ICD-10: History and Context.

In recent months, organized medicine has been consumed by the anticipated transition to the 10th iteration of the International Classification of Disease system. Implementation has come and gone without the disruptive effects predicted by many. Despite the fundamental role the International Classification of Disease system plays in health care delivery and payment policy, few neuroradiologists are familiar with the history of its implementation and implications beyond coding for diseases.

Hydrocodone bitartrate for chronic pain.

Hydrocodone bitartrate is the most commonly used drug for acute and chronic pain in the U.S. with over 135 million prescriptions in 2012. The U.S. is the primary consumer of hydrocodone, using 99% of the global supply for 4.4% of the global population. With its easy availability and abuse patterns, hydrocodone has been touted as a primary driver of opioid-related abuse and misuse. There are no clinical efficacy studies of hydrocodone in short-acting form in combination with acetaminophen or ibuprofen in chronic pain. Hydrocodone has been approved with two long-term formulations since 2014. The FDA has rescheduled hydrocodone from Schedule III to Schedule II which went into effect on October 6, 2014, along with a limit on added acetaminophen of 325 mg for each dose of hydrocodone. This review examines the evolution of hydrocodone into a common and yet controversial drug in the U.S. with its pharmacokinetics, pharmacodynamics, safety and efficacy.

Comparative effectiveness research.

The goal of comparative effectiveness research is to improve health care while dealing with the seemingly ever-rising cost. An understanding of comparative effectiveness research as a core topic is important for neuroradiologists. It can be used in a variety of ways. Its goal is to look at alternative methods of interacting with a clinical condition, ideally, while improving delivery of care. While the Patient-Centered Outcome Research initiative is the most mature US-based foray into comparative effectiveness research, it has been used more robustly in decision-making in other countries for quite some time. The National Institute for Health and Clinical Excellence of the United Kingdom is a noteworthy example of comparative effectiveness research in action.

Medicare physician payment rules for 2011: a primer for the neurointerventionalist.

Physicians generally have been affected by significant changes in the patterns of medical practice evolving over the past several decades. The Patient Protection and Affordable Care Act of 2010, also called ACA for short, impacts physician professional practice dramatically. Physicians are paid in the USA for their personal services. The payment system is highly variable in the private insurance market; however, governmental systems have a formula based payment, mostly based on the Medicare payment system. Physician services are billed under part B. The Neurointerventional practice is typically performed in a hospital setting. The VA system is a frequently cited successful implementation of a government supported health care program. Availability of neurointerventional services at many VA medical centers is limited. Since the inception of the Medicare program in 1965, several methods have been used to determine the amounts paid to physicians for each covered service. Initially, the payment systems compensated physicians on the basis of their charges. In 1975, just over 10 years after the inception of the Medicare program, payments changed so as not to exceed the increase in medical economic index. The involvement of medical economic index failed to curb increases in costs, leading to the determination of a yearly change in fees by legislation from 1984 to 1991. In 1992, the fee schedule essentially replaced the prior payment system that was based on the physician's charges, which also failed to curb the growth in spending. Thus, in 1998, the sustainable growth rate system was introduced. In 2009, multiple unsuccessful attempts were made by Congress to repeal the formula. The mechanism of the sustainable growth rate includes three components that are incorporated into a statutory formula: expenditure targets, growth rate period and annual adjustments of payment rates for physician services.

Provocative discography in low back pain patients with or without somatization disorder: a randomized prospective evaluation.

