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Marcin Karcz,1 Alaa Abd-Elsayed,2 Krishnan Chakravarthy,3 Aman Mansoor,4 Natalie Strand,5 Mark N Malinowski,6 Usman Latif,7 David Dickerson,8 Tolga Suvar,9 Timothy Lubenow,9 Evan Peskin,10 Ryan D’Souza,5 Eric Cornidez,11 Andrew Dudas,12 Christopher Lam,7 Michael Farrell II,13 Geum Yeon Sim,14 Mohamad Sebai,15 Rosa Garcia,16 Lucas Bracero,1 Yussr Ibrahim,17 Syed Jafar Mahmood,18 Marco Lawandy,19 Daniel Jimenez,20 Leili Shahgholi,15 Kamil Sochacki,21 Mohamed Ehab Ramadan,15 Vinny Francio,22 Dawood Syed,7 Timothy Deer1 1The Spine and Nerve Centers of the Virginias, Charleston, WV, USA; 2Department of Anesthesiology, University of Wisconsin, Madison, WI, USA; 3Innovative Pain Treatment Solutions, San Diego, CA, USA; 4Aurora Pain Management, Aurora Health Care, Oshkosh, WI, USA; 5Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA; 6Department of Anesthesiology, Ohio Health System, Columbus, OH, USA; 7Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA; 8Department of Pain Medicine, Northshore University Health System, Skokie, IL, USA; 9Department of Anesthesiology and Pain Medicine, Rush University Medical Center, Oak Park, IL, USA; 10Department of Pain Management, Insight Institute of Neurosurgery & Neuroscience, Flint, MI, USA; 11Pain Institute of Southern Arizona, Tucson, AZ, USA; 12Mays and Schnapp Neurospine and Pain, Memphis, TN, USA; 13Department of Pain Management, Erie County Medical Center, Buffalo, NY, USA; 14Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA; 15Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 16Department of Physical Medicine & Rehabilitation, Larkin Hospital Health System, Miami, FL, USA; 17Department of Pain Management at Northern Light Health – Eastern Maine Medical Center, Bangor, ME, USA; 18Department of Pain Medicine, University of California Davis Health System, Sacramento, CA, USA; 19Department of Physical Medicine & Rehabilitation, Montefiore Medical Center, Bronx, NY, USA; 20Department of Physical Medicine & Rehabilitation, Michigan State University, Lansing, MI, USA; 21Department of Anesthesiology and Perioperative Medicine, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA; 22Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USACorrespondence: Marcin Karcz, The Spine and Nerve Centers of the Virginias, Charleston, WV, USA, Email drmarcinkarcz@gmail.comAbstract: Pain serves as a vital innate defense mechanism that can significantly impact an individual’s quality of life. Understanding the physiological effects of pain well plays an important role in developing novel pain treatments. Nociceptor neurons play a key role in pain and inflammation. Interactions between nociceptors and the immune system occur both at the site of injury and within the central nervous system. Modulating chemical mediators and nociceptor activity offers promising new approaches to pain management. Essentially, the sensory nervous system is essential for modulating the body’s protective response, making it critical to understand these interactions to discover new pain treatment strategies. New innovations in neuromodulation have led to alternatives to opioids individuals with chronic pain with consequent improvement in disease-based treatment and nerve targeting. New neural targets from cellular and structural perspectives have revolutionized the field of neuromodulation. This narrative review aims to elucidate the mechanisms of pain transmission and processing, examine the characteristics and properties of nociceptors, and explore how the immune system influences pain perception. It further provides an updated overview of the physiology of pain and neuromodulatory mechanisms essential for managing acute and chronic pain. We assess the current understanding of different pain types, focusing on key molecules involved in each type and their physiological effects. Additionally, we compare painful and painless neuropathies and discuss the neuroimmune interactions involved in pain manifestation.Keywords: neurons, nociceptive pain, neuropathic pain, nociplastic pain, physiological effects, pain pathways, sensitization

Anthony Giuffrida,1 Christy Saia-Owenby,2 Chris Andriano,3,* Douglas Beall,4,* Ashley Bailey-Classen,5,* Patrick Buchanan,6,* Ryan Budwany,7,* Mehul J Desai,8,* Ashley Comer,9,* Andrew Dudas,10,* Vinicius Tieppo Francio,11,* Warren Grace,12,* Benjamin Gill,13,* Betsy Grunch,14,* Andrew Goldblum,13,* Rosa A Garcia,15,* David W Lee,16,* Chad Lavender,17,* Marco Lawandy,18,* Lyric Mandell,2,* Robin Mata,19,* Morteza Rabii,20,* Kiran Patel,21,* Raj G Patel,22,* Ankur A Patel,23,* Dawood Sayed,24,* Gurtej Singh,25,* Natalie Strand,26,* Jordan Tate,27,* Michael E Schatman,28 Timothy Deer29 1Cantor Spine Center, Paley Orthopedic and Spine Institute, Fort Lauderdale, FL, USA; 2MOXY Company, Covington, LA, USA; 3Georgia Pain Care, Stockbridge, GA, USA; 4Oklahoma Spine Hospital, Oklahoma City, OK, USA; 5Trinity Pain Medicine Associates, Fort Worth, TX, USA; 6Spanish Hills Interventional Pain Specialists, Camarillo, CA, USA; 7Center for Pain Relief, Charleston Area Medical Center, Charleston, WV, USA; 8International Spine, Pain, and Performance Center, Washington, DC, USA; 9The Spine and Nerve Centers of the Virginias, Charleston, WV, USA; 10Maya & Schnapp, Neurospine and Pain, Memphis, TN, USA; 11Anesthesiology and Pain Medicine, University of Kansas, Kansas City, KS, USA; 12Redefine Healthcare, Orthopedic Pain and Spine Center, Edison, NJ, USA; 13Physical Medicine and Rehabilitation, University of Missouri, Columbia, MO, USA; 14Longstreet Clinic, Gainesville, GA, USA; 15Larkin Hospital Health Systems, Miami, FL, USA; 16Interventional Pain and Spine, Fullerton Orthopedics, Yorba Linda, CA, USA; 17Department of Orthopaedics, Marshall University, Huntington, WV, USA; 18Physical Medicine and Rehabilitation, Montefiore Medical Center, New York, NY, USA; 19Department of Physical Medicine and Rehabilitation, University of Miami, Miami, FL, USA; 20Crimson Pain Management, Overland Park, KS, USA; 21Pain Medicine and Anesthesiology, Northwell Health, New York, NY, USA; 22Central Texas Interventional Pain Doctor, Capitol Pain Institute, Austin, TX, USA; 23Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, TX, USA; 24Department of Pain Medicine and Neurology, University of Kansas Health System, Kansas City, KS, USA; 25Department of Pain Medicine, Rehabilitation, and Pain Medicine, the Center for Advance Orthopaedics, Cantonsville, MD, USA; 26Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA; 27Department of Pain Medicine and Physical Medicine and Rehabilitation, Southern Pain and Spine, Jasper, GA, USA; 28Department of Anesthesiology, Perioperative Care, and Pain Medicine at NYU Grossman School of Medicine, New York, NY, USA; 29Department of Pain Management, Spine and Nerve Centers of the Virginias, Charleston, WV, USA*These authors contributed equally to this workCorrespondence: Lyric Mandell, MOXY Company, Covington, LA, USA, Email lyric@moxycompany.comPurpose: The American Society of Pain and Neuroscience (ASPN) identified a significant gap in resources and guidelines that aim to educate healthcare providers for best practices when engaging on social media. As part of the broader initiatives on Spine and Nerve practice, the executive board of ASPN has decided it would be beneficial to include comprehensive guidance for healthcare providers when engaging on social media.Methods: A panel of experts was chosen based on expertise, publications, diversity, and their social media presence. Along with expert guidance, the committee conducted an extensive analysis of peer-reviewed literature in communication and medical journals to determine best practices for healthcare practitioners on social media.Results: Social media messages significantly impact patients’ and colleagues’ perceptions and actions regarding medical issues. As such, providers and their teams must be aware of legal and ethical considerations in healthcare while maintaining a consistent, educational, and digestible persona online.Conclusion: The advancement of communication and medical technologies and systems necessitates continued education and resources to adapt to our rapidly changing media and medical landscape.Keywords: digital communication, social networking sites, healthcare providers, best practices, physician communication, social media, medical marketing, spine

Timothy Deer,1,* Robert Heros,2,* Edward Tavel,3 Sayed Wahezi,4 Robert Funk,5 Patrick Buchanan,6 Anne Christopher,7 Jacqueline Weisbein,8 Christopher Gilligan,9 Denis Patterson,10 Ajay Antony,11 Mohab Ibrahim,12 Nathan Miller,13 Keith Scarfo,14 Gayle Johnson,15 Thadchaigeni Panchalingam,15 Udoka Okaro,15 James Yue16 1Pain Management, The Spine and Nerve Center of the Virginias, Charleston, WV, USA; 2Pain Management, Spinal Diagnostics, Tualatin, OR, USA; 3Pain Management, Clinical Trials of South Carolina, Charleston, SC, USA; 4Pain Management, Montefiore Medical Center, Bronx, NY, USA; 5Pain Management, Indiana Spine Group, Indianapolis, IN, USA; 6Pain Management, Spanish Hills Interventional Pain Specialists, Camarillo, CA, USA; 7Pain Management, Saint Louis Pain Consultants, Chesterfield, MO, USA; 8Pain Management, Napa Valley Orthopedic Medical Group, Napa, CA, USA; 9Pain Management, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA; 10Pain Management, Nevada Advanced Pain Specialists, Reno, NV, USA; 11Pain Management, the Orthopedic Institute, Gainesville, FL, USA; 12Pain Management, Coastal Pain & Spinal Diagnostics Medical Group, Carlsbad, CA, USA; 13Pain Management, Banner University Medical Center, Tucson, AZ, USA; 14Pain Management, Rhode Island Hospital, Providence, RI, USA; 15Neuromodulation, Abbott Labs, Austin, TX, USA; 16Orthopaedic spine Surgery, Connecticut Orthopedics, Hamden, CT, USA*These authors contributed equally to this workCorrespondence: Timothy Deer, Pain Management, The Spine and Nerve Center of the Virginias, 400 Court Street, Suite 100, Charleston, WV, 25301, USA, Tel +1 304 347 – 6120, Fax +1 304 347 – 6126, Email doctdeer@aol.comAim: Low Back Pain (LBP) is a prevalent condition. Spinal cord stimulation (SCS) has emerged as a more effective, long-term treatment compared to conventional medical management (CMM). The DISTINCT study enrolled and randomized chronic LBP patients with no indication of traditional spine surgery. This analysis focuses comparing study outcomes on patients initially randomized to receive CMM treatment and subsequently crossed over to SCS after 6 months.Purpose: To compare the therapeutic effectiveness and cost-efficiency of passive recharge burst SCS to CMM.Patients and Methods: A total of 269 patients were enrolled with 162 randomly assigned to SCS and 107 to CMM. The DISTINCT study design allowed a crossover to the alternative treatment arm after 6 months. Patients underwent a trial and received a permanent implant if they reported ≥ 50% pain reduction. Outcome analysis included pain (NRS), disability (ODI), catastrophizing (PCS), quality of life (PROMIS-29) and health care utilization.Results: Seventy out of eighty-one patients opted to cross over to trial SCS at 6M with 94% (66/70) undergoing a trial. Among those, 88% (58/66) reported a ≥ 50% or more pain relief and 55 received a permanent implant. At 12M visit, 71.4% reported a ≥ 50% pain improvement sustained at the 18M visit, with 24.5% (12/49) indicating a ≥ 80% improvement. Disability reductions (79% meeting the minimally important difference of a 13-point decrease), decreased catastrophizing, and significant improvements in all PROMIS-29 domains were noted. Furthermore, 42% of the patients reported decreased or discontinued opioid usage. Clinical benefits at the 12M visit were sustained through the 18M visit accompanied by a significant reduction in healthcare utilization and a $1214 cost savings.Conclusion: SCS demonstrates superior, long-term performance and safety outcomes compared to CMM therapy in LBP patients who received both CMM and SCS therapy. Additionally, SCS patients experienced reduced healthcare resource utilization and lower costs compared to those receiving CMM.Keywords: DISTINCT, low back pain, BurstDR, spinal cord stimulation, healthcare utilization, persistent spinal pain syndrome, neuromodulation

