Search

Mark C Kendall,1 Lucas J Castro Alves,2 Edward I Suh,1 Zachary L McCormick,3 Gildasio S De Oliveira1 1Department of Anesthesiology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA; 2Department of Anesthesiology, Sao Paulo State University, Sao Paulo, Brazil; 3Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA Abstract: Regional anesthesia is becoming increasingly popular among anesthesiologists in the management of postoperative analgesia following pediatric surgery. The main objective of this review was to systematically evaluate the last 5 years of randomized controlled trials on the role of regional anesthesia techniques in alleviating postoperative pain associated with various pediatric surgical procedures. Forty studies on 2,408 pediatric patients were evaluated. The majority of the articles published from 2013 to 2017 reported that the use of regional anesthesia minimized postoperative pain and reduced opioid consumption. Only a few surgical procedures (cholecystectomy, inguinal hernia repair, and non-laparoscopic major abdominal surgery) reported no significant difference in the postoperative pain relief compared with the standard anesthetic management. The growing number of randomized controlled trials in the pediatric literature is very promising; however, additional confirmation is needed to reinforce the use of specific regional anesthesia techniques to provide optimal postoperative pain relief for a few surgical procedures (reconstructive ear surgery, chest wall deformity, hypospadias, umbilical hernia, cleft palate repair) in pediatric patients. More randomized controlled trials are needed to establish regional anesthesia as an essential component of postoperative analgesia management in children. Keywords: regional anesthesia, peripheral nerve block, pediatrics

Invasive meningococcal disease (IMD) is an uncommon but serious and potentially fatal condition that can result in reduced life expectancy and a broad spectrum of sequelae, many of which may be lifelong and devastating for those who survive the acute disease period. In the United States of America (USA), vaccination is available against the five meningococcal serogroups (A, B, C, W, and Y), but meningococcal vaccination rates among healthy USA adolescents and individuals at high risk because of medical conditions are low, rendering them vulnerable to IMD and its sequelae. Despite the severity of the disease, the clinical impact and rates of IMD sequelae in the USA are poorly understood, as USA-specific data are limited, and the methodology of existing research is heterogenous. This commentary presents clinical experts' perspectives on IMD sequelae based on the available published evidence and direct clinical experience. Among sequelae previously identified in a global systematic literature review, 16 conditions were considered as related to IMD by the present authors. These sequelae include short- and long-term physical, neurological, and emotional consequences that impose a substantial humanistic burden on survivors and their caregivers and result in considerable healthcare and societal costs. This commentary highlights existing knowledge gaps concerning IMD sequelae, including the unclear relationship between IMD and mental health disorders, the contribution of sequelae to the disease burden, prevalence of late-onset sequelae among survivors, and timing of the development of sequelae in different age groups. Addressing these knowledge gaps can inform decisions regarding clinical management in the post-acute period and help quantify the impact of prevention through meningococcal vaccination., (© 2024. GSK.)

Background Context: Randomized trials have demonstrated the superiority of intraosseous basivertebral nerve ablation (BVNA) compared with sham and standard care in terms of improvements in pain, disability, and health-related quality of life in patients with vertebrogenic chronic low back pain (cLBP)., Purpose: To assess the cost effectiveness of BVNA in patients with vertebrogenic cLBP compared to standard care alone., Study Design/setting: A model-based economic analysis., Patient Sample: Base case analysis used INTRACEPT, a randomized trial comparing BVNA with standard care in 140 patients with vertebrogenic cLBP, recruited from 23 sites across the United States, with a follow-up, up to 5 years. Scenario analyses compared data from the Surgical Multicenter Assessment of Radiofrequency Ablation for the Treatment of Vertebrogenic Back Pain (SMART) randomized trial against a sham control, and a single-arm study., Outcome Measures: Costs and quality-adjusted life years (QALYs) were calculated to determine the incremental cost-effectiveness ratio (ICER)., Methods: A cost-effectiveness model was built in Microsoft Excel to evaluate the costs and health outcomes of patients undergoing BVNA using the Intracept Procedure (Relievant Medsystems) to treat vertebrogenic cLBP from a US payor perspective. Alternative scenario sensitivity analyses and probabilistic sensitivity analyses were conducted to assess the robustness of the model results. QALYs were discounted at 3.0% per year., Results: Base case analysis showed that BVNA relative to standard care alone was a cost-effective strategy for the management of patients with vertebrogenic cLBP, with an ICER of US$11,376 per QALY at a 5-year time horizon from introduction of the procedure. Modeling demonstrated a >99% probability that this was cost effective in the US, based on a willingness-to-pay threshold of US$100,000 to US$150,000. Various sensitivity and scenario analyses produced ICERs that all remained below this threshold., Conclusions: BVNA with the Intracept Procedure offers patients with vertebrogenic cLBP, clinicians, and healthcare systems a cost-effective treatment compared to standard care alone., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Given the high prevalence of chronic shoulder pain and encouraging early results of terminal sensory articular branch radiofrequency ablation to treat shoulder pain, research is warranted to refine the procedural technique on the basis of updated neuroanatomic knowledge with the goal of further improving patient outcomes., Objective: We describe an updated radiofrequency ablation protocol that accounts for varied locations of the terminal sensory articular branches of the suprascapular, axillary, subscapular, and lateral pectoral nerves within individual patients., Design: Technical note., Methods: Cadaveric studies delineating the sensory innervation of the shoulder joint were reviewed, and a more comprehensive radiofrequency ablation protocol is proposed relative to historical descriptions., Conclusions: The proposed radiofrequency ablation protocol, which is based on neuroanatomic dissections of the shoulder joint, will provide a safe means of more complete sensory denervation and potentially improve clinical outcomes compared with historical descriptions, the efficacy of the new protocol must be confirmed in prospective studies., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.)

Introduction: Chronic knee pain often results from degenerative conditions such as knee osteoarthritis (OA) and can worsen after surgical interventions like total knee arthroplasty (TKA). Knee OA affects approximately 86 million individuals globally, leading to decreased function, mobility limitations, and disability. While TKA is a common surgical treatment for refractory knee OA, though up to 20 % of patients experience chronic post-operative knee pain worse than their pre-operative pain. Genicular nerve radiofrequency ablation (GnRFA) has emerged as a promising intervention for knee OA pain unresponsive to conservative management and for chronic post-TKA pain. GnRFA is an evidence-based technique supported by multiple prospective cohort studies and randomized controlled trials (RCTs). However, practice patterns and GnRFA techniques vary, and no peer-reviewed publication has yet quantified these variations in real-world clinical practice., Objective: This study aims to understand the practice patterns of interventional pain physicians regarding patient selection, use of prognostic blocks, imaging, nerve targets, GnRFA types, and GnRFA techniques in treating knee pain secondary to OA or persistent post-TKA pain., Methods: An anonymous 29-question survey was distributed via electronic mail to members of the International Pain and Spine Intervention Society (IPSIS) from January 16, 2024, to February 29, 2024. The survey assessed practice patterns related to patient selection, prognostic block use, and GnRFA techniques. Data were collected and stored using REDCap software, with descriptive statistics calculated., Results: A total of 150 completed surveys were analyzed, representing a completion rate of 2.0 % of surveys sent, 3.5 % of emails opened, and 56.8 % of those who clicked on the survey link. Respondents generally use common selection protocols regarding OA grade (Kelgren-Lawrence 3 and 4), duration of failed conservative care (3-6 months), a single anesthetic block paradigm, and use of fluoroscopic guidance for the GnRFA procedure. More variability was reported between respondents regarding the volume of anesthetic used during prognostic blocks, the threshold to consider a prognostic block "positive," the technology used, and nerves targeted during the GnRFA procedure., Conclusion: The study provides valuable insights into the current practice patterns of GnRFA among interventional pain physicians. While there is consensus on some aspects of patient selection and procedural techniques, significant variability exists in prognostic block protocols and nerve targets for GnRFA. These findings highlight the need for further research to explore the long-term efficacy and safety of GnRFA and to standardize techniques and protocols across different practice settings, ultimately improving patient outcomes and quality of life. The low response rate may limit generalizability, and the survey did not include data on active tip sizes used for ablation or whether other procedures should be exhausted before resorting to GnRFA. Additionally, a survey to IPSIS membership only may not fully represent a diverse cohort of pain management specialists, potentially introducing sampling bias. Future studies should include members from a broader range of professional organizations to enhance representativeness., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Co-Authors: 1) Taylor Burnham, DO MS receives research grant funding from DIROS technology (paid directly to the University of Utah) and does consulting work with AVANOS Medical. 2) Zachary L. McCormick, MD serves on the Board of Directors of the International Pain and Spine Intervention Society (IPSIS), has research grants from Avanos Medical, Boston Scientific, Relievant Medsystems, Saol Therapeutics, Spine Biopharma, SPR Therapeutics, Stratus Medical (paid directly to the University of Utah), and also consultancies with Avanos Medical, Saol Therapetuics, Stryker, and OrthoSon.If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Competing Interests: BIM is the founder and CEO of STATIX, LLC, a paid research consulting firm, discussed herein. ZM receives research funding from Avanos Medical, Boston Scientific, Relievant Medsystems, Saol Therapeutics, Spine Biopharma, SPR Therapeutics, Stratus Medical, NIH, DOD. Consultancies: Avanos Medical, Saol Therapeutics, Stryker, OrthoSon. All other authors declare that they have no competing interests.

