Background Intra-articular corticosteroid (IACS) injection and peri-articular corticosteroid injection are commonly used to treat musculoskeletal conditions. Results vary by musculoskeletal region, but most studies report short-term benefit with mixed results on long-term relief. Publications showed adverse events from single corticosteroid injections. Recommended effective doses were lower than those currently used by clinicians. Methods Development of the practice guideline for joint injections was approved by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine and the participating societies. A Corticosteroid Safety Work Group coordinated the development of three guidelines: peripheral nerve blocks and trigger points; joints; and neuraxial, facet, and sacroiliac joint injections. The topics included safety of the technique in relation to landmark-guided, ultrasound-guided, or radiology-aided injections; effect of the addition of the corticosteroid on the efficacy of the injectate; and adverse events related to the injection. Experts on the topics were assigned to extensively review the literature and initially develop consensus statements and recommendations. A modified version of the US Preventive Services Task Force grading of evidence and strength of recommendation was followed. A modified Delphi process was adhered to in arriving at a consensus. Results This guideline focuses on the safety and efficacy of corticosteroid joint injections for managing joint chronic pain in adults. The joints that were addressed included the shoulder, elbow, hand, wrist, hip, knee, and small joints of the hands and feet. All the statements and recommendations were approved by all participants and the Board of Directors of the participating societies after four rounds of discussion. There is little evidence to guide the selection of one corticosteroid over another. Ultrasound guidance increases the accuracy of injections and reduces procedural pain. A dose of 20 mg triamcinolone is as effective as 40 mg for both shoulder IACS and subacromial subdeltoid bursa corticosteroid injections. The commonly used dose for hip IACS is 40 mg triamcinolone or methylprednisolone. Triamcinolone 40 mg is as effective as 80 mg for knee IACS. Overall, IACS injections result in short-term pain relief from a few weeks to a few months. The adverse events include an increase in blood glucose, adrenal suppression, detrimental effect on cartilage lining the joint, reduction of bone mineral density, and postoperative joint infection. Conclusions In this practice guideline, we provided specific recommendations on the role of corticosteroids in joint, bursa, and peritendon injections for musculoskeletal pain.

Fluoroscopically-guided percutaneous vertebral augmentation may be associated with prolonged procedure time and substantial radiation exposure to the patient and staff. This study examined the technological features affecting the potential radiation exposure reduction of new angiography systems, compared to older systems. The air kerma at the reference point (Ka,r), kerma-area product ( KAP), and fluoroscopic time (FT) were compared between Artis icono and Artis zee systems (Siemens). The number of procedures was 346 [median (range) age, 71 (27-96) years] on Artis zee and 408 [74 (25-101) years] on Artis icono, without significant difference in age (p= 0.22) or weight (p=0.21). K-a,K-r was 566.1 (520.1 - 612.0) mGy [mean (95% CI)], KAP was 40.7 (36.6 - 44.7) Gy center dot cm(2), and FT was 10.7 (10.1 - 11.2) minutes on Artis zee. The exposure measures were 38-42% lower on Artis icono, 328.0 (298.6 - 357.3) mGy (K-a,K-r) and 25.3 (22.5 - 28.2) Gy center dot cm(2) (KAP), and FT was 25% lower at 8.0 (7.7 - 8.3) minutes. The newer system had changes in both hardware and software, including a new contrast-to-noise driven automatic exposure control system. Dose reduction was enabled by the use of thicker copper filters, 0.6 (0.1-0.9) mm [median(range)] on Artis icono vs 0.2 (0.1-0.6) mm on Artis zee and shorter pulse widths, 6.0 +/- 1.7 (mean +/- std. dev.) ms vs 12.9 +/- 4.6 ms respectively, with the same average pulse rate of 7.5 per second. The newer system resulted in significantly lower patient doses with about 60% as much radiation exposure and 75% as much fluoroscopic time compared to the older reference system.

