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In regenerative medicine, cells, tissues and organs are often replaced, engineered or regrown in order to restore their function after they have been damaged or lost. Local anesthetics, corticosteroids and contrast agents are commonly employed for both diagnostic and therapeutic objectives in interventional pain and musculoskeletal treatments for regenerative medicine. There is growing evidence that routine injectables promote catabolism and disease processes. Thus, understanding the effects of these compounds on regenerative medicine injectates and target tissues such as tenocytes, chondrocytes, nucleus pulposus and ligamentous tissue is critical. This review includes the current research on the effects of local anesthetics and contrast agents, as well as their use and recommendations in regenerative medicine operations.In regenerative medicine, various human organs are often modified to restore their function after being damaged. Various substances are commonly injected in pain and musculoskeletal treatments for regenerative medicine. A growing body of literature indicates that common injectable substances may promote cellular destruction and pathologies. Therefore, understanding their effects on various musculoskeletal tissue and cellular components is critical. This review includes the current research on the effects of local anesthetics and contrast agents, as well as their use and recommendations in regenerative medicine operations.

Context Shoulder and neck pain are leading causes of disability worldwide. Rotator cuff pathology has strong associations with such pain and is extensively targeted by healthcare practitioners. A dysfunctional lower trapezius muscle has also been shown to contribute to neck and shoulder pain, yet it is often overlooked. Objectives This systematic review analyzes those with a history of, or who are currently managing, shoulder or neck pain to indicate differences in measures of lower trapezius function when compared to subjects without that pain. Methods Studies with no age restrictions were included in the study. Studies could determine lower trapezius muscle function with any quantifiable measurement tool or clinical assessment. If the study included a control group (no pain) and a comparator group (pain), and if lower trapezius muscle function was assessed in both, the study was typically included. The significance of the lower trapezius muscle function change was summarized in these pain patients. From a final total of 18 studies identified, level of muscle activity, muscle activation, time to onset, muscle strength, and muscle thickness were reported. Results The 18 included articles involved 485 participants with shoulder and/or neck pain and 455 without. Half of the shoulder pain studies (6/12), and all of the neck pain studies (6/6), demonstrated that the lower trapezius had a noticeable impact. The lower trapezius muscle in participants with shoulder and neck pain tended to show decreased muscle strength, and decreased time to onset/latency. Conclusions The findings from this systematic review should be taken into consideration when assessing and treating patients with shoulder and neck pain. Future studies that define the type and duration of shoulder and neck pain, as well as prospectively assessing lower trapezius muscle function in those with and without that pain, are needed.

The currently available drugs to treat neuropathic pain do not provide adequate pain management. As such, other treatments including stem cells, platelet-rich plasma and plasma-derived molecules such as alpha-2 macroglobulin (A2M) are being explored because they show promising potential for neuropathic pain. The various mechanisms and immunomodulatory effects could be a desirable approach in targeting neuropathic pain. This review indicates that A2M can be highly efficacious due to its conformational change during activation and specificity of action on various cytokines. Its ability to reduce neuropathic pain can further the future of neuropathic intervention. However, there is a lack of robust clinical studies and thus further research is needed to verify and expand the understanding of its therapeutic effects.The currently available drugs to treat neuropathic pain do not provide adequate pain control. As such, other various regenerative treatments modalities are being explored because they show promising potential for neuropathic pain. The various mechanisms and immunity-focused effects could be a desirable approach in targeting neuropathic pain. This review indicates that alpha-2 macroglobulin, a specific plasma derived molecule, can be highly effective due to its shape change during activation and highly specific action on various proteins. Its ability to reduce neuropathic pain can further the future of neuropathic intervention. However, there is a lack of robust clinical studies and thus further research is needed to verify and expand the understanding of its therapeutic effects.

Sayed D, Grider J, Strand N, et al. J Pain Res. 2022;15:3729-3832. The authors have advised that there is an error in Table 32 on page 3797. Row six Gilligan et al 2021, fourth column level of evidence, the text “I-C” should read “I-A”. The correct Table 32 is as follows. Table 32 Evidence Summary for Multifidus Activation via Medial Branch Nerve Stimulation The authors apologize for this error.

