OBJECTIVE:Management of refractory chronic low back pain (CLBP) includes a range of treatments (eg, physical therapy, injections, ablations, neurostimulation, surgery) with varying utilization and effectiveness. This pragmatic randomized controlled trial (RCT) evaluated the effectiveness of one treatment option, percutaneous 60-day peripheral nerve stimulation (PNS), compared to usual care with standard interventional management for CLBP. METHODS:Two hundred thirty patients with CLBP were randomized in a 1:1 ratio to Group 1 (percutaneous 60-day PNS) or Group 2 (physician-directed usual care with standard interventional management). The Primary Clinical Endpoint evaluated the proportion of participants with ≥50% reductions in CLBP at 3 months post-treatment compared to baseline. RESULTS:At the Primary Endpoint, a greater proportion of participants receiving percutaneous 60-day PNS (55%; n = 112; 95% confidence interval [CI] = 45-65) experienced ≥50% pain relief compared to usual care with standard interventional management (26%; n = 110; 95% CI = 17-34; P < .001). Concordant with the Primary Endpoint, percutaneous 60-day PNS also produced greater improvements in patient-centric secondary endpoints, including disability, pain interference, health-related quality of life, and analgesic consumption. Reductions in pain and resulting improvements in function were sustained through 6 months with percutaneous 60-day PNS. CONCLUSIONS:This prospective multicenter pragmatic RCT met its Primary Clinical Endpoint and found that more participants with CLBP reported pain relief at 3 months after receiving percutaneous 60-day PNS as compared to usual care with standard interventional management. Participants treated with 60-day PNS showed greater reductions in pain and more substantial improvements in functional outcomes through 6 months. CLINICALTRIALS.GOV:NCT04246281; Primary funding: Department of Defense (DoD), with additional funding needed to complete the study provided by the study's sponsor, SPR.The protocol is available on ClinicalTrials.gov. The statistical analysis plan and results will be made available within 12 months of the study's completion.

Background Vertebral compression fractures (VCFs) contribute substantially to pain, disability, and healthcare burden. Vertebroplasty and balloon kyphoplasty (KP) are widely used but limited by cement leakage and inconsistent vertebral height restoration. Mechanical vertebral augmentation (MVA) techniques were developed to improve vertebral alignment and cement containment, yet their comparative outcomes remain incompletely defined. Objectives To map and synthesize the existing evidence on MVA compared with KP or vertebroplasty across seven clinically relevant domains, including cement extravasation, alignment correction, pain and disability outcomes, morbidity and mortality, and feasibility in complex fracture patterns. Methods A comprehensive search of MEDLINE, Embase, and Web of Science identified studies evaluating MVA in adult VCFs. Data were charted according to seven predefined research questions and synthesized descriptively using scoping-review methodology. Forest plots were used to visualize the ranges and distributions of reported outcomes across studies. Results Fifty-two studies met inclusion criteria. Across studies, MVA demonstrated a trend toward lower cement extravasation rates compared with KP, although definitions and detection methods varied and intradiscal leakage was generally reported as asymptomatic. Vertebral height restoration and alignment correction were often greater or more consistently achieved with MVA devices, but the clinical relevance of these differences remains uncertain. However, improved structural correction did not consistently translate into superior clinical outcomes across studies. Adjacent fracture rates ranged widely, with some studies describing lower rates after MVA and others showing similar or higher rates, particularly in cases involving more aggressive correction. Evidence describing morbidity or mortality differences across augmentation techniques was limited, and long-term comparative data remain sparse. Overall, available findings support the feasibility and short-term safety of MVA, though heterogeneity in reporting limits firm conclusions. Conclusions Current evidence suggests that MVA is a feasible and safe treatment option for VCFs, including complex morphologies. Although some studies report differences in radiographic correction or cement leakage patterns between MVA and KP, the clinical significance remains uncertain, and improved structural correction does not consistently translate into superior clinical outcomes. High-quality randomized trials with standardized imaging and clinical outcome reporting are needed to clarify how different augmentation strategies compare and whether structural restoration achieved with MVA leads to consistent, meaningful improvements in patient outcomes.

