Search

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

Carola Santi,1 Thomas Haag,2 Christian Cooke,2 Michael E Schatman,3,4 Andrea Tinnirello5 1Anesthesia, Intensive Care and Pain Management Unit, Manerbio Hospital, ASST Del Garda, Brescia, Italy; 2Pain Management Unit-Wrexham Maelor Hospital, Wrexham, UK; 3Department of Anesthesiology, Perioperative Care, & Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 4Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA; 5Anesthesia and Pain Management Unit, Iseo Hospital, ASST Franciacorta, Brescia, ItalyCorrespondence: Andrea Tinnirello, Ospedale di Iseo-Asst Franciacorta, Via Giardini Garibaldi 1, Iseo, BS, 25049, Italy, Tel +390303422, Email andrea.tinnirello@asst-franciacorta.itPurpose: Radiofrequency ablation has been used to treat chronic shoulder pain with mixed results. Thanks to recent anatomical studies, the precise location of articular branches of the suprascapular, lateropectoral and axillary nerves has been determined. Cooled radiofrequency is a neuroablative modality of treatment which has been demonstrated as efficient in different anatomical locations, and targeting the aforementioned nerves could result in a complete and efficient denervation of the shoulder. The aim of this study is to assess the efficacy of a fluoroscopic guided cooled radiofrequency technique for chronic shoulder pain.Patients and Methods: This is a retrospective observational study performed in two hospital in Wales and Italy (Wrexham NHS trust and Iseo Hospital). Forty-four patients were treated between December 2019 and January 2023. Follow-up was provided at 1-, 6- and 12-months post-procedure. Pain intensity was measured with a 0– 10-point Numerical Rating Scale (NRS), and was assessed at rest and during movement. Disability was assessed with the Oxford Shoulder Score (OSS). All patients were treated with cooled radiofrequency under fluoroscopic guidance targeting the articular branches of the suprascapular, axillary and lateropectoral nerves.Results: In the 44 patients treated, the mean NRS significantly decreased at all follow ups, pain relief of > 50% was obtained in 70.4%, 61% and 51% of the patients at 1.6 and 12 month follow-ups, respectively. Disability improved significantly, with a mean OSS at 12 months follow up of 30 ± 17.5, compared to 15 ± 3 at baseline. Medication intake (non-steroidal anti-inflammatory drugs (NSAIDS) and/or opioids) significantly decreased at all follow ups.Conclusion: Cooled radiofrequency denervation can be an effective procedure to manage chronic shoulder pain, providing sustained pain relief and functional improvement in more than 50% of the patients.Keywords: radiofrequency, neuromodulation, shoulder pain, pain management

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

Matthew Slitzky,1 R Jason Yong,2 Giuliano Lo Bianco,3 Trent Emerick,4 Michael E Schatman,5,6 Christopher L Robinson2 1Burke Rehabilitation, Montefiore Health System, White Plains, NY, USA; 2Department of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA; 3Anesthesiology and Pain Department, Fondazione Istituto G. Giglio Cefalù, Palermo, Italy; 4Department of Anesthesiology and Perioperative Medicine, Chronic Pain Division, University of Pittsburgh Medical Center, Pittsburgh, PA, 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, USACorrespondence: Christopher L Robinson, Department of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School, Brigham and Women’s Hospital, 75 Francis Street Boston, Boston, MA, 02118, USA, Email crobinson48@bwh.harvard.edu

Sayed E Wahezi,1 Corey W Hunter,2 Farshad M Ahadian,3 Charles E Argoff,4 Michael E Schatman5,6 1Department of Physical Medicine & Rehabilitation, Montefiore Medical Center, Bronx, NY, USA; 2Ainsworth Institute of Pain Management, New York, NY, USA; 3Department of Anesthesiology, Center for Pain and Palliative Medicine, University of California, San Diego Medical Center, San Diego, CA, USA; 4Department of Neurology, Albany Medical Center, Albany, 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, USACorrespondence: Sayed E Wahezi, Department of Physical Medicine and Rehabilitation, Montefiore Medical Center, 1250 Waters Place, Tower #2 8th Floor, Bronx, NY, 10461, USA, Tel +1 718-920-7246, Fax +1 929-263-3950, Email swahezi@montefiore.orgAbstract: The last decade has seen a boom in pain medicine, basic science and interventional pain management. Concomitantly, there is a need to educate trainees, young attendings, and seasoned attendings on these innovations. There has been a growth in the number of societies that represent pain medicine physicians, each with its own philosophy and guiding principles. The variety of thought within pain management, within the various groups that practice this field, and amongst the societies which protect those missions inherently creates divergence and isolation within these different communities. There is the enormous opportunity for our field to grow, but we need the voices of all different specialties and sub-specialties which practice pain medicine to collectively design the future of our emerging field. The explosion of revolutionary percutaneous surgeries, medications, psychotherapy, and research and development in our field has outpaced the ability of payers to fully embrace them. There is an increased number of pain practitioners using novel therapies, postgraduate training programs do not adequately train users in these techniques thereby creating a potential for sub-optimal outcomes. In part, this is a reason why payers for many of our more novel treatments have decreased patient access or eliminated remuneration for some of them. We believe that society-based collaborative regulation of education, research, and treatment guidelines is needed to improve visibility for payers and end users who provide these treatments. Furthermore, postgraduate chronic pain fellowship education has been deemed by many to be insufficient to educate on all of the necessary requirements needed for the independent practice of pain medicine, especially the consummation of newer technologies. Here, we draw comparison with this tenuous stage in pain management history with the last United States recession to remind us of how poor institutional regulation and neglect for long-term growth hampers a community.Keywords: fellowship, training, future

