Low-Dose Naltrexone (LDN) for Chronic Pain at a Single Institution: A Case Series.

Purpose: Low-dose naltrexone (LDN) has increased in popularity as a non-opioid medication that may decrease chronic pain symptoms. LDN is most commonly used to treat fibromyalgia, complex regional pain syndrome (CRPS), and painful diabetic neuropathy. Other studies suggest that LDN provides general symptom reduction in inflammatory conditions such as Crohn's disease and multiple sclerosis. We reviewed our experience with patients to whom we have prescribed LDN to see what types of painful conditions were most responsive to LDN in our patient population. Patients and Methods: Charts from patients who came to the Pain Center between 2014 and 2021 were reviewed. Results: Of the n = 137 patients who were prescribed LDN, 44% had no evidence of ever filling the prescription, and 4.4% of the responses were not charted. Of the remaining who took LDN (n = 70), 64% had some relief and were designated as 'Responders'. The most common pain diagnosis was neuropathic pain which, when added to the diagnosis of complex regional pain syndrome, accounted for 51% of responders to LDN. Patients who experienced greater than 50% pain relief from LDN were more likely to have the diagnosis of neuropathic pain or complex regional pain syndrome (p = 0.038, Fisher's Exact Test). There was a significant difference in the diagnosis of patients who responded to LDN. Patients with spondylosis were much less likely to respond to LDN when compared with other diagnoses (p = 0.00435, Chi-Square Test). Conclusion: Patients with all types of neuropathic pain, including CRPS, were significantly more likely to have pain relief from LDN than patients with spondylosis (p=0.018). The diagnosis of spondylosis was more often associated with a lack of response to LDN than any other diagnosis. Patients may need to have a trial of several weeks before analgesic effects are seen with LDN.

Pain Medicine Milestones 2.0: a step into the future.

OBJECTIVE: To describe the process of revising the Pain Medicine Milestones 1.0 and implementing changes into the Pain Medicine Milestones 2.0 along with implications for pain medicine trainees. BACKGROUND: Competency-based medical education has been implemented in graduate medical education, including pain medicine. Milestones 1.0, introduced by the Accreditation Council for Graduate Medical Education (ACGME), has been used to assess learners in six competencies and respective sub-competencies. Recognizing areas for improvement in Milestones 1.0, the ACGME initiated the process of Milestones 2.0 and a working group was created to execute this task for pain medicine. The working group discussed revisions; consensus was sought when changes were introduced. Final milestones were agreed upon and made available for public comment prior to publication. RESULTS: Redundant sub-competencies were either merged or eliminated, reducing the number of sub-competencies. A maximum of three rows representing skill, knowledge, behavior and attitude were included for each sub-competency. Harmonized Milestones, aligning with other specialties in a predetermined ACGME framework, were adopted and modified to meet the needs of pain medicine. A supplemental guide was developed to assist educators in implementation of Milestones 2.0 and assessment of trainees. CONCLUSIONS: The intent of the Milestones 2.0 was to create an improved tool that is comprehensive, easier to utilize, and of increased value for pain medicine training programs. It is expected that implementation of Milestones 2.0 will streamline pain medicine trainee assessments by educators and prepare trainees for the future practice of pain medicine while serving to be the foundation of an iterative process to match the evolution of the specialty.

Pain experiences among those living with hidradenitis suppurativa: a qualitative study.

