scholarly journals Methods For Evidence Synthesis in Interventional Pain Management

2003 ◽  
Vol 1;6 (1;1) ◽  
pp. 89-111
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Pain Management ◽  
Evidence Synthesis ◽  
Interventional Pain Management

scholarly journals Evidence-Based Interventional Pain Management: Principles, Problems, Potential and Applications

2007 ◽  
Vol 2;10 (3;2) ◽  
pp. 329-356
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Clinical Practice ◽  
Pain Management ◽  
Systematic Reviews ◽  
Evidence Based Medicine ◽  
Randomized Trials ◽  
Evidence Synthesis ◽  
Evidence Based ◽  
Interventional Pain Management ◽  
Based Medicine

Background: The past decade has been marked by unprecedented interest in evidencebased medicine (EBM) and a focus upon the use of innovative methods and protocols to provide valid and reliable information for and about healthcare. Thus (it is at least purported that), healthcare decisions are increasingly being based upon research-derived evidence, rather than on expert opinion or clinical experience alone. But this quest for evidence to support clinical practice also compels the question of whether the methods employed to acquire information, the ranking of information that is acquired, and the prudent use of this information are sound enough to actually sustain the validity of an evidence-based paradigm in practice. Moreover, it is becoming apparent that the scope, depth, and applicability of available evidence to effectively and ethically guide the myriad of situational decisions in clinical practice is not uniform across all medical fields or disciplines. In particular, comprehensive evidence synthesis or complete guidelines for clinical decision-making in interventional pain management remain relatively scarce. EBM is defined as the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients. Thus, the practice of EBM requires the integration of individual clinical expertise with the best available external evidence from systematic research. To arrive at evidence-based medical decisions all valid and relevant evidence should be considered alongside randomized controlled trials, patient preferences, and resources. Objective: To describe principles of EBM, and the methods and relative utility of evidence synthesis in interventional pain management. Description: This review provides 1) an understanding of evidence-based medicine, 2) an overview of issues related to evaluating the quality of individual studies, analyses, narrative, and systematic reviews, 3) discussion of factors affecting the strength and value(s) of evidence, 4) analysis of specific reviews of interventional techniques, and finally, 5) the utility and purpose of guidelines in interventional pain management. Conclusion: Interpreting and understanding evidence synthesis, systematic reviews and other analytic literature is a difficult task. It is crucial for pain physicians to understand the goals, principles, and process(es) of EBM so as to meaningfully improve its application(s). This knowledge affords better insight into not only the analytic reviews in interventional pain management provided herein, but ultimately allows future information to be selected, evaluated, and used with prudence in technically competent, ethically sound medical practice. Key words: Interventional pain management, interventional techniques, evidence-based medicine, evidence synthesis, pragmatic or practical clinical trials, randomized trials, observational studies, non-randomized trials, systematic reviews, quality of evidence

scholarly journals Steroid Distancing in Interventional Pain Management During COVID-19 and Beyond: Safe, Effective and Practical Approach

2020 ◽  
Vol 4S;23 (8;4S) ◽  
pp. S319-S350
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Pain Management ◽  
Side Effects ◽  
Local Anesthetic ◽  
Facet Joint ◽  
Evidence Synthesis ◽  
Nerve Blocks ◽  
Epidural Injections ◽  
Significant Difference ◽  
Interventional Pain Management ◽  
Joint Injections

Background: Since the late 1940s, corticosteroids have been a mainstay class of agents in multiple interventional techniques and intra-articular injections. Exogenous glucocorticoids are structurally and pharmacologically similar to the endogenous hormones. As such, multiple actions of corticosteroids are exhibited, including those of anti-inflammatory and immunosuppressive effects. Epidural injections, with or without steroids, have been extensively used throughout the world. There are reports of epidural injections starting in 1901, with steroids being added to the local anesthetic since 1952, when steroids were administered into the sacral foramen. Purpose: Due to the extensive side effects of steroids in various injections, some have proposed limiting their use in epidurals and intraarticular injections. With the COVID-19 pandemic, the multiple side effects of the steroids have elevated the level of concern and recommendations have been made to utilize local anesthetic alone or the lowest dose of steroids. Fashioned from common expressions of the day, the term “steroid distancing” began to be used and proposed for intraarticular injections of the knee. Consequently, we sought to evaluate the evidence and feasibility of steroid distancing in interventional pain management. Methods: This focused review of local anesthetics and steroids utilized in interventional pain management for epidural injections, peripheral nerve blocks, and intraarticular injections by multiple database searches. This is a focused narrative review and not a systematic review. Consequently, evidence synthesis was not performed traditionally, but was based on an overview of the available evidence. Results: No significant difference was identified based on whether steroids are added to local anesthetic or not for epidural as well as facet joint injections. However, there was not enough evidence to compare these 2 groups for peripheral intraarticular injections. Limitations: The present review is limited by the paucity of literature with bupivacaine alone or bupivacaine with steroids local anesthetic alone or with steroids of intraarticular injections of knee, hip, shoulder and other joints, and intraarticular facet joint injections. Conclusion: This review shows an overall lack of significant difference between lidocaine alone and lidocaine with steroids in epidural injections. However, available evidence is limited for bupivacaine alone or with steroids. Evidence is also not available comparing local anesthetic alone with steroids for facet joint or peripheral joint intraarticular injections. Thus, it is concluded that local anesthetic with lidocaine may be utilized for epidural injections, with appropriate patient selection and steroids reserved for non-responsive patients with local anesthetic and with significant radiculitis. Key words: Steroid distancing, chronic pain, steroids, epidural injections, local anesthetic alone, local anesthetic with steroid, steroid distancing, physical distancing

scholarly journals Guidelines Warfare Over Interventional Techniques: Is There a Lack of Discourse or Straw Man?

