Pain physician
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We describe a case report and technique for using a portable ultrasound scanner and a curvilinear transducer (4-5MHz) (SonoSite Micromaxx SonoSite, Inc. 21919 30th Drive SE Bothwell W. A.) to guide sacroiliac joint (SIJ) injection. A 42-year-old male presented with chronic lower back pain centered on his left SIJ. ⋯ Ultrasound guidance does not expose patients and personnel to radiation and is readily accessible. Ultrasound-guided SIJ injections may have particular applications in the management of chronic lower back pain in certain clinical scenarios (e.g. pregnancy). Future studies to demonstrate efficacy and reproducibility are needed.
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Case Reports
Use of spinal cord stimulator for treatment of lumbar radiculopathy in a patient with severe kyphoscoliosis.
Spinal cord stimulation (SCS) has been a therapeutic option for chronic pain for over 40 years with a common indication being failed back surgery syndrome (FBSS). This case reports the successful implantation of a spinal cord stimulator in a patient with FBSS and kyphoscoliosis for treatment of radicular pain. Technical considerations and anatomical difficulties that may be encountered during placement with kyphoscoliosis will be discussed. ⋯ Fourteen weeks later, the patient reported being pain free with an increased physical activity level and opioid discontinuation. Technical considerations with kyphoscoliosis may discourage pain physicians from attempting SCS. This case illustrates that with careful selection, some of these patients may be candidates for SCS with good results.
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Case Reports
Pulsed radiofrequency of lumbar dorsal root ganglia for chronic post-amputation stump pain.
Chronic pain following limb amputations is now a recognized chronic pain syndrome usually described in a combination of phantom and stump pain. Both stump and phantom pain continue to be significant treatment challenges. If pharmacotherapy does not provide effective analgesia for stump pain, a clinician has interventional options that frequently give only transient benefit, or have a high chance of failure in the long run. ⋯ PRF treatment of the DRG at the L4 and L5 nerve root level may be a therapeutic option for patients with peripherally mediated intractable stump pain. A decrease in pain intensity and improved toleration of the limb prosthesis was appreciated in both patients.
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Review Case Reports
Tension pseudomeningocele associated with retained intrathecal catheter: a case report with a review of literature.
Catheter related complications are not uncommon with permanently implanted intrathecal drug delivery systems. Pericatheter leak of cerebrospinal fluid usually responds to conservative treatment. We report a case of tension pseudomeningocele due to retained lumbar intrathecal catheter. ⋯ If a patient with IDDS develops a complete fracture of the catheter at the spinal end, all attempts should be made to define the 2 ends of the catheter and establish the continuity with a titanium connector. If the spinal end of the catheter is retracted deep into the interspinous ligaments and not recoverable, avoid entering the intrethecal space at the same level. If a patient develops pseudomeningocele in the postoperative period of IDDS and conservative methods including autologous epidural blood patch fail, we recommend an MRI of the spine for a detailed study along with prompt neurosurgical consultation.
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Today, with the growing interest of the medical community and others in practice guidelines, there is greater emphasis on formal procedures and methods for arriving at a widely scrutinized and endorsed consensus than ever before. Conflicts in terminology and technique are notable for the confusion that guidelines create and for what they reflect about differences in values, experiences, and interests among different parties. While public and private development activities continue to multiply, the means for coordinating these efforts to resolve inconsistencies, fill in gaps, track applications and results, and assess the soundness of particular guidelines continue to be limited. In this era of widespread guideline development by private organizations, the American College of Occupational and Environment Medicine (ACOEM) has developed guidelines that evaluate areas of clinical practice well beyond the scope of occupational medicine and yet fail to properly involve physicians expert in these, especially those in the field of interventional pain management. As the field of guidelines suffers from imperfect and incomplete scientific knowledge as well as imperfect and uneven means of applying that knowledge without a single or correct way to develop guidelines, ACOEM guidelines have been alleged to hinder patient care, reduce access to interventional pain management procedures, and transfer patients into a system of disability, Medicare, and Medicaid. ⋯ Both the low back pain and chronic pain chapters of the ACOEM guidelines may not be ideal for clinical use based on the assessment by the AGREE instrument, AMA attributes, and criteria established by Shaneyfelt et al. They also scored low on IOM criteria (37.5%). These guidelines may not be applicable for clinical use.