Introduction:The sacroiliac (SI) joint can be a source of low back pain. Surgical techniques for fusion include lateral transiliac, posterolateral, sacro-alar iliac and posterior interpositional fixations. Although these various trajectories are supported by the literature, the lateral transiliac approach is the most extensively studied. However, this technique has been associated with concern for potential injury to branches of the superior gluteal artery (SGA). Currently, no preoperative workup includes the evaluation of SGA and its branches for location and potential injury during lateral fusion. We propose a clinical pathway for the identification and risk stratification of SGA injuries using preoperative CT of the pelvic vasculature and measurements of the proposed transiliac screw sites. Purpose:To determine whether preprocedural CT angiography (CTA) can identify the course of the SGA and its branches in relation to planned lateral transiliac SI joint fusion trajectories, thereby informing surgical planning and potentially reducing vascular risk. Patients and Methods:Twenty patients underwent preoperative CTA. Angiographic images were processed to generate a 3D vascular reconstruction. The proposed screw locations were identified, measured, and analyzed using descriptive statistics. Results:20 patients' images were analyzed with the average distance to the nearest SGA branch on the right being 19.0 mm ± 9.4 mm (minimum distance 5.75mm) and 17.3 mm ± 7.9 mm (minimum distance 5.97mm) on the left. Screw placement was altered in 1 of the 10 patients with an average total estimated blood loss (EBL) of 6.5mL ± 2.4mL in surgical patients. Conclusion:This pilot study suggests that preoperative CTA may aid proceduralists in planning lateral transiliac sacroiliac joint fusion by identifying the course of the SGA and its branches, potentially reducing the risk of vascular injury.

From the *Department of Anesthesiology and Perioperative Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University †Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky. Accepted for publication August 13, 2024. Conflicts of Interest, Funding: Please see DISCLOSURES at the end of this article. Reprints will not be available from the authors. Address correspondence to Salim M. Hayek, MD, PhD, Department of Anesthesiology and Perioperative Medicine, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44118. Address e-mail to [email protected].

Objective:As therapeutic options are rapidly expanding to treat pain of discogenic and vertebrogenic origin, it is important for the clinician to have an evidence-based understanding of the latest information regarding the normal and pathological anatomy of the intervertebral disc as well as imaging characteristics and treatment strategies. The American Society of Pain and Neuroscience (ASPN) commissioned the DISC project to inform and update the interventional spine community about anterior column pain syndromes. Methods:Using established literature review methods a clinical oversight group was convened to create an outline covering topics that will be key to meeting the objectives delineated by the ASPN scientific and guidelines leadership. This oversight group, using the created outline, selected key opinion leaders and experts to assemble the latest information on anterior column and intervertebral disc anatomy and treatment to serve as a living document that can be continuously updated to drive best practices and innovation. Results:A review of normal and pathological anatomy, a comprehensive understanding of biophysics applied to the anterior spinal column, and understanding of the current state of practice with regard to imaging, diagnostic classification systems and treatment.

BackgroundTo provide recommendations on risk mitigation, diagnosis and treatment of infectious complications associated with the practice of regional anesthesia, acute and chronic pain management.MethodsFollowing board approval, in 2020 the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) commissioned evidence-based guidelines for best practices for infection control. More than 80 research questions were developed and literature searches undertaken by assigned working groups comprising four to five members. Modified US Preventive Services Task Force criteria were used to determine levels of evidence and certainty. Using a modified Delphi method, >50% agreement was needed to accept a recommendation for author review, and >75% agreement for a recommendation to be accepted. The ASRA Pain Medicine Board of Directors reviewed and approved the final guidelines.ResultsAfter documenting the incidence and infectious complications associated with regional anesthesia and interventional pain procedures including implanted devices, we made recommendations regarding the role of the anesthesiologist and pain physician in infection control, preoperative patient risk factors and management, sterile technique, equipment use and maintenance, healthcare setting (office, hospital, operating room), surgical technique, postoperative risk reduction, and infection symptoms, diagnosis, and treatment. Consensus recommendations were based on risks associated with different settings and procedures, and keeping in mind each patient’s unique characteristics.ConclusionsThe recommendations are intended to be multidisciplinary guidelines for clinical care and clinical decision-making in the regional anesthesia and chronic interventional pain practice. The issues addressed are constantly evolving, therefore, consistent updating will be required.