Christopher M Lam,1 Sarah A Keim,2 Dawood Sayed,1 Alaa Abd-Elsayed,3 Amitabh Gulati,4 Michael E Schatman,5,6 Timothy Deer,7 Usman Latif1 1Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas Medical Center, Kansas City, KS, USA; 2Department of Surgery, University of Kansas Medical Center, Kansas City, KS, USA; 3Department of Anesthesiology and Perioperative Medicine, University of Wisconsin, Madison, WI, USA; 4Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, 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; 7The Spine and Nerve Center of the Virginias, Charleston, WV, USACorrespondence: Christopher M Lam, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mail Stop 1034, Kansas City, KS, 66160, USA, Tel +1-(704)-488-5665, Fax +1-913-588-3365, Email clam2@kumc.eduBackground: Chronic abdominal pain (CAP) is a common and challenging to treat condition with a global prevalence of up to 25%. Despite extensive evaluation, approximately 40% of patients with CAP have an unknown diagnosis. Medications may be ineffective, and surgery is rarely indicated. Interventional treatment including sympathetic blocks, sympathetic neurolysis, and transversus abdominal plane (TAP) blocks may be an option, but their efficacy can wane over time. Neuromodulation has emerged as an option for these patients, as there is evidence of success with dorsal column spinal cord and dorsal root ganglion (DRG) stimulation. Peripheral nerve stimulation (PNS) may be an alternative option, particularly in higher risk patients or in patients for whom neuraxial access may be unsafe or too technically challenging. Thoracoabdominal nerve peripheral nerve stimulation via a TAP approach may be more specifically targeted in comparison to dorsal column or DRG stimulation. In this short report, we detail a technique that the authors have successfully used for thoracoabdominal nerve PNS via a TAP approach for management of CAP.Methods: This article describes a novel medial to lateral ultrasound guided thoracoabdominal nerve PNS via a TAP approach technique for lead placement and implantation.Results: A medial to lateral ultrasound guided TAP approach as described to successfully implant percutaneous thoracoabdominal nerve PNS leads for management of CAP.Conclusion: The thoracoabdominal nerve PNS via a TAP approach lead placement technique noted in this report has been used as a means for management of CAP utilizing peripheral neuromodulation. Here, we present a short report detailing a potential technique for PNS utilization for management of CAP. Further studies are needed to validate the safety and efficacy of this therapy modality, although the authors have found it to be a viable management option for patients with medically refractory neuropathic CAP.Keywords: peripheral nerve stimulator, neuromodulation, neuropathic pain, ultrasound, thoracic nerves

Timothy Deer,1 Ankur A Patel,2 Dawood Sayed,3 Ashley Bailey-Classen,4 Ashley Comer,1 Benjamin Gill,5 Kiran Patel,6 Alaa Abd-Elsayed,7 Natalie Strand,8 Jonathan M Hagedorn,9 Zohra Hussaini,3 Nasir Khatri,10 Ryan Budwany,1 Melissa Murphy,11 Dan Nguyen,12 Vwaire Orhurhu,13 Morteza Rabii,14 Douglas Beall,15 Stephen Hochschuler,16 Michael E Schatman,17,18 Timothy Lubenow,19 Richard Guyer,16,20 Ahmed M Raslan21 1The Spine and Nerve Center of the Virginias, Charleston, WV, USA; 2Weill Cornell Tri-Institutional Pain Medicine Program, Department of Anesthesiology, Weill Medical College of Cornell University, New York, NY, USA; 3Department of Anesthesiology and Pain Medicine, the University of Kansas Medical Center, Kansas City, KS, USA; 4Trinity Pain Medicine Associates, Fort Worth, TX, USA; 5Department of Physical Medicine and Rehabilitation, University of Missouri, Columbia, MO, USA; 6Lenox Hill Hospital, Northwell Health, New York, NY, USA; 7Department of Anesthesiology, University of Wisconsin, Madison, WI, USA; 8Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA; 9Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA; 10Novant Health Spine Specialists, Charlotte, NC, USA; 11North Texas Orthopedics and Spine Center, Grapevine, TX, USA; 12Neuroradiology and Pain Solutions of Oklahoma, Oklahoma City, OK, USA; 13Department of Anesthesia, University of Pittsburgh Medical Center, Susquehanna, PA, USA; 14Crimson Pain Management, Overland Park, Kansas, KS, USA; 15Comprehensive Specialty Care, Edmond, OK, USA; 16Texas Back Institute, Plano, TX, USA; 17Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 18Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA; 19Department of Anesthesiology, Rush University Medical Center, Chicago, IL, USA; 20Department of Orthopedic Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA; 21Department of Neurological Surgery, Oregon Health and Science University, Portland, OR, USACorrespondence: Dawood Sayed, The University of Kansas Health System, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA, Tel +1 913-588-5521, Email dsayed@kumc.eduIntroduction: The evolution of treatment options for painful spinal disorders in diverse settings has produced a variety of approaches to patient care among clinicians from multiple professional backgrounds. The American Society of Pain and Neuroscience (ASPN) Best Practice group identified a need for a multidisciplinary guideline regarding appropriate and effective informed consent processes for spine procedures.Objective: The ASPN Informed Consent Guideline was developed to provide clinicians with a comprehensive evaluation of patient consent practices during the treatment of spine pathology.Methods: After a needs assessment, ASPN determined that best practice regarding proper informed consent for spinal procedures was needed and a process of selecting faculty was developed based on expertise, diversity, and knowledge of the subject matter. A comprehensive literature search was conducted and when appropriate, evidence grading was performed. Recommendations were based on evidence when available, and when limited, based on consensus opinion.Results: Following a comprehensive review and analysis of the available evidence, the ASPN Informed Consent Guideline group rated the literature to assist with specification of best practice regarding patient consent during the management of spine disorders.Conclusion: Careful attention to informed consent is critical in achieving an optimal outcome and properly educating patients. This process involves a discussion of risks, advantages, and alternatives to treatment. As the field of interventional pain and spine continues to grow, it is imperative that clinicians effectively educate patients and obtain comprehensive informed consent for invasive procedures. This consent should be tailored to the patient’s specific needs to ensure an essential recognition of patient autonomy and reasonable expectations of treatment.Keywords: informed consent, best practice, clinical guideline, pain medicine, spine intervention, spine surgery

Thomas Hedman,1 James Yu,2 Harwant Singh,3 Timothy Deer4 1F. Joseph Halcomb III, M.D. Department of Biomedical Engineering, University of Kentucky, Lexington, KY, USA; 2Sydney Spine and Pain, Waratah Private Hospital, Hurstville, New South Wales, Australia; 3Spine and Joint Centre, Pantai Hospital, Kuala Lumpur, Malaysia; 4The Spine and Nerve Center of the Virginias, Charleston, WV, USACorrespondence: Thomas Hedman, Tel +1 512 818-8468, Email tomhedman@alum.mit.eduBackground: Genipin is a polymer-forming collagen bonding substance that can be dissolved in a buffered carrier and injected into disc annulus tissues. Therapeutic benefit is derived from the mechanical support provided by a large number of genipin polymers attached to collagen fibers in a degraded disc.Study Design/Setting: IRB-approved prospective, multi-site, single-arm, 12-month feasibility studies were undertaken in two countries to evaluate the safety and efficacy of the genipin-based implant for treating discogenic chronic low back pain (CLBP).Patient Sample: Twenty CLBP patients with symptomatic discs at one or two levels were enrolled in the study.Outcome Measures: The primary safety endpoint was serious adverse events at 1 month, and the primary efficacy endpoint was reduction of pain and disability at 3 months. Secondary efficacy endpoints included reduction of pain and disability at 2 weeks, 1 month, 6 months, and 12 months; reduction of flexion–extension instability; increase in segmental lordosis and rotation; and patient satisfaction.Methods: Fluoroscopic image-guidance was used to deliver two posterolateral injections of buffered genipin to each symptomatic disc. Flexion–extension radiographs were used to quantify joint kinematics at three time-points.Results: Clinically meaningful improvements in pain and disability scores were reported in 80% or more of patients from 2 weeks to 1 year post-treatment. For the more severely unstable joints, treatment significantly reduced the instability score from a pre-treatment level of 2.4 standard deviations above the mean for an asymptomatic population to the asymptomatic mean at the 3-month follow-up.Conclusion: These initial clinical data demonstrate the safety and efficacy of a genipin-based collagen tethering device capable of improving spinal joint stability while successfully addressing CLBP. This work merits additional randomized clinical studies.Keywords: disc disease, lumbar spine, collagen, degenerative disc disease

