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Bright Etumuse,1 Majesty Greer,2 Jane Onyemachi,1 Youshaa El-Abed,3 Sai Kamma,1 Jay D Shah,4 Henry Tuan Tran,1 Nasir Hussain,5 Thomas P Pittelkow,6 Ryan S D’Souza6 1University of Texas Medical Branch School of Medicine, Galveston, TX, USA; 2Howard University College of Medicine, Washington, DC, USA; 3Kansas City University, Kansas City, MO, USA; 4Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA; 5Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 6Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USACorrespondence: Ryan S D’Souza, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic 200 First St. SW, Rochester, MN, 55905, USA, Email Dsouza.ryan@mayo.eduBackground: As cannabis legalization expands nationally and globally, its use for chronic pain increases, prompting people to seek information on social media platforms like YouTube. This study evaluates the accuracy and quality of information of popular YouTube videos on cannabis for chronic pain.Methods: Using search terms related to cannabis for pain, the top 66 videos by view count were selected. Each video was classified as useful, misleading, or neither. The quality and reliability of each video were assessed using the modified DISCERN, mDISCERN, score and the Global Quality Scale, GQS. The video characteristics, usefulness classification, mDISCERN scores, and GQS scores were summarized. Continuous and categorical outcomes were compared using t-test and chi-square, respectively.Results: Of the 66 videos, 22.73% (n=15) were classified as useful, and 77.27% (n=51) were classified as neither. Of useful videos, 40.00% (n=6) were uploaded by physicians, 40.00% (n=6) were uploaded by corporations, and 6.67% (n=1) were uploaded by an independent user. Of videos classified as neither useful nor misleading, news sources uploaded 27.45% (n=14) of these videos (P=0.02). Physicians uploaded 37.50% (n = 18) of videos with a GQS score ≥ 3 (P=0.04), while independent users uploaded significantly more videos with a mDISCERN score < 3 (22.20%, P=0.02). Useful videos had a mean GQS of 4.00 ± 0.65 compared to a mean GQS of 2.76 ± 0.86 for videos deemed neither (P< 0.0001).Conclusion: This study suggests a moderate quality of YouTube content on cannabis use for chronic pain. Given cannabis’s growing popularity and potential for misinformation on popular social media platforms, healthcare professionals and organizations should consider uploading educational videos on this topic on YouTube.Keywords: social media, cannabis, medical cannabis, analgesics, YouTube

Addyson E Sand,1 Tyler E Powell,1 Helen T Marry,1 Heather R Rathbun,1 Jenna R Steege,1 Allison LeMahieu,2 Adam K Jacob,1 Ryan S D’Souza,1 Oludare O Olatoye1 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA; 2Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USACorrespondence: Oludare O Olatoye, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA, Email Olatoye.Oludare@mayo.eduBackground: Patients receiving methadone, buprenorphine, and naltrexone for either chronic pain or substance use disorder (SUD) pose perioperative challenges. Due to their complex pharmacology, perioperative recommendations continue to evolve. Deviations from these recommendations may result in worse perioperative outcomes. A formal preoperative evaluation (POE) and optimization of patients on these medications are recommended to address these concerns.Methods: A single-center retrospective electronic health record review was performed with adult patients on methadone, buprenorphine, and naltrexone undergoing elective surgery between January 1, 2010 and December 31, 2020. The primary outcome of interest was the percentage of patients referred to the POE clinic for evaluation prior to the scheduled elective surgery. In addition, we assessed differences in variables (perioperative opioid, hospital length of stay, perioperative multimodal analgesics, perioperative complications, inpatient pain service consult, readmission within 30 days, cancellation of surgery, addiction medicine consult) based on POE clinic evaluation. This analysis was performed separately for patients prescribed these medications for SUD versus chronic pain. Continuous outcomes were analyzed using linear regression with generalized estimating equations (GEE) and robust variance estimates.Results: A total of 714 patients were included in the final analysis, of which 572 (80%) took buprenorphine, methadone, or naltrexone for chronic pain and 142 (20%) took these medications for SUD. Within the chronic pain and SUD subpopulations, 193 (34%) and 35 (25%) patients had formal POE clinic assessments, respectively. Among those taking these medications for chronic pain, POE clinic evaluation was associated with a higher likelihood for receiving non-opioid multimodal analgesics perioperatively (p = 0.016).Conclusion: Formal preoperative evaluations are currently underutilized in patients who take buprenorphine, methadone, or naltrexone for chronic pain or SUD. These patients may benefit from POE clinic assessment to optimize perioperative outcomes.Keywords: preoperative evaluation, chronic opioid therapy, substance use disorder, naltrexone, buprenorphine, methadone, perioperative pain management

Ryan S D’Souza,1 Yeng F Her,1 Nasir Hussain,2 Jay Karri,3 Michael E Schatman,4 Aaron K Calodney,5 Christopher Lam,6 Thomas Buchheit,7 Brennan J Boettcher,8 George C Chang Chien,9 Scott G Pritzlaff,10 Christopher Centeno,11 Shane A Shapiro,12 Johana Klasova,1 Jay S Grider,13 Ryan Hubbard,14 Eliana Ege,15 Shelby Johnson,8 Max H Epstein,16 Eva Kubrova,8 Mohamed Ehab Ramadan,17 Alexandra Michelle Moreira,18 Swarnima Vardhan,19 Yashar Eshraghi,20 Saba Javed,21 Newaj M Abdullah,22 Paul J Christo,17 Sudhir Diwan,23 Leslie C Hassett,24 Dawood Sayed,6 Timothy R Deer25 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA; 2Department of Anesthesiology, The Ohio State Wexner Medical Center, Columbus, OH, USA; 3Departments of Orthopedic Surgery and Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA; 4Department of Anesthesiology, Perioperative Care, & Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 5Precision Spine Care, Tyler, TX, USA; 6Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA; 7Department of Anesthesiology, Duke University, Durham, NC, USA; 8Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA; 9Department of Regenerative Medicine, GCC Institute, Torrance, CA, USA; 10Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA, USA; 11Centeno-Schultz Clinic, Broomfield, CO, USA; 12Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA; 13Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA; 14Department of Sports Medicine, Anderson Orthopedic Clinic, Arlington, VA, USA; 15Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX, USA; 16Department of Physical Medicine & Rehabilitation, Harvard Medical School, Boston, MA, USA; 17Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA; 18Department of Physical Medicine & Rehabilitation, University of Miami/Jackson Memorial Hospital, Miami, FL, USA; 19Department of Internal Medicine, Yale New Haven Health – Bridgeport Hospital, Bridgeport, CT, USA; 20Department of Anesthesiology & Critical Care Medicine, Ochsner Health System, New Orleans, LA, USA; 21Department of Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA; 22Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA; 23Department of Pain Medicine, Advanced Spine on Park Avenue, New York City, NY, USA; 24Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, USA; 25Department of Anesthesiology and Pain Medicine, West Virginia University School of Medicine, Charleston, WV, USACorrespondence: Ryan S D’Souza, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA, Tel +1-(507)-284-9696, Fax +1-(507)-266-7732, Email dsouza.ryan@mayo.eduPurpose: Injectable biologics have not only been described and developed to treat dermal wounds, cardiovascular disease, and cancer, but have also been reported to treat chronic pain conditions. Despite emerging evidence supporting regenerative medicine therapy for pain, many aspects remain controversial.Methods: The American Society of Pain and Neuroscience (ASPN) identified the educational need for an evidence-based guideline on regenerative medicine therapy for chronic pain. The executive board nominated experts spanning multiple specialties including anesthesiology, physical medicine and rehabilitation, and sports medicine based on expertise, publications, research, and clinical practice. A steering committee selected preliminary questions, which were reviewed and refined. Evidence was appraised using the United States Preventive Services Task Force (USPSTF) criteria for evidence level and degree of recommendation. Using a modified Delphi approach, consensus points were distributed to all collaborators and each collaborator voted on each point. If collaborators provided a decision of “disagree” or “abstain”, they were invited to provide a rationale in a non-blinded fashion to the committee chair, who incorporated the respective comments and distributed revised versions to the committee until consensus was achieved.Results: Sixteen questions were selected for guideline development. Questions that were addressed included type of injectable biologics and mechanism, evidence in treating chronic pain indications (eg, tendinopathy, muscular pathology, osteoarthritis, intervertebral disc disease, neuropathic pain), role in surgical augmentation, dosing, comparative efficacy between injectable biologics, peri-procedural practices to optimize therapeutic response and quality of injectate, federal regulations, and complications with mitigating strategies.Conclusion: In well-selected individuals with certain chronic pain indications, use of injectable biologics may provide superior analgesia, functionality, and/or quality of life compared to conventional medical management or placebo. Future high-quality randomized clinical trials are warranted with implementation of minimum reporting standards, standardization of preparation protocols, investigation of dose–response associations, and comparative analysis between different injectable biologics.Keywords: regenerative medicine, injectable biologics, platelet-rich plasma, mesenchymal stem cell, bone marrow aspirate concentrate, pain medicine

Dawood Sayed,1 Timothy R Deer,2,3 Vinicius Tieppo Francio,1 Christopher M Lam,1 Kamil Sochacki,4 Nasir Hussain,5 Tristan E Weaver,5 Jay Karri,6,7 Vwaire Orhurhu,8,9 Natalie Holmes Strand,10 Jacqueline Soicher Weisbein,11 Jonathan M Hagedorn,12 Ryan S D’Souza,12 Ryan R Budwany,2 Ahish Chitneni,13 Kasra Amirdelfan,14 Michael J Dorsi,15 Dan TD Nguyen,16 Christopher Bovinet,17 Alaa Abd-Elsayed18 1Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA; 2Pain Services, Spine and Nerve Center of the Virginias, Charleston, WV, USA; 3Anesthesiology and Pain Medicine, West Virginia University School of Medicine, Charleston, WV, USA; 4Department of Anesthesiology and Perioperative Medicine, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA; 5Anesthesiology, the Ohio State University Wexner Medical Center, Columbus, OH, USA; 6Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; 7Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA; 8Department of Anesthesiology, University of Pittsburgh Medical Center, Williamsport, PA, USA; 9Pain Medicine, MVM Health, East Stroudsburg, PA, USA; 10Anesthesiology and Pain Medicine, Mayo Clinic, Phoenix, AZ, USA; 11Interventional Pain Management, Napa Valley Orthopaedic Medical Group, Napa, CA, USA; 12Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA; 13Department of Rehabilitation & Regenerative Medicine, New York Presbyterian – Columbia & Cornell, New York, NY, USA; 14Director of Clinical Research, Boomerang Healthcare, Walnut Creek, CA, USA; 15Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA; 16Neuroradiology & Pain Solutions of Oklahoma, Edmond, OK, USA; 17The Spine Center of SE Georgia, Brunswick, GA, USA; 18Anesthesiology, University of Wisconsin, Madison, WI, USACorrespondence: Dawood Sayed, Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA, Tel +1 785-550-5800, Email dsayed@kumc.eduAbstract: Clinical management of sacroiliac disease has proven challenging from both diagnostic and therapeutic perspectives. Although it is widely regarded as a common source of low back pain, little consensus exists on the appropriate clinical management of sacroiliac joint pain and dysfunction. Understanding the biomechanics, innervation, and function of this complex load bearing joint is critical to formulating appropriate treatment algorithms for SI joint disorders. ASPN has developed this comprehensive practice guideline to serve as a foundational reference on the appropriate management of SI joint disorders utilizing the best available evidence and serve as a foundational guide for the treatment of adult patients in the United States and globally.Keywords: sacroiliac joint, sacroiliitis, chronic pain, best practices, radiofrequency ablation, sacroiliac joint fusion

