Interventional Pain Procedures Research Articles

Survey of Interventional Pain Physicians on Bending Spinal Needles for Chronic Pain Procedures

Background: Interventional pain procedures involve placement of fine-gauge spinal needles, which practitioners will frequently bend to facilitate both driving the needle through tissue, and to increase accuracy of placement at a specific spinal structure or nerve target. This bend is commonly performed by hand, leaving the proceduralist at risk for fingerstick injury, and the patient at risk of site contamination. However, few case studies have been published, and there are almost no data on physician preference or practice. Objectives: The purpose of this study was to survey interventional pain physicians on their practice of spinal needle manipulation before performing lumbar medial branch nerve blocks. Specific aims were to assess the prevalence of manual needle bending, and to determine possible associations with practitioner experience, clinical environment, and fingerstick injury. Study Design: A survey. Setting: Annual 2018 American Society for Interventional Pain Physicians conference in Orlando, Florida. Methods: A convenience sample of participants were screened for eligibility and asked to voluntarily participate in a de-identified IRB-approved survey (IRB201703055). The survey consisted of 5 questions, 2 with binary answer choices and the remaining 3 with multiple answer choices. Data were collected on an iPad via Qualtrics software. Data were analyzed by descriptive statistics (counts, percentages). Results: Of 480 interventional pain physician attendees at the conference, 154 (32.1%) completed the survey. The majority (114/154; 74%) reported ‘always’ bending the distal tip of spinal needles, and a further 21 (14%) reported ‘sometimes’; 19 (12%) said they do not bend their needles. Only 25 (18%) respondents used an instrument to bend their needles; 112 (82%) bend their needles by hand. Eight respondents (6%) reported a fingerstick injury while bending a spinal needle, one while using an instrument, and 7 during a manual bend. Approximately half of respondents had been practicing for greater than 15 years; 78% work in a private practice environment. Limitations: Due to the setting, the recruitment method presents the possibility of selection bias. Furthermore, although the response rate may appear low, it is higher than similarly performed studies. Conclusions: Spinal needle manipulation is common prior to performing interventional pain procedures, and most spinal needle manipulations are performed by hand. Rate of fingerstick injury was low in this sample, but cannot be evaluated without comparative data. Factors to be considered in a subsequent study are the effects of needle bend variability relative to practitioner experience and alternative means of needle manipulation. Key words: Interventional pain procedures, spinal needles, facet joint injections, needle bending, fingerstick injuries

Update of a Study of Not Ceasing Anticoagulants for Patients Undergoing Injection Procedures for Spinal Pain

To determine prevalence rates of hemorrhagic complications in patients who either ceased or continued anticoagulants during interventional pain procedures. A total of 1,936 consecutive patients were prospectively monitored during a total of 12,723 injection procedures. The prevalence of hemorrhagic complications was tallied for a variety of procedures performed on patients who ceased or continued various anticoagulants. No hemorrhagic complications occurred in any patient who continued anticoagulants. Sufficiently large sample sizes were obtained to conclude that, in patients who continued warfarin or clopidrogel during lumbar transforaminal injections and for lumbar facet procedures, the zero prevalence of complications had 95% confidence intervals of 0% to 0.3%. This prevalence was significantly lower than the risk of medical complications in patients who ceased warfarin. Lumbar transforaminal injections and lumbar facet injections have a very low rate of hemorrhagic complications when patients continue to take anticoagulants.

Pain Medicine Board Certification Status Among Physicians Performing Interventional Pain Procedures in the State of Florida Between 2010 and 2016