Timothy Deer,1 Anuj Shah,2 Konstantin Slavin,3 Kevin E Vorenkamp,4 Shalini Shah,5 Michael Leong,6 W Porter McRoberts7 1The Spine and Nerve Center of the Virginias, Charleston, WV, USA; 2Department of Physical Medicine and Rehabilitation, Detroit Medical Center, Detroit, MI, USA; 3Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA; 4Department of Anesthesiology, Duke University, Durham, NC, USA; 5Department of Anesthesiology & Perioperative Care, University of California Irvine, Orange, CA, USA; 6Department of Anesthesiology and Pain Medicine, Stanford University School of Medicine, San Jose, CA, USA; 7Florida Spine and Sports Specialists, Margate, FL, USACorrespondence: Timothy Deer, The Spine and Nerve Center of the Virginias, Charleston, WV, USA, Tel +1 304 610-4604, Email timothydeermd@gmail.comAbstract: Peripheral nerve stimulation (PNS) has become an essential component in the pain management plan for individuals suffering from peripheral nerve-mediated pain. The recent surge in interest in PNS can be attributed to the advancements in imaging techniques and the availability of minimally invasive stimulation systems along with a deeper grasp of PNS physiology. These advancements have made PNS more accessible to clinicians and patients alike. However, it is important to note that PNS requires a different set of technical requirements and skills compared to other pain management procedures. The work, knowledge, and surgical and interventional skillset required for PNS are in a class of their own. This article aims to educate and clarify the differences between procedures that may have similar names but are vastly different in terms of technology, expertise, and skill sets necessary for their safe implementation. Some of the procedures that this article will cover include indirect peripheral nerve field stimulation (PNfS), indirect percutaneous electrical nerve stimulation (PENS), PENS-Field Stimulation (PENFS), and transcutaneous electrical nerve stimulation (TENS). By understanding the differences between these procedures, patients and health-care providers can make informed decisions about the best approach for managing pain.Keywords: peripheral nerve stimulation, neuromodulation, minimally invasive stimulation systems

Kenneth B Chapman,1– 3 Dawood Sayed,4 Tim Lamer,5 Corey Hunter,6 Jacqueline Weisbein,7 Kiran V Patel,1– 3 David Dickerson,8,9 Jonathan M Hagedorn,10 David W Lee,11 Kasra Amirdelfan,12 Timothy Deer,13 Krishnan Chakravarthy14,15 1The Spine & Pain Institute of New York, New York, NY, USA; 2Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA; 3Department of Anesthesiology, NYU Langone Medical Center, New York, NY, USA; 4Department of Anesthesiology, The University of Kansas Medical Center (KUMC), Kansas City, KS, USA; 5Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA; 6Ainsworth Institute of Pain Management, New York, NY, USA; 7Napa Valley Orthopedic Medical Group, Napa, CA, USA; 8Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University Health System, Evanston, IL, USA; 9Department of Anesthesia & Critical Care, University of Chicago, Chicago, IL, USA; 10iSpine Pain Physicians, Maple Grove, MN, USA; 11Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA; 12IPM Medical Group, Inc., Walnut Creek, CA, USA; 13The Spine and Nerve Center of the Virginias, Charleston, WV, USA; 14Department of Anesthesiology and Pain Medicine, University of California San Diego Health Sciences, San Diego, CA, USA; 15VA San Diego Healthcare System, San Diego, CA, USACorrespondence: Kenneth B Chapman, NYU Langone Medical Center, Zucker School of Medicine at Hofstra/Northwell, Pain Medicine at Staten Island University Hospital, 1360 Hylan Boulevard, Staten Island, NY, 10305, USA, Email chapmanken@spinepainny.comAbstract: With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion stimulation (DRG-S) has significantly improved the treatment of complex regional pain syndrome (CRPS), and it has broad applicability across a wide range of other conditions. Through funding and organizational leadership by the American Society for Pain and Neuroscience (ASPN), this best practices consensus document has been developed for the selection, implantation, and use of DRG stimulation for the treatment of chronic pain syndromes. This document is composed of a comprehensive narrative literature review that has been performed regarding the role of the DRG in chronic pain and the clinical evidence for DRG-S as a treatment for multiple pain etiologies. Best practice recommendations encompass safety management, implantation techniques, and mitigation of the potential complications reported in the literature. Looking to the future of neuromodulation, DRG-S holds promise as a robust intervention for otherwise intractable pain.Keywords: dorsal root ganglion, neurostimulation, chronic pain, best practice, guidelines

Timothy Deer,1 Alaa Abd-Elsayed,2 Krishnan Chakravarthy,3 Joshua M Rosenow,4 Steven Falowski,5 Erika Petersen,6 Julie Pilitsis,7 Corey Hunter,8 Dawood Sayed,9 Michael E Schatman10,11 1The Spine and Nerve Center of the Virginias, Charleston, WV, USA; 2Department of Anesthesiology, Pain Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; 3Anesthesiology and Pain Medicine, Coastal Pain and Spinal Diagnostics Medical Group, San Diego, CA, USA; 4Neurosurgery, Neurology and Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; 5Department Functional Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA; 6Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA; 7Department of Clinical Neurosciences, Florida Atlantic University, Boca Raton, FL, USA; 8Department of Physical Medicine and Rehabilitation, Icahn School of Medicine at Mt Sinai Medical Center, NY, NY, USA; 9Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA; 10Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 11Department of Population Health-Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USACorrespondence: Michael E Schatman, Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, 550 1st Ave, New York, NY, 10016, Tel +1 425-647-4880, Email Michael.Schatman@NYULangone.org

Dawood Sayed,1 Jay Grider,2 Natalie Strand,3 Jonathan M Hagedorn,4 Steven Falowski,5 Christopher M Lam,1 Vinicius Tieppo Francio,6 Douglas P Beall,7 Nestor D Tomycz,8 Justin R Davanzo,9 Rohit Aiyer,10 David W Lee,11 Hemant Kalia,12,13 Soun Sheen,13 Mark N Malinowski,14,15 Michael Verdolin,16 Shashank Vodapally,17 Alexios Carayannopoulos,18– 20 Sameer Jain,21 Nomen Azeem,22,23 Reda Tolba,24,25 George C Chang Chien,26,27 Priyanka Ghosh,28 Anthony J Mazzola,29 Kasra Amirdelfan,30 Krishnan Chakravarthy,31,32 Erika Petersen,33 Michael E Schatman,34,35 Timothy Deer36 1Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA; 2University of Kentucky, Lexington, KY, USA; 3Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA; 4iSpine Pain Physicians, Maple Grove, MN, USA; 5Functional Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA; 6Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA; 7Comprehensive Specialty Care, Edmond, OK, USA; 8AHN Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA; 9AHN Neurosurgery, Forbes Hospital, Monroeville, PA, USA; 10Interventional Pain Management and Pain Psychiatry, Henry Ford Health System, Detroit, MI, USA; 11Physical Medicine & Rehabilitation and Pain Medicine, Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA; 12Rochester Regional Health System, Rochester, NY, USA; 13Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA; 14Adena Spine Center, Adena Health System, Chillicothe, OH, USA; 15Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA; 16Anesthesiology and Pain Medicine, Pain Consultants of San Diego, San Diego, CA, USA; 17Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA; 18Department of Physical Medicine and Rehabilitation, Rhode Island Hospital, Newport Hospital, Lifespan Physician Group, Providence, RI, USA; 19Comprehensive Spine Center at Rhode Island Hospital, Newport Hospital, Providence, RI, USA; 20Neurosurgery, Brown University, Providence, RI, USA; 21Interventional Pain Management, Pain Treatment Centers of America, Little Rock, AR, USA; 22Department of Neurology, University of South Florida, Tampa, FL, USA; 23Florida Spine & Pain Specialists, Riverview, FL, USA; 24Pain Management, Cleveland Clinic, Abu Dhabi, United Arab Emirates; 25Anesthesiology, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA; 26Pain Management, Ventura County Medical Center, Ventura, CA, USA; 27Center for Regenerative Medicine, University Southern California, Los Angeles, CA, USA; 28Remedy Medical Group, San Francisco, CA, USA; 29Mount Sinai Health System, New York City, NY, USA; 30IPM Medical Group, Inc., Walnut Creek, CA, USA; 31Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA; 32Va San Diego Healthcare, San Diego, CA, USA; 33Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, AR, USA; 34Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA; 35Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA; 36The Spine and Nerve Center of the Virginias, Charleston, WV, USACorrespondence: Dawood Sayed, The University of Kansas Health System, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA, Tel +1 913-588-5521, Email dsayed@kumc.eduIntroduction: Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety.Objective: The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders.Methods: The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented.Results: After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain.Conclusion: The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.Keywords: back pain, intervention, clinical guideline, spinal cord stimulation, minimally invasive spine procedure, lumbar disorder, epidural steroid injection, radiofrequency ablation

Jennifer M Lee,1 David Lee,2 Sandy Christiansen,3 Jonathan M Hagedorn,4 Zheyan Chen,3 Timothy Deer5 1Department of Sports & Spine, EvergreenHealth Medical Group, Kirkland, WA, USA; 2Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA; 3Department of Anesthesiology & Perioperative Medicine, Oregon Health Sciences University, Portland, OR, USA; 4iSpine Pain Physicians, Maple Grove, MN, USA; 5The Spine and Nerve Center of the Virginias, Charleston, WV, USACorrespondence: Jennifer M Lee, Email jelee@evergreenhealthcare.orgAbstract: Chronic bleeding disorders, allergy to implants, and chronic infections are all complicating factors when considering neuromodulation therapies. The American Society of Pain and Neuroscience (ASPN) determined a need for clinical guidance in these special patient populations that have increased risk of complications, in order to ensure patient safety and optimal outcomes with device implantation. The purpose of this publication was to review the published literature and explore the unique clinical challenges encountered among several special patient populations with relation to spinal cord stimulation. The executive board of the ASPN appointed a diverse group of well-established physicians to develop best practice guidelines regarding spinal cord stimulation implantation in these special populations. The physicians used the United States Preventive Services Task Force (USPSTF) structured guidelines for grading and level of certainty to make evidence-based recommendations about clinical practice. Where sufficient evidence was lacking to justify a USPSTF ranking, the physicians queried experts in neuromodulation and achieved consensus. These best practices and interventional guideline found the evidence for the use of neuromodulation in specialized patient populations to be relatively modest.Keywords: guidelines, metallurgic allergy, epidural hematoma, epidural abscess

Abd-Sayed A, Fiala K, Weisbein J, et al. J Pain Res. 2022;15:1305–1314. The authors have advised there is an error in the author list on page 1305. The author name “Alaa Abd-Sayed” should read “Alaa Abd-Elsayed”. The authors apologize for this error.

