Comparative Analysis of Utilization of Epidural Procedures in Managing Chronic Pain in the Medicare Population: Pre and Post Affordable Care Act

An update on epidural steroid injections: is there still a role for particulate corticosteroids?

Epidural steroid injections (ESIs) play an important role in the multifaceted management of neck and back pain. Corticosteroid preparations used in ESIs may be considered "particulate" or "non-particulate" based on whether they form a crystalline suspension or a soluble clear solution, respectively. In the past two decades, there have been reports of rare but severe and permanent neurological complications as a result of ESI. These complications have principally occurred with particulate corticosteroid preparations when using a transforaminal injection technique at cervical or thoracic levels, and only rarely in the lumbosacral spine. As a result, some published clinical guidelines and recommendations have advised against the use of particulate corticosteroids for transforaminal ESI, and the FDA introduced a warning label for injectable corticosteroids regarding the risk of serious neurological adverse events. There is growing evidence that the efficacy of non-particulate corticosteroids for pain relief and functional improvement after ESI is non-inferior to particulate agents, and that non-particulate injections almost never result in permanent neurological injury. Despite this, particulate corticosteroids continue to be routinely used for transforaminal epidural injections. More consistent clinical guidelines and societal recommendations are required alongside increased awareness of the comparative efficacy of non-particulate agents among specialists who perform ESIs. The current role for particulate corticosteroids in ESIs should be limited to caudal and interlaminar approaches, or transforaminal injections in the lumbar spine only if initial non-particulate ESI resulted in a significant but short-lived improvement.

The Influence of COVID-19 on Utilization of Epidural Procedures in Managing Chronic Spinal Pain in the Medicare Population

STUDY DESIGN

A retrospective cohort study of utilization patterns and variables of epidural injections in the fee-for-service (FFS) Medicare population.

OBJECTIVES

To update the utilization of epidural injections in managing chronic pain in the FFS Medicare population, from 2000 to 2020, and assess the impact of COVID-19.

SUMMARY OF BACKGROUND DATA

The analysis of the utilization of interventional techniques also showed an annual decrease of 2.5% per 100,000 FFS Medicare enrollees from 2009 to 2018, contrasting to an annual increase of 7.3% from 2000 to 2009. The impact of the COVID-19 pandemic has not been assessed.

METHODS

This analysis was performed by utilizing master data from the Centers for Medicare and Medicaid Services, physician/supplier procedure summary from 2000 to 2020. The analysis was performed by the assessment of utilization patterns using guidance from Strengthening the Reporting of Observational Studies in Epidemiology.

RESULTS

Epidural procedures declined at a rate of 19% per 100,000 Medicare enrollees in the FFS Medicare population in the United States from 2019 to 2020, with an annual decline of 3% from 2010 to 2019. From 2000 to 2010, there was an annual increase of 8.3%. This analysis showed a decline in all categories of epidural procedures from 2019 to 2020. The major impact of COVID-19, with closures taking effect from April 1, 2020, through December 31, 2020, will be steeper and rather dramatic compared with April 1 to December 31, 2019. However, monthly data from the Centers for Medicare and Medicaid Services is not available as of now. Overall declines from 2010 to 2019 showed a decrease for cervical and thoracic transforaminal injections with an annual decrease of 5.6%, followed by lumbar interlaminar and caudal epidural injections of 4.9%, followed by 1.8% for lumbar/sacral transforaminal epidurals, and 0.9% for cervical and thoracic interlaminar epidurals.

CONCLUSION

Declining utilization of epidural injections in all categories was exacerbated to a decrease of 19% from 2019 to 2020, related, in part, to the COVID-19 pandemic. This followed declining patterns of epidural procedures of 3% overall annually from 2010 to 2019.

Percutaneous fully endoscopic surgical management of the ruptured epidural catheter: Rescue of the novice anesthesiologist from his dilemma

BACKGROUND

Epidural nerve block and analgesia are basic anesthetic techniques for anesthesia. Epidural catheter rupture and partial retention are adverse events and rare complications of epidural catheterization technique. The probability of occurrence when applied by novice doctors is high. Removal of the residual catheter by conventional surgery causes more trauma and bleeding, slows recovery, and may causes medical disputes. We hypothesized that percutaneous spinal endoscopy a safe and effective remediation technique. This study was to analyze the efficacy and safety of removing the residual dural catheter by a percutaneous full-endoscopic technique(PFET) and discuss the clinical technique and precautions.