The US Department of Health and Human Services has recommended that physicians performing interventional pain procedures be credentialed based on criteria based guidelines and minimum training requirements. To quantitatively assess gaps in certification related to pain medicine fellowship requirements, we studied the distribution of such procedures in Florida between 2010 and 2016. This research involved a retrospective analysis with a sample size of n = 1,885,442 interventional pain procedures. Data describing interventional pain procedures performed in Florida between January 2010 and December 2016 were obtained from the Florida Department of Health. The National Provider Identifier file and board certification lists from the American Board of Medical Specialties (ABMS), the American Board of Pain Medicine (ABPM), and the American Board of Interventional Pain Physicians (ABIPP) corresponding to this time frame were also obtained. The datasets were linked to determine the specialty of physicians performing interventional pain procedures, and whether or not they were pain medicine diplomates of the ABMS, the ABPM, or the ABIPP. The similarity index theta was calculated for the distribution of interventional pain procedure codes among medical specialty groups, and with respect to the practitioners' pain medicine board certification status. Of the interventional pain procedures, anesthesiologists performed 63.5%, physiatrists 19.1%, neurologists or psychiatrists 5.2%, and other practitioners 12.3%. Among procedures performed by anesthesiologists, physiatrists, and psychiatrists or neurologists, 66.2%, 50.3%, and 50.4% were by ABMS pain board-certified practitioners, respectively. Practitioners without ABMS pain medicine boards performed 45.8% of interventional pain procedures. Practitioners without such boards from either the ABMS, ABPM, or ABIPP performed 37.7%. There was very large similarity (theta > 0.9) in the distribution of procedures comparing ABMS pain medicine board-certified practitioners to non-ABMS pain medicine board-certified anesthesiologists, physiatrists, or all other specialties. In countries other than the United States, where pain medicine board certification is relatively recent, there may be a higher percentage of interventional pain procedures performed by individuals without certification than we report. In "opt-out" states, where nurse anesthetists can independently perform interventional pain procedures, the percentage of interventional pain procedures performed by individuals without physician pain medicine board certification may also be higher. The datasets we used do not contain information to allow assessment of outcomes or effectiveness resulting from pain medicine board certification. Approximately one-third of interventional pain procedures were performed by physicians without at least 1 of the 3 pain medicine board certifications. In addition, the practitioners performed very similar distributions of procedures (i.e., those without pain medicine board certification, overall, have not restricted their practice). These results suggest the need for additional accredited pain medicine fellowship training positions for newly graduated residents. The results also show that, for the recommendations of the Department of Health and Human Services to be satisfied, physicians without board certification performing intervention procedures would need to obtain ABPM or ABIPP certification, or ABMS certification after completion of a full-time Accreditation Council of Graduate Medical Education pain medicine fellowship. Chronic pain, education, medical, graduate, specialty boards.

Chronic hip pain in adults: Current knowledge and future prospective.

Chronic hip pain is distressing to the patient as it not only impairs the daily activities of life but also affects the quality of life. Chronic hip pain is difficult to diagnose as patients often present with associated chronic lumbar spine and/or knee joint pain. Moreover, nonorthopaedic causes may also present as chronic hip pain. The accurate diagnosis of chronic hip pain starts with a detailed history of the patient and thorough knowledge of anatomy of the hip joint. Various physical tests are performed to look for the causes of hip pain and investigations to confirm the diagnosis. Management of chronic hip pain should be mechanistic-based multimodal therapy targeting the pain pathway. This narrative review will describe relevant anatomy, causes, assessment, investigation, and management of chronic hip pain. The focus will be on current evidence-based management of hip osteoarthritis, greater trochanteric pain syndrome, meralgia paresthetica, and piriformis syndrome. Recently, there is emphasis on the role of ultrasound in interventional pain procedures. The use of fluoroscopic-guided radiofrequency in periarticular branches of hip joint has reported to provide pain relief of up to 36 months. However, the current evidence for use of platelet-rich plasma in chronic hip osteoarthritis pain is inconclusive. Further research is required in the management of chronic hip pain regarding comparison of fluoroscopic- and ultrasound-guided procedures, role of platelet-rich plasma, and radiofrequency procedures with long-term follow-up of patients.

Risks of Precipitate Formation When Combining Corticosteroids with Local Anesthetic for Use During Interventional Pain Procedures.

Risks of Precipitate Formation When Combining Corticosteroids with Local Anesthetic for Use During Interventional Pain Procedures.

Opioids and the Predilection for Violence in the Pain Clinic: A Physician's Perspective.

