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The dorsal root ganglion (DRG) serves as a pivotal site for managing chronic pain through dorsal root ganglion stimulation (DRG-S). In recent years, the DRG-S has emerged as an attractive modality in the armamentarium of neuromodulation therapy due to its accessibility and efficacy in alleviating chronic pain refractory to conventional treatments. Despite its therapeutic advantages, the precise mechanisms underlying DRG-S-induced analgesia remain elusive, attributed in part to the diverse sensory neuron population within the DRG and its modulation of both peripheral and central sensory processing pathways. Emerging evidence suggests that DRG-S may alleviate pain by several mechanisms, including the reduction of nociceptive signals at the T-junction of sensory neurons, modulation of pain gating pathways within the dorsal horn, and regulation of neuronal excitability within the DRG itself. However, elucidating the full extent of DRG-S mechanisms necessitates further exploration, particularly regarding its supraspinal effects and its interactions with cognitive and affective networks. Understanding these mechanisms is crucial for optimizing neurostimulation technologies and improving clinical outcomes of DRG-S for chronic pain management. This review provides a comprehensive overview of the DRG anatomy, mechanisms of action of the DRG-S, and its significance in neuromodulation therapy for chronic pain.

Low back pain (LBP) is a common and complex health issue with a multifactorial origin, involving structures such as the lumbar intervertebral discs (IVDs), facet joints, muscles, ligaments, and nerve roots. Typically, traditional pain management approaches target isolated pain generators. However, recent advancements, particularly regenerative injection techniques, have shifted the focus toward a more comprehensive treatment model that addresses the entire functional spinal unit (FSU), providing a disease-modifying approach. The purpose of this narrative review is to provide a scoping overview of the concept of the FSU and evaluate the potential role of orthobiologics, such as platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs), in treating back pain associated with various spinal conditions. Narrative literature review. Relevant peer-reviewed manuscripts were identified through a comprehensive search of electronic databases, such as PubMed, Embase, and Google Scholar. Studies focusing on the anatomy, biomechanics, and pathology of the FSU, as well as those concerning the application of PRP and MSCs in spinal disorders, were included. The FSU, the smallest structural unit of the spine, consists of 2 vertebrae, an IVD, facet joints, and associated supporting ligaments. The FSU is crucial for absorbing shock, distributing mechanical loads, protecting the spinal cord and nerve roots, and maintaining spinal stability and mobility. Orthobiologic therapies, including PRP and MSCs, have shown promise in modulating disease processes and promoting tissue repair in spinal conditions. Emerging evidence supports the efficacy of these therapies in reducing pain and improving functional outcomes by targeting multiple components of the FSU. A thorough understanding of the biomechanical processes and the dynamic distribution of mechanical load across its various structures is essential to recognizing that chronic LBP often arises from multiple pain generators rather than a single source. Therefore, an integrated treatment approach that addresses these multiple pain generators collectively, considering the FSU and the entire spine, is critical for optimizing patient outcomes. Rather than being systematic, this narrative review is focused on providing an overview of the effects of orthobiologics in the treatment of chronic LBP using an FSU approach. The heterogeneity of study designs, variability in treatment protocols, and limited long-term data pose challenges in establishing standardized guidelines for orthobiologic therapies in LBP management. Orthobiologic treatments offer a promising disease-modifying approach by addressing the entire FSU rather than isolated pain generators. Future research should focus on optimizing multitarget injection strategies, thereby standardizing treatment protocols.

Osteoarthritis is the most prevalent joint disorder, marked by significant pain, reduced functionality, and diminished quality of life. The prevalence of chronic knee osteoarthritis is increasing as the population ages. Minimally invasive therapeutic interventions, including platelet-rich plasma and radiofrequency ablation of genicular nerves, have demonstrated substantial efficacy in alleviating pain in these patients. The objective of this study was to compare the efficacy of intraarticular platelet-rich plasma (PRP) injection and genicular nerve radiofrequency ablation (GNRFA) in alleviating pain associated with knee osteoarthritis. An open-label, prospective, randomized clinical trial. A university hospital. This prospective, randomized, open-label clinical trial was conducted on 200 patients with Grade II-III knee osteoarthritis. Of these, 100 patients were assigned to the PRP group, receiving a single intraarticular PRP injection, while the remaining patients in the GNRFA group underwent radiofrequency ablation of the superomedial, superolateral, and inferomedial genicular nerves following a successful diagnostic block. Outcomes were assessed using the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) at the baseline and subsequently at 2 weeks, 3 months, 6 months, one year, and 2 years post-intervention. VAS scores were significantly lower in the PRP group than in the GNRFA group at 12 and 24 months, with P-values < 0.001. The PRP group also exhibited statistically significant reductions in ODI scores at all pre-specified time points. No adverse effects were reported in either treatment group. The study did not include a control group, and the assessment of efficacy was primarily based on clinical scores without evaluating structural changes through MRI. Additionally, physical and analgesic therapies were not considered in the data collection. For patients with chronic knee osteoarthritis, intraarticular platelet-rich plasma therapy may offer superior sustained pain relief and a lower disability index compared to conventional radiofrequency ablation of the genicular nerves.

