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Objective The statistical analysis typically used to compare pain before and after interventions assumes that scores are normally distributed. The present study evaluates whether numeric rating scale (NRS) scores, specifically NRS-11 scores, are indeed normally distributed in a clinically relevant cohort of adults with chronic axial spine pain before and after analgesic intervention. Methods Retrospective review from 4 academic medical centers of prospectively collected data from a uniform pain diary administered to consecutive patients after they had undergone medial branch blocks. The pain diary assessed NRS-11 scores immediately before injection and at 12 different time points after injection up to 48 hours. D'Agostino–Pearson tests were used to test normality at all time points. Results One hundred fifty pain diaries were reviewed, and despite normally distributed pre-injection NRS-11 scores (K 2 = 0.655, P  = .72), all post-injection NRS-11 data were not normally distributed (K 2 = 9.70– 17.62, P  = .0001–.008). Conclusions Although the results of parametric analyses of NRS-11 scores are commonly reported in pain research, some properties of the NRS-11 do not satisfy the assumptions required for these analyses. The data demonstrate non-normal distributions in post-intervention NRS-11 scores, thereby violating a key requisite for parametric analysis. We urge pain researchers to consider appropriate statistical analysis and reporting for non-normally distributed NRS-11 scores to ensure accurate interpretation and communication of these data. Practicing pain physicians should similarly recognize that parametric post-intervention pain score statistics might not accurately describe the data and should expect articles to utilize measures of normality to justify the selected statistical methods. [ABSTRACT FROM AUTHOR]

Key Points: Question: Among patients with acute or subacute spine pain, does a multidisciplinary biopsychosocial intervention or an individualized postural therapy intervention improve disability and reduce health care spending? Findings: In this cluster randomized clinical trial that included 2971 patients from 33 centers, both the biopsychosocial intervention and the postural therapy intervention, each compared with usual care, significantly reduced pain-related disability at 3 months. Compared with usual care at 1 year, the biopsychosocial intervention resulted in no significant difference in spine-related health care spending, and the postural therapy intervention significantly increased spine-related health care spending. Meaning: Among patients with acute or subacute spine pain, both a biopsychosocial intervention and a postural therapy intervention resulted in modest statistically significant reductions in disability at 3 months compared with usual care; however, the biopsychosocial intervention resulted in no significant difference in spending and the postural therapy intervention resulted in greater spending at 1 year. Importance: Low back and neck pain are often self-limited, but health care spending remains high. Objective: To evaluate the effects of 2 interventions that emphasize noninvasive care for spine pain. Design, Setting, and Participants: Pragmatic, cluster, randomized clinical trial conducted at 33 centers in the US that enrolled 2971 participants with neck or back pain of 3 months' duration or less (enrollment, June 2017 to March 2020; final follow-up, March 2021). Interventions: Participants were randomized at the clinic-level to (1) usual care (n = 992); (2) a risk-stratified, multidisciplinary intervention (the identify, coordinate, and enhance [ICE] care model that combines physical therapy, health coach counseling, and consultation from a specialist in pain medicine or rehabilitation) (n = 829); or (3) individualized postural therapy (IPT), a postural therapy approach that combines physical therapy with building self-efficacy and self-management (n = 1150). Main Outcomes and Measures: The primary outcomes were change in Oswestry Disability Index (ODI) score at 3 months (range, 0 [best] to 100 [worst]; minimal clinically important difference, 6) and spine-related health care spending at 1 year. A 2-sided significance threshold of.025 was used to define statistical significance. Results: Among 2971 participants randomized (mean age, 51.7 years; 1792 women [60.3%]), 2733 (92%) finished the trial. Between baseline and 3-month follow-up, mean ODI scores changed from 31.2 to 15.4 for ICE, from 29.3 to 15.4 for IPT, and from 28.9 to 19.5 for usual care. At 3-month follow-up, absolute differences compared with usual care were −5.8 (95% CI, −7.7 to −3.9; P <.001) for ICE and −4.3 (95% CI, −5.9 to −2.6; P <.001) for IPT. Mean 12-month spending was $1448, $2528, and $1587 in the ICE, IPT, and usual care groups, respectively. Differences in spending compared with usual care were −$139 (risk ratio, 0.93 [95% CI, 0.87 to 0.997]; P =.04) for ICE and $941 (risk ratio, 1.40 [95% CI, 1.35 to 1.45]; P <.001) for IPT. Conclusions and Relevance: Among patients with acute or subacute spine pain, a multidisciplinary biopsychosocial intervention or an individualized postural therapy intervention, each compared with usual care, resulted in small but statistically significant reductions in pain-related disability at 3 months. However, compared with usual care, the biopsychosocial intervention resulted in no significant difference in spine-related health care spending and the postural therapy intervention resulted in significantly greater spine-related health care spending at 1 year. Trial Registration: ClinicalTrials.gov Identifier: NCT03083886 This cluster randomized clinical trial compares the efficacy of 2 interventions that emphasize noninvasive care for spine pain vs usual care in reducing pain-related disability and health care spending among patients with acute or subacute spine pain. [ABSTRACT FROM AUTHOR]