Pain physicians, more so than any other specialty, interact with a patient population that is significantly more likely to engage in violence. In this commentary on the article “Patient-on-Provider Violence in the Pain Clinic” by Judy George, we echo some of the points mentioned in the manuscript. There needs to be a better system in place to identify and to deal with problem patients seeking drugs. Although there has been a push recently to move away from opioids with a patient-specific multimodal analgesic treatment plan with a focus on interventional pain procedures, opioids are still a part of the pain physician’s practice. The medical community must stand behind ensuring these doctors and their staff can practice in an environment that is safe for them and the patients they are caring for. This response fully complies with ethical guidelines. This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by any of the authors.

The Lumbar Ligamentum Flavum Does Not Have Two Layers and Is Confluent with the Interspinous Ligament: Anatomical Study with Application to Surgical and Interventional Pain Procedures

Numerous authors over the years have reported that the lumbar ligamentum flavum has two layers. Our routine cadaveric dissections raised the question whether this understanding is correct, as we always have observed only one layer. Thus, the goal of this cadaveric study was to reevaluate the layers of the ligamentum flavum. Twenty lumbar levels from five fresh-frozen cadaveric specimens were used in this study. After dissection of the lumbar spine, the ligamentum flavum and interspinous ligament were exposed. Each lumbar level was transected through the zygapophyseal joint, and hematoxylin and eosin staining, Masson's trichrome staining and Verhoeff-van Gieson staining were performed. Continuation of the interspinous ligament and ligamentum flavum were observed invariably. There was no evidence of the existence of a two-layered ligamentum flavum. The lumbar ligamentum flavum does not consist of two layers, but is confluent instead with the interspinous ligament that attaches to the zygapophyseal joints. To convey this anatomy better, we suggest describing the lumbar ligamentum flavum as a structure that consists of interlaminar and interspinous parts. Precise knowledge of the ligamentum flavum's anatomy can be of clinical value, particularly when epidural anesthesia or lumbar puncture are performed. Clin. Anat. 32:34-40, 2019. © 2019 Wiley Periodicals, Inc.

A Contemporary Medicolegal Analysis of Outpatient Interventional Pain Procedures: 2009-2016.

Closed malpractice claim studies allow a review of rare but often severe complications, yielding useful insight into improving patient safety and decreasing practitioner liability. This retrospective observational study of pain medicine malpractice claims utilizes the Controlled Risk Insurance Company Comparative Benchmarking System database, which contains nearly 400,000 malpractice claims drawn from >400 academic and community medical centers. The Controlled Risk Insurance Company Comparative Benchmarking System database was queried for January 1, 2009 through December 31, 2016, for cases with pain medicine as the primary service. Cases involving outpatient interventional pain management were identified. Controlled Risk Insurance Company-coded data fields and the narrative summaries were reviewed by the study authors. A total of 126 closed claims were identified. Forty-one claims resulted in payments to the plaintiffs, with a median payment of $175,000 (range, $2600-$2,950,000). Lumbar interlaminar epidural steroid injections were the most common procedures associated with claims (n = 34), followed by cervical interlaminar epidural steroid injections (n = 31) and trigger point injections (n = 13). The most common alleged injuring events were an improper performance of a procedure (n = 38); alleged nonsterile technique (n = 17); unintentional dural puncture (n = 13); needle misdirected to the spinal cord (n = 11); and needle misdirected to the lung (n = 10). The most common alleged outcomes were worsening pain (n = 26); spinal cord infarct (n = 16); epidural hematoma (n = 9); soft-tissue infection (n = 9); postdural puncture headache (n = 9); and pneumothorax (n = 9). According to the Controlled Risk Insurance Company proprietary contributing factor system, perceived deficits in technical skill were present in 83% of claims. Epidural steroid injections are among the most commonly performed interventional pain procedures and, while a familiar procedure to pain management practitioners, may result in significant neurological injury. Trigger point injections, while generally considered safe, may result in pneumothorax or injury to other deep structures. Ultimately, the efforts to minimize practitioner liability and patient harm, like the claims themselves, will be multifactorial. Best outcomes will likely come from continued robust training in procedural skills, attention paid to published best practice recommendations, documentation that includes an inclusive consent discussion, and thoughtful patient selection. Limitations for this study are that closed claim data do not cover all complications that occur and skew toward more severe complications. In addition, the data from Controlled Risk Insurance Company Comparative Benchmarking System cannot be independently verified.

