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Background: Pain medicine care has expanded to encompass a wider range of conditions, necessitating updated education and training for pain specialists to utilize emerging technologies effectively. A national survey was conducted through several verified Pain organizations regarding pain physician employers' perspectives on pain medicine fellowship training and education. The survey aimed to gather insights from a diverse range of geographic locations, practice types (academic and private practice), and practice settings. The findings emphasize the need for educational programs to adapt to the evolving landscape of pain medicine. Methods: A survey was disseminated through several national professional pain societies, including the AAPM, ASIPP, NANS, and ASPN, and Pain DocMatters forum, an online verified pain physician forum to ensure a wide reach among potential respondents. The survey received responses from 196 participants, 39 from the Pain DocMatters forum and 157 through pain societies' channels. Results: Most survey respondents reported a need for additional training and experience beyond what is offered during the one-year ACGME-approved fellowship. Professionalism and basic interventional skills were identified as the highest valued attributes of pain physician candidates by potential employers. Employers rated spinal cord stimulator (SCS) trials as the most important advanced procedure for trainees to learn. Other advanced procedures such as SCS implants, PNS implants, interspinous spacers, and percutaneous procedures involving the vertebral body were also rated as either very important or somewhat important by most respondents. A significant gap in training has been identified, with only 7% of respondents feeling that fellows were adequately prepared to independently practice in the current educational model. A vast majority of respondents stated that fellows need additional training following graduation from fellowship to practice independently. Conclusion: Training programs should provide more robust education to prepare their graduates for independent practice. [ABSTRACT FROM AUTHOR]

The last decade has seen a boom in pain medicine, basic science and interventional pain management. Concomitantly, there is a need to educate trainees, young attendings, and seasoned attendings on these innovations. There has been a growth in the number of societies that represent pain medicine physicians, each with its own philosophy and guiding principles. The variety of thought within pain management, within the various groups that practice this field, and amongst the societies which protect those missions inherently creates divergence and isolation within these different communities. There is the enormous opportunity for our field to grow, but we need the voices of all different specialties and sub-specialties which practice pain medicine to collectively design the future of our emerging field. The explosion of revolutionary percutaneous surgeries, medications, psychotherapy, and research and development in our field has outpaced the ability of payers to fully embrace them. There is an increased number of pain practitioners using novel therapies, postgraduate training programs do not adequately train users in these techniques thereby creating a potential for sub-optimal outcomes. In part, this is a reason why payers for many of our more novel treatments have decreased patient access or eliminated remuneration for some of them. We believe that society-based collaborative regulation of education, research, and treatment guidelines is needed to improve visibility for payers and end users who provide these treatments. Furthermore, postgraduate chronic pain fellowship education has been deemed by many to be insufficient to educate on all of the necessary requirements needed for the independent practice of pain medicine, especially the consummation of newer technologies. Here, we draw comparison with this tenuous stage in pain management history with the last United States recession to remind us of how poor institutional regulation and neglect for long-term growth hampers a community. [ABSTRACT FROM AUTHOR]

The article discusses the challenges faced by pain medicine fellows and proposes an extension of the fellowship duration to address these challenges. The authors argue that the current one-year fellowship structure is insufficient to provide comprehensive training in pain medicine due to the evolving landscape of the field and the increasing complexity of treatments. They suggest that a multi-year training program would allow for a more in-depth education and mentorship, better preparing fellows for their future careers. The authors acknowledge that their proposal may not be universally accepted but hope to initiate a discussion within the pain medicine community about the need for training program adaptations. [Extracted from the article]

