PURPOSE:To create an evidence-based guideline for the evaluation and management of acute low back pain. METHODS:A multidisciplinary guideline development group formulated recommendations based on systematic review (PROSPERO Registration 537276) of evidence and using a protocol based on the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) working group methodology. INTENDED USERS AND SETTINGS:Clinicians providing care to individuals presenting with acute low back pain (<6 weeks duration) with or without radiculopathy in outpatient settings.
BACKGROUND:Training programs seek to match fellows who will perform well during training. The National Resident Matching Program (NRMP) allows programs to choose the most capable trainees, with higher ranked applicants expected to perform better. Pain medicine is one of the most popular non-internal medicine fellowships in the U.S., and multiple specialty pathways for entry make selecting candidates challenging. OBJECTIVE:The aim of this study is to correlate fellow rank order and match number with academic performance. METHODS:Match information and fellow performance from 4 highly-ranked multispecialty pain programs was obtained with performance evaluated based on the 6 final Accreditation Council for Graduate Medical Education (ACGME) core competencies. The primary analysis correlated each fellow's relative rank-list position with relative subsequent ACGME performance within the same institution and fellowship cohort using cohort-relative percentile ranks, Spearman correlation, stratified permutation testing, and stratified bootstrap confidence intervals. Sensitivity and exploratory analyses used absolute/converted match-number fixed-effects regression, Kendall Tau-B, sex stratification, and domain-specific correlations with false discovery rate adjustment. RESULTS:The primary analysis included 93 fellows across 20 institution/cohort strata. Rank-list standing was not significantly associated with ACGME performance (Spearman r = 0.06; 95% CI, -0.19 to 0.32; p = 0.63), and sensitivity, sex-stratified, and domain-specific analyses were also nonsignificant. When stratified according to top-, middle- and bottom-ranked applicants, all domains were significant with bottom-ranked fellows faring worse than other groups. CONCLUSIONS:Pain medicine rank lists correlate poorly with fellowship performance, though a weak association was noted wherein bottom-ranked applicants performed worse. This suggests that either the metrics used to rank pain medicine applicants and/or those used to measure performance require modification.
OBJECTIVE:This study aimed to compare conventional radiofrequency thermocoagulation (RFT) with chemical neurolysis in patients who underwent knee arthroplasty and continued to experience pain. MATERIALS AND METHODS:This was a prospective, quasi-randomized controlled trial. A total of 109 patients who underwent knee arthroplasty were evaluated and assigned to two groups according to the interventional procedures applied to the genicular nerves: Group 1 included patients who underwent conventional RFT, and Group 2 included patients who underwent chemical neurolysis of the genicular nerves using phenol. The Numeric Rating Scale (NRS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were used to assess pain intensity before the procedure and at 1, 3, and 6-month follow-ups. RESULTS:The demographic and clinical characteristics were similar between the conventional RFT and phenol groups. At one month, the mean NRS was 4.09±0.73 in the RFT group and 3.67±0.73 in the phenol group, significantly lower in the phenol group (p = 0.015)[d = 0.503; 95% CI]. The mean NRS scores were 5.57±0.81 and 4.64±0.75, respectively, at the third month (p < 0.001)[d:1.195 95%CI], and 6.52±1.38 and 5.02±1.46 at the sixth month (p < 0.001)[d:1.055 95%CI]. At three months, the NRS ≥50% improvement rate was 29.6% in the RFT group and 49.1% in the phenol group, with a significant difference in favor of the phenol group (p = 0.038)[OR:2.290 95% CI]. At six months, the NRS ≥50% improvement rate was 18.5% and 43.6%, respectively, and the difference was statistically significant in favor of the phenol group (p = 0.005)[OR:3.406 95% CI]. NRS≥30% improvement rate was similar at 1 month, at 98.1% in the RFT group and 98.2% in the phenol group (p = 1.000)[OR: 1.019 95% CI]. At three months, these rates were 83.3% and 90.9%, respectively, with no statistically significant difference (p = 0.237)[OR: 2.000 95% CI]. At six months, NRS ≥30% improvement was observed in 72.2% of the RFT group and 87.3% of the phenol group, with a borderline statistically significant difference (p = 0.050)[OR: 2.637 95% CI]. The complication rate was 3.7% in the RFT group and 5.5% in the phenol group, with no significant difference between the two groups (p = 1.000) [OR: 1.500 95% CI]. CONCLUSION:Phenol neurolysis and conventional RFT of the genicular nerves are effective treatments for patients with persistent pain after knee arthroplasty. The results demonstrating the short-term efficacy of phenol neurolysis in patients undergoing arthroplasty should be supported by long-term follow-up studies.
