Try a new search

Format these results:

Searched for:



Total Results:


Evaluation and Treatment of Sacroiliac Joint Pain in Patients with History of Vertebral Compression Fractures: A Retrospective Case Series

Umer, Ibrahim M; Gharibo, Christopher; Diwan, Sudhir; Aydin, Steve M
BACKGROUND:Vertebral compression fractures (VCFs) can affect the entire spinopelvic complex and cause unpredictable patterns of back pain due to their effects on spinal tensegrity and biomechanical compensation. They can lead to significant morbidity and mortality in the aging population and are difficult to diagnose. We aimed to establish a relationship between VCFs and sacroiliac (SI) joint pain. OBJECTIVES/OBJECTIVE:Demonstration of SI joint (SIJ) pain relief at up to 6 months after kyphoplasty (KP) in patients with VCFs and diagnosed SI dysfunction. STUDY DESIGN/METHODS:Retrospective study. SETTING/METHODS:All patients were from a private chronic pain and orthopedics practice in the northeastern United States. METHODS:Fifty-one patients with VCFs diagnosed through imaging and SIJ dysfunction diagnosed through 2 diagnostic SIJ blocks who had failed conservative management were considered for KP. Numeric Rating Scale (NRS 11) scores were recorded at the baseline, after each SIJ block, and at 4 weeks and then 6 months after KP. RESULTS:Forty-nine patients underwent KP. At 4 weeks after the procedure, there was an 84% average reduction in NRS scores from the baseline (P < 0.01). At 6 months after the procedure, there was an 80% reduction in NRS scores from the baseline (P < 0.01). LIMITATIONS/CONCLUSIONS:Larger sample sizes and a randomized control trial would be important steps in furthering the relationship between VCFs and SIJ. CONCLUSION/CONCLUSIONS:VCFs can cause a referred pain pattern to the SIJ that is best treated by KP for long-term management.
PMID: 38506686
ISSN: 2150-1149
CID: 5640542

Peripheral Nervous System Pain Modulation

Karcz, Marcin; Gharibo, Christopher
The percutaneous technique of electrode insertion in the vicinity of the greater occipital nerves to treat occipital neuralgia was first described in the 1990s by Weiner and Reed. This subsequently stimulated awareness of peripheral nerve stimulation (PNS). The more recent advent emergence of a minimally invasive percutaneous approach by way of using ultrasound has further increased the interest in PNS as a viable alternative to more invasive techniques. PNS has become more popular recently and is increasingly used to treat various pain conditions. Its foundation is fundamentally based on the gate control theory, although the precise mechanism underlying its analgesic effect is still indefinite. Studies have demonstrated the peripheral and central analgesic mechanisms of PNS by modulating the inflammatory pathways, the autonomic nervous system, the endogenous pain inhibition pathways, and the involvement of the cortical and subcortical areas. Peripheral nerve stimulation exhibits its neuromodulatory effect both peripherally and centrally. Further understanding of the modulation of PNS mechanisms can help guide stimulation approaches and parameters to optimize the use of PNS. his chapter aims to review the background and mechanisms of PNS modulation. PNS is becoming one of the most diverse therapies in neuromodulation due to rapid evolution and expansion. It is an attractive option for clinicians due to the simplicity and versatility of procedures that can be combined with other neuromodulation treatments or used alone. It has a distinct role in the modulation of functional conditions.
PMID: 37534790
ISSN: 1875-6190
CID: 5607702

Comprehensive, Evidence-Based, Consensus Guidelines for Prescription of Opioids for Chronic Non-Cancer Pain from the American Society of Interventional Pain Physicians (ASIPP)

