Assessment of the Escalating Growth of Facet Joint Interventions in the Medicare Population in the United States From 2000 to 2011.

Assessment of the escalating growth of facet joint interventions in the medicare population in the United States from 2000 to 2011.

Pain Physician. 2013 Jul-Aug; 16(4): E365-78
Manchikanti L, Pampati V, Singh V, Falco FJ

Both the Office of Inspector General (OIG) and reports from studies of the utilization of facet joint interventions have expressed that explosive increases in facet joint interventions provided to spinal pain patients are a major concern.The study is designed to assess the growth of facet joint interventions in managing spinal chronic pain in Medicare beneficiaries from 2000 to 2011.To assess the use of facet joint interventions in chronic pain management.The study was performed utilizing the Centers for Medicare and Medicaid Services (CMS) physician supplier procedure summary master data from 2000 to 2011.The utilization of all types of facet joint interventions increased enormously from 2000 to 2011, with an overall increase of 308% per 100,000 Medicare beneficiaries and a 13.6% average annual increase. In addition, the highest increases were seen for cervical/thoracic radiofrequency neurotomy with 836%, followed by an increase of 662% for lumbar/sacral radiofrequency neurotomy, a 359% increase in cervical/thoracic facet joint injections, and 228% increase in lumbosacral facet joint injections. In reference to the number of procedures performed, however, the highest numbers were in the lumbosacral region with 990,449 total procedures of lumbar facet joint blocks and 406,378 lumbosacral radiofreqency neurotomies in 2011. Cervical and thoracic facet joint nerve blocks were 317,220, whereas cervical and thoracic radiofrequency neurotomies were 97,526 in 2011. The data also showed that there were enormous increases in the proportion of procedures performed by the specialty of physical medicine and rehabilitation, with an increase of 781% and an annual increase of 21.9% excluding physicians of physical medicine and rehabilitation enrolled as interventional pain management or pain management. Even though the numbers were very low for nurse anesthetists, nurse practitioners, and physician assistants, the increases were from 143 in 2000 to 21,263 in 2011, providing an annual increase of 55.2%, an overall increase of 12,460%.The limitations of this study included a lack of inclusion of Medicare participants in Medicare Advantage plans, as well as potential documentation, coding, and billing errors. Furthermore, the data provided for state utilizations is based on claims data for that state which also may include patients from contiguous or other states receiving services in those states.The explosive increase in the number of lumbar facet joint interventions performed began to wane in 2008. From 2008 to 2010, the utilization of facet joint interventions declined by 6%. HubMed – rehab

Assessment of the growth of epidural injections in the medicare population from 2000 to 2011.

Pain Physician. 2013 Jul-Aug; 16(4): E349-64
Manchikanti L, Pampati V, Falco FJ, Hirsch JA

Among the many diagnostic and therapeutic interventions available for the management of chronic pain, epidural steroid injections are one of the most commonly used modalities. The explosive growth of this technique is relevant in light of the high cost of health care in the United States and abroad, the previous literature assessing the effectiveness of epidural injections has been sparse with highly variable outcomes based on technique, outcome measures, patient selection, and methodology. However, the recent assessment of fluoroscopically directed epidural injections has shown improved evidence with proper inclusion criteria, methodology, and outcome measures. The exponential growth of epidural injections is illustrated in multiple reports. The present report is an update of the analysis of the growth of epidural injections in the Medicare population from 2000 to 2011 in the United States.Analysis of utilization patterns of epidural procedures in the Medicare population in the United States from 2000 to 2011.The primary purpose of this assessment was to evaluate the use of all types of epidural injections (i.e., caudal, interlaminar, and transforaminal in the lumbar, cervical, and thoracic regions) with an assessment of specialty and regional characteristics.This assessment was performed utilizing the Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) Master data from 2000 to 2011.Epidural injections in Medicare beneficiaries increased significantly from 2000 to 2011. Overall, epidural injections increased 130% per 100,000 Medicare beneficiaries with an annual increase of 7.5%. The increases per 100,000 Medicare recipients were 123% for cervical/thoracic interlaminar epidural injections; 25% for lumbar/sacral interlaminar, or caudal epidural injections; 142% for cervical/thoracic transforaminal epidural injections; and 665% for lumbar/sacral transforaminal epidural injections. The use of epidurals increased 224% in the radiologic specialties (interventional radiology and diagnostic radiology) and 145% in psychiatric settings, whereas and physical medicine and rehabilitation physicians’ use of epidurals increased 520%.Study limitatations include lack of inclusion of Medicare Advantage patients. In addition, the statewide data is based on claims which may include the contiguous or other states.Epidural injections in Medicare recipients increased significantly. The growth was significant for some specialties (radiology, physical medicine and rehabilitation, and psychiatry) and for certain procedures (lumbosacral transforaminal epidural injections). HubMed – rehab

The current state of endoscopic disc surgery: review of controlled studies comparing full-endoscopic procedures for disc herniations to standard procedures.

