Artificial Intelligence and Virtual Reality in Headache Disorder Diagnosis, Classification, and Management.

PURPOSE OF REVIEW: This review provides an overview of the current and future role of artificial intelligence (AI) and virtual reality (VR) in addressing the complexities inherent to the diagnosis, classification, and management of headache disorders. RECENT FINDINGS: Through machine learning and natural language processing approaches, AI offers unprecedented opportunities to identify patterns within complex and voluminous datasets, including brain imaging data. This technology has demonstrated promise in optimizing diagnostic approaches to headache disorders and automating their classification, an attribute particularly beneficial for non-specialist providers. Furthermore, AI can enhance headache disorder management by enabling the forecasting of acute events of interest, such as migraine headaches or medication overuse, and by guiding treatment selection based on insights from predictive modeling. Additionally, AI may facilitate the streamlining of treatment efficacy monitoring and enable the automation of real-time treatment parameter adjustments. VR technology, on the other hand, offers controllable and immersive experiences, thus providing a unique avenue for the investigation of the sensory-perceptual symptomatology associated with certain headache disorders. Moreover, recent studies suggest that VR, combined with biofeedback, may serve as a viable adjunct to conventional treatment. Addressing challenges to the widespread adoption of AI and VR in headache medicine, including reimbursement policies and data privacy concerns, mandates collaborative efforts from stakeholders to enable the equitable, safe, and effective utilization of these technologies in advancing headache disorder care. This review highlights the potential of AI and VR to support precise diagnostics, automate classification, and enhance management strategies for headache disorders.

Four Decades of Occipital Nerve Stimulation for Headache Disorders: A Systematic Review.

PURPOSE OF REVIEW: Chronic headaches are a significant source of disability worldwide. Despite the development of conventional strategies, a subset of patients remain refractory and/or experience side effects following these treatments. Hence, occipital nerve stimulation (ONS) should be considered as an alternative strategy for intractable chronic headaches. This review aims to provide a comprehensive overview of the effectiveness, safety, mechanisms and practical application of ONS for the treatment of headache disorders. RECENT FINDINGS: Overall response rate of ONS is 35.7-100%, 17-100%, and 63-100% in patients with cluster headache, chronic migraine and occipital neuralgia respectively. Regarding the long-term effectivity in all groups, 41.6-88.0% of patients remain responders after ≥ 18.3 months. The most frequently reported adverse events include lead migration/fracture (13%) and local pain (7.3%). Based on our results, ONS can be considered a safe and effective treatment for chronic intractable headache disorders. To support more widespread application of ONS, additional research with larger sample sizes should be conducted.

Extended reality navigation for pain procedures: a narrative review.

BACKGROUND: Extended reality (XR) technology, encompassing virtual reality, augmented reality, and mixed reality, has been widely studied for procedural navigation in surgical specialties. Similar to how ultrasound transformed regional anesthesia, XR has the potential to reshape how anesthesiologists and pain physicians perform procedures to relieve pain. OBJECTIVE: This narrative review examines the clinical benefits of XR for navigation in various pain procedures. It defines key terms and concepts related to XR technology and explores characteristics of procedures that are most amenable to XR-based navigation. Finally, it suggests best practices for developing XR navigation systems and discusses the role of emerging technology in the future of XR in regional anesthesia and pain medicine. EVIDENCE REVIEW: A search was performed across PubMed, Embase, and Cochrane Central Register of Controlled Trials for primary literature investigating the clinical benefits of XR navigation for pain procedures. FINDINGS: Thirteen studies using XR for procedural navigation are included. The evidence includes randomized controlled trials, retrospective studies, and case series. CONCLUSIONS: Early randomized controlled trials show potential for XR to improve procedural efficiency, but more comprehensive research is needed to determine if there are significant clinical benefits. Case reports demonstrate XR's utility in generating patient-specific navigation plans when difficult anatomy is encountered. Procedures that facilitate the generation and registration of XR images are most conducive to XR navigation, whereas those that rely on frequent re-imaging will continue to depend on traditional modes of navigation.

Virtual Reality in Acute and Chronic Pain Medicine: An Updated Review.