OBJECTIVE:Tailoring postoperative opioid recommendations to patient needs requires nuanced understanding of factors contributing to post-discharge opioid use. The study aims to identify key predictors of opioid prescribing and consumption while exploring the interplay between clinical factors that underlie these phenomena. DESIGN:We analyzed Michigan Surgical Quality Collaborative registry from 2017- 2019 to identify factors predicting sequential opioid-related outcomes following surgery: 1) prescription receipt, 2) likelihood of consumption, and 3) amount consumed. METHODS:To enhance predictive accuracy, we used a three-part model applying machine learning methods (random forests, support vector machines, extreme gradient boosting) and ranking predictive factors by variable importance scores. RESULTS:: Among 34,505 patients (57% female, mean age 56 years), 10,572 (31%) received no prescription, 6,069 (18%) received a prescription but reported no opioid consumption, and 17,864 (52%) received a prescription and reported some consumption. The most important factors predicting prescription receipt included younger age, procedure type, inpatient/outpatient location, urgent/emergent status, and higher body mass index (BMI). Top factors for likelihood to consume included younger age, prescription quantity, higher BMI, smoking, and procedure type. For amount consumed, prescription quantity was the most important factor, with lesser contributions from preoperative opioid prescriptions, younger age, surgery type, and smoking. CONCLUSIONS:: These findings suggest an overlapping set of key factors of age, procedure type, BMI, prescription quantity, and smoking influence post-discharge opioid use. These factors may help identify patients at higher risk for post-discharge use and inform targeted opioid stewardship strategies, including interventions focused on modifiable factors such as prescription quantity.
OBJECTIVE:To evaluate whether repeated intravenous lidocaine infusions provide clinically meaningful benefit beyond placebo for pain reduction in probable nociplastic chronic non-specific low back pain. METHODS:In this prospective, randomized, double-blind, placebo-controlled equivalence trial, 84 adults with CNSLBP and probable nociplastic pain features were randomized equally to receive either intravenous lidocaine (1 mg/kg bolus followed by 4 mg/kg infusion weekly for 4 weeks) or placebo saline infusion. All participants received background multimodal pain management consisting of amitriptyline and aerobic exercise. The primary endpoint was the between-group difference in VAS pain intensity at 3 months. Therapeutic equivalence was assessed using a prespecified equivalence margin of ± 1.5 VAS units and the two one-sided tests (TOST) framework. Secondary outcomes included sleep quality (PSQI) and functional disability (QBPDS). RESULTS:At 3 months, the between-group difference in VAS was 0.24 (90% confidence interval -0.33 to 0.81), entirely within the predefined equivalence bounds, confirming therapeutic equivalence (TOST p < 0.001). Both groups improved significantly over time without a significant group × time interaction. Improvement in sleep quality was greater in the lidocaine group (mean difference in change score 1.81; 95% CI 0.49-3.14; p = 0.027). Functional improvement numerically favored lidocaine, although continuous disability outcomes were not significantly different. Adverse events were more common in the lidocaine group but were mild, transient, and self-limiting. CONCLUSION:Repeated intravenous lidocaine infusions did not provide additional analgesic benefit over saline infusions administered alongside multimodal pain management in patients with probable nociplastic chronic non-specific low back pain.
