Pain physician
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Observational Study
Occipital Nerve Stimulation for Refractory Chronic Migraine: Results of a Long-Term Prospective Study.
Refractory chronic migraine affects approximately 4% of the population worldwide and results in severe pain, lifestyle limitations, and decreased quality of life. Occipital nerve stimulation (ONS) refers to the electric stimulation of the distal branches of greater and lesser occipital nerves; the surgical technique has previously been described and has demonstrated efficacy in the treatment of a wide variety of headache disorders. ⋯ We consider that the trigemino-cervical autonomous and cervical connection may explain why ONS might relieve chronic migraine pain, but this is just a theoretical explanation which should be demonstrated in future studies. The results achieved in this study suggest that ONS may provide long-term benefits for patients with medically intractable chronic migraine. These outcomes are slightly better than previous reports and were maintained over the 7-year follow-up. We believe that an accurate selection of patients, realization of diagnostic occipital nerve blocks, psychological evaluations, rigorous surgical technique, and appropriate parameter programming helped us achieve these outcomes. Key words: Refractory chronic migraine, headache, occipital nerve stimulatino, peripheral nerve stimulation, occipital nerve block.
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Failed back surgery syndrome (FBSS) is a frequently encountered disease entity following lumbar spinal surgery. Although many plausible reasons have been investigated, the exact pathophysiology remains unknown. Various medications, reoperations, interventions such as spinal cord stimulation, epidural adhesiolysis or epidural injection, exercise therapy, and psychotherapy have been suggested treatment options. However, the evidence of the clinical outcome for each treatment has not been clearly determined. ⋯ Epidural adhesiolysis or spinal cord stimulation can be effective in order to control chronic back pain or leg pain due to FBSS, and its recommendation grades are A and B, respectively. Other treatments showed poor or inconclusive evidence.Key words: Failed back surgery syndrome, post spinal surgery syndrome, chronic low back pain, post lumbar surgery syndrome, epidural adhesiolysis, spinal cord stimulation, epidural injection, revision.
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Merit-Based Incentive Payment System: Meaningful Changes in the Final Rule Brings Cautious Optimism.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) eliminated the flawed Sustainable Growth Rate (SGR) act formula - a longstanding crucial issue of concern for health care providers and Medicare beneficiaries. MACRA also included a quality improvement program entitled, "The Merit-Based Incentive Payment System, or MIPS." The proposed rule of MIPS sought to streamline existing federal quality efforts and therefore linked 4 distinct programs into one. Three existing programs, meaningful use (MU), Physician Quality Reporting System (PQRS), value-based payment (VBP) system were merged with the addition of Clinical Improvement Activity category. ⋯ In addition, the final rule reduced the burden of ACI, improved the coordination of performance, reduced improvement activities burden from 60 points to 40 points, and finally improved coordination between performance categories. Multiple concerns remain regarding the reduction in scoring for quality improvement in future years, increase in proportion of MIPS scoring for resource use utilizing flawed, claims based methodology and the continuation of the disproportionate importance of ACI, an expensive program that can be onerous for providers which in many ways has not lived up to its promise. Key words: Medicare Access and CHIP Reauthorization Act of 2015, merit-based incentive payment system, quality performance measures, resource use, improvement activities, advancing care information performance category.
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Observational Study
Modified Percutaneous Lumbar Foraminoplasty and Percutaneous Endoscopic Lumbar Discectomy: Instrument Design, Technique Notes, and 5 Years Follow-up.
Conventional percutaneous endoscopic lumbar discectomy (PELD) with an "inside-outside" technique has 4.3% - 10.3% surgical failure rate, especially in central herniated discs (HDs), migrated HDs, and axillary type HDs. PELD with foraminoplasty has been used for complex HDs. Percutaneous lumbar foraminoplasty (PLF), which is performed with a trephine or bone reamer introduced over a guidewire without a protective working cannula in the original Tessys technique, can quickly cut the hypertrophied bony structure under fluoroscopic guidance, and risk injury to the exiting and traversing nerve roots. ⋯ Modified PLF-PELD with a specially designed instrument is a less invasive, effective and safe surgery for complex uncontained lumbar DH.Key words: Lumbar disc herniation, minimally invasive treatment, foraminoplasty, percutaneous endoscopic lumbar discectomy.
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Observational Study
Percutaneous Endoscopic Lumbar Discectomy for Highly Migrated Lumbar Disc Herniation.
Percutaneous endoscopic lumbar discectomy (PELD) has been growing in popularity for the treatment of lumbar disc herniation (LDH) due to its irreplaceable advantages over conventional open surgery. Compared with common lumbar disc herniations, discectomy of highly migrated LDH by PELD is known to be very difficult. Highly migrated lumbar disc herniation has long been a challenge for its specific characteristics. Three approaches for PELD have been applied to access a highly migrated LDH, including an interlaminar approach (IL), transforaminal approach (TF), and contralateral transforaminal approach (CTF). However, none of the existing research has systematically described the selection of the most appropriate procedure from the 3 approaches or the individualization of an operative procedure in different cases. ⋯ In our research, PELD with all 3 approaches was similarly effective to highly migrated disc herniation. The CTF approach required the longest operation duration and the most intraoperative times. On the contrary, the least operation time and radiographfrequency was required with the IL approach. In addition, we came to a conclusion of surgery approach selection when it comes to varied HM-LDH. Key words: Highly migrated, lumbar disc herniation, percutaneous endoscopic lumbar discectomy, minimally invasive treatment.