Introducción: La Sociedad Internacional de Neuromodulación convocó a un grupo de médicos de múltiples especialidades según su experiencia y la representación internacional para establecer directrices basadas en evidencia sobre la mitigación de las complicaciones de la neuromodulación. Este proyecto del Comité de Consenso sobre la Adecuación en la Neuroestimulación (NACC)® tiene la intención de actualizar las directrices basadas en evidencia y ofrecer opiniones de expertos que mejoren la eficacia y la seguridad.Materiales y Métodos: Los autores fueron elegidos en base a su experiencia clínica, familiaridad con la literatura revisada por pares, productividad en investigación y contribuciones a la literatura de neuromodulación. Los líderes de sección supervisaron búsquedas de literatura en MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar y PubMed desde 2017 (cuando NACC publicó por última vez directrices) hasta octubre de 2023. Los estudios identificados fueron clasificados utilizando los criterios del Grupo de Trabajo de Servicios Preventivos de los Estados Unidos para evidencia y certeza de beneficio neto. Las recomendaciones se basan en la solidez de la evidencia o consenso cuando la evidencia era escasa.Resultados: El NACC examinó la literatura publicada y estableció recomendaciones basadas en evidencia y consenso para guiar las mejores prácticas. Se proporcionará orientación adicional a medida que se desarrolle nueva evidencia en futuras versiones de este proceso.Conclusiones: El NACC recomienda las mejores practicas relativas a la mitigación de complicaciones asociadas con la neuroestimulación para mejorar la seguridad y eficacia. Las recomendaciones basadas en la evidencia y el consenso deberían ser usadas como guía para asistir a la toma de decisiones, cuando sea apropiado clínicamente.

Introduction The International Neuromodulation Society convened a multispecialty group of physicians based on expertise with international representation to establish evidence-based guidance on using intrathecal drug delivery in chronic pain treatment. This Polyanalgesic Consensus Conference (PACC)® project’s scope is to provide evidence-based guidance for clinical pharmacology and best practices for intrathecal drug delivery for cancer pain. Materials and Methods Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Meeting Abstracts, and Scopus from 2017 (when the PACC last published guidelines) to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations were based on the strength of evidence, and when evidence was scant, recommendations were based on expert consensus. Results The PACC evaluated the published literature and established evidence- and consensus-based expert opinion recommendations to guide best practices in treating cancer pain. Additional guidance will occur as new evidence is developed in future iterations of this process. Conclusions The PACC recommends best practices regarding the use of intrathecal drug delivery in cancer pain, with an emphasis on managing the unique disease and patient characteristics encountered in oncology. These evidence- and consensus-based expert opinion recommendations should be used as a guide to assist decision-making when clinically appropriate.

IntroductionThe International Neuromodulation Society convened a multispecialty group of physicians and scientists based on expertise with international representation to establish evidence-based guidance on intrathecal drug delivery in treating chronic pain. This Polyanalgesic Consensus Conference (PACC)® project, created more than two decades ago, intends to provide evidence-based guidance for important safety and efficacy issues surrounding intrathecal drug delivery and its impact on the practice of neuromodulation.Materials and MethodsAuthors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when PACC® last published guidelines) to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence is scant.ResultsThe PACC® examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process.ConclusionsThe PACC® recommends best practices regarding intrathecal drug delivery to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.