Alaa Abd-Sayed,1 Kenneth Fiala,1 Jacqueline Weibstein,2 Pooja Chopra,3 Christopher Lam,4 Hemant Kalia,5 Navdeep Jassal,6 Amitabh Gulati,7 Dawood Sayed,4 Timothy Deer8 1Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792-3272, USA; 2Napa Valley Orthopedic Medical Group, Napa, CA, 94558, USA; 3Bux Pain Management, Danville, KY, 40422, USA; 4Department of Anesthesiology, University of Kansas, Kansas City, KS, 66160, USA; 5Rochester Regional Health, Rochester, NY, 14626, USA; 6Excel Pain and Spine, Lakeland, FL, 33805, USA; 7Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, NY, NY, 10604, USA; 8Department of Anesthesiology, University of West Virginia, Charleston, WV, 25301, USACorrespondence: Alaa Abd-Sayed, Email alaaawny@hotmail.comBackground: The use of intrathecal drug delivery for chronic and cancer pain medicine has been established for decades. However, optimization and utilization of this technique still lag behind other modalities for pain control. Some of this may be due to variability of surgical technique, medication usage and education. It is currently unclear on whether or not practitioners follow available algorithms for the use of intrathecal drug delivery systems.Methods: A survey developed by the American Society of Pain and Neuroscience (ASPN) was sent to its members via email using the cloud-based SurveyMonkey. After 30 days of being available, 159 different providers responded to the survey that consisted of 31 various multiple choice and free response questions. Each question was not required and the number of responses to each varied from 128 to 159.Results: Approximately 9% of those who successfully received and opened the email containing the survey responded, likely due to a small number of providers working with intrathecal drug delivery systems. Eighty-six of respondents practice medicine in the United States, and 87% of the respondents were attending physicians. A majority of respondents, approximately 74%, were board certified in pain medicine with 69% of respondents being train in anesthesiology. The first and second most used medications for intrathecal pump trial were morphine and fentanyl, respectively. Most respondents, approximately 96%, provide pre-operative/intra-operative antibiotics. The most common first-choice medication for implanted intrathecal pumps was also morphine with the most common implanted location being the abdomen.Conclusion: Interestingly, there is currently fairly substantial variation in the way providers utilize intrathecal pump delivery for both chronic and cancer pain. There is variation from the training background of the providers providing care, to the pre-implantation trial medications, to where the pump is implanted for each patient, to if the patient has the option to give themselves boluses once implanted. Further research is needed to elucidate current and best practices for intrathecal drug delivery system trials, implantations, and utilization.Keywords: pain management, intrathecal, chronic pain, cancer pain, neuromodulation, analgesia

Sayed E Wahezi,1 Terence Hillery,2 Rene Przkora,3 Tim Lubenow,4 Tim Deer,5 Chong Kim,2 Dawood Sayed,6 Jonathan Krystal,7 Merritt Kinon,8 Kishan Sitapara,7 Kim Nguyen,7 Daniel Wong,7 Karen Sperling7 1Montefiore Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, NY, USA; 2The MetroHealth System, Cleveland, OH, USA; 3Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA; 4Department of Anesthesiology, Rush University Medical Center, Chicago, IL, USA; 5Department of Anesthesiology, West Virginia University, Morgantown, WV, USA; 6The University of Kansas Health System, Kansas City, KS, USA; 7Montefiore Medical Center, Bronx, NY, USA; 8Department of Neurosurgery, USA Brain and Spine Institute, Westchester Medical Center Health Network, New York Medical College, Valhalla, NY, USACorrespondence: Sayed E Wahezi, Montefiore Health System, Montefiore Multidisciplinary Pain Program, 1250 Waters Place, Tower #2, Bronx, NY, 10461, USA, Tel +1 929-263-3852, Fax +1 929-263-3950, Email swahezi@montefiore.orgPurpose: Neuroforaminal stenosis (NFS), a narrowing of the intervertebral foramen, is a cause of disability in the aging population. Formal magnetic resonance imaging (MRI) classification of NSF has been developed recently and contradictory findings have been reported. This study aims to assess whether in-plane, anatomically conformed two-dimensional (2D) views of the neuroforamen characterize NFS more accurately than traditional axial, coronal, and sagittal views in healthy individuals with and without simulated scoliosis.Patients and methods: This observational study was approved by the designated institutional review board at our academic tertiary care center. Four volunteers underwent lumbar spine MRI twice, once in the supine position and once with intentionally introduced hip tilt. The latter resulted in lumbar curvature mimicking positioning errors approximating degenerative lumbar scoliosis. Anatomically oriented cuts such as axial with endplate correction and coronally obliqued parasagittals, also called coronal obliques, were performed. Standard sagittal and axial views were also performed in both the supine and rotated groups.Results: Coronal oblique and anatomically oriented axial views demonstrated the highest correlation with true neuroforaminal caliber. Deviation from anatomical congruence resulted in false measurements of neuroforaminal size. The hip-tilt studies produced MR that were less favorable to characterization of the caliber of neuroforamina. Coronal sections demonstrated reliability only when performed at the mid-pedicular lines. Standard axial views were reliable only when taken at the upper one-third of the neuroforamen. Coronal oblique views demonstrated superiority when evaluating consecutive neuroforamen on one image compared to non-obliqued parasagittal slices.Conclusion: To minimize error in neuroforaminal analysis, imaging specialists should perform anatomically oriented cuts to conform to individual patient anatomy. When this cannot be performed due to a patient’s spine rotation or position, the MRI reader should view oblique, axial, and coronal images simultaneously and dynamically for proper foraminal characterization.Keywords: foraminal stenosis, lumbar vertebrae, magnetic resonance imaging, neural foramen, scoliosis

Alaa Abd-Elsayed,1 Natalie Strand,2 Karina Gritsenko,3 Joshua Martens,1 Krishnan Chakravarthy,4 Dawood Sayed,5 Timothy Deer6 1University of Wisconsin, School of Medicine and Public Health, Department of Anesthesiology, Madison, WI, USA; 2Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA; 3Montefiore Multidisciplinary Pain Program, Bronx, NY, USA; 4University of California San Diego, San Diego, CA, USA; 5University of Kansas Medical Center, Kansas City, KS, USA; 6The Spine and Nerve Center of the Virginias, Charleston, WV, USACorrespondence: Alaa Abd-Elsayed, University of Wisconsin School of Medicine and Public Health, Department of Anesthesiology, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA, Tel +1 608-263-8100, Fax +1 608-263-0575, Email alaaawny@hotmail.comBackground: Genicular nerve radiofrequency ablation (RFA) is an effective, minimally invasive procedure often used to treat patients with intractable knee pain secondary to knee osteoarthritis and failed knee replacements. The prevalence of knee pain in adults has been estimated to be as high as 40% and is continuously increasing with an aging population. Over the past two decades, proceduralists have adopted variations in patient preparation, procedural steps, and post-operative care for genicular nerve RFA procedures. A survey was dispensed via the American Society of Pain and Neuroscience (ASPN) to gain a popular assessment of common practices for genicular nerve RFA.Methods: A 29 question survey was dispensed via SurveyMonkey to all members of ASPN. Members were able to respond to the survey a single time and were unable to make changes to their responses once the survey was submitted. After responses were compiled, each question was assessed in order to determine common practices for genicular nerve RFA.Results: A total of 378 proceduralists responded to the survey. There was high consensus with the three most commonly targeted nerves. The inferomedial, superomedial, and superolateral genicular branches were treated by 95– 96% of respondents, while other targets were less commonly treated. There remains some debate among proceduralists regarding the need for a second diagnostic nerve block and the type of steroid used for diagnostic nerve blocks.Conclusion: Pain physicians use a wide variety of methods to perform genicular nerve ablations. The data offered by the survey show that there is no standardized protocol when it comes to treating knee pain via genicular nerve block and ablation and highlights controversies among proceduralists that ought to serve as the targets of future clinical research aimed at establishing a standardized protocol.Keywords: genicular nerve ablation, knee radiofrequency ablation, genicular nerve survey, genicular nerve block, radiofrequency ablation

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

Patrick Buchanan,1 Shashank Vodapally,2 David W Lee,3 Jonathan M Hagedorn,4 Christopher Bovinet,5 Natalie Strand,6 Dawood Sayed,7 Timothy Deer8 1Department of Pain Medicine, Spanish Hills Interventional Pain Specialists, Camarillo, CA, USA; 2Department of Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA; 3Department of Pain Medicine, Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA; 4Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA; 5Department of Pain Medicine, The Spine Center of Southeast Georgia, Brunswick, GA, USA; 6Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA; 7Department of Anesthesiology, Division of Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA; 8Department of Pain Medicine, The Spine and Nerve Center of the Virginias, Charleston, WV, USACorrespondence: Patrick Buchanan Email pbuchana@gmail.comBackground: Sacroiliac joint (SIJ) pain is one of the most common causes of low back pain, accounting for 15 to 30% of all cases. Although SIJ dysfunction accounts for a large portion of chronic low back pain prevalence, it is often overlooked or under diagnosed and subsequently under treated. The purpose of this review was to establish a best practices model to effectively diagnose SIJ pain through detailed history, physical exam, review of imaging, and diagnostic block.Methods: A literature search was performed on the diagnosis of sacroiliac joint pain and sacroiliac joint dysfunction. The authors proposed diagnostic recommendations based upon the available literature and a detailed understanding of diagnosing SIJ pain.Results: The practitioner must focus on the history, location of pain, observed gait pattern, and perform key points of the physical exam including sacroiliac provocative maneuvers. If the patient exhibits at least three provocative maneuvers then the SIJ may be considered as a possible source of pain. Additionally, a thorough review of the imaging should be performed to rule out other etiologies of low back pain. In the absence of any pathognomonic tests or examination findings, diagnostic SIJ blocks have evolved as the diagnostic standard.Conclusion: The diagnosis of SIJ pain is a multifaceted process that involves a careful assessment including differentiating other pain generators in the region. This involves careful history taking, appropriate physical examination including provocative maneuvers and diagnostic injections. Once the diagnosis is confirmed, long-term solutions may be considered, including recent advances in sacral lateral branch denervation and sacroiliac joint fusion.Keywords: sacroiliac joint, SIJ, low back pain, diagnosis, best practices, review

Ramana K Naidu,1 Rahul Chaturvedi,2 Alyson M Engle,3 Pankaj Mehta,4 Brian Su,1 Krishnan Chakravarthy,5 Kasra Amirdelfan,6 Jeffrey Henn,7 Dawood Sayed,8 Jay Grider,9 Timothy Deer3 1California Orthopedics & Spine, Larkspur, CA, USA; 2School of Medicine, University of California – San Diego, San Diego, CA, USA; 3The Spine & Nerve Centers of the Virginias, Charleston, WV, USA; 4Pain Specialists of America, Killeen, TX, USA; 5Department of Anesthesiology, University of California – San Diego, San Diego, CA, USA; 6Integrated Pain Management, Walnut Creek, CA, USA; 7Joint Implant Surgeons of Florida, Fort Myers, FL, USA; 8Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA; 9Department of Anesthesiology, University of Kentucky, Lexington, KY, USACorrespondence: Ramana K Naidu Email ramonaidu@me.comBackground: The discipline of interventional pain management has changed significantly over the past decade with an expected greater evolution in the next decade. Not only have the number of procedures increased, some of the procedures that were created for spine surgeons are becoming more facile in the hands of the interventional pain physician. Such change has outpaced academic institutions, societies, and boards. When a pain physician is in the credentialing process for novel procedure privileges, it can leave the healthcare system in a challenging situation with little to base their decision upon.Methods: This paper was developed by a consensus working group from the American Society of Pain and Neuroscience from various disciplines. The goal was to develop processes and resources to aid in the credentialing process.Results: These guidelines from the American Society of Pain and Neuroscience provide background information to help facilities create a process to appropriately credential physicians on novel procedures. They are not intended to serve as a standard or legal precedent.Conclusion: This paper serves as a guide for facilities to credential physicians on novel procedures.Keywords: interventional pain management, interventional spine care, credentialing, guidelines