Background Basivertebral nerve ablation (BVNA) is a minimally invasive intraosseous radiofrequency procedure for vertebrogenic chronic low back pain (CLBP). Although randomized controlled trials have established its efficacy, real-world safety data remain limited. Purpose Post-market adverse event (AE) characterization associated with BVNA using the U.S. Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database. Study design Retrospective analysis of a national medical device adverse event database. Methods The MAUDE database was queried for all reports involving FDA-cleared BVNA systems from inception to 2025. Reports were manually reviewed, deduplicated, and coded for AE type, severity, timing, and outcome. Frequencies were summarized with descriptive statistics. Results A total of 96 unique medical device reports were analyzed. Vertebral compression fracture was the most frequently reported AE, occurring in 21.9% (21/96) of reports. Among the 21 VCF-containing reports, timing was documented in 12 (57.1%): 6 occurred within 30 days post-procedure (range: 4-21 days) and 6 occurred beyond 30 days (range: 33-294 days). Timing was not reported in the remaining 9 reports. An additional 2 reports described posterior element fractures and are reported separately (2.1%, 2/96). Other common AEs included increased low back pain (10.4%), superficial bleeding (2.1%), and emergency department visits (7.3%). Severe AEs were infrequent, including hospitalization (9.4%), retroperitoneal hematoma (7.3%), and death (2.1%). Both deaths were associated with anesthesia-related events rather than the BVNA device or procedure. No cases of infection, spinal/epidural hematoma, or major neurologic injury were identified. Most reports were manufacturer-submitted, with few voluntary reports or device returns. Conclusions This MAUDE-based review complements clinical trial data by characterizing the distribution of post-market adverse event reports associated with BVNA. Vertebral fracture was the most frequently reported event, with variable timing ranging from the day of the procedure to nearly 300 days post-BVNA; no consistent temporal pattern could be established. These findings do not permit conclusions about incidence or causality but identify vertebral fracture and pain as the most represented post-market signals, and highlight the need for prospective registries with standardized follow-up, pre-procedural bone health documentation, and detailed AE capture to more precisely define the long-term safety profile of BVNA.

Background Fluoroscopically guided lumbar epidural steroid injections (ESIs) are commonly performed to treat lumbar radicular pain. Intraprocedural pain is an important patient centered aspect of the procedural experience and may influence satisfaction, anxiety, and willingness to undergo repeat interventions. Although prior studies have suggested that interlaminar approaches may be less painful than transforaminal injections, the patient and procedure related factors associated with intraprocedural pain in routine clinical practice remain incompletely characterized. Objective 1. To evaluate the association between patient- and procedure-related factors and intraprocedural pain during lumbar epidural steroid injections. 2. To compare intraprocedural pain between lumbar transforaminal epidural steroid injections (LTFESI), lumbar interlaminar epidural steroid injections (LIESI) and caudal epidural steroid injections. Methods This single-center observational cohort study analyzed consecutive adult patients who underwent fluoroscopically guided LTFESI, LIESI or caudal injections between February 2022 and June 2022. Pain scores were collected immediately before and after the procedure, with intraprocedural pain assessed using immediate recall. Scores were obtained by non-physician staff while the performing physician was not present. Demographic variables including age, sex, and body mass index were obtained through electronic medical record review. Multivariable linear regression analyses were performed to evaluate associations between patient- and procedure-related factors and intraprocedural pain scores. Results A total of 582 injections were performed. The mean intraprocedural pain score was 4.57 ± 2.79 on a 0 to 10 numeric rating scale. Increasing age was significantly associated with lower intraprocedural pain scores (β = −0.029; 95% CI −0.043 to −0.014; p < 0.001), while male sex was associated with lower reported pain compared with female sex (β = −0.59; 95% CI −1.05 to −0.12; p = 0.013). Higher pre-procedure pain (β = 0.24; 95% CI 0.14 to 0.34; p < 0.001) and greater injectate volume (β = 0.45; 95% CI 0.12 to 0.77; p = 0.007) were independently associated with higher intraprocedural pain after adjustment for injection approach and other covariates. In contrast, injection approach (LTFESI vs. LIESI vs. caudal ESI) itself was not associated with intraprocedural pain. Conclusion In this real-world cohort, younger age, female sex, higher pre-procedure pain and higher injectate volume were associated with increased intraprocedural pain during fluoroscopically-guided lumbar ESIs. There were no differences in intraprocedural pain scores between LTFESI, LIESI, and caudal injections. These findings highlight the importance of considering patient-specific demographic factors when counseling patients and optimizing strategies to improve procedural comfort.

