Pain physician
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A growing number of patients suffer from severe low back pain of discogenic origin that is not responsive to conservative medical management. These patients must consider the option of surgical spinal fusion or minimally-invasive intradiscal electrothermal therapy (IDET). ⋯ The majority of patients reported improvement in symptoms following both spinal fusion and the IDET procedure. The IDET procedure appears to offer sufficiently similar symptom amelioration to spinal fusion without the attendant complications.
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Chronic low back pain is a major social, economic, and healthcare issue in the United States. Various techniques are utilized in managing discogenic pain, with or without disc herniation. Percutaneous techniques are rapidly replacing traditional open surgery in operations requiring discectomy, decompression, and fusion. ⋯ The most often stated goal of central nuclear decompression is to lower the pressure in the nucleus and to allow room for the herniated fragment to implode inward. Provocative discography prior to percutaneous lumbar disc decompression is recommended. Percutaneous disc decompression may result in a small number of complications but occasionally, these could be serious.
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The sacroiliac joint (SIJ) is a putative source of low back pain. The objective of this article is to provide clinicians with a concise review of SIJ structure and function, diagnostic indicators of SIJ-mediated pain, and therapeutic considerations. The SIJ is a true diarthrodial joint with unique characteristics not typically found in other diarthrodial joints. ⋯ Conservative management includes manual medicine techniques, pelvic stabilization exercises to allow dynamic postural control, and muscle balancing of the trunk and lower extremities. Interventional treatments include sacroiliac joint, intra-articular joint injections, radiofrequency neurotomy, prolotherapy, cryotherapy, and surgical treatment. The evidence for intra-articular injections and radiofrequency neurotomy has been shown to be limited in managing sacroiliac joint pain.
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Review Practice Guideline
Opioid guidelines in the management of chronic non-cancer pain.
Opioid abuse has increased at an alarming rate. However, available evidence suggests a wide variance in the use of opioids, as documented by different medical specialties, medical boards, advocacy groups, and the Drug Enforcement Administration (DEA). ⋯ These guidelines evaluated the evidence for the use of opioids in the management of chronic non-cancer pain and recommendations for management. These guidelines are based on the best available scientific evidence and do not constitute inflexible treatment recommendations. Because of the changing body of evidence, this document is not intended to be a "standard of care."
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Although established as a field of specialization, pain medicine remains somewhat fractionated. Such lack of cohesion creates dissonance on multiple levels, and thus, impedes the provision of effective pain care. ⋯ The intricate relationship between pain, the pain patient, and the pain physician creates pragmatic and moral dilemmas that may not be well served by the use of prima facie principles. It is argued that an agent-based, virtue ethics best enable the clinician to both apprehend the complexity of this relationship and appreciate other ethical approaches in the discourse arising from issues of care.