Evidence Analysis of Sympathetic Blocks for Visceral Pain

This paper aims to review common sympathetic nerve blocks to treat visceral pain. Extensive reviews exist exploring the approach to care for those with visceral pain due to malignancy. These often include interventional pain procedures. Research demonstrates these procedures may reduce opioid use. Research is ongoing to assess the efficacy when treating non-malignant source of visceral pain. Recently, several case reports and small-scale studies demonstrate benefits for non-painful entities, such as improved cardiac function after such procedures. The management of visceral algesia is complex. The approach to visceral pain should recognize the benefit of early discussions for the use of sympathetic blocks. Additionally, since most procedures have multiple techniques, analgesia can be achieved even in the setting of distorted anatomy due to tumor mass effects or post-radiation fibrosis, among other etiologies.

Observational Study of the Distribution and Diversity of Interventional Pain Procedures Among Hospitals in the State of Iowa

Background: Critical access hospitals represent 61% of hospitals in the rural United States, and 68% of hospitals in Iowa. The role of small hospitals, such as critical access hospitals, in providing interventional chronic pain procedures is unknown. Objectives: We evaluated whether: a) the diversity of interventional pain procedures offered by hospitals is related to their size and is attributable principally to lumbosacral epidural injections; b) critical access hospitals contribute substantively to the count and diversity of pain procedures; and c) whether most interventional pain procedures performed at hospitals’ facilities are performed by relatively few proceduralists or by the cumulative activity of many clinicians. Study Design: This research involved an observational cohort design with a sample size of n = 283,940 interventional pain procedures. Setting: Data were collected from hospital-owned facilities in the state of Iowa from July 2012 through September 2017. Methods: The diversity of types of interventional pain procedures performed statewide was quantified in terms of the relative proportions of procedures at each hospital using the Herfindahl index. Bilinear weighted least squares regression quantified the relationship between the inverse of the Herfindahl and the percentage of procedures that were lumbar or caudal epidural. Kendall tau concordances quantified the relationship between counts of interventional pain procedures and hospital size. Using a blinded version of the National Provider Identifier of the clinician with primary responsibility for performing the principal procedure of the ambulatory visit, we calculated the percentage shares of interventional pain procedures performed by the 1% and 5% of proceduralists who performed the most procedures. Results: The diversity of types of procedures substantively differentiated among hospitals. Heterogeneity among hospitals in the proportion of procedures that were lumbar or caudal epidural injections substantively contributed to the heterogeneity among hospitals (P < .001). Hospitals performing more procedures tended to have greater diversity of types of procedures (P < .001). However, the strength of the concordance was small (Kendall τb = 0.332), showing substantial heterogeneity among hospitals. The 82 critical access hospitals statewide cumulatively accounted for 23.9% of interventional pain procedures. The critical access hospitals’ procedures were mostly (67.7%) lumbar or caudal epidural injections (P < .001), greater than the 48.9% of the other 41 hospitals (P < .001). Procedures were concentrated among proceduralists. The 1.0% of the proceduralists performing the most procedures performed 64.8% of procedures. The 5.0% of proceduralists performing the most procedures performed 87.7% of procedures. Limitations: The data are procedures were performed in hospital-owned facilities of Iowa. Conclusions: Although busier pain programs, based on procedures per week, generally performed more types of procedures, the variability was so large that the number of procedures a pain program performs per week cannot validly be used to infer the diversity of the hospital’s pain medicine practice. Hospitals with pain medicine programs that lack diversity in the types of procedures performed may provide limited options for patients and be susceptible to changes in payment for individual procedures. Relatively few proceduralists performed the vast majority of the procedures. Key words: Critical access hospitals, Herfindahl, interventional pain procedures, managerial epidemiology, pain medicine, state outpatient procedure database, lumbar epidural

US critical access hospitals' listings of pain medicine physicians and other clinicians performing interventional pain procedures

