Pain medicine : the official journal of the American Academy of Pain Medicine
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Radiofrequency denervation of the zygapophysial (facet) joint is a frequently performed procedure for chronic low back pain. Several studies have shown considerable efficacy of the procedure, but none of the randomized controlled trials performed to date has used anatomically correct placement of radiofrequency cannula parallel to the target nerve. Three main techniques have been utilized for many years: North American, European, and Australian. Each has conceptual and technical limitations. This review analyzes these techniques and proposes a standardized technique of radiofrequency denervation of lumbar zygapophysial joints. ⋯ We believe that the technique using "tunnel vision" with anatomically appropriate cannula placement and use of a large-bore, curved needle with a 10-mm active tip may improve the results of radiofrequency denervation of lumbar zygapophysial joints. Providing a detailed description of an anatomically accurate technique should be of value to those seeking to perform this procedure in a valid manner.
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Randomized Controlled Trial
A randomized double-blind placebo-controlled study of low-dose intravenous Lorazepam to reduce procedural pain during bone marrow aspiration and biopsy.
To evaluate the efficacy of intravenous lorazepam as premedication for bone marrow aspiration and biopsy (BMAB). ⋯ Intravenous lorazepam was safe in patients undergoing BMAB and was more effective than placebo in enhancing cooperation during BMAB and willingness to undergo another procedure. However, use of lorazepam 1 mg provided no reduction in the pain associated with BMAB. Further studies should focus on providing appropriate analgesia for this potentially painful procedure.
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Case Reports
An N-of-1 trial as an aid to decision-making prior to implanting a permanent spinal cord stimulator.
Limited evidence supports the efficacy of spinal cord stimulation (SCS). Therefore, it is crucial to assess the usefulness of this invasive procedure before implanting permanent electrodes in each patient. An N-of-1 trial is an experiment in which a single participant undergoes periods of comparative treatments. We illustrate how an N-of-1 trial design may permit clinicians to conduct such an assessment in an individual patient. ⋯ We encourage clinicians to perform an N-of-1 trial in every patient before implanting permanent electrodes for SCS.
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Ketamine, noncompetitive antagonist of N-methyl-D-aspartate (NMDA) receptors, has been used in the treatment of chronic neuropathic pain for almost 15 years. The aim of the study was to describe and evaluate side effects of this drug in the group of 32 patients with diabetic polyneuropathy and with postherpetic neuralgia. ⋯ Ketamine is evaluated as a nonoptimal, however, available NMDA blocker suitable for clinical use. Studying its effects in clinics can be expected to increase our knowledge necessary for the development of new, effective, and safe "antineuralgic drug."
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The purpose of this study was to document particulate size in commonly used corticosteroid preparations. Inadvertent injection of particulate corticosteroids into a vertebral or foraminal artery can cause brain and spinal cord embolic infarcts and the size of the particles could be directly related to the chance that a clinically significant infarct would occur. One might assume that corticosteroids with particles significantly smaller than red blood cells might be safer. ⋯ Compared with the particulate steroid solutions, dexamethasone sodium phosphate had particles that were significantly smaller than red blood cells, had the least tendency to aggregation, and had the lowest density. These characteristics should significantly reduce the risk of embolic infarcts or prevent them from occurring after intra-arterial injection. Until shown otherwise in clinical studies, interventionalists might consider using dexamethasone or another corticosteroid preparation with similar high solubility and negligible particle size when performing epidural injections.