Ramana K Naidu,1 Oth V Tran,2 Michael E Schatman3,4 1Pain Management, Marin Health Medical Center, Greenbrae, CA, USA; 2Health Economics & Outcomes Research, Boston Scientific, Marlborough, MA, USA; 3Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 4Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USACorrespondence: Oth V Tran, Email Oth.v.tran@gmail.comBackground: Evidence regarding the frequency and timing of treatment for lumbar spinal stenosis (LSS) fails to offer clear consensus. We describe the LSS care journey from initial diagnosis to first surgical intervention.Methods: Using Medicare claims database from 2009 through 2020, we identified patients who were diagnosed with LSS. The use and timing of conservative and surgical treatments during the entire follow-up from the initial diagnosis were reported.Results: Of the 143,849 patients identified, 68% received conservative care within 8.4 months and 25.3% received a surgical or minimally invasive intervention over 5.7 years following initial diagnosis, with 12.6% undergoing open decompression alone, 10.2% undergoing open decompression with fusion, and 5.1% undergoing fusion surgery alone. Fewer than 1% were provided with interspinous spacers or a percutaneous image-guided lumbar decompression.Conclusion: Approximately three-quarters of patients in the study received no surgical or non-invasive interventions for approximately six years following diagnosis with LSS.Keywords: lumbar spinal stenosis, interspinous spacer, lumbar decompression, chronic pain

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

Roxanne Bavarian,1,2 Tamunodiyepriye Gift Ngo,3 Michael E Schatman,4,5 Ronald J Kulich3,6 1Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA, USA; 2Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, MA, USA; 3Orofacial Pain Center, Tufts University School of Dental Medicine, Boston, MA, USA; 4Department of Anesthesiology, Perioperative Care, & Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 5Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA; 6Department of Anesthesia, Critical Care and Pain Medicine/Department of Psychiatry Massachusetts General Hospital, Boston, MA, USACorrespondence: Michael E Schatman, Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA, Tel +1 425-647-4880, Email Michael.Schatman@NYULangone.org

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

Christopher 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

Mayank Gupta,1,* Anand S Patil,2,* 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*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

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

Shravani Durbhakula,1 Tony Y Wang,2 Kara G Segna,2 Gerard R Limerick,2,3 Mustafa Y Broachwala,3 Michael E Schatman,4 Munfarid A Zaidi,5 Ingharan James Siddarthan,6 Serkan Toy7 1Department of Anesthesiology, Division of Pain Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; 2Department of Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA; 3Department of Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD, USA; 4Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA; 5Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA; 6Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; 7Departments of Basic Science Education and Health Systems & Implementation Science, Virginia Tech Carilion School of Medicine, Roanoke, VA, USACorrespondence: Shravani Durbhakula, Department of Anesthesiology, Division of Pain Medicine, Vanderbilt University Medical Center, Nashville, TN, USA, Email s.durbhakula@vumc.orgObjective: To examine the immediate effects of a comprehensive pain course on medical students’ pre-existing perceptions and attitudes toward pain patients and opioid management.Methods: First-year medical students at a major academic medical center enrolled in a required pre-clerkship pain course in June 2020 and completed pre- and post-course online surveys with Likert-scale questions about their attitudes toward pain management and opioid-related issues. Additionally, the surveys included a free-text question where the students listed the first five words that came to mind when hearing the word “opioids”. These words were categorized as “professional” or “lay” words and further as having “positive”, “negative”, or “neutral” connotations. Data analyses included descriptive statistics, as well as non-parametric and parametric tests.Results: Fifty-four of the 119 students responded to pretest and posttest surveys and were included in paired analyses. There was a significant difference between the number of professional words used before (M=1.21, SD=0.97) and after the course (M=2.40 SD=1.33); t(52)=− 6.39, P< 0.001. Students also used more lay-positive words after the course (M=0.81, SD=0.63) than they used pre-course (M=0.23, SD=0.43); t(51)=− 5.98, P< 0.001. Students’ post-course responses to several key Likert-scale questions showed significant shifts toward more positive attitudes about caring for patients with pain. For example, students acknowledged greater comfort in providing opioids for chronic pain (P< 0.001) where appropriate, and enhanced interest in handling complex pain cases (P< 0.001).Conclusion: Results showed that a comprehensive, multi-disciplinary pain course could greatly enhance first-year medical students’ attitudes toward pain management, chronic pain patients, and the complex issues surrounding opioids.Keywords: medical education, opioids, stigma, epidemic, biases, pain

Matthew Slitzky,1 R Jason Yong,2 Giuliano Lo Bianco,3 Trent Emerick,4 Michael E Schatman,5,6 Christopher L Robinson2 1Burke Rehabilitation, Montefiore Health System, White Plains, NY, USA; 2Department of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA; 3Anesthesiology and Pain Department, Fondazione Istituto G. Giglio Cefalù, Palermo, Italy; 4Department of Anesthesiology and Perioperative Medicine, Chronic Pain Division, University of Pittsburgh Medical Center, Pittsburgh, PA, 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, USACorrespondence: Christopher L Robinson, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA, 02118, USA, Email crobinson48@bwh.harvard.edu

Scott G Pritzlaff,1 Michael E Schatman2,3 1Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA, USA; 2Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 3Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USACorrespondence: Michael E Schatman, Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA, Tel +1 425-647-4880, Email Michael.Schatman@NYULangone.org

Matthanja Bieze,1,2,&ast; Annelotte Pauline van Haaps,3,4,&ast; Leonardo Kapural,5 Sean Li,6 Kris Ferguson,7 Ralph de Vries,8 Michael E Schatman,9,10 Velja Mijatovic,3,4 Jan Willem Kallewaard1,11 1Department of Anesthesiology and Pain Management, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands; 2Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; 3Department of Reproductive Medicine, Amsterdam University Medical Center location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; 4Amsterdam Reproduction and Development, Amsterdam University Medical Centers, Amsterdam, the Netherlands; 5Carolina’s Pain Institute and Center for Clinical Research, Winston Salem, North Carolina, USA; 6National Spine and Pain Centers, Shrewsbury, New Jersey, USA; 7Aspirus Langlade Hospital Pain Clinic, Antigo, Wisconsin, USA; 8Medical Library, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; 9Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA; 10Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA; 11Department of Anesthesiology and Pain Management, Rijnstate Ziekenhuis, Arnhem, the Netherlands&ast;These authors contributed equally to this workCorrespondence: Jan Willem Kallewaard, Department of Anaesthesiology and Pain Management, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands, Email j.w.kallewaard@amsterdamumc.nlAim: Visceral pain, characterized by pain that is diffuse and challenging to localize, occurs frequently and is difficult to treat. In cases where the pain becomes intractable despite optimal medical management, it can affect patients’ Quality of Life (QoL). Spinal Cord Stimulation (SCS) has emerged as a potential solution for intractable visceral pain.Purpose: In this narrative review, we collected all evidence regarding the efficacy of SCS for visceral pain across various underlying conditions.Methods: A comprehensive literature search was conducted in PubMed, Embase, and Web of Science in which articles published from October 1st, 1963 up to March 7th, 2023 were identified.Results: Seventy articles were included in this review of which most were retrospective cohort studies, case series and case reports. The studies, often with a small number of participants, reported on SCS for chronic pancreatitis, anorectal pain and bowel disorders, gynaecological diagnoses, visceral pelvic pain, urological disorders and finally general visceral pain. They found positive effects on pain and/or symptom relief, opioid consumption, anxiety and depression and QoL. Complications occurred frequently but were often minor and reversible.Conclusion: Better screening and selection criteria need to be established to optimally evaluate eligible patients who might benefit from SCS. A positive outcome of a sympathetic nerve block appears to be a potential indicator of SCS effectiveness. Additionally, women receiving SCS for endometriosis had a better outcome compared to other indications. Finally, SCS could also relief functional symptoms such as voiding problems and gastroparesis. Complications could often be resolved with revision surgery. Since SCS is expensive and not always covered by standard health insurance, the incorporation of cost-analyses is recommended. In order to establish a comprehensive treatment plan, including selection criteria for SCS, rigorous prospective, possibly randomized and controlled studies that are diagnosis-oriented, with substantial follow-up and adequate sample sizes, are needed.Keywords: neuromodulation, SCS, spinal cord stimulation, visceral pain, chronic pelvic pain, chronic pain

