Systematic Review and Meta-Analysis of the Effectiveness of Radiofrequency Ablation of the Sacroiliac Joint.

PURPOSE OF REVIEW: To evaluate the effectiveness of radiofrequency neurotomy in managing sacroiliac joint pain utilizing a systematic review with meta-analysis of randomized controlled trials (RCTs) and observational studies. RECENT FINDINGS: The prevalence of sacroiliac joint pain is estimated at around 25% of low back pain cases, and its diagnosis lacks a gold standard. Treatments include exercise therapy, injections, ablation, and fusion, with variable effectiveness. COVID-19 altered utilization patterns of interventions, including sacroiliac joint procedures, and the evidence for these interventions remains inconclusive. Recently, Medicare has issued its local coverage determinations (LCDs) in the United States, which provides noncoverage of sacroiliac joint radiofrequency neurotomy. Additionally, a recent systematic review of sacroiliac joint injections showed Level III or fair evidence. The sacroiliac joint, a critical axial joint linking the spine and pelvis, contributes to low back pain. Its complex innervation pattern varies among individuals. Sacroiliac joint dysfunction, causing pain and stiffness, arises from diverse factors.The present systematic review and meta-analysis aimed to evaluate radiofrequency neurotomy's effectiveness for sacroiliac joint pain management by applying rigorous methodology, considering both RCTs and observational studies. Despite methodological disparities, the evidence from this review, supported by changes in pain scores and functional improvement, suggests Level III evidence with fair recommendation for radiofrequency neurotomy as a treatment option. The review's strengths include its comprehensive approach and quality assessment. However, limitations persist, including variations in criteria and technical factors, underscoring the need for further high-quality studies in real-world scenarios.

A Comprehensive Update of the Superior Hypogastric Block for the Management of Chronic Pelvic Pain.

PURPOSE OF REVIEW: This is a comprehensive review of the superior hypogastric block for the management of chronic pelvic pain. It reviews the background, including etiology, epidemiology, and current treatment available for chronic pelvic pain. It then presents the superior hypogastric block and reviews the seminal and most recent evidence about its use in chronic pelvic pain. RECENT FINDINGS: Several definitions exist for chronic pelvic pain (CPP), making the diagnosis more challenging for the clinician; however, they commonly describe continuous pain lasting 6 months in the pelvis, with an overwhelming majority of patients being reproductive-aged women. This pain is often one of mechanical, inflammatory, or neuropathic. It is generally underdiagnosed and affects anywhere between 5 and 26% of women. The diagnosis of chronic pelvic pain is clinical, consisting of mainly of a thorough history and physical and ruling out other causes. The pathophysiology is often endometriosis (70%) and also includes PID, adhesions, adenomyosis, uterine fibroids, chronic processes of the GI and urinary tracts, as well as pelvic-intrinsic musculoskeletal causes. Treatment includes physical therapy, cognitive behavioral therapy, and oral and parenteral opioids. Interventional techniques provide an added tier of treatment and may help to reduce the requirement for chronic opioid use. Superior hypogastric plexus block is one of the available interventional techniques; first described in 1990, it has been shown to provide long-lasting relief in 50-70% of patients who underwent the procedure. Two approaches described so far, both under fluoroscopy, have seen similar results. More recently, ultrasound and CT-guided procedures have also been described with similar success. The injectate includes local anesthetic, steroids, and neurolytic agents such as phenol or ethanol. CPP is a common debilitating condition. It is diagnosed clinically and is underdiagnosed globally. Current treatments can be helpful at times but may fall short of satisfactory pain relief. Interventional techniques provide an added layer of treatment as well as reduce the requirement for opioids. Superior hypogastric plexus block provides long-lasting relief in many patients, regardless of approach. Evidence level is limited, and further RCTs could help provide better tools for evaluation and patient selection.

Utilization of Vertebral Augmentation Procedures in the USA: a Comparative Analysis in Medicare Fee-for-Service Population Pre- and Post-2009 Trials.

