Background Epidural steroid injections (ESIs) are widely used for the treatment of chronic spinal pain, particularly in cervical and lumbar radiculopathy. Corticosteroids used in ESIs are broadly classified as particulate or non-particulate formulations, each with distinct safety and pharmacologic profiles. Comparative efficacy remains controversial. However, safety concerns regarding particulate steroid use in transforaminal injections are well established. However, physician perception of steroid effectiveness may influence clinical decision-making and practice patterns. Objective To evaluate physician perceptions regarding the comparative efficacy of particulate versus non-particulate corticosteroids in ESIs. Methods A survey-based study was conducted assessing physician beliefs on the duration and effectiveness of pain relief achieved with particulate and non-particulate steroids in ESIs. Responses were analyzed descriptively and compared to current literature. Results Most physicians perceived particulate steroids to provide either equivalent or longer-lasting pain relief compared to non-particulate steroids, with a slight majority favoring particulate formulations. Very few respondents believed particulate steroids were inferior. These findings align with existing literature demonstrating largely comparable efficacy between steroid types, with inconsistent evidence suggesting minor differences in duration of pain relief. Conclusions Despite mixed evidence regarding comparative efficacy, physician perception continues to favor particulate steroids for longer duration of analgesia. Given the known safety risks associated with particulate steroids, clinical decision-making should incorporate both efficacy data and patient-specific risk profiles. These findings highlight the importance of aligning physician perception with evolving evidence and safety guidelines.

Introduction: Interlaminar epidural steroid injections (ESIs) are widely used for chronic spinal pain caused by disc herniation and degenerative stenosis. The interlaminar approach allows for broad medication distribution across multiple nerve roots. However, technical variations, including loss-of-resistance (LOR) technique and injection site selection, may influence efficacy and complication rates. This study examines practice patterns among interventional pain physicians, assessing technique variations and their clinical impact while exploring opportunities for standardization. Methods: A questionnaire was distributed to interventional pain physicians from a range of specialties and practice settings who perform ESIs. Practice parameters of lumbar ESIs were surveyed including loss-of-resistance (LOR) technique, methods of accessing the epidural space via the interlaminar approach, and contrast spread patterns when using the midline approach. Results: Among 92 respondents, 53.3% use LOR to saline, while 42.4% use LOR to air. When accessing the epidural space, 80.4% prefer an ipsilateral approach to the side of pain or pathology. Use of a paramedian approach showed wide variation, with 24.2% reporting "always", 33.0% "most of the time", 30.8% "sometimes", and 12.1% "rarely". For midline approaches, only 4.4% of physicians reported always achieving bilateral contrast spread. The majority noted achieving it "most of the time" (54.4%) or "sometimes" (36.7%). A minority indicated they rarely (2.2%) or never (2.2%) achieve bilateral spread when performing midline ILESIs. Conclusion: Despite widespread use, significant variability exists in ESI technique. While consensus guidelines offer safety recommendations, standardization remains limited. Identifying common practices can help refine techniques and improve patient outcomes.

Lumbar transforaminal epidural steroid injections (TFESIs) are a widely used interventional procedure for managing lumbosacral radicular pain and other spinal conditions. TFESIs help reduce inflammation and enhance function by delivering corticosteroids into the nerve root and epidural space. The transforaminal approach is commonly utilized for its precise targeting, offering both diagnostic and therapeutic benefits. Furthermore, this technique can be performed in patients with a history of laminectomy or contraindications to performing an interlaminar approach at the targeted levels. This study reviews current practice patterns, technical preferences, and procedural experiences of interventional pain physicians performing lumbar TFESIs. A survey was distributed to interventional pain physicians via email, web links, and social media platforms. Respondents included academic physicians in ACGME-accredited fellowship programs, as well as hospital-based and private practice physicians. The survey contained questions focusing on fluoroscopic views used for TFESIs, frequency of one-level versus two-level injections, and the occurrence of paresthesias during lumbar TFESIs. Data were collected anonymously, and descriptive statistics were used to analyze responses. A total of 87 respondents completed the survey. For fluoroscopic guidance, 60.9

