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A Systematic Review and Meta-analysis of the Effectiveness of Radiofrequency Neurotomy in Managing Chronic Neck Pain

Manchikanti, Laxmaiah; Knezevic, Nebojsa Nick; Knezevic, Emilija; Abdi, Salahadin; Sanapati, Mahendra R; Soin, Amol; Wargo, Bradley W; Navani, Annu; Atluri, Sairam; Gharibo, Christopher G; Simopoulos, Thomas T; Kosanovic, Radomir; Abd-Elsayed, Alaa; Kaye, Alan D; Hirsch, Joshua A
BACKGROUND:Extensive research into potential sources of neck pain and referred pain into the upper extremities and head has shown that the cervical facet joints can be a potential pain source confirmed by precision, diagnostic blocks. STUDY DESIGN/METHODS:Systematic review and meta-analysis utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, quality assessment of the included studies, conventional and single-arm meta-analysis, and best evidence synthesis. OBJECTIVE:The objective of this systematic review and meta-analysis is to evaluate the effectiveness of radiofrequency neurotomy as a therapeutic cervical facet joint intervention in managing chronic neck pain. METHODS:Available literature was included. Methodologic quality assessment of studies was performed from 1996 to September 2021. The level of evidence of effectiveness was determined. RESULTS:Based on the qualitative and quantitative analysis with single-arm meta-analysis and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system of appraisal, with inclusion of one randomized controlled trial (RCT) of 12 patients in the treatment group and eight positive observational studies with inclusion of 589 patients showing positive outcomes with moderate to high clinical applicability, the evidence is level II in managing neck pain with cervical radiofrequency neurotomy. The evidence for managing cervicogenic headache was level III to IV with qualitative analysis and single-arm meta-analysis and GRADE system of appraisal, with the inclusion of 15 patients in the treatment group in a positive RCT and 134 patients in observational studies. An overwhelming majority of the studies produced multiple lesions. LIMITATIONS/CONCLUSIONS:There was a paucity of literature and heterogeneity among the available studies. CONCLUSION/CONCLUSIONS:This systematic review and meta-analysis shows level II evidence with radiofrequency neurotomy on a long-term basis in managing chronic neck pain with level III to IV evidence in managing cervicogenic headaches.
PMID: 36422818
ISSN: 2193-8237
CID: 5384362

Comparative Systematic Review and Meta-Analysis of Cochrane Review of Epidural Injections for Lumbar Radiculopathy or Sciatica

Manchikanti, Laxmaiah; Knezevic, Emilija; Latchaw, Richard E; Knezevic, Nebojsa Nick; Abdi, Salahadin; Sanapati, Mahendra R; Staats, Peter S; Gharibo, Christopher G; Simopoulos, Thomas T; Shah, Shalini; Abd-Elsayed, Alaa; Navani, Annu; Kaye, Alan D; Albers, Sheri L; Hirsch, Joshua A
BACKGROUND:Epidural injections are among the most commonly performed procedures for managing low back and lower extremity pain. Pinto et al and Chou et al previously performed systematic reviews and meta-analyses, which, along with a recent update from Oliveira et al showing the lack of effectiveness of epidural steroid injections in managing lumbar disc herniation, spinal stenosis, and radiculopathy. In contrast to these papers, multiple other systematic reviews and meta-analyses have supported the effectiveness and use of epidural injections utilizing fluoroscopically guided techniques. A major flaw in the review can be related to attributing active-controlled trials to placebo-controlled trials. The assumption that local anesthetics do not provide sustained benefit, despite extensive evidence that local anesthetics provide long-term relief, similar to a combination of local anesthetic with steroids is flawed. STUDY DESIGN/METHODS:The Cochrane Review of randomized controlled trials (RCTs) of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy were reanalyzed using systematic methodology and meta-analysis. OBJECTIVES/OBJECTIVE:To re-evaluate Cochrane data on RCTs of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy utilizing qualitative and quantitative techniques with dual-arm and single-arm analysis. METHODS:In this systematic review, we have used the same RCTs from the Cochrane Review of a minimum of 20% change in pain scale or significant pain relief of >= 50%. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Our review was performed utilizing the Cochrane Review methodologic quality assessment and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Evidence was summarized utilizing the principles of best evidence synthesis and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Clinical relevance of the pragmatic nature of each study was assessed. RESULTS:In evaluating the RCTs in the Cochrane Review, we identified 16 trials having placebo-control design and 9 trials with an active-control design performed with fluoroscopic guidance. Utilizing conventional dual-arm and single-arm meta-analysis, the evidence is vastly different from the interpretation of the data within the Cochrane Review. The overall combined evidence is Level I, or strong evidence, at one and 3 months, and Level II, or moderate evidence, at 6 and 12 months. LIMITATIONS/CONCLUSIONS:The limitation of this study is that only data contained in the Cochrane Review were analyzed. CONCLUSION/CONCLUSIONS:A comparative systematic review and meta-analysis of the Cochrane Review of randomized controlled trials (RCTs) of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy yielded different results. This review, based on the evidence derived from placebo-controlled trials and active-controlled trials showed Level I, or strong evidence, at one and 3 months and Level II at 6 and 12 months. This review once again emphasizes the importance of the allocation of studies to placebo-control and active-control groups, utilizing standards of practice with inclusion of only the studies performed under fluoroscopic guidance.
PMID: 36288577
ISSN: 2150-1149
CID: 5358052

