Introduction: S1 root block is performed for pain in the lower limbs due to S1 nerve root inflamm... more Introduction: S1 root block is performed for pain in the lower limbs due to S1 nerve root inflammation at the L5/S1 disc level or compression in the lateral recess. We often note anterior or posterior spread of contrast away from the L5/S1 disc through an anatomically appropriate needle tip placement. We frequently encounter vascular spread when performing S1 root blocks, and the reported incidence varies between 10.4% and 27.8%. There is no clear strategy published to manage these challenges. In such clinical scenarios, we propose a double needle and/or a multilevel needle technique. Case: A 39-year-old male presented with radicular pain in the left S1 distribution which matched the magnetic resonance imaging (MRI) scan findings and thus he was listed for a left S1 root block. A 22G needle was placed at the S1 level and upon injecting the contrast, vascular spread and anterior and distal spread along the nerve root were noted and the contrast did not reach the site of the pathology...
Pain medicine practices vary across different regions within a country and between countries. The... more Pain medicine practices vary across different regions within a country and between countries. The objective of the survey was to study the variation in interventional pain medicine practices in the United Kingdom (UK) and the United States (US). A survey was designed in 2019 on Survey Monkey®. Pain physicians from the UK and the US were invited to respond. A total of 120 responses were received from pain physicians in the UK and 122 from the US. Twenty-six percent and 90% of pain physicians in the UK and US, respectively, are in full-time pain medicine practice. There was marked variation in the utilization of diagnostic medial branch blocks before performing radiofrequency denervation (RFD) between the UK and the US. In the UK, 42% of pain physicians, and 50% in the US, use a 20-gauge or a 22-gauge radiofrequency needle for lumbar RFD. Around 30% to 50% of pain physicians, both in the UK and the US, discontinued antithrombotic agents before medial branch blocks at all the spinal le...
Clinical guidelines are a constructive response to the reality that practicing physicians require... more Clinical guidelines are a constructive response to the reality that practicing physicians require assistance in assimilating and applying the exponentially expanding, often contradictory, body of medical knowledge. They attempt to define practices that meet the needs of most patients under most circumstances. Ideally, specific clinical recommendations contained within practice guidelines are systematically developed by expert panels who have access to all the available evidence, have an understanding of the clinical problem, and have clinical experience with the procedure being assessed, as well as knowledge of relevant research methods. The recent development of American Pain Society (APS) guidelines has created substantial controversy because of their perceived lack of objective analysis and recommendations perceived to be biased due to conflicts of interest. To formally and carefully assess the APS guidelines' evidence synthesis for low back pain for therapeutic interventions...
Background: Pain medicine practices vary across different regions within a country and between co... more Background: Pain medicine practices vary across different regions within a country and between countries. Objectives: The objective of the survey was to study the variation in interventional pain medicine practices in the United Kingdom (UK) and the United States (US). Methods: A survey was designed in 2019 on Survey Monkey®. Pain physicians from the UK and the US were invited to respond. Results: A total of 120 responses were received from pain physicians in the UK and 122 from the US. Twenty-six percent and 90% of pain physicians in the UK and US, respectively, are in full-time pain medicine practice. There was marked variation in the utilization of diagnostic medial branch blocks before performing radiofrequency denervation (RFD) between the UK and the US. In the UK, 42% of pain physicians, and 50% in the US, use a 20-gauge or a 22-gauge radiofrequency needle for lumbar RFD. Around 30% to 50% of pain physicians, both in the UK and the US, discontinued antithrombotic agents before...
BACKGROUND Lumbar facet joints are a well recognized source of low back pain and referred pain in... more BACKGROUND Lumbar facet joints are a well recognized source of low back pain and referred pain in the lower extremity in patients with chronic low back pain. Conventional clinical features and other non-invasive diagnostic modalities are unreliable in diagnosing lumbar zygapophysial joint pain. Controlled diagnostic studies with at least 80% pain relief as the criterion standard have shown the prevalence of lumbar facet joint pain to be 16% to 41% of patients with chronic low back pain without disc displacement or radiculitis, with a false-positive rate of 17% to 49% with a single diagnostic block. STUDY DESIGN A systematic review of the diagnostic accuracy of lumbar facet joint nerve blocks. OBJECTIVE To determine and update the diagnostic accuracy of lumbar facet joint nerve blocks in the assessment of chronic low back pain. METHODS A methodological quality assessment of included studies was performed using Quality Appraisal of Reliability Studies (QAREL). Only diagnostic accuracy...
