The Pain Intervention & Digital Research Program: an operational report on combining digital research with outpatient chronic disease management.

Chronic pain affects up to 28% of U.S. adults, costing ∼$560 billion each year. Chronic pain is an instantiation of the perennial complexity of how to best assess and treat chronic diseases over time, especially in populations where age, medical comorbidities, and socioeconomic barriers may limit access to care. Chronic disease management poses a particular challenge for the healthcare system's transition from fee-for-service to value and risk-based reimbursement models. Remote, passive real-time data from smartphones could enable more timely interventions and simultaneously manage risk and promote better patient outcomes through predicting and preventing costly adverse outcomes; however, there is limited evidence whether remote monitoring is feasible, especially in the case of older patients with chronic pain. Here, we introduce the Pain Intervention and Digital Research (Pain-IDR) Program as a pilot initiative launched in 2022 that combines outpatient clinical care and digital health research. The Pain-IDR seeks to test whether functional status can be assessed passively, through a smartphone application, in older patients with chronic pain. We discuss two perspectives-a narrative approach that describes the clinical settings and rationale behind changes to the operational design, and a quantitative approach that measures patient recruitment, patient experience, and HERMES data characteristics. Since launch, we have had 77 participants with a mean age of 55.52, of which n = 38 have fully completed the 6 months of data collection necessitated to be considered in the study, with an active data collection rate of 51% and passive data rate of 78%. We further present preliminary operational strategies that we have adopted as we have learned to adapt the Pain-IDR to a productive clinical service. Overall, the Pain-IDR has successfully engaged older patients with chronic pain and presents useful insights for others seeking to implement digital phenotyping in other chronic disease settings.

Reporting of Facet Joint Inflammation in Lumbar Spine MRI Studies in Patients With Low Back Pain.

STUDY DESIGN: Retrospective. OBJECTIVE: We aimed to assess the frequency of facet joint inflammatory features noted in routine radiology reports of lumbar spine magnetic resonance imaging (MRI) studies among patients with chronic low back pain. SUMMARY OF BACKGROUND DATA: Facet joint arthropathy is one of the most common causes of chronic low back pain. It may encompass various inflammatory imaging characteristics, such as facet joint effusion, bone marrow edema, and soft tissue edema. The extent to which radiology reports mention inflammatory features of the lumbar facet joints and the accuracy of these reports have not been investigated. MATERIALS AND METHODS: The authors performed a chart review on 49 subjects with previous facet-related interventions ( i.e . medial branch blocks or intra-articular facet joint injection) and MRI available in the medical record. One senior musculoskeletal radiologist and a musculoskeletal radiology fellow graded the inflammatory features using a published facet joint inflammation grading system [Gold Standard (GS)]. The authors identified the inflammatory markers mentioned in the radiology reports and calculated the sensitivity and positive predictive value of the radiology reports compared with GS readings. RESULTS: Compared with the GS, the sensitivity of radiology reports for facet joint effusion, bone marrow, and soft tissue edema ranged from 6% to 22%, and the positive predictive value ranged from 25% to 100%. L4/5 had the highest number of cases with inflammatory features noted on the reports. CONCLUSION: Inflammatory findings, such as facet joint effusion, bone marrow edema, and soft tissue edema, are not commonly identified in radiology reports. Further investigations are needed to determine the clinical importance of MRI-detected lumbar facet joint inflammatory features as a potential mechanism of nociception and as a predictor of outcomes following injections or other therapies.

Comprehensive Grading System of Inflammatory Features of the Lumbar Facet Joints on Magnetic Resonance Imaging.

STUDY DESIGN: Retrospective. OBJECTIVE: We aimed to describe a magnetic resonance imaging (MRI)-based grading system of inflammatory features of the lumbar facet joints using an atlas and assess its reliability. SUMMARY OF BACKGROUND DATA: Chronic low back pain is often caused by facet joint arthropathy. Inflammatory features are often evident on MRI. While several grading systems of facet arthropathy have been described, there is scant data on the reliability of these systems, and none focus exclusively on inflammatory features. MATERIALS AND METHODS: We describe a grading system that assesses facet joint effusion, bone marrow edema, and soft tissue edema. Each feature was graded from 0 to 3 (facet edema) or 0 to 2 (bone marrow edema intensity and extent, soft tissue edema intensity and extent). Four spine experts graded MRIs of 50 subjects at the bilateral L3/4, L4/5, and L5/S1 levels. All subjects had symptomatic facet arthropathy and received therapeutic facet joint injections. We assessed the intra-reader and inter-reader reliability of each feature at each joint and summarized across all six joints. RESULTS: The mean age of subjects was 56 years (SD = 17), and 48% were female. The injections occurred at the L3/4 level in 12% of cases, at L4/5 in 88%, and at L5/S1 in 80% of cases. The intra-reader reliability kappa's for each feature ranged from 0.42 to 0.81. In contrast, the inter-reader reliability kappa values for each feature ranged from 0.37 to 0.54. CONCLUSION: MRI inflammatory features of the lumbar facet joints are often noted in patients with low back pain. The proposed grading system is reliable and could serve as a research tool for studies assessing the clinical relevance and prognostic value of these features.