Background Emerging literature supports the use of basivertebral nerve ablation (BVNA) for a specific cohort of patients with chronic low back pain and Type 1 or Type 2 Modic changes from vertebral levels L3–S1. The early literature warrants further evaluation. Studies establishing the efficacy of BVNA use highly selective patient criteria. Objective Provide a first estimate of the prevalence of BVNA candidates in a spine clinic over a year using the foundational studies patient selection criteria? Methods A retrospective review of four fellowhsip trained spine physiatrists patient encounters at a large academic medical center using relevant ICD-10 codes to isolate chronic low back pain without radiating symptoms from January 1, 2019 to January 1, 2020. Charts were then reviewed by a team of physicians for exclusionary criteria from the foundational studies which have demonstrated benefit from BVNA. MRI's from qualifying charts which did not meet exclusionary criteria were then independently reviewed by four physician for localization and characterization of Modic changes. Results The relevant diagnostic codes query yielded 338 unique patient records. Based on exclusionary criteria or lack of imaging availability, 318 charts were eliminated. The remaining 20 charts qualified for imaging review. There were 11 charts in which there was 100% agreement between all reviewers regarding the presence and either Type 1 or Type 2 Modic changes between vertebral levels L3 to S1. Accordingly, the prevalence of eligibility for BVNA was 3% (11/338, 95% CI 1–5%). Conclusion The population which may benefit from BVNA is small. Our study demonstrated that over a year, the prevalence for BVNA candidacy using the foundational studies criteria was 3% (95% CI 1% – 5%). While physicians may be tempted to use less stringent selection criteria in practice, upon doing so they cannot cite the foundational studies as evidence for the outcomes they expect to achieve. Those outcomes will require more studies which formally assess the benefits of BVNA when selection criteria are relaxed. [ABSTRACT FROM AUTHOR]

Background The past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial. Methods In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4–5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement. Results Twenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation. Conclusions Cervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice. [ABSTRACT FROM AUTHOR]

BACKGROUND: Back pain is a leading reason for seeking care in the United States (US), and is a major cause of morbidity. OBJECTIVE: To analyze demographic, patient, and visit characteristics of adult ambulatory spine clinic visits in the United States from 2009–2016. METHODS: Data from the National Ambulatory Medical Care Survey from 2009–2016 were used and were sample weighted. RESULTS: Most patients presenting for ambulatory spine care were 45–64 years (45%), were most commonly female (56.8%), and private insurance (45%) and Medicare (26%) were most common payors. The percentage of visits for spine care done at a primary care setting was 50.1% in 2009–2010 and 48.3% in 2014–2015. Approximately 15.5% were seen in orthopedic surgery clinics in 2009–2010 and 7.3% in 2015–2016. MRI was utilized in 11.7% in 2009–2010 and 11.0% in 2015–2016. Physical therapy was prescribed in 13.2% and narcotic analgesic medications were prescribed in 36.2% of patients in 2015–2016. CONCLUSIONS: MRI was used more frequently than guidelines recommended, and physical therapy was less frequently utilized despite evidence. A relatively high use of opiates in treatment of back pain was reported and is concerning. Although back pain represents a substantial public health burden in the United States, the delivery of care is not evidence-based. [ABSTRACT FROM AUTHOR]