Background: Lumbar radiofrequency neurotomy (LRFN) effectively alleviates zygapophyseal joint-mediated pain by coagulating medial branch nerves to disrupt nociceptive signaling pathways. The concomitant denervation of multifidus fibers has led to concern that LRFN may increase segmental instability and accelerate degenerative changes in patients with certain pre-existing spinal pathologies. There is a paucity of literature evaluating whether LRFN increases the progression of spinal curvature in patients with adult scoliosis., Objective: Compare the lumbosacral Cobb angle progression rate in patients with adult scoliosis who underwent LRFN to the annual progression rate of 0.83 ± 1.1° expected by natural history., Design: Cross-sectional study., Methods: Consecutive patients diagnosed with adult scoliosis who underwent LRFN to treat zygapophyseal joint-related low back pain were identified. Patient demographics, LRFN procedure details, and radiographs confirming scoliosis were collected from electronic medical records. Pre- and post-LRFN radiographs were used to calculate the average annual rate of Cobb angle progression. Data were analyzed using a Wilcoxon signed-rank test and a linear regression model., Results: Sixty patients (mean age 69.2 ± 11.6 years; 70.0 % female) met the criteria and were included in the analyses. The mean time to radiographic follow-up was 35.0 ± 22.7 months post-LRFN. The average Cobb angle progression was 0.54 ± 3.03° per year and did not differ significantly from the known natural progression rate of 0.83 ± 1.1° per year. None of the included covariates (body mass index, LRFN laterality, and number of levels denervated) were significantly associated with the average annual Cobb angle progression rate., Conclusions: Our results suggest that LRFN has no appreciable effect on the rate of Cobb angle progression in patients with adult scoliosis., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Zachary McCormick reports financial support was provided by Skaggs Foundation for Research. Zachary McCormick reports financial support was provided by Mitchell and June Morris Foundation. Zachary McCormick reports a relationship with International Pain and Spine Intervention Society that includes: board membership. Zachary McCormick reports a relationship with Avanos Medical Inc that includes: funding grants. Taylor Burnham reports a relationship with Avanos Medical Inc that includes: consulting or advisory. Taylor Burnham reports a relationship with Diros Technology Inc that includes: funding grants. Aaron Conger reports a relationship with Stratus that includes: funding grants. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: Genicular radiofrequency neurotomy (GRFN) is an effective treatment for a subset of individuals with chronic knee pain. Previous studies demonstrate that Medicare and Medicaid beneficiaries report worse outcomes following various interventional procedures compared with commercially insured patients., Objective: Evaluate the association of payer type on GRFN treatment outcomes., Methods: Consecutive patients who underwent GRFN at a tertiary academic center were contacted for participation. Demographic, clinical, and procedural characteristics were collected from electronic medical records. Outcome data were collected by standardized telephone survey at 6-12 months, 12-24 months and ≥24 months. Treatment success was defined as ≥50% numerical pain rating scale (NPRS) score reduction from baseline. Data were analyzed using descriptive statistics for demographic, clinical, and procedural characteristics. Logistic and Poisson regression analyses were performed to examine the association of variables of interest and pain reduction., Results: One hundred thirty-four patients treated with GRFN (mean 65.6 ± 12.7 years of age, 59.7% female) with a mean follow-up time of 23.3 ± 11.3 months were included. Payer type composition was 48.5% commercial (n = 65), 45.5% Medicare (n = 61), 3.7% Medicaid (n = 5), 1.5% government (n = 2), and 0.8% self-pay (n = 1). Overall, 47.8% of patients (n = 64) reported ≥50% NPRS score reduction after GRFN. After adjusting for age, follow-up duration, Kellgren-Lawrence osteoarthritis grade, baseline opioid use, antidepressant/antianxiety medication use, history of knee replacement, and number of RFN lesions placed, the logistic regression model showed no statically significant association between payer type and treatment outcome (OR = 2.11; 95% CI = 0.87, 5.11; p  = 0.098)., Discussion/conclusion: In this study, after adjusting for demographic, clinical, and procedural characteristics, we found no association between payer type and treatment success following GRFN. This observation contrasts findings from other interventional studies reporting an association between payer category and treatment success., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Zachary McCormick reports financial support was provided by Skaggs Foundation for Research. Zachary McCormick reports financial support was provided by Mitchell and June Morris Foundation. Zachary McCormick reports a relationship with International Pain and Spine Intervention Society that includes: board membership. Zachary McCormick reports a relationship with Avanos Medical Inc that includes: funding grants. Taylor Burnham reports a relationship with Avanos Medical Inc that includes: consulting or advisory. Taylor Burnham reports a relationship with Diros Technology Inc that includes: funding grants. Aaron Conger reports a relationship with Stratus that includes: funding grants. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: Physician turnover and job instability have profound implications for healthcare systems, private facilities, and patient outcomes. High physician turnover disrupts continuity of care, impedes establishment of patient-physician relationships, and may compromise overall healthcare quality., Objective: This survey study explores the rate of job turnover in the field of Interventional Spine and Pain Medicine, based on a 2022 survey of physicians of the International Pain and Spine Intervention Society., Methods: A standardized, anonymous survey was distributed by email via Research Electronic Data Capture (REDCap) software to physician members of the International Pain and Spine Interventional Society (IPSIS)., Results: Our survey results indicate that interventional spine/pain physicians with initially lower starting salaries were more likely to leave their first job. We also found that those currently in a productivity-based compensation models were more likely to have left their first job., Conclusions: Of the interventional pain and spine physicians who had been in practice for at least three years, over 65% reported leaving their initial job after training., Competing Interests: Byron Schneider, MD and Zachary L. McCormick, MD serve on the Board of Directors of the Interventional Pain and Spine Intervention Society. Allen Chen, MD, MPH is the Vice Chair for Education and a Senior Instructor for the Interventional Pain and Spine Intervention Society. There are no other relevant conflicts of interest to disclose on the part of any of the other authors. There were no sources of support for this study., (© 2024 The Authors.)