PURPOSE OF REVIEW: This review critically analyzes the recent literature on virtual reality's (VR) use in acute and chronic pain management, offering insights into its efficacy, applications, and limitations. RECENT FINDINGS: Recent studies, including meta-analyses and randomized controlled trials, have demonstrated VR's effectiveness in reducing pain intensity in various acute pain scenarios, such as procedural/acute pain and in chronic pain conditions. The role of factors such as immersion and presence in enhancing VR's efficacy has been emphasized. Further benefits have been identified in the use of VR for assessment as well as symptom gathering through conversational avatars. However, studies are limited, and strong conclusions will require further investigation. VR is emerging as a promising non-pharmacological intervention in pain management for acute and chronic pain. However, its long-term efficacy, particularly in chronic pain management, remains an area requiring further research. Key findings highlight that VR programs vary in efficacy depending on the specificity of the origin of pain.

Telehealth and Virtual Reality Technologies in Chronic Pain Management: A Narrative Review.

PURPOSE OF REVIEW: This review provides medical practitioners with an overview of the present and emergent roles of telehealth and associated virtual reality (VR) applications in chronic pain (CP) management, particularly in the post-COVID-19 healthcare landscape. RECENT FINDINGS: Accumulated evidence points to the efficacy of now well-established telehealth modalities, such as videoconferencing, short messaging service (SMS), and mobile health (mHealth) applications in complementing remote CP care. More recently, and although still in early phases of clinical implementation, a wide range of VR-based interventions have demonstrated potential for improving the asynchronous remote management of CP. Additionally, VR-associated technologies at the leading edge of science and engineering, such as VR-assisted biofeedback, haptic technology, high-definition three-dimensional (HD3D) conferencing, VR-enabled interactions in a Metaverse, and the use of wearable monitoring devices, herald a new era for remote, synchronous patient-physician interactions. These advancements hold the potential to facilitate remote physical examinations, personalized remote care, and innovative interventions such as ultra-realistic biofeedback. Despite the promise of VR-associated technologies, several limitations remain, including the paucity of robust long-term effectiveness data, heterogeneity of reported pain-related outcomes, challenges with scalability and insurance coverage, and demographic-specific barriers to patient acceptability. Future research efforts should be directed toward mitigating these limitations to facilitate the integration of telehealth-associated VR into the conventional management of CP. Despite ongoing barriers to widespread adoption, recent evidence suggests that VR-based interventions hold an increasing potential to complement and enhance the remote delivery of CP care.

ReActiv8 Stimulation Therapy vs. Optimal Medical Management: A Randomized Controlled Trial for the Treatment of Intractable Mechanical Chronic Low Back Pain (RESTORE Trial Protocol).

INTRODUCTION: Chronic low back pain (CLBP) is the leading cause of years lived with disability globally. The role of restorative neurostimulation in the treatment of patients with refractory mechanical CLBP and multifidus muscle dysfunction has been established in one randomized controlled trial (RCT) and several clinical studies that demonstrated both safety and clinical benefit. This post-market trial provides a direct comparison to optimized medical management to test the hypothesis that the addition of restorative neurostimulation to current care paradigms results in significant improvements in back pain-related disability. METHODS AND ANALYSIS: This trial will include people who have reported significant levels of back pain and back pain-related disability with symptoms that have persisted for longer than 6 months prior to enrollment and resulted in pain on most days in the 12 months prior to enrollment. Eligible patients will be randomized to either optimal medical management or optimal medical management plus ReActiv8® restorative neurostimulation therapy. Patient-reported outcomes will be collected at regular intervals out to the 1-year primary endpoint, at which time the patients in the control arm will be offered implantation with the ReActiv8 system. Assessment of each group will continue for an additional year. ETHICS AND DISSEMINATION: The RESTORE trial follows the principles of the Declaration of Helsinki. The WCG IRB acts as the Central Institutional Review Board (IRB) for most sites and some sites will receive local IRB approval prior to enrollment of patients. Each IRB assessed the protocol and related documentation. The protocol complies with Good Clinical Practice (GCP). All patients provide written informed consent to participate in the trial. PROTOCOL VERSION: Version C, 07 Sep 2022. CLINICALTRIALS: gov registration number. NCT04803214 registered March 17, 2021.