Radiofrequency ablation of the sacral lateral branches targets the innervation of the posterior sacroiliac ligaments and posterior portion of the sacroiliac joint. These structures are also collectively referred to as the posterior sacroiliac joint complex. This review will discuss current diagnostic block paradigms and selection criteria for sacral lateral branch radiofrequency ablation, varying techniques and technologies utilized for sacral lateral branch radiofrequency ablation, and updates on the clinical outcome literature. The current evidence suggests that sacral lateral branch radiofrequency ablation can provide relief for posterior sacroiliac joint complex pain, but the literature is limited by variability in selection criteria, the specific nerves targeted by radiofrequency ablation, and the types of radiofrequency ablation technology and techniques utilized in clinical outcome studies. [ABSTRACT FROM AUTHOR]

Objective To determine the effectiveness of cervical medial branch thermal radiofrequency neurotomy in the treatment of neck pain or cervicogenic headache based on different selection criteria. Design Comprehensive systematic review. Methods A comprehensive literature search was conducted, and the authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies. Outcome Measures The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief. Results Results varied by selection criteria, which included triple placebo-controlled medial branch blocks, dual comparative medial branch blocks, single medial branch blocks, intra-articular blocks, physical examination findings, and symptoms alone. Outcome data showed a greater degree of pain relief more often when patients were selected by triple placebo-controlled medial branch blocks or dual comparative medial branch blocks, producing 100% relief of the index pain. The degree of pain relief was similar when triple or dual comparative blocks were used. Conclusions Higher degrees of relief from cervical medial branch thermal radiofrequency neurotomy are more often achieved, to a statistically significant extent, if patients are selected on the basis of complete relief of index pain following comparative diagnostic blocks. If selected based on lesser degrees of relief, patients are less likely to obtain complete relief. [ABSTRACT FROM AUTHOR]

Objective Examine the interrelationship between smoking and pain in the US population. Design A cross-sectional population-based study. Setting Nationwide survey. Methods Comprehensive pain reports categorically defined as head, spine, trunk, and limb pain; smoking history; demographics; medical history from a total of 2,307 subjects from the 2003–2004 National Health and Nutrition Examination Survey obtained from the Centers for Disease Control were analyzed. Unpaired t tests were used to analyze independent continuous variables, and chi-square tests were used to analyze categorical variables between smoker and nonsmoker groups. Weighted multivariate logistic regression analyses determined the association of current smoking with the presence of pain in various body regions. Results Smoking is most strongly associated with spine pain (odds ratio [OR] = 2.89, 95% confidence interval [CI] = 2.21–3.77), followed by headache (OR = 2.47, 95% CI = 1.73–3.53), trunk pain (OR = 2.17, 95% CI = 1.45–2.74), and limb pain (OR = 1.99, 95% CI = 1.45–2.73). Conclusions Current smoking is associated with pain in every region of the body. This association is strongest for spine and head pain. Given that pain is a strong motivator and that current smoking was associated with pain in all body regions, we recommend that these results be used to further raise public awareness about the potential harms of smoking. [ABSTRACT FROM AUTHOR]

The article examines whether a corticosteroid injection increases the risk of contracting COVID-19 or alters the clinical course of a subsequent infection. It mentions that therapeutic corticosteroids have wide-ranging physiologic effects. It also mentions that intra-articular corticosteroid injections are known to have systemic endocrine effects similar to those of epidural corticosteroid injections.