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to improve our understanding and management of patients with potential contraindications to epidural steroid injections., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Objective: Determine the effectiveness of intradiscal corticosteroid injection (IDCI) for the treatment of discovertebral low back pain., Design: Systematic review., Population: Adults with chronic low back pain attributed to disc or vertebral end plate pain, as evidenced by positive provocation discography or Modic 1 or 2 changes on magnetic resonance imaging., Intervention: Fluoroscopically guided or computed tomography-guided IDCI., Comparison: Sham/placebo procedure including intradiscal saline, anesthetic, discography alone, or other active treatment., Outcomes: Reduction in chronic low back pain reported on a visual analog scale or numeric rating scale and reduction in disability reported by a validated scale such as the Oswestry Disability Index., Methods: Four reviewers independently assessed articles published before January 31, 2023, in Medline, Embase, CENTRAL, and CINAHL. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The risk of bias in randomized trials was evaluated with the Cochrane Risk of Bias tool (version 2)., Results: Of the 7806 unique records screened, 6 randomized controlled trials featuring 603 total participants ultimately met the inclusion criteria. In multiple randomized controlled trials, IDCI was found to reduce pain and disability for 1-6 months in those with Modic 1 and 2 changes but not in those selected by provocation discography., Conclusion: According to GRADE, there is low-quality evidence that IDCI reduces pain and disability for up to 6 months in individuals with chronic discovertebral low back pain as evidenced by Modic 1 and 2 changes but not in individuals selected by provocation discography., Study Registration: PROSPERO (CRD42021287421)., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The effectiveness and safety of intraosseous basivertebral nerve ablation (BVNA) for treating vertebrogenic pain is established, but low back pain-related healthcare utilization (LBPr-HU) following BVNA continues to be defined., Methods: LBPr-HU data were pooled from 3 prospective studies. LBPr-HU categories of interest included non-invasive conservative care, opioid utilization, lumbosacral spinal injection (LSI), lumbosacral radiofrequency ablation (LRFA), and lumbosacral spinal surgery. Pre- and post-BVNA LBPr-HU were compared at both 1- and 5-years using McNemar's test for proportions and paired t-tests for means., Results: Two hundred forty-seven patients received BVNA and had 1-year follow-up; 205 had long-term follow-up (mean of 5.3 ± 1.33 years). Twenty-seven percent fewer participants initiated conservative care in the year post-BVNA compared to the year preceding BVNA (P < .001; 95% CI 19.8-34.5). Of 77/247 participants taking opioids at baseline, 40.3% and 61.7% fewer were taking them at one-year and 5.3 ± 1.33 years post-BVNA, respectively (P < .001). Of participants receiving LSIs in the year preceding BVNA, 81.2% fewer received LSI(s) in the year post-BVNA (P < .001; 95% CI 70.7-90.7); a 76.4% reduction in LSIs was maintained through a mean of 5.3 ± 1.33 years post-BVNA. LRFA rates were 1.6% at 1-year post-BVNA and 8.3% at 5.3 ± 1.33 years post-BVNA. Lumbar fusion surgery was 0.8% at 1-year post-BVNA and 6.5% at 5.3 ± 1.33 years post-BVNA., Conclusions: In this aggregate analysis of patients with vertebrogenic pain, utilization of conservative care, opioids, LSIs, and LRFA were substantially reduced through 5 years post-BVNA compared to baseline. Lumbar fusion rates were less than half the published value at 5 years in similar populations., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.)

Objectives: To evaluate the effectiveness of cervical transforaminal epidural steroid injection (CTFESI) for the treatment of unilateral cervical radicular pain., Design: Single-group prospective cohort study., Methods: Outcomes included ≥50% reductions in Numeric Rating Scale (NRS) for arm pain, ≥30% Neck Disability Index (NDI-5) improvement, health-related quality of life (EQ-5D), global improvement (PGIC), personal goal achievement (COMBI), Chronic Pain Sleep Index (CPSI), and healthcare utilization at one, three, six, and 12 months. Data analysis included descriptive statistics with the calculations of 95% confidence intervals (CIs), contingency table analysis, and multilevel logistic regression (LR) analysis, including a worst-case (WC) sensitivity analysis in which missing data were treated as treatment failure. Participants who were treated surgically were considered failures in the categorical analyses., Results: 33 consecutively enrolled participants (63.6% females, 51.2 ± 12.2 years of age, BMI 28.3 ± 4.5 kg/m 2 ) were analyzed. Success rates for ≥50% reduction in NRS for arm pain at one, three, six and 12 months were 57.6% (95% CI 40.8-72.8%), 71.9% (95% CI 54.6-84.4%), 64.5% (95% CI 46.9-78.9%), and 64.5% (95% CI 46.9-78.9%). Success rates for ≥30% improvement in NDI-5 were 60.6% (95% CI 43.7-75.3%), 68.8% (95% CI 51.4-82.0%), 61.3% (95% CI 43.8-76.3%), and 71.0% (95% CI 53.4-83.9%). In WC analysis, success rates for ≥50% arm NRS and NDI-5 were 0-4.3% lower between 1 and 12 months. PGIC scores were at least "much improved" or "very much improved," in 48.4-65.6% of participants between 1 and 12 months. 6.1%, 6.1%, and 3.0% had one, two, or three repeat injections, respectively. 18.2% of participants underwent surgery by 12 months. Participants showed significant improvements in arm NRS and NDI-5 after treatment ( p  < 0.05), multilevel logistic regression models showed no significant decline in improvements across the follow-up time points ( p  > 0.05)., Conclusion: Statistically significant and clinically meaningful improvements in pain and disability were observed after CTFESI for up to 12 months in individuals with unilateral cervical radicular pain., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background: Lumbar medial branch radiofrequency ablation (LRFA) and intraarticular facet steroid injections (FJI) are commonly performed for recalcitrant facet joint-mediated pain. However, no study has compared clinical outcomes of the two treatments in patients selected using dual medial branch blocks (MBBs) with an 80% relief threshold., Objective: Compare the effectiveness of cooled LRFA (C-LRFA) to FIJ as assessed by pain and functional improvements., Design: Prospective randomized comparative trial., Methods: Patients with dual MBB-confirmed facet joint-mediated pain were randomized to receive C-LRFA or FIJ. Outcomes were assessed at 1, 3, 6, and 12 months. The primary outcome was ≥50% improvement in numerical pain rating scale (NPRS) score at 3 months. Secondary outcomes included ≥30% Oswestry Disability Index (ODI) improvement and Patient Global Impression of Chance (PGIC) ≥6 points, among others. Data were analyzed using contingency tables and mixed-effects logistic regression models., Results: Of 1128 patients screened, 32 met eligibility criteria, were randomized, and received their allocated study treatment. In total, 20 (62.5%) and 12 (37.5%) participants received C-LRFA and FIJ, respectively. In the C-LRFA group, 70% (95% CI 48-85), 55% (95% CI 34-74), and 45% (95% CI 26-66) of participants met the NPRS responder definition, compared to 25% (95%CI 9-53), 25% (95% CI 9-53), and 17% (95% CI 5-45) in the FJI group at 3, 6, and 12 months, respectively (P = .014 at 3 months). The PGIC responder proportion was higher in the C-LRFA compared to FJI group at 3 and 6 months (P < .05)., Conclusions: C-LRFA demonstrated superior success rates compared to FJI across pain and functional outcome domains., Trial Registration Details: ClinicalTrials.gov (NCT03614793); August 3, 2018., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.)