OBJECTIVES:To evaluate the incidence and risk factors of chronic opioid use following head and neck adenoid cystic carcinoma (HNACC) surgery and explore the association between postoperative opioid use and survival outcomes. DESIGN:Observational retrospective cohort study. SETTINGS:Perioperative care of cancer patients at the UT - MD Anderson Cancer Center. SUBJECTS:Adults (≥18 years) who underwent HNACC surgery with curative intent were included; while those with recurrent or metastatic disease at the time of surgery or who received palliative treatment were excluded. METHODS:Multivariable logistics and Cox regression analyses were performed to identify predictors of chronic opioid use and explore associations with recurrence-free survival (RFS) and overall survival (OS). Chronic opioid use was defined as an active opioid prescription documented and reconciled by a clinician on postoperative day 90 (POD90). RESULTS:Among 102 subjects included in the study, 47.1% were taking opioids chronically after surgery. Preoperative opioid use was associated with more than double the odds of chronic postoperative opioid use, whereas older age and ASA class 1-2 were associated with reduced odds. Positive surgical margins, bone graft procedures, and neck dissection were independently associated with poorer prognosis. No statistically significant association between opioid use an RFS and OS was observed. CONCLUSIONS:These findings suggest that patients with HNACC exhibit several risk factors for chronic opioid use, underscoring the importance of careful opioid prescribing and monitoring in this population.
BACKGROUND:MR-107A-02 is a novel, oral meloxicam formulation designed to enhance dissolution and absorption for rapid analgesia in acute pain. It demonstrates a favorable pharmacokinetic profile, with a higher Cmax and shorter Tmax than Mobic® (meloxicam tablets), while maintaining similar overall extent of exposure. METHODS:This phase 2b, randomized, double-blind, placebo-controlled, dose-ranging study assessed the efficacy and safety of MR-107A-02 at doses of 1.25, 5, and 15 mg twice daily (BID) following third molar extraction. The primary endpoint was SPID0-24, analyzed in the mITT population using W6LOCF to account for rescue medication use. Pain intensity and categorical ratings were evaluated using standardized pain scales. Onset of perceptible and meaningful pain relief were measured using the double-stopwatch technique. Effect sizes and associated standard errors, p-values, and 95% CIs were estimated using an Emax model. RESULTS:Among 110 participants, MR-107A-02 demonstrated positive dose-dependent analgesia, with mean SPID0-24 Emax values of 70.7 (1.25 mg), 86.7 (5 mg), and 94.8 (15 mg), versus 52.0 for placebo. Significant improvement in SPID0-24 occurred at 5 mg and 15 mg versus placebo (p < 0.001). The 15 mg dose achieved perceptible and meaningful pain relief within 0.6 and 1.5 hours, respectively, and had the lowest rescue medication use (29.6%) compared to 42.9%, 57.1%, and 74.1% in the 1.25 mg, 5 mg, and placebo. No severe TEAEs, SAEs, or discontinuations were reported. CONCLUSIONS:MR-107A-02 was generally well tolerated and demonstrated dose-dependent efficacy, with the 15 mg BID dose providing rapid analgesia and a reduction in rescue medication use.