CMS has maintained budget neutrality in the Medicare Physician Fee Schedule through decreases in the conversion factor, but reduced reimbursement may have secondary access-to-care consequences for Medicare beneficiaries. Hence, this study examined the association between inflation-adjusted conversion factor declines and changes in care utilization for various socioeconomically defined subgroups of Medicare beneficiaries. Using all claims from a nationally representative 5% sample of Medicare fee-for-service beneficiaries, we determined by year (2005-2023) whether beneficiaries used care. Care utilization was compared between subgroups: metropolitan versus small/rural communities, high-income versus low-income communities, and least-deprived versus most-deprived (Area Deprivation Index [ADI]) communities. Care-utilization rates were normalized to account for within and between year differences in subgroup characteristics using multivariable logistic regression. Care-utilization gaps were computed as the difference in normalized utilization values between subgroups. The temporal association between gap size and the inflation-adjusted conversion factor was assessed with linear regression. There were 32,764,305 beneficiary years (4,662,729 unique beneficiaries) that met the selection criteria. Over the 2005-2023 period, the care-utilization gaps for any physician care increased 1.76, 5.89, and 3.82 percentage points for the urbanicity, community-income, and ADI gaps, respectively. Gap growth was significantly associated with the inflation-adjusted conversion factor, which decreased 48.3% between 2005 and 2025. This inflation-adjusted conversion factor decrease was associated with care-utilization gap increases of 2.46 (urbanicity), 7.00 (community-income), and 5.31 (ADI) percentage points across all physicians. Percentage-point gap increases varied by specialty and were largest for family practice physicians: 21.31 (urbanicity), 14.02 (community-income), and 19.55 (ADI) percentage points. Hence, decreased reimbursement resulting from the Medicare budget neutrality mandate may exacerbate disparities in access to care for traditionally underserved Americans.

This review aims to assess the effectiveness of epidural injections of mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) in treating chronic spinal pain. While existing literature has primarily concentrated on intradiscal regenerative therapies, this systematic review focuses specifically on the efficacy of PRP and MSCs when administered into the epidural space for managing chronic spinal pain. Due to their anti-inflammatory and regenerative properties, emerging studies underscore the therapeutic promise of epidural biologics, including MSCs, platelet-rich plasma, and alpha-2-macroglobulin. Epidural administration offers key advantages: it avoids the risk of discitis and minimizes the chance of disc injury from needle penetration. Moreover, this route enables simultaneous treatment of multiple affected discs without discography or multiple intradiscal injections. This is particularly relevant in elderly patients who often present with advanced disc degeneration and narrowed disc spaces, making intradiscal injections technically difficult. Clinical findings suggest notable improvements in pain reduction, physical functionality, and overall quality of life following these epidural treatments. A total of 9 randomized controlled trials (RCTs) were included in the review to evaluate epidural biologics for chronic spinal pain management. No RCTs investigating stem cells were identified. The quality of evidence was rated as fair (Level III), with moderate effect size and recommendation strength based on a qualitative synthesis and GRADE (Grading of Recommendations, Assessment, Development and Evaluations) methodology.

BACKGROUND AND PURPOSE:Carotid webs (CWs) are shelf-like fibrous intimal projections in the carotid bulb that perturb laminar flow, promote local stasis, and predispose to embolic stroke. While morphology correlates with events, in vivo hemodynamic markers of stasis are lacking. We hypothesized that multiphase CT angiography can quantify contrast persistence within web recess, and impaired washout may be associated with stroke/transient ischemic attack. MATERIALS AND METHODS:We retrospectively reviewed head and neck CTA performed between January 2021 and June 2024 in adults whose radiology reports mentioned "web." CWs were confirmed by independent review. Patients were classified as stroke/TIA causing if their ischemic event was attributed to the web, and asymptomatic if the web was incidentally identified or contralateral to the presenting event. Only symptomatic patients and age- and sex-matched asymptomatic patients who underwent multiphase neck CTA were included. ROIs were placed in posterior recess of CWs, proximal and distal arterial lumens. HU were recorded in ROIs on arterial (A) and delayed (D) phases. Aweb and Dweb were defined as web posterior recess HU in both phases; Aref and Dref were defined as the averaged HU from the adjacent proximal and distal arteries. Two indices were derived: contrast-washout ratio (CWR) = (Aweb - Dweb)/(Aref - Dref); contrast-pooling index (CPI) = (Dweb/Dref) - (Aweb/Aref). Continuous variables were compared with t test or Mann-Whitney U test, and categoric variables with Fisher exact tests. RESULTS:Among 190 patients with 206 confirmed webs, we identified 7 symptomatic patients with ischemic stroke/TIA attributed to CW who had neck multiphase CTA and compared with 7 age- and sex-matched asymptomatic patients. Baseline demographics and CW morphology did not differ between cohorts. CWR was lower in symptomatic patients than controls (median [interquartile range (IQR)] 0.672 [0.652-0.920] versus 0.918 [0.819-1.076]; P = .04), indicating reduced washout. CPI was higher in symptomatic patients (median [IQR] 0.098 [0.074-0.212] versus -0.009 [-0.169-0.060]; P = .04), consistent with contrast persistence and blood stasis. CONCLUSIONS:These findings suggest that contrast persistence metrics on multiphase CTA may reflect local stasis within CWs; however, results are preliminary and warrant validation in larger cohorts.

