Pain physician最新文献_第7页

Physician Payment Reform in Interventional Pain Management: Balancing Cost, Quality, Access, and Survival of Independent Practices. 介入性疼痛管理中的医生报酬改革：平衡成本、质量、可及性和独立实践的生存。

IF 2.5 2区医学 Q2 ANESTHESIOLOGY

Pain physician

Pub Date : 2025-09-01

Laxmaiah Manchikanti, Mahendra Sanapati, Vidyasagar Pampati, Paul J Hubbell Iii, Ann Conn, Ramarao Pasupuleti, Mayank Gupta, Alan D Kaye, Alaa Abd-Elsayed, Annu Navani, Miles Day, Devi Nampiaparampil, Christopher G Gharibo, Joshua A Hirsch

On July 14, 2025, the Centers for Medicare and Medicaid Services (CMS) released the 2026 Physician Proposed Payment Rule aimed at reducing wasteful spending, enhancing quality measures, improving chronic disease management, and protecting independent practices from systemic financial pressures that have favored large healthcare systems and plagued independent practices. The goals are admirable, but the proposed measures with uniform reductions of 2.5% in physician payments based on efficiency adjustments apply across the board to all physicians. Further, practice expense (PE) reductions of 4% to 6%, meant to apply for hospital-based physicians will inadvertently apply to independent physicians constituting 43% of the physician workforce providing services in ambulatory surgery centers (ASCs), as well as hospitals. Thus, reductions of work relative value unit (wRVU) based on efficiency adjustment of 2.5% and PE reductions of 4% to 6%, with total reductions of 7% to 9%, compromise and limit patient care by putting additional pressure on independent physicians. Further, CMS' proposal to start Ambulatory Specialty Model (ASM) for low back pain with specialties of interventional pain management (IPM) and pain management involved. These specialties have no control over costs incurred as an overwhelming majority of patients are chronic pain patients and managed by family physicians, chiropractors, physical therapists, neurosurgeons, and others, resulting in 9% reductions, or increase in reimbursement over a period of 3 years with recurring changes of 3% each year.The proposal includes a 3.8% conversion factor (CF) payment update and increased reimbursement for office-based services, including evaluation, management, and procedures. The changes will increase reimbursement by 8% to 10% for office-based services, but they also decrease reimbursement for all procedures performed outside offices by 7% to 9%. These proposals arrive at a time when non-physician health care providers are striking for wage increase tied to inflation, and ironically, physicians have experienced repeated cuts in reimbursement with occasional stagnation, leading to 33% reduction from 2001 to 2025 in general, and 41% reductions in reimbursement for interventional pain physicians. In addition, there is an additional 2% sequester cut each year from 2011 to last until 2031, and there is a potential for 4% PAYGO cuts starting next year. Further, supply costs have increased 56% to 80% during these years. Further, despite technological advancements such as EMRs and AI, administrative burdens have intensified rather than improved. Independent physicians contend with complex prior authorizations, evolving Medicare coverage policies, growing audit risk with increased documentation and compliance demands from all payers' sources, 30% of interventional pain physicians under audit at any time. Our data on interventional pain physicians and published data on other physicians shows that eff

2025年7月14日，医疗保险和医疗补助服务中心（CMS）发布了2026年医生建议支付规则，旨在减少浪费的支出，加强质量措施，改善慢性病管理，并保护独立实践免受系统性财务压力的影响，这些压力有利于大型医疗保健系统并困扰独立实践。这些目标是令人钦佩的，但提议的基于效率调整将医生薪酬统一削减2.5%的措施适用于所有医生。此外，本应适用于医院医生的执业费用（PE）减少了4%至6%，却无意中适用于在门诊手术中心（ASCs）和医院提供服务的独立医生，这些独立医生占医生劳动力的43%。因此，基于效率调整的工作相对价值单位（wRVU）减少2.5%，PE减少4%至6%，总减少7%至9%，通过给独立医生施加额外压力来妥协和限制患者护理。此外，CMS建议启动涉及介入性疼痛管理（IPM）和疼痛管理专业的腰痛门诊专科模型（ASM）。这些专科无法控制所产生的费用，因为绝大多数患者是慢性疼痛患者，由家庭医生、脊椎指压治疗师、物理治疗师、神经外科医生和其他人管理，导致在3年内报销减少9%，或增加3%，每年反复发生变化。该提案包括3.8%的转换系数（CF）付款更新和增加办公室服务的报销，包括评估、管理和程序。这些变化将使办公室服务的报销额增加8%至10%，但也使在办公室以外进行的所有程序的报销额减少7%至9%。这些建议提出的时候，非医师医疗保健提供者正在罢工，要求与通货膨胀挂钩的工资增长，具有讽刺意味的是，医生经历了反复的报销削减，偶尔停滞不前，导致2001年至2025年总体减少33%，而介入疼痛医生的报销减少了41%。此外，从2011年到2031年，每年都有2%的自动减支，从明年开始，可能会有4%的现收现付减支。此外，这些年来，供应成本增加了56%至80%。此外，尽管电子病历和人工智能等技术取得了进步，但行政负担非但没有改善，反而加剧了。独立医生与复杂的事先授权、不断发展的医疗保险覆盖政策、越来越多的文件和来自所有付款人来源的合规性要求的审计风险不断增加、30%的介入疼痛医生随时都在接受审计。我们关于介入性疼痛医生的数据和关于其他医生的公开数据表明，效率下降了，pe飙升了。具有讽刺意味的是，CMS在2025年1月10日提议，将医疗保险优势计划的支付增加4.3%，到2026年将达到210亿美元。为了火上浇油，CMS于2025年4月7日发布了2025年至2026年平均增长5.06%的最终规定。这些提议是在人们越来越担心医疗保险优势支付的情况下提出的，其中包括440亿美元的优惠选择，400亿美元的风险调整差异，以及150亿美元的重复覆盖已经通过退伍军人管理局（VA）获得福利的退伍军人。此外，根据医疗保险支付咨询委员会（MedPAC）的数据，传统的医疗保险受益人也面临着更高的成本，每年额外支付198美元，总计约为130亿美元。所有这些加在一起，CMS每年在医疗保险优势上的支出超过1100亿美元。因此，随着独立执业不断受到攻击，美国介入疼痛医师协会（ASIPP）和其他协会敦促CMS为独立疼痛医师创建一个单独的标识符，以区分他们与医院的医生，并防止这些削减损害独立执业。这种独立但平等对待独立医生的做法最终会干扰病人的护理。

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引用次数: 0

Effectiveness of Peripheral Nerve Stimulation in Managing Chronic Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials. 外周神经刺激治疗慢性疼痛的有效性：随机对照试验的系统回顾和荟萃分析。

IF 2.5 2区医学 Q2 ANESTHESIOLOGY

Pain physician

Pub Date : 2025-09-01

Laxmaiah Manchikanti, Massab Bashir Khaira, Amol Soin, Alan D Kaye, Nebojsa Nick Knezevic, Alaa Abd-Elsayed, Mahendra Sanapati, Vivekanand A Manocha, Joshua A Hirsch

Background: Peripheral nerve stimulation (PNS) has been used for over 50 years to treat chronic pain. Since 2015, the Food and Drug Administration (FDA) has approved percutaneously implanted PNS leads and neurostimulators, offering a minimally invasive, non-opioid alternative for managing persistent and refractory chronic pain.