Mansoor M Aman,1 Ammar Mahmoud,2 Timothy Deer,3 Dawood Sayed,4 Jonathan M Hagedorn,5 Shane E Brogan,6 Vinita Singh,7 Amitabh Gulati,8 Natalie Strand,9 Jacqueline Weisbein,10 Johnathan H Goree,11 Fangfang Xing,12 Ali Valimahomed,13 Daniel J Pak,14 Antonios El Helou,15 Priyanka Ghosh,16 Krishna Shah,17 Vishal Patel,1 Alexander Escobar,18 Keith Schmidt,19 Jay Shah,20 Vishal Varshney,21 William Rosenberg,22 Sanjeet Narang23 1Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA; 2Department of Anesthesiology, Division of Pain Medicine, Northern Light Health Eastern Maine Medical Center, Bangor, ME, USA; 3The Spine and Nerve Center of the Virginias, Charleston, WV, USA; 4Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas Medical Center, Kansas City, KS, USA; 5Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA; 6Department of Anesthesiology, Division of Pain Medicine, University of Utah, Salt Lake City, UT, USA; 7Department of Anesthesiology, Division of Pain Medicine, Emory University, Atlanta, GA, USA; 8Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA; 9Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA; 10Department of Anesthesiology, Chronic Pain Division, University of Arkansas for Medical Sciences, Little Rock, AR, USA; 11Interventional Pain Medicine, Napa Valley Orthopedic Medical Group, Napa, CA, USA; 12Swedish Pain Services, Swedish Health Services, Seattle, WA, USA; 13Gramercy Pain Center, Holmdel, NJ, & Advanced Orthopedics Sports Medicine Institute, Freehold, NJ, USA; 14Department of Anesthesiology, Division of Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA; 15Department of Neurosciences, Division of Neurosurgery, The Moncton Hospital, Moncton, NB. Assistant Professor, Department of Surgery, Dalhousie University, Halifax, NS, Canada; 16Remedy Medical Group, San Francisco, CA, USA; 17Assistant Professor of Anesthesiology, Baylor St. Luke’s Medical Center, Baylor College of Medicine, Houston, TX, USA; 18Department of Anesthesiology and Pain Medicine, University of Toledo Medical Center, Toledo, OH, USA; 19AMITA Neurosciences Institute, Comprehensive Pain Management Program, St. Alexius Medical Center, Hoffman Estates, IL, USA; 20SamWell Institute for Pain Management, Colonia, NJ, USA; 21Department of Anesthesia, Providence Healthcare, Vancouver, BC, Canada & Department of Anesthesiology, Pharmacology, Therapeutics, University of British Columbia, Vancouver, BC, Canada; 22Center for the Relief of Pain, Midwest Neurosurgery Associates, Kansas City, Missouri, USA; 23Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USACorrespondence: Mansoor M AmanInterventional Pain Medicine, Department of Anesthesiology, Advocate Aurora Health, Oshkosh, WI, 54904, USATel +1 920-456-7715Email aman.mansoorm@gmail.comAbstract: Moderate to severe pain occurs in many cancer patients during their clinical course and may stem from the primary pathology, metastasis, or as treatment side effects. Uncontrolled pain using conservative medical therapy can often lead to patient distress, loss of productivity, shorter life expectancy, longer hospital stays, and increase in healthcare utilization. Various publications shed light on strategies for conservative medical management for cancer pain and a few international publications have reviewed limited interventional data. Our multi-institutional working group was assembled to review and highlight the body of evidence that exists for opioid utilization for cancer pain, adjunct medication such as ketamine and methadone and interventional therapies. We discuss neurolysis via injections, neuromodulation including targeted drug delivery and spinal cord stimulation, vertebral tumor ablation and augmentation, radiotherapy and surgical techniques. In the United States, there is a significant variance in the interventional treatment of cancer pain based on fellowship training. As a first of its kind, this best practices and interventional guideline will offer evidenced-based recommendations for reducing pain and suffering associated with malignancy.Keywords: cancer pain, neurolysis, ketamine, pain pump, intrathecal drug delivery, neuromodulation, radiofrequency, spinal cord stimulation, vertebral augmentation

Timothy Deer,1 Christopher Kim,1 Sayed Emal Wahezi,2 Huaguang Qu,3 Dawood Sayed4 On Behalf of The MOTION Study Investigators1The Spine & Nerve Centers of the Virginias, Charleston, WV, USA; 2Montefiore Health System, Bronx, NY, USA; 3Pennsylvania Pain & Spine Institute, Chalfont, PA, USA; 4The University of Kansas Medical Center, Kansas City, KS, USACorrespondence: Timothy DeerThe Spine & Nerve Centers of the Virginias, 400 Court Street, Suite 100, Charleston, WV, 25301, USATel +1 304 347 6120Fax +1 304 347 6126Email doctdeer@aol.comBackground: Lumbar spinal stenosis (LSS) is a serious degenerative condition of the spine that can cause significant functional disability. Therapies for these patients generally begin with conservative management, since more invasive interventions such as open surgery and spinal implants are associated with higher complication rates. Early in the treatment algorithm for LSS patients, multiple conventional medical management (CMM) therapies are often combined as an initial low-risk treatment strategy. This composite first-line treatment plan may include conservative care together with early interventional treatment options such as epidural steroid injections, radiofrequency ablation and the mild® Procedure.Methods: This prospective randomized controlled trial evaluates patients aged 50 to 80 years treated with mild plus CMM, compared to those treated with CMM alone, as the active control. Walking tolerance test outcomes and incidence of subsequent disallowed procedures provided objective real-world outcome data. The incidence of device or procedure-related adverse events was analyzed. Follow-up includes 6-month, 1-year and 2-year assessments, with 1-year being primary. Patients in the mild+CMM group are followed at 3, 4, and 5 years. This is a report of interim 6-month outcomes.Results: Of 155 patients enrolled at 19 US interventional pain management centers, 78 were allocated to CMM-Alone, and 77 to mild+CMM. At 6-months, the validated walking tolerance test demonstrated statistical superiority of mild+CMM versus CMM-Alone (p< 0.001). The incidence of patients receiving a subsequent disallowed procedure, and thereby considered treatment failures in their study group, was statistically significantly higher in CMM-Alone versus mild+CMM (p< 0.001). There were no device or procedure-related adverse events in either group.Conclusion: At 6-months, the mild Procedure combined with CMM provided statistically superior objective real-world outcomes versus CMM-Alone. There were no device or procedure-related adverse events reported in either study group. With its excellent safety profile and superior efficacy, mild is uniquely positioned as early first-line therapy.Keywords: mild®, minimally invasive lumbar decompression, lumbar spinal stenosis, neurogenic claudication, ligamentum flavum

Yashar Eshraghi,1– 3 Krishnan Chakravarthy,4,5 Natalie H Strand,6 Prasad Shirvalkar,7 Nathaniel M Schuster,4 Rany T Abdallah,8 Ricardo Vallejo,9,10 Dawood Sayed,11 David Kim,11 Chong Kim,12 Kathleen Meacham,13 Timothy Deer14,15 On Behalf of Translational Research Committee American Society of Pain and Neuroscience (ASPN)1Department of Anesthesia, Interventional Pain Management, Ochsner Health System, New Orleans, LA, USA; 2University of Queensland Ochsner Clinical School. Academics Department, Ochsner Health System, New Orleans, LA, USA; 3Louisiana State University School of Medicine, New Orleans, LA, USA; 4Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA; 5VA San Diego Health Care, San Diego, CA, USA; 6Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Phoenix, Arizona, USA; 7Department of Anesthesiology (Pain Management), Department of Neurology, UCSF School of Medicine, San Francisco, CA, USA; 8Center for Interventional Pain and Spine, Wilmington, DE, USA; 9National Spine and Pain Center, Bloomington, IL, USA; 10Psychology Department, Illinois Wesleyan University, Bloomington, IL, USA; 11University of Kansas Medical Center, Kansas City, KS, USA; 12Departments of Physical Medicine and Rehabilitation and Anesthesiology, Case Western Reserve University/MetroHealth, Cleveland, OH, USA; 13Division of Pain Management, Department of Anesthesiology, Washington University School of Medicine, St Louis, MO; 14The Spine and Nerve Center of the Virginias, Charleston, WV, USA; 15West Virginia University, School of Medicine, Charleston, WV, USACorrespondence: Yashar Eshraghi Email Yashar.Eshraghi@gmail.comBackground: Healthcare clinical and even policy decisions are progressively made based on research-based evidence. The process by which the appropriate trials are developed and well-written manuscripts by means of evidence-based medicine recommendations has resulted in unprecedented necessity in evidence-based medicine in neuromodulation.Methods: The essential considerations in the planning of neuromodulation research are discussed in the light of available scientific literature as well as the authors’ scientific expertise regarding research study design and scientific manuscript preparation.Conclusion: This article should enable the reader to understand how to appropriately design a clinical research study and prepare scientific manuscripts. The high-quality and well-designed studies, when performed and reported effectively, support evidence-based medicine and foster improved patient outcomes.Keywords: research, study design, neuromodulation, neurostimulation, clinical evidence review

Krishnan Chakravarthy,1,2 Natalie Strand,3 Anne Frosch,4,5 Dawood Sayed,6 Lakshmi Rekha Narra,1 Rahul Chaturvedi,1 Prabhdeep K Grewal,7 Jason Pope,8 Michael E Schatman,9,10 Timothy Deer11 1Department of Anesthesiology and Pain Medicine, University of California San Diego Health Sciences, San Diego, CA, USA; 2VA San Diego Healthcare System, San Diego, CA, USA; 3Department of Anesthesiology and Pain Medicine, Mayo Clinic, Phoenix, AZ, USA; 4Hennepin Healthcare Research Institute, Minneapolis, MN, USA; 5Department of Medicine, University of Minnesota, Minneapolis, MN, USA; 6Department of Anesthesiology and Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA; 7Pain Medicine, TSAOG Orthopaedics, San Antonio, TX, USA; 8Evolve Restorative Center, Santa Rosa, CA, USA; 9Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA; 10Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA; 11Department of Pain Medicine, The Spine and Nerve Center of the Virginias, Charleston, WV, USACorrespondence: Michael E Schatman Tel +1(425)647-4880Email Michael.Schatman@tufts.eduAbstract: To date, COVID-19 has spread to more than 108 million people globally, with a death toll surpassing 2 1/2 million. With the United States Food and Drug Administration (FDA) approval of two highly effective COVID-19 vaccines from Pfizer-BioNtech and Moderna, we now have a novel approach to contain COVID-19 related morbidity and mortality. Chronic pain care has faced unprecedented challenges for patients and providers in this ever-changing climate. With the approval of COVID-19 vaccines, we now face questions relating to the potential effects of pain treatments utilizing steroids on vaccine efficacy. In this analysis, we address these issues and provide guidance for steroid therapies based on available data and expert recommendations.Keywords: vaccines, chronic pain, interventional pain therapy, epidural steroid injections, COVID-19