Restorative neurostimulation is a treatment for intractable CLBP associated with dysfunction of the multifidus muscle, which normally provides functional stability to the lumbar spine. To date, ReActiv8^® (Mainstay Medical) is the only neurostimulator specifically developed and approved for this indication. Electrical stimulation of the muscle's nerve overrides the dysfunction and reactivates it. Several prior studies demonstrated that the most of participants experienced clinically substantial and durable symptom relief compared to baseline. This protocol describes a second RCT in which all participants are on individualized optimal medical management and half of them are randomly selected to be implanted with a ReActiv8 system to receive restorative neurostimulation. The purpose of this design is to measure if there is any clinical benefit of restorative neurostimulation over individualized optimal medical management alone over the course of a full year.

Prevalence of chronic pain among adults in the United States.

ABSTRACT: Chronic pain is associated with reduced quality of life, increased medical expenditures, and significant economic costs. Chronic pain is among the most common chronic conditions in the United States, although estimates vary widely regarding its precise prevalence. Understanding the scope of the problem using the most contemporaneous data is therefore an important goal. This study sought to determine the prevalence of chronic pain and its impacts among adults in the United States using the National Health Interview Survey, a household-based annual survey of self-reported health status of U.S. adults that can be used to generate national-level estimates. Using a chronic pain module introduced in the 2019 edition of National Health Interview Survey, we found that 50.2 million adults (20.5%) reported pain on most days or every day. The most common pain locations were back pain and hip, knee, or foot pain. The most commonly used management strategies for chronic pain were physical therapy and massage. Respondents with chronic pain reported limitations in daily functioning, including social activities and activities of daily living. Respondents with chronic pain reported significantly more workdays missed compared with those without chronic pain (10.3 vs 2.8, P < 0.001). Overall, these findings indicate that more than 1 in 5 adults in America experiences chronic pain; additional attention to managing the burden of this disease is warranted.

Spinal Cord Stimulation for Painful Diabetic Peripheral Neuropathy: A Systematic Review.

Painful diabetic neuropathy is a common disease that results in significant pain and disability. Treatment options have traditionally consisted of conservative measures including topical and oral medication management as well as transcutaneous electrical stimulation units. These treatments demonstrate various degrees of efficacy, and many times initial treatments are discontinued, indicating low levels of satisfaction or poor tolerability. Spinal cord stimulation has been proposed as an alternative therapy for treatment of painful diabetic neuropathy of the lower extremities. We performed a systematic literature review to evaluate the safety and effectiveness of this procedure. A literature search identified 14 prospective studies. Based on our analysis of the available evidence, there is moderate-quality evidence for the safety and efficacy of spinal cord stimulation for painful diabetic neuropathy. However, further high-quality research, including a large-scale randomized controlled trial is warranted.

Racial and Ethnic Disparities in the Treatment of Chronic Pain.

OBJECTIVE: To summarize the current literature on disparities in the treatment of chronic pain. METHODS: We focused on studies conducted in the United States and published from 2000 and onward. Studies of cross-sectional, longitudinal, and interventional designs were included. RESULTS: A review of the current literature revealed that an adverse association between non-White race and treatment of chronic pain is well supported. Studies have also shown that racial differences exist in the long-term monitoring for opioid misuse among patients suffering from chronic pain. In addition, a patient's sociodemographic profile appears to influence the relationship between chronic pain and quality of life. Results from interventional studies were mixed. CONCLUSIONS: Disparities exist within the treatment of chronic pain. Currently, it is unclear how to best combat these disparities. Further work is needed to understand why disparities exist and to identify points in patients' treatment when they are most vulnerable to unequal care. Such work will help guide the development and implementation of effective interventions.

Perioperative Point of Care Ultrasound (POCUS) for Anesthesiologists: an Overview.

