Interventional Spine Procedures Research Articles

Does AI have a role in discharge instructions? exploring the clinical utility of AI-generated discharge instructions following interventional spine procedures

Does AI have a role in discharge instructions? exploring the clinical utility of AI-generated discharge instructions following interventional spine procedures

Physiatry for Treating Hip, Knee, and Back Pain.

Physical Medicine and Rehabilitation (PM&R) is a rapidly expanding field. Physicians who practice PM&R are known as physiatrists and provide care primarily for patients who have disabilities or physical impairments affecting the musculoskeletal system, brain, and spinal cord. Physiatrists may work in an inpatient or outpatient setting, with outpatient physiatrists being an invaluable resource in treating patients experiencing pain. It is worthwhile to refer patients experiencing hip, knee, or back pain to a PM&R specialist because of their skill in making specific and accurate diagnoses, as well as providing a wide range of modalities to treat pain and augment function such as management of pain medications, osteopathic manipulative therapy, trigger point injections, intra-articular steroid injections, orthobiologic therapy, and interventional spinal procedures. Emphasis is on the use of the least invasive modality before employing more invasive treatments. The need for physiatrists to help individuals maximize function and enhance quality of life is increasing with the aging population, expanding workforce of older adults, and a growing population of people with a disability, especially since the COVID-19 pandemic.

Ultrasound-guided procedures for the management of chronic thoracic back pain: a technical review.

Pain arising from the thoracic region has been reported to be potentially as debilitating as cervical or lumbar back pain, and may stem from a vast number of spinal sources, including zygapophysial, costovertebral and costotransverse joints, intervertebral discs, ligaments, fascia, muscles, and nerve roots. Over the last two decades, the use of ultrasound in interventional spinal procedures has been rapidly evolving, due to the ultrasound capabilities of visualizing soft tissues, including muscle layers, pleura, nerves, and blood vessels, allowing for real-time needle tracking, while also reducing radiation exposure to both patient and physician, when compared to traditional fluoroscopy guidance. However, its limitations still preclude it from being the imaging modality of choice for some thoracic spinal procedures, notably epidural (interlaminar and transforaminal approaches) and intradiscal injections. In this technical review, we provide an overview of five thoracic spinal injections that are amenable to ultrasound guidance. We start by discussing their clinical utility, followed by the relevant topographic anatomy, and then provide an illustrated technical description of each of the procedures discussed: (1) erector spinae plane block; (2) intra-articular thoracic zygapophyseal (facet) joint injection; (3) thoracic medial branch block; (4) costotransverse joint injection; and (5) costovertebral joint injection.

ASK! Preoperative Safety Checklist Protocol in Interventional Spine Procedures: A Quality Improvement Study Thirty Month Follow-up

Medical errors can have devastating consequences for patients. Therefore, it is crucial to prevent sentinel and wrong-side events in order to ensure patient safety. One effective tool for achieving this goal is the World Health Organization (WHO) Surgical Safety Checklist, which can be used in conjunction with a pre-procedural, multidisciplinary checklist and physician-led time-out. In a QI project that focused on interventional pain procedures, a pre-procedural, multidisciplinary checklist and physician-led time-out were implemented. Over a period of 30 months and 5,017 procedures, no near misses or incidents were recorded. These preliminary results suggest that the use of multi-disciplinary checklists and attending-led time outs can significantly improve patient safety in interventional pain procedures.

The Effect of BMI on Fluoroscopy Time and Radiation Dose for Common Interventional Spine and Musculoskeletal Medicine Procedures: A Narrative Review

The Effect of BMI on Fluoroscopy Time and Radiation Dose for Common Interventional Spine and Musculoskeletal Medicine Procedures: A Narrative Review

Interventional Spine Course: Improving Fluoroscopic Safety and Procedural Efficacy Among Physical Medicine and Rehabilitation Residents Using a Lecture and Model-Based Curriculum.