Background: Genicular nerve radiofrequency ablation (GNRFA) is an effective treatment for chronic knee pain. However, there has been minimal investigation of real-world, long-term outcomes and factors that predict treatment success after GNRFA., Objectives: To evaluate the effectiveness of GNRFA for chronic knee pain in a real-world population and identify predictive factors., Methods: Consecutive patients who underwent GNRFA at a tertiary academic center were identified. Demographic, clinical, and procedural characteristics were collected from the medical record. Outcome data were numeric rating scale (NRS) pain reduction and Patient Global Impression of Change (PGIC). Data were collected by standardized telephone survey. Predictors of success were evaluated with logistic and Poisson regression analyses., Results: Of the 226 total patients identified, 134 (65.6 ± 12.7; 59.7% female) were successfully contacted and analyzed, with a mean follow-up time of 23.3 ± 11.0 months. Of those, 47.8% (n = 64; 95% CI: 39.5%-56.2%) and 61.2% (n = 82; 95% CI: 52.7%-69.0%) reported ≥50% NRS score reduction and ≥2-point NRS score reduction, respectively, and 59.0% (n = 79; 95% CI: 50.5%-66.9%) reported "much improved" on the PGIC questionnaire. Factors associated with a greater likelihood of treatment success (P < .05) were higher Kellgren-Lawrence osteoarthritis grade (2-4 vs 0-1); no baseline opioid, antidepressant, or anxiolytic medication use; and >3 nerves targeted., Conclusion: In this real-world cohort, approximately half of the participants experienced clinically meaningful improvements in knee pain after GNRFA at an average follow-up time of nearly 2 years. Factors associated with higher likelihood of treatment success were more advanced osteoarthritis (Kellgren-Lawrence Grade 2-4); no opioid, antidepressant, or anxiolytic medication use; and >3 nerves targeted., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Lumbar radiofrequency neurotomy (LRFN) effectively treats lumbar zygapophyseal joint pain by coagulating medial branch nerves (MBNs) carrying nociceptive signals. MBNs also innervate deep paraspinal muscles. There is a paucity of literature on whether LRFN accelerates the progression of vertebral displacement in patients with degenerative lumbar spondylolisthesis (DLS)., Objective: Compare the rate of spondylolisthesis progression in adults with DLS who underwent LRFN to the 2% annual rate of progression expected by natural history., Design: Cross-sectional cohort study., Methods: Consecutive patients with pre-existing DLS who underwent LRFN for zygapophyseal joint-mediated low back pain were identified. Patient demographics, LRFN procedure details, and radiographic images confirming Meyerding Grade (I-II) spondylolisthesis were collected from electronic medical records. The quantitative magnitude of spondylolisthesis progression and the annualized rate were calculated from pre-and post-LRFN radiographs. Data were analyzed using Wilcoxon signed-rank tests and a linear regression model., Results: 152 patients (mean age 65.9 ± 12.3 years; 59.2% female) met eligibility criteria and were included in the analyses. Average time to radiographic follow-up was 35.6 ± 24.7 months post-LRFN. The average spondylolisthesis progression rate of 1.63 ± 2.91% per year calculated for the LRFN cohort was significantly lower than the 2% annual rate of progression associated with natural history ( p  < 0.001). None of the included covariates, such as age, BMI, LRFN laterality, number of levels denervated, or history of prior lumbar spinal surgery, were significantly associated with the average annual rate of progression., Conclusions: Our results suggest that spondylolisthesis progression rate is no different or worse than the expected natural progression rate in patients with pre-existing DLS who have undergone LRFN., Competing Interests: Zachary L. McCormick, MD has received research funding from Avanos Medical (paid directly to the 10.13039/100007747University of Utah) and serves on the Board of Directors of the Spine Intervention Society (SIS). Aaron Conger, DO has received research funding from Stratus Medical (paid directly to the 10.13039/100007747University of Utah). Taylor Burnham, DO MS has received research funding from DIROS Technology (paid directly to the 10.13039/100007747University of Utah). There are no other potential conflicts of interest to disclose on the part of any of the other authors., (© 2023 The Authors.)

Summary of Background Data: Although evaluated within other specialties, physicians' beliefs towards climate change and human health have not been described within Interventional Pain Medicine (IPM). Understanding belief systems is essential for developing solutions to build sustainable practices., Objectives: Assess beliefs toward climate change within the field of IPM., Methods: Spine Intervention Society (SIS) members were invited to participate in an anonymous RedCap survey by email, social media, and advertisement at the 2022 SIS Annual Meeting. Descriptive statistics were calculated, and associations were estimated using Chi-Square (significance: p < 0.05)., Results: One hundred and seventy-five participants responded to the survey. Participants most often identified as white (66 %; 95 % CI 57-73 %), male (78 %; 95 % CI 71-84 %), and from the United States (US) (76 %; CI 95 % 58-72 %), with 87 % (n = 123/141; 95 % CI 82-93 %) agreeing that climate change is happening (agree or strongly agree). While 78 % (95 % CI 80-92 %) agree that climate change and sustainability are important to them, only 47 % (95 % CI 34-51 %) agree that these are important to their patients. Those beliefs did not differ by age or geographical area (p > 0.05). However, physicians in non-leadership positions are more likely to disagree or strongly disagree that climate change is important to them (χ 2 (2) = 15.98; p < 0.05), to their patients (χ 2 (2) = 17.21; p < 0.05), or that societies should advocate for climate policies (χ 2 (2) = 9.19; p < 0.05). Non-US physicians were more likely to believe that physicians have responsibilities to bring awareness to the health effects of climate change (χ 2 (2) = 6.58; p < 0.05) and to agree that climate change is important to their patients (χ 2 (2) = 10.50; p < 0.05)., Discussion/conclusion: Understanding specialty-specific physician views on climate change is essential for developing solutions to reduce the carbon footprint of medical practice and improve sustainability. The majority of SIS members believe that climate change is happening. Non-US physicians and physician-leaders are more likely to believe that climate change impacts their patients and that societies should advocate for climate policies., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to improve our understanding and management of several potential local anesthetic-related complications. Evidence in support of the following facts is presented. (1) Chondrotoxicity: Which Local Anesthetics are Safest for Intraarticular Injection? -- There are drug-, concentration-, and time-dependent chondrotoxic effects that vary between local anesthetics. Current evidence related to commonly used local anesthetics indicates that with exposure to equivalent volumes, bupivacaine, at concentrations of 0.5 % or higher, is the most chondrotoxic agent, while ropivacaine, at concentrations equal to or less than 0.5 %, is the least chondrotoxic in vitro. There is minimal published evidence that confirms these findings in vivo. (2) Minimizing Risks with Stellate Ganglion Blocks -- Evidence suggests that fluoroscopic or ultrasound guidance reduces the risk and increases the accuracy of SGB. Utilizing ultrasound guidance has the added benefit of soft tissue visualization, especially vascular structures, which has the potential to prevent adverse outcomes when compared to the fluoroscopic technique., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Introduction: Multiple factors (patient age, wait time, depression, etc.) have been associated with lower patient satisfaction as assessed by the Press Ganey® Outpatient Medical Practice Survey (PGOMPS). Social deprivation has been shown to impact multiple aspects of patient care but its impact on patient satisfaction in Physical Medicine and Rehabilitation (PM&R) is limited., Objective: We hypothesized that increased social deprivation would independently predict lower patient satisfaction, as measured by the PGOMPS., Design: Retrospective large cohort study., Setting: Single tertiary academic institution., Patients: Adult patients seen by PM&R physicians practicing outpatient interventional spine and musculoskeletal medicine who completed PGOMPS between January 1, 2014 and December 31, 2019., Interventions: Independent variables include: Social deprivation as measured by 2015 Area Deprivation Index (ADI), wait time, patient age, and sex., Main Outcome Measure: Patient satisfaction was defined as receiving a perfect PGOMPS Total Score., Results: A totla of 64,875 patients (mean age 52.7 ± 21.8 years, 41.4% male, mean ADI 29.9 ± 18.8) were included. Univariate analysis showed a decreased odds of achieving satisfaction for each decile increase in ADI (odds ratio 0.965; 95% confidence interval 0.957-0.973; p < 0.001). The most socially deprived quartile was significantly less likely to report satisfaction on PGOMPS compared to the least deprived quartile (91.1 vs 93.2; p < 0.001). Multivariable analysis revealed that the odds of achieving satisfaction was 0.99 (95% confidence interval 0.980 to 0.997; p = 0.009) for the Total Score, independent of age, wait time, and patient sex for each decile increase in ADI., Conclusions: In this cohort, increased social deprivation independently predicted patient dissatisfaction in PM&R., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to improve our understanding and management of several potential procedure-related complications. Evidence in support of the following facts is presented. (1)  Vasovagal Reactions During Interventional Pain Procedures  -- The overall incidence of vasovagal reactions (VVR) ranges from 1 to 8% during interventional pain procedures, though certain patient populations may be at greater risk. Younger age, male sex, and a history of a VVR are associated with an increased likelihood of VVR. In select patients, moderate sedation may be considered for prevention of a repeat vasovagal reaction. (2)  Spinal Cord Stimulator Trial Lead Migration --  Suturing percutaneous SCS leads does not mitigate the risk of migration compared to taping alone during a trial. Most lead migration does not pose a safety concern during the trial period., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 Published by Elsevier Inc. on behalf of Spine Intervention Society.)