Background Radiofrequency ablation (RFA) is a validated treatment option for the treatment of chronic pain in patients with lumbar spondylosis. Lesion size has been suggested to correlate with good clinical outcomes. This has created an abundance of scientific interest in the development of products with larger lesion characteristics. Needle characteristics, energy transfer, and heat rate are known to modify lesion size. Here, we demonstrate that common intraoperative solutions, such as lidocaine, iodine, and gadolinium-based products, can also affect lesion shape. Objectives To determine whether lidocaine and contrast agents modify lesion characteristics during the performance of monopolar RFA. Study design Controlled, ex vivo study using clinically relevant conditions and pre-injections. Setting Academic institution in a procedural setting. Methods RFA lesion size was compared among six cohorts: 1) lidocaine 1%, 2) lidocaine 2%, 3) iohexol 180, 4) iohexol 240, 5) gadodiamide, and 6) control (no fluid control). Radiofrequency (RF) current was applied for 90 seconds at 80°C via 20-gauge 100-mm standard RFA needles with 10-mm active tips in orgranic chicken breasts without preservative at room temperature (21°C). Twelve lesions were performed for each medication cohort. The length, width, and depth of each lesion were measured. The statistical significance between each medication group and the control group was evaluated by t test. Results The mean lesion surface area of monopolar RFA without any pre-injection used was 80.8 mm2. The mean surface area of the monopolar RF lesion with a pre-injection of 0.2 mL of 2% lidocaine was 114 mm2, and the mean surface area of the monopolar RF lesion with a pre-injection of 0.2 mL of iohexol 240 was 130.6 mm2. The statistical analysis demonstrated that the control group had significantly smaller lesion sizes than did the groups in which lidocaine 2% and iohexol 240 were used (P <0.01). There were no statistically significant differences among the groups in which lidocaine 1%, iohexol 180, and gadodiamide were used. A notable difference was a 20% longer lesion with iohexol 240 compared with the control group and a 20% wider lesion with lidocaine 2% compared with the control group. Limitations In vivo anatomy within a human was not used in this study, nor were the chicken breasts heated to physiological temperature. Randomization of pieces of chicken breast did not occur, and thus intrinsic differences among the chicken breast pieces could play a confounding role. Conclusions Lidocaine 2% and iohexol 240, when used as pre-injections in RFAs, were found to be associated with statistically significant increases in lesion surface area. However, RFAs with lidocaine 1%, iohexol 180, or gadodiamide were not found to produce a statistically significant difference in lesion size compared with monopolar RFA without the use of injectate. [ABSTRACT FROM AUTHOR]

Background Increased utilization of telemedicine has created a need for supplemental pain medicine education, especially for the virtual physical assessment of the pain patient. Traditional clinical training utilizes manual and tactile approaches to the physical examination. Telemedicine limits this approach and thus alternative adaptations are necessary to acquire information needed for sound clinical judgement and development of a treatment plan. Clinical assessment of pain is often challenging given the myriad of underlying etiologies contributing to the sensory experience. The COVID-19 pandemic has led to a dramatic increase in the use of virtual and telemedicine visits, further complicating the ease of assessing patients in pain. The increased reliance on telemedicine visits requires clinicians to develop skills to obtain objective information from afar. While eliciting a comprehensive history and medication assessment are performed in a standard fashion via telemedicine, a virtual targeted physical examination is a new endeavor in our current times. In order to appropriately diagnose and treat patients not directly in front of you, a pivot in education adaptations are necessary. Objective To summarize best care practices in the telemedicine physical exam while presenting an algorithmic approach towards virtual assessment for the pain practitioner. Design Review of the literature and expert multidisciplinary panel opinion. Setting Nationally recognized academic tertiary care centers. Subjects Multidisciplinary academic experts in pain medicine. Methods Expert consensus opinion from the literature review. Results An algorithm for the virtual physical exam for pain physicians was created using literature review and multidisciplinary expert opinion. Conclusions The authors here present simple, comprehensive algorithms for physical exam evaluations for the pain physician stemming from a review of the literature. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study is to provide Level-1 objective, real-world outcome data for patients with lumbar spinal stenosis suffering from neurogenic claudication secondary to hypertrophic ligamentum flavum. Design The MOTION Study is a prospective, multicenter, randomized controlled trial comparing the mild ® Procedure (minimally invasive lumbar decompression; Vertos Medical, Aliso Viejo, CA, USA) as a first-line therapy in combination with nonsurgical conventional medical management (CMM) vs CMM alone as the active control. Methods Patients in the test group received the mild Procedure at baseline. Both the mild +CMM group and the control group were allowed unrestricted access to conventional real-world therapies. Patient-reported outcomes included the Oswestry Disability Index, the Zurich Claudication Questionnaire, and the Numeric Pain Rating Scale. A validated Walking Tolerance Test, the incidence of subsequent lumbar spine interventions, and the occurrence of adverse events were used to measure objective outcomes. Results Sixty-nine patients in each group were analyzed at 1-year follow-up. No device- or procedure-related adverse events were reported in either group. Results from all primary and secondary outcome measures showed statistical significance in favor of mild +CMM. Conclusions One-year results of this Level-1 study demonstrated superiority of mild +CMM over CMM alone for patients with lumbar spinal stenosis who were suffering from neurogenic claudication secondary to hypertrophic ligamentum flavum. Use of the validated Walking Tolerance Test to objectively measure increased ability to walk without severe symptoms provided evidence of statistically significantly better outcomes for mild +CMM than for CMM alone. With no reported device or procedure-related adverse events, the long-standing safety profile of the mild Procedure was reaffirmed. mild is a safe, durable, minimally invasive procedure that has been shown to be effective as an early interventional therapy for patients suffering from symptomatic lumbar spinal stenosis. [ABSTRACT FROM AUTHOR]