Background:There is debate about whether a standalone anteroposterior (AP) view can distinguish epidural contrast from non-epidural contrast spread. Objectives:This study aims to assess the accuracy of the AP (anteroposterior) and Contralateral Oblique (CLO) views in distinguishing epidural contrast spread patterns from non-epidural contrast spread patterns. Methods:Patients undergoing lumbar epidural steroid injections consented to participate in the study. A 20-gauge Tuohy needle was advanced very close to the epidural space, and 0.5-1 ml of contrast was then injected. CLO, AP, and lateral images of non-epidural spread were saved. The AP and CLO images were randomly mixed with images from historical controls with actual epidural spread. Results:A total of 24 false epidurograms in the AP and CLO views were mixed with an equal number of true epidurograms, resulting in 48 images each in the AP and the CLO views, respectively. Among the cohort of 10 experienced interventional pain physicians, the mean accuracy of correctly identifying epidural spread as epidural using the AP view alone was 51 % (SD 19 %). In addition, the accuracy of correctly identifying non-epidural spread as non-epidural using the AP view alone was 64 % (SD 15 %). Cohen's Kappa was 0.15, indicating minimal agreement between the interventionalists. In contrast, the mean accuracy of correctly identifying epidural spread as epidural using the CLO view alone was 99 % (SD 2 %). In addition, the accuracy of correctly identifying non-epidural spread as non-epidural using the CLO view alone was 96 % (SD 9 %). Excluding one outlier, the accuracy for the rest of the reviewers in determining non-epidural spread as non-epidural was 99 %. Cohens' Kappa was 0.95, indicating a high degree of agreement between the interventionalists. Conclusion:This study reveals that utilizing a standalone AP view without a CLO view was inadequate to distinguish epidural from non-epidural spread. Specifically, our study supports the continued use of CLO depth views to identify epidural contrast spread correctly.

A comprehensive review of device-related complications from cylindrical lead spinal cord stimulator (SCS) implants was previously published. [1] Although SCS remains a minimally invasive treatment for neuropathic pain, hardware-related problems such as lead migration, lead fracture, lead disconnection, generator malfunction, loss of charge, generator flipping, pocket pain, and paresthesia intolerance are reported more often than biologic complications. [1,2] Understanding these issues, their clinical presentations, diagnostic evaluation, and management strategies is critical for long-term outcomes. This infographic was designed to present the key findings of the review in a clear and accessible visual format.

We want to thank the authors for their excellent publication showing that the contralateral oblique (CLO) view has the potential of reducing complications related to cervical epidural access.[1][1] We have few comments to make in regard to this study. First, the zones as described in this study