Spine-related leg pain (SRLP) is a common and clinically important presentation, affecting a substantial proportion of individuals with lumbar spine disorders. Compared to those with isolated axial low back pain, these patients experience higher pain intensity, greater disability, worse long-term outcomes, and increased healthcare utilization. Clinical management is complicated by inconsistent terminology among musculoskeletal healthcare providers, with the widespread and imprecise use of the term sciatica contributing to diagnostic uncertainty and treatment variability across heterogeneous conditions. The International Association for the Study of Pain (IASP) distinguishes three categories of SRLP: radiculopathy, radicular pain, and somatic referred pain, each differing in underlying mechanisms, clinical presentation, prognosis, and management considerations. Lumbar radiculopathy is characterized by nerve root loss of function and corresponding neurologic deficits; radicular pain involves irritation of the nerve root with neural gain of function; and somatic referred pain results from nociceptive input from spinal structures that produce distal pain without direct nerve root dysfunction. This commentary operationalizes the updated IASP framework for physical therapists by synthesizing contemporary mechanistic concepts into a pragmatic, clinically oriented resource to support structured, mechanism-based clinical reasoning. Emphasis is placed on differentiating SRLP phenotypes during examination, setting appropriate expectations, guiding conservative management, and identifying when escalation, interdisciplinary collaboration, or referral is warranted. By adopting standardized terminology and applying a structured yet adaptable reasoning framework, physical therapists may enhance diagnostic precision, improve individualized decision-making, and more effectively guide patients with SRLP toward meaningful recovery.

Background:Patient selection for lumbar medial branch radiofrequency neurotomy (LMBRFN) remains a topic of debate. Different block paradigms may influence LMBRFN outcomes. This study examined the relationships between block paradigms and treatment results following LMBRFN. Methods:A retrospective cohort study of consecutive patients undergoing first-time LMBRFN between 2016 and 2022 at two associated Canadian clinics was performed. Patients were grouped into six prognostic block paradigms based on block type (medial branch block [MBB] vs. intra-articular block [IAB]), number of blocks (single vs. dual), and percent pain relief (50-79% vs. ≥80%): 1 = MBB/MBB ≥80%, 2 = MBB/MBB 50-79%, 3 = IAB/MBB ≥80%, 4 = IAB/MBB 50-79%, 5 = MBB ≥80%, and 6 = MBB 50-79%. Treatment success was defined by (1) ≥50% reduction in numerical rating scale (NRS) pain score and (2) the minimal clinically important difference (MCID) in Pain Disability Quality-of-Life Questionnaire-Spine (PDQQ-S) at 3 months post-procedure. Logistic regression was used to assess associations between block paradigm and outcomes while controlling for select demographic and clinical factors. Results:Among 631 included patients (57.1% female; mean age 62.3 ± 12.9 years), 46.9% achieved ≥50% NRS reduction and 47.7% met the MCID for PDQQ-S at 3 months. No significant associations were found between block paradigms and ≥50% pain relief. However, the IAB/MBB 50-79% paradigm was associated with significantly lower odds of functional improvement by the PDQQ-S (OR = 0.31; p = 0.02). Patients who were working at the time of the procedure had higher odds of treatment success with respect to pain (OR = 2.51; p < 0.01) and function (OR = 2.21; p < 0.01). Conclusion:In this cohort, nearly half of patients experienced clinically meaningful pain reduction at 3 months post-LMBRFN, regardless of block selection criteria, challenging the need for restrictive paradigms. However, patients selected by IAB/MBB with 50-79% pain relief were less likely to experience clinically significant improvements to function. Active employment was linked to better 3-month outcomes for both pain and function, highlighting potential psychosocial factors. Larger prospective studies with long-term follow-up are needed to confirm these findings and optimize patient selection for LMBRFN.