Michael E Schatman,1,2 Danielle Levin1 1Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 2Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USACorrespondence: Michael E Schatman, Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA, Tel +1 425-647-4880, Email Michael.Schatman@NYULangone.org

Scott G Pritzlaff,1 Miles Day,2 Sayed E Wahezi,3 Michael E Schatman4,5 On behalf of Pain Medicine Luminaries1Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA, USA; 2Traweek-Racz Endowed Professor in Pain Research, Department of Anesthesiology, Texas Tech University HSC, Lubbock, TX, USA; 3Departments of Rehabilitation Medicine, Anesthesiology, and Orthopedic Surgery, Montefiore Medical Center, Bronx, NY, USA; 4Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 5Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USACorrespondence: Michael E Schatman, Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA, Tel +1 425-647-4880, Email Michael.Schatman@NYULangone.org

Giuliano Lo Bianco,1 Sean Li,2 Miles Day,3 Michael E Schatman4,5 1Anesthesiology and Pain Department, Fondazione Istituto ”G. Giglio”, Cefalù, Palermo, Italy; 2National Spine and Pain Centers, Shrewsbury, NJ, USA; 3Pain Research, The Pain Center at Grace Clinic, Department of Anesthesiology, Texas Tech University HSC, Lubbock, TX, USA; 4Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 5Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USACorrespondence: Michael E Schatman, Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA, Tel +1 425-647-4880, Email Michael.Schatman@NYULangone.org

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

Giuliano Lo Bianco,1 Michael E Schatman2,3 1Anesthesiology and Pain Department, Fondazione Istituto “G. Giglio”, Cefalù, Palermo, Italy; 2Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 3Department 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, USA, Tel +1 425-647-4880, Email Michael.Schatman@NYULangone.org

Sunil Agarwal,1 Christopher Gharibo,2 Michael E Schatman2,3 1Department of Anesthesiology, Division of Pain Medicine, Emory University School of Medicine, Atlanta, GA, USA; 2Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 3Department 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, USA, Tel +1 425-647-4880, Email Michael.Schatman@NYULangone.org

Giuliano Lo Bianco,1,2 Andrea Tinnirello,3 Alfonso Papa,4 Vito Torrano,5 Gianluca Russo,6 Agnes Stogicza,7 Sebastiano Mercadante,8 Andrea Cortegiani,9 Silvia Mazzoleni,3 Michael E Schatman10,11 1Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy; 2Department of Anesthesiology and Pain, Fondazione Istituto G. Giglio, Cefalù, Italy; 3Department of Anesthesiology and Pain Medicine, ASST Franciacorta, Ospedale di Iseo, Iseo, Italy; 4Department of Pain Management– AO “Ospedali dei Colli” – Monaldi Hospital, Naples, Italy; 5Department of Anesthesia, Critical Care and Pain Medicine, Asst Grande Ospedale Metropolitano Niguarda, Milan, Italy; 6Department of Anesthesia, Postoperative Intensive Care and Pain Therapy, Lodi Hospital, Lodi, Italy; 7Department of Anesthesiology Saint Magdolna Hospital, Budapest, Hungary; 8Department of Pain Relief and Supportive Care, Private Hospital La Maddalena, Palermo, Sicilia, Italy; 9Department of Anesthesiology and Intensive Care, Università degli Studi di Palermo, Palermo, Italy; 10Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU School of Medicine, New York, NY, USA; 11Department of Population Health – Division of Medical Ethics, NYU School of Medicine, New York, NY, USACorrespondence: Andrea Tinnirello, Department of Anesthesiology and Pain Medicine, ASST Franciacorta, Ospedale di Iseo, Via Giardini Garibaldi 4, Iseo, 25049, Italy, Tel +393392599568, Email andreatinny@libero.itAbstract: In recent years, there has been a considerable increase in the number of image-guided interventional procedures performed for the management of acute and chronic pain. Concomitantly, there has also been an increase in the complication rate related to these procedures. The aim of this narrative review is to summarize the primary complications associated with commonly performed image-guided (fluoroscopic- or ultrasound-guided) interventional procedures. We conclude that although complications from interventional pain procedures can be mitigated to a certain degree, they cannot be eliminated altogether. In order to avoid adverse events, patient safety should be given considerable attention and physicians should be constantly aware of the possibility of developing complications.Keywords: chronic pain, pain management, analgesics, opioid, epidural injection, facet joints

