Neuromodulation Techniques in Chronic Refractory Coccydynia: A Narrative Review

Refractory coccydynia is a condition characterized by severe coccygeal pain and poses a challenging management dilemma for clinicians. Advancements in neuromodulation (NM) technology have provided benefits to people experiencing chronic pain that is resistant to standard treatments. This review aims to summarize the spectrum of current NM techniques employed in the treatment of refractory coccydynia along with their effectiveness. A review of studies in the scientific literature from 2012 to 2023 was conducted, revealing a limited number of case reports. Although the available evidence at this time suggests significant pain relief with the utilization of NM techniques, the limited scope and nature of the studies reviewed emphasize the need for large-scale, rigorous, high-level research in this domain in order to establish a comprehensive understanding of the role of NM and its effectiveness in the management of intractable coccydynia.

The painful shoulder arthroplasty: appropriate work-up and review of interventional pain treatments

Shoulder arthroplasty is a successful surgical procedure for several conditions when patients become refractory to conservative management modalities. Unfortunately, some patients experience persistent chronic pain after shoulder arthroplasty. These individuals should undergo a comprehensive evaluation by an orthopedic surgeon to determine whether structural pathology is responsible for the pain and to decide whether reoperation is indicated. At times, a surgical solution does not exist. In these circumstances, a thorough and specific plan for the management of persistent chronic pain should be developed and instituted. In this article, we review common reasons for persistent pain after shoulder arthroplasty and outline the evaluation of the painful shoulder arthroplasty. We then provide a thorough review of interventional pain management strategies. Finally, we hypothesize developments in our field that might provide better outcomes in the future for patients suffering with chronic intractable pain after shoulder arthroplasty.

Cervical Spinal Cord Stimulation for Trigeminal Neuralgia: a Narrative Review

BACKGROUND

Trigeminal neuralgia (TN) is a chronic neuropathic pain condition affecting one or more divisions of the fifth cranial (trigeminal) nerve. TN is defined by recurrent unilateral electric shock-like pain that is abrupt in both onset and termination. The pain is triggered by innocuous sensory stimuli and is classified as either classic TN, related to vascular compression; secondary TN, due to a tumor along the trigeminal nerve or an underlying disease like multiple sclerosis; or idiopathic TN. Among the various therapies available for TN, carbamazepine remains the first-line treatment. Newer medications have demonstrated efficacy in patients who do not respond to or cannot tolerate carbamazepine. When medical management and neuroablative procedures fail, spinal cord stimulation (SCS) serves as a promising and popular option, with an estimated 34,000 SCS procedures performed annually worldwide. SCS employs the implantation of electrical leads in the epidural space to manage pain.

PURPOSE OF REVIEW

A review of literature was conducted to explore the use of cervical spinal cord stimulation (SCS) for the treatment of trigeminal neuralgia.

METHODS

A MEDLINE/PubMed search using the search terms "spinal cord stimulation" and "trigeminal neuralgia" was employed to find any case reports and research studies (retrospective studies, double-blinded studies, observational studies) on the topic. No date limiters were used for the search. The initial search resulted in 76 non-duplicate entries from the database. After application of the search criteria, 58 studies were excluded because they were not relevant to the study. A further detailed review of the included articles was conducted by all the reviewers. During this phase of the review, additional 6 studies were excluded. A total of 11 studies were included: 7 case reports and 4 retrospective review studies.

RECENT FINDINGS

In the review, we discuss 7 different case reports on the use of cervical SCS for trigeminal neuralgia and an additional 4 retrospective studies reviewing outcomes and pain relief in patients who underwent treatment. The case reports and retrospective studies reviewed demonstrated that TN patients realized > 50% pain relief following permanent electrode implantation. In all the cases discussed, complications from SCS were rare and/or not reported. Additionally, most of the cases report that patients who had adequate pain relief from SCS were able to wean off, or significantly reduce, oral medications given the vast improvement in pain reduction.