The article addresses concerns about the adequacy of current pain medicine fellowship education and suggests reforms for comprehensive training. It highlights the need for an expanded curriculum to encompass diverse specialties, the changing landscape of fellowship applicants, and proposed solutions for enhanced pain medicine education, including options like extended fellowship lengths and advanced tracks within residency programs.

Background: This manuscript presents the challenges of treating various forms of headaches and the potential of interventional techniques targeting the greater occipital nerve (GON) to alleviate the burden on patients. Occipital neuralgia, characterized by stabbing or shooting pain in the base of the skull, is often associated with primary, cervicogenic, or migraine headaches. While occipital nerve blocks offer temporary relief, durable treatment options are limited. Pulsed radiofrequency (PRF) and thermal radiofrequency ablation (TRFA) have shown promise as minimally invasive procedures for long-term treatment. However, GON is not easily identified using ultrasound or fluoroscopic analysis; thereby, minimizing success of proper ablation. Here, the authors provide a percutaneous strategy to localize the GON and maximize lesion performance. We intend to provide an ex-vivo description of staggered bipolar radiofrequency (RF) lesioning and include the use of staggered bipolar lesioning of the GON and stimulation of the semispinalis capitis. We also analyzed the effectiveness and side effects from this ablation, retrospectively., Methods: Patients with chronic refractory GON neuralgia were selected for GON TRFA. A novel double needle technique of sequential electrical stimulation was used to localize the GON and approximate needle to nerve distance. Once the needles were positioned adjacent to the GON, TRFA was performed using a bipolar staggered technique., Results: Twenty-two patients with GON were treated with TRFA using a novel double needle technique. Seventy-two percent of these patients reported greater than 50% pain relief at both 1 and 6 months following the procedure. The results of our ex-vivo study demonstrate that performing TRFA using the parallel needle bipolar approach separated 8 mm apart produced the most desirable lesion dimensions that may correlate with effective ablation of the GON., Conclusions: This study demonstrates a new localization and ablation technique to treat refractory headaches. However, larger studies are needed to confirm our findings., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-24-72/coif). The authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Radiofrequency ablation (RFA) of the articular branches of the femoral and obturator nerves (the innervation of the anterior capsule of the hip) is an emerging treatment for chronic hip pain. Body mass index (BMI) greater than 30, older age, large acetabular/femoral head bone marrow lesions, chronic widespread pain, depression, and female sex increase the risk of developing hip pain. Chronic hip pain is a common condition with a wide range of etiologies, including hip osteoarthritis (OA), labral tears, osteonecrosis, post total hip arthroplasty (THA), post-operative dislocation/fracture, and cancer. The most common and well studied is hip OA. Management of chronic hip pain includes conservative measures (pharmacotherapy and exercise), surgery, and percutaneous procedures such as RFA. While surgery is effective, those whose medical comorbidities preclude surgery, those who do not wish to have surgery, and those whose pain persists after surgery (11-36% of patients) could benefit from RFA. Because of the aforementioned circumstances, hip RFA is often a palliative intervention. Hip RFA is an effective treatment, one recent retrospective study of 138 patients found 69% had >50% pain relief at 6 months. The most frequent adverse event reported for hip RFA is pain from needle placement. No serious bleeding events have been reported, despite the valid concern of the procedure's proximity to vasculature. This descriptive review details the pathophysiology of hip pain, its etiologies, its clinical presentation, conservative management, the anatomy/technique of hip RFA, hip RFA efficacy, and RFA adverse events.

