Publications by authors named "Amol Soin"

46 Publications

An Observational Study on the Use of a Patient Navigator to Help Improve Outcomes in Patients on Chronic Opioids.

Pain Physician 2022 Aug;25(5):381-386

Dartmouth College Geisel School of Medicine, Hanover, NH.

Background: In the United States, the prevalence of opioid use disorders has increased in recent years along with an attendant rise in the incidence of chronic pain disorders and prescription opioid use. Patient navigation services have been used to improve health outcomes in cancer and other chronic disease states, but it is unclear whether the implementation of patient navigation services can facilitate improved outcomes among patients receiving chronic opioid therapy.

Objectives: The objective of this study was to compare the outcomes of patients receiving chronic opioid therapy plus patient navigation services and those receiving chronic opioid therapy as a part of usual care.

Study Design: This was a prospective, observational study. Consecutive patients receiving chronic opioid therapy were enrolled, with alternating assignments to patient navigation (n = 30) or usual care (n = 30). Participants in the patient navigation group received support from a non-physician, non-advanced practice provider staff member who initiated frequent contact via telephone, telemedicine, or in-clinic visits to discuss the patient's health goals. The minimum follow-up period was 90 days. Outcomes qualitatively compared across groups included final pain score, final morphine milligram equivalent (MME) per day, and discharge rates. Risk factors for discharge within the navigation group were assessed. Patient feedback was also solicited.

Setting: This study was conducted at a single independent pain clinic in the United States.

Results: Demographic features were similar between the navigator group and the control group. The control group had a higher average initial pain score (7.0/10) than the intervention group (5.9/10) and were receiving a higher initial dose of opioids (23.1 vs 19.0 MME/d). After an average follow-up of 108.7 days, patients in the navigator group had a 16% decrease in final opioid dose compared with a 23% increase in the control group. Furthermore, patients in the control group were discharged from the practice at a higher rate (23.3% vs 6.6%), suggesting increased opioid misuse in the control group compared with the navigator group. In the navigator group, higher levels of anxiety and depression were the primary predictors of discharge.

Limitations: This was a single-center study with a small sample size. The generalizability of these results to other clinic settings is unknown.

Conclusions: Patient navigation decreased opioid use and practice discharge compared with usual care in an independent pain clinic, suggesting a role for patient navigation in reducing opioid misuse and potentially reducing adverse events.
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August 2022

Impact Of COVID-19 Pandemic and Updated Utilization Patterns of Sacroiliac Joint Injections from 2000 to 2020 in The Fee-For-Service (FFS) Medicare Population.

Pain Physician 2022 05;25(3):239-250

Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: Among the multiple causes of low back and lower extremity pain, sacroiliac joint pain has shown to be prevalent in 10% to 25% of patients with persistent axial low back pain without disc herniation, discogenic pain, or radiculitis. Over the years, multiple Current Procedural Terminology (CPT) codes have evolved with the inclusion of intraarticular injections, nerve blocks, and radiofrequency neurotomy, in addition to percutaneous sacroiliac joint fusions. Previous assessments of utilization patterns of sacroiliac joint interventions only included sacroiliac joint intraarticular injections, since the data was not available prior to the introduction of new codes. A recent assessment revealed an increase of 11.3%, and an annual increase of 1.2% per 100,000 Medicare population from 2009 to 2018, showing a decline in growth patterns. During the past 2 years, the COVID-19 pandemic has also had significant effects on the utilization patterns of sacroiliac joint interventions.

Study Design: The impact of the COVID-19 pandemic and analysis of growth patterns of sacroiliac joint interventions (intraarticular injections, nerve blocks, radiofrequency neurotomy, arthrodesis and fusion) was evaluated from 2010 to 2019 and 2010 to 2020, with a comparative analysis from 2019 to 2020 to assess the impact of the COVID-19 pandemic.

Objectives: To update utilization patterns of sacroiliac joint interventions with assessment of the impact of the COVID-19 pandemic.

Methods: The Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) Master dataset was utilized in the present analysis.

Results: The results of this evaluation demonstrated a significant impact of the COVID-19 pandemic with a 19.2% decrease of utilization of sacroiliac joint intraarticular injections from 2019 to 2020. There was a 23.3% increase in sacroiliac joint arthrodesis and a 5.3% decrease for sacroiliac joint fusions with small numbers from 2019 to 2020. However, data was not available for sacroiliac joint nerve blocks and sacroiliac joint radiofrequency neurotomy as these codes were incorporated in 2020. Overall, from 2010 to 2019, sacroiliac joint intraarticular injections showed an annual increase of 0.9% per 100,000 Medicare population. Sacroiliac joint arthrodesis and fusion showed an annual increase from 2010 to 2020 per 100,000 Medicare population of 29% for arthrodesis and 13.3% for fusion.

Limitations: Limitations of this study include a lack of inclusion of Medicare Advantage patients constituting approximately 30% to 40% of the overall Medicare population. As with all claims-based data analyses, this study is retrospective and thus potentially limited by bias. Finally, patients who are non-Medicare are not part of the dataset.

Conclusions: The study shows the impact of the COVID-19 pandemic with a significant decrease of intraarticular injections of 19.2% from 2019 to 2020 per 100,000 Medicare population. These decreases of intraarticular injections are accompanied by a 5.3% decrease of fusion, but a 23.3% increase of arthrodesis from 2019 to 2020 per 100,000 Medicare population. Overall, the results showed an annual increase of 0.9% per 100,000 Medicare population for intraarticular injections, a 35.4% annual increase for sacroiliac joint arthrodesis and an increase of 15.5% for sacroiliac joint fusion from 2010 to 2019.
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May 2022

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.

Pain Physician 2022 05;25(3):223-238

Massachusetts General Hospital and Harvard Medical School, Boston, MA.

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.
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May 2022

Equivalent Outcomes of Lumbar Therapeutic Facet Joint Nerve Blocks and Radiofrequency Neurotomy: Comparative Evaluation of Clinical Outcomes and Cost Utility.

Pain Physician 2022 03;25(2):179-192

Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: Chronic low back pain secondary to facet joint pathology is prevalent in 27% to 40% of selected populations using controlled comparative local anesthetic blocks. Lumbar facet joint nerve blocks and radiofrequency neurotomy are the most common interventional procedures for lower back pain. Nonetheless, questions remain regarding the effectiveness of each modality. Moreover, there is no agreement in reference to superiority or inferiority of lumbar facet joint nerve blocks when compared with radiofrequency neurotomy. Centers for Medicare and Medicaid Services (CMS) and almost all payers prefer radiofrequency ablation. Both procedures have been extensively studied with randomized controlled trials, systematic reviews, and cost utility analysis.

Objective: To assess the clinical outcomes and cost utility of therapeutic lumbar facet joint nerve blocks (lumbar facet joint nerve blocks with L5 dorsal ramus block) compared with radiofrequency neurotomy in managing chronic low back pain of facet joint origin.

Study Design: A retrospective, case-control, comparative evaluation of outcomes and cost utility.

Setting: The study was conducted in an interventional pain management practice, a specialty referral center, a private practice setting in the United States.

Methods: The study was performed utilizing the Strengthening the Reporting of Observational Studies in Epidemiology Analysis (STROBE) criteria. Only the patients meeting the diagnostic criteria of facet joint pain by means of comparative, controlled diagnostic local anesthetic blocks were included.The main outcome measure was pain relief measured by the Numeric Rating Scale (NRS) evaluated at 3, 6, and 12 months. Significant improvement was defined as at least 50% improvement in pain relief. Cost utility was calculated utilizing direct payment data for the procedures with the addition of estimated indirect costs over a period of one year based on highly regarded surgical literature and previously published interventional pain management literature.

Results: A total of 326 patients met the inclusion criteria with 99 patients receiving lumbar facet joint nerve blocks (lumbar facet joint nerve blocks with L5 dorsal ramus block) and 227 receiving lumbar radiofrequency neurotomy. Forty-eight patients in the facet joint nerve block group and 148 patients in the radiofrequency group completed one-year follow-up. Patients experienced significant improvement in both groups from baseline to 12 months with significant pain relief (≥ 50%) Significant pain relief was recorded in 100%, 99%, and 79% of the patients in the facet joint nerve block group, whereas, it was 100%, 74%, and 65% in the radiofrequency neurotomy group at the 3, 6, and 12 month follow-up, with a significant difference at 6 months. Cost utility analysis showed average costs for quality-adjusted life year (QALY) of $4,664 for lumbar facet joint nerve blocks and $5,446 for lumbar radiofrequency neurotomy. Twelve patients (12%) in the lumbar facet joint nerve block group and 79 patients (35%) in the lumbar radiofrequency group were converted to other treatments, either due to side effects or inadequate relief.

