Interventional Pain Management Techniques Research Articles

Long-term outcomes of Gamma Knife radiosurgery in treating glossopharyngeal neuralgia.

Glossopharyngeal neuralgia (GPN) is an unusual disorder causing severe, brief pain episodes in the areas supplied by the glossopharyngeal nerve. Initial treatment involves medications like carbamazepine, but if these are ineffective or cause side effects, interventional pain management techniques or surgery may be considered. Gamma Knife radiosurgery is becoming popular in managing GPN due to its lower risk of complications than surgical interventions like microvascular decompression or rhizotomy. In this retrospective case series, we examined the outcomes of Gamma Knife radiosurgery in eight patients with GPN. The decision to utilize Gamma Knife radiosurgery was made following specific criteria, including failed surgical interventions, patient preference against surgery, or contraindications to surgical procedures. Patients were administered radiation doses within the range of 80 to 90 Gy, targeting either the cisternal glossopharyngeal nerve or glossopharyngeal meatus of the jugular foramen. Evaluations were conducted before the Gamma Knife radiosurgery; at 3, 6, and 12 months after Gamma Knife radiosurgery; and annually thereafter. Pain severity was assessed using the modified Barrow Neurological Institute scale grades, with patients achieving grade I-IIIa considered to have a good treatment outcome and grade IV-V to have a poor treatment outcome. Pain control and absence of radiosurgery-related complications were primary endpoints. The median age of the patients was 46.5 years, varying from 8 to 72 years. The median duration of pain was 32 months (range, 12-120 months). All patients, except one, were on polydrug therapy. All cases exhibited preoperative grade V pain. The median follow-up duration after Gamma Knife radiosurgery was 54.5 months, varying from 14 to 90 months. The overall clinical assessments revealed a gradual neurological improvement, particularly within the first 8.5 weeks (range, 1-12 weeks). The immediate outcomes at 3 months revealed that all patients (8/8, 100%) experienced pain relief, with 25% (2/8) achieving a medication-free status (Grade I). Three patients (37%) experienced a recurrence during the follow-up and were managed with repeat Gamma Knife radiosurgery (n = 2) and radiofrequency rhizotomy (n = 1). At the last follow-up, 88% (7/8) of patients had pain relief (Grades I-IIIa), with three (37%) achieving a medication-free status (Grade I). No adverse events or neurological complications occurred. The patient who underwent radiofrequency rhizotomy continued to experience inadequately controlled pain despite medication (Grade IV). Gamma Knife radiosurgery is a non-invasive, efficacious treatment option for idiopathic GPN, offering short- and long-term relief without permanent complications.

Interventional Techniques for the Management of Knee Osteoarthritis: A Literature Review.

Osteoarthritis of the knee is a prevalent condition that causes pain, discomfort, and disability that can severely impact the quality of life. This literature review aims to review the various interventional pain management techniques available to treat knee osteoarthritis. It analyzes the efficacy of various interventions such as intra-articular corticosteroids, prolotherapy, viscosupplementation, platelet-rich plasma, and genicular nerve blocks with radiofrequency ablation or cryoneurolysis. We searched databases for studies published in the past 20 years. A total of 37 articles were included. The literature supports the idea that a comprehensive treatment plan consisting of the various aforementioned techniques can provide relief for patients while delaying or avoiding joint replacement surgery.

Role of Interventional Techniques in the Management of Cancer Pain

Pain is the major cause of morbidity in cancer patients. Interventional techniques should be considered for the management of pain that is refractory to traditional analgesics or when patients are unable to tolerate opioids. Interventional techniques are intended to stop pain signals through neural pathways from the periphery to the brain. This article deals with major interventional pain management techniques such as central neuraxial block, sympathetic block, peripheral nerve block, percutaneous cordotomy, percutaneous vertebroplasty and kyphoplasty, radiofrequency ablation, and cryoablation. Besides this, the role of radiotherapy and radionuclides in cancer pain have also been discussed. Central neuraxial block can effectively reduce pain while preventing opioid toxicity. It involves a percutaneous epidural or intrathecal catheter, an external syringe pump, or a fully implanted intrathecal drug delivery system to give medication. Sympathetic blocks such as celiac plexus and superior hypogastric block have role in patients with visceral abdominal pain. Peripheral nerve blocks may be employed when the distribution of somatic pain is restricted to a single nerve or plexus. Percutaneous cordotomy could be useful for any unilateral cancer pain below C4 dermatome. Percutaneous vertebroplasty (PV) treatment is used to alleviate axial back pain due to osteoporotic wedge fracture or malignant vertebral body disease. RFA and cryoablation techniques are now widely used for back pain due to osteoporotic and malignant vertebral collapse that are resistant to conservative treatment. External beam radiotherapy and radionuclides are useful in relieving cancer pain due to bone metastasis. This article aims at summarizing the indications, mechanisms, drug agents, contraindications, and complications of interventional pain management techniques that may offer benefits to patients coping with cancer and its terrible symptoms. Even though there is some risk involved with the techniques discussed in this article, the advantages of reduced pain and enhanced quality of life usually outweigh the risk.