Manchikanti, Laxmaiah; Kaye, Adam M; Knezevic, Nebojsa Nick; Giordano, James; Applewhite, Megan K; Bautista, Alexander; Soin, Amol; Blank, Susan K; Sanapati, Mahendra R; Karri, Jay; Christo, Paul J; Abd-Elsayed, Alaa; Kaye, Alan D; Calodney, Aaron; Navani, Annu; Gharibo, Christopher G; Harned, Michael; Gupta, Mayank; Broachwala, Mustafa; Sehgal, Nalini; Kaufman, Andrew; Wargo, Bradley; Solanki, Daneshvari R; Hsu, Eric S; Limerick, Gerard; Dennis, Allen; Swicegood, John R; Slavin, Konstantin; Snook, Lee; Pasupuleti, Ramarao; Kosanovic, Radomir; Justiz, Rafael; Barkin, Robert; Atluri, Sairam; Shah, Shalini; Pampati, Vidyasagar; Helm Ii, Standiford; Grami, Vahid; Myckowiak, Vicki; Galan, Vincent; Singh, Vijay; Manocha, Vivek; Hirsch, Joshua A
BACKGROUND:Opioid prescribing in the United States is decreasing, however, the opioid epidemic is continuing at an uncontrollable rate. Available data show a significant number of opioid deaths, primarily associated with illicit fentanyl use. It is interesting to also note that the data show no clear correlation between opioid prescribing (either number of prescriptions or morphine milligram equivalent [MME] per capita), opioid hospitalizations, and deaths. Furthermore, the data suggest that the 2016 guidelines from the Centers for Disease Control and Prevention (CDC) have resulted in notable problems including increased hospitalizations and mental health disorders due to the lack of appropriate opioid prescribing as well as inaptly rapid tapering or weaning processes. Consequently, when examined in light of other policies and complications caused by COVID-19, a fourth wave of the opioid epidemic has been emerging. OBJECTIVES/OBJECTIVE:In light of this, we herein seek to provide guidance for the prescription of opioids for the management of chronic non-cancer pain. These clinical practice guidelines are based upon a systematic review of both clinical and epidemiological evidence and have been developed by a panel of multidisciplinary experts assessing the quality of the evidence and the strength of recommendations and offer a clear explanation of logical relationships between various care options and health outcomes. METHODS:The methods utilized included the development of objectives and key questions for the various facets of opioid prescribing practice. Also utilized were employment of trustworthy standards, and appropriate disclosures of conflicts of interest(s). The literature pertaining to opioid use, abuse, effectiveness, and adverse consequences was reviewed. The recommendations were developed after the appropriate review of text and questions by a panel of multidisciplinary subject matter experts, who tabulated comments, incorporated changes, and developed focal responses to questions posed. The multidisciplinary panel finalized 20 guideline recommendations for prescription of opioids for chronic non-cancer pain. Summary of the results showed over 90% agreement for the final 20 recommendations with strong consensus. The consensus guidelines included 4 sections specific to opioid therapy with 1) ten recommendations particular to initial steps of opioid therapy; 2) five recommendations for assessment of effectiveness of opioid therapy; 3) three recommendations regarding monitoring adherence and side effects; and 4) two general, final phase recommendations. LIMITATIONS/CONCLUSIONS:There is a continued paucity of literature of long-term opioid therapy addressing chronic non-cancer pain. Further, significant biases exist in the preparation of guidelines, which has led to highly variable rules and regulations across various states. CONCLUSION/CONCLUSIONS:These guidelines were developed based upon a comprehensive review of the literature, consensus among expert panelists, and in alignment with patient preferences, and shared decision-making so as to improve the long-term pain relief and function in patients with chronic non-cancer pain. Consequently, it was concluded - and herein recommended - that chronic opioid therapy should be provided in low doses with appropriate adherence monitoring and understanding of adverse events only to those patients with a proven medical necessity, and who exhibit stable improvement in both pain relief and activities of daily function, either independently or in conjunction with other modalities of treatments.
PMID: 38117465
ISSN: 2150-1149
CID: 5620212