Majesty Greer,1 Sai Kamma,2 Henry Tran,2 Bright Etumuse,2 Jay D Shah,3 Youshaa El-Abed,4 Jane O Onyemachi,2 Nasir Hussain,5 Thomas P Pittelkow,6 Ryan S D’Souza6 1Howard University College of Medicine, Washington, DC, USA; 2University of Texas Medical Branch School of Medicine, Galveston, TX, USA; 3Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA; 4College of Osteopathic Medicine, Kansas City University, Kansas City, MO, USA; 5Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 6Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USACorrespondence: Ryan S D’Souza, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA, Email Dsouza.ryan@mayo.eduIntroduction: Acupuncture is commonly used to treat chronic pain. Patients often access public social media platforms for healthcare information when querying acupuncture. Our study aims to appraise the utility, accuracy, and quality of information available on YouTube, a popular social media platform, on acupuncture for chronic pain treatment.Methods: Using search terms such as “acupuncture for chronic pain” and “acupuncture pain relief”, the top 54 videos by view count were selected. Included videos were > 1 minute duration, contained audio in English, had > 7000 views, and was related to acupuncture. One primary outcome of interest was categorizing each video’s usefulness as useful, misleading, or neither. Another primary outcome of interest was the quality and reliability of each video using validated instruments, including the modified DISCERN (mDISCERN) tool and the Global Quality Scale (GQS). The means were calculated for the video production characteristics, production sources, and mDISCERN and GQS scores. Continuous and categorical outcomes were compared using Student’s t-test and chi-square test, respectively.Results: Of the 54 videos, 57.4% were categorized as useful, 14.8% were misleading, and 27.8% were neither. Useful videos had a mean GQS and mDISCERN score of 3.77± 0.67 and 3.48± 0.63, respectively, while misleading videos had mean GQS and mDISCERN score of 2.50± 0.53 and 2.38± 0.52, respectively. 41.8% of the useful videos were produced by a healthcare institution while none of the misleading videos were produced by a healthcare institution. However, 87.5% of the misleading videos were produced by health media compared to only 25.8% of useful videos from health media.Discussion: As patients increasingly depend on platforms like YouTube for trustworthy information on complementary health practices such as acupuncture, our study emphasizes the critical need for more higher-quality videos from unbiased healthcare institutions and physicians to ensure patients are receiving reliable information regarding this topic.Keywords: acupuncture, chronic pain, social media, anesthesia, information dissemination, internet

Dawood Sayed,1 Timothy Ray Deer,2 Jonathan M Hagedorn,3 Asim Sayed,4 Ryan S D’Souza,3 Christopher M Lam,1 Nasir Khatri,5 Zohra Hussaini,1 Scott G Pritzlaff,6 Newaj Mohammad Abdullah,7 Vinicius Tieppo Francio,1 Steven Michael Falowski,8 Yussr M Ibrahim,9 Mark N Malinowski,10 Ryan R Budwany,2 Natalie Holmes Strand,11 Kamil M Sochacki,12 Anuj Shah,13 Tyler M Dunn,11 Morad Nasseri,14 David W Lee,15 Leonardo Kapural,16 Marshall David Bedder,17,18 Erika A Petersen,19 Kasra Amirdelfan,20 Michael E Schatman,21,22 Jay Samuel Grider23 1Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA; 2Pain Services, Spine and Nerve Center of the Virginias, Charleston, WV, USA; 3Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA; 4Podiatry/Surgery, Susan B. Allen Memorial Hospital, El Dorado, KS, USA; 5Interventional Pain Medicine, Novant Spine Specialists, Charlotte, NC, USA; 6Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA, USA; 7Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA; 8Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA; 9Pain Medicine, Northern Light Eastern Maine Medical Center, Bangor, ME, USA; 10OhioHealth Neurological Physicians, OhioHealth, Columbus, OH, USA; 11Anesthesiology and Pain Medicine, Mayo Clinic, Phoenix, AZ, USA; 12Department of Anesthesiology and Perioperative Medicine, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA; 13Department of Physical Medicine and Rehabilitation, Detroit Medical Center, Detroit, MI, USA; 14Interventional Pain Medicine / Neurology, Boomerang Healthcare, Walnut Creek, CA, USA; 15Pain Management Specialist, Fullerton Orthopedic, Fullerton, CA, USA; 16Carolinas Pain Institute, Winston Salem, NC, USA; 17Chief of Pain Medicine Service, Augusta VAMC, Augusta, GA, USA; 18Associate Professor and Director, Addiction Medicine Fellowship Program, Department Psychiatry and Health Behavior, Medical College of Georgia at Augusta University, Augusta, GA, USA; 19Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA; 20Director of Clinical Research, Boomerang Healthcare, Walnut Creek, CA, USA; 21Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 22Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA; 23Anesthesiology, Division of Pain Medicine, University of Kentucky College of Medicine, Lexington, KY, USACorrespondence: Dawood Sayed, Anesthesiology and Pain Medicine, the University of Kansas Medical Center, Kansas City, KS, USA, Tel +1 785-550-5800, Email dsayed@kumc.eduIntroduction: Painful diabetic neuropathy (PDN) is a leading cause of pain and disability globally with a lack of consensus on the appropriate treatment of those suffering from this condition. Recent advancements in both pharmacotherapy and interventional approaches have broadened the treatment options for PDN. There exists a need for a comprehensive guideline for the safe and effective treatment of patients suffering from PDN.Objective: The SWEET Guideline was developed to provide clinicians with the most comprehensive guideline for the safe and appropriate treatment of patients suffering from PDN.Methods: The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations for PDN. A multidisciplinary group of international experts developed the SWEET guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Meeting Abstracts, and Scopus to identify and compile the evidence for diabetic neuropathy pain treatments (per section as listed in the manuscript) for the treatment of pain. Manuscripts from 2000-present were included in the search process.Results: After a comprehensive review and analysis of the available evidence, the ASPN SWEET guideline was able to rate the literature and provide therapy grades for most available treatments for PDN utilizing the United States Preventive Services Task Force criteria.Conclusion: The ASPN SWEET Guideline represents the most comprehensive review of the available treatments for PDN and their appropriate and safe utilization.Keywords: diabetes, painful diabetic neuropathy, neuropathy, spinal cord stimulation, chronic pain, diabetic neuropathy

Christopher L Robinson,1,&ast; Alexandra CG Fonseca,2,&ast; Efemena M Diejomaoh,3,&ast; Ryan S D’Souza,4 Michael E Schatman,5,6,&ast; Vwaire Orhurhu,7,8,&ast; Trent Emerick9,&ast; 1Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA; 2Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women’s Hospital, Boston, MA, USA; 3Department of Psychiatry & Behavioral Science, Meharry Medical College, Nashville, TN, USA; 4Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Rochester, Rochester, MN, USA; 5Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 6Department of Population Health-Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA; 7University of Pittsburgh Medical Center, Susquehanna, Williamsport, PA, USA; 8MVM Health, East Stroudsburg, PA, USA; 9University of Pittsburgh Medical Center, Department of Anesthesiology and Perioperative Medicine, Chronic Pain Division, Pittsburgh, PA, USA&ast;These authors contributed equally to this workCorrespondence: Vwaire Orhurhu, University of Pittsburgh Medical Center, Susquehanna, Williamsport, PA, USA, Email vwo569@mail.harvard.eduIntroduction: Amid a lack of effective chronic pain treatments, psychedelics have gained attention as a potential solution, although their Schedule 1 classification poses challenges. Psychedelics, such as lysergic acid diethylamide (LSD) and psilocybin, have gained popularity as alternatives and adjuncts for chronic pain treatment. Studies suggest that they may modulate pain processing through agonism primarily at the serotonin receptor, 5-HT2A. One of the first of its nature, we present an artificial intelligence (AI)-powered scoping review primarily focusing on evaluating psychedelics for chronic pain conditions such as cluster headache, phantom limb pain, and fibromyalgia.Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we used an AI-powered comprehensive search strategy utilizing the ChatGPT4.0 Bing chat to search Medline, Embase, Cochrane, and Google Scholar for articles addressing chronic pain. The query was performed on June 1, 2023, focusing on psychedelics for chronic, non-cancer pain including headache disorders. Inclusion criteria were English-only, peer-reviewed articles involving human participants > 18 years, focusing on chronic pain conditions (eg, phantom limb pain and cluster headache), using LSD, 2.5-dimethoxy-4-bromophenethylamine (2C-B), N, N-dimethyltryptamine (DMT), psilocybin, or mescaline. Exclusion criteria were reviews, editorials, and opinion articles and studies focusing on tetrahydrocannabinol/cannabis and/or ketamine.Results: A total of 186 unique database entries were retrieved, of which nine studies were included in the scoping review. These included four case reports/series, an open-label study, a cohort study, two online surveys, and a randomized, double-blind, placebo-controlled trial. They comprised three studies addressing phantom limb pain, four addressing cluster headaches, and two addressing fibromyalgia, spinal cord injury, complex regional pain syndrome, and lumbar radiculopathy.Conclusion: Psychedelics may have potential in alleviating pain symptoms secondary to a multitude of chronic pain conditions. However, further randomized, double-blind, placebo-controlled trials are needed to further explore and evaluate the role of psychedelics in chronic, non-cancer pain.Keywords: psilocybin, mescaline, lysergic acid diethylamide, headache, phantom limb pain, scoping review