This updated review evaluates utilization patterns of sacroiliac joint (SIJ) interventions, including SIJ injections, radiofrequency neurolysis, and SIJ fusion, using data from the Centers for Medicare and Medicaid Services (CMS) and Physician Supplier Procedure Summary (PSPS) database. Between 2019 and 2022, Medicare data revealed a notable significant decline in SIJ intervention utilization, with a cumulative drop of 28.9

BACKGROUND:Recent analysis of epidural procedure utilization has demonstrated significant shifts over the past 25 years. Utilization increased substantially until 2004, continued with modest growth through 2011, and then gradually declined through 2019 among the Medicare population. Influences from the COVID-19 pandemic, the Affordable Care Act (ACA), and economic pressures have continued to contribute to declining utilization patterns. OBJECTIVE:The present investigation provides an updated evaluation of epidural procedure utilization for chronic pain management in the U.S. Medicare population, focusing on the time periods of 2000 to 2010, 2010 to 2019, and 2019 to 2024. STUDY DESIGN:A retrospective cohort study evaluating utilization patterns and variables for epidural injections in the fee-for-service (FFS) traditional Medicare population in the U.S. from 2000 to 2024. METHODS:A retrospective longitudinal analysis of Medicare Part B data from 2000 through 2024 was completed. Epidural injection services included cervical/thoracic and lumbar/caudal interlaminar injections, and cervical/thoracic and lumbar/sacral transforaminal injections, identified using procedure codes in the study database. A procedure or service represented all interventions performed during a treatment episode, incorporating add-on codes and bilateral services. Episodes were defined as one unit regardless of bilateral or additional services, reflecting the number of times patients received treatment. Utilization was assessed through counts, rates per 100,000 beneficiaries, geometric mean changes, and percent changes across key intervals (2000-2010, 2010-2019, 2019-2024). Trends by provider's specialty and place of service were also evaluated. RESULTS:From 2000 to 2010, services, episodes, and rates per 100,000 beneficiaries increased 144.3%, 126.1%, and 103%. From 2010 to 2019, this pattern shifted to declining utilization, with reductions of 9.5% in services, 0.4% in episodes, and 9% in rates per 100,000. From 2019 to 2024, procedural rates declined 13%, episodes declined 22.6%, and episode rates declined 11.9%, corresponding to average annual reductions of 2.8%, 4.3%, and 2.6%.Comparative analysis showed that from 2000 to 2010, interlaminar epidural rates increased 43.8%, whereas transforaminal epidural rates increased 579.1%. From 2010 to 2019, interlaminar rates declined 18.4%, while transforaminal rates increased 5%. From 2019 to 2024, interlaminar rates declined 14.6% compared to 8.7% for transforaminal procedures. By 2024, interventional pain specialists performed over 92% of all epidural injections, while other specialties showed decreasing participation. A continued shift toward office settings and ambulatory surgery centers (ASCs) was also observed. LIMITATIONS:The study includes data only through 2024 and is limited to the FFS Medicare population, excluding Medicare Advantage beneficiaries who accounted for 54% of Medicare enrollment by 2024. Limitations inherent to retrospective claims data also apply. CONCLUSION:Epidural injection utilization has shifted substantially over the last 25 years, driven by changes in clinical practice, regulatory and economic influences, and pandemic-related disruptions. The increasing concentration of procedure utilization among interventional pain specialists, together with the continued expansion of transforaminal techniques, underscores the progressive specialization and refinement of interventional pain management within the Medicare population.

