Explore the vast range of titles available.

Abstract Objective Peripheral nerve stimulation (PNS) of the lower extremity has progressed significantly over the last decade. From the proof of concept that ultrasound-guided, percutaneous implantation was possible to advances in waveforms, the field has been rapidly evolving. While most nerves in the lower extremity can be PNS targets, consideration must be given to the ergonomics of pulse generator placement, patient comfort, and avoidance of lead migration. For this paper, we examine some of the conditions amenable to lower extremity PNS, review the evidence and history behind PNS for these conditions, and describe approaches for the tibial, sural, and superficial peroneal nerves. Methods A literature search was conducted using PubMed. Search terms used were “peripheral nerve stimulation,” “lower extremity entrapment neuropathies,” “sural nerve,” “superficial peroneal nerve,” “tibial nerve,” and “tarsal tunnel syndrome.” Emphasis was placed on randomized controlled studies, anatomical dissections, and comprehensive review articles. Approaches to nerves and ultrasound images were based on anecdotal PNS cases from an experienced implanter (SP). Conclusions The development of ultrasound as a viable method of image guidance for percutaneous peripheral nerve stimulation has led to an exponential growth in the field. Lower extremity percutaneous lead placement is both feasible and an appropriate treatment modality for certain pain conditions.

Scott G Pritzlaff,1 Michael E Schatman2,31Department 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 [email protected]

Scott G Pritzlaff,1 Naileshni Singh,1 Chinar Sanghvi,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 +1425-647-4880, 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 [email protected]

Sayed E Wahezi,1 Ugur Yener,1 Miles Day,2 Peter S Staats,3 Christopher Gilligan,4 Michael E Schatman,5,6 Scott G Pritzlaff7 1Department of Physical Medicine and Rehabilitation, Multidisciplinary Pain Center, Montefiore Medical Center, Bronx, NY, USA; 2Department of Anesthesiology, Texas Tech University Health Sciences Center, Lubbock, TX, USA; 3National Spine and Pain Centers, Atlantic Beach, FL, USA; 4Chief Medical and Quality Officer, Senior Vice President, Robert Wood Johnson University Hospital, New Brunswick, NJ, 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; 7Department of Anesthesiology and Pain Medicine, University of California, Davis, CA, USACorrespondence: 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

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,1 Ugur Yener,1 Peter S Staats,2 Yashar Eshraghi,3 Miles Day,4 Michael E Schatman,5,6 Scott G Pritzlaff7 1Department of Physical Medicine & Rehabilitation, Multidisciplinary Pain Center, Montefiore Medical Center, Bronx, NY, USA; 2National Spine and Pain Centers, Atlantic Beach, FL, USA; 3Department of Anesthesia, Ochsner Medical Health Center, New Orleans, LA, USA; 4Department of Anesthesiology, Texas Tech University Health Sciences Center, Lubbock, TX, 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; 7Department of Anesthesiology and Pain Medicine, University of California, Davis, CA, USACorrespondence: 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

Scott G Pritzlaff,1 Victoria Flower,2 Vafi Salmasi,3 Samir J Sheth,2 Michael E Schatman4,5 1Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA, USA; 2Sutter Neuroscience Institute, Interventional Pain Medicine, Sutter Health, Roseville, CA, USA; 3Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, 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 and Pain Medicine, NYU Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA, Tel +1425-647-4880, Email Michael.Schatman@NYULangone.org

Chronic pain affects 20.5% of the US population, costing $296 billion annually in lost productivity. Spinal cord stimulation (SCS) has become a key treatment for refractory neuropathic and nociceptive pain, with increasing usage due to technological advancements. However, the durability of SCS therapy, including explantation rates, remains a concern. Understanding explantation causes is essential for improving patient selection and device effectiveness. This study aims to analyze SCS explantation rates and reasons, as well as evaluate the financial burden of these procedures on the healthcare system. Three primary screening methods were used: manual search with keywords, MeSH term query, and reference list screening. The search covered PubMed, Cochrane, and Web of Science databases from inception to November 2024, yielding 719 articles. After applying eligibility criteria, 72 articles were identified, and 25 were selected for analysis. Data extraction was done by independent reviewers, with a second reviewer ensuring accuracy. Discrepancies were resolved by the corresponding editor. We reviewed data from 13,026 patients who underwent permanent SCS implantation between 1984 and 2024, across 25 studies. A total of 1882 patients (9.82%) underwent explantation. The most common reason was lack of efficacy and inadequate pain relief (38%), followed by lead failure (15%) and infection (14%). While SCS is generally effective, issues related to device longevity and patient satisfaction persist, with explantation rates due to technical failures and lack of efficacy being concerns. SCS efficacy varies, with explantation rates reaching up to 38%, often due to inadequate pain relief. Most explantations occur within the first year, despite SCS being a safe and effective treatment. High implantation costs ($35,000 to $70,000) and revision costs ($15,000 to $25,000) raise concerns among payors. The hardware-driven model limits waveform flexibility, highlighting the need for innovation.

Pain medicine care has expanded to encompass a wider range of conditions, necessitating updated education and training for pain specialists to utilize emerging technologies effectively. A national survey was conducted through several verified Pain organizations regarding pain physician employers' perspectives on pain medicine fellowship training and education. The survey aimed to gather insights from a diverse range of geographic locations, practice types (academic and private practice), and practice settings. The findings emphasize the need for educational programs to adapt to the evolving landscape of pain medicine. A survey was disseminated through several national professional pain societies, including the AAPM, ASIPP, NANS, and ASPN, and Pain DocMatters forum, an online verified pain physician forum to ensure a wide reach among potential respondents. The survey received responses from 196 participants, 39 from the Pain DocMatters forum and 157 through pain societies' channels. Most survey respondents reported a need for additional training and experience beyond what is offered during the one-year ACGME-approved fellowship. Professionalism and basic interventional skills were identified as the highest valued attributes of pain physician candidates by potential employers. Employers rated spinal cord stimulator (SCS) trials as the most important advanced procedure for trainees to learn. Other advanced procedures such as SCS implants, PNS implants, interspinous spacers, and percutaneous procedures involving the vertebral body were also rated as either very important or somewhat important by most respondents. A significant gap in training has been identified, with only 7% of respondents feeling that fellows were adequately prepared to independently practice in the current educational model. A vast majority of respondents stated that fellows need additional training following graduation from fellowship to practice independently. Training programs should provide more robust education to prepare their graduates for independent practice.