OBJECTIVE:To determine whether Dermabond (2-octyl cyanoacrylate) provides superior lead stability to suture for percutaneous spinal cord stimulator (SCS) trial leads, and whether migration reflects patient-level factors rather than anchoring method. DESIGN:Prospective, randomized, within-patient controlled trial (ClinicalTrials.gov NCT05914311). SETTING:Interventional Pain and Spine Medicine Center at an academic medical center. SUBJECTS:Forty-eight adults (96 leads) undergoing bilateral thoracic percutaneous SCS trial implantation. METHODS:Within each patient, one lead was randomized to Dermabond and the contralateral lead to suture. The primary outcome was absolute radiographic lead migration (mm) between placement and end-of-trial, both imaged upright. All analyses accounted for within-patient correlation; a post hoc non-inferiority framing used the a priori 9 mm clinically meaningful threshold. RESULTS:Mean absolute migration was 9.15 ± 14.49 mm (Dermabond) and 10.60 ± 17.42 mm (suture); the paired difference was -1.46 mm (95% CI, -6.73 to 3.81; p = 0.58), with the upper bound well below the 9 mm threshold. In adjusted analyses, male sex (+8.17 mm; p = 0.036) and prior spine surgery (+7.08 mm; p = 0.048) predicted greater migration; BMI, age, and fixation method did not. Clinically significant (≥9 mm) migration occurred in 27.1% of Dermabond and 22.9% of suture leads (McNemar p = 0.77). CONCLUSIONS:Dermabond was not superior to suture but showed clinically comparable stability, supporting it as a noninvasive alternative. The stronger signal was at the patient level: Male sex and prior spine surgery, but not BMI, predicted migration. Future efforts to reduce migration should target patient-level drivers rather than anchor choice.
BACKGROUND:Knee osteoarthritis (KOA) is a leading cause of chronic pain and disability worldwide, yet clinical guidelines disagree on how to escalate care when conservative management fails. Procedural interventions, including intra-articular injections, genicular nerve blocks (GNB), and genicular nerve radiofrequency ablation (GN-RFA), are used widely, but head-to-head comparative evidence is limited and recent RFA trials have produced inconsistent results, in part because prior studies have used controls that do not adequately mimic the procedural experience of the active arm. METHODS/DESIGN:SKOAP Phase 2 is a multisite, pragmatic, randomized comparative-effectiveness trial that is expected to enroll at least 900 knees across 30 U.S. centers. Knees will be randomized 1:1:1 to one of three interventions: (1) image-guided intra-articular hyaluronic acid combined with corticosteroid and local anesthetic (IA-HA+); (2) image-guided GNB with sustained-release liposomal bupivacaine and corticosteroid, followed by a sham radiofrequency procedure; or (3) comprehensive GN-RFA with post-lesioning corticosteroid injection. Participants randomized to GNB or GN-RFA will remain blinded to allocation for 12 weeks, supported by harmonized procedural environments, identical sedation and imaging protocols, a standardized sham-RFA sequence, and restricted documentation. This blinding design is rarely implemented in prior RFA trials and is central to the study's methodological rigor. The primary outcome is change in the modified Brief Pain Inventory (mBPI) from baseline to 12 weeks; secondary outcomes included pain interference, physical function, quality of life, and global improvement. Effectiveness will be evaluated using three prespecified estimands (modified intention-to-treat, receipt of intervention, and minimum effective dose) using augmented inverse-weighting methods that account for off-schedule assessments, loss to follow-up, and when appropriate non-adherence. DISCUSSION:By combining pragmatic design with rigorous sham-controlled blinding and prespecified estimands, SKOAP Phase 2 will generate the most methodologically robust comparative evidence to date on procedural management of KOA pain and will directly inform guidelines and clinical decision-making on non-operative interventions including when and whether to escalate from intra-articular injection to nerve block to ablation.
