This series of Fact Finders presents a brief summary of the evidence and outlines recommendations regarding the injection of preservative-containing steroid formulations in the epidural space and the practice of swabbing newly opened vial tops before drawing up injectate.The evidence in support of the following facts is presented: (1) No adverse events have been documented from the administration of preservative-containing steroids into the epidural space; however, neurological injuries have been reported following intrathecal injection of these preservatives. (2) Swabbing newly opened vial tops before drawing up an injectate has been a standard procedure in healthcare settings. However, the evidence supporting its efficacy is mixed. While a recent study has found no significant benefit, guidelines from the American Society of Anesthesiologists (ASA), Centers for Disease Control and Prevention (CDC), and World Health Organization (WHO) still recommend this practice. (3) Greater than 60% isopropyl alcohol is not universally effective against all pathogens.

This protocol reviews the recognition and management of allergic reactions and anaphylaxis during interventional pain procedures. It describes the spectrum of hypersensitivity reactions, ranging from mild dermatologic symptoms to life-threatening multisystem anaphylaxis with airway compromise and cardiovascular collapse. Emphasis is placed on early recognition, immediate epinephrine administration, airway stabilization, intravenous fluid resuscitation, and transfer to higher-level care.

BACKGROUND:Spine pathologies are associated with an inflammatory microenvironment, with previous studies demonstrating systemic inflammation based on analysis of serum from patients with low back pain (LBP). This pilot study used gene expression profiling to identify candidate cellular mechanisms mediating systemic inflammation in patients with LBP, with and without radicular pain, compared to asymptomatic controls. OBJECTIVE:To identify differences in expression of inflammation- and immune-related genes in whole blood from patients with LBP and spine pathology compared to control participants. Also, identify relationships between differentially expressed (DE) genes and patient-reported outcomes (PROs) for pain (Visual Analog Scale [VAS]) and disability (Oswestry Disability Index [ODI]). DESIGN:Case control, observational study. SETTING:Outpatient clinic at academic institution. PATIENTS:Nine participants with LBP who were 18 years or older and diagnosed with lumbar disc herniation, spinal stenosis, or disc degeneration. Eight control participants who were 18 years or older and had no history of LBP or spinal treatment. INTERVENTIONS:N/A. MAIN OUTCOME MEASURE:Expression levels of inflammation- and immune-related genes in patients with LBP compared to control participants measured using Nanostring nCounter analysis. RESULTS:Analysis of patients with LBP versus controls resulted in 11 DE genes (p-adj < .05) and 9 trending genes (p-adj < .1) falling into three clusters: "Interferon α/β Signaling," "Immunoglobulin Binding," and "Toll-like Receptor (TLR) Binding." VAS scores were also associated with expression level of FCER1G, FCGR3A/B, and KLRK1. Further analysis showed significantly lower expression of FCER1G in patients with high versus low VAS (p < .05). No relationships between DE gene expression and ODI was identified; however, a significant correlation between VAS and ODI scores was observed (p < .05). CONCLUSIONS:Clustering of DE and trending genes suggested increased interferon α/β signaling and TLR signaling may contribute to systemic inflammation related to LBP. Immunoglobulin binding was also implicated and varied with pain severity in patients with LBP.

This FactFinder presents a brief summary of the evidence regarding the safety of gadolinium-based contrast media (GBCM) for spinal interventions.