Giuliano Lo Bianco,1,2 Giovanni Misseri,2 Agnes R Stogicza,3 Gregoretti Cesare,2,4 Sean Li,5 Miles Day,6 David J Kennedy,7 Michael E Schatman8,9 1Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy; 2Anesthesiology and Pain Department, Fondazione Istituto “G. Giglio”, Cefalù, Palermo, Italy; 3Anesthesia and Pain, Saint Magdolna Private Hospital, Budapest, Hungary; 4Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy; 5National Spine and Pain Centers, Shrewsbury, NJ, USA; 6Pain Research, The Pain Center at Grace Clinic, Texas Tech University HSC, Lubbock, TX, USA; 7Department of PM&R, Vanderbilt University Medical Center, Nashville, TN, USA; 8Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 9Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USACorrespondence: Giuliano Lo Bianco, Anesthesia and Pain Medicine Department, Fondazione Giglio Cefalù, Contrada Pietrapollastra, Via Pisciotto, Cefalù, Palermo, 90015, Italy, Tel +393289682219, Email giulianolobianco@gmail.comBackground: Lumbar zygapophyseal joint dysfunction represents one of the major sources of chronic low back pain. Radiofrequency ablation (RFA) using a V-shaped active tip needle may offer a larger lesion of the medial branch nerves, improving clinical outcome. The aim of our study is to evaluate the efficacy and the feasibility of RFA using V-shaped active tip needles.Methods: This is a single-center observational retrospective study. Clinical records were screened and analyzed if they met the following inclusion criteria: adult patients (> 18 years), diagnosis of chronic lumbar zygapophyseal joint pain, failure of conservative treatments, ability to provide informed consent for data analysis and publication. Exclusion criteria: lumbar pain not related to zygapophyseal joints, previous spinal/lumbar surgery, incomplete data, absence or withdrawal of informed consent. The primary outcome of the study was a change in pain intensity at follow-up. The secondary outcomes were the evaluation of quality-of-life improvement, the occurrence of adverse events and the impact on post-procedural analgesic consumption. For these purposes, pre- and post-treatment numeric rating scale (NRS), neuropathic pain 4 questions (DN4), EuroQoL - EQ-5D-3L, EQ-VAS, EQ-index and North American Spine Society (NASS) index were retrieved and analysed.Results: Sixty-four patients were included. 7.8% of patients at 1-month (CI95% 0.026, 0.173), 37.5% at 3-month (CI95% 0.257, 0.505), 40.6% at 6-month (CI95% 0.285, 0.536) and 35.9% at 9-month (CI95% 0.243, 0.489) follow-up reported a reduction of more than 80% in NRS Statistical analysis indicated a significant change in NRS, DN4, EQ-index and EQ-5D-VAS (p-value < 0.001) at the different time-points.Conclusion: RFA using a V-shaped active tip needle might be a feasible and effective treatment for chronic lumbar zygapophyseal joint pain.Keywords: arthralgia, chronic pain, zygapophyseal joint, pain management, radiofrequency ablation, neuromodulation, lumbar facet joint

Giuliano Lo Bianco,1,2 Andrea Tinnirello,3 Alfonso Papa,4 Maurizio Marchesini,5 Miles Day,6 Gaetano Joseph Palumbo,7 Gaetano Terranova,8 Maria Teresa Di Dato,4 Simon J Thomson,9 Michael E Schatman10,11 1Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy; 2Anesthesiology and Pain Department, Fondazione Istituto G. Giglio, Cefalù, Italy; 3Anesthesiology and Pain Medicine Department, ASST Franciacorta, Ospedale di Iseo, Iseo, 25049, Italy; 4Pain Department, AO “Ospedali dei Colli”, Monaldi Hospital, Naples, Italy; 5Mininvasive Surgery Department, Unit of Pain Medicine IRCCS Maugeri Pavia, Pavia, 27100, Italy; 6Pain Research, The Pain Center at Grace Clinic, Texas Tech University HSC, Lubbock, TX, USA; 7Azienda Ospedale - Università Padova, Department of Anesthesia and Intensive Care, Padova, Italy; 8Anaesthesia and Intensive Care Department, Asst Gaetano Pini, Milano, Italy; 9Pain Management, Mid and South Essex University Hospitals NHSFT, Basildon, SS16 5NL, UK; 10Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU School of Medicine, New York, NY, USA; 11Department of Population Health – Division of Medical Ethics, NYU School of Medicine, New York, NY, USACorrespondence: Giuliano Lo Bianco, Email giulianolobianco@gmail.comAbstract: In patients where conservative approaches have failed to relieve from chronic pain, interventional procedures may be an option in well selected patients. In recent years there has been an increase in the use and development of invasive procedures. Concomitantly, there has also been an increase in the complications associated with these procedures. Taken this into consideration, it is important for healthcare providers to take a cautious and vigilant approach, with a focus on patient safety, in order to minimize the risk of adverse events and ensure the best possible outcome for the patient. This may include careful selection of patients for procedures, use of proper techniques and equipment, and close monitoring and follow-up after the procedure. The aim of this narrative review is to summarize the primary complications associated with commonly performed image-guided (fluoroscopy or ultrasound-guided) interventional procedures and provide strategies to reduce the risk of these complications. We conclude that although complications from interventional pain procedures can be mitigated to a certain degree, they cannot be eliminated altogether. In order to avoid adverse events, patient safety should be given considerable attention and physicians should be constantly aware of the possibility of developing complications.Keywords: chronic pain, pain management procedures, complications, spinal cord stimulation, intrathecal drug delivery, low back pain

Tonya M Palermo,1 Karen Deborah Davis,2 Didier Bouhassira,3 Robert W Hurley,4 Joel D Katz,5 Francis J Keefe,6 Michael E Schatman,7,8 Dennis C Turk,1 David Yarnitsky9 1Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington, USA; 2Department of Surgery and Institute of Medical Science, Krembil Brain Institute, University Health Network; University of Toronto, Toronto, Ontario, Canada; 3Inserm U987, APHP, UVSQ, Paris-Saclay University, Ambroise Pare Hospital, Boulogne-Billancourt, France; 4Department of Anesthesiology, Neurobiology and Anatomy, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA; 5Department of Psychology, York University, Toronto, Ontario, Canada; 6Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA; 7Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA; 8Department of Population Health − Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA; 9Department of Neurology, Rambam Medical Center, and Laboratory of Clinical Neurophysiology, Technion Faculty of Medicine, Haifa, IsraelThis article is being published concurrently in Journal of Pain, PAIN, European Journal of Pain, Pain Medicine, Canadian Journal of Pain, Journal of Pain Research, Clinical Journal of Pain, and PAIN Reports. The articles are identical except for minor stylistic and spelling differences in keeping with each journal’s style. Citation from any of the journals can be used when citing this article.Correspondence: Tonya M Palermo, PhD, Department of Anesthesiology & Pain Medicine, University of Washington, P.O. Box 5371, M/S BC-3, Seattle Children’s Research Institute, Seattle, WA 98145-5005, USA, E-mail address: tonya.palermo@seattlechildrens.org

