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.

Background Vagus nerve stimulation (VNS) devices are commonly used for extracranial neuromodulation of drug-resistant epilepsy. These devices are implanted by multiple surgical subspecialties and managed by practitioners with varying levels of epilepsy-specific expertise. The North American Neuromodulation Society (NANS) education committee presents a curriculum defining level-dependent recommendations within the six-core competency rubric for the implantation and management of VNS devices. Material and Methods A multidisciplinary (anesthesiology, neurology, neurosurgery, and physiatrists) and diverse (advanced practice providers, physicians, and surgeons) subcommittee of the NANS education committee met virtually over a year to develop a curriculum following the Accreditation Council for Graduate Medical Education (ACGME) core competencies. The subcommittee used a consensus approach, evidence-based development strategy; once completed, the VNS curriculum was approved by the NANS board. Results The subcommittee developed a VNS curriculum as a standard to be used for implanting surgeons, managing physicians, and advanced practice providers. The vertical orientation of the curriculum uses the ACGME educational core competencies framework; within this paradigm is a horizontal progression of skills with distinct competency groups for implanting surgeons and/or managing physicians. The horizontal progression defines the expected competence for early learner, advanced learner, and independent practitioner. Conclusion A NANS education subcommittee iteratively developed a VNS curriculum for defining progressive competence of myriad care providers, including clinicians and advanced practice providers, within the ACGME six core competencies.

The number of facilities and physicians that offer pain management services has grown significantly since the 1970s. Despite the rise in prevalence of individuals with chronic pain during that time, interventional pain physicians remain underutilized. One reason why this may be the case is a large number of patients are referred directly to surgical specialists prior to being seen by an interventional pain physician. With the rising cost of healthcare, a shift away from surgical specialists and towards pain specialists as part of a multidisciplinary care team may help reduce the cost of care for chronic pain patients. Through comparing the costs for patients with various types of chronic back pain, it was found that those who were treated by a pain physician rather than a surgeon saved up to over 8000 USD. Despite the cost benefits, it is important to recognize that healthcare disparities still exist which prevent patients from accessing interventional pain physicians. These disparities include patient location and insurance coverage. Overall, the treatment paradigm should start with non-invasive treatments, followed by minimally invasive procedures, with surgical interventions reserved as a last resort for when less invasive measures fail. Early incorporation of a multidisciplinary care team that includes chronic pain management services is critical for providing appropriate and cost-effective patient care.

Data sharing is not applicable to this article as no data sets were generated or analyzed during the current study.

