Cervical

• M54.2 — Cervicalgia (Primary)

• M47.812 — Facet syndrome, cervical

• M54.12 — Radiculopathy, cervical

• M50.20 — Disc herniation, cervical (unspecified level)

• M48.02 — Spinal stenosis, cervical

Thoracic

• M54.6 — Thoracic back pain (Primary)

• M47.814 — Facet syndrome, thoracic

• M54.14 — Radiculopathy, thoracic

• M51.24 — Disc herniation, thoracic

• M48.04 — Spinal stenosis, thoracic

Lumbar

• M54.50 — Lumbar back pain (Primary)

• M47.816 — Facet syndrome, lumbar

• M54.16 — Radiculopathy, lumbar

• M51.26 — Disc herniation, lumbar

• M48.06 — Spinal stenosis, lumbar

SI Joint

• M53.3 — SI joint pain (Primary)

• M46.1 — Sacroiliitis

• M54.18 — Radiculopathy, sacral

Note: For level-specific cervical disc codes, use M50.221 (C4-C5), M50.222 (C5-C6), M50.223 (C6-C7). For lumbosacral disc herniation, use M51.27. 

Note: For stenosis with neurogenic claudication, use M48.061 (lumbar with neurogenic claudication) or M48.062 (lumbar without neurogenic claudication) if greater specificity is needed.

During the emergency resuscitation, the clinical algorithm directed the trauma team to execute a jaw-thrust maneuver to manage the patient presenting with severe dyspnea, acute hypoxia, and systemic malaise secondary to severe pneumonia. Point-of-care imaging identified an occult deep tissue abscess adjacent to the ilium, clearly distinguished from the adjacent loops of the ileum, alongside an incidental abdominal aortic aneurysm that posed a high risk for catastrophic hemorrhage. While cardiac telemetry was continuously monitored for any fatal arrhythmia that could degenerate into asystole, the attending physician performed targeted auscultation of the chest before proceeding with endotracheal intubation and central venous catheter placement. Given the patient’s complex history of poorly controlled diabetes and end-stage liver cirrhosis—which manifested as intractable pruritus and chronic diarrhea—the team requested consultations with ophthalmology for diabetic retinopathy screening, otolaryngology for concurrent otitis, and psychiatry for acute hyperactive delirium, while surgical services evaluated the lesion for bedside curettage. 

Curettage is a medical procedure that uses a spoon-shaped tool called a curette to scrape or remove tissue from the body. 

EXAMPLE 1: CERVICAL EPIDURAL STEROID INJECTION + GREATER OCCIPITAL NERVE BLOCK

CPT Codes:

• 62321 — Cervical interlaminar ESI (primary, higher RVU)

• 64405-59/XS — Greater occipital nerve block (distinct anatomic site)

• 77003 — Fluoroscopic guidance

ICD-10 Codes:

• M54.12 — Radiculopathy, cervical region

• M54.81 — Occipital neuralgia

Medical Necessity:

• Cervical radiculopathy causing upper extremity pain/paresthesias

• Concurrent occipital neuralgia with suboccipital headaches radiating over vertex

• Failed conservative management (oral analgesics, NSAIDs, physical therapy) ≥6 weeks

• CESI targets epidural inflammation causing radiculopathy

• Occipital nerve block targets distinct peripheral nerve pain generator

• Separate anatomic sites, separate diagnoses, separate interventions

EXAMPLE 2: SI JOINT INJECTION + TRAPEZIUS TRIGGER POINT INJECTIONS

CPT Codes:

• 27096 — SI joint injection (primary, higher RVU)

• 20553-59/XS — Trigger point injection, ≥3 muscles (distinct anatomic site)

  • Use 20552 if 1–2 muscles

• 77003 — Fluoroscopic guidance (SI joint)

ICD-10 Codes:

• M53.3 — Sacrococcygeal disorders, NEC (or M46.1 — Sacroiliitis, NEC)

• M79.18 — Myalgia, other site (or M79.12 — Myalgia, auxiliary muscles, head/neck)

Medical Necessity:

• SI joint dysfunction with ≥3 positive provocative tests (FABER, Gaenslen's, compression/distraction)

• Low back/buttock pain from SI joint

• Concurrent myofascial pain syndrome of trapezius with palpable trigger points and referred pain

• Failed conservative measures (PT, home exercise, oral medications)

• SI joint injection addresses intra-articular inflammation at pelvis

• Trigger point injections target muscular pain generators in upper back/shoulder girdle

• Separate anatomic sites, independent diagnoses

EXAMPLE 3: LUMBAR EPIDURAL STEROID INJECTION + LUMBAR FACET JOINT INJECTION

CPT Codes:

• 62323 — Lumbar interlaminar ESI (primary, higher RVU)

• 64493-59/XS — Lumbar facet joint injection, 1st level (distinct target)

• 64494 — Lumbar facet joint injection, 2nd level (add-on, no modifier needed)

• 77003 — Fluoroscopic guidance

ICD-10 Codes:

• M54.17 — Radiculopathy, lumbosacral region

• M47.816 — Spondylosis without myelopathy/radiculopathy, lumbar region

• M47.817 — Spondylosis without myelopathy/radiculopathy, lumbosacral region

Medical Necessity:

• Lumbosacral radiculopathy with dermatomal leg pain, confirmed by MRI (disc herniation/foraminal stenosis)

• Concurrent axial low back pain from facet arthropathy with imaging-confirmed facet hypertrophy

• Paraspinal tenderness exacerbated by extension/rotation

• Failed conservative treatment (PT, NSAIDs, activity modification) ≥6 weeks

• LESI targets epidural inflammation causing radicular symptoms

• Facet injections target separate articular pain generator (zygapophysial joint)

• Anatomically and pathophysiologically distinct targets

EXAMPLE 4: GENICULAR NERVE BLOCK + KNEE JOINT INJECTION

CPT Codes:

• 64454 — Genicular nerve block (primary, higher RVU)

• 20610-59/XS — Knee joint injection, major joint (distinct structure)

• 76942 — Ultrasound guidance (if used)

ICD-10 Codes:

• M17.11 — Unilateral primary osteoarthritis, right knee (or M17.12 for left)

Medical Necessity:

• Advanced knee osteoarthritis, Kellgren-Lawrence grade III–IV

• Significant functional impairment, pain refractory to oral analgesics, PT, bracing, prior injections

• Genicular nerve block targets sensory nerve branches (superomedial, superolateral, inferomedial) innervating knee capsule

• Serves as diagnostic block prior to potential genicular nerve radiofrequency ablation

• Intra-articular injection delivers corticosteroid/viscosupplementation into joint space for synovial inflammation

• Distinct anatomic structures: peripheral nerves vs. intra-articular space

• Different mechanisms of action justify same-day performance

EXAMPLE 5: STELLATE GANGLION BLOCK + CERVICAL FACET JOINT INJECTION

CPT Codes:

• 64490 — Cervical facet joint injection, 1st level (primary, higher RVU)

• 64491 — Cervical facet joint injection, 2nd level (add-on, no modifier needed)

• 64510-59/XS — Stellate ganglion block (distinct anatomic target)

• 77003 — Fluoroscopic guidance

ICD-10 Codes:

• M47.812 — Spondylosis without myelopathy/radiculopathy, cervical region

• G90.511 — Complex regional pain syndrome I, right upper limb (or G90.512 for left)

Medical Necessity:

• Cervical facet arthropathy with axial neck pain, paraspinal tenderness, pain with extension/lateral rotation

• Imaging confirms facet hypertrophy/degeneration

• Concurrent CRPS type I of upper extremity meeting Budapest criteria (allodynia, vasomotor changes, edema, trophic changes)

• Failed conservative management (PT, desensitization, oral medications)

• Cervical facet injections target zygapophysial joints for mechanical neck pain

• Stellate ganglion block targets cervical sympathetic chain for sympathetically maintained pain

• Entirely different anatomic structures and pathophysiologic mechanisms

GENERAL BILLING PRINCIPLES

Modifier Usage:

• Bill higher-RVU procedure first without modifier

• Secondary procedure receives -59 (Distinct Procedural Service) or -XS (Separate Structure)

• CMS prefers -X modifiers (XE, XS, XP, XU) over -59 when applicable

Documentation Requirements:

• Each diagnosis independently documented with distinct H&P and imaging (when applicable)

• Document failure of conservative management — type, duration, response — for each condition

• Clearly state distinct anatomic targets and rationale for same-day performance

• Link each CPT code to its specific ICD-10 diagnosis via claim pointer fields

• Include pre-/post-procedure pain scores for each treated condition

Imaging Guidance:

• 77003 (fluoroscopy) or 76942 (ultrasound) — typically billed once per session

• May be bundled depending on payer; check LCD/NCD policies

Same-Day Multiple Treatment Examples

1. Cervical ESI + Greater Occipital Nerve Block

CPT

• 62321 – Cervical/thoracic interlaminar epidural injection

• 64405-XS or 64405-59 – Greater occipital nerve block, distinct anatomical site

ICD-10-CM

• M54.12 – Cervical radiculopathy

• M54.81 – Occipital neuralgia

Plan/Medical Necessity: Persistent cervical radicular pain and separately identifiable occipital neuralgia remain functionally limiting despite conservative treatment. Proceed with cervical epidural steroid injection and separately targeted occipital nerve block for distinct diagnoses and anatomical pain generators.

2. SI Joint Injection + Trapezius Trigger-Point Injection

CPT

• 27096 – Fluoroscopically guided SI joint injection

• 20552-XS or 20552-59 – Trigger-point injection, one or two muscles

ICD-10-CM

• M53.3 – Sacroiliac joint disorder/pain

• M79.18 – Myofascial pain

Plan/Medical Necessity: Examination demonstrates SI joint-mediated pain and separate symptomatic trapezius trigger points that have not adequately responded to conservative care. Proceed with image-guided SI joint injection and distinct trapezius trigger-point injection.

3. Lumbar Interlaminar ESI + Right Knee Injection

CPT

• 62323 – Lumbar/sacral interlaminar epidural injection

• 20610-RT – Right major-joint injection; add XS/59 only when required

ICD-10-CM

• M54.16 – Lumbar radiculopathy

• M17.11 – Unilateral primary osteoarthritis, right knee

Plan/Medical Necessity: Lumbar radicular pain and right knee osteoarthritis represent separate pain generators causing functional impairment despite conservative treatment. Proceed with lumbar epidural steroid injection and separately indicated right knee intra-articular injection.

4. Lumbar Transforaminal ESI + Right Shoulder Injection

CPT

• 64483 – Lumbar/sacral transforaminal epidural injection, first level

• 20610-RT – Right shoulder major-joint injection; add XS/59 when required

ICD-10-CM

• M54.16 – Lumbar radiculopathy

• M19.011 – Primary osteoarthritis, right shoulder

Plan/Medical Necessity: The patient has persistent lumbar radiculopathy and independently symptomatic right shoulder osteoarthritis with reduced function despite conservative care. Proceed with lumbar transforaminal epidural injection and separate right shoulder injection.

5. Lumbar Medial Branch Block + Trapezius Trigger-Point Injection

CPT

• 64493 – Lumbar medial branch block, first level

• 64494 – Each additional level, when performed

• 20552-XS or 20552-59 – Trigger-point injection, one or two muscles

ICD-10-CM

• M47.816 – Lumbar spondylosis without myelopathy or radiculopathy

• M79.18 – Myofascial pain

Plan/Medical Necessity: Examination supports lumbar facet-mediated pain and separately identifiable trapezius myofascial pain unresponsive to conservative measures. Proceed with diagnostic lumbar medial branch block and anatomically distinct trapezius trigger-point injection.

A graded return to exercise is well-supported for patients with L5 HNP. Guidelines strongly recommend structured, progressive exercise programs including both aerobic and strengthening components for LBP with radiculopathy. 

[1-2]

 The proposed approach of 50% upper body and 25% lower body loading is a reasonable starting framework, though no specific percentage-based protocol exists in the literature — the key principle is symptom-guided progression. 