Objective: Evaluate outcomes of genicular nerve chemical neurolysis (GChN) in a real-world population with chronic knee pain., Design: Restrospective, observational cohort study., Setting: Tertiary academic medical center., Subjects: Consecutive patients who had undergone GChN ≥3 months prior., Methods: Standardized surveys were collected by telephone and included the numerical rating scale, opioid analgesic use, and Patient Global Impression of Change. Age, sex, body mass index, duration of pain, history of arthroplasty, lack of effect from previous radiofrequency ablation, percentage relief from a prognostic block, and volume of phenol used at each injection site were extracted from charts. Descriptive statistics were calculated, and logistic regression analyses were performed to identify factors influencing treatment outcome., Results: At the time of follow-up after GChN (mean ± SD: 9.9 ± 6.1 months), 43.5% (95% CI = 33.5-54.1) of participants reported ≥50% sustained pain reduction. On the Patient Global Impression of Change assessment, 45.9% (95% CI = 35.5-56.7) of participants reported themselves to be "very much improved" or "much improved." Of 40 participants taking opioids at baseline, 11 (27.5%; 95% CI = 14.6-43.9) ceased use. Of participants with a native knee treated, 46.3% reported ≥50% pain reduction, whereas of participants with an arthroplasty in the treated knee, 33.3% reported this threshold of pain reduction (P = .326). Logistic regression analyses did not reveal associations between treatment success and any of the factors that we evaluated., Conclusions: GChN could provide a robust and durable treatment effect in a subset of individuals with chronic knee pain with complicating factors traditionally associated with poor treatment outcomes, such as those with pain refractory to radiofrequency ablation or those who have undergone arthroplasty., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To assess the effectiveness and safety of sacral lateral branch radiofrequency neurotomy (SLBRFN) in treating posterior sacroiliac joint complex (PSIJC) pain, stratifying results by patient selection criteria and technique., Design: Systematic review., Population: Adults over 18 years old with suspected PSIJC pain., Intervention: SLBRFN with image guidance (including computed tomography, fluoroscopy, ultrasound)., Comparison: Any other treatment, sham, or no treatment., Outcomes: The primary outcome was improvement in pain reported as continuous data or the proportion of patients obtaining ≥50% reduction in pain scores on either the visual analog scale (VAS) or numeric rating scale (NRS). Secondary outcomes included functional improvement, reported as continuous data or the proportion of patients obtaining ≥30% in function from baseline, and adverse events., Methods: Six reviewers independently assessed publications prior to December 2022 in PubMed, EMBASE, Web of Science, and Google Scholar and utilized the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework to evaluate the overall quality of evidence., Results: Of the 415 publications screened, 37 met the inclusion criteria, with 33 providing sufficient data regarding the effectiveness of SLBRFN. Of the included studies, there were four explanatory randomized controlled trials (RCTs), four pragmatic RCTs, 11 prospective cohort studies, 14 retrospective cohort studies, and four case reports describing adverse events. At 6 months, the proportion of patients with ≥50% pain relief ranged from 19 to 89%. Studies providing continuous data reported that patients achieved 40-60% pain relief sustained at 12 months. There was heterogeneity in reporting functional improvement, but most studies noted improvement. While all studies that reported categorical outcomes targeted the S1-3 sacral lateral branches, the majority also included RFN of the L5 dorsal ramus. Successful outcomes were reported in patients selected by the response to intra-articular blocks (single or dual) or sacral lateral branch blocks (single or dual). Twenty-nine total adverse events and three serious adverse events (SAE) were reported across 1367 patients. According to the GRADE system, there is moderate-quality evidence overall that SLBRFN effectively reduces pain and disability in a majority of patients with PSIJC pain at 1, 3, 6, and 12 months. When anatomically validated SLBRFN techniques are assessed, the level of evidence is upgraded to high quality., Discussion/conclusion: Despite the variability in types of radiofrequency technology, technique, nerve targets, and study methodology, most studies found that substantial proportions of patients achieved ≥50% relief at 1, 3, 6, and 12 months following SLBRFN. When anatomically validated SLBRFN techniques are applied, there is a high level of confidence that the procedure effectively reduces pain and improves function in patients with PSIJC pain. Additional high-quality studies exploring the prognostic value of different block protocols and the relative effectiveness of the various SLBRFN procedure techniques are needed to further optimize the clinical outcomes of SLBRFN., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: David W. Lee, MD reports a relationship with Abbott that includes: speaking and lecture fees. David W. Lee, MD reports a relationship with Mainstay Medical that includes: consulting or advisory. David W. Lee, MD reports a relationship with Boston Scientific Corp that includes: consulting or advisory. David W. Lee, MD reports a relationship with Medtronic that includes: consulting or advisory. David W. Lee, MD reports a relationship with Petal Surgical that includes: consulting or advisory. Sayed Wahezi, MD reports a relationship with Boston Scientific Corp that includes: consulting or advisory. Sayed Wahezi, MD reports a relationship with Abbott that includes: funding grants. Sayed Wahezi, MD reports a relationship with Boston Scientific Corp that includes: funding grants. Sayed Wahezi, MD reports a relationship with Vertos that includes: funding grants. Zachary L. McCormick, MD reports a relationship with Spine Intervention Society that includes: board membership. Zachary L. McCormick, MD reports a relationship with Avanos Medical Inc that includes: funding grants. Zachary L. McCormick, MD reports a relationship with SI-BONE Inc that includes: consulting or advisory. Zachary L. McCormick, MD reports a relationship with Stryker that includes: consulting or advisory., (© 2023 The Authors.)

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to improve our understanding and management of several potential procedure-related complications. The evidence in support of the following facts is presented: (1) Multifidus Atrophy After Lumbar Medial Branch Radiofrequency Neurotomy (LMBRFN) -- There is no conclusive published literature indicating that LMBRFN leads to increased multifidus atrophy relative to natural history. High-quality prospective studies with a natural history comparison group evaluating immediate pre-procedure as well as post-procedure longitudinal cross-sectional imaging are needed to accurately assess for any possible influence of LMBRFN on multifidus atrophy as well as the clinical relevance. (2) Intradiscal Biologics -- Although the available evidence on intradiscal biologic interventions is limited, it nonetheless shows a non-zero risk of complications. Until larger sample sizes are reported, the actual magnitude of the risk cannot be ascertained. In the meantime, physicians who perform intradiscal injections of biologics should conscientiously consider the risk-benefit of these procedures. (3) Lumbar Facet Synovial Cyst Rupture -- There have been few reports of complications secondary to lumbar facet synovial cyst rupture. Risks of may include increased pain, infection, and nerve root compression., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Summary of Background Data: Establishing routine intravenous (IV) access prior to interventional pain procedures performed without sedation is controversial. Anecdotally, practices very in terms of their use of routine IV access., Objectives: To determine the frequency with which routine IV access is obtained for various common interventional pain procedures among interventional pain providers., Methods: An anonymous survey was distributed to physician members of the Spine Intervention Society (SIS) on 08/13/2020, and remained open until 10/13/2020. Respondents provided information regarding demographics and current practice patterns., Results: 141 SIS members completed the survey. A bimodal distribution was noted for most procedures, with most providers obtaining routine IV access either 0% of the time or 81-100% of the time. Routine IV access was used more frequently when performing cervical spine procedures, splanchnic or hypogastric plexus blocks, lumbar sympathetic blocks, and spinal cord stimulator trials. Excluding cases where IV's were used for sedation, the only procedures which providers obtained routine IV access more often than not were spinal cord stimulator trials, splanchnic/celiac plexus blocks, and hypogastric plexus blocks. Over half (52.5%) of respondents reported using an IV for an emergent situation in their career. While most providers would not modify their IV usage based on practice location, those that would were significantly more likely to decrease IV use if working in clinic-based procedures suites ( n  ​= ​25) compared to hospital-based surgical centers ( n  ​= ​2) or ambulatory surgical centers ( n  ​= ​9, p ​< ​0.001)., Discussions/conclusions: There remains wide variation among practitioners in establishing routine intravenous access prior to interventional procedures. Most providers surveyed do not routinely establish IV access for the majority of interventional pain procedures. Routine IV access is more commonly obtained for cervical spine procedures than other spinal regions. Overall, complications precipitating the need for IV use are rare in interventional spine but likely to happen over the course of a career., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