CONCLUSIONS

Cervical spinal cord stimulation (SCS) is a safe and effective procedure for patients with trigeminal neuralgia (TN) who have refractory pain despite the use of medications. In many cases, the procedure provides an adequate level of pain relief with very few complications or side effects. The vast majority of current research on the use of cervical SCS for TN currently consists of case reports and retrospective analysis. In order to further evaluate the efficacy of SCS for treatment, large-scale randomized controlled studies or observational studies need to be conducted to properly evaluate SCS as a treatment modality for trigeminal neuralgia.

COVID-19 Pandemic Reduced Utilization Of Interventional Techniques 18.7% In Managing Chronic Pain In The Medicare Population In 2020: Analysis Of Utilization Data From 2000 To 2020

BACKGROUND

Multiple publications have shown the significant impact of the COVID-19 pandemic on US healthcare and increasing costs over the recent years in managing low back and neck pain as well as other musculoskeletal disorders. The COVID-19 pandemic has affected many modalities of treatments, including those related to chronic pain management, including both interventional techniques and opioids. While there have not been assessments of utilization of interventional techniques specific to the ongoing COVID-19 pandemic, previous analysis published with data from 2000 to 2018 demonstrated a decline in utilization of interventional techniques from 2009 to 2018 of 6.7%, with an annual decline of 0.8% per 100,000 fee-for-service (FFS) in the Medicare population. During that same time, the Medicare population has grown by 3% annually.

OBJECTIVES

The objectives of this analysis include an evaluation of the impact of the COVID-19 pandemic, as well as an updated assessment of the utilization of interventional techniques in managing chronic pain in the Medicare population from 2010 to 2019, 2010 to 2020, and 2019 to 2020 in the FFS Medicare population of the United States.

STUDY DESIGN

Utilization patterns and variables of interventional techniques with the impact of the COVID-19 pandemic in managing chronic pain were assessed from 2000 to 2020 in the FFS Medicare population of the United States.

METHODS

The data for the analysis was obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2020.

RESULTS

The results of the present investigation revealed an 18.7% decrease in utilization of all interventional techniques per 100,000 Medicare beneficiaries from 2019 to 2020, with a 19% decrease for epidural and adhesiolysis procedures, a 17.5% decrease for facet joint interventions and sacroiliac joint blocks, and a 25.4% decrease for disc procedures and other types of nerve blocks. The results differed from 2000 to 2010 with an annualized increase of 10.2% per 100,000 Medicare population compared to an annualized decrease of 0.4% from 2010 to 2019, and a 2.5% decrease from 2010 to 2020 for all interventional techniques. For epidural and adhesiolysis procedures decreases were more significant and annualized at 3.1% from 2010 to 2019, increasing the decline to 4.8% from 2010 to 2020. For facet joint interventions and sacroiliac joint blocks, the reversal of growth patterns was observed but maintained at an annualized rate increase of 2.1% from 2010 to 2019, which changed to a decrease of 0.01% from 2010 to 2020. Disc procedures and other types of nerve blocks showed similar patterns as epidurals with an 0.8% annualized reduction from 2010 to 2019, which was further reduced to 3.6% from 2010 to 2020 due to COVID-19.

LIMITATIONS

Data for the COVID-19 pandemic impact were available only for 2019 and 2020 and only the FFS Medicare population was utilized; utilization patterns in Medicare Advantage Plans, which constitutes almost 40% of the Medicare enrollment in 2020 were not available. Moreover, this analysis shares the limitations present in all retrospective reviews of claims based datasets.

CONCLUSION

The decline driven by the COVID-19 pandemic was 18.7% from 2019 to 2020. Overall decline in utilization in interventional techniques from 2010 to 2020 was 22.0% per 100,000 Medicare population, with an annual diminution of 2.5%, despite an increase in the population rate of 3.3% annualized (38.9% overall) and Medicare enrollees of 33.4% and 2.9% annually.