Study objectiveThere is little knowledge of rural hospitals' roles in the care of chronic pain patients nationwide in the United States of America. We hypothesized that very few (≅5%) critical access hospitals provide patients with interventional pain procedures performed by pain medicine physicians. DesignRandom sample of the 1346 critical access hospitals in USA. MeasurementsPublic websites were used for collection of listed services. Main resultsNine pain medicine physicians were listed as performing interventional chronic pain procedures at 7 of the 110 randomly selected critical access hospitals nationwide (6.4%; P = 0.63 compared with 5.0%). All listed locations for the care provided by the pain medicine physicians were within a critical access hospital or a hospital building adjacent to the hospital. Seven of the 9 physicians were listed as having active American Board of Medical Specialties (ABMS) certification in pain medicine. The 7 physicians with ABMS certification were at 6 of the hospitals, giving a percentage of 5.5% (P = 0.95).The proportions of critical access hospitals reporting interventional pain procedures were homogeneously distributed among census bureau divisions (P = 0.38). Fewer than half of the clinicians listed as providing pain management were pain medicine physicians (26.5% [9/34]; P = 0.0090). ConclusionsA very small percentage of critical access hospitals list at their websites that they offer interventional pain services by pain medicine-trained physicians, and most clinicians listed as performing these procedures are not pain medicine certified. Increasing access to pain medicine physicians may present an opportunity for improved pain care in rural communities.

INFERIOR ALVEOLAR NERVE RADIOFREQUENCY ABLATION FOR REFRACTORY TRIGEMINAL NEURALGIA: A CASE REPORT

Trigeminal neuralgia, also known as tic douloureux, is a disorder characterized by pain in the distribution of the trigeminal nerve. Chronic pain secondary to this condition can have a significant negative impact on a patient’s quality of life. We present an educational case of refractory trigeminal neuralgia responsive to a novel painalleviating procedure. An 80-year-old man with recurrent trigeminal neuralgia presented with episodic pain refractory to multimodal pharmacologic treatment, as well as interventional pain procedures. Radiofrequency ablation (RFA) to the mandibular and maxillary branches of the trigeminal nerve was attempted, but deemed unsuccessful. In an attempt to relieve the patient’s pain in the mandibular region, an inferior alveolar nerve block with radiofrequency ablation was performed. The patient reported a significant longterm reduction of his pain and improved ability to perform activities of daily living. Key words: Trigeminal neuralgia, tic douloureux, radiofrequency ablation, trigeminal nerve, inferior alveolar nerve

Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines

Interventional pain management involves diagnosis and treatment of chronic pain. This specialty utilizes minimally invasive procedures to target therapeutics to the central nervous system and the spinal column. A subset of patients encountered in interventional pain are medicated using anticoagulant or antithrombotic drugs to mitigate thrombosis risk. Since these drugs target the clotting system, bleeding risk is a consideration accompanying interventional procedures. Importantly, discontinuation of anticoagulant or antithrombotic drugs exposes underlying thrombosis risk, which can lead to significant morbidity and mortality especially in those with coronary artery or cerebrovascular disease. This review summarizes the literature and provides guidelines based on best evidence for patients receiving anti-clotting therapy during interventional pain procedures. Best evidence synthesis. To provide a current and concise appraisal of the literature regarding an assessment of the bleeding risk during interventional techniques for patients taking anticoagulant and/or antithrombotic medications. A review of the available literature published on bleeding risk during interventional pain procedures, practice patterns and perioperative management of anticoagulant and antithrombotic therapy was conducted. Data sources included relevant literature identified through searches of EMBASE and PubMed from 1966 through August 2018 and manual searches of the bibliographies of known primary and review articles. 1. There is good evidence for risk stratification by categorizing multiple interventional techniques into low-risk, moderate-risk, and high-risk. Also, their risk should be upgraded based on other risk factors.2. There is good evidence for the risk of thromboembolic events in patients who interrupt antithrombotic therapy. 3. There is good evidence supporting discontinuation of low dose aspirin for high risk and moderate risk procedures for at least 3 days, and there is moderate evidence that these may be continued for low risk or some intermediate risk procedures.4. There is good evidence that discontinuation of anticoagulant therapy with warfarin, heparin, dabigatran (Pradaxa®), argatroban (Acova®), bivalirudin (Angiomax®), lepirudin (Refludan®), desirudin (Iprivask®), hirudin, apixaban (Eliquis®), rivaroxaban (Xarelto®), edoxaban (Savaysa®, Lixiana®), Betrixaban(Bevyxxa®), fondaparinux (Arixtra®) prior to interventional techniques with individual consideration of pharmacokinetics and pharmacodynamics of the drugs and individual risk factors increases safety.5. There is good evidence that diagnosis of epidural hematoma is based on severe pain at the site of the injection, rapid neurological deterioration, and MRI with surgical decompression with progressive neurological dysfunction to avoid neurological sequelae.6. There is good evidence that if thromboembolic risk is high, low molecular weight heparin bridge therapy can be instituted during cessation of the anticoagulant, and the low molecular weight heparin can be discontinued 24 hours before the pain procedure.7. There is fair evidence that the risk of thromboembolic events is higher than that of epidural hematoma formation with the interruption of antiplatelet therapy preceding interventional techniques, though both risks are significant.8. There is fair evidence that multiple variables including anatomic pathology with spinal stenosis and ankylosing spondylitis; high risk procedures and moderate risk procedures combined with anatomic risk factors; bleeding observed during the procedure, and multiple attempts during the procedures increase the risk for bleeding complications and epidural hematoma.9. There is fair evidence that discontinuation of phosphodiesterase inhibitors is optional (dipyridamole [Persantine], cilostazol [Pletal]. However, there is also fair evidence to discontinue Aggrenox [dipyridamole plus aspirin]) 3 days prior to undergoing interventional techniques of moderate and high risk. 10. There is fair evidence to make shared decision making between the patient and the treating physicians with the treating physician and to consider all the appropriate risks associated with continuation or discontinuation of antithrombotic or anticoagulant therapy.11. There is fair evidence that if thromboembolic risk is high antithrombotic therapy may be resumed 12 hours after the interventional procedure is performed.12. There is limited evidence that discontinuation of antiplatelet therapy (clopidogrel [Plavix®], ticlopidine [Ticlid®], Ticagrelor [Brilinta®] and prasugrel [Effient®]) avoids complications of significant bleeding and epidural hematomas.13. There is very limited evidence supporting the continuation or discontinuation of most NSAIDs, excluding aspirin, for 1 to 2 days and some 4 to 10 days, since these are utilized for pain management without cardiac or cerebral protective effect. The continued paucity of the literature with discordant recommendations. Based on the survey of current literature, and published clinical guidelines, recommendations for patients presenting with ongoing antithrombotic therapy prior to interventional techniques are variable, and are based on comprehensive analysis of each patient and the risk-benefit analysis of intervention. Perioperative bleeding, bleeding risk, practice patterns, anticoagulant therapy, antithrombotic therapy, interventional techniques, safety precautions, pain.

Patients with a history of hypersensitivity reaction to iodinated contrast medium and given iodinated contrast during an interventional pain procedure

In patients with a history of a hypersensitivity reaction to iodinated contrast medium, iodinated contrast medium is avoided, antihistamine and steroid premedication are given, or a gadolinium-based contrast agent is...

Gadolinium use for interventional pain procedures: where we are and where we are heading.

In recent years as the use of interventional pain procedures has soared, so too has outside and internal scrutiny. This scrutiny includes agreater emphasis on weighing the risks and benefits of procedures, increased surveillance for adverse events, and cost containment strategies. In 2016, the first reports of gadolinium deposition in the central nervous system began to surface, though retention in other organ systems has been appreciated for over a decade. In this issue of Regional Anesthesia & Pain Medicine, Benzon et al. report a series of patients with document edhypersensitivity reactions to iodinated contrast medium who were inadvertently administered iodine-based contrast without adverse consequences. In this article, we discuss the epidemiology of contrast-mediated adverse effects, the mechanistic basis for hypersensitivity reactions, the risks and benefits of various approaches in the patient with a documented contrast hypersensitivity reaction, and risk mitigation strategies.

