Pain physician
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Chronic persistent neck pain with or without upper extremity pain is common in the general adult population with prevalence of 48% for women and 38% for men, with persistent complaints in 22% of women and 16% of men. Multiple modalities of treatments are exploding in managing chronic neck pain along with increasing prevalence. However, there is a paucity of evidence for all modalities of treatments in managing chronic neck pain. Cervical epidural injections for managing chronic neck pain are one of the commonly performed interventions in the United States. However, the literature supporting cervical epidural steroids in managing chronic pain problems has been scant. ⋯ The evidence is good for radiculitis secondary to disc herniation with local anesthetics and steroids, fair with local anesthetic only; whereas, it is fair for local anesthetics with or without steroids, for axial or discogenic pain, pain of central spinal stenosis, and pain of post surgery syndrome.
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Human Immunodeficiency Virus (HIV) patients have an increased rate of chronic pain, particularly peripheral neuropathy. This disease burden causes considerable disability and negatively affects quality of life. Pain is undertreated and more complex to manage in these patients for a number of reasons, including complex anti-retroviral drug regimens, higher risks of side effects, and higher rates of comorbid psychiatric illness and substance abuse. Pain management must take these factors into account and use all available modalities, including nonopioid pain relievers, adjuvant medications, and psychosocial therapies in addition to opioid analgesics. Here we review recent recommendations regarding acute and chronic opioid treatment of pain and the treatment of opioid dependence in HIV-infected patients, and provide suggestions regarding aberrant behavior in pain treatment. ⋯ Pain management in HIV patients must take these factors into account and use all available modalities for treatment, including nonopioid analgesics, adjuvant medications, and psychosocial therapies. Opioid analgesics should be prescribed with caution in accordance with current guidelines and after careful risk assessment.
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Randomized Controlled Trial
Effect of fluoroscopically guided caudal epidural steroid or local anesthetic injections in the treatment of lumbar disc herniation and radiculitis: a randomized, controlled, double blind trial with a two-year follow-up.
Lumbar disc herniation and radiculitis are common elements of low back and lower extremity pain. Among minimally invasive treatments, epidural injections are one of the most commonly performed interventions. However, the literature is mixed about their effectiveness in managing low back and lower extremity pain. In general, individual studies and systematic reviews of epidural steroid injections have been hampered by their study design, baseline differences between treatment groups, inadequate sample sizes, highly controlled settings, lack of validated outcome measures, and the inability to confirm the injectate location because fluoroscopy was not used. ⋯ Caudal epidural injections of local anesthetic with or without steroids might be an effective therapy for patients with disc herniation or radiculitis. The present evidence illustrates the potential superiority of steroids compared with local anesthetic at two year follow up based on average relief per procedure.
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There is a paucity of literature on the use of epidural injections for the treatment of chronic mid and upper back pain due to disc herniation and radiculitis, axial or discogenic pain, spinal stenosis, post surgery syndrome, and post thoracotomy pain syndrome. ⋯ The evidence based on this systematic review for thoracic epidural injection in treating chronic thoracic pain is considered fair and limited for post thoracotomy pain.
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Randomized Controlled Trial
Efficacy of intrathecally administered dexmedetomidine versus dexmedetomidine with fentanyl in patients undergoing major abdominal cancer surgery.
Most of the clinical experience gained in the use of intrathecal alpha-2- adrenoceptor agonists has been described with clonidine. Human studies using a combination of intrathecal dexmedetomidine and local anesthetics are lacking. ⋯ Dexmedetomidine 5 μg given intrathecally improves the quality and the duration of postoperative analgesia and also provides an analgesic sparing effect in patients undergoing major abdominal cancer surgery. Furthermore, the addition of intrathecal fentanyl 25 μg has no valuable clinical effect.