METHODS

This was a retrospective analysis of 7 patients with ruptured epidural catheters treated in our department from October 2015 to October 2019 using the PFET to remove the remaining epidural catheter. The operation time, intraoperative bleeding volume, surgical complications, and neurological symptoms before and after surgery were recorded. The Self-Rating Anxiety Scale (SAS) was used to assess the anxiety level of the anesthesiologist and the patient before and after the catheter removal operation, and the postoperative low back pain VAS score was recorded.

RESULTS

The remaining epidural catheter was successfully removed from all 7 patients. The operation time was 54.14 ± 14.45 (32-78) minutes, and the intraoperative blood loss was 9.134 ± 3.078 (5-15) ml. There were no cases of dural damage, cerebrospinal fluid leakage, sensorimotor dysfunction of the lower limbs, or bowel dysfunction. The anxiety symptoms of the patient and the anesthesiologist disappeared after removal of the residual epidural catheter. The patients' postoperative back pain VAS score was 0 to 2 points.

CONCLUSION

PFET is a safe and effective minimally invasive technique for removing residual epidural catheters. It causes less trauma and less bleeding, allows a faster recovery. It does not affect the recovery of patients from other surgical operations and reduces both medical risks and medical costs. At the same time, it avoids or reduces the occurrence of medical disputes and eliminates the pressure on novice anesthesiologists regarding similar adverse events.

Intradiscal oxygen-ozone chemonucleolysis versus microdiscectomy for lumbar disc herniation radiculopathy: a non-inferiority randomized control trial

BACKGROUND CONTEXT

Low back pain with or without radicular leg pain is an extremely common health condition significantly impacting patient's activities and quality of life. When conservative management fails, epidural injections providing only temporary relief, are frequently utilized. Intradiscal oxygen-ozone may offer an alternative to epidural injections and further reduce the need for microdiscectomy.

PURPOSE

To compare the non-inferiority treatment status and clinical outcomes of intradiscal oxygen-ozone with microdiscectomy in patients with refractory radicular leg pain due to single-level contained lumbar disc herniations.

STUDY DESIGN / SETTING

Multicenter pilot prospective non-inferiority blocked randomized control trial conducted in three European hospital spine centers.

PATIENT SAMPLE

Forty-nine patients (mean 40 years of age, 17 females/32 males) with a single-level contained lumbar disc herniation, radicular leg pain for more than six weeks, and resistant to medical management were randomized, 25 to intradiscal oxygen-ozone and 24 to microdiscectomy. 88% (43 of 49) received their assigned treatment and constituted the AS-Treated (AT) population.

OUTCOME MEASURES

Primary outcome was overall 6-month improvement over baseline in leg pain. Other validated clinical outcomes, including back numerical rating pain scores (NRS), Roland Morris Disability Index (RMDI) and EQ-5D, were collected at baseline, 1 week, 1-, 3-, and 6-months. Procedural technical outcomes were recorded and adverse events were evaluated at all follow-up intervals.

METHODS

Oxygen-ozone treatment performed as outpatient day surgeries, included a one-time intradiscal injection delivered at a concentration of 35±3 μg/cc of oxygen-ozone by a calibrated delivery system. Discectomies performed as open microdiscectomy inpatient surgeries, were without spinal instrumentation, and not as subtotal microdiscectomies. Primary analyses with a non-inferiority margin of -1.94-point difference in 6-month cumulative weighted mean leg pain NRS scores were conducted using As-Treated (AT) and Intent-to-Treat (ITT) populations. In post hoc analyses, differences between treatment groups in improvement over baseline were compared at each follow-up visit, using baseline leg pain as a covariate.

RESULTS

In the primary analysis, the overall 6-month difference between treatment groups in leg pain improvement using the AT population was -0.31 (SE, 0.84) points in favor of microdiscectomy and using the ITT population, the difference was 0.32 (SE, 0.88) points in favor of oxygen-ozone. The difference between oxygen-ozone and microdiscectomy did not exceed the non-inferiority 95% confidence lower limit of treatment difference in either the AT (95% lower limit, -1.72) or ITT (95% lower limit, -1.13) populations. Both treatments resulted in rapid and statistically significant improvements over baseline in leg pain, back pain, RMDI, and EQ-5D that persisted in follow-up. Between group differences were not significant for any outcomes. During 6-month follow-up, 71% (17 of 24) of patients receiving oxygen-ozone, avoided microdiscectomy. The mean procedure time for oxygen-ozone was significantly faster than microdiscectomy by 58 minutes (p<.0010) and the mean discharge time from procedure was significantly shorter for the oxygen-ozone procedure (4.3±2.9 hours vs. 44.2±29.9 hours, p<.001). No major adverse events occurred in either treatment group.