BACKGROUND: Pain is rated by patients with hidradenitis suppurativa (HS) as the disease's most impactful symptom. HS therapies are often insufficient to control inflammatory disease activity and pain. A better understanding of patient experiences with pain may improve patient-provider relationships and help identify strategies for addressing HS pain. OBJECTIVES: This qualitative study sought to characterize lived pain experiences of those with HS. METHODS: English-speaking patients ≥ 18 years old with a dermatologist-confirmed diagnosis of HS and an average numerical rating scale pain score of ≥ 1 over the preceding week were recruited from a single academic medical centre in Atlanta, Georgia, USA. Semistructured interviews were conducted from November 2019 to March 2020 to explore participants' HS pain experiences and the subsequent impact on their lives. Thematic saturation was reached after interviewing 21 participants. Interviews were audio recorded, transcribed, and analysed using thematic analysis. RESULTS: Among 21 study participants, the median 7-day average pain score was 6 (interquartile range 3-7; scale ranges from 0 to 10, with 10 being most pain). Participants' descriptions of pain were consistent with nociceptive pain, neuropathic pain and itch. Pain impacted multiple life domains, including physical limitations (decreased mobility and impaired sleep), decreased psychological wellbeing (irritability, depression, loss of control, and difficulty communicating pain experiences) and impaired social relationships (social isolation, intimacy problems and difficulty fulfilling social responsibilities). Although participants reported chronic discomfort, acutely painful and unpredictable HS disease flares caused more distress and quality-of-life (QoL) burden. Participants frequently treated their pain without input from the medical team, sometimes with unsafe medication doses or combinations. Factors contributing to self-management of pain included difficulty accessing timely outpatient care during disease flares and fear of stigma from healthcare providers. CONCLUSIONS: When present, HS-related pain may impact not only physical wellbeing but also mental health and relationships. In addition to therapies that target the inflammatory disease burden, treating the symptom of pain may improve patients' QoL and wellbeing. Because patients with HS have difficulty explaining their pain, proactively asking them about pain may identify unmet needs, facilitate better pain control and improve QoL. Further, the influence of HS-related pain on numerous aspects of QoL suggests the need for multidisciplinary, patient-centred approaches to HS pain management.

#ChronicPain: Automated Building of a Chronic Pain Cohort from Twitter Using Machine Learning.

Background: Due to the high burden of chronic pain, and the detrimental public health consequences of its treatment with opioids, there is a high-priority need to identify effective alternative therapies. Social media is a potentially valuable resource for knowledge about self-reported therapies by chronic pain sufferers. Methods: We attempted to (a) verify the presence of large-scale chronic pain-related chatter on Twitter, (b) develop natural language processing and machine learning methods for automatically detecting self-disclosures, (c) collect longitudinal data posted by them, and (d) semiautomatically analyze the types of chronic pain-related information reported by them. We collected data using chronic pain-related hashtags and keywords and manually annotated 4,998 posts to indicate if they were self-reports of chronic pain experiences. We trained and evaluated several state-of-the-art supervised text classification models and deployed the best-performing classifier. We collected all publicly available posts from detected cohort members and conducted manual and natural language processing-driven descriptive analyses. Results: Interannotator agreement for the binary annotation was 0.82 (Cohen's kappa). The RoBERTa model performed best (F1 score: 0.84; 95% confidence interval: 0.80 to 0.89), and we used this model to classify all collected unlabeled posts. We discovered 22,795 self-reported chronic pain sufferers and collected over 3 million of their past posts. Further analyses revealed information about, but not limited to, alternative treatments, patient sentiments about treatments, side effects, and self-management strategies. Conclusion: Our social media based approach will result in an automatically growing large cohort over time, and the data can be leveraged to identify effective opioid-alternative therapies for diverse chronic pain types.

Randomized, wait-list-controlled pilot study of app-delivered mindfulness for patients reporting chronic pain.

INTRODUCTION: Chronic pain creates economic burden and exerts profound individual and societal harm. Mobile application (app)-delivered mindfulness meditation may be an important approach to self-management of chronic pain. OBJECTIVES: We examined the feasibility, acceptability, and impact of app-delivered mindfulness meditation on pain cognition and daily functioning among patients reporting chronic pain. METHODS: We used a longitudinal, randomized, and wait-list-controlled design (NCT03495726) to evaluate changes in self-reported pain severity, pain catastrophizing, and social and physical functioning among participants randomized to 6 weeks of app-delivered mindfulness meditation, compared with participants randomized to a wait-list control group. RESULTS: Although most participants randomized to the mindfulness group used the app at least once, fewer than half adhered to the instructed program. Participants who did not use the app scored higher on the helplessness component of pain catastrophizing at the start of the study and were less likely to have completed 4 years of college. Participants who reported feeling pressured to enroll in the study were also less likely to adhere to the intervention. Compared with participants randomized to wait-list, those in the mindfulness group reported significant improvements in social functioning, even after controlling for pain severity. Participants randomized to the mindfulness intervention also reported significant improvements in helplessness. App usage was not significantly correlated with changes in social functioning or helplessness scores. CONCLUSIONS: These results suggest that app-delivered mindfulness meditation is beneficial to patients with chronic pain. Identifying characteristics of patients who were adherent highlights important considerations for clinical settings.

