Search

Objective: To perform a thorough assessment of the recently published Mint Trials in order to illustrate how to read and analyze a study critically, according to principles of evidence-based medicine., Design: Narrative review., Method: We have applied the recently published guidelines for composing and assessing studies on the treatment of pain to a recently published article describing a large study that claimed its "findings do not support the use of radiofrequency denervation to treat chronic low back pain." These guidelines describe the critical components of a high-quality manuscript that allows communication of all relevant information from authors to readers., Results: Application of evidence-based medicine principles to the publication describing the Mint Trials reveals significant issues with the methodology and conclusions drawn by the authors. A thorough assessment demonstrates issues with inclusion/exclusion criteria, diagnostic block protocols, radiofrequency neurotomy technique, co-interventions, outcome measurement, power analysis, study sample characteristics, data analysis, and loss to follow-up. A failure to definitively establish a diagnosis, combined with use of an inadequate technique for radiofrequency neurotomy and numerous other methodological flaws, leaves the reader unable to draw meaningful conclusions from the study data., Conclusions: Critical analysis, rooted in principles of evidence-based medicine, must be employed by writers and readers alike in order to encourage transparency and ensure that appropriate conclusions are drawn from study data.

Background and Objectives: Genicular nerve radiofrequency ablation is an effective treatment for patients with chronic pain due to knee osteoarthritis; however, little is known about factors that predict procedure success. The current study evaluated the utility of genicular nerve blocks to predict the outcome of genicular nerve cooled radiofrequency ablation (cRFA) in patients with osteoarthritis., Methods: This randomized comparative trial included patients with chronic knee pain due to osteoarthritis. Participants were randomized to receive a genicular nerve block or no block prior to cRFA. Patients receiving a prognostic block that demonstrated ≥50% pain relief for six hours received cRFA. The primary outcome was the proportion of participants with ≥50% reduction in knee pain at six months., Results: Twenty-nine participants (36 knees) had cRFA following a prognostic block, and 25 patients (35 knees) had cRFA without a block. Seventeen participants (58.6%) in the prognostic block group and 16 (64.0%) in the no block group had ≥50% pain relief at six months (P = 0.34). A 15-point decrease in the Western Ontario and McMaster Universities Osteoarthritis Index at six months was present in 17 of 29 (55.2%) in the prognostic block group and 15 of 25 (60%) in the no block group (P = 0.36)., Conclusions: This study demonstrated clinically meaningful improvements in pain and physical function up to six months following cRFA. A prognostic genicular nerve block using a local anesthetic volume of 1 mL at each injection site and a threshold of ≥ 50% pain relief for subsequent cRFA eligibility did not improve the rate of treatment success.

Corticosteroid injections are commonly used in the treatment of disorders of the large joints. This review assimilates the available literature on corticosteroid injections into the glenohumeral joint, subacromial space, hip joint, and knee joint. A systematic method to review available literature revealed 84 articles that fit the inclusion criteria. For each injection location, four items were examined: overall efficacy of injection, superior type of steroid, superior dose of steroid, and superior volume of injectate. Most research demonstrates positive short-term outcomes in pain and function for corticosteroid injections of the large joints. Methylprednisolone and triamcinolone seem similar in efficacy, with minor differences seen in specific studies. Larger doses may last longer, but need to be balanced with the systemic effects from higher doses. Volume has not been studied extensively. Due to heterogeneity in study types, subject populations, and outcomes, it is not possible to identify a single defining trend for a superior type, dose, or volume of steroid. Future prospective studies examining these factors may better reveal the optimum regimen for each injection location., Level of Evidence: III., (Copyright © 2018 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the risks of continuing or ceasing anticoagulant or antiplatelet medications prior to image-guided procedures for spine pain., Design: Systematic review of the literature with comprehensive analysis of the published data., Interventions: Following a search of the literature for studies pertaining to spine pain interventions in patients on anticoagulant medication, seven reviewers appraised the studies identified and assessed the quality of evidence presented., Outcome Measures: Evidence was sought regarding risks associated with either continuing or ceasing anticoagulant and antiplatelet medication in patients having image-guided interventional spine procedures. The evidence was evaluated in accordance with the Grades of Recommendation, Assessment, Development, and Evaluation system., Results: From a source of 120 potentially relevant articles, 14 provided applicable evidence. Procedures involving interlaminar access carry a nonzero risk of hemorrhagic complications, regardless of whether anticoagulants are ceased or continued. For other procedures, hemorrhagic complications have not been reported, and case series indicate that they are safe when performed in patients who continue anticoagulants. Three articles reported the adverse effects of ceasing anticoagulants, with serious consequences, including death., Conclusions: Other than for interlaminar procedures, the evidence does not support the view that anticoagulant and antiplatelet medication must be ceased before image-guided spine pain procedures. Meanwhile, the evidence shows that ceasing anticoagulants carries a risk of serious consequences, including death. Guidelines on the use of anticoagulants should reflect these opposing bodies of evidence.

Cervical epidural steroid injections are a common treatment of cervical radicular pain. Important safety considerations include attention to the possibility of spinal cord infarction and spinal epidural hematoma. When appropriate, radiographic, technical, and pharmacologic principals are used, these procedures are relatively safe. Cervical epidural steroid injections are effective for the short-term treatment of radicular pain. More rigorously designed clinical outcomes studies of both cervical interlaminar and transforaminal epidural steroid injections are needed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

