Interventional Pain Management Procedures Research Articles

Healthcare Economic Burden of Unresolved Slipping Rib Syndrome

ObjectiveTo evaluate the healthcare costs associated with unresolved slipping rib syndrome (SRS). MethodsData pertaining to patients who underwent operative repair for SRS at our academic institution were retrospectively analyzed. Duration of symptoms, previous management efforts, number of healthcare provider consultations, imaging studies, adjunctive surgical and pain management procedures performed to treat the symptoms, and prior unsuccessful SRS operations were cataloged. US Medicare billing standards were used to average costs for provider visits and overall cost of surgical and interventional pain management procedures. Analgesic medication costs were determined using generic pricing. ResultsFrom February, 2019 to January, 2024 a total of 435 consecutive patients spent a median of 36 months searching for a diagnosis and symptom relief prior to evaluation at our institution. The median number of physicians consulted was 6 (range 0-75). Cost of physician visits totaled $2,990,434 USD. Median number of imaging studies was 5 (range 0-55), totaling $965,949. Cholecystectomy was performed in 47 patients (11%) totaling $716,750. Previous SRS surgery had been attempted 150 times at various institutions and accounted for $4,500,000 (estimated $30,000/operation in billing). Intercostal nerve blocks, ablations, and spinal cord stimulator placement had been performed in 30%, 15%, and 5%, respectively, totaling $963,821. Median analgesic medications used per patient was 1 (mean 1.3, range 0-5). Total medication cost was $1,111,860. Total preoperative healthcare cost in our series was $12,445,173. Averaged per patient, cost totaled $28,610. ConclusionsSlipping rib syndrome remains poorly understood. Symptoms can be severe and debilitating and patients frequently consume significant healthcare resources. With recognition and definitive surgical management, SRS may be addressed successfully. Prompt treatment has the potential for significant healthcare savings.

Assessment of Radiation Exposure with Mandatory Two Fluoroscopic Views for Epidural Procedures

BACKGROUND: Various regulations and practice patterns develop on the basis of Local Coverage Determination (LCD), which are variably perceived as guidelines and/or mandated polices/ regulations. LCDs developed in 2021 and effective since December 2021 mandated a minimum of 2 views for final needle placement with contrast injection which includes both anteroposterior (AP) and lateral or oblique view. Radiation safety has been a major concern for pain physicians and multiple tools have been developed to reduce radiation dose, along with improvement in technologies to limit radiation exposure while performing fluoroscopically guided interventional procedures, with implementation of principles of As Low As Reasonably Achievable (ALARA). The mandated 2 views of epidural injections have caused concern among some physicians, because of the potential of increased exposure to ionizing radiation, despite application of various principles to minimize radiation exposure. Others, including policymakers are of the opinion that it reduces potential abuse and improves safety. OBJECTIVE: To assess variations in the performance of epidural procedures prior to the implementation of the new LCD compared with after the implementation of the new LCD by comparing time and dosage for all types of epidural procedures. STUDY DESIGN: A retrospective, case controlled, comparative evaluation of radiation exposure during epidural procedures in interventional pain management. SETTING: An interventional pain management practice and a specialty referral center in a private practice setting in the United States. METHODS: The study was performed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria. The main outcome measure was radiation exposure time measured in seconds and dose measured in mGy-kG2 (milligray to kilogray squared per procedure). RESULTS: Changes in exposure and dose varied by procedural type and location. Exposure time in seconds increased overall by 21%, whereas radiation dose mGy-kG increased 133%. Fluoroscopy time increased most for lumbar interlaminar epidural injections of 43%, followed by 29% for cervical interlaminar epidural injections, 20% for caudal epidural injections, and 14% for lumbar transforaminal epidural injections. In contrast, highest increases were observed in the radiation dose mGy of 191% for caudal epidural injections, followed by 173% for lumbar interlaminar epidural injections, 113% for lumbar transforaminal epidural injections, and the lowest being cervical interlaminar epidural injections of 94%. This study also shows lesser increases for cervical interlaminar epidural injections because an oblique view is utilized rather than a lateral view resulting in a radiation dosage increase of 94% compared to overall increase of 133%, whereas the duration of time of 29% was higher than the overall combined duration of all procedures which only increased by 21%. LIMITATIONS: A retrospective evaluation utilizing the experience of a single physician. CONCLUSION: The results of this study showed significant increases in radiation exposure time and dosage; however, increase of dosage was overall 21% median Interquartile Range (IQR) compared to 133% of radiation dose median IQR. In addition, the results also showed variations for procedure, overall showing highest increases for lumbar interlaminar epidural injections for time (43%) and caudal epidural injections for dosage (191%). KEY WORDS: Spinal interventional procedures, cervical epidural injections, lumbar epidural injections, caudal epidural injections, lumbar transforaminal epidural injections, radiation exposure time, radiation dose

Brachioradial Pruritus: An Etiologic Review and Treatment Summary.