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

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

Evan Peskin,1 Jeffrey Gudin,2 Michael E Schatman3,4 1Department of Pain Management - Insight Institute of Neurosurgery & Neuroscience, Flint, MI, USA; 2Professor of Anesthesiology, Perioperative Medicine and Pain Management - University of Miami, Miller School of Medicine, Miami, Fl, USA; 3Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 4Department 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, USA, 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

Jeffrey J Bettinger,1 William Amarquaye,2 Jeffrey Fudin,3– 6 Michael E Schatman7– 9 1Saratoga Hospital Medical Group, Saratoga Springs, NY, USA; 2HCA Florida Brandon Hospital, Brandon, FL, USA; 3President, Remitigate Therapeutics, Delmar, NY, USA; 4Department of Pharmacy Practice, Albany College of Pharmacy & Health Sciences, Albany, NY, USA; 5Department of Pharmacy Practice, Western New England University College of Pharmacy, Springfield, MA, USA; 6Department of Pharmacy and Pain Management, Stratton VA Medical Center, Albany, NY, USA; 7Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 8Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA; 9School of Social Work, North Carolina State University, Raleigh, NC, USACorrespondence: Michael E Schatman, Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA, Tel +425-647-4880, Email Michael.Schatman@NYULangone.org

Gabriela Toutin Dias,1 Michael E Schatman2– 4 1Psychology Assessment Center, Massachusetts General Hospital, Boston, MA, USA; 2Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU School of Medicine, New York, NY, USA; 3Division of Medical Ethics, NYU School of Medicine, New York, NY, USA; 4School of Social Work, North Carolina State University, Raleigh, NC, USACorrespondence: Michael E SchatmanDepartment of Anesthesiology, Perioperative Care and Pain Medicine, NYU School of Medicine, 550 First Avenue, New York, NY, 10016, USATel +1 425-647-4880Email Michael.Schatman@NYULangone.org

Alaa Abd-Elsayed,1 Joshua M Martens,2 Kenneth J Fiala,2 Michael E Schatman3,4 1Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; 2University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; 3Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU School of Medicine, New York, NY, USA; 4School of Social Work, North Carolina State University, Raleigh, NC, USACorrespondence: Alaa Abd-ElsayedDepartment of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USATel +1 608 263 6039Email alaaawny@hotmail.comBackground: Approximately 10– 15% of the population over the age of 60 suffers from hip pain. Greater trochanteric pain syndrome (GTPS) is one of the most common diagnoses in patients with chronic hip pain, includes a number of disorders, and has a broad differential diagnosis. Conservative managements of GTPS, including pharmacologic interventions, physical therapy, chiropractic intervention, acupuncture, and more invasive techniques, such as intra-articular injections, commonly fail to provide patients with sufficient, long-term relief. While radiofrequency ablation (RFA) has been used to treat intra-articular hip pain in the past, there is little evidence for the feasibility of RFA for managing patients with GTPS. This case series builds on previous evidence that cooled radiofrequency ablation (CRF) of the trochanteric branch of the femoral nerve may offer patients with GTPS effective, safe, and lasting pain improvement.Cases: A series of eight patients with GTPS underwent CRF of the nervus females to the trochanter. CRF procedures were either targeted at the left, right, or bilateral nerves.Conclusion: This case series provides additional evidence for the safety and effectiveness of CRF of the nervus femoralis to the trochanter for offering long-term pain relief in patients with GTPS. All patients experienced at least two months of relief, with most patients experiencing ongoing relief from the procedure.Keywords: greater trochanteric pain syndrome, GTPS, radiofrequency ablation, nervus femoralis, trochanter

Michael E Schatman,1,2 Kelly Kooharian,3 Patricia Guerrero4 1Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 2Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA; 3Hospice Department, VNA of Cape Cod, Hyannis, MA, USA; 4Department of Diagnostic Sciences, Tufts School of Dental Medicine, Boston, MA, USACorrespondence: Michael E Schatman, Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, 550 1st Ave, New York, NY, 10016, USA, Tel +1 425-647-4880, Email Michael.Schatman@NYULangone.org

Michael E Schatman,1– 3 Hannah Shapiro3,4 1Division of Medical Ethics, NYU School of Medicine, New York, NY, USA; 2Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU School of Medicine, New York, NY, USA; 3School of Social Work, North Carolina State University, Raleigh, NC, USA; 4McLean Hospital, Division of Alcohol, Drugs, and Addiction, Harvard Medical School, Boston, MA, USACorrespondence: Michael E SchatmanDivision of Medical Ethics, Department of Population Health, NYU School of Medicine, 550 First Avenue, New York, NY, 10016, USATel +1 425-647-4880Email Michael.Schatman@NYULangone.org

Roxanne Bavarian,1,2 Michael E Schatman,3,4 David A Keith1,2 1Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA, USA; 2Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, Ma, USA; 3Department of Anesthesiology, Perioperative Care, & Pain Medicine, NYU School of Medicine, New York, NY, USA; 4School of Social Work, North Carolina State University, Raleigh, NC, USACorrespondence: David A KeithDepartment of Oral and Maxillofacial Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USATel +1 617 643-1425Fax +1 617 726-2814Email dkeith@mgh.harvard.eduAbstract: Over three decades ago, hundreds of predominantly young women with temporomandibular joint pain and other symptoms were implanted with a prosthetic device composed of Proplast-Teflon that subsequently caused considerable harm, with patients developing chronic pain, dysfunction, and disability. This perspective review presents such a patient who suffered for decades with severe pain despite extensive pharmacotherapy, injection therapy, multiple surgeries, and behavioral health interventions. The details of the origin and subsequent events regarding the use of Proplast-Teflon interpositional implants in the temporomandibular joint are described with resources from several different perspectives. The lessons learned demonstrate failures at the federal, professional, and individual level.Keywords: Proplast-Teflon, implants, temporomandibular joint surgery, temporomandibular joint replacement, risk management, medicolegal, chronic pain

