Pain physician
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Guideline development seems to have lost some of its grounding as a medical science. At their best, guidelines should be a constructive response to assist practicing physicians in applying the exponentially expanding body of medical knowledge. In fact, guideline development seems to be evolving into a cottage industry with multiple, frequently discordant guidance on the same subject. ⋯ A recent manuscript published by Chou et al, in addition to previous publications, appears to have limited clinician involvement in the development of APS guidelines, and demonstrates some of these challenges clearly. This manuscript illustrates the deficiencies of Chou et al's criticisms, and demonstrates their significant conflicts of interest, and use a lack of appropriate evaluations in interventional pain management as a straw man to support their argument. Further, this review will attempt to demonstrate that excessive focus on this straw man has inhibited critique of what we believe to be flaws in the approach.
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Epidural injection of corticosteroids is a commonly used treatment for radicular pain. However, the benefits are often short lived, and repeated injections are often limited secondary to concerns of side effects from cumulative steroid doses. In addition, rare, catastrophic complications, including brain and spinal cord embolic infarcts have been attributed to particulate steroid injections. A previous study has shown that dexamethasone has less particulate than other corticosteroids, possibly reducing embolic risk. Furthermore, a recent study indicated that clonidine may be useful in the treatment of radicular pain when administered via epidural steroid injection. The combination of corticosteroid and clonidine is an intriguing, yet unstudied, alternative to traditional treatment. ⋯ Mixing clonidine with corticosteroids did not increase particulation compared to corticosteroids alone. Combining clonidine and corticosteroids for epidural injection may prove to be a useful treatment for radicular pain. The combination of these is unlikely to result in a solution that is more likely to cause embolic infarcts than the use of corticosteroids alone.
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Degenerative spondylolisthesis is one of the major causes for low back pain. Morphological abnormalities of the zygapophysial joints are a predisposing factor in the development of degenerative spondylolisthesis. Therefore, radiofrequency neurotomy seems to be a rational therapy. ⋯ Zygapophysial joints are a possible source of pain in patients with spondylolisthesis. Radiofrequency neurotomy is a rational, specific nonoperative therapy in addition to other nonoperative therapy methods with a success rate of 65%. This is the first study to determine the effect of radiofrequency neurotomy in patients with minor degenerative spondylolisthesis.
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Effective early antiviral treatments reduce both acute zoster pain and the risk of postherpetic neuralgia. The authors hypothesized that the direct neuraxial administration of acyclovir could provide superior drug application to the spinal neural structures with a higher viral burden and have various advantages over the other routes of drug administration in terms of required doses, side effects, and efficacy. ⋯ There was no evidence of neurological and histopathological abnormalities following intrathecal acyclovir injection.