Caution in Using Gadolinium-Based Contrast Agents in Interventional Pain Procedures.

Caution in Using Gadolinium-Based Contrast Agents in Interventional Pain Procedures.

Exploring the Role of Chronic Pain Clinics: Potential for Opioid Reduction

The management of chronic nonmalignant pain with high-dose opioids has partially contributed to the current opioid epidemic, with some responsibility shared by chronic pain clinics. Traditionally, both primary care providers and patients used chronic pain clinics as a source for continued medical management of patients on high-dose opioids, often resulting in tolerance and escalating doses. Although opioids continue to be an important component of the management of some chronic pain conditions, improvement in function and comfort must be documented. Pain clinics are ideally suited for reducing opioid usage while improving pain and function with the use of a multimodal approach to pain management. We assessed whether the application of multimodal treatment directed by pain specialists in a pain clinic provides for improved function and reduced dosages of opioid analgesics. We evaluated the role of a pain clinic staffed by fellowship-trained pain physicians in reducing pain and opioid use in chronic nonmalignant pain patients. This study used a retrospective design. The research took place in an outpatient pain clinic in a tertiary referral center/teaching hospital. Of 1268 charts reviewed, 296 patients were on chronic opioids at the time of first evaluation. After a thorough evaluation, the patients were treated with nonopioid pharmacotherapy and interventional pain procedures as necessary. The data utilized from patients' latest follow-up visit included current pain level using the Numerical Rating Scale (NRS-11), opioid usage, and various functional parameters. NRS-11 scores decreased by 33.8% from 6.8 (± 0.1)/10 to 4.5 (± 0.2)/10. The pain frequency and number of pain episodes improved by 36.8 ± 2 and 36.2 ± 2.1, respectively. Additionally, the ability to sleep, work, and perform chores significantly improved. Total opioid use decreased by about 55.4% from 53.8 ± 4 to about 24 ± 2.8 MME/patient/day. This study is not a randomized prospective controlled study. The patients analyzed are still getting therapy and their pain status may change. Some opioids are underrepresented in the analyzed cohort. Finally, this study lacks in-depth stratification by type of pain, age, gender, and duration of opioid use. Chronic pain clinics can play a pivotal role in reducing opioid usage while improving pain and function in patients on chronic opioids. We wish to emphasize the importance of allocating resources toward nonopioid treatments that may improve the function and well-being of patients. Pain clinic, pain management, multimodal pain management, chronic pain, opioid reduction, improved pain, improved functional capacity.

10 kHz spinal cord stimulation: a retrospective analysis of real-world data from a community-based, interdisciplinary pain facility.

ObjectiveTo evaluate clinical outcomes and health care utilization at 12 months post spinal cord stimulator (SCS) implantation compared with baseline and a matched sample of patients receiving conventional medical management (CMM) for the treatment of low back and lower extremity pain.PatientsA retrospective study of patients with at least 24 months of active treatment at an interdisciplinary community pain center between December 1, 2014 and December 31, 2017. Thirty-two patients receiving implantation of a high-frequency (10 kHz) SCS and 64 patients receiving CMM were identified through propensity matching at a ratio of 2:1.MethodsData were extracted from medical records, including pain severity, prescribed opioid dose in morphine milligram equivalents, patient perception of disability, and volume of interventional pain procedures and total office visits to the pain center.ResultsReductions in opioid dose were significantly greater for the SCS group than the CMM group. The 26.2 mg morphine equivalent dose reduction represents a 28% reduction from baseline, with 71.4% of those prescribed opioids in the SCS group reducing their dose at 12 months post-implant. Among those with SCS, there were significant within-group reductions in numerical pain score for low back and lower extremity pain, reducing by 46.2% and 50.9% from baseline, respectively. Change in functional pain score was not significant for either SCS group or CMM. Both groups had significant within-group reduction in disability. Reduction of interventional procedure volume was significant for both groups with a greater reduction observed in the SCS group. Office visit volume reduction was significant for the CMM group, but this was not a significant difference from the SCS group.ConclusionsResults support the efficacy of 10 kHz SCS for analgesia, reduction of opioid utilization, reduction of interventional pain procedures, and patient perception of disability.

