Pain physician
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Opioid use in the management of chronic pain is widespread in chronic pain settings. Opioid prescriptions for non-cancer pain and overall opioid sales have been soaring with the increasing nonmedical use of opioids in the United States. Prolonged use of high dose opioids has been associated with adverse consequences including tolerance, abuse, addiction, hyperalgesia, hormonal effects, and immunosuppression. Studies of high dose therapy have shown pain relief with a 30% decrease in the intensity of pain and that only 44% of the patients continue the treatment between 7 and 24 months. However, there is no data available on the prevalence of side effects associated with low or moderate dose opioid use in chronic non-cancer pain when administered in conjunction with interventional techniques. ⋯ Moderate or low dose opioid therapy in conjunction with or without benzodiazepines, antidepressants, or in combinations are associated with minor side effects.
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In recent years, progress and innovations in healthcare are measured by evidence-based medicine (EBM), systematic reviews, and meta-analyses. A systematic review is defined as, "the application of scientific strategies that limit bias by the systematic assembly, critical appraisal, and synthesis of all relevant studies on a specific topic." In contrast, meta-analysis is the statistical pooling of data across studies to generate pooled estimates of effects. Meta-analysis usually is the final step in a systematic review. ⋯ The Quality of Reporting of Meta-analysis (QUOROM) statement provides a checklist and a flow diagram. The checklist describes the preferred way to present the abstract, introduction, methods, results, and discussion sections of the report of an analysis. This review describes various aspects of systematic reviews and meta-analyses of randomized trials with a special focus on interventional pain management.
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Evidence-based medicine (EBM) stresses the examination of evidence from clinical research and describes it as a shift in medical paradigms, in contrast to intuition, unsystematic clinical experience, and pathophysiologic rationale. While the importance of randomized trials has been created by the concept of the hierarchy of evidence in guiding therapy, much of the medical research is observational. There is competition, contrast, and a feeling of inferiority and uselessness for observational studies, created by a lack of understanding of medical research. ⋯ The STROBE statement consists of a checklist of 22 items, which relate to the title, abstract, introduction, methods, results, and discussion sections of articles. Multiple types of observational studies are conducted; however, 3 types have been highlighted in the STROBE document and also in the present review, which include cohort studies, case-controlled studies, and cross-sectional studies. This comprehensive review provides an introduction and rationale, types, design, and reporting of observational studies; outcomes assessment and data presentation and analysis; statistical analysis, results, and a discussion of observational studies.
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Low back pain with or without lower extremity pain is the most common problem among chronic pain disorders with significant economic, societal, and health impact. Epidural injections are one of the most commonly performed interventions in the United States in managing chronic low back pain. However the evidence is highly variable among different techniques utilized - namely interlaminar, caudal, transforaminal - and for various conditions, namely - intervertebral disc herniation, spinal stenosis, and discogenic pain without disc herniation or radiculitis. ⋯ The evidence based on this systematic review is limited for blind interlaminar epidurals in managing all types of pain except for short-term relief of pain secondary to disc herniation and radiculitis. This evidence does not represent contemporary interventional pain management practices and also the evidence may not be extrapolated to fluoroscopically directed lumbar interlaminar epidural injections.
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Review
Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain.
Chronic neck pain is a common problem in the adult population with a typical 12-month prevalence of 30% to 50%, and 14% of the patients reporting grade II to IV neck pain with high pain intensity and disability that has a substantial impact on health care and society. Cervical epidural injections for managing chronic neck pain are one of the commonly performed interventions in the United States. However, the literature supporting cervical epidural steroids in managing chronic pain problems has been scant and no systematic review dedicated to the evaluation of cervical interlaminar epidurals has been performed in the past. ⋯ The results of this systematic evaluation of cervical interlaminar epidural injection showed significant effect in relieving chronic intractable pain of cervical origin and also providing long-term relief with an indicated evidence level of Level II-1.