The Impact of COVID-19 on Interventional Pain Management Practices is Significant and Long-Lasting: An Interventional Pain Management Physician Survey

BACKGROUND

As with many others in the house of medicine, the COVID-19 pandemic has adversely impacted the practice of interventional pain management. This in part relates to various  state health authority or medical board restrictions with reductions in patient volume for evaluations, follow-ups, and procedures. Of course, the pandemic continues to persist which is in turn leading to longer-lasting effects. Our previous survey was performed in March 2020. At that time, there was a national lockdown in the United States with COVID-19 disease qualifying as a pandemic by the World Health Organization (WHO). The pandemic caused by COVID-19 disease continues to have far-reaching implications on how we deliver routine care to patients and its effect on patient care, economic aspects, and health of interventional pain management providers.

OBJECTIVE

To assess the current and expected future impact of the COVID-19 pandemic on interventional pain management practices in a physician survey. The study was performed based on performance in 2021 compared to the 2019 pre-COVID era.

METHODS

The American Society of Interventional Pain Physicians (ASIPP) administered a 16-question survey to their members by contacting them via a commercially available online marketing company platform. The survey was completed on www.constantcontact.com.

RESULTS

The results showed that 88% of the providers experienced a reduction in income and a similar number expect decreases over the next 12 months. A large proportion of respondents (73.3%) reported a reduction in revenue of 11%-25%. In contrast, another 21.5% reported a revenue decline of 26%-50%, and 29% reported 11%-25% increase in expenses. Overall, new patient volume decreased 11%-25% based on the response from almost 63%, whereas almost 9% reported a decline of 26%-50%. In contrast, established patient volume declined 1%-10% as reported by 64% of the respondents, compared to an 11%-25% decrease by a small proportion of 14%. All interventional procedures showed significant decreases across the board, with 69% of the respondents reporting a decline in-office procedures, 64% in ambulatory surgery center (ASC) procedures, and 57% in hospital outpatient department (HOPD) procedures, ranging from 11%-25%.

LIMITATIONS

The survey included a relatively small number of member physicians which could introduce sampling error. Consequently, it may not be generalizable for other specialties or even to pain medicine.

CONCLUSION

The COVID-19 pandemic has put interventional pain practices throughout the United States under considerable financial and psychological stress. This study seeks to quantify the extent of economic loss and other challenges resultant from the pandemic. Almost 99% reported a decrease in revenues in the last 12 months, with 86% reporting an expected reduction in the next 12 months and 49% reporting an increase in expenses. Declines have been reported in all sectors with new patients, office procedures, ASC, and HOPD procedures, except for established patient visits, which have shown minor declines compared to other domains. Understanding the issues facing interventional pain management physicians facilitates the development of strategies to actively manage provider practice/well-being, and to minimize risk to personnel to keep patients safe.

Interventional Therapies for Pain in Cancer Patients: a Narrative Review

PURPOSE OF REVIEW

Pain is a prevalent symptom in the lives of patients with cancer. In light of the ongoing opioid epidemic and increasing awareness of the potential for opioid abuse and addiction, clinicians are progressively turning to interventional therapies. This article reviews the interventional techniques available to mitigate the debilitating effects that untreated or poorly treated pain have in this population.

RECENT FINDINGS

A range of interventional therapies and technical approaches are available for the treatment of cancer-related pain. Many of the techniques described may offer effective analgesia with less systemic toxicity and dependency than first- and second-line oral and parenteral agents. Neuromodulatory techniques including dorsal root ganglion stimulation and peripheral nerve stimulation are increasingly finding roles in the management of oncologic pain. The goal of this pragmatic narrative review is to discuss interventional approaches to cancer-related pain and the potential of such therapies to improve the quality of life of cancer patients.

An anatomical neurovascular study for procedures targeting peri-articular nerves in patients with anterior knee pain

BACKGROUND

Radiofrequency ablation (RFA) of the articular branches innervating the anterior knee capsule has been studied as a possible alternative to surgery for degenerative arthritis. However, the neurovascular topography of the anterior knee capsule remains unclear.