Predictors of Outcomes After Lumbar Intra-Articular Facet Joint Injections and Medial Branch Blocks: A Scoping Review.

STUDY DESIGN: A scoping review. OBJECTIVE: We aimed to identify and describe the factors associated with the patient-reported response after lumbar intra-articular facet joint (FJ) injections or medial branch blocks (MBBs). SUMMARY OF BACKGROUND DATA: FJ osteoarthritis is among the most common causes of chronic low back pain. Management often includes FJ intra-articular injection and MBBs (which may be followed by radiofrequency ablation of the nerves innervating these joints). However, the success of these approaches is variable, prompting interest in identifying patient characteristics (imaging features, clinical signs, and among others) associated with response to these types of facet injections. MATERIALS AND METHODS: We performed a literature search on factors associated with patient-reported outcomes after lumbar FJ intra-articular injections or MBBs for patients with low back pain published in English or Spanish between 2000 and 2023. We excluded duplicate papers that did not describe factors associated with outcomes or those describing other interventions. We collected data on the association of these factors with patient-reported outcomes. RESULTS: Thirty-seven studies met the inclusion criteria and were analyzed. These studies evaluated factors, such as age, depression, and single photon emission computed tomography (SPECT), and among variables. Age and imaging findings of facet arthropathy were the most frequently described factors. Imaging findings of FJ arthropathy and positive SPECT were often associated with positive results after intra-articular FJ injections or MBBs. In contrast, younger age and smoking were frequently associated with less favorable clinical outcomes. CONCLUSION: Numerous factors were considered in the 37 studies included in this review. Imaging findings of facet arthropathy, duration of pain, and positive SPECT were consistently associated with favorable results after facet interventions.

Grading Systems of Lumbar Facet Joint Inflammatory Changes on Magnetic Resonance Imaging: A Scoping Review.

STUDY DESIGN: A scoping review. OBJECTIVE: We aimed to identify and characterize grading systems of the inflammatory features of the lumbar facet joints (FJs) noted on magnetic resonance imaging and summarize their reliability. SUMMARY OF BACKGROUND DATA: Chronic low back pain is one of the most common causes of disability worldwide and is frequently accompanied by FJ osteoarthritis. Inflammatory changes in the lumbar FJs are commonly noted in imaging studies of patients with FJ osteoarthritis and low back pain. Several grading systems for these inflammatory changes have been developed. However, these grading system's features and reliability have yet to be reviewed. MATERIALS AND METHODS: We performed a literature search of studies reporting grading systems for FJ inflammatory changes published in English or Spanish between 1985 and 2022. We collected data on reported interreader reliability measures of each grading system. Finally, we compared the features of inflammation described by each system. RESULTS: Six studies met the inclusion criteria and were used in our analysis. Features commonly graded in these systems are the hyperintensity signal noted within the FJ, bone marrow edema, and the extent of the soft-tissue edema surrounding the FJs. We found that the interreader reliability measures ranged from 0.56 to 0.96. CONCLUSIONS: Only 6 studies have reported methods for documenting inflammation in the FJs. Studies varied in the precise tissues and phenomena included in the grading systems. However, the systems were generally reliable. Future studies should document the reliability of these methods when independent investigators are not involved in developing the classification schemes. Further work might combine one or more of these measures to establish a standard and reliable grading system for inflammatory changes in the FJs, including signal intensity within the joint, bone marrow edema, and soft-tissue inflammation.

Simplified Universal Grading of Lumbar Spine MRI Degenerative Findings: Inter-Reader Agreement of Non-Radiologist Spine Experts.