PURPOSE OF REVIEW: Point of care ultrasound (POCUS) has played a role across almost every medical specialty. Although anesthesiologists have been using bedside ultrasound for nerve blocks and vascular access for many years now, there has been a recent push to incorporate whole-body POCUS into anesthesiologists' training and daily practice. This article provides a brief overview of the indications, techniques for image acquisition, and general principles in interpreting basic images. RECENT FINDINGS: Whole-body POCUS can provide quick diagnoses and impact clinical management across relevant pre-, intra-, and post-operative settings. Anesthesia providers need to understand different applications for POCUS, including focused cardiac ultrasound (FoCUS), lung ultrasound (LUS), gastric ultrasound, abdominopelvic ultrasound, and the use of ultrasound for airway management. Currently, there is no standard ultrasound curriculum for anesthesiology residents, and teaching methods include informal bedside teaching, structured expert demonstration, didactic lectures, and simulations. Model/simulation-based lecture series may be effective in teaching ultrasound to anesthesiology residents, and e-learning and traditional didactics are both equally effective in teaching POCUS applications such as LUS and focused assessment with sonography in trauma (FAST). Creating protocol-guided frameworks for POCUS, such as I-AIM (indication, acquisition, interpretation, medical decision making), can also ensure more consistent and reliable diagnoses and interpretations of findings. Applications of POCUS should be focused, goal-oriented, easily learned, rapidly performable at bedside, accurate, and reliable. A variety of studies have shown this potential for POCUS in assessing cardiac, pulmonary, and intraabdominal pathologies, making it an emerging area of interest in medicine. The incorporation of POCUS into perioperative medicine provides an important tool to ensure continued improvement in coordinating care for patients in the perioperative period.

Patient and Surgery-Related Predictors of Acute Postoperative Pain.

PURPOSE OF REVIEW: The purpose of the present investigation is to provide a comprehensive review of both patient and procedure specific predictors of acute postoperative pain. RECENT FINDINGS: As the global number of surgeries continues to increase, as well as evidence of worse patient outcomes in those who suffer from poorly controlled postoperative pain, it is becoming more critical for perioperative physicians to have a deep understanding of the risks which might lead to increased pain in the immediate postoperative settings. It is also important to recognize potential tools to prevent the development and intensity of surgical pain. This manuscript begins with an investigation of the theorized mechanisms of postoperative pain, at the peripheral and central levels, which is followed by a discussion of current pain evaluation in humans. Additionally, an evaluation of patient- and procedure-specific predictors for the development of acute pain is summarized. As operative and patient specific risk factors continue to be revealed, they will ultimately serve as important tools to provide high-quality individualized patient care aimed at reducing incidence of severe postsurgical pain.

An Analysis of Predictors of Persistent Postoperative Pain in Spine Surgery.

PURPOSE OF REVIEW: This review aims to identify perioperative patient-related factors that are associated with the development of persistent postoperative pain (PPP) in patients undergoing spine surgery. RECENT FINDINGS: Twenty-one studies published between 2000 and 2019 were included in this literature review. The following five patient-related factors were identified to be associated with the development of PPP after spine surgery: anxiety, depression, pain catastrophizing, pain sensitivity, and preoperative opioid consumption. The existing literature suggests that the risk factors for developing chronic pain after spine surgery appear to be similar to those for other types of surgery. Psychological factors and preoperative opioid consumption are associated with developing chronic pain after spinal surgery. Other factors such as gender, age, preoperative pain intensity, and immediate postoperative pain may also be involved but the evidence on this is limited.

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.

The Role of Cannabidiol (CBD) in Chronic Pain Management: An Assessment of Current Evidence.

PURPOSE OF REVIEW: Given the growing challenges in chronic pain management coupled with the ongoing consequences of the opioid epidemic, pain management practitioners are looking into more effective, innovative, and safer alternatives to treat pain. Cannabis-based medicine had been described for hundreds of years but only recently have we seen the more scientific, evidence-based approach to its use, and ongoing investigations continue to explore its potential medical benefits. While historically more attention has been paid to the psychoactive component of the cannabis plant Δ9-tetrahydrocannabinol (THC), there have been fewer scientific studies on the medical use of the cannabidiol (CBD) - a non-psychoactive component of the cannabis plant. RECENT FINDINGS: By examining recent literature, we investigated the use of CBD and its potential role in pain management. Since there are currently no approved pharmaceutical products that contain CBD alone for the management of pain, this review focused on nabiximols (which is a combined product of THC/CBD in a 1:1 ratio) as the only pharmaceutical product available that contains CBD and is being used for the management of pain. It is difficult to definitely attribute the therapeutic properties to CBD alone since it is always administered with THC. Based on the available literature, it is difficult to make a recommendation for the use of CBD in chronic pain management. It is also important to note that there are many CBD products currently available as supplements, but these products are non-pharmaceuticals and lack the appropriate clinical studies to support their efficacy claims.