Therapeutic interventional techniques using fluoroscopy are often used in the management of spinal pain. Currently, there are no standardized means of instruction and assessment of fluoroscopic interventional spinal procedures for physiatry trainees. The aim of our study is to evaluate the utility of an interventional spine training course for physical medicine and rehabilitation residents in improving safety and efficacy when performing these procedures. We performed a prospective multiple cohort study analyzing interventional spine knowledge and procedural ability among physical medicine and rehabilitation residents after implementing a training course that used lectures, hands-on training, and video-recorded objective structured clinical examination self-assessments. Of the total of 28 physical medicine and rehabilitation residents over the 2-yr study period, each class saw a statistically significant improvement in mean objective structured clinical examination scores from pre-examination to postexamination ( P < 0.05). Written examination scores also had a statistically significant preimprovement to postimprovement in the postgraduate years 2 and 3 classes. Our study supports the use of an interventional spine course for physical medicine and rehabilitation residents, and by following the existing cohorts and adding more cohorts in the future, we will continue to demonstrate valuable and comprehensive results.

Development and evaluation of an open-source virtual reality C-Arm simulator

ABSTRACT C-Arm positioning for interventional spine procedures is often associated with a steep learning curve. This task requires mentally reconstructing 3D surgical tools and patient anatomy from a 2D X-ray image, which is non-trivial and acquired through years of experience. Standard training via apprenticeship-based programs must be limited due to the unnecessary exposure to ionizing radiation. To this end, we propose a Virtual Reality C-Arm simulator for interventional spine procedure training. We implemented the simulator as an open-source module in Slicer, and evaluated its efficacy through a user study, recruiting medical residents and expert clinicians. Users showed an overall significant improvement in C-Arm placement with regards to angular accuracy (mean ~2 degree improvement), and total procedure time (mean 11 minutes less time). The face and content validity was evaluated positively through a Likert scale questionnaire, with a mean score of 4 (out of 5) or higher for each of the questions. The results show the simulator provides effective training for C-Arm positioning, while eliminating the exposure to ionizing radiation associated with the current training standard. Although this work is catered towards spinal procedures, the system is extendable to other fields, such as cardiac and orthopaedic, and will be explored in future works.

Improving resident confidence with a low-cost interventional spine course

BackgroundProcedure training is highly desired by residents pursuing a career in interventional pain medicine; however, the opportunities for hands-on training may vary amongst residency programs for various reasons. ObjectiveTo evaluate the change in residents’ self-perceive competence after participation in a novel low-cost resident interventional spine course, as well as how resident experience (years of training) influences change over time. This article offers step-by-step details on how to implement a resident interventional spine course. MethodsResidents completed a pre- and post-course survey in the domains of self-perceived confidence, knowledge, and skills related to interventional spine procedures. ResultsOver five years, 19 individual residents participated in an annual elective interventional spine course (four residents chose to repeat the course during their training, one of which repeated it twice). The dimensions with highest percent improved change included the ability to perform a procedure kit set-up, followed by post-procedure complication management. Residents earlier in their training showed significantly greater improvement in rating their ability to conduct a pre-procedure chart review and addressing post-procedure complications compared to more experienced residents. In addition, resident feedback regarding the course was resoundingly positive. Of the 12 graduated residents, half applied and successfully matched into a pain medicine or sports medicine fellowship. ConclusionA low-cost interventional spine course appears to be a practical option to help improve residents’ confidence related to various aspects of interventional spine procedures.

ID:15827 Virtually Simulated Fluoroscopic Training to Enhance Resident Procedural Skill and Neuromodulation Exposure During COVID-19 Pandemic

Residency training has faced substantial challenges during the COVID-19 pandemic. Understandably, interventional pain procedures have seen an associated reduction in case volume due to global healthcare recommendations, especially due to many interventional spine procedures being categorized as elective.

The effect of patient satisfaction scores on physician clinical decision making: A possible factor driving utilization of opioid prescriptions, magnetic resonance imaging, and interventional spine procedures

ObjectiveTo survey the effect of patient satisfaction scores on pain physicians’ medical decision making, with an emphasis on resource utilization. DesignEmail-based Survey. MethodsSetting & Subjects: A 23-question survey was approved for dissemination to membership of a medical society and emailed to all members. The survey was also available online and via a promoted QR code. ResultsAn email with link to the survey was viewed 1,116 times, and clicked on 223 times, with 75 members completing the survey online once the link was clicked. Thirty-three additional physicians directly accessed the survey online and completed it. Seventy-seven percent of physicians reported that patient satisfaction scores were tracked by their institution and were used as a consideration in financial compensation (22%) or performance review (36%). Over half of the physicians surveyed reported feeling that satisfaction scores would decline if they did not order MRI imaging, prescribe opioids or provide work restrictions/disability. Thirty percent reported to have performed a spine injection due to concern about patient satisfaction scores. Twenty-one reported that they had prescribed an opioid medication because of this concern. Lastly 25% and 24% have filled out disability paperwork or provided a disability parking placard respectively. ConclusionsOver half of physicians surveyed reported having ordered physical therapy, MRIs, opioid medications, spine injections, or provided disability documentation over concern about how providing or not providing such things impacts patient satisfaction scores. This may be an unintended consequence of the current emphasis placed on patient satisfaction scores.