INTRODUCTION:10 randomized controlled trials (RCTs) have compared general anesthesia (GA) with non-GA sedation for endovascular thrombectomy (EVT) in patients with emergent large vessel occlusion (ELVO). We performed an updated meta-analysis of the existing trials. METHODS:Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, all RCTs comparing GA versus non-GA during EVT for ELVO published between May 2022 and October 2025 were identified. Two meta-analyses were performed. The primary meta-analysis included all trials, whereas the secondary analysis included only those trials with inclusion criteria similar to those used in the pivotal thrombectomy trials. RESULTS:10 RCTs were identified, of which six were included in the secondary analysis. Across all 10 trials, GA significantly increased the odds of successful revascularization compared with non-GA (n=1584; pooled OR 1.79, 95% CI 1.35 to 2.36; P<0.001; I²=0%), but no significant difference was observed in the resulting functional independence of treated patients. In the secondary analysis of six trials, GA was associated with a significant improvement in functional independence (n=648; pooled OR 1.58, 95% CI 1.15 to 2.18; P=0.005; I²=0%), in addition to higher revascularization rates. Mortality at 90 days and hemorrhagic complications did not differ significantly between the groups in either analysis. CONCLUSIONS:GA significantly improved successful revascularization rates in patients undergoing EVT. In RCTs that enrolled patients based on established EVT inclusion criteria, the rate of good functional outcome at 90 days was significantly higher in patients undergoing EVT with GA compared with non-GA.

BACKGROUND:A recent surge of publications on interventional techniques has questioned their effectiveness, based on a rapid review and network meta-analysis of randomized trials. This was followed by releasing a clinical practice guideline recommending a global ban on these techniques. Understandably, such recommendations have raised significant concern worldwide. Interventional techniques are widely used in chronic pain management, yet their effectiveness has been debated, with longstanding concerns about overuse, misuse, fraud, and abuse. OBJECTIVES:To provide a comprehensive review and critical analysis of the BMJ rapid reviews and associated guidelines, with particular attention to the application-or absence-of basic appropriateness criteria published in the same journal, and the improper incorporation of such evidence into guideline recommendations. METHODS:A review of the available literature was conducted to assess the appropriate criteria for rapid reviews and guideline development. RESULTS:The absence of established appropriateness criteria led to an inadequately conducted rapid review and poorly developed guidelines. These, in turn, resulted in sweeping, globally applicable recommendations that lack a sound evidentiary basis. CONCLUSION:A thorough examination of BMJ publications and related literature demonstrates that the BMJ's rapid reviews and subsequent guidelines on interventional techniques fail to meet recognized appropriateness criteria for conducting rapid reviews and developing consequential clinical guidelines based on such reviews.

BACKGROUND:Vertebral compression fractures (VCFs), characterized by middle column involvement, osteonecrotic clefts, split morphology, or pedicle fractures, pose biomechanical challenges that reduce the effectiveness of conventional vertebroplasty and kyphoplasty. We evaluated the feasibility, safety, and clinical outcomes of the Calibrated Screw Technique (CAST), a minimally invasive approach combining percutaneous pedicle screw fixation and targeted cement augmentation, in patients with complex VCFs. METHODS:We retrospectively analyzed 147 consecutive patients (155 vertebral levels; mean age 80.1 years), primarily with osteoporotic fractures (80.6%), treated using CAST. Demographic, clinical, and radiographic data were collected at baseline, and at 1 and 6 months. Pain intensity was measured by the numeric rating scale (NRS), and patient perceived outcomes were assessed using patient global impression of change (PGIC). Radiographic outcomes included refracture rates at treated vertebrae, incidence of new fractures, and kyphotic angle correction in mobile fractures. RESULTS:CAST was technically feasible in all cases without major complications. Mean NRS scores improved significantly from 7.7 before the procedure to 3.6 at 1 month and 2.7 at 6 months (P < 0.0001). At the 1 month follow-up, 55.3% of patients reported feeling 'extremely' or 'much improved' on PGIC, increasing to 69.8% at 6 months. Radiographically, only one asymptomatic refracture occurred at 1 month (0.8%) and none at 6 months. New fracture incidence decreased from 13.8% at 1 month to 4.2% at 6 months. CONCLUSIONS:In this study, CAST provided a safe, technically feasible, and durable solution for stabilization and pain relief in complex VCFs unsuitable for conventional augmentation, highlighting its value for challenging VCFs.