Background: Neuromodulation is a standard and well-accepted treatment for chronic refractory neuropathic pain. There has been progressive innovation in the field over the last decade, particularly in areas of spinal cord stimulation (SCS) and dorsal root ganglion stimulation. Improved outcomes using proprietary waveforms have become customary in the field, leading to an unprecedented expansion of these products and a plethora of options for the management of pain. Although advances in waveform technology have improved our fundamental understanding of neuromodulation, a scoping review describing new energy platforms and their associated clinical effects and outcomes is needed. The authors submit that understanding electrophysiological neuromodulation may be important for clinical decision-making and programming selection for personalized patient care., Objective: This review aims to characterize ways differences in mechanism of action and clinical outcomes of current spinal neuromodulation products may affect contemporary clinical decision-making while outlining a possible path for the future SCS., Study Design: The study is a scoping review of the literature about newer generation SCS waveforms., Materials and Methods: A literature report was performed on PubMed and chapters to include articles on spine neuromodulation mechanism of action and efficacy., Results: A total of 8469 studies were identified, 75 of which were included for the scoping review after keywords defining recent waveform technology were added., Conclusions: Clinical data suggest that neuromodulation remains a promising tool in the treatment of chronic pain. The evidence for SCS for treating chronic pain seems compelling; however, more long-term and comparative data are needed for a comparison of waveforms when it comes to the etiology of pain. In addition, an exploration into combination waveform therapy and waveform cycling may be paramount for future clinical studies and the development of new technologies., Competing Interests: Conflict of Interest Sayed E. Wahezi is a consultant for Boston Scientific and receives research funding from Vertos, Boston Scientific, and Abbott. Dr. Wahezi has filed for a neuromodulation patent during the production of this manuscript. Corey W. Hunter is a consultant for Abbott, Averitas, Biotronik, Boston Scientific, Mainstay, Nalu, PainTEQ, Saluda, SKK, and Vivex and holds stock and/or stock options with Mainstay, Nalu, PainTEQ, Spine Biopharma, and Vivex. Magdalena Anitescu reports consulting fees from Boston Scientific and Medtronic. Lynn Kohan reports consulting fees from Avanos. The remaining authors have no conflict of interest to report., (Copyright © 2023 International Neuromodulation Society. Published by Elsevier Inc. All rights reserved.)

Background: Radiofrequency ablation (RFA) is a common treatment in which radiofrequency (RF) is used to heat neural tissue and reduce pain. The impact of adipose content in tissue on the lesion size may impact efficacy, and to date, there is little, if any, data comparing its influence on RFA., Objectives: We evaluated the influence of adipose tissue on RF lesion size., Study Design: Controlled, ex vivo study., Setting: Academic institution in a procedural setting., Methods: RF lesions were created using 20-G 10-mm protruding electrode (PE) needles inserted into unbrined chicken breasts and thighs at 21°C. RF current was applied for 90 seconds at 80°C. Chicken breasts were used as the control group and chicken thighs were used as the high adipose variant. Four different groups were examined: 1- Standard 20 g RFA needle, 2- 20 g RFA PE needle, 3- Standard RFA needle with lidocaine 2% injectate, and 4- Standard RFA needle with iohexol 240 mg injectate. There were 12 lesions performed in each group; length, width, and depth were measured., Results: The control group had significantly deeper lesions in all 4 cohorts. Lesions' lengths were smaller in the fat-rich group. The control and PE cohorts showed a significant difference in width between the 2 fat-rich and nonfatty groups., Limitations: Radiofrequency ablation was performed at room temperature and not heated to physiological temperature. This was an ex vivo study, thus factors of human anatomy and physiology could not be evaluated., Conclusions: Adipose tissue content was inversely related to lesion size in all samples. This factor should be considered when assessing methods of enhancing lesion size in human models.