The article focuses on the with the chronic low back pain (CLBP) population, a presenting complaint that reflects a multitude of potential anatomical and physiologic etiologies, often associated with behavioral and psychosocial complications. It mentions that expectations of complete pain relief may be higher in the patients with CLBP. It also mentions that invasive procedures demonstrate robust placebo responses in participants with CLBP.

Objective. To determine the effectiveness of lumbar medial branch thermal radiofrequency neurotomy based on different selection criteria and procedural techniques. Design. Comprehensive systematic review. Methods. A comprehensive literature search was conducted, and all authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies. Outcome Measures. The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief, as well as procedural technique with perpendicular or parallel placement of electrodes. Results. Results varied by selection criteria and procedural technique. At six months, 26% of patients selected via single medial branch block with 50% pain relief and treated via perpendicular technique achieved at least 50% pain relief; 49% of patients selected via dual medial branch blocks with 50% pain relief and treated via parallel technique achieved at least 50% pain relief. The most rigorous patient selection and technique—two diagnostic medial branch blocks with 100% pain relief and parallel electrode placement—resulted in 56% of patients experiencing 100% relief of pain at six months. Conclusions. This comprehensive systematic review found differences in the effectiveness of lumbar medial branch radiofrequency neurotomy when studies were stratified by patient selection criteria and procedural technique. The best outcomes are achieved when patients are selected based on high degrees of pain relief from dual medial branch blocks with a technique employing parallel electrode placement. [ABSTRACT FROM AUTHOR]

Objectives To identify significant bleeding complications following spinal interventions in patients taking medications with antiplatelet or anticoagulation effect. Design Retrospective chart review of a 12-month period. Setting Outpatient academic medical practice. Interventions Injections during outpatient interventional spine clinical encounters, including 14 cervical transforaminal epidural steroid injections, 26 cervical medial branch blocks, seven cervical radiofrequency neurotomies, three cervical facet joint injections, 88 lumbar transforaminal epidural steroid injections, 66 lumbosacral medial branch blocks, 18 lumbosacral radiofrequency neurotomies, 13 lumbar facet joint injections, one caudal epidural steroid injection, 11 sacral transforaminal epidural steroid injections, and 32 sacroiliac joint injections. Main Outcome Measure Epidural hematoma or other serious bleeding. Results In this cohort of 275 consecutive encounters with available records in which patients underwent a spinal injection while continuing medications with antiplatelet or anticoagulant effect, zero of the 275 clinical encounters (0%, 95% confidence interval = 0–1.4%) resulted in epidural hematoma or other serious bleeding. For antiplatelet medication, nonsteroidal anti-inflammatory drugs were continued in 102 procedures, aspirin in 142, clopidogrel in 21, and meloxicam and/or Celebrex in 81; for anticoagulation medication, warfarin was continued in four procedures, apixaban in six, dabigatran in one, and fondaparinux in two. Of note, one patient suffered a deep vein thrombosis, which was identified at two-week follow-up despite continuing aspirin therapy. Conclusions This cohort adds to the growing evidence that the risk of serious bleeding complications from select spine interventions while continuing medications with antiplatelet or anticoagulant effect appears low. [ABSTRACT FROM AUTHOR]