PURPOSE OF REVIEW: To review the utilization patterns of vertebral augmentation procedures in the US Medicare population from 2004 to 2017 surrounding concurrent developments in the literature and the enactment of the Affordable Care Act (ACA). RECENT FINDINGS: The analysis of vertebroplasty and kyphoplasty utilization patterns was carried out using specialty utilization data from the Centers for Medicare and Medicaid Services Database. Of note, over the period of time between 2009 and 2017, the number of people aged 65 or older showed a 3.2% rate of annual increase, and the number of Medicare beneficiaries increased by 27.6% with a 3.1% rate of annual increase. Concurrently, vertebroplasty utilization decreased 72.8% (annual decline of 15% per 100,000 Medicare beneficiaries), and balloon kyphoplasty utilization decreased 19% (annual decline of 2.6% per 100,000 Medicare beneficiaries). This translates to a 38.3% decrease in vertebroplasty and balloon kyphoplasty utilization (annual decline of 5.9% per 100,000 Medicare beneficiaries) from 2009 to 2017. By contrast, from 2004 to 2009, there was a total 188% increase in vertebroplasty and balloon kyphoplasty utilization (annual increase rate of 23.6% per 100,000 Medicare beneficiaries). The majority of vertebroplasty procedures were done by radiologists, and the majority of kyphoplasties were done by aggregate groups of spine surgeons. These results illustrate a significant decline in vertebral augmentation procedures in the fee-for-service Medicare population between 2004 and 2017, with dramatic decreases following the publication of two 2009 trials that failed to demonstrate benefit of vertebroplasty over sham and the enactment of the ACA.

Minimally Invasive Lumbar Decompression and Interspinous Process Device for the Management of Symptomatic Lumbar Spinal Stenosis: a Literature Review.

PURPOSE OF REVIEW: Symptomatic lumbar spinal stenosis (LSS) is a condition affecting a growing number of individuals resulting in significant disability and pain. Traditionally, treatment options have consisted of conservative measures such as physical therapy, medication management, epidural injections and percutaneous adhesiolysis, or surgery. There exists a treatment gap for patients failing conservative measures who are not candidates for surgery. Minimally invasive lumbar decompression (MILD®) and interspinous process device (IPD) with Superion® represent minimally invasive novel treatment options that may help fill this gap in management. We performed a literature review to separately evaluate these procedures and assess the effectiveness and safety. RECENT FINDINGS: The available evidence for MILD and Superion has been continuously debated. Overall, it is considered that while the procedures are safe, there is only modest evidence for effectiveness. For both procedures, we have reviewed 13 studies. Based on the available evidence, MILD and Superion are safe and modestly effective minimally invasive procedures for patients with symptomatic LSS. It is our recommendation that these procedures may be incorporated as part of the continuum of treatment options for patients meeting clinical criteria.

Evaluation of Cost-Utility of Thoracic Interlaminar Epidural Injections.

PURPOSE OF REVIEW: Chronic thoracic pain, even though not as prevalent as low back and neck pain, appears in approximately 30% of the general population. The severity of thoracic pain and degree of disability seems to be similar to other painful conditions. Despite this severity, interventions in managing chronic thoracic pain are less frequent, and there is a paucity of literature regarding epidural injections and facet joint interventions. RECENT FINDINGS: As with lumbar and cervical spine, a multitude of interventions are offered in managing chronic thoracic pain, including interventional techniques with epidural injections and facet joint interventions. A single randomized controlled trial (RCT) has been published with a 2-year follow-up of clinical effectiveness of the results. However, there have not been any cost-utility analysis studies pertaining to either epidural injections or facet joint interventions in thoracic pain. Based on the results of the RCT, a cost-utility analysis of thoracic interlaminar epidural injections was undertaken. Evaluation of the cost-utility analysis of thoracic interlaminar epidural injections with or without steroids in managing thoracic disc herniation, thoracic spinal stenosis, and thoracic discogenic or axial pain was assessed in 110 patients with a 2-year follow-up. Direct payment data from 2018 was utilized for procedural costs and indirect costs. Costs, including drug costs, were determined by multiplication of direct procedural payment data by a factor of 1.67 or addition of 40% of cost to accommodate for indirect payments and arrive at overall costs. Cost-utility analysis showed direct procedural cost of USD $1943.19, whereas total estimated costs year per QALY were USD $3245.12.