Case Report of a Giant Tarlov Cyst and the Importance of Advanced Imaging Prior to Interventional Spine Procedures

Case Report of a Giant Tarlov Cyst and the Importance of Advanced Imaging Prior to Interventional Spine Procedures

Biomarkers in the Degenerative Human Intervertebral Disc Tissue and Blood.

Patients with back pain comprise a large proportion of the outpatient practice among physiatrists. Diagnostic tools are limited to clinical history, physical examinations, and imaging. Nonsurgical treatments are largely empirical, encompassing medications, physical therapy, manual treatments, and interventional spinal procedures. A body of literature is emerging confirming elevated levels of biomarkers including inflammatory cytokines in patients with back pain and/or radiculopathy, largely because the protein assay sensitivity has increased. These biomarkers may serve as tools to assist diagnosis and assess outcomes.The presence of inflammatory mediators in the intervertebral disc tissues and blood helped to confirm the inflammatory underpinnings of back pain related to intervertebral disc degeneration. Literature reviewed here suggests that biomarkers could assist clinical diagnosis and monitor physiological outcomes during and after treatments for spine-related pain. Biomarkers must be measured in a large and diverse asymptomatic population, in the context of age and comorbidities to prevent false-positive tests. These levels can then be rationally compared with those in patients with back disorders including discogenic back pain, radiculopathy, and spinal stenosis. While studies reviewed here used "candidate marker" approaches, future nonbiased approaches in clearly defined patient populations could uncover novel biomarkers in clinical management of patients.

Radiation-Shielding Devices: The Best Combination for Spine Interventional Procedures

PurposeAlthough many studies have examined the efficiency of various protective devices for reducing the dose of radiation exposure to physicians during interventional pain procedures, no study has compared the protective effect of these devices when they are used in combination. The purpose of this prospective experimental study was to determine the best combination of radiation-shielding devices. Materials and MethodsUsing anthropomorphic phantoms of a physician and patient, we measured the radiation protection efficiency (RPE) of each of the following protection methods and in combination during C-arm–guided simulated lumbar epidural injection: (a) personal protective equipment (PPE), (b) bedside curtain shield (Curtain), (c) x-ray tube filter (Filter), and (d) fluoroscopic collimation method (Collimation). We measured exposure doses using personal electronic dosimeters at the eye, thyroid, and gonad levels for 1 minute. Each experiment was repeated 15 times. ResultsThe radiation exposure dose and RPE with the best single-, double-, and triple-protection methods were as follows: PPE for the single-protection method (11.82 μSv/min, 80.04%), PPE + Collimation for the double-combination method (4.68 μSv/min, 92.09%), and PPE + Collimation + Curtain for the triple-combination method (3.08 μSv/min, 93.39%). Additionally, PPE + Collimation + Curtain + Filter for the quadruple-combination method resulted in a radiation exposure and RPE of 2.91 μSv/min and 93.61%, respectively, compared with nonprotection. ConclusionsThe best single-, double-, and triple-protection method was PPE, PPE + Collimation, and PPE + Collimation + Curtain, respectively. While preparing protective equipment, we recommend prioritizing equipment in this order.

Development of a Cadaver Laboratory Curriculum for Interventional Spine Procedures for Physical Medicine and Rehabilitation Residents.

There is no standardized curriculum for teaching interventional spine procedures during residency. The objective of this protocol was to share a curriculum using a cadaver laboratory for teaching Physical Medicine and Rehabilitation residents interventional spine procedures, which can be an effective and safe medium to train residents. This protocol provides a checklist that can guide the residents while they are in the cadaver laboratory with a focus on some of the most common lumbar procedures. Twelve physical medicine and rehabilitation resident's confidence in their ability to maneuver the x-ray image intensifier (C-arm), identify spine anatomy under fluoroscopy, and drive the needle improved after the training curriculum (P < 0.005). Although the cadaver laboratory curriculum is not a replacement for the required Accreditation Council for Graduate Medical Education training, it may serve as a tool to improve resident preparedness for spine procedures.