A 77 year old man with a biventricular ICD-pacemaker complained of painful, electric jolts disturbing him nightly from sleep. Extensive work-up including device interrogation revealed no defibrillations or arrhythmia, and he was subsequently diagnosed with phantom shocks (PS). His nightly PS symptoms terminated after starting zolpidem 10 mg each night. To date, literature review reveals fifteen articles reporting 163 phantom shock (PS) cases. PS affects 5-9% of ICD recipients. Risk factors include psychiatric disease, atrial fibrillation, NYHA functional status III or greater, prior shock storm, and intraoperative awareness during ICD placement, with defibrillation threshold testing. This report describes a successful PS intervention, and reviews the current knowledge available in the pathophysiology and treatment of PS., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background Context: Patients with lumbosacral radiculopathy from an intervertebral disc herniation are frequently treated by transforaminal epidural steroid injections (TFESIs). The long-term outcomes of these patients are poorly described., Purpose: We aimed to determine the long-term outcomes for a homogenous group of patients with acute unilateral lumbar radicular pain due to single-level herniated nucleus after lumbar epidural steroid injection at ≥5 years., Design: This is a prospective cohort study., Patient Sample: Subjects enrolled into a previous reported multi-institutional randomized controlled trial, ≥18 years old with single leg radicular pain rating ≥4/10 for less than 6 months' duration, with radiographic imaging demonstrating an anatomically congruent single-level herniated nucleus pulposus., Outcome Measures: Presence of recurrent or persistent pain, pain within the previous week, current opioid use for radicular symptoms, additional spine injections for radicular pain, progression to surgery, and unemployment due to pain as determined by independent phone interview at least 5 years after enrolment due to the initial pain complaint were the outcome measures., Methods: All patients initially underwent a single-level lumbar TFESIs due to failure of conservative care, but could elect to pursue surgical intervention or repeat injections through shared decision making with the treating physician when and if pain control was deemed inadequate. After ≥5 years, an independent assessor contacted the subjects by phone and performed a standardized interview to determine outcomes. Fisher exact test was used to compare outcomes for those who pursued versus those who did not pursue surgery., Results: During the recruitment period (December 2008 to December 2012), 78 subjects were enrolled. At 5 years, 39 (50%) of the 78 subjects were reachable for independent phone follow-up. Of these, 30 (76.9%, 95% confidence interval [CI] 61.7%-87.4%) had a history of recurrent pain since the initial TFESI. However, only 9 (23.1%, 95% CI 12.7%-38.3%) had current pain, while 3 (7.7%, 95% CI 2.7%-20.3%) were currently taking opioid medications. Nine (23.1%, 95% CI 12.7%-38.3%) had received additional TFESIs, and 19 (48.7%, 95% CI 33.9%-63.8%) had received surgery. Only 3 (7.7%, 95% CI 2.7%-20.3%) were unemployed due to related pain at time of follow-up. When comparing the group that had surgery versus those that did not, there were no differences in the rates of recurrent pain (16, 84.2% vs. 14, 70.0%, p=.81), current pain (6, 31.6% vs. 3, 15.0%, p=.47), opioid use (2, 10.5% vs. 1, 5.0%, p=1.00), rate of additional injections (6, 31.6% vs. 3, 15.0%, p=.47), or unemployment status (2, 10.5% vs. 1, 5.0%, p=1.00)., Conclusions: Despite a high success rate at 6 months, the majority of subjects experienced a recurrence of symptoms at some time during the subsequent 5 years. Fortunately, few reported current symptoms, and a small minority required additional injections, surgery, or opioid pain medications. Lumbar disc herniation is a disease that can be effectively treated in the short-term by TFESI or surgery, but long-term recurrence rates are high regardless of treatment received., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Low-dose local anesthetic is often used in cervical interlaminar epidural steroid injections (CIESI), yet its effect on upper extremity strength has not been studied. The presence of consequent weakness has potential implications for postprocedure safety. This study aimed to determine whether low-dose lidocaine in a C7-T1 CIESI causes objective weakness., Design: Prospective case series., Setting: Academic pain center., Subjects: Adults, cervical radicular pain., Methods: Participants underwent CIESI with 1 mL of 1% lidocaine (3 mL total injectate). Elbow flexion (EF), wrist extension (WE), elbow extension (EE), and handgrip strength were measured by dynamometry at baseline, 15 minutes, and 30 minutes postinjection. Changes in strength from baseline and the proportion of participants with a minimum perceptible change in EF, WE, EE, and handgrip strength (≥20%) and 95% confidence intervals (CIs) were calculated., Results: Twenty-seven participants were included. At 15 and 30 minutes postinjection, there was no within-participant difference in EF, WE, EE, and handgrip strength from baseline overall. Nonetheless, five (19%, 95% CI = 4-33) of the participants demonstrated a 20% or greater strength decrease in at least one myotomal distribution. A 20% or greater decrease in strength was present in left EF 4% (95% CI = 0-11%), right EF 7% (95% CI = 0-17%), left WE 4% (95% CI = 0-11%), and right WE 7% (95% CI = 0-17%)., Conclusions: The present data suggest that CIESI with an injectate volume of 3 mL that includes 1 mL of 1% lidocaine may result in objective upper extremity weakness that is above the minimum threshold of perception in a subset of patients., (© 2017 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Study Objective: To review research highlights of manuscripts published in 2016 that pertain to all aspects of the clinical practice of anesthesiology., Design: Narrative review., Setting: N/A., Materials: The major themes address broad categories of general anesthesia including airway management, abdominal surgery, and obstetrical and gynaecological anesthesia. In addition, recent advancements in specialties of anesthesiology including regional anesthesia are reviewed., Interventions: N/A., Main Results: N/A., Conclusions: This recent body of