Nasir Hussain,1,2 Michael E Schatman,3– 5 Alaa Abd-Elsayed6 1Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard, Boston, MA, USA; 2Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, OH, USA; 3Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 4Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA; 5School of Social Work, North Carolina State University, Raleigh, NC, USA; 6Department of Anesthesiology and Pain Medicine, University of Wisconsin-Madison, Madison, WI, USACorrespondence: Michael E Schatman, Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA, Email Michael.Schatman@NYULangone.org

Alfonso Papa,1 Maria Teresa Di Dato,1 Giuliano Lo Bianco,1– 3 Giuseppe Gazzerro,1 Anna Maria Salzano,1 Emilio Di Costanzo,1 Dario Tammaro,1 Michael E Schatman,4,5 Giustino Varrassi6 1Pain Department AO “Ospedali dei Colli”, Monaldi Hospital, Naples, Italy; 2Department of Biomedical and Biotechnological Sciences (BIOMETEC), University of Catania, Catania, Italy; 3Anesthesiology and Pain Department, Fondazione Istituto G. Giglio, Cefalù, Italy; 4Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU School of Medicine, New York, NY, USA; 5School of Social Work, North Carolina State University, Raleigh, NC, USA; 6Paolo Procacci Foundation, Rome, ItalyCorrespondence: Giuliano Lo Bianco Tel +393289682219Email giulianolobianco@gmail.comObjective: Osteoarthritis (OA) is the most common cause of chronic knee pain, often a debilitating condition that can cause a significant reduction in functional capacity. Radiofrequency is a form of neuromodulation that modulates pain signal transmission and has become progressively more common as a treatment for knee pain. This retrospective study aims to evaluate the efficacy of intraarticular radiofrequency in patients with chronic knee OA pain.Materials and Methods: In this retrospective study, we included 129 patients undergoing intraarticular pulsed radiofrequency using the Poisson curve for energy distribution (Sluijter-Teixeira Poisson radiofrequency) (STP) from March 2018 to November 2019. Knee osteoarthritis severity was assessed prior to the procedure using the Lequesne Index, classifying patients into six groups based on level of severity. Pain intensity was assessed through a 10-cm visual analog scale (VAS), and level of patient satisfaction was assessed through a questionnaire.Results: In the sample, pain reduction as measured by VAS compared to baseline prior to the procedure was statistically significant immediately following the procedure, at 30 days and at 90 days (p< 0.001); this difference was less significant at 180 days (p< 0.005). Efficacy in patients with moderate to severe disability was considerably greater than in patients with very severe to extremely severe disability. 57.36% reported that they were very satisfied, 29.46% satisfied, 9.3% neither satisfied nor dissatisfied, 2.33% dissatisfied, and 1.55% very dissatisfied.Conclusion: Our results suggest that STP radiofrequency may be a safe and effective procedure for knee OA, able to signi&filig;cantly reduce VAS scores at 1 month and 3 months compared to baseline. Based on our results, a key factor to consider when treating knee OA with STP radiofrequency is that it is more effective among patients with a lower level of disability. Due to the retrospective observational study design, prospective longitudinal investigation is required to further support the recommendation of STP radiofrequency for knee OA.Keywords: pulsed radiofrequency treatment, knee joint, osteoarthritis, knee, chronic pain

Chelsey Hoffmann,1 Michael E Schatman2,3 1Department of Medical Education, Mayo Clinic School of Health Sciences, Rochester, MN, USA; 2Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 3Department 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, USA, Tel +1 425-647-4880, Email Michael.Schatman@NYULangone.org

Steven J Scrivani,1 David A Keith,2 Ronald J Kulich,1,3 Alexandre F DaSilva,4,5 R Bruce Donoff,2 Shruti Handa,2 Nicole Holland,6 Mark A Lerman,7 Jenna L McCauley,8 Lori Reisner,9,10 Cory M Resnick,11– 13 Christian S Stohler,14,15 Alexis Vasciannie,1 Matthew Fortino,1,16 Michael E Schatman1,17,18 1Department of Diagnostic Sciences, Craniofacial Pain and Headache Center, Tufts University School of Dental Medicine, Boston, MA, USA; 2Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA; 3Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; 4Department of Biological and Material Sciences & Prosthodontics, University of Michigan School of Dentistry, Headache and Orofacial Pain Effort, University of Michigan, Ann Harbor, MI, USA; 5fNIRS Laboratory, University of Michigan, Ann Harbor, MI, USA; 6Department of Public Health and Community Service, Tufts University School of Dental Medicine, Boston, MA, USA; 7Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA; 8Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA; 9Department of Pharmaceutical Services, School of Pharmacy University of California, San Francisco, CA, USA; 10Department of Clinical Pharmacy, San Francisco Medical Center, San Francisco, CA, USA; 11Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA, USA; 12Harvard School of Dental Medicine, Boston, MA, USA; 13Harvard Medical School, Boston, MA, USA; 14Columbia University College of Dental Medicine, New York, NY, USA; 15Columbia University Medical Center, New York, NY, USA; 16Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA; 17Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA, USA; 18School of Social Work, North Carolina State University, Raleigh, NC, USACorrespondence: Michael E Schatman Tel +1 425647-4880Email Michael.Schatman@Tufts.eduAbstract: Over the past year our attention has inevitably been on the coronavirus pandemic, the health and welfare of our families, patients, and office staffs as well as the re-opening of our dental practices. In addition, the opioid crisis continues, is very likely to worsen as a result of the pandemic and continues to be a challenge to Dentistry. National public health issues and healthcare disparities continue and have created a global concern for providing evidence-based, adequate pain management in the dental setting. We have brought together a group of national thought leaders and experts in this field who will share their insights on the current state of opioid prescribing in Dentistry and describe some of the exciting work being done in advancing pain management.The learning objectives for this conference proceedings were:Describing the implications of current public health concerns for safe and effective pain management in dental medicine.Identifying risk factors and understanding the current guidelines for the use of opioid and non-opioid medications in dental medicine.Analyzing the interprofessional collaborations necessary for effective pain management in dental medicine.Recognizing the challenges and opportunities brought about by the COVID-19 pandemic for the dental profession.Applying evidence-based strategies for managing the complex pain patient in the dental setting.Appraising new and future modalities for the assessment and management of orofacial pain.Keywords: pain management, Dentistry, opioid analgesia, COVID-19

