Pain physician
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Little attention has been afforded to the potential adverse sequelae of withholding anticoagulation therapy in a patient after neuraxial interventions. ⋯ Thromboembolism is a potentially devastating complication associated with atrial fibrillation. Twenty percent of thromboembolic events in patients with atrial fibrillation are fatal, and greater than 50% result in permanent disability. While thromboembolic events following a brief period of normalization of coagulation for interventions appear rare, so is the incidence of epidural hematomas. Considering the high mortality and permanent rate of disability with thromboembolic events associated with atrial fibrillation, perhaps it is time to balance our focus on the complications of withholding anticoagulation with those of bleeding.
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Chronic discogenic low back pain is a common problem with significant personal and societal costs. Thermal annular procedures (TAPs) have been developed in an effort to provide a minimally invasive treatment for this disorder. Multiple techniques utilized are intradiscal electrothermal therapy (IDET), radiofrequency annuloplasty, and intradiscal biacuplasty (IDB). However, these treatments continue to be controversial, coupled with a paucity of evidence. ⋯ IDET offers functionally significant relief in approximately one-half of appropriately chosen chronic discogenic low back pain patients. There is minimal evidence supporting the use of radiofrequency annuloplasty and IDB.
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There is ongoing controversy regarding the validity of controlled diagnostic blocks due to variability in sensitivity, specificity, and accuracy. Consequently, identification of false-positive rates, false-negative rates, and placebo responses is crucial. The reasons described for false-positive responses to diagnostic anesthetic blocks are many; however, sedation and psychological factors have been implied as causes. Further, there is no consensus with regards to sedation prior to controlled diagnostic blocks and their influence on the accuracy and validity of a diagnosis. ⋯ This systematic review provides no significant evidence of the influence of sedation either with midazolam or fentanyl in the evaluation of cervical and lumbar facet joint pain with controlled cervical and lumbar facet joint nerve blocks with an indicated evidence of Level II-1, with application of stringent criteria of at least 80% pain relief and the ability to perform previously painful movements after the diagnostic blocks.
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Caudal epidural injection of local anesthetics with or without steroids is one of the most commonly used interventions in managing chronic low back and lower extremity pain. However, there has been a lack of well-designed randomized, controlled studies to determine the effectiveness of caudal epidural injections in various conditions - disc herniation and radiculitis, post-lumbar laminectomy syndrome, spinal stenosis, and chronic low back pain of disc origin without disc herniation or radiculitis. ⋯ This systematic review shows Level I evidence for relief of chronic pain secondary to disc herniation or radiculitis and discogenic pain without disc herniation or radiculitis. Further, the indicated evidence is Level II-1 or II-2 for caudal epidural injections in managing chronic pain of post lumbar laminectomy syndrome and spinal stenosis.
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Clinical Trial
Continuous cervical epidural analgesia for rehabilitation after shoulder surgery: a retrospective evaluation.
Patients with frozen shoulder who fail conservative therapy need surgical treatment and aggressive post-operative rehabilitation. ⋯ Our data show that the continuous infusion of epidural opioids and local anesthetics through a tunneled cervical epidural catheter during the rehabilitation phase after shoulder surgery for adhesive capsulitis may be a safe and effective tool for post-operative pain control and to facilitate rehabilitation.