An update on technical and safety practice patterns of interlaminar epidural steroid injections.

Introduction: Interlaminar epidural steroid injections (ILESIs) are mainstay in the management of low back, neck and radicular pain and are a commonly performed pain management procedure in the United States. Our survey aims to provide an update in practice patterns of ILESIs among interventional pain physicians. Methods: We distributed a 91-item survey nationwide to private and academic interventional pain physicians who perform epidural steroid injections (ESIs). The survey was distributed via REDCap with a series of questions inquiring about current practices in epidural steroid injections from March 2021 to March 2022. Cross sectional data from survey responses specific to ILESI-related practices were captured and synthesized. Results: Of 103 complete survey responses, 96 physicians perform ILESIs (cervical, 87.5 %; thoracic, 82.3 %; lumbar 99 %). Nearly all surveyed physicians utilize fluoroscopy (98.1 %) over other modalities like MRI and ultrasound. For CIESIs, dexamethasone was the preferred steroid (52.4 %) over methylprednisolone (23.7 %); the converse was true for LIESIs in which methylprednisolone (44.2 %) was preferred over dexamethasone (32.6 %). The majority of providers performing ILESI's (91.7 %) preferred a Tuohy/Weiss needle while only a small fraction preferred the Quincke needle (7.2 %). Sedation practices were more varied with only about half of providers (47.6 %) offering medications. Furthermore, a great fraction of providers continue to use contrast for LIESIs (97.9 %) and CIESIs (89.6 %). Discussion: Our survey suggests that despite updated consensus recommendations, variability continues to exist in procedural practice patterns. Highlighting areas of variable adherence to current safety guidelines can assist with what is emphasized in the generation of future evidence-based guidelines. Though our survey was conducted in the context of the COVID-19 pandemic with resultant supply chain shortages, more research is needed to elucidate what variables may factor into why proceduralists may stray from guideline concordant care.

An update on technical and safety practice patterns in transforaminal epidural steroid injections.

Introduction: Previous studies have suggested variability in practice patterns for transforaminal epidural steroid injections (TFESIs) despite published safety guidance. The purpose of this study was to understand recent trends in periprocedural safety practices in TFESIs and how some aspects of interventional pain practice may have been influenced by the coronavirus disease 2019 (COVID-19) pandemic and related supply chain shortages. Methods: A 91-item survey was distributed to 111 program directors of Accreditation Council for Graduate Medical Education accredited Pain Management fellowships, 42 North American Spine Society and Interventional Spine and Musculoskeletal Medicine recognized fellowship directors, and 100 private practice interventional pain physicians to capture current practices in epidural steroid injections from March 2021 to March 2022. Additional responses were obtained through advertising on social media platforms consisting of interventional pain physicians. Cross sectional data from survey responses specific to TFESI-related practices were gathered and analyzed. Results: Of 103 complete survey responses, 102 physicians perform TFESIs (cervical, 33.3%; thoracic, 40.2%; lumbar, 100%; sacral, 89.2%). There was variability in preprocedural imaging review, sedation practices, contrast and fluoroscopy techniques, and type and dose of steroid preferred. Many physicians saw a decrease in number of procedures performed weekly as a result of the COVID-19 pandemic. Conclusions: There remains practice variability in various periprocedural aspects of TFESIs despite existing safety recommendations. Further research is needed to identify ongoing barriers to adherence to established guidelines. Recent practice trends may have been affected by unique challenges posed by the COVID-19 pandemic, and these trends should be considered in the event of future supply chain limitations and/or need for disaster response.

Neck and back pain: musculoskeletal disorders.

In this article, non-neurologic causes of neck and back pain are reviewed. Musculoskeletal pain generators include muscle, tendon, ligament, intervertebral disc, articular cartilage, and bone. Disorders that can produce neck and back pain include muscle strain, ligament sprain, myofascial pain, fibromyalgia, facet joint pain, internal disc disruption, somatic dysfunction, spinal fracture, vertebral osteomyelitis, and polymyalgia rheumatica. Atlantoaxial instability and atlanto-occipital joint pain are additional causes of neck pain. Back pain resulting from vertebral compression fracture, Scheuermann's disease, spondylolysis and spondylolisthesis, pregnancy, Baastrup's disease, sacroiliac joint dysfunction, and sacral stress fracture is discussed.

Muscle relaxants and antispasticity agents.

Muscle relaxants make up a heterogeneous group of agents and can have a clinically significant role in the treatment of chronic muscle pain. These medications are not without possible serious side effects; hence, care should be taken in deciding on their appropriateness and ongoing monitoring performed, if prescribed.

Structural integration as an adjunct to outpatient rehabilitation for chronic nonspecific low back pain: a randomized pilot clinical trial.

