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Regenerative medicine is an evolving medical subspecialty dedicated to enhancing the body's natural healing mechanisms to repair or replace damaged tissues. By using autologous or allogeneic biologics, it offers the potential to restore function where conventional therapies have shown limited success. While this field holds great promise and continues to generate enthusiasm among both patients and clinicians, it remains in early stages of clinical validation. Therefore, it must be approached with careful optimism and responsible application, ensuring that its presentation, promotion, and use in clinical settings are grounded in evidence and ethical standards. To provide updated, evidence-based recommendations for the role of regenerative therapies in managing moderate to severe chronic low back pain. A multidisciplinary panel of experts, convened by the American Society of Interventional Pain Physicians (ASIPP), systematically reviewed the current evidence and incorporated patient perspectives to develop practical, evidence-informed recommendations. The process included defining key clinical questions, reviewing the literature, formulating evidence-based statements, and reaching consensus through structured discussions and formal voting. A total of 35 authors contributed to the development of these guidelines, with 33 experts participating in the formal consensus process. Altogether, 19 recommendations were generated, with all of them achieving 100% agreement. These recommendations were informed by a comprehensive review of systematic reviews, randomized controlled trials (RCTs), and observational studies encompassing a broad range of regenerative therapies.Evidence was appraised using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to determine certainty levels. Both qualitative and quantitative analyses were applied to synthesize the best available data, resulting in evidence-based recommendations summarized below.Intradiscal Injections (PRP): Evidence Level: III, Fair; Consensus-Based Clinical Recommendation: ModerateIntradiscal Injections (BMAC): Evidence Level: III, Fair; Consensus-Based Clinical Recommendation: ModerateEpidural Injections (PRP): Evidence Level: III, Fair; Consensus-Based Clinical Recommendation: ModerateFacet Joint Injections (PRP and MSCs): Evidence Level: IV, Limited; Consensus-Based Clinical Recommendation: Moderate Sacroiliac Joint Injections (PRP): Evidence Level: IV, Limited; Consensus-Based Clinical Recommendation:  Low Functional Spine Unit Injections Evidence Level: Very Low; Consensus-Based Clinical Recommendation:Low. The primary limitation of these guidelines is the scarcity of high-quality studies, with much of the available evidence derived from small or heterogeneous trials. Regenerative therapies should be considered only after a thorough diagnostic evaluation confirming clinical necessity. Treatment decisions must account for the patient's medical condition, preferences, and expectations. Patients should be fully informed about the nature, potential benefits, risks, and costs of regenerative treatments, most of which are not covered by commercial insurance.These therapies may be used alone or in conjunction with other evidence-based modalities, such as structured exercise, physical therapy, behavioral therapy, or conventional medical management. Clinicians must follow all applicable U.S. Food and Drug Administration (FDA) regulations and adhere to safety and ethical standards outlined in these guidelines. Based on current evidence, lumbar intradiscal injections of platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs) are supported by Level III evidence. Lumbar epidural PRP injections are also supported by Level III evidence, while PRP injections for lumbar facet joints and sacroiliac joints are supported by Level IV evidence. Given the emerging status of biologic therapies and the limited quality of existing studies, the panel provides moderate, consensus-based recommendations for the use of all biologics in the lumbar spine.

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 [email protected]

Based on recent data, the pain fellowship match is decreasing in competitiveness. The most recent 2023-2024 match cycle had the most unfilled positions and the highest match rate in the last five years. Although there has been some speculation about potential factors contributing to these trends, our study aimed to gather insight from pain fellowship program directors (PDs) nationwide to provide valuable perspectives on recent match trends. We created an anonymous online survey, with questions regarding potential factors contributing to match trends over the last five years. Our survey was emailed to 115 program directors (PDs), and one follow-up Email was sent three weeks later to maximize responses. Surveys were completed by 25.2% (29/115) of PDs. Over the past five years, 82.8% of PDs (24/29) reported a decrease in applications to their program. For residency specialty of pain fellowship applicants, 100% of PDs (29/29) reported a decline in anesthesiology applicants. Most PDs reported an increase in applicants from PM&R (62.1%, 18/29), Neurology (69.0%, 20/29), and Emergency Medicine (93.1%, 27/29). For potential contributors to these trends, increasing compensation in primary residency specialty was the most significant perceived contributor, with a weighted average of 4.89/5. Decreasing pain reimbursement was the second strongest contributor, with a weighted average of 4.31/5. Increasing compensation in primary residency specialty and declining pain reimbursements were the two most significant perceived contributors to the recent decline in interest in pain fellowship to resident trainees. Pain medicine is now attracting a more diverse applicant pool with a decrease in anesthesiology applicants and an increase in PM&R, Internal Medicine, Neurology, Emergency Medicine, and Psychiatry applicants. Future pain fellows' increased variety of training backgrounds may present an opportunity to critically assess the current pain medicine curriculum to suit the needs of a more diverse cohort.