Does Epidural Bupivacaine with or Without Steroids Provide Long-Term Relief? A Systematic Review and Meta-analysis.

PURPOSE OF REVIEW: Low back and lower extremity pain have been treated since 1901 with local anesthetics alone and since 1952 in combination with steroids. Over the years, multiple randomized controlled trials, systematic reviews with or without meta-analysis have been reaching discordant conclusions regarding the effectiveness of sodium chloride solution, local anesthetics, and steroids in managing spinal pain. Further, related to lack of understanding, multiple reviewers have considered local anesthetics including lidocaine and bupivacaine as equivalent to placebo based on theory that steroid is the only drug effective in the epidural space. In this review, we assessed effectiveness of epidurally administered bupivacaine with or without steroids to rule out misconceptions of placebo and to show the comparative effectiveness of epidural bupivacaine alone compared to epidural bupivacaine with steroids. RECENT FINDINGS: Multiple systematic reviews performed in assessing the effectiveness of epidural injections have converted epidurally administered lidocaine and bupivacaine to placebo. This led to inappropriate conclusions of lack of effectiveness of epidural local anesthetics with or without steroids as showing equal effectiveness when analyzed with conventional dual-arm meta-analysis. Thus, true placebo control trials with injection of an inactive substance into unrelated structures have been almost non-existent. Epidurally administered bupivacaine alone or with steroids are effective in managing low back and lower extremity pain. The findings of this review provide appropriate information of epidurally administered bupivacaine as an active agent (not a placebo) with level 1 evidence and almost equally effective as bupivacaine with steroids with level II evidence.

Is Percutaneous Adhesiolysis Effective in Managing Chronic Low Back and Lower Extremity Pain in Post-surgery Syndrome: a Systematic Review and Meta-analysis.

PURPOSE OF REVIEW: The growing prevalence of spinal pain in the USA continues to produce substantial economic impact and strain on health-related quality of life. Percutaneous adhesiolysis is utilized for recalcitrant, resistant conditions involving spinal pain when epidural injections have failed to provide adequate improvement, especially low back and lower extremity pain, specifically in post-lumbar surgery syndrome. Despite multiple publications and systematic reviews, the debate continues in reference to effectiveness, safety, appropriate utilization, and medical necessity of percutaneous adhesiolysis in chronic pain. This systematic review, therefore, was undertaken to evaluate and to update effectiveness of percutaneous adhesiolysis to treat chronic refractory low back and lower extremity pain, post-surgical patients of the lumbar spine. RECENT FINDINGS: From 2009 to 2016, there was a decline of 53.2% utilization of percutaneous adhesiolysis with an annual decline of 10.3% per 100,000 fee-for-service (FFS) Medicare population. Multiple insurers, including Medicare, with Medicare area contractors of Noridian and Palmetto have issued noncoverage policies for percutaneous adhesiolysis resulting in these steep declines and continued noncoverage by Medicare Advantage plans, Managed Care plans of Medicaid, and other insurers. Since 2005, 4 systematic reviews of percutaneous adhesiolysis were published with 3 of them showing proper methodology and appropriate results with effectiveness of adhesiolysis, whereas one poorly performed systematic review showed negative results. In addition, there were only 4 randomized controlled trials (RCTs) to be included in the previous systematic reviews of post-surgery syndrome, whereas now, the RCTs and other studies have increased. This systematic review shows level I or strong evidence for the effectiveness of percutaneous adhesiolysis in managing chronic low back and lower extremity pain related to post-lumbar surgery syndrome.

A Comprehensive Update on the Treatment and Management of Postdural Puncture Headache.