Background: Peripheral nerve stimulation (PNS) has been used for over 50 years to treat chronic pain by delivering electrical pulses through small electrodes placed near targeted peripheral nerves those outside the brain and spinal cord. Early PNS systems often required invasive neurosurgical procedures. However, since 2015, the Food and Drug Administration (FDA) approved percutaneously implanted PNS leads and neurostimulators offering a much less invasive, non-opioid option for managing recalcitrant chronic pain. The following FDA-cleared PNS systems are commercially available in the United States for the management of chronic, intractable pain: center dot Freedom (R) Peripheral Nerve Stimulator (PNS) System (Curonix LLC, 2017) center dot StimRouter (R) Neuromodulation System (Bioness, now Bioventus, 2015) center dot SPRINT (R) PNS System (SPR (R) Therapeutics, Inc., 2016) center dot Nalu (TM) Neurostimulation System (Nalu Medical Inc., 2019) center dot ReActiv8 (R) Implantable Neurostimulation System (Mainstay Medical Limited, 2020) The American Society of Interventional Pain Physicians (ASIPP) has published evidence-based consensus guidelines for the application of PNS systems in managing chronic pain. Objective: The guidelines aim to provide evidence-based recommendations for the utilization of peripheral nerve stimulation (PNS) in the management of moderate to severe chronic pain. These guidelines exclude field stimulation, or sacral nerve stimulation. Methods: A multidisciplinary panel of experts in various medical and pharmaceutical fields, convened by ASIPP, reviewed the evidence, considered patient perspectives, and formulated recommendations for implantable peripheral nerve stimulation in chronic pain management. The methodology included developing key questions with evidence-based statements and recommendations. The grading of evidence and recommendations followed a modified approach described by ASIPP, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method, and the Agency for Healthcare Research and Quality (AHRQ) strength of recommendations methods. The evidence review includes existing guidelines, systematic reviews, comprehensive reviews, randomized controlled trials (RCTs), and observational studies on the effectiveness and safety of implantable peripheral nerve stimulation in managing chronic pain The quality of published studies was assessed using appropriate instruments for systematic reviews, RCTs, and observational studies.In the development of consensus statements and guidelines, we used a modified Delphi technique, which has been described to minimize bias related to group interactions. Panelists without a primary conflict of interest voted to approve specific guideline statements. Each panelist could suggest edits to the guideline statement wording and could suggest additional qualifying remarks or comments as to the implementation of the guideline in clinical practice to achieve consensus and for inclusion in the final guidelines, each guideline statement required at least 80% agreement among eligible panel members without primary conflict of interest.Results: A total of 31 authors participated in the development of these guidelines. Of these, 23 participated in the voting process. A total of 8 recommendations were developed. Overall, 100% acceptance was obtained for 8 of 8 items. Thus, with appropriate literature review, consensus-based statements were developed for implantable peripheral nerve stimulation in chronic pain management. In preparation of these guidelines, evidence synthesis included 7 systematic reviews, 8 RCTs, and 9 observational studies covering all PNS treatments. The evidence was developed using GRADE criteria or certainty of evidence, and qualitative synthesis based on the best available evidence. The evidence level and recommendations are as follows: center dot For implantable peripheral nerve stimulation systems following a trial or selective lumbar medial branch stimulation without a trial, the evidence is Level III or fair with moderate certainty. Evidence Level: Fair; Strength of Recommendation: Moderate center dot For temporary peripheral nerve stimulation for 60 days, the evidence is Level III or fair, with moderate certainty. Evidence Level: Fair; Strength of Recommendation: ModerateBased on the available evidence, it is our recommendation to expand the existing PNS related local coverage determination (LCD) to include craniofacial pain, phantom limb pain, and nociceptive pain in the lower back as present evidence shows Level III or fair with moderate certainty.Limitations: The primary limitation of these guidelines is the paucity of the available literature. Conclusion: These evidence-based guidelines support the use of implantable peripheral nerve stimulation leads and neurostimulators in patients with moderate to severe chronic pain refractory to two or more conservative treatments. These guidelines aim to optimize patient outcomes and promote health equity through the integration of PNS technology in clinical practice.

A significant number of people are victims of vertebral fractures that may lead to debilitating symptoms. Conventional treatment options may not be successful due to the patient’s medical history. Vertebral augmentation procedures offer a different treatment option for vertebral fractures. Proper patient selection for any procedure is essential to ensure the most successful outcomes. Weighing the benefits and risks for a procedure is of critical importance. This chapter describes the candidate selection process behind vertebral augmentation procedures, including relevant anatomy, relevant pathophysiology, indications for the procedure, and contraindications for the procedure.

BACKGROUND:Radiofrequency ablation (RFA) has many treatment capabilities, one of which includes long term management of chronic headache. As a result, it has been increasingly used, especially in cases of refractory headache pain. Headaches can be classified as primary and secondary and can result from a variety of serious conditions. Types of primary headaches include tension, migraine, and cluster headaches whereas secondary headaches include headaches because of infection or vascular disease, and cervicogenic headaches. Both types can result in serious debility and diminished quality of life. The treatment of chronic headache pain commonly consists of lifestyle modifications, oral medications, and injectable medications. The aim of this study was to investigate the primary and secondary outcomes of RFA for chronic headache pain. METHODS:A systematic review was conducted using three different databases including PubMed, MEDLINE, and the Cochrane Database. The key concepts of "radiofrequency ablation" and "headache" were used. The search took place in June 2023, and it included articles from the past twenty years. RESULTS:Of the 580 articles found, 32 were included in the review. Most studies focused on pain scores, duration of relief, function, and patient satisfaction. In several studies, RFA was used to target various nerves as the pain generator and compared with modalities such as local anesthetic or corticosteroid. CONCLUSIONS:Overall, RFA shows favorable outcomes in the management of chronic headache pain. Therefore, RFA can serve as an alternative treatment option for patients who fail other conservative treatment regimens. Understanding the outcomes of RFA for headache pain can provide patients and clinicians with evidence for the most appropriate treatment strategies.