CONCLUSIONS

Intradiscal oxygen-ozone chemonucleolysis for single-level lumbar disc herniations unresponsive to medical management, met the non-inferiority criteria to microdiscectomy on 6-month mean leg pain improvement. Both treatment groups achieved similar rapid significant clinical improvements that persisted and overall, 71% undergoing intradiscal oxygen-ozone were able to avoid surgery.

Effectiveness of plasma rich in growth factors in the management of chronic spinal pain: a case series of 32 patients

Background: This prospective, case-series study aimed to assess the clinical effectiveness of plasma rich in growth factors (PRGF) in patients with chronic low back pain (LBP) and to identify the features of the responsive patients. Materials & methods: PRGF was injected into the intervertebral disc, epidural space and/or facet and sacroiliac joints of 32 patients with chronic LBP. The efficacy of the treatment was assessed by algo-functional scores after 3 and 6 months. Results: Overall, the patients did not ameliorate after PRGF treatment, although eight patients showed an algo-functional improvement. They were mainly males treated at two sites who were younger, less sedentary and with fewer musculoskeletal co-morbidities than the nonresponders. Conclusion: PRGF is a potential treatment in a specific subpopulation of difficult-to-treat patients affected by chronic LBP.

Epidural Steroid Injections for Low Back Pain: A Narrative Review

Low back pain represents a significant socioeconomic burden. Several nonsurgical medical treatments have been proposed for the treatment of this disabling condition. Epidural steroid injections (ESIs) are commonly used to treat lumbosacral radicular pain and to avoid surgery. Even though it is still not clear which type of conservative intervention is superior, several studies have proved that ESIs are able to increase patients' quality of life, relieve lumbosacral radicular pain and finally, reduce or delay more invasive interventions, such as spinal surgery. The aim of this narrative review is to analyze the mechanism of action of ESIs in patients affected by low back pain and investigate their current application in treating this widespread pathology.

Multicenter study evaluating factors associated with treatment outcome for low back pain injections

BACKGROUND

There has been a worldwide surge in interventional procedures for low back pain (LBP), with studies yielding mixed results. These data support the need for identifying outcome predictors based on unique characteristics in a pragmatic setting.

METHODS

We prospectively evaluated the association between over two dozen demographic, clinical and technical factors on treatment outcomes for three procedures: epidural steroid injections (ESIs) for sciatica, and sacroiliac joint (SIJ) injections and facet interventions for axial LBP. The primary outcome was change in patient-reported average pain intensity on a numerical rating scale (average NRS-PI) using linear regression. For SIJ injections and facet radiofrequency ablation, this was average LBP score at 1 and 3 months postprocedure, respectively. For ESI, it was average leg pain 1- month postinjection. Secondary outcomes included a binary indicator of treatment response (success).

RESULTS

346 patients were enrolled at seven hospitals. All groups experienced a decrease in average NRS-PI (p<0.0001; mean 1.8±2.6). There were no differences in change in average NRS-PI among procedural groups (p=0.50). Lower baseline pain score (adjusted coefficient -0.32, 95% CI -0.48 to -0.16, p<0.0001), depressive symptomatology (adjusted coefficient 0.076, 95% CI 0.039 to 0.113, p<0.0001) and obesity (adjusted coefficient 0.62, 95% CI 0.038 to 1.21, p=0.037) were associated with smaller pain reductions. For procedural outcome, depression (adjusted OR 0.94, 95% CI 0.91, 0.97, p<0.0001) and poorer baseline function (adjusted OR 0.59, 95% CI 0.36, 0.96, p=0.034) were associated with failure. Smoking, sleep dysfunction and non-organic signs were associated with negative outcomes in univariate but not multivariate analyses.

CONCLUSIONS

Identifying treatment responders is a critical endeavor for the viability of procedures in LBP. Patients with greater disease burden, depression and obesity are more likely to fail interventions. Steps to address these should be considered before or concurrent with procedures as considerations dictate.

TRIAL REGISTRATION NUMBER

NCT02329951.

Efficacy of Radiofrequency Neurotomy in Chronic Low Back Pain: A Systematic Review and Meta-Analysis

Purpose

The objective of the systematic review and meta-analysis is to evaluate the efficacy of radiofrequency neurotomy as a therapeutic lumbar facet joint intervention.

Patients and Methods

Utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, a systematic review and meta-analysis was performed. A comprehensive literature search of multiple data sources from 1966 to September 2020 including manual searches of bibliography of known review articles was performed. The inclusion criteria were based on the selection of patients with chronic low back pain with diagnosis confirmed based on controlled diagnostic blocks and with the publication of at least 6 months of results of appropriate outcome parameters. Quality assessment of the trials was performed with Cochrane review criteria and interventional pain management techniques-quality appraisal of reliability and risk of bias assessment (IPM-QRB). The level of evidence of effectiveness is classified at five levels ranging from Level I to Level V. The primary outcome measure was a significant reduction in pain, eg, short term (up to 6 months) and long term (more than 6 months). The secondary outcome measure was an improvement in functional status.