Spinal cord stimulation (SCS) is an established therapy for chronic pain, but uncertainties remain regarding long-term real-world outcomes and the role of standardized selection pathways. This study aimed to evaluate real-world, longitudinal outcomes of SCS over 24 months within a structured clinical pathway, focusing on pain intensity, neuropathic symptoms, and health-related quality of life. A single-center, retrospective observational cohort study was conducted at the Fondazione Istituto G. Giglio (Cefalù, Italy). Data were drawn from the continuing, prospective institutional \"SCS Pathway\" and included consecutive patients implanted between May 2021 and September 2024. Eligible patients were ≥18 years of age with chronic pain refractory to conventional medical management. Outcomes included pain intensity (VAS, visual analog scale), neuropathic features (DN4, douleur neuropathique 4), and health-related quality of life (EQ-5D, EuroQol 5 Dimensions), assessed at baseline and 3, 6, 12, 18, and 24 months post-implantation. Multilevel models with full information maximum likelihood (FIML) were applied to repeated measures. Seventy-six patients were included (mean age 67.3 ± 10.3 years; 39.5% female). The most frequent diagnoses were post-surgical pain syndrome (42.1%, 32/76) and chronic back and leg pain (40.8%, 31/76). 42.1% (32/76) had previous spine surgery, and 78.9% (60/76) reported neuropathic pain. Across 452 observations, mean VAS scores decreased from 7.9 ± 0.7 at baseline to 3.1 ± 1.1 at 3 months (61% reduction, < 0.001), with sustained benefit at 24 months (4.5 ± 1.5; 43% reduction, < 0.001). DN4 scores improved from 7.4 ± 0.8 to 3.2 ± 1.0 at 3 months (56% reduction, < 0.001), with persistent decreases at 24 months (4.2 ± 1.2; 43% reduction, < 0.001). EQ-5D improved from 22.8 ± 6.6 at baseline to 70.2 ± 10.6 at 3 months (increase of 208%, < 0.001), with clinically meaningful gains sustained at 24 months (55.4 ± 13.7, increase of 143%, < 0.001). In this real-world cohort, SCS therapy results in sustained, clinically significant improvements in pain, neuropathic symptoms, and quality of life. Findings highlight the value of structured selection and follow-up pathways. These data provide a benchmark for multicenter studies linking standardized referral frameworks to long-term, patient-centered outcomes.

Background: Chronic persistent neck pain with or without upper extremity pain is common in the general adult population with prevalence of 48% for women and 38% for men, with persistent complaints in 22% of women and 16% of men. Multiple modalities of treatments are exploding in managing chronic neck pain along with increasing prevalence. However, there is a paucity of evidence for all modalities of treatments in managing chronic neck pain. Cervical epidural injections for managing chronic neck pain are one of the commonly performed interventions in the United States. However, the literature supporting cervical epidural steroids in managing chronic pain problems has been scant. Study Design: A systematic review of cervical interlaminar epidural injections for cervical disc herniation, cervical axial discogenic pain, cervical central stenosis, and cervical postsurgery syndrome. Objective: To evaluate the effect of cervical interlaminar epidural injections in managing various types of chronic neck and upper extremity pain emanating as a result of cervical spine pathology. Methods: The available literature on cervical interlaminar epidural injections in managing chronic neck and upper extremity pain were reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and limited based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to December 2011, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results: For this systematic review, 34 studies were identified. Of these, 24 studies were excluded and a total of 9 randomized trials, with 2 duplicate studies, met inclusion criteria for methodological quality assessment. For cervical disc herniation, the evidence is good for cervical epidural with local anesthetic and steroids; whereas, it is fair with local anesthetic only. For axial or discogenic pain, the evidence is fair for local anesthetic, with or without steroids. For spinal stenosis, the evidence is fair for local anesthetic, with or without steroids. For postsurgery syndrome, the evidence is fair for local anesthetic, with or without steroids. Limitations: The limitations of this systematic review continue to be the paucity of literature. Conclusion: The evidence is good for radiculitis secondary to disc herniation with local anesthetics and steroids, fair with local anesthetic only; whereas, it is fair for local anesthetics with or without steroids, for axial or discogenic pain, pain of central spinal stenosis, and pain of post surgery syndrome. Key words: Cervical disc herniation, cervical axial discogenic pain, cervical central spinal stenosis, cervical post surgery syndrome, cervical radiculitis, cervical interlaminar epidural injections, local anesthetic, steroids

