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Radiofrequency ablation (RFA) is a neuromodulation technique that uses electrocautery to damage nerves with thermal energy and interrupt nociception and has primarily been used to treat patients with chronic back pain. While the use of RFA to modulate neuronal innervation of cervical and lumbar facet joints is well studied, research on the applications of RFA to target the thoracic spine is limited despite these facet joints accounting for pain in over 25% of patients with chronic mid-back and upper-back pain. The purpose of this paper is thus to describe RFA and its utilization in the thoracic spine for chronic back pain. A review of the literature on PubMed was conducted to identify primary evidence for RFA with a focus on only the thoracic spine. Nine papers were identified and reviewed in this article. Primary literature published on RFA-naive patients with thoracic facet joint pain has provided evidence in support of RFA for short-term and long-term pain relief in this spinal region. However, all but two of these studies utilized a cohort study design. Future studies with larger patient cohorts or that utilize a randomized control trial study design are crucial to better establish the effectiveness and long-term utility of this neuromodulation technique.

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BACKGROUND: Sacroiliac joint (SIJ) dysfunction can occur as a result of injury, degeneration, or inflammation. This dysfunction presents symptoms of pain at various locations, including the low back, hips, buttocks, and legs. The diagnosis of SIJ dysfunction is challenging and cannot be achieved solely with imaging studies such as X-rays, MRI, or CT. The current gold standard diagnostic modality is intra-articular SIJ blocks using two differing local anesthetics. Current treatments for SIJ dysfunction may be beneficial for short-term relief but lack long-term efficacy. The purpose of our study was to examine the outcomes of patients who underwent minimally invasive, posterior SIJ fusion using allograft at a single center. METHODS: This was a retrospective study which received exemption from the WCG IRB. Data regarding preoperative and postoperative pain levels, surgical time, complications, and medication usage were obtained retrospectively from patient electronic medical records and prescription drug monitoring program reports. No mapping was completed prior to the procedure. Pain was assessed with the 11-point (0-10) Visual Analogue Scale (VAS) and medication usage was assessed using Morphine Milligram Equivalents (MME). Patients were included if they had been diagnosed with SIJ dysfunction using two intra-articular diagnostic blocks that resulted in at least an 80% decrease in pain and had failed conservative management. Patients with sacral insufficiency fractures were excluded. RESULTS: VAS scores reduced from 8.26 (SD = 1.09) at baseline to 2.59 (SD = 2.57), 2.55 (SD = 2.56), 2.71 (SD = 2.88), and 2.71 (SD = 2.88) at 3, 6, 9, and 12 months, respectively. MME reduced from 78.21 mg (SD = 51.33) to 58.95 mg (SD = 48.64), 57.61 mg (SD = 47.92), 61.71 mg (SD = 45.64), and 66.29 mg (SD = 51.65) at 3, 6, 9, and 12 months, respectively. All reductions in VAS scores and MME were statistically significant. No adverse events occurred, and the average operating room time was 40.16 min (SD = 6.27). CONCLUSION: Minimally invasive, posterior SIJ fusion using allograft is a safe and efficacious method for managing SIJ dysfunction.