Intervertebral Foramen - A Gateway to Epidural Space in Severe Lumbar Scoliosis.

We describe cases in which a preoperative computed tomography was used to guide the placement of an epidural catheter through the defect in the intervertebral foramina in patients with severe lumbar scoliosis. We demonstrate the adroitness with which epidural catheters were inserted through the intervertebral foramina. Computed tomography scan illustrates and plots the needle path creating a 3-dimensional image of the vertebral body rotation, needle trajectory, and the distance from the skin to the intervertebral foramina. Severe scoliosis is defined as a lateral curvature (Cobb's angle) of more than 50 degrees. It was proposed in severe idiopathic scoliosis that interventional pain management techniques are managed with fluoroscopic imaging or an alternative form. However, after a computed tomography evaluation of the scoliotic spine, we assumed that the intervertebral foraminal anatomy would facilitate a safe and efficient epidural needle and subsequent catheter positioning in severe scoliotic patients.

The Reasons for the Rejection of Spinal Interventional Pain Management Techniques in Patients with Chronic Lower Back Pain

We investigated the reasons for the rejection of spinal interventional pain management techniques (SIPMT) in patients with lower back pain. The patients included in the study applied to an algology outpatient clinic with complaints of chronic lower back pain and were recommended SIPMT. The demographic data, systemic diseases, diagnoses, suggested SIPMT, and reasons why certain patients refused SIPMT, were all evaluated. Among the 196 patients who were recommended SIPMT, 61 (31.1%) refused the treatment. The most common reasons for refusing SIPMT was a belief that the injection would not be a definitive solution (63.9%), belief that the pain would recur after the injection (55.7%), the inability to avoid work that would strain the lower back after the injection (39.3%), and the fear that the pain would worsen (37.7%). Patients have a wide range of concerns about SIMPT. If the wide range of concerns patients have about SIMPT can be more comprehensively considered, refusal of such treatments due to unnecessary concerns can be prevented.

Safety and Efficacy of Radiofrequency Ablation and Epidural Steroid Injection for Management of Cervicogenic Headaches and Neck Pain: Meta-Analysis and Literature Review.

Dysfunction of the cervical spine and its anatomical features, mostly innervated by the C1, C2, and C3 spinal nerves, can result in a secondary headache known as cervicogenic headache (CHA), mainlycharacterized by unilateral pain. The usefulness of pharmaceutical medications and physical therapy is currently the subject of scant literature. Interventional pain management techniques can be applied when conservative treatment is unsuccessful. This study looks at radiofrequency ablation (RFA)and epidural steroid injection (ESI)to identify their safety and efficacy in managing patients with cervicogenic headaches and neck pain.Three databases - PubMed, Cochrane CENTRAL Library, and Embase were searched, and 110 studies were identified. Nine screening processes were included for review and meta-analysis. Statistical evaluation was conducted through STATA version 17 (College Station, TX: StataCorpLLC) and effect measures were reported through random effects model risk ratios.The main subject of focus included three following outcomes: incidences of pain relief, degree and duration of pain, and incidences of adverse effects. The findings showed both interventions relieved pain by afactor of >50%, demonstrating a relative effects risk ratio of 1.45 (-0.50, 3.39) for RFA: pain relief, 84.76 (82.82, 86.69) RFA: adverse effects, and 19.46 (18.80, 20.11) ESI: pain relief at 95% confidence interval.The efficacy of RFA and ESI differ. Both interventions are effective in the reduction of cervicogenic headache pain intensity. However, their complication rates and pain duration are considerably different. With ESI,the headaches can still recur weekly, demanding the use of oral analgesics to deal with them. On the other hand,RFA has a low complication rate.Improving guidance from imaging technologies, RFA has the potential to be the most effective interventional treatment.