In this article, we propose a new diagnostic paradigm known as Chronic Abdominal Discomfort Syndrome (CADS). Patient's presentation centers around chronic abdominal pain not explained by acute pathology with or without accompanying dyspepsia, bloating, nausea and vomiting among other symptoms. The pathophysiology is noted to be neurogenic, possibly stemming from visceral sympathetic nerves or abdominal wall afferent nerves. Diagnosis is supported by signs or symptoms traversing clinical, diagnostic and functional criteria. Included is a tool which can assist clinicians in diagnosing patients with CADS per those domains. We hope to facilitate primary care physicians' and gastroenterologists' utilization of our criteria to provide guidance for selecting which patients may benefit from further interventions or evaluation by a pain physician. The pain physician may then offer interventions to provide the patient with relief.

Minimally invasive discectomy techniques are commonly employed by interventional chronic pain physicians to either remove herniated discs, or to alter the disc itself to relieve the pain and pressure it may be causing on nearby neuronal structures. Various techniques are employed that use mechanical, ablation, and laser to remove and alter the disc. Importantly discectomy has been shown to result in faster relief of symptoms than conservative medical management. In this chapter, we explore the indications, clinical applications, technical approaches, and complications for minimally invasive discectomy techniques for the treatment of disc herniations and disc pain caused by disc herniations.

Since the advent of spinal cord stimulation (SCS), advances in technology have allowed for improvement and treatment of various conditions, especially chronic pain. Additionally, as the system has developed, the ability to provide different stimulation waveforms for patients to treat different conditions has improved. The purpose and objective of the paper is to discuss basics of waveforms and present the most up-to-date literature and research studies on the different types of waveforms that currently exist. During our literature search, we came across over sixty articles that discuss the various waveforms we intend to evaluate. There are several publications on several waveforms used in clinical practice, but to our knowledge, this is the only educational document teaching on waveforms which provides essential knowledge. There is a gap of knowledge related to understanding wave forms and how they work.

Sacral neuromodulation (SNM) has emerged as promising therapy for a variety of bowel and bladder disorders, as well as chronic pelvic pain. Since its inception, it has evolved into a minimally invasive procedure that facilitated its rapid uptake into daily clinical practice. Mechanistically, it is thought to modulation spinal nerves that innervate the bladder, bowel and pelvic floor muscles, and evidence is beginning to emerge regarding its effectiveness. It is also used experimentally alongside interventions such as spinal cord stimulation and dorsal root ganglion stimulation in the treatment of chronic pelvic pain. As the use of SNM continues to expand, physicians should be well equipped to understand evidence regarding its use and the technical aspects for device placement. In this chapter we will briefly review the evidence regarding SNM and dive deeper into the therapeutic approaches, the relevant anatomy, indications for therapy, contraindications, and complications of the procedure.

BACKGROUND AND OBJECTIVE:Chronic pain is a pervasive and often-complex condition that can severely detract from an individual's quality of life. When conservative measures of treatment fail, radiofrequency ablation (RFA) has emerged as a potential alternative. This narrative review subsequently explores recent advancements in the use of RFA on peripheral nerves as a means of attenuating chronic pain and providing relief to patients. METHODS:A comprehensive literature search was conducted on the PubMed database using the keywords "Radiofrequency", "Ablation", "Pain", "Chronic", "Peripheral", and "Nerve". The search focused on articles published between 2018 to 2023 that discussed an application of RFA in a peripheral nerve. In total, 30 articles were selected for inclusion in this review. KEY CONTENT AND FINDINGS:Results indicate the successful use of RFA in an array of chronic pain conditions and anatomical sites. Applications include the treatment of trigeminal neuralgia (TN), occipital neuralgia, cluster headaches, knee pain derived from osteoarthritis (OA), hip pain, abdominal pain associated with pancreatic cancer, and several other chronic pain conditions. CONCLUSIONS:These findings suggest RFA is a viable option for reducing patient's pain scores and improving quality of life. Future research should build off extensive case reports/series with double-blind, randomized controlled studies to further investigate anecdotal successes.

Abstract The understanding of pain and the factors that influence it has come a long way from the strictly biological perspective of the past. Now, experts agree, pain is best understood with a biobehavioral or biopsychosocial model. These models integrate the physiological, social, and psychological components that influence pain and its perception across the lifetime of the patient. This is a broad and expanding area of study, but this chapter will focus on the highlights of these influences.