Interventional Pain Procedures Research Articles

Pilot study of early integration of interventional pain management for patients with chronic cancer pain.

e24080 Background: Pain is a common, distressing, and costly complication of cancer. Treatment guidelines recommend consideration of interventional pain procedures in addition to pharmacotherapy, yet they are underutilized and often only considered for refractory pain despite high-dose opioids. We examined the feasibility of early integration of interventional pain management among ambulatory patients with chronic cancer pain. Methods: This single arm pilot feasibility study recruited patients from outpatient clinics at the Dana-Farber Cancer Institute. Eligible patients had metastatic or locally advanced solid tumors, persistent pain secondary to cancer/cancer treatment, average pain rating of 4 or higher (0-10 scale), and prognosis > 6 months. Patients could not be taking more than 200 oral morphine equivalents per day. Patients were systematically referred to an interventional pain specialist for consideration of pain procedures, with monthly visits for 4 months. Measures of feasibility included the proportion of patients seen by the pain specialist within 4 weeks, and the proportion undergoing pain procedures. Patients completed surveys at baseline, 2 and 4 months; using the Consumer Assessment of Healthcare Providers and Systems (CAHPS), patients rated their satisfaction with pain clinic (range 0-10), and how often the pain doctor treated them with courtesy and respect, listened carefully, and explained things in a way they could understand (range 1-4, higher scores better). Among those undergoing procedures, patients indicated the percent pain relief they had from the procedure. Results: Between May 2022 and October 2023, 30 patients were enrolled (4 remain on study); mean age, 59.5, 50% male, with a variety of solid tumors; baseline “average pain” and “worst pain” scores were 4.3( SD,1.2) and 6.5( SD,1.6). All but one patient (96.7%) was seen in the pain clinic within four weeks; 57% (n = 17) received one or more pain procedure, with 20% (n = 6) undergoing repeat procedures. The most common procedures were neural blockade (8), celiac plexus neurolysis (n = 4), trigger point injection (n = 3), and epidural steroid injection (n = 3). Among patients receiving a procedure, the median percentage relief was 65% (IQR:30,80). Patients rated the quality of care from the pain clinic highly, with a mean score of 8.6( SD,1.6); and were satisfied with their pain physicians with a mean rating of 3.8( SD,0.4) on treating with respect, 3.7( SD,0.6) for listening, and 3.6( SD,0.6) for explaining. Conclusions: In this study of patients with cancer pain, systematic referral to interventional pain management specialists was feasible, and led to most patients receiving a pain procedure. Patients were satisfied with their pain care and reported meaningful relief of symptoms. Further study is needed to examine whether early integration of interventional pain management improves pain control. Clinical trial information: NCT05366413 .

Relationship of pain relief with catastrophizing following interventional pain procedures for low back pain

IntroductionCatastrophizing is associated with worse pain outcomes after various procedures suggesting its utility in predicting response. However, the stability of pain catastrophizing as a static predictor has been challenged. We...

Healthcare Utilization (HCU) Reduction with High-Frequency (10 kHz) Spinal Cord Stimulation (SCS) Therapy.

Spinal cord stimulation (SCS) is a well-established treatment for patients with chronic pain. With increasing healthcare costs, it is important to determine the benefits of SCS in healthcare utilization (HCU). This retrospective, single-center observational study involved 160 subjects who underwent implantation of a high-frequency (10 kHz) SCS device. We focused on assessing trends in HCU by measuring opioid consumption in morphine milligram equivalents (MME), as well as monitoring emergency department (ED) and office visits for interventional pain procedures during the 12-month period preceding and following the SCS implant. Our results revealed a statistically significant reduction in HCU in all domains assessed. The mean MME was 51.05 and 26.52 pre- and post-implant, respectively. There was a 24.53 MME overall decrease and a mean of 78.2% statistically significant dose reduction (p < 0.0001). Of these, 91.5% reached a minimally clinically important difference (MCID) in opioid reduction. Similarly, we found a statistically significant (p < 0.01) decrease in ED visits, with a mean of 0.12 pre- and 0.03 post-implant, and a decrease in office visits for interventional pain procedures from a 1.39 pre- to 0.28 post-10 kHz SCS implant, representing a 1.11 statistically significant (p < 0.0001) mean reduction. Our study reports the largest cohort of real-world data published to date analyzing HCU trends with 10 kHz SCS for multiple pain etiologies. Furthermore, this is the first and only study evaluating HCU trends with 10 kHz SCS by assessing opioid use, ED visits, and outpatient visits for interventional pain procedures collectively. Preceding studies have individually investigated these outcomes, consistently yielding positive results comparable to our findings.

