Pain physician
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Healthcare decisions are increasingly being made on research-based evidence, rather than on expert opinion or clinical experience alone. Consequently, the process by which the strength of scientific evidence is evaluated and developed by means of evidence-based medicine recommendations and guidelines has become crucial resulting in the past decade in unprecedented interest in evidence-based medicine and clinical practice guidelines. Systematic reviews, also known as evidence-based technology assessments, attempt to minimize bias by the comprehensiveness and reproducibility of the search for and selection of articles for review. ⋯ The complex processes of guideline development depend on integration of a number of activities, from collection and processing of scientific literature to evaluation of the evidence, development of evidence-based recommendations or guidelines and implementation and dissemination of the guidelines to relevant professionals and consumers. Guidelines are being designed to improve the quality of healthcare and decrease the use of unnecessary, ineffective or harmful interventions. This review describes various aspects of evidence-based medicine, systematic reviews in interventional pain management, evaluation of the strength of scientific evidence, differences between systematic and narrative reviews, rating the quality of individual articles, grading the strength of the body of evidence and appropriate methods for searching for the evidence.
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This is a preliminary report of a new concept of lumbar medial branch neurotomy by measurement of minimal sensory threshold. This technique is not recommended for routine clinical use until further controlled data are available. The lumbar zygapophysial joints (Z-joint) or facet joints, are a potential source of low back pain. ⋯ The other is that the Z-joint is innervated by the sensory fibers of the medial branches. As a result, the multifidus may be successfully denervated as demonstrated by electromyography but the Z-joints may be inadequately denervated. As a result, this technique describes measurement of minimal sensory threshold prior to lesioning and seeking to double that threshold as an additional, intra-operative measure of successful sensory denervation of the Z-joint.
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Zygapophysial or facet joints have been implicated as cause of low back, mid back, upper back and neck pain with referred pain. Cervical, thoracic and lumbar facet joints are innervated by the medial branches of the dorsal rami. Zygapophysial (facet) joints have been implicated as the source of chronic pain in 15% to 45% of the patients with chronic low back pain, 54% to 60% of the patients with chronic neck pain and 48% of the patients with thoracic pain. ⋯ Both studies showed positive results. Similar to randomized trials, prospective, as well as retrospective evaluations showed positive evidence, both in short-term and long-term. The results of this systematic review of 2 well-designed randomized trials, 4 prospective well-designed trials without randomization and 3 retrospective evaluations provided strong evidence that radiofrequency denervation offers short-term relief and moderate evidence of long-term pain relief of facet joint origin.
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This prospective, non-randomized clinical trial was designed to determine the clinical outcome of patients who underwent Intradiscal Electrotherapy (IDET) for the treatment of chronic discogenic low back pain. Twenty-seven consecutive patients undergoing IDET were prospectively evaluated. All patients, as determined by provocative discography and/or MRI, had discogenic disease with chronic low back pain and were non-responsive to conservative treatment for at least 6 months. ⋯ This did not translate into a significant improvement in the SF-36 survey scores. The risks are negligible, and recovery time is minimal. The procedure may be useful in selected patients who would otherwise undergo an interbody fusion procedure.
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Fluoroscopically guided, minimum threshold electrical stimulation of the right first, second, third, and fourth lumbar medial branches and the fifth lumbar dorsal ramus in each of eight healthy test subjects was performed. The stimulation thresholds and referral patterns were recorded. A composite drawing of the referral patterns was created. The composite drawings were compared to documented referral patterns already published by other authors. ⋯ All of the subjects' mapped referral sites coincided with each other, creating a well defined composite drawing. These referral zones are different than those reported after injection of the lumbar Z-joint, which may have clinical and therapeutic implications. These referral maps may provide the clinician with additional insight when evaluating a patient with lumbar, flank, or gluteal pain of undetermined etiology.