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BACKGROUND: The frequency of performance of interventional techniques in chronic pain patients receiving anticoagulant and antiplatelet therapy continues to increase. Understanding the importance of continuing chronic anticoagulant therapy, the need for interventional techniques, and determining the duration and discontinuation or temporary suspension of anticoagulation is crucial to avoiding devastating complications, primarily when neuraxial procedures are performed. Anticoagulants and antiplatelets target the clotting system, increasing the bleeding risk. However, discontinuation of anticoagulant or antiplatelet drugs exposes patients to thrombosis risk, which can lead to significant morbidity and mortality, especially in those with coronary artery or cerebrovascular disease. These guidelines summarize the current peer reviewed literature and develop consensus-based guidelines based on the best evidence synthesis for patients receiving anticoagulant and antiplatelet therapy during interventional procedures. STUDY DESIGN: Review of the literature and development of guidelines based on best evidence synthesis. OBJECTIVES: To provide a current and concise appraisal of the literature regarding the assessment of bleeding and thrombosis risk during interventional techniques for patients taking anticoagulant and/or antiplatelet medications. METHODS: Development of consensus guidelines based on best evidence synthesis included review of the literature on bleeding risks during interventional pain procedures, practice patterns, and perioperative management of anticoagulant and antiplatelet therapy. A multidisciplinary panel of experts developed methodology, risk stratification based on best evidence synthesis, and management of anticoagulant and antiplatelet therapy. It also included risk of cessation of anticoagulant and antiplatelet therapy based on a multitude of factors. Multiple data sources on bleeding risk, practice patterns, risk of thrombosis, and perioperative management of anticoagulant and antiplatelet therapy were identified. The relevant literature was identified through searches of multiple databases from 1966 through 2023. In the development of consensus statements and guidelines, we used a modified Delphi technique, which has been described to minimize bias related to group interactions. Panelists without a primary conflict of interest voted on approving specific guideline statements. Each panelist could suggest edits to the guideline statement wording and could suggest additional qualifying remarks or comments as to the implementation of the guideline in clinical practice to achieve consensus and for inclusion in the final guidelines, each guideline statement required at least 80% agreement among eligible panel members without primary conflict of interest. RESULTS: A total of 34 authors participated in the development of these guidelines. Of these, 29 participated in the voting process. A total of 20 recommendations were developed. Overall, 100% acceptance was obtained for 16 of 20 items. Total items were reduced to 18 with second and third round voting. The final results were 100% acceptance for 16 items (89%). There was disagreement for 2 statements (statements 6 and 7) and recommendations by 3 authors. These remaining 2 items had an acceptance of 94% and 89%. The disagreement and dissent were by Byron J. Schneider, MD, with recommendation that all transforaminals be classified into low risk, whereas Sanjeeva Gupta, MD, desired all transforaminals to be in intermediate risk. The second disagreement was related to Vivekanand A. Manocha, MD, recommending that cervical and thoracic transforaminal to be high risk procedures.Thus, with appropriate literature review, consensus-based statements were developed for the perioperative management of patients receiving anticoagulants and antiplatelets These included the following: estimation of the thromboembolic risk, estimation of bleeding risk, and determination of the timing of restarting of anticoagulant or antiplatelet therapy.Risk stratification was provided classifying the interventional techniques into three categories of low risk, moderate or intermediate risk, and high risk. Further, on multiple occasions in low risk and moderate or intermediate risk categories, recommendations were provided against cessation of anticoagulant or antiplatelet therapy. LIMITATIONS: The continued paucity of literature with discordant recommendations. CONCLUSION: Based on the review of available literature, published clinical guidelines, and recommendations, a multidisciplinary panel of experts presented guidelines in managing interventional techniques in patients on anticoagulant or antiplatelet therapy in the perioperative period. These guidelines provide a comprehensive assessment of classification of risk, appropriate recommendations, and recommendations based on the best available evidence.

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BACKGROUND: Tendinopathy significantly impacts the quality of life and imposes a high economic burden, accounting for a large proportion of sports and musculoskeletal injuries. Traditionally considered a collagen-related inflammatory disorder, emerging evidence suggests a critical role of neuropathic processes in chronic tendon pain. OBJECTIVE: This review aims to evaluate the neuropathic mechanisms in tendinopathy and discuss innovative treatments targeting these pathways. METHODS: We analyze recent studies highlighting the tendon innervation, pathological nerve sprouting neuronal ingrowth in tendinopathy, and the associated increase in pain and neuronal mediators. RESULTS: Chronic tendinopathy exhibits nociceptive sprouting from paratenon into the fibrous tendon proper. Innovative treatments such as Percutaneous Ultrasound-Guided Tenotomy (PUT) or high-frequency ultrasound interventions show promise in targeting these neuropathic components by paratenon separation. These approaches focus on disrupting the pathological innervation cycle. CONCLUSION: Chronic tendon pain may be predominantly neuropathic, driven by pathologic neuronal ingrowth from paratenon into the tendon proper. Interventions that accurately target and disrupt these nerve pathways could revolutionize the treatment of tendinopathy. Further research is required to validate these findings and refine treatment modalities to ensure safety and efficacy.