Review of Opioid Sparing Interventional Pain Management Options and Techniques for Radiofrequency Ablations for Sacroiliac Joint Pain.

The goal of this clinical review was to provide an update about the existing treatment options and associated evidence for various radiofrequency ablation techniques for sacroiliac joint pain. An electronic literature search on radiofrequency for the treatment of sacroiliac joint pain was conducted using PubMed, NCBI and Google Scholar. The following search keywords were used: radiofrequency ablation (cooled, pulsed, conventional, bipolar, intra-articular), sacroiliac joint and sacroiliac pain. The search was limited to human subjects, English language and articles with available full text. The bibliographic sections of all manuscripts were further searched for additional relevant citations. The full text of the relevant articles was reviewed by all the authors. Our study showed that radiofrequency ablation is a safe and effective treatment option that can be utilized to manage sacroiliac joint pain. It offers accessibility to the primary care physician, reduces office visits with "pain" as the primary complaint and provides the added benefit of acting as a non-opioid sparing means of analgesia.

Cancer Pain Management—New Therapies

Despite the rapid advance in anti-cancer treatment in recent years, the treatment to cancer-related pain remains largely unchanged. One systemic review has shown that approximately 32% of patient with cancer-related pain were undertreated. While in patients responding to strong opioids, long-term use of opioids will lead to many undesired side effects such as constipation, tolerance, and addiction. The goals of this review are to re visit the current algorism of cancer pain management and bring attention to the emerging interventional pain management techniques. Peripheral nerve stimulation (PNS) has been successfully used to treat certain types of chronic non-cancer pain with long-term analgesic effect. PNS has also brought some promising results in treating localized cancer-related pain in a pilot study. More studies are needed to advance the novel and safe treatment of cancer-related pain. Incorporating interventional techniques such as PNS properly can optimize the current treatment strategy and improve outcomes.

New ultrasound-guided techniques in chronic pain management: an update.

The introduction of ultrasound guidance in interventional pain management leads to the development of new interventional pain management techniques. Ultrasound-guided (UG) interventional pain management is rapidly developing and increasingly more commonly used, due to its many advantages over traditional radiologic imaging modalities. This review will summarize recent literature around novel interventional pain techniques with ultrasound guidance published over the last 18 months. Many new interventional pain management methods have been described in the last few years in the literature. The use of ultrasonography in interventional pain management played a crucial role in these developments. This review includes newly described interventional methods in the literature. The review particularly focussed on the methods that are used to treat the pain in the hip, shoulder, knee, and lumbar area. These new techniques hold promise for significant improvements in the efficacy and safety of interventional pain management. There have been many innovations in UG interventional procedures, however, some of them require more rigorous validation before their widespread use.

Peripheral Nerve Stimulation in Pain Management: A Systematic Review

Peripheral nerve stimulation (PNS) has been increasingly used to manage acute and chronic pain. However, the level of clinical evidence to support its use is not clear. To assess the clinical evidence of PNS in the treatment of acute or chronic pain. A systematic review of the efficacy and safety of PNS in managing acute or chronic pain. Data sources were PubMed, Cochrane Library, Scopus, CINAHL Plus, Google Scholar, and reference lists. The literature search was performed up to December 2019. Study selection included randomized trials, observational studies, and case reports of PNS in acute or chronic pain. Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR). The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5. Data syntheses: 227 studies met inclusion criteria and were included in qualitative synthesis. Evidence synthesis based on randomized controlled trials (RCTs) and observational studies showed Level I and II evidence of PNS in chronic migraine headache; Level II evidence in cluster headache, postamputation pain, chronic pelvic pain, chronic low back and lower extremity pain; and Level IV evidence in peripheral neuropathic pain, and postsurgical pain. Peripheral field stimulation has Level II evidence in chronic low back pain, and Level IV evidence in cranial pain. Lack of high-quality RCTs. Meta-analysis was not possible due to wide variations in experimental design, research protocol, and heterogeneity of study population. The findings of this systematic review suggest that PNS may be effective in managing chronic headaches, postamputation pain, chronic pelvic pain, and chronic low back and lower extremity pain, with variable levels of evidence in favor of this technique.

