Pain physician
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Persistent pain interfering with daily activities is common. Chronic pain has been defined in many ways. Chronic pain syndrome is a separate entity from chronic pain. ⋯ The additional costs of misuse, abuse, and addiction are enormous. Comorbidities including psychological and physical conditions and numerous other risk factors are common in spinal pain and add significant complexities to the interventionalist's clinical task. This section of the American Society of Interventional Pain Physicians (ASIPP)/Evidence-Based Medicine (EBM) guidelines evaluates the epidemiology, scope, and impact of spinal pain and its relevance to health care interventions.
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Calcineurin may be involved in affecting nociceptive processes in multiple circumstances. It is conceivable that interfering with calcineurin's normal role in contributing to glial resting membrane potential, via its effects on the ion channel (TRESK) [tandem-pore-domain weakly inward rectifying potassium channels (TWIK)-related spinal cord potassium channels] may facilitate nociception. Another aspect of calcineurin function may be its role in the pronociceptive signaling of nuclear factor of activated T-cells (NFAT). ⋯ In fact, multiple articles have described the clinical use of calcineurin-inhibitors leading to pain, a phenomenon referred to as calcineurin inhibitor-induced pain syndrome (CIPS). Thus, it appears that calcineurin functions may encompass actions which promote or dampen nociceptive processes. A greater understanding of the physiology of calcineurin, especially as it relates to modulating nociception may lead to the development of novel analgesic targets in attempts to optimally alleviate patient discomfort.
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Interventional pain management, and the interventional techniques which are an integral part of that specialty, are subject to widely varying definitions and practices. How interventional techniques are applied by various specialties is highly variable, even for the most common procedures and conditions. At the same time, many payors, publications, and guidelines are showing increasing interest in the performance and costs of interventional techniques. ⋯ Based on the literature available in the United States, cervical facet joints account for 40% to 50% of cases of chronic neck pain without disc herniation, while discogenic pain accounts for approximately 20% of the patients. The management algorithm includes either facet joint interventions or epidural injections with surgical referral for disc-related pain and rarely implantable therapy. In managing thoracic pain, a diagnostic and therapeutic algorithmic approach includes either facet joint interventions or epidural injections.
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Practice guidelines are systematically developed statements to assist practitioners and patients in making decisions about appropriate health care for specific clinical circumstances. Clinical practice guidelines present statements of best practice based on a thorough evaluation of the evidence from published studies on the outcomes of treatment. In November 1989, Congress mandated the creation of the Agency for Healthcare Policy and Research (AHCPR). ⋯ The ASIPP guidelines are based on evidence-based medicine (EBM). EBM is in turn based on 4 basic contingencies: the recognition of the patient's problem and the construction of a structured clinical question; the ability to efficiently and effectively search the medical literature to retrieve the best available evidence to answer the clinical question; clinical appraisal of the evidence; and integration of the evidence with all aspects of the individual patient's decision-making to determine the best clinical care of the patient. Evidence synthesis for guidelines includes the review of all relevant systematic reviews and individual articles, grading them for relevance, methodologic quality, consistency, and recommendations.
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Neuropathic pain following breast cancer surgery can have a profoundly negative impact on the physical and psychosocial functioning of patients. Radiofrequency treatment has been used as therapy for chronic pain, which also has a problem under debate of its neurodestructive nature. Although the efficacy and safety of using glucocorticoids in nerve block treatment are controversial, they have been used to treat neuropathic pain for many years and have been used to alleviate acute and continued postoperative pain. Neither radiofrequency combined with glucocorticoids nor radiofrequency treatment of the thoracic paravertebral nerve for neuropathic pain following breast cancer surgery has been reported. ⋯ This case series suggests that it is possible that radiofrequency treatment of the thoracic paravertebral nerve combined with glucocorticoid may help in pain relief and improve the quality of life of patients with refractory neuropathic pain following breast cancer surgery.