P58. Telemedicine visits generate accurate interventional procedure plans in spine patients without in person evaluations

<h3>BACKGROUND CONTEXT</h3> The role of telemedicine in the evaluation and treatment of patients with spinal disorders is rapidly expanding. Health systems are working to understand the potential of this modality and optimally leverage telemedicine for spine service line care delivery. Specifically, the ability of pain management specialists (eg, physiatry and anesthesia) to accurately diagnose and plan appropriate interventional spine procedures based on virtual visits remains to be established. <h3>PURPOSE</h3> To assess whether spine procedure plans established solely from virtual visits changed following in person evaluation. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study. <h3>PATIENT SAMPLE</h3> We evaluated the records of new patients who were seen virtually between March-June 2020, who were indicated for interventional spine procedures with documented procedure plans, and who subsequently underwent in-person evaluation prior to the procedure. <h3>OUTCOME MEASURES</h3> The primary outcome of interest was agreement between procedure plans generated by new virtual visit encounters and subsequent in-person evaluations. Secondarily, we characterized virtual physical exam variability across interventional spine specialists. <h3>METHODS</h3> We reviewed virtual and in-person clinical encounters from our academic health system's 10 interventional spine specialists (anesthesiology and physiatry). We included patients who were seen exclusively via telemedicine encounters and indicated for an interventional procedure with documented procedural plans. Virtual plans were compared to procedures performed following in person evaluation. Demographic data, patient primary complaint, and the extent of physical examination performed by the interventional spine specialist were also recorded. <h3>RESULTS</h3> Of the 87 patients included, the pre-procedural plan established by telemedicine did not change for 76 individuals (87%; 95% CI 0.79, 0.94) following in-person evaluation. There was wide variability in the use and extent of virtual physical exams performed by interventional providers. <h3>CONCLUSIONS</h3> Our findings indicate that telemedicine evaluations are an accurate means of pre-procedural assessment and demonstrate the capabilities of telemedicine in the evaluation of spine patients and the planning of interventional spine procedures. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Interventional procedure plans generated by telemedicine visits in spine patients are rarely changed after in-person evaluation

Background and objectivesThe role of telemedicine in the evaluation and treatment of patients with spinal disorders is rapidly expanding, brought on largely by the COVID-19 pandemic. Within this context, the...

Infections Following Interventional Spine Procedures: A Systematic Review

Interventional spine procedures, such as discography, epidural steroid injections (ESIs), facet joint procedures, and intradiscal therapies, are commonly used to treat pain and improve function in patients with spine conditions. Although infections are known to occur following these procedures, there is a lack of comprehensive studies on this topic in recent years. To assess and characterize infections following interventional spine procedures. Systematic review. Studies that were published from January 2010 to January 2020 and provided information on infections or infection rates following discography, ESIs, facet joint procedures, and intradiscal therapies were included. PubMed (Medline), EMBASE, and Cochrane Library databases were searched, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Infection data were extracted from included studies, and infection rates were calculated for each procedure type. Case reports and infection-only articles were not included in infection rate calculations. Seventy-two studies met the eligibility criteria and were included in the systematic review. The overall incidence of infection across all studies was 0.12% (231/200,588). The majority of studies (n = 51) were linked to ESIs. Infections related to ESIs were more common than those related to discography or facet joint procedures (0.13% [219/174,431] vs. 0% [0/269] or 0.04% [9/25,697], respectively). Intradiscal therapies had the highest calculated rate of infections (1.05%; 2/191). Quality assessments of the included studies ranged widely. There was an abundance of case reports in comparison to other study designs; to minimize skewing of the analysis, case reports and infection-only articles were not included in the infection rate. Studies that reported combined infection data for multiple procedures could not be included. Many cohort studies and case series were of lower quality because of their retrospective nature. Additionally, the true incidence of infections related to these procedures is unknown because the majority of these infections often go unreported, and information on regions of the spine and procedure details are often lacking. Based on our systematic review, the risk of infections following interventional spine procedures appears to be low overall. More studies focusing on infectious complications with larger sample sizes are needed, particularly for intradiscal therapies, in which the microbiome may be an underlying cause of disc infection. To achieve a true incidence of the risk of infections with these procedures, large prospective registries that collect complication rates are necessary.