Pain Physician. 2013 Jul-Aug; 16(4): 335-44
Birkenmaier C, Komp M, Leu HF, Wegener B, Ruetten S

Neuropathic pain originating from spinal disc herniations is a very common problem. The majority of disc surgeries are performed to alleviate this pain once conservative measures and targeted injections have failed. Endoscopic spinal surgery is increasingly popular because it minimizes access trauma and hastens recovery from the intervention. This clinically oriented review evaluates controlled studies that investigate the clinical results and the complications of full-endoscopic lumbar and cervical procedures for symptomatic disc herniations in comparison to a microsurgical standard procedure. This review focuses exclusively on modern, full-endoscopic disc surgery irrespective of the specific access technique (e.g., interlaminar vs. transforaminal) and irrespective of the spinal region.Comprehensive review of the literature.To assess the clinical outcomes and complication rates of full-endoscopic disc surgery compared to the microsurgical standard procedures.A PubMed and Embase search was performed, considering entries up to January 2013. All 504 results were screened and categorized. Only 4 randomized controlled trials (RCTs) and one controlled studies (CS) could finally be considered for evaluation. All 5 manuscripts were meticulously analyzed with regards to randomization mode, inclusion/exclusion criteria, clinical results, and complication rates.Overall, the endoscopic techniques had shorter operating times, less blood loss, less operative site pain, and faster postoperative rehabilitation/shorter hospital stay/faster return to work than the microsurgical techniques. There were no significant differences in the main clinical outcome criteria between the endoscopic and the microsurgical techniques in any of the trials. All 5 studies had fewer complications with the endoscopic technique and this was statistically significant in 2 of the studies. One study showed a lower rate of revision surgeries requiring arthrodesis with the endoscopic technique.All 5 studies that could be considered originate from experienced investigators and all 4 RCTs came from one group. This limits the transferability of their results to surgeons less experienced in endoscopic disc surgery.The studies show that full-endoscopic disc surgery can achieve the same clinical results in symptomatic cervical and lumbar disc herniations as the microsurgical standard techniques. This does not appear to come at the price of higher complication rates. HubMed – rehab

Central sensitization in urogynecological chronic pelvic pain: a systematic literature review.

Pain Physician. 2013 Jul-Aug; 16(4): 291-308
Kaya S, Hermans L, Willems T, Roussel N, Meeus M

Chronic pelvic pain (CPP) is a complex pain syndrome. Since its pathogenesis is still poorly understood and structural alterations in pain related brain regions may be present, there is a greater acceptance that sensitization of the central nervous system (CNS) plays an important role in the development and maintenance of chronicity.The purpose of this study is to systematically review the scientific evidence regarding central sensitization (CS) in female patients with urogynecological CPP.Systematic review of the literature.A systematic literature search was conducted in PubMed and Web of Science using different keyword combinations related to urogynecological CPP and central sensitization. Full text clinical reports addressing CS in adult women with urogynecological CPP were included and assessed for methodological quality by 2 independent reviewers.After screening for the eligibility, a total of 29 full-text articles with low to good methodological quality were retained. All studies were observational, 27 of which were case-control and 2 of which were cohorts. Sensitivity of the CNS was investigated by using a variety of methods. Although different central mechanisms seem to be involved in pain processing, the present evidence suggests hyperexcitability of the CNS in patients with urogynecological CPP. Altered brain morphology and function, generalized hyperalgesia to different type of stimuli, overactive bottom-up nociceptive mechanisms, and autonomic dysregulation were established in patients with urogynecological CPP. Nevertheless, diffuse noxious inhibitory control seemed normal, and therefore the contribution of an impaired endogenous pain inhibition mechanism to CPP requires further study. The same goes for the contribution of psychological factors.The level of evidence of retained studies is low due to the observational study designs and a wide range of diagnoses and assessment methods.Although the majority of the literature provides evidence for the presence of CS in urogynecological CPP with changes in brain morphology/function and sensory function, it is unclear whether these changes in central pain processing are secondary or primary to CPP, especially since evidence regarding the function of endogenous pain inhibition and the role of psychosocial pain facilitation is scarce. Further studies with good methodological quality are needed in order to clarify exact mechanisms. HubMed – rehab

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