Background: The COVID-19 pandemic has emerged and has challenged us to look for alternatives to bring about a paradigm shift in interventional chronic pain management. As the disease lowers the body’s immune system, the use of medications that suppress the immune system are not recommended during the COVID-19 pandemic. Objective: The purpose of this study was to review medications other than steroids used for interventional pain management and the emphasis on mitigation of the untoward consequences of steroid injections on the immune system during the COVID-19 pandemic. Literature Search: The literature was searched for articles in English with key words COVID-19, immunity, steroid for pain management injections with steroid, local anesthetics, dextrose water, normal saline, pain and genetic medicine, pain, and regenerative medicine. The sources of articles were PubMed, Embase, and open Google search. Literature Review: The medications used for interventional pain management include steroids and opioids. The side effects of these medications are well known but have never been looked at as critically as they are now. Many other medications have been used for interventional pain procedures to relieve pain, such as dextrose water, normal saline solution, local anesthetics, and many adjuvants. Regarding regenerative therapy, despite plenty of evidence in literature, we have not yet considered it as a routine therapy for chronic pain injections. It is now time to move on beyond steroids and consider other types of medications and treatment options. The use of these medications in clinical practice is less auspicious, and thus more research is needed on the practical applications. Further areas for research include studies to determine definitive efficacy and safety assessment and determine whether or not the analgesic effects of these drugs are duration or dose-dependent. The optimal identification of candidates, volume, concentration, and intervals of injection are essential for routine application in interventional chronic pain practice. Conclusions: The future of interventional pain practice is trending toward regenerative medicine and genetic research. Numerous scientific studies have been conducted to investigate the genetic basis of phenotypic variability in individuals with different ethnic groups in terms of susceptibility to chronic pain, as well as response to treatment for the personalized medicine model. Despite the preliminary data on genetic variations, there is no evidence for the use of a pharmacogenomicsbased approach to personalized medicine for patients with chronic pain. The field of medicine therefore needs further research in pharmacogenetics, including large-scale prospective studies that focus on pain pathways. However, recent research, including larger studies and larger-scale genomic perspectives, may yield more promising findings in the future. The COVID-19 pandemic proved the need for medications with the most impact and least complications. Key words: COVID-19, steroid, pain injections, chronic pain, immune system, regenerative medicine

Lower back and extremity pain in the amputee patient can be challenging to classify and treat. Radicular compression in a patient with lower limb amputation may present as or be superimposed upon phantom limb pain, creating diagnostic difficulties. Both patients and physicians classically find it difficult to discern phantom sensation from phantom limb pain and stump pain; radicular compression is often not considered. Many studies have shown back pain to be a significant cause of pain in lower limb amputees, but sciatica has been rarely reported in amputees. We present a case of L4/5 radiculitis in an above-knee amputee presenting as phantom radiculitis. Our patient is a 67 year old gentleman with new onset 10/10 pain in a phantom extremity superimposed upon a 40 year history of previously stable phantom limb pain. MRI showed a central disc herniation at L4/5 with compression of the traversing left L4 nerve root. Two fluoroscopically guided left transforaminal epidural steroid injections at the level of the L4 and L5 spinal nerve roots totally alleviated his new onset pain. At one year post injection, his phantom radiculitis pain was completely gone, though his underlying phantom limb pain remained. Lumbar radiculitis in lower extremity amputee patients may be difficult to differentiate from baseline phantom limb pain. When conservative techniques fail, fluoroscopically guided spinal nerve injection may be valuable in determining the etiology of lower extremity pain. Our experience supports the notion that epidural steroid injections can effectively treat phantom lumbar radiculitis in lower extremity amputees. Key words: amputee, phantom pain, phantom sensation, phantom radiculitis, disc herniation, interlaminar, transforaminal, epidural steroid injection