PURPOSE OF REVIEW: The purpose of this manuscript is to provide a comprehensive review of postdural puncture headache (PDPH) with a focus on epidemiology, pathophysiology, treatment, and prophylaxis. RECENT FINDINGS: PDPH is an adverse iatrogenic complication of neuraxial anesthesia that occurs following inadvertent puncture of the dura after epidural or spinal anesthesia. The overall incidence of PDPH after neuraxial procedures varies from 6 to 36%. The occurrence of PDPH can lead to increased patient morbidity, delayed discharge, and increased readmission. PDPH is a self-limiting postural headache that most often will resolve within 1 week, without need for treatment. Various prophylactic measures have been studied; however, more studies have been recommended to be undertaken in order to establish a proven benefit. For mild PDPH, conservative treatments are currently focused around bed rest, as well as oral caffeine. For moderate-to-severe PDPH, epidural blood patch (EBP) remains the most effective treatment; however, this invasive treatment is not without inherent risks. Further less invasive treatments have been explored such as epidural saline, dextran 40 mg solutions, hydration, caffeine, sphenopalatine ganglion blocks, greater occipital nerve blocks, and surgical closure of the gap; all have shown promise. Further studies are essential to prove efficacy as well as safety over the proven treatment of epidural blood patches. There is still limited evidence in literature about the understanding of PDPH and optimal treatment.

Current Concepts in the Management of Vertebral Compression Fractures.

PURPOSE OF REVIEW: This comprehensive review of current concepts in the management of vertebral compression fractures is a manuscript of vertebral augmentation literature of risk factors, clinical presentation, and management. The objective of this review is to compare outcomes between multiple augmentation techniques and ongoing discussions of effectiveness of vertebral augmentation procedures. RECENT FINDINGS: Vertebral compression fractures (VCFs) are a prevalent disease affecting approximately 1.5 million US adults annually. VCFs can cause severe physical limitations, including back pain, functional disability, and progressive kyphosis of the thoracic spine that ultimately results in decreased appetite, poor nutrition, impaired pulmonary function, and spinal cord compression with motor and sensory deficits. The deconditioning that affects patients with vertebral compression fractures leads to mortality at a far higher rate than age-matched controls. The management of vertebral compression fractures has been extensively discussed with opponents arguing in favor or restricting conservative management and against augmentation, while proponents argue in favor of augmentation. The literature is well established in reference to the effects on mortality when patients undergo treatment with vertebral augmentation; in over a million patients with vertebral compression fractures treated with vertebral augmentation as compared with patients treated with non-surgical management, the patients receiving augmentation performed well with a decrease in morbidity and mortality. Summary of the literature review shows that understanding the risk factors, appropriate clinical evaluation, and management strategies are crucial. Analysis of the evidence shows, based on level I and II studies, balloon kyphoplasty had significantly better and vertebroplasty tended to have better pain reduction compared with non-surgical management. In addition, balloon kyphoplasty tended to have better height restoration than vertebroplasty.

Clinical Effectiveness and Mechanism of Action of Spinal Cord Stimulation for Treating Chronic Low Back and Lower Extremity Pain: a Systematic Review.

PURPOSE OF REVIEW: The purpose of the present systematic review is to provide a current understanding of the mechanism of action and the evidence available to support clinical decision-making. The focus is to summarize randomized controlled trials (RCTs) and nonrandomized or observational studies of spinal cord stimulation in chronic pain to understand clinical effectiveness and the mechanism of action. RECENT FINDINGS: Several recent studies have demonstrated the benefit of spinal cord stimulation in managing chronic pain. Until recently, the mechanism of action was founded on a central paradigm derived from gate control theory, which is the need to stimulate the dorsal column of the spinal cord to generate paresthesia. The recent development of new therapies that do not rely on paresthesia has left the field without a clear mechanism of action that could serve as a strong foundation to further improve clinical outcomes. Consequently, multiple theories have emerged to explain how electrical pulse applied to the spinal cord could alleviate pain, including activation of specific supraspinal pathways, and segmental modulation of the neurological interaction. Recent systematic reviews also have shown the clinical effectiveness of spinal cord stimulation in managing chronic spinal pain, phantom limb pain, complex regional pain syndrome, and other chronic painful conditions. Spinal cord stimulation for the treatment of chronic pain is rapidly evolving with technology at its forefront. This comprehensive focused review evaluated 11 RCTs and 7 nonrandomized/observational studies which provided levels of evidence ranging from I to II.

A Comprehensive Review of the Treatment and Management of Myofascial Pain Syndrome.