Treatment Disparities in Hispanic Patients with Chronic Pain: An Evidence-Based Narrative Review.

The purpose of this narrative review is to summarize healthcare disparities experienced by Hispanic and Latino/Latinx patients with chronic pain, evaluate the existing literature exploring the specific therapeutic inequities affecting this patient population, and identify gaps in the literature requiring future study. Hispanic and Latino/Latinx patients experience disparities in chronic pain management. They are less likely to be prescribed pharmacologic therapies, including non-steroidal anti-inflammatory drugs and opioids. Hispanic and Latino/Latinx patients are also less likely to receive spinal cord stimulators and may be charged higher costs for them. There are no published studies specifically assessing Hispanic and Latino/Latinx patients' utilization and outcomes from other common interventional pain procedures (e.g., epidural steroid injections, radiofrequency ablation). Limited data suggest non-pharmacologic treatments, such as cognitive behavioral therapy and complementary/integrative health modalities, might have more benefit for this population, potentially because of greater utilization. Hispanic and Latino/Latinx patients experience disparities in chronic pain management. There is a paucity of data available pertaining specifically to pain-related outcomes and the utilization of pain treatment modalities, especially in regard to interventional procedures. Additional research is urgently needed in order to understand the full extent of these disparities and develop solutions to provide more equitable care.

Evaluation of the efficacy of pulsed radiofrequency therapy in patients with lumbosacral radicular pain: An analysis of single-center data.

Lumbosacral radicular pain (LRP) is one of the most common causes of neuropathic pain. This pain often arises from inflammation in the dorsal root ganglia (DRG) or spinal nerves. Despite various treatment modalities, success rates are not very high in chronic LRP cases. Pulsed radiofrequency (PRF) therapy, frequently applied to the DRG, is widely used, but its effectiveness is often questioned in various studies. The primary aim of our study is to evaluate the effectiveness of PRF treatment in 154 patients. Patients with LRP for longer than 3 months, treated with PRF, were included in this study. To assess the efficacy of PRF treatment, numerical rating scale (NRS) scores were evaluated at the 4th-week and 6th-month follow-ups. The NRS scores were significantly lower at the 4th-week and 6th-month follow-ups compared to pre-treatment levels (p<0.001). However, there was no significant difference between the mean NRS scores at the 4th week and 6th month. Success in interventional pain procedures is often considered as at least a 50% reduction in pain scores. The success rate for PRF treatment for LRP in the literature varies between 30% and 60%, which is similar to our findings at the 4th week and 6th month. PRF treatment is widely used due to its low side-effect profile and cost-effectiveness in the long term. There is no fully standardized practice regarding procedural aspects, such as the duration of the application, and prospective studies with larger participation are needed.

Interventional procedures for refractory neuropathic pain

Neuropathic pain is an increasingly common disease affecting millions of individuals worldwide. Refractory pain poses a significant impact on patients’ quality of life, financial and economic stability, and social interaction. Numerous effective modalities for treatment of refractory neuropathic pain are presently available. Currently, many options provide symptomatic treatment but are associated with an unfavorable side effect profile and increased risk of addiction. The present investigation reviews current medical management for refractory neuropathic pain including the use of antidepressants, anticonvulsants, gabapentinoids and opioid therapy, as well as interventional pain procedures such as spinal cord stimulation (SCS) and intrathecal targeted drug delivery. While multidisciplinary management with lifestyle modification and pharmacologic regimens remains at the forefront of treating many of these patients, interventional modalities are growing in popularity and have been demonstrated to be highly efficacious. In this regard, continued understanding of the pathophysiology surrounding refractory neuropathic pain has led to the development of interventional procedures and better outcomes for patients suffering from refractory neuropathic pain. When and if patients fail conservative therapy, interventional techniques are desirable alternatives for pain management. SCS and intrathecal targeted drug delivery are important tools for the treatment of refractory neuropathic pain. In summary, treatment modalities for refractory neuropathic pain are evolving with demonstrated efficacy. This review aims to outline the efficacy of various interventional procedures for refractory neuropathic pain in comparison to traditional drug therapies.