Background There is potential for adverse events from corticosteroid injections, including increase in blood glucose, decrease in bone mineral density and suppression of the hypothalamic-pituitary axis. Published studies note that doses lower than those commonly injected provide similar benefit.Methods Development of the practice guideline was approved by the Board of Directors of American Society of Regional Anesthesia and Pain Medicine with several other societies agreeing to participate. The scope of guidelines was agreed on to include safety of the injection technique (landmark-guided, ultrasound or radiology-aided injections); effect of the addition of the corticosteroid on the efficacy of the injectate (local anesthetic or saline); and adverse events related to the injection. Based on preliminary discussions, it was decided to structure the topics into three separate guidelines as follows: (1) sympathetic, peripheral nerve blocks and trigger point injections; (2) joints; and (3) neuraxial, facet, sacroiliac joints and related topics (vaccine and anticoagulants). Experts were assigned topics to perform a comprehensive review of the literature and to draft statements and recommendations, which were refined and voted for consensus (>= 75% agreement) using a modified Delphi process. The United States Preventive Services Task Force grading of evidence and strength of recommendation was followed.Results This guideline deals with the use and safety of corticosteroid injections for sympathetic, peripheral nerve blocks and trigger point injections for adult chronic pain conditions. All the statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Board of Directors of the participating societies also approved all the statements and recommendations. The safety of some procedures, including stellate blocks, lower extremity peripheral nerve blocks and some sites of trigger point injections, is improved by imaging guidance. The addition of non-particulate corticosteroid to the local anesthetic is beneficial in cluster headaches but not in other types of headaches. Corticosteroid may provide additional benefit in transverse abdominal plane blocks and ilioinguinal/iliohypogastric nerve blocks in postherniorrhaphy pain but there is no evidence for pudendal nerve blocks. There is minimal benefit for the use of corticosteroids in trigger point injections.Conclusions In this practice guideline, we provided recommendations on the use of corticosteroids in sympathetic blocks, peripheral nerve blocks, and trigger point injections to assist clinicians in making informed decisions.

Imaging and intervention for spinal facetogenic pain has evolved continuously, with radiologists at the helm of several new advanced techniques including CT-guided interventions to ensure accurate needle placement, biologic therapies including platelet-rich plasma, and new noninvasive therapies such as MR-guided focused ultrasound. Though advances have been made in both imaging localization of painful facet joints and therapies offered, awareness of these techniques and the reimbursement landscape are varied. We hope to elucidate the current state of practice for both diagnosis and treatment of this common painful ailment, and highlight the ways that radiologists are at the forefront of advancement in these techniques.

BACKGROUND:Chronic axial spinal pain is a major cause of disability. The literature shows that expenditures related to low back and neck pain and other musculoskeletal disorders continue to rise, not only due to disability but also due to increasing healthcare costs, accounting for the highest expenditure among various disease categories. Based on current evidence utilizing controlled diagnostic blocks, facet joints, nerve root dura, and sacroiliac joints have been identified as potential sources of spinal pain. Therapeutic facet joint interventional modalities for axial spinal pain include radiofrequency ablation, therapeutic facet joint nerve blocks, and therapeutic intraarticular injections. OBJECTIVE:The objective of this systematic review and meta-analysis is to evaluate the effectiveness of radiofrequency ablation as a therapeutic modality in managing chronic axial spinal pain of facet joint origin. STUDY DESIGN:A systematic review and meta-analysis of randomized controlled trials (RCTs) utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. METHODS:The available literature on radiofrequency ablation in axial spinal pain was reviewed. The quality assessment criteria utilized included the Cochrane review criteria to assess risk of bias and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) for randomized therapeutic trials. The evidence was graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. The level of evidence was determined based on best evidence synthesis with modified grading of qualitative evidence from Level I to Level V.A comprehensive literature search of multiple databases from 1966 to June 2025, including manual searches of the bibliographies of relevant review articles, was performed. Quality assessment of the included studies and best evidence synthesis were incorporated into both qualitative and quantitative analyses. OUTCOME MEASURES:The primary outcome measure was the proportion of patients achieving significant pain relief and functional improvement of greater than 50% for at least 6 months. Duration of relief was categorized as short-term (less than 6 months) and long-term (greater than 6 months). RESULTS:This assessment identified 17 RCTs, including 14 high-quality and 3 moderate-quality studies based on Cochrane criteria, and 11 high-quality and 6 moderate-quality studies based on IPM-QRB criteria. Based on the GRADE assessment, 8 trials demonstrated at least moderate levels of impact and certainty, whereas 7 trials showed low impact with low certainty, and 2 trials demonstrated very low impact and certainty. LIMITATIONS:Despite the availability of multiple studies, the relative paucity of high-quality literature remains a major limitation. CONCLUSION:Based on this systematic review and meta-analysis of 17 RCTs, the evidence is Level II with moderate certainty and a moderate strength of recommendation for the use of radiofrequency ablation in managing chronic axial spinal pain of facet joint origin.