Christopher L Robinson,1,&ast; Ryan S D’Souza,2,&ast; Cyrus Yazdi,1 Efemena M Diejomaoh,3 Michael E Schatman,4,5,&ast; Trent Emerick,6,&ast; Vwaire Orhurhu7,8,&ast; 1Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; 2Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA; 3Department of Psychiatry & Behavioral Science, Meharry Medical College, Nashville, TN, USA; 4Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 5Department of Population Health-Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA; 6Department of Anesthesiology and Perioperative Medicine, Chronic Pain Division, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; 7University of Pittsburgh Medical Center, Susquehanna, Williamsport, PA, USA; 8MVM Health, East Stroudsburg, PA, USA&ast;These authors contributed equally to this workCorrespondence: Vwaire Orhurhu, MVM Health, East Stroudsburg, Williamsport, PA, USA, Email vwo569@mail.harvard.eduAbstract: The integration of artificial intelligence (AI) in patient pain medicine education has the potential to revolutionize pain management. By harnessing the power of AI, patient education becomes more personalized, interactive, and supportive, empowering patients to understand their pain, make informed decisions, and actively participate in their pain management journey. AI tailors the educational content to individual patients’ needs, providing personalized recommendations. It introduces interactive elements through chatbots and virtual assistants, enhancing engagement and motivation. AI-powered platforms improve accessibility by providing easy access to educational resources and adapting content to diverse patient populations. Future AI applications in pain management include explaining pain mechanisms, treatment options, predicting outcomes based on individualized patient-specific factors, and supporting monitoring and adherence. Though the literature on AI in pain medicine and its applications are scarce yet growing, we propose avenues where AI may be applied and review the potential applications of AI in pain management education. Additionally, we address ethical considerations, patient empowerment, and accessibility barriers.Keywords: ethics, chatbots, machine learning, natural language processing, patient education

Jonathan M Hagedorn,1 Tony K George,2 Rohit Aiyer,3 Keith Schmidt,4 John Halamka,5 Ryan S D’Souza1 1Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA; 2Department of Physical Medicine and Rehabilitation, University Orthopedic Associates, Somerset, NJ, USA; 3Integrative Sports & Spine, Long Beach, CA, USA; 4Comprehensive Pain Management Program, St. Alexius Medical Center, Hoffman Estates, IL, USA; 5Mayo Clinic Platform, Mayo Clinic, Rochester, MN, USACorrespondence: Jonathan M Hagedorn, Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA, Tel +1-507-284-9696, Fax +1-507-266-7732, Email jonhagedornmd@yahoo.comAbstract: Artificial intelligence was introduced 60 years ago and has evolved immensely since that time. While artificial intelligence is found in nearly all aspects of our life, the use of artificial intelligence in the healthcare industry has only recently become apparent and more widely discussed. It is expected that artificial intelligence will allow improved disease recognition, treatment optimization, cost and time savings, product development, decision making, and marketing. For pain medicine specifically, these same benefits will be translatable and we can expect better disease recognition and treatment selection. As adoption occurs with this impressive technology, it will be imperative for the pain medicine community to be informed on proper definitions and expected use cases for artificial intelligence. Our objective was to provide pain medicine physicians an overview of artificial intelligence, including important definitions to aid understanding, and to offer potential clinical applications pertinent to the specialty.Keywords: artificial intelligence, pain medicine, chronic pain, education

Natalie Strand,1 Ryan S D’Souza,2 Jay Karri,3 Hemant Kalia,4 Jackie Weisbein,5 Brian J Kassa,6 Nasir Hussain,7 Ahish Chitneni,8 Ryan R Budwany,9 Jonathan Hagedorn,2 Jason E Pope,10 Timothy R Deer,11 Dawood Sayed,12 Alaa Abd-Elsayed13 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA; 2Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA; 3Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA; 4Department of Physical Medicine and Rehabilitation, Rochester Regional Health, Rochester, NY, USA; 5Napa Valley Orthopaedic, Napa, CA, USA; 6Resident in the Department of Physical Medicine and Rehabilitation, Wayne State University School of Medicine at the Rehabilitation Institute of Michigan, Detroit, MI, USA; 7Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 8Department of Physical Medicine & Rehabilitation, New York-Presbyterian, New York, NY, USA; 9Resident in the Department of Anesthesiology, West Virginia University, Charleston, WV, USA; 10Interventional Pain Management, Evolve Restorative Center, Santa Rosa, CA, USA; 11Department of Anesthesiology, West Virginia University School of Medicine, Morgantown, WV, USA; 12Department of Anesthesiology, The University of Kansas Medical Center, Kansas City, KS, USA; 13Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USACorrespondence: Natalie Strand, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA, Email Strand.Natalie@mayo.eduAbstract: Cannabinoids have recently gained a renewed interest due to their potential applicability to various medical conditions, specifically the management of chronic pain conditions. Unlike many other medications, medical cannabis is not associated with serious adverse events, and no overdose deaths have been reported. However, both safety and efficacy data for medical cannabis treatment of chronic, nonmalignant pain conditions are lacking. Therefore, representatives from the American Society of Pain and Neuroscience summarize the evidence, according to level and grade, for medical cannabis treatment of several different pain conditions. Treatment of cancer-related pain has prospective evidentiary support for the use of medical cannabis. Although 3 large and well-designed randomized controlled trials investigated cannabis treatment of cancer-related pain, the evidence yielded only a grade D recommendation. Neuropathic pain has been investigated in prospective studies, but a lack of high-quality evidence renders cannabis treatment for this indication a grade C recommendation. Both safety and efficacy data are lacking for use of medical cannabis to treat chronic nonmalignant pain conditions.Keywords: analgesia, chronic pain, marijuana treatment, neuralgia, postoperative pain

Jillian A Maloney,1 Ryan S D’Souza,2 Skye A Buckner Petty,3 Michal J Turkiewicz,4 Debarshi Sinha,4 Ajay Patel,5 Natalie H Strand1 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA; 2Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA; 3Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ, USA; 4Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA; 5Department of Rehabilitation & Regenerative Medicine (Patel), New York-Presbyterian Hospital-University Hospital of Columbia and Cornell, New York, NY, USACorrespondence: Jillian A Maloney, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA, Email Maloney.jillian@mayo.eduPurpose: Data are lacking on the factors that contribute to job satisfaction among pain medicine physicians. We sought to determine how sociodemographic and professional characteristics relate to job satisfaction among pain medicine physicians.Methods: In this nationwide, multicenter, cross-sectional observational study, an electronic questionnaire related to job satisfaction was emailed in 2021 to pain medicine physicians who were members of the American Society of Anesthesiologists or the American Society of Pain and Neuroscience. The 28-item questionnaire asked physicians about sociodemographic and professional factors. Eight questions related to job satisfaction were based on a 10-point Likert scale, and 1 question was a binary (yes/no) variable. Differences in responses based on sociodemographic and professional factors were assessed with the Kruskal–Wallis rank sum test for Likert scale questions and with the Pearson χ2 test for yes/no questions.Results: We determined that several variables, including gender, parental status, geographic location, specialty, years of practice, and volume of patients, are associated with pain medicine physicians’ outlook on job satisfaction. Overall, 74.9% of respondents surveyed would choose pain medicine as a specialty again.Conclusion: High rates of poor job satisfaction persist among pain medicine physicians. This survey study identified several sociodemographic and professional factors that are associated with job satisfaction among pain medicine physicians. By identifying physicians at high risk for poor job satisfaction, healthcare leadership and occupational health agencies can aim to protect physicians’ well-being, enhance working conditions, and raise awareness about burnout.Keywords: economics, outcomes, pain management

Yeng F Her,1 Eva Kubrova,2 Gabriel A Martinez Alvarez,2 Ryan S D’Souza1 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, 55905, USA; 2Department of Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Rochester, MN, 55905, USACorrespondence: Ryan S D’Souza, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA, Tel +507-284-9696, Email Dsouza.ryan@mayo.eduAbstract: Pain originating from the intervertebral disc (discogenic pain) is a prevalent manifestation of low back pain and is often challenging to treat. Of recent interest, regenerative medicine options with injectable biologics have been trialed in discogenic pain and a wide variety of other painful musculoskeletal conditions. In particular, the role of bone marrow aspirate concentrate (BMAC) and culture-expanded bone marrow derived mesenchymal stromal cells (BM-MSCs) in treating discogenic pain remains unclear. The primary objective of this systematic review was to appraise the evidence of intradiscal injection with BMAC and culture-expanded BM-MSCs in alleviating pain intensity from discogenic pain. Secondary outcomes included changes in physical function after intradiscal injection, correlation between stromal cell count and pain intensity, and anatomical changes of the disc assessed by radiographic imaging after intradiscal injection. Overall, 16 studies consisting of 607 participants were included in qualitative synthesis without pooling. Our synthesis revealed that generally intradiscal autologous or allogeneic BMAC and culture-expanded BM-MSCs improved discogenic pain compared to baseline. Intradiscal injection was also associated with improvements in physical functioning and positive anatomical changes on spine magnetic resonance imaging (improved disc height, disc water content, Pfirrmann grading) although anatomical findings were inconsistent across studies. However, the overall GRADEscore for this study was very low due to heterogeneity and poor generalizability. There were no serious adverse events reported post intradiscal injection except for a case of discitis.Keywords: BMAC, discogenic pain, bone marrow mesenchymal stromal cells

