Pain physician
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The intervertebral disc has been implicated as an etiology of chronic lumbar spine pain based on clinical, basic science, and epidemiological research. However, there is lack of consensus regarding the diagnosis and treatment of intervertebral disc disorders. Based on controlled evaluations, the lumbar intervertebral discs have been shown to be sources of chronic back pain without disc herniation in 26% to 39%. Lumbar provocation discography, which includes disc stimulation and morphological evaluation, is often used to distinguish a painful disc from other potential sources of pain. Despite the extensive literature, controversy continues about provocation lumbar discography. ⋯ Based on the current systematic review, lumbar provocation discography performed according to the IASP criteria with control disc (s) with minimum pain intensity of 7 of 10, or at least 70% reproduction of worst pain (i.e. worst spontaneous pain of 7 = 7 x 70% = 5) may be a useful tool for evaluating chronic lumbar discogenic pain. Discography is an important imaging and pain evaluation tool in identifying a subset of patients with chronic low back pain secondary to intervertebral disc disorders.
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Case Reports
Serial stellate ganglion blocks for intractable postherpetic itching in a pediatric patient: a case report.
While intractable itching may be rarely associated with postherpetic neuralgia, it can have catastrophic complications if present. ⋯ The use of serial stellate ganglion blocks may be a treatment option for patients with intractable itching and postherpertic neuralgia of the neck and arm region. This technique may lead to more permanent solutions such as pulse radiofrequency lesion or chemical neurolysis of sympathetic ganglions for postherpetic itch.
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Since the descriptions by Mixter and Barr of open surgical treatment for rupture of the intervertebral disc in 1934, open surgical procedures have become a common practice. Disc herniations have been reported as being contained and non-contained. The results of open surgical discectomy for contained disc herniation have been poor. Consequently, several alternative techniques have been developed which are minimally invasive including percutaneous laser disc decompression. ⋯ This systematic review illustrates Level II-2 evidence for percutaneous laser disc decompression which is equivalent to automated percutaneous lumbar disc decompression.
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Review
Systematic review of percutaneous lumbar mechanical disc decompression utilizing Dekompressor.
In recent years, a number of minimally invasive nuclear decompression techniques for lumbar disc prolapse, protrusion, and/or herniation have been introduced, including the Dekompressor a device utilizing an Archimedes screw. The primary goal of the surgical treatment of nerve root compression from a disc protrusion continues to be the relief of compression by removing the herniated nuclear material with open discectomy. However, poor results have been reported for contained disc herniations with open surgical interventions. The results with several alternative techniques including the Dekompressor, automated percutaneous discectomy, and laser discectomy have been described, but are not convincing. There is a paucity of evidence for all decompression techniques. ⋯ This systematic review illustrates Level III evidence for mechanical percutaneous disc decompression procedures with the high RPM device or Dekompressor.
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Review Case Reports
The marginalization of chronic pain patients on chronic opioid therapy.
The realities of treating chronic pain do not reflect the attention that marginalization of patients taking opioids has received. Physicians continue the same prejudices and biases that were present decades ago. One theory proposed to explain this poor treatment has been titled, the "barriers to pain management." The barriers are not treated as moral issues, but rather as clinical aberrations and do not explain continued poor treatment. ⋯ It is proposed that there may be more complex psychosocial issues involved in the marginalization of chronic pain patients. This case series illustrates a ubiquitous problem demanding further examination and discussion. It is hoped that this case series will create interest in further research in this area.