Sayed E Wahezi, Professor of Physical Medicine and Rehabilitation, 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.org

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.

Sayed E Wahezi, Department of Physical Medicine & Rehabilitation, Multidisciplinary Pain Center, Montefiore Medical Center, 1250 Waters Place, Tower #2  8th Floor, Bronx, NY, 10461, USA, Tel: +1 929-263-3950, Email swahezi@montefiore.org

Giuliano Lo Bianco,1 Sean Li,2 Miles Day,3 Michael E Schatman4,51Anesthesiology 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 [email protected]

Chronic knee pain from osteoarthritis (OA) affects a significant proportion of adults over 40. Total knee arthroplasty (TKA) remains the standard for advanced OA, yet up to 20% of patients experience chronic postsurgical pain (CPSP). Genicular nerve radiofrequency ablation (GNRFA) can alleviate pain in those unresponsive to conservative treatments or TKA. However, anatomical variability of the genicular nerves may limit treatment durability. This retrospective, single-center observational study investigated whether using a novel V-shaped active tip needle-which creates larger lesions-could improve outcomes. Fifty patients with symptomatic knee OA or CPSP, who had a ≥50% reduction in pain after diagnostic genicular nerve blocks, underwent GNRFA with a V-shaped active tip needle between September 2020 and January 2022. Pain and function were assessed using the visual analogue scale (VAS) at rest and during movement, Western Ontario and McMaster Universities Arthritis Index (WOMAC), Douleur Neuropathique en 4 Questions (DN4), and EuroQol-5 Dimensions (EQ-5D) at baseline and 1, 3, 6, and 9 months post-procedure. By 6 months, 64% of patients showed ≥50% reduction in VAS pain scores, sustained at 9 months (p<0.0001). Median WOMAC scores improved from 62.0 at baseline to 40.0 at 6 months (p<0.0001). DN4 scores declined from a median of 4.0 at baseline to 2.0 at 6 months and 1.0 at 9 months (p<0.001). EQ-5D scores demonstrated significant enhancement in quality of life (p<0.01). Pain intensity differences at rest and during movement remained substantially improved at 9 months (p<0.0001). GNRFA using a V-shaped active tip needle is a promising intervention for chronic knee pain, offering significant and sustained pain relief and functional improvement. Larger lesions created by the novel needle may overcome anatomical challenges, though further randomized studies are warranted to validate efficacy and safety.

Ideally, a physical or chemical nonsurgical neurolytic procedure provides targeted neurolysis to relieve pain for a suitable length of time without causing complications. This narrative review focuses on five nonsurgical neurolytic procedures that are well-established and well-documented in the literature for the treatment of refractory neuropathic pain and peripheral neuropathies, in particular: two physical nonsurgical neurolytic techniques (cryoablation and radiofrequency ablation) and three chemoneurolytic agents (alcohol injection, phenol injection, and a high-concentration capsaicin 8% topical system). Using the definition of nonsurgical physical and chemical neurolytic procedures for neuropathic pain, a focused literature search of the PubMed database for English-language, human studies published through July 2024 included, but was not limited to, the following search terms: \"neuropathic pain\" AND \"cryoablation\", \"cryoneurolysis\", \"radiofrequency ablation\", \"alcohol neurolysis\", \"alcohol injection\", \"phenol neurolysis\", \"phenol injection\", \"chemoneurolysis\", \"topical capsaicin\", and \"TRPV1.\" While attempts were made to identify prospective clinical trials for each type of neurolytic procedure, information regarding the conduct and safety and efficacy of some of these nonsurgical neurolytic procedures was primarily limited to case studies and anecdotal evidence. The risk benefit basis of each technique is discussed, and recommendations for proper use based on the literature are summarized. Most techniques require ultrasound or fluoroscopy guidance. Pain relief typically ranges from 3 to 12 months, with repeat neurolytic procedures often required to maintain suitable levels of pain relief. The authors provide their insights as to the best utilization of these identified nonsurgical physical and chemoneurolytic procedures for the treatment of refractory neuropathic pain in different patient populations based on neural targets. Together, these five nonsurgical neurolytic techniques provide patients and physicians with a variety of options for the treatment of refractory neuropathic pain.

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. 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. 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. RFA using a V-shaped active tip needle might be a feasible and effective treatment for chronic lumbar zygapophyseal joint pain.