Faculty Bibliography

BACKGROUND:Epidural steroid injections (ESI) are one of the most commonly performed pain procedures; however, there has been variation in techniques and approaches amongst pain physicians in the United States. The formation of a multidisciplinary working group was made with considerations to help guide ESI practice. OBJECTIVE:Pain medicine physicians in the United States were surveyed in order to provide an update on current practices for both transforaminal and interlaminar ESI. STUDY DESIGN AND SETTING/METHODS:This was a cross-sectional survey of pain medicine physicians in the United States. METHODS:This study was approved by the institutional review board of our institution. Based on the American Society of Interventional Pain Physicians membership database, an email list was generated, and a web-based survey was sent to interventional pain physicians at academic centers, private practices, government hospitals, and community settings across the United States. Cervical, lumbar, and caudal ESI sections were divided into questions regarding preferences for fluoroscopic views, injectates, and techniques. RESULTS:A total of 261 responses were analyzed. All but one used fluoroscopy for lumbar ESI. There were variations in methods to detect intravascular uptake, choice of injectate, and the use of particulate steroids for lumbar transforaminal epidural steroid injection (TFESI). LIMITATIONS/CONCLUSIONS:The response rate is a limitation, and thus the results may not be representative of all pain medicine physicians in the United States. CONCLUSIONS:Since the 2015 multidisciplinary pain workgroup recommendations were made for ESI, there appears to be a trend towards following these guidelines compared to prior surveys looking at ESI practices. However, our survey shows there continues to be variations in ESI practice that deviates from these guidelines.

The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public-private partnership which led to the publication of its report in 2019. The report emphasized the need for individualized, multimodal, and multidisciplinary approaches to pain management that decrease the over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders. The Task Force specifically called on specialty organizations to work together to develop evidence-based guidelines. In response to this report's recommendations, a consortium of 14 professional healthcare societies committed to a 2-year project to advance pain management for the surgical patient and improve opioid safety. The modified Delphi process included two rounds of electronic voting and culminated in a live virtual event in February 2021, during which seven common guiding principles were established for acute perioperative pain management. These principles should help to inform local action and future development of clinical practice recommendations.

To examine the association of preoperative opioids and/or benzodiazepines on postoperative outcomes in total knee and hip arthroplasty, we retrospectively compared postoperative outcomes in those prescribed preoperative opioids and/or benzodiazepines versus those who were not who underwent elective total knee and hip arthroplasty at a single urban academic institution. Multivariable logistic regression was performed for readmission rate, respiratory failure, infection, and adverse cardiac events. Multivariable zero-truncated negative binomial regression was used for length of stay. After exclusions, there were 4307 adult patients in the study population, 2009 of whom underwent total knee arthroplasty and 2298 of whom underwent total hip arthroplasty. After adjusting for potential confounders, preoperative benzodiazepine use was associated with increased odds of readmission (p < 0.01). Preoperative benzodiazepines were not associated with increased odds of respiratory failure nor increased length of stay. Preoperative opioids were not associated with increased odds of the examined outcomes. There were insufficient numbers of infection and cardiac events for analysis. In this study population, preoperative benzodiazepines were associated with increased odds of readmission. Preoperative opioids were not associated with increased odds of the examined outcomes. Studies are needed to further examine risks associated with preoperative benzodiazepine use.

BACKGROUND:Advances in human neuroimaging has enabled us to study functional connections among various brain regions in pain states. Despite a wealth of studies at high anatomic resolution, the exact neural signals for the timing of pain remain little known. Identifying the onset of pain signals from distributed cortical circuits may reveal the temporal dynamics of pain responses and subsequently provide important feedback for closed-loop neuromodulation for pain. NEW METHOD/UNASSIGNED:Here we developed an unsupervised learning method for sequential detection of acute pain signals based on multichannel human EEG recordings. Following EEG source localization, we used a state-space model (SSM) to detect the onset of acute pain signals based on the localized regions of interest (ROIs). RESULTS:We validated the SSM-based detection strategy using two human EEG datasets, including one public EEG recordings of 50 subjects. We found that the detection accuracy varied across tested subjects and detection methods. We also demonstrated the feasibility for cross-subject and cross-modality prediction of detecting the acute pain signals. COMPARISON WITH EXISTING METHODS/UNASSIGNED:In contrast to the batch supervised learning analysis based on a support vector machine (SVM) classifier, the unsupervised learning method requires fewer number of training trials in the online experiment, and shows comparable or improved performance than the supervised method. CONCLUSIONS:Our unsupervised SSM-based method combined with EEG source localization showed robust performance in detecting the onset of acute pain signals.

OBJECTIVE:To determine the effectiveness of lumbar medial branch thermal radiofrequency neurotomy based on different selection criteria and procedural techniques. DESIGN/METHODS:Comprehensive systematic review. METHODS:A comprehensive literature search was conducted, and all authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies. OUTCOME MEASURES/METHODS:The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief, as well as procedural technique with perpendicular or parallel placement of electrodes. RESULTS:Results varied by selection criteria and procedural technique. At six months, 26% of patients selected via single medial branch block with 50% pain relief and treated via perpendicular technique achieved at least 50% pain relief; 49% of patients selected via dual medial branch blocks with 50% pain relief and treated via parallel technique achieved at least 50% pain relief. The most rigorous patient selection and technique-two diagnostic medial branch blocks with 100% pain relief and parallel electrode placement-resulted in 56% of patients experiencing 100% relief of pain at six months. CONCLUSIONS:This comprehensive systematic review found differences in the effectiveness of lumbar medial branch radiofrequency neurotomy when studies were stratified by patient selection criteria and procedural technique. The best outcomes are achieved when patients are selected based on high degrees of pain relief from dual medial branch blocks with a technique employing parallel electrode placement.