Conclusion: This study shows similar outcomes of therapeutic lumbar facet joint nerve blocks when compared with radiofrequency neurotomy as indicated by significant pain relief and cost utility.
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March 2022

The Analysis of Pain Research through the Lens of Artificial Intelligence and Machine Learning.

Pain Physician 2022 03;25(2):E211-E243

Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA.

Background: Traditional pain assessment methods have significant limitations due to the high variability in patient reported pain scores and perception of pain by different individuals. There is a need for generalized and automatic pain detection and recognition methods. In this paper, state-of-the-art machine learning (ML) and deep learning methods in this field are analyzed as well as pain management techniques.

Objective: The objective of the study is to analyze the current use of artificial intelligence (AI) and ML in the analysis and management of pain and to disseminate this knowledge prompting future utilization by medical professionals.

Study Design: A narrative review of the literature focusing on the latest algorithms in AI and ML for pain assessment and management.

Methods: Research studies were collected using a literature search on PubMed, Science Direct and IEEE Xplore between 2018 and 2020.

Results: The results of our assessment resulted in the identification of 47 studies meeting inclusion criteria. Pain assessment was the most studied subject with 11 studies, followed by automated measurements with 10 studies, spinal diagnosis with 8 studies, facial expression with 7 studies, pain assessment in special settings evaluated in 5 studies, 4 studies described treatment algorithms, and 2 studies assessed neonatal pain. These studies varied from simple to highly complex methodology. The majority of the studies suffered from inclusion of a small number of patients and without replication of results. However, considering AI and ML are dynamic and emerging specialties, the results shown here are promising. Consequently, we have described all the available literature in summary formats with commentary. Among the various assessments, facial expression and spinal diagnosis and management appear to be ready for inclusion as we continue to progress.

Limitations: This review is not a systematic review of ML and AI applications in pain research. This review only provides a general idea of the upcoming techniques but does not provide an authoritative evidence-based conclusive opinion of their clinical application and effectiveness.

Conclusion: While a majority of the studies focused on classification tasks, very few studies have explored the diagnosis and management of pain. Usage of ML techniques as support tools for clinicians holds an immense potential in the field of pain management.
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March 2022

A Pilot Study Implementing a Machine Learning Algorithm to Use Artificial Intelligence to Diagnose Spinal Conditions.

Pain Physician 2022 03;25(2):171-178

Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA.

Background: Chronic spinal pain is the most prevalent chronic disease, with chronic persistent spinal pain lasting longer than one-year reported in 25% to 60% of the patients. Health care expenditures have been escalating and the financial impact on the US economy is growing. Among multiple modalities of treatments available, facet joint interventions and epidural interventions are the most common ones, in addition to surgical interventions and numerous other conservative modalities of treatments. Despite these increasing costs in the diagnosis and management, disability continues to increase. Consequently, algorithmic approaches have been described as providing a disciplined approach to the use of spinal interventional techniques in managing spinal pain. This approach includes evaluative, diagnostic, and therapeutic approaches, which avoids unnecessary care, as well as poorly documented practices.  Recently, techniques involving artificial intelligence and machine learning have been demonstrated to contribute to the improved understanding, diagnosis, and management of both acute and chronic disease in line with well-designed algorithmic approach. The use of artificial intelligence and machine-learning techniques for the diagnosis of spinal pain has not been widely investigated or adopted.

Objectives: To evaluate whether it is possible to use artificial intelligence via machine learning algorithms to analyze specific data points and to predict the most likely diagnosis related to spinal pain.

Study Design: This was a prospective, observational pilot study.

Setting: A single pain management center in the United States.

Methods: A total of 246 consecutive patients with spinal pain were enrolled. Patients were given an iPad to complete a Google form with 85 specific data points, including demographic information, type of pain, pain score, pain location, pain duration, and functional status scores. The data were then input into a decision tree machine learning software program that attempted to learn which data points were most likely to correspond to the practitioner-assigned diagnosis. These outcomes were then compared with the practitioner-assigned diagnosis in the chart.

Results: The average age of the included patients was 57.4 years (range, 18-91 years). The majority of patients were women and the average pain history was approximately 2 years. The most common practitioner-assigned diagnoses included lumbar radiculopathy and lumbar facet disease/spondylosis. Comparison of the software-predicted diagnosis based on reported symptoms with practitioner-assigned diagnosis revealed that the software was accurate approximately 72% of the time.

Limitations: Additional studies are needed to expand the data set, confirm the predictive ability of the data set, and determine whether it is broadly applicable across pain practices.

Conclusions: Software-predicted diagnoses based on the data from patients with spinal pain had an accuracy rate of 72%, suggesting promise for augmented decision making using artificial intelligence in this setting.
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March 2022

The Impact of COVID-19 on Interventional Pain Management Practices is Significant and Long-Lasting: An Interventional Pain Management Physician Survey.

Pain Physician 2022 03;25(2):131-144

Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: As with many others in the house of medicine, the COVID-19 pandemic has adversely impacted the practice of interventional pain management. This in part relates to various  state health authority or medical board restrictions with reductions in patient volume for evaluations, follow-ups, and procedures. Of course, the pandemic continues to persist which is in turn leading to longer-lasting effects. Our previous survey was performed in March 2020. At that time, there was a national lockdown in the United States with COVID-19 disease qualifying as a pandemic by the World Health Organization (WHO). The pandemic caused by COVID-19 disease continues to have far-reaching implications on how we deliver routine care to patients and its effect on patient care, economic aspects, and health of interventional pain management providers.

Objective: To assess the current and expected future impact of the COVID-19 pandemic on interventional pain management practices in a physician survey. The study was performed based on performance in 2021 compared to the 2019 pre-COVID era.

Methods: The American Society of Interventional Pain Physicians (ASIPP) administered a 16-question survey to their members by contacting them via a commercially available online marketing company platform. The survey was completed on www.constantcontact.com.

Results: The results showed that 88% of the providers experienced a reduction in income and a similar number expect decreases over the next 12 months. A large proportion of respondents (73.3%) reported a reduction in revenue of 11%-25%. In contrast, another 21.5% reported a revenue decline of 26%-50%, and 29% reported 11%-25% increase in expenses. Overall, new patient volume decreased 11%-25% based on the response from almost 63%, whereas almost 9% reported a decline of 26%-50%. In contrast, established patient volume declined 1%-10% as reported by 64% of the respondents, compared to an 11%-25% decrease by a small proportion of 14%. All interventional procedures showed significant decreases across the board, with 69% of the respondents reporting a decline in-office procedures, 64% in ambulatory surgery center (ASC) procedures, and 57% in hospital outpatient department (HOPD) procedures, ranging from 11%-25%.

Limitations: The survey included a relatively small number of member physicians which could introduce sampling error. Consequently, it may not be generalizable for other specialties or even to pain medicine.

Conclusion: The COVID-19 pandemic has put interventional pain practices throughout the United States under considerable financial and psychological stress. This study seeks to quantify the extent of economic loss and other challenges resultant from the pandemic. Almost 99% reported a decrease in revenues in the last 12 months, with 86% reporting an expected reduction in the next 12 months and 49% reporting an increase in expenses. Declines have been reported in all sectors with new patients, office procedures, ASC, and HOPD procedures, except for established patient visits, which have shown minor declines compared to other domains. Understanding the issues facing interventional pain management physicians facilitates the development of strategies to actively manage provider practice/well-being, and to minimize risk to personnel to keep patients safe.
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March 2022

Fourth Wave of Opioid (Illicit Drug) Overdose Deaths and Diminishing Access to Prescription Opioids and Interventional Techniques: Cause and Effect.