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

Alaa Abd-Elsayed,1 Ann M Heyer,1 Michael E Schatman2– 4 1Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; 2Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU School of Medicine, New York, NY, USA; 3Division of Medical Ethics, NYU School of Medicine, New York, NY, USA; 4School of Social Work, North Carolina State University, Raleigh, NC, USACorrespondence: Alaa Abd-ElsayedDepartment of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI 53792-3272, USATel +1 608 263 6039Email alaaawny@hotmail.com

Natalie Strand,1 Layth Mahdi,2 Michael E Schatman,3,4 Jillian Maloney,1 Christopher Wie1 1Division of Pain Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA; 2Mayo Clinic Alix School of Medicine, Phoenix, AZ, USA; 3Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA; 4Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USACorrespondence: Michael E Schatman Tel +1 425 647-4880Email Michael.Schatman@tufts.edu

John F Peppin,1 Robert B Raffa,2– 5 Michael E Schatman6,7 1Department of Internal Medicine, Marian University College of Osteopathic Medicine, Indianapolis, IN, USA; 2Temple University School of Pharmacy, Philadelphia, PA, USA; 3University of Arizona College of Pharmacy, Tucson, AZ, USA; 4Neumentum, Inc., Morristown, NJ, USA; 5Enalare Therapeutics, Naples, FL, USA; 6Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA; 7Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USACorrespondence: Michael E Schatman Tel +1 425 647-4880Email Michael.Schatman@tufts.edu In the late 1990s and early 2000s, it was recognized that an increasing number of people were dying from opioid overdose, and regulatory agencies, professional societies, and legislative bodies actively adopted and promulgated efforts to reduce the “epidemic”. Yet, despite multiple guidelines, legislative enactions (often draconian), and attempts at legal and financial-penalty remedies, death rates continue to climb. The literature is now replete with the terms “opioid-induced respiratory depression” and “opioid overdose death” to describe the cause of death in many of these cases. Unfortunately, this terminology is too simplistic and now woefully outdated. It understates the complexities of these deaths, and the fact that the majority of overdose deaths currently involve multiple substances – that is, it is now a polysubstance-overdose death crisis.

Michael E Schatman,1,2 Matthew G Fortino1,3,4 1Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA; 2Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA; 3Department of Clinical Psychology, William James College, Newton, MA, USA; 4Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USACorrespondence: Michael E Schatman Tel +1425647-4880Email Michael.Schatman@tufts.eduAmerican chronic pain medicine has been in a state of crisis for many years, with the overall quality of care continuing to deteriorate. In a 3-part series published in 2008, Giordano and Schatman discussed this crisis,1–3 elucidating the notion thatchronic pain care would not reach its potential if we failed to emphasize multidisciplinary care focused on the needs of patients. More than a decade later, it is quite apparent that our warnings were not heeded. Much of this failure has been related to the devolution of the “profession” of pain medicine to the “business” of pain medicine,4 which has been due to numerous factors. These have included, but not necessarily been limited to, the malevolent dominance of the health insurance industry,5,6 progressive corporatization,7 fraudulent marketing,8 industry’s detrimental influence on medical education,9,10 a lack of undergraduate medical education in pain management,11 and, of course, the profound swing of the “opioid pendulum” from reckless opiophilia to its current zeitgeist of often cruel opiophobia,12–14 and last but not least, the demise of interdisciplinary paincare.15–18

Malini Ghoshal,1 Hannah Shapiro,2 Knox Todd,3 Michael E Schatman4,5 1Inspirra Healthcare, Plano, Texas, USA; 2Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, Massachusetts, USA; 3Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center Houston, Texas, USA; 4Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, Massachusetts, USA; 5Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USACorrespondence: Michael E Schatman Tel +1(425)647-4880Email Michael.Schatman@tufts.edu Although it is widely recognized that the United States has a severe and broad systemic racism problem, recent events have dramatically elevated the issue. Widespread protests in the US and around the world have brought much-deserved attention to the plights of Blacks, Indigenous and People of Color (BIPOC) regarding injustices that they experience on a daily basis. For the sake not only of BIPOC, but communities and societies as a whole, racial injustice can no longer be ignored or minimalized.1

Michael E Schatman,1,2 Hannah Shapiro,3 Jeffrey Fudin4– 7 1Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA; 2Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA; 3McLean Hospital, Division of Alcohol, Drugs, and Addiction, Harvard Medical School, Boston, MA, USA; 4Remitigate Therapeutics, Delmar, NY, USA; 5Department of Pharmacy Practice, Albany College of Pharmacy, Albany, NY, USA; 6Department of Pharmacy Practice, Western New England University, Springfield, MA, USA; 7Stratton VA Medical Center, Albany, NY, USACorrespondence: Michael E Schatman Tel +1 (425) 647-4880Email Michael.Schatman@tufts.edu The Affordable Care Act (ACA) was signed into law in March of 2010 by President Barack Obama, and represented the most significant expansion of health care coverage and regulatory overhaul since the establishment of Medicare and Medicaid in 1965.1 The expansion of the number of individuals covered by health insurance under the ACA, most notably the clause prohibiting insurers from refusing to cover those with pre-existing conditions, has dramatically improved access to chronic pain management for approximately 50 million Americans living with chronic pain.2 For a number of years, we have been writing about the urgent need to improve the deteriorating quality of pain management in the United States.3–6 Many patients believe that the war on prescription opioids, patients who rely upon them, and physicians with the audacity to still prescribe them has resulted in the marginalization of the nation’s pain care system.7–11 However, the looming potential demise of the ACA based purely on political motivations and characterological flaws presents an existential threat of colossal proportions to chronic pain patients.

