Interventional Pain Management: Current Evidence and Innovative Advances

Background: Cervical radiculopathy is a common and disabling condition with both nociceptive and neuropathic pain components. Epidural steroid injections (ESIs) are widely used as an interventional treatment modality; however, the optimal cervicothoracic interlaminar access level and injectate volume remain subjects of ongoing debate. Because injection level and injectate volume have historically been varied together in routine practice rather than independently, prospectively designed comparative data are lacking. Methods: In this retrospective, multicenter cohort study, 166 patients with MRI-confirmed cervical radiculopathy treated between January 2022 and December 2025 at three participating institutions received fluoroscopy-guided cervicothoracic interlaminar epidural steroid injections with dexamethasone and bupivacaine at either C7/T1 (6 mL; n = 87) or T1/T2 (8 mL; n = 79), with protocol determined by the treating institution rather than randomization. The prespecified primary outcome was the baseline-adjusted between-group difference in arm-pain Numeric Rating Scale (NRS) score at 3 months, analyzed by analysis of covariance (ANCOVA) adjusted for a directed acyclic graph-informed covariate set (age, symptom duration, baseline pain severity, number of stenotic levels, DN4 score, and treatment center); the same covariates were used in a generalized estimating equation (GEE) model with a group-by-time interaction and in a multivariable logistic regression for treatment response. Secondary outcomes—neck-pain NRS and VAS, neuropathic pain (DN4), functional disability (NDI), quality of life (SF-36, EQ-5D), Patient Global Impression of Change (PGIC), analgesic consumption, and cardiovascular/metabolic safety outcomes—were assessed at baseline, 3 months, and 6 months. Results: Both groups showed significant within-group reductions in arm-pain NRS (C7/T1: 8.7 ± 0.4 to 3.5 ± 0.4 at 3 months and 4.1 ± 0.6 at 6 months; T1/T2: 9.2 ± 0.7 to 3.9 ± 0.5 at 3 months and 4.9 ± 0.7 at 6 months; both p < 0.001). Baseline pain scores and symptom duration were not balanced between groups (baseline-adjusted analysis was therefore used). After adjustment for baseline severity, age, symptom duration, and center, the T1/T2–8 mL protocol was associated with higher (worse) adjusted arm-pain NRS than the C7/T1–6 mL protocol at 3 months (adjusted difference 0.41 points, 95% CI 0.21–0.61) and 6 months (0.66 points, 95% CI 0.35–0.97); a multivariable-adjusted logistic regression model likewise showed lower odds of achieving a ≥50% arm-pain reduction at 3 months with the T1/T2–8 mL protocol (adjusted OR 0.18, 95% CI 0.04–0.82). NDI decreased from a mean of 48.1 points at baseline to 28.1 points at 3 months (pooled cohort, score capped at the 0–50 scale maximum; the majority of baseline NDI source records could not be individually verified and this is reported as a limitation), and analgesic consumption decreased over follow-up. Among hypertensive patients (45/166, 27.1%), 78% experienced transient blood pressure elevation and 40% required temporary antihypertensive adjustment; among diabetic patients (13/166, 7.8%), 92% developed transient hyperglycemia. Because injection level, injectate volume, and treatment center were confounded by design, these findings should be interpreted as a comparison of two center-specific treatment protocols rather than an isolated effect of anatomical level or volume. Conclusions: Both center-specific cervicothoracic interlaminar epidural steroid injection protocols were associated with improvements in pain and function over six months, with no catastrophic procedural complications documented; however, near-complete confounding of injection level with injectate volume and treatment center, together with imbalanced baseline pain severity, precludes conclusions about the comparative effectiveness of C7/T1 versus T1/T2 access. Transient cardiovascular and metabolic effects were common and support consideration of post-procedural monitoring in patients with pre-existing hypertension or diabetes. Full article

Background: Chronic pain is the leading cause of years lived with disability worldwide, with low back pain representing the most prevalent and disabling condition. Spinal cord stimulation (SCS) and intrathecal drug delivery (IDD) systems are established neuromodulation techniques for refractory chronic pain. However, a subset of patients experiences partial or declining benefit with either modality alone. In such cases, combined therapy may represent a rescue strategy. Methods: retrospective case series at a single center, including patients previously implanted with SCS who subsequently required IDD due to loss of efficacy or inadequate pain coverage. Pain intensity, opioid consumption, health-related quality of life, and patient satisfaction were assessed using validated instruments. Results: Twelve patients were included. Persistent low back pain with mixed nociceptive–neuropathic features was the most common indication. Combined therapy was observed in association with a mean reduction of 3.5 points on the Numeric Rating Scale, corresponding to an approximate 40% decrease in pain intensity. More than half of the patients discontinued systemic opioids. Complications occurred in seven patients (58.3%), mostly hardware-related and manageable with surgical revision; only one patient developed a device-related infection. Conclusions: In this case series, combined SCS and IDD therapy was observed in association with clinically meaningful pain reduction, decreased opioid use, and high patient-reported satisfaction. Although quality-of-life scores remained below population norms, patients consistently reported subjective improvement. Combined neuromodulation may represent a valid rescue option in selected patients with insufficient response to SCS alone. Full article

Background/Objectives: To evaluate preliminary clinical outcomes, functional changes, and procedural safety associated with fluoroscopy- and ultrasound-guided intra-articular pulsed radiofrequency (PRF) of the atlanto-occipital joint in patients with chronic post-traumatic cervical pain. Methods: This retrospective preliminary case series included eight patients with chronic neck and/or head pain persisting for at least 6 months following whiplash injury or cervical hyperextension trauma. All patients underwent dual-guided intra-articular PRF of the atlanto-occipital joint. Pain intensity (Numeric Rating Scale, NRS), functional outcomes (Neck Disability Index, NDI; Patient-Specific Functional Scale, PSFS), and medication use were assessed at baseline and at 2, 3, and 6 months following the procedure. Results: Mean baseline NRS was 8.0 ± 0.76 and decreased to 2.38 ± 1.06 at 2 months, 3.38 ± 0.74 at 3 months, and 3.75 ± 1.16 at 6 months. A ≥ 50% reduction in pain intensity was observed in 87.5% of patients at 2 and 3 months and in 75.0% at 6 months. Functional outcome measures also showed improvement, with mean NDI scores decreasing from 60% at baseline to 25% at 2 months, with partial maintenance of improvement during follow-up. Mean PSFS scores increased from 3 at baseline to 7 at 2 months. Reduced use of analgesic and adjuvant medications was observed during follow-up. No serious procedure-related complications were identified. Conclusions: In this small retrospective case series, intra-articular PRF of the atlanto-occipital joint was associated with reductions in pain intensity, improvement in patient-reported functional outcomes, and reduced medication use in patients with chronic post-traumatic cervical pain. The procedure appeared technically feasible and well-tolerated. However, given the limited sample size and uncontrolled retrospective design, these findings should be interpreted cautiously and considered preliminary and hypothesis-generating rather than confirmatory. Prospective controlled studies are required to further evaluate potential efficacy, safety, and long-term outcomes. Full article