Scrambler Therapy for Patients With Complex Regional Pain Syndrome: A Case Series.

Complex regional pain syndrome is a chronic debilitating pain disorder that is difficult to manage, in part due to its heterogeneous clinical presentation and lack of clearly defined pathophysiology. Patients usually require a multidisciplinary approach to treatment, which can entail pharmacotherapy, physical therapy, behavioral therapy, and interventional pain procedures, such as sympathetic nerve blocks, spinal cord stimulation, and dorsal root ganglion stimulation. However, many patients continue to experience pain refractory to these multimodal strategies. Scrambler therapy (ST) is a noninvasive method of neuromodulation that is applied through cutaneous electrodes, and can alleviate chronic neuropathic pain by stimulating C-fibers and replacing endogenous pain signals with synthetic non-nociceptive signals. Although the use of ST has been reported for several types of refractory central and peripheral neuropathic pain, there is a paucity of data regarding the use of ST for complex regional pain syndrome. We present two patients with complex regional pain syndrome of the right lower extremity, who each underwent ST and experienced significant pain relief and improvement in function and quality of life.

Ultrasound vs. fluoroscopic guidance in genicular nerve radiofrequency thermocoagulation for chronic knee pain: which one is the future?

Fluoroscopic guiding is commonly utilized for interventional pain management procedures. However, ultrasonography has started to be used more widely in interventional pain procedures. It has become even more popular with its advantages. The clinician who performs the pain procedure and the patient are not exposed to radiation. Vascular structures can be directly visualized. Ultrasonography is more accessible and portable than fluoroscopy. For all these reasons, its use will increase. So, in this study, we aimed to compare the efficacy of the genicular nerve radiofrequency thermocoagulation application under ultrasound guidance and fluoroscopy guidance. Patients with stage 2 and 3 osteoarthritis, according to the Kellgren-Lawrence classification, were included in our study (n=180). Seventy percent of patients were women. Sixty patients received medical treatment only. Genicular nerve radiofrequency thermocoagulation was performed with fluoroscopy in sixty patients and with ultrasonography guidance in sixty other patients. Visual Analogue Scale at 1 month (VAS1) and Western Ontario and McMaster Universities Arthritis (WOMAC1) were recorded before the procedure, while VAS2 and WOMAC2 were recorded at 3 months. In the ultrasound and fluoroscopy group, a statistically significant difference was found between VAS1 and VAS2, WOMAC1 and WOMAC2 (p<0.05). VAS1 of the patients in the fluoroscopy group was 6.65±0.93, and it was 5.88±0.92 in the ultrasonography group, which was similar (p<0.0001). VAS2 was 2.26±1.16 in the ultrasonography group and 3.83±1.66 in the fluoroscopy group (p<0.0001). The reduction rate in pain severity in patients undergoing the procedure under ultrasonography guidance was more marked than that in the fluoroscopy group (p<0.0001). For the radiofrequency thermocoagulation of the genicular nerve, both imaging approaches are available. Ultrasonography guidance appears to be better than fluoroscopy guidance in this technique because of the lower radiation dose and the ability to detect the target location and neighboring tissues more precisely under ultrasonography guidance.

Assessment of Factors Affecting the Preference of Pain Medicine Subspecialty Choices and Training Course in Turkey: A Cross-Sectional Survey Study.