BACKGROUND:Sleep disturbances following total abdominal hysterectomy (TAH) impair recovery and satisfaction. Whether regional blocks improve postoperative sleep quality remains unexplored in gynecological surgery. OBJECTIVES:To evaluate the effect of adjunctive regional blocks on postoperative sleep quality in patients undergoing TAH under general anesthesia. METHODS:This prospective observational study (ClinicalTrials.gov: NCT07069322) enrolled 66 women (ASA I-II) undergoing elective TAH. After excluding six patients (two for delirium, four voluntary withdrawals), 60 were analyzed: General anesthesia alone (GA, n = 29) or with adjunctive regional block (GA+RB, n = 31). Primary outcome was Richards-Campbell Sleep Questionnaire (RCSQ) score. Secondary outcomes included Pittsburgh Sleep Quality Index (modified PSQI), Visual Analog Scale (VAS) pain scores at 1, 6, 12, and 24 hours, and satisfaction (5-point Likert). RESULTS:Groups were demographically comparable. GA+RB had significantly higher RCSQ scores (73.0 ± 11.1 vs. 47.9 ± 16.9; P < 0.001). Postoperative modified PSQI worsened in the GA group (9.0 ± 2.4 to 11.7 ± 2.2; P < 0.001) but remained stable in GA+RB (8.1 ± 2.4 to 7.2 ± 2.3; P = 0.232). VAS scores were lower in GA+RB at all time points (all P < 0.001). Satisfaction was higher in GA+RB (4.0 ± 1.0 vs. 2.2 ± 1.2; P < 0.001). Regression identified 12-hour VAS (β = 0.56, P < 0.001) as the strongest predictor of postoperative modified PSQI. CONCLUSIONS:Adjunctive regional blocks were associated with improved postoperative sleep quality, reduced pain, and higher patient satisfaction following TAH. Pain at 12 hours is the strongest modifiable predictor of sleep disturbance, supporting regional analgesia integration into multimodal perioperative protocols.
BACKGROUND:Cervical fusion alters regional biomechanics and increases load transmission through adjacent facet joints, which may produce facet-mediated pain. Cervical medial branch blocks (MBBs) and radiofrequency ablation (RFA) remain highly useful diagnostic and therapeutic interventions, yet surgical approaches used in cervical fusion frequently disrupt the cervical medial branch nerves (MBNs) at treated levels. Identifying which MBNs remain anatomically intact is essential for accurate diagnostic and therapeutic targeting of relevant nerves (and sensate facet joints), and for avoiding unnecessary procedure levels or procedures altogether. OBJECTIVE:To present an approach to determining which cervical medial branches require management after fusion, drawing upon surgical approach, anatomic landmarks, implant trajectory, and cross-sectional imaging. DESIGN:Technical Note. SETTING:Cervical radiofrequency ablation following spinal fusion surgery. CONCLUSIONS:A systematic, anatomy-based method improves diagnostic precision, reduces unnecessary procedures, and helps identify patients most likely to benefit from interventions. Posterior cervical fusion using modern screw and rod instrumentation will essentially always result in denervation of the MBN at the operated level(s). Anterior surgical approaches reliably preserve the MBNs, making them viable targets for cervical RFA.
OBJECTIVE:Chronic pain patients experience more work disability leading to unemployment and major individual, societal and economic burden. Implanted neurostimulation has proven good results in terms of pain relief for chronic pain patients. As new stimulation techniques, paradigms and targets are being researched, a comprehensive synthesis of the effects of implanted neurostimulation on occupational outcomes remains undetermined. METHODS:MEDLINE (via PubMed), Embase, Scopus & Web of Science were systematically searched. Risk-of-bias was assessed using the modified Downs & Black checklist. Random-effects meta-analyses, including a Bayesian approach, were conducted to provide estimates of work status and return to work rates. The study protocol was prospectively registered on PROSPERO (CRD42024501152). RESULTS:67 studies were identified for inclusion in the review; 56 were included in the meta-analysis. The paired odds to work following neurostimulator implantation increased significantly (OR 5.17; 95%CI 2.89-9.23; I2=49.0%; n = 56; P < 0.0001) and were confirmed in the conservative random-effects (OR 3.39; 95%CI 2.00-5.75; n = 56; P < 0.0001) and Bayesian model with uniform prior (OR 5.68; 95%CI 3.08-11.79; n = 56). The pooled estimate for the proportion of patients returning to work across neurostimulation modalities was 26.05% (95%CI 20.73%-32.18%; I2=68.9%; n = 55). CONCLUSIONS:Implanted electrical neurostimulation is associated with increased paired odds to work and enabled chronic pain patients to return to work. The best effects were achieved following peripheral nerve stimulation and in patients suffering head-related pain.
