Pain physician
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Low back pain is an important medical, social, and economic problem involving approximately 15% to 39% of the population. Of the numerous therapeutic interventions available for treatment of chronic low back pain, including surgery, epidural administration of corticosteroids is one such intervention commonly used. Several approaches available to access the lumbar epidural space are the caudal, interlaminar, and transforaminal, also known as nerve root or selective epidural injection. ⋯ Reports of the effectiveness of epidural corticosteroids have varied from 18% to 90%. However, reports of the effectiveness of transforaminal epidural steroids have shown it to be superior, with outcome data indicating cost effectiveness as well as safety. This review describes various aspects of transforaminal epidural steroid injections in managing chronic low back pain.
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Internal disc disruption is a common cause of disabling low back pain in a substantial number of young, healthy adults. A clinical diagnosis of internal disruption, in absence of objective clinical findings, is convincingly established only by means of provocation discography. Intradiscal electrothermal therapy has been shown to be effective in managing chronic disabling discogenic pain. ⋯ Further, the assessment of functional status showed significant improvement with standing and walking, whereas sitting also demonstrated significant improvement in 62% of the patients, though it was not statistically significant. No complications were noted in the perioperative period or during the follow-up period. In conclusion, intradiscal electrothermal therapy is a safe and effective procedure in patients suffering with chronic functionally limiting discogenic pain who fail to respond to aggressive conservative modalities of treatments as well as interventional therapy with injections.
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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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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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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.