Objective: To evaluate the current evidence on PNS through a systematic review and meta-analysis.

Study design: A systematic review and meta-analysis of randomized controlled trials (RCTs) on PNS for chronic pain management, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Methods: Quality was assessed using Cochrane review criteria for risk of bias and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) for randomized therapeutic trials.A comprehensive literature search was conducted across multiple databases (1966-February 2025), supplemented by manual searches of bibliographies from relevant review articles. Included studies underwent quality assessment, best evidence synthesis, and grading using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. Evidence levels were classified from Level I to Level V.

Outcome measures: The primary outcome was the proportion of patients achieving significant pain relief and functional improvement (>= 50%) sustained for at least 12 months.

Results: The present investigation identified 7 high-quality and 2 moderate-quality RCTs based on Cochrane criteria and 9 moderate-quality trials based on IPM-QRB criteria. Utilizing GRADE criteria, 7 of 9 studies demonstrated moderate evidence and clinical applicability, and 2 of 9 showed low evidence and applicability.Overall, the combined qualitative and quantitative analysis supported a fair (Level III) evidence level, with moderate certainty and moderate strength of recommendation for:Implantable PNS systems following a trial or selective lumbar medial branch stimulation without a trialTemporary PNS therapy for 60 days.

Limitations: A key limitation remains the scarcity of high-quality studies.

Conclusion: The evidence supports a fair (Level III) level of evidence with moderate certainty and recommendation strength, based on qualitative and quantitative analyses and GRADE assessment.

背景：外周神经刺激（PNS）用于治疗慢性疼痛已有50多年的历史。自2015年以来，美国食品和药物管理局（FDA）已批准经皮植入PNS导联和神经刺激器，为治疗持续性和难治性慢性疼痛提供了一种微创、非阿片类药物的替代方案。目的：通过系统回顾和荟萃分析对PNS的现有证据进行评价。研究设计：遵循系统评价和荟萃分析（PRISMA）指南的首选报告项目，对PNS治疗慢性疼痛的随机对照试验（rct）进行系统评价和荟萃分析。方法：采用Cochrane偏倚风险评价标准和介入疼痛管理技术-可靠性和偏倚风险评价质量评价（IPM-QRB）对随机治疗试验进行质量评价。对多个数据库（1966- 2025年2月）进行了全面的文献检索，并辅以人工检索相关综述文章的参考书目。纳入的研究进行了质量评估、最佳证据合成，并使用建议、评估、发展和评价分级（GRADE）框架进行了分级。证据水平分为I级到v级。结局指标：主要结局是持续至少12个月获得显著疼痛缓解和功能改善的患者比例（>= 50%）。结果：本研究确定了基于Cochrane标准的7项高质量rct和2项中等质量rct，以及基于IPM-QRB标准的9项中等质量试验。使用GRADE标准，9项研究中有7项具有中等证据和临床适用性，9项研究中有2项具有低证据和临床适用性。总体而言，综合定性和定量分析支持一个公平的（III级）证据水平，具有中等确定性和中等强度的推荐：在试验后植入PNS系统或选择性腰椎内侧支刺激后不进行试验临时PNS治疗60天。局限性：一个关键的局限性仍然是缺乏高质量的研究。结论：基于定性和定量分析以及GRADE评估，证据支持公平（III级）证据水平，具有中等确定性和推荐强度。

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引用次数: 0

BMJ Publications on Interventional Techniques Do Not Meet Appropriateness Criteria of Conducting a Rapid Review: A Comprehensive Review. 英国医学杂志关于介入技术的出版物不符合进行快速审查的适当性标准：一项全面审查。

IF 2.5 2区医学 Q2 ANESTHESIOLOGY

Pain physician

Pub Date : 2025-09-01

Laxmaiah Manchikanti, Mahendra Sanapati, Amol Soin, Alan D Kaye, Alaa Abd-Elsayed, Christopher G Gharibo, Allen Dennis, Joshua A Hirsch

Background: A recent surge of publications on interventional techniques has questioned their effectiveness, based on a rapid review and network meta-analysis of randomized trials. This was followed by releasing a clinical practice guideline recommending a global ban on these techniques. Understandably, such recommendations have raised significant concern worldwide. Interventional techniques are widely used in chronic pain management, yet their effectiveness has been debated, with longstanding concerns about overuse, misuse, fraud, and abuse.

Objectives: To provide a comprehensive review and critical analysis of the BMJ rapid reviews and associated guidelines, with particular attention to the application-or absence-of basic appropriateness criteria published in the same journal, and the improper incorporation of such evidence into guideline recommendations.

Methods: A review of the available literature was conducted to assess the appropriate criteria for rapid reviews and guideline development.

Results: The absence of established appropriateness criteria led to an inadequately conducted rapid review and poorly developed guidelines. These, in turn, resulted in sweeping, globally applicable recommendations that lack a sound evidentiary basis.

Conclusion: A thorough examination of BMJ publications and related literature demonstrates that the BMJ's rapid reviews and subsequent guidelines on interventional techniques fail to meet recognized appropriateness criteria for conducting rapid reviews and developing consequential clinical guidelines based on such reviews.