Background Percutaneous 60-day peripheral nerve stimulation (PNS) of the lumbar medial branches is a minimally invasive treatment option for chronic low back pain (CLBP). A recent randomized controlled trial (RESET Clinical Trial) met its primary endpoint, with a significantly greater proportion of participants treated with 60-day PNS (n = 112) reporting ≥50% reductions in average low back pain compared to those treated with physician-directed usual care with standard interventional management (n = 110; e.g., ablations, injections, physical therapy) at 3 months post start of treatment. Objective Building on the published findings from the Full Analysis Set, this post-hoc analysis primarily explored whether per protocol treatment delivery (bilateral stimulation that generated sensations covering the majority of the painful region in the low back for 6-12 h per day) was associated with response to 60-day PNS. Additional post-hoc evaluations explored the influence of clinical variables across the study population and investigated outcomes within exploratory subgroups of common clinical pain profiles (e.g., patients with characteristics typical of facetogenic and discovertebral pain). Methods Univariate logistic regressions evaluated associations between variables (treatment delivery and clinical variables) and responder rate (≥50% reduction in average pain at 3 months). Results The results suggest per protocol treatment delivery is associated with positive outcomes following treatment with 60-day PNS for CLBP (odds ratio = 3.04, 95% confidence interval = [1.16, 7.93], p = 0.023). Within this clinical trial's population as defined by the inclusion and exclusion criteria, neither clinical variables (e.g., age, pain duration, gender, average pain intensity, pain interference, and disability) nor response to a medial branch block had a significant impact on treatment response. Additional post-hoc analyses showed positive outcomes with 60-day PNS among exploratory cohorts defined by common facetogenic and discovertebral pain features. Reductions in pain extended to improvements in pain interference and disability, with benefits sustained at all completed timepoints through 6 months (follow-up beyond 6 months is ongoing). Conclusions Together, these findings suggest that 60-day PNS treatment delivery is an important determinant of outcomes, underscoring the role of proper lead implantation, patient education, and treatment adherence in clinical practice. ClinicalTrials gov identifier NCT04246281.

Abstract Objectives Epidural spinal cord stimulation (SCS) is an emerging therapy for motor rehabilitation following spinal cord injury (SCI) and other motor disorders. Conventionally, SCS leads are placed along the dorsal spinal cord (SCS D ), where stimulation activates large diameter afferent fibers, which indirectly activate motoneurons through reflex pathways. This leads to broad activation of flexor and extensor muscles and limited fine-tuned control of motor output. Targeting the ventral spinal cord (SCS V ) may enable more direct activation of motoneuron pools, potentially improving the specificity of muscle activation; however, there is currently no established method to place leads ventrally. To address this, we evaluated the feasibility of four modified percutaneous implantation techniques to target the ventrolateral thoracolumbar spinal cord. Materials and methods Percutaneous SCS V implantation was performed in three human cadaver torso specimens under fluoroscopic guidance. The following approaches were evaluated: sacral hiatus, transforaminal, interlaminar contralateral, and interlaminar ipsilateral. The leads in the latter 3 approaches were inserted between L1 and L5. Eighteen implants were attempted, with nine leads retained for analysis. Lead and electrode position were assessed using computed tomography (CT) with three-dimensional reconstruction, along with anatomical dissection to verify lead and electrode placement within the epidural space. Results Successful ventral epidural lead placement was achieved using all four implantation approaches. The sacral hiatus (16/16 electrodes) and transforaminal (8/8 electrodes) approaches resulted in exclusively ventrolateral placement. The interlaminar contralateral approach led to 27/32 electrodes positioned ventrolaterally and 5/32 dorsally. The interlaminar ipsilateral implantation approach led to 14/32 electrodes positioned ventrolaterally and 18/32 positioned ventromedially. Conclusions These findings demonstrate that ventral epidural SCS lead placement can be achieved using modified percutaneous implant techniques. The four approaches outlined here provide a clinically feasible pathway to SCS V and establishes a foundation for future clinical studies investigating SCS V for motor rehabilitation following SCI.