Results

A total of 12 randomized controlled trials (RCTs) met the inclusion criteria for evaluating the efficacy of lumbar radiofrequency neurotomy. Radiofrequency neurotomy showed Level II evidence for efficacy for both the short term and long term.

Conclusion

This systematic review of the assessment of the efficacy of radiofrequency neurotomy in managing chronic low back pain was based on the inclusion of 12 RCTs with a diagnostic block and at least 6 months of follow-up results that showed Level II evidence for both short-term and long-term improvement.

Safety of Epidural Steroid Injections for Lumbosacral Radicular Pain: Unmet Medical Need

OBJECTIVE

Epidural steroid injections (ESIs) are a commonly utilized treatment for lumbosacral radicular pain caused by intervertebral disc herniation or stenosis. Although effective in certain patient populations, ESIs have been associated with serious complications, including paralysis and death. In 2014, the US Food and Drug Administration (FDA) issued a safety warning on the risk of injecting corticosteroids into the epidural space. The aims of this article were to review the neurological complications associated with ESIs and to compare the formulations, safety, and effectiveness of commercially available corticosteroids given by transforaminal, interlaminar, or caudal injection.

METHODS

Serious adverse events associated with ESIs were identified by a search of the FDA Adverse Event Reporting System (FAERS) database. A MEDLINE search of the literature was conducted to identify clinical trials comparing the safety and effectiveness of nonparticulate and particulate corticosteroid formulations.

RESULTS

Neurological complications with ESIs were rare and more often associated with the use of particulate corticosteroids administered by transforaminal injection. Among the 10 comparative-effectiveness studies reviewed, 7 found nonparticulate steroids had comparable efficacy to particulate steroids, and 3 studies suggested reduced efficacy or shorter duration of effect for nonparticulate steroids.

DISCUSSION

The risk of complications for transforaminal ESI is greater with particulate corticosteroids. Nonparticulate corticosteroids, which are often recommended as first-line therapy, may have a short duration of effect, and many commercial formulations contain neurotoxic preservatives. The safety profile of ESIs may continue to improve with the development of safer, sterile formulations that reduce the risk of complications while maintaining efficacy.

Changes in racial and ethnic disparities in lumbar spinal surgery associated with the passage of the Affordable Care Act, 2006-2014

BACKGROUND CONTEXT

Since implementation of the Patient Protection and Affordable Care Act (ACA) in 2010, more Americans have health insurance, and many racial/ethnic disparities in healthcare have improved. We previously reported that Black and Hispanic patients undergo surgery for spinal stenosis at lower rates than do white patients.

PURPOSE

To assess changes in racial/ethnic disparities in rates of lumbar spinal surgery after passage of the ACA.

STUDY DESIGN

Retrospective analysis.

PATIENT SAMPLE

Approximately 3.2 million adults who underwent lumbar spinal surgery in the US from 2006 through 2014.

OUTCOME MEASURES

Racial disparities in discharge rates before versus after ACA passage.

METHODS

Using the Nationwide Inpatient Sample, the U.S. Census Bureau Current Population Survey Supplement, and International Classification of Diseases, Ninth Revision, Clinical Modification, criteria for definite lumbar spinal surgery, we calculated rates of lumbar spinal surgery as the number of hospital discharges divided by population estimates and stratified patients by race/ethnicity after controlling for sociodemographic characteristics. Calendar years were stratified as before ACA passage (2006-2010) or after ACA passage (2011-2014). Poisson regression was used to model hospital discharge rates as a function of race/ethnicity before and after ACA passage after adjustment for potential confounders.

RESULTS

All rates are expressed per 1,000 persons. The overall median discharge rate decreased from 1.9 before ACA passage to 1.6 after ACA passage (p < .001). After adjustment for sociodemographic factors, the Black:White disparity in discharge rates decreased from 0.40:1 before ACA to 0.44:1 after ACA (p < .001). A similar decrease in the Hispanic:White disparity occurred, from 0.35:1 before ACA to 0.38:1 after ACA (p < .001).

CONCLUSION

Small but significant decreases occurred in racial/ethnic disparities in hospital discharge rates for lumbar spinal surgery after ACA passage.

Epidural Corticosteroid Injections for Sciatica: An Abridged Cochrane Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic with meta-analysis OBJECTIVES.: The aim of this study was to investigate the efficacy and safety of epidural corticosteroid injections compared with placebo injection in reducing leg pain and disability in patients with sciatica.

