Pain physician
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Randomized Controlled Trial Multicenter Study
MiDAS ENCORE: Randomized Controlled Study Design and Protocol.
Epidural steroid injections (ESIs) are commonly used for treatment of symptomatic lumbar spinal stenosis (LSS). ESIs are generally administered after failure of conservative therapy. For LSS patients suffering from neurogenic claudication, the mild® procedure provides an alternative to ESIs via minimally invasive lumbar decompression. Both ESIs and mild offer interventional pain treatment options for LSS patients experiencing neurogenic claudication refractory to more conservative therapies. ⋯ This prospective, multi-center, randomized controlled study will provide Level I evidence of the safety and effectiveness of mild versus ESIs in managing neurogenic claudication symptoms in LSS patients.
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Ischial bursitis or ischiogluteal bursitis is the inflammation of the ischiogluteal bursa due to excessive or inappropriate physical exercise, prolonged sitting, running, repetitive jumping, and kicking. Since ischial bursitis is a rare, infrequently recognized pathology and is difficult to differentiate from the soft tissue disease and tumors (both malignant and benign), herein exemplified is a case with ischiogluteal bursitis whereby the role of magnetic resonance imaging (MRI) in the prompt diagnosis has been highlighted.
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We present the case of a 74-year-old man with Stage IV metastatic, multifocal, malignant fibrous histiocytoma (T2b, N1, M1, G4) invading the proximal area of the left lower extremity and resulting in intractable neuropathic pain along the distribution of the femoral nerve. He described the pain as being so severe to cause inability to ambulate without assistance or to sleep in a supine or prone position. After a spinal cord stimulation trial and a trial of intrathecal (IT) hydromorphone, both performed at an outside institution, had failed to achieve adequate pain relief, we decided to perform a femoral nerve chemical neurolysis with phenol under ultrasound (US) guidance. ⋯ The patient reported complete pain relief with the procedure and no sensory-motor related side effects or complications. He was able to enjoy the last 6 weeks of life with his wife and family, pain-free. With this report we add to the limited literature available regarding the management of intractable cancer pain with chemical neurolysis in and around the epidural space.
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Complex regional pain syndrome (CRPS) is a severe chronic pain condition that most often develops following trauma. Some investigators have postulated CRPS to be a post-traumatic neuralgia associated with distal degeneration of small-diameter peripheral axons. Intravenous immunoglobulin treatment (IVIG) has been shown to be efficacious in the treatment of painful polyneuropathies. Some CRPS patients have been reported to respond to IVIG. Based on a recent hypothesis proposing an autoimmune etiology for CRPS, we decided to offer plasma exchange therapy (PE) to CRPS patients with a clinical presentation suggestive of a small fiber neuropathy. ⋯ This study shows that PE is effective in a subset of patients with severe long-standing CRPS and that the reduction in pain following the initial series of PE treatments can be maintained on a weekly PE schedule, IVIG, or with other immune modulating drugs. Large, randomized, placebo controlled studies may be required to confirm and expand these results. Such studies may lead to new therapies for this severe life-altering condition.
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Many chronic pain patients (CPPs) cannot be cured of their pain, but can learn to manage it. This has led to research on pain "acceptance" which is defined as a behavior pattern with awareness of pain but not directed at changing pain. ⋯ APPs versus CPPs differ on their affirmation on acknowledgement that a cure is unlikely.