D'Souza, Ryan S

Abstract Background Spinal cord stimulation (SCS) is an important modality for treating chronic pain in patients who have failed conservative therapy and a substantial portion of the population rely on fee-for-service Medicare or Medicaid for coverage. We aimed to determine physician professional fee reimbursement rates and the ratio of Medicaid to Medicare professional fee reimbursement (MMI) for three common Current Procedural Terminology (CPT) codes related to SCS therapy (63650, 63685, and 63655) across states. Secondarily, we explored trends in utilization and reimbursement of these procedures by Medicare at the national level between 2013 and 2023. Methods Medicaid professional fee reimbursement data were extracted from publicly available fee schedules where available for individual states, while Medicare reimbursement data were extracted from the Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule. Baseline and wage-adjusted MMI values were calculated for each state. Results Medicaid reimbursed 11.5–21.0% less than Medicare across the evaluated CPT codes after wage adjustment, with differences of 11.8% for CPT 63650 (facility), 18.0% for CPT 63650 (non-facility), 11.5% for CPT 63685 (facility), and 21.0% for CPT 63655 (facility). Medicaid MMI values ranged from 0.397–1.87 across codes and settings. State-level Medicaid professional fee reimbursement varied substantially, ranging from $194.52–$639.38 for CPT 63650 (facility), $978.72–$2,781.65 for CPT 63650 (non-facility), $160.82–$558.00 for CPT 63685 (facility), and $375.97–$1,045.15 for CPT 63655 (facility); Medicare reimbursement was substantially less variable. From 2013–2023, Medicare utilization, rendering providers, beneficiaries, and standardized payments generally increased, although trends varied by CPT code and site of service. Conclusions Medicare physician professional fee reimbursement largely exceeds Medicaid physician professional fee reimbursement for three of the most common SCS procedural codes, suggesting potential access barriers to chronic pain procedures. Medicaid reimbursement shows considerable variation across states and among procedural codes, suggesting substantial interstate heterogeneity in Medicaid rate-setting that may reflect differences in state policy priorities or other factors not analyzed in this study.

Abstract Objective Genicular nerve radiofrequency (gRF) treatment is a widely used intervention for chronic pain from knee osteoarthritis (KOA). This systematic review and meta-analysis focuses on RCTs utilizing image guidance to address inconsistencies in previous reviews and provide higher-quality evidence. Design, Setting, and Methods This study included RCTs that compared gRF techniques (conventional, cooled, pulsed, bipolar) to non-gRF treatments, including sham procedures, intra-articular injections, ozone therapy, and oral medications. Primary and secondary outcomes were changes in pain and total WOMAC scores at 3, 6, and 12 months post-gRF treatments. Subgroup analyses explored differences by lesion size, use of prognostic blocks, industry sponsorship, and study location. Statistical heterogeneity was assessed via I 2 statistics. Results Eleven RCTs with 868 knee osteoarthritis patients (435 gRF, 433 non-gRF) were included. At 3 months, gRF significantly reduced pain (SMD -1.65, 95% CI: -3.20 to -0.10, I 2 = 98%, P = 0.040), but not at 6 months or 12 months. Secondary analyses showed no significant differences in total WOMAC scores between the gRF and control groups at 3, 6, and 12 months. Subgroup analysis showed that industry-sponsored studies reported significant 3-month pain reduction, whereas non-sponsored studies did not. This effect was independent of study location. Conclusions GRF provides short-term pain relief (up to 3 months) but neither functional improvement nor sustained pain reduction compared to non-gRF treatments. Our findings do not support the routine use of gRF for long-term chronic pain due to KOA.

Background Knee osteoarthritis (OA) is a leading cause of chronic pain and disability, with limited disease modifying therapies. While glucagon-like peptide 1 receptor agonists (GLP-1 RAs) have established cardiometabolic benefits and have been associated with reductions in knee OA related pain, it is unclear whether they can reduce progression to total knee arthroplasty (TKA). Methods We conducted a retrospective cohort study using the TriNetX Global Research Network, identifying adults with knee OA diagnosed between January 1, 2010, and December 31, 2024. Patients were stratified by GLP-1 RA exposure class (any GLP-1 RA or new generation agents, semaglutide or tirzepatide) and treatment duration (1 or 3 years), and then compared with propensity score matched non-exposed cohorts balanced for age, sex, race, musculoskeletal diagnoses, obesity related conditions, body mass index, and proxies for healthcare access. The primary outcome was cumulative incidence of TKA at 1, 3, 5, and 8 years. Hazard ratios (HRs) were estimated by Cox proportional hazards models and absolute risk differences from Kaplan–Meier curves, expressed as exposed minus non-exposed. Results After propensity score matching, cohort sizes ranged from 13 351 (new generation GLP-1 RA, 3 year exposure) to 42 062 patients (any GLP-1 RA, 1 year exposure). GLP-1 RA use was associated with significantly lower cumulative TKA incidence across all exposure classes, durations, and follow-up intervals (all p<0.001). With 1 year exposure to any GLP-1 RA, the absolute risk difference at 8 years was −2.80 percentage points (HR 0.90, 95% CI 0.83 to 0.98). Risk reductions were greater with new generation agents and longer duration: 3 year exposure to semaglutide or tirzepatide gave an absolute risk difference of −4.71 percentage points at 8 years (HR 0.72, 95% CI 0.67 to 0.78). Conclusions In this large, multicenter, real world cohort study, GLP-1 RA use was associated with a significantly reduced long term risk of TKA in patients with knee OA, with effects that were greater with longer treatment duration and newer generation agents. These duration and agent dependent associations are consistent with potential disease modifying activity beyond weight loss alone, although prospective trials are needed to establish causality and define optimal treatment targets.