SUMMARY OF BACKGROUND DATA

Conservative treatments, including pharmacological and nonpharmacological treatments, are typically the first treatment options for sciatica but the evidence to support their use is limited. The overall quality of evidence found by previous systematic reviews varies between moderate and high, which suggests that future trials may change the conclusions. New placebo-controlled randomized trials have been published recently which highlights the importance of an updated systematic review.

METHODS

The searches were performed without language restrictions in the following databases from 2012 to 25 September 2019: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PubMed, Embase, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and trial registers. We included placebo-controlled randomized trials investigating epidural corticosteroid injections in patients with sciatica. The primary outcomes were leg pain intensity and disability. The secondary outcomes were adverse events, overall pain, and back pain intensity. We grouped similar trials according to outcome measures and their respective follow-up time points. Short-term follow-up (>2 weeks but ≤3 months) was considered the primary follow-up time point due to the expected mechanism of action of epidural corticosteroid injection. Weighted mean differences (MDs) and risk ratios (RRs) with their respective 95% confidence intervals (CIs) were estimated. We assessed the overall quality of evidence using the GRADE approach and conducted the analyses using random effects.

RESULTS

We included 25 clinical trials (from 29 publications) providing data for a total of 2470 participants with sciatica, an increase of six trials when compared to the previous review. Epidural corticosteroid injections were probably more effective than placebo in reducing short-term leg pain (MD -4.93, 95% CI -8.77 to -1.09 on a 0-100 scale), short-term disability (MD -4.18, 95% CI: -6.04 to -2.17 on a 0-100 scale) and may be slightly more effective in reducing short-term overall pain (MD -9.35, 95% CI -14.05 to -4.65 on a 0-100 scale). There were mostly minor adverse events (i.e., without hospitalization) after epidural corticosteroid injections and placebo injections without difference between groups (RR 1.14, 95% CI: 0.91-1.42). The quality of evidence was at best moderate mostly due to problems with trial design and inconsistency.

CONCLUSION

A review of 25 placebo-controlled trials provides moderate-quality evidence that epidural corticosteroid injections are effective, although the effects are small and short-term. There is uncertainty on safety due to very low-quality evidence.

LEVEL OF EVIDENCE

1.

Clinical Effectiveness and Mechanism of Action of Spinal Cord Stimulation for Treating Chronic Low Back and Lower Extremity Pain: a Systematic Review

PURPOSE OF REVIEW

The purpose of the present systematic review is to provide a current understanding of the mechanism of action and the evidence available to support clinical decision-making. The focus is to summarize randomized controlled trials (RCTs) and nonrandomized or observational studies of spinal cord stimulation in chronic pain to understand clinical effectiveness and the mechanism of action.

RECENT FINDINGS

Several recent studies have demonstrated the benefit of spinal cord stimulation in managing chronic pain. Until recently, the mechanism of action was founded on a central paradigm derived from gate control theory, which is the need to stimulate the dorsal column of the spinal cord to generate paresthesia. The recent development of new therapies that do not rely on paresthesia has left the field without a clear mechanism of action that could serve as a strong foundation to further improve clinical outcomes. Consequently, multiple theories have emerged to explain how electrical pulse applied to the spinal cord could alleviate pain, including activation of specific supraspinal pathways, and segmental modulation of the neurological interaction. Recent systematic reviews also have shown the clinical effectiveness of spinal cord stimulation in managing chronic spinal pain, phantom limb pain, complex regional pain syndrome, and other chronic painful conditions. Spinal cord stimulation for the treatment of chronic pain is rapidly evolving with technology at its forefront. This comprehensive focused review evaluated 11 RCTs and 7 nonrandomized/observational studies which provided levels of evidence ranging from I to II.

Current Concepts of Minimally Invasive Treatment Options for Plantar Fasciitis: a Comprehensive Review

PURPOSE OF REVIEW

Chronic foot pain constitutes a large portion of the chronic pain burden in the overall population. Plantar fasciitis is one of the most common and most easily identifiable causes of chronic foot pain. The syndrome has been estimated to cause 11 to 15% of foot pain visits, requiring professional care. Moreover, studies have suggested that 1 in 10 people will develop plantar fasciitis at some point in their life. Conservative management has been shown to be effective and considered first-line treatment. Minimally invasive treatment options are typically reserved for those who fail conservative management. With the advent of new techniques and improvements in current therapeutic options, there has been an expansion of available minimally invasive treatment options. The purpose of this review is to provide a comprehensive update on the current understanding of minimally invasive treatments of plantar fasciitis.

