David Kloth

The Appropriate Use of Neurostimulation of the Spinal Cord and Peripheral Nervous System for the Treatment of Chronic Pain and Ischemic Diseases: The Neuromodulation Appropriateness Consensus Committee

The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society (INS) evaluated evidence regarding the safety and efficacy of neurostimulation to treat chronic pain, chronic critical limb ischemia, and refractory angina and recommended appropriate clinical applications.

The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases

The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society (INS) evaluated evidence regarding the safety and efficacy of neurostimulation to treat chronic pain, chronic critical limb ischemia, and refractory angina and recommended appropriate clinical applications.

Safeguards to Prevent Neurologic Complications after Epidural Steroid Injections: Consensus Opinions from a Multidisciplinary Working Group and National Organizations

Background: Epidural corticosteroid injections are a common treatment for radicular pain caused by intervertebral disc herniations, spinal stenosis, and other disorders. Although rare, catastrophic neurologic injuries, including stroke and spinal cord injury, have occurred with these injections. Methods: A collaboration was undertaken between the U.S. Food and Drug Administration Safe Use Initiative, an expert multidisciplinary working group, and 13 specialty stakeholder societies. The goal of this collaboration was to review the existing evidence regarding neurologic complications associated with epidural corticosteroid injections and produce consensus procedural clinical considerations aimed at enhancing the safety of these injections. U.S. Food and Drug Administration Safe Use Initiative representatives helped convene and facilitate meetings without actively participating in the deliberations or decision-making process. Results: Seventeen clinical considerations aimed at improving safety were produced by the stakeholder societies. Specific clinical considerations for performing transforaminal and interlaminar injections, including the use of nonparticulate steroid, anatomic considerations, and use of radiographic guidance are given along with the existing scientific evidence for each clinical consideration. Conclusion: Adherence to specific recommended practices when performing epidural corticosteroid injections should lead to a reduction in the incidence of neurologic injuries.

In Response To: Are We Lemmings Going Off a Cliff? The Case Against the “Interventional” Pain Medicine Label

Dear Editor, We appreciate and agree with what seems to be the crux of Dr Richeimers editorial: “… we want pain medicine to be viewed as a legitimate medical specialty, with a broad knowledge base & a wide arsenal of treatments …”. However, we strongly disagree with his statement: “Hopefully, it is clear that the trend toward the use of the label ‘interventional pain medicine’ is very problematic for our specialty.” The valid points that the author makes are diminished by the derisive tone of this letter. The two anecdotes that he provides upon which he builds his arguments (there are no data or statistics presented) seem to be attestations to the superiority of his skills over those of the referring physicians: 1. The 23-year-old woman with complex regional pain syndrom (CRPS) who was “… referred to a community pain specialist who immediately started procedural treatment.” Following this, the patient was referred to the authors pain clinic and received two years of medications and psychological therapy without much relief before finally receiving a spinal cord stimulation (SCS) with 60% reduction in pain. The ASIPP guidelines indicate that this patient should have been offered not only psychological INTERVENTION but …

The MIST Guidelines: The Lumbar Spinal Stenosis Consensus Group Guidelines for Minimally Invasive Spine Treatment

Lumbar spinal stenosis (LSS) can lead to compression of neural elements and manifest as low back and leg pain. LSS has traditionally been treated with a variety of conservative (pain medications, physical therapy, epidural spinal injections) and invasive (surgical decompression) options. Recently, several minimally invasive procedures have expanded the treatment options.

Platelet-Rich Plasma (PRP): Procedural Techniques for Musculoskeletal Injuries

Platelet-rich plasma (PRP) and regenerative medicine has many potential applications, and advancements in its acceptance has increased its use. In terms of pain management, it appears that its greatest benefit may be to aid in healing of soft tissue injury. Many musculoskeletal structures, such as tendons, ligaments, entheses, and muscle belly, can be treated with PRP. Given the multitude of potential sites of treatment, it is important to understand the proper technique and possible complications when using such a therapy.

Lumbar Percutaneous Mechanical Disc Decompression

Minimally invasive disc decompression procedures performed in the United States include microdiscectomy, chemonucleolysis, automated percutaneous discectomy, laser discectomy, radiofrequency Coblation® (ArthroCare Corporation, Austin, TX), hydrodiscectomy, and use of a Dekompressor® (Stryker, Kalamazoo, MI). The evidence for percutaneous discectomy procedures is lacking due to a paucity of literature, a lack of high-quality randomized controlled trials (RCTs), which show conflicting results when they are present. Thus, the evidence based on a best evidence synthesis is Level II to IV for long-term improvement, which is essentially based on small, randomized controlled trials, multiple observational studies, and consensus.