METHODS

One leg from each of the 20 formalin-embalmed cadaveric specimens was investigated. Modified ablation points (MAPs) were evaluated for a possible alternative for conventional target points (CAPs).

RESULTS

For the nerve to vastus medialis (NVM), the probability of identifying the nerve was higher at MAP compared with CAP (62.5% vs. 25%). The mean shortest distance from the nerve was shorter at MAP compared with CAP (18.0 mm vs. 29.9 mm). The probabilities and distances for other nerves were not significantly different between the points. However, the probability of identifying the artery was significantly lower at MAPs compared with CAPs for arteries (0%, 5.3%, and 0% vs. 84.2%, 84.2%, and 73.3% for superior medial genicular, superior lateral genicular, and inferior medial genicular artery, respectively). For the recurrent peroneal nerve (RPN), a new target point was set in MAPs.

CONCLUSIONS

The current landmark for genicular nerve procedures may not accurately target the correct nerve position, or reduce the risk for vessel damage. A more proximal target may reduce complications and increase the probability of successful procedures, although clinical correlation is needed.

Post-herpetic Neuralgia: A Systematic Review of Current Interventional Pain Management Strategies

Background:

Post-herpetic neuralgia (PHN) is usually a constant or intermittent burning, stabbing, or sharp shooting pain with hyperalgesia or allodynia, persisting beyond the healing of herpetic skin lesions. This review was carried out in concordance to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We used PICOS (Population, Intervention, Control, and Outcome Study) design for inclusion of potential studies into this review. Online literature available in PubMed, Cochrane, and Embase was searched for studies from January 1995 till March 2020, which evaluated interventional treatments in PHN by an independent reviewer, using the relevant medical subject heading (MeSH) terms. We analyzed the following outcome parameters with regard to each intervention—pain status at predefined fixed intervals after the intervention, quality of sleep using any of the reported questionnaires, analgesic consumption, functional evaluation, and quality of life assessment after the intervention.

Conclusion:

Interventional pain management options provide effective and long-lasting pain relief to patients not responding to medical management. The choice of intervention will depend on the region involved, cost, and invasiveness. Simple procedures such as intercostal nerve blocks/neurolysis, stellate ganglion blocks, paravertebral neurolysis, epidural steroid injections, and dorsal root ganglion–radiofrequency ablation are effective interventions, and if they fail, spinal cord stimulators could be effective in the hands of experienced pain physicians.

Pain Management During the COVID-19 Pandemic

Chronic pain management during the coronavirus disease 2019 (COVID-19) pandemic is a challenging process, especially with growing evidence that COVID-19 infection is associated with myalgias, referred pain, and widespread hyperalgesia. In light of the limited data available for COVID-19-related impact on chronic pain patients, this review explores the changes in the healthcare delivery system due to social distancing and safety precautions to provide the appropriate management of chronic pain patients during the COVID-19 pandemic. Understanding both the general problems facing chronic pain patients as well as specific problems in the COVID-19 era including deconditioning, increased mental health concerns, financial burdens, and potential for medication-induced immune-suppression is vital in the appropriate management of patients. Telemedicine, the practice of caring for patients remotely when the provider and patient are not physically present with each other, is becoming increasingly used and recognized as a valuable tool to both health care providers and patients. This paper concentrates on the proper utilization of the available resources to help patients with the most severe conditions as well as the most vulnerable group. COVID-19 may be associated with a profound effect on both the health care system and patients with chronic pain. As a result, delaying, or stopping, treatment for chronic pain patients will have negative consequences, and strong pain evaluations must be administered to triage patients appropriately. Recent recommendations for the safe use of non-opioid analgesics, opioid analgesics, and interventional pain management procedures are vital to know and understand specifically during the pandemic era. Further researches are needed to identify the advance planning and rapid responses to reduce the impact of the pandemic.