Background: The past two decades have witnessed tremendous growth in the appreciation and treatment of sacroiliac joint (SIJ) complex pain, including anatomical dissections that shed light on innervation, an appreciation for the contribution of extra-articular components to SIJ complex pain, the advent of radiofrequency ablation (RFA) and a host of minimally-invasive surgical techniques. Yet, there is no standardization of diagnosis and treatment paradigms. Methods: In February 2023, the Boards of Directors for the American Academy of Pain Medicine (AAPM) and American Society of Regional Anesthesia & Pain Medicine (ASRA-PM) approved the development of multispecialty guidelines on SIJ complex pain. Thirty partner organizations with clinical and scientific interests in SIJ complex pain were identified, and formal letters of request-for-participation were sent to each, along with a request for nominees to serve on the committee. Twenty five organizations agreed to participate in addition to the Departments of Defense and Veterans Affairs. A steering committee developed 21 questions, which spanned criteria for diagnosis, non-interventional and interventional treatments including surgery, technical parameters on how to optimize results, and what constitutes positive outcomes. Questions were methodically assigned to specialized modules comprising 4-5 members with complementary expertise, who collaborated with the Subcommittee Lead and one of three Committee Chairs to develop preliminary drafts. Following thorough revisions, these drafts were subsequently submitted to the full committee for comprehensive review. A modified Delphi method was used in which the answers to questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was achieved. During a committee meeting before commencement, it was agreed that recommendations would be noted when there was >50% agreement among committee members, but that a formal recommendation would require >= 75% consensus. Results: Twenty-one organizations formally endorsed the guidelines. The American Society of Anesthesiologists, and American Academy of Physical Medicine & Rehabilitation, and the North American Spine Society affirmed the benefit of the guidelines but did not officially endorse them. The American Academy of Neurology declined to affirm the benefit of the guidelines citing 'lack of relevance to their membership.' Per policies, while the Departments of Defense and Veterans Affairs did not formally review the guidelines for endorsement, their representatives approved them. In addition to being endorsed or the benefit affirmed by all voting organizations, complete consensus from committee members was obtained on all 21 questions. On two recommendations, there were dissensions from three societies who thought that selecting patients for sacral lateral branch RFA and minimally-invasive fusion should be based on >= 75% relief from two blocks instead of at least 50% relief from a single block before RFA, and greater than 50% pain relief with documented functional improvement after a single block before fusion. One additional society (Latin American Society of Regional Anesthesia) abstained on the statement that the evidence is stronger for extra-articular than intra-articular injections. The committee found that a battery of physical exam tests has reasonable sensitivity, but lower specificity, for identifying intra-articular but not extra-articular pain, with negative tests having greater predictive value than positive ones. Intra-articular injections have diagnostic validity for SIJ intra-articular, but not extra-articular, pain. There is unclear or negative evidence for imaging. The prevalence rates of intra-articular and extra-articular pathology are comparable, with both intra- and extra-articular steroid injections providing at least 4 weeks of relief in well-selected patients. However, the evidence is slightly stronger for extra-articular corticosteroid injections to provide short-term relief. The evidence base for non-interventional therapies is indirect, extrapolated mostly from low back pain studies. There is weak evidence supporting dextrose-based prolotherapy and platelet-rich plasma to provide at least 3 months of pain relief. There is strong evidence for sacral lateral branch RFA to provide relief for at least 6 months in individuals with extra-articular pathology, with face validity and indirect evidence from randomized trials supporting sacral lateral branch blocks as a prognostic tool. There is stronger evidence for larger lesions or more aggressive lesioning strategies than for less stringent techniques. There is weak evidence to support non-steroidal anti-inflammatory drugs to prevent neuritis after RFA, and in most cases anticoagulation does not require cessation in the periprocedural period. With an aggressive lesioning strategy, sensory stimulation provides minimal therapeutic benefit, with weak, extrapolated evidence that motor stimulation can provide safety benefit. The cut-off to designate diagnostic or prognostic blocks as positive is most commonly set at 50%, with higher values not shown to improve outcomes for more definitive procedures; for therapeutic treatment outcomes, the evidence supports a lower threshold of >= 30% pain relief or meaningful benefit on non-pain outcomes (eg, opioid cessation) for designation of a positive response. For carefully selected patients with intra-articular SIJ complex pain based on controlled blocks who have failed conservative therapies, there is weak or very weak evidence that minimally invasive SIJ fusion can provide benefit for at least one year. Conclusions: SIJ complex pain remains an underappreciated source of chronic low back pain, affecting between 15% and 30% of patients with axial pain predominantly below L5. Answers to many questions were limited by low-quality evidence, indicating the need for better research. SIJ complex pain is a multifarious condition (ie, pain can be from different portions of both the intra- and extra-articular components of the joint) for which an interdisciplinary, multimodal treatment plan can optimize treatment outcomes.