BACKGROUND:Since the initial introduction in 1967 of spinal cord stimulation (SCS) in the field of neuromodulation, SCS has been utilized to treat a multitude of chronic pain disorders refractory to both conservative and surgical management. Although efficacious when indicated, SCS has associated risks. OBJECTIVES:The goals of this study are to explore the trend of rates of SCS complications in 2 approximately equally sized cohorts (1999-2015 and 2016-2021) within a single institution over a 22-year period. STUDY DESIGN:A retrospective cohort study. SETTING:A tertiary care academic hospital. METHODS:A retrospective chart review with pre-existing institutional review board approval was performed on 2 cohorts, one comprising 257 patients between 2016 and 2021 and the other comprising 262 patients between 1999 and 2015, who underwent percutaneous SCS implantation provided by 2 experienced interventional chronic pain specialists. The patients' demographics and complications were recorded in the REDCAP database. Data were collected on complications of both the biological (allergic/foreign-body reactions, dural puncture/leaks, infections, pain over implantation site, poor wound healing, skin erosions, neurological injuries, and subcutaneous/epidural hematomas) and device-related (electrical leaks, inadequate pain coverage, lead fractures, lead migrations, ligamentum flavum stimulation, recharging/battery failures, and unwanted stimulation) varieties. The chart review included records that started 6 months prior to SCS placement and ended at a period of at least one year of follow-up after placement. RESULTS:Of the patients studied between 2016 and 2021, the mean age was 58.5 ± 13.0 years, with men representing 46.3% and women 53.7% of the patients studied. Of those studied between 1999 and 2015, the mean age was 50.6 +/- 12.3 years, with men representing 42.4% of the patients and women 57.6%. The overall complication rates were 14.0% (36/257) and 38.9% (102/262) for 2016-2021 and 1999-2015, respectively. The rate of biological complications was nearly 3 times lower in the 2016-2021 group than in the 1999-2015 group (4.3% [11/257] vs 12.2% [32/262], P < 0.001). In the 1999-2015 group, the leading biological complication was infection, the rate of which decreased in the 2016-2021 group (3.4% [9/262] vs 1.9% [5/257], P < 0.42). The rate of device complications was nearly 3 times lower in the 2016-2021 group than in the 1999-2015 group (9.7% [25/257] vs. 26.7% [70/262], P < 0.0001). The leading device complication was inadequate pain coverage (12.2% [32/262] vs 7.4% [19/257], P < 0.08). No serious neurological injury or death occurred in either cohort. LIMITATIONS:Limitations were inherent to this study's design, since it was a retrospective cohort study. CONCLUSION:The rate of SCS-related complications decreased from one group to the next, with the most recent group demonstrating a statistically significant decrease in both device and biological complications. Our results are consistent with SCS literature trends that demonstrate decreasing complications, which may be due to technological advancements in SCS device technology and improved complication mitigation strategies. Further prospective research utilizing multicenter data is needed to better define the overall trend of SCS complications.

BACKGROUND:Spinal cord stimulation (SCS) is often an option of last resort for patients with post-laminectomy syndrome or an alternative option for patients with complex regional pain syndrome, chronic nonsurgical low back pain, or painful diabetic peripheral neuropathy when conservative management has failed. Although SCS is a helpful option, it is not without complications that can frequently lead to explantation of the SCS device and dissatisfaction with the treatment. Furthermore, as with any technology, SCS has potential issues that may lead to patient frustration and ultimately result in patient noncompliance and lack of follow-up visits. OBJECTIVES:The goals of this study are to explore the magnitude of and reasons for patient loss to follow-up after SCS device implantation. STUDY DESIGN:A cross-sectional phone survey. SETTING:A tertiary-care academic hospital. METHODS:A cross-sectional phone survey was performed on 49 patients who were deemed lost to follow-up when they did not return to the clinic one month after being implanted with permanent SCS devices at Beth Israel Deaconess Medical Center. Patients were administered an institutional review board-approved questionnaire exploring their reasons for not returning to the clinic. RESULTS:Over a 5-year period, 257 patients underwent full implantation of an SCS device. Of the 49 patients lost to follow-up, 24 were able to be contacted, and they completed the questionnaire. Twenty of the patients continued to use the SCS device but were lost to follow-up for the following reasons: 58% (14/24) due to improvement of pain, 13% (3/24) due to minimal improvement in pain control, 4% (1/24) due to other urgent health conditions, and 8% (2/24) due to patient noncompliance and missing follow-up appointments (4/24). Four patients discontinued using the SCS device after an average of 1.5 years +/- one year, 12% (3/24) due to inadequate pain control and 4% (1/24) due to inability to recharge the device (1/24). Of these patients, 2 of the 4 contacted their SCS representatives for help with troubleshooting prior to discontinuation. None of the patients was explanted. LIMITATIONS:The main limitation of this study was the incompletion rate, which was 51.0% (25 out of 49 patients). CONCLUSIONS:This paper, the first cross-sectional study of loss to follow-up among patients who are implanted with SCS devices, identifies that up to 19% of patients are quickly lost to follow-up after implantation. Only half of the patients in this study could be reached, with most successfully using their device for meaningful pain control, but a substantial number of patients likely required additional device optimization for pain relief.