背景：基于随机试验的快速回顾和网络荟萃分析，最近大量关于介入技术的出版物质疑其有效性。随后发布了一份临床实践指南，建议在全球范围内禁止这些技术。可以理解的是，这些建议在全世界引起了重大关注。介入技术广泛应用于慢性疼痛治疗，但其有效性一直存在争议，长期以来人们一直担心过度使用、误用、欺诈和滥用。目的：对BMJ快速评论和相关指南进行全面回顾和批判性分析，特别关注在同一期刊上发表的基本适当性标准的应用或缺失，以及将这些证据不适当地纳入指南建议。方法：对现有文献进行回顾，以评估快速审查和指南制定的适当标准。结果：由于缺乏既定的适当性标准，导致了不充分的快速审查和不完善的指南。这反过来又产生了广泛的、全球适用的建议，但缺乏可靠的证据基础。结论：对BMJ出版物和相关文献的全面检查表明，BMJ的快速审查和随后的介入技术指南未能满足进行快速审查和基于此类审查制定相应临床指南的公认适当标准。

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引用次数: 0

A Comparative Analysis of Single versus Double Intravertebral Reduction Device Implantation for Single-Level Osteoporotic Vertebral Fractures: Radiological and Clinical Outcomes. 单节段骨质疏松性椎体骨折单节段与双节段椎体复位器植入的对比分析：影像学和临床结果。

IF 2.5 2区医学 Q2 ANESTHESIOLOGY

Pain physician

Pub Date : 2025-09-01

Yuan-Fu Liu, Hao-Jun Chuang, Yu-Chia Hsu, Fu-Yao Fan, Chao-Jui Chang, Cheng-Li Lin

Background: Intravertebral reduction devices have been used for treating osteoporotic vertebral fractures (OVFs), with the advantage of fracture reduction before cement injection and the potential to prevent the secondary loss of vertebral height. While double devices via bipedicle insertion are commonly recommended, there is currently no report on the safety and efficacy of using a single device to treat OVFs.Objective: This study aims to compare the radiological and clinical outcomes of single intravertebral reduction device implantation to those of double intravertebral reduction device implantation in the treatment of single-level OVFs.Study design: Observational cohort study.Setting: The study was conducted at a tertiary medical center. Data were collected by reviewing the electronic medical records of a consecutive series of individuals from January 2015 to December 2020.Methods: Patients with single-level OVFs between T8 and L4 who underwent single (n = 27) or double (n = 56) intravertebral device implantation were included in the study and analyzed. Outcome measures included radiographic assessments and the evaluation of clinical outcomes. Multiple linear regression analysis was used to examine the associations among the number of implants, body mass index (BMI), bone mineral density, and presence of radiographic vacuum clefts on vertebral height correction.Results: Both the single- and double-device groups demonstrated significant improvements in fracture reduction and functional outcomes. The single-device group had a shorter operating time (36.0 ± 2.82 min vs. 62.92 ± 16.49 min, P = 0.012) and lower cement volume usage (3.60 ± 0.00 mL vs. 5.04 ± 1.56 mL, P = 0.032).However, the double-device group showed greater improvement in anterior vertebral height (7.02 ± 3.34 mm, 95% CI: 6.13-7.91 vs. 5.24 ± 3.94 mm, 95% CI: 3.68-6.80, p = 0.034) and regional kyphotic angle correction (6.79 ± 6.50°, 95% CI: 4.83-8.75 vs. 2.79 ± 6.79°, 95% CI: 0.10-5.48, P = 0.011). Despite these radiological differences, long-term functional outcomes at the last follow-up were comparable between groups. There were no significant differences in complication rates between the 2 groups. Higher BMI and the presence of an intravertebral vacuum cleft appeared as potential risk factors for the re-collapse of vertebral body height.Limitations: This study is retrospective and has inherent limitations related to sample size and variability. Some measurements showed a high degree of variability, which could have led to overlapping confidence intervals and a potential risk of Type II errors.Conclusion: Single intravertebral reduction device implantation is an effective and safe treatment option for OVFs, yielding clinical outcomes comparable to those of double device implantation. Additiona

背景：椎体内复位装置已被用于治疗骨质疏松性椎体骨折（OVFs），其优点是在骨水泥注射前骨折复位，并有可能防止继发性椎体高度损失。虽然通常推荐通过双椎弓根插入双装置，但目前还没有关于使用单个装置治疗ovf的安全性和有效性的报道。目的：本研究旨在比较单一椎体复位器与双重椎体复位器在治疗单节段ovf中的放射学和临床效果。研究设计：观察性队列研究。环境：本研究在三级医疗中心进行。通过审查2015年1月至2020年12月连续一系列个人的电子病历收集数据。方法：选取T8 ~ L4间单节段ovf患者（27例）或双节段ovf患者（56例）进行研究分析。结果测量包括影像学评估和临床结果评估。采用多元线性回归分析来检验植入物数量、身体质量指数（BMI）、骨密度和x线摄影真空裂缝的存在与椎体高度矫正之间的关系。结果：单装置组和双装置组在骨折复位和功能预后方面均有显著改善。单器械组手术时间较短（36.0±2.82 min vs. 62.92±16.49 min, P = 0.012），水泥用量较低（3.60±0.00 mL vs. 5.04±1.56 mL, P = 0.032）。然而，双装置组在椎体前高度（7.02±3.34 mm, 95% CI: 6.13-7.91 vs. 5.24±3.94 mm, 95% CI: 3.68-6.80, p = 0.034）和局部后凸角矫正（6.79±6.50°，95% CI: 4.83-8.75 vs. 2.79±6.79°，95% CI: 0.10-5.48, p = 0.011）方面有较大改善。尽管有这些放射学上的差异，但在最后一次随访时，两组之间的长期功能结果是可比较的。两组患者并发症发生率无显著差异。较高的BMI和椎内真空裂的存在是椎体高度再次塌陷的潜在危险因素。局限性：本研究是回顾性的，在样本量和可变性方面存在固有的局限性。一些测量显示出高度的可变性，这可能导致重叠的置信区间和II型错误的潜在风险。结论：单椎体复位器植入术是治疗ovf的一种安全有效的方法，其临床效果与双椎体复位器植入术相当。此外，某些危险因素，如较高的BMI和椎内真空裂的存在，应该仔细评估，因为它们可能导致可伸缩装置增强后椎体高度再次塌陷。然而，前瞻性随机对照试验仍有必要进一步评估单装置与双装置植入的疗效。

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引用次数: 0

A Prospective, Randomized, Controlled Clinical Trial of High-Frequency Electromagnetic Coupling Powered Permanent Peripheral Nerve Stimulator for the Treatment of Chronic Craniofacial Pain. 高频电磁耦合驱动的永久性周围神经刺激器治疗慢性颅面疼痛的前瞻性、随机、对照临床试验。

IF 2.5 2区医学 Q2 ANESTHESIOLOGY

Pain physician

Pub Date : 2025-09-01

Salim M Hayek, Nameer Haider, Ashwin Viswanathan, Mehul Desai, Jeffrey Rosenberg, Niek E Vanquathem