Ballengee et al. propose an implementation science framework for de-implementing epidural steroid injections (ESIs) for chronic low back pain (CLBP). This commentary identifies several critical limitations of their proposal. First, the target population is inadequately defined; the term “non-specific” CLBP is never operationalized, inviting misapplication to patients with specific pathoanatomical diagnoses. Second, the evidentiary anchor, a recent BMJ clinical practice guideline, is subject to a formal retraction request from 34 professional organizations citing inappropriate pooling of heterogeneous procedures, data extraction errors, and violations of GRADE methodology. Third, the proposed replacement therapies (including cognitive behavioral therapy, physical therapy modalities) demonstrate comparably modest effect sizes, yet are held to a lower evidentiary standard. Fourth, indirect cost-utility comparisons do not favor de-implementation: published analyses consistently place ESIs within accepted willingness-to-pay thresholds, while behavioral alternatives carry higher cost-per-QALY ratios. Fifth, the structural incentive analysis applied to proceduralists must be applied symmetrically to the professions that would absorb redirected clinical volume. De-implementation should be held to the same evidentiary rigor as implementation, requiring head-to-head comparative effectiveness and cost-effectiveness data before removing a therapeutic modality from the clinical armamentarium. Perspective This commentary argues that de-implementing epidural steroid injections without head-to-head comparative effectiveness and cost-effectiveness evidence risks restricting access to a therapy that remains cost-effective and that may facilitate participation in multimodal care.

SUMMARY OF BACKGROUND DATA:Multiple clinical trials have demonstrated the effectiveness of intraosseous basivertebral nerve radiofrequency ablation (BVNA) for treating chronic vertebrogenic low back pain (vLBP). Few studies have evaluated the effectiveness in a real-world population. OBJECTIVES:To evaluate the effectiveness of BVNA for vLBP in a real-world population. METHODS:A single-arm prospective cohort study of patients with LBP ≥ 6 months and Type 1 or Type 2 Modic changes on MRI. The primary outcome was mean improvement in Oswestry Disability Index (ODI) post-BVNA. Secondary outcomes included the proportion of participants with (1) ≥30% and ≥15-point ODI improvements, (2) ≥2-point and ≥50% reductions in pain on Numerical Rating Scale (NRS), and (3) ≥ "much improved" on Patient Global Impression of Change (PGIC) at 3- and 12-month follow-up. RESULTS:In total, 60 participants were included (mean age 57.0 ± 13.4 years; 45.0% female). Mean ODI score improvement was 13.9 ± 18.7 and 14.0 ± 15.7 points at 3- and 12-month follow-up, respectively. At 12 months, 52.8% (95% CI, 39.7-65.6) of participants reported ≥30% ODI improvement and 39.6% (95% CI, 27.6-53.1) of participants reported ≥15-point improvement in ODI. Twelve-month responder rates for ≥2-point and ≥50% NRS improvement were 67.9% (95% CI, 54.5-78.9) and 49.1% (95% CI, 36.1-62.1). Moreover, 54.7% (95% CI, 41.5-67.3) of participants reported being "much or very much improved" on the PGIC at 12 months. DISCUSSION/CONCLUSION:In this real-world cohort, over half of participants with vLBP experienced clinically meaningful improvements in pain and function at 12-month post-BVNA. TRIAL REGISTRATION DETAILS:ClinicalTrials.gov (original study: NCT04449835; continuation study: NCT05660512); [original study: June 25, 2020; continuation study: December 13, 2022].

BACKGROUND AND PURPOSE:Low back pain (LBP) is a leading cause of disability and health care costs in the U.S., with the sacroiliac joint (SIJ) implicated in up to 30% of cases. Treatments such as steroid/anesthetic injection (SAI) and opioids offer short-term relief but are associated with systemic side effects and potential for dependency. Platelet-rich plasma (PRP), a biologically active autologous treatment, has demonstrated regenerative and anti-inflammatory properties that may offer a safer and more durable alternative, with some promise seen in the spine on prior trials. This study aimed to compare clinical effectiveness of CT-guided PRP versus SAI for SIJ-mediated low back pain using robust inclusion criteria. MATERIALS AND METHODS:This single-blinded, randomized controlled trial enrolled 44 adult patients with chronic SIJ pain confirmed by ≥50% pain relief following anesthetic block. Participants were then randomized to receive either PRP or SAI by CT-guidance, with outcomes assessed over 3 months. Primary outcome was change in numeric rating scale (NRS) pain scores. Secondary outcomes included modified Oswestry disability questionnaire, SF-12 quality-of-life metrics, functional mobility, and opioid use. RESULTS:Forty participants (20 per arm) remained for analysis at 3 months with both groups showing significant pain reduction (PRP vs. SAI; -3.0 ± 3.2 vs. -1.8 ± 2.4 mean change ± SD, p=.24). SAI produced greater early relief, while PRP demonstrated more sustained improvement, including a non-significant trend toward higher responder rates (≥50% NRS reduction; 60% vs. 35%, p=.11) and greater gains in disability and physical quality of life at 3 months outcome assessment. CONCLUSIONS:PRP and SAI both improved SIJ-related LBP, with PRP demonstrating a slower onset but potentially more durable benefit. PRP appears to be a viable, safe alternative to corticosteroids in managing chronic SIJ pain. Larger trials with longer follow-up are warranted to validate these findings and inform clinical guidelines.