Brachioradial pruritus (BRP) is a relatively uncommon neuropathic dysesthesia localized to the dorsolateral arms that causes unrelenting itching, burning, tingling, or stinging sensations. There is no identifiable cause of BRP to date, though it is thought to be secondary to either cervical spine pathology or exposure to UV radiation (UVR). Gold-standard treatment of BRP remains unknown. This article reviews previously trialed conservative management options, including chiropractic manipulation, acupuncture, physiotherapy, and photoprotection, as well as medical management options that have been utilized to treat BRP, such as medications, interventional pain management procedures, and surgery. We compiled an updated comprehensive list of possible treatment strategies to be utilized by future providers.

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.

Recent trends in chronic pain medicine.

Chronic pain presents as an unequalled challenge for physicians, owing to the complexity of biochemical and biological pathways involved in pain transmission and high variability of pain perception among individuals. Often, there is an inadequate response to conservative treatment, and opioid treatment has its own drawbacks, such as side effects and opioid dependence. Hence, novel strategies have evolved for the effective and safe management of chronic pain. Radiofrequency technique, regenerative biomaterial, platelet-rich plasma, mesenchymal stem cells, reactive oxygen species scavenger nanomaterial, ultrasound-guided interventional pain management procedures, endoscopic spinal procedures, vertebral augmentation therapy, and neuromodulation are some of the promising and upcoming modalities in the armamentarium of pain physicians.

Vasovagal Reactions during Interventional Pain Management Procedures-A Review of Pathophysiology, Incidence, Risk Factors, Prevention, and Management.

Vasovagal reactions are a benign but common outcome of interventional pain management procedures that can negatively impact patient care, including aborted procedures and fear of future procedures that would otherwise help the patient. Research has been done on the incidence, risk factors, and management of vasovagal reactions resulting from such procedures, but less is known about how to prevent these reactions from occurring. In this paper, we present a literature review of the pathophysiology, incidence, risk factors, prevention, and management of vasovagal reactions during interventional pain management procedures, with an emphasis on the relative lack of research and conflicting advice on preventive measures. We found that moderate sedation and anxiolytics have been used prophylactically to prevent vasovagal reactions, but their side-effect profiles prevent them from being used commonly. Less studied is the prophylactic administration of antimuscarinics and IV fluids, despite the potential benefit of these measures and relatively low side-effect profile. We explore these topics here and offer advice for future research to fill the gaps in our knowledge.

Impact of Opioid Use on Results of Interventional Back-Pain Management on Patients with Chronic Back Pain

Objectives Preoperative exposure to opiates has recently shown to be associated with poor outcomes after elective major surgery, but little is known as to how pretreatment opioid use affects results of interventional back-pain management. We investigated the impact of preoperative opioid use on outcomes after interventional pain management procedures on patients with chronic back pain. Methods A high-volume, single-center quality register analysis was performed on patients who underwent interventional pain management for chronic back pain as a part of multidisciplinary pain management program. Chronic opioid use was defined as having an opioid prescription concurrent with 90 days. Results: A total of 797 patients underwent intervention during the study period 2019-2020. Pretreatment opioid use was present in 262 patients (33%). Patients with chronic back-pain using opiates reported significantly more pain and discomfort before treatment as well as lowered working ability. Facet-joint medial branch blocks resulted for significant improvement for both groups directly after the treatment as well as at 2-hours follow-up. However, non-opiate group reported significantly more improvement at 2-days follow up as well as at one- month follow-up compared to opiate users. Opiate users reported nearly the same pain level at one-month follow-up as before treatment. Conclusions: Pretreatment opioid use is associated with greater pain discomfort, impairment and reduced functional ability, as well as poorer long-term effect of interventional back pain treatment at 1-month follow-up. In our study opiate users reported same positive effects of facet-joint nerve blocks immediately after the treatment and 2 hours after the treatment but significantly smaller effect at one-month follow-up. This could indicate that opiate use may diminish effects of pain treatments by affecting relearning, behavioral changes and central pain modulation. These findings may help to understand the impact of pretreatment opioid use on patient care, and its implications on hospital and societal cost.

