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Background Decreasing pain catastrophizing and improving self-efficacy to self-manage chronic pain symptoms are important treatment targets in the context of interdisciplinary pain rehabilitation. Greater pain catastrophizing has been shown to be associated with greater impact of pain symptoms on functioning; conversely, greater pain self-efficacy has been associated with lower pain intensity and lower levels of disability. Objective To prospectively evaluate interdisciplinary pain rehabilitation outcomes, as well as to evaluate the mediating effects of both pain catastrophizing and pain self-efficacy on outcome. Methods Participants were 315 patients with chronic pain between April 2017 and April 2018 who completed a 3-week interdisciplinary pain rehabilitation program. Pain severity, pain interference, pain catastrophizing, pain self-efficacy, quality of life, depressive symptom questionnaires, and measures of physical performance were assessed before and after treatment. Follow-up questionnaires were returned by 163 participants. Effect size and reliable change analyses were conducted from pre- to posttreatment and from pretreatment to 6-month follow-up. Mediation analyses were conducted to determine the mediating effect of pain catastrophizing and pain self-efficacy on pain outcome. Results Significant improvements from pre- to posttreatment in pain outcomes were observed, and more than 80% evidenced a reliable change in at least one pain-relevant measure. Pain catastrophizing and pain self-efficacy mediated the relationship between changes in pain outcomes. Conclusions Interdisciplinary pain rehabilitation is an effective treatment, and decreasing pain catastrophizing and increasing pain self-efficacy can influence maintenance of treatment gains.

Objective The aim of this study was to determine 1) if repeat lumbar transforaminal epidural steroid injections (TFESIs) resulted in recovery of pain relief, which has waned since an index injection, and 2) if cumulative benefit could be achieved by repeat injections within 3 months of the index injection. Design Retrospective observational study with statistical modeling of the response to repeat TFESI. Setting Academic radiology practice. Patients Two thousand eighty-seven single-level TFESIs were performed for radicular pain on 933 subjects. Subjects received repeat TFESIs >2 weeks and

Objective To assess whether a nonparticulate steroid (dexamethasone, 10 mg) is less clinically effective than the particulate steroids (triamcinolone, 80 mg; betamethasone, 12 mg) in lumbar transforaminal epidural steroid injections (TFESIs) in subjects with radicular pain with or without radiculopathy. Design Retrospective observational study with noninferiority analysis of dexamethasone relative to particulate steroids. Setting Single academic radiology pain management practice. Subjects Three thousand six hundred forty-five lumbar TFESIs at the L4-5, L5-S1, or S1 neural foramina, performed on 2,634 subjects. Methods/Outcome Measures Subjects were assessed with a pain numerical rating scale (NRS, 0–10) and Roland–Morris disability questionnaire (R-M) prior to TFESI, and at 2 weeks and 2 months follow-up. For categorical outcomes, successful pain relief was defined as either ≥50% reduction in NRS or pain 0/10; functional success was defined as ≥40% reduction in R-M score. Noninferiority analysis was performed with δ = −10% as the limit of noninferiority. Continuous outcomes (mean NRS, R-M scores) were analyzed for noninferiority with difference bounds of 0.3 for NRS scores and 1.0 for R-M scores. Results With categorical outcomes, dexamethasone was demonstrated to be noninferior to the particulate steroids in pain relief and functional improvement at 2 months. Using continuous outcomes, dexamethasone was demonstrated to be superior to the particulate steroids in both pain relief and functional improvement at 2 months. Conclusion This retrospective observational study reveals no evidence that dexamethasone is less effective than particulate steroids in lumbar TFESIs performed for radicular pain with or without radiculopathy.

Objective To assess frequency of sedation in transforaminal epidural steroid injections (TFESI) and to analyze patient dissatisfaction and vasovagal rates. Design Retrospective audit over a 6-year period, January 1, 2006–December 31, 2011. Setting Single academic center radiology pain management practice. Subjects Four thousand four hundred thirty-two patients undergoing 6,878 consecutive TFESI. Outcome Measures Frequency of sedation for TFESI was assessed. Vasovagal and patient dissatisfaction rates were assessed, the latter by patients' responses to two follow-up survey questions at 2 weeks postprocedure. Results Six thousand eight hundred seventy-eight TFESI were performed, of which only 0.1% (N = 7) were performed with sedation. Only 0.4% (N = 28) of TFESI were complicated by vasovagal reaction. Seventy-two percent (N = 4,980) of nonsedated patients responded to the survey. Overall medical care in the nonsedated was rated as: excellent 51%, very good 30%, good 15%, fair 3%, and poor 1%. Ninety-five percent confidence interval (CI) for the 3.9% of the nonsedated patients who rated their care at best “fair” was (3.3, 4.4%). Likelihood of referring friends/family members in nonsedated patients was: definitely 53%, probably 28%, uncertain 16%, probably not 3%, definitely not 0.2%. Ninety-five percent CI for the 3.2% of the nonsedated patients who would at best “probably not refer” their friends/family was (2.7, 3.7%). Conclusions In our radiology pain management practice, sedation was rarely utilized for TFESI. A small minority of nonsedated patients rated their care at best fair and would at best probably not refer friends/family members. TFESI can be performed without sedation with low patient dissatisfaction and low vasovagal rates.

Background. Transforaminal epidural steroid injections (TFESI) have demonstrated efficacy and effectiveness in treatment of radicular pain. Despite little evidence of efficacy/effectiveness, interlaminar epidural steroid injections (ILESI) are advocated by some as primary therapy for radicular pain due to purported greater safety. Objective. To assess immediate and delayed adverse event rates of TFESI and ILESI injections at three academic medical centers utilizing International Spine Intervention Society practice guidelines. Methods. Quality assurance databases from a Radiology and two physical medicine and rehabilitation (PM&R) practices were interrogated. Medical records were reviewed, verifying immediate and delayed adverse events. Results. There were no immediate major adverse events of neurologic injury or hemorrhage in 16,638 consecutive procedures in all spine segments (14,956 TFESI; 1,682 ILESI). Vasovagal reactions occurred in 1.2% of procedures, more frequently ( P = 0.004) in TFESI (1.3%) than ILESI (0.5%). Dural punctures occurred in 0.06% of procedures, more commonly after ILESI (0.2% vs 0.04%, P = 0.006). Delayed follow up on PM&R patients (92.5% and 78.5, next business day) and radiology patients (63.1%, 2 weeks) identified no major adverse events of neurologic injury, hemorrhage, or infection. There were no significant differences in delayed minor adverse event rates. Central steroid response (sleeplessness, flushing, nonpositional headache) was seen in 2.6% of both TFESI and ILESI patients. 2.1% of TFESI and 1.8% of ILESI patients reported increased pain. No long-term sequelae were seen from any immediate or delayed minor adverse event. Conclusions. Both transforaminal and ILESI are safely performed with low immediate and delayed adverse event rates when informed by evidence-based procedural guidelines. By demonstrating comparable safety, this study suggests that the choice between ILESI and TFESIs can be based on documented efficacy and effectiveness and not driven by safety concerns.