BACKGROUND:Radicular symptoms from lumbosacral spinal stenosis (LSS) are commonly managed with conservative measures, including transforaminal epidural steroid injection (TFESI). However, repeated use may cause systemic side effects in some patients. Human amniotic fluid filtrate (hAF), containing anti-inflammatory, neuroprotective, and regenerative factors, has shown therapeutic potential in pre-clinical models and other medical conditions. OBJECTIVES:Compare the safety and effectiveness of transforaminal epidural injections with hAF versus dexamethasone for treating radicular pain from LSS. DESIGN:Double-blinded, prospective, randomized comparative trial. METHODS:Fifty-eight participants were included, with outcomes assessed at 3 weeks, 6 weeks, 3 months (primary endpoint), and 6 months. Primary outcomes were adverse events (AEs) and proportions of participants reporting ≥50% numerical pain rating scale (NPRS) back and leg pain reductions at 3 months. Secondary outcomes included Oswestry Disability Index (ODI), Swiss Spinal Stenosis Questionnaire (SSSQ), and PROMIS Physical Health Summary (PHS). Linear mixed-effects models evaluated between-group differences while accounting for repeated measures. RESULTS:At 3 months, a significantly greater proportion of participants receiving dexamethasone achieved ≥50% reductions in back pain (45.8% [95%CI = 27.9%-64.9%] vs. 15.0% [95%CI = 5.2%-36.0%]; P = .050) and leg pain (60.0% [95%CI = 40.7%-76.6%] vs. 25.0% [95%CI = 11.2%-46.9%]; P = .034) compared with hAF. Secondary outcome trends similarly favored dexamethasone at 3 months. Mixed-effects models showed greater improvements to 6-week pain and function scores with dexamethasone relative to hAF. Group AE rates were comparable, and no serious intervention-related AEs occurred. CONCLUSION:Dexamethasone demonstrated significantly greater short- and intermediate-term benefits over hAF across multiple clinical outcome domains for radicular pain due to LSS, prompting early trial discontinuation. TRIAL REGISTRATION:ClinicalTrials.gov (NCT04537026); September 3, 2020.

BACKGROUND:Knee osteoarthritis (KOA) is a leading cause of chronic pain and disability worldwide, yet clinical guidelines disagree on how to escalate care when conservative management fails. Procedural interventions, including intra-articular injections, genicular nerve blocks (GNB), and genicular nerve radiofrequency ablation (GN-RFA), are used widely, but head-to-head comparative evidence is limited and recent RFA trials have produced inconsistent results, in part because prior studies have used controls that do not adequately mimic the procedural experience of the active arm. METHODS/DESIGN:SKOAP Phase 2 is a multisite, pragmatic, randomized comparative-effectiveness trial that is expected to enroll at least 900 knees across 30 U.S. centers. Knees will be randomized 1:1:1 to one of three interventions: (1) image-guided intra-articular hyaluronic acid combined with corticosteroid and local anesthetic (IA-HA+); (2) image-guided GNB with sustained-release liposomal bupivacaine and corticosteroid, followed by a sham radiofrequency procedure; or (3) comprehensive GN-RFA with post-lesioning corticosteroid injection. Participants randomized to GNB or GN-RFA will remain blinded to allocation for 12 weeks, supported by harmonized procedural environments, identical sedation and imaging protocols, a standardized sham-RFA sequence, and restricted documentation. This blinding design is rarely implemented in prior RFA trials and is central to the study's methodological rigor. The primary outcome is change in the modified Brief Pain Inventory (mBPI) from baseline to 12 weeks; secondary outcomes included pain interference, physical function, quality of life, and global improvement. Effectiveness will be evaluated using three prespecified estimands (modified intention-to-treat, receipt of intervention, and minimum effective dose) using augmented inverse-weighting methods that account for off-schedule assessments, loss to follow-up, and when appropriate non-adherence. DISCUSSION:By combining pragmatic design with rigorous sham-controlled blinding and prespecified estimands, SKOAP Phase 2 will generate the most methodologically robust comparative evidence to date on procedural management of KOA pain and will directly inform guidelines and clinical decision-making on non-operative interventions including when and whether to escalate from intra-articular injection to nerve block to ablation.