Evidence based Interventional pain medicine techniques

Interventional pain management techniques have a definite place in the management of chronic pain. Inclusion of interventional pain management techniques in the patient’s treatment plan should be guided by the best available evidence on efficacy and safety with respect to the diagnosis. Between 2009 and 2011 a series of 26 articles on evidence-based medicine for interventional pain medicine according to clinical diagnoses were published but during the last years the high number of publications justified an update. These new data were published in Pain Practice on 2019. For 28 different pain indications a total of 113 interventions were evaluated. Twenty-seven (24%) interventions were new compared to the previous guidelines and the recommendation changed for only 3 (2.6%) of the interventions. The quality of evidence may seem rather low and the strength of the recommendations weak. However, this must be viewed in the context of guideline methodology. The fact that the quality of the evidence is rather low does not mean that the effect of the treatment is minimal; it indicates the need for clinical research. However, performing RCTs for (interventional) pain management techniques have many difficulties. When the quality of the evidence is low, this does not mean that the intervention is not effective. And the quality of the evidence may be high, indicating that the intervention is not effective. When the recommendation is very low, there is a high need for more research. The recommendations formulated in guidelines are valid for a specific patient population; however, they may not be valid for the individual patient with comorbidities. The correct application of interventional pain management techniques requires an excellent knowledge of the neuroanatomy, experience in the interpretation of the images obtained during the procedure, and adequate training. Therefore, it is preferred that such interventions be performed in specialized centers.

Is Epidural Injection of Sodium Chloride Solution a True Placebo or an Active Control Agent? A Systematic Review and Meta-Analysis

BACKGROUND: Epidural injections have been extensively used since their description in 1901, and steroids since their first utilization in 1952. Multiple randomized controlled trials and systematic reviews have reached discordant conclusions regarding the effectiveness of sodium chloride solution and steroids in managing spinal pain. True placebo-controlled trials with the injection of an inactive substance to unrelated structures have been nonexistent. Consequently, the discussions continue to escalate, seemingly without proper discourse. In this review, we sought to assess the true placebo nature of saline and the effectiveness of steroids. OBJECTIVES: This assessment of sodium chloride solution is undertaken to assess if it is a true placebo when injected into the epidural space, is effective alone, and whether steroids are effective when injected with sodium chloride solution rather than local anesthetic in managing spinal pain. STUDY DESIGN: A systematic review of randomized controlled trials utilizing sodium chloride solution alone, steroids alone, or sodium chloride solution with steroids in managing spinal pain secondary to disc herniation or spinal stenosis. METHODS: The systematic review was performed utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Cochrane review criteria and Interventional Pain Management techniques--Quality Appraisal of Reliability and Risk of Bias Assessment (IPM–QRB) was used to assess the methodological quality assessment. Qualitative analysis was performed by utilizing best evidence synthesis principles, and quantitative analysis was performed utilizing meta-analysis with conventional methodology and single-arm meta-analysis. PubMed, Cochrane Library, US National Guideline Clearinghouse, Google Scholar, and prior systematic reviews and reference lists were utilized in the literature search from 1966 through December 2018. The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5. Outcome measures for the present analysis, 20% improvement from the baseline pain scores or disability scores was considered clinically significant. Effectiveness was determined short-term if it was less than 6 months, whereas longer than 6 months was considered to be long-term. RESULTS: Of the 8 trials meeting inclusion criteria, 2 trials utilized fluoroscopic imaging and one study utilized ultrasound. All other studies performed the procedure without fluoroscopy. With dual-arm meta-analysis, there was no significant difference between epidural sodium chloride solution and epidural steroids with sodium chloride solution. Utilizing single-arm analysis, both epidural saline and epidural steroids with saline were effective in reducing 20% of pain, however, only reducing disability scores by 10% to 12%. Based on the qualitative analysis, epidural saline and epidural steroids with saline showed effect beyond placebo and showed level I, or strong evidence, that neither epidural saline, nor epidural steroids with saline are placebo and that both are effective. LIMITATIONS: Despite 8 randomized controlled trials, only 2 of them utilized fluoroscopy. Overall evidence is considered less than optimal and further studies elucidating these actions are strongly recommended. CONCLUSIONS: The findings of this systematic review and meta-analysis show that epidurally administered sodium chloride solution and sodium chloride solution with steroids may be effective in managing low back and lower extremity pain. Consequently, the findings of this review provide information that epidurally administered sodium chloride solution is not a true placebo. KEY WORDS: Chronic low back pain, epidural injections, local anesthetic, sodium chloride solution, steroids, placebo effect