BACKGROUND:Chronic axial spinal pain is one of the leading causes of disability. The literature demonstrates that expenditures for low back and neck pain continue to rise, not only in parallel with increasing disability, but also with escalating healthcare costs, accounting for the highest spending among multiple disease categories. Based on current evidence utilizing controlled diagnostic blocks, facet joints, nerve root dura, and sacroiliac joints have been identified as potential sources of spinal pain. STUDY DESIGN:A systematic review of the diagnostic accuracy of spinal facet joint nerve blocks. OBJECTIVE:To determine the diagnostic accuracy of spinal facet joint nerve blocks in chronic spinal pain. METHODS:Methodological quality of the included studies was assessed using the Quality Appraisal of Reliability Studies (QAREL) instrument. Only diagnostic accuracy studies meeting at least 50% of the predefined inclusion criteria were included in the analysis.The strength of evidence was graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. Levels of evidence were classified using a modified best evidence synthesis, ranging from Level I to Level V.Data sources included relevant literature identified through PubMed and other electronic searches published from 1966 through September 2025, Cochrane reviews, and manual searches of the bibliographies of primary and review articles. OUTCOME MEASURES:Eligible studies were required to use placebo-controlled or comparative local anesthetic blocks. A positive diagnostic standard was defined as at least 50% pain relief from baseline scores along with the ability to perform previously painful movements. RESULTS:The available evidence demonstrated Level I for lumbar facet joint nerve blocks, based on 18 studies employing dual diagnostic blocks, demonstrating 75% to 80% pain relief, with an average prevalence of 16% to 45% and estimated or presumed false-positive rates of 25% to 50%.Evidence for the diagnosis of cervical facet joint pain using cervical facet joint nerve blocks is Level II, derived from 12 controlled diagnostic accuracy studies, showing substantial heterogeneity and internal inconsistency. Reported prevalence ranged from 36% to 67% with ≥ 80% pain relief and estimated or presumed false-positive rates of 26% to 63%.The level of evidence for the diagnostic accuracy of thoracic facet joint nerve blocks is Level II, based on 3 studies using dual diagnostic blocks, demonstrating 80% or greater pain relief, with prevalence ranging from 34% to 48% and estimated or presumed false-positive rates ranging from 42% to 58%. LIMITATIONS:Limitations of this systematic review include the limited number of studies involving the thoracic spine, ongoing debate regarding the appropriate reference standard, challenges in determining false-positive rates, concerns regarding the appropriateness of diagnostic blocks, the scarcity of recent publications, and issues related to clinical utility. CONCLUSION:There is Level I evidence for the diagnostic accuracy of lumbar facet joint nerve blocks and Level II evidence for cervical and thoracic facet joint nerve blocks in the evaluation of chronic spinal pain.