Pain Physician 2022 03;25(2):97-124

Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: In the midst of the COVID-19 pandemic, data has shown that age-adjusted overdose death rates involving synthetic opioids, psychostimulants, cocaine, and heroin have been increasing, including prescription opioid deaths, which were declining, but, recently, reversing the trends. Contrary to widely held perceptions, the problem of misuse, abuse, and diversion of prescription opioids has been the least of all the factors in recent years. Consequently, it is important to properly distinguish between the role of illicit and prescription opioids in the current opioid crisis. Multiple efforts have been based on consensus on administrative policies for certain harm reduction strategies for individuals actively using illicit drugs and reducing opioid prescriptions leading to curbing of medically needed opioids, which have been ineffective. While there is no denial that prescription opioids can be misused, abused, and diverted, the policies have oversimplified the issue by curbing prescription opioids and the pendulum has swung too far in the direction of severely limiting prescription opioids, without acknowledgement that opioids have legitimate uses for persons suffering from chronic pain. Similar to the opioid crisis, interventional pain management procedures have been affected by various policies being applied to reduce overuse, abuse, and finally utilization. Medical policies have been becoming more restrictive with reduction of access to certain procedures, with the pendulum swinging too far in the direction of limiting interventional techniques. Recent utilization assessments have shown a consistent decline for most interventional techniques, with a 18.7% decrease from 2019 to 2020. The causes for these dynamic changes are multifactorial likely including the misapplication of the 2016 Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for chronic pain, the relative ease of access to illicit synthetic opioids and more recently issues related to the COVID-19 pandemic. In addition, recent publications have shown association of dose tapering with overdose or mental health crisis among patients prescribed long-term opioids. These findings are leading to the hypothesis that federal guidelines may inadvertently be contributing to an increase in overall opioid deaths and diminished access to interventional techniques. Together, these have resulted in a fourth wave of the opioid epidemic.

Methods: A narrative review.

Results: The fourth wave results from a confluence of multiple factors, including misapplication of CDC guidelines, the increased availability of illicit drugs, the COVID-19 pandemic, and policies reducing access to interventional procedures. The CDC guidelines and subsequent regulatory atmosphere have led to aggressive tapering up to and including, at times, the overall reduction or stoppage of opioid prescriptions. Forced tapering has been linked to an increase of 69% for overdoses and 130% for mental health crisis. The data thus suggests that the diminution in access to opioid prescriptions may be occurring simultaneously with an increase in illicit narcotic use.Combined with CDC guidelines, the curbing of opioid prescriptions to medically needed individuals, among non-opioid treatments, interventional techniques have been affected with declining utilization rates and medical policies reducing access to such modalities.

Conclusion: The opioid overdose waves over the past three decades have resulted from different etiologies. Wave one was associated with prescription opioid overdose deaths and wave two with the rise in heroin and overdose deaths from 1999 to 2013. Wave three was associated with a rise in synthetic opioid overdose deaths. Sadly, wave four continues to escalate with increasing number of deaths as a confluence of factors including the CDC guidelines, the COVID pandemic, increased availability of illicit synthetic opioids and the reduction of access to interventional techniques, which leads patients to seek remedies on their own.
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March 2022

Peripheral Nerve Stimulation for Chronic Pain: A Systematic Review of Effectiveness and Safety.

Pain Ther 2021 Dec 3;10(2):985-1002. Epub 2021 Sep 3.

Physician Partners of America, Orange Park, FL, USA.

Peripheral nerve stimulation (PNS) was the first application of neuromodulation. Widespread application of PNS was limited by technical concerns. Recent advances now allow the percutaneous placement of leads with ultrasound or fluoroscopic guidance, while the transcutaneous powering of these leads removes the need for leads to cross major joints. This systematic review was written to assess the current status of high-quality evidence supporting the use of PNS for pain conditions treated by interventional pain physicians. The available literature on PNS, limited to conditions treated by interventional pain physicians, was reviewed and the quality assessed. Literature from 1966 to June 2021 was reviewed. The outcome measures were pain relief and functional improvement. One hundred and two studies were identified. Five randomized controlled trials (RCT) and four observational studies, all case series, met the inclusion criteria. One RCT was of high quality and four were of moderate quality; all four case series were of moderate quality. Three of the RCTs and all four case series evaluated peripheral nerve neuropathic pain. Based upon these studies, there is level II evidence supporting the use of PNS to treat refractory peripheral nerve injury. One moderate-quality RCT evaluated tibial nerve stimulation for pelvic pain, providing level III evidence for this indication. One moderate-quality RCT evaluated surgically placed cylindrical leads for cluster headaches, providing level III evidence for this indication. The evidence suggests that approximately two-thirds of patients with peripheral neuropathic pain will have at least 50% sustained pain relief. Adverse events from PNS are generally minor. A major advantage of PNS over spinal cord stimulation is the absence of any risk of central cord injury. The study was limited by the paucity of literature for some indications. No studies dealt with joint-related osteoarthritic pain.
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http://dx.doi.org/10.1007/s40122-021-00306-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8586061PMC
December 2021

Spinal Cord Stimulation Trends of Utilization and Expenditures in Fee-For-Service (FFS) Medicare Population from 2009 to 2018.

Pain Physician 2021 08;24(5):293-308

Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: Spinal cord stimulation has been utilized with increasing frequency in managing chronic intractable spinal pain and complex regional pain syndrome (CRPS) in addition to other neuropathic pain states. The literature has shown the effectiveness of spinal cord stimulation in managing chronic pain with improvement in quality of life and cost utility. There have not been any reviews performed in the fee-for-service (FFS) Medicare population in reference to utilization and expenditure patterns of spinal cord stimulators.

Objectives: This investigation was undertaken to assess the utilization and expenditures for spinal cord stimulation in the FFS Medicare population from 2009 to 2018.

Study Design: The present study was designed to assess the utilization patterns and expenditures in all settings, for all providers in the FFS Medicare population from 2009 to 2018 in the United States. A standard 5% national sample of the Centers for Medicare and Medicaid Services (CMS) physician outpatient billing claims data. All the expenditures were presented with allowed costs and adjusted to inflation to 2018 US dollars only trials and implants were included.

Results: Utilization patterns showed that spinal cord stimulation trials increased from 12,680 in 2009 to 36,280 in 2018, a 186% increase with an annual increase of 12.4%. The rate of trials per 100,000 population increased from 28 in 2009 to 61 in 2018 with a 120% increase, or an annual increase of 9.1%. The pulse generator implants increased from 7,640 in 2009 to 22,960 in 2018, an increase of 201%, with an annual increase of 13%. In addition, percutaneous placement with pulse generator implants increased from 4,080 in 2009 to 14,316 in 2018, a 252% increase, or 15% annual increase. In contrast, implantation of neurostimulator electrodes with paddle leads with laminectomy and placement of spinal pulse generator increased from 3,560 in 2009 to 8,600 in 2018, a 142% increase or an annual increase of 10.3%. Analysis of expenditures showed total inflation-adjusted expenditures increased from $292,153,701 in 2009 to $1,142,434,137 in 2018, a 291% increase from 2009 to 2018 and 16.4% annual increase. These expenditures were 125% higher than facet joint interventions and 138% higher than epidural interventions in 2018. In contrast, these expenditures were 55% below the expenditures of facet joint interventions and 66% lower than epidural injections in 2009.Trial to implant ratio improved from 42.5% in 2009 to 63.6% in 2018. An overwhelming majority of trials (90%) were performed by nonsurgical physicians, whereas, 56% of implants were performed by non-surgeons.

Limitations: This assessment includes only FFS Medicare population, thus eliminating approximately 30% of the population with Medicare Advantage plans. In addition, this study has not taken into consideration various revisions not included in 3 specific codes.

Conclusions: The analysis of spinal cord stimulators in the FFS Medicare population from 2009 to 2018 showed explosive increases of trials, implants and overall costs.
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August 2021

Low-Dose Naltrexone Use for Patients with Chronic Regional Pain Syndrome: A Systematic Literature Review.

Pain Physician 2021 07;24(4):E393-E406

Wright State University Boonshoft School of Medicine, Fairborn, OH.

Background: Complex regional pain syndrome is a rare, neuropathic disorder that affects fewer than 200,000 individuals in the United States annually. Current treatments often focus on pain management and fall short of relieving symptoms of pain and dystonia in patients.

Objective: The goal of this systematic qualitative review is to evaluate the evidence for the use of low-dose naltrexone in the treatment of chronic pain syndromes.

Study Design: This is a systematic review.