Ryan S D’Souza,1 Julie G Pilitsis,2 Brendan J Langford,1 Vwaire Orhurhu,3 Nasir Hussain,4,5 Chelsey M Hoffmann,1 Magdalena Anitescu,6 Stephanie Vanterpool,7 Rushna Ali,8 Kiran Patel,9 Susan M Moeschler1 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA; 2Department of Clinical Neurosciences, Florida Atlantic University, Boca Raton, FL, USA; 3Department of Pain Medicine, University of Pittsburgh, Pittsburgh, PA, USA; 4Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, MA, USA; 5Department of Anesthesiology, The Ohio State University, Columbus, OH, USA; 6Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA; 7Department of Anesthesiology, University of Tennessee, Knoxville, TN, USA; 8Division of Neurosurgery, Spectrum Health, Grand Rapids, MI, USA; 9Department of Anesthesiology, New York University Langone Medical Center, New York City, NY, USACorrespondence: Ryan S D’Souza, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA, Email Dsouza.ryan@mayo.eduBackground: Speaker gender representation at medical conferences is a significant site of gender disparity. Our primary objective was to quantify the proportion of female speakers and compare plenary session opportunities by gender at the North American Neuromodulation Society (NANS) Annual Conference.Methods: Data from the 2017– 2021 NANS Annual Conference presentations were abstracted. Primary outcomes included gender composition of speaker slots, gender composition of individual speakers, and comparison of plenary speaker slots by gender. Secondary outcomes included comparisons of session size, age, professional degree, and number of presentations per speaker based on gender.Results: Gender composition of annual speaker slots was (% slots presented by women): 2017:14.6%; 2018:20.5%; 2019:23.5%; 2020:21.0%; 2021:41.4%. Annual gender composition of individual speakers was (% women): 2017:18.7%; 2018:20.6%; 2019:24.6%; 2020:24.9%; 2021:33.8%. Of all speaker slots, the percentage of plenary slots did not differ based on gender, with 11.4% presented by female speakers versus 11.2% presented by male speakers (OR 1.0, 95% CI 0.7– 1.5, P=0.893). Compared to male speaker slots, there was an association of lower age (43.9± 5.6 vs 50.8± 8.9, P< 0.001), lower odds of holding a single doctorate degree (OR 0.3, 95% CI 0.2– 0.5, P< 0.001), and lower odds of holding a dual MD/PhD or DO/PhD degree (OR 0.3, 95% CI 0.1– 0.5, P< 0.001) in female speaker slots. Compared to male speakers, there was an association of higher number of presentations per female speaker at the 2021 NANS Annual Meeting (2.48± 1.60 vs 1.79± 1.30, P=0.008).Conclusion: Although the volume of female speaker slots and individual speakers trailed behind their male counterparts, female speaker representation steadily increased at each subsequent annual NANS meeting. We identified no difference in plenary session slots based on gender.Keywords: education, leadership, academic advancement, chronic pain, neuromodulation, gender

Corey W Hunter,1,2 Timothy R Deer,3 Mark R Jones,4 George Chiang Chien,5 Ryan S D’Souza,6 Timothy Davis,7 Erica R Eldon,2 Michael F Esposito,8 Johnathan H Goree,9 Lissa Hewan-Lowe,2 Jillian A Maloney,10 Anthony J Mazzola,2 John S Michels,4 Annie Layno-Moses,7 Shachi Patel,11 Jeanmarie Tari,1 Jacqueline S Weisbein,12 Krista A Goulding,13 Anikar Chhabra,13 Jeffrey Hassebrock,13 Chris Wie,10 Douglas Beall,14 Dawood Sayed,15 Natalie Strand10 1Ainsworth Institute of Pain Management, New York, NY, USA; 2Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA; 3The Spine and Nerve Center of the Virginias, Charleston, WV, USA; 4Interventional Spine and Pain, Dallas, TX, USA; 5County Medical Center, Ventura, CA, USA; 6Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA; 7Source Healthcare, Santa Monica, CA, USA; 8Interventional Spine and Pain Institute, Vero Beach, FL, USA; 9Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA; 10Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA; 11Delmarva Pain and Spine Center, Newark, DE, USA; 12Napa Valley Orthopaedic Medical Group, Napa, CA, USA; 13Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA; 14Comprehensive Specialty Care, Oklahoma City, OK, USA; 15Department of Anesthesiology, Division of Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USACorrespondence: Corey W Hunter, Email chunter@ainPain.comAbstract: Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from – unfortunately, there is no consensus on which treatments are “better” and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option.Keywords: knee, knee pain, genicular nerve, ablation, regenerative medicine, platelet-rich plasma, dorsal root ganglion, peripheral nerve stimulation

Chelsey M Hoffmann,1 Ryan S D’Souza,1 Jonathan M Hagedorn2 1Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA; 2Department of Pain Medicine, iSpine Pain Physicians, Maple Grove, MN, USACorrespondence: Chelsey M Hoffmann, Tel +1 507-422-6378, Fax +1 507-266-7732, Email Hoffmann.chelsey@mayo.eduObjective: To describe the team approach of an interventional pain management practice, with particular emphasis on advanced practice providers (APPs), in the selection, education, care, and management of peripheral nerve stimulation (PNS) patients.Materials and Methods: We devised an APP guide to PNS based on an in-depth search of multiple databases for studies on neuromodulation, pain management, and APPs.Results: Of 65 articles captured in the search strategy, three articles were pertinent to the topic of APP involvement in neuromodulation. More specifically, only one of the three publications on neuromodulation discussed APP involvement in PNS. This single publication was from 1995 and focused on electrical stimulation of the trigeminal ganglion using a permanent percutaneously placed electrode.Conclusion: PNS is growing in clinical indication and use for both acute and chronic pain conditions. With the increasing need for APPs in both general and specialty medicine, it is imperative that APPs are well educated on PNS. Here, we have outlined ways in which APPs can optimize the care of PNS patients and how the skillset of the APP in a PNS practice can potentially improve patient outcomes.Keywords: advanced practice provider, peripheral nerve stimulation, interventional pain management, nurse practitioner, physician assistant

Natalie Strand,1 Ryan S D’Souza,2 Jonathan M Hagedorn,3 Scott Pritzlaff,4 Dawood Sayed,5 Nomen Azeem,6 Alaa Abd-Elsayed,7 Alexander Escobar,8 Mark A Huntoon,9 Christopher M Lam,5 Timothy R Deer10 1Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Scottsdale, AZ, USA; 2Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA; 3iSpine Pain Physicians, Burnsville, MN, USA; 4Department of Anesthesiology and Pain Medicine, Division of Pain Medicine, University of California-Davis, Sacramento, CA, USA; 5The University of Kansas Medical Center, Kansas City, KS, USA; 6Florida Spine & Pain Specialists, Bradenton, FL, USA; 7Department of Anesthesiology, University of Wisconsin, Madison, WI, USA; 8Comprehensive Centers for Pain Management, Toledo, OH, USA; 9Department of Anesthesiology, Virginia Commonwealth University, Henrico, VA, USA; 10The Spine and Nerve Center of the Virginias, Charleston, WV, USACorrespondence: Natalie Strand, Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Scottsdale, AZ, USA, Tel +1 480-301-8000, Fax +1 480-342-2986, Email strand.natalie@mayo.eduAbstract: The objective of this peripheral nerve stimulation consensus guideline is to add to the current family of consensus practice guidelines and incorporate a systematic review process. The published literature was searched from relevant electronic databases, including PubMed, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science from database inception to March 29, 2021. Inclusion criteria encompassed studies that described peripheral nerve stimulation in patients in terms of clinical outcomes for various pain conditions, physiological mechanism of action, surgical technique, technique of placement, and adverse events. Twenty randomized controlled trials and 33 prospective observational studies were included in the systematic review process. There is Level I evidence supporting the efficacy of PNS for treatment of chronic migraine headaches via occipital nerve stimulation; chronic hemiplegic shoulder pain via stimulation of nerves innervating the trapezius, supraspinatus, and deltoid muscles; failed back surgery syndrome via subcutaneous peripheral field stimulation; and lower extremity neuropathic and lower extremity post-amputation pain. Evidence from current Level I studies combined with newer technologies facilitating less invasive and easier electrode placement make peripheral nerve stimulation an attractive alternative for managing patients with complex pain disorders. Peripheral nerve stimulation should be used judiciously as an adjunct for chronic and acute postoperative pain following adequate patient screening and positive diagnostic nerve block or stimulation trial.Keywords: post-amputation pain, low back pain, peripheral neuropathy, chronic postoperative pain

Mehul J Desai,1,2 Nasir Khatri,3,4 Jonathan M Hagedorn,5 Natalie Strand,6 Ryan S D’Souza,7 Vinicius Tieppo Francio,8 Alaa Abd-Elsayed,9 David W Lee,10 Erika Petersen,11 Johnathan H Goree,12 Jacqueline S Weisbein,13 Timothy R Deer14 1International Spine, Pain & Performance Center, Washington, DC, USA; 2George Washington University, School of Medicine & Health Sciences, Washington, DC, USA; 3University of Kansas, Department of Anesthesiology, Kansas City, KS, USA; 4Novant Spine Specialists, Division of Interventional Pain Medicine, Charlotte, NC, USA; 5iSpine Pain Physicians, Maple Grove, MN, USA; 6Mayo Clinic, Division of Pain Medicine, Phoenix, AZ, USA; 7Mayo Clinic, Department of Anesthesiology, Rochester, MN, USA; 8University of Kansas, Department of Rehabilitation Medicine, Kansas City, KS, USA; 9University of Wisconsin, Department of Anesthesiology, Madison, WI, USA; 10Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA; 11University of Arkansas, Department of Neurosurgery, Little Rock, AR, USA; 12University of Arkansas, Department of Anesthesiology, Little Rock, AR, USA; 13Interventional Pain Management, Napa Valley Orthopaedic Medical Group, Napa, CA, USA; 14Spine & Nerve Centers of the Virginias, Charleston, WV, USACorrespondence: Mehul J Desai, International Spine, Pain & Performance Center, 2021 K St NW Suite 615, Washington, DC, 20006, USA, Email drdesai@isppcenter.comAbstract: Social media has revolutionized internet communication and become ubiquitous in modern life. Though it originated as a medium for friendship, social media has evolved into an ideal venue for professional networking, scientific exchange, and brand building. As such, it is a powerful tool with which interventional pain physicians should become familiar. However, given the permanence and visibility of online posts, it is prudent for interventional pain physicians to utilize social media in a manner that is consistent with the ethical and professionalism standards to which they are held by their patients, employers, peers, and state medical boards. While there are extensive publications of professional codes of conduct by medical societies, there is a paucity of literature regarding social media best practices guidelines. Further, to date there have been no social media best practices recommendations specific to interventional pain medicine physicians. While not exhaustive, the aim of this document is to provide recommendations to pain physicians on how to maintain an effective professional and ethical online presence. Specifically, we provide guidance on online persona and professional image, patient–physician interactions online, patient privacy, industry relations, patient education, and brand building.Keywords: professionalism, social media, ethics, best practices, LinkedIn, Instagram, Twitter, Facebook