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PURPOSE OF REVIEW: Conservative management is consistently recommended as a first line intervention for occipital neuralgia (ON); however, there is limited clinical research regarding conservative intervention for ON. This lack of research may lead to underutilization or unwarranted variability in conservative treatment. This article provides mechanism-based guidance for conservative management of ON as a component of a multimodal treatment approach, and discusses the role of the physical therapist in the care team. It also highlights opportunities for further research to refine conservative management of this condition. RECENT FINDINGS: Published research on conservative interventions specific to ON is limited to very low-quality evidence for the use of TENS. The contemporary shift toward precision pain management emphasizing treatment based on a patient's constellation of clinical features-a phenotype-rather than solely a diagnosis provides more personalized and specifically targeted pain treatment. This paradigm can guide treatment in cases where diagnosis-specific research is lacking and can be used to inform conservative treatment in this case. Various conservative interventions have demonstrated efficacy in treating many of the symptoms and accepted etiologies of ON. Conservative interventions provided by a physical therapist including exercise, manual therapy, posture and biomechanical training, TENS, patient education, and desensitization have mechanistic justification to treat symptoms and causes of ON. Physical therapists have adequate time and skill to provide such progressive and iterative interventions and should be included in a multimodal treatment plan for ON. Further research is required to determine appropriate dosing, sequencing, and progression of conservative treatments.

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BACKGROUND: Chronic pain, defined as pain persisting for more than 3-6 months, has a mean one-year prevalence in the United States of 25.8% and is one of the most frequent reasons adults seek medical care. Treatment options include physical therapy, analgesics, anticonvulsants, exercise, and muscle relaxants. Even with conventional treatment modalities, in a subset of patients, pain may persist. Cooled radiofrequency ablation (c-RFA), a minimally invasive therapy, employs thermal energy generated by electrical currents to disrupt the transmission of pain stimuli along nociceptive pathways. This leads to an attenuation of pain impulses, primarily through nerve tissue necrosis. The potential of c-RFA to alleviate chronic pain for patients who struggle to find relief elsewhere accentuates the importance of rigorously investigating its outcomes. This study investigates whether patients receiving c-RFA for relief of chronic neck pain caused by cervical facet joint arthropathy experience a reduction in pain scores, the length of this reduction in pain scores, and the magnitude of this reduction in pain. METHODS: This study was a retrospective analysis of data extracted from UW-Health Electronic Medical Health records (EMR), encompassing cervical c-RFA procedures performed from 2015 through 2022. Patient data were obtained, including diagnosis, pre-operative pain score, post-operative pain score, duration of relief, patient age, sex, and BMI. A two-tailed paired t-test was used to statistically analyze the pre-operative and post-operative pain scores, in which a p-value ≤0.05 was considered significant. RESULTS: A total of 450 cervical c-RFA procedures were reviewed, 152 were excluded due to absent pre- or post-op pain scores. 298 were included in the analysis, comprising 203 unique patients: 129 females and 74 males with an average age of 56.03 ± 12.76 and a BMI of 28.76 ± 6.05. Improvement of pain symptoms was reported in 85.23% (n = 263), 6% (n = 19) reported complete pain remission, 8.72% (n = 26) reported no change, and 3.02% (n = 9) reported worsening symptoms. Patients reported an average pre-operative pain score of 6.15 (M = 6.15, SD = 1.55) and an average post-operative pain score of 3.64 (M = 3.64, SD = 2.09) this achieved significance (p < 0.0001). Of the 85.23% (n = 263) charts that noted improvement, there is an average of 48.04% ± 26.53 reduction from their pre-operative pain scores. The average duration of relief lasted 6.67 ± 4.84 months. CONCLUSION: This study supports the potential efficacy of c-RFA as a minimally invasive treatment for chronic neck pain secondary to cervical facet joint arthropathy refractory to conventional treatment measures, demonstrating significant relief for a substantial length of time. Due to chronic pain's detrimental effect on one's quality of life, finding effective treatment options is essential, especially for those refractory to conventional treatments.

