Pain physician
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Disability, societal, and health impact of chronic intractable pain secondary to various failed therapies is a major issue. As advanced therapy, implantable therapies, which include intrathecal devices and spinal cord stimulation systems, are frequently used in managing chronic intractable pain. Thus, continuous infusion of intrathecal medication is one of the methods used for the control of chronic, refractory, cancer, and non-cancer pain. However, despite the high costs of chronic non-cancer pain, it has been claimed that there is a lack of evidence for intrathecal infusion systems and the cost effectiveness of these systems has been questioned in improving pain and function. ⋯ This systematic review illustrates Level II-3 or Level III (limited) evidence for intrathecal infusion systems for long-term relief in chronic non-cancer pain.
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Lumbar facet joints are a well recognized source of low back pain and referred pain in the lower extremity in patients with chronic low back pain. Conventional clinical features and other non-invasive diagnostic modalities are unreliable in diagnosing lumbar zygapophysial joint pain. Controlled diagnostic studies have shown the prevalence of lumbar facet joint pain in 27% to 40% of the patients with chronic low back pain without disc displacement or radiculitis, with a false-positive rate of 27% to 47% with a single diagnostic block. ⋯ The evidence for diagnosis of lumbar facet joint pain with controlled local anesthetic blocks is Level I or II-1. The indicated level of evidence for therapeutic lumbar facet joint interventions is Level II-1 or II-2 for lumbar facet joint nerve blocks, Level II-2 or II-3 evidence for radiofrequency neurotomy, and Level III (limited) evidence for intraarticular injections.
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The sacroiliac joint has been implicated as a source of low back and lower extremity pain. There are no definite historical, physical, or radiological features that can definitively establish a diagnosis of sacroiliac joint pain. Based on the present knowledge, an accurate diagnosis is made only by controlled sacroiliac joint diagnostic blocks. The sacroiliac joint has been shown to be a source of pain in 10% to 27% of suspected patients with chronic low back pain utilizing controlled comparative local anesthetic blocks. ⋯ The indicated evidence for the validity of diagnostic sacroiliac joint injections is Level II-2. The evidence for the accuracy of provocative maneuvers in the diagnosing of sacroiliac joint pain is limited (Level II-3). The evidence for radiofrequency neurotomy is also limited (Level II-3).
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Post lumbar surgery syndrome with persistent chronic low back and lower extremity pain is common in the United States. Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome (FBSS). Percutaneous adhesiolysis with a catheter or direct visualization of the spinal canal and the contents with an endoscope are techniques employed in resistant cases when patients fail to respond to conservative modalities of treatment, including fluoroscopically directed epidural injections. Some patients failing to respond to percutaneous adhesiolysis are candidates for spinal endoscopic adhesiolysis. However, literature evaluating the effectiveness of spinal endoscopic adhesiolysis is sparse and discussions continue about its effectiveness, utility, and complications. ⋯ Spinal endoscopic adhesiolysis may be used as an effective treatment modality for chronic refractory low back pain and radiculopathy that is related to epidural adhesions.
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Failed back surgery syndrome is common in the United States. Management of post lumbar surgery syndrome with multiple modalities includes interventional techniques, resulting in moderate improvement, leaving a proportion of patients in intractable pain. The systematic reviews of long-term benefits and risks of spinal cord stimulation (SCS) for patients with failed back surgery syndrome showed limited to moderate evidence and cost effectiveness. However, with the exponential increase in surgery in the United States, spinal cord implants are also increasing. Thus, the discussion continues with claims of lack of evidence on one hand and escalating increases in utilization on the other hand. ⋯ This systematic review evaluating the effectiveness of SCS in relieving chronic intractable pain of failed back surgery syndrome indicated the evidence to be Level II-1 or II-2 for clinical use on a long-term basis.