Estimates of fibromyalgia prevalence vary widely worldwide due to differences in diagnostic criteria, study methodology, and population characteristics. Accurate estimates are essential to inform population-level surveillance, guide resource allocation, and highlight disparities in disease recognition and access to care. The objective of this systematic review and meta-analysis was to determine the global prevalence of fibromyalgia in the general population, and secondarily to identify factors moderating prevalence variation and to assess prevalence in defined at-risk subpopulations. Pooled prevalence estimates with 95% confidence intervals (CIs) were calculated using the inverse variance heterogeneity model with Freeman–Tukey transformation. Subgroup analyses were performed by sex, diagnostic criteria, country, and other study characteristics, and meta-regression assessed moderators including publication year and Human Development Index (HDI). Of 21,645 records identified, 1,728 underwent full-text review and 882 studies were included in the final analysis. Across 38 countries and 30,070,032 individuals (188 studies), the pooled fibromyalgia prevalence in the general population was 1.40% (95% CI, 0.49–2.47), with substantial heterogeneity (I 2 = 100%) and very low certainty of evidence. Among at-risk subpopulations (9,771,123 participants; 768 studies), prevalence was markedly higher in autoimmune and inflammatory conditions, such as chronic urticaria (37.1%), interstitial cystitis (30.8%), systemic sclerosis (20.6%), celiac disease (20.5%), and inflammatory bowel disease (19.9%), and elevated in chronic pain, rheumatologic, and post-infection cohorts. Meta-regression identified publication year (β = 0.008, P < .001) and HDI (β = 0.725, P = .002) as significant moderators of prevalence. In conclusion, fibromyalgia affects 1% to 2% of the global population, with substantially higher rates in at-risk subpopulations. Temporal and socioeconomic trends emphasize diagnostic inconsistency and global disparities in care.

Importance Chronic pain is a leading cause of disability, and many affected patients rely on long-term opioid therapy despite its unfavorable adverse effect profile. Spinal cord stimulation is an established therapy for chronic pain that may secondarily reduce opioid consumption by providing sustained analgesia. Objective To quantify changes in opioid use following spinal cord stimulation implantation for the treatment of chronic pain through a systematic review and meta-analysis. Data sources We conducted a comprehensive search of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Scopus from each database’s inception to July 1, 2024. Study selection We included studies describing patients who underwent spinal cord stimulator implantation for the treatment of chronic pain. A total of 2,784 potential studies were identified and screened by multiple independent reviewers, yielding a final total of 43 studies included in the systematic review. Data extraction and synthesis Data extraction was completed by multiple independent reviewers following Preferred Reporting Items for Systematic Reviews and Meta-Analysis and Meta-analysis Of Observational Studies in Epidemiology guidelines. A random effects model with Hartung-Knapp-Sidik-Jonkman adjustment was used to estimate pooled estimates. Certainty assessment was performed following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Main outcome(s) and measure(s) The primary outcomes were change in continuous opioid use (ie, morphine milligram equivalent (MME)) and categorical opioid use (yes/no) from preimplantation to 12 months following spinal cord stimulator implantation. Results Meta-analysis of 12 month continuous MME use comprising 22 study comparisons (1,666 individuals) revealed a weighted mean difference of −18.06 MME (95% CI −24.41 to −11.70; 95% prediction interval −38.29 to 2.17; p<0.001). Meta-analysis of categorical opioid use at 12 months comprising 24 study comparisons (1,527 individuals) revealed an OR of 0.47 (95% CI 0.30 to 0.75; 95% prediction interval 0.10 to 2.11; p=0.003), signifying lower odds of opioid continuation. Conclusions and relevance Spinal cord stimulation is associated with reduced opioid dose consumption and increased odds of opioid cessation at 12 months postimplantation compared with baseline in patients with chronic pain; however, both of these conclusions are supported by evidence of very low GRADE certainty. PROSPERO registration number CRD42024574921.

Introduction Psychological comorbidities can negatively impact outcomes of spinal cord stimulation (SCS) for chronic pain. While psychological assessment is commonly required before SCS implantation, evidence supporting its impact on outcomes is limited, and such assessments may be unnecessary for many patients and contribute to delays in care. Our center implemented a screening tool incorporating validated questionnaires and a mental health checklist to triage the need for formal psychological evaluation. This prospective, observational cohort study compared outcomes of SCS trials and implants between patients who bypassed (fast track: FT) versus those who underwent a formal assessment by a psychologist (AP). Methods Data were collected from patients undergoing SCS trials between July 2017 and December 2021. The screening tool used thresholds on validated questionnaires assessing anxiety, depression, catastrophizing, and opioid misuse risk, along with a checklist capturing significant anxiety or depression, self-harm, substance abuse, or mental-health-related hospitalization. Patients screening positive underwent an AP; others proceeded directly to trial (FT). 1 year post implantation outcomes were collected, with successful implantation defined as ≥30% pain reduction from baseline. Results Of 171 patients (114 AP, 57 FT), trial-to-implant rates were similar (72% AP vs 70% FT, p=0.811). The proportion of responders at 1 year post implant was also comparable (53% AP vs 60% FT, p=0.927). Multivariate logistic regression identified that higher baseline pain intensity (adjusted OR (aOR) 0.70, 95% CI 0.53 to 0.92, p=0.011) and use of tricyclic antidepressants (aOR 0.15, 95% CI 0.04 to 0.56, p=0.005) were associated with implant failure, whereas pain duration >10 years was associated with implant success (aOR 3.09, 95% CI 1.06 to 9.02, p=0.039). Conclusions This screening tool effectively identifies patients who can bypass routine psychological assessment without compromising 1 year SCS outcomes. Implementation can streamline patient flow, reduce wait times, and reserve psychological resources for those who need formal evaluation.