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possible future MRI. Pregnant or lactating women

Source: Adapted from McJunkin et al., 2009; NTAC, 2008; Wallace & Staats, 2005.

Source: Adapted from McJunkin et al., 2009; NTAC, 2008; Wallace & Staats, 2005.

aspect of SCS is that it is minimally invasive, reversible, and nondestructive, and if the neuromodulation does not provide the expected result, the lead(s) and generator can be explanted (D'Arcy, 2010; NTAC, 2008) (Table 7.1).

With both implanted techniques, patient selection and preim-plantation medication manipulation and dose adjustment should all be tried prior to considering an implanted modality. Because the device mat require frequent adjustment the patient needs to commit to follow-up visits. Choosing the right technique and the right patient will provide more positive outcomes.

Returning the Patient to the Referring Practice

When the patient returns to the referring practice after treatment by a pain clinic, it is essential to let the patient know you are comfortable with the treatment regimen that the pain clinic specialist has prescribed. By presenting a united front to the patient, there is little room for any deviation from the plan, unless the practitioners and patient agree to an adjustment.

Establishing good communication with the pain clinic specialists will be especially important once the patient is no longer being seen in their clinic. If the practitioner who refers the patient has a good understanding of the medication or therapy regimen, there is no reason that the primary care provider cannot provide the same level of pain management care. It is also important for the two practitioners to have access to current records to confirm medications, dosages, and any adjustments that were made to the plan of care.

Case Study

Mabel Jones is a 57-year-old patient who was in a car accident 2 years ago and had significant trauma to her back and chest. She has had multiple back surgeries, and at the time of the accident, a thoraco-tomy was performed. She has been seeing her surgeon and her primary care health care provider for several years, and they have been managing her pain with short-acting opioids, such as oxy-codone and hydrocodone with acetaminophen. She is still complaining of significant pain in her back and down her legs, and she has some areas on her chest wall that have what she describes as a burning sensation. Her health care provider has manipulated her medications many times, tried several different types and classes of medications, and now feels that Mabel would benefit from a pain clinic referral to make sure they are doing all that they can do to help alleviate the pain.

When Mabel sees the pain specialist, she asks Mabel to fill out a multidimensional pain assessment form, talks to her about her medications and how they work, and does a complete examination and reviews the most current x-rays, MRIs, and CT results. When she speaks to Mabel about her pain, Mabel tells the pain specialist, "The pain is always there. It really never goes away. If I have to stand or walk any distance, I really feel the pain down my legs. On most days, I can live with the pain at about a 5/10, but when it gets higher than that, I really have a hard time. When it gets like that, the pain medicine doesn't work too well. It takes so long to work. Then I have this nagging burning pain in my chest since I had the accident and surgery. It feels like someone is holding a match to my chest right in that spot. It really bothers me, and I can't sleep too well because of it. I wish I had never gone out to shop on that day. If only I had not had that accident, I might have an entirely different life now."

Mabel's current medications are as follows:

■ oxycodone with acetaminophen: two tablets 3 times per day

■ Zolpidem for sleep

■ ibuprofen for her back pain as needed

Questions to Consider

1. What type of pain does Mabel have? More than one type? How do you know there are different types of pain? Will the type of pain she has make a difference in how the pain specialist treats her pain?

2. Will changing her medications to a long-acting opioid medication with a short-acting medication benefit Mabel? Should there be other types of medications that are used for her pain?

3. What types of interventional options would be helpful for Mabel?

4. Because of the mixed nature of Mabel's pain, what is the best way to treat each component?

5. Does Mabel have any contraindications for use of interven-tional options for pain relief?

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