RECENT FINDINGS

This review shows that conservative management continues to be the first-line therapy, whereas other treatment options were those who failed conservative management using modern techniques that have shown improving effectiveness, with successful restoration of patient functionality, recovery, and satisfaction. However, a multitude of these minimally invasive treatment options are evolving.

CONCLUSION

While conservative management continues to be the mainstay of treatment for plantar fasciitis, multiple minimally invasive treatment options are emerging with potential effectiveness in reducing pain and improving the function.

A Comprehensive Review of the Treatment and Management of Myofascial Pain Syndrome

PURPOSE OF REVIEW

Myofascial pain syndrome (MPS) is a musculoskeletal pain condition that stems from localized, taut regions of skeletal muscle and fascia, termed trigger points. The purpose of this comprehensive review is to provide updated information on prevalence, pathophysiology, and treatment modalities with a focus on interventional modalities in managing MPS.

RECENT FINDINGS

Though MPS can present acutely, it frequently presents as a chronic condition, affecting up to 85% of adults during their lifetime. MPS is an often-overlooked component of pain with overarching effects on society, including patient quality of life, physical and social functioning, emotional well-being, energy, and costs on health care. The prevalence of MPS is generally increased among patients with other chronic pain disorders and has been associated with various other conditions such as bladder pain syndrome, endometriosis, and anxiety. MPS is poorly understood and remains a challenging condition to treat. Non-pharmacologic treatment modalities such as acupuncture, massage, transcutaneous electrical stimulation, and interferential current therapy may offer relief to some patients with MPS. Additional studies are warranted to get a better understanding of managing myofascial pain.

A Comprehensive Review of the Celiac Plexus Block for the Management of Chronic Abdominal Pain

PURPOSE OF REVIEW

Chronic abdominal pain (CAP) is a significant health problem that can dramatically affect quality of life and survival. Pancreatic cancer is recognized as one of the most painful malignancies with 70-80% suffering from substantial pain, often unresponsive to typical medical management. Celiac plexus neurolysis and celiac plexus block (CPB) can be performed to mitigate pain through direct destruction or blockade of visceral afferent nerves. The objective of this manuscript is to provide a comprehensive review of the CPB as it pertains to CAP with a focus on the associated anatomy, indications, techniques, neurolysis/blocking agents, and complications observed in patients who undergo CPB for the treatment of CAP.

RECENT FINDINGS

The CAP is difficult to manage due to lack of precision in diagnosis and limited evidence from available treatments. CAP can arise from both benign and malignant causes. Treatment options include pharmacologic, interventional, and biopsychosocial treatments. Opioid therapy is typically utilized for the treatment of CAP; however, opioid therapy is associated with multiple complications. CPB has successfully been used to treat a variety of conditions resulting in CAP. The majority of the literature specifically related to CPB is surrounding chronic pain associated with pancreatic cancer. The literature shows emerging evidence in managing CAP with CPB, specifically in pancreatic cancer. This review provides multiple aspects of CAP and CPB, including anatomy, medical necessity, indications, technical considerations, available evidence, and finally complications related to the management.

The Role of the Cannabinoid System in Pain Control: Basic and Clinical Implications

PURPOSE OF REVIEW

The purpose of this review is to provide a comprehensive update of the different known components of the endogenous cannabinoid system and the mechanisms of action, as it applies to analgesia.

RECENT FINDINGS

Following the discovery of the endogenous cannabinoid system in the early 1990s and the subsequent characterization of the cannabinoid receptor, there has been a renewed interest in cannabinoid research. Recent work has demonstrated its efficacy as a pharmacologic agent. There is limited evidence in the literature about the understanding of the endocannabinoid system and its role in the treatment and management of acute and chronic pain. Further work may elucidate additional roles for the endocannabinoid system within our nervous system and, moreover, additional subtypes of cannabinoid receptors have yet to be discovered. Cannabinoid compounds mediate their biological effects via binding and subsequent activation of cannabinoid receptors. These receptors are located throughout the body and make up the endocannabinoid system. These receptors are best understood and have been cloned, type 1 (CB₁) and type 2 (CB₂) [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)]. The CB₂ receptor is located primarily in the immune system. CB₁ receptors are primarily located in the nervous system with the highest concentrations in the brain and lower concentrations in the spine and peripheral nervous tissues. Cannabinoids may be promising treatments for neuropathic pain with limited evidence, whereas, the evidence for other uses is insufficient.