A Systematic Literature Review of Peripheral Nerve Stimulation Therapies for the Treatment of Pain

To conduct a systematic literature review of peripheral nerve stimulation (PNS) for pain. Grade the evidence for PNS. An international interdisciplinary work group conducted a literature search for PNS. Abstracts were reviewed to select studies for grading. Inclusion/exclusion criteria included prospective randomized controlled trials (RCTs) with meaningful clinical outcomes that were not part of a larger or previously reported group. Excluded studies were retrospective, had less than two months of follow-up, or existed only as abstracts. Full studies were graded by two independent reviewers using the modified Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the US Preventative Services Task Force level-of-evidence criteria. Peripheral nerve stimulation was studied in 14 RCTs for a variety of painful conditions (headache, shoulder, pelvic, back, extremity, and trunk pain). Moderate to strong evidence supported the use of PNS to treat pain. Peripheral nerve stimulation has moderate/strong evidence. Additional prospective trials could further refine appropriate populations and pain diagnoses.

A Systematic Literature Review of Spine Neurostimulation Therapies for the Treatment of Pain.

To conduct a systematic literature review of spinal cord stimulation (SCS) for pain. Grade the evidence for SCS. An international, interdisciplinary work group conducted literature searches, reviewed abstracts, and selected studies for grading. Inclusion/exclusion criteria included randomized controlled trials (RCTs) of patients with intractable pain of greater than one year's duration. Full studies were graded by two independent reviewers. Excluded studies were retrospective, had small numbers of subjects, or existed only as abstracts. Studies were graded using the modified Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the US Preventative Services Task Force level-of-evidence criteria. SCS has Level 1 evidence (strong) for axial back/lumbar radiculopathy or neuralgia (five high-quality RCTs) and complex regional pain syndrome (one high-quality RCT). High-level evidence supports SCS for treating chronic pain and complex regional pain syndrome. For patients with failed back surgery syndrome, SCS was more effective than reoperation or medical management. New stimulation waveforms and frequencies may provide a greater likelihood of pain relief compared with conventional SCS for patients with axial back pain, with or without radicular pain.

A Systematic Literature Review of Brain Neurostimulation Therapies for the Treatment of Pain.

To conduct a systematic literature review of brain neurostimulation for pain. Grade the evidence for deep brain neurostimulation (DBS). An international, interdisciplinary work group conducted a literature search for brain stimulation. Abstracts were reviewed to select studies for grading. Randomized controlled trials (RCTs) meeting inclusion/exclusion criteria were graded by two independent reviewers. General inclusion criteria were prospective trials (RCTs and observational) that were not part of a larger or previously reported group. Excluded studies were retrospective or existed only as abstracts. Studies were graded using the modified Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the United States Preventative Services Task Force level-of-evidence criteria. Two high-quality RCTs and three observational trials supported DBS, resulting in Level II (moderate) evidence. Moderate evidence supports DBS to treat chronic pain. Additional Level I RCTs are needed to further the strength of the evidence in this important area of medicine, but the current evidence suggests that DBS should be considered as an option in treating complex pain cases.

Effectiveness of Percutaneous Adhesiolysis in Managing Chronic Central Lumbar Spinal Stenosis: A Systematic Review and Meta-Analysis