This series of FactFinders presents a brief summary of the evidence and outlines recommendations regarding the use of motor stimulation testing in lumbar radiofrequency neurotomy and performance of radiofrequency neurotomy in patients with posterior spinal hardware. The evidence in support of the following facts is presented: (1) Motor stimulation does not inherently protect against unwanted damage to the spinal nerve, exiting spinal nerve root or its ventral ramus due to a lack of sensitivity of this test for identification of electrode contact or close proximity to sensorimotor nerves. Even when motor stimulation is performed, verification of correct electrode placement with multiplanar imaging including a minimum of true anterior-posterior and lateral fluoroscopic views is a recommended safeguard. (2) The existence of posterior spinal hardware is not an absolute contraindication to radiofrequency neurotomy, but direct contact with hardware should be avoided., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Intro: Genicular nerve radiofrequency ablation (GNRFA) is an effective treatment for chronic knee pain related to osteoarthritis. It is often utilized when conservative management has failed and patients wish to avoid arthroplasty, are poor surgical candidates due to comorbid medical conditions, or in those suffering from persistent pain after arthroplasty. The classic targets for GNRFA include the superior lateral genicular nerve, superior medial genicular nerve, and inferior medial genicular nerve but multiple anatomic studies have demonstrated additional sensory innervation to the knee., Objective: In this research article, we propose an image-guided technique that can safely target the infrapatellar branch of the saphenous nerve which also provides sensory innervation to the anterior capsule., Proposal: The proposed technique includes variations for conventional bipolar radiofrequency ablation, cooled radiofrequency ablation, dual-tined bipolar radiofrequency ablation, and monopolar radiofrequency ablation using a long axis approach. The described technique is based on updated anatomic studies and takes into account safety concerns such as thermal risk to the skin and/or pes anserine tendons and breaching of the synovial cavity., Conclusion: Future clinical research should be performed to confirm the safety and effectiveness of this specific approach., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Instrumented lumbar spinal fusion is common and results in biomechanical changes at adjacent spinal segments that increase facet load bearing. This can cause facet-mediated pain at levels adjacent to the surgical construct. Medial branch nerve radiofrequency ablation (RFA) exists as a treatment for some cases. It is important to acknowledge that the approach and instrumentation used during some specific lumbar fusion approaches will disrupt the medial branch nerve(s). Thus, the proceduralist must consider the fusion approach when determining which medial branch nerves are necessary to anesthetize for diagnosis and then to potentially target with RFA. This article discusses the relevant technical considerations for preparing for RFA to denervate lumbosacral facet joints adjacent to fusion constructs., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Residual limb pain (RLP) and phantom limb pain (PLP) profoundly affect the lives of many individuals who have undergone lower- or upper-extremity amputation. Despite the considerable impact of RLP/PLP on quality of life in persons with amputation, there have been few attempts to evaluate the efficacy of percutaneous interventions in the treatment of RLP and/or PLP. This narrative review evaluates the effectiveness of percutaneous treatments for RLP and/or PLP in patients after lower-extremity amputation. Peripheral nerve stimulation, alcohol neurolysis, conventional thermal radiofrequency ablation, perineural corticosteroid injection, botulinum toxin injection, and etanercept injection were associated with varying success rates. Wide confidence intervals and small treatment cohorts impede assessments of overall success. High-quality studies of nonsurgical, percutaneous treatments for RLP and/or PLP are lacking. Well-designed randomized controlled trials and large cohort studies with comparison groups using validated outcomes are needed to determine the effectiveness of nonsurgical interventions for the treatment of RLP and PLP., (© 2021 American Academy of Physical Medicine and Rehabilitation.)

Representatives from the Spine Intervention Society (SIS) Standards Division and Evidence Analysis Committee have developed the following best practice recommendations for the performance of interventional pain procedures in the setting of a local anesthetic shortage. The practice advisory has been endorsed by SIS, the American Academy of Pain Medicine, the American College of Radiology, the American Society of Neuroradiology, the American Society of Spine Radiology, the North American Neuromodulation Society, the North American Spine Society, and the Society of Interventional Radiology, who support the following best practice recommendations and statements for the performance of intra-articular, extra-articular, paraspinal, and epidural injections in the setting of a local anesthetic shortage. 1.Use of preservative-containing local anesthetics is discouraged in the performance of neuraxial procedures where the injectate may enter the epidural (or intrathecal) spaces.2.When performing procedures with risk of arterial injection, ropivacaine should not be mixed with dexamethasone and injected due to the risk of crystallization and embolization.3.Physicians should not withdraw directly from vials of local anesthetic for multiple patients due to infection risk as per Centers for Disease Control and Prevention (CDC) and Joint Commission guidelines [1].4.Only pharmacists may repackage local anesthetic vials for multiple patients. This must be performed under strict, sterile conditions and only in times of critical need. In such situations, physicians must adhere to the beyond-use-date and storage conditions on the repackaged label [2,3].5.Joint, tendon, bursa, and/or ligament injections may be performed with local anesthetic with or without preservative.6.Interventional pain physicians should weigh the relative chondrotoxicity risks associated with each anesthetic when performing joint injections.7.Topical anesthetics, infiltration with diphenhydramine, and nonpharmacologic therapies ( i.e., cognitive behavioral therapy, guided imagery, virtual reality, mechanodesensitization) may be used as alternatives to skin infiltration of local anesthetic for reducing procedural pain.8.Use of small-gauge needles (25 gauge or thinner) mitigates the need for local anesthetic prior to needle insertion.9.For local anesthetic infiltration prior to insertion of large bore needles or incision, 0.5% lidocaine may be as effective as 1%, and for that reason current supplies of lidocaine can be stretched by dilution with normal saline.10.If using an ester local anesthetic due to an amide local anesthetic shortage, interventional pain physicians should be aware (as always) of the potential for an allergic reaction and should be able to respond accordingly.11.Local anesthetic systemic toxicity (LAST) differs between the varying local anesthetics, and interventional pain physicians should be well acquainted with these differences when switching between local anesthetics. Physicians should carefully weigh the risks and benefits of performing procedures without local anesthetic or using an alternative agent in the context of each unique patient's situation and should involve patients in shared decision making before proceeding. Procedures should be performed following Spine Intervention Society Guidelines [4]. The physician should confirm placement of the needle in at least two imaging planes. Please refer to the SIS Practice Guidelines for the full details and standards related to each unique procedure [4]., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

