Pain physician
-
Case Reports
Peripheral nerve stimulation of the thoracic paravertebral plexus for chronic neuropathic pain.
Persistent post surgical pain is reported in 70% of patients following thoracotomy and mastectomy. This pain is often neuropathic in nature and occasionally it is refractory to traditional medical and interventional management. Neurostimulation of peripheral nerves can be a highly effective clinical modality for the management of neuropathic pain. ⋯ The limitations include only 2 case reports, considered as the lowest level of evidence available in the era of evidence-based medicine, and lack of utilization of multiple other modalities of treatments utilized in managing neuropathic pain. In conclusion, these cases demonstrate the effectiveness of peripheral nerve stimulation of the thoracic paravertebral plexus in the long-term management of refractory neuropathic pain. They also serve to underline the importance of clinical awareness in order to improve patient safety.
-
Practice Guideline Meta Analysis
Comprehensive consensus based guidelines on intrathecal drug delivery systems in the treatment of pain caused by cancer pain.
Chronic persistent pain as a result of terminal illness, either as a consequence of the disease or the necessary treatment, is common in patients with cancer. For these patients with moderate-to-severe intractable pain, intrathecal (IT) drug delivery systems may represent an effective option for pain management. Thus, IT drug delivery is a viable treatment strategy for both neuropathy and nociceptive pain in the cancer population. However, there is a scarcity of comprehensive guidelines in implanting IT drug delivery systems in the treatment of pain caused by cancer. ⋯ These consensus guidelines are intended to assist clinicians in identifying the candidacy of patients with cancer-related pain and end of life diseases causing pain that may benefit from intrathecal drug delivery. With careful consideration of the patient's medical comorbidities and prior therapies, communication with the oncologist, proper psychological evaluation, and appropriate trialing technique, clinicians can effectively optimize the use of IT therapy for cancer pain. The panel advocates for a much wider application of IT therapy to provide meaningful analgesia for patients with cancer pain, including those at the end of life from a variety of causes.
-
Review Comparative Study
The impact of comparative effectiveness research on interventional pain management: evolution from Medicare Modernization Act to Patient Protection and Affordable Care Act and the Patient-Centered Outcomes Research Institute.
The Patient-Centered Outcomes Research Institute (PCORI) was established by the Affordable Care Act of 2010 to promote comparative effectiveness research (CER) to assist patients, clinicians, purchasers, and policy-makers in making informed health decisions by advancing the quality and relevance of evidence concerning the manner in which diseases, disorders, and other health conditions can effectively and appropriately be prevented, diagnosed, treated, monitored, and managed through research and evidence synthesis. The development of PCORI is vested in the Medicare Modernization Act (MMA) and the American Recovery and Reinvestment Act (ARRA). The framework of CER and PCORI describes multiple elements which are vested in all 3 regulations including stakeholder involvement, public participation, and open transparent decision-making process. ⋯ Further, stakeholders in PCORI are not scientists, are not balanced, and will set an agenda with an ultimate problem of comparative effectiveness and PCORI that it is not based on medical science, but rather on political science and not even under congressional authority, leading to unprecedented negative changes to health care. Thus, PCORI is operating in an ad hoc manner that is incompatible with the principles of evidence-based practice. This manuscript describes the framework of PCORI, and the role of CER and its impact on interventional pain management.
-
Multicenter Study Clinical Trial
Improving the safety of transforaminal epidural steroid injections in the treatment of cervical radiculopathy.
Unplanned vascular trespass occurs in 20% of cervical transforaminal epidural steroid injections (CTFESI) and rarely results in devastating neurologic complications. The Trucath Spinal Injection System is a novel integrated catheter and needle device that is specifically designed to minimize vascular trespass risk. ⋯ The Trucath Spinal Injection System demonstrated a statistically significant reduction in the rate of intravenous and intra-arterial trespass, procedural pain, and paresthesia, and has similar accuracy and performance versus standard spinal needles for CTFESI treatment of cervical radiculopathy.
-
Intrathecal drug infusion therapy is usually considered when spinal-acting analgesics or antispasmodics administered via the oral or transdermal routes fail to control patients' pain or are associated with unacceptable side effects. The intrathecal administration of centrally acting agents bypasses the blood-brain-barrier resulting in much higher cerebrospinal fluid (CSF) concentrations while using reduced amounts of medication to achieve equipotent doses. The intrathecal approach is associated with higher rates of satisfactory pain relief and lower rates of treatment failures and technical complications compared to the epidural route. A paucity of randomized controlled trials (RCTs) has led to concern regarding proper use, selection criteria, and safety of these devices. Cost effectiveness and comparative therapies have now also become a focus of discussion. ⋯ Based on the available evidence, the recommendation for intrathecal infusion systems for cancer-related pain is moderate recommendation based on the high quality of evidence and the recommendation is limited to moderate based on the moderate quality of evidence from non-randomized studies for non-cancer related pain.