Is Percutaneous Adhesiolysis Effective in Managing Chronic Low Back and Lower Extremity Pain in Post-surgery Syndrome: a Systematic Review and Meta-analysis

PURPOSE OF REVIEW

The growing prevalence of spinal pain in the USA continues to produce substantial economic impact and strain on health-related quality of life. Percutaneous adhesiolysis is utilized for recalcitrant, resistant conditions involving spinal pain when epidural injections have failed to provide adequate improvement, especially low back and lower extremity pain, specifically in post-lumbar surgery syndrome. Despite multiple publications and systematic reviews, the debate continues in reference to effectiveness, safety, appropriate utilization, and medical necessity of percutaneous adhesiolysis in chronic pain. This systematic review, therefore, was undertaken to evaluate and to update effectiveness of percutaneous adhesiolysis to treat chronic refractory low back and lower extremity pain, post-surgical patients of the lumbar spine.

RECENT FINDINGS

From 2009 to 2016, there was a decline of 53.2% utilization of percutaneous adhesiolysis with an annual decline of 10.3% per 100,000 fee-for-service (FFS) Medicare population. Multiple insurers, including Medicare, with Medicare area contractors of Noridian and Palmetto have issued noncoverage policies for percutaneous adhesiolysis resulting in these steep declines and continued noncoverage by Medicare Advantage plans, Managed Care plans of Medicaid, and other insurers. Since 2005, 4 systematic reviews of percutaneous adhesiolysis were published with 3 of them showing proper methodology and appropriate results with effectiveness of adhesiolysis, whereas one poorly performed systematic review showed negative results. In addition, there were only 4 randomized controlled trials (RCTs) to be included in the previous systematic reviews of post-surgery syndrome, whereas now, the RCTs and other studies have increased. This systematic review shows level I or strong evidence for the effectiveness of percutaneous adhesiolysis in managing chronic low back and lower extremity pain related to post-lumbar surgery syndrome.

Current Concepts in the Management of Vertebral Compression Fractures

PURPOSE OF REVIEW

This comprehensive review of current concepts in the management of vertebral compression fractures is a manuscript of vertebral augmentation literature of risk factors, clinical presentation, and management. The objective of this review is to compare outcomes between multiple augmentation techniques and ongoing discussions of effectiveness of vertebral augmentation procedures.

RECENT FINDINGS

Vertebral compression fractures (VCFs) are a prevalent disease affecting approximately 1.5 million US adults annually. VCFs can cause severe physical limitations, including back pain, functional disability, and progressive kyphosis of the thoracic spine that ultimately results in decreased appetite, poor nutrition, impaired pulmonary function, and spinal cord compression with motor and sensory deficits. The deconditioning that affects patients with vertebral compression fractures leads to mortality at a far higher rate than age-matched controls. The management of vertebral compression fractures has been extensively discussed with opponents arguing in favor or restricting conservative management and against augmentation, while proponents argue in favor of augmentation. The literature is well established in reference to the effects on mortality when patients undergo treatment with vertebral augmentation; in over a million patients with vertebral compression fractures treated with vertebral augmentation as compared with patients treated with non-surgical management, the patients receiving augmentation performed well with a decrease in morbidity and mortality. Summary of the literature review shows that understanding the risk factors, appropriate clinical evaluation, and management strategies are crucial. Analysis of the evidence shows, based on level I and II studies, balloon kyphoplasty had significantly better and vertebroplasty tended to have better pain reduction compared with non-surgical management. In addition, balloon kyphoplasty tended to have better height restoration than vertebroplasty.

Minimally Invasive Lumbar Decompression and Interspinous Process Device for the Management of Symptomatic Lumbar Spinal Stenosis: a Literature Review

PURPOSE OF REVIEW

Symptomatic lumbar spinal stenosis (LSS) is a condition affecting a growing number of individuals resulting in significant disability and pain. Traditionally, treatment options have consisted of conservative measures such as physical therapy, medication management, epidural injections and percutaneous adhesiolysis, or surgery. There exists a treatment gap for patients failing conservative measures who are not candidates for surgery. Minimally invasive lumbar decompression (MILD®) and interspinous process device (IPD) with Superion® represent minimally invasive novel treatment options that may help fill this gap in management. We performed a literature review to separately evaluate these procedures and assess the effectiveness and safety.

RECENT FINDINGS

The available evidence for MILD and Superion has been continuously debated. Overall, it is considered that while the procedures are safe, there is only modest evidence for effectiveness. For both procedures, we have reviewed 13 studies. Based on the available evidence, MILD and Superion are safe and modestly effective minimally invasive procedures for patients with symptomatic LSS. It is our recommendation that these procedures may be incorporated as part of the continuum of treatment options for patients meeting clinical criteria.