Ryan S D’Souza, Jennifer Eller, Chelsey Hoffmann Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USACorrespondence: Ryan S D’Souza, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, USA, Email Dsouza.ryan@mayo.eduPurpose: There is a paucity of data on pain diagnoses and analgesic utilization in medically underserved areas (MUAs). This study compared the prevalence of pain diagnoses and analgesic medication use between MUAs and non-medically underserved areas (N-MUAs) in Southern Minnesota and Western Wisconsin using the Rochester Epidemiology Project (REP) database.Methods: Five-year prevalence per 100 people (January 1, 2011 to January 1, 2016) was extracted from the REP database for multiple pain diagnosis variables and analgesic medications. Primary outcomes included comparison of five-year prevalence of each pain diagnosis and analgesic between MUA and N-MUA; and association between index of medical underservice (IMU) score and five-year prevalence for each pain diagnosis and analgesic. Linear regression models were performed to assess associations and significance thresholds were adjusted per the Bonferroni approach to account for multiplicity.Results: The prevalence per 100 people for a diagnosis of chronic pain was similar between MUAs and N-MUAs (13.8 ± 2.5 vs 14.6 ± 2.0, P = 0.543). Similarly, prevalence per 100 people for other specific pain diagnoses including nonspecific chest pain, abdominal pain, lumbago, somatoform disorder, and painful respiration did not differ based on MUA status. In terms of analgesic use, prevalence per 100 people for use of opioids, non-opioid analgesics, salicylates, and NSAIDs did not differ based on MUA status. An association between higher IMU scores and lower prevalence of painful respiration was identified, although this was not significant after significance threshold adjustment per the Bonferroni method.Conclusion: Our data suggest that there are no differences in several pain diagnoses and analgesic utilization between MUAs versus N-MUAs, and that the IMU score did not predict changes in prevalence of pain diagnoses or analgesic utilization. Future powered and national database studies are warranted to increase validity of findings to other populations outside of Southern Minnesota and Western Wisconsin.Keywords: medically underserved area, vulnerable populations, chronic pain, opioid, analgesia, pain management

Alaa Abd-Elsayed,1 Nomen Azeem,2 Pooja Chopra,3 Ryan S D’Souza,4 Dawood Sayed,5 Timothy Deer6 1Department of Anesthesiology, University of Wisconsin, Madison, WI, USA; 2Florida Spine & Pain Specialists, Tampa, FL, USA; 3Bux Pain Management, Danville, KY, USA; 4Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA; 5Department of Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA; 6The Spine and Nerve Centers, Charleston, WV, USACorrespondence: Alaa Abd-Elsayed, Department of Anesthesiology University of Wisconsin Madison, WI, USA, Email alaaawny@hotmail.comObjective: The objective of this study was to survey current clinical practice related to lumbar radiofrequency (RFA) for the treatment of zygapophyseal (facet)-mediated low back pain.Methods: Survey questions regarding the clinical practice of lumbar RFA were created and piloted by the American Society of Pain and Neuroscience (ASPN) leadership. After revision for clarity, health-care professionals worldwide who hold membership status within the ASPN Society and who offer lumbar RFA in their clinical practice were recruited to participate in this online survey. All responses were tabulated and summarized descriptively.Results: A total of 329 participants responded in the survey. Most participants specialized in anesthesiology (68.4%) and physical medicine and rehabilitation (21.8%) and had been practicing pain management for more than five years (70.5%). Of physician respondents, 27.5% did not complete an Accreditation Council for Graduate Medical Education (ACGME)-accredited pain medicine fellowship and 16.5% were not board-certified in pain medicine. The majority of providers (69.7%) reported that they perform two diagnostic medial branch blocks prior to proceeding with lumbar RFA. Bupivacaine 0.5% was the most common medication utilized for both the first (37.4%) and second (37.1%) diagnostic blocks. There were 32.6% of total respondents who reported not utilizing contrast dye when performing diagnostic blocks. The vast majority of providers (91.4%) reported using conventional RFA for lumbar medial branch neurotomy.Conclusion: This survey study provides a summary of the application of lumbar RFA for the treatment of axial low back pain in the real-world setting. We highlight a significant portion of providers who perform lumbar RFA yet do not have pain fellowship training at an ACGME-accredited institution or do not maintain current pain medicine board certification. We also report deviations from standard practice, specifically the type of local anesthetic used for comparative diagnostic blocks and the omission of contrast injection during diagnostic blocks.Keywords: radiofrequency ablation, low back pain, medial branch block, survey, clinical practice

Jonathan M Hagedorn,1 Joshua Gunn,2 Ryan Budwany,3 Ryan S D’Souza,1 Krishnan Chakravarthy,4 Timothy R Deer5 1Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA; 2Ethos Research & Development, Newport, KY, USA; 3West Virginia University, Charleston, WV, USA; 4University of California – San Diego, San Diego, CA, USA; 5The Spine & Nerve Centers of the Virginias, Charleston, WV, USACorrespondence: Timothy R DeerThe Spine & Nerve Centers of the Virginias, Charleston, West Virginia, 25301, USATel +1 304-347-6120Email doctdeer@aol.comObjective: Decision-making in chronic pain patients involves a combination of subjective and objective criteria, including patient history, physical examination, imaging, and patient response to prior treatments, clinical experience, probabilities, and recognition of patterns. However, there is a distinct lack of objective laboratory biomarkers in use in routine clinical care. The objective was to review the literature to identify and describe specific biomarkers in chronic pain management.Methods: This is a narrative review of the literature regarding the use of laboratory biomarkers in chronic pain. A librarian-assisted literature search of the PubMed, Science Direct, and Google Scholar databases was performed and resulted in 304 possible manuscripts. We included manuscripts assessing laboratory collected biomarkers from urine, serum, cerebrospinal fluid, and saliva. After screening and review of the initial literature search results, a total of 75 manuscripts were included in the narrative review.Conclusion: The studies reviewed suggested that specific biomarkers may help identify those patients at risk of disease development and function as a prognostic indicator for disease progression and treatment response. However, additional research is necessary before specific recommendations can be made, and current clinical decision-making is modified.Keywords: chronic pain, biomarkers, outcomes

Ryan S D’Souza, Brendan J Langford, David A Olsen, Rebecca L Johnson Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USACorrespondence: Rebecca L JohnsonDepartment of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN, USA, 55905 Email johnson.rebecca@mayo.eduAbstract: Posterior knee pain after total knee arthroplasty (TKA) is common despite multimodal analgesia and regional anesthesia use. This review included randomized controlled trials (RCTs) comparing analgesic outcomes after inclusion of local anesthetic infiltration between the popliteal artery and capsule of the knee (iPACK) block versus pathways without iPACK. Electronic databases (MEDLINE, Cochrane Library, Web of Science, Scopus) were searched from inception to 10/11/2020. Eligible studies evaluated iPACK use on primary outcomes: opioid consumption and pain scores with movement. Secondary outcomes included rest pain, patient satisfaction, length of stay (LOS), gait distance, knee range of motion (ROM), and complications. Bias and quality were appraised using the Cochrane Risk of Bias tool and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines. Eight RCTs (777 patients) were included. iPACK block use demonstrated similar opioid consumption in the PACU (4/7 RCTs) and 24 hours after TKA (5/7 RCTs) compared to without iPACK (moderate-quality GRADE evidence). Additionally, iPACK block use demonstrated lower movement pain scores in PACU (3/5 RCTs) but similar or higher pain scores after 24 hours (5/7 RCTs; low-quality GRADE evidence). Studies consistently reported no difference in gait distance (4/4 RCTs) or complications (7/7 RCTs) between treatment arms (high-quality GRADE evidence), although differing effect estimates were observed with resting pain, satisfaction, LOS, and knee ROM. This review provides a foundation of knowledge on iPACK efficacy. While evidence does not currently support widespread inclusion of iPACK within enhanced recovery pathways for TKA, limitations suggest further study is warranted.Keywords: regional anesthesia, analgesia, total knee arthroplasty, pain, treatment outcome, systematic review, meta-analysis

Jonathan M Hagedorn, Thomas P Pittelkow, Christine L Hunt, Ryan S D’Souza, Tim J Lamer Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USACorrespondence: Tim J LamerDepartment of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN 55905, USATel +1-507-284-2511Email Lamer.Tim@mayo.eduAbstract: Cancer and cancer treatment-related chronic pain affect a significant number of patients. The etiology of this pain is diverse and may include nociceptive and/or neuropathic characteristics. Treatment is often multifactorial and may require advanced interventional techniques, such as spinal cord stimulation (SCS). This narrative review provides a thorough overview of cancer-related pain mechanisms and the use of SCS for cancer-related pain. Additionally, a review of the precautions that should be considered when caring for this patient population is provided with recommendations for safe care when utilizing these techniques.Keywords: spinal cord stimulation, cancer pain, neuromodulation, radiation, chemotherapy, surgery

Abstract: This article describes minimally invasive treatments for managing chronic low back pain (LBP) related to lumbar spinal stenosis, facetogenic LBP, vertebrogenic LBP, or discogenic LBP. We also propose a clinical decision-making tool to guide clinicians in appropriate patient selection for various treatments., (Copyright © 2024 American Academy of Physician Associates.)

