Pain physician
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Any spine structure that is innervated by afferent nociceptive nerve fibers is a potential pain generator. In the lumbar spine, the most studied pain generators include: sacroiliac joints, the zygapophysial joints, the intervertebral discs, myofascial structures. Anomalous lumbosacral articulations, the spinous processes, and lumbar spine osteophytes are less commonly reported. ⋯ Painful adjacent and closely opposed spinous processes can be a source of axial low back pain. We have described MRI features and the responses to fluoroscopically-guided injections in 3 patients with this condition.
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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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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.
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In the modern day environment, workers' compensation costs continue to be a challenge, with a need to balance costs, benefits, and quality of medical care. The cost of workers' compensation care affects all stakeholders including workers, employers, providers, regulators, legislators, and insurers. Consequently, a continued commitment to quality, accessibility to care, and cost containment will help ensure that workers are afforded accessible, high quality, and cost-effective care. ⋯ The evidence ratings for intradiscal electrothermal therapy (IDET), an automated percutaneous disc decompression and also deserve further scrutiny and analysis. In conclusion, these ACOEM guidelines for interventional pain management have no applicability in modern patient care due to lack of expertise by the developing organization (ACOEM), lack of utilization of appropriate and current EBM principles, and lack of significant involvement of experts in these techniques resulting in a lack of clinical relevance. Thus, they may result in reduced medical quality of care; may severely hinder access to appropriate, medically needed and essential medical care; and finally, they may increase costs for injured workers, third party payors, and the government by transferring the injured worker into a non-productive disability system.