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

Ganesan Baranidharan,1,2 Beatrice Bretherton,1,3 Richard G Feltbower,4 Jake Timothy,5 Almas Latif Khan,6,7 Ashok Subramanian,8 Mushtaq Ahmed,9 Tracey A Crowther,1,10 Helen Radford,10,11 Harun Gupta,12 Muthusamy Chandramohan,13 Douglas P Beall,14 Timothy R Deer,15 Thomas Hedman16 1Pain Management Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK; 2School of Medicine, University of Leeds, Leeds, UK; 3School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK; 4Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, UK; 5Department of Neuroscience, Leeds Teaching Hospitals NHS Trust, Leeds, UK; 6Department of Spine Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK; 7Institute of Medical and Biological Engineering, University of Leeds, Leeds, UK; 8Somerset Spinal Surgery Service, Musgrove Park Hospital, Taunton, UK; 9Department of Trauma and Orthopaedic Surgery, Dudley Group NHS Foundation Trust, Dudley, UK; 10Research & Innovation, Leeds Teaching Hospitals NHS Trust, Leeds, UK; 11Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK; 12Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK; 13Radiology Department, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK; 14Comprehensive Specialty Care, Edmond, OK, USA; 15The Spine and Nerve Center of the Virginias, Charleston, WV, USA; 16Department of Biomedical Engineering, University of Kentucky, Lexington, KY, USACorrespondence: Ganesan Baranidharan, Pain Management Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK, Email g.baranidharan@nhs.netPurpose: An early-stage, multi-centre, prospective, randomised control trial with five-year follow-up was approved by Health Research Authority to compare the efficacy of a minimally invasive, laterally implanted interspinous fixation device (IFD) to open direct surgical decompression in treating lumbar spinal stenosis (LSS). Two-year results are presented.Patients and Methods: Forty-eight participants were randomly assigned to IFD or decompression. Primary study endpoints included changes from baseline at 8-weeks, 6, 12 and 24-months follow-ups for leg pain (visual analogue scale, VAS), back pain (VAS), disability (Oswestry Disability Index, ODI), LSS physical function (Zurich Claudication Questionnaire), distance walked in five minutes and number of repetitions of sitting-to-standing in one minute. Secondary study endpoints included patient and clinician global impression of change, adverse events, reoperations, operating parameters, and fusion rate.Results: Both treatment groups demonstrated statistically significant improvements in mean leg pain, back pain, ODI disability, LSS physical function, walking distance and sitting-to-standing repetitions compared to baseline over 24 months. Mean reduction of ODI from baseline levels was between 35% and 56% for IFD (p< 0.002), and 49% to 55% for decompression (p< 0.001) for all follow-up time points. Mean reduction of IFD group leg pain was between 57% and 78% for all time points (p< 0.001), with 72% to 94% of participants having at least 30% reduction of leg pain from 8-weeks through 24-months. Walking distance for the IFD group increased from 66% to 94% and sitting-to-standing repetitions increased from 44% to 64% for all follow-up time points. Blood loss was 88% less in the IFD group (p=0.024) and operating time parameters strongly favoured IFD compared to decompression (p< 0.001). An 89% fusion rate was assessed in a subset of IFD participants. There were no intraoperative device issues or re-operations in the IFD group, and only one healed and non-symptomatic spinous process fracture observed within 24 months.Conclusion: Despite a low number of participants in the IFD group, the study demonstrated successful two-year safety and clinical outcomes for the IFD with significant operation-related advantages compared to surgical decompression.Keywords: lumbar spinal stenosis, surgical decompression, posterior lateral arthrodesis, patient reported outcomes, minimally invasive spine, interspinous fixation device

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

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

Aaron Calodney,1 Nomen Azeem,2 Patrick Buchanan,3 Ioannis Skaribas,4 Ajay Antony,5 Christopher Kim,6 George Girardi,7 Chau Vu,8 Christopher Bovinet,9 Rainer Vogel,10 Sean Li,11 Navdeep Jassal,12 Youssef Josephson,13 Timothy Lubenow,14 Christopher M Lam,15 Timothy R Deer6 1Precision Spine Care, Tyler, TX, USA; 2Florida Spine and Pain Specialists, Tampa, FL, USA; 3Spanish Hills Interventional Pain Specialists, Camarillo, CA, USA; 4Expert Pain P.A, Houston, TX, USA; 5The Orthopaedic Institute, Gainesville, FL, USA; 6The Spine and Nerve Center, Charleston, WV, USA; 7Front Range Pain Medicine, Fort Collins, CO, USA; 8Evolve Restoration Center, Santa Rosa, CA, USA; 9The Spine Center of Southeast Georgia, Brunswick, GA, USA; 10Comprehensive and Interventional Pain Management, Henderson, NV, USA; 11Premier Pain Centers, Shrewsbury, NJ, USA; 12Excel Pain and Spine, Lakeland, FL, USA; 13The Pain Management Center, Voorhees Township, NJ, USA; 14Rush University Medical Center, Chicago, IL, USA; 15University of Kansas Medical Center, Kansas City, KS, USACorrespondence: Aaron Calodney, Precision Spine Care, Tyler, TX, USA, Email aaroncalodney@me.comIntroduction: Research suggests that sacroiliac joint (SIJ) dysfunction is responsible for 15% to 30% of reported low back pain cases. Recently, there has been an increasing interest in SIJ fusion using minimally invasive surgery (MIS) due to safety. Initially, devices designed for MIS were intended for lateral approaches. A minimally invasive sacroiliac fusion implant for use with a posterior approach has been developed and is regulated for clinical use under the regulatory framework required for human cells, tissues, or cellular or tissue-based products (HCT/Ps).Methods: A multi-center, prospective, single-arm study was launched after initial studies provided preliminary data to support safety, efficacy, and durability of this minimally invasive sacroiliac posterior fusion LinQ allograft implant (NCT04423120). Preliminary results were reported previously. Final results for the full participant cohort are presented here.Results: One-hundred and fifty-nine (159) participants were enrolled across 16 investigational sites in the US between January 2020 and March 2022. One-hundred and twenty-two (122) participants were implanted. At the 1-month follow-up, 82 participants satisfied all criteria for the composite responder endpoint, representing 73.2% of the study cohort. These results stayed consistent across the remaining study timepoints with 66.0%, 74.4%, and 73.5% of participants classified as responders at the 3-, 6- and 12-month follow-up visits, respectively. VAS scores were significantly reduced (p < 0.0001) and ODI scores were significantly improved (p < 0.0001). All domains of the PROMIS-29 were also significantly improved (all p’s < 0.0001). Only one procedure-related serious AE was reported in the study.Conclusion: These results suggest that the posterior approach LinQ Implant System is a safe and effective treatment for sacroiliac joint dysfunction at 12 months, with results that are favorable compared to outcomes reported for an FDA-cleared lateral approach.Keywords: sacroiliac joint disease, sacroiliac fusion, single point posterior fusion, back pain, minimally invasive spine surgery, sacroiliitis

Mayank Gupta,1,&ast; Anand S Patil,2,&ast; Ahish Chitneni,3 Michael E Schatman,4 Hemant Kalia,5 Timothy R Deer,6 Dawood Sayed,7 Amol Soin,8 Ganesan Baranidharan,9 Peter Staats,10 Leonardo Kapural,11 Phani Ashok Attaluri,12 Paul Verrills,13 Sudhir Diwan,14 Danielle Levin,4 Nimisha Halder,15 Alaa A Abd-Elsayed16 1Kansas Pain Management & Neuroscience Research Center, LLC, Overland Park, KS, USA; 2St. Luke’s Rehabilitation Medical Center, Spokane, WA, USA; 3Newyork-Presbyterian, New York, NY, USA; 4Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 5Rochester Regional Health System, Rochester, NY, USA; 6The Spine and Nerve Center of the Virginias, Charleston, WV, USA; 7The University of Kansas Health System, Kansas City, KS, USA; 8The Ohio Pain Clinic, Dayton, OH, USA; 9Leeds Teaching Hospitals NHS Trust, Leeds, UK; 10National Spine & Pain Centers, Frederick, MD, USA; 11Carolinas Pain Institute, Winston-Salem, NC, USA; 12Olathe Health, Olathe, KS, USA; 13Metro Pain Group, Clayton, VIC, Australia; 14Manhattan Spine & Pain, New York, NY, USA; 15Kansas City University, Kansas City, MO, USA; 16UW Health Pain Services, University of Wisconsin-Madison, Madison, WI, USA&ast;These authors contributed equally to this workCorrespondence: Mayank Gupta, Kansas Pain Management & Neuroscience Research Center, LLC, Overland Park, KS, USA, Email mayank.g@kansaspainmanagement.comAbstract: In this article, we propose a new diagnostic paradigm known as Chronic Abdominal Discomfort Syndrome (CADS). Patient’s presentation centers around chronic abdominal pain not explained by acute pathology with or without accompanying dyspepsia, bloating, nausea and vomiting among other symptoms. The pathophysiology is noted to be neurogenic, possibly stemming from visceral sympathetic nerves or abdominal wall afferent nerves. Diagnosis is supported by signs or symptoms traversing clinical, diagnostic and functional criteria. Included is a tool which can assist clinicians in diagnosing patients with CADS per those domains. We hope to facilitate primary care physicians’ and gastroenterologists’ utilization of our criteria to provide guidance for selecting which patients may benefit from further interventions or evaluation by a pain physician. The pain physician may then offer interventions to provide the patient with relief.Keywords: CADS, chronic abdominal pain, neurogenic abdominal pain, chronic abdominal discomfort