Background A combination of physical examination maneuvers is currently considered necessary to help predict who will respond to injections in the sacroiliac joint. However, the literature on this topic currently consists of conflicting studies, with one showing the value of a combination of exam maneuvers and the other showing no real value. Objective To determine the diagnostic validity of sacroiliac joint (SIJ) physical exam maneuvers using anesthetic intra-articular injection as a reference standard. Design A single institution prospective study. Participants Patients with the clinical diagnosis of SIJ pain and referred for SIJ injection were enrolled. Main Outcome Measure Numeric rating scale (NRS) to assess pain intensity Results Participants underwent fluoroscopically guided SIJ intra-articular injection with 1 cc of 2% lidocaine and 1 cc of triamcinolone 40 mg. Patients' pain was assessed via 0–10 NRS pre-injection and immediately postinjection to determine positive anesthetic response to the injection. Six physical exam maneuvers (thigh thrust, Geanslen's test, FABER test, distraction test, compression test, and sacral thrust) were performed pre-injection and 15 minutes postinjection. The results of these SIJ physical exam maneuvers were evaluated singly and in combinations for diagnostic power in relation to a positive anesthetic response (>80% relief) to the injection. No association was found between a single SIJ physical exam maneuver or combination of maneuvers and anesthetic response to the injection. Conclusions In this cohort, patient physical exam maneuvers to identify intra-articular SIJ pain did not demonstrate diagnostic value when compared with the reference standard of an intra-articular anesthetic block. [ABSTRACT FROM AUTHOR]

Objective To evaluate sacroiliac joint (SIJ) injection outcomes with local anesthetic and corticosteroid. Design Prospective cohort. Setting Single academic medical center. Methods Thirty-four patients referred for SIJ injection with a clinical diagnosis of SIJ pain underwent injections with 1:1 mixture of 2% lidocaine and triamcinolone 40 mg/mL. Pain provocation physical exam (PE) maneuvers were recorded immediately before and after injection. Outcome measures at two to four weeks and six months included pain numeric rating scale (NRS) and Oswestry Disability Index (ODI). Results For the analysis of outcomes by the overall group (not stratified by PE and/or anesthetic block), a 58.8% (95% confidence interval [CI] = +/-16.5%) ≥2 NRS reduction, a 32.4% (95% CI = +/-15.7%) ≥50% NRS reduction, and a 38.2% (95% CI = +/-16.3%) ≥30% ODI reduction were observed at two to four weeks, with similar improvements at six months. Outcomes stratified based on pre-injection PE did not reveal significant differences at either time point. The stratification based on the presence of 100% postinjection anesthetic response demonstrated a significant difference at two to four weeks for ≥50% NRS improvement. The true positive/true negative group (TP/TN) stratification demonstrated a significant difference for ≥50% NRS improvement at two to four weeks, whereas six-month outcomes for TP/TN demonstrated significant differences for ≥50% NRS and ≥30% ODI improvement. An increased injection response was observed with stratification of patients more likely to have true SIJ pain (i.e., TP), with TP/TN stratification demonstrating a 75% (95% CI = +/-30.0%) ≥2 NRS improvement and a 62.5% (95% CI = +/-33.5%) improvement of ≥50% NRS and ≥30% ODI for the TP group at two to four weeks, with similar results at six months. Conclusions SIJ steroid injection based on referral clinical diagnosis is unlikely to demonstrate true injection efficacy, and more specific selection criteria are warranted. [ABSTRACT FROM AUTHOR]

Background Given the unacceptably high miss rates of non-image-guided injections into the sacroiliac joint, either fluoroscopy or ultrasound is recommended for guidance. The real success rate of both techniques was assessed by cadaver dissection. Methods Twenty bodies donated to science (40 joints: 15 female and 5 male) were investigated bilaterally. Fluoroscopy and a lower ultrasound-guided approach were performed in 10 bodies each. Conditions during puncture, the subjective feeling of the needle being intra-articular, and, for fluoroscopic guidance, the intra-articular spread of the contrast were assessed. First, 0.5 cc of Iopamidol was injected, followed by 2 mL of red-colored latex. The spread was investigated by dissection via anterior opening of the sacroiliac joint and the dorsal ligaments. Results Ultrasound guidance was used in 1/20 (5%, 95% CI = 0.9–23.6%) intra-articular injections. In 19/20 (95%, 95% CI = 0.9–23.6%) cases, latex spread in the interosseous sacroiliac ligament was used. Conditions of structural visibility were classified as good in 11/20 (55%, 95% CI = 34.2–74.2%) cases, puncture condition as good in 16/20 (80%, 95% CI = 58.4–91.9%) cases, and subjective feeling of the needle being intra-articular was present in 10/20 (50%, 95% CI = 34.2–74.2%) cases. Fluoroscopy showed an intra-articular injection in 10/20 (50%, 95% CI = 34.2–74.2%) cases. The structure visibility in fluoroscopy was good in 9/20 (45%, 95% CI = 25.8–65.8%), puncture conditions good in 8/20 (40%, 95% CI = 21.9–61.3%), intra-articular contrast spread visible in 10/20 (50%, 95% CI = 34.2–74.2%), and subjective feeling of being intra-articular was present in 17/20 (85%, 95% CI = 64.0–94.8%) cases. Conclusions Fluoroscopy clearly showed a higher success rate of intra-articular sacroiliac joint injection. [ABSTRACT FROM AUTHOR]