[2]

Upper Body (starting at 50% baseline)

• This is generally safe, as most upper body lifts impose relatively low axial load on the lumbar spine. Seated exercises with back support (e.g., seated press, rows) are preferable initially over standing overhead movements.

• Avoid Valsalva maneuvers and heavy loads that increase intradiscal pressure. Progress by ~10% per week as tolerated without worsening radicular symptoms.

Lower Body / Lumbar Loading (starting at 25% baseline)

• This is appropriately conservative. Exercises that increase lumbar flexion under load (e.g., conventional deadlifts, barbell back squats) carry the highest risk of symptom exacerbation and should be reintroduced last.

• Safer starting options include leg press, hip bridges, bodyweight squats, and hip hinge patterns with minimal load. Stabilization exercises targeting the lumbar/abdominal/hip musculature ("core") are recommended as a foundation. 

• [2]

• Progress based on pain response: a modest, temporary increase in back pain during exercise is acceptable, but worsening or new radicular symptoms (leg pain, numbness, weakness) should prompt load reduction. 

• [2]

Regarding Calisthenics

Bodyweight exercises are appropriate and align with guideline recommendations for motor control and stabilization training. 

[1-2]

 Specific guidance:

• Recommended: Bird-dogs, planks (front and side), glute bridges, bodyweight squats, wall sits, modified push-ups. These develop spine stability with low compressive load.

• Use caution with: Sit-ups/crunches (high intradiscal pressure in flexion), burpees, and any explosive plyometric movement that loads the spine dynamically.

• Avoid initially: Full range-of-motion lumbar flexion movements (e.g., toe touches, V-ups), heavy jumping, and loaded rotational movements.

General Principles

• A progressive walking program (45 min, 4x/week at ~60% max HR) should be a cornerstone of the rehabilitation. 

• [2]

• Directional preference exercises (often McKenzie extension) should be incorporated if they centralize or abolish pain. 

• [2]

• Outcomes for lumbar disc herniation with conservative management including active rehabilitation are excellent, with 90% good-to-excellent results. 

• [3]

• A modest increase in LBP during activity does not indicate damage and can be expected. The key red flags requiring reassessment are progressive neurological deficits or worsening radicular symptoms. 

• [2]

1.

Diagnosis and Treatment of Low Back Pain (LBP) (2022).

Department of Veterans Affairs. 2022. Maj Danielle Anderson DPT DSc OCS FAAOMPT, Thiru M. Annaswamy MD MA, LTC Adam J. Bevevino MD, et alGuideline

2.

Non-Invasive and Minimally Invasive Management of Low Back Disorders.

Journal of Occupational and Environmental Medicine. 2020. Hegmann KT, Travis R, Andersson GBJ, et al.Guideline

3.

Evaluation of persons with suspected lumbosacral and cervical radiculopathy: Electrodiagnostic assessment and implications for treatment and outcomes ( Part II ).

Muscle & Nerve. 2020. Dillingham TR, Annaswamy TM, Plastaras CT.Review

I. Blood Pressure

A. Generally Acceptable

• 90–179/60–109 mm Hg

• Patient asymptomatic

• Stable compared with baseline

• Note: The 2024 AHA/ACC Perioperative Guidelines indicate little evidence for increased perioperative risk at blood pressure below 180/110 mm Hg in the absence of Revised Cardiac Risk Index components (coronary artery disease, heart failure, cerebrovascular disease, creatinine greater than 2.0 mg/dL, insulin-dependent diabetes) 

• [1]

B. Reassess Before Proceeding

• Systolic 180–199 mm Hg or diastolic 110–119 mm Hg without cardiovascular risk factors

• Systolic 90–99 mm Hg

• Repeat after rest and assess pain, anxiety, hydration, medication adherence, and baseline blood pressure

• Elective procedures should not be cancelled based solely upon a preoperative arterial pressure value; clinical context must be considered 

• [2]

C. Usually Unacceptable for Elective Procedures

• Systolic blood pressure ≥180 mm Hg and/or diastolic blood pressure ≥110 mm Hg with cardiovascular risk factors, persistent after reassessment