Background: Craniofacial pain is one of the most common chronic pain conditions, affecting more than one-fifth of the US population. While various medications and conservative treatment modalities are available for this condition, many patients have refractory symptoms. These patients suffer from social impairment, reduced quality of life, and increased financial burdens.Objective: The objective of this study was to examine the clinical outcomes of patients receiving a permanent, high-frequency electromagnetic coupling (HF-EMC) powered peripheral nerve stimulator (PNS) system for the treatment of chronic craniofacial neuropathic pain.Study design: This study was a multicenter, randomized, controlled clinical trial conducted under an investigational device exemption (IDE).Setting: This study was conducted in 7 clinical sites in the US.Methods: All patients in this randomized controlled trial (RCT) were permanently implanted with the Freedom® Peripheral Nerve Stimulator (PNS) System (Curonix LLC). All patients completed an initial 7-day therapy assessment period following the permanent implantation. The patients who successfully completed the initial 7-day therapy assessment period (>= 50% pain relief) were randomly assigned to either a patient group that received continued stimulation (the "active" arm) or a patient group whose treatment was discontinued for 3 months after the initial positive 7-day therapy assessment period (the "deactivated" stimulation arm). After the 3-month follow-up visit, the deactivated patients were reactivated. The primary efficacy outcome included the proportion of patients who experienced significant pain relief (>= 50%) 3 months after the permanent implant procedure. The visual analog scale (VAS), Brief Pain Inventory Facial (BPIF) questionnaire, and Short-Form McGill Pain Questionnaire 2 (MPQ-SF-2) were used to measure changes in pain. Additional functional outcome measures included the Patient Global Impression of Change (PGIC) and the 36-Item Short-Form Survey (SF-36).Results: During the 7-day therapy assessment period, 56 out of 60 patients reported significant pain relief (>= 50%), representing a 93% responder rate. At 3 months, 69% of the active stimulation group experienced significant pain relief, while only 11% of the deactivated group reported significant pain relief. The mean VAS scores were reduced by 62% and 8.5% in the active and deactivated stimulation groups. When patients within the deactivated group were reactivated after 3 months, the reactivated patients reported similar reduction in pain scores to those reported by the active arm patients. Similar results were found for the functional outcome measures. After the reactivation, significant pain relief was maintained through the 12-month follow-up period. No SAEs were reported throughout the study for any of the

颅面疼痛是最常见的慢性疼痛之一，影响了超过五分之一的美国人口。虽然各种药物和保守治疗方式可用于这种情况，但许多患者有难治性症状。这些患者患有社交障碍，生活质量下降，经济负担增加。目的：本研究的目的是观察永久性高频电磁耦合（HF-EMC）供电周围神经刺激器（PNS）系统治疗慢性颅面神经性疼痛的临床效果。研究设计：本研究是一项多中心、随机、对照临床试验，在研究器械豁免（IDE）下进行。环境：本研究在美国的7个临床地点进行。方法：本随机对照试验（RCT）的所有患者均永久植入Freedom®外周神经刺激器（PNS）系统（Curonix LLC）。所有患者在永久植入后完成了最初的7天治疗评估期。成功完成最初7天治疗评估期（>= 50%疼痛缓解）的患者被随机分配到接受持续刺激的患者组（“活跃”组）或在最初7天治疗评估期阳性后停止治疗3个月的患者组（“停用”刺激组）。3个月的随访后，停用的患者被重新激活。主要疗效指标包括永久性种植体手术后3个月疼痛明显缓解的患者比例（>= 50%）。采用视觉模拟量表（VAS）、简短面部疼痛量表（BPIF）和简短McGill疼痛问卷2 （MPQ-SF-2）测量疼痛的变化。其他功能结果测量包括患者整体变化印象（PGIC）和36项简短问卷调查（SF-36）。结果：在7天的治疗评估期内，60例患者中有56例报告明显的疼痛缓解（>= 50%），反应率为93%。在3个月时，69%的积极刺激组的疼痛明显缓解，而只有11%的不积极刺激组的疼痛明显缓解。有刺激组和无刺激组的平均VAS评分分别降低了62%和8.5%。当停用组的患者在3个月后重新激活时，重新激活的患者报告的疼痛评分与活动组患者报告的疼痛评分相似。在功能结果测量中也发现了类似的结果。再激活后，在12个月的随访期间，疼痛得到了显著缓解。在整个研究过程中，没有任何患者报告发生急性呼吸窘迫症。局限性：局限性包括缺乏真正的安慰剂，因为根据研究设计需要使用或不使用外部传递器作为对照，可选择使用超阈或亚阈刺激，以及由于COVID-19大流行导致患者随访的变化。结论：该随机对照试验在需要FDA监管的IDE下进行。本研究为PNS治疗提供了一级证据。本研究的积极结果支持扩大PNS治疗颅面疼痛的适应症。该研究证实，HF-EMC供电的永久性PNS是一种有效且安全的治疗难治性慢性颅面神经性疼痛的干预手段。

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引用次数: 0

Full Endoscopic Decompression Surgery for Far-Out Syndrome Via Pseudoarthrosis Formed by L5 Transverse Process and Sacral Ala: A Preliminary Outcome. 经L5横突和骶翼形成的假关节形成的远端综合征的全内镜减压手术：初步结果。

IF 2.5 2区医学 Q2 ANESTHESIOLOGY

Pain physician

Pub Date : 2025-09-01

Hao Hu, Fu-Kuan Zhu, Lei Shi, Rui Deng, Xi-Zi Miao, Ya-Feng Wen, Zhen-Yong Ke, Xiao-Min Sheng, Lei Chu, Zhong-Liang Deng

Background: Far-out syndrome (FOS) refers to the compression of the L5 nerve root in the extraforaminal region by a pseudoarthrosis formed between the L5 transverse process and the sacral ala. If conservative treatment for this condition fails, surgical intervention should be considered.

Objectives: This study aims to introduce a minimally invasive endoscopic technique for treating FOS via the pseudoarthrosis approach.

Study design: A technical note and preliminary outcome.

Methods: We retrospectively analyzed the medical history, physical examination, auxiliary examinations, and imaging data as well as the visual analog scale (VAS), Oswestry Disability Index (ODI), and Macnab scores of 5 FOS patients treated with minimally invasive endoscopic surgery at our hospital from April 2024 to July 2024. The implementation process of this surgical technique is illustrated through typical cases.

Results: We performed decompression surgery via the L5 transverse process-sacral ala pseudoarthrosis approach using full endoscopy, which successfully relieved the clinical symptoms in the 5 patients. The patients' postoperative VAS scores were significantly lower than the preoperative scores (P = 0.041). Similarly, the postoperative ODI scores were markedly decreased (P = 0.043), and the last follow-up showed a 100% excellent rate (Macnab score). Imaging examination indicated a sufficiently expanded extraforaminal outlet, and the nerve roots were adequately decompressed.

Limitations: The study involved a relatively small number of samples and a short follow-up period.

Conclusions: The full endoscopic decompression surgery via the L5 transverse process-sacral ala pseudoarthrosis approach can address the extraforaminal compression in FOS. This procedure is a feasible endoscopic surgical option that serves as a valuable supplement to the minimally invasive treatment for FOS.