evidence will both help inform anesthesiologists of the developing trends in anesthesiology and will also pose new challenges for further studies., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Determine outcomes of cooled radiofrequency ablation (C-RFA) of the genicular nerves for treatment of chronic knee pain due to osteoarthritis (OA)., Design: Cross-sectional survey., Setting: Academic pain medicine center., Subjects: Consecutive patients with knee OA and 50% or greater pain relief following genicular nerve blocks who underwent genicular nerve C-RFA., Methods: Survey administration six or more months after C-RFA. Pain numeric rating scale (NRS), Medication Quantification Scale III (MQSIII), Patient Global Impression of Change (PGIC), and total knee arthroplasty (TKA) data were collected. Logistic regression was used to identify factors that predicted treatment success., Results: Thirty-three patients (52 discrete knees) met inclusion criteria. Thirty-five percent (95% confidence interval [CI] = 22-48) of procedures resulted in the combined outcome of 50% or greater reduction in NRS score, reduction of 3.4 or more points in MQSIII score, and PGIC score consistent with "very much improved/improved." Nineteen percent (95% CI = 10-33) of procedures resulted in complete pain relief. Greater duration of pain and greater than 80% pain relief from diagnostic blocks were identified as predictors of treatment success. The accuracy of the model was 0.88 (95% CI = 0.78-0.97, P  <   0.001)., Conclusions: Genicular C-RFA demonstrated a success rate of 35% based on a robust combination of outcome measures, and 19% of procedures resulted in complete relief of pain at a minimum of six months of follow-up. Report of 80% or greater relief from diagnostic blocks and duration of pain of less than five years are associated with high accuracy in predicting treatment success. Further prospective study is needed to optimize the patient selection protocol and success rate of this procedure., (© 2017 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Background: The challenge of obtaining medical imaging in individuals with higher body mass index (BMI) is described, but there is minimal data regarding the relationship between BMI and fluoroscopy time during cervical interlaminar epidural steroid injection (CIESI)., Objective: To determine the relationship between BMI and fluoroscopy time during CIESI., Methods: Retrospective cohort study of patients who underwent fluoroscopically guided CIESI between January 2014 and February 2015 at an academic pain medicine center. Fluoroscopy time data were collected. Comparisons based on analysis of variance were made between patients with normal (<25.0 kg/m 2 ), overweight (25.0-29.9 kg/m 2 ), and obese (≥30.0 kg/m 2 ) BMI., Results: Of 399 procedure encounters, 366 had documented BMI and fluoroscopy time data and were included for analysis. Mean age (± SD) in this cohort was 53 ± 13 years, including 189 females (52%) and 205 first-time injections. Mean fluoroscopy time for all injections was 18 ± 10 seconds. Separated by categorical BMI class, the mean fluoroscopy time was 18 ± 9 seconds for normal weight patients, 17 ± 10 seconds for overweight patients, and 20 ± 11 seconds for obese patients, respectively. Post hoc analysis showed that fluoroscopy time was significantly longer only in obese compared with overweight patients ( P  = 0.02). Trainee involvement and first-time vs repeat injection did not significantly alter fluoroscopy time ( P  = 0.17 and P  = 0.12, respectively)., Conclusions: The findings of this study indicate that BMI does not appear to have a clinically significant impact on fluoroscopy time during cervical interlaminar epidural steroid injection procedures. Future study is needed to directly quantify radiation exposure in patients and practitioners, as well as the associated health risk., (© 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Background: Higher body mass index (BMI) is associated with difficulty in obtaining imaging studies. While there is a small body of literature regarding the relationship between fluoroscopy time and BMI during injections for pain management, this has not been studied for intraarticular (IA) hip injections. Further, in academic training centers, trainee involvement may affect this relationship., Objective: To determine the relationship between BMI and fluoroscopy time during IA hip injections, both with and without involvement of a trainee., Study Design: Multicenter retrospective cohort study., Setting: Three academic, outpatient musculoskeletal and pain medicine centers., Methods: Patients who underwent fluoroscopically guided IA hip injections with encounter data regarding fluoroscopy time during the procedure and BMI were included. Mean and standard deviation fluoroscopy time were recorded. Comparisons were made between BMI categories of normal (18.5 - 24.9 kg/m2), overweight (25.0 - 29.9 kg/m2), and obese (greater than or equal to30.0 kg/m2). Statistical significance was set at P = 0.01 due to multiple comparisons., Results: A total of 559 IA hip injections are represented in this cohort. Patients had a mean age of 58 (standard deviation [SD] 14) years and 63% were women. There was no significant difference in fluoroscopy time when comparing BMI categories (P = 0.02). However, when trainees were not involved in the injection, fluoroscopy times were significantly shorter with decreasing BMI category, with normal weight patients requiring the shortest fluoroscopy times (P = 0.01)., Limitations: This study evaluated total fluoroscopy time, not radiation dose exposure per injection, which provides more direct and precise information with regard to provider and patient radiation exposure and overall safety. Future study of the impact of BMI on radiation dose during fluoroscopically guided IA hip injections is needed., Conclusions: Fluoroscopy times during IA hip injections increase with higher BMI categories in a statistically significant manner when performed by experienced clinicians but this relationship is not observed when injections are performed with a trainee in a teaching institution. This finding appears to be related to longer fluoroscopy time required to complete an IA hip injection in patients with lower BMI when a trainee is involved., Key Words: Hip, injections, obesity, overweight, body mass index, fluoroscopy, radiation, pain.