PURPOSE OF REVIEW: Myofascial pain syndrome (MPS) is a musculoskeletal pain condition that stems from localized, taut regions of skeletal muscle and fascia, termed trigger points. The purpose of this comprehensive review is to provide updated information on prevalence, pathophysiology, and treatment modalities with a focus on interventional modalities in managing MPS. RECENT FINDINGS: Though MPS can present acutely, it frequently presents as a chronic condition, affecting up to 85% of adults during their lifetime. MPS is an often-overlooked component of pain with overarching effects on society, including patient quality of life, physical and social functioning, emotional well-being, energy, and costs on health care. The prevalence of MPS is generally increased among patients with other chronic pain disorders and has been associated with various other conditions such as bladder pain syndrome, endometriosis, and anxiety. MPS is poorly understood and remains a challenging condition to treat. Non-pharmacologic treatment modalities such as acupuncture, massage, transcutaneous electrical stimulation, and interferential current therapy may offer relief to some patients with MPS. Additional studies are warranted to get a better understanding of managing myofascial pain.

A Comprehensive Review of the Celiac Plexus Block for the Management of Chronic Abdominal Pain.

PURPOSE OF REVIEW: Chronic abdominal pain (CAP) is a significant health problem that can dramatically affect quality of life and survival. Pancreatic cancer is recognized as one of the most painful malignancies with 70-80% suffering from substantial pain, often unresponsive to typical medical management. Celiac plexus neurolysis and celiac plexus block (CPB) can be performed to mitigate pain through direct destruction or blockade of visceral afferent nerves. The objective of this manuscript is to provide a comprehensive review of the CPB as it pertains to CAP with a focus on the associated anatomy, indications, techniques, neurolysis/blocking agents, and complications observed in patients who undergo CPB for the treatment of CAP. RECENT FINDINGS: The CAP is difficult to manage due to lack of precision in diagnosis and limited evidence from available treatments. CAP can arise from both benign and malignant causes. Treatment options include pharmacologic, interventional, and biopsychosocial treatments. Opioid therapy is typically utilized for the treatment of CAP; however, opioid therapy is associated with multiple complications. CPB has successfully been used to treat a variety of conditions resulting in CAP. The majority of the literature specifically related to CPB is surrounding chronic pain associated with pancreatic cancer. The literature shows emerging evidence in managing CAP with CPB, specifically in pancreatic cancer. This review provides multiple aspects of CAP and CPB, including anatomy, medical necessity, indications, technical considerations, available evidence, and finally complications related to the management.

The Role of the Cannabinoid System in Pain Control: Basic and Clinical Implications.

PURPOSE OF REVIEW: The purpose of this review is to provide a comprehensive update of the different known components of the endogenous cannabinoid system and the mechanisms of action, as it applies to analgesia. RECENT FINDINGS: Following the discovery of the endogenous cannabinoid system in the early 1990s and the subsequent characterization of the cannabinoid receptor, there has been a renewed interest in cannabinoid research. Recent work has demonstrated its efficacy as a pharmacologic agent. There is limited evidence in the literature about the understanding of the endocannabinoid system and its role in the treatment and management of acute and chronic pain. Further work may elucidate additional roles for the endocannabinoid system within our nervous system and, moreover, additional subtypes of cannabinoid receptors have yet to be discovered. Cannabinoid compounds mediate their biological effects via binding and subsequent activation of cannabinoid receptors. These receptors are located throughout the body and make up the endocannabinoid system. These receptors are best understood and have been cloned, type 1 (CB1) and type 2 (CB2) [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)]. The CB2 receptor is located primarily in the immune system. CB1 receptors are primarily located in the nervous system with the highest concentrations in the brain and lower concentrations in the spine and peripheral nervous tissues. Cannabinoids may be promising treatments for neuropathic pain with limited evidence, whereas, the evidence for other uses is insufficient.

Current Concepts of Minimally Invasive Treatment Options for Plantar Fasciitis: a Comprehensive Review.