Methods: PubMed, Embase, and Web of Science were searched for articles containing the keywords "low-dose naltrexone" AND ("pain" OR "chronic pain" OR "fibromyalgia" OR "complex regional pain syndrome" OR "neuropathic pain" OR "nociceptive pain") between 1950 and July 17, 2020. A total of 30 publications were systematically reviewed. Exclusion criteria were articles that were unavailable in English, focused on acute pain only, and evaluated only animal models. Case studies were included for the purposes of our qualitative review.

Results: Out of 29 articles, we reviewed 11 prospective studies, 10 case studies, 3 systematic reviews, 2 retrospective studies, 2 simulation models, and one combination study. Articles focused on chronic pain syndromes as well as painful rheumatologic disorders and neurological disorders. We found that low-dose naltrexone treatment was positively associated with symptom relief in patients experiencing chronic pain, dystonia, and sleep disturbances.

Limitations: Due to the limited number of available articles focusing on the treatment of complex regional pain syndrome with low-dose naltrexone, the majority of studies analyzed focused on other chronic pain syndromes.

Conclusions: There is a need for additional prospective and interventional studies addressing the use of low-dose naltrexone in the treatment of complex regional pain syndrome symptoms.
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July 2021

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

Pain Physician 2021 01;24(S1):S27-S208

, Advanced Pain Institute, Covington, LA.

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: 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.
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January 2021

Methodology for Evidence Synthesis and Development of Comprehensive Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain.

Pain Physician 2021 01;24(S1):S1-S26

Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: The re-engineered definition of clinical guidelines in 2011 from the IOM (Institute of Medicine) states, "clinical practice guidelines are statements that include recommendations intended to optimize patient care that is informed by a systematic review of evidence and an assessment of the benefit and harms of alternative care options." The revised definition distinguishes between the term "clinical practice guideline" and other forms of clinical guidance derived from widely disparate development processes, such as consensus statements, expert advice, and appropriate use criteria.

Objective: To assess the literature and develop methodology for evidence synthesis and development of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain.

Methods: A systematic review of the literature including methodology of guideline development encompassing GRADE approach for guidance on evidence synthesis with recommendations.

Results: Some of the many factors described in 2011 continue as of 2020 and impede the development of clinical practice guidelines. These impediments include biases due to a variety of conflicts and confluence of interest, inappropriate and poor methodological quality, poor writing and ambiguous presentation, projecting a view that these are not applicable to individual patients or too restrictive with the elimination of clinician autonomy, and overzealous and inappropriate recommendations, either positive, negative, or non-committal. Thus, ideally, a knowledgeable, multidisciplinary panel of experts with true lack of bias and confluence of interest must develop guidelines based on a systematic review of the existing evidence. This manuscript describes evidence synthesis from observational studies, various types of randomized controlled trials (RCTs), and, finally, methodological and reporting quality of systematic reviews. The manuscript also describes various methods utilized in the assessment of the quality of observational studies, diagnostic accuracy studies, RCTs, and systematic reviews.

Limitations: Paucity of publications with appropriate evidence synthesis methodology in reference to interventional techniques.

Conclusion: This review described comprehensive evidence synthesis derived from systematic reviews, including methodologic quality and bias measurement. The manuscript described various methods utilized in the assessment of the quality of the systematic reviews, RCTs, diagnostic accuracy studies, and observational studies.
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January 2021

Declining Utilization and Inflation-Adjusted Expenditures for Epidural Procedures in Chronic Spinal Pain in the Medicare Population.

Pain Physician 2021 01;24(1):1-15

Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: Despite epidurals being one of the most common interventional pain procedures for managing chronic spinal pain in the United States, expenditure analysis lacks assessment in correlation with utilization patterns.

Objectives: This investigation was undertaken to assess expenditures for epidural procedures in the fee-for-service (FFS) Medicare population from 2009 to 2018.

Study Design: The present study was designed to assess expenditures in all settings, for all providers in the FFS Medicare population from 2009 to 2018 in the United States. In this manuscript: • A patient was described as receiving epidural procedures throughout the year.• A visit was considered to include all regions treated during the visit. • An episode was considered as one treatment per region utilizing primary codes only.• Services or procedures were considered as all procedures including bilateral and multiple levels. A standard 5% national sample of the Centers for Medicare and Medicaid Services (CMS) physician outpatient billing claims data for those enrolled in the FFS Medicare program from 2009 to 2018 was utilized. All the expenditures were presented with allowed costs and adjusted to inflation to 2018 US dollars.

Results: Total expenditures were $723,981,594 in 2009, whereas expenditures of 2018 were $829,987,636, with an overall 14.6% increase, or an annual increase of 1.5%. However, the inflation-adjusted rate was $847,058,465 in 2009, compared to $829,987,636 in 2018, a reduction overall of 2% and an annual reduction of 0.2%. Inflation-adjusted per patient annual costs decreased from $988.93 in 2009 to $819.27 in 2018 with a decrease of 17.2% or an annual decline of 2.1%. In addition, inflation-adjusted costs per procedure decreased from $399.77 to $377.94, or 5.5% overall and 0.6% annually. Per procedure, episode, visit, and patient expenses were higher for transforaminal epidural procedures than lumbar interlaminar/caudal epidural procedures. Overall, costs of transforaminal epidurals increased 27.6% or 2.7% annually, whereas lumbar interlaminar and caudal epidural injections cost were reduced 2.7%, or 0.3% annually. Inflation-adjusted costs for transforaminal epidurals increased 9.1% or 1.0% annually and declined 16.9 or 2.0% annually for lumbar interlaminar and caudal epidural injections.

Limitations: Expenditures for epidural procedures in chronic spinal pain were assessed only in the FFS Medicare population. This excluded over 30% of the Medicare population, which is enrolled in Medicare Advantage plans.

Conclusions: After adjusting for inflation, there was a decrease of expenditures for epidural procedures of 2%, or 0.2% annually, from 2009 to 2018. However, prior to inflation, the increases were noted at 14.6% and 1.5%. Inflation-adjusted costs per patient, per visit, and per procedure also declined. The proportion of Medicare patients per 100,000 receiving epidural procedures decreased 9.1%, or 1.1% annually. However, assessment of individual procedures showed higher costs for transforaminal epidural procedures compared to lumbar interlaminar and caudal epidural procedures.
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January 2021

Assessment of Prevalence of Cervical Facet Joint Pain with Diagnostic Cervical Medial Branch Blocks: Analysis Based on Chronic Pain Model.

Pain Physician 2020 11;23(6):531-540

Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: Research into cervical spinal pain syndromes has indicated that the cervical facet joints can be a potent source of neck pain, headache, and referred pain into the upper extremities. There have been multiple diagnostic accuracy studies, most commonly utilizing diagnostic facet joint nerve blocks and an acute pain model, as Bogduk has proposed. Subsequently, Manchikanti has focused on the importance of the chronic pain model and longer lasting relief with diagnostic blocks.

Objective: To assess diagnostic accuracy of cervical facet joint nerve blocks with controlled comparative local anesthetic blocks, with updated assessment of prevalence, false-positive rate, and a description of philosophical paradigm shift from acute to chronic pain model, with concordant pain relief.

Study Design: This diagnostic accuracy study was performed with retrospective assessment of data to assess prevalence and false-positive rates.

Setting: The study was performed in a non-university-based, multidisciplinary, interventional pain management, private practice in the United States.

Methods: Cervical medial branch blocks were performed utilizing lidocaine 1% followed by bupivacaine 0.25% when appropriate response was obtained in an operating room under fluoroscopic guidance with 0.5 mL of lidocaine or bupivacaine from C3-C6 medial branches (levels blocked on joints involved). If a patient failed to respond to lidocaine with appropriate >= 80% pain relief, that patient was considered as negative for facet joint pain. If the response was positive with lidocaine block, a bupivacaine block was performed.

Results: The chronic cervical facet joint pain was diagnosed with cervical facet joint nerve blocks at a prevalence of 49.3% (95% CI, 43.6%, 55.0%) and with a false-positive rate of 25.6% (95% CI, 19.5%, 32.8%). This study also showed a single block prevalence rate of 66.3% (95% CI, 71.7%, 60.9%). Assessment of the duration of relief with each block showed greater than 80% for 6 days with lidocaine block and total relief of >= 50% of 31 days. In contrast, with bupivacaine, average duration of pain relief of >= 80% was 12 days with a total relief of >= 50% lasting for 55 days.