Background: Symptomatic lumbar spinal stenosis is a condition affecting a growing number of individuals resulting in significant disability and pain, leading to a multitude of interventions ranging from simple over the counter medication to opioids, and, finally, to complex surgical fusions. After failure of conservative treatment with drug therapy, physical therapy, and other conservative modalities including epidural injections, percutaneous adhesiolysis with targeted delivery of drugs into the epidural space can be offered in lumbar central spinal stenosis prior to minimally invasive surgical options or complex surgical fusions. To date there has been only one systematic review which has assessed the role of percutaneous adhesiolysis in treating central spinal stenosis, compared to post lumbar surgery syndrome which has multiple systematic reviews and randomized controlled trials (RCTs). Study Design: A systematic review of RCTs and observational studies assessing the role of percutaneous adhesiolysis in managing lumbar central spinal stenosis. Objective: To evaluate the effectiveness of percutaneous adhesiolysis in managing central lumbar spinal stenosis, utilizing currently available literature. Methods: This systematic review was performed utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for literature search, Cochrane review criteria, Interventional Pain Management techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPMQRB), and Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR) to assess methodologic quality assessment and qualitative analysis utilizing best evidence synthesis principles, and meta-analysis. PubMed, Cochrane library, US National Guideline Clearinghouse, Google Scholar, and prior systematic reviews and reference lists were utilized in the literature search from 1966 through June 2019. The evidence was summarized utilizing principles of the best evidence synthesis on a scale of 1 to 5. Outcome Measures: The primary outcome or hard endpoint was defined as the proportion of patients with 50% pain relief and improvement in functionality, whereas the secondary outcome measures or soft endpoints were pain relief and/or improvement in functionality. Short-term effectiveness was defined as improvement of 6 months or less, whereas long-term effectiveness was defined as more than 6 months. Results: Based on search criteria, 9 manuscripts were identified and considered for inclusion with final inclusion of 2 RCTs and 4 observational studies in this systematic review and 5 studies for single arm meta-analysis. The results showed Level II evidence for short-term and long-term improvement in pain and function with application of percutaneous adhesiolysis in managing central lumbar spinal stenosis. Limitations: There was a significant paucity of evidence assessing the role of percutaneous adhesiolysis in managing lumbar central spinal stenosis, leading to Level II or moderate evidence.Conclusion: Overall, the present analysis shows Level II (moderate) evidence for percutaneous adhesiolysis in managing lumbar central spinal stenosis based on relevant high quality RCTs and observational studies. Key Words: Lumbar central spinal stenosis, percutaneous adhesiolysis, randomized controlled trials, systematic reviews, neuroplasty

Chronic Headache: a Review of Interventional Treatment Strategies in Headache Management.

To provide an overview of current interventional pain management techniques for primary headaches with a focus on peripheral nerve stimulation and nerve blocks. Despite a plethora of treatment modalities, some forms of headaches remain intractable to conservative therapies. Interventional pain modalities have found a niche in treating headaches. Individuals resistant to common regimens, intolerant to pharmaceutical agents, or those with co-morbid factors that cause interactions with their therapies are some instances where interventions could be considered in the therapeutic algorithm. In this review, we will discuss these techniques including peripheral nerve stimulation, third occipital nerve block (TON), lesser occipital nerve block (LON), greater occipital nerve block (GON), sphenopalatine block (SPG), radiofrequency ablation (RFA), and cervical epidural steroid injections (CESI). Physicians have used several interventional techniques to treat primary headaches. While many can be treated pharmacologically, those who continue to suffer from refractory or severe headaches may see tremendous benefit from a range of more invasive treatments which focus on directly inhibiting the painful nerves. While there is a plethora of evidence suggesting these methods are effective and possibly durable interventions, there is still a need for large, prospective, randomized trials to clearly demonstrate their efficacy.

Effectiveness of Percutaneous Adhesiolysis in Post Lumbar Surgery Syndrome: A Systematic Analysis of Findings of Systematic Reviews

Background: Post lumbar surgery syndrome is common and often results in chronic, persistent pain and disability, which can lead to multiple interventions. After failure of conservative treatment, either surgical treatment or a nonsurgical modality of treatment such as epidural injections, percutaneous adhesiolysis are often contemplated in managing post lumbar surgery syndrome. Multiple previous systematic reviews have reached discordant conclusions about the level of evidence for the effectiveness of percutaneous adhesiolysis in managing post lumbar surgery syndrome and other conditions. Study Design: A systematic review of previously published systematic reviews assessing efficacy of percutaneous adhesiolysis in managing post lumbar surgery syndrome. Objective: To evaluate the value and validity of previous systematic reviews performed after 2015 on effectiveness of percutaneous adhesiolysis in managing chronic refractory low back and lower extremity pain secondary to post lumbar surgery syndrome. Methods: Previous systematic reviews on percutaneous adhesiolysis were evaluated. The quality of each systematic review was assessed by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and A Measurement Tool to Assess Systematic Reviews (AMSTAR). The randomized trials included in the available systematic reviews were assessed by Cochrane review criteria and Interventional Pain Management techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) for methodologic quality. Data sources included relevant systematic reviews and the randomized trials included in those systematic reviews published since 2015 with searches of PubMed, Cochrane reviews, and Google Scholar through February 2019. Outcome Measures: Outcome measures were significant improvement defined as 50% pain relief and improvement in functional status. Short-term efficacy was defined as improvement of 6 months or less, whereas long-term efficacy was defined as more than 6 months. Results: Three systematic reviews and 4 randomized controlled trials (RCTs) of post lumbar surgery syndrome with chronic refractory low back and lower extremity pain showed notable evidence of significant pain relief. Only one systematic review, which was of low quality with inappropriate analysis, showed lack of evidence. Conclusion: Overall, the present analysis shows Level I evidence for percutaneous adhesiolysis based on significant evidence from published RCTs and 3 of the 4 systematic reviews. Key words: Post lumbar surgery syndrome, epidural fibrosis, percutaneous adhesiolysis, systematic reviews, randomized controlled trials