The aim of this study is to assess the factors affecting the preference for the Pain Medicine subspecialty and the fellowship training programs by the pain specialists who have completed or continued the Pain Medicine fellowship training program from 2014 to 2021 in Turkey. The study was conducted in October 2020 and March 2021. By reaching out to the pain specialists who completed their fellowship or had been continuing their training by getting the right to receive a Pain Medicine fellowship. Via e-mail or WhatsApp application, an e-questionnaire link was sent to the participants, and data were collected on demographics, factors affecting the choice of Pain Medicine subspecialty, level of realization of the expectations during the training course and the level of proficiency in the field of pain specialization. Data analysis was performed using IBM SPSS Statistics 20.0 software, and tests were considered statistically significant if P < 0.05. Participants reported that the factors that most affected their preferences were personal interest (55.1%), more comfortable working conditions (43.6%), and interest in an academic career (38.5%). Seventy-six participants answered the level of realization of expectations about performing interventional pain procedures using ultrasound imaging, and 31.6% reported that their expectations were not met, and 25% reported that their expectations were partially realised. We hope that our findings will lead to improving Pain Medicine subspecialty training programs, upgrading standards, and more comprehensive studies on these issues.

Ultrasonography in Pain Medicine and Regional Anesthesia Expert Consensus

Ultrasound has revolutionized interventional pain medicine and regional anesthesia. It allows visualization of nervoussystem structures, which are the primary targets in pain management and regional anesthesia procedures. Precise andsafe deposition of local anesthetics around nerve structures is made possible with ultrasound, resulting in rapid regionalanesthesia and modulation of pathological pain signals. In diagnostic and prognostic pain treatments, the precisionof drug administration and deposition of small volumes are crucial. Proper identification of the nerve responsible fortransmitting pathological pain signals is key to achieving the desired effect in neurodestructive procedures such asneurolysis, cryoablation, thermocoagulation, or pulsed neuromodulation. Visualization of structures to avoid, such asblood vessels or parenchymal organs, reduces the risk of adverse events like hematoma or damage to sensitive internalorgans. Real-time needle tracking during procedures shortens the duration and increases precision. Monitoring thespread of the administered therapeutic substance during the procedure enhances the effectiveness and selectivityof the block. When combined with X-ray imaging, using ultrasound reduces procedure time and exposure to X-rayradiation. Furthermore, ultrasound does not expose clinicians and patients to harmful X-ray radiation. Widespreadadoption of ultrasound in imaging nervous system structures during regional anesthesia and interventional painprocedures necessitates the development of new procedural standards.

FactFinders for patient safety: Preventing potential procedure-related complications: Vasovagal reactions and spinal cord stimulator lead migration

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.

Better late than never? Impact of delayed elective interventional pain procedures due to the COVID-19 pandemic

Despite the well documented importance and success of interventional pain procedures in the management of painful spine conditions, detractors have questioned their role as part of the care paradigm since their inception. One of the many unexpected consequences of the COVID-19 pandemic in the United States was the forced shut down of elective procedures in early 2020. This caused many patients suffering with pain, who had already been deemed appropriate for an interventional procedure to have to wait an extended period of time. This unprecedented period in modern healthcare provided the opportunity for a long term examination of how this cohort of patients suffering with pain faired while being forced to wait for pain relieving intervention, and to demonstrate the vital importance of these procedures for not only pain relief but for improvement in quality of life. This study will show that an overwhelming number of patients reported that their pain had not improved spontaneously over time, and were anxious to proceed with intervention once given the opportunity.

ID: 209316 Improved Functional Outcomes and Pain Relief Using SCS in Patients With No Prior Back Surgery

Chronic intractable pain, often defined as pain persisting for ≥6-months which has not responded to conservative treatment(s), is complex and dynamic. Hence, varying results between various treatment approaches including medications, physical therapy, stimulation etc. are often reported. Treatments like physical therapy and interventional pain procedures (e.g., intraspinal injections, vertebroplasty, pulsed RF) are often attempted, sometimes followed by chronic high dose opioids and back surgery, if indicated. However, earlier neuromodulation interventions such as Spinal Cord Stimulation (SCS) prior to spinal surgery may result in acceptable patient outcomes. Hence, we sought to examine outcomes for the use of SCS in treatment of chronic pain in patients with no prior back surgery as part of two ongoing real-world studies.