Recent reports of provocative discography not only instill confusion, but also create numerous questions about its value in evaluating low back pain. It was reported that provocative discography produced pain in patients who were not suffering with low back pain but suffering with somatization disorder and depression. This study was designed to evaluate 50 randomly assigned patients, with 25 patients in Group I without somatization disorder and 25 patients in Group II with diagnosis of somatization disorder. In addition, depression, generalized anxiety disorder and combinations thereof were also evaluated. All patients underwent discography, investigating two to three discs in each patient. All studies included a control level with a disc that did not produce the patient's pain upon injection of contrast medium. Provocation with exact pain reproduction concordant with the symptom complex upon injection of contrast into the disc was considered positive. Any other response, with or without pain, was considered negative. Results showed positive provocative discography in 46% of the patients in the somatization group compared to 54% in the non-somatization group; in 46% of patients with depression compared to 54% of patients without depression; in 15 of 30 patients with generalized anxiety disorder; in 11 of 20 patients without generalized anxiety disorder; and in 42% of patients with combined somatization and depression, with negative discography in 58% of the patients. It is concluded that provocative discography provides similar results in patients with or without somatization, with or without depression, with somatization but with or without depression or with other combinations of the psychological triad of somatization disorder, depression, and generalized anxiety disorder.

Spinal endoscopy and lysis of epidural adhesions in the management of chronic low back pain.

Spinal endoscopy with epidural adhesiolysis is an interventional pain management technique which emerged during the 1990s. It is an invasive but important treatment modality in managing chronic low back pain that is nonresponsive to other modalities of treatment, including percutaneous spring guided adhesiolysis and transforaminal epidural injections. While epidural adhesions most commonly result following surgical intervention of the spine, leakage of disc material into the epidural space following an anular tear, or an inflammatory response can also result in their formation. Even though advanced technology, including computerized tomography and magnetic resonance imaging,have made significant advances in the diagnosis of epidural fibrosis, it is believed that epidural adhesions resulting in chronic persistent pain are poorly managed. Percutaneous endoscopic lysis of epidural scar tissue has been shown to be cost effective and a safe modality. This review discusses various aspects of endoscopic adhesiolysis, including clinical effectiveness, complications, rationale, and indications.

Evaluation of the role of facet joints in persistent low back pain in obesity: a controlled, prospective, comparative evaluation.

Chronic low back pain and obesity are two common medical conditions. Obesity has been associated with symptoms such as adverse fat distribution and multiple secondary disorders, including low back pain. Obesity is defined as being 30% over ideal weight, which influences normal body mechanics as well as recovery from an injury. Facet joints have been described as contributing to a significant proportion of patients suffering with persistent or chronic low back pain, variably from 15% to 45%. Since an obese patient is at a higher risk of disability compared to a patient with normal weight, obesity has been described as a confounding factor in persistent low back pain. This study included 100 patients, with 50 patients in Group I who were of normal weight and 50 patients in group II who were obese, by random allocation. Facet joints were investigated with diagnostic blocks using lidocaine 1% initially, followed by bupivacaine 0.25%. The results showed that the prevalence rate of facet joint pain in chronic low back pain in Group I or nonobese patients was 36%, in contrast to 40% in Group II, or the obese patient group, with no significant differences among the two groups. The study also showed a false-positive rate of 39% in the total sample, or 44% in Group I nonobese patients and 33% in Group II, or obese patients. It is concluded that the prevalence of lumbar facet joint mediated pain of 40% in obese patients and 36% in patients of normal weight with a false-positive rate of 33% in obese patients and 44% in nonobese patients is similar to the results of multiple previous studies concluding that facet joint mediated pain is a common occurrence in obese patients; however, the incidence of facet joint mediated pain is similar in obese patients and nonobese patients.

Evaluation of the relative contributions of various structures in chronic low back pain.

An attempt was made to determine the relative contribution of various structures to chronic low back pain, including facet joint(s), disc(s), and sacroiliac joint(s) in a prospective evaluation. Precision diagnostic blocks, including disc injections, facet joint blocks, and sacroiliac joint injections, are frequently used. In contrast, selective nerve root blocks or transforaminal epidural injections are used occasionally to evaluate persistent or recurrent low back pain in patients without appropriate radiologic or neurophysiologic diagnosis. One hundred and twenty patients with a chief complaint of low back pain were evaluated with precision diagnostic injections, which included medial branch blocks, provocative discography and sacroiliac joint injections. In 40% (95% CL, 31%, 49%), of the patients, facet joint pain was diagnosed; and in 26% (95% CL, 18%, 34%) of the patients discogenic pain was diagnosed; and 2% of the patients were diagnosed with sacroiliac joint pain.