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to minimize risks associated with cervical epidural injections.Evidence in support of the following facts is presented.Minimizing Risks with Cervical Interlaminar Epidural Steroid Injections – 1) CILESIs should be performed at C6-C7 or below, with C7-T1 as the preferred access point due to the more generous dorsal epidural space at this level compared to the more cephalad interlaminar segments. This reduces the risk of the minor complication of dural puncture and the major complication of spinal cord injury due to inadvertent needle placement. 2) LF gaps are most prevalent in the midline cervical spine. This can result in diminished tactile feedback with loss of resistance (LOR), increasing the risk for inadvertent dural puncture or spinal cord injury. Based on current evidence, needle placement in the paramedian portion of the interlaminar space is safest to avoid LF gaps. 3) An optimal AP trajectory view and the physician's ability to discern engagement in the LF and subsequent LOR are crucial. Confirmation of minimal needle insertion depth relative to the ventral margin of the lamina with either a lateral or contralateral oblique (CLO) safety view is critical to minimize the risk of inadvertently inserting the needle too ventral. 4) There have been closed claims and case reports of patients who have suffered catastrophic neurologic injuries while receiving CILESIs under deep sedation. If sedation is administered, the least amount necessary should be utilized to ensure the patient can provide verbal feedback during the procedure. 5) CILESIs are an elective procedure; therefore, necessity and likelihood of benefit must be foremost considerations. Current guidelines recommend holding ACAP therapy before CILESIs due to the potentially catastrophic complications associated with epidural hematoma (EH) formation. However, there is also a risk of severe systemic complications with ceasing ACAP in specific clinical scenarios. The treating physician is obligated to determine if the procedure is indicated and can ultimately decide to delay the intervention or not perform the procedure if the benefit does not outweigh the risks.Minimizing Risks with Cervical Transforaminal Epidural Steroid Injections – the Role of Preprocedural Review of Advanced Imaging -- Variations in vascular anatomy may warrant a modified approach to CTFESI. Preprocedural review of cross-sectional imaging can provide critical information for safe injection angle planning specific to individual patients and may help to decrease the risk of unintended vascular events with potentially catastrophic outcomes.Safety of Multi-level or Bilateral Fluoroscopically-Guided Cervical Transforaminal Epidural Steroid Injections -- Safe performance of a CTFESI procedure requires the ability to detect inadvertent arterial injection. Contrast medium placed into the epidural space and/or along the exiting spinal nerves during an initial CTFESI may obscure the detection of inadvertent cannulation of a radiculomedullary artery by a subsequent CTFESI. While no available literature directly addresses the potential risk that exists with a multi-level or bilateral CTFESI, caution is still warranted.

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to improve our understanding and management of patients with potential contraindications to epidural steroid injections.

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to improve our understanding and management of potential procedure-related complications.Evidence in support of the following facts is presented. (1) Epidural Steroid injections for Radicular Pain Due to Spinal Stenosis Caused by Lipomatosis -- There is low-level evidence of an association between epidural steroid injections (ESIs) and the development and/or worsening of spinal epidural lipomatosis (SEL). However, there is insufficient evidence to establish whether ESIs independently result in an increase in spinal stenosis with neurological compromise in individuals with pre-existing SEL. (2) Steroid Exposure Postpartum -- There is no absolute contraindication to steroid injections based on postpartum or lactating status, but there may be disruption of both maternal and breastfed child hypothalamic-pituitary-adrenal (HPA) axis response to steroid administration. For the duration of breastfeeding, milk production may be affected after steroid exposure, and withholding breast milk produced for several hours after exposure minimizes infant exposure.