Radiofrequency ablation (RFA) of the sacral lateral branches targets the innervation of the posterior sacroiliac ligaments and posterior portion of the sacroiliac joint, also referred to as the posterior sacroiliac joint complex. This review assesses the published evidence on local anesthetic blocks for the diagnosis of posterior sacroiliac joint complex pain and the efficacy of RFA of the sacral lateral branches as a treatment. The current evidence suggests that RFA can provide relief of pain that originates from the posterior sacroiliac joint complex, but interpretation of this literature is limited by variability in patient selection criteria, the specific nerves targeted for ablation, and the types of RFA technology and technique utilized. [ABSTRACT FROM AUTHOR]

Injections into the intraarticular sacroiliac joint (SIJ) are commonly done for both diagnostic and therapeutic reasons. Injection of an anesthetic can aid in the diagnosis of SIJ pain. Corticosteroids can be administered with the goal of providing a therapeutic effect. This article summarizes the literature regarding the diagnostic and therapeutic effects of these injections. It includes a review of the various imaging modalities including fluoroscopy, ultrasound, and computed tomography guidance, as well as a discussion on the prevalence data and other variables that may affect the reported outcomes. [ABSTRACT FROM AUTHOR]

Accurate diagnosis of sacroiliac joint (SIJ) pain is challenging. Diagnosis can be aided by pain referral patterns, historical features, physical examination maneuvers, and imaging. However, all of these diagnostic tools have limitations. The most reliable clinical tools may be a combination of three or more positive physical exam maneuvers, although the evidence is inconsistent even for this strategy. Intra-articular diagnostic SIJ injections are often used as the reference standard for "true" sacroiliac pain. However, such injections do not consider extra-articular sources of pain that may also exist as part of the sacroiliac joint complex. Research has established the posterior sacral ligaments as a possible source of pain, and the innervation of these ligaments has been anatomically defined. It is possible that by expanding our focus from the articular portion of the sacroiliac complex structure to both the joint and extra-capsular ligaments, advancements in clinical diagnosis and treatment will be possible. [ABSTRACT FROM AUTHOR]

Objective To determine if intra-articular (IA) injection of corticosteroids is effective in reducing the need for radiofrequency ablation (RFA) in those with dual comparative medial branch block (MBB)–confirmed lumbar z-joint pain. Design This was a randomized, double blind, placebo-controlled study. Setting Two academic medical centers. Subjects Fifty-six consecutive subjects who had ≥80% pain relief during an initial screening MBB were recruited. Methods Patients received a second confirmatory MBB and concurrent IA injection of either corticosteroid or saline per randomization. Twenty-nine of 56 received intra-articular corticosteroid (triamcinolone 20 mg), of whom 24 also had a positive confirmatory MBB per Spine Interventional Society guidelines, with ≥80% pain relief from both MBBs. Twenty-seven of 56 received IA saline into the z-joint during the confirmatory MBB, of whom 22 also had a positive confirmatory MBB. The primary outcome measure was the categorical need for RFA due to insufficient pain relief with intra-articular injection, and the secondary outcome was time to RFA. Results There was no statistically significant difference in the need for an RFA between the groups (16/24 steroid, 67%, 95% confidence interval [CI] = 47–82%) vs 15/22 saline (68%, 95% CI = 47–84%, P  = 1.00). The average time to RFA was also not different, at 6.00 weeks for steroids vs 6.55 weeks for saline (P  = 0.82). Conclusions Intra-articular corticosteroids were not effective in reducing the need for or the time to a radiofrequency ablation of the medial branches in those with dual MBB–confirmed lumbar z-joint pain. [ABSTRACT FROM AUTHOR]