Jonathan Greenberg,1,2 Ryan A Mace,1,2 Paula J Popok,1 Ronald J Kulich,2,3 Kushang V Patel,4 John W Burns,5 Tamara J Somers,6 Francis J Keefe,7 Michael E Schatman,8,9 Ana-Maria Vrancenanu1,2 1Integrated Brain Health Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA; 2Harvard Medical School, Boston, MA, USA; 3Center for Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; 4Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA; 5Division of Behavioral Sciences, Rush Medical College, Chicago, IL, USA; 6Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; 7Department of Medicine, Duke University School of Medicine, Durham, NC, US; 8Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA; 9Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USACorrespondence: Ana-Maria Vrancenanu Email avranceanu@mgh.harvard.eduBackground: Improving all aspects of physical function is an important goal of chronic pain management. Few studies follow recent guidelines to comprehensively assess physical function via patient-reported, performance-based, and objective/ambulatory measures.Purpose: To test 1) the interrelation between the 3 types of physical function measurement and 2) the association between psychosocial factors and each type of physical function measurement.Methods: Patients with chronic pain (N=79) completed measures of: 1) physical function (patient-reported disability; performance-based 6-minute walk-test; objective accelerometer step count); 2) pain and non-adaptive coping (pain during rest and activity, pain-catastrophizing, kinesiophobia); 3) adaptive coping (mindfulness, general coping, pain-resilience); and 4) social-emotional dysfunction (anxiety, depression, social isolation and emotional support). First, we tested the interrelation among the 3 aspects of physical function. Second, we used structural equation modeling to test associations between psychosocial factors (pain and non-adaptive coping, adaptive coping, and social-emotional dysfunction) and each measurement of physical function.Results: Performance-based and objective physical function were significantly interrelated (r=0.48, p< 0.001) but did not correlate with patient-reported disability. Pain and non-adaptive coping (β=0.68, p< 0.001), adaptive coping (β=− 0.65, p< 0.001) and social-emotional dysfunction (β=0.65, p< 0.001) were associated with patient-reported disability but not to performance-based or objective physical function (ps> 0.1).Conclusion: Results suggest that patient-reported physical function may provide limited information about patients’ physical capacity or ambulatory activity. While pain and non-adaptive reactions to it, adaptive coping, and social-emotional dysfunction may potentially improve patient-reported physical function, additional targets may be needed to improve functional capacity and ambulatory activity.Trial Registration: ClinicalTrials.gov NCT03412916.Keywords: physical function, chronic pain, six-minute walk test, accelerometer, psychosocial factors

Hannah Shapiro, 1 Ronald J Kulich, 2, 3 Michael E Schatman 3, 4 1Department of Biopsychology, Tufts University, Medford, MA, USA; 2Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School/Massachusetts General Hospital, Boston, MA, USA; 3Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA; 4Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USACorrespondence: Michael E Schatman Tel +1 425 647-4880Email Michael.Schatman@tufts.eduTo the best of our knowledge, no one has ever suggested that it is “easy” to suffer from intractable chronic pain, with some subgroups impacted more than others. This burden has had a particularly strong impact in the United States, where the chronic pain treatment system has demonstrated failings with respect to access to care1–8 Because chronic pain is so poorly treated in the United States, patients have struggled not only with their pain and its sequelae but also with mounting frustration and downstream psychological consequences. Depression and suicidality have been linked to poorly controlled pain,9,10 and the authors of a recent study11 noted that these phenomena are a concern within the context of opioid tapering. Similarly, Lembke has recently acknowledged that even mention of tapering can trigger severe anxiety in chronic pain patients,12 with data supporting the relationship between undertreated chronic pain and anxiety.13,14 Although myriad investigations have supported the existence of a reciprocal relationship between chronic pain and depression15–17 as well as between chronic pain and anxiety,18–20 detailed discussion of causality is beyond the scope of this analysis.

Matteo Luigi Giuseppe Leoni,1 Michael E Schatman,2,3 Laura Demartini,4 Giuliano Lo Bianco,5– 7 Gaetano Terranova8 1Unit of Interventional Pain Management, Guglielmo da Saliceto Hospital, Piacenza, Italy; 2Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA; 3Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA; 4Pain Unit, Istituti Clinici Scientifici Maugeri, Pavia, Italy; 5Basildon and Thurrock University Hospital, Essex, London, Orsett Hospital, Pain Management and Neuromodulation, London, Essex, UK; 6IRCCS Centro Regionale Oncologico Basilicata, Rionero in Vulture, Italy; 7Department of Biomedical and Biotechnological Sciences (Biometec), Università di Catania, Catania, Italy; 8Anaesthesia and Intensive Care Department, Asst Gaetano Pini, Milano, ItalyCorrespondence: Matteo Luigi Giuseppe LeoniUnit of Interventional Pain Management, G. da Saliceto Hospital, via Taverna 49, 29121, Piacenza, ItalyEmail matteolg.leoni@gmail.comBackground: Chronic knee osteoarthritic (OA) pain is a common and debilitating complaint in elderly patients. Despite numerous pharmaceutical options, the majority of patients still experience long-term pain. Genicular nerve (GN) radiofrequency has become increasingly popular as a treatment for knee pain. This retrospective study aimed to evaluate the effects of pulse dose radiofrequency (PDRF) in patients with chronic knee OA pain.Patients and Methods: Propensity score matching analysis was performed in a retrospective cohort of 78 patients with moderate-severe knee OA pain unresponsive to conservative treatment who underwent PDRF GN or intra-articular (IA) and PDRF GN. Pain relief was measured using the numeric rating scale (NRS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Patient Global Impression of Change (PGIC) at 3 and 6 months post-intervention.Results: A significant reduction in NRS scores was reported at 3 (p< 0.001) and 6 months (p< 0.001) after PDRF in both groups. NRS was lower in PDRF IA + GN than PDRF GN (p< 0.0001). WOMAC pain was significantly reduced at 3 months in PDRF IA + GN group (baseline: 10.12± 3.14, 3 months: 6.25± 2.44, p=0.0001). WOMAC stiffness and function were improved only at 3 months in PDRF IA + GN compared to baseline (p=0.007 and p=0.006, respectively). A longer period of pain relief was reported after PDRF IA + GN (6.75± 2.42 months) compared to PDRF GN (4.31± 2.85 months, p< 0.001) in association with higher PGIC scores.Conclusion: This is the first study that compared two different PDRF techniques. PDRF GN and PDRF IA + GN were both effective in reducing pain at 3 and 6 months follow-up. However, only PDRF IA + GN was able to improve WOMAC scores at 3 months after the treatment with a longer period of efficacy compared to PDRF GN alone.Keywords: knee pain, pulse dose radiofrequency; PDRF, radiofrequency; genicular nerve, osteoarthritis, chronic pain, WOMAC, interventional pain management