Structural Integration (SI) is an alternative method of manipulation and movement education. To obtain preliminary data on feasibility, effectiveness, and adverse events (AE), 46 outpatients from Boston area with chronic nonspecific low back pain (CNSLBP) were randomized to parallel treatment groups of SI plus outpatient rehabilitation (OR) versus OR alone. Feasibility data were acceptable except for low compliance with OR and lengthy recruitment time. Intent-to-treat data on effectiveness were analyzed by Wilcoxon rank sum, n = 23 per group. Median reductions in VAS Pain, the primary outcome, of -26 mm in SI + OR versus 0 in OR alone were not significantly different (P = 0.075). Median reductions in RMDQ, the secondary outcome, of -2 points in SI + OR versus 0 in OR alone were significantly different (P = 0.007). Neither the proportions of participants with nor the seriousness of AE were significantly different. SI as an adjunct to OR for CNSLBP is not likely to provide additional reductions in pain but is likely to augment short term improvements in disability with a low additional burden of AE. A more definitive trial is feasible, but OR compliance and recruitment might be challenging. This trial is registered with ClinicalTrials.gov (NCT01322399).

Nutrition and eating behavior in patients with chronic pain receiving long-term opioid therapy.

OBJECTIVE: To assess eating behavior and nutrient intake in a group of patients who were diagnosed with chronic pain and received long-term opioid analgesic therapy. DESIGN: A descriptive, exploratory study with a convenience sample. SETTING: An outpatient pain rehabilitation center. PARTICIPANTS: Patients diagnosed with chronic pain who received long-term opioid analgesic therapy (N = 50). MAIN OUTCOME MEASUREMENTS: Body mass index, the Food Frequency Questionnaire developed by the Nutrition Assessment Shared Resource of Fred Hutchinson Cancer Research Center, and the Eating Behavior Inventory. RESULTS: Of 50 participants, 14 (28%) and 22 (44%) were found to be overweight and obese, respectively. Mean (±SD) daily caloric intake (kcal) was 2008.5 ± 926.0 among men and 1694.8 ± 672.4 among women. Daily mean (±SD) consumption of fruit and vegetable servings, calculated with the summation method, was found to be 1.8 ± 1.1 and 1.9 ± 1.5, respectively. Our patient sample showed the following mean (±SD) daily intake of the following substances: added sugars (g), 74.4 ± 43.0; fiber (g), 17.3 ± 7.5; cholesterol (mg), 266.5 ± 234; saturated fat (g), 25.8 ± 16.8; omega-3 fatty acids (g), 1.6 ± 0.99; trans-fatty acids (g), 2.7 ± 1.7; sodium (mg), 2868.5 ± 1388.1; caffeine (mg), 199.9 ± 160.8; alcohol (g), 1.6 ± 0.5; vitamin D (IU), 244 ± 208; and calcium (mg), 1111.7 ± 672.1. The mean (±SD) score as calculated by the Eating Behavior Inventory was 74.9 ± 9.1. CONCLUSIONS: Obesity, deficient nutrient intake, and poor eating behavior were highly prevalent in our sample of patients with chronic pain who underwent long-term opioid therapy. Larger prospective studies are necessary to assess the eating behavior of patients with chronic pain who are treated with or without opioid analgesics.

Demographics and attitudes of chronic-pain patients who seek online pain-related medical information: implications for healthcare providers.

OBJECTIVE: To identify the demographics, search characteristics, and attitudes of chronic-pain patients who access online pain-related medical information. DESIGN: This is a cross-sectional survey study. RESULTS: Ninety percent of patients had access to the Internet; 63% of patients used the Internet to obtain online pain-related medical information, of which 57% and 55% believed that the information was "useful" and "credible," respectively. Ninety-five percent of current online pain-related medical information users and 52% of nonusers planned to use the Internet in the future to obtain online pain-related medical information. Only half of our subjects ever shared the information found on Internet with their treating healthcare provider. CONCLUSIONS: A large proportion of chronic-pain patients use the Internet to obtain online pain-related medical information. This behavior was found to show significant correlation with patients' level of education. Despite multiple previous studies suggesting inaccurate and low quality of online medical information, most of the patients felt confident in the credibility of online pain-related medical information obtained. Furthermore, many patients choose not to share this information with their healthcare providers. Healthcare providers must acknowledge the growing importance of Internet-based health information, be prepared to entertain questions and assist patients in evaluating the quality of online pain-related medical information, and possibly proactively suggest quality third-party pain-related websites.

Neuropathic low back pain.

In this discussion, we hope to advance a clinical approach to low back pain that is more in line with our modern understanding of neuropathic pain. We review the current understanding of normal and pathologic neuroanatomy of the lumbar spine and then outline how pathology in the different structures can lead to neuropathic pain and cause common pain patterns seen in clinical practice. We also detail the available treatments for neuropathic low back pain.