Aromatherapy for Procedural Anxiety in Pain Management and Interventional Spine Procedures: A Randomized Trial.

The aim of this study was to evaluate a nonsedating agent, lavender aromatherapy, to reduce anxiety before interventional spinal procedures. In this prospective, single-blind study performed at a tertiary care center for an academic institution, 144 patients undergoing spinal procedures (epidural steroid injection, medial branch block, or radiofrequency ablation) were randomized into two groups of 72 patients. The experimental group was exposed to a tablet formulation of lavender aromatherapy, while the control group was exposed to tablets devoid of any scent. The exposure duration for each group was 5 mins. The primary outcome measurement was patients' anxiety state before the spinal procedure using the six-item State-Trait Anxiety Inventory. Secondary outcomes quantified the rate of vasovagal events and aborted procedures because of patient intolerance. Compared with the control group, the posttreatment anxiety score of those exposed to lavender aromatherapy revealed a statistically significant difference as measured by the six-item State-Trait Anxiety Inventory (12.15 ± 2.67 and 10.67 ± 2.81, P < 0.05). Within group, the experimental group's anxiety level decreased from 12.26 ± 2.75 to 10.67 ± 2.81 (P < 0.05). There were two vasovagal episodes and one aborted procedure in the control group, whereas there was one vasovagal episode and no aborted procedures in the aromatherapy group. Lavender-based aromatherapy is effective in reducing preprocedural anxiety before interventional spine procedures for pain management.

Evaluation of transforaminal epidural steroid injections for discogenic axial lumbosacral back pain utilizing PROMIS as an outcome measure

Background contextDiscogenic lumbosacral back pain continues to present a challenging clinical entity with limited, controversial therapeutic options. No study to date has evaluated the efficacy of fluoroscopically guided transforaminal epidural steroid injections (TFESI) in a homogenous patient population with axial lumbosacral back pain from discogenic pathology utilizing strict, explicitly clinical and radiographic criteria. Additionally, there is a paucity of published data utilizing Patient Reported Outcome Measurement Information System (PROMIS) scores as an outcome measure for interventional spine procedures. PurposeEvaluate the therapeutic effect of TFESIs in a specific subset of patients with discogenic axial lumbosacral back pain. Investigate PROMIS as an outcome measure for interventional spine procedures targeting focal degenerative spinal pathology. Study design/settingRetrospective review of patients presenting to a multidisciplinary, tertiary academic spine center. Patient sampleThree thousand eight hundred eighty-one patients were screened for inclusion. A total of 26 patients with discogenic axial low back, based on strict clinical and radiographic criteria, underwent TFESIs. All patients had axial low back pain without radicular pain, ≥3 clinical features of discogenic pain, corroborative radiographic features of active discogenic pathology on lumbar spine magnetic resonance imaging without confounding spinal pathology. Outcome measuresPROMIS Pain Interference (PI) v1.1, PROMIS Physical Function (PF) v1.2/v2.0, and PROMIS Depression (D) v1.0 outcome scores were collected at baseline and postprocedure follow-up. MethodsQuery of an institutional, patient reported outcome database and subsequent retrospective review of electronic medical records was performed. Statistical analysis comparing baseline and postprocedural PROMIS outcome scores and correlation between these instruments was performed. Additionally, an exploratory investigation of minimal clinically important difference achievement rates was performed. ResultsAnalysis determined a statistically significant improvement in PROMIS PI (p=.017, 95% CI=−8.02 to −1.82) and PROMIS PF (p=.003, 95% CI=0.91–8.72) scores after treatment with TFESIs. At post treatment time points, TFESI had medium effect size on pain (d=0.55) and function (d=0.59). Change in PROMIS D scores (p=.488, 95% CI −1.74–3.54; d=.08) did not demonstrate statistical significance. Pearson correlation demonstrated a moderate negative correlation (r=−0.544, p=.004) between PROMIS PF with PROMIS PI. Correlation between PROMIS PF (r=−0.239, p=.24) and PROMIS PI (r=0.198, p=.33) with PROMIS D was not significant. Fourteen (53.8%) and 9 (34.6%) subjects achieved minimum clinically important difference (MCID) for PROMIS PI and PROMIS PF, respectively. Nine subjects (34.6%) achieved MCID for PROMIS D despite not otherwise reaching statistical significance otherwise. ConclusionsUtilizing PROMIS as an outcome measure, discogenic axial lumbosacral back pain patients appear to benefit from TFESI in terms of pain and physical function. This study contributes to the growing body of literature utilizing PROMIS scores in patients with clinical sequelae of degenerative spinal pathology; however, prospective studies are needed.