Lumbar Spondylolisthesis Progression: What is the Effect of Lumbar Medial Branch Nerve Radiofrequency Ablation on Lumbar Spondylolisthesis Progression? A Single-Center, Observational Study.

BACKGROUND: Radiofrequency ablation (RFA) is a denervation therapy commonly performed for pain of facet etiology. Degenerative spondylolisthesis, a malalignment of the spinal vertebrae, may be a co-existing condition contributing to pain; yet the effect of RFA on advancing listhesis is unknown. To the extent that denervating RFA may weaken paraspinal muscles that provide stability to the spine, the therapy can potentially contribute to progressive spinal instability. METHODS: Single-center, prospective, observational pilot study in an interventional pain practice to test the hypothesis that RFA of painful facets in the setting of spondylolisthesis may contribute to advancement of further degenerative spondylolisthesis. Fifteen participants with pre-existing degenerative Grade I or Grade II spondylolisthesis and coexisting axial lumbar pain underwent lumbar RFA encompassing spondylolisthesis level and followed with post-RFA imaging at 12 months and beyond to measure percent change in spondylolisthesis. RESULTS: The primary outcome was the percent advancement of spondylolisthesis per year measured on post-RFA lateral lumbar spine imaging compared with non-intervention inferred baseline advancement of 2% per very limited observational studies. Among the 15 participants enrolled, 14 completed the study (median age 66; 64.3% women; median BMI 33.5; mean follow-up time 23.9 months). The mean advancement of spondylolisthesis per year after RFA was 1.30% (95% CI -0.14 to 2.78%), with 9/14 below 1.25%. CONCLUSION: Among patients with lumbar pain originating from facets in the setting of degenerative spondylolisthesis who underwent lumbar RFA, the observed advancement of spondylolisthesis is clinically similar to the estimated maximum baseline of 2% per year change. The study findings did not find a destabilizing effect of lumbar RFA in advancing spondylolisthesis in this patient population.

The Anesthesiology Milestones 2.0: An Improved Competency-Based Assessment for Residency Training.

The evolution of medical education, from a time-based to a competency-based platform, began nearly 30 years ago and continues to slowly take shape. The development of valid and reproducible assessment tools is the first step. Medical educators across specialties acknowledge the challenges and remain motivated to develop a relevant, generalizable, and measurable system. The Accreditation Council for Graduate Medical Education (ACGME) remains committed to its responsibility to the public by assuring that the process and outcome of graduate medical education in the nation's residency programs produce competent, safe, and compassionate doctors. The Milestones Project is the ACGME's current strategy in the evolution to a competency-based system, which allows each specialty to develop its own set of subcompetencies and 5-level progression, or milestones, along a continuum of novice to expert. The education community has now had nearly 5 years of experience with these rubrics. While not perfect, Milestones 1.0 provided important foundational information and insights. The first iteration of the Anesthesiology Milestones highlighted some mismatch between subcompetencies and current and future clinical practices. They have also highlighted challenges with assessment and evaluation of learners, and the need for faculty development tools. Committed to an iterative process, the ACGME assembled representatives from stakeholder groups within the Anesthesiology community to develop the second generation of Milestones. This special article describes the foundational data from Milestones 1.0 that was useful in the development process of Milestones 2.0, the rationale behind the important changes, and the additional tools made available with this iteration.

Pain management in hidradenitis suppurativa and a proposed treatment algorithm.

Pain contributes substantially to reduced quality of life in individuals living with hidradenitis suppurativa (HS). Although improved understanding of HS pathogenesis and treatment has resulted in improved evidence-based HS management guidelines, comprehensive pain management guidelines have yet to be developed. Few HS-specific data exist to guide pharmacologic analgesia; however, recognizing HS pain as either acute or chronic and predominantly nociceptive (aching and gnawing pain due to tissue damage) versus neuropathic (burning-type pain due to somatosensory nervous system dysfunction) provides a conceptual framework for applying outside pain management practices to HS management. This article incorporates the best available evidence from the HS and pain literature to propose an HS pain algorithm that integrates psychological, pharmacologic, and complementary and alternative treatment modalities.

Erector Spinae Regional Anesthesia for Robotic Coronary Artery Bypass Surgery Is Not Associated With Reduced Postoperative Opioid Use: A Retrospective Observational Study.