Background: Intrathecal baclofen (ITB) often is used to treat severe spasticity of cerebral origin. Although literature exists regarding the efficacy of ITB, there has been minimal investigation related to dosing in the adult-acquired brain injury population, particularly at long-term duration., Objective: To investigate long-term dosing of ITB in adult patients with spasticity of cerebral origin due traumatic brain injury (TBI), stroke, and hypoxic-ischemic encephalopathy (HIE)., Design: Retrospective cohort study., Setting: An academic outpatient rehabilitation clinic., Patients: Forty-two adult patients with spasticity secondary to TBI, stroke, or HIE treated with ITB for greater than 3 years., Methods: Medical records and device manufacturer records of included patients were reviewed to obtain demographic data, dosing information, dates of pump and catheter placements, and revisions., Main Outcome Measure: Average daily ITB doses and mean change in ITB dose over 1, 2, and 3 years. Goal of ITB treatment (active function versus comfort/care/positioning) also was compared., Results: Of 42 total patients, spasticity was attributed to either TBI (n = 19), stroke (n = 11), or HIE (n = 12). The mean (standard deviation) age was 35.21 (10.17), 56.7 (13.1), and 35.1 (12.4) years for the TBI, stroke, and HIE groups, respectively (P < .001). There was a significant difference in the goal of therapy with "improving functional independence," accounting for 27.8%, 72.8%, and 0% in the TBI, stroke, and HIE groups, respectively (P = .002). The mean duration of ITB therapy was 8.5 (5.0), 7.8 (3.4), and 9.1 (4.6) years in the TBI, stroke, and HIE groups, respectively (P = .79). The mean daily ITB dose was 596.9 (322.8) μg/d, 513.2 (405.7) μg/d, and 705.2 (271.7) μg/d for the TBI, stroke, and HIE groups, respectively (P = .39). In the subset of the cohort with ITB therapy for more than 5 years, the mean percent change in daily ITB dose between time of chart review and 1, 2, and 3 years previously was 7.3% (13.6), 12.7% (16), and 24.7% (50.3), respectively. A complex dosing pattern was used more frequently in those with stroke (36.4%) compared with the TBI and HIE (9.7%) groups (P = .04)., Conclusion: Despite the long-term use of ITB therapy in this cohort, the mean daily dose of ITB continued to require adjustments. There was no significant difference in the mean daily dose between patients with a diagnosis of TBI, stroke, or HIE. A complex dosing pattern was used more frequently in patients with stroke., Level of Evidence: III., (Copyright © 2017 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the relationship between body mass index (BMI) and fluoroscopy time and radiation dose during fluoroscopy-guided glenohumeral joint injections., Methods: This was a retrospective analysis of prospectively collected data. Physicians with board certification in Physical Medicine and Rehabilitation and/or Sports Medicine performed or supervised all injections. BMI was calculated within three months of the injection. Fluoroscopy time and radiation dose data were recorded by the fluoroscopy system and transcribed into the clinical database after each procedure., Results: A total of 335 intra-articular GHJ injections were performed, 230 on the right shoulder and 105 on the left shoulder; none were bilateral. The mean fluoroscopy time for all injections was 18.8±12.6s, and the mean radiation DAP was 656±1190mGy-cm2. There was no significant difference in fluoroscopy time or dose between first-time and repeat injections (P=.405; P=.011) and no significant differences in fluoroscopy time or radiation dose when a trainee was involved (P=.756 for time and P=.149 for dose). Needle lengths of 1.5, 2.5, or 3.5in. were used during the injection, and there was no significant difference in needle length selection between BMI groups (P=.319)., Conclusions: Intra-articular glenohumeral joint injection fluoroscopy time and radiation dose are not affected by body mass index, age, gender, trainee-involvement, first versus repeat injection, or needle length. This procedure is associated with a dose of radiation that likely has minimal to no clinical significance., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background and Objectives: No study has compared cervical interlaminar epidural steroid injection (CIESI) with epidural catheter advancement to the side and level of pathology versus standard C7-T1 CIESI. This study investigated whether cervical radicular pain is more effectively treated by CIESI with a targeted epidural catheter versus a standard C7-T1 approach., Methods: Prospective, randomized, single-blinded trial., Primary Outcome: Numerical Rating Scale (NRS) pain at 1 month., Secondary Outcomes: Oswestry Neck Disability Index (ONDI), Pain Disability Index (PDI), McGill Pain Questionnaire (MPQ), Patient Global Impression of Change (PGIC), daily morphine equivalents (DME), and Medication Quantification Scale (MQS) III scores., Results: Seventy-six participants with a median age of 48 years (IQR, 40-56 years), 59% female, with C4 (n = 2), C5 (n = 27), or C6 (n = 47) radicular pain were enrolled. At 1 month in the catheter and no catheter groups, respectively: 26 (72%, 95% confidence interval [CI], 57%-87%) and 23 (60%; 95% CI, 45%-75%) participants reported 50% or greater NRS reduction; 24 (67%; 95% CI, 52%-84%) and 23 (58%; 95% CI, 42%-73%) participants reported 30% or greater ONDI reduction. There were no group differences in median NRS, ONDI, PDI, MPQ, PGIC, DME, or MQSIII scores (P > 0.05). Intergroup differences were not observed at any follow-up interval., Conclusions: This trial showed no significant difference in clinical outcomes with CIESI using a targeted epidural catheter compared to a standard C7-T1 approach for the treatment of unilateral cervical radicular pain at the C5 or C6 level. Both techniques were associated with clinically meaningful improvement across outcome domains of pain, function, disability, and medication use. These effects persisted to 6-month follow-up.The study was registered at Clinical Trials.gov (NCT02095197).