Caudal epidural injections with sarapin or steroids in chronic low back pain.

Epidural steroid injections are the most commonly used procedures to manage chronic low back pain in interventional pain management settings. Approaches available to access the epidural space in the lumbosacral spine include the interlaminar, transforaminal, and caudal. The overall effectiveness of epidural steroid injections has been highly variable. This study included 65 patients who underwent diagnostic facet joint nerve blocks utilizing comparative local anesthetic blocks and were shown to be negative for facet joint pain and other problems such as sacroiliac joint pain before enrollment into the study. They were randomly selected from 105 patients negative for facet joint pain allocated into three groups, with Group I consisting of 15 patients comprising a convenience control sample treated conservatively; Group II, consisting of 22 patients treated with caudal epidural with local anesthetic and Sarapin(R); and Group III, consisting of 33 patients treated with caudal epidural with a mixture of local anesthetic, and betamethasone. The study period lasted for 3 years. Results showed that there was significant improvement in patients receiving caudal epidural injections, with a decrease in pain associated with improved physical, functional and mental status; and decreased narcotic intake combined with return to work. The study showed that at 1 month 96% of the patients evaluated showed significant improvement, which declined to 56% at 3 months and 16% at 6 months, with administration of 1 to 3 injections. Cumulative relief with 1 to 12 injections was noted in 96% of the patients at 1 month, 95% at 3 months, 85% at 6 months, and 67% at 1 year. The study also showed cost effectiveness of this treatment, with a cost of $ 2550 for 1-year improvement of quality of life . In conclusion, caudal epidural injections with steroids or Sarapin are an effective modality of treatment in managing chronic, persistent low back pain that fails to respond to conservative modalities of treatments and is also negative for facet joint pain. The treatment is not only effective clinically but also is cost effective.

Influence of psychological factors on the ability to diagnose chronic low back pain of facet joint origin.

This study was designed to determine the prevalence of lumbar facet joint pain in patients suffering with or without somatization disorder. The study was performed using comparative local anesthetic blocks. One hundred consecutive patients with chronic low back pain, with or without somatization, were evaluated. The results showed that, among patients suffering with chronic low back pain, 44% of the patients without somatization and 38% of the patients with somatization were positive for facet joint pain. The diagnosis of facet joint pain was not influenced by the presence or absence of somatization disorder. The evaluation also was extended to depression, generalized anxiety disorder and combinations with or without somatization thereof which showed no significant differences in the prevalence of facet joint pain. The results of this study demonstrated that the facet joint was a source of pain in chronic low back pain patients in 44% of the patients without somatization and 38% of the patients with somatization. This study also showed that there was no correlation between the presence or absence of facet joint pain and the presence or absence of somatization disorder or any other psychological condition or combination thereof.

Prevalence of opioid abuse in interventional pain medicine practice settings: a randomized clinical evaluation.

While drug therapy is one of the most commonly used modalities of treatment in managing persistent or chronic pain, controversy continues with regards to the appropriate use of controlled substances, specifically opioid analgesics, in interventional pain medicine settings. This study included 100 randomly selected patients receiving opioids in an interventional pain medicine setting. The patient's controlled substance profile was evaluated using multiple means. The patients were divided into two groups, with 76 patients in the non-abuse group and 24 patients in the abuse group after data collection. There were no significant differences noted either in demographic characteristics or psychological characteristics, except for a higher prevalence of depression in the abuse group. In conclusion, there was significant abuse of opioids in an interventional pain medicine setting, with an incidence of 24%, with frequent abuse seen in almost half of these patients. Thus, it is important for interventional pain physicians to recognize this possibility and also to recognize that there is no definite physiologic, psychologic or demographic information to suggest abuse, even though depression was more prevalent in abuse patients.