OBJECTIVE: 1) To describe a simplified multidisciplinary grading system for the most clinically relevant lumbar spine degenerative changes. 2) To measure the inter-reader variability among non-radiologist spine experts in their use of the classification system for interpretation of a consecutive series of lumbar spine magnetic resonance imaging (MRI) examinations. METHODS: ATS multidisciplinary and collaborative standardized grading of spinal stenosis, foraminal stenosis, lateral recess stenosis, and facet arthropathy was developed. Our institution's picture archiving and communication system was searched for 50 consecutive patients who underwent non-contrast MRI of the lumbar spine for chronic back pain, radiculopathy, or symptoms of spinal stenosis. Three fellowship-trained spine subspecialists from neurosurgery, orthopedic surgery, and physiatry interpreted the 50 exams using the classification at the L4-L5 and L5-S1 levels. Inter-reader agreement was assessed with Cohen's kappa coefficient. RESULTS: For spinal stenosis, the readers demonstrated substantial agreement (κ = 0.702). For foraminal stenosis and facet arthropathy, the three readers demonstrated moderate agreement (κ = 0.544, and 0.557, respectively). For lateral recess stenosis, there was fair agreement (κ = 0.323). CONCLUSIONS: A simplified universal grading system of lumbar spine MRI degenerative findings is newly described. Use of this multidisciplinary grading system in the assessment of clinically relevant degenerative changes revealed moderate to substantial agreement among non-radiologist spine physicians. This standardized grading system could serve as a foundation for interdisciplinary communication.

Atlanto-axial Pannus in Patients with and without Rheumatoid Arthritis.

OBJECTIVE: Pannus formation in the atlanto-axial joint is a well-recognized complication of rheumatoid arthritis (RA). Occasionally, atlanto-axial pannus is reported when patients without a history of RA undergo magnetic resonance imaging (MRI) of the cervical spine. We sought to further characterize these patients. METHODS: The Partners HealthCare Research Patient Data Registry was free-text searched for "atlanto-axial" AND "pannus" in cervical spine MRI reports from 2001 to 2015. Cases with MRI reports describing pannus were reviewed. Clinical data were extracted by chart review in cases with confirmed atlanto-axial pannus (n = 105). RESULTS: Twenty-nine patients (27.6%) had RA, all of whom except one carried this diagnosis at the time of the MRI scan. Only 1 of 77 patients without a history of RA was subsequently diagnosed with RA (1.3%, 95% CI 0.1-7.0%, median followup 3.6 yrs). Non-RA patients were significantly older (median age 79 vs 63 yrs, p < 0.0001), less frequently female (55% vs 86%, p = 0.0032), and more likely to have undergone prior cervical spine surgery (18% vs 0%, p = 0.016) compared with RA patients. Thirty-four non-RA patients (44.7%) either had a clinical diagnosis of calcium pyrophosphate dihydrate disease (CPPD) or imaging evidence for tissue calcification. There were no significant differences in age or sex between the CPPD subgroup and other non-RA patients. Twenty-eight patients (26.7%) underwent cervical spine surgery. CONCLUSION: Patients without RA diagnosis and incidental atlanto-axial pannus on cervical spine MRI are unlikely to have previously unrecognized RA. Degenerative disease and tissue calcification may contribute to pannus formation in these patients.

Are facet joint bone marrow lesions and other facet joint features associated with low back pain? A pilot study.

OBJECTIVE: To determine the frequency of facet joint (FJ) bone marrow lesions, high FJ periarticular signal intensity, and FJ effusions in a convenience sample of patients with axial low back pain (LBP). DESIGN: A cross-sectional pilot study with retrospective data collection. SETTING: Outpatient spine clinics. PATIENTS: Sixty-four adults with axial LBP scheduled to receive an FJ intra-articular corticosteroid injection. METHODS: Clinical data were abstracted from the medical record by 1 physician, who was blinded to results of the magnetic resonance imaging evaluations. A musculoskeletal radiologist blinded to clinical information performed standardized assessments of the L1-S1 spinal levels for FJ bone marrow lesions, effusions, and high periarticular signal intensity on lumbar magnetic resonance imaging, including short tau inversion recovery sequences. We calculated the frequency of these FJ features and used generalized estimating equations to examine side-specific associations between the location of FJ features and the side on which LBP was experienced. RESULTS: The sample included 64 participants with a mean (standard deviation) age of 59.9 ± 14.5 years. FJ bone marrow lesions were present in 64.1%, effusions in 70.3%, and high periarticular signal intensity in 65.6% of participants. All the features were most common at the L4-L5 level. These FJ features showed significant associations with the side on which LBP was experienced or statistical trends toward an association, with or without adjustment for age, gender, and body mass index. The strongest side-specific associations were seen for the number of bone marrow lesions (odds ratio [OR] 1.60 [95% confidence interval {CI},1.05-2.43]), any FJ effusion (OR 2.23 [95% CI, 1.02-4.85]), and the number of joints with high periarticular signal intensity (OR 1.75 [95% CI, 1.16-2.63]). CONCLUSIONS: FJ bone marrow lesions, effusions, and high periarticular signal intensity were common in this sample of patients with axial LBP and substantially more frequent than in prior reports from unselected samples of patients with or without radicular pain. These FJ features demonstrate side-specific associations with LBP. Further study of associations between these FJ features and LBP are warranted.

