Pain physician
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Proper coding and documentation for evaluation and management services continuously and progressively are becoming not only complicated, but also confusing. Although medical evaluation of patients has been a fact of life since the beginnings of medical history, medicine has been substantially influenced by federal regulations since the enactment of Medicare. Physicians' fear of being prosecuted is increasing. ⋯ While the history is the same for all types of visits except for the complexity for each level, four types of physical examination are available, either in a general multisystem examination or a single-system examination. However, the complexity of medical decision making is the essential factor in deciding to which level the evaluation and management belong. This review will discuss various aspects of evaluation and management guidelines in interventional practice and also guide the physician in performing these evaluations in an appropriate manner with proper documentation, thus avoiding the pitfalls of fraud and abuse.
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The caudal approach to the epidural space was first reported in 1901. Injection of steroids to treat low back pain was introduced in 1952. ⋯ Caudal epidural injections are associated with inaccurate needle placement when performed blindly in a substantial number of patients, resulting in intravascular injections as well as other complications. This review will discuss anatomic and technical considerations of caudal epidural injections, along with advantages, disadvantages, complications, and indications.
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Epidural neuroplasty (lysis of epidural adhesions) is an interventional technique that has emerged over the last 10 years as part of a multidisciplinary approach to treating radiculopathy with low back pain when conservative management has failed. Neuroplasty was at one time performed as a single-catheter technique using the caudal approach. It now has many variations, including placement of the catheter tip in the anterior epidural space. This article will discuss the evolution and refinement of epidural neuroplasty at our institution.
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Spinal pain is an important public health problem affecting the population indiscriminately. The structures responsible for pain in the spine include the vertebrae, intervertebral discs, spinal cord, nerve roots, facet joints, ligaments, muscles, atlanto-occipital joints, atlanto-axial joints, and sacroiliac joints. Even though disc herniation, facet joints, strained muscles, and torn ligaments have been attributed to be the cause of most spinal pain, either in the neck and upper extremities, upper and mid back, or low back and lower extremities, disorders of the disc other than disc herniation have been implicated more frequently than any other disorders. ⋯ The three primary components of diagnostic disc injection are: provocation/analgesia, discometry, and nucleography. Despite the recent exponential growth of noninvasive spinal technology, diagnostic disc injection remains the sole direct method for definitively determining whether a disc is a physiological pain generator. It is clear that discography is a safe and powerful complement to the overall clinical context.
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Facet joints, as a source of low back pain, have attracted considerable attention and been a source of controversy in recent years. Significant progress has been made in precision diagnosis of chronic low back pain with neural blockade. In the face of less than optimal diagnostic information offered by imaging and neurophysiologic studies, and in the face of mounting evidence showing lack of correlation between clinical features, physical findings, and diagnosis of facet joint mediated pain, controversial features have been described to validate the assumption of facet joint mediated pain by set criteria. ⋯ However, these six feature involved only a small number of patients. In conclusion, facet joint mediated pain is a common entity in patients suffering with chronic low back pain nonresponsive to conservative care, who present to a nonuniversity pain management practice. However, the history, clinical features, and radiological features are of no significance or assistance in making the diagnosis of facet joint mediated pain with certainty.