背景：远端综合征（Far-out syndrome， FOS）是指椎间孔外区域L5神经根被L5横突和骶翼之间形成的假关节压迫。如果保守治疗失败，应考虑手术治疗。目的：本研究旨在介绍一种经假关节入路治疗FOS的微创内镜技术。研究设计：技术说明和初步结果。方法：回顾性分析我院于2024年4月至2024年7月行微创内镜手术的5例FOS患者的病史、体格检查、辅助检查、影像学资料及视觉模拟评分（VAS）、Oswestry残疾指数（ODI）、Macnab评分。通过典型病例说明该手术技术的实施过程。结果：我们在全内镜下经L5横突-骶翼假关节入路行减压手术，成功缓解了5例患者的临床症状。患者术后VAS评分明显低于术前评分（P = 0.041）。同样，术后ODI评分明显降低（P = 0.043），末次随访优良率为100% （Macnab评分）。影像学检查显示椎间孔外出口充分扩张，神经根充分减压。局限性：本研究样本量相对较少，随访时间较短。结论：经L5横突-骶翼假关节入路的全内镜减压手术可以解决FOS的椎间孔外压迫。该手术是一种可行的内窥镜手术选择，可作为FOS微创治疗的宝贵补充。

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引用次数: 0

Minimally Invasive Sacroiliac Joint Fusion: Posterior Graft Implant vs. Lateral Arthrodesis with Compression Screw Hardware at a Pain Management Center. 微创骶髂关节融合术：疼痛管理中心后路植骨植入与侧位关节融合术的比较。

IF 2.5 2区医学 Q2 ANESTHESIOLOGY

Pain physician

Pub Date : 2025-09-01

Ramis Gheith, Mindy Wortmann, Michel Najjar

Background: The sacroiliac joint (SIJ) is a frequently overlooked source of lower back pain (LBP), contributing to 15-30% of cases. Nonoperative treatments such as NSAIDs, physical therapy, and SIJ injections have limited effectiveness on LBP. When conservative measures fail, SIJ fusion is recommended, with minimally invasive techniques showing better outcomes than traditional open surgery. However, there is no clear agreement on the optimal approach for SIJ fusion.

Objectives: This study aims to evaluate the outcomes of minimally invasive SIJ fusion performed by a single surgeon, comparing the lateral and posterior approaches to another in terms of pain relief, functional improvement, and procedure durability.

Study design: A retrospective comparative study.

Setting: A single pain management center at the Interventional Pain Institute, where patients underwent SIJ fusion between April 2020 and May 2024.

Methods: A total of 115 patients who underwent minimally invasive SIJ fusion and met the inclusion criteria were included in the study. Patients were assessed before and after the procedure for pain using the Visual Analog Scale (VAS), functional outcomes using the Oswestry Disability Index (ODI), opioid consumption, sleep quality, and procedure durability. Statistical comparisons between the lateral and posterior approaches were performed using the chi-square (c²), Fisher's exact test, and t-test as appropriate, while durability was analyzed with the Kaplan-Meier curve and log-rank test.

Results: The average follow-up duration was 11.3 ± 5.8 months. Lateral SIJ fusion demonstrated longer procedural durability compared to the posterior approach, with greater improvements in VAS pain scores (66.3% vs. 53.8%, P = 0.017), ODI functional outcomes (45.0% vs. 30.7%, P = 0.002), higher rates of sleep improvement (83.9% vs. 61.0%, P = 0.006), and lower recurrence rates (12.5% vs. 28.8%, P = 0.031). At the last follow-up, most patients (79.1%) maintained their improvements.

Limitations: This study is limited by its retrospective design, its single-center setting, and the lack of randomization between the lateral and posterior approaches.

Conclusion: Both the lateral and posterior approaches to minimally invasive SIJ fusion were beneficial. However, the lateral approach used in our study demonstrated superior outcomes in the areas of pain relief, functional improvement, and procedure durability. Further multicenter prospective studies with larger patient populations are recommended to confirm these findings.

背景：骶髂关节（SIJ）是一个经常被忽视的腰痛（LBP）的来源，贡献15-30%的病例。非手术治疗如非甾体抗炎药、物理治疗和SIJ注射对LBP的疗效有限。当保守措施失败时，推荐SIJ融合，微创技术比传统开放手术效果更好。然而，对于SIJ融合的最佳方法尚无明确的共识。目的：本研究旨在评估由单一外科医生进行微创SIJ融合的结果，比较外侧和后路入路与另一种入路在疼痛缓解、功能改善和手术持久性方面的效果。研究设计：回顾性比较研究。环境：介入性疼痛研究所的单一疼痛管理中心，患者在2020年4月至2024年5月期间接受了SIJ融合。方法：纳入115例符合纳入标准的微创SIJ融合患者。采用视觉模拟量表（VAS）评估手术前后患者的疼痛，采用Oswestry残疾指数（ODI）评估功能结果，阿片类药物消耗，睡眠质量和手术持久性。采用卡方（c²）、Fisher精确检验和适当的t检验对侧入路和后入路进行统计比较，同时采用Kaplan-Meier曲线和log-rank检验对耐久性进行分析。结果：平均随访时间11.3±5.8个月。与后路入路相比，侧侧SIJ融合显示出更长的手术持久性，VAS疼痛评分（66.3%比53.8%,P = 0.017）、ODI功能结局（45.0%比30.7%,P = 0.002）、更高的睡眠改善率（83.9%比61.0%,P = 0.006）和更低的复发率（12.5%比28.8%,P = 0.031）有更大的改善。在最后一次随访中，大多数患者（79.1%）保持了改善。局限性：该研究的局限性在于其回顾性设计、单中心设置以及缺乏侧入路和后路的随机化。结论：侧路入路和后路入路对微创SIJ融合术都是有益的。然而，在我们的研究中使用的侧入路在疼痛缓解、功能改善和手术持久性方面显示出更好的结果。建议进一步开展多中心前瞻性研究，纳入更大的患者群体，以证实这些发现。

