Faculty Bibliography

BACKGROUND:Millions of interventional pain procedures are performed each year to address chronic pain. The increase in these procedures also raises the concern of health risks associated with ionizing radiation for interventional pain management physicians who perform fluoroscopy-guided operations. Some health concerns include cancers, cataracts, and even pregnancy abnormalities. Little is known regarding the long-term and cumulative effects of small radiation doses. OBJECTIVES/OBJECTIVE:The objective of this systematic review was to identify common body parts that are exposed to ionizing radiation during interventional pain procedures and examine methods to help physicians reduce their radiation exposure. STUDY DESIGN/METHODS:The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist was used to comprehensively identify articles from 2 medical databases. The radiation dose to interventional pain management physicians obtained from relevant peer-reviewed articles were aggregated and used for analysis. METHODS:PubMed was first used to collect the articles for two broad keyword searches of "radiation exposure pain management" and "radiation exposure interventionalist" with years ranging from 1956 - February 2023. EMBASE was also used to collect the articles for the two keyword searches of "radiation exposure pain management" and "radiation exposure interventionalist" with years ranging from 1969 - February 2023. This systematic approach yielded a total of 2,736 articles; 24 were included in our paper. The risk of bias for these articles was performed using the Cochrane Risk of Bias tool and the National Institutes of Health tool. RESULTS:Through our systematic literature search, more than 3,577 patients were treated by 30 interventional pain management physicians. Some areas of exposure to radiation include the physician's neck, chest, groin, hands, and eyes. One common body region that is exposed to radiation is the chest; our review found that wearing lead aprons can lower the radiation dose by more than 95%. Wearing protective equipment and managing the distance between the operator and fluoroscope can both independently lower the radiation dose by more than 90% as well. Our literature review also found that other body parts that are often overlooked in regard to radiation exposure are the eyes and hands. In our study, the radiation dose to the outside (unprotected) chest ranged from 0.008 ± 27 mrem to 1,345 mrem, the outside neck ranged from 572 mrem to 2,032 mrem, the outside groin ranged from 176 mrem to 1,292 mrem, the hands ranged from 0.006 ± 27.4 mrem to 0.114 ± 269 mrem, and the eyes ranged from 40 mrem to 369 mrem. When protective equipment was worn, the radiation exposure to the inside chest ranged from 0 mrem to 108 mrem, the inside neck ranged from 0 mrem to 68 mrem, and the inside groin ranged from 0 mrem to 15 mrem. LIMITATIONS/CONCLUSIONS:Limitations of this study include its small sample size; only the radiation exposure of 30 interventional pain management physicians were examined. Furthermore, this review mainly consisted of observational studies rather than randomized clinical trials. CONCLUSION/CONCLUSIONS:  Implementing safety precautions, such as wearing protective gear, providing educational programs, and keeping a safe distance, demonstrated a significant decrease in radiation exposure. The experience of interventional pain management physicians also factored into their radiation exposure during procedures. Radiation is a known carcinogen, and more research is needed to better understand its risk to interventional pain management physicians.

Introduction: Abrupt cessation of intrathecal baclofen and opioids can cause severe life-threatening withdrawal syndromes. Intrathecal pump (ITP) administration of baclofen and opioids allows for continuous, potent, and effective targeted drug delivery with consistent cerebrospinal fluid concentrations in a relatively tamper-resistant system for chronic intractable pain treatment. Routine management of the pumps is an important component of care. Incarceration of patients managed on ITP presents unique challenges to this mode of care. Case Report: We present a 54- year-old man with CRPS II of his right upper extremity who was stably managed for eight years on an ITP regimen consisting of baclofen 248mcg/d and hydromorphone 3mg/d (4,500 morphine oral equivalents) with additional oral oxycodone and diazepam. He was incarcerated for a period of nine months, during which his reservoir was allowed to run empty. Attempts by outpatient providers were made to have this refilled, but instead he was bridged with oral baclofen 60 mg daily and, at maximum, morphine 30 mg daily by prison providers. He did not suffer life-threatening withdrawal. At his first outpatient pain clinic visit after being released, the patient had effectively been weaned off all controlled substances without significant sequelae.
Conclusion(s): Prison systems face the challenge of encountering patients with pharmacological dependence, especially in the management of complex pain conditions. For this patient, the specialized care needed for ITP management was jettisoned in favor of a relatively miniscule oral weaning regimen that was surprisingly tolerated. This is contradictory to the conventional practice of gradual tapering of intrathecal medications

OBJECTIVE: The concept of neuromodulation via the use of spinal cord stimulators (SCS) was first established over forty years ago. Since then, its popularity has grown as numerous studies have demonstrated its utility to reduce chronic pain, improve patient function, and reduce long-term health care costs. The aim of this study was to update the pain medicine community on the evolution of SCS practice trends in academic centers. DESIGN: Ninety-three pain medicine fellowship programs in the United States were identified from the Accreditation Council for Graduate Medical Education Website and were contacted to participate in an internet survey. A 37-item questionnaire was inspired by a previous study performed by Fanciullo et al. Questions focused on three main themes regarding SCS clinical application, namely demographics, education, and technical matters. RESULTS: Completed surveys were received from 50 institutions, all of which reported performing SCS interventions. Annual implants ranged from 0 to 150. Fellowship training was cited as the most valuable modality for learning implantation. Nearly all programs reported manufacturer representative participation during SCS procedures, with a minority of program directors discouraging their involvement in fellow education. SCS trials were performed exclusively on an outpatient basis. The average length for trials was 4-7 days. The most common indication for SCS implantation was failed back surgery syndrome, which also had the highest 2-year success rate. Post procedure, patients generally were followed up every 2-4 weeks for device reprogramming, which was performed by company representatives 92% of the time. CONCLUSION: Standardized SCS training is imperative as the implementation of neuromodulation therapy continues to increase.