Aim: To describe the successful treatment of bone marrow edema in the setting of hip osteoarthritis using ultrasound-guided injection of photoactivated leukocyte-rich platelet-rich plasma (LR-PRP). Setting: Outpatient clinic. Patient: 65-year old female with antalgic and listing gait. Case description: The patient presented with a 2-week history of left hip pain. Exam revealed restriction and pain at end range of motion. Imaging showed extensive bone marrow edema and hip effusion. The patient underwent four weekly photoactivated LR-PRP treatments. Results: The patient reported a significant reduction in pain with MRI showing an extensive resolution of bone marrow edema and complete pain relief at 2 and 6 months post-treatment, respectively. Conclusion: Photoactivated LR-PRP may be considered as a treatment option for patients with marrow edema in the setting of hip osteoarthritis.

Background: Lumbosacral plexus entrapment syndrome (LPES) is a little-known but common cause of chronic lumbopelvic and lower extremity pain. The authors document the clinical course of 61 patients who were diagnosed and treated for LPES between May 2016 and October 2018. The study is aimed to evaluate the efficacy of our proposed diagnostic and conservative treatment protocol for LPES, clinically.Methodology: This is a retrospective cohort study of patients suffering from LPES. Patients were included in this study if they compatible symptoms with LPES with symptoms of low back, pelvic, groin, genital, thigh or calf pain after other more common etiologies have been excluded. Additionally, these patients had at least 5 positive provocative Tinel’s tests applied to various lumbopelvic and lower extremity (LPLE) nerve branches yielding => 7 (numeric rating scale) NRS, and weakness of one or more myotomes of the lower body. The group in its entirety was treated with gentle strengthening of the psoas major and piriformis muscles. The primary outcome measure was patient reported satisfaction and improvement including: Full, significant, moderate, slight, or no improvement in pain and symptoms. Patients were followed for up to two years.Results: The most common complaints amongst the patient pool were low back, groin, pelvic, posterior/lateral calf pain. Additionally, 17 patients (28%) stated that everything in the LPLE hurts, consistent with plexalgia. 13 patients were lost to follow-up as they did not reschedule treatment, for unknown reasons. Amongst the remaining 48 patients, 25 recovered fully (52%), 12 significantly (25%), and five moderately (10,4%). Five patients had a slight improvement (10,4%), and two no improvement whatsoever (4%). The average recovery times were mostly consistent with the time of affliction. Patients with a symptom duration of less than one year, generally recovered within 4 months. One to four years, within 10,5 months. Five to nine years, 7,5 months. And, finally, more than 10 years, within 18 months.Conclusion: Non-specific pain syndromes in the LPLE where other causes have been excluded, may be attributable to underlying LPES. In this study, a high correlation between the diagnostic & interventional protocols, and beneficial patient outcomes were demonstrated. However, more statistical and long-term research is needed.Citation: Larsen K, Chien GCC. Lumbosacral plexus entrapment syndrome. Part Two: Symptomology and rehabilitative trials. Anaesth pain & intensiv care 2019;23(2):138-144

Lumbosacral plexus entrapment syndrome (LPES) is a little-known but common cause of chronic lumbopelvic and lower extremity pain. The lumbar plexus, including the lumbosacral tunks emerge through the fibers of the psoas major, and the proximal sciatic nerve beneath the piriformis muscles. Severe weakness of these muscles may lead to entrapment plexopathy, resulting in diffuse and non-specific pain patterns throughout the lumbopelvic complex and lower extremities (LPLE), easily mimicking other diagnoses and is therefore likely to mislead the interpreting clinician. It is a pathology very similar to that of thoracic outlet syndrome, but for the lower body. This two-part manuscript series was written in an attempt to demonstrate the existence, pathophysiology, diagnostic protocol as well as interventional strategy for LPES, and its efficacy.Piriformis syndrome; Nerve entrapment; Double-crush; Pain, Chronic; Fibromyalgia Citation: Larsen K, Chien GCC. Lumbosacral plexus entrapment syndrome. Part one: A common yet little-known cause of chronic pelvic and lower extremity pain. Anaesth pain & intensiv care 2019;23(2):124-137

