Pain physician
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Degenerative lumbar spinal stenosis is a frequent cause of disability in the elderly population. Epidural steroid injections are a commonly used conservative modality in the treatment of patients with degenerative lumbar spinal stenosis. Relatively few studies have specifically addressed the efficacy of epidural steroid injections for spinal stenosis, with success rates varying from 20% to 100%. ⋯ Caudally placed fluoroscopically guided epidural steroid injections offered a safe, minimally invasive option for managing pain caused by lumbar spinal stenosis. The concurrent presence of degenerative spondylolisthesis appears to be an independent positive prognostic factor for successful outcome.
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Lumbar transforaminal epidural injections have been utilized in the treatment of radicular pain with proven success. It was postulated that interlaminar epidural injections result in a dorsal flow of contrast while transforaminal epidural steroid injections showed good ventral flow limited to one single spinal motion segment. There have been no published studies evaluating epidurography/contrast patterns utilizing fluoroscopy. ⋯ Contrast appeared ventrally and unilaterally in all injections. Dorsal flow occurred in 20% of these injections. No contrast flow crossed the midline. The observed contrast flow patterns should be studied clinically to determine whether they have any effect on clinical outcome. Intravascular injections were noted in 10% of cases.
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Over the past decade granulomas have been noted to occur at or near the tip of intrathecal catheters used for spinal infusions. The majority of cases involved morphine infusions, although other drugs have been implicated. Granulomas may be asymptomatic or cause significant neurological deficits. ⋯ Intrathecal granulomas were identified in 3% of patients imaged in this series. Eighty percent of the patients were asymptomatic. MRI imaging remains the diagnostic method of choice for most patients, and can be done safely when scans are taken at the level of the catheter tip. Given the low incidence of granulomas with intrathecal catheters, routine imaging to identify granulomas is not warranted.
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Postherpetic neuralgia (PHN) remains a difficult pain problem for patients and physicians alike. This review describes the epidemiology and pathophysiology of PHN and discusses proposed mechanisms of pain generation and the various treatments currently available. Evidence is scant for the value of surgical and procedural interventions in general, although there are numerous small studies supporting the use of specific interventions such as nerve blocks, neurosurgical procedures and neuroaugmentation. ⋯ Interventions with low risk, such as TENS are appropriate. Although prevention of postherpetic neuralgia appears to be an appropriate strategy, there is little evidence to support the position that medical or interventional approaches (nerve blocks) will prevent PHN after a patient develops acute herpes zoster (HZ). Although antivirals are appropriate for acute HZ, and the use of neural blockade and sympathetic blockade may be helpful in reducing pain in selected patients with HZ, there is little evidence that these interventions will reduce the likelihood of developing PHN.
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The sphenopalatine ganglion block has been utilized over the last century for a wide variety of maladies. This paper provides a brief history of the use of the sphenopalatine ganglion block, a review of the sphenopalatine ganglion anatomy, and the diagnoses which currently warrant its use. The traditional transnasal sphenopalatine ganglion block is described and our modification of the traditional technique is proposed. A case study is described in which sphenopalatine block pain control in a patient with a 20-year history of poorly controlled pain from bilateral herpetic keratitis.