Nationally representative rates of incident prescription opioid use in the United States adult population and selected subpopulations are unknown. Using the National Health Interview Survey (2019-2020) longitudinal cohort, a cohort with 1-year follow-up created using random cluster probability sampling of noninstitutionalized civilian U.S. adults, we estimated rates and predictors of incident opioid use. Of 21,161 baseline (2019) participants randomly chosen for follow-up, the final analytic sample included 10,415 who also participated in 2020. Exposure variables were selected per the socio-behavioral model of health care utilization: predisposing characteristics (sex, age, race, etc), enabling characteristics (socioeconomic status, insurance status), health status (pain, disability, comorbidities, etc), and health care use (office visits, emergency room visits, and hospitalizations). Among adults who did not use prescription opioids in 2019, a 1-year cumulative incidence of 4.1% (95% confidence interval [CI]: 3.5-4.6) was seen in 2020, with an incidence rate (IR) of 32.6 cases of new prescription opioid use per 1,000 person-years (PYs). Cumulative incidence, IR, and adjusted relative risk (RR) varied by participant characteristics. We observed the highest IR in those with ineffective pain treatment (81.6 cases per 1,000 PY) and those who visited the emergency room ≥3 times (93.8 cases per 1,000 PY). Participants reporting ≥4 painful conditions had an adjusted RR of 2.9 (95% CI: 2.0-4.1), while the RR for those with sleep problems was 2.3 (95% CI: 1.7-3.1). Overall, this study presents nationally representative rates of incident prescription opioid use and suggests that some participants are using prescription opioids as an early-resort analgesic contrary to best-practice guidelines. PERSPECTIVE: This longitudinal cohort study presents nationally representative rates of incident prescription opioid use in U.S. adults and selected subpopulations. Our data suggest that some participants are using prescription opioids as a first-line or early-resort analgesic, contrary to best-practice guidelines., (Copyright © 2024 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

PURPOSE OF REVIEW: The purpose of this narrative review is to evaluate the efficacy of the most commonly studied intradiscal biologics used for the treatment and alleviation of chronic intractable discogenic low back pain. Additionally, it explores the therapeutic potential and durability of these novel treatment options. RECENT FINDINGS: Recently published literature highlights the therapeutic potential of intradiscal biologics, such as mesenchymal stem cells, platelet-rich plasma, and alpha-2-macroglobulin, in promoting chondrogenesis within the lumbar intervertebral discs to treat discogenic low back pain. Studies demonstrate significant improvements in pain relief, physical function, and quality of life post-treatment. A comprehensive review of the literature evaluating the efficacy of intradiscal biologics suggests some evidence supporting its efficacy in treating discogenic low back pain. However, more rigorous studies into mechanistic modulation and large-scale randomized trials as well as a more thorough understanding of adverse events will be instrumental for including these therapies into clinical practice paradigms., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Gabapentin, a widely prescribed medication for various neuropathic pain conditions, has demonstrated efficacy in managing diverse neurological disorders. While conventional side effects are well-documented, a growing body of evidence suggests the existence of atypical side effects, necessitating comprehensive exploration. This paper aims to systematically review and summarize the literature on the atypical side effects of gabapentin, shedding light on manifestations beyond the conventional spectrum., Methods: A systematic review was conducted, encompassing peer-reviewed articles published up to the knowledge cutoff date in November 2023. Databases, specifically PubMed, were searched for relevant studies, focusing on atypical side effects such as myoclonus, ataxia, pediatric aggression, respiratory depression, pneumonia, pregnancy complications, sleep interference, encephalopathy, peripheral edema, suicidal ideation, dyskinesia, anorgasmia, and myopathy. Inclusion criteria comprised studies with a focus on gabapentin-related atypical side effects, published in recognized journals and involving human subjects., Results: The review identified a spectrum of atypical side effects associated with gabapentin use, ranging from neurological manifestations like myoclonus and ataxia to behavioral changes such as pediatric aggression and suicidal ideation. Additionally, respiratory complications, pregnancy-related issues, sleep disturbances, and rare complications like encephalopathy and myopathy were observed. Literature synthesis provided insights into the incidence, clinical presentation, and potential mechanisms underlying these atypical side effects., Conclusion: This comprehensive review highlights the diverse range of atypical side effects associated with gabapentin use, expanding beyond conventional knowledge. Healthcare practitioners must be cognizant of these manifestations, recognizing their potential impact on patient well-being. As clinical decision-making relies on a thorough understanding of a medication's side effect profile, this review contributes to enhancing awareness and fostering informed practices in the prescription and management of gabapentin. Further research is warranted to elucidate the mechanisms and risk factors associated with these atypical side effects, refining our understanding of gabapentin's safety profile., (© 2024 World Institute of Pain.)

Menopause is a biological process marking the end of a woman's reproductive years, typically occurring between the ages of 45 and 55. While often associated with hot flashes, mood swings, and hormonal changes, pain is a frequently overlooked and under-addressed aspect of the menopausal experience. This review article explores the multifaceted nature of pain during menopause, and sheds light on its various manifestations and the factors contributing to its prevalence and severity. Pain during menopause may include musculoskeletal discomfort, headaches or migraines, and vulvovaginal pain. The etiology of these is intricate, involving hormonal fluctuations, psychosocial factors, and genetic predispositions. Fluctuations in estrogen and progesterone levels play a pivotal role in musculoskeletal pain and joint stiffness, and increase susceptibility to conditions such as osteoarthritis. Furthermore, mood disorders, stress, and sleep disturbances may exacerbate the perception of pain. Gender norms, as well as changes in reproductive capacity and societal views on aging, may adversely the impact the self-esteem of individuals undergoing menopause. These symptoms can significantly impact a woman's quality of life, underscoring the need for early identification and appropriate management strategies. This review article highlights the factors contributing to pain during menopause, evaluates the effects of hormones on menopausal pain, and investigates management strategies for pain during menopause, including both pharmacological and non-pharmacological approaches. It also emphasizes the need for further research to better understand the interplay of factors contributing to pain during menopause, in order to allow for more tailored and effective interventions. In understanding and addressing this often-neglected aspect of menopause, healthcare providers can enhance the overall wellbeing and quality of life for women transitioning through this natural life stage., Competing Interests: Declaration of competing interest The authors declare that they have no competing interest., (Copyright © 2024. Published by Elsevier B.V.)

Objectives: Sympathetically mediated orofacial pain is a rare form of craniofacial pain that may be refractory to conventional medical management. We report two cases of orofacial pain with sympathetic features treated with cervical spinal cord stimulation (SCS) using burst waveform with passive recharge. In addition, we present a narrative review of cervical SCS use in the management of orofacial pain., Materials and Methods: The MEDLINE (PubMed) data base was queried for studies of orofacial pain and cervical SCS by searching applicable keywords including "face," "facial pain," "trigeminal neuralgia," "complex regional pain syndrome," and "spinal cord stimulation." Studies in the English language published between January 1, 2010 and December 31, 2023 were reviewed for relevance., Results: Our literature review identified eight studies of cervical SCS use for treating orofacial pain. Our case series and literature review indicate that cervical SCS is probably safe and promising in the treatment of orofacial pain unresponsive to conventional management. Prior studies report positive results in patients with trigeminal nerve-related pain but are retrospective, include a small sample size, and are heterogenous regarding the follow-up period. We report significant analgesia in two patients with sympathetically mediated orofacial pain treated with cervical SCS using burst waveform with passive recharge., Conclusions: Cervical SCS is a viable therapeutic option for patients with orofacial pain syndromes including those with sympathetic features, although further randomized clinical studies are warranted that should include a comprehensive set of outcomes measuring pain intensity, physical function, emotional function, quality of life, and general well-being., Competing Interests: Conflict of Interest Ryan S. D’Souza receives investigator-initiated research grant funding paid to his institution from Nevro Corp and Saol Therapeutics. The remaining authors reported no conflict of interest., (Copyright © 2024 International Neuromodulation Society. Published by Elsevier Inc. All rights reserved.)

Background: Clinical interest in and utilization of peripheral nerve stimulation (PNS) for treating chronic pain has significantly increased in recent years owing to its potential for providing analgesia and improved function and quality of life in comparison with pharmacologic treatments. However, the relative infancy of PNS-specific systems and limited clinical practice guidance likely contribute to significant variation in PNS utilization patterns., Objectives: We sought to conduct a survey study to characterize PNS-specific clinical practices and propose the next steps in standardizing key practices for PNS utilization., Materials and Methods: A 19-question survey exploring PNS-relevant clinical parameters was disseminated online to pain physicians in practice. Descriptive statistics were used to summarize results., Results: A total of 94 responses were collected. Regarding patient selection, most practitioners would apply PNS to treat nociceptive pain from major joint osteoarthritis (77.7%) and chronic low back pain (64.9%), but not for axial neck pain (50.0%). In contrast, most would apply PNS to treat neuropathic pain from peripheral neuralgia (94.7%), pericranial neuralgia (77.7%), and cancer-related neuropathic pain (64.9%). In treating complex regional pain syndrome, most practitioners would apply PNS before all other forms of neuraxial neuromodulation (>50% for each form). Similarly, for treating nonsurgical low back pain, most would apply PNS before neuraxial neuromodulation (>50% for each form) but not before radiofrequency ablation (19.2%). Most routinely performed nerve blocks before PNS, mainly to confirm anatomical coverage (84.0%), and regarded a 50% to 75% interquartile range as the minimum analgesic benefit required before proceeding with PNS. Regarding nerve target selection for treating complex regional pain syndrome of the wrist/hand or ankle/foot, or knee osteoarthritis, we observed a very wide variance of PNS target locations and discrete nerves. Regarding "minor" adverse events, most reported not changing PNS utilization on encountering skin/soft tissue reactions (85.1%), minor infections (76.6%), or lead migration/loss of efficacy (50.0%). In comparison, most reported reducing PNS utilization on encountering skin erosion (58.5%), major infections (58.5%), or lead fractures (41.5%)., Conclusions: There is significant practice variation regarding the utilization of PNS across numerous key clinical considerations. Future research that explores the reasons driving these differences might help optimize patient selection, target selection, periprocedural management, and ultimately outcomes., Competing Interests: Conflict of Interest Amitabh Gulati reports consulting for Medtronic, AIS HealthCare, Neurovasis, SPR Therapeutics, Tersera Medical, Hinge Health, Nalu Medical, and Bausch Health, outside the submitted work. Ryan S. D’Souza receives investigator-initiated research grant funding paid to his institution from Nevro Corp and Saol Therapeutics. The remaining authors reported no conflict of interest., (Copyright © 2024 International Neuromodulation Society. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: RSD is an Associate Editor of Regional Anesthesia and Pain Medicine. RSD receives investigator-initiated research grant funding paid to his institution from Nevro Corp and Saol Therapeutics.

