Pain physician
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Randomized Controlled Trial
Evaluation of the effectiveness of lumbar interlaminar epidural injections in managing chronic pain of lumbar disc herniation or radiculitis: a randomized, double-blind, controlled trial.
The pathophysiology of lumbar radicular pain is the subject of ongoing research, with a reported prevalence of sciatica or radiculitis ranging from 1.2% to 43%. Among the numerous non-surgical interventions available, epidural injections are the most commonly performed interventions in the United States in managing chronic low back and lower extremity pain. ⋯ Overall, 74% of patients in Group I without steroids and 86% in Group II with steroids with lumbar disc herniation or radiculitis might benefit from lumbar interlaminar epidural injections.
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Ketamine is opioid-sparing. It attenuates the onset of opioid tolerance, and suppresses opioid-induced hyperalgesia. This study evaluated whether or not repeated outpatient infusions of intravenous ketamine reduced the amount of pain and the amount of opioid requirements for patients suffering with chronic, non-cancerous pain. ⋯ Outpatient intravenous ketamine infusions did not improve long-term pain scores in patients with high opioid requirements and only a few were able to substantially reduce opioid use. Considering infusion risks and cost of such outpatient treatment, ketamine infusions do not appear to be a feasible option for improving pain relief and decreasing opioid use in high-opioid requirement patients.
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Case Reports
Respiratory failure following delayed intrathecal morphine pump refill: a valuable, but costly lesson.
Spinal analgesia, mediated by opioid receptors, requires only a fraction of the opioid dose that is needed systemically. By infusing a small amount of opioid into the cerebrospinal fluid in close proximity to the receptor sites in the spinal cord, profound analgesia may be achieved while sparing some of the side effects due to systemic opioids. Intraspinal drug delivery (IDD) has been increasingly used in patients with intractable chronic pain, when these patients have developed untoward side effects with systemic opioid usage. The introduction of intrathecal opioids has been considered one of the most important breakthroughs in pain management in the past three decades. A variety of side effects associated with the long-term usage of IDD have been recognized. Among them, respiratory depression is the most feared. ⋯ Loss of opioid tolerance due to delayed pump refill may subject patients to the development of severe respiratory depression. Meticulous approach should be employed when refilling pumps in these patients when their pumps are completely empty. To our knowledge, this is the first reported case of this type.
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Case Reports
A report of paraparesis following spinal cord stimulator trial, implantation and revision.
Spinal cord injury has been reported as a rare complication of spinal cord stimulation (SCS). A review of the literature shows a very low incidence of neurological injury after spinal cord stimulation trial, implantation and revision. The most common reported complication is equipment failure without neurologic injury. The incidence of spinal cord injury after SCS trial, implantation and revision is unknown. There have been limited reports of neurologic injury secondary to dural puncture, infection, cord contusion, actual needle penetration of the spinal cord and epidural hematoma. ⋯ SCS is considered a safe procedure. Further investigation into the true incidence of neurologic injury after SCS is warranted.
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Practice Guideline
Guidelines for the speciality of interventional pain management.