Pain physician
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Chronic low back pain and obesity are two common medical conditions. Obesity has been associated with symptoms such as adverse fat distribution and multiple secondary disorders, including low back pain. Obesity is defined as being 30% over ideal weight, which influences normal body mechanics as well as recovery from an injury. ⋯ The results showed that the prevalence rate of facet joint pain in chronic low back pain in Group I or nonobese patients was 36%, in contrast to 40% in Group II, or the obese patient group, with no significant differences among the two groups. The study also showed a false-positive rate of 39% in the total sample, or 44% in Group I nonobese patients and 33% in Group II, or obese patients. It is concluded that the prevalence of lumbar facet joint mediated pain of 40% in obese patients and 36% in patients of normal weight with a false-positive rate of 33% in obese patients and 44% in nonobese patients is similar to the results of multiple previous studies concluding that facet joint mediated pain is a common occurrence in obese patients; however, the incidence of facet joint mediated pain is similar in obese patients and nonobese patients.
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Recent reports of provocative discography not only instill confusion, but also create numerous questions about its value in evaluating low back pain. It was reported that provocative discography produced pain in patients who were not suffering with low back pain but suffering with somatization disorder and depression. This study was designed to evaluate 50 randomly assigned patients, with 25 patients in Group I without somatization disorder and 25 patients in Group II with diagnosis of somatization disorder. ⋯ Any other response, with or without pain, was considered negative. Results showed positive provocative discography in 46% of the patients in the somatization group compared to 54% in the non-somatization group; in 46% of patients with depression compared to 54% of patients without depression; in 15 of 30 patients with generalized anxiety disorder; in 11 of 20 patients without generalized anxiety disorder; and in 42% of patients with combined somatization and depression, with negative discography in 58% of the patients. It is concluded that provocative discography provides similar results in patients with or without somatization, with or without depression, with somatization but with or without depression or with other combinations of the psychological triad of somatization disorder, depression, and generalized anxiety disorder.
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Biochemical mechanisms to explain pain generation began relatively recently. Evaluating pain originating from the spine can be challenging because no historical or physical examination findings are sufficiently sensitive or specific for identifying each of the myriad of potential pain generators. These discrete anatomic structures include the nerve root, disc annulus, posterior longitudinal ligament, sacroiliac joint, and facet joint. ⋯ However, this test may not be necessary in the patient when the specific radiculopathy level diagnosis is apparent; this is the case when a characteristic history and physical examination have a corroborative single-level imaging lesion. Determining which level is generating symptoms has implications for subsequent physical therapy, therapeutic injections, and surgery. This review of selective nerve root blocks describes the relevant anatomy, pathophysiology, rationale, clinical utility, and complications.
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Postlumbar laminectomy syndrome, or pain following operative procedures of the lumbar spine, is increasingly a common entity in modern medicine. Multiple causes proposed for recurrence of pain after lumbar laminectomy are: epidural fibrosis, recurrent disc herniation, instability, and facet joints. Even though the prevalence of persistent low back pain secondary to the involvement of lumbosacral facet joints has been described in controlled studies from 15% to 45%, the prevalence of facet joint mediated pain in postlumbar laminectomy syndrome has not been studied. ⋯ Results showed that the prevalence of facet joint mediated pain in non-surgical patients was 44% compared to 32% in post surgical patients determined by comparative controlled local anesthetic blocks utilizing lidocaine and bupivacaine. This study also showed a false positive rate of 36% in non-surgical group and 24% in post-surgical group. In conclusion, this study shows that facet joint mediated symptomatology in chronic low back pain is prevalent, both in non-surgical as well as post-surgical patients even though prevalence was somewhat higher in the non-surgical group compared to post-surgical group.
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Epidural fibrosis is seen as a common phenomenon among postlumbar laminectomy syndrome patients, contributing to approximately 60% of symptom recurrence. Percutaneous epidural lysis of adhesions has been described as a modality to effectively manage chronic low back pain secondary to epidural fibrosis. Forty-five patients were randomly assigned, with fifteen patients in the control group, or Group I, who were treated with conservative modalities of treatments, including medication, physical therapy, and an exercise program; and, thirty patients in Group II, who were treated with percutaneous epidural adhesiolysis and hypertonic saline neurolysis. ⋯ The study also showed that overall health status improved significantly in the treatment group in all parameters with average pain, physical health, mental health, functional status, psychological status and narcotic intake. Analysis also showed that this is a cost-effective treatment, with cost for 1-year improvement of quality of life at $2693. In conclusion, epidural adhesiolysis with hypertonic saline neurolysis performed on a 1-day basis is an effective modality of treatment in managing chronic low back pain in patients who failed to respond to fluoroscopically directed epidural steroid injections and also were demonstrated not to have facet joint mediated pain.