Background: Randomized clinical trials (RCTs) are considered the gold standard for evaluating the efficacy of healthcare interventions. However, conflicts of interest (COIs) can compromise the scientific integrity in these trials. This study characterized COIs in RCTs on spinal cord stimulation for chronic pain, focusing on the prevalence, disclosure, and monetary value of COIs., Methods: This cross-sectional study analyzed RCTs published from January 1, 2013 to July 27, 2023. Primary outcomes included the presence, disclosure, and monetary value of COIs, while secondary outcomes assessed the presence of direct/indirect COIs, sponsor access to data, and associations between COIs and select variables, including journal impact factor, publication year, and study outcomes., Results: Of 38 RCTs, 30 (78.9%) reported COIs. On average, 35.6% of authors per RCT had at least one COI, with a mean of 0.7 COIs per author. The mean annual monetary value of COIs was US$41,157.83 per author per RCT. 29 RCTs (76.3%) had undisclosed COIs, with an average of 24.2% of authors per RCT having undisclosed COIs. Sponsor access to data was reported in 67.6% of RCTs. No associations were observed between the mean percentage of authors with COIs and the monetary value of COIs and select dependent variables (impact factor, publication year, and study outcomes)., Conclusions: A substantial majority of RCTs reported COIs with many authors having undisclosed conflicts, highlighting the need for stringent COI disclosure guidelines to maintain research integrity. Expanding COI registry systems globally and increasing non-industry funding are crucial steps toward enhancing transparency and reducing biases in medical research., Competing Interests: Competing interests: RSD received investigator-initiated grant funding from Nevro and Saol Therapeutics paid to his institution., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To retrospectively assess the Thoracolumbar Injury Classification and Severity Score (TLICS) in patients with osteoporotic vertebral compression fractures (OVCF) and compare the treatment given with that predicted by the TLICS score., Methods: All medical records of patients presenting from January 2014 to November 2017 for acute atraumatic or low impact OVCF were screened, and eligible patients were retrospectively reviewed. The TLICS score was determined based upon magnetic resonance imaging (MRI) findings and clinical records. Clinical records (including pain score data), imaging data, operative procedures, and stability of neurological examination were tracked over three months for each patient., Results: Of the 56 patients included, 36 patients had a TLICS score of 1, 18 had a TLICS score of 2, and two had a TLICS score of 4. Only one patient with a TLICS score of 4 underwent surgical stabilization, while the rest of the cohort was managed non-operatively, with or without kyphoplasty. TLICS score 1 corresponded to simple compression and TLICS score 2 corresponded to burst morphology with retropulsion and without neurological deficits. Of the patients with a TLICS score of 1 and 2 who underwent kyphoplasty, there was a statistically significant improvement in pain scores in both groups; however no significant difference was observed, between each TLICS score (i.e., 1 or 2). None of the patients developed instability or neurological decline., Conclusion: TLICS score correctly predicted operative versus non-operative management in all patients with OVCF. TLICS may be used in making management decisions, and in the triage of these patients for operative versus non-operative evaluations. Our study suggests that patients with TLICS score of 4 or higher require surgical evaluation, while those with TLICS of 1 or 2 are likely to have satisfactory non-surgical management with augmentation or conservative care. In general, patients with OVCF typically present with low TLICS score. Kyphoplasty appears to be similarly beneficial in patients with a TLICS score of 1 or a TLICS score of 2. A modification of the TLICS score by adding TLICS Zero to include uncompressed OVCF with edema is suggested. The limitations of this study include a small size; a larger study is needed to confirm these findings., (© 2024 The Authors.)

Competing Interests: Competing interests: None declared.

Objectives: Lumbar spine surgery is a common procedure for treating disabling spine-related pain. In recent decades, both the number and cost of spine surgeries have increased despite technological advances and modification in surgical technique. For those patients that have continued uncontrolled back and/or lower extremity pain following lumbar spine surgery, spinal cord stimulation (SCS) has emerged as a viable treatment option. However, the impact of lumbar spine surgical history remains largely unstudied. Specifically, the current study considers the impact of number of prior lumbar spine surgeries on pain relief outcomes following SCS implantation., Materials and Methods: We queried the electronic medical record of five separate pain practices for all patients who have undergone a SCS implant between January 1, 2017, and March 1, 2020. Inclusion criteria consisted of any patients with an SCS implant who underwent a prior lumbar spine surgery. The primary outcome was the mean calculated percentage pain relief in patients based on number of prior lumbar spine surgeries., Results: There was a total of 1974 total SCS implant cases identified across five separate pain clinics. There was no difference in mean calculated pain relief in patients with one prior spine surgery versus those with two or more prior spine surgeries (28.2% vs. 25.8%, adjusted β-coefficient -3.1, 95% CI -8.9 to 2.7, p = 0.290). Similarly, when analyzing number of spine surgeries as a continuous variable, there was no association between number of spine surgeries and calculated pain relief (adjusted β-coefficient -1.5, 95% CI -4.0 to 1.1, p = 0.257). Additionally, after patients were stratified based on waveform, there was no association between number of prior lumbar spine surgeries (analyzed both as a categorical and continuous variable) and calculated percentage pain relief., Conclusions: This multicentered retrospective study found that there was no significant difference in pain scores in individuals who received SCS following one or more lumbar spine surgeries. Additionally, the waveform of the SCS device had no statistically significant impact on post-operative pain scores following one or more lumbar spine surgeries., (© 2024 World Institute of Pain.)

Chronic pain is increasing in prevalence, with new cases now outnumbering those of diabetes, depression, or hypertension. Advanced practice providers have reported that their training in pain management inadequately prepared them to care for patients suffering from painful conditions. In response, the authors of this work developed a basic pain management conceptual framework to provide physician assistant (PA) students with the foundational knowledge necessary to manage and treat patients suffering from a wide variety of painful conditions. The devised framework activity includes categories of pain management such as conservative therapies, medications, injections, minimally invasive procedures, and moderately to highly invasive procedures. This framework can be incorporated into the existing PA educational curriculum and presented alongside a realistic pain patient case study. Furthermore, other health science educational programs, such as nurse practitioner or pharmacy programs, could adopt this framework to increase student knowledge in pain management.

Competing Interests: Competing interests: RSD is an associate editor of Regional Anesthesia & Pain Medicine. RSD receives investigator-initiated research grant funding paid to his institution from Nevro Corp and Saol Therapeutics.

Neuromodulation is being utilized across a variety of medical subspecialties to treat both painful and non-painful medical conditions. However, publications on neuromodulation topics infrequently occur in journals targeting generalists and medical specialties outside of pain medicine and neurosurgery. This study reviewed implantable neuromodulation devices, their respective Food and Drug Administration-approved indications for use, as well as off-label usage, and the associated potential risks and benefits for each device. PubMed and Medline databases were queried for systematic reviews with or without meta-analyses and randomized controlled trials of implantable neuromodulation devices. The literature review resulted in 106 studies eligible for inclusion, and 67 were included in the final review. In conclusion, as the clinical volume of neuromodulation continues to grow, supporting and educating medical professionals who care for patients that receive implanted neuromodulation devices is paramount. It is likely the use of neuromodulation will continue to expand across all medical subspecialties, and as such, every clinician should have a baseline understanding of this treatment.

Objectives: Inadvertent dural puncture (IDP) is a known complication associated with traditional neuraxial procedures; however, its characterization after percutaneous spinal cord stimulation (SCS) lead placement has yet to be clearly established in large population studies. This retrospective analysis aims to understand the incidence and associated characteristics of patients with IDP after percutaneous SCS lead placement., Materials and Methods: The PearlDiver Mariner database of national all-payer claims was used to identify patients who received percutaneous SCS leads and had a claim for IDP (intraoperative IDP or postdural puncture headache [PDPH] claim) within 45 days. The primary outcome was to determine the overall incidence of IDP. Secondary outcomes included an evaluation of associated risk factors for IDP and treatments used in symptomatic management., Results: A total of 90,952 patients who underwent percutaneous lead SCS placement were included. The incidence of IDP was 0.48% (436/90,952 patients). Older age (odds ratio [OR]: 0.96; 95% CI: 0.95-0.97; p < 0.0001) and male sex (OR: 0.66; 95% CI: 0.53-0.81; p < 0.001) had a lower odds of having a claim for IDP, whereas a history of IDP was associated with a higher OR (95% CI) by 13.72 times (10.72-17.58) (p < 0.0001). Of the IDP patients, 64% (277/436 patients) had a claim for a therapeutic blood patch. Discrepancy in type of claim for IDP was observed, with most being for PDPH., Conclusions: Our findings suggest that IDP after percutaneous SCS lead placement is an uncommon event; however, certain factors are associated with its development. Overall, early recognition of IDP after percutaneous SCS lead placement is imperative to facilitate the delivery of targeted treatments and prevent further harmful consequences to the patient., (Copyright © 2022 International Neuromodulation Society. Published by Elsevier Inc. All rights reserved.)

Objectives: Chemotherapy-induced peripheral neuropathy (CIPN) is a complication that may occur after treatment with various anticancer drugs. In refractory CIPN cases, spinal cord stimulation (SCS) has garnered increased attention. The use of gait analysis and psychophysical quantitative sensory testing (QST) as an objective measurement of CIPN-related damage has burgeoned; however, these changes have not been reported for patients with CIPN after SCS implantation using either burst or tonic stimulation., Materials and Methods: This manuscript encompasses two parts: 1) a presentation of pain improvement in a series of patients who underwent tonic vs burst SCS for CIPN measured by gait and QST analysis and 2) a narrative review on gait and psychophysical QST outcomes between burst and tonic SCS stimulation pertaining to pain and the extrapolation to CIPN-related sequalae., Results: In these cases, gait scores improved in both patients. Touch thresholds were higher before SCS whereas skin temperatures were lower at the dorsal foot, subtalus, and posterior calf. Sharpness detection was drastically improved after SCS. In the review, the patients aligned with pain relief, suggesting good response to interventional outcomes with SCS. QST outcomes, particularly touch, sharpness, heat, and cold stimuli, however, were not fully corroborated. Similarly to other non-CIPN SCS gait studies, both tonic and burst studies provided positive outcomes on spatiotemporal gait parameters, gait form, and standardized gait scales., Conclusion: We emphasize the use of different SCS waveforms as a therapy for CIPN management and the use of psychophysical testing as a measure for diagnosis and monitoring CIPN's progress in our case series and review., Competing Interests: Conflict of Interest The authors reported no conflict of interest., (Copyright © 2024 International Neuromodulation Society. Published by Elsevier Inc. All rights reserved.)