Evaluation of Safety and Efficacy of Radiofrequency Lesioning of Thoracic Dorsal Root Ganglion in Chest Cancer Pain Patients

Background: since cancer-associated pain is a common occurrence in malignancies involving the chest. In these cases, pain is complex and may have visceral, somatic or neuropathic components. It has been noticed that the number of cancer patients with refractory chest pain is increasing with more cancer prevalence, also with the advances in therapy and prolonged life expectancy. The demand for interventional procedures to control pain for these patients also increases. Interventional pain procedures are indicated for refractory pain when analgesic drugs are ineffective or associated with intolerable side effects. In controlling cancer pain it is commonly inadequately managed for these patients leading to suffer form of physical disabilities, psychological disturbance and avoiding treatment. Aim of the work: this study was designed to test both the efficacy and safety of thermo-coagulative ablation of the thoracic dorsal root ganglia for pain control in cancer patients that have refractory chest pain. Methodology: this prospective randomized study was conducted in the National Cancer Institute, Cairo University and Aswan University after board approval from October 2016 to March 2018. Sixty-five patients with Refractory Chronic Chest Cancer Pain were selected randomly and prospectively from the pain clinic of both the National Cancer Institute of Cairo University and Aswan University, after taken an informed written consent from the patient. The complete duration of the follow up lasted 3 months post-interventional with assessments after 1 week, 1 month and 3 months. At each follow up each patient was re-assessed with the following assessments; VAS, ECOG Performance Status. Results: we found that with effective pain relief there was a significant reduction in the mean VAS values; which means that there was functional improvement, in all the postinterventional follow ups. Also, there was an improvement in the functional state of the patients throughout the follow-up post-intervention with regards to the ECOG performance status from the results.Conclusion: we concluded that thermal radiofrequency ablation is considered an alternative for treating refractory chronic chest cancer pain of several types and causes. This is because of its efficacy, safety and ease of use. It also requires a minimal hospital stay or can even be performed on an outpatient basis.

Evaluation of Safety and Efficacy of Radiofrequency Lesioning of Thoracic Dorsal Root Ganglion in Chest Cancer Pain Patients

Background: since cancer-associated pain is a common occurrence in malignancies involving the chest. In these cases, pain is complex and may have visceral, somatic or neuropathic components. It has been noticed that the number of cancer patients with refractory chest pain is increasing with more cancer prevalence, also with the advances in therapy and prolonged life expectancy. The demand for interventional procedures to control pain for these patients also increases. Interventional pain procedures are indicated for refractory pain when analgesic drugs are ineffective or associated with intolerable side effects. In controlling cancer pain it is commonly inadequately managed for these patients leading to suffer form of physical disabilities, psychological disturbance and avoiding treatment. Aim of the work: this study was designed to test both the efficacy and safety of thermo-coagulative ablation of the thoracic dorsal root ganglia for pain control in cancer patients that have refractory chest pain. Methodology: this prospective randomized study was conducted in the National Cancer Institute, Cairo University and Aswan University after board approval from October 2016 to March 2018. Sixty-five patients with Refractory Chronic Chest Cancer Pain were selected randomly and prospectively from the pain clinic of both the National Cancer Institute of Cairo University and Aswan University, after taken an informed written consent from the patient. The complete duration of the follow up lasted 3 months post-interventional with assessments after 1 week, 1 month and 3 months. At each follow up each patient was re-assessed with the following assessments; VAS, ECOG Performance Status. Results: we found that with effective pain relief there was a significant reduction in the mean VAS values; which means that there was functional improvement, in all the postinterventional follow ups. Also, there was an improvement in the functional state of the patients throughout the follow-up post-intervention with regards to the ECOG performance status from the results.Conclusion: we concluded that thermal radiofrequency ablation is considered an alternative for treating refractory chronic chest cancer pain of several types and causes. This is because of its efficacy, safety and ease of use. It also requires a minimal hospital stay or can even be performed on an outpatient basis.