BACKGROUND The prevalence of chronic, recurrent neck pain is approximately 15% of the adult gener... more BACKGROUND The prevalence of chronic, recurrent neck pain is approximately 15% of the adult general population. Controlled studies have supported the existence of cervical facet or zygapophysial joint pain in 36% to 67% of these patients, when disc herniation, radiculitis, and discogenic are not pathognomic. However, these studies also have shown false-positive results in 27% to 63% of the patients with a single diagnostic block. There is also a paucity of literature investigating therapeutic interventions of cervical facet joint pain. STUDY DESIGN Systematic review of therapeutic cervical facet joint interventions. OBJECTIVE To determine and update the clinical utility of therapeutic cervical facet joint interventions in the management of chronic neck pain. METHODS The available literature for utility of facet joint interventions in therapeutic management of cervical facet joint pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Mus...
BACKGROUND The sacroiliac joint is well known as a cause of low back and lower extremity pain. Pr... more BACKGROUND The sacroiliac joint is well known as a cause of low back and lower extremity pain. Prevalence estimates are 10% to 25% in patients with persistent axial low back pain without disc herniation, discogenic pain, or radiculitis based on multiple diagnostic studies and systematic reviews. However, at present there are no definitive management options for treating sacroiliac joint pain. OBJECTIVE To evaluate the diagnostic accuracy and therapeutic effectiveness of sacroiliac joint interventions. STUDY DESIGN A systematic review of the diagnostic accuracy and therapeutic effectiveness of sacroiliac joint interventions. METHODS The available literature on diagnostic and therapeutic sacroiliac joint interventions was reviewed. The quality assessment criteria utilized were the Quality Appraisal of Reliability Studies (QAREL) checklist for diagnostic accuracy studies, Cochrane review criteria to assess sources of risk of bias, and Interventional Pain Management Techniques-Quality A...
BACKGROUND The re-engineered definition of clinical guidelines in 2011 from the IOM (Institute of... more BACKGROUND The re-engineered definition of clinical guidelines in 2011 from the IOM (Institute of Medicine) states, "clinical practice guidelines are statements that include recommendations intended to optimize patient care that is informed by a systematic review of evidence and an assessment of the benefit and harms of alternative care options." The revised definition distinguishes between the term "clinical practice guideline" and other forms of clinical guidance derived from widely disparate development processes, such as consensus statements, expert advice, and appropriate use criteria. OBJECTIVE To assess the literature and develop methodology for evidence synthesis and development of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. METHODS A systematic review of the literature including methodology of guideline development encompassing GRADE approach for guidance on evidence synthesis with recommendations. RESULT...
BACKGROUND Among the multiple interventions used in managing chronic spinal pain, lumbar epidural... more BACKGROUND Among the multiple interventions used in managing chronic spinal pain, lumbar epidural injections have been used extensively to treat lumbar radicular pain. Among caudal, interlaminar, and transforaminal, transforaminal epidural injections have gained rapid and widespread acceptance for the treatment of lumbar and lower extremity pain. The potential advantages of transforaminal over interlaminar and caudal, include targeted delivery of a steroid to the site of pathology, presumably onto an inflamed nerve root. However, there are only a few well-designed, randomized, controlled studies on the effectiveness of steroid injections. Consequently, multiple systematic reviews with diverse opinions have been published. STUDY DESIGN A systematic review of therapeutic transforaminal epidural injection therapy for low back and lower extremity pain. OBJECTIVE To evaluate the effect of therapeutic transforaminal lumbar epidural steroid injections in managing low back and lower extremi...
