Articles: prospective-studies.
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Chronic refractory spinal pain poses a peculiar diagnostic challenge because of multiple putative pain sources, overlapping clinical features, and nonspecific radiologic findings. Diagnostic injection techniques are employed to isolate the source(s) of pain. Facet or zygapophysial joint pain is an example of spinal pain diagnosed by local anesthetic injections of the facet joint or its nerve supply. Diagnostic facet joint injections are expected to meet the cardinal features of a diagnostic test (i.e., accuracy, safety and reproducibility). Accuracy must be compared with a "gold" or criterion standard that can confirm presence or absence of a disease. There is, however, no available gold standard, such as biopsy, to measure presence or absence of pain. Hence, there is a degree of uncertainty concerning the accuracy of diagnostic facet joint injections. ⋯ The evidence obtained from literature review suggests that controlled comparative local anesthetic blocks of facet joint nerves (medial branch or dorsal ramus) are reproducible, reasonably accurate, and safe. The sensitivity, specificity, false-positive rates, and predictive values of these diagnostic tests for neck and low back pain have been validated and reproduced in multiple studies.
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The sacroiliac joint is an accepted source of low back pain with or without associated lower extremity symptoms. The diagnosis and management of sacroiliac joint pain and the role of interventional techniques have been controversial. ⋯ The evidence for the specificity and validity of diagnostic sacroiliac joint injections was moderate.The evidence for therapeutic intraarticular sacroiliac joint injections was limited to moderate. The evidence for radiofrequency neurotomy in managing chronic sacroiliac joint pain was limited.
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Discogenic low back pain is a common cause of chronic low back pain that remains a treatment challenge. The innervation and transmission of nociceptive information from painful lumbar discs has only recently been better described. ⋯ Radiofrequency lesioning of the L2 ramus communicans seems to offer partial relief for patients suffering from discogenic pain. Further studies are needed to confirm our results.
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Interact Cardiovasc Thorac Surg · Dec 2004
In aortic arch surgery is there any benefit in using antegrade cerebral perfusion or retrograde cerebral perfusion as an adjunct to hypothermic circulatory arrest?
A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether patients having aortic arch surgery benefit from antegrade or retrograde cerebral perfusion in addition to hypothermic circulatory arrest to reduce neurological injury or mortality. ⋯ The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that antegrade cerebral perfusion is superior as an adjunct to hypothermic circulatory arrest when compared to retrograde cerebral perfusion or hypothermic circulatory arrest alone, although clinical evidence for this from prospective clinical trials is weak.
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Over the years, there has been a shift toward the increased reliance on opioids for the treatment of chronic pain. It is well known that some patients do not provide an appropriate history or underestimate their drug intake, and may exaggerate reported pain levels. Numerous studies have documented the incidence of illicit drug use and abuse of opioids in chronic pain patients. It is not known what proportion of patients have already been exposed to controlled substances prior to presenting for interventional pain management. ⋯ Ninety percent of these patients were taking opioids. Twenty-seven patients incorrectly reported opioid use, either underuse or overuse, with 23 patients using illicit drugs, 12 using non-prescription opioids, and with 35 of 100 patients at initial evaluation exhibiting one of the abuse behaviors.