2012 ◽  
Vol 1;15 (1;1) ◽  
pp. E1-E26 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Pain Management ◽  
Evidence Based Medicine ◽  
Conflicts Of Interest ◽  
Guideline Development ◽  
Evidence Synthesis ◽  
Medical Science ◽  
Medical Knowledge ◽  
Evidence Based ◽  
Interventional Pain Management ◽  
Based Medicine

Guideline development seems to have lost some of its grounding as a medical science. At their best, guidelines should be a constructive response to assist practicing physicians in applying the exponentially expanding body of medical knowledge. In fact, guideline development seems to be evolving into a cottage industry with multiple, frequently discordant guidance on the same subject. Evidence Based Medicine does not always provide for conclusive opinions. With competing interests of payers, practitioners, health policy makers, and third parties benefiting from development of the guidelines as cost saving measures, guideline preparation has been described as based on pre-possession, vagary, rationalization, or congeniality of conclusion. Beyond legitimate differences in opinions regarding the evidence that could yield different guidelines there are potentials for conflicts of interest and various other issues play a major role in guideline development. As is always the case, conflicts of interest in guideline preparation must be evaluated and considered. Following the development of American Pain Society (APS) guidelines there has been an uproar in interventional pain management communities on various issues related to not only the evidence synthesis, but conflicts of interest. A recent manuscript published by Chou et al, in addition to previous publications appear to have limited clinician involvement in the development of APS guidelines, demonstrates some of these challenges clearly. This manuscript illustrates the deficiencies of Chou et al’s criticisms, and demonstrates their significant conflicts of interest, and use a lack of appropriate evaluations in interventional pain management as a straw man to support their argument. Further, this review will attempt to demonstrate that excessive focus on this straw man has inhibited critique of what we believe to be flaws in the approach. Key words: Guidelines, interventional pain management, professionalism, discourse, disclosure, conflicts of interest, evidence-based medicine, comparative effectiveness research, Patient-Centered Outcomes Research Institute

scholarly journals Assessment of Infection Control Practices for Interventional Techniques: A Best Evidence Synthesis of Safe Injection Practices and Use of Single-Dose Medication Vials

2012 ◽  
Vol 5;15 (5;9) ◽  
pp. E573-E614 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Single Dose ◽  
Pain Management ◽  
Infection Control ◽  
Case Reports ◽  
Evidence Synthesis ◽  
Interventional Techniques ◽  
Management Procedures ◽  
Best Evidence Synthesis ◽  
Interventional Pain Management ◽  
Multiple Patients

Background: It is universally accepted that transmission of bloodborne pathogens during health care procedures continues to occur because of the use of unsafe and improper injection, infusion, and medication administration practices by health care professionals in various clinical settings. This resulted in development of multiple guidelines based on case reports; however, these case reports are confounded by multiple factors without causal relationship to a single factor. Even then, singledose vials used for multiple patients have been singled out and became the focus of infection control policies resulting in inordinate expenses for practices without improving patient safety. The cost of implementation of single dose vial policy in Interventional Pain Management for drugs alone may cost $750 million, whereas with single use radional gloves may exceed $1 billion per year. Study Design: Best evidence synthesis. Objective: To critically appraise and synthesize the literature on infection control practices for interventional techniques, including safe injection and medication vial utilization. Methods: The available literature on infection control practices was reviewed. Due to the nature of the studies involved, with the majority being case reports, and a few prospective evaluations, quality assessment and clinical relevance criteria were not applied. Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 through June 2012, literature from the Centers for Disease Control and Prevention (CDC), the U.S. Food and Drug Administration (FDA), and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was correlating infection to a breach of standards in infection control practices. The secondary objective was to assess the contribution of single-dose vials independently for infection. Results: A total of 60 reports met inclusion criteria, with 16 reports related to pain management and other procedures, of which 9 reports were attributed to issues related to interventional techniques. Based on an estimated 37 infections occurring during 200 million interventional techniques from 1997 through 2011, the rate of infection is speculated to be one infection for every 5 million interventional pain management procedures. However, if 10 times more infections are estimated, the infection rate appears to be one infection for every 500,000 interventional pain management procedures. The evidence is good for infection related to a breach of infection control practices. There is good evidence that contamination of multi-dose or single-dose vials can contribute to infection. There was poor evidence that the use of single-dose vials on multiple patients with appropriate infection control practices cause infection in interventional pain management. Limitations: The limitations of this comprehensive best evidence synthesis include the paucity of literature and dependence of governmental agencies on their literature without applying Institute of Medicine (IOM) criteria for guideline synthesis

Procedural Coding for Interventional Pain Management

2020 ◽  
Vol 23 (4) ◽  
pp. 100703
Author(s):  
Shantanu Warhadpande ◽  
Stephanie L. Dybul ◽  
Minhaj S. Khaja
Keyword(s):  
Pain Management ◽  
Interventional Pain Management

scholarly journals Radiation safety: a focus on lead aprons and thyroid shields in interventional pain management

2018 ◽  
Vol 31 (4) ◽  
pp. 244 ◽  
Author(s):  
Bo Kyung Cheon ◽  
Cho Long Kim ◽  
Ka Ram Kim ◽  
Min Hye Kang ◽  
Jeong Ae Lim ◽  
...  
Keyword(s):  
Pain Management ◽  
Radiation Safety ◽  
Interventional Pain Management

Interventional Pain Management Procedures

2020 ◽  
pp. 523-653
Author(s):  
Gabor Bela Racz ◽  
Gabor J. Racz ◽  
Tibor A. Racz
Keyword(s):  
Pain Management ◽  
Management Procedures ◽  
Interventional Pain Management
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