Variations in Epidural Steroid Injection Practice Patterns by Pain Medicine Physicians in the United States

Bingham, Nishan; Dhall, Raymon; Montuori, Michael; Padjen, Kristoffer; Gharibo, Christopher; Doan, Lisa
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.
PMID: 36122269
ISSN: 2150-1149
CID: 5333042

Peripheral Nerve Stimulation for Treatment of Cluneal Neuropathy Case Study [Case Report]

Soteropoulos, Costa; Pergolizzi, Joseph; Nagarakanti, Sindhu; Gharibo, Christopher
Chronic low back pain is a prevalent and sometimes debilitating condition. This case report describes a 69-year-old female presenting with axial spine pain. The pain was inadequately controlled by opioids as she was treated unsuccessfully with hydrocodone and remained to have the pain between 7/10 and 10/10. Peripheral neural stimulation (PNS) was trialed and then used to control her pain. PNS is a device-based treatment option that appears effective in a subset of patients. It has been effectively used to treat many different chronic pain syndromes. The patient responded well to the treatment, with her pain intensity going down to between 2/10 and 5/10 on the same scale. She was able to discontinue her use of opioids. PNS can be a safe and effective treatment in patients who have not responded well to pharmacologic analgesia.
PMID: 36120219
ISSN: 2168-8184
CID: 5335242

Pharmacotherapeutic management of trigeminal neuropathic pain: an update

Pergolizzi, Joseph V; Gharibo, Christopher; Magnusson, Peter; Breve, Frank; LeQuang, Jo Ann; Varrassi, Giustino
INTRODUCTION/UNASSIGNED:Guidelines recommend a number of pharmacotherapeutic options used as monotherapy or in combination with others for treating the pain of trigeminal neuropathy. AREAS COVERED/UNASSIGNED:The authors examine the pharmacotherapeutic options for treating trigeminal neuralgia and supporting evidence in the literature. Guidelines reported the most effective treatment for trigeminal neuropathy, in particular trigeminal neuralgia, appears to be carbamazepine or oxcabazepine, but side effects can be treatment limiting. Lamotrigine and gabapentin are also recommended in guidance. In real-world clinical practice, baclofen, cannabinoids, eslicarbazepine, levetiracetam, brivaracetam, lidocaine, misoprostol, opioids, phenytoin, fosphenytoin, pimozide, sodium valproate, sumatriptan, tizanidine, tocainide, tricyclic antidepressants, and vixotrigine are sometimes used, either as monotherapy or in combination. The relatively small patient population has limited the number of large-scale studies and there is limited evidence on which to base prescribing choices. EXPERT OPINION/UNASSIGNED:While there is no optimal pharmacotherapy for treating trigeminal neuropathy, advancements in our understanding of the underlying mechanisms of this condition and drug development indicate promise for NaV inhibitors, despite the fact that not all patients respond to them and they may have potentially treatment-limiting side effects. Nevertheless, better understanding of NaV channels may be important avenues for future drug development for trigeminal neuropathy.
PMID: 35695796
ISSN: 1744-7666
CID: 5275912

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

Manchikanti, Laxmaiah; Pampati, Vidyasagar; Sanapati, Mahendra R; Kosanovic, Radomir; Beall, Douglas P; Atluri, Sairam; Abdi, Salahadin; Shah, Shalini; Boswell, Mark V; Kaye, Alan D; Soin, Amol; Gharibo, Christopher G; Wargo, Bradley W; Hirsch, Joshua A
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.
PMID: 35652763
ISSN: 2150-1149
CID: 5236122

Short-term prediction of opioid prescribing patterns for orthopaedic surgical procedures: a machine learning framework