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BACKGROUND: There is potential for adverse events from corticosteroid injections, including increase in blood glucose, decrease in bone mineral density and suppression of the hypothalamic-pituitary axis. Published studies note that doses lower than those commonly injected provide similar benefit. METHODS: Development of the practice guideline was approved by the Board of Directors of American Society of Regional Anesthesia and Pain Medicine with several other societies agreeing to participate. The scope of guidelines was agreed on to include safety of the injection technique (landmark-guided, ultrasound or radiology-aided injections); effect of the addition of the corticosteroid on the efficacy of the injectate (local anesthetic or saline); and adverse events related to the injection. Based on preliminary discussions, it was decided to structure the topics into three separate guidelines as follows: (1) sympathetic, peripheral nerve blocks and trigger point injections; (2) joints; and (3) neuraxial, facet, sacroiliac joints and related topics (vaccine and anticoagulants). Experts were assigned topics to perform a comprehensive review of the literature and to draft statements and recommendations, which were refined and voted for consensus (≥75% agreement) using a modified Delphi process. The United States Preventive Services Task Force grading of evidence and strength of recommendation was followed. RESULTS: This guideline deals with the use and safety of corticosteroid injections for sympathetic, peripheral nerve blocks and trigger point injections for adult chronic pain conditions. All the statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Board of Directors of the participating societies also approved all the statements and recommendations. The safety of some procedures, including stellate blocks, lower extremity peripheral nerve blocks and some sites of trigger point injections, is improved by imaging guidance. The addition of non-particulate corticosteroid to the local anesthetic is beneficial in cluster headaches but not in other types of headaches. Corticosteroid may provide additional benefit in transverse abdominal plane blocks and ilioinguinal/iliohypogastric nerve blocks in postherniorrhaphy pain but there is no evidence for pudendal nerve blocks. There is minimal benefit for the use of corticosteroids in trigger point injections. CONCLUSIONS: In this practice guideline, we provided recommendations on the use of corticosteroids in sympathetic blocks, peripheral nerve blocks, and trigger point injections to assist clinicians in making informed decisions.

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BACKGROUND: Radiofrequency ablation (RFA) is a treatment modality that has been increasingly used for the management of chronic shoulder pain. Serious conditions that can identified as the cause of chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, osteoarthritis, glenohumeral instability, and acromioclavicular joint disorders. Treatment of chronic shoulder pain typically consists of physical therapy, oral and topical medications, intra-articular corticosteroid injections, and even surgery. The aim of this study was to examine the most recent primary and secondary outcomes of RFA for chronic shoulder pain. METHODS: A systematic review was conducted using three different databases including PubMed, MEDLINE, and the Cochrane Database. The key concepts of "radiofrequency ablation" and "shoulder pain" were used. The search took place in June 2023, and it included articles from the past 20 years. RESULTS: Of the 396 articles found, 29 were included in the review. Most studies focused on reduction in pain scores, duration of relief, function, and patient satisfaction. In several studies, RFA was compared to conservative options such as physical therapy or corticosteroid injections. CONCLUSIONS: Overall, RFA shows positive outcomes in terms of the management of chronic shoulder pain. Therefore, RFA can serve as another treatment option for patients who fail conservative management or are not strong surgical candidates. Understanding the outcomes of RFA for chronic shoulder pain can provide patients and clinicians with evidence for the most appropriate treatment.

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BACKGROUND: Radiofrequency ablation (RFA) has many treatment capabilities, one of which includes long term management of chronic headache. As a result, it has been increasingly used, especially in cases of refractory headache pain. Headaches can be classified as primary and secondary and can result from a variety of serious conditions. Types of primary headaches include tension, migraine, and cluster headaches whereas secondary headaches include headaches because of infection or vascular disease, and cervicogenic headaches. Both types can result in serious debility and diminished quality of life. The treatment of chronic headache pain commonly consists of lifestyle modifications, oral medications, and injectable medications. The aim of this study was to investigate the primary and secondary outcomes of RFA for chronic headache pain. METHODS: A systematic review was conducted using three different databases including PubMed, MEDLINE, and the Cochrane Database. The key concepts of "radiofrequency ablation" and "headache" were used. The search took place in June 2023, and it included articles from the past twenty years. RESULTS: Of the 580 articles found, 32 were included in the review. Most studies focused on pain scores, duration of relief, function, and patient satisfaction. In several studies, RFA was used to target various nerves as the pain generator and compared with modalities such as local anesthetic or corticosteroid. CONCLUSIONS: Overall, RFA shows favorable outcomes in the management of chronic headache pain. Therefore, RFA can serve as an alternative treatment option for patients who fail other conservative treatment regimens. Understanding the outcomes of RFA for headache pain can provide patients and clinicians with evidence for the most appropriate treatment strategies.