{"title":"Minimally Invasive Sacroiliac Joint Fusion: Posterior Graft Implant vs. Lateral Arthrodesis with Compression Screw Hardware at a Pain Management Center.","authors":"Ramis Gheith, Mindy Wortmann, Michel Najjar","doi":"","DOIUrl":"","url":null,"abstract":"Background: The sacroiliac joint (SIJ) is a frequently overlooked source of lower back pain (LBP), contributing to 15-30% of cases. Nonoperative treatments such as NSAIDs, physical therapy, and SIJ injections have limited effectiveness on LBP. When conservative measures fail, SIJ fusion is recommended, with minimally invasive techniques showing better outcomes than traditional open surgery. However, there is no clear agreement on the optimal approach for SIJ fusion.Objectives: This study aims to evaluate the outcomes of minimally invasive SIJ fusion performed by a single surgeon, comparing the lateral and posterior approaches to another in terms of pain relief, functional improvement, and procedure durability.Study design: A retrospective comparative study.Setting: A single pain management center at the Interventional Pain Institute, where patients underwent SIJ fusion between April 2020 and May 2024.Methods: A total of 115 patients who underwent minimally invasive SIJ fusion and met the inclusion criteria were included in the study. Patients were assessed before and after the procedure for pain using the Visual Analog Scale (VAS), functional outcomes using the Oswestry Disability Index (ODI), opioid consumption, sleep quality, and procedure durability. Statistical comparisons between the lateral and posterior approaches were performed using the chi-square (c²), Fisher's exact test, and t-test as appropriate, while durability was analyzed with the Kaplan-Meier curve and log-rank test.Results: The average follow-up duration was 11.3 ± 5.8 months. Lateral SIJ fusion demonstrated longer procedural durability compared to the posterior approach, with greater improvements in VAS pain scores (66.3% vs. 53.8%, P = 0.017), ODI functional outcomes (45.0% vs. 30.7%, P = 0.002), higher rates of sleep improvement (83.9% vs. 61.0%, P = 0.006), and lower recurrence rates (12.5% vs. 28.8%, P = 0.031). At the last follow-up, most patients (79.1%) maintained their improvements.Limitations: This study is limited by its retrospective design, its single-center setting, and the lack of randomization between the lateral and posterior approaches.Conclusion: Both the lateral and posterior approaches to minimally invasive SIJ fusion were beneficial. However, the lateral approach used in our study demonstrated superior outcomes in the areas of pain relief, functional improvement, and procedure durability. Further multicenter prospective studies with larger patient populations are recommended to confirm these findings.","PeriodicalId":19841,"journal":{"name":"Pain physician","volume":"28 5","pages":"E555-E566"},"PeriodicalIF":2.5,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145131650","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

HbA1c is Associated with Hyperglycemia After Local Dexamethasone Injection in Diabetes Mellitus Patients: A Cohort Study. 糖尿病患者局部注射地塞米松后HbA1c与高血糖相关：一项队列研究

IF 2.5 2区医学 Q2 ANESTHESIOLOGY

Pain physician

Pub Date : 2025-09-01

Kumiko Tanabe, Takuma Ishihara, Yoshimi Nakamura, Hiroki Iida

Background: Glucocorticoids (GCs) are often administered locally to inhibit the synthesis and release of pro-inflammatory cytokines, thereby alleviating local pain. While GCs are known to exacerbate hyperglycemia, we previously reported changes in glucose levels following a single-dose dexamethasone injection in patients who did not have diabetes mellitus (DM). In patients without DM, blood glucose levels increased on the first day but were generally not critical. However, the exact changes in blood glucose levels due to GCs and the risk factors for blood glucose elevation in DM patients remain unclear.Objectives: To measure changes in glucose levels following a single-dose dexamethasone injection in patients with DM and identify the risk factors for hyperglycemia.Study design: Cohort study.Setting: Gifu University Hospital, Japan.Method: Fifty DM patients undergoing elective pulsed radiofrequency of the lumbar or sacral nerve root or radiofrequency of the lumbar medial branch of the posterior primary ramus were analyzed. Each patient received 0.1 mg/kg of dexamethasone and was subjected to interstitial glucose monitoring using a continuous glucose monitoring system. Hyperglycemia was defined as a blood glucose level >= 200 mg/dL. The area under the curve (AUC) for glucose levels >= 200 mg/dL was calculated. Risk factors for hyperglycemia were analyzed using an ordinal regression model, with AUC as the objective variable and 4 factors (glycosylated hemoglobin [HbA1c], age, body mass index, and pre-procedure glucose levels) as explanatory variables. Nonlinear regression models were used to predict the blood glucose trends.Results: Blood glucose levels increased immediately after the dexamethasone injections. The median (interquartile range) maximum glucose level was 328 (250-386) mg/dL, with a median time to peak of 592 (400-700) min. Among the 4 factors, age and HbA1c level were significant predictors of hyperglycemia (P = 0.035 and 0.023, respectively). Patients treated with insulin were predicted to have significantly higher blood glucose levels than those treated for DM with non-insulin medications or no pharmacological medications (P < 0.001).Limitations: Firstly, GCs are metabolized by cytochrome p450 3A4, and medications that affect this pathway may alter the clearance of GCs. Some of our patients were taking medications that influenced the cytochrome pathway. Secondly, preoperative insulin management details (dosing, timing, and types) were not fully documented. Thirdly, stress-induced hyperglycemia could not be ruled out. Finally, patients' meal timing and caloric intake were not recorded.Conclusion: Patients with DM experienced significant hyperglycemia even after a single dose of dexamethasone. Age and HbA1c levels were risk factors for hyperglycemia.

背景：糖皮质激素（GCs）经常局部使用，以抑制促炎细胞因子的合成和释放，从而减轻局部疼痛。虽然已知GCs会加剧高血糖，但我们之前报道了非糖尿病（DM）患者单剂量地塞米松注射后葡萄糖水平的变化。在非糖尿病患者中，血糖水平在第一天升高，但通常不严重。然而，糖尿病患者由于GCs引起的血糖水平的确切变化和血糖升高的危险因素尚不清楚。目的：测量糖尿病患者单剂量地塞米松注射后血糖水平的变化，并确定高血糖的危险因素。研究设计：队列研究。地点：日本岐阜大学附属医院。方法：对50例糖尿病患者行选择性脉冲射频腰、骶神经根或腰后支内侧支射频治疗的临床资料进行分析。每位患者接受0.1 mg/kg地塞米松治疗，并使用连续血糖监测系统进行间质血糖监测。高血糖定义为血糖水平>= 200 mg/dL。计算葡萄糖浓度>= 200 mg/dL时曲线下面积（AUC）。采用有序回归模型分析高血糖危险因素，以AUC为客观变量，糖化血红蛋白[HbA1c]、年龄、体重指数、术前血糖水平4个因素为解释变量。采用非线性回归模型预测血糖变化趋势。结果：注射地塞米松后血糖立即升高。最大血糖水平中位数（四分位间距）为328 (250-386)mg/dL，达到峰值的中位数时间为592 (400-700)min。在4个因素中，年龄和HbA1c水平是高血糖的显著预测因子（P值分别为0.035和0.023）。预计胰岛素治疗的患者血糖水平明显高于非胰岛素治疗或不使用药物治疗的糖尿病患者（P < 0.001）。局限性：首先，GCs是通过细胞色素p450 3A4代谢的，影响这一途径的药物可能会改变GCs的清除。我们的一些病人正在服用影响细胞色素通路的药物。其次，术前胰岛素管理细节（剂量、时间和类型）没有完整的记录。第三，不能排除应激性高血糖。最后，不记录患者的进餐时间和热量摄入。结论：糖尿病患者即使在单次地塞米松治疗后也会出现明显的高血糖。年龄和HbA1c水平是高血糖的危险因素。手术前较高的HbA1c水平，反映较差的每日血糖控制，与血糖水平升高有关。