Conclusion: Based on this investigation, utilizing a chronic pain model, there was significant difference in the relief patterns. This assessment showed prevalence and false-positive rates of 49.3% and 25.6% in chronic neck pain. Duration of relief >= 80% pain relief was 6 days with lidocaine and 12 days with bupivacaine, with total relief of >= 50% of 31 days with 55 days respectively.
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November 2020

Low Back Pain and Diagnostic Lumbar Facet Joint Nerve Blocks: Assessment of Prevalence, False-Positive Rates, and a Philosophical Paradigm Shift from an Acute to a Chronic Pain Model.

Pain Physician 2020 09;23(5):519-530

Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: Lumbar facet joints are a clinically important source of chronic low back pain. There have been extensive diagnostic accuracy studies, along with studies of influence on the diagnostic process, but most of them have utilized the acute pain model. One group of investigators have emphasized the importance of the chronic pain model and longer lasting relief with diagnostic blocks.

Objective: To assess the diagnostic accuracy of lumbar facet joint nerve blocks with controlled comparative local anesthetic blocks and concordant pain relief with an updated assessment of the prevalence, false-positive rates, and a description of a philosophical paradigm shift from an acute to a chronic pain model.

Study Design: Retrospective study to determine diagnostic accuracy, prevalence and false-positive rates.

Setting: A multidisciplinary, non-university based interventional pain management practice in the United States.

Methods: Controlled comparative local anesthetic blocks were performed initially with 1% lidocaine, followed by 0.25% bupivacaine if appropriate response was obtained, in an operating room under fluoroscopic guidance utilizing 0.5 mL of lidocaine or bupivacaine at L3, L4 medial branches and L5 dorsal ramus. All patients non-responsive to lidocaine blocks were considered to be negative for facet joint pain. All patients were assessed after the diagnostic blocks were performed with >= 80% pain relief for their ability to perform previously painful movements.

Results: The prevalence of lumbar facet joint pain in chronic low back pain was 34.1% (95% CI, 28.8%, 39.8%), with a false-positive rate of 49.8% (95% CI, 42.7%, 56.8%). This study also showed a single block prevalence rate of 67.9% (95% CI, 62.9%, 73.2%). Average duration of pain relief >= 80% was 6 days with lidocaine block and total relief of >= 50% of 32 days. With bupivacaine, the average duration of pain relief >= 80% was 13 days with total relief of >= 50% lasting for 55 days.

Conclusion: This study demonstrated that the chronic pain model is more accurate and reliable with concordant pain relief. This updated assessment also showed prevalence and false-positive rates of 34.1% and 49.8%.
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September 2020

Ohio Response to COVID-19 and Its Impact on Interventional Pain Management Practices.

Pain Physician 2020 08;23(4S):S439-S448

Wright State University Boonshoft School of Medicine, Ohio.

Background: The coronavirus disease 2019 (COVID-19) pandemic has drastically altered daily living and medical care for Ohio residents and the practice of medicine for the interventional pain management physician. As a state, Ohio tends to be demographically representative of the broader US population.

Objective: Reviewing the efforts deployed by Ohio to flatten the COVID-19 infection curve and reduce the spread of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an important component of determining optimal procedures for mitigating the effects of the COVID-19 pandemic.

Methods: Over the course of several announcements and orders during the months of March and April, new policies were put into place to prevent COVID-19 transmission, which included efforts to facilitate social distancing and ensure the health care system could manage the number of COVID-19 cases at peak infection rate. Efforts directed toward medical providers included delay of elective procedures, expansion of telehealth options, and new temporary guidance for prescribing controlled substances.

Results: The Ohio COVID-19 containment approach resulted in a substantial reduction in COVID-19 cases compared with early models of disease spread, and the state has begun a phased reopening. Continued vigilance in applying social distancing and infection control measures will be a critical component of preventing or reducing the impact of a second wave of COVID-19 in Ohio.

Limitations: A narrative review with paucity of literature.
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August 2020

The Technological Impact of COVID-19 on the Future of Education and Health Care Delivery.

Pain Physician 2020 08;23(4S):S367-S380

Pain Diagnostics and Interventional Care, Sewickley, Pennsylvania.

Background: The unexpected COVID-19 crisis has disrupted medical education and patient care in unprecedented ways. Despite the challenges, the health-care system and patients have been both creative and resilient in finding robust "temporary" solutions to these challenges. It is not clear if some of these COVID-era transitional steps will be preserved in the future of medical education and telemedicine.

Objectives: The goal of this commentary is to address the sometimes substantial changes in medical education, continuing medical education (CME) activities, residency and fellowship programs, specialty society meetings, and telemedicine, and to consider the value of some of these profound shifts to "business as usual" in the health-care sector.

Methods: This is a commentary is based on the limited available literature, online information, and the front-line experiences of the authors.

Results: COVID-19 has clearly changed residency and fellowship programs by limiting the amount of hands-on time physicians could spend with patients. Accreditation Council for Graduate Medicine Education has endorsed certain policy changes to promote greater flexibility in programs but still rigorously upholds specific standards. Technological interventions such as telemedicine visits with patients, virtual meetings with colleagues, and online interviews have been introduced, and many trainees are "techno-omnivores" who are comfortable using a variety of technology platforms and techniques. Webinars and e-learning are gaining traction now, and their use, practicality, and cost-effectiveness may make them important in the post-COVID era. CME activities have migrated increasingly to virtual events and online programs, a trend that may also continue due to its practicality and cost-effectiveness. While many medical meetings of specialty societies have been postponed or cancelled altogether, technology allows for virtual meetings that may offer versatility and time-saving opportunities for busy clinicians. It may be that future medical meetings embrace a hybrid approach of blending digital with face-to-face experience. Telemedicine was already in place prior to the COVID-19 crisis but barriers are rapidly coming down to its widespread use and patients seem to embrace this, even as health-care systems navigate the complicated issues of cybersecurity and patient privacy. Regulatory guidance may be needed to develop safe, secure, and patient-friendly telehealth applications. Telemedicine has affected the prescribing of controlled substances in which online counseling, informed consent, and follow-up must be done in a virtual setting. For example, pill counts can be done in a video call and patients can still get questions answered about their pain therapy, although it is likely that after the crisis, prescribing controlled substances may revert to face-to-face visits.

Limitations: The health-care system finds itself in a very fluid situation at the time this was written and changes are still occurring and being assessed.

Conclusions: Many of the technological changes imposed so abruptly on the health-care system by the COVID-19 pandemic may be positive and it may be beneficial that some of these transitions be preserved or modified as we move forward. Clinicians must be objective in assessing these changes and retaining those changes that clearly improve health-care education and patient care as we enter the COVID era.
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August 2020

Steroid Distancing in Interventional Pain Management During COVID-19 and Beyond: Safe, Effective and Practical Approach.

Pain Physician 2020 08;23(4S):S319-S350

Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: Since the late 1940s, corticosteroids have been a mainstay class of agents in multiple interventional techniques and intra-articular injections. Exogenous glucocorticoids are structurally and pharmacologically similar to the endogenous hormones. As such, multiple actions of corticosteroids are exhibited, including those of anti-inflammatory and immunosuppressive effects. Epidural injections, with or without steroids, have been extensively used throughout the world. There are reports of epidural injections starting in 1901, with steroids being added to the local anesthetic since 1952, when steroids were administered into the sacral foramen.

Purpose: Due to the extensive side effects of steroids in various injections, some have proposed limiting their use in epidurals and intraarticular injections. With the COVID-19 pandemic, the multiple side effects of the steroids have elevated the level of concern and recommendations have been made to utilize local anesthetic alone or the lowest dose of steroids. Fashioned from common expressions of the day, the term "steroid distancing" began to be used and proposed for intraarticular injections of the knee. Consequently, we sought to evaluate the evidence and feasibility of steroid distancing in interventional pain management.

Methods: This focused review of local anesthetics and steroids utilized in interventional pain management for epidural injections, peripheral nerve blocks, and intraarticular injections by multiple database searches. This is a focused narrative review and not a systematic review. Consequently, evidence synthesis was not performed traditionally, but was based on an overview of the available evidence.

