Provenzano, David Anthony

Background Corticosteroid injections (CSIs) are widely employed in facet and sacroiliac joint pain. Similar to CSIs at other sites (peripheral nerve blocks, joints, epidural), these injections are associated with potential adverse events. These multisociety consensus recommendations aim to develop evidence-based statements and recommendations on the safe use of CSIs in facet joint and sacroiliac joint injections. Methods Development of the consensus recommendations was approved by the American Society of Regional Anesthesia and Pain Medicine Board of Directors and several other societies that agreed to participate. The scope of statements and recommendations was agreed on to include safety of the injection technique (landmark-guided, ultrasound, or radiology-aided injections); effect of the addition of the corticosteroid on effectiveness (vs local anesthetic or saline); and adverse events related to the injection. Experts were assigned topics to perform a comprehensive literature review and draft statements and recommendations, which were refined and voted for consensus (>75% agreement) using a modified Delphi process. A modified version of the US Preventive Services Task Force grading of evidence and strength of recommendation was followed. Results All statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Boards of Directors of the participating societies also approved all statements and recommendations. Injection of corticosteroid into the facet joint in patients with joint inflammation may relieve pain and improves function. Intra-articular, extra-articular (periarticular), and combined administration are effective for sacroiliac joint injections. No dose-response studies exist, but CSIs containing 10 mg of methylprednisolone or triamcinolone per facet joint and 40 mg per sacroiliac joint (SIJ) (or their respective pharmacologic equivalents) are reasonable. Conclusions In this practice recommendation, we provide statements and recommendations on facet and sacroiliac joint CSIs, the optimal doses, and intervals and criteria for repeating the CSIs in patients with facet joint and sacroiliac joint pain.

Background/importance Patient selection for spinal cord stimulation (SCS) therapy is crucial and is traditionally performed with clinical selection followed by a screening trial. The factors influencing patient selection and the importance of trialing have not been systematically evaluated. Objective We report a narrative review conducted to synthesize evidence regarding patient selection and the role of SCS trials. Evidence review Medline, EMBASE and Cochrane databases were searched for reports (any design) of SCS in adult patients, from their inception until March 30, 2022. Study selection and data extraction were carried out using DistillerSR. Data were organized into tables and narrative summaries, categorized by study design. Importance of patient variables and trialing was considered by looking at their influence on the long-term therapy success. Findings Among 7321 citations, 201 reports consisting of 60 systematic reviews, 36 randomized controlled trials (RCTs), 41 observational studies (OSs), 51 registry-based reports, and 13 case reports on complications during trialing were included. Based on RCTs and OSs, the median trial success rate was 72% and 82%, and therapy success was 65% and 61% at 12 months, respectively. Although several psychological and non-psychological determinants have been investigated, studies do not report a consistent approach to patient selection. Among psychological factors, untreated depression was associated with poor long-term outcomes, but the effect of others was inconsistent. Most RCTs except for chronic angina involved trialing and only one RCT compared patient selection with or without trial. The median (range) trial duration was 10 (0–30) and 7 (0–56) days among RCTs and OSs, respectively. Conclusions Due to lack of a consistent approach to identify responders for SCS therapy, trialing complements patient selection to exclude patients who do not find the therapy helpful and/or intolerant of the SCS system. However, more rigorous and large studies are necessary to better evaluate its role.