The elbow is a common site for sports related injuries of the upper extremity. Ultrasonography (US) is a noninvasive imaging modality that offers several distinct advantages over its cross sectional counterparts. These include real time dynamic evaluation, direct patient feedback, ability to guide therapeutic interventions, and among many others. This chapter will review the normal anatomy of the elbow and its sonographic appearance, the approach to US imaging, the commonly encountered disease pathologies, and several fundamental therapeutic interventions for the elbow.

The knee joint is amongst the most commonly injured joints in the human body, and ultrasound has played an increasingly important role in accurate diagnoses of various structural pathologies. Given the generally superficial location of the knee, a high frequency linear probe is frequently used to identify various knee abnormalities, such as medial or lateral collateral ligament tear, tendinopathy, and bursitis. The more internal structures, such as the menisci and cruciate ligaments, can be a bit more difficult to visualize, nonetheless partial imaging of these structures still proves valuable. This chapter will review the sonoanatomy, structural pathology and when applicable, injection techniques for the knee joint under ultrasound guidance.

The wrist is among the most commonly utilized joints in the human body, and a great number of vital structures pass through the wrist to reach the distal digits. Given its high usage and the significant structures involved, the wrist encounters a great number of potential disorders. There are also a number of ultrasound-guided injections that can be performed here with great efficacy. The following will review sonographic wrist anatomy, and when applicable, injection techniques to perform with ultrasound guidance.

Hip pain is a common complaint that can be symptoms from a wide variety of conditions. Despite the deep location of the hip compared to other joints, ultrasound has proven to be helpful in both diagnosis of pathology and treatment via various ultrasound guided injections. Given its deep location, a low frequency curvilinear probe is typically utilized. The following chapter will review hip sonoanatomy, and when applicable, injection techniques chapter under ultrasound guidance.

The use of regenerative therapies, such as platelet-rich plasma (PRP) and stem cell therapies have been widely incorporated into the treatment algorithm of various peripheral nerve disorders, including trigeminal neuralgia and other trigeminal nerve conditions. The concept of “stimulating repair of damaged tissue” is the forefront of the field of regenerative medicine. The versatile use of these therapies for many peripheral neuralgias makes these treatment modalities appealing. The primary focus of this chapter is to discuss the use of regenerative therapies in peripheral nerve conditions, including trigeminal neuralgia and other trigeminal neuropathies.

Contains fulltext : 229021.pdf (Publisher’s version ) (Open Access) We present 4 cases of dorsal root ganglion stimulation lead fracture. In these cases, the surgical technique involved (1) traversing fascial layers for placement of leads via a Tuohy needle in the upper low back, (2) subcutaneous tunneling from the implantable pulse generator site to the lead puncture site without dissecting below the superficial fascial plane at the puncture site, and (3) connection of the lead/extension with the generator. All fractures occurred adjacent to the original lead puncture site. These cases suggest lead entrapment within the membranous fascial plane, with tension on a thin lead, is a mechanism underlying lead fracture.

Background: Neural blockade of the cervical medial branches is a validated procedure in the diagnosis and treatment of cervical zygapophyseal joint pain. Fluoroscopic visualization of the lower cervical medial branch target zones (CMBTZs) in lateral view is sometimes challenging or not possible due to the patient’s shoulders obscuring the target. Large shoulders and short necks often exacerbate the problem. Clear visualization is critical to accuracy and safety. Objective: We aim to describe a method for optimal fluoroscopic visualization of the lower CMBTZs using a modified swimmer’s view. Study Design: A technical report. Setting: A private practice. Methods: Discussion with accompanying fluoroscopic images of the cervical spine, focusing on the lateral aspects of the lower cervical articular pillars in both the traditional lateral view and modified swimmer’s view. Four authors served as volunteers for undergoing fluoroscopic x-rays in both views. Visualization of each lower CMBTZ was attempted and stored. The most caudal, clearly visualized levels were compared in both views for each participant. Results: Visualization of the lower CMBTZs can be successfully obtained with the modified swimmer’s view and in select patients is superior to a lateral view. Limitations: A limitation to this study is the design as a technical report. A future prospective study is warranted. Conclusions: Modified swimmer’s view can serve as a primary method of visualizing the lower CMBTZs or an alternate view when a lateral view is unable to clearly demonstrate target landmarks. This can improve the ease, accuracy, and safety of performing diagnostic cervical medial branch blocks (CMBBs). Key words: Swimmer’s view, cervical medial branch block, facet joint, fluoroscopy

