Objective Arthritis of the knee affects 46 million Americans. We aimed to determine the level of evidence of intraarticular knee injections in the management of arthritic knee pain. Methods We systematically searched PUBMED/MEDLINE and the Cochrane databases for articles published on knee injections and evaluated their level of evidence and recommendations according to established criteria. Results The evidence supports the use of intraarticular corticosteroid injections for rheumatoid arthritis (1A+ level), osteoarthritis (1A+ level), and juvenile idiopathic arthritis (2C+ level). Pain relief and functional improvement are significant for months up to one year after the injection. Triamcinolone hexacetonide offers an advantage over triamcinolone acetonide and should be the intraarticular steroid of choice (2B+ level). Intraarticular injection of hyaluronate may provide longer pain relief than steroid injection in osteoarthritis (2B+ level). It can also be effective for rheumatoid arthritis knee pain (1A+ level). However, it is only recommended for patients with significant surgical risk factors and for patients with mild radiographic disease in whom conservative treatment has failed (2B± level). Botulinum toxin Type A injection is effective in reducing arthritic knee pain (2B+ level) and so is tropisetron (2B+ level) and tanezumab (2B+ level). The new agents, such as rAAV2-TNFR:Fc, SB-210396/CE 9.1, and various radioisotopes have provided various degrees of success, but their long-term safety and efficacy remains to be determined. Conclusions We conclude that strong evidence supports the use of intraarticular knee injection as a valuable intervention in the continuum of management of arthritis between conservative treatment and knee surgeries.

The combination of obesity and pain may worsen a patient's functional status and quality of life more than each condition in isolation. We systematically searched PubMed/MEDLINE and the Cochrane databases for all reports published on obesity and pain. The prevalence of combined obesity and pain was substantial. Good evidence shows that weight reduction can alleviate pain and diminish pain-related functional impairment. However, inadequate pain control can be a barrier to effective lifestyle modification and rehabilitation. This article examines specific pain management approaches for obese patients and reviews novel interventional techniques for treatment of obesity. The infrastructure for simultaneous treatment of obesity and pain already exists in pain medicine (eg, patient education, behavioral medicine approaches, physical rehabilitation, medications, and interventional treatment). Screening for obesity, pain-related disability, and behavioral disorders as well as monitoring of functional performance should become routine in pain medicine practices. Such an approach requires additional physician and staff training. Further research should focus on better understanding the interplay between these 2 very common conditions and the development of effective treatment strategies.

& AbstractBackground Goals: Intrathecal drug delivery is an effective method to treat intractable pain. However, intrathecal catheter tip granuloma (ICTG) is a devastating complication of intrathecal drug delivery systems. It typically occurs in the thoracic region; particularly, in patients receiving high doses or high concentrations of intrathecal drug infusions. Materials and Methods: The PUBMED/MEDLINE and Cochrane databases were also systematically searched for all reports on ICTG published in any language. The key words included "intrathecal," "granuloma," and "spine surgery," and all related publications between the earliest available date (the first granuloma-related chronic complication of intrathecal infusion reported in PUBMED/MEDLINE in 1996) and June (week 1) of 2012 were searched. This case report is unique because it describes the formation of an intrathecal granuloma in the lumbar region of a patient who received a low-dose intrathecal infusion. Results and Conclusion: Cerebrospinal fluid flow dynamics within the spinal canal along with the physical, chemical, and immunological properties of intrathecal medications have been suggested to be responsible for the growth of inflammatory mass lesions at the tips of intrathecal drug delivery catheters. Our literature review supports the possible role of certain factors, specifically previous spine surgery or spinal injury, in granuloma formation. The rate of development of ICTG appears to be higher in patients who have had previous spine surgery or spinal injury (68%) than in a general cohort of patients (48%), with an intrathecal pump. Therefore patients with a history of spine surgery or injury may be at increased risk of ICTG when receiving chronic intrathecal analgesia. &

The creation of a training phantom allows the pain physician to practice needle positioning technique while simultaneously visualizing both targeted and avoidable vascular structures under US and fluoroscopic guidance. This low-cost CUF-P is easy to prepare and is reusable, making it an attractive alternative to current homemade and commercially available phantom simulators.

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