Pain is an integrated sensory and affective experience. Cortical mechanisms of sensory and affective integration, however, remain poorly defined. Here, we investigate the projection from the primary somatosensory cortex (S1), which encodes the sensory pain information, to the anterior cingulate cortex (ACC), a key area for processing pain affect, in freely behaving rats. By using a combination of optogenetics, in vivo electrophysiology, and machine learning analysis, we find that a subset of neurons in the ACC receives S1 inputs, and activation of the S1 axon terminals increases the response to noxious stimuli in ACC neurons. Chronic pain enhances this cortico-cortical connection, as manifested by an increased number of ACC neurons that respond to S1 inputs and the magnified contribution of these neurons to the nociceptive response in the ACC. Furthermore, modulation of this S1→ACC projection regulates aversive responses to pain. Our results thus define a cortical circuit that plays a potentially important role in integrating sensory and affective pain signals.

Purpose of Review/UNASSIGNED:This review summarizes selected recent evidence on issues important for preoperative pain evaluation. Recent Findings/UNASSIGNED:Opioids, though a mainstay of postoperative pain management, are associated with both short and increasingly recognized long-term risks, including persistent opioid use. Risk factors for high levels of acute postoperative pain as well as chronic postsurgical pain may overlap, including psychological factors such as depression, anxiety, and catastrophizing. Tools to predict those at risk for poor postoperative pain outcomes are being studied. Summary/UNASSIGNED:Preoperative pain and psychological factors can affect postoperative pain outcomes. More work is needed in the future to develop practical interventions in the preoperative period to address these factors.

OBJECTIVES/OBJECTIVE:To compare postoperative outcomes in patients prescribed long-acting opioids vs opioid-naïve patients who underwent elective noncardiac surgeries. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Single urban academic institution. METHODS AND SUBJECTS/METHODS:We retrospectively compared postoperative outcomes in long-acting opioid users vs opioid-naïve patients who underwent elective noncardiac surgeries. Inpatient and ambulatory surgery cohorts were separately analyzed. Preoperative medication lists were queried for the presence of long-acting opioids or absence of opioids. Multivariable logistic regression was performed to analyze the impact of long-acting opioid use on readmission rate, respiratory failure, and adverse cardiac events. Multivariable zero-truncated negative binomial regression was used to examine length of stay. RESULTS:After exclusions, there were 93,644 adult patients in the study population, 23,605 of whom underwent inpatient surgeries and 70,039 of whom underwent ambulatory surgeries. After adjusting for potential confounders and inpatient surgeries, preoperative long-acting opioid use was associated with increased risk of prolonged length of stay (incidence rate ratio = 1.1, 99% confidence interval [CI] = 1.0-1.2, P < 0.01) but not readmission. For ambulatory surgeries, preoperative long-acting opioid use was associated with increased risk of all-cause as well as pain-related readmission (odds ratio [OR] = 2.1, 99% CI = 1.5-2.9, P < 0.001; OR = 2.0, 99% CI = 0.85-4.2, P = 0.02, respectively). There were no significant differences for respiratory failure or adverse cardiac events. CONCLUSIONS:The use of preoperative long-acting opioids was associated with prolonged length of stay for inpatient surgeries and increased risk of all-cause and pain-related readmission for ambulatory surgeries. Timely interventions for patients on preoperative long-acting opioids may be needed to improve these outcomes.

BACKGROUND:Interlaminar and transforaminal epidural steroid injections (ILESI and TFESI) are commonly performed procedures. However, the United States Food and Drug Administration has required the addition of drug warning labels for injectable corticosteroids. Updated evidence and scrutiny from regulatory agencies may affect practice patterns. OBJECTIVE:To characterize TFESI practices as well as to provide an update on periprocedural practices for any type of epidural steroid injection (ESI), we surveyed pain medicine physicians in the United States. STUDY DESIGN AND SETTING/METHODS:This was a cross-sectional survey of pain medicine physicians in the United States. METHODS:A web-based survey was distributed to pain medicine physicians in the United States selected from the Accreditation Council for Graduate Medical Education accredited pain medicine fellowship program list as well as the American Society of Interventional Pain Physicians membership database. Physicians were queried about TFESI practices, including needle size, use of image guidance, methods to detect vascular uptake, and preference for injectate. RESULTS:A total of 249 responses were analyzed. Only a minority of respondents reported performing cervical TFESI. There were variations in needle size, methods to detect vascular uptake, and choice of injectate. There were also variations in monitoring practices. LIMITATIONS/CONCLUSIONS:The response rate is a limitation. Thus the results may not be representative of all US pain medicine physicians. CONCLUSIONS:Though all respondents used image guidance for TFESI, variations in other TFESI practices exist. There are also differences in periprocedural practices. Since the closure of this survey, a multisociety pain workgroup published recommendations regarding ESI practices. Our survey findings support the need for more evidence-based guidelines regarding ESI. KEY WORDS/UNASSIGNED:Epidrual steroid injections, transforaminal epidural steroid injection, steroids, local anesthetic, survey, interventional pain.

Spontaneous intracranial hypotension is an uncommon disorder with symptoms including postural headache that can be debilitating to patients. Diagnosis is mainly clinical, aided by imaging of the brain and spine with or without diagnostic procedures. Treatment can vary depending on severity, but most cases involve an epidural blood patch. We describe a case of a patient with clinical findings of spontaneous intracranial hypotension but with normal brain imaging. The patient responded to lumbar epidural blood patches and did not require additional tests to confirm the diagnosis.