Introduction: S1 root block is performed for pain in the lower limbs due to S1 nerve root inflamm... more Introduction: S1 root block is performed for pain in the lower limbs due to S1 nerve root inflammation at the L5/S1 disc level or compression in the lateral recess. We often note anterior or posterior spread of contrast away from the L5/S1 disc through an anatomically appropriate needle tip placement. We frequently encounter vascular spread when performing S1 root blocks, and the reported incidence varies between 10.4% and 27.8%. There is no clear strategy published to manage these challenges. In such clinical scenarios, we propose a double needle and/or a multilevel needle technique. Case: A 39-year-old male presented with radicular pain in the left S1 distribution which matched the magnetic resonance imaging (MRI) scan findings and thus he was listed for a left S1 root block. A 22G needle was placed at the S1 level and upon injecting the contrast, vascular spread and anterior and distal spread along the nerve root were noted and the contrast did not reach the site of the pathology...
Pain medicine practices vary across different regions within a country and between countries. The... more Pain medicine practices vary across different regions within a country and between countries. The objective of the survey was to study the variation in interventional pain medicine practices in the United Kingdom (UK) and the United States (US). A survey was designed in 2019 on Survey Monkey®. Pain physicians from the UK and the US were invited to respond. A total of 120 responses were received from pain physicians in the UK and 122 from the US. Twenty-six percent and 90% of pain physicians in the UK and US, respectively, are in full-time pain medicine practice. There was marked variation in the utilization of diagnostic medial branch blocks before performing radiofrequency denervation (RFD) between the UK and the US. In the UK, 42% of pain physicians, and 50% in the US, use a 20-gauge or a 22-gauge radiofrequency needle for lumbar RFD. Around 30% to 50% of pain physicians, both in the UK and the US, discontinued antithrombotic agents before medial branch blocks at all the spinal le...
Clinical guidelines are a constructive response to the reality that practicing physicians require... more Clinical guidelines are a constructive response to the reality that practicing physicians require assistance in assimilating and applying the exponentially expanding, often contradictory, body of medical knowledge. They attempt to define practices that meet the needs of most patients under most circumstances. Ideally, specific clinical recommendations contained within practice guidelines are systematically developed by expert panels who have access to all the available evidence, have an understanding of the clinical problem, and have clinical experience with the procedure being assessed, as well as knowledge of relevant research methods. The recent development of American Pain Society (APS) guidelines has created substantial controversy because of their perceived lack of objective analysis and recommendations perceived to be biased due to conflicts of interest. To formally and carefully assess the APS guidelines' evidence synthesis for low back pain for therapeutic interventions...
Background: Pain medicine practices vary across different regions within a country and between co... more Background: Pain medicine practices vary across different regions within a country and between countries. Objectives: The objective of the survey was to study the variation in interventional pain medicine practices in the United Kingdom (UK) and the United States (US). Methods: A survey was designed in 2019 on Survey Monkey®. Pain physicians from the UK and the US were invited to respond. Results: A total of 120 responses were received from pain physicians in the UK and 122 from the US. Twenty-six percent and 90% of pain physicians in the UK and US, respectively, are in full-time pain medicine practice. There was marked variation in the utilization of diagnostic medial branch blocks before performing radiofrequency denervation (RFD) between the UK and the US. In the UK, 42% of pain physicians, and 50% in the US, use a 20-gauge or a 22-gauge radiofrequency needle for lumbar RFD. Around 30% to 50% of pain physicians, both in the UK and the US, discontinued antithrombotic agents before...
BACKGROUND Lumbar facet joints are a well recognized source of low back pain and referred pain in... more BACKGROUND Lumbar facet joints are a well recognized source of low back pain and referred pain in the lower extremity in patients with chronic low back pain. Conventional clinical features and other non-invasive diagnostic modalities are unreliable in diagnosing lumbar zygapophysial joint pain. Controlled diagnostic studies with at least 80% pain relief as the criterion standard have shown the prevalence of lumbar facet joint pain to be 16% to 41% of patients with chronic low back pain without disc displacement or radiculitis, with a false-positive rate of 17% to 49% with a single diagnostic block. STUDY DESIGN A systematic review of the diagnostic accuracy of lumbar facet joint nerve blocks. OBJECTIVE To determine and update the diagnostic accuracy of lumbar facet joint nerve blocks in the assessment of chronic low back pain. METHODS A methodological quality assessment of included studies was performed using Quality Appraisal of Reliability Studies (QAREL). Only diagnostic accuracy...