Objective To assess the effect depression has on outcomes after cervical epidural steroid injections (CESIs). Design Retrospective review of a prospectively collected database. Setting Single institution tertiary care center. Subjects Fifty-seven patients with cervical spondylosis and cervical radicular pain who were deemed appropriate surgical candidates but elected to undergo CESI first were included. Methods Twenty-one of 57 (37%) patients with depression (defined as Zung Depression Scale >33) were included. Patient-reported outcomes including Neck Disability Index (NDI), numeric rating scale (NRS) for arm pain (AP), NRS for neck pain (NP), and EuroQol-5D (EQ-5D) were collected at baseline and three-month follow-up. Minimal clinically important differences were then calculated to provide dichotomous outcome measures of success. Results Overall, 24 and 28 patients achieved at least 50% improvement in AP and NP, respectively. In terms of disability, 25/57 (43.9%) patients achieved >13.2-point improvement on the NDI overall. In patients with depression, 4/21 (19.0%) and 5/21 (23.8%) achieved at least 50% improvement on the NRS for AP and NP, respectively, compared with 20/36 (55.5%) and 23/36 (63.8%) in patients without depression. This difference was statistically significant for both pain measures (P  < 0.002 AP, P  < 0.006 NP). Statistically fewer patients, 5/21 (24%), with depression achieved ≥13.2-point improvement on the NDI compared with 20/36 (55%) nondepressed patients (P  < 0.01). There was no difference in outcomes between groups on the EQ-5D. Conclusions Patients with cervical spondylosis and comorbid depression who undergo CESI are less likely to achieve successful outcomes in both pain and function compared with nondepressed patients at three months. [ABSTRACT FROM AUTHOR]

The article offers information on the changes in Orthopaedic rehabilitation in the management of musculoskeletal disorders. It mentions an increased focus on opioid use in the U.S. and also multicenter cross-sectional survey of emergency department providers who prescribe opioid medications characterized current prescribing trends in U.S. emergency departments.

Objectives. To determine if immediate pain response following an injection with local anesthetic and corticosteroid predicts subsequent relief. Design. Prospective observational cohort. Setting. An institutional review board-approved prospective study from a single academic medical center. Methods. Patients with clinical diagnosis of sacroiliac (SIJ) pain and referred for SIJ injection were enrolled; 1 cc of 2% lidocaine and 1 cc of triamcinolone 40 mg/mL were injected into the SIJ. Pain score on 0-10 numeric rating scale (NRS) during provocation maneuvers was recorded immediately before injection, immediately after injection, and at two and four weeks of follow-up. Oswestry Disability Index (ODI) was also recorded. Results. Various cutoffs were identified to establish positive anesthetic response and successful outcomes at follow-up. These were used to calculated likelihood ratios. Of those with 100% anesthetic response, six of 11 (54.5%, 95% confidence interval [CI]1/229.4%, 1LR 2.6, 95% CI51.1-5.9) demonstrated 50% or greater pain relief at follow-up, and four of 11 (36.5%, 95% CI1/228.4%, 1LR 3.00, 95% CI51.4-5.1) had 100% relief at two to four weeks. Fourteen of 14 (100%, 95% CI1/221.5%, 2LR 0.0, 95% CI50.0-2.1) with an initial negative block failed to achieve 100% relief at follow-up. Conclusions. Patients who fail to achieve initial relief after SIJ injection with anesthetic and steroid are very unlikely to achieve significant pain relief at follow-up; negative likelihood ratios (LR) in this study, based on how success is defined, range between 0 and 0.9. Clinically significant positive likelihood ratios of anesthetic response to SIJ injection are more limited and less robust, but are valuable in predicting 50% relief or 100% relief at two to four weeks. [ABSTRACT FROM AUTHOR]