This series of FactFinders presents a brief summary of the evidence and outlines recommendations regarding the use of antibiotics for disc access and spinal cord stimulation trials. The evidence in support of the following facts is presented: (1) There is a low but nonzero risk of discitis due to percutaneous intervertebral disc access. Strategies to mitigate this risk include use of strict aseptic technique, use of a needle stylet, and prophylactic intravenous or intra-discal antibiotics. (2) In low-risk patients, it may not be necessary to continue antibiotics throughout the percutaneous or staged trial period; however, in high-risk patients, or in trials lasting more than five days, antibiotics should be considered on a case-by-case basis., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Objective: Determine the efficacy, effectiveness, and safety of fluoroscopically- or ultrasound-guided caudal epidural steroid injections (ESIs) with or without catheter placement for the treatment of chronic low back (CLBP), radicular pain, and/or chronic post-surgical back pain (CPSBP)., Design: Systematic review., Population: Adults ≥18 years with CLBP, radicular pain, or CPSBP ≥3 months., Intervention: Fluoroscopically- or ultrasound-guided caudal ESI with or without a catheter including epidural neuroplasty., Comparison: Sham, placebo procedure, active standard care treatment, or none., Outcomes: The primary outcome was the proportion of individuals with reduction of pain by ​≥ ​50%. Secondary outcomes included functional improvement, analgesic use, subsequent spinal surgery, healthcare utilization, and mean improvement in pain. Reported adverse events were also cataloged., Methods: Four reviewers independently assessed publications before January 2, 2022 in PubMed, Ovid MEDLINE, and Scopus. Quality of evidence was evaluated using the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) framework., Results: Of 364 records screened, 23 publications met inclusion criteria. The success rates for the primary outcome could only be extrapolated from one study. Another study used a composite improvement scale that included pain and functional outcomes. The reported success rates in these two studies ranged from 40 to 58% at three months, 25%-67% at six months, and 58%-61% at one year. Data on secondary outcomes were limited; however, rates of functional improvement as measured by mean improvement in Oswestry Disability Index (ODI) ranged from 2% to 55%., Conclusion: There is moderate-quality evidence that caudal ESIs using an in-dwelling catheter for two days is an effective treatment for pain and dysfunction associated with disc herniation with radicular pain and for CPSBP at three, six, and 12 months. There is low-quality evidence supporting the effectiveness of other caudal ESI techniques for pain and dysfunction associated with central lumbar spinal stenosis with neurogenic claudication, discogenic CLBP, and CLBP without disc herniation or radiculitis., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Objective: The SARS-CoV-2 pandemic has had an immense impact on healthcare, but little has been published on its impact on sports medicine physicians. This study aimed to assess the perceived impacts of the pandemic on practice changes, financial implications, and mental health of the physician members of the American Medical Society for Sports Medicine (AMSSM)., Methods: Online surveys were sent to physician members of the AMSSM, with questions asking about demographic information and personal associations to COVID-19. The main outcome measures included self-reported clinical practice volumes, visit types (telemedicine, face-to-face), Patient Health Questionnaire (PHQ-4) scores, personal finances, clarity of practice guidelines, and personal protective equipment (PPE) availability., Results: A total of 825 respondents completed the initial survey, with a subset completing follow-ups. In-person clinical and procedural volumes were reported to be reduced to just 17.9% and 13.7% of the pre-pandemic baseline volumes at the first survey (March 2020), but increased to 81.1% and 77.3% (August 2020), respectively. PHQ-4 anxiety subscores significantly decreased over time ( p < 0.001); younger physicians and female physicians were more likely to have higher scores ( p < 0.05). Reported physician income significantly increased over time ( p < 0.05), and financial concerns steadily decreased ( p < 0.001). The perception of having an adequate PPE significantly increased over the study ( p < 0.001) but not for having clear practice guidelines ( p > 0.05). Physicians have become increasingly aware of others testing positive for the virus, but not themselves or someone they live with., Conclusions: Sports medicine physicians have been heavily impacted by the SARS-CoV-2 pandemic, with some recovery since it started. Sports medicine physicians should be aware of pandemic-related practice changes and resulting mental health and financial implications.

Objective: The Press Ganey® Outpatient Medical Practice Survey (PGOMPS) is a frequently used patient satisfaction metric comprised of provider-specific and non-provider-specific questions. The PGOMPS results are used by many administrators to improve the patient experience and are linked to physician reimbursements in some cases. This study aimed to determine the frequency of patient satisfaction for the provider-specific and non-provider-specific PGOMPS questions and their association with the likelihood of a patient recommending their provider's clinic., Design: A retrospective review., Methods: Adult patients attending a university interventional spine clinic between January 2014 and December 2019 were included in this study. We retrospectively reviewed prospectively collected patient satisfaction using PGOMPS. Data was collected within 30 days after an outpatient interventional spine clinic appointment. Satisfaction was defined as receiving a perfect total score. The frequency of perfect scores for each question was calculated. Chi-square (goodness-of-fit) analysis was performed between the number of patients who gave perfect satisfaction on all provider specific questions and the number of patients who gave perfect satisfaction for non-provider scores irrespective of their provider specific scoring. Spearman correlation between individual PGOMPS questions and the likelihood to recommend the practice question were calculated., Results: 53,118 patients patient encounters were included. 2078 (66.65%) provider-specific questions received perfect satisfaction versus 1121 (35.95%) with perfect satisfaction for non-provider specific questions (p ​< ​0.001). The five questions most likely to receive perfect satisfaction were: physician spoke using clear language (92.90%), physician friendliness/courtesy (82.74%), cleanliness of the practice (82.67%) likelihood to recommend practice (81.27%), and likelihood to recommend physician (80.96%). The 5 least likely were: convenience of office hours (64.30%), wait time (63.00%), ease of getting on phone (60.77%), information about delays (60.19%), and ability to get desired appointment (58.92%). Of the 10 questions that had the strongest correlation with likelihood to recommend the practice 7 were related to the physician. None of the 10 questions with the least correlation were related to the physician., Conclusions: Most interventional spine patients are satisfied with their providers and less satisfied with non-provider-related aspects of their encounters. Provider-specific factors carry the greatest influence in the patient's perceived satisfaction with the experience as a whole and likelihood to recommend the practice., (© 2022 The Authors.)

Objective: To provide an estimate of the effectiveness of basivertebral nerve (BVN) radiofrequency ablation (RFA) to treat vertebrogenic low back pain (LBP)., Design: Systematic review with single-arm meta-analysis., Population: Persons ≥18 years of age with chronic LBP associated with type 1 or 2 Modic changes., Intervention: Intraosseous BVN RFA., Comparison: Sham, placebo procedure, active standard care treatment, or none., Outcomes: The proportion of patients treated with BVN RFA who reported ≥50% pain score improvement on a visual analog scale or numeric rating scale. The main secondary outcome was ≥15-point improvement in Oswestry Disability Index score., Methods: Three reviewers independently assessed articles published before December 6, 2021, in MEDLINE and Embase. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was used to evaluate the overall quality of evidence., Results: Of the 856 unique records screened, 12 publications met the inclusion criteria, representing six unique study populations, with 414 participants allocated to receive BVN RFA. Single-arm meta-analysis showed a success rate of 65% (95% confidence interval [CI] 51-78%) and 64% (95% CI 43-82%) for ≥50% pain relief at 6 and 12 months, respectively. Rates of ≥15-point Oswestry Disability Index score improvement were 75% (95% CI 63-86%) and 75% (95% CI 63-85%) at 6 and 12 months, respectively., Conclusion: According to GRADE, there is moderate-quality evidence that BVN RFA effectively reduces pain and disability in most patients with vertebrogenic LBP. Further high-quality studies will likely improve our understanding of the effectiveness of this procedure., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.)