Anuj Shah,1 Jonathan M Hagedorn,2 Usman Latif,3 Ashley Bailey-Classen,4 Nomen Azeem,5 Douglas P Beall,6 Pankaj Mehta,7 Chad Stephens,8 Larry Khoo,9 Timothy Ray Deer10 1Department of Physical Medicine and Rehabilitation, Detroit Medical Center, Detroit, MI, USA; 2Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA; 3Department of Anesthesiology and Pain Medicine, University of Kansas Health System, Kansas City, KS, USA; 4Trinity Pain Medicine Associates, Fort Worth, TX, USA; 5Florida Spine & Pain Specialists, Riverview, FL, USA; 6Comprehensive Specialty Care, Edmond, OK, USA; 7Pain Specialists of Austin and Central Texas Pain Center, Austin, TX, USA; 8Noble Pain Management and Sports Medicine, Southlake, TX, USA; 9The Spine Clinic of Los Angeles, Los Angeles, CA, USA; 10The Spine and Nerve Center of the Virginias, Charleston, WV, USACorrespondence: Anuj Shah, Department of Physical Medicine and Rehabilitation, Detroit Medical Center, 261 Mack Ave, Detroit, MI, 48220, USA, Tel +1 734646-0321, Email Anujshah74@gmail.comIntroduction: Lumbar spinal stenosis (LSS) is a common condition caused by degenerative changes in the lumbar spine with age. LSS is caused by a variety of factors, including degenerative spondylosis and spondylolisthesis. People suffering with LSS experience neurogenic claudication, which causes severe physical limitations, discomfort, and a decrease in quality of life. Less invasive procedures are now being researched to improve the prognosis, success rate, and safety of LSS treatments. Posterior lateral spinal arthrodesis (PLSA) is a new surgical treatment for LSS. This study looks at the procedural and patient safety of PLSA.Materials and methods: This study is a multicenter retrospective analysis of the safety of PLSA who met the clinical indications for PLSA and underwent the procedure at eight interventional spine practices. Data was collected on demographical information, pre-procedural numeric rating scale score (NRS), post-procedural NRS, and complication reporting. Patients who were included had LSS with or without spondylolisthesis and had failed conservative treatments. A descriptive statistical analysis was performed to report the outcomes. Results were reported as mean and standard deviations for continuous outcomes, and frequency (%) for categorical outcomes.Results: This retrospective analysis involved 191 patients and 202 PLSA implants. The majority of patients were male Caucasians with a mean age of 69.2 years and a BMI of 31.1. A large majority of implants were placed at the L4-5 level, and the average pre-procedural NRS was 6.3 while the average post-procedural NRS was 3.1, indicating a 50.8% reduction in pain (p < 0.0001). Two patients reported complications, but they were unrelated to the device or surgical procedure; no infections, device malfunctions, or migrations were reported in the patient cohort.Conclusion: Preliminary results with PLSA implants indicate that it is a safe treatment option for patients with moderate LSS who do not respond to conservative management.Keywords: lumbar spinal stenosis, spondylolisthesis, interspinous fusion, Minuteman, spinal simplicity, posterior lateral spinal arthrodesis

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

Timothy Sowder,1 Dawood Sayed,1 Tyler Concannon,1 Scott H Pew,2 Natalie H Strand,2 Alaa Abd-Elsayed,3 Christopher S Wie,2 Daniel E Gomez Ramos,4 Ahmed M Raslan,5 Timothy R Deer6 1Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA; 2Department of Anesthesiology, Mayo Clinic, Phoenix, AZ, USA; 3Department of Anesthesiology, University of Wisconsin, Madison, WI, USA; 4Department of Neurology, Mayo Clinic, Phoenix, AZ, USA; 5Department of Neurological Surgery, Oregon Health and Science University, Portland, OR, USA; 6The Spine and Nerve Center of the Virginias, Charleston, WV, USACorrespondence: Timothy Sowder, Department of Anesthesiology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mail Stop 1034, Kansas City, KS, 66160, USA, Tel +1-913-588-6670, Fax +1-913-588-3365, Email tsowder@kumc.eduAbstract: Radiofrequency ablation (RFA) is a treatment modality used in interventional pain management to treat several conditions including chronic neck or back pain, sacroiliac joint pain, major joint pain, and pain from sites that can be isolated to a sensory nerve amenable to RFA. The goals of such procedures are to reduce pain, improve function, delay need for surgical intervention, and reduce pain medication consumption. As applications for RFA expand through novel techniques and nerve targets, there is concern with how RFA may impact patients with implanted medical devices. Specifically, the electrical currents used in RFA produce electromagnetic interference, which can result in unintentional energy transfer to implanted devices. This may also interfere with device function or cause damage to the device itself. As the number of patients with implanted devices increases, it is imperative to establish guidelines for the management of implanted devices during RFA procedures. This review aims to establish guidelines to assist physicians in the preoperative, intraoperative, and postoperative management of implanted devices in patients undergoing procedures using radiofrequency energy. Here, we provide physicians with background knowledge and a summary of current evidence to allow safe utilization of RFA treatment in patients with implanted devices such as cardiac implantable electronic devices, spinal cord stimulators, intrathecal pumps, and deep brain stimulators. While these guidelines are intended to be comprehensive, each patient should be assessed on an individual basis to optimize outcomes.Keywords: radiofrequency ablation, implanted medical devices, cardiac implantable electronic device, spinal cord stimulator, intrathecal pump, deep brain stimulator

Scott G Pritzlaff,1 Johnathan H Goree,2 Jonathan M Hagedorn,3 David W Lee,4 Kenneth B Chapman,5 Sandy Christiansen,6 Andrew Dudas,7 Alexander Escobar,8 Christopher J Gilligan,9 Maged Guirguis,10 Amitabh Gulati,11 Jessica Jameson,12 Christopher J Mallard,13 Melissa Murphy,14 Kiran V Patel,15 Raj G Patel,16 Samir J Sheth,17 Stephanie Vanterpool,18 Vinita Singh,19 Gregory Smith,2 Natalie H Strand,20 Chau M Vu,21 Tolga Suvar,22 Krishnan Chakravarthy,23 Leonardo Kapural,24 Michael S Leong,25 Timothy R Lubenow,22 Alaa Abd-Elsayed,26 Jason E Pope,21 Dawood Sayed,27 Timothy R Deer28 1Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA, USA; 2Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA; 3Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Mayo Clinic, Rochester, MN, USA; 4Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA; 5The Spine & Pain Institute of New York, New York, NY, USA; 6Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA; 7Mays & Schnapp Neurospine and Pain, Memphis, TN, USA; 8Department of Anesthesiology, University of Toledo, Toledo, OH, USA; 9Division of Pain Medicine, Brigham and Women’s Hospital Harvard Medical School, Boston, MA, USA; 10Division of Pain Management, Ochsner Health, New Orleans, LA, USA; 11Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA; 12Axis Spine Center, Coeur D’Alene, ID, USA; 13Department of Anesthesiology, University of Kentucky, Lexington, KY, USA; 14North Texas Orthopedics and Spine Center, Grapevine, TX, USA; 15Department of Anesthesiology and Pain Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA; 16Capitol Pain Institute, Austin, TX, USA; 17Interventional Pain Management, Sutter Health, Roseville, CA, USA; 18Department of Anesthesiology, University of Tennessee, Knoxville, TN, USA; 19Department of Anesthesiology, Emory University, Atlanta, GA, USA; 20Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA; 21Evolve Restorative Center, Santa Rosa, CA, USA; 22Department of Anesthesiology and Pain Medicine, Rush University Medical Center, Chicago, IL, USA; 23Coastal Pain and Spinal Diagnostics Medical Group, San Diego, CA, USA; 24Carolinas Pain Institute, Winston-Salem, NC, USA; 25Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA; 26Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; 27Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas, Kansas City, KS, USA; 28The Spine and Nerve Center of the Virginias, Charleston, WV, USACorrespondence: Scott G Pritzlaff, University of California, Davis, 4860 Y Street, Suite 3020, Sacramento, CA, 95817, USA, Tel +1 916 734-6824, Fax +1 916 734-6827, Email spritzlaff@ucdavis.eduAbstract: The need to be competent in neuromodulation is and should be a prerequisite prior to completing a fellowship in interventional pain medicine. Unfortunately, many programs lack acceptable candidates for these advanced therapies, and fellows may not receive adequate exposure to neuromodulation procedures. The American Society of Pain and Neuroscience (ASPN) desires to create a consensus of experts to set a minimum standard of competence for neurostimulation procedures, including spinal cord stimulation (SCS), dorsal root ganglion stimulation (DRG-S), and peripheral nerve stimulation (PNS). The executive board of ASPN accepted nominations for colleagues with excellence in the subject matter of neuromodulation and physician education. This diverse group used peer-reviewed literature and, based on grading of evidence and expert opinion, developed critical consensus guides for training that all accredited fellowship programs should adopt. For each consensus point, transparency and recusal were used to eliminate bias, and an author was nominated for evidence grading oversight and bias control. Pain Education and Knowledge (PEAK) Consensus Guidelines for Neuromodulation sets a standard for neuromodulation training in pain fellowship training programs. The consensus panel has determined several recommendations to improve care in the United States for patients undergoing neuromodulation. As neuromodulation training in the United States has evolved dramatically, these therapies have become ubiquitous in pain medicine. Unfortunately, fellowship programs and the Accreditation Council for Graduate Medical Education (ACGME) pain program requirements have not progressed training to match the demands of modern advancements. PEAK sets a new standard for fellowship training and presents thirteen practice areas vital for physician competence in neuromodulation.Keywords: neuromodulation, pain education, spinal cord stimulation, dorsal root ganglion stimulation, peripheral nerve stimulation, fellowship training

Erika A Petersen,1,* Timothy R Deer,2,* Stana Bojanic,3 Lauren R Sankary,4 Natalie H Strand,5 Adnan Al Kaisy,6 Frank Huygen,7 Dawood Sayed,8 Monique Steegers,9 Paul Verrills,10 Michael E Schatman11,12 1Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA; 2Spine and Nerve Center of the Virginias, Charleston, WV, USA; 3Department of Neurosurgery, John Radcliffe University Hospitals NHS Trust, Oxford, UK; 4Neuroethics Program, Cleveland Clinic, Cleveland, OH, USA; 5Department of Anesthesiology, Mayo Clinic, Phoenix, AZ, USA; 6The Pain Management and Neuromodulation Centre, Guy’s & St. Thomas’ NHS Foundation Trust, London, UK; 7Department of Anesthesiology, Center of Pain Medicine, Erasmus MC, Rotterdam, the Netherlands; 8Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA; 9Departments of Anesthesiology and Pain and Palliative Medicine, Amsterdam UMC, Amsterdam, the Netherlands; 10Pain Medicine, Metro Pain Clinic, Melbourne, Australia; 11Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 12Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA*These authors contributed equally to this workCorrespondence: Erika A Petersen, Department of Neurosurgery, University of Arkansas for Medical Science, 4301 West Markham Slot #507, Little Rock, AR, 72205, USA, Tel +15016865270, Email eapetersen@uams.eduAbstract: The COVID-19 pandemic caught many areas of medicine in a state of unpreparedness for conducting research and completing ongoing projects during a global crisis, including the field of pain medicine. Waves of infection led to a disjointed ability to provide care and conduct clinical research. The American Society of Pain and Neuroscience (ASPN) Research Group has created guidance for pragmatic and ethical considerations for research during future emergency or disaster situations. This analysis uses governmental guidance, scientific best practices, and expert opinion to address procedure-based or device-based clinical trials during such times. Current literature offers limited recommendations on this important issue, and the findings of this group fill a void for protocols to improve patient safety and efficacy, especially as we anticipate the impact of future disasters and spreading global infectious diseases. We recommend local adaptations to best practices and innovations to enable continued research while respecting the stressors to the research subjects, investigator teams, health-care systems, and to local infrastructure.Keywords: research, pain, emergency, pandemic, protocols