Chronic pelvic pain (CPP), or chronic urogenital pain, is a ubiquitous and complex uro-gynecological condition affecting both men and women and is associated with a wide range of psychiatric co-morbidities. Psychological factors are known to play a vital role in the associated behaviors of CPP and recognizing these are vital in both the treatment and referral of patients to appropriate psychological services. Here we will review the psychological principles associated with CPP, important clinical variables to assess, and the various psychological treatment approaches.

As it is responsible for a wide range of fine motor operations, the musculoskeletal structure of the hand is highly intricate and involves a host of minuscule bones, joints, and tendons working in concert to coordinate movement with great dexterity. Additionally, these operations also require the assistance of numerous vascular, nervous, and supportive tissues all located in a confined compartment. Therefore, the close proximity and abundance of these structures predisposes towards a host of hand conditions that can alter physical structures and generate pain to collectively hinder motor movement. These conditions often involve arthropathies, tendinopathies, and nerve entrapments. The appropriate diagnosis and management is instrumental in helping restore hand function.

Chronic pain and its related health effects and costs is among the most important clinical issues for pain physicians. The multifactorial nature of pain, and especially chronic pain, requires a comprehensive understanding of the most influential factors involved in the experience of pain, lost productivity, and the health care costs associated with it. Among the important factors to consider are work history and education.

Appropriate diagnosis of musculoskeletal pain involves a multifactorial approach that includes the history of the disease, a thorough physical evaluation, and using indicated diagnostic approaches. This comprehensive approach in conjunction with understanding the relevant epidemiological dispositions is instrumental in diagnosing the various etiologies of pain in musculoskeletal disorders.

Functional Capacity Evaluations (FCEs) encompass formalized testing of physical and occupational capacity. FCEs are performed by specially trained physical and occupational therapists. FCEs typically require the evaluator to determine the worker’s capability to perform various work-related tasks and whether there is a match between these abilities and the essential job performance components. This may include return to work status, including recommendations for part-time, or full-time duty, duty modifications, or work-site modifications.

Occupational injuries and work-related diseases and disorders often present with a variety of additional factors outside of the multidimensional treatment of pain. Work disability exists when an employee is not able to perform his/her usual work as a result of a health problem. In the treatment of work-related injuries, the traditional medical model for health care and rehabilitation is not sufficient, because the relationship between disease, symptoms, disability and incapacity for work is non-linear. Facilitation of early return to work can reduce negative effects of prolonged time away from work.

Disability is a significant public health problem in the United States with dynamic and complex factors. A holistic approach should be taken towards early intervention and early return to work in order to reduce absence with the goals of maximizing physical, mental, social and economic function in these individuals

Casting and splinting remain a mainstay in the management of musculoskeletal injuries. Understanding the basic principles of immobilization, indications in clinical care, and potential pitfalls are important in a pain practice.

Of the greater than 200 clinical therapies available to address back pain, none is more studied than spinal manipulation. The past decade has seen an explosion in the mainstream integration of physical modalities such as spinal manipulation and mobilization, massage and spinal traction for the management of common musculoskeletal pain. The growing role of physical modalities in the treatment of pain is at least partly related to the relative ineffectiveness and/or risks of traditional treatments such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and muscle relaxants. Concerns surrounding medical therapy are especially true for opioids, which may be no more effective in musculoskeletal pain than safer classes of drugs. The benefit of including physical modalities centers on their favorable side effect profile and high rates of patient satisfaction.