Objective: Multiple studies have demonstrated the safety and effectiveness of basivertebral nerve radiofrequency ablation (BVN RFA) for improving low back pain related to the vertebral endplate. However, the influence of patient demographic and clinical characteristics on treatment outcome is unknown., Design: Pooled cohort study of three clinical trials of patients with vertebral endplate pain identified by Type 1 and/or Type 2 Modic changes and a correlating presentation of anterior spinal element pain., Setting: Thirty-three global study centers., Subjects: Patients (n = 296) successfully treated with BVN RFA., Methods: Participant demographic and clinical characteristics were analyzed with stepwise logistic regression to identify predictors of treatment success. Three definitions of treatment success were defined: 1) ≥50% visual analog scale pain improvement, 2) ≥15-point Oswestry Disability Index (ODI) improvement, and 3) ≥50% visual analog scale or ≥15-point ODI improvement from baseline., Results: Low back pain of ≥5 years' duration and higher ODI scores at baseline increased the odds of treatment success, whereas baseline opioid use and higher Beck Depression Inventory scores reduced these odds. However, the three regression models demonstrated receiver-operating characteristics of 62-70% areas under the curve, and thus, limited predictive capacity., Conclusions: This analysis identified no demographic or clinical characteristic that meaningfully increased or reduced the odds of treatment success from BVN RFA. On the basis of these findings and the high response rates from the three analyzed trials, we recommend the use of objective imaging biomarkers (Type 1 and/or 2 Modic changes) and a correlating presentation of anterior spinal element pain to determine optimal candidacy for BVN RFA., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.)

Objective: Develop pain location "maps" and investigate the relationship between low back pain (LBP)-exacerbating activities and treatment response to basivertebral nerve radiofrequency ablation (BVN RFA) in patients with clinically suspected vertebral endplate pain (VEP)., Design: Aggregated cohort study of 296 patients treated with BVN RFA at 33 centers in three prospective trials., Methods: Participant demographics, pain diagrams, and LBP-exacerbating activities were analyzed for predictors using stepwise logistic regression. Treatment success definitions were: (1) ≥50% LBP visual analog scale (VAS), (2) ≥15-point Oswestry Disability Index (ODI), and (3) ≥50% VAS or ≥15-point ODI improvements at 3 months post-BVN RFA., Results: Midline LBP correlated with BVN RFA treatment success in individuals with clinically-suspected VEP. Duration of pain ≥5 years (OR 2.366), lack of epidural steroid injection within 6 months before BVN RFA (OR 1.800), lack of baseline opioid use (OR 1.965), LBP exacerbation with activity (OR 2.099), and a lack of LBP with spinal extension (OR 1.845) were factors associated with increased odds of treatment success. Regressions areas under the curve (AUCs) were under 70%, indicative of low predictive value., Conclusions: This study demonstrates that midline LBP correlates with BVN RFA treatment success in individuals with VEP. While none of the regression models demonstrated strong predictive value, the pain location and exacerbating factors identified in this analysis may aid clinicians in identifying patients where VEP should be more strongly suspected. The use of objective imaging biomarkers (Type 1 and/or 2 Modic changes) and a correlating presentation of anterior spinal element pain remain the most useful patient selection factors for BVN RFA., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.)

Objective: Investigate associations between endplate and motion segment magnetic resonance imaging (MRI) characteristics and treatment outcomes following basivertebral nerve radiofrequency ablation (BVN RFA) in patients with clinically suspected vertebral endplate pain (VEP)., Design: Aggregated cohort study of 296 participants treated with BVN RFA from three prospective clinical trials., Methods: Baseline MRI characteristics were analyzed using stepwise logistic regression to identify factors associated with treatment success. Predictive models used three definitions of treatment success: (1) ≥50% low back pain (LBP) visual analog scale (VAS), (2) ≥15-point Oswestry Disability Index (ODI), and (3) ≥50% VAS or ≥15-point ODI improvements at 3-months post-BVN RFA., Results: The presence of lumbar facet joint fluid (odds ratio [OR] 0.586) reduced the odds of BVN RFA treatment success in individuals with clinically suspected VEP. In patients with a less advanced degenerative disc disease (DDD) profile, a > 50% area of the endplate with bone marrow intensity changes (BMIC) was predictive of treatment success (OR 4.689). Both regressions areas under the curve (AUCs) were under 70%, indicating low predictive value. All other vertebral endplate, intervertebral disc, nerve roots facet joint, spinal segmental alignment, neuroforamina, lateral recesses, and central canal MRI characteristics were not associated with BVN RFA success., Conclusions: In patients with vertebrogenic low back pain with Modic changes, the presence of degenerative findings of the anterior and posterior column was not associated with a clinically important impact on BVN RFA treatment success. None of the models demonstrated strong predictive value, indicating that the use of objective imaging biomarkers (Type 1 and/or 2 Modic changes) and a correlating presentation of pain remain the most useful patient selection factors for BVN RFA., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.)

Representatives from the Spine Intervention Society (SIS) and American Academy of Pain Medicine (AAPM) have developed the following best practice recommendations for the performance of interventional pain procedures in the setting of an iodinated contrast media shortage. The practice advisory has been endorsed by SIS, AAPM, American Academy of Physical Medicine and Rehabilitation (AAPMR), American Society of Neuroradiology (ASNR), American Society of Spine Radiology (ASSR), North American Neuromodulation Society (NANS), North American Spine Society (NASS), and Society of Interventional Radiology (SIR)., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

This series of FactFinders presents a brief summary of the evidence and outlines recommendations regarding the safety of anticoagulant and antiplatelet agents for cervical medial branch blocks and cervical medial branch radiofrequency neurotomy. The evidence in support of the following facts is presented: (1) In patients maintained on therapeutic anticoagulant (AC) and/or antiplatelet (AP) therapy, for whom cervical medial branch blocks (CMBBs) are being considered, there is strong evidence to guide decisions on continuing or discontinuing these AC/AP agents in preparation for the procedure. (2) Therapeutic anticoagulation (AC) and antiplatelet (APT) agents should be discontinued prior to cervical medial branch radiofrequency neurotomy (CMBRFN) due to serious hemorrhagic risks., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Consultant: Saol Therapeutics, Stryker, FUSMobile; Research support: Avanos Medical, 10.13039/100008497Boston Scientific, Relievant Medsystems, SPR Therapeutics – ZM. Meals/entertainment: Boston Scientific; Tenex Health – MS., (© 2022 Published by Elsevier Inc. on behalf of Spine Intervention Society.)

Radiofrequency ablation for spinal zygapophyseal joint pain is a safe and effective procedure in carefully selected patients when an appropriate technique is used. The equipment and techniques for performing this procedure have evolved over the past several decades. Likewise, the selection criteria have been refined to optimize results. This article provides an overview of the epidemiology of zygapophyseal joint pain, patient selection and outcomes data associated with RFA, and risks and contraindications of the procedure., Competing Interests: Disclosure Dr Z.L. McCormick serves on the Board of Directors of the Spine Intervention Society and has received investigator-initiated research funding from Avanos Medical (paid directly to the University of Utah). None of the other authors have any financial conflicts of interest to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Abstract: The objective was to determine the effectiveness of fluoroscopically guided genicular nerve radiofrequency ablation for painful knee osteoarthritis. Primary outcome measure was improvement in pain after 6 mos. Secondary outcomes included the Oxford Knee Score and Western Ontario and McMaster Universities Osteoarthritis Index. Two reviewers independently assessed publications before October 10, 2020. The Cochrane Risk of Bias Tool and Grades of Recommendation, Assessment, Development, and Evaluation system were used. One hundred ninety-nine publications were screened, and nine were included. Six-month success rates for 50% or greater pain relief after radiofrequency ablation ranged from 49% to 74%. When compared with intra-articular steroid injection, the probability of success was 4.5 times higher for radiofrequency ablation (relative risk = 4.58 [95% confidence interval = 2.61-8.04]). When radiofrequency ablation was compared with hyaluronic acid injection, the probability of treatment success was 1.8 times higher (relative risk = 1.88, 95% confidence interval = 1.38-2.57). The group mean Oxford Knee Score and Western Ontario and McMaster Universities Osteoarthritis Index scores improved in participants receiving genicular radiofrequency ablation compared with intra-articular steroid injection and hyaluronic acid injection. According to Grades of Recommendation, Assessment, Development, and Evaluation, there is moderate-quality evidence that fluoroscopically guided genicular radiofrequency ablation is effective for reducing pain associated with knee osteoarthritis at minimum of 6 mos. Further research is likely to have an important impact on the current understanding of the long-term effectiveness of this treatment., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)