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to improve our understanding and management of several potential procedure-related complications. The evidence in support of the following facts is presented: (1) Multifidus Atrophy After Lumbar Medial Branch Radiofrequency Neurotomy (LMBRFN) -- There is no conclusive published literature indicating that LMBRFN leads to increased multifidus atrophy relative to natural history. High-quality prospective studies with a natural history comparison group evaluating immediate pre-procedure as well as post-procedure longitudinal cross-sectional imaging are needed to accurately assess for any possible influence of LMBRFN on multifidus atrophy as well as the clinical relevance. (2) Intradiscal Biologics -- Although the available evidence on intradiscal biologic interventions is limited, it nonetheless shows a non-zero risk of complications. Until larger sample sizes are reported, the actual magnitude of the risk cannot be ascertained. In the meantime, physicians who perform intradiscal injections of biologics should conscientiously consider the risk-benefit of these procedures. (3) Lumbar Facet Synovial Cyst Rupture -- There have been few reports of complications secondary to lumbar facet synovial cyst rupture. Risks of may include increased pain, infection, and nerve root compression.

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to improve our understanding and management of several potential local anesthetic-related complications. Evidence in support of the following facts is presented. (1) Chondrotoxicity: Which Local Anesthetics are Safest for Intraarticular Injection? -- There are drug-, concentration-, and time-dependent chondrotoxic effects that vary between local anesthetics. Current evidence related to commonly used local anesthetics indicates that with exposure to equivalent volumes, bupivacaine, at concentrations of 0.5 % or higher, is the most chondrotoxic agent, while ropivacaine, at concentrations equal to or less than 0.5 %, is the least chondrotoxic in vitro. There is minimal published evidence that confirms these findings in vivo. (2) Minimizing Risks with Stellate Ganglion Blocks -- Evidence suggests that fluoroscopic or ultrasound guidance reduces the risk and increases the accuracy of SGB. Utilizing ultrasound guidance has the added benefit of soft tissue visualization, especially vascular structures, which has the potential to prevent adverse outcomes when compared to the fluoroscopic technique.

Objective:To assess the effectiveness and safety of sacral lateral branch radiofrequency neurotomy (SLBRFN) in treating posterior sacroiliac joint complex (PSIJC) pain, stratifying results by patient selection criteria and technique. Design:Systematic review. Population:Adults over 18 years old with suspected PSIJC pain. Intervention:SLBRFN with image guidance (including computed tomography, fluoroscopy, ultrasound). Comparison:Any other treatment, sham, or no treatment. Outcomes:The primary outcome was improvement in pain reported as continuous data or the proportion of patients obtaining ≥50% reduction in pain scores on either the visual analog scale (VAS) or numeric rating scale (NRS). Secondary outcomes included functional improvement, reported as continuous data or the proportion of patients obtaining ≥30% in function from baseline, and adverse events. Methods:Six reviewers independently assessed publications prior to December 2022 in PubMed, EMBASE, Web of Science, and Google Scholar and utilized the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework to evaluate the overall quality of evidence. Results:Of the 415 publications screened, 37 met the inclusion criteria, with 33 providing sufficient data regarding the effectiveness of SLBRFN. Of the included studies, there were four explanatory randomized controlled trials (RCTs), four pragmatic RCTs, 11 prospective cohort studies, 14 retrospective cohort studies, and four case reports describing adverse events. At 6 months, the proportion of patients with ≥50% pain relief ranged from 19 to 89%. Studies providing continuous data reported that patients achieved 40-60% pain relief sustained at 12 months. There was heterogeneity in reporting functional improvement, but most studies noted improvement. While all studies that reported categorical outcomes targeted the S1-3 sacral lateral branches, the majority also included RFN of the L5 dorsal ramus. Successful outcomes were reported in patients selected by the response to intra-articular blocks (single or dual) or sacral lateral branch blocks (single or dual). Twenty-nine total adverse events and three serious adverse events (SAE) were reported across 1367 patients. According to the GRADE system, there is moderate-quality evidence overall that SLBRFN effectively reduces pain and disability in a majority of patients with PSIJC pain at 1, 3, 6, and 12 months. When anatomically validated SLBRFN techniques are assessed, the level of evidence is upgraded to high quality. Discussion/conclusion:Despite the variability in types of radiofrequency technology, technique, nerve targets, and study methodology, most studies found that substantial proportions of patients achieved ≥50% relief at 1, 3, 6, and 12 months following SLBRFN. When anatomically validated SLBRFN techniques are applied, there is a high level of confidence that the procedure effectively reduces pain and improves function in patients with PSIJC pain. Additional high-quality studies exploring the prognostic value of different block protocols and the relative effectiveness of the various SLBRFN procedure techniques are needed to further optimize the clinical outcomes of SLBRFN.

