What are the principles of interventional pain management ?
B ) What are the modalities used in this ?
A 9 A ) DEFINITION
1 An operational definition of EBM is the conscentious , explicit and judicious use of current best evidence in making decisions about the care of individual patients
2 Is essentially focused upon the use of right ( types and extent of knowledge ) to guide the right and good intentions and actions of medical practice
3 Is fundamental in clinical decision making
4 Hence , the practice of EBM requires the prudent , specific contextual application of knowledge gained by integration of individual clinical expertise and experience in concert with the best available external evidence gained from systematic research.
PRINCIPLES
1 scientific evidence alone is never sufficient to make a clinical decision , so decision makers must always consider the patient values when evaluating the benefits , risks and burdens associated with any treatment strategies
2 heirchary of decision making is not absolute and always right and is upheld / affected by 4 basic contingencies such as -
A ) Is crucial to recognise the patient problem and construct a structured clinical question
B ) medical literature should be thouroughly searched to retrieve the best available medicine to answer the clinical question
C ) the available evidence must be critically appraised
D ) final body of evidence must be integrated with all aspects and contexts of the clinical circumstances
STAGES OF HEIRCHARY IN THE DESCENDING ORDER
A ) SYSTEMATIC REVIEWS OF RANDOMISED TRIALS
B ) SINGLE RANDOMISED TRIALS
C ) SYSTEMATIC REVIEWS OF OBSERVATIONAL STUDIES
D ) SINGLE OBSERVATIONAL STUDIES ADDRESSING PATIENT IMPORTANT OUTCOMES
E ) PHYSIOLOGIC STUDIES
F ) UNSYSTEMATIC CLINICAL OBSERVATION
ROLE OF EBM IN INTERVENTIONAL PAIN MANAGEMENT
A ) TO PROVIDE CONSCIENTIOUS , EXPLICIT AND JUDICIOUS USE OF CURRENT BEST EVIDENCE IN MAKING DECISIONS ABOUT THE CARE OF INDIVIDUAL PATIENTS
B ) To answer the questions or to understand it - who did the review , whether or not sufficient resources were available , what was the objective of the review , how was the review done
WHY EVIDENCE BASED MEDICINE / MERITS / ADVANTAGES
1 Better understanding of pathologic mechanisms of different types of pain
2 More specific applications of interventional techniques
3 More stringent analysis of methods
ASIPP ( American Society of interventional pain physicians ) SYSTEMATIC REVIEWS AND GUIDELINES
1 For diagnostic interventions Facet joint nerve blocks for diagnosis of lumbar and cervical facet joint pain are accurate whereas moderate for diagnosis of thoracic facet joint pain
2 Evidence is stronger for lumbar discography than cervical and thoracic
3 Transforaminal epidural injections or selective nerve root blocks or sacroiliac joint injections have moderate evidence
4 The evidence for therapeutic lumbar intraarticular facet injections , median branch neurotomy ( cervical and lumbar ) is moderate
5 There is also strong evidence for percutaneous epidural adhesiolysis for short term and moderate for long term
6 There is strong evidence for intradiscal electrothermal therapy
7 Evidence is moderate for both kyphoplasty and vertebroplasty
8 vv imp evidence for spinal cord stimulation in failed back syndrome and complex regional pain syndrome is strong for short term and moderate for long term
INDICATIONS
conditions in which interventional pain management techniques commonly treat include vv imp -
A ) chronic headaches
B ) mouth, or face pain
C ) low back pain
D ) muscle and/or bone pain
E ) neck pain
CONTRAINDICATIONS
1 Allergy to the drugs to be injected
2 Anemia
3 Asthma
4 Bleeding problems
5 Infection
6 Kidney disease
7 Pregnancy/breast-feeding
8 Severe spinal abnormality
B ) MODALITIES USED -
1 - INJECTIONS
A ) One of the most common injections is an epidural steroid injection in lumbar spine (low back). This injection sends steroids directly to the nerve root that’s inflamed.
B ) Other common injections are facet joint injections, single nerve root blocks, and sacroiliac joint injections.
2 Radiofrequency Rhizotomy
A ) Using x-ray guidance and a needle with an electrode at the tip that gets heated, radiofrequency rhizotomy temporarily turns off a nerve’s ability to send pain messages to your brain.
B ) Other names for radiofrequency rhizotomy are radiofrequency ablation and neuroablation.
C ) For many patients, this procedure can provide pain relief for 6 to 12 months.
D ) During these pain-free months, physical therapy is recommended
E ) A physical therapist can help you address underlying physical problems that are causing pain.
3 Intrathecal Pump Implants
A ) Intrathecal pump implants, also known as pain pumps, provide potent medications straight to the source of your pain. They’re a type of neuromodulation—a treatment that interrupts pain signals to your brain.
B ) Pain pumps are commonly used for cancer pain and failed back syndrome
1 - With this procedure, a small device—called a pump—gets implanted under your skin.
2 In this the pump delivers a specific amount of medication, and he or she will need to refill the pump every few months.
3 The main benefits of pain pumps are that they provide consistent pain relief, and if you’re taking oral medications, you don’t have to rely on them as much.
4 Because this is a more invasive procedure than an injection, a pain pump is typically used only if other treatments have been unsuccessful.
4 Electrical Stimulation
A ) Electrical stimulation is another type of neuromodulation.
B ) Similar to a pain pump, something gets implanted in your body with electrical stimulation.
C ) But with this procedure, a stimulator is implanted along with an electrical lead to send electrical pulses directly to the area that’s causing pain—the spinal cord, nerves, or brain, for instance.
D ) Electrical stimulation can be used for certain spine conditions as well as conditions that affect your brain or nerves, such as Parkinson’s disease, epilepsy, and diabetic peripheral neuropathy.
E ) Instead of pain, some people feel a tingling sensation with this treatment.
F ) However, as with a pain pump, electrical stimulation is usually one of the last interventional pain management treatments tried.
5 Other Interventional Pain Management Techniques
A ) Intradiscal electrothermic therapy, for example, uses heat to destroy nerve fibers to reduce your pain.
B ) Another example is cryogenic cooling, which is similar to radiofrequency rhizotomy, but instead temporarily shuts nerves down by freezing them.
Patient Preparation: At Home
1 Stop blood thinning medication 2 days prior to the test
2 Do not take any aspirin product 5 days prior to the testStop anti-inflammatory medication 5 days prior to the test
3 Stop pain medication 8 hours prior to the test
4 Do not eat or drink 6 hours prior to the test
5 Arrange for someone to provide transportation home
Patient Preparation: At the Medical Facility
1 The medical staff will review the patient’s history, condition, medications taken on a daily basis, food and/or drug allergies, and other information.
2 The patient changes into a gown and lies down in a hospital bed. The facility provides a secure place for the patient’s personal items.
3 An EKG monitor (heart function), automatic blood pressure cuff (blood pressure), and oximeter (measures blood-oxygen levels) are attached to the patient. This equipment enables the medical staff to consistently monitor the patient’s vital signs before, during and after the procedure.
4 Medication to relax the patient is administered by injection. In some cases, light intravenous sedation may be given.