The Effect of COVID-19 on Interventional Pain Management Practices: A Physician Burnout Survey

BACKGROUND

Burnout has been a commonly discussed issue for the past ten years among physicians and other health care workers. A survey of interventional pain physicians published in 2016 reported high levels of emotional exhaustion, often considered the most taxing aspect of burnout. Job dissatisfaction appeared to be the leading agent in the development of burnout in pain medicine physicians in the United States. The COVID-19 pandemic has drastically affected the entire health care workforce and interventional pain management, with other surgical specialties, has been affected significantly. The COVID-19 pandemic has placed several physical and emotional stressors on interventional pain management physicians and this may lead to increased physician burnout.

OBJECTIVE

To assess the presence of burnout specific to COVID-19 pandemic among practicing interventional pain physicians.

METHODS

American Society of Interventional Pain Physicians (ASIPP) administered a 32 question survey to their members by contacting them via commercially available online marketing company platform. The survey was completed on www.constantcontact.com.

RESULTS

Of 179 surveys sent, 100 responses were obtained. The data from the survey demonstrated that 98% of physician practices were affected by COVID and 91% of physicians felt it had a significant financial impact. Sixty seven percent of the physicians responded that in-house billing was responsible for their increased level of burnout, whereas 73% responded that electronic medical records (EMRs) were one of the causes. Overall, 78% were very concerned. Almost all respondents have been affected with a reduction in interventional procedures. 60% had a negative opinion about the future of their practice, whereas 66% were negative about the entire health care industry.

LIMITATIONS

The survey included only a small number of member physicians. Consequently, it may not be generalized for other specialties or even pain medicine. However, it does represent the sentiment and present status of interventional pain management.

CONCLUSION

The COVID-19 pandemic has put interventional pain practices throughout the United States under considerable financial and psychological stress. It is essential to quantify the extent of economic loss, offer strategies to actively manage provider practice/wellbeing, and minimize risk to personnel to keep patients safe.

Patient perspectives on interventional pain management: thematic analysis of a qualitative interview study

Background

Chronic pain is a widespread problem that is usually approached by focusing on its psychological aspects or on trying to reduce the pain from the pain generator. Patients report that they feel responsible for their pain and that they are disempowered and stigmatized because of it. Here, we explored interventional pain management from the patient’s perspective to understand the process better.

Methods

A purposive sample of 19 subjects was interviewed by an independent interviewer. The interviews were transcribed into text and thematic analysis was performed.

Results

The subjects’ perceptions covered three key themes: themselves as objects; the caregivers, including the process of tests and retests, the encounters and interactions with professionals, and the availability of the caregivers; and finally the outcomes, including the results of the tests and treatments and how these inspired them to think of other people with pain. Linking these themes, the subjects reported something best described as “gained empowerment” during interventional pain management; they were feeling heard and seen, they gained knowledge that helped them understand their problem better, they could ask questions and receive answers, and they felt safe and listened to.

Conclusions

Many of the themes evolved in relation to the subjects’ contact with the healthcare services they received, but when the themes were merged and structured into the model, a cohesive pattern of empowerment appeared. If empowerment is a major factor in the positive effects of interventional pain management, it is important to facilitate and not hinder empowerment.

Trial registration

Clinicaltrials.gov 2013-04-24 (Protocol ID SE-Dnr-2012-446-31 M-3, ClinicalTrials ID NCT01838603).

The Effect of Interventional Pain Management on Treating Postherpetic Neuralgia

Background:

Herpes zoster (HZ) is identified to induce postherpetic neuralgia (PHN) which is difficult to cure. PHN-related pain brings patients not only physical discomfort but also mental depression and anxiety. Currently, the main purpose of PHN treatment is to reduce patients’ pain. Now treatment combining some international pain management and drug therapy has come up.

Aims and Objective:

This study aims to evaluate the effect of interventional management through meta-analysis.