This series of FactFinders presents a brief summary of the evidence and outlines recommendations regarding the use of motor stimulation testing in lumbar radiofrequency neurotomy and performance of radiofrequency neurotomy in patients with posterior spinal hardware. The evidence in support of the following facts is presented: (1) Motor stimulation does not inherently protect against unwanted damage to the spinal nerve, exiting spinal nerve root or its ventral ramus due to a lack of sensitivity of this test for identification of electrode contact or close proximity to sensorimotor nerves. Even when motor stimulation is performed, verification of correct electrode placement with multiplanar imaging including a minimum of true anterior-posterior and lateral fluoroscopic views is a recommended safeguard. (2) The existence of posterior spinal hardware is not an absolute contraindication to radiofrequency neurotomy, but direct contact with hardware should be avoided.

This series of FactFinders presents a brief summary of the evidence and outlines recommendations regarding the use of antibiotics for disc access and spinal cord stimulation trials. The evidence in support of the following facts is presented: (1) There is a low but nonzero risk of discitis due to percutaneous intervertebral disc access. Strategies to mitigate this risk include use of strict aseptic technique, use of a needle stylet, and prophylactic intravenous or intra-discal antibiotics. (2) In low-risk patients, it may not be necessary to continue antibiotics throughout the percutaneous or staged trial period; however, in high-risk patients, or in trials lasting more than five days, antibiotics should be considered on a case-by-case basis.

Objective Using stringent inclusion criteria, a double-blinded study protocol, and fluoroscopically guided injections, we compare intra-articular sacroiliac joint platelet-rich plasma injections with intra-articular steroids. Design Double-blind, randomized controlled trial. Setting Two large university-based interdisciplinary spine centers. Subjects A total of 26 patients with a positive diagnostic block (>80% relief). Methods Subjects who had a positive diagnostic block were randomized to undergo either a fluoroscopically guided intra-articular injection of steroid or a platelet-rich plasma injection. Follow-up was at 1 month, 3 months, and 6 months. Outcomes included level of pain, as indicated on a 0- to 100-mm numeric pain rating scale, and functional disability score, obtained via the Oswestry Disability Index (ODI). Results At 1, 3, and 6 months, both groups improved; however, subjects who received steroid injections reported lower pain scores than did subjects who received platelet-rich plasma. Using categorical data, we observed significantly more responders (defined as pain scores that improved by 50% or more from baseline) at 1 and 3 months in the group who received steroids than in the group who received platelet-rich plasma. Conclusion Although both groups showed improvements in pain and function, the steroid group had significantly greater response and significantly more responders than did the platelet-rich plasma group.

This series of FactFinders presents a brief summary of the evidence and outlines recommendations regarding the safety of antithrombotics and two interventional pain procedures - lumbar transforaminal epidural steroid injections and lumbar medial branch radiofrequency neurotomy. The evidence in support of the following facts is presented: (1) The decision to withhold antiplatelet therapy prior to lumbar transforaminal epidural steroid injections should be made on a case-by-case basis, weighing the relative risk of hemorrhage versus the risk of thrombosis for each patient. (2) A clinically significant hemorrhagic complication has never been reported in the medical literature in association with a lumbar medial branch radiofrequency neurotomy procedure. (3) Discontinuing antithrombotics for lumbar radiofrequency neurotomy procedures, even for a short period of time, may lead to an increased incidence of cardiovascular and cerebrovascular events.

1 Columbia University Medical Center, Rehabilitation and Regenerative Medicine, New York, New York, U.S.; 2 Emory University, Department of Orthopaedics, Atlanta, Georgia, U.S.; 3 Colorado Permanente Medical Group, Department of Neurosurgery, Denver, Colorado, U.S.; 4 Napa Pain Institute, Napa, California, U.S.; 5 University of Utah School of Medicine, Department of Physical Medicine & Rehabilitation, Salt Lake City, Utah, U.S.