Sacral Insufficiency Fractures: a Review of Risk Factors, Clinical Presentation, and Management

PURPOSE OF THE REVIEW

Sacral insufficiency fractures (SIF) are a common and often underdiagnosed source of low back pain. In patients with SIF, there is both a compromised sacroiliac joint and weakened sacrum, resulting in decreased resistance to torsional stress, leading to fracture. While conservative medical management is a safe option, minimally invasive intervention may provide improved short and long-term relief of low back pain in patients presenting with SIF. This comprehensive review is undertaken to provide an update to the current understanding of SIF with description of risk factors, clinical presentation, and management.

RECENT FINDINGS

Sacroplasty is a minimally invasive procedure in which polymethylmethacrylate (PMMA) cement is inserted into bone to improve its structural integrity and alleviate symptoms. Balloon sacroplasty (BSP) has also been successful in alleviating pain with minimal cement leakage in SIF patients. Various other interventional techniques, including navigation-assisted screw fixation have been used to address SIF and have shown improvement in pain with minimal side effects. This review included various modalities of treatments available to manage SIF. This review shows that in comparison with nonsurgical management, sacroplasty has been shown to have greater pain reduction and improved mobility.

Heterogeneity Among Hospitals in the Percentages of All Lumbosacral Epidural Steroid Injections Where the Patient Had Received 4 or More in the Previous Year

BACKGROUND

Current guidelines for the administration of therapeutic epidural injections suggest that these be limited to a maximum of 4 per year. We sought to gain an understanding of the proportion of lumbosacral epidural injections administered to patients who had received ≥4 such injections during the preceding 364 days, and whether these proportions varied among hospitals.

METHODS

This observational cohort study included data from all facilities owned by the 121 nonfederal hospitals in the State of Iowa, July 2012 through September 2017. One end point was the percentage of all lumbar or sacral transforaminal or interlaminar epidural injections where the patient had received ≥4 such injections during the preceding 364 days. Comparisons also were made among hospitals' percentages of injections that were the fifth or greater (ie, patient had already received ≥4 during preceding 364 days) using Bonferroni-adjusted conservative 95% confidence intervals.

RESULTS

There were 48,270 unique patients who underwent at least 1 lumbosacral epidural steroid injection. The patients received care at 112 hospitals' facilities. Most patients received no additional steroid injections within 364 subsequent calendar days after the first steroid injection (54.1%). There were ≥5 steroid injections for 1.27% of patients (ie, the injection was the fifth or greater). Among the 39 hospitals in Iowa that performed overall at least 1 steroid injection every 4 days, there were 6 hospitals at which the percentages of injections that were the fifth or greater significantly exceeded the overall prevalence of 1.91% (range: 3.0%-6.4%). There were 14 of the 39 hospitals with prevalences significantly less.

CONCLUSIONS

Although most patients received only 1 lumbosacral steroid injection within 1 year, 1.27% of patients received 5 or more, and 1.91% of injections were the fifth or greater. Several hospitals had significantly greater than the overall average percent of steroid injections which were fifth or more. This heterogeneity warrants study of whether annual steroid injections per patient should be a clinical quality measure for the care received by patients with lower back pain or whether payment should be greater when injections are in accordance with guidelines.

Evaluation of Cost-Utility of Thoracic Interlaminar Epidural Injections

PURPOSE OF REVIEW

Chronic thoracic pain, even though not as prevalent as low back and neck pain, appears in approximately 30% of the general population. The severity of thoracic pain and degree of disability seems to be similar to other painful conditions. Despite this severity, interventions in managing chronic thoracic pain are less frequent, and there is a paucity of literature regarding epidural injections and facet joint interventions.

RECENT FINDINGS

As with lumbar and cervical spine, a multitude of interventions are offered in managing chronic thoracic pain, including interventional techniques with epidural injections and facet joint interventions. A single randomized controlled trial (RCT) has been published with a 2-year follow-up of clinical effectiveness of the results. However, there have not been any cost-utility analysis studies pertaining to either epidural injections or facet joint interventions in thoracic pain. Based on the results of the RCT, a cost-utility analysis of thoracic interlaminar epidural injections was undertaken. Evaluation of the cost-utility analysis of thoracic interlaminar epidural injections with or without steroids in managing thoracic disc herniation, thoracic spinal stenosis, and thoracic discogenic or axial pain was assessed in 110 patients with a 2-year follow-up. Direct payment data from 2018 was utilized for procedural costs and indirect costs. Costs, including drug costs, were determined by multiplication of direct procedural payment data by a factor of 1.67 or addition of 40% of cost to accommodate for indirect payments and arrive at overall costs. Cost-utility analysis showed direct procedural cost of USD $1943.19, whereas total estimated costs year per QALY were USD $3245.12.