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Radiofrequency ablation (RFA) is a minimally invasive treatment modality that utilizes high-frequency alternating current to destroy targeted tissues through thermal ablation. This manuscript provides an overview of the advancements in RFA, focusing on its mechanism of action and technological innovations. RFA technology was first introduced in the early 1900's, and its use has expanded and evolved, especially in its current utility in the treatment of painful conditions. As the technology has evolved, new techniques, applications and modalities have expanded its use and improved its efficacy. RFA works by applying radiofrequency energy through specialized electrodes, leading to resistive heating and coagulation necrosis. Its advantages include precise tissue targeting, minimal invasiveness, reduced complications, and faster recovery compared to traditional surgical interventions. Technological advancements in RFA have led to improved treatment outcomes. Multi-electrode systems allow for larger ablation zones. Image-guided RFA improves treatment planning and minimizes damage to healthy tissues. Cooled-tip and perfusion electrodes address limitations such as heat sink effects, enhancing RFA's efficacy in challenging anatomical regions. These developments have expanded RFA's applications to liver tumors, lung tumors, renal tumors, cardiac arrhythmias, and chronic pain syndromes. In conclusion, RFA has emerged as a safe and effective thermal ablation technique. Understanding its mechanism of action and integrating advanced technologies have significantly enhanced treatment outcomes. Continued research and innovation in RFA hold immense potential for further improving patient care and outcomes.

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PURPOSE OF REVIEW: Neuromodulation techniques have emerged as promising strategies for managing chronic pain. These techniques encompass various modalities of nerve stimulation, including Spinal Cord Stimulation (SCS), Dorsal Root Ganglion Stimulation (DRG-S), and Peripheral Nerve Stimulation (PNS). Studies consistently demonstrate significant improvements in pain intensity, quality of life, and reduced opioid usage among patients treated with these modalities. However, neuromodulation presents challenges, such as the need for frequent in-person follow-up visits to ensure proper functionality of the implanted device. Our review explored factors impacting compliance in current neuromodulation users and examined how remote monitoring can mitigate some of these challenges. We also discuss outcomes of recent studies related to remote monitoring of neuromodulation. RECENT FINDINGS: While remote monitoring capabilities for neuromodulation devices is an emerging development, there are promising results supporting its role in improving outcomes for chronic pain patients. Higher patient satisfaction, improved pain control, and reduced caretaker burdens have been observed with the use of remote monitoring. This review discusses the current challenges with neuromodulation therapy and highlights the role of remote monitoring. As the field continues to evolve, understanding the importance of remote monitoring for neuromodulation is crucial for optimizing pain management outcomes.

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Fibromyalgia, a chronic pain condition marked by abnormal pain processing, impacts a significant part of the population, leading to reduced quality of life and function. Hallmark symptoms include widespread persistent pain, sleep disturbances, fatigue, cognitive dysfunction, and mood changes. Through this updated review, we aim to contribute to the evolving understanding and management of fibromyalgia, offering insights into the diverse tools available to improve the lives of those affected by this challenging condition. Management begins with educating patients to ultimately relieve them of unnecessary testing and provide reassurance. Treatment emphasizes a comprehensive approach, combining nonpharmacological interventions such as aforementioned education, exercise, and psychotherapy, alongside pharmacologic management-namely duloxetine, milnacipran, pregabalin, and amitriptyline-which have consistent benefits for a range of symptoms across the spectrum of fibromyalgia. Notably, drugs like nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are generally not recommended due to limited efficacy and associated risks. Lastly, a variety of other medications have shown promise, including NMDA-receptor antagonists, naltrexone, and cannabinoids; however, they should be used with caution due to a small amount of evidence and potential for adverse effects.