Objective: This study aimed to assess the relationship between BMI and fluoroscopy time during lumbar epidural steroid injections (LESIs) performed for lumbosacral radicular pain., Design: Multicenter retrospective cohort study., Setting: Three academic, outpatient pain treatment centers., Subjects: Patients who underwent fluoroscopically guided LESI., Methods: Mean and standard deviation (SD) fluoroscopy time were compared between patients with normal (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30.0 kg/m2) BMI. Statistical significance was set at P=0.01 due to multiple comparisons., Results: A total of 2,930 procedure encounters were included, consisting of 598 interlaminar LESIs and 2,332 transforaminal LESIs. Fluoroscopy time was significantly longer in the obese patients compared to normal and overweight patients during interlaminar LESI (P < 0.01). Fluoroscopy time was significantly longer with each increasing BMI category in during transforaminal LESI (P < 0.01). These relationships remained when a trainee was involved (P < 0.01; P<0.01), during repeat injections (P < 0.01; P < 0.01), and during bilateral transforaminal LESIs (P < 0.01). While longer fluoroscopy times were required in high BMI categories during L5-S1 transforaminal LESI (P < 0.01), there was no relationship between fluoroscopy time and BMI during L4-L5 and S1 transforaminal LESI (P = 0.02; P = 0.13). Fluoroscopy time during interlaminar LESI compared to transforaminal LESI was significantly lower within all BMI categories (all P<0.01)., Conclusions: The findings of this study indicate that fluoroscopy time is increased during interlaminar LESIs and during L5-S1 transforaminal LESIs in patients who are obese. These relationships are not affected by injection number, performance of bilateral injections, or trainee involvement. Further study is needed to determine if this increase in fluoroscopy time is indicative of a clinically significant associated increase in radiation dose., (© 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Setting: Interventional procedures directed toward sources of pain in the axial and appendicular musculoskeletal system are performed with increasing frequency. Despite the presence of evidence-based guidelines for such procedures, there are wide variations in practice. Case reports of serious complications such as spinal cord infarction or infection from spine injections lack appropriate context and create a misleading view of the risks of appropriately performed interventional pain procedures., Objective: To evaluate adverse event rate for interventional spine procedures performed at three academic interventional spine practices., Methods: Quality assurance databases at three academic interventional pain management practices that utilize evidence-based guidelines [1] were interrogated for immediate complications from interventional pain procedures. Review of the electronic medical record verified or refuted the occurrence of a complication. Same-day emergency department transfers or visits were also identified by a records search., Results: Immediate complication data were available for 26,061 consecutive procedures. A radiology practice performed 19,170 epidural steroid (primarily transforaminal), facet, sacroiliac, and trigger point injections (2006-2013). A physiatry practice performed 6,190 spine interventions (2004-2009). A second physiatry practice performed 701 spine procedures (2009-2010). There were no major complications (permanent neurologic deficit or clinically significant bleeding [e.g., epidural hematoma]) with any procedure. Overall complication rate was 1.9% (493/26,061). Vasovagal reactions were the most frequent event (1.1%). Nineteen patients (<0.1%) were transferred to emergency departments for: allergic reactions, chest pain, symptomatic hypertension, and a vasovagal reaction., Conclusion: This study demonstrates that interventional pain procedures are safely performed with extremely low immediate adverse event rates when evidence-based guidelines are observed., (© 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The corticosteroid choice for a lumbar transforaminal epidural steroid injection (TFESI) remains controversial. Whether to utilize particulate or nonparticulate steroid preparations for these injections remains an unanswered question in the literature., Objective: To determine if a particulate or nonparticulate steroid is more effective in the treatment of electromyography (EMG)-confirmed lumbosacral radiculopathy., Design: Multicenter retrospective cohort study., Setting: Two tertiary academic spine centers., Patients: Consecutive patients, aged 18 years or older, with EMG-confirmed lumbosacral radiculopathy., Interventions: TFESI with a particulate or nonparticulate steroid to treat radicular pain within 6 months of EMG., Main Outcome Measures: The primary outcome was the proportion of patients with ≥50% pain reduction on the numerical rating scale after TFESI. Secondary outcomes included mean numerical rating scale score reduction and number of repeat TFESIs. Short-term (<30 days) and intermediate (≥30 days) outcomes were compared between patients who received a TFESI with a particulate versus nonparticulate steroid., Results: Seventy-eight patients, with an age ± standard deviation of 56 ± 16 years and a mean symptom duration of 49 ± 71 months, were included. Forty-one patients (52%) received dexamethasone, 23 (30%) received triamcinolone, and 14 (18%) received betamethasone. There was no statistically significant difference in the proportion of patients who reported ≥50% pain reduction between the particulate and nonparticulate groups at short-term follow-up (35%; 95% confidence interval [CI], 21-51 versus 28%; 95% CI, 13-43) or at intermediate follow-up (40%; 95% CI, 21-59 versus 39%; 95% CI, 19-59). There was no difference in the mean number of injections administered between groups at intermediate follow-up (P = .26)., Conclusions: This study demonstrates no significant differences in pain reduction or the number of repeat injections with particulate compared with nonparticulate transforaminal epidural steroid injection in patients with EMG-confirmed painful lumbosacral radiculopathy. These findings suggest a new population for whom nonparticulate steroid appears to be an appropriate first-line therapy, although confirmation with a randomized study is needed., Level of Evidence: III., (Copyright © 2016 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Background: Intra-articular hip injections are commonly performed for both diagnostic and therapeutic interventions. Because of the risk of damage to neurovascular structures, fluoroscopic guidance with injection of contrast material has been established as the gold standard to ensure proper needle placement into the intra-articular space. However, fluoroscopically guided intra-articular hip injections put patients at risk due to radiation exposure., Objective: To examine the relationship between body mass index (BMI) and fluoroscopy time and radiation dose during intra-articular hip injections., Design: Retrospective study., Setting: The study was conducted at an academic orthopedic center. All procedures were performed by physicians board-certified in PM&R and/or with subspecialty certification in sports medicine, or by a trainee under close supervision from an attending physician., Participants: All patients who underwent fluoroscopically guided intra-articular hip injections between the years 2003-2014 with a documented height/weight, fluoroscopy time, and radiation dose., Interventions: All patients received unilateral or bilateral intra-articular hip injections with fluoroscopic guidance. Fluoroscopy time and dose were recorded., Main Outcome Measures: The main outcome measures were fluoroscopy time and radiation dose. A Bonferroni correction was implemented for multiple comparisons, defining statistical significance at P < .01., Results: A total of 438 subjects (446 injections) were included. Mean fluoroscopy times were 17.4 ± 9.9, 17.5 ± 11.4, and 19.1 ± 13.4 seconds for normal, overweight, and obese body mass (BMI) index groups, respectively, with no significant difference between groups (P = .148). The mean radiation doses were 601 ± 690, 678 ± 558, and 1049 ± 812 mGy-cm(2), respectively (P < .001, r = 0.29). There was no association of age (P = .03), needle length (P = .34) or trainee involvement (P = .159) with fluoroscopy time., Conclusion: This study demonstrates that increasing BMI leads to elevated radiation dose during fluoroscopically guided intra-articular hip injections. The increased radiation experienced by patients with a larger BMI, however, is likely negligible., (Copyright © 2016 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Intrathecal baclofen (ITB) therapy is a common treatment used to reduce spasticity due to neurologic disorders and injuries. A variety of factors can increase the difficulty of ITB pump refill. Excess subcutaneous fat overlying the pump, spasticity, suboptimal positioning, pump rotation or inversion, and scar formation over the reservoir fill port can create challenges during pump refill. As a result, multiple unsuccessful attempts at accessing the reservoir fill port can be painful and increase the risk of infection, particularly when repeat skin puncture is required. Blind attempts to refill a pump in challenging cases may also result in subcutaneous injection or pocket fill, resulting in a potentially fatal baclofen withdrawal syndrome. We describe 3 successful ITB pump refills in technically challenging cases when using ultrasound guidance. This represents an innovative approach to using ultrasound guidance to facilitate ITB refill in adults with intractable spasticity. We present these new clinical data with a literature review of potential complications related to inaccurate pump refill procedures and discuss the utility of ultrasound guidance for preventing such adverse events.