Background: The unexpected COVID-19 crisis has disrupted medical education and patient care in unprecedented ways. Despite the challenges, the health-care system and patients have been both creative and resilient in finding robust “temporary” solutions to these challenges. It is not clear if some of these COVID-era transitional steps will be preserved in the future of medical education and telemedicine. Objectives: The goal of this commentary is to address the sometimes substantial changes in medical education, continuing medical education (CME) activities, residency and fellowship programs, specialty society meetings, and telemedicine, and to consider the value of some of these profound shifts to “business as usual” in the health-care sector. Methods: This is a commentary is based on the limited available literature, online information, and the front-line experiences of the authors. Results: COVID-19 has clearly changed residency and fellowship programs by limiting the amount of hands-on time physicians could spend with patients. Accreditation Council for Graduate Medicine Education has endorsed certain policy changes to promote greater flexibility in programs but still rigorously upholds specific standards. Technological interventions such as telemedicine visits with patients, virtual meetings with colleagues, and online interviews have been introduced, and many trainees are “technoomnivores” who are comfortable using a variety of technology platforms and techniques. Webinars and e-learning are gaining traction now, and their use, practicality, and cost-effectiveness may make them important in the post-COVID era. CME activities have migrated increasingly to virtual events and online programs, a trend that may also continue due to its practicality and cost-effectiveness. While many medical meetings of specialty societies have been postponed or cancelled altogether, technology allows for virtual meetings that may offer versatility and time-saving opportunities for busy clinicians. It may be that future medical meetings embrace a hybrid approach of blending digital with face-toface experience. Telemedicine was already in place prior to the COVID-19 crisis but barriers are rapidly coming down to its widespread use and patients seem to embrace this, even as health-care systems navigate the complicated issues of cybersecurity and patient privacy. Regulatory guidance may be needed to develop safe, secure, and patient-friendly telehealth applications. Telemedicine has affected the prescribing of controlled substances in which online counseling, informed consent, and follow-up must be done in a virtual setting. For example, pill counts can be done in a video call and patients can still get questions answered about their pain therapy, although it is likely that after the crisis, prescribing controlled substances may revert to face-to-face visits. Limitations: The health-care system finds itself in a very fluid situation at the time this was written and changes are still occurring and being assessed. Conclusions: Many of the technological changes imposed so abruptly on the health-care system by the COVID-19 pandemic may be positive and it may be beneficial that some of these transitions be preserved or modified as we move forward. Clinicians must be objective in assessing these changes and retaining those changes that clearly improve health-care education and patient care as we enter the COVID era. Key words: Continuing medical education, COVID-19, fellowship program, medical education, medical meetings, residency program, telehealth, telemedicine

Purpose of Review This review explores the current applications of artificial intelligence (AI) in the field of pain medicine with a focus on machine learning. Recent Findings Utilizing a literature search conducted through the PubMed database, several current trends were identified, including the use of AI as a tool for diagnostics, predicting pain progression, predicting treatment response, and performance of therapy and pain management. Results of these studies show promise for the improvement of patient outcomes. Summary Current gaps in the research and subsequent directions for future study involve AI in optimizing and improving nerve stimulation and more thoroughly predicting patients’ responses to treatment.

Introduction: The synthetic opioid methadone is a promising analgesic for the management of chronic neuropathic pain. Methadone therapy is increasing as its advantages are being realized over other opioids. Methadone’s lack of known active metabolites, high oral bioavailability, low cost, and its additional receptor activity as an antagonist of N-methyl-D-aspartate receptors make it an attractive analgesic. Methods: We surveyed 550 pain physicians to determine their prescribing practices of methadone. The study was approved by our Institutional Review Board. A list of 550 pain physicians, which included practitioners in private practice, university settings, and community hospitals, were obtained and surveys sent via mail. The list was obtained through the American Pain Society’s membership list. Out of 550 surveys sent, 124 replies were returned. Results: The 124 surveys that were returned included pain physicians from various settings: 20 responses from physicians practicing at a university setting, 16 responses from a community setting, 54 responses from a private setting, one from university and community settings, 7 from community and private settings, 3 from university and community and private settings; 23 did not specify. Of the 124 physicians, 111 prescribe methadone in their pain practice. Of the 13 physicians who do not prescribe methadone, the main reason for not using the drug for 5 physicians was because of social stigma, 2 because of minimal experience with the drug, 2 because the drug was not effective, one because of lack of knowledge, and one because of potential adverse effects. Of the 111 physicians who use methadone, 55 stated that social stigma was the most common reason patients refuse to take methadone for the treatment of pain, 44 because of adverse effects, and 5 stated “other” as the reason patients refuse to take methadone. Of 111 physicians who prescribe methadone, 100 prescribed it for neuropathic pain, 101 for somatic pain, 80 for visceral pain, 78 for cancer pain, and 34 for sickle cell pain. Also, 21 stated that methadone was the primary opioid they prescribed. Of the 111 physicians who prescribe methadone, 86 start methadone at low dose and titrate up to minimize side effects. Fourteen clinicians load methadone and titrate down to minimize adverse effects while maintaining analgesia. Conclusion: The majority of survey responders (90%) prescribed methadone in their pain practice, but on a very limited basis; 59% state <20% of their patients are on methadone. Three times a day dosing schedule was the most typical regimen (57%) while 77% prefer to titrate up on the dosage. It seems interesting that many clinicians do not prescribe methadone as a primary analgesic. One reason for this is due to the social stigma of its use in treatment of heroin addicts. Also, a lack of widely recognized treatment algorithms or guidelines to assist clinicians with opioid conversions and maintenance might be playing a role. The role of stigma as a barrier to adequate treatment of chronic pain among pain physicians prescribing practices is a fundamental, yet unexplored issue. Key words: Methadone, chronic pain, behavior, stigma, survey, opioid, education, society