{"title":"HbA1c is Associated with Hyperglycemia After Local Dexamethasone Injection in Diabetes Mellitus Patients: A Cohort Study.","authors":"Kumiko Tanabe, Takuma Ishihara, Yoshimi Nakamura, Hiroki Iida","doi":"","DOIUrl":"","url":null,"abstract":"Background: Glucocorticoids (GCs) are often administered locally to inhibit the synthesis and release of pro-inflammatory cytokines, thereby alleviating local pain. While GCs are known to exacerbate hyperglycemia, we previously reported changes in glucose levels following a single-dose dexamethasone injection in patients who did not have diabetes mellitus (DM). In patients without DM, blood glucose levels increased on the first day but were generally not critical. However, the exact changes in blood glucose levels due to GCs and the risk factors for blood glucose elevation in DM patients remain unclear.Objectives: To measure changes in glucose levels following a single-dose dexamethasone injection in patients with DM and identify the risk factors for hyperglycemia.Study design: Cohort study.Setting: Gifu University Hospital, Japan.Method: Fifty DM patients undergoing elective pulsed radiofrequency of the lumbar or sacral nerve root or radiofrequency of the lumbar medial branch of the posterior primary ramus were analyzed. Each patient received 0.1 mg/kg of dexamethasone and was subjected to interstitial glucose monitoring using a continuous glucose monitoring system. Hyperglycemia was defined as a blood glucose level >= 200 mg/dL. The area under the curve (AUC) for glucose levels >= 200 mg/dL was calculated. Risk factors for hyperglycemia were analyzed using an ordinal regression model, with AUC as the objective variable and 4 factors (glycosylated hemoglobin [HbA1c], age, body mass index, and pre-procedure glucose levels) as explanatory variables. Nonlinear regression models were used to predict the blood glucose trends.Results: Blood glucose levels increased immediately after the dexamethasone injections. The median (interquartile range) maximum glucose level was 328 (250-386) mg/dL, with a median time to peak of 592 (400-700) min. Among the 4 factors, age and HbA1c level were significant predictors of hyperglycemia (P = 0.035 and 0.023, respectively). Patients treated with insulin were predicted to have significantly higher blood glucose levels than those treated for DM with non-insulin medications or no pharmacological medications (P < 0.001).Limitations: Firstly, GCs are metabolized by cytochrome p450 3A4, and medications that affect this pathway may alter the clearance of GCs. Some of our patients were taking medications that influenced the cytochrome pathway. Secondly, preoperative insulin management details (dosing, timing, and types) were not fully documented. Thirdly, stress-induced hyperglycemia could not be ruled out. Finally, patients' meal timing and caloric intake were not recorded.Conclusion: Patients with DM experienced significant hyperglycemia even after a single dose of dexamethasone. Age and HbA1c levels were risk factors for hyperglycemia. ","PeriodicalId":19841,"journal":{"name":"Pain physician","volume":"28 5","pages":"E547-E554"},"PeriodicalIF":2.5,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145131658","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

The Role of the Subcutaneous Fat Index in Predicting Transforaminal Epidural Steroid Injection Treatment Success: An Observational Prospective Study. 皮下脂肪指数在预测经椎间孔硬膜外类固醇注射治疗成功中的作用：一项观察性前瞻性研究。

IF 2.5 2区医学 Q2 ANESTHESIOLOGY

Pain physician

Pub Date : 2025-07-01

Ahmet Sac, Erhan Biyikli, Savas Sencan, Serdar Kokar, Osman Hakan Gunduz, Umit Suleyman Sehirli

Background: Obesity is thought to be one factor that contributes to low back pain (LBP). Classifying obesity according to body mass index (BMI) and its use in general health-related predictions is often considered inadequate. For this reason, a new parameter known as the subcutaneous fat index (SFI) has been defined to provide insight into spine health. SFI is the thickness of subcutaneous fat tissue (SFTT) at the L1-L2 level.

Objectives: This study aimed to investigate the answer to the question "Is this new index, which has been shown to be successful in predicting spinal degeneration and morphological changes, effective in predicting the success of transforaminal epidural steroid injection (TFESI) treatment?"

Study design: An observational prospective clinical study.

Setting: A university hospital's interventional pain management center.

Methods: Patients with spinal radicular pain due to intervertebral disc herniation, for whom TFESI was planned, were categorized into two groups according to SFI (was measured as the vertical distance from the tip of the spinous process of the L1 vertebra to the skin on axial T2-weighted lumbar spine magnetic resonance images cut-off values (9.4 mm in men and 8.45 mm in women) and were followed up for 3 months after the procedure. During patient follow-up, evaluations were performed with the Numeric Rating Scale, Oswetry Disability Index, and 12-Item Short-Form Health Survey. Additionally, intervertebral disc degeneration (IVDD) related to injection level and nerve compression grading were evaluated radiologically.

Results: A total of 50 patients' IVDD as related to injection level was significantly higher in the SFI > 9.4/8.45 mm group. According to the 3rd month's follow-up results, significant treatment success was observed in all parameters in both groups. However, no significant difference was found in predicting treatment success between the SFI < 9.4/8.45 mm and SFI > 9.4/8.45 mm groups.

Limitations: Our sample sizes were asymmetric, and a single radiologist performed the evaluation.

Conclusion: The newly defined SFI parameter was not effective enough to provide a significant difference in nerve compression grading or in predicting treatment success.

背景：肥胖被认为是导致腰痛（LBP）的一个因素。根据身体质量指数（BMI）对肥胖进行分类及其在一般健康相关预测中的应用通常被认为是不充分的。由于这个原因，一个新的参数被称为皮下脂肪指数（SFI）已被定义，以提供深入了解脊柱健康。SFI为L1-L2水平皮下脂肪组织（SFTT）的厚度。目的：本研究旨在探讨以下问题的答案：“这个已被证明能成功预测脊柱退变和形态改变的新指标，是否能有效预测经椎间孔硬膜外类固醇注射（TFESI）治疗的成功？”研究设计：一项观察性前瞻性临床研究。地点：大学附属医院介入性疼痛管理中心。方法：对计划行TFESI的腰椎间盘突出性脊髓根性疼痛患者，根据SFI（在t2轴向加权腰椎磁共振图像上测量L1椎体棘突尖端到皮肤的垂直距离，男性为9.4 mm，女性为8.45 mm）分为两组，术后随访3个月。在患者随访期间，采用数字评定量表、Oswetry残疾指数和12项简短健康调查进行评估。此外，椎间盘退变（IVDD）与注射水平和神经压迫分级相关的放射学评估。结果：50例患者中，SFI > 9.4/8.45 mm组IVDD与注射水平相关显著增高。随访3个月，两组患者各项指标均取得显著治疗成功。然而，SFI < 9.4/8.45 mm组和SFI > 9.4/8.45 mm组在预测治疗成功方面没有显著差异。局限性：我们的样本量是不对称的，并且由一位放射科医生进行评估。结论：新定义的SFI参数不足以在神经压迫分级或预测治疗成功方面提供显着差异。