BACKGROUND The prevalence of chronic, recurrent neck pain is approximately 15% of the adult gener... more BACKGROUND The prevalence of chronic, recurrent neck pain is approximately 15% of the adult general population. Controlled studies have supported the existence of cervical facet or zygapophysial joint pain in 36% to 67% of these patients, when disc herniation, radiculitis, and discogenic are not pathognomic. However, these studies also have shown false-positive results in 27% to 63% of the patients with a single diagnostic block. There is also a paucity of literature investigating therapeutic interventions of cervical facet joint pain. STUDY DESIGN Systematic review of therapeutic cervical facet joint interventions. OBJECTIVE To determine and update the clinical utility of therapeutic cervical facet joint interventions in the management of chronic neck pain. METHODS The available literature for utility of facet joint interventions in therapeutic management of cervical facet joint pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Mus...
BACKGROUND The sacroiliac joint is well known as a cause of low back and lower extremity pain. Pr... more BACKGROUND The sacroiliac joint is well known as a cause of low back and lower extremity pain. Prevalence estimates are 10% to 25% in patients with persistent axial low back pain without disc herniation, discogenic pain, or radiculitis based on multiple diagnostic studies and systematic reviews. However, at present there are no definitive management options for treating sacroiliac joint pain. OBJECTIVE To evaluate the diagnostic accuracy and therapeutic effectiveness of sacroiliac joint interventions. STUDY DESIGN A systematic review of the diagnostic accuracy and therapeutic effectiveness of sacroiliac joint interventions. METHODS The available literature on diagnostic and therapeutic sacroiliac joint interventions was reviewed. The quality assessment criteria utilized were the Quality Appraisal of Reliability Studies (QAREL) checklist for diagnostic accuracy studies, Cochrane review criteria to assess sources of risk of bias, and Interventional Pain Management Techniques-Quality A...
BACKGROUND The re-engineered definition of clinical guidelines in 2011 from the IOM (Institute of... more BACKGROUND The re-engineered definition of clinical guidelines in 2011 from the IOM (Institute of Medicine) states, "clinical practice guidelines are statements that include recommendations intended to optimize patient care that is informed by a systematic review of evidence and an assessment of the benefit and harms of alternative care options." The revised definition distinguishes between the term "clinical practice guideline" and other forms of clinical guidance derived from widely disparate development processes, such as consensus statements, expert advice, and appropriate use criteria. OBJECTIVE To assess the literature and develop methodology for evidence synthesis and development of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. METHODS A systematic review of the literature including methodology of guideline development encompassing GRADE approach for guidance on evidence synthesis with recommendations. RESULT...
BACKGROUND Among the multiple interventions used in managing chronic spinal pain, lumbar epidural... more BACKGROUND Among the multiple interventions used in managing chronic spinal pain, lumbar epidural injections have been used extensively to treat lumbar radicular pain. Among caudal, interlaminar, and transforaminal, transforaminal epidural injections have gained rapid and widespread acceptance for the treatment of lumbar and lower extremity pain. The potential advantages of transforaminal over interlaminar and caudal, include targeted delivery of a steroid to the site of pathology, presumably onto an inflamed nerve root. However, there are only a few well-designed, randomized, controlled studies on the effectiveness of steroid injections. Consequently, multiple systematic reviews with diverse opinions have been published. STUDY DESIGN A systematic review of therapeutic transforaminal epidural injection therapy for low back and lower extremity pain. OBJECTIVE To evaluate the effect of therapeutic transforaminal lumbar epidural steroid injections in managing low back and lower extremi...
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