PURPOSE OF REVIEW: Chronic foot pain constitutes a large portion of the chronic pain burden in the overall population. Plantar fasciitis is one of the most common and most easily identifiable causes of chronic foot pain. The syndrome has been estimated to cause 11 to 15% of foot pain visits, requiring professional care. Moreover, studies have suggested that 1 in 10 people will develop plantar fasciitis at some point in their life. Conservative management has been shown to be effective and considered first-line treatment. Minimally invasive treatment options are typically reserved for those who fail conservative management. With the advent of new techniques and improvements in current therapeutic options, there has been an expansion of available minimally invasive treatment options. The purpose of this review is to provide a comprehensive update on the current understanding of minimally invasive treatments of plantar fasciitis. RECENT FINDINGS: This review shows that conservative management continues to be the first-line therapy, whereas other treatment options were those who failed conservative management using modern techniques that have shown improving effectiveness, with successful restoration of patient functionality, recovery, and satisfaction. However, a multitude of these minimally invasive treatment options are evolving. CONCLUSION: While conservative management continues to be the mainstay of treatment for plantar fasciitis, multiple minimally invasive treatment options are emerging with potential effectiveness in reducing pain and improving the function.

Minimally Invasive Treatment of Chronic Ankle Instability: a Comprehensive Review.

PURPOSE OF REVIEW: Chronic ankle pain is a prevalent and significant cause of chronic pain. While the definition of chronic ankle pain is heterogeneous and poorly defined in the literature, systematic reviews and meta-analyses have estimated this condition to be a prevalent and debilitating source of chronic pain. The most identifiable and prominent cause of chronic ankle pain is chronic ankle instability (CAI), a condition defined by instability of the ankle-joint complex. It is a common consequence of lateral ankle sprains or ligamentous injuries and can be described as a failure of the lateral ankle joint complex after an acute, or recurring, ankle injury. The objective of this manuscript is to provide a comprehensive review of CAI diagnosis and our current understanding of minimally invasive treatment options. RECENT FINDINGS: First-line treatment is conservative management, some of which includes neuromuscular rehabilitation, balance training, nonsteroidal anti-inflammatory drugs (NSAIDs), manual mobilization, ice therapy, and compression. While conservative management is effective, additional treatments for those who fail conservative management, or who seek alternative options also have been explored. Recent advances and modern techniques have expanded available treatment options, many of which are becoming less invasive, and have shown improving functionality, recovery, and patient satisfaction. Minimally invasive treatments highlighted in this review include: arthroscopic surgery, steroid injections, plasma-rich plasma injections, hyaluronic acid (HA) injections, medicinal signaling cell injections, radiofrequency therapies, and shockwave therapies. This review will discuss some of these current treatments for minimally invasive treatment of CAI, as well as suggest novel treatments for clinical trials and further investigation.

Sacral Insufficiency Fractures: a Review of Risk Factors, Clinical Presentation, and Management.

PURPOSE OF THE REVIEW: Sacral insufficiency fractures (SIF) are a common and often underdiagnosed source of low back pain. In patients with SIF, there is both a compromised sacroiliac joint and weakened sacrum, resulting in decreased resistance to torsional stress, leading to fracture. While conservative medical management is a safe option, minimally invasive intervention may provide improved short and long-term relief of low back pain in patients presenting with SIF. This comprehensive review is undertaken to provide an update to the current understanding of SIF with description of risk factors, clinical presentation, and management. RECENT FINDINGS: Sacroplasty is a minimally invasive procedure in which polymethylmethacrylate (PMMA) cement is inserted into bone to improve its structural integrity and alleviate symptoms. Balloon sacroplasty (BSP) has also been successful in alleviating pain with minimal cement leakage in SIF patients. Various other interventional techniques, including navigation-assisted screw fixation have been used to address SIF and have shown improvement in pain with minimal side effects. This review included various modalities of treatments available to manage SIF. This review shows that in comparison with nonsurgical management, sacroplasty has been shown to have greater pain reduction and improved mobility.

Treatment of Discogenic Low Back Pain: Current Treatment Strategies and Future Options-a Literature Review.