Effect of Preoperative Opioid Use on Adverse Outcomes, Medical Spending, and Persistent Opioid Use Following Elective Total Joint Arthroplasty in the United States: A Large Retrospective Cohort Study of Administrative Claims Data.

OBJECTIVE: Between 17% and 40% of patients undergoing elective arthroplasty are preoperative opioid users. This US study analyzed patients in this population to illustrate the relationship between preoperative opioid use and adverse surgical outcomes. DESIGN: Retrospective study of administrative medical and pharmaceutical claims data. SUBJECTS: Adults (aged 18+) who received elective total knee, hip, or shoulder replacement in 2014-2015. METHODS: A patient was a preoperative opioid user if opioid prescription fills occurred in two periods: 1-30 and 31-90 days presurgery. Zero-truncated Poisson (incidence rate ratio [IRR]), logistic (odds ratio [OR]), Cox (hazard ratio [HR]), and quantile regressions modeled the effects of preoperative opioid use and opioid dose, adjusted for demographics, comorbidities, and utilization. RESULTS: Among 34,792 patients (38% hip, 58% knee, 4% shoulder), 6,043 (17.4%) were preoperative opioid users with a median morphine equivalent daily dose of 32 mg. Preoperative opioid users had increased length of stay (IRR = 1.03, 95% CI = 1.02 to 1.05), nonhome discharge (OR = 1.10, 95% CI = 1.00 to 1.21), and 30-day unplanned readmission (OR = 1.43, 95% CI = 1.17 to 1.74); experienced 35% higher surgical site infection (HR = 1.35, 95% CI = 1.14 to 1.59) and 44% higher surgical revision (HR = 1.44, 95% CI = 1.21 to 1.71); had a median $1,084 (95% CI = $833 to $1334) increase in medical spend during the 365 days after discharge; and had a 64% lower rate of opioid cessation (HR = 0.34, 95% CI = 0.33 to 0.35) compared with patients not filling two or more prescriptions across periods. CONCLUSIONS: Preoperative opioid users had longer length of stay, increased revision rates, higher spend, and persistent opioid use, which worsened with dose. Adverse outcomes after elective joint replacement may be reduced if preoperative opioid risk is managed through increased monitoring or opioid cessation.

Spinal Cord Stimulation: Comparing Traditional Low-frequency Tonic Waveforms to Novel High Frequency and Burst Stimulation for the Treatment of Chronic Low Back Pain.

PURPOSE OF REVIEW: The purpose of the present investigation is to summarize supporting evidence for novel sub-perception spinal cord stimulation (SCS) therapy over traditional paresthesia inducing low-frequency waveforms for the treatment of chronic pain. The focus of this review is to summarize key studies comparing traditional low-frequency tonic waveforms to modern high frequency and burst stimulation for the treatment of patients with chronic intractable low back pain and/or leg pain. RECENT FINDINGS: Several recent studies have demonstrated the benefit of novel SCS therapies over traditional low-frequency SCS for the treatment of patients with chronic low back and/or leg pain. SENZA-RTC showed that paresthesia-free high-frequency SCS was superior to low-frequency stimulation for treatment of chronic low back pain with leg pain. The SUNBURST crossover trial recently found that high-frequency burst stimulation was preferred over low-frequency tonic SCS with patients citing better pain relief and a preference for paresthesia-free SCS. The new ongoing EVOLVE workflow retrospective multicenter study uses technology that can deliver both low-dose and high-dose SCS. Further, the wavewriter technology addresses patient variability with its ability to layer sub-perception waveforms and paresthesia inducing low-frequency stimulation tailored to patient needs via an interactive feedback feature. Neuromodulation for the treatment of chronic pain is rapidly evolving with technology at its forefront. Modern SCS systems use novel waveforms, frequencies, and stimulation modes to deliver paresthesia-free pain relief to patients suffering from chronic low back pain and/or leg pain with better results than traditional tonic low-frequency SCS. As the field advances, new studies are needed comparing new waveform and delivery systems to optimize patient selection and treatment response.

