Pain physician
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Today, with the growing interest of the medical community and others in practice guidelines, there is greater emphasis on formal procedures and methods for arriving at a widely scrutinized and endorsed consensus than ever before. Conflicts in terminology and technique are notable for the confusion that guidelines create and for what they reflect about differences in values, experiences, and interests among different parties. While public and private development activities continue to multiply, the means for coordinating these efforts to resolve inconsistencies, fill in gaps, track applications and results, and assess the soundness of particular guidelines continue to be limited. In this era of widespread guideline development by private organizations, the American College of Occupational and Environment Medicine (ACOEM) has developed guidelines that evaluate areas of clinical practice well beyond the scope of occupational medicine and yet fail to properly involve physicians expert in these, especially those in the field of interventional pain management. As the field of guidelines suffers from imperfect and incomplete scientific knowledge as well as imperfect and uneven means of applying that knowledge without a single or correct way to develop guidelines, ACOEM guidelines have been alleged to hinder patient care, reduce access to interventional pain management procedures, and transfer patients into a system of disability, Medicare, and Medicaid. ⋯ Both the low back pain and chronic pain chapters of the ACOEM guidelines may not be ideal for clinical use based on the assessment by the AGREE instrument, AMA attributes, and criteria established by Shaneyfelt et al. They also scored low on IOM criteria (37.5%). These guidelines may not be applicable for clinical use.
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Review Case Reports
Tension pseudomeningocele associated with retained intrathecal catheter: a case report with a review of literature.
Catheter related complications are not uncommon with permanently implanted intrathecal drug delivery systems. Pericatheter leak of cerebrospinal fluid usually responds to conservative treatment. We report a case of tension pseudomeningocele due to retained lumbar intrathecal catheter. ⋯ If a patient with IDDS develops a complete fracture of the catheter at the spinal end, all attempts should be made to define the 2 ends of the catheter and establish the continuity with a titanium connector. If the spinal end of the catheter is retracted deep into the interspinous ligaments and not recoverable, avoid entering the intrethecal space at the same level. If a patient develops pseudomeningocele in the postoperative period of IDDS and conservative methods including autologous epidural blood patch fail, we recommend an MRI of the spine for a detailed study along with prompt neurosurgical consultation.
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In the modern day environment, workers' compensation costs continue to be a challenge, with a need to balance costs, benefits, and quality of medical care. The cost of workers' compensation care affects all stakeholders including workers, employers, providers, regulators, legislators, and insurers. Consequently, a continued commitment to quality, accessibility to care, and cost containment will help ensure that workers are afforded accessible, high quality, and cost-effective care. ⋯ The evidence ratings for intradiscal electrothermal therapy (IDET), an automated percutaneous disc decompression and also deserve further scrutiny and analysis. In conclusion, these ACOEM guidelines for interventional pain management have no applicability in modern patient care due to lack of expertise by the developing organization (ACOEM), lack of utilization of appropriate and current EBM principles, and lack of significant involvement of experts in these techniques resulting in a lack of clinical relevance. Thus, they may result in reduced medical quality of care; may severely hinder access to appropriate, medically needed and essential medical care; and finally, they may increase costs for injured workers, third party payors, and the government by transferring the injured worker into a non-productive disability system.