Physicians most often work to address biological and structural factors affecting patients with pain, but there is strong evidence that psychosocial variables play an equally prominent role in chronic pain. The multidimensional experience of chronic pain results in individualized perceptions and coping mechanisms that reflect the complex biopsychosocial aspects of a patient in chronic pain. Functional restoration, or, interdisciplinary pain management programs incorporate this model into assessing and treating pain and have demonstrated lasting results in improved functional activities, quality of life, psychological functioning, and pain reduction. The key component to program success is collaborative ongoing communication among team members, the patient, and their support system.

Peripheral stimulation using therapeutic modalities encompasses a large variety of treatments to help strengthen, relax, heal, and decrease pain in patients. Modalities include low level laser therapy (LLLT), radial shockwave therapy, superficial heat, diathermy (ultrasound, shortwave diathermy, microwave diathermy), electrotherapy and massage. These modalities provide direct low-risk interventions in the treatment of pain.

Pain and suffering are the most common reasons people apply for disability benefits. Oftentimes, in the evaluation of chronic pain, clinical information solely is insufficient to predict symptoms and psychosocial factors need to be considered. This chapter discusses a multitude of psychosocial factors that have been associated with disability.

Although symptoms and illness may originate from a health condition, the development of chronic problems and incapacity often depends on psychosocial factors. These psychosocial factors may be obstacles to recovery. Recognizing and addressing these obstacles to recovery and return to work is fundamental to successful rehabilitation.

Interventional pain management procedures are generally well-tolerated and have a low incidence of complications. This chapter aims to provide an overview of potential iatrogenic complications arising from interventional pain. Likewise, identification and management of such complications as well as risk management strategies to improve patient safety and minimize risk following an adverse event will also be addressed.

Nerves in the upper extremity can become compressed at areas of anatomical compromise and produce neuropathic pain and sensorimotor deficits. Symptom severity is related to the degree and chronicity of nerve injury. Nerve compression is often associated with certain occupational or muscle overuse patterns. Electrodiagnostics often carry high utility in diagnosing and localizing these syndromes. Conservative management using rest, activity modification, and rehabilitation can produce improvement in many cases.

Pain from spinal cord injury (SCI) is one of the pain syndromes that is recalcitrant to treatment. It is often a result of injury associated with mechanical trauma and vascular compromise of the spinal cord parenchyma. SCI pain is associated with substantial impact on the patient’s life, interfering with activities of daily living, effective rehabilitation, and quality of life. The underlying mechanism for the development of SCI pain includes neuronal hyperexcitability, reduced inhibition, neuronal reorganization, and plasticity. The diverse factors associated with SCI pain warrant the need for an interdisciplinary approach tailored to the individual patient. The goals of treatment should encompass four domains: pain management, spinal rehabilitation, psychological treatment, and social and environmental modification.

Glossopharyngeal neuralgia (GPN) is both an uncommon and poorly recognized cause of face and neck pain. Because of its potential underdiagnosis, this condition may be more common than reported in the literature. GPN presents with symptoms similar to tic douloureux (trigeminal neuralgia); however, the pathology is not from the trigeminal nerve but rather from the glossopharyngeal nerve. GPN is characterized by unilateral paroxysmal pain in the oropharynx, nasopharynx, larynx, base of the tongue, tonsillar region, and lower jaw, as well as the ipsilateral ear. There are several causes, including tumors, elongated styloid process (Eagle’s syndrome), and vascular compression; however, most cases are considered idiopathic. Treatment for GPN includes treatment of the secondary causes, while medical treatment is similar to that for trigeminal neuralgia. Techniques for cervical, extraoral, intraoral, fluoroscopic, or ultrasound-assisted glossopharyngeal nerve block have been described, and neurolytic techniques such as cryoneuroablation and radiofrequency denervation are available. Because of the location, complications from injections can be serious, and so the injections must be performed with care and knowledge of the anatomy.