Looking Back, Moving Forward in Pain Medicine

Paladini, Antonella; Gharibo, Christopher; Khalbous, Sonia; Salti, Ammar; Ergönenç, Tolga; Pasqualucci, Alberto; Varrassi, Giustino
Pain is an ancient medical complaint and a clinical riddle that has never been entirely solved. Looking back into history was the springboard to a look into the future of pain medicine. This article was based on a series of presentations given in a recent congress (May 2023) and represents the research, views, and opinions of the authors. Opium has been used for millennia to treat pain, but when it gained broad use in the United States in the 1980s and 1990s, it was so vastly overprescribed and mis-prescribed that it led to a public health crisis. This, in turn, led to the reaction where opioids at times were under-prescribed, leaving out many patients who may have benefited from opioids while leaving many legacy pain patients to manage withdrawal on their own and with few analgesic options. Cannabinoids (CB) were likewise widely used for various conditions, including pain, but were outlawed in the 20th century, only to be brought back as a potential analgesic agent. Interventional pain medicine is a developing discipline and has reinforced the concept of the interdisciplinary pain clinic. It plays an increasingly important part in modern medicine overall, especially with the support of ultrasound, for both diagnosis and therapy. Today, the views about pain have changed. Anyone has accepted that pain is not purely a physical phenomenon but a biopsychosocial phenomenon that occurs within a cultural context. Pain management remains a small but vitally important medical subspecialty that is critical from a functional enablement and population health perspective, which is helping to navigate new therapeutic targets, new drugs and routes of administration, greater understanding of pain psychology, and new technologies. Pain control today means early intervention, functional enablement through pain alleviation, educating patients about pain management, and minimizing the transition from acute to chronic pain.
PMID: 37809214
ISSN: 2168-8184
CID: 5605412

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

Impact of the COVID-19 Pandemic on Utilization Patterns of Facet Joint Interventions in Managing Spinal Pain in a Medicare Population

Manchikanti, Laxmaiah; Kaye, Alan D.; Latchaw, Richard E.; Sanapati, Mahendra R.; Pampati, Vidyasagar; Gharibo, Christopher G.; Albers, Sheri L.; Hirsch, Joshua A.
Introduction: The COVID-19 pandemic resulted in major disruptions in all aspects of human life including a decline of medical services utilized during 2020. An analysis of the impact of COVID-19 pandemic showed an 18.7% reduction in utilization patterns of interventional techniques in managing chronic pain in the Medicare population from 2019 to 2020. However, specific changes in utilization patterns of facet joint interventions have not been studied. Thus, we sought to assess the utilization patterns including an update of facet joint interventions from 2018 to 2020, with analysis of the impact of COVID-19 pandemic in managing chronic spinal pain utilizing facet joint interventions in the fee-for-service Medicare population of the United States. Methods: The present investigation was designed to assess utilization patterns and variables of facet joint interventions, in managing chronic spinal pain from 2010 to 2020 in the fee-for-service (FFS) Medicare population in the United States (US), and how the COVID-19 pandemic impacted these utilization patterns. Data for the analysis were obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2020. Results: Results of this analysis showed significant impact of COVID-19 with overall decrease of 18.5% of all facet joint interventions per 100,000 Medicare population compared to 20.2 and 20.5% decrease for lumbar and cervical facet joint injections, 15 and 13.1% decrease per 100,000 Medicare population of lumbosacral and cervicothoracic facet joint neurolysis procedures. The results are significant in that comparative analysis from 2000 to 2010 and 2010 to 2019 showing an annual increase of 14.4 vs. 2.2%, illustrating a decelerating pattern. There were also significant growth patterns noted with decreases in facet joint injections and nerve blocks compared to facet joint neurolytic procedures. Conclusions: This analysis shows a significant effect of COVID-19 producing an overall decrease in utilization of facet joint interventions relative to pre-COVID data. Further, the analysis demonstrates continued deceleration of utilization patterns of facet joint interventions compared to the periods of 2000"“2010 and 2010"“2019.
ISSN: 2193-8237
CID: 5424332

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