The lateral atlanto-axial joint as a source of headache in congenital atlanto-occipital fusion.

A 47-yr-old woman presented with severe right-sided neck pain and headache, predominantly in the right-occipital region, for 3 yrs. The symptoms persisted despite using nonsteroidal antiinflammatory medications and undergoing physical therapy. The patient's examination was unremarkable except for reduced neck motion and prominent right-occipital tenderness. Imaging showed congenital fusion of the atlanto-occipital joints bilaterally. A fluoroscopically guided diagnostic right-lateral atlanto-axial joint injection was positive. We are reporting the first case of clinically proven lateral atlanto-axial joint arthropathy with neck pain and headache in a patient with congenital atlanto-occipital joint fusion. Subsequently, the patient received a set of two therapeutic lateral atlanto-axial joint injections. She had remarkable improvement of her headache and neck pain. At 1-yr follow-up, the patient continued to have significant improvement of the right-sided neck pain and headache.

Discography in practice: a clinical and historical review.

Chronic low back pain is the most common cause of disability in individuals between the ages of 45 and 65. Given the variety of anatomic and pathophysiologic causes of persistent low back pain, it is a difficult diagnosis for clinicians to treat. Discography is a diagnostic option that may link a patient's subjective complaints of spinal pain to symptomatic disk disease when non-invasive imaging, such as magnetic resonance imaging (MRI), does not find structural abnormalities. A controversial procedure, discography is only necessary to assess painful discs prior to surgical interventions. For accurate discogram interpretation an experienced spine interventionalist must be careful to exclude false positive results and be aware of the patient's underlying psychological state. This literature review will discuss the following: anatomy and function of the spine and intervertebral disc, intervertebral disc degeneration and discogenic pain, history of discography, indications and contraindications, a description of the procedure, complications, and the current debate regarding its outcomes.

Clean versus sterile technique for common joint injections: a review from the physiatry perspective.

Preparation of the skin prior to joint injection varies widely among disciplines and across regional borders. This is likely due to the paucity of literature on the most effective and efficient methods of preparation. There is no standard definition of clean technique prior to joint injection. Review of the available literature suggests that alcohol is effective preparation for the skin prior to most procedures. Surveys of current clinical practice demonstrate that the use of gloves may be favored, but no conclusions can be drawn in regards to whether sterile gloves are required. Clean technique should be defined as use of non-sterile gloves and agents such as alcohol or soap prior to injection. Significant cost savings may be achieved with the consistent use of clean technique for preparation of the skin prior to joint injection. Further study should address the incidence of iatrogenic bacterial arthritis following clean technique versus sterile technique for joint injection.

The role of intradiscal steroids in the treatment of discogenic low back pain.

LBP is one of the most common reasons for visiting a doctor and is the most common cause of disability under age 45.Amongst a variety of etiologies, internal disc disruption (IDD) has been postulated as an important cause of low back pain. Treating discogenic low back pain continues to be a challenge to physicians. Inflammation, either from direct chemical irritation or secondary to an autoimmune response to the nucleus pulposus has been implicated as the primary pain source. Both steroids and non-steroidal anti-inflammatory drugs have partial effectiveness in treating pain associated with inflammation. Therefore, the rationale for using intradiscal steroids is to suppress the inflammation within the disc, thereby alleviating the patient's symptoms. The goal of this article is to review the literature regarding the efficacy of intradiscal steroids to treat low back pain of discogenic origin.

When should a cervical collar be used to treat neck pain?