Materials and Methods:

Interventional pain management was defined as a direct strategy on nerve through physical or chemical method. Drug therapy was always regarded as control. Potentially relevant articles were searched in PubMed, EMBASE, and the Cochrane Library through key words by consensus. Pain severity was evaluated by a validated visual analog scale (VAS). Moreover, the weighted mean difference was used to calculate pain intensity. Some trails recorded the efficiency rate and odds ratio was used to calculate the effectiveness. Statistical heterogeneity was measured by the value of I², and when statistical I² > 50%, subgroup analysis was used to seek for the source of heterogeneity.

Results:

Pulsed radiofrequency (PRF) combined with medication reduced the VAS scores at 1, 2, 4, and 8 weeks after treatment. The nerve block combined with medication reduced VAS scores at 8 weeks after treatment, but there is no difference between the results of medication alone at 1, 2, and 4 weeks after treatment.

Conclusion:

The interventional mean of PRF combined with medication has a good effect on PHN. The effect of nerve block combined with medication on PHN seems to be the same as that of medication alone. Besides, a long period with high-quality randomized controlled trial should be done to verify the results.

New frontier: cancer pain management clinical fellowship

Cancer pain is a multi-dimensional experience, varies from person to person both physically and psycho-socially, and impacts all aspects of the patients' quality of life. Majority of patients with an advanced or metastatic cancer will experience pain. It is estimated that as many as half of cancer patients are under-treated and as many as 20% experience pain refractory to the conventional WHO ladder of pain management. The McGill University Health Centre (MUHC) Cancer Pain Clinic (CPC) was created to meet the needs of those patients with a diagnosis of cancer whose pain had become a main symptom and those who failed to respond to conventional treatment. The clinic offers a unique interdisciplinary approach with a core team that includes an anesthesiologist, a palliative care physician, a radiation oncologist, a nurse clinician specialist in oncology and palliative care, and, recently, also an interventional radiologist. A cancer pain clinical fellowship was offered for the first time in July 2016. It provides intense training in the classification, epidemiology, pathophysiology, and treatment of cancer pain. Through our education program, the fellow learns to appreciate, weigh, and respond to the full spectrum of factors influencing a specific patient's condition and to develop a tailor-made care plan. To our knowledge, it is the only fellowship program in existence that focuses exclusively on cancer pain. We see it as a beacon and hope that our graduate fellows become professional leaders with a quest not only to provide the best possible care but also to raise awareness of the humanitarian need to control cancer pain.

Interventional Techniques for Management of Pain in Older Adults

Chronic pain in older patients is often treated with pain medications, physical rehabilitation, interventional pain management, and/or psychological interventions. The administration of pain medications is the most common form of chronic pain treatment. Physiologic changes in older adults make them more susceptible to the potential side effects of oral pain medications, especially opioids. Interventional pain management offers an alternative treatment option. This article reviews some of the interventional techniques used to treat the most common sites of pain in older adults: back, knee, and hip.

The Role of Invasive Pain Management Modalities in the Treatment of Chronic Pain

Invasive analgesic therapies provide an alternative to medical management of chronic pain. With the increasing incidence of chronic pain not only in the United States but worldwide, more therapies have evolved to address the growing need for pain relief options. These therapies include spinal injections, nerve blocks, radiofrequency ablation, neurostimulation, and intrathecal drug delivery.

Interventional pain management for spinal disorders: a review of injection techniques

Chronic spinal pain has a high prevalence and a severe economic, societal and health impact. In the last decades the practice and research of interventional techniques for the diagnosis and treatment of spinal pain has increased sharply. The level of evidence of the most common techniques is well documented. With image-guided precise diagnostic blocks it is possible to identify the source of chronic spinal pain in well over 60% of the cases. Nonsurgical specialties such as PM&R increasingly resort to the possibilities of interventional pain management for musculoskeletal disorders. For many forms of spinal pain there is at least fair evidence for long-term pain relief after a guided therapeutic injection often reducing the intake of analgesic medication or the need for surgery. This review focuses on the evidence, the application spectrum and special considerations of injection techniques for the treatment of spinal disorders.