The article offers information on various advancements in orthopaedics. Topics discussed include the value driven reimbursement system adopted in Utah which aims to promote cost effectiveness while offering positive medical outcome, the effectiveness of the Ponseti treatment, a novel treatment methodology for congenital clubfoot in children, and the use of Liposomal bupivacaine in providing long term pain relief for postoperative anterior cruciate ligament pain.

In this article, the author discusses the challenges of research interventions for low back pain and randomized trial of glucocorticoid intradiscal injection for patients with chronic low back pain associated with active discopathy. It mentions researchers followed the National Institutes of Health recommendations and patients who received glucocorticoid intradiscal injection. It also mentions patients progress to chronic low back pain, a leading cause of disability worldwide.

The article focuses on comparative or noncomparative dual medial branch blocks (MBBs) be used to select individuals with low back pain for medial branch radiofrequency neurotomy (MBRFN). Topics include the effectiveness of lumbar MBRFN stratified by diagnostic methods and procedural technique, and the authors indicated that comparative blocks have been validated in a placebo-controlled study of cervical MBBs, but that the analogous study for lumbar MBBs has yet to be conducted.

A correction is presented to the article "Does Immediate Pain Relief after an Injection into the Sacroiliac Joint with Anesthetic and Corticosteroid Predict Subsequent Pain Relief."

The article discusses the study of Anticoagulants and Antiplatelets for Lumbar Medial Branch Blocks. Topics discussed include Therapeutic anticoagulation (AC) and antiplatelet agents (APAs) should be discontinued prior to lumbar medial branch blocks (LMBBs) due to hemorrhagic risks of clinically significant neurological complications; and demonstrated zero hemorrhagic complications for consecutive patients for which AC and APA therapy was continued during LMBBs.

The article focuses on the Epidural steroid injections (ESIs), a low risk procedure used to treat radicular pain. It mention that there is limited evidence related to infection risk associated with lumbar microdiscectomy. It also mentions the relationship between preoperative ESI and spinal surgery is of insufficient quality to draw definitive conclusions.

The article discusses that Epidural steroid injections (ESIs) can be repeated without concern regarding the duration of time between injections; and mentions the frequency of ESIs is dependent on both the number of injections performed within a given time period and the amount of time that has passed between repeat injections.

The article examines that exposure to steroid via epidural injection introduces risk of potential systemic side effects due to steroid. It explores the Cumulative Lifetime Steroid Exposure via Epidural Administration. It further discusses the set number of epidural steroid injections (ESIs) that is safe over the course of a patient's life.

The article presents the Practice Guidelines for Preoperative Fasting from the American Society of Anesthesiology (ASA). The recommendations for healthy adults include an acceptable light meal six hours before and clear liquids might be consumed up to two hours before anesthesia. The recommendations of ASA for fasting do not apply to patients undergoing procedures having no anesthesia or just local anesthesia.

The article sheds insights into patient safety concerns associated with sedation and analgesia. One of the myth associated with conscious sedation is that it is typically needed when performing most interventional pain procedures. A continuum of states of consciousness ranging from minimal sedation to general anesthesia is included in sedation and analgesia.

The article reports that the intra-articular administration of steroids may result in hyperglycemia in diabetic patients and in nondiabetic patients. The complications are rare, but may be mitigated with proper evaluation of existing risk factors, patient education, and close. Intra-articular injection of steroids is commonly performed to treat sacroiliac.