regarding adding the possibility of these catastrophic events in the informed consent process for lumbar TFESIs, as it has for cervical TFESI. Utilizing blunt needles or larger bevel needles in place of sharp, cutting needles may minimize the chances of this event occurring. Considering eliminating use of particulate steroids for TFESI should be evaluated, although the use of nonparticulate agents remains controversial due to the perception that their respective duration of action is less than that of particulate steroids.
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Neuropathic pain is a relatively common outcome of Lyme disease. Pain management options for these patients have been limited to pharmaceutical treatments. ⋯ Spinal cord stimulation may be an effective option for relieving chronic pain originating from Lyme disease.