Effectiveness of percutaneous adhesiolysis with hypertonic saline neurolysis in refractory spinal stenosis.

The increasing proportion of elderly patients, coupled with increasing longevity, causes the problem of lumbosacral pain secondary to spinal stenosis of the lumbar spine to be an important issue. Symptoms of spinal stenosis are caused by entrapment and compression of intraspinal vascular and nervous structures; which may lead to inactivity, loss of productivity, and potential loss of independence, particularly in the elderly. Surgical decompression is considered as the natural treatment. However, the results of surgical treatments have been mixed. Results of conservative treatment are also not encouraging. While the effectiveness of caudal epidural blocks for lumbar canal stenosis was positive, the effectiveness of interlaminar epidural steroid injections showed no beneficial effects on symptomatology of spinal stenosis. Percutaneous epidural adhesiolysis with hypertonic saline neurolysis has been studied in patients with refractory low back pain secondary to post lumbar laminectomy syndrome, as well as spinal stenosis. The specific role of adhesiolysis and hypertonic saline neurolysis in the management of refractory low back and lower extremity pain secondary to spinal stenosis has not been studied. This retrospective evaluation included 18 patients derived from a total sample of 239 patients undergoing adhesiolysis and hypertonic saline neurolysis over a period of 3 years. The results showed significant improvement with reduction of pain; with improvement of physical health, mental health, and functional status. Improvement in psychological status was also noted, with decrease in narcotic intake. Epidural adhesiolysis with hypertonic saline neurolysis is a safe and probably effective modality of treatment in managing symptomatic moderate to severe lumbar spinal canal stenosis.

Role of correct coding for interventional techniques.

There has been enormous emphasis on the description and definition of what the physician does for and to the patient, with fraud and abuse evolving as an important aspect of interventional pain medicine. Compliance with the laws and regulations encompassing documentation with coding, billing, and collections, and medical records, is crucial in today's interventional pain medicine practices. The Health Insurance Portability and Accountability Act of 1996, provided the Office of Inspector General and the Federal Bureau of Investigations with broad powers and directed them to identify and prosecute health-care fraud and abuse. The National Correct Coding Council was created by Centers for Medicare and Medicaid Services to help ensure that providers across various jurisdictions receive like payments for the same services, use the same codes and provide similar documentation for services performed. As a direct outgrowth of the National Correct Coding Council's work, the Centers for Medicare and Medicaid Services established the National Correct Coding Policy in 1996 and eventually implemented the Correct Coding Initiative (CCI) to identify and isolate inappropriate coding, unbundling, and other irregularities in coding. Multiple versions of National Correct Coding Policies have been released in the form of National Correct Coding manuals ranging from version 5.0 to 7.2. This review discusses various aspects of correct coding in interventional pain medicine.

Characteristics of chronic low back pain in patients in an interventional pain management setting: a prospective evaluation.

Chronic low back pain patients are seen in multiple practice settings and managed with a multitude of therapeutic interventions. Studies conducted by various groups have made some generalizations in the literature describing low back pain patients. However, there are no studies evaluating the demographic features of patients presenting to therapeutic interventional pain medicine programs. This prospective study was undertaken to evaluate and explore various demographic features of patients with chronic low back pain presenting to a therapeutic interventional pain medicine program. Two hundred patients were studied, with evaluation of demographic features of age, mode of onset of pain, work status, history of surgery, and pain characteristics. The results showed that, among patients presenting to an interventional pain medicine program, 17% are over 65 years of age: they are predominantly women; two thirds are either overweight or obese; the mean duration of pain is 7 years, predominantly involving multiple regions, with an average pain intensity of 7.6, significant associated psychological conditions; they have undergone multiple interventions, and were seen by, on average, six physicians; and the majority of patients were not employed, with 31% unemployed and 52% disabled or retired.