Understanding the role of patient preference in the treatment algorithm for chronic low back pain: results from a survey-based study.

Aims: Interventional pain treatments range from injections to established radiofrequency ablation techniques and finally neuromodulation. In addition to safety, efficacyand cost dominance, patient preference for type of treatment is important. Methods: Chronic pain patients (n=129) completed a preference scale to determine which interventional pain management procedures they would prefer from among radiofrequency ablation, temporary (60-day) peripheral nerve stimulation (PNS), conventional PNS and spinal cord stimulation/dorsal root ganglion stimulation. A second survey (n=347) specific to assessing the preference for radiofrequency ablation or temporary PNS treatment was completed by patients with low back pain. Results: On the basis of mean rank, temporary PNS percutaneously implanted for up to 60days was the most preferred treatment compared with the other options presented (p=0.002). Conclusions: Patient preference should be unbiased and considered as an independent variable for physician discussion in treatment options and future research.

Moderate and deep procedural sedation-the role of proper monitoring and safe techniques in clinical practice.

Interventional pain management procedures provide significant improvement to patient quality of life and functionality. In-office procedures are becoming an increasingly more common site of pain management intervention for patients with minimal risk of harm. Moderate and deep sedation techniques can be used in patients with high anxiety, complex pharmacotherapy, or a low pain threshold. Proper guidance and oversight by an attending anesthesiologist, in addition to appropriate monitoring, are key. Epidural steroid injection complications rates have been cited at 2.4%, with the most common complications noted as persistent pain and flushing. Serious complication errors can be avoided with proper supervision and monitoring. The adherence to published societal recommendations and guidelines for indications of when to use moderate to deep sedation techniques, and appropriate supervision and monitoring methods, can avoid errors in interventional pain management procedures.

Pain Management During the COVID-19 Pandemic.

Chronic pain management during the coronavirus disease 2019 (COVID-19) pandemic is a challenging process, especially with growing evidence that COVID-19 infection is associated with myalgias, referred pain, and widespread hyperalgesia. In light of the limited data available for COVID-19-related impact on chronic pain patients, this review explores the changes in the healthcare delivery system due to social distancing and safety precautions to provide the appropriate management of chronic pain patients during the COVID-19 pandemic. Understanding both the general problems facing chronic pain patients as well as specific problems in the COVID-19 era including deconditioning, increased mental health concerns, financial burdens, and potential for medication-induced immune-suppression is vital in the appropriate management of patients. Telemedicine, the practice of caring for patients remotely when the provider and patient are not physically present with each other, is becoming increasingly used and recognized as a valuable tool to both health care providers and patients. This paper concentrates on the proper utilization of the available resources to help patients with the most severe conditions as well as the most vulnerable group. COVID-19 may be associated with a profound effect on both the health care system and patients with chronic pain. As a result, delaying, or stopping, treatment for chronic pain patients will have negative consequences, and strong pain evaluations must be administered to triage patients appropriately. Recent recommendations for the safe use of non-opioid analgesics, opioid analgesics, and interventional pain management procedures are vital to know and understand specifically during the pandemic era. Further researches are needed to identify the advance planning and rapid responses to reduce the impact of the pandemic.

Triaging Interventional Pain Procedures During COVID-19 or Related Elective Surgery Restrictions: Evidence-Informed Guidance from the American Society of Interventional Pain Physicians (ASIPP)