Background: Chronic knee pain from osteoarthritis (OA) is common in the aging and the obese population. Radiofrequency ablation of the genicular nerves has been introduced as a potential surgery-sparing treatment for chronic knee pain from OA, yet only two outcome studies have been published and optimal patient selection for this procedure has not been established., Objectives: We describe a standardized protocol for selecting patients for cooled radiofrequency ablation (C-RFA) of the genicular nerves, as well as the clinical outcomes of four patients ages 63-65 years., Methods: The threshold for selection based on diagnostic genicular nerve block was ≥ 80% pain reduction. Following successful block, C-RFA of the genicular nerves was performed. Outcomes included pain, function, analgesic medication use, opioid use, and progression to total knee arthroplasty at a minimum of 6 month follow up., Results: C-RFA of the genicular nerves after using the described selection protocol resulted in > 90% pain reduction, improved function and avoidance of surgery at 6 months in all four cases. All opioid and analgesic medication use decreased or was unchanged in all cases. No serious adverse events occurred., Conclusions: The accompanying case series suggests that this protocol is deserving of randomized, prospective study.

Objective: To determine the relationship between BMI and fluoroscopy time during intra-articular sacroiliac joint (SIJ) injections performed for a pain indication., Design: Multicenter retrospective cohort study., Setting: Three academic, outpatient pain treatment centers., Subjects: Patients who underwent fluoroscopy guided SIJ injection with encounter data regarding fluoroscopy time during the procedure and body mass index (BMI)., Main Outcome Measure: Median and 25-75% Interquartile Range (IQR) fluoroscopy time., Results: 459 SIJ injections (350 patients) were included in this study. Patients had a median age of 57 (IQR 44, 70) years, and 72% were female. The median BMI in the normal weight, overweight, and obese groups were 23 (IQR 21, 24), 27 (IQR 26, 29), and 35 (IQR 32, 40), respectively. There was no significant difference in the median fluoroscopy time recorded between these BMI classes (p = 0.45). First-time SIJ injection (p = 0.53), bilateral injection (p = 0.30), trainee involvement (p = 0.47), and new trainee involvement (trainee participation during the first 2 months of the academic year) (p = 0.85) were not associated with increased fluoroscopy time for any of the three BMI categories., Conclusions: Fluoroscopy time during sacroiliac joint injection is not increased in patients who are overweight or obese, regardless of whether a first-time sacroiliac joint injection was performed, bilateral injections were performed, a trainee was involved, or a new trainee was involved., (© 2015 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Transforaminal epidural steroid injections (TFESIs) are a commonly used, effective treatment for radicular pain. Accurate delivery of the injected medication helps to ensure maximum therapeutic efficacy and to decrease possible adverse events, and fluoroscopy is the preferred and most common image-guidance modality used to ensure accurate needle placement during lumbar TFESIs. However, fluoroscopic-guided lumbar TFESIs put patients at risk because of radiation exposure. The purpose of this study was to determine the relationship between body mass index (BMI) and fluoroscopy time and radiation dose during lumbar TFESIs., Design: A retrospective study design was used., Setting: The study was conducted at an academic orthopedic center. All procedures were performed by physicians board-certified in Physical Medicine and Rehabilitation (PM&R) and with subspecialty certification in sports medicine, or by a trainee under close supervision from an attending physician., Participants: Participants were patients who underwent fluoroscopic-guided lumbar TFESIs between February 2013 and March 2015 with a documented height/weight, fluoroscopy time, and radiation dose., Interventions: All patients received unilateral or bilateral lumbar TFESIs with fluoroscopic guidance. Fluoroscopy time and dose were recorded., Main Outcome Measures: The main outcome measures were fluoroscopy time and radiation dose. A Bonferroni correction was implemented for multiple comparisons, defining statistical significance at p<.01., Results: A total of 2,443 injections were performed on 1,548 patients. There were 419 normal, 572 overweight, and 557 obese patients, respectively. There were 1,426 first-time injections and 1,017 repeat injections. Sixty-nine percent (1,681) were unilateral injections, and 26.4% (645) were single level injections. A trainee was involved in 1,361 (55.7%) of the injections performed. The mean fluoroscopy time for all injections was 30.0±17.5 seconds, and the mean radiation dose was 2,164±1,484 mGy-cm(2). The mean fluoroscopy time was 27.7±15.2 seconds for normal weight patients, 30.0±21.0 seconds for overweight patients, and 32.2±15.1 seconds for obese patients, showing a significant difference between groups (p<.001). The mean radiation doses for each group were 1,376±450, 1,911±653, and 3,029±640 mGy-cm(2), respectively, with a significant increase in radiation dose with increasing BMI (p<.001)., Conclusions: The findings of this study demonstrate that fluoroscopy radiation dose and fluoroscopy time during lumbar TFESIs are increased in patients with an elevated BMI, and in patients of greater age, but the presence of a trainee had no effect on fluoroscopy time., (Copyright © 2016. Published by Elsevier Inc.)

Background Data: Few studies have investigated the long-term efficacy of percutaneous lumbar disc decompression (PLDD) with Dekompressor (Stryker, Kalamazoo, MI) for discogenic radicular pain that has failed conservative management., Objective: Determine long-term outcomes of Dekompressor PLDD for discogenic radicular pain., Methods: Prospective cohort study at a tertiary academic spine center of consecutive patients (12/2004-11/2005) with discogenic lumbosacral radicular pain who underwent PLDD with Dekompressor. Numerical Rating Scale (NRS) leg pain score and Oswestry Disability Index (ODI) score data were collected at 6 months and 1 year. These two measures, 5-point Likert scale patient satisfaction, and surgical rate data were collected at 8 years., Results: Seventy patients underwent PLDD. Forty and 25 patients were successfully contacted at 1-year and 8-year follow-up, respectively. Using intention to treat analysis, at 1 year and 8 years, NRS leg pain scores were reduced >50% in 47% (95% confidence interval [CI] 35%, 59%) and 29% (95% confidence interval [CI] 18%, 40%) of patients, respectively; ODI score improved >30% in 43% (CI 32%, 55%) and 26% (CI 19%, 41%) of patients, respectively. Of the patients who followed up at 8 years, 36% (CI 17%, 55%) had undergone surgery and the median satisfaction was "4" (interquartile range 2,5)., Conclusions: While limited by loss-to-follow-up, this study suggests that treatment of discogenic lumbosacral radicular pain with Dekompressor results in decreased leg pain and disability and favorable satisfaction at long-term follow-up. Further study with adequate follow-up retention is needed to confirm that Dekompressor spares open spinal surgery., (© 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Baclofen commonly is used to manage spasticity caused by central nervous system lesions or dysfunction. Although both intrathecal and oral delivery routes are possible, no study has directly compared clinical outcomes associated with these 2 routes of treatment., Objective: To compare spasticity levels, pain, sleep, fatigue, and quality of life between individuals receiving treatment with intrathecal versus oral baclofen., Design: Cross-sectional matched cohort survey study., Setting: Urban academic rehabilitation outpatient clinics., Participants: Adult patients with spasticity, treated with intrathecal or oral baclofen for at least 1 year, matched 1:1 for age, gender, and diagnosis., Methods: Standardized surveys were administered during clinic appointments or by telephone., Main Outcome Measures: Surveys included the Penn Spasm Frequency Scale, Brief Pain Inventory, Epworth Sleepiness Scale, Fatigue Severity Scale, Life Satisfaction Questionnaire, and Diener Satisfaction with Life Scale., Results: A total of 62 matched subjects were enrolled. The mean (standard deviation [SD]) age was 46 (11) years with a mean duration of intrathecal baclofen or oral baclofen treatment of 11 (6) and 13 (11) years, respectively. There were 40 (64%) male and 22 (36%) female subjects. Primary diagnoses included spinal cord injury (n = 38), cerebral palsy (n = 10), stroke (n = 10), and multiple sclerosis (n = 4). The mean (SD) dose of intrathecal and oral baclofen at the time of survey were 577 (1429) μg/day and 86 (50) mg/day, respectively. Patients receiving intrathecal compared with oral baclofen experienced significantly fewer (1.44 [0.92] versus 2.37 [1.12]) and less severe (1.44 [0.92] versus 2.16 [0.83]) spasms, respectively as measured by the Penn Spasm Frequency Scale (P < .01; P < .01). There were no significant differences in pain, sleep, fatigue, and quality of life between groups. Subanalysis of patients with SCI mirrored results of the entire study sample, with significant decreases in spasm frequency and severity associated with intrathecal compared to oral baclofen (P < .01; P < .01), but no other between group differences. The mean (SD) percent change in dose of oral (21% [33%]) compared with intrathecal (3% [28%]) baclofen was significantly larger two years prior to the date of survey (P = .02)., Conclusions: Long-term treatment with intrathecal compared with oral baclofen is associated with reduced spasm frequency and severity as well as greater dose stability. These benefits must be weighed against the risks of internal pump and catheter placement in patients considering intrathecal baclofen therapy., (Copyright © 2016 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Background: Transforaminal epidural steroid injections (TFESI) have demonstrated efficacy and effectiveness in treatment of radicular pain. Despite little evidence of efficacy/effectiveness, interlaminar epidural steroid injections (ILESI) are advocated by some as primary therapy for radicular pain due to purported greater safety., Objective: To assess immediate and delayed adverse event rates of TFESI and ILESI injections at three academic medical centers utilizing International Spine Intervention Society practice guidelines., Methods: Quality assurance databases from a Radiology and two physical medicine and rehabilitation (PM&R) practices were interrogated. Medical records were reviewed, verifying immediate and delayed adverse events., Results: There were no immediate major adverse events of neurologic injury or hemorrhage in 16,638 consecutive procedures in all spine segments (14,956 TFESI; 1,682 ILESI). Vasovagal reactions occurred in 1.2% of procedures, more frequently (P = 0.004) in TFESI (1.3%) than ILESI (0.5%). Dural punctures occurred in 0.06% of procedures, more commonly after ILESI (0.2% vs 0.04%, P = 0.006). Delayed follow up on PM&R patients (92.5% and 78.5, next business day) and radiology patients (63.1%, 2 weeks) identified no major adverse events of neurologic injury, hemorrhage, or infection. There were no significant differences in delayed minor adverse event rates. Central steroid response (sleeplessness, flushing, nonpositional headache) was seen in 2.6% of both TFESI and ILESI patients. 2.1% of TFESI and 1.8% of ILESI patients reported increased pain. No long-term sequelae were seen from any immediate or delayed minor adverse event., Conclusions: Both transforaminal and ILESI are safely performed with low immediate and delayed adverse event rates when informed by evidence-based procedural guidelines. By demonstrating comparable safety, this study suggests that the choice between ILESI and TFESIs can be based on documented efficacy and effectiveness and not driven by safety concerns.