Mortaz, Ebrahim; Dag, Ali; Hutzler, Lorraine; Gharibo, Christopher; Anzisi, Lisa; Bosco, Joseph
Overprescribing of opioids after surgical procedures can increase the risk of addiction in patients, and under prescribing can lead to poor quality of care. In this study, we propose a machine learning-based predictive framework to identify the varying effects of factors that are related to the opioid prescription amount after orthopaedic surgery. To predict the prescription classes, we train multiple classifiers combined with random and SMOTE over-sampling and weight-balancing techniques to cope with the imbalance state of the dataset. Our results show that the gradient boosting machines (XGB) with SMOTE achieve the highest classification accuracy. Our proposed analytical framework can be employed to assist and therefore, enable the surgeons to determine the timely changing effects of these variables.
ISSN: 2573-234x
CID: 4770092

Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines

Manchikanti, Laxmaiah; Knezevic, Nebojsa Nick; Navani, Annu; Christo, Paul J; Limerick, Gerard; Calodney, Aaron K; Grider, Jay; Harned, Michael E; Cintron, Lynn; Gharibo, Christopher G; Shah, Shalini; Nampiaparampil, Devi E; Candido, Kenneth D; Soin, Amol; Kaye, Alan D; Kosanovic, Radomir; Magee, Trevor R; Beall, Douglas P; Atluri, Sairam; Gupta, Myank; Helm Ii, Standiford; Wargo, Bradley W; Diwan, Sudhir; Aydin, Steve M; Boswell, Mark V; Haney, Bill W; Albers, Sheri L; Latchaw, Richard; Abd-Elsayed, Alaa; Conn, Ann; Hansen, Hans; Simopoulos, Thomas T; Swicegood, John R; Bryce, David A; Singh, Vijay; Abdi, Salahadin; Bakshi, Sanjay; Buenaventura, Ricardo M; Cabaret, Joseph A; Jameson, Jessica; Jha, Sunny; Kaye, Adam M; Pasupuleti, Ramarao; Rajput, Kartic; Sanapati, Mahendra R; Sehgal, Nalini; Trescot, Andrea M; Racz, Gabor B; Gupta, Sanjeeva; Sharma, Manohar Lal; Grami, Vahid; Parr, Allan T; Knezevic, Emilija; Datta, Sukdeb; Patel, Kunj G; Tracy, Deborah H; Cordner, Harold J; Snook, Lee T; Benyamin, Ramsin M; Hirsch, Joshua A
BACKGROUND:Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. OBJECTIVE:To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. METHODS:The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and  recommendations were provided. RESULTS:In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives.The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness.Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness.The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. LIMITATIONS/CONCLUSIONS:The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. CONCLUSIONS:These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations.
PMID: 33492918
ISSN: 2150-1149
CID: 4766982

Pain Management and Opioid Therapy: Persistent Knowledge Gaps Among Primary Care Providers

Williamson, Chad; Martin, Barbara J; Argoff, Charles; Gharibo, Christopher; McCarberg, Bill; Atkinson, Timothy; Berger, Leanne; Sullivan, Thomas
Introduction/UNASSIGNED:Given the opioid epidemic in the US, it is vital that clinicians who prescribe opioids for pain management to do so in an evidence-based manner, eg considering all pharmacologic and non-pharmacologic options, assessing risk of opioid use disorder prior to initiating opioids. Continuing education regarding the evidence-based prescribing of opioids is now required for US healthcare providers who prescribe opioids. A "blueprint" of the content to be included in continuing education programs was developed by the US Food and Drug Administration and updated in 2018. Methods/UNASSIGNED:To understand the baseline knowledge and confidence of healthcare professionals in prescribing opioids for pain management, we posed 27 unique knowledge-based questions and 1 confidence question to clinician participants before or during 2 continuing educational programs that were based respectively on the 2016 and 2018 FDA Risk Evaluation and Mitigation Strategy (REMS) educational blueprints for pain management. Results/UNASSIGNED:Overall, 5571 clinicians completed these programs, including 1925 physicians (1516 [79%] identifying as primary care), 1181 physician assistants, 737 advanced practice nurses, 719 nurses, and 479 pharmacists. Responses to pretest questions in both programs indicated profound and persistent gaps in knowledge, particularly in definitions and mechanisms of pain, general principles of pharmacologic analgesic therapy, and specific aspects of opioid analgesic therapy and addiction. Participants in both programs also expressed limited confidence in their abilities to incorporate patient engagement techniques into pain management or develop a treatment plan for a patient with chronic pain. Discussion/UNASSIGNED:These data support an ongoing need for comprehensive clinician-based education as outlined in the FDA REMS educational blueprint, especially given recent data of escalating overdose deaths during the COVID-19 pandemic.
PMID: 34703298
ISSN: 1178-7090
CID: 5042412

Pain Management During the COVID-19 Pandemic

El-Tallawy, Salah N; Nalamasu, Rohit; Pergolizzi, Joseph V; Gharibo, Christopher
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.
PMID: 32840756
ISSN: 2193-8237
CID: 5066362