Objective: Peripheral nerve stimulation (PNS) is an emerging neuromodulation modality, yet there remains limited data highlighting its long-term effectiveness. The objective of this study was to report real-world data on pain intensity and opioid consumption after temporary and permanent PNS for chronic pain up to 24 months postimplantation., Methods: A retrospective study was conducted on all patients who received PNS implants at a multi-centered enterprise between January 1, 2014 and February 24, 2022. The two co-primary outcomes were: (1) change in pain intensity (11-point Numerical Rating Scale) from baseline to 12 months postimplant; and (2) comparison of the change in pain intensity between temporary and permanent PNS cohorts 12 months postimplant., Results: 126 patients were included in this analysis. Pain intensity significantly decreased 12 months postimplant in the overall cohort (mean difference (MD) -3.0 (95% CI -3.5 to -2.4), p<0.0001). No significant difference in this reduction was identified between temporary and permanent PNS cohorts (MD 0.0 (95% CI -1.1 to 1.0), p=1.00) 12 months postimplantation. Pain intensity significantly decreased in the overall, temporary, and permanent cohorts at all secondary time points (3, 6, and 24 months). No change in daily opioid consumption was observed at 6 and 12 months postimplant in the overall cohort., Conclusion: This study found that both temporary and permanent PNS may be effective for reducing pain intensity in patients with chronic pain up to 24 months postimplantation, although no changes in opioid consumption were observed. The decrease in pain intensity was comparable between patients receiving temporary versus permanent implants, highlighting that temporary PNS may achieve long-lasting clinical benefits. However, given the substantial loss to follow-up, further large-scale studies are needed to solidify conclusions about the efficacy of PNS., Competing Interests: Competing interests: AB has received consultancy fees from Medtronic and Bioventus. His institution has also received funding for studies to track outcomes of neuromodulation therapies from Medtronic. RSD has received investigator-initiated grant funding paid to his institution from Nevro Corp and Saol Therapeutics., (© American Society of Regional Anesthesia & Pain Medicine 2024. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.)

Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the mainstays of multimodal pain management. While effective for acute pain control, recent pre-clinical evidence has raised concerns regarding an association between NSAIDs and chronic pain and potential opioid use. Our objective was to explore the association between peri-operative use of prescription NSAIDs and the need for continued opioid prescriptions lasting 90-180 days in previously opioid-naïve patients undergoing total knee arthroplasty. A database of health claims in the USA was used to identify all opioid-naïve adult patients who underwent primary knee arthroplasty between January 2010 and October 2021. We evaluated the magnitude of association between peri-operative prescription NSAID claims and claims for opioids at 90 days postoperatively using multivariable logistic regression models. Secondary outcomes included: the magnitude of association between peri-operative NSAID prescription and claims for opioids at 180 days postoperatively; and identifying other potential factors associated with opioid claims at 90 days postoperatively. After risk adjustment using multivariable logistic regression models in the 789,736-patient cohort, the adjusted odds ratio (95%CI) for a continuous claim of opioids at 90 and 180 days postoperatively among patients with a peri-operative NSAID prescription within 30 days was 1.32 (1.30-1.35), p < 0.001; and 1.12 (1.10-1.15), p < 0.001, respectively. This estimate of effect remained robust at 90 days after accounting for known potential confounders, including pre-existing knee pain and acute postoperative pain severity. Similar analysis of other pain medications (e.g. paracetamol) did not detect such an association. This population-based cohort study suggests that peri-operative prescription NSAID use may be associated with continued opioid prescription claims at 90 and 180 days after knee arthroplasty, even after adjusting for other observed covariates for continuous opioid claims. These novel findings can inform clinical decision-making for post-surgical pain management, risk-benefit discussions with patients and future research., (© 2024 Association of Anaesthetists.)

Competing Interests: The authors declare no conflicts of interest.

Objectives: This study aimed to assess whether patient response to targeted diagnostic peripheral nerve block before peripheral nerve stimulator (PNS) device implantation is associated with efficacy after PNS implantation., Materials and Methods: The electronic medical records from the Mayo Clinic Enterprise (three quarternary care medical centers and additional satellite medical centers) were reviewed to identify patients who underwent PNS implantation between January 2014 and January 2023. A primary outcome of interest was to assess whether administration of a preimplant diagnostic peripheral nerve block predicted pain relief at three months and six months after temporary and permanent PNS implantation. Another primary outcome was to investigate whether there was an association between the pain relief from a preimplant diagnostic peripheral nerve block and pain relief after three and six months after temporary or permanent PNS therapy. Linear regression analysis was conducted for outcomes of interest., Results: Of 193 eligible patients who underwent PNS therapy, a total of 173 patients were included in the final analysis and were stratified into either the temporary PNS cohort (n = 112) or the permanent PNS cohort (n = 61). Overall, 77.5% of all patients (134/173) underwent a preimplant diagnostic peripheral nerve block and reported a mean percentage relief of 70.1 ± 27.0 from the diagnostic block. Of patients in the temporary PNS cohort, there was no difference in postimplant percentage pain relief between patients who received a diagnostic block (n = 93) and control patients (n = 19) at three months (35.4 ± 36.0 vs 49.8 ± 36.1, respectively; β -14.45, 95% CI -32.98 to 4.07, p = 0.125) or at six months (23.3 ± 30.8 vs 45.7 ± 40.0, respectively; β -22.39, 95% CI -46.86 to 2.08, p = 0.072). Of patients in the permanent PNS cohort, there was no difference in postimplant percentage pain relief between patients who received a diagnostic block (n = 41) and control patients (n = 20) at three months (42.4 ± 34.3 vs 43.2 ± 42.4, respectively; β -0.79, 95% CI -23.56 to 21.99, p = 0.945) or at six months (44.3 ± 35.0 vs 38.8 ± 40.9, respectively; β 5.42, 95% CI -20.04 to 30.88, p = 0.669). Pain relief from preimplant diagnostic blocks was associated with postimplant pain relief from temporary PNS at three months (β 0.33, 95% CI 0.04-0.61, p = 0.025). However, pain relief from preimplant diagnostic blocks did not predict postimplant pain relief from temporary PNS at six months, or permanent PNS at three months and six months., Conclusions: Administration of a diagnostic block is not associated with superior pain relief at three or six months after PNS implantation to that of an approach without diagnostic block. Pain relief from a diagnostic block may potentially predict short-term pain relief after temporary PNS therapy, although future prospective studies are warranted to evaluate the prognostic utility of diagnostic blocks., Competing Interests: Conflict of Interest Chelsey M. Hoffmann provides general consulting for Nalu Medical and SPR Therapeutics. Ryan S. D’Souza receives investigator-initiated research funding from Nevro Corp and Saol Therapeutics that is paid to his institution. The remaining authors reported no conflict of interest., (Copyright © 2023 International Neuromodulation Society. Published by Elsevier Inc. All rights reserved.)

Background: The efficacy of spinal cord stimulation (SCS) in chronic pain studies is traditionally assessed by pain scores, which do not reflect the multidimensional nature of pain perception. Despite the evidence of SCS's influence on emotional functioning comprehensive assessments of its effect remain lacking., Objective: To assess changes in emotional and psychosocial functioning in patients who underwent SCS implantation for chronic pain., Evidence Review: Ovid MEDLINE, EMBASE, PsychINFO, Cochrane CENTRAL and Scopus databases were searched for original peer-reviewed publications reporting emotional functioning after SCS. The primary outcomes were a pooled mean difference (MD) in anxiety, depression, global functioning, mental well-being and pain catastrophizing at 12 months. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) was used to determine the quality of evidence., Findings: Thirty-two studies were included in the primary analysis. Statistically significant improvements were observed in anxiety (MD -2.16; 95% CI -2.84 to -1.49; p<0.001), depression (MD -4.66; 95% CI -6.26 to -3.06; p<0.001), global functioning (MD 20.30; 95% CI 14.69 to 25.90; p<0.001), mental well-being (MD 4.95; 95% CI 3.60 to 6.31; p<0.001), and pain catastrophizing (MD -12.09; 95% CI -14.94 to -9.23; p<0.001). Subgroup analyses revealed differences in Global Assessment of Functioning and mental well-being based on study design and in depression based on waveform paradigm., Conclusion: The results highlight the statistically and clinically significant improvements in emotional and psychosocial outcomes in patients with chronic pain undergoing SCS therapy. However, these results need to be interpreted with caution due to the very low certainty of evidence per the GRADE criteria., Prospero Registration: CRD42023446326., Competing Interests: Competing interests: RDS received investigator-initiated grant funding pain to his institution from Nevro Corp and Saol Therapeutics., (© American Society of Regional Anesthesia & Pain Medicine 2024. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.)

Competing Interests: Competing interests: RSD is an Associate Editor of Regional Anesthesia and Pain Medicine. RSD receives investigator-initiated research grant funding paid to his institution from Nevro Corp and Saol Therapeutics.

Well-established guidelines and checklists for authors, reviewers, and readers of systematic reviews and scoping reviews are readily available. However, the availability of such for narrative reviews is lacking, including, but not limited to, field-specific guidelines in the field of anesthesia and pain medicine. In this brief article, we review the differences between the major types of reviews, followed by a more detailed description of narrative reviews that clearly differentiates them from other types of reviews. We include a recommended checklist that will aid producers, editors, reviewers, and consumers of narrative reviews as well as examples specific to the field of anesthesia and pain medicine. It is the hope that the guidelines recommended here will aid producers, editors, reviewers, and consumers of narrative reviews in anesthesia and pain medicine, including Regional Anesthesia & Pain Medicine Adherence to such should help differentiate between narrative reviews and other types of reviews as well as provide consistency in what elements are necessary to include in a narrative review in the field of anesthesia and pain medicine., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.)

In Part I of this series, we provide guidance for preparing a systematic review protocol. In this article, we highlight important steps and supplement with exemplars on conducting and reporting the results of a systematic review. We suggest how authors can manage protocol violations, multiplicity of outcomes and analyses, and heterogeneity. The quality (certainty) of the evidence and strength of recommendations should follow the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. It is our goal that Part II of this series provides valid guidance to authors and peer reviewers who conduct systematic reviews to adhere to important constructs of transparency, structure, reproducibility, and accountability. This will likely result in more rigorous systematic reviews being submitted for publication to the journals like Regional Anesthesia & Pain Medicine and Anesthesia & Analgesia ., Competing Interests: Competing interests: RSD’S is an Associate Editor for Anesthesia & Analgesia, and an Associate Editor for Regional Anesthesia & Pain Medicine. MJB is a Regional Anesthesia and Acute Pain Medicine Executive Section Editor of Anesthesia & Analgesia. AS received a honorarium for his contribution to this manuscript. EJM is Statistical Editor for Anesthesia & Analgesia. GAK is the Statistical Advisor for Systematic Reviews and Meta-analyses for Regional Anesthesia & Pain Medicine., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)