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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.

Background: The COVID pandemic has impacted almost every aspect of human interaction, causing global changes in financial, health care, and social environments for the foreseeable future. More than 1.3 million of the 4 million cases of COVID-19 confirmed globally as of May 2020 have been identified in the United States, testing the capacity and resilience of our hospitals and health care workers. The impacts of the ongoing pandemic, caused by a novel strain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have far-reaching implications for the future of our health care system and how we deliver routine care to patients. The adoption of social distancing during this pandemic has demonstrated efficacy in controlling the spread of this virus and has been the only proven means of infection control thus far. Social distancing has prompted hospital closures and the reduction of all non-COVID clinical visits, causing widespread financial despair to many outpatient centers. However, the need to treat patients for non-COVID problems remains important despite this pandemic, as care must continue to be delivered to patients despite their ability or desire to report to outpatient centers for their general care. Our national health care system has realized this need and has incentivized providers to adopt distance-based care in the form of telemedicine and video medicine visits. Many institutions have since incorporated these into their practices without financial penalty because of Medicare's 1135 waiver, which currently reimburses telemedicine at the same rate as evaluation and management codes (E/M Codes). Although the financial burden has been alleviated by this policy, the practitioner remains accountable for providing proper assessment with this new modality of health care delivery. This is a challenge for most physicians, so our team of national experts has created a reference guide for musculoskeletal and neurologic examination selection to retrofit into the telemedicine experience., Objectives: To describe and illustrate musculoskeletal and neurologic examination techniques that can be used effectively in telemedicine., Study Design: Consensus-based multispecialty guidelines., Setting: Tertiary care center., Methods: Literature review of the neck, shoulder, elbow, wrist, hand, lumbar, hip, and knee physical examinations were performed. A multidisciplinary team comprised of physical medicine and rehabilitation, orthopedics, rheumatology, neurology, and anesthesia experts evaluated each examination and provided consensus opinion to select the examinations most appropriate for telemedicine evaluation. The team also provided consensus opinion on how to modify some examinations to incorporate into a nonhealth care office setting., Results: Sixty-nine examinations were selected by the consensus team. Household objects were identified that modified standard and validated examinations, which could facilitate the examinations.The consensus review team did not believe that the modified tests altered the validity of the standardized tests., Limitations: Examinations selected are not validated for telemedicine. Qualitative and quantitative analyses were not performed., Conclusions: The physical examination is an essential component for sound clinical judgment and patient care planning. The physical examinations described in this manuscript provide a comprehensive framework for the musculoskeletal and neurologic examination, which has been vetted by a committee of national experts for incorporation into the telemedicine evaluation.

Electrode migration/displacement is reported to be the most common complication of spinal cord stimulator (SCS) implantation, with the literature reporting incidences from 13.2% to 22.6%. There have been numerous publications describing techniques preventing lead migration, with most involving tying leads to skin and fascia for trial and permanent leads, respectively. However, few have addressed how to prevent migration in the case of hypermobile tissue seen in the morbidly obese. We describe the creation of subcutaneous tension loops to prevent lead migration.

Multiple myeloma is a hematologic malignancy associated with destructive bone loss. Lytic lesions, a hallmark of this cancer, can result in significant morbidity because of associated pain and structural osseous compromise. Osteoplasty has demonstrated efficacy in the treatment of myelomatous pain within the axial skeleton; however, there is limited evidence supporting the utility of osteoplasty to treat extra-spinal lesions. We describe a 67 year-old woman with stable IgA lambda multiple myeloma with sentinel bilateral greater trochanteric lytic lesions that was referred to our interventional pain management clinic for evaluation of bilateral lateral hip pain. Conservative treatment options including physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), oral opiates, and local corticosteroid injections to bilateral trochanteric bursae failed to offer pain relief. The patient underwent minimally invasive percutaneous trochanteroplasty with concomitant core biopsy of her bilateral trochanteric lytic lesions. The intended goals of this novel procedure were to determine the cause of the suspected lytic lesions, provide pain relief, and offer structural stability by safely implanting bone cement as part of a fracture prevention strategy. At 12 month follow-up, the patient's pain improved by 70% and she no longer required the use of pain medication. The patient also displayed a significant improvement in her day-to-day functioning and quality of life.