Pain physician
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Postherpetic neuralgia (PHN) remains a difficult pain problem for patients and physicians alike. This review describes the epidemiology and pathophysiology of PHN and discusses proposed mechanisms of pain generation and the various treatments currently available. Evidence is scant for the value of surgical and procedural interventions in general, although there are numerous small studies supporting the use of specific interventions such as nerve blocks, neurosurgical procedures and neuroaugmentation. ⋯ Interventions with low risk, such as TENS are appropriate. Although prevention of postherpetic neuralgia appears to be an appropriate strategy, there is little evidence to support the position that medical or interventional approaches (nerve blocks) will prevent PHN after a patient develops acute herpes zoster (HZ). Although antivirals are appropriate for acute HZ, and the use of neural blockade and sympathetic blockade may be helpful in reducing pain in selected patients with HZ, there is little evidence that these interventions will reduce the likelihood of developing PHN.
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The California Workers' Compensation system mandates the use of occupational medicine practice guidelines developed by the American College of Occupational and Environmental Medicine (ACOEM). These Guidelines cover the treatment of acute (less than three months' duration) injuries. The presence in the ACOEM Guidelines of references to procedures which may be of use after the three-month acute period creates ambiguity as to whether the ACOEM Guidelines are applicable after three months. ASIPP's "Evidence-Based Practice Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain" are comprehensive, focusing on management of chronic spinal pain. ACOEM guidelines, mandated by the legislature, do not deal explicitly with chronic pain. Their application in managing chronic pain may result in denial of access to appropriate treatment. Thus, ASIPP guidelines may be supplemental to the ACOEM Guidelines. Evaluation of the two Guidelines may clarify which should be followed in the event of ambiguity or conflict. ⋯ The ASIPP Guidelines may be considered the applicable Guidelines for the treatment of work-related low back activity limitations persisting beyond three months.
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Lumbar transforaminal epidural injections have been utilized in the treatment of radicular pain with proven success. It was postulated that interlaminar epidural injections result in a dorsal flow of contrast while transforaminal epidural steroid injections showed good ventral flow limited to one single spinal motion segment. There have been no published studies evaluating epidurography/contrast patterns utilizing fluoroscopy. ⋯ Contrast appeared ventrally and unilaterally in all injections. Dorsal flow occurred in 20% of these injections. No contrast flow crossed the midline. The observed contrast flow patterns should be studied clinically to determine whether they have any effect on clinical outcome. Intravascular injections were noted in 10% of cases.
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The sphenopalatine ganglion block has been utilized over the last century for a wide variety of maladies. This paper provides a brief history of the use of the sphenopalatine ganglion block, a review of the sphenopalatine ganglion anatomy, and the diagnoses which currently warrant its use. The traditional transnasal sphenopalatine ganglion block is described and our modification of the traditional technique is proposed. A case study is described in which sphenopalatine block pain control in a patient with a 20-year history of poorly controlled pain from bilateral herpetic keratitis.
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The high prevalence of persistent neck pain due to involvement of cervical facet joints has been described in controlled studies. Therapeutic interventions utilized in managing chronic neck pain of facet joint origin include intraarticular injections, medial branch nerve blocks, and neurolysis of medial branch nerves by means of radiofrequency. ⋯ Cervical medial branch blocks were an effective modality of treatment in managing chronic neck pain secondary to facet joint involvement confirmed by controlled, comparative local anesthetic blocks.