Results: No significant difference was identified based on whether steroids are added to local anesthetic or not for epidural as well as facet joint injections. However, there was not enough evidence to compare these two groups for peripheral intraarticular injections.

Limitations: The present review is limited by the paucity of literature with bupivacaine alone or bupivacaine with steroids local anesthetic alone or with steroids of intraarticular injections of knee, hip, shoulder and other joints, and intraarticular facet joint injections.

Conclusion: This review shows an overall lack of significant difference between lidocaine alone and lidocaine with steroids in epidural injections. However, available evidence is limited for bupivacaine alone or with steroids. Evidence is also not available comparing local anesthetic alone with steroids for facet joint or peripheral joint intraarticular injections. Thus, it is concluded that local anesthetic with lidocaine may be utilized for epidural injections, with appropriate patient selection and steroids reserved for non-responsive patients with local anesthetic and with significant radiculitis.
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August 2020

The Effect of COVID-19 on Interventional Pain Management Practices: A Physician Burnout Survey.

Pain Physician 2020 08;23(4S):S271-S282

Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA.

Background: Burnout has been a commonly discussed issue for the past ten years among physicians and other health care workers. A survey of interventional pain physicians published in 2016 reported high levels of emotional exhaustion, often considered the most taxing aspect of burnout. Job dissatisfaction appeared to be the leading agent in the development of burnout in pain medicine physicians in the United States. The COVID-19 pandemic has drastically affected the entire health care workforce and interventional pain management, with other surgical specialties, has been affected significantly. The COVID-19 pandemic has placed several physical and emotional stressors on interventional pain management physicians and this may lead to increased physician burnout.

Objective: To assess the presence of burnout specific to COVID-19 pandemic among practicing interventional pain physicians.

Methods: American Society of Interventional Pain Physicians (ASIPP) administered a 32 question survey to their members by contacting them via commercially available online marketing company platform. The survey was completed on www.constantcontact.com.

Results: Of 179 surveys sent, 100 responses were obtained. The data from the survey demonstrated that 98% of physician practices were affected by COVID and 91% of physicians felt it had a significant financial impact. Sixty seven percent of the physicians responded that in-house billing was responsible for their increased level of burnout, whereas 73% responded that electronic medical records (EMRs) were one of the causes. Overall, 78% were very concerned. Almost all respondents have been affected with a reduction in interventional procedures. 60% had a negative opinion about the future of their practice, whereas 66% were negative about the entire health care industry.

Limitations: The survey included only a small number of member physicians. Consequently, it may not be generalized for other specialties or even pain medicine. However, it does represent the sentiment and present status of interventional pain management.

Conclusion: The COVID-19 pandemic has put interventional pain practices throughout the United States under considerable financial and psychological stress. It is essential to quantify the extent of economic loss, offer strategies to actively manage provider practice/wellbeing, and minimize risk to personnel to keep patients safe.
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August 2020

Lack of Superiority of Epidural Injections with Lidocaine with Steroids Compared to Without Steroids in Spinal Pain: A Systematic Review and Meta-Analysis.

Pain Physician 2020 08;23(4S):S239-S270

Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: Multiple randomized controlled trials (RCTs) and systematic reviews have been conducted to summarize the evidence for administration of local anesthetic (lidocaine) alone or with steroids, with discordant opinions, more in favor of equal effect with local anesthetic alone or with steroids.

Objective: To evaluate the comparative effectiveness of lidocaine alone and lidocaine with steroids in managing spinal pain to assess superiority or equivalency.

Study Design: A systematic review of RCTs assessing the effectiveness of lidocaine alone compared with addition of steroids to lidocaine in managing spinal pain secondary to multiple causes (disc herniation, radiculitis, discogenic pain, spinal stenosis, and post-surgery syndrome).

Methods: This systematic review was performed utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) for literature search, Cochrane review criteria, and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) to assess the methodologic quality assessment and qualitative analysis utilizing best evidence synthesis principles, and quantitative analysis utilizing conventional and single-arm meta-analysis. PubMed, Cochrane Library, US National Guideline Clearinghouse, Google Scholar, and prior systematic reviews and reference lists were utilized in the literature search from 1966 through December 2019. The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5.

Outcome Measures: A hard endpoint for the primary outcome was defined as the proportion of patients with 50% pain relief and improvement in function. Secondary outcome measures, or soft endpoints, were pain relief and/or improvement in function. Effectiveness was determined as short-term if it was less than 6 months. Improvement that lasted longer than 6 months, was defined as long-term.

Results: Based on search criteria, 15 manuscripts were identified and considered for inclusion for qualitative analysis, quantitative analysis with conventional meta-analysis, and single-arm meta-analysis. The results showed Level II, moderate evidence, for short-term and long-term improvement in pain and function with the application of epidural injections with local anesthetic with or without steroid in managing spinal pain of multiple origins.

Limitations: Despite 15 RCTs, evidence may still be considered as less than optimal and further studies are recommended.

Conclusion: Overall, the present meta-analysis shows moderate (Level II) evidence for epidural injections with lidocaine with or without steroids in managing spinal pain secondary to disc herniation, spinal stenosis, discogenic pain, and post-surgery syndrome based on relevant, high-quality RCTs. Results were similar for lidocaine, with or without steroids.
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August 2020

Triaging Interventional Pain Procedures During COVID-19 or Related Elective Surgery Restrictions: Evidence-Informed Guidance from the American Society of Interventional Pain Physicians (ASIPP).

Pain Physician 2020 08;23(4S):S183-204

Sutter Gould Medical Foundation, Stockton, CA.

Background: The COVID-19 pandemic has worsened the pain and suffering of chronic pain patients due to stoppage of "elective" interventional pain management and office visits across the United States. The reopening of America and restarting of interventional techniques and elective surgical procedures has started. Unfortunately, with resurgence in some states, restrictions are once again being imposed. In addition, even during the Phase II and III of reopening, chronic pain patients and interventional pain physicians have faced difficulties because of the priority selection of elective surgical procedures.Chronic pain patients require high intensity care, specifically during a pandemic such as COVID-19. Consequently, it has become necessary to provide guidance for triaging interventional pain procedures, or related elective surgery restrictions during a pandemic.

Objectives: The aim of these guidelines is to provide education and guidance for physicians, healthcare administrators, the public and patients during the COVID-19 pandemic. Our goal is to restore the opportunity to receive appropriate care for our patients who may benefit from interventional techniques.

Methods: The American Society of Interventional Pain Physicians (ASIPP) has created the COVID-19 Task Force in order to provide guidance for triaging interventional pain procedures or related elective surgery restrictions to provide appropriate access to interventional pain management (IPM) procedures in par with other elective surgical procedures. In developing the guidance, trustworthy standards and appropriate disclosures of conflicts of interest were applied with a section of a panel of experts from various regions, specialties, types of practices (private practice, community hospital and academic institutes) and groups. The literature pertaining to all aspects of COVID-19, specifically related to epidemiology, risk factors, complications, morbidity and mortality, and literature related to risk mitigation and stratification was reviewed. The evidence -- informed with the incorporation of the best available research and practice knowledge was utilized, instead of a simplified evidence-based approach. Consequently, these guidelines are considered evidence-informed with the incorporation of the best available research and practice knowledge.

Results: The Task Force defined the medical urgency of a case and developed an IPM acuity scale for elective IPM procedures with 3 tiers. These included urgent, emergency, and elective procedures. Examples of urgent and emergency procedures included new onset or exacerbation of complex regional pain syndrome (CRPS), acute trauma or acute exacerbation of degenerative or neurological disease resulting in impaired mobility and inability to perform activities of daily living. Examples include painful rib fractures affecting oxygenation and post-dural puncture headaches limiting the ability to sit upright, stand and walk. In addition, emergency procedures include procedures to treat any severe or debilitating disease that prevents the patient from carrying out activities of daily living. Elective procedures were considered as any condition that is stable and can be safely managed with alternatives.

Limitations: COVID-19 continues to be an ongoing pandemic. When these recommendations were developed, different stages of reopening based on geographical regulations were in process. The pandemic continues to be dynamic creating every changing evidence-based guidance. Consequently, we provided evidence-informed guidance.