Objective:To delineate the trend of use of botulinum toxin, including onabotulinum toxinA (OTA), in active military personnel and veterans with the diagnoses of migraine and post-traumatic headache (PTH) and describe the efficacy of botulinum toxin administration. Background:Service members and veterans represent a unique population in the medical management of headache disorders, particularly migraine. They exhibit higher susceptibility to pain of greater intensity and longer durations, possibly due to their history of exposure to combat, trauma, and the associated psychological stresses. Given the burden and morbid nature of these headache disorders, prophylactic measures to reduce migraine attacks and disability are imperative. Specifically, the use of OTA for migraine prophylaxis has been well validated in chronic migraine. Methods:The scoping review conformed to guidelines delineated by Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The databases Medline, Embase, and Google Scholar were accessed for our literature search, and the time frame of the search was set from database inception to April 1, 2024. Results:A total of 8 articles meeting the inclusion criteria were obtained after screening a total of 43 papers. Studies were primarily conducted in the United States (87.5%), with a single article published on veterans from Taiwan. Study types were mainly retrospective chart reviews with the exception of 2 randomized controlled trials. Chronic migraine was the most common headache diagnosis examined, being assessed in 6 studies, followed by PTH, which was represented in the remaining 2 studies. Conclusion:The occupational exposure of service members appears to result in a higher incidence of headache disorders such as chronic migraine and PTH, which are amenable to preventative management such as that with botulinum toxin. Despite its effectiveness, the use of botulinum toxin in treating headaches and craniofacial pain in service members remains under-researched, warranting further exploration in this population, specifically.

Objective To retrospectively assess the Thoracolumbar Injury Classification and Severity Score (TLICS) in patients with osteoporotic vertebral compression fractures (OVCF) and compare the treatment given with that predicted by the TLICS score. Methods All medical records of patients presenting from January 2014 to November 2017 for acute atraumatic or low impact OVCF were screened, and eligible patients were retrospectively reviewed. The TLICS score was determined based upon magnetic resonance imaging (MRI) findings and clinical records. Clinical records (including pain score data), imaging data, operative procedures, and stability of neurological examination were tracked over three months for each patient. Results Of the 56 patients included, 36 patients had a TLICS score of 1, 18 had a TLICS score of 2, and two had a TLICS score of 4. Only one patient with a TLICS score of 4 underwent surgical stabilization, while the rest of the cohort was managed non-operatively, with or without kyphoplasty. TLICS score 1 corresponded to simple compression and TLICS score 2 corresponded to burst morphology with retropulsion and without neurological deficits. Of the patients with a TLICS score of 1 and 2 who underwent kyphoplasty, there was a statistically significant improvement in pain scores in both groups; however no significant difference was observed, between each TLICS score (i.e., 1 or 2). None of the patients developed instability or neurological decline. Conclusion TLICS score correctly predicted operative versus non-operative management in all patients with OVCF. TLICS may be used in making management decisions, and in the triage of these patients for operative versus non-operative evaluations. Our study suggests that patients with TLICS score of 4 or higher require surgical evaluation, while those with TLICS of 1 or 2 are likely to have satisfactory non-surgical management with augmentation or conservative care. In general, patients with OVCF typically present with low TLICS score. Kyphoplasty appears to be similarly beneficial in patients with a TLICS score of 1 or a TLICS score of 2. A modification of the TLICS score by adding TLICS Zero to include uncompressed OVCF with edema is suggested. The limitations of this study include a small size; a larger study is needed to confirm these findings.

Spinal cord stimulation (SCS) is an increasingly utilized therapy for the treatment of neuropathic pain conditions. Though minimally invasive and reversable, there are several important device-related complications that physicians should be aware of before offering this therapy to patients. The aim of this review is to synthesize recent studies in device-related SCS complications pertaining to cylindrical lead implantation and to discuss etiologies, symptoms and presentations, diagnostic evaluation, clinical implications, and treatment options. Device-related complications are more common than biologic complications. Device-related complications covered in this review include lead migration, lead fracture, lead disconnection, generator failure, loss of charge, generator flipping, hardware related pain, and paresthesia intolerance. The use of SCS continues to be an effective option for neuropathic pain conditions. Consideration of complications prior to moving forward with SCS trials and implantation is a vital part of patient management and device selection. Knowledge of these complications can provide physicians and other healthcare professionals the ability to maximize patient outcomes.