OBJECTIVE: Regional anesthesia techniques are gaining traction in cardiac surgery. The aim of this study was to compare the analgesic efficacy of erector spinae plane block catheters (ESPBC), serratus anterior plane block catheters (SAPBC), and paravertebral single-shot block (PVB) versus no block after robotic minimally invasive direct coronary artery bypass (MIDCAB). DESIGN: This was a retrospective observational study of routinely recorded data. SETTING: The study was performed at a single healthcare system. PARTICIPANTS: All patients underwent robotic MIDCAB. INTERVENTION: Data were analyzed from 346 patients during a 53-month period. The clinical data warehouse was queried for all robotic MIDCAB surgeries. Variables abstracted included type of nerve block, age, sex, use of adjuncts, Society of Thoracic Surgeons predicted short length of stay (PSLOS), total opioid consumption during the 72 hours after surgery, and postoperative hospital length of stay (LOS). The primary outcome was total oral morphine milligram equivalents (MME) consumed during the first 72 hours after surgery. The secondary outcome was hospital LOS. MEASUREMENTS AND MAIN RESULTS: In a model adjusting for PSLOS, the authors did not observe an association between ESPBC and the reduction of total administered oral MME within 72 hours after surgery. There was no significant difference in MME when comparing patients who received PVB to patients with ESPBC. Older age and female sex were associated with significantly lower MME. Patients who received ESPBC had a significantly shorter hospital LOS than patients with SAPBC. CONCLUSIONS: These findings suggested that postoperative pain after MIDCAB surgery might not be completely covered by ESPBC. Prospective studies are needed to further elucidate the value of this technique for robotic MIDCAB.

Perception of Benefits and Harms of Medical Cannabis among Seriously Ill Patients in an Outpatient Palliative Care Practice.

Introduction: Patients with serious illness often have pain, uncontrolled symptoms, and poor quality of life. Evidence continues to evolve regarding the role of cannabis to treat chronic pain, nausea, and anorexia. Little is known about how patients with serious illness perceive its benefits and harms. Given that an increasing number of clinicians across the United States are treating patients with medical cannabis, it is important for providers to understand patient beliefs about this modality. We assessed patient perceptions of benefits and harms of cannabis who obtained a medical cannabis card within an ambulatory palliative care (APC) practice. Methods: We recruited patients with a medical cannabis card, allowing for legal possession of cannabis oil, from an APC practice in Georgia. All participants reported using cannabis products. Patients completed an online survey that included questions about their cannabis use, concurrent opiate or controlled medication use, and perceptions of benefits and harms of cannabis. Results: All 101 patients invited to participate completed the survey. A majority had cancer (76%) and were married (61%), disabled or retired (75%), older than 50 years of age (64%), and men (56%). Most patients ingested (61%) or vaporized (49%) cannabis products. A majority of respondents perceived cannabis to be important for their pain (96%) management. They reported that side effects were minimally bothersome, and drowsiness was the most commonly reported bothersome harm (28%). A minority of patients reported cannabis withdrawal symptoms (19%) and concerns for dependency (14%). The majority of patients were using concurrent prescription opioids (65%). Furthermore, a majority of cancer patients reported cannabis as being important for cancer cure (59%). Conclusion: Patients living with serious illnesses who use cannabis in the context of a multidisciplinary APC practice use cannabis for curative intent and for pain and symptom control. Patients reported improved pain, other symptoms, and a sense of well-being with few reported harms.

The impact of pruritus on quality of life: the skin equivalent of pain.

OBJECTIVE: To compare the impact of chronic pruritus and chronic pain on quality of life (QoL) using directly elicited health utility scores. DESIGN: Cross-sectional study. SETTING: Convenience sample of patients attending the Emory Dermatology Clinic, Emory Spine Center, and Emory Center for Pain Management, Atlanta, Georgia. PARTICIPANTS: Adult men and women (aged ≥ 18 years) experiencing chronic pain or pruritus for 6 weeks or more. MAIN OUTCOME MEASURES: The mean utility score of patients with chronic pruritus was compared with that of patients with chronic pain. A regression analysis was performed to determine the impact of the primary predictor variable-symptom type-on the primary outcome variable-mean utility score (a metric representing the impact on QoL). RESULTS: The study included 73 patients with chronic pruritus and 138 patients with chronic pain. The mean (SD) utility among patients with pruritus was 0.87 (0.27) compared with 0.77 (0.31) for patients with pain (P < .01). After symptom severity, duration, and demographic factors were controlled for, only symptom severity (0.03 [P < .05]) and single marital status (-0.12 [P = .02]), but not symptom type (P = .43), remained significant predictors of the mean symptom utility score. CONCLUSIONS: Chronic pruritus has a substantial impact on QoL, one that may be comparable to that of pain. The severity of symptoms and the use of support networks are the main factors that determine the degree to which patients are affected by their symptoms. Addressing support networks in addition to developing new therapies may improve the QoL of itchy patients.