Conclusion: The COVID-19 pandemic has created unprecedented challenges in IPM creating needless suffering for pain patients. Many IPM procedures cannot be indefinitely postponed without adverse consequences. Chronic pain exacerbations are associated with marked functional declines and risks with alternative treatment modalities. They must be treated with the concern that they deserve. Clinicians must assess patients, local healthcare resources, and weigh the risks and benefits of a procedure against the risks of suffering from disabling pain and exposure to the COVID-19 virus.
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August 2020

Evidence-Based Risk Mitigation and Stratification During COVID-19 for Return to Interventional Pain Practice: American Society of Interventional Pain Physicians (ASIPP) Guidelines.

Pain Physician 2020 08;23(4S):S161-S182

Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY.

Background: Chronic pain patients require continuity of care even during the COVID-19 pandemic, which has drastically changed healthcare and other societal practices. The American Society of Interventional Pain Physicians (ASIPP) has created the COVID-ASIPP Risk Mitigation & Stratification (COVID-ARMS) Return to Practice Task Force in order to provide guidance for safe and strategic reopening.

Objectives: The aims are to provide education and guidance for interventional pain specialists and their patients during the COVID-19 pandemic that minimizes COVID-related morbidity while allowing a return to interventional pain care.

Methods: The methodology utilized included the development of objectives and key questions with utilization of trustworthy standards, appropriate disclosures of conflicts of interest, as well as a panel of experts from various regions, specialities, and groups. The literature pertaining to all aspects of COVID-19, specifically related to epidemiology, risk factors, complications, morbidity and mortality, and literature related to risk mitigation and stratification were reviewed. The principles of best evidence synthesis of available literature and grading for recommendations as described by the Agency for Healthcare Research and Quality (AHRQ) typically utilized in ASIPP guideline preparation was not utilized in these guidelines due to limitations because of their lack of available literature on COVID-19, risk mitigation and stratification. These guidelines are considered evidence -- informed with incorporation of best available research and practice knowledge. Consequently, these guidelines are considered evidence-informed with incorporation of best available research and practice knowledge.

Results: Numerous risk factors have emerged that predispose patients to contracting COVID-19 and/or having a more severe course of the infection. COVID-19 may have mild symptoms, even be asymptomatic, or may be severe and life threatening. Older age and certain comorbidities, such as underlying pulmonary or cardiovascular disease, have been associated with worse outcomes. In pain care, COVID-19 patients are a heterogeneous group with some individuals relatively healthy and having only a short course of manageable symptoms while others become critically ill. It is necessary to assess patients on a case-by-case basis and craft individualized care recommendations. A COVID-ARMS risk stratification tool was created to quickly and objectively assess patients. Interventional pain specialists and their patients may derive important benefits from evidence-informed risk stratification, protective strategies to prevent infection, and the gradual resumption of treatments and procedures to manage pain.

Limitations: COVID-19 was an ongoing pandemic at the time during which these recommendations were developed. The pandemic has created a fluid situation in terms of evidence-informed guidance. As more and better evidence is gathered, these recommendations may be modified.

Conclusions: Chronic pain patients require continuity of care but during the time of the COVID-19 pandemic, steps must be taken to stratify risks and protect patients from possible infection to safeguard them from COVID-19-related illness and transmitting the disease to others. Pain specialists should optimize telemedicine encounters with their pain patients, be cognizant of risks of COVID-19 morbidity, and take steps to evaluate risk-benefit on a case-by-case basis. Pain specialists may return to practice with lower-risk patients and appropriate safeguards.
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August 2020

Trends of Expenditures and Utilization of Facet Joint Interventions in Fee-For-Service (FFS) Medicare Population from 2009-2018.

Pain Physician 2020 05;23(3S):S129-S147

Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: The trends of the expenditures of facet joint interventions have not been specifically assessed in the fee-for-service (FFS) Medicare population since 2009.

Objective: The objective of this investigation is to assess trends of expenditures and utilization of facet joint interventions in FFS Medicare population from 2009 to 2018.

Study Design: The study was designed to analyze trends of expenditures and utilization of facet joint interventions in FFS Medicare population from 2009-2018 in the United States. In this manuscript: • A patient was considered as undergoing facet joint interventions throughout the year. • A visit included all regions treated during the visit. • An episode was considered as one per region utilizing primary codes only. • Services or procedures were considered all procedures (multiple levels). Data for the analysis was obtained from the standard 5% national sample of the Centers for Medicare & Medicaid Services (CMS) physician outpatient billing claims for those enrolled in the FFS Medicare program from 2009 to 2018. All the expenditures were presented with allowed costs and also were inflation adjusted to 2018 US dollars.

Results: This analysis showed expenditures increased by 79% from 2009 to 2018 in the form of total cost for facet joint interventions, at an annual rate of 6.7%. Cervical and lumbar radiofrequency neurotomy procedures increased 185% and 169%. However, inflation-adjusted expenditures with 2018 US dollars showed an overall increase of 53% with an annual increase of 4.9%. In addition, using inflation-adjusted expenditures per procedures increased, the overall 6% with an annual increase of 0.7%. Overall, per patient costs, with inflation adjustment, decreased from $1,925 to $1,785 with a decline of 7% and an annual decline of 0.8%. Allowed charges per visit also declined after inflation adjustment from $951.76 to $849.86 with an overall decline of 11% and an annual decline of 1.3%. Staged episodes of radiofrequency neurotomy were performed in 23.9% of patients and more than 2 episodes for radiofrequency neurotomy in 6.9%, in lumbar spine and 19.6% staged and 5.1% more than 2 episodes in cervical spine of patients in 2018.

Limitations: This analysis is limited by inclusion of only the FFS Medicare population, without adding utilization patterns of Medicare Advantage plans, which constitutes almost 30% of the Medicare population.

Conclusions: Even after adjusting for inflation, there was a significant increase for the expenditures of facet joint interventions with an overall 53% increase. Costs per patient and cost per visit declined. Inflation-adjusted cost per year declined 7% overall and 0.8% annually from $1,925 to $1,785, and inflation-adjusted cost per visit also declined 11% annually and 1.3% per year from $952 in 2009 to $850 in 2018.

Key Words: Facet joint interventions, facet joint nerve blocks, facet joint neurolysis, facet joint injections, Medicare expenditures.
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May 2020

Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines Facet Joint Interventions 2020 Guidelines.

Pain Physician 2020 05;23(3S):S1-S127

Axis Spine Center, Coeur d'Alene, ID.

Background: Chronic axial spinal pain is one of the major causes of significant disability and health care costs, with facet joints as one of the proven causes of pain.

Objective: To provide evidence-based guidance in performing diagnostic and therapeutic facet joint interventions.