• Systolic blood pressure less than 90 mm Hg

• Mean arterial pressure less than 60–65 mm Hg

• Blood pressure ≥180 and/or ≥120 mm Hg with concerning symptoms (headache, visual changes, chest pain, dyspnea) requires emergency evaluation for hypertensive crisis; note that either value alone qualifies 

• [1]

II. Heart Rate

A. Generally Acceptable

• 50–100 beats per minute

• Regular rhythm or documented stable chronic rhythm (e.g., rate-controlled atrial fibrillation)

• Asymptomatic sinus bradycardia of 45–49 beats per minute may be acceptable in conditioned athletes or patients on beta-blocker therapy

B. Reassess Before Proceeding

• 40–49 beats per minute

• 101–120 beats per minute

• Repeat measurement and consider ECG

• Evaluate for pain, anxiety, dehydration, fever, medication effect

C. Usually Unacceptable

• Persistent heart rate less than 40 beats per minute

• Persistent heart rate greater than 120 beats per minute

• New irregular rhythm not previously documented

• High-grade heart block

• Associated syncope, chest pain, dyspnea, or hypotension

III. Respiratory Rate

A. Generally Acceptable

• 12–24 breaths per minute

• Unlabored breathing

B. Reassess Before Proceeding

• 10–11 breaths per minute

• 25–29 breaths per minute

• Evaluate for anxiety, pain, opioids, sedatives, or pulmonary disease

C. Usually Unacceptable

• Respiratory rate less than 10 breaths per minute (pre-procedure, before any sedation)

• Respiratory rate 30 breaths per minute or greater

• Apnea or shallow breathing

• Accessory muscle use

• Altered mental status

• Inability to speak in full sentences

IV. Oxygen Saturation

A. Generally Acceptable

• SpO₂ 94% or greater on room air

• SpO₂ 88–92% may be acceptable when this is the documented target for COPD or chronic hypercapnic respiratory disease

B. Reassess Before Proceeding

• SpO₂ 90–93% in a patient without known chronic lung disease

• Significant decrease from documented baseline (even if above 90%)

• Confirm waveform quality and probe placement

C. Usually Unacceptable

• SpO₂ less than 90% without a documented chronic baseline at that level

• Oxygen saturation below prescribed target despite supplemental oxygen

• New or increasing oxygen requirement

• Cyanosis or respiratory distress

V. Temperature

A. Generally Acceptable

• 36.0–37.9°C (96.8–100.2°F)

• No systemic symptoms

B. Reassess Before Proceeding

• Borderline elevation (37.5–37.9°C or 99.5–100.2°F) with recent infection, chills, or current antibiotic use

• Unexpectedly low temperature (35.5–35.9°C or 95.9–96.7°F)

C. Usually Unacceptable

• Temperature 38.0°C (100.4°F) or greater with suspected or confirmed infection; defer and evaluate infection source, especially before neuraxial injections, joint injections, or device implantation 

• [3]

• Temperature less than 35.5°C (95.9°F) with illness, hemodynamic instability, or altered mental status

VI. Blood Glucose

Note: The Society for Ambulatory Anesthesia (2024) states there are insufficient data to recommend a specific blood glucose level above which elective ambulatory surgery should be postponed. The thresholds below represent a practical framework derived from ADA, Endocrine Society, and SAMBA guidelines. 

[4-5]

A. Generally Acceptable

• 80–180 mg/dL (ideal preprocedural target per ADA and Endocrine Society)

B. Reassess or Treat

• 70–79 mg/dL: treat with oral glucose, recheck in 15 minutes; proceed only when 80 mg/dL or greater and stable

• 181–250 mg/dL: may proceed for short procedures if long-term control is adequate (HbA1c less than 8%), no ketones, and patient is asymptomatic; administer correctional insulin and recheck in 1–2 hours

C. Caution — Strongly Consider Deferral

• 251–400 mg/dL: check for ketones (urine or serum); if negative and patient is asymptomatic with adequate long-term control, may proceed for short clinic procedures with insulin correction on a case-by-case basis; for ambulatory surgery center procedures, strongly consider deferral