Neck pain is one of the most prevalent and costly health problems in the United States. It remains a complex, subjective experience with a variety of musculoskeletal causes. Although, cervical collars are a seemingly benign intervention, they can have adverse effects, especially when used for longer periods of time. It is feared that a long period of immobilization, can result in atrophy-related secondary damage. Many physicians cite anecdotal evidence of their clinical utility and soft cervical collars are often prescribed by convention for patients complaining of neck pain. The use of cervical collars to treat neck pain is an area of controversy. This review article examines the current evidence and studies related to recommending cervical collars for neck pain of a variety of etiologies.

Side effects and complications after percutaneous disc decompression using coblation technology.

OBJECTIVE: To report the short-term side effects and complications after percutaneous disc decompression utilizing coblation technology. DESIGN: Following institutional review board approval, consecutive patients who were to undergo percutaneous disc decompression using coblation technology (nucleoplasty) were prospectively enrolled. Patients were questioned preoperatively, postoperatively, and 24 hrs, 72 hrs, 1 wk, and 2 wks postprocedure by an independent reviewer regarding 17 possible symptom complications, which included bowel or bladder symptoms, muscle spasm, new pain, numbness/tingling or weakness, fevers/chills, rash/pruritus, headaches, nausea/vomiting, bleeding, and needle insertion site soreness. Statistical analysis was performed using Wilcoxon's signed-rank test. RESULTS: A total of 53 patients enrolled, of whom four patients dropped out. Two patients had increased symptoms and opted for surgery. Two patients could not be contacted. The most common side effects at 24 hrs postprocedure was soreness at the needle insertion site (76%), new numbness and tingling (26%), increased intensity of preprocedure back pain (15%), and new areas of back pain (15%). At 2 wks, no patient had soreness at the needle insertion site or new areas of back pain; however, new numbness and tingling was present in 15% of patients. Two patients (4%) had increased intensity of preprocedure back pain. There were statistically significant reductions in visual analog scale score for back pain and leg pain (P < 0.05). CONCLUSIONS: Based on this preliminary data, nucleoplasty seems to be associated with short-term increased pain at the needle insertion site and increased preprocedure back pain and tingling numbness but without other side effects.

Provocative cervical discography symptom mapping.

BACKGROUND CONTEXT: In a small prospective study assessing 10 symptomatic and 10 asymptomatic subjects, Schellhas et al. compared cervical discography to magnetic resonance imaging. Within that study he reported on the distribution of pain for the C3-C4 to C6-C7 levels. Four years later, Grubb and Ellis reported retrospective data from his 12-year experience using cervical discography from C2-C3 to C7-T1 in 173 patients. To date, no large prospective study defining pain referral patterns for each cervical disc has been performed. PURPOSE: To conduct a prospective visual and statistical descriptive study of pain provocation of a cohort of subjects undergoing cervical discography. STUDY DESIGN/SETTING: Prospective multicenter descriptive study. METHODS: Pain referral maps were generated for each disc level from patients undergoing cervical discography with at least two levels assessed. If concordant pain was reproduced in a morphologically abnormal disc, the subject immediately completed a pain diagram. An independent observer interviewed the subject and recorded the location of provoked symptoms. Visual data were compiled using a body sector bit map, which consisted of 48 clinically relevant body regions. Visual maps with graduated color codes and frequencies of symptom location at each cervical disc level were generated. RESULTS: A total of 101 symptom provocation maps were recorded during cervical discography on 41 subjects. There were 10 at C2-C3, 19 at C3-C4, 27 at C4-C5, 27 at C5-C6, 16 at C6-C7 and 2 at C7-T1. Predominantly unilateral symptoms were provoked just as often as bilateral symptoms. The C2-C3 disc referred pain to the neck, subocciput and face. The C3-C4 disc referred pain to the neck, subocciput, trapezius, anterior neck, face, shoulder, interscapular and limb. The C4-C5 disc referred pain to the neck, shoulder, interscapular, trapezius, extremity, face, chest and subocciput. The C5-C6 disc referred pain to the neck, trapezius, interscapular, suboccipital, anterior neck, chest and face. The C6-C7 disc referred pain to the neck, interscapular, trapezius, shoulder, extremity and subocciput. At C7-T1 we produced neck and interscapular pain. Visual maps with graduated color codes and frequencies of symptom location at each cervical disc level were generated. CONCLUSIONS: In conclusion, these results confirm the observations of prior investigators that cervical internal disc disruption can elicit axial and peripheral symptoms. The particular patterns of pain generation allow the discographer to preprocedurally anticipate disc levels to assess. With these data, the number of disc punctures that are required can be limited rather than routinely assessing all cervical discs.