BACKGROUND: Trigger point (TrPs) identification has become the mainstay of diagnosis for the treatment of Myofascial Pain Syndrome; however, manual pressure (MP) to identify TrPs by determining low-pressure pain threshold has low interrater reliability and may lack validity since it is done on inactive muscles. To elicit contractions and mimic an active muscle or movement that 'causes' pain, a Muscle Pain Detection Device (MPDD) has been developed. A selected muscle is stimulated and painful muscles are precisely detected, allowing distinctions between primary and referred muscle pain as well as distinguishing other functional muscle pain thought to cause MPS. METHODS: An IRB approved randomized controlled study is presented of MP (20 patients) control vs MPDD (20 patients) to identify which muscle(s) was the source of pain in subjects presenting to the NYU Pain Management Center with a minimum 3 months history of back pain. Patients were unaware of their diagnostic method. Subjects were injected in 1-3 sites identified via MP or MPDD by a separate, blinded physician. Prior to, and following treatment at one week and one month, the patients were administered Oswestry and visual analog scale pain questionnaires by a blinded evaluator, and their range of motion was measured by a blinded physical therapist. RESULTS: The MPDD group reported significantly larger improvements in pain, mood and Oswestry scores compared with the control (P < 0.05). Moreover, the MPDD group reported 82.5% pain relief at 1 month, compared with 53.2% in the control (P < 0.001). The range of motion measurements failed to reveal any significant difference between the groups. CONCLUSIONS: Using the MPDD appears to be more valid and potentially more reliable than palpation to identify muscles causing regional pain that could benefit from injections

Introduction: Manual pressure (MP) to identify Trigger Points (TrPs) by determining low pressure pain threshold has low inter-rater reliability and may lack validity since it is done on inactive muscles. Muscle pain is generally experienced with activity. To elicit a muscle contraction and mimic movement that causes pain, a Muscle Pain Detection Device (MPDD) has been developed. A selected muscle is stimulated and painful muscles are precisely detected, allowing distinctions between primary and referred muscle pain [in our nomenclature, Muscle Pain Amenable to Injection vs. TrPs] as well as distinguishing other functional muscle pain thought to cause myofascial pain syndrome. MPDD could provide a valid, reliable assessment of muscle pain which is frequently ignored/mistreated. Methods: An IRB approved doubleblind, randomized controlled study of the MPDD (20 patients) vs. MP (20 patients) control to identify which muscle(s) was the source of pain in 40 subjects presenting to the NYU Pain Management Center with a minimum 3 month history of back pain. Patients were unaware of their diagnostic group. Subjects were injected in 1-3 sites identified via MP or MPDD by a separate physician blinded from the method of detection. Prior to, and following treatment at one week and one month, the patients are given a physical exam and administered Oswestry and VAS pain questionnaires by a blinded evaluator. Results: The MPDD group reported statistically significant improvement in pain, mood and Oswestry scores at 1 week and one month (P < 0.004 - 0.001). The control reported no statistical improvements except for the Oswestry scores at 1 week. Moreover, the MPDD group reported 82.5% pain relief at 1 month, compared to 53.2% in the control (P < 0.001). Conclusion: Using the MPDD appears to be more valid and reliable than palpation to identify muscles causing regional pain that could benefit from muscle injections

Objective. Spinal cord stimulator (SCS) parameter settings have been well studied; however, the goal of this exploratory study was to examine the SCS parameters used during intra-operative stimulation (IOS) at trial lead placement. Methods. In this retrospective study, we report the IOS parameter settings for 22 patients who underwent thoracic SCS lead trial for treatment of refractory low back and/or leg pain. Results. Paresthesia coverage was shown to differ depending upon the pain syndrome and the region involved (back and/or leg, p = 0.03). Certain stimulation parameters were demonstrated to be linked, including pulse width with rate (p = 0.04) and bipolar activation distance with amplitude (p < 0.01). Important variations in field configuration practice patterns also emerged. Conclusions. Larger prospective studies are required to confirm and extend the current results. The ultimate goal for this report is to establish a foundation for future studies to create an evidence-based standardized algorithm for IOS to enhance the success rate of SCS trial screening

Phantom limb pain has been well described in the literature. However, new-onset lumbar radicular pain superimposed on baseline lower extremity phantom pain is a clinical scenario that can be challenging to recognize. Furthermore, literature on recognition and treatment of phantom radiculopathy is all but lacking. We present a patient who experienced new-onset lumbar radiculopathy superimposed on her phantom pain that was successfully treated with fluoroscopic interlaminar and transforaminal epidural steroid injections