Vertebral compression fractures are characterized by a break in the vertebrae comprising the spinal column, most likely on the anterior side and most commonly occurring when the osseous matrix has been weakened. The high morbidity and mortality associated with VCFs have given rise to an estimated annual medical cost of $13.8 billion in the United States alone. Prevention includes screening at-risk individuals’ bone marrow density and augmenting individuals with decreased bone density with bisphosphonates or RANK ligand inhibitors. The management of VCFs has been heavily debated with arguments for both conservative management and invasive augmentation through vertebroplasty and kyphoplasty. Invasive management should be considered in patients with uncontrolled pain, significant vertebral misalignment, and height deformities.

The gut microbiome is the community of organisms that occupies the humangastrointestinal tract. The human microbiome consists of approximately 1014 microbes, including bacteria, bacteriophages, archaea, eukaryotic viruses, fungi, and protozoa. The microbiome is influenced by genetic and environmental factors, most clearly diet. Microbiome research is becoming increasingly robust as the microbiome becomes increasingly linked with various disease states and potential therapies. The majority of research to date has focused on exploring the role of microbiota and dysbiosis in various autoimmune disorders, but interest has grown in their interplay with chronic pain disorders. The microbiome has primarily been linked to human disorders through modulation of inflammatory pathways. Most studies have taken place in animal models, introducing the challenge of translating this research to human interventional models. Pre/probiotics, fermented foods, dietary fiber, NAIOSs, fecal transplants, and novel therapies have been proposed to treat dysbiosis. Further investigation of the link between the microbiome and nociception may help with diagnosis and management of conditions like OA, fibromyalgia, and neuropathic pain.

Neuropathic pain (NP) is a common complication of spinal cord injury (SCI) that is difficult to treat. Chronic NP is associated with increased levels of inflammatory mediators and ion channel dysfunction, as well as nerve damage and nerve-glia crosstalk. Recent studies have made headway in identifying novel biomarkers, including microRNA and psycho-social attributes that can predict progress from SCI to chronic NP (CNP). Conventional medical treatment has limited success, but recent studies have identified new biomarkers and promising drugs, such as baclofen and ziconotide, that can provide pain relief. However, further studies are needed to determine the safety profile of these drugs. Nonmedical interventions, such as brain sensitization and biofeedback techniques, have also shown promise in managing CNP. A multidisciplinary approach, including psycho-social support, medical and nonmedical interventions, is necessary to effectively manage CNP in SCI patients.

Endogenous cannabinoid system was discovered in the early 1990s. The endocannabinoid system includes cannabinoid receptors, ligands, and metabolic enzymes found within the central nervous system (CNS). Inhibition or slowing of the degradation of endocannabinoids in select tissues may confer analgesic or anxiolytic effects. Cannabinoids are becoming increasingly prescribed and studied as potential analgesic agents. Cannabinoid therapy may offer a viable alternative to opioids for management of chronic pain. Studies have demonstrated the presence of endocannabinoids and cannabinoid receptors throughout the nervous system. Cannabinoids have been shown to induce analgesic effects through mechanisms different from traditional antinociceptive pathways. Investigations of the clinical applications of cannabinoids have been limited. Clinical trials suggest that extracts containing THC or its derivatives may be efficacious in the treatment of inflammatory, neuropathic, and oncologic pain. Pharmacologic agents aimed at increasing levels of endogenous endocannabinoids may represent an alternative way of producing analgesia. There is a need for further double-blinded placebo-controlled clinicals to support the use of cannabinoids for pain control.

Sacral insufficiency fracture (SIF) is not uncommon, especially in the elderly, and is associated with a significant decrease in quality of life. SIF is most frequently found in patients with sacroiliac joint pathology in the setting of a sacrum compromised due to conditions such as osteoporosis, rheumatoid arthritis, or radiation therapy. Nonspecific symptoms of SIF make diagnosis challenging. MRI is the gold standard for diagnosis of SIF. Traditional therapies revolved around conservative measures such as bed rest, physical therapy, and analgesia. Conservative management is safe; minimally invasive treatments such as sacroplasty may provide improved short- and long-term relief. Surgical management with screw fixation is a viable option for qualifying patients and can be offered in conjunction with cement augmentation.

Trigeminal neuralgia (TN), or tic douloureux, is characterized by recurrent attacks of lancinating, neuropathic facial pain in the dermatomal distribution of the trigeminal nerve. It was first described as early as in the first century, but accurate descriptions were not documented until the 1700s. Tic douloureux refers to the distinctive facial muscle spasms associated with condition. In patients with TN, minimal stimulation (e.g., light touch, tooth brushing, chewing, talking, wind) causes debilitating pain. Mainstays of treatment include medication, surgery, and complementary approaches. Surgical management is indicated for those who have failed medical treatment with three or more medications, suffer from intolerable side effects, or have intractable symptoms.