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引用次数: 0

Diagnostic Guidance for Chronic Complex Regional Pain Syndrome Type I and Type II from The American Society of Interventional Physicians (ASIPP). 美国介入医师学会（ASIPP）慢性复杂区域性疼痛综合征I型和II型诊断指南。

IF 2.5 2区医学 Q2 ANESTHESIOLOGY

Pain physician

Pub Date : 2025-07-01

Christopher Gharibo, Miles Day, Steve M Aydin, Alan D Kaye, Salahadin Abdi, Sudhir Diwan, Lisa V Doan, Danielle Feng, Kris Ferguson, Kirolos Georges, Andrew Kaufman, Nebojsa Nick Knezevic, Sean Li, Franzes A Liongson, Devi Nampiaparampil, Annu Navani, Mahendra Sanapati, Michael E Schatman, Amol Soin, Peter S Staats, Giustino Varrassi, Jing Wang, Laxmaiah Manchikanti

Background: Complex Regional Pain Syndrome (CRPS) is a challenging and often disabling condition marked by persistent pain, most commonly in a limb following injury or surgery. It presents with a wide array of symptoms, including intense pain, swelling, alterations in skin color and temperature, motor dysfunction, and trophic changes such as skin and tissue atrophy. While the precise cause of CRPS is not fully understood, it is thought to stem from abnormal nervous system activity, leading to heightened pain sensitivity and inflammatory responses. A thorough understanding of CRPS is essential for accurate diagnosis, effective treatment, and enhancing patients' quality of life.Although attempts have been made to distinguish between acute and chronic CRPS, there are currently no established diagnostic criteria specific to chronic CRPS in medical literature.Objective: This ASIPP guidance document offers updated, evidence-based recommendations for the diagnosis and management of Chronic Complex Regional Pain Syndrome (CRPS), with a primary focus on introducing novel, time-based diagnostic criteria specific to the chronic phase. These proposed criteria address significant gaps in the current literature, where existing standards, such as the Budapest Criteria, do not sufficiently differentiate between the acute and chronic stages of the condition.Methods: An expert panel convened by the American Society of Interventional Pain Physicians (ASIPP) conducted a comprehensive literature review and employed a structured consensus process to develop recommendations. Acknowledging that the clinical and pathological characteristics of CRPS change significantly beyond 12 months, the panel proposed chronic-specific diagnostic criteria based on disease duration, clinical history, physical examination findings, and optional diagnostic tests. These draft criteria were refined through multidisciplinary input and expert consensus.Results: The diagnostic framework for chronic CRPS consists of four key components:General Criteria - Require fulfillment of the Budapest Criteria for at least 12 months, continued recognition of CRPS as a diagnosis of exclusion, and differentiation from generalized nociplastic pain syndromes.History-Based Criteria - Mandate the presence of at least three out of five specific historical features.Physical Examination Criteria - Include asymmetric limb findings, sensory disturbances, and musculoskeletal changes.Optional Diagnostic Testing - May involve assessments such as intraepidermal nerve fiber density (IENFD) and imaging evidence of regional bone demineralization.This framework builds upon the Budapest Criteria by incorporating time-dependent features of chronic CRPS, including musculoskeletal dystrophy, neurogenic inflammation, and sympathetic dysfunction. Emerging objective tools-such as quantitative sensory testing (QST), skin biopsy for IENFD, fu

背景：复杂区域疼痛综合征（CRPS）是一种具有挑战性且常致残的疾病，其特征是持续疼痛，最常见于肢体损伤或手术后。它表现为一系列广泛的症状，包括剧烈疼痛、肿胀、皮肤颜色和温度的改变、运动功能障碍和营养变化，如皮肤和组织萎缩。虽然CRPS的确切原因尚不完全清楚，但人们认为它源于神经系统活动异常，导致疼痛敏感性升高和炎症反应。深入了解CRPS对于准确诊断、有效治疗、提高患者生活质量至关重要。虽然已经尝试区分急性和慢性CRPS，但目前在医学文献中尚无针对慢性CRPS的既定诊断标准。目的：本ASIPP指南文件为慢性复杂区域性疼痛综合征（CRPS）的诊断和管理提供了最新的、基于证据的建议，主要侧重于引入针对慢性期的新的、基于时间的诊断标准。这些拟议的标准解决了当前文献中的重大空白，其中现有标准，如布达佩斯标准，不能充分区分病情的急性和慢性阶段。方法：由美国介入疼痛医师协会（ASIPP）召集的专家小组进行了全面的文献综述，并采用结构化的共识过程来制定建议。考虑到CRPS的临床和病理特征在12个月后会发生显著变化，专家小组提出了基于病程、临床病史、体格检查结果和可选诊断测试的慢性特异性诊断标准。这些标准草案是通过多学科投入和专家共识加以完善的。结果：慢性CRPS的诊断框架由四个关键部分组成：一般标准-需要满足布达佩斯标准至少12个月，继续承认CRPS为排除性诊断，并与广泛性伤害性疼痛综合征区分开来。基于历史的标准-要求至少存在五个特定历史特征中的三个。体格检查标准-包括肢体不对称、感觉障碍和肌肉骨骼改变。可选诊断测试-可能包括评估，如表皮内神经纤维密度（IENFD）和局部骨脱矿的影像学证据。该框架建立在布达佩斯标准的基础上，结合了慢性CRPS的时间依赖性特征，包括肌肉骨骼营养不良、神经源性炎症和交感神经功能障碍。新兴的客观工具——如定量感觉测试（QST）、IENFD的皮肤活检、功能性MRI和神经炎症的血清生物标志物——可能进一步支持复杂或不确定病例的诊断。治疗建议强调多模式策略，包括物理康复、神经性疼痛的药物治疗、交感神经阻滞和高级神经调节。重点放在个性化的护理途径量身定制的疾病阶段和患者的具体特点。结论：本文提出了第一个结构化的、时间敏感的慢性CRPS诊断标准，旨在提高诊断准确性并为治疗策略提供信息。采用这些标准可以提高临床结果，并促进对CRPS进展的自然史和病理生理学的进一步研究。

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