Background In 2023, there was a sudden decline in the popularity of Accreditation Council for Graduate Medical Education (ACGME) Pain Medicine fellowship programs, as demonstrated by National Resident Matching Program (NRMP) application and match data. In comparison, little is known about the application rates and match performance of the North American Spine Society (NASS)-recognized Interventional Spine and Musculoskeletal Medicine (ISMM) fellowships established in 2020. Objective We aimed to compare the characteristics of NASS-recognized ISMM applicants and their match results with those of NRMP-sponsored Pain Medicine applicants to determine whether both pathways faced similar challenges in recruiting and successfully matching trainees in recent years. Methods This longitudinal observational study examines and describes the total number of applicants, match rate, and position fill percentage results of the ACGME NRMP and NASS ISMM from 2020 to 2025, stratified by gender and primary specialty. Results Over the study period, match rates did not markedly change for ISMM, but for ACGME they increased suddenly in 2023 and remained at this level. For ISMM and ACGME, the percentage of positions filled through the match trended downward. For both, the number of female applicants remained low and stable despite fluctuations in the total number of applicants. The distribution of applicants by primary specialties changed for the ACGME; notably, Anesthesiology applicants decreased by 65% from 2021 to 2025, while applications from all other specialties increased, including an increase in Emergency Medicine applicants by 221%. Since its inception, the NASS ISMM match has been primarily composed of Physical Medicine and Rehabilitation (PM&R) physicians, who accounted for 88% of applicants and 90% of successful matches. Conclusion ACGME and NASS ISMM pain fellowships have been at the forefront of evolving trends in program fill rates from 2020 to 2025. Match rates for applicants remained high, reflecting a less competitive and more accessible process for those pursuing careers in pain and spine care.In 2025, male PM&R physicians were the largest group of applicants across both fellowship pathways, highlighting continued strong engagement from this specialty. Although overall applicant numbers have shifted, these trends present an opportunity to broaden outreach, strengthen early mentorship programs, and expand the pipeline of future pain and spine specialists.

Objective The study aimed to assess the long-term durability of pain relief among patients with cervicogenic headache (CGH) or occipital neuralgia (ON) following percutaneous 60-day peripheral nerve stimulation (PNS) treatment. Background Cervicogenic headache (CGH) and occipital neuralgia (ON) are challenging headache conditions with significant impact on function and quality of life. The present feasibility study initially reported that percutaneous 60-day PNS can reduce headache, facilitating functional improvements such as improved quality of life and reduced neck disability. This work evaluates the durability of clinical outcomes through 12 months within the study cohort. Methods Twenty participants with CGH or ON (and without migraine) received bilateral, percutaneous leads stimulating the occipital nerves. Leads were left indwelling for up to 60 days before being withdrawn. During prospectively defined follow-up through 12 months, participants reported on their occipital pain intensity and pain interference, as well as secondary outcomes. Results Through 12 months, 82% of participants reported sustained, substantial reductions (≥50%) in pain and/or pain interference. Clinically meaningful changes in secondary outcomes, including pain-related neck disability, impact of headache on daily life, and quality of life, were also observed. Results through 3 months on device effectiveness and safety have been previously published. No new device-related adverse events were reported in the follow-up phase of the study among these participants. Conclusions A majority of participants with CGH or ON had sustained relief from pain and pain interference, resulting improvements in function, and reductions in disability through 12 months following a percutaneous 60-day PNS treatment without any new device-related adverse events reported after the 3-month follow-up. These findings support the feasibility for 60-day PNS in the treatment of refractory pain due to CGH or ON.