Pain physician
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The frequency of performance of interventional techniques in chronic pain patients receiving anticoagulant and antiplatelet therapy continues to increase. Understanding the importance of continuing chronic anticoagulant therapy, the need for interventional techniques, and determining the duration and discontinuation or temporary suspension of anticoagulation is crucial to avoiding devastating complications, primarily when neuraxial procedures are performed. Anticoagulants and antiplatelets target the clotting system, increasing the bleeding risk. However, discontinuation of anticoagulant or antiplatelet drugs exposes patients to thrombosis risk, which can lead to significant morbidity and mortality, especially in those with coronary artery or cerebrovascular disease. These guidelines summarize the current peer reviewed literature and develop consensus-based guidelines based on the best evidence synthesis for patients receiving anticoagulant and antiplatelet therapy during interventional procedures. ⋯ Based on the review of available literature, published clinical guidelines, and recommendations, a multidisciplinary panel of experts presented guidelines in managing interventional techniques in patients on anticoagulant or antiplatelet therapy in the perioperative period. These guidelines provide a comprehensive assessment of classification of risk, appropriate recommendations, and recommendations based on the best available evidence.
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The role of antiplatelet/anticoagulant therapy is well known for its primary and secondary prevention of sequela from cardiovascular disease by decreasing the incidence of acute cerebral, cardiovascular, peripheral vascular, and other thrombo-embolicevents. The overwhelming data show that the risk of thrombotic events is significantly higher than that of bleeding during surgery after antiplatelet drug discontinuation. It has been assumed that discontinuing antiplatelet therapy prior to performing interventional pain management techniques is a common practice, even though doing so may potentially increase the risk of acute cerebral and cardiovascular events. A survey of practice patterns was conducted in 2012, since then the risks associated with thromboembolic events and bleeding, has not been systematically evaluated. ⋯ The results in the 2021 survey illustrate a continued pattern of discontinuing antiplatelet and anticoagulant therapy in the perioperative period. The majority of discontinuation patterns appear to fall within guidelines.
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Fascial plane block techniques have evolved considerably in recent years. Unlike the conventional peripheral nerve block methods, the fascial plane block's effect can be predicted based on fascial anatomy and does not require a clear vision of the target nerves. The anatomy of the retroperitoneal interfascial space is complex, since it comprises multiple compartments, including the transversalis fascia (TF), the retroperitoneal fasciae (RF), and the peritoneum. For this reason, an in-depth, accurate understanding of the retroperitoneal interfascial space's anatomical characteristics is necessary for perceiving the related regional blocks and mechanisms that lie underlie the dissemination of local anesthetics (LAs) outside or within the various retroperitoneal compartments. ⋯ Familiarity with the anatomy of the retroperitoneal fascial space could enhance our understanding of peripheral nerve blocks. By examining the circulation in the fascial space, we may gain a more comprehensive understanding of the direction and degree of injectate diffusion during RA as well as the block's plane and scope, possibly resulting in effective analgesia and fewer harmful clinical consequences.
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The gender bias in academic anesthesiology is well known. Women are not only a minority in the field but also underrepresented in leadership positions. Reported reasons for this underrepresentation include barriers to career advancement, lack of mentorship, and differences in compensation, among others. Interventional pain, a competitive procedural subspecialty of anesthesiology, sees the trickle-down effects of this disparity. According to a report from the ACGME that sorted medical subspecialties by number of female trainees, pain medicine ranked in the bottom quartile across all disciplines from 2008-2016. ⋯ While the gender disparity in academia is well documented for both anesthesiology and pain medicine, the reasons for this disparity have not been fully explored. Moreover, it is also unknown whether the minority of female physicians who select pain medicine as a subspecialty gravitate toward an academic or a private-practice path. To address the existing gender disparity, it is necessary to explore the landscape of interventional pain medicine in both academic and private practices and understand pain physicians' beliefs and sentiments regarding their subspecialty.
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Randomized Controlled Trial
The MuscleSCS Technique (4-8Hz BurstDRTM Octrode™): A Randomized Clinical Study of MuscleSCS Stimulation in the Treatment of Chronic Back Pain.
MuscleSCS is a new technique that combines spinal cord stimulation (SCS) with muscle stimulation to relieve pain. ⋯ This study showed that the combined application of SCS (BurstDRTM) and additional MuscleSCS stimulation using a rod electrode could significantly improve outcomes for patients suffering from chronic back pain.