Sacroiliac joint interventions: a systematic review.

BACKGROUND: The sacroiliac joint is a diarthrodial synovial joint with abundant innervation and capability of being a source of low back pain and referred pain in the lower extremity. There are no definite historical, physical, or radiological features to provide definite diagnosis of sacroiliac joint pain, although many authors have advocated provocational maneuvers to suggest sacroiliac joint as a pain generator. An accurate diagnosis is made by controlled sacroiliac joint diagnostic blocks. The sacroiliac joint has been shown to be a source of pain in 10% to 27% of suspected cases with chronic low back pain utilizing controlled comparative local anesthetic blocks. Intraarticular injections, and radiofrequency neurotomy have been described as therapeutic measures. This systematic review was performed to assess diagnostic testing (non-invasive versus interventional diagnostic techniques) and to evaluate the clinical usefulness of interventional techniques in the management of chronic sacroiliac joint pain. OBJECTIVE: To evaluate and update the available evidence regarding diagnostic and therapeutic sacroiliac joint interventions in the management of sacroiliac joint pain. STUDY DESIGN: A systematic review using the criteria as outlined by the Agency for Healthcare Research and Quality (AHRQ), Cochrane Review Group Criteria for therapeutic interventions and AHRQ, and Quality Assessment for Diagnostic Accuracy Studies (QUADAS) for diagnostic studies. METHODS: The databases of EMBASE and MEDLINE (1966 to December 2006), and Cochrane Reviews were searched. The searches included systematic reviews, narrative reviews, prospective and retrospective studies, and cross-references from articles reviewed. The search strategy included sacroiliac joint pain and dysfunction, sacroiliac joint injections, interventions, and radiofrequency. RESULTS: The results of this systematic evaluation revealed that for diagnostic purposes, there is moderate evidence showing the accuracy of comparative, controlled local anesthetic blocks. Prevalence of sacroiliac joint pain is estimated to range between 10% and 27% using a double block paradigm. The false-positive rate of single, uncontrolled, sacroiliac joint injections is around 20%. The evidence for provocative testing to diagnose sacroiliac joint pain is limited. For therapeutic purposes, intraarticular sacroiliac joint injections with steroid and radiofrequency neurotomy were evaluated. Based on this review, there is limited evidence for short-term and long-term relief with intraarticular sacroiliac joint injections and radiofrequency thermoneurolysis. CONCLUSIONS: The evidence for the specificity and validity of diagnostic sacroiliac joint injections is moderate. The evidence for accuracy of provocative maneuvers in diagnosis of sacroiliac joint pain is limited. The evidence for therapeutic intraarticular sacroiliac joint injections is limited. The evidence for radiofrequency neurotomy in managing chronic sacroiliac joint pain is limited.

Discography as a diagnostic test for spinal pain: a systematic and narrative review.

BACKGROUND: The intervertebral disc has been implicated as an etiology of chronic spine pain based on clinical, basic science, and epidemiological research. Unfortunately, there is no way to determine with absolute certainty whether or not the disc is a spinal pain generator. Recent advances in the neurobiology of pain processing further underscore the possibility that we may never know the source of a patient's pain. At our current level of understanding, from an empirical standpoint, discography is thought of as the best tool to evaluate disc-related pain. STUDY DESIGN: A systematic review OBJECTIVES: To systematically assess the quality of clinical studies evaluating the diagnostic accuracy of discography with respect to chronic spinal pain. METHODS: A systematic review of the literature was performed to assess the diagnostic accuracy of discography with respect to chronic spinal pain. Study inclusion/exclusion criteria were based on the modern practice of discography. Selected studies were then subjected to two rating instruments for diagnostic accuracy studies (AHRQ and QUADAS). Specific data were then culled from these studies and tabulated. Evidence was then classified into five levels: conclusive, strong, moderate, limited, or indeterminate. RESULTS: Evidence is strong for the diagnostic accuracy of discography as an imaging tool. Evidence is also strong for the ability of discography to evoke pain. There is strong evidence supporting the role of discography in identifying that subset of patients with lumbar discogenic pain. There is moderate evidence supporting the role of discography in identifying a subset of patients with cervical discogenic pain. There is limited evidence supporting the role of discography in identifying a subset of patients with thoracic discogenic pain. CONCLUSION: Discography is a useful imaging and pain evaluation tool in identifying a subset of patients with chronic spinal pain secondary to intervertebral disc disorders.

Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: a systematic review of evidence.

BACKGROUND: Chronic refractory spinal pain poses a peculiar diagnostic challenge because of multiple putative pain sources, overlapping clinical features, and nonspecific radiologic findings. Diagnostic injection techniques are employed to isolate the source(s) of pain. Facet or zygapophysial joint pain is an example of spinal pain diagnosed by local anesthetic injections of the facet joint or its nerve supply. Diagnostic facet joint injections are expected to meet the cardinal features of a diagnostic test (i.e., accuracy, safety and reproducibility). Accuracy must be compared with a "gold" or criterion standard that can confirm presence or absence of a disease. There is, however, no available gold standard, such as biopsy, to measure presence or absence of pain. Hence, there is a degree of uncertainty concerning the accuracy of diagnostic facet joint injections. OBJECTIVES: To evaluate accuracy, safety and reproducibility of facet or zygapophysial joint injections in diagnosing chronic spinal pain of facet joint origin. STUDY DESIGN: A systematic review of the literature for clinical studies on efficacy and utility of facet joint/nerve injections in diagnosing spinal pain from facet joints. METHODS: Relevant literature on diagnostic facet injections was identified through database searches. Excluded were abstracts, reviews, book chapters, case reports and studies based on single blocks or blocks without radiologic control. Prospective studies with placebo control, or controlled comparative local anesthetic blocks, were given priority over retrospective studies. Each study was graded using AHRQ and QUADAS criteria. The level of evidence was classified as conclusive, strong, moderate, limited, or inconclusive. RESULTS: Available literature pointed to strong evidence for controlled comparative local anesthetic facet joint medial branch blocks in the diagnosis of neck and low back pain. There was moderate evidence in the diagnosis of pain arising from thoracic facet joints. CONCLUSION: The evidence obtained from literature review suggests that controlled comparative local anesthetic blocks of facet joint nerves (medial branch or dorsal ramus) are reproducible, reasonably accurate, and safe. The sensitivity, specificity, false-positive rates, and predictive values of these diagnostic tests for neck and low back pain have been validated and reproduced in multiple studies.

A systematic review of diagnostic utility of selective nerve root blocks.

BACKGROUND: Transforaminal epidural injections, or selective nerve root blocks, are used for a myriad of different spinal disorders. A clear consensus on the use of selective nerve root injections as a diagnostic tool does not currently exist. Additionally, the effectiveness of this procedure as a diagnostic tool is not clear. OBJECTIVE: The objective was to evaluate the accuracy of selective nerve root injections in diagnosing spinal disorders. STUDY DESIGN: The study involved a systematic review of diagnostic studies about selective nerve root blocks for the diagnosis of spinal pain. METHODS: A systematic review of the literature for clinical studies was performed to assess the accuracy of selective nerve root injections in diagnosing spinal disorders. Methodologic quality evaluation was performed utilizing AHRQ and QUADAS criteria. The methodology of the studies was graded and the evidence was classified into five levels: conclusive, strong, moderate, limited, or indeterminate. RESULTS: There is limited evidence on the effectiveness of selective nerve root injections as a diagnostic tool in spinal disorder. There is insufficient research into this area for strong support, but the available literature is supportive of selective nerve root injections as a diagnostic test in equivocal radicular pain. The current analysis provides moderate evidence of transforaminal epidural injections in the preoperative evaluation of patients with negative or inconclusive imaging studies. CONCLUSIONS: Selective nerve root injections may be helpful as a diagnostic addition in evaluating spinal disorders with radicular features, but the role of this diagnostic test needs to be further clarified by additional research and consensus on technique.