Pain: A Review Guide

Pain: A Review Guide is edited by Alaa Abd-Elsayed, who is affiliated with the University of Wisconsin as an assistant professor in the Department of Anesthesiology. Along with his team of other well-known authors, he has made an honest effort to assemble a compendium of various aspects of pain medicine and allied disciplines including physiotherapy, rehabilitation, and palliative care. This book is written in an easy-to-read format and covers almost every aspect of pain in a systematic manner, with up-to-date references. The book is divided into 31 parts and further subdivided into 277 chapters. In effect, each part is a chapter, and the chapters of the book are short subsections. Apportioning of the content into 277 segments makes it very easy for the reader to master almost all information communicated on a given topic in as little as 10–20 minutes. Considering the strengths first, the book is a quick and comprehensive source for fellows preparing for board examinations. The book covers most pain medicine topics covered in international curricula. Chapters have a consistent format including high yield points for examinations and multiple-choice questions at the end of each chapter. In total, the book posits 831 questions, a significant quantity, which is comparable to any other pain medicine or board review resource available on the market. We were particularly pleased to see chapters that cover research and study design (Part II); psychological, social, and cultural aspects of pain (Parts VI and VII); palliative and hospice care (Part XIX); physical medicine and work rehabilitation (Parts XXII and XXIII); complementary medicine (Part XXIV); and pain relief in areas of deprivation and conflict (Part XXIX), topics which we find are often neglected in review materials. The book also concludes with a chapter discussing learning theories and examination taking strategies, which is a good way to finish on a positive note. A major limitation of the text is the paucity of relevant figures, tables, and flowcharts. Chapter 97, on anticoagulation in interventional pain management, is one of the most egregious examples of this lack of visual aids. In the article by Narouze et al,1 the guidelines for antiplatelet and anticoagulant medications for interventional spine and pain procedures are expressed very nicely unlike what is presented in the 9-page prose explanation that is used in this review book. No book on pain medicine is complete unless procedures that involve an understanding of anatomy are supplemented by figures showing the relevant anatomy. Chapter 157 on the sacroiliac joint (SIJ) shows anatomic details of the anterior aspect of the joint, but for an interventional pain specialist, a detailed knowledge of posterior view is more important. The posterior aspect of the joint is the most common entry point for SIJ procedures, and figures to assist in image-guided interventions or even diagnostic tests for SIJ pain are lacking. Similarly, although Chapters 104–107 (nerve blocks of upper extremity) do contain several anatomical figures, other chapters highlighting important blocks are devoid of figures detailing the imaging of these procedures, including Chapters 108–120 and 150 (nerve blocks of the lower extremity and pelvis); Chapters 129, 130, 133, and 134 (nerve blocks of head and neck); and Chapters 98–100 and 189–191 (ganglion nerve blocks and stimulation, kyphoplasty, and vertebroplasty), although the authors did provide good textual details. Interestingly, every chapter begins on an odd page on the right-hand side of the book. This leaves at least half a page and up to one and half pages blank at the end of a previous chapter, which can be utilized for student notes between the chapters. However, we feel the authors could have used this space to accommodate more figures and tables in the book. Also, no digital version of the book was made available for review. In summary, Pain: AReview Guide by Alaa Abd-Elsayed is a high-quality review of the diverse specialty of pain medicine. As reviewers, we would recommend this book to residents or fellows who are preparing for their board examination on pain medicine. An eBook would be a better alternative for residents, and the hardcover would be more useful in a departmental library. If additional tables, flowcharts, and figures on image-guided interventions were to be included along with the text in subsequent editions, the book may prove to be one of the best and ready resources to refresh one’s knowledge when seeing patients in a busy pain clinic. Rajesh Mahajan, MD, FIAPMSmriti Gulati, MDDepartment of Anesthesia, Critical Care, and Pain MedicineGovernment Medical CollegeJammu, Jammu and Kashmir, India[email protected]