Background: The Center for Disease Control, American Heart Association, and American College of Sports Medicine recommendations for duration and intensity of exercise are based on the amount of energy expenditure required to maintain cardiovascular health in able body individuals; 1000 Kilocalories (Kcals) per week of energy expenditure has been demonstrated to achieve this effect. Manual wheelchair propulsion (MWP) represents a practical and accessible form of exercise for individuals with paraplegia., Objective: To describe a method to determine the duration of MWP required to expend 1000 Kcals, when performed by individuals with paraplegia due to motor-complete spinal cord injury (SCI)., Study Design: Cross-sectional study., Setting: Rehabilitation Research Laboratory., Participants: Sixteen adults with motor complete T3-T12 paraplegia (body mass index < 35, duration of paraplegia > 3 months)., Interventions: Not applicable., Main Outcome Measures: Indirect calorimetry during MWP was measured in order to calculate caloric expenditure per minute. These data were used to calculate the number of minutes of MWP required to expend 1000 Kcal in one week., Results: During MWP, participants expended 3.3 ± 1.0 Kcal/minute. Based on this figure, 1000 Kcal of energy expenditure in one week would require 303 minutes of MWP per week, or 43.3 minutes per day, 7 days per week., Conclusions: Our data suggest that it is feasible to create a practical and accessible exercise recommendation based on manual wheelchair propulsion for individuals with paraplegia due to motor-complete SCI. Larger studies are needed in order to develop accurate exercise recommendations for persons with SCI.

Objective: the aim of this study is to report satisfaction rates and identify factors predicting satisfaction in the Pennsylvania Workers' Compensation (WC) system., Methods: Cross-sectional survey data on satisfaction and care experience of injured workers were collected annually for 14 years with 27,712 injured workers responding., Results: The overall response rate was 19.44%. The overall proportion of satisfied workers was 83.97% with a range of 80.43% to 88.13%. Obtaining a correct initial diagnosis [odds ratio (OR) = 4.26], explanation of WC rights (OR = 2.58), and physician explanation of treatment options (OR = 1.83) most strongly predicted satisfaction., Conclusions: Injured worker satisfaction with their medical care exceeded 80% in all years surveyed. Patient perception of a correct initial diagnosis, explanation of WC rights, and explanation of treatment options were the strongest predictors of satisfaction during the 14-year study period.

Background: Complex regional pain syndrome (CRPS) is difficult to effectively treat with unimodal approaches., Objective: To investigate whether CRPS can be effectively treated in a comprehensive interdisciplinary pain management program., Design: Observational cohort study of 49 patients aged 18-89 who fulfilled 'Budapest Criteria' for CRPS and completed an interdisciplinary pain management program. Preprogram to postprogram changes in physical functioning, perceived disability, emotional functioning, acceptance, coping, and pain were assessed. The measures used included: Pain Disability Index, Six minute walk test, 2-minute sit-to-stand, Numerical Rating Scale, Center for Epidemiologic Studies Depression Scale, Pain Anxiety Symptoms Scale, Chronic Pain Acceptance Questionnaire, Coping Strategies Questionnaire-Revised, RIC- Multidimensional Patient Global Impression of Change (RIC-MPGIC), and Medication Quantification Scale. For worker's compensation patients, the rate of successful release to work at the end of the program was calculated., Results: Results indicated significant improvements in physical functioning and perceived disability (P's<0.001). Patients reported increased usage of an adaptive coping strategy, distraction (P = 0.010), and decreased usage of maladaptive and passive strategies (P's < 0.001). Patients showed greater chronic pain acceptance (P's ≤ 0.010) and reductions in emotional distress (P's < 0.001). Medication usage at 1-month follow-up was significantly reduced compared to program start (P < 0.001) and discharge (P = 0.004). Patients reported "much improvement" in overall functioning, physical functioning, mood, and their ability to cope with pain and flare-ups (RIC-MPGIC). Patient report of pain was not significantly reduced at discharge (P =0.078). Fourteen (88%) of 16 total worker's compensation patients were successfully released to work at the end of the program., Conclusions: This study demonstrates short-term improvements in physical and emotional functioning, pain coping, and medication usage. These findings are consistent with the rehabilitation philosophy of improving functioning and sense of well-being as of equal value and relevance to pain reduction., (© 2015 Wiley Periodicals, Inc.)

