Pain practice : the official journal of World Institute of Pain
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Randomized Controlled Trial Clinical Trial
The role of adding hyaluronidase to fluoroscopically guided caudal steroid and hypertonic saline injection in patients with failed back surgery syndrome: a prospective, double-blinded, randomized study.
Failed back surgery syndrome (FBSS) has been reported to account for up to 40% of patients with chronic low back pain. Epidural fibrosis may be responsible for up to 30% of all cases of FBSS. Perineural fibrosis can interfere with cerebrospinal fluid-mediated nutrition, rendering the nerve root hyperesthetic and hypersensitive to compression. Traditionally, steroid injection has been used to treat low back pain and radiculopathy. The addition of hyaluronidase to the injectate has been reported to reduce the degree of fibrosis. ⋯ The addition of hyaluronidase to fluoroscopically guided caudal epidural steroid and hypertonic saline combination improved long-term pain relief in patients with FBSS.
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An estimated 40% of chronic lumbosacral spinal pain is attributed to the discus intervertebralis. Degenerative changes following loss of hydration of the nucleus pulposus lead to circumferential or radial tears within the annulus fibrosus. Annular tears within the outer annulus stimulate the ingrowth of blood vessels and accompanying nociceptors into the outer and occasionally inner annulus. ⋯ There is currently insufficient proof to recommend intradiscal electrothermal therapy (2 B±) and intradiscal biacuplasty (0). It is advised that ozone discolysis, nucleoplasty, and targeted disc decompression should only be performed as part of a study protocol. Future studies should include more strict inclusion criteria.
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To examine the relationship between average daily dose (ADD) of duloxetine, adherence to therapy, and health-care costs among patients with diabetic peripheral neuropathic pain (DPNP). ⋯ The findings suggest that having an ADD of 60 mg for duloxetine among commercially insured DPNP patients is associated with improved medication adherence and lower health-care costs.
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Case Reports
Occipital neuromodulation: ultrasound guidance for peripheral nerve stimulator implantation.
We report a case of chronic left-sided occipital neuralgia in a 21-year old female patient. The patient in question suffered from chronic greater occipital neuralgia for a duration of many years, which had been refractory to other conservative medical management strategies. Blockade of the greater occipital nerve with local anesthetic was consistently useful in attenuating the patient's pain, though the effects were always short lived. ⋯ The specific use of high-frequency ultrasound guidance for this procedure simplified the initial device placement and allowed proper visualization of soft tissue structures, which facilitates precise device deployment. Additionally, the ability to identify relevant vascular structures may further increase the safety of stimulator lead placement. The potential advantages of ultrasound-augmented procedural techniques, specifically as they pertain to occipital stimulator lead placement, are discussed with particular emphasis on potentially decreasing intraoperative and postoperative complications while optimizing stimulation efficacy.
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Opioid analgesics must be prescribed with discernment and their appropriate use should be periodically assessed. Urine drug testing, although not designed specifically for this role, is a widely available and familiar method for monitoring opioid use in chronic pain patients. Urine drug testing can help track patient compliance and expose possible drug misuse and abuse. ⋯ The literature does not thoroughly address the role of urine drug testing in this patient population. Most respondents did random rather than scheduled testing; few had any urine testing protocol. The study found motivations for urine testing and testing practices varied widely, and urine testing, despite its clinical utility, is not used consistently.