Purpose:Injectable biologics have not only been described and developed to treat dermal wounds, cardiovascular disease, and cancer, but have also been reported to treat chronic pain conditions. Despite emerging evidence supporting regenerative medicine therapy for pain, many aspects remain controversial. Methods:The American Society of Pain and Neuroscience (ASPN) identified the educational need for an evidence-based guideline on regenerative medicine therapy for chronic pain. The executive board nominated experts spanning multiple specialties including anesthesiology, physical medicine and rehabilitation, and sports medicine based on expertise, publications, research, and clinical practice. A steering committee selected preliminary questions, which were reviewed and refined. Evidence was appraised using the United States Preventive Services Task Force (USPSTF) criteria for evidence level and degree of recommendation. Using a modified Delphi approach, consensus points were distributed to all collaborators and each collaborator voted on each point. If collaborators provided a decision of "disagree" or "abstain", they were invited to provide a rationale in a non-blinded fashion to the committee chair, who incorporated the respective comments and distributed revised versions to the committee until consensus was achieved. Results:Sixteen questions were selected for guideline development. Questions that were addressed included type of injectable biologics and mechanism, evidence in treating chronic pain indications (eg, tendinopathy, muscular pathology, osteoarthritis, intervertebral disc disease, neuropathic pain), role in surgical augmentation, dosing, comparative efficacy between injectable biologics, peri-procedural practices to optimize therapeutic response and quality of injectate, federal regulations, and complications with mitigating strategies. Conclusion:In well-selected individuals with certain chronic pain indications, use of injectable biologics may provide superior analgesia, functionality, and/or quality of life compared to conventional medical management or placebo. Future high-quality randomized clinical trials are warranted with implementation of minimum reporting standards, standardization of preparation protocols, investigation of dose-response associations, and comparative analysis between different injectable biologics.

IntroductionThe International Neuromodulation Society convened a multispecialty group of physicians based on expertise and international representation to establish evidence-based guidance on the mitigation of neuromodulation complications. This Neurostimulation Appropriateness Consensus Committee (NACC)® project intends to update evidence-based guidance and offer expert opinion that will improve efficacy and safety.Materials and MethodsAuthors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when NACC last published guidelines) to October 2023. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence was scant.ResultsThe NACC examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process.ConclusionsThe NACC recommends best practices regarding the mitigation of complications associated with neurostimulation to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.

INTRODUCTION:The International Neuromodulation Society (INS) has recognized a need to establish best practices for optimizing implantable devices and salvage when ideal outcomes are not realized. This group has established the Neurostimulation Appropriateness Consensus Committee (NACC)® to offer guidance on matters needed for both our members and the broader community of those affected by neuromodulation devices. MATERIALS AND METHODS:The executive committee of the INS nominated faculty for this NACC® publication on the basis of expertise, publications, and career work on the issue. In addition, the faculty was chosen in consideration of diversity and inclusion of different career paths and demographic categories. Once chosen, the faculty was asked to grade current evidence and along with expert opinion create consensus recommendations to address the lapses in information on this topic. RESULTS:The NACC® group established informative and authoritative recommendations on the salvage and optimization of care for those with indwelling devices. The recommendations are based on evidence and expert opinion and will be expected to evolve as new data are generated for each topic. CONCLUSIONS:NACC® guidance should be considered for any patient with less-than-optimal outcomes with a stimulation device implanted for treating chronic pain. Consideration should be given to these consensus points to salvage a potentially failed device before explant.

Intrathecal drug delivery systems (IDDS) utilizing a low dose opioid strategy have proven durable in relieving pain without significant dose escalation (1). However, in a subset of patients, dose escalation is needed to maintain pain relief. Adjuvants such as bupivacaine are often used to augment pain relief in IDDS (2). We present a case series where bupivacaine was added to a low dose opioid strategy to slow the opioid escalation.

BurstDR spinal cord stimulation (SCS) is a waveform delivering stimulation of 5-spike chains at a rate of 500Hz with a pulse width of 1000 μsec pulse with. These 5 spike packets cycle at a 40Hz (1). The T9-10-disc interspace is the usual target for the treatment of back and leg pain as a result of failed back surgery syndrome (FBSS) (2). We present two cases where leads placed above this level resulted in severe and intractable abdominal pain resolved only by lead revision.