OBJECTIVE:To provide an evidence-based framework for healthcare professionals to use neuromodulation technologies to restore neuromuscular function and relieve pain. METHODS:An expert panel, convened by the American Academy of Pain Medicine Foundation, conducted a literature review of English-language studies published between 2015 and 2025 using PubMed, the Cochrane Library, Web of Science, and Scopus (detailed in Supplement 2). The panel screened abstracts, extracted key data, and evaluated evidence quality using a modified United States Preventive Services Task Force criteria. A Delphi process was used to achieve expert consensus on clinical recommendations for various neuromodulation technologies: Artificial intelligence-guided and robotic rehabilitation systems, virtual/augmented reality interfaces, brain-computer interfaces, electrical nerve stimulation (encompassing peripheral nerve stimulation transcutaneous electrical stimulation), vagus nerve stimulation, multifidus neurostimulation, surgery (eg,, regenerative peripheral nerve interface), scrambler therapy, spinal cord stimulation for motor restoration, and transcranial magnetic stimulation. RESULTS:The panel provided clinical recommendations and discussed mechanisms of action, evidence, and clinical considerations for each intervention. Evidence for these technologies is evolving, with some showing promising results in areas like improving upper limb function post-stroke, improving functional spine-related outcomes, and reducing chronic pain. CONCLUSIONS:Neuromodulation technologies offer a promising approach for neuromuscular restoration, focusing on interventions that promote functional recovery rather than solely providing symptomatic care. Areas for future research include more high-quality, large-scale studies with consistent outcome measures.
INTRODUCTION:Facet and sacroiliac joint (SIJ) pathology are common causes of chronic low back pain. Corticosteroid (CS) injections provide short-term relief but limited durability. Platelet-rich plasma (PRP), an autologous biologic, may offer longer-lasting benefit. We performed a systematic review and meta-analysis of randomized and quasi-randomized controlled trials comparing PRP with corticosteroids. MATERIAL AND METHODS:PubMed, Cochrane Library, Scopus, Embase, Web of Science, CINAHL Complete, Virtual Health Library, and ScienceDirect were searched up to 21 June 2025. Eligible studies were randomized or quasi-randomized controlled trials comparing intra- or peri-articular PRP with corticosteroids for facet or sacroiliac joint pain. Primary outcome was the mean pain scores changes from baseline to first, third, and sixth months using a scale of 10 scores (0= no pain, and 10= worst pain). Secondary outcome was disability using Oswestry Disability Index (ODI) or Modified ODI (MODQ). Data was pooled using mean difference (MD) for pain scores outcome, and standardized mean difference (SMD) for disability outcome. Random-effects meta-analysis was performed using 'Meta' package in R (RStudio version 4.4.3), with subgroup analyses by joint (facet vs SIJ) to facilitate further interpretation. RESULTS:Ten randomized and quasi-randomized controlled trials (six facet, and four SIJ) enrolling 392 patients (mean age 47.04 years, 50.6% male) were included. At one month, pain outcomes favored PRP but did not reach statistical significance (MD -0.35, 95% CI -1.30 to 0.60; p = 0.4696; I2 = 90.6%). At three months, PRP significantly reduced pain versus corticosteroids (MD -1.32, 95% CI -2.14 to -0.50; p = 0.0015), with consistent benefit across facet and SIJ subgroups. Superiority persisted at six months (MD -1.70, 95% CI -3.10 to -0.30; P = 0.0171). Disability outcome showed no significant difference at one month (SMD 0.05, 95% CI -0.45 to 0.54), and at three months (SMD -0.63, 95% CI -1.29 to 0.03; P = 0.0613). CONCLUSION:PRP appears to be a promising intervention; however, current evidence remains inconclusive. Available data suggest that PRP may provide superior medium- and long-term pain reduction compared with corticosteroid injections for facet and SIJ, supporting its potential role as a biologic therapy in spinal pain management. Nevertheless, the certainty of this evidence is limited, and further well-designed, adequately powered studies with standardized PRP protocols are required to confirm these findings.