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Radiofrequency ablation (RFA), a minimally invasive procedure for pain reduction, is increasingly used for managing chronic neck pain and headaches. This article offers a concise overview of cervical spine RFA. In the context of RFA, heat is applied to specific nerve tissues to interrupt pain signals. Wallarian degeneration occurs as a result of the thermal injury to the nerve. The heat generated by the RFA procedure can damage the nerve fibers, initiating the degenerative process. Wallarian degeneration is a process that occurs in a nerve axon due to the thermal injury, leading to the breakdown and eventual degradation of the axon and its myelin sheath. However, nerves have regeneration capacity, especially the peripheral nerves, which are often the target of RFA for pain management. After Wallarian degeneration takes place, the nerve sheath, or the connective tissue surrounding the nerve, can serve as a scaffold for the growth of new nerve fibers. Over time, these new fibers can regenerate and re-establish connections, potentially restoring nerve function. Three common types are traditional thermal, water-cooled, and pulsed radio frequency ablation. Given the regenerative potential of nerves, these procedures are typically effective for 1 to 2 years, with some variability. Despite a 112% increase in Medicare claims for RFA from 2009 to 2018, it's recommended for patients who respond positively to diagnostic medial branch blocks, with recent guidelines suggesting a single block may be sufficient. Although generally effective, the procedure carries risks, including nerve and tissue injury. Notably, the procedure's increased utilization notably surpasses the most commonly reported prevalence rates of conditions it aims to treat. Moreover, diagnostic blocks performed before cervical RFA also have their risks, such as inadvertent vascular injections leading to seizures or paralysis. In summary, the risks and benefits of cervical RFA must be considered with regards to the patient's comorbidities and specific pain issues. The skill and experience of the practitioner plays a significant role in minimizing these risks. Detailed discussions with healthcare providers about the risks, benefits, and alternatives can help in making an informed decision about the procedure.

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PURPOSE OF REVIEW: Chronic headaches are a significant source of disability worldwide. Despite the development of conventional strategies, a subset of patients remain refractory and/or experience side effects following these treatments. Hence, occipital nerve stimulation (ONS) should be considered as an alternative strategy for intractable chronic headaches. This review aims to provide a comprehensive overview of the effectiveness, safety, mechanisms and practical application of ONS for the treatment of headache disorders. RECENT FINDINGS: Overall response rate of ONS is 35.7-100%, 17-100%, and 63-100% in patients with cluster headache, chronic migraine and occipital neuralgia respectively. Regarding the long-term effectivity in all groups, 41.6-88.0% of patients remain responders after ≥ 18.3 months. The most frequently reported adverse events include lead migration/fracture (13%) and local pain (7.3%). Based on our results, ONS can be considered a safe and effective treatment for chronic intractable headache disorders. To support more widespread application of ONS, additional research with larger sample sizes should be conducted.

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PURPOSE OF REVIEW: Pain is a complex phenomenon that affects millions of individuals worldwide and poses a significant burden on public health. While pain management typically focuses on pharmacological and physical interventions, emerging research suggests that nutrition plays a crucial role in pain modulation. This narrative review aims to explore the relationship between nutrition and pain, providing a comprehensive overview of recent literature. The review covers various dietary factors, including macronutrients, micronutrients, dietary patterns, and specific dietary interventions. Additionally, the potential mechanisms underlying the impact of nutrition on pain are discussed. The findings highlight the potential for dietary interventions to complement traditional pain management approaches and provide valuable insights for future research and clinical practice. RECENT FINDINGS: Literature suggested the impact of healthy nutrition on improvement in pain and that certain types of food may increase and worsen different pain conditions. Nutrition plays an important role in modulating pain. It is important to counsel patients in pain on best diet for their pain condition to alleviate pain. Our article summarizes very well the issue of nutrition and pain and provides a guide to all practitioners caring for patients with chronic pain.