Background: The COVID-19 pandemic has worsened the pain and suffering of chronic pain patients due to stoppage of “elective” interventional pain management and office visits across the United States. The reopening of America and restarting of interventional techniques and elective surgical procedures has started. Unfortunately, with resurgence in some states, restrictions are once again being imposed. In addition, even during the Phase II and III of reopening, chronic pain patients and interventional pain physicians have faced difficulties because of the priority selection of elective surgical procedures. Chronic pain patients require high intensity care, specifically during a pandemic such as COVID-19. Consequently, it has become necessary to provide guidance for triaging interventional pain procedures, or related elective surgery restrictions during a pandemic. Objectives: The aim of these guidelines is to provide education and guidance for physicians, healthcare administrators, the public and patients during the COVID-19 pandemic. Our goal is to restore the opportunity to receive appropriate care for our patients who may benefit from interventional techniques. Methods: The American Society of Interventional Pain Physicians (ASIPP) has created the COVID-19 Task Force in order to provide guidance for triaging interventional pain procedures or related elective surgery restrictions to provide appropriate access to interventional pain management (IPM) procedures in par with other elective surgical procedures. In developing the guidance, trustworthy standards and appropriate disclosures of conflicts of interest were applied with a section of a panel of experts from various regions, specialties, types of practices (private practice, community hospital and academic institutes) and groups. The literature pertaining to all aspects of COVID-19, specifically related to epidemiology, risk factors, complications, morbidity and mortality, and literature related to risk mitigation and stratification was reviewed. The evidence -- informed with the incorporation of the best available research and practice knowledge was utilized, instead of a simplified evidence-based approach. Consequently, these guidelines are considered evidence-informed with the incorporation of the best available research and practice knowledge. Results: The Task Force defined the medical urgency of a case and developed an IPM acuity scale for elective IPM procedures with 3 tiers. These included emergent, urgent, and elective procedures. Examples of emergent and urgent procedures included new onset or exacerbation of complex regional pain syndrome (CRPS), acute trauma or acute exacerbation of degenerative or neurological disease resulting in impaired mobility and inability to perform activities of daily living. Examples include painful rib fractures affecting oxygenation and post-dural puncture headaches limiting the ability to sit upright, stand and walk. In addition, urgent procedures include procedures to treat any severe or debilitating disease that prevents the patient from carrying out activities of daily living. Elective procedures were considered as any condition that is stable and can be safely managed with alternatives. Limitations: COVID-19 continues to be an ongoing pandemic. When these recommendations were developed, different stages of reopening based on geographical regulations were in process. The pandemic continues to be dynamic creating every changing evidence-based guidance. Consequently, we provided evidence-informed guidance. Conclusion: The COVID-19 pandemic has created unprecedented challenges in IPM creating needless suffering for pain patients. Many IPM procedures cannot be indefinitely postponed without adverse consequences. Chronic pain exacerbations are associated with marked functional declines and risks with alternative treatment modalities. They must be treated with the concern that they deserve. Clinicians must assess patients, local healthcare resources, and weigh the risks and benefits of a procedure against the risks of suffering from disabling pain and exposure to the COVID-19 virus. Key words: Coronavirus, COVID-19, interventional pain management, COVID risk factors, elective surgeries, interventional techniques, chronic pain, immunosuppression

COVID-19 and its impact on pain management practices: A nation-wide survey of Indian pain physicians.

COVID-19 and its impact on pain management practices: A nation-wide survey of Indian pain physicians.

Atlas of Ultrasound-Guided Procedures in Interventional Pain Management, 2nd ed

The first edition of this book was published in 2011, and I was lucky enough to have it on my shelf to compare it with the present one that is reviewed. Since 2011, an update was to keep up with the huge volume of new techniques and information about ultrasound-guided techniques for pain and regional anesthesia. This is a single-editor book with several well-known authors contributing who cover the wide range of subjects reviewed in the text. The volume is nicely presented with a color hard cover, and the pages are of good-quality paper, although not as bright as in the First Edition that made the ultrasound pictures look better. The book is organized in 7 parts, covering imaging in interventional pain and basics of ultrasound, spine sonoanatomy and ultrasound-guided spine injections, ultrasound-guided abdominal and pelvic blocks, ultrasound-guided peripheral blocks and catheters, diagnostic and musculoskeletal ultrasound, diagnostic neurosonology, and advanced and new applications of ultrasound. In total, there are 36 chapters, a few more than in the First Edition, spread over 334 pages. Nineteen out of the 36 chapters unfortunately are carbon copies of the old ones from the first edition and 8 years having passed between publication times. In most of the areas, there are many new references and a much larger paradigm that were left unexplained to the reader. Among these “old chapters,” however, the reader may find real jewels requiring no changes or perhaps minimal updates like spine sonoanatomy by Dr Bernard Moriggl, basics of ultrasound: pitfalls and limitations by Drs Vincent Chan and Anahi Perlas, and essential knobology for ultrasound-guided regional and interventional pain management by Drs Alan J. R. Macfarlane, Cyrus C. H. Tse, and Richard Brull. Some of the newly written chapters are outstanding like the one on ultrasound-guided upper extremity blocks by Jason McVicar, Sheila Riazi, and Anahi Perlas with excellent text and beautiful and well-explained figures, ultrasound-guided superficial trigeminal nerve blocks by David A. Spinner and Jonathan S. Kirschner, ultrasound-guided greater occipital nerve block by Bernhard Moriggl and Manfred Greher, ultrasound of peripheral nerves by Swati Deshmukh and Jonathan Samet, and, finally, occipital neuralgia: sonoanatomy and sonopathology of the occipital nerves by the editor Samer N. Narouze. Pictures and drawings explaining procedures are well presented with nice colors, but in some cases, it is intriguing and disappointing not to find actual pictures with the needle in the tissue despite the fact that the authors are experienced in these techniques and must have a good collection of nice images from their work in the last 8 years. Both for the newcomer in the field of ultrasound-guided pain management as well as for the seasoned practitioner, this second edition is an outstanding text from a leader in the field. Some chapters, as explained by the editor in the prologue, include excellent step-by step descriptions of the techniques. We hope the next edition will come with some missed procedures like trans quadratus lumborum block, erector spinae block, sympathetic blocks at the lumbar region, pectoralis nerve, and serratus plane blocks. Juan Francisco Asenjo, MD, FRCPCDepartment of AnesthesiaThe Montreal General HospitalMcGill University Health CentreMontreal, Quebec, Canada[email protected] Julia Jackson, BScDepartment of AnesthesiaThe Montreal General HospitalMcGill UniversityMontreal, Quebec, Canada