Do Regenerative Medicine Therapies Provide Long-Term Relief in Chronic Low Back Pain: A Systematic Review and Metaanalysis

Several cell-based therapies have been proposed in recent years the management of low back pain, including the injection of medicinal signaling cells or mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP). However, there is only emerging clinical evidence to support their use at this time. To assess the effectiveness of MSCs or PRP injections in the treatment of low back and lower extremity pain. A systematic review and metaanalysis of the effectiveness of PRP and MSCs injections in managing low back and lower extremity pain. PubMed, Cochrane Library, US National Guideline Clearinghouse, prior systematic reviews, and reference lists. The literature search was performed from 1966 through June 2018. Randomized trials, observational studies, and case reports of injections of biologics into the disc, epidural space, facet joints, or sacroiliac joints. Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR). The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5. Twenty-one injection studies met inclusion criteria. There were 12 lumbar disc injections, 5 epidural, 3 lumbar facet joint, and 3 sacroiliac joint studies RESULTS: Evidence synthesis based on a single-arm metaanalysis, randomized controlled trials (RCTs), and observational studies, disc injections of PRP and MSCs showed Level 3 evidence (on a scale of Level I through V). Evidence for epidural injections based on single-arm metaanalysis, a single randomized controlled trial and other available studies demonstrated Level 4 (on a scale of Level I through V) evidence. Similarly, evidence for lumbar facet joint injections and sacroiliac joint injections without metaanalysis demonstrated Level 4 evidence (on a scale of Level I through V). Lack of high quality RCTs. The findings of this systematic review and single-arm metaanalysis shows that MSCs and PRP may be effective in managing discogenic low back pain, radicular pain, facet joint pain, and sacroiliac joint pain, with variable levels of evidence in favor of these techniques. Chronic low back pain, regenerative therapy, medicinal signaling or mesenchymal stem cells, platelet-rich plasma, disc injection, lumbar facet joint injections, sacroiliac joint injections.

Functional Connectivity Alterations: Novel Therapy and Future Implications in Chronic Pain Management

Background: Chronic pain is a major public health problem resulting in physical and emotional pain for individuals and families, loss of productivity, and an annual cost of billions of dollars. The lack of objective measures available to aid in diagnosis and evaluation of therapies for chronic pain continues to be a challenge for the clinician. Objectives: Functional magnetic resonance imaging (fMRI) is an imaging technique that can establish regional areas of interest and examine synchronous neuronal activity in functionally related but anatomically distinct regions of the brain, known as functional connectivity. Study Design: The present investigation examines changes in functional connectivity in 4 common pain syndromes: chronic back pain (CBP), fibromyalgia, diabetic neuropathy, and complex regional pain syndrome (CRPS). Setting: This is a review of the current understanding of functional connectivity. Methods: Utilizing functional imaging, patients with these conditions have been shown to have significant structural and functional differences when compared to healthy controls. Results: Functional connectivity, therefore, has the potential to assist in diagnostic classification of different pain conditions, predict individual responses to specific therapeutic interventions, and serve as a gateway for personalized medicine. Indirect activation of brain activity can be seen by the blood flow to the brain at specific sites, with chronic pain patients having increased brain activity. Limitations: The present investigation is limited in that few studies have examined this relatively new modality. Conclusions: Knowing and observing the brain’s activity as related to pain gives pain patients an opportunity to decrease pain-related brain activity and decrease severe chronic pain. This modality can be used along with interventional pain management techniques in order to provide optimum pain relief. Key words: Functional connectivity, fMRI, chronic pain, chronic back pain, fibromyalgia, diabetic neuropathy, chronic regional pain syndrome