PURPOSE OF REVIEW: Many studies have demonstrated that discogenic low back pain is the most common type of chronic low back pain (CLBP), one of the major causes of disability, and has a major socioeconomic impact. Our aim is to review present therapeutic interventions for discogenic low back pain. RECENT FINDINGS: There are a multitude of treatments used in clinical practice to treat CLBP, but there is continued debate and lack of consensus among clinicians and the policy makers as to which modality is the best approach. Based on controlled evaluations, lumbar intervertebral discs have been shown to be the source of chronic back pain without disc herniation in 26 to 39% of patients. Treatment modalities include noninvasive treatments such as drug therapy, multiple physical modalities, and multidisciplinary biopsychosocial rehabilitation; interventional modalities such as intradiscal therapies and epidural injections; and regenerative modalities with disc injections of various solutions; and, finally, surgical approaches such as fusion and artificial disc replacement, all of which are accompanied by significant discussion, limited evidence, and lack of consensus. The results of this evaluation show that the evidence for drug therapy in chronic discogenic low back pain is limited; for multidisciplinary biopsychosocial rehabilitation, it is moderate; and for multiple physical and behavioral therapies, the evidence is limited. For intradiscal therapies, it is poor; for epidural injections, it is moderate; and for regenerative therapies, evidence levels of 3 to 4. The evidence for surgical fusions and disc replacement is similar, without superiority when compared with multidisciplinary biopsychosocial rehabilitation, well-designed physical therapy, or epidural injections.

Utilization Patterns of Facet Joint Interventions in Managing Spinal Pain: a Retrospective Cohort Study in the US Fee-for-Service Medicare Population.

PURPOSE OF REVIEW: To assess patterns of utilization and variables of facet joint interventions in managing chronic spinal pain in a fee-for-service (FFS) Medicare population from 2009 to 2016, with a comparative analysis from 2000 to 2009 and 2009 to 2016. RECENT FINDINGS: From 2009 to 2016, facet joint interventions increased at an annual rate of 2% per 100,000 Medicare population compared to 10.2% annual rate of increase from 2000 to 2009. Lumbosacral facet joint nerve block episodes decreased at an annual rate of 0.1% from 2009 to 2016, with an increase of 16.2% from 2000 to 2009. In contrast, lumbosacral facet joint neurolysis episodes increased at an annual rate of 7.6% from 2009 to 2016 and the utilization rate also increased at an annual rate of 26% from 2000 to 2009. The ratio of lumbar facet joint block episodes to lumbosacral facet joint neurolysis episodes changed from 6.7 in 2000 to 2.2 in 2016. From 2009 to 2016, cervical and thoracic facet joint injections increased at an annual rate of 0.6% compared to cervicothoracic facet neurolysis episodes of 9.2%. During 2000 to 2009, annual increase of cervical facet joint injections was 18% compared to neurolysis procedures of 26%. The ratio of cervical facet joint injections episodes to neurolysis episodes changed from 8.85 in 2000 to 2.8 in 2016. In summary, based on available data, utilization patterns of facet joint interventions demonstrated an increase of 2% per 100,000 Medicare population from 2009 to 2016, with an annual decline of lumbar facet joint injection episodes.

Pain States, the Opioid Epidemic, and the Role of Radiologists.

PURPOSE OF REVIEW: The prevalence of chronic pain and prescription opioid abuse has resulted in epidemic problems for patients and clinicians. The consequences are taking a heavy toll on patients, physicians, and society. Specific to radiology, a significant need exists for best practice assessment and treatment approaches for pain management, as patients with chronic pain often undergo radiological tests of unclear clinical relevance. RECENT FINDINGS: The USA is amid an opioid-prescribing epidemic and resultant overdose public health emergency. A variety of reasons, which are examined in this manuscript, have contributed to the dramatic increase in the use of chronic opioid therapy for chronic non-cancer pain. This increase of opioid prescriptions and related deaths is based on many factors including the perception that there was systemic undertreatment of pain, the philosophical approach of advocacy groups for pain relief, promotion by the pharmaceutical industry, Joint Commission's Fifth Vital Sign, and permissive regulations by boards of medical licensures promoting excessive use of opioids. Overall, opioid treatment has been based on subjective pain relief and radiographic findings, which may not correlate with the source of pain generation. Radiologists, along with interventionalists, frequently interact with patients on chronic opioid therapy and at times take responsibility for patients with chronic pain. Beyond reading studies, diagnostic radiologists provide care to larger percentages of patients taking narcotics than ever before. This manuscript focuses on chronic pain, escalating opioid therapy, and adverse consequences, including the epidemic of overdoses and deaths. Radiologists' expertise can potentially reduce unnecessary radiological tests and inappropriate prescribing of medications.