DOSE AREA PRODUCT VALUES OF FLUOROSCOPICALLY GUIDED PAIN MANAGEMENT PROCEDURES: COMPARISON OF A BELGIAN TEACHING HOSPITAL WITH NATIONAL DIAGNOSTIC REFERENCE LEVELS.

In 2011, national diagnostic reference levels (DRLs) were proposed for pain management fluoroscopic procedures in Belgium. The primary goal of this work is to compare the dose area product values (DAP) recorded at the Saint-Luc University Hospital to these DRLs. From 2012 to 2015, 7664 interventional pain management procedures (4740 epidural, 2097 medial branch and 807 transforaminal infiltrations) were performed. Uni/multivariable analyses were done regarding the influence of different factors. The fluoroscopy duration and the DAP are lower to the DRLs (p < 0.001). From 7644 procedures' DAP, 1431 (18.7%) were higher than the DRLs: 1397 epidural (29.5%), 16 medial branch (0.8%) and 18 transforaminal infiltrations (2.2%) (p < 0.001 between procedures). The main factor that significantly modifies DAP, as duration, is the practitioner. Additionally, we obtained [IQR: 25-75] values for epidural [0.0174-0.055 mGy m2], medial branch block [0.0194-0.0472] and transforaminal infiltrations [0.0499-0.1067 mGy m2] (p < 0.05 vs. DRLs, respectively, 0.05, 0.25 and 0.3 mGy m2). Systematic use of contrast confirmation significantly increases DAP (p < 0.001). This retrospective analysis shows differences in DAP, mainly driven by the practitioner. This suggests the existence of modifiable factors. Programs aiming to determine these factors to reduce this DAP are justified.

Waldman’s Comprehensive Atlas of Diagnostic Ultrasound of Painful Conditions

Waldman’s Comprehensive Atlas of Diagnostic Ultrasound of Painful Conditions

Prospective Assessment of Pain and Comfort in Chronic Pain Patients Undergoing Interventional Pain Management Procedures.

Interventional pain management procedures have an important role in the management of chronic pain. The present study seeks to identify the proportion of patients who experience severe pain during pain procedures either with or without sedation. There is then an attempt to identify any association of high pain levels with factors such as age, gender, ethnicity, preprocedure pain level, procedure type, tobacco use, and baseline pharmaceuticals taken for both pain and/or mood disorder management. This is a prospective survey study evaluating patients' discomfort during interventional pain procedures in an outpatient academic facility. Patient discomfort was assessed by the PROcedural Sedation Assessment Survey (PROSAS) and modified for nonsedation cases. There were 155 patients in the survey, with 20 of these receiving nonspinal injections. Of the remaining 135 patients who underwent spinal injections, only 10 received conscious sedation. On average, 14.2% experienced severe pain during spinal injections, whereas 20% experienced severe pain with nonspinal injections. Though few patients received conscious sedation, most of these (60%) experienced high levels of pain. There was no correlation between level of procedural pain with age, gender, ethnicity, preprocedure pain level, procedure type, tobacco use, or medication type used. The majority of patients who undergo nonsedated interventional pain management procedures do not experience severe pain. There is a small but appreciable group of subjects who seem to experience severe pain that cannot be correlated to any particular clinical characteristic in a standard patient evaluation. Even with standard conscious sedation, there is no clear best method to ensure patient comfort for this high-pain level group.