ID: 219407 The Cardiac Patient and Neuromodulation; When Anticoagulation Dictates the Intervention

Patients with cardiac comorbidities present unique challenges for undergoing interventional pain procedures. Consensus guidelines on safe anticoagulation management are categorized by procedure, patient specific bleeding risk factors, and class of anticoagulation (Table 1, Table 2).1 Specifically, some procedures occur in close proximity to the spinal cord, require large gauge needles and styletted leads, while others are in compressible locations with minimal tissue disruption. Further, pain-induced hypercoagulation increases the risk of thrombo-vascular events.1 This accentuates the importance of interdisciplinary perioperative coordination with the prescribing cardiologist.

ID: 205925 Real-World Outcomes Using Thermal Radiofrequency (TRF) Ablation for Chronic Pain

Minimally invasive interventional pain procedures, such as thermal radiofrequency (TRF) ablation, have steadily progressed to become a key segment of the therapeutic armamentarium now available to the chronic pain patient population. Here, we report real world-collected outcomes from a study of patients treated with TRF for management of chronic pain.

Needle Navigation; a New Era in the Interventional Pain Practice: A Narrative Review

Background: The hazardous effects of x-ray based technologies and shortcomings of other imaging systems like ultrasound have raised attention to create a new guiding system for interventional practice. After the introduction of virtual reality, the next challenge was how to implement it in the medical guiding systems. Medical engineering used registration aligned features of one imaging modality with real anatomical points and merged them into one single hybrid model. This augmented reality made the foundation and provided a level surface for the construction of every other new level. The next level was how to track a device in this augmented reality, which was accomplished with trackers and registration. To overcome the shortcomings of each imaging modality, the solution was fusion imaging, the combination of more than one modality to overcome the limitations of each. Nowadays, this fusion imaging plus needle tracking is the most sophisticated of navigational systems that interventionists work with. Despite clinical improvements in other medical fields like neurosurgery and urology, most of the work in the interventional pain practice has been done on phantom models and human cadavers, and there is still low experience in clinical studies about this new guiding system. Methods: The electronic search for this review included full text English article between 1990-2021 in PubMed and Google Scholar databases. The terms that have been searched are: “virtual reality”, “augmented reality”, “needle navigation”, “needle tracking”, and “fusion imaging”. Results: The navigation imaging guided system can be a practical, safe, efficient, reproducible, feasible guiding option for interventional pain procedure. Conclusions: The navigation based interventional injection is a new era in the interventional pain practice and can omit X-ray based hazardous.

Interventional Pain Procedures: A Narrative Review Focusing on Safety and Complications. Part 1 Injections for Spinal Pain.

In recent years, there has been a considerable increase in the number of image-guided interventional procedures performed for the management of acute and chronic pain. Concomitantly, there has also been an increase in the complication rate related to these procedures. The aim of this narrative review is to summarize the primary complications associated with commonly performed image-guided (fluoroscopic- or ultrasound-guided) interventional procedures. We conclude that although complications from interventional pain procedures can be mitigated to a certain degree, they cannot be eliminated altogether. In order to avoid adverse events, patient safety should be given considerable attention and physicians should be constantly aware of the possibility of developing complications.

Is routine intravenous access commonly established before interventional pain procedures? Results of a spine intervention society practice pattern survey

Summary of background dataEstablishing 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. ObjectivesTo determine the frequency with which routine IV access is obtained for various common interventional pain procedures among interventional pain providers. MethodsAn 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. Results141 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/conclusionsThere 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.

Nonsurgical Interventional Spine Pain Procedures

Nonsurgical interventional spine pain procedures provide an additional treatment option for lower back pain at the traditional bifurcation of conversative vs. operative management. Transforaminal epidural steroid injections, radiofrequency ablations, intrathecal drug delivery, and spinal cord stimulation were found to be effective and safe techniques when applied to their specific indication. Thermal annuloplasty and minimally invasive lumbar decompression showed mixed support. Discography, sacroiliac joint injections, and spinous process spacers lacked sufficient evidence to support efficacy. Medial branch blocks and facet joint injections were found to be useful diagnostic tools.

Multidisciplinary simulation of local anaesthetic systemic toxicity improves diagnostic and treatment skills and self-confidence for pain clinic procedural staff

Local anaesthetic systemic toxicity (LAST) is a rare complication after outpatient interventional pain procedures, which can present as an emergent and life-threatening condition. Proficiency and confidence in managing this rare...