Common elements in opioid use disorder guidelines for buprenorphine prescribing.

OBJECTIVES: This study sought to formulate a consolidation of guidelines representing best practices related to office-based opioid treatment (OBOT) of opioid use disorder (OUD) using buprenorphine. It also demonstrates how a set of evidence-based guidelines may be linked with claims data to leverage analytic techniques that drive cost-effective, positive health outcomes. STUDY DESIGN: Literature review of US and international guidelines for OBOT using buprenorphine for OUD. METHODS: The study conducted a review of currently available US and several international guidelines from 2009 to 2018 published on OUD and the use of buprenorphine in OBOT. Guidelines were consolidated based on common elements. The process of correlating common elements with available commercial and state Medicaid claims data is described, including which elements are amenable to analysis along with relative complexity. RESULTS: Seven guidelines met inclusion criteria and are presented as 3 tables, organized by clinical themes and phase of care related to OBOT use of buprenorphine for OUD. Themes included establishing care, monitoring treatment stability and engagement, and nonpharmacologic treatment to improve outcomes. Areas of agreement and divergence between guidelines are highlighted. Specific components are identified as they relate to metrics of interest to public and private payers. CONCLUSIONS: Among US and international guidelines for treatment of OUD, common themes are readily identified and may indicate agreement in regard to interventions. Linking pharmacy and medical billing claims data to evidence-supported best practices provides public and private payers the ability to track individual patients, facilitate high-quality care, and monitor outcomes.

Regenerative Techniques for Neuraxial Back Pain: a Systematic Review.

PURPOSE OF REVIEW: Regenerative modalities have been identified in numerous clinical studies as beneficial in various settings. The focus of this review is to summarize key studies and current concepts for the role of regenerative medicine in the treatment of neuraxial back pain. RECENT FINDINGS: Recent studies have demonstrated the benefit of regenerative therapies for the treatment of neuraxial back pain. A literature review of clinical trials published between 2015 and 2017 was performed using OVID, PubMed, and Google Scholar to identify investigations attempting to determine the efficacy of various regenerative modalities on two primary sources of low back pain: facet arthropathy and degenerative disc disease. The seven articles analyzed in this systematic review present promising data regarding the use of these autologous biologic treatments, but many of these investigations have several limitations in common including small sample size. Regenerative medicine has been shown to demonstrate efficacy in the treatment of neuraxial back pain. As the field advances, new studies are needed comparing efficacy and safety profiles to better determine best practice techniques and standards in the future.

Intrathecal Drug Delivery and Spinal Cord Stimulation for the Treatment of Cancer Pain.

PURPOSE OF REVIEW: The purpose of the present investigation is to summarize the body and quality of evidence including the most recent studies in support of intrathecal drug delivery systems and spinal cord stimulation for the treatment of cancer-related pain. RECENT FINDINGS: In the past 3 years, a number of prospective studies have been published supporting intrathecal drug delivery systems for cancer pain. Additional investigation with adjuvants to morphine-based analgesia including dexmedetomidine and ziconotide support drug-induced benefits of patient-controlled intrathecal analgesia. A study has also been recently published regarding cost-savings for intrathecal drug delivery system compared to pharmacologic management, but an analysis in the Ontario, Canada healthcare system projects additional financial costs. Finally, the Polyanalgesic Consensus Committee has updated its recommendations regarding clinical guidelines for intrathecal drug delivery systems to include new information on dosing, trialing, safety, and systemic opioid reduction. There is still a paucity of clinical evidence for spinal cord stimulation in the treatment of cancer pain. There are new intrathecal drugs under investigation including various conopeptides and AYX1. Large, prospective, modern, randomized controlled studies are still needed to support the use of both intrathecal drug delivery systems as well as spinal cord stimulation for cancer pain populations. There are multiple prospective and small randomized controlled studies that highlight a potential promising future for these interventional modalities. Related to the challenge and urgency of cancer pain, the pain practitioner community is moving toward a multimodal approach that includes discussions regarding the role of intrathecal therapies and spinal cord stimulation to the individualized treatment of patients.