BACKGROUND:The use of facet joint interventions for spinal pain management increased rapidly between 2000 and 2010, followed by slower growth from 2010 to 2019. Post-COVID analyses demonstrated a marked decline in facet joint interventions despite an increasing prevalence of chronic pain among traditional Medicare beneficiaries after 2019, together with multiple contributing factors over time, including enactment of the Affordable Care Act, COVID-19, the Inflation Reduction Act, and other influences. OBJECTIVE:This study aims to update and analyze utilization patterns of facet joint interventions for chronic pain management in the U.S. traditional Medicare population across multiple periods from 2000 to 2024. STUDY DESIGN:A retrospective cohort study evaluating utilization trends and influencing factors for facet joint interventions in the fee-for-service (FFS) traditional Medicare population in the United States from 2000 to 2024. METHODS:Data were derived from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary database (2000-2024). Utilization rates per 100,000 Medicare beneficiaries, percentage of change, and geometric average changes were calculated. RESULTS:Facet joint intervention utilization increased rapidly from 2000 to 2010 (15.5% annually), slowed from 2010 to 2019 (4.2% annually), and declined from 2019 to 2024 (-6.1% annually). Episodes followed similar patterns but declined less steeply than procedures (-6.7% vs. -27.1%). By 2024, service rates had returned to approximately 2012 levels (5,016 vs 5,046 per 100,000 beneficiaries). From 2000 to 2010, lumbar and cervical/thoracic facet joint blocks and radiofrequency ablation procedures increased substantially (13.5%-24.6% annually), followed by slower growth from 2010 to 2019 (2.8%-11.0%), a sharp pandemic-related decline from 2019 to 2020 (10.6%-17.4%), and partial recovery with modest growth or stabilization through 2024. Between 2019 and 2024, the episode ratio of facet joint nerve blocks to radiofrequency ablation declined from 1.9 to 1.7 for lumbar procedures and from 2.4 to 2.0 for cervical procedures, attributed to the mandatory radiofrequency policy. Interventional pain-related specialties accounted for the majority of facet joint procedures, increasing their share from 87.3% in 2010 to 95% by 2024, while surgical specialties declined from 4.8% to 2.0%. During the same period, the site of service shifted modestly from office settings (50.7% to 48.8%) and hospital outpatient departments (HOPD) (declining to 20.5%) toward ambulatory surgery centers (ASCs) (25.6% to 30.6%). These findings reflect increasing specialization, recent reductions in treatment intensity, and the influence of policy changes, Medicare Advantage shifts, and broader system pressures on pain management. LIMITATIONS:The analysis was limited to the FFS traditional Medicare population and data availability through 2024, excluding utilization patterns for Medicare Advantage Plans, which covered 54% of Medicare enrollees in 2024. As with other retrospective claims-based studies, inherent limitations related to coding and administrative data apply. CONCLUSION:This retrospective analysis demonstrates a substantial decline in facet joint intervention episodes, with an overall reduction of 6.7% per 100,000 Medicare beneficiaries and an annual decline rate of 1.4% for episodes from 2019 to 2024. In contrast, services or procedures declined more markedly, with an overall reduction of 27.1% and an annual decline rate of 6.1% per 100,000 Medicare beneficiaries.

BACKGROUND:Chronic axial spinal pain is a major contributor to disability and healthcare expenditures, with facet joints recognized as one of the established sources of pain. OBJECTIVE:To provide evidence-based guidance in performing diagnostic and therapeutic facet joint interventions. METHODS:A multidisciplinary panel of experts from various medical and pharmaceutical disciplines, convened by the American Society of Interventional Pain Physicians (ASIPP), reviewed the available evidence, considered patient perspectives, and formulated recommendations for facet joint interventions in the management of chronic pain.The methodology included the development of key questions with evidence-based statements and recommendations. Grading of the evidence and recommendations followed a modified approach described by ASIPP, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and the Agency for Healthcare Research and Quality (AHRQ) methods for grading strength of recommendations. The evidence review included existing guidelines, systematic reviews, comprehensive reviews, randomized controlled trials (RCTs), and observational studies evaluating the effectiveness and safety of facet joint interventions in chronic pain management.In the development of consensus statements and guidelines, a modified Delphi technique was utilized to minimize bias related to group interactions. Panelists without a primary conflict of interest voted on approval of specific guideline statements. Each panelist was permitted to suggest revisions to guideline wording and provide additional qualifying remarks or comments regarding implementation of the guidelines in clinical practice. To achieve consensus and inclusion in the final guidelines, each guideline statement required at least 80% agreement among eligible panel members without a primary conflict of interest. RESULTS:A total of 48 authors participated in the development of these guidelines, of whom 39 participated in the voting process. A total of 37 recommendations were developed, with 100% acceptance for all items. The Summary of Recommendations is presented separately. These recommendations addressed diagnostic, therapeutic, and special considerations related to facet joint interventions. For diagnostic and therapeutic interventions, the level of evidence ranged from II to III, with moderate to strong recommendations. For special considerations and safety assessments, the level of evidence ranged from II to V. The evidence provided recommendations regarding diagnosis, treatment, sedation, concurrent antithrombotic therapy, and precautions required in special clinical circumstances. LIMITATIONS:The limitations of these guidelines include a paucity of high-quality studies in some aspects of diagnosis and therapy. CONCLUSION:These guidelines for facet joint interventions were developed through a comprehensive review of the literature, including methodologic quality assessment and determination of the level of evidence and strength of recommendations. DISCLAIMER:These guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a "standard of care."