Introducción: El campo de la neuroestimulación para el tratamiento del dolor crónico es un área de la medicina en rápido desarrollo. Aunque las terapias de neuroestimulación han avanzado significativamente como resultado de las mejoras tecnológicas; la planificación quirúrgica, la colocación del dispositivo y la atención posoperatoria son de igual importancia para optimizar los resultados. Este proyecto del Comité de Consenso sobre la Adecuación de la Neuroestimulación (NACC, por sus siglas en inglés) pretende proporcionar orientación basada en la evidencia que a menudo se pasa por alto para estas áreas de la práctica de la neuroestimulación.Materiales y métodos: Los autores se eligieron en función de su experiencia clínica, familiaridad con la literatura revisada por pares, productividad de la investigación y contribuciones a la literatura sobre neuromodulación. Los líderes de sección supervisaron las búsquedas bibliográficas en MEDLINE, BioMed Central, Current Contents Connect, Embase, Internatio-nal Pharmaceutical Abstracts, Web of Science, Google Scholar y PubMed desde la última publicación de NACC en 2017 hasta el presente. Los estudios identificados se calificaron utilizando los criterios del Grupo de trabajo de servicios preventivos de los Estados Unidos para la evidencia y la certeza del beneficio neto. Las recomendaciones se basan en la solidez de la evidencia y el consenso cuando la evidencia era escasa.Resultados: Este proyecto NACC brinda orientación sobre la evaluación preoperatoria, las técnicas intraoperatorias y el manejo posoperatorio en forma de puntos de consenso con apoyo en la evidencia. Estos resultados se basan en el grado de evidencia, la fuerza del consenso y la opinión de expertos.Conclusiones: El NACC ha brindado orientación para un plan quirúrgico que abarca la atención del paciente desde la etapa de planificación hasta la experiencia quirúrgica y la atención posoperatoria. Las recomendaciones generales están diseñadas para mejorar la eficacia y la seguridad de estos procedimientos de neuromodulación a los que se someten los pacientes y están destinadas a aplicarse en toda la comunidad internacional.

INTRODUCTION:The International Neuromodulation Society convened a multispecialty group of physicians based on expertise with international representation to establish evidence-based guidance on the use of neurostimulation in the cervical region to improve outcomes. This Neurostimulation Appropriateness Consensus Committee (NACC) project intends to provide evidence-based guidance for an often-overlooked area of neurostimulation practice.MATERIALS AND METHODS:Authors were chosen based upon their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when NACC last published guidelines) to the present. Identified studies were graded using the US Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence was scant.RESULTS:The NACC examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process.CONCLUSIONS:The NACC recommends best practices regarding the use of cervical neuromodulation to improve safety and efficacy. The evidence- and consensus-based recommendations should be utilized as a guide to assist decision making when clinically appropriate.

Introduction The field of neurostimulation for the treatment of chronic pain is a rapidly developing area of medicine. Although neurostimulation therapies have advanced significantly as a result of technologic improvements, surgical planning, device placement, and postoperative care are of equal importance to optimize outcomes. This Neurostimulation Appropriateness Consensus Committee (NACC) project intends to provide evidence-based guidance for these often-overlooked areas of neurostimulation practice. Materials and Methods Authors were chosen based on their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from the last NACC publication in 2017 to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on evidence strength and consensus when evidence was scant. Results This NACC project provides guidance on preoperative assessment, intraoperative techniques, and postoperative management in the form of consensus points with supportive evidence. These results are based on grade of evidence, strength of consensus, and expert opinion. Conclusions The NACC has given guidance for a surgical plan that encompasses the patient journey from the planning stage through the surgical experience and postoperative care. The overall recommendations are designed to improve efficacy and the safety of patients undergoing these neuromodulation procedures and are intended to apply throughout the international community.

Intrathecal (IT) opioids are often used for treating chronic pain in patients refractory to conventional medical treatment or intolerant to side effects. Currently, there is little research on the efficacy of adding bupivacaine to an intrathecal dosing regimen in non-cancer patients with pain refractory to traditional therapy. This study aims to evaluate the effect of adding IT bupivacaine on opioid escalation and pain scores of all the patients in our practice who were initially implanted with opioid monotherapy

Introduction Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety. Objective The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders. Methods The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented. Results After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain. Conclusion The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.

Chronic refractory pain can be difficult to manage. Intrathecal Ziconotide has proven to be effective at treating refractory nociceptive and neuropathic pain. Ziconotide’s analgesic effect is via selective blockade of N-type calcium channels. Ziconotide is trialed with a bolus of 3 mcg or 5 mcg. After intrathecal pump implant, therapy is initiated at 1.2-2.4 mcg/day. After 7-14 days the medication is exchanged and the dose kept the same. Subsequently, the dose is titrated every 7-14 days by 0.5-1.2 mcg/day. Adverse events of Ziconotide include neuropsychiatric adverse events and is contraindicated in patients with a history of psychosis.