Novel approach: Ultrasound 3D/4D-guided procedures in interventional pain management

Novel approach: Ultrasound 3D/4D-guided procedures in interventional pain management

Patient with Chronic Pelvic Pain from Endometriosis

Endometriosis, a chronic and progressive condition characterized by the presence of endometrial tissue outside the uterus, accounts for about one third of the cases of chronic pelvic pain in women. Pain in endometriosis may be due to nociceptive, inflammatory, and/or neu­ropathic mechanisms. The clinical presentation is often variable between patients, and diagnostic laparoscopy for visualization and biopsy of lesions is the gold standard for diagnosis. The treatment may consist of two elements: chronic pelvic pain itself as a diagnosis and endometriosis as a disease. Hormonal therapy is used to reduce the amount of estrogen and hence reduce symptoms such as pelvic pain and dysmenorrhea. In patients with severe endometriosis, surgical removal of lesions, adhesions, and cysts and restoration of pelvic anatomy may be preferred. Both hormonal and surgical treatments have been shown to be effective in decreasing pain symptoms associated with endometriosis. A variety of analgesics, including nonsteroidal antiinflammatory drugs, opioids, tricyclic antidepressants, dual reuptake inhibitors of serotonin and norepinephrine, and antiepileptic drugs, have been used to ameliorate pain in endometriosis, with varying degrees of success. In patients with persistent symptoms, interventional pain management procedures may be performed to target the visceral and somatic organs and their innervations. Infertility is the most common complication of endometriosis. Between 10 and 20% of women with endometriosis have recurrence of the disease regardless of the treatment they receive. The recurrence of pain may be due to remodeling of the central nervous system, the role of the reproductive tract in reactivating pain, and incomplete removal or recurrence of lesions. This review contains 2 tables and 52 references Key words: chronic abdominal pain, chronic pelvic pain, dyschezia, dysmenorrhea, dyspareunia, endometrioma, endometriosis, hormonal therapy, infertility, retrograde menstruation, visceral pain

Facility Payments for Interventional Pain Management Procedures: Impact of Proposed Rules

In the face of the progressive implementation of the Affordable Care Act (ACA), a significant regulatory regime, and the Merit-Based Incentive Payment System (MIPS), the Centers for Medicare and Medicaid Services (CMS) released its proposed 2017 hospital outpatient department (HOPD) and ambulatory surgery center (ASC) payment rules on July 14, 2016, and the physician payment schedule was released July 15, 2016. U.S. health care costs continue to increase, occupying 17.5% of the gross domestic product (GDP) in 2014 and surpassing $3 trillion in overall health care expenditure. Solo and independent practices face unique challenges and many are being acquired by hospitals or larger groups. This transfer of services to hospital settings is indisputably leading to an increase in the net cost to the system. Comparison of facility payments for interventional techniques in HOPD, ASC, and in-office settings shows wide variation for multiple interventional techniques. Major discrepancies in payment schedules are related to higher payments for hospitals than comparable treatments in in-office settings and ASCs. In-office procedures, which have been converted to ASC procedures, are reimbursed at as high as 1,366% higher than ASCs and 2,156% higher than in-office settings. The Medicare Payment Advisory Commission (MedPAC) has made recommendations on avoiding the discrepancies and site-of-service differentials in in-office settings, hospital outpatient settings, and ASCs. These have not been implemented by CMS. In addition, there have been slow reductions in reimbursements over the recent years, which continue to accumulate, leading to significant reductions in payments In conclusion, equalization of site-of-service differentials will simultaneously improve reimbursement patterns for interventional pain management procedures, increase access and quality of care, and finally, reduce costs for CMS, extending Medicare solvency. Key words: Hospital outpatient departments, ambulatory surgery centers, physician inoffice services, interventional pain management, interventional techniques

Do Interventional Pain Management Procedures during the Acute Phase of Herpes Zoster Prevent Postherpetic Neuralgia in the Elderly?: A Meta-Analysis of Randomized Controlled Trials.

Do Interventional Pain Management Procedures during the Acute Phase of Herpes Zoster Prevent Postherpetic Neuralgia in the Elderly?: A Meta-Analysis of Randomized Controlled Trials.