Background Context: Although the types and incidence of adverse events (AEs) associated with transforaminal epidural steroid injection (TFESI) have been described, no study has used a systematic standardized questionnaire to solicit AEs from patients to capture an accurate range and incidence of complications., Purpose: The aim was to systematically identify the types and incidence of AEs associated with TFESI. Additionally, this study evaluated demographic and clinical factors that may predict a higher risk of an AE., Study Design/setting: This was a retrospective cohort study from a multiphysician academic PM&R clinic., Patient Sample: Patients, aged 19 to 89, who underwent a fluoroscopically guided TFESI for lumbosacral radicular pain between 2004 and 2007 were included., Outcome Measures: The relationship of AEs with gender, age, trainee presence, steroid type, preprocedure visual analog scale (VAS) pain score, systolic blood pressure, fluoroscopy time, and corticosteroid injectate volume was analyzed., Methods: Adverse event data were collected using a survey both immediately and at 24 to 72 hours after TFESI. Statistical analysis was performed using the chi-square, Fisher exact, or Wilcoxon rank sum two-sided tests. Logistic regression analysis was also performed. C.P. is the owner of Rehabilitation Institute of Chicago Physiatric Log & Analysis System computer software., Results: In 1,295 consecutive patients undergoing 2,025 TFESI procedures, immediate AEs and delayed AEs occurred after 182 (9.2%) and 305 (20.0%) injections, respectively. The most common immediate AEs were: vasovagal reaction (4.2%) and interrupted procedure from intravascular flow (1.7%). Common delayed AEs included: pain exacerbation (5.0%), injection site soreness (3.9%), headache (3.9%), facial flushing/sweating (1.8%), and insomnia (1.6%). Significant associations were identified between AEs and gender, age, preprocedure VAS, steroid type, and fluoroscopy time. Trainee involvement in the procedure did not impact the complication rate., Conclusions: Fluoroscopically guided lumbosacral TFESI is associated with a similar rate of minor AEs both immediately and 24 to 72 hours after procedure that are typical of other axial corticosteroid injections. Permanent AEs were not found in this sample. The most common AEs associated with TFESI include vasovagal episodes, procedure interruption from intravascular flow, pain exacerbation, injection site soreness, headache, and insomnia., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The number of individuals with heart failure and the treatment modalities available to manage heart failure are increasing. Continuous inotropic support is a treatment modality used in cases of severe heart failure. Although most patients initiated on continuous inotropic support are discharged home, those with greater functional compromise, comorbid conditions that cause disability, or other significant medical complexity may be referred to acute inpatient rehabilitation. The feasibility and benefits of acute inpatient rehabilitation in this population, however, has yet to be investigated. We report the functional progress and medical complications of 3 patients on continuous inotropic support who participated in acute inpatient rehabilitation. The patients demonstrated varying levels of success, highlighting a need for evidence-based, preadmission screening criteria for this population., (Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Somatic tinnitus is a common disorder, yet few treatments described in the literature have demonstrated strong efficacy. We report a case of a 61-year-old male with refractory somatic tinnitus, temporally related to a prior bacterial otitis media, wherein auditory symptoms were successfully treated with cervical epidural injections of long-acting corticosteroid. We discuss the proposed mechanism of somatic tinnitus and the means by which neuraxial steroids may inhibit somatic tinnitus symptoms., (© 2014 World Institute of Pain.)

Objective: Radiofrequency ablation (RFA) of the medial branch nerves for facet-mediated low back pain demonstrates clinical benefit for 6-12 months and possibly up to 2 years. This study investigated function, pain, and medication use outcomes of RFA for lumbar facet syndrome in a cohort with long-term follow-up., Methods: Individuals evaluated in a tertiary academic pain practice between January, 2007-December, 2013, 18-60 years of age, with a clinical and radiologic diagnosis of lumbar facet syndrome, who underwent ≥1set of diagnostic medial branch blocks with resultant >75% pain relief and subsequent RFA were included. Outcomes measured were the proportion of individuals who reported ≥50% improvement in function, ≥50% improvement in pain; change in median NRS pain score, daily morphine equivalent consumption (DME), Medication Quantification Scale III (MSQ III) score and procedure complications., Results: Sixty-two consecutive individuals with a median age and 25%-75% interquartile range (IQR) of 34 years (35, 52) met inclusion criteria. Seven individuals were lost to follow-up. Duration of pain was <2 years in 42%, 2-5 years in 40%, >5 years in 18% of individuals. Median duration of follow-up was 39 months (16, 60). Function and pain improved by ≥50% in 58% (CI 45%, 71%) and 53% (CI 40%, 66%) of individuals, respectively. The median reduction in MQS III score was 3.4 points (0, 8.8). No complications occurred in this cohort., Conclusions: This study demonstrates a durable treatment effect of RFA for lumbar facet syndrome at long-term follow-up, as measured by improvement in function, pain, and analgesic use.

Background: While cooled radiofrequency ablation (C-RFA) appears to be a promising technology for joint denervation, outcomes of this technique for the treatment of lumbar facet syndrome have not been described. We report clinical outcomes in a case series of patients treated with C-RFA for lumbar facet syndrome., Methods: Consecutive patients aged 18-60 years diagnosed with lumbar facet syndrome, confirmed by ≥75% symptom relief with at least one set of diagnostic medial branch nerve blocks, who underwent C-RFA between January 2007 and December 2013 in an urban academic pain center were included. The respective proportions of participants who reported ≥50% improvement in pain and in function were calculated. Change in median NRS score, daily morphine equivalent consumption (DME), and medication quantification scale III (MQS III) score were measured., Results: Twelve patients underwent C-RFA; three were lost to follow-up. The median and 25%-75% interquartile range (IQR) for age was 44 years (35, 54). The median duration of follow-up was 34 months, IQR (21, 55). The percentage and 95% confidence interval (CI) of patients who reported ≥50% improvement in pain was 33% CI (12%, 64%) and in function was 78%, CI (41%, 96%). There was no significant change in DME or MSQ III score. Approximately 50% of patients sought additional healthcare by long-term follow-up. No complications were reported., Conclusions: This case series suggests that C-RFA may improve function and to a lesser degree pain at long-term follow-up. A randomized, controlled trial is warranted.