Methods: The methodology utilized included the development of objectives and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of facet joint interventions, was reviewed, with a best evidence synthesis of available literature and utilizing grading for recommendations.Summary of Evidence and Recommendations:Non-interventional diagnosis: • The level of evidence is II in selecting patients for facet joint nerve blocks at least 3 months after onset and failure of conservative management, with strong strength of recommendation for physical examination and clinical assessment. • The level of evidence is IV for accurate diagnosis of facet joint pain with physical examination based on symptoms and signs, with weak strength of recommendation. Imaging: • The level of evidence is I with strong strength of recommendation, for mandatory fluoroscopic or computed tomography (CT) guidance for all facet joint interventions. • The level of evidence is III with weak strength of recommendation for single photon emission computed tomography (SPECT) . • The level of evidence is V with weak strength of recommendation for scintography, magnetic resonance imaging (MRI), and computed tomography (CT) .Interventional Diagnosis:Lumbar Spine: • The level of evidence is I to II with moderate to strong strength of recommendation for lumbar diagnostic facet joint nerve blocks. • Ten relevant diagnostic accuracy studies with 4 of 10 studies utilizing controlled comparative local anesthetics with concordant pain relief criterion standard of ≥80% were included. • The prevalence rates ranged from 27% to 40% with false-positive rates of 27% to 47%, with ≥80% pain relief.Cervical Spine: • The level of evidence is II with moderate strength of recommendation. • Ten relevant diagnostic accuracy studies, 9 of the 10 studies with either controlled comparative local anesthetic blocks or placebo controls with concordant pain relief with a criterion standard of ≥80% were included. • The prevalence and false-positive rates ranged from 29% to 60% and of 27% to 63%, with high variability. Thoracic Spine: • The level of evidence is II with moderate strength of recommendation. • Three relevant diagnostic accuracy studies, with controlled comparative local anesthetic blocks, with concordant pain relief, with a criterion standard of ≥80% were included. • The prevalence varied from 34% to 48%, whereas false-positive rates varied from 42% to 58%.Therapeutic Facet Joint Interventions: Lumbar Spine: • The level of evidence is II with moderate strength of recommendation for lumbar radiofrequency ablation with inclusion of 11 relevant randomized controlled trials (RCTs) with 2 negative studies and 4 studies with long-term improvement. • The level of evidence is II with moderate strength of recommendation for therapeutic lumbar facet joint nerve blocks with inclusion of 3 relevant randomized controlled trials, with long-term improvement. • The level of evidence is IV with weak strength of recommendation for lumbar facet joint intraarticular injections with inclusion of 9 relevant randomized controlled trials, with majority of them showing lack of effectiveness without the use of local anesthetic. Cervical Spine: • The level of evidence is II with moderate strength of recommendation for cervical radiofrequency ablation with inclusion of one randomized controlled trial with positive results and 2 observational studies with long-term improvement. • The level of evidence is II with moderate strength of recommendation for therapeutic cervical facet joint nerve blocks with inclusion of one relevant randomized controlled trial and 3 observational studies, with long-term improvement. • The level of evidence is V with weak strength of recommendation for cervical intraarticular facet joint injections with inclusion of 3 relevant randomized controlled trials, with 2 observational studies, the majority showing lack of effectiveness, whereas one study with 6-month follow-up, showed lack of long-term improvement. Thoracic Spine: • The level of evidence is III with weak to moderate strength of recommendation with emerging evidence for thoracic radiofrequency ablation with inclusion of one relevant randomized controlled trial and 3 observational studies. • The level of evidence is II with moderate strength of recommendation for thoracic therapeutic facet joint nerve blocks with inclusion of 2 randomized controlled trials and one observational study with long-term improvement. • The level of evidence is III with weak to moderate strength of recommendation for thoracic intraarticular facet joint injections with inclusion of one randomized controlled trial with 6 month follow-up, with emerging evidence. Antithrombotic Therapy: • Facet joint interventions are considered as moderate to low risk procedures; consequently, antithrombotic therapy may be continued based on overall general status. Sedation: • The level of evidence is II with moderate strength of recommendation to avoid opioid analgesics during the diagnosis with interventional techniques. • The level of evidence is II with moderate strength of recommendation that moderate sedation may be utilized for patient comfort and to control anxiety for therapeutic facet joint interventions.

Limitations: The limitations of these guidelines include a paucity of high-quality studies in the majority of aspects of diagnosis and therapy.

Conclusions: These facet joint intervention guidelines were prepared with a comprehensive review of the literature with methodologic quality assessment with determination of level of evidence and strength of recommendations.

Key Words: Chronic spinal pain, interventional techniques, diagnostic blocks, therapeutic interventions, facet joint nerve blocks, intraarticular injections, radiofrequency neurolysis.
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May 2020

Update of Utilization Patterns of Facet Joint Interventions in Managing Spinal Pain from 2000 to 2018 in the US Fee-for-Service Medicare Population.

Pain Physician 2020 03;23(2):E133-E149

Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: Interventional techniques for managing spinal pain, from conservative modalities to surgical interventions, are thought to have been growing rapidly. Interventional techniques take center stage in managing chronic spinal pain. Specifically, facet joint interventions experienced explosive growth rates from 2000 to 2009, with a reversal of these growth patterns and in some settings, a trend of decline after 2009.

Objectives: The objectives of this assessment of utilization patterns include providing an update of facet joint interventions in managing chronic spinal pain in the fee-for-service (FFS) Medicare population of the United States from 2000 to 2018.

Study Design: The study was designed to assess utilization patterns and variables of facet joint interventions in managing chronic spinal pain from 2000 to 2018 in the FFS Medicare population in the United States.

Methods: 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 2018.

Results: Facet joint interventions increased 1.9% annually and 18.8% total from 2009 to 2018 per 100,000 FFS Medicare population compared with an annual increase of 17% and overall increase of 309.9% from 2000 to 2009. Lumbosacral facet joint nerve block sessions or visits decreased at an annual rate of 0.2% from 2009 to 2018, with an increase of 15.2% from 2000 to 2009. In contrast, lumbosacral facet joint neurolysis sessions increased at an annual rate of 7.4% from 2009 to 2018, and the utilization rate also increased at an annual rate of 23.0% from 2000 to 2009. The proportion of lumbar facet joint blocks sessions to lumbosacral facet joint neurolysis sessions changed from 6.7 in 2000 to 1.9 in 2018. Cervical and thoracic facet joint injections increased at an annual rate of 0.5% compared with cervicothoracic facet neurolysis sessions of 8.7% from 2009 to 2018. Cervical facet joint injections increased to 4.9% from 2009 to 2018 compared with neurolysis procedures of 112%. The proportion of cervical facet joint injection sessions to neurolysis sessions changed from 8.9 in 2000 to 2.4 in 2018.

Limitations: This analysis is limited by inclusion of only the FFS Medicare population, without adding utilization patterns of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. The utilization data for individual states also continues to be sparse and may not be accurate.

Conclusions: Utilization patterns of facet joint interventions increased 1.9% per 100,000 Medicare population from 2009 to 2018. This results from an annual decline of - 0.2% lumbar facet joint injection sessions but with an increase of facet joint radiofrequency sessions of 7.4%.

Key Words: Interventional techniques, facet joint interventions, facet joint nerve blocks, facet joint neurolysis.
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March 2020

An Updated Analysis of Utilization of Epidural Procedures in Managing Chronic Pain in the Medicare Population from 2000 to 2018.

Pain Physician 2020 03;23(2):111-126

Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: With increasing costs of health care in the United States, attention is focused on expensive conditions. Musculoskeletal disorders with low back and neck pain account for the third highest amount of various disease categories. Minimally invasive interventional techniques for managing spinal pain, including epidural injections, have been considered to be growing rapidly. However, recent analyses of utilization of interventional techniques from 2000 to 2018 has shown a decline of 2.6% and a decline of 21% from 2009 to 2018 for epidural and adhesiolysis procedures.

Objectives: The objectives of this analysis of epidural procedures from 2000 to 2018 are to provide an update on utilization of epidural injections in managing chronic pain in the fee-for-service (FFS) Medicare population, with a comparative analysis of 2000 to 2009 and 2009 to 2018.

Study Design: Utilization patterns and variables of epidural injections in managing chronic spinal pain from 2000 to 2009 and from 2009 to 2018 in the FFS Medicare population in the United States.

Methods: This analysis was performed by utilizing master data from CMS, physician/supplier procedure summary from 2000 to 2018. The analysis was performed by the assessment of utilization patterns using guidance from Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

Results: Overall, epidural procedures declined at a rate of 20.7% per 100,000 Medicare enrollees in FFS Medicare in the United States from 2009 to 2018, with an annual decline of 2.5%. However, from 2000 to 2009, there was an increase of 89.2%, with an annual increase of 7.3%. This analysis showed a decline in all categories, with an annual decrease of 4.7% for lumbar interlaminar and caudal epidural injections, 4.7% decline for cervical/thoracic transforaminal epidural injections, 1.1% decline for lumbar/sacral transforaminal epidural injections, and finally 0.4% decline for cervical/thoracic interlaminar epidural injections. Overall declines from 2009 to 2018 were highest for cervical and thoracic transforaminal injections with 35.1%, followed by lumbar interlaminar and caudal epidural injections of 34.9%, followed by 9.4% for lumbar/sacral transforaminal epidurals, and 3.5% for cervical and thoracic interlaminar epidurals.

Limitations: This analysis was limited by noninclusion of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. In addition, utilization data for individual states continues to be sparse and may not be accurate or representative of the population.

Conclusions: The declining utilization of epidural injections in all categories with an annual of 2.5% and overall decrease of 20.7% from 2009 to 2018 compared with annual increases of 7.3% and overall increase of 89.2% from 2000 to 2009 shows a slow decline of utilization of all epidural injections.

Key Words: Chronic spinal pain, interlaminar epidural injections, caudal epidural injections, transforaminal epidural injections, utilization patterns.
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March 2020
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