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

Dawood Sayed,1 Ramana K Naidu,2,3 Kiran V Patel,4 Natalie H Strand,5 Pankaj Mehta,6 Christopher M Lam,1 Vinicius Tieppo Francio,7 Samir Sheth,8 Anthony Giuffrida,9 Brian Durkin,10 Nasir Khatri,11 Shashank Vodapally,12 Christopher O James,13 Benjamin D Westerhaus,9 Adam Rupp,7 Newaj M Abdullah,14 Kasra Amirdelfan,15 Erika A Petersen,16 Douglas P Beall,17 Timothy R Deer18 1Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA; 2Anesthesiology, California Orthopedics & Spine, Marin, CA, USA; 3Pain Management, MarinHealth Medical Center, Marin, CA, USA; 4Interventional Pain Management/ Anesthesiology, The Spine & Pain Institute of New York, New York City, NY, USA; 5Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA; 6Clinical Research, Pain Specialists of Austin, Austin, TX, USA; 7Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA; 8Interventional Pain Management, Sutter Health, Roseville, CA, USA; 9Cantor Spine Center, Paley Orthopedic and Spine Institute, Fort Lauderdale, FL, USA; 10Pain Institute of Long Island, Port Jefferson, NY, USA; 11Interventional Pain Medicine, Novant Health, Charlotte, NC, USA; 12Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA; 13Department of Physical Medicine and Rehabilitation, University of Kentucky, Lexington, KY, USA; 14Pain Medicine and Anesthesiology, University of Utah, Salt Lake City, UT, USA; 15Clinical Research, IPM Medical Group, Inc, Walnut Creek, CA, USA; 16Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, AR, USA; 17Comprehensive Specialty Care, Edmond, OK, USA; 18The Spine and Nerve Center of the Virginias, Charleston, WV, USACorrespondence: Dawood Sayed, The University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA, Tel +1 913-588-5521, Email dsayed1@yahoo.comAbstract: Chronic low back pain is a worldwide leading cause of pain and disability. Degenerative disc disease has been the presumptive etiology in the majority of cases of chronic low back pain (CLBP). More recent study and treatments have discovered that the vertebral endplates play a large role in CLBP in a term defined as vertebrogenic back pain. As the vertebral endplates are highly innervated via the basivertebral nerve (BVN), this has resulted in a reliable target in treating patients suffering from vertebrogenic low back pain (VLBP). The application of BVN ablation for patients suffering from VLBP is still in its early stages of adoption and integration into spine care pathways. BVN ablation is grounded in a solid foundation of both pre-clinical and clinical evidence. With the emergence of this therapeutic option, the American Society of Pain and Neuroscience (ASPN) identified the need for formal evidence-based guidelines for the proper identification and selection of patients for BVN ablation in patients with VLBP. ASPN formed a multidisciplinary work group tasked to examine the available literature and form best practice guidelines on this subject. Based on the United States Preventative Task Force (USPSTF) criteria for grading evidence, gives BVN ablation Level A grade evidence with high certainty that the net benefit is substantial in appropriately selected individuals.Keywords: back pain, vertebrogenic pain, lumbar degenerative disc, radiofrequency ablation, basivertebral nerve, guidelines

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

Timothy R Deer,1 Jay S Grider,2 Jason E Pope,3 Tim J Lamer,4 Sayed E Wahezi,5 Jonathan M Hagedorn,6 Steven Falowski,7 Reda Tolba,8 Jay M Shah,9 Natalie Strand,10 Alex Escobar,11 Mark Malinowski,12 Anjum Bux,13 Navdeep Jassal,14 Jennifer Hah,15 Jacqueline Weisbein,16 Nestor D Tomycz,17 Jessica Jameson,18 Erika A Petersen,19 Dawood Sayed20 1Centers for Pain Relief, Charleston, WV, USA; 2UK HealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA; 3Evolve Restorative Center, Santa Rosa, CA, USA; 4Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA; 5Montefiore Medical Center, SUNY-Buffalo, Buffalo, NY, USA; 6Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA; 7Director Functional Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA; 8Pain Management Department, Anesthesiology Institute, Cleveland Clinic, Abu Dhabi, UAE; 9SamWell Institute for Pain Management, Colonia, NJ, USA; 10Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA; 11Department of Anesthesiology and Pain Medicine, University of Toledo Medical Center, Toledo, OH, USA; 12OhioHealth, Neurological Physicians, Columbus, OH, USA; 13Bux Pain Management, Lexington, KY, USA; 14Excel Pain and Spine, Lakeland, FL, USA; 15Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, CA, USA; 16Napa Valley Orthopaedic Medical Group, Inc., Napa, CA, USA; 17Department of Neurological Surgery, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA; 18Axis Spine Center, Coeur d’Alene, ID, USA; 19Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA; 20Pain Medicine, Multidisciplinary Pain Fellowship, The University of Kansas Health System, Kansas City, KS, USACorrespondence: Timothy R Deer, The Spine and Nerve Centers of the Virginias, 400 Court Street, Suite 100, Charleston, WV, 25301, USA, Tel +1 304 347-6141, Email doctdeer@aol.comIntroduction: Lumbar spinal stenosis (LSS) is a common spinal disease of aging with a growing patient population, paralleling population growth. Minimally invasive treatments are evolving, and the use of these techniques needs guidance to provide the optimal patient safety and efficacy outcomes.Methods: The American Society of Pain and Neuroscience (ASPN) identified an educational need for guidance on the prudent use of the innovative minimally invasive surgical therapies for the treatment of symptomatic LSS. The executive board nominated experts spanning anesthesiology, physiatry, orthopedic surgery, and neurosurgery based on expertise, publications, research, diversity and field of practice. Evidence was reviewed, graded using the United States Preventive Services Task Force (USPSTF) criteria for evidence and recommendation strength and grade, and expert opinion was added to make consensus points for best practice.Results: The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for LSS-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using USPSTF criteria and consensus points are presented.Discussion: The algorithm for patient selection in the management of symptomatic spinal stenosis is evolving. Careful consideration of patient selection and anatomic architecture variance is critical for improved outcomes and patient safety.Conclusion: ASPN created a guidance for best practice for minimally invasive surgical treatment of symptomatic spinal stenosis.Keywords: percutaneous image-guided lumbar decompression, interspinous spacers, intrathecal drug delivery, open decompression, neurostimulation, epidural steroid injections

Patrick Buchanan,1 David W Lee,2 Ashley Comer,3 Zohra Hussaini,4 Casey Grillo,5 Shashank Vodapally,6 Natalie H Strand,7 Dawood Sayed,4 Timothy R Deer3 1Department of Pain Medicine, Spanish Hills Interventional Pain Specialists, Camarillo, CA, USA; 2Department of Pain Medicine, Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA; 3Department of Pain Medicine, The Spine and Nerve Center of the Virginias, Charleston, WV, USA; 4Department of Anesthesiology, Division of Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA; 5Department of Pain Medicine, The Spine & Pain Institute of New York, New York, NY, USA; 6Department of Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA; 7Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USACorrespondence: Patrick Buchanan, Email pbuchana@gmail.comAbstract: Sacroiliac joint (SIJ) pain is a common cause of low back pain. Traditionally, treatment for SIJ joint pain and dysfunction has consisted of physical therapy, medication management, SIJ injections, and SIJ ablations. Improved recognition of the SIJ as an etiology for back pain has led to advances in treatment options. Radiofrequency of the lateral sacral branches has been shown to be effective, though evidence is fraught with inconsistent patient selection, study design and procedural technique. It also does not directly address the mechanical dysfunction of the SIJ. In order to create a more enduring approach SIJ fusion has become an attractive option to reduce pain and to improve function. This method of SI joint treatment requires guidance in the perioperative phase of care from both the physicians and advanced practice providers (APP). In order to improve care and outcomes of those undergoing posterior SI joint fusion the American Society of Pain and Neuroscience appointed an expert panel of physicians and advanced practice providers to create a best practice for the post operative care of this approach. As with any best practice, the panel considered current peer reviewed literature and clinical expertise to create guidance today. This is intended to be a living document with modifications as additional evidence comes to light in data publication. The goals of this paper are to focus on (1) wound care, (2) medication use, (3) physical activity and (4) therapeutic exercises.Keywords: sacroiliac joint, SIJ, low back pain, postoperative care, best practices, review, physical therapy, minimally invasive

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

Timothy R Deer,1 Michael F Esposito,2 Eric G Cornidez,3 Udoka Okaro,4 Marie E Fahey,4 Kenneth B Chapman5 1Spine and Nerve Center of the Virginias, Charleston, WV, USA; 2Florida Pain Institute, Melbourne, FL, USA; 3Pain Institute of Southern Arizona, Tucson, AZ, USA; 4Abbott, Austin, TX, USA; 5The Spine Institute of New York, New York, NY, USACorrespondence: Marie E FaheyAbbott, 8701 Bee Cave Road, Bldg 1 West FM 2244, Austin, TX, 78746, USATel +1 737 208 9348Fax +1 737-309-8710Email marie.fahey@abbott.comBackground: Chronic pain patients implanted with a neurostimulation device typically require follow-up and device programming visits to address changes in symptoms or treatment. Follow-up visits require access to specialty care and necessitate patients to take time off work, commute long distances, arrange for travel, and/or work with a caregiver’s schedule. Telemedicine was adopted for some patient management as a result of the Sars-Cov-2 pandemic; however, remote optimization for neuromodulation still required an in-person visit to adjust device parameters. An FDA-approved digital platform enables remote programming of an implanted neuromodulation device using a real-time audio-video link from the clinical programmer to the patient controller. The Remote Optimization, Adjustment, and Measurement for Chronic Pain Therapy (ROAM-CPT) is a multi-center, prospective study that is currently underway to access the effectiveness of the teleprogramming system in fulfilling patients’ clinical demands.Methods: This pilot study surveyed 16 patients to determine the ability of the teleprogramming platform to provide a rapid solution safely and effectively for patient’s chronic pain. Data were collected using a questionnaire that asked 6 clinician-centric questions and 5 patient-centric questions.Results: 4/4 surveyed physicians were able to address patients’ needs. 16/16 surveyed patients reported a quick resolution to pain and 15/16 did not require additional follow-up. Data curated from this pilot study show that the teleprogramming application greatly improves patient care, is preferred by both clinicians and patients with minimal disruptions to patients’ everyday lives.Conclusion: Teleprogramming provides real-time virtual programming capabilities and optimizes patients’ therapy.Perspective: This article describes remote device programming and analysis as an alternative to in-person programming/treatment sessions for neuromodulation patients. This remote option gives patients access to timely and clinically appropriate device management when in-person care may not be available.Keywords: neuromodulation, neurosphere, remote DRG stimulation, remote SCS stimulation, virtual clinic