• Note: Preoperative glucose 200 mg/dL or greater has been associated with greater than 2-fold higher all-cause mortality in noncardiac surgery 

• [1]

D. Usually Unacceptable

• Less than 70 mg/dL until treated and glucose is stable at 80 mg/dL or greater

• Less than 54 mg/dL: clinically significant hypoglycemia requiring emergent treatment

• Greater than 400 mg/dL: defer and evaluate urgently for diabetic ketoacidosis or hyperosmolar hyperglycemic state (check ketones, basic metabolic panel, anion gap)

• Any glucose level associated with ketones, vomiting, dehydration, acidosis, altered mental status, diabetic ketoacidosis, or hyperosmolar hyperglycemic state

E. Preoperative HbA1c

• Target less than 8% within 3 months of elective procedure (recommended but not mandatory for cancellation; postponing surgery based on HbA1c alone is not recommended per ADA 2026 and AHA/ACC 2024) 

• [1][5]

• 
  

VII. Office Clinic Setting

A. Appropriate Cases

• Stable vital signs within parameters above

• Local anesthesia or minimal anxiolysis (e.g., oral benzodiazepine, nitrous oxide)

• No evidence of acute cardiopulmonary or metabolic instability

B. Reasons to Defer

• Persistent blood pressure ≥180 and/or ≥110 mm Hg with cardiovascular risk factors

• Systolic blood pressure less than 90 mm Hg or mean arterial pressure less than 60–65 mm Hg

• Significant arrhythmia (new or hemodynamically significant)

• SpO₂ less than 90% without documented chronic baseline

• Respiratory distress

• Temperature 38.0°C (100.4°F) or greater with suspected infection

• Blood glucose less than 70 mg/dL or greater than 400 mg/dL

• Altered mental status

VIII. Ambulatory Surgery Center Setting

A. Additional Capabilities

• Monitored anesthesia care

• General anesthesia

• Advanced airway equipment

• Continuous monitoring (ECG, pulse oximetry, capnography, blood pressure)

• Intravenous medications and vasopressors

• Prolonged postoperative observation

B. Conditions That Remain Unacceptable for Elective Procedures

• Hemodynamic instability (systolic blood pressure less than 90 mm Hg, mean arterial pressure less than 60–65 mm Hg)

• Persistent severe uncontrolled hypertension (≥180 and/or ≥120 mm Hg) with end-organ symptoms

• Significant untreated arrhythmia

• Acute coronary syndrome

• Acute stroke or transient ischemic attack

• Active respiratory compromise or persistent hypoxemia

• Diabetic ketoacidosis or hyperosmolar hyperglycemic state

• Active systemic infection or sepsis

IX. Symptoms That Override Numeric Values

Urgent evaluation is required regardless of vital sign values for:

• Chest pain or pressure

• Acute shortness of breath

• Focal neurologic deficit

• Syncope or presyncope

• Confusion or altered mental status

• Cyanosis

• Severe headache with neurologic symptoms

• Signs of diabetic ketoacidosis or hyperosmolar hyperglycemic state (nausea, vomiting, abdominal pain, Kussmaul breathing, fruity breath, dehydration)

• Anaphylaxis signs (urticaria, angioedema, wheezing with hypotension)

• Active bleeding or signs of hemorrhage

• Acute abdominal pain with hemodynamic instability

X. Discharge Criteria (Post-Procedure)

Discharge requires meeting all of the following:

• Blood pressure and heart rate within 20% of preoperative baseline

• SpO₂ at baseline or 92% or greater on room air

• Awake, alert, and oriented (or at patient's baseline mental status)

• Pain controlled (numeric rating scale 4 or less, or acceptable to patient)

• Nausea and vomiting minimal or absent

• Able to ambulate without dizziness (or at baseline mobility)

• Minimal procedural bleeding

• For diabetic patients: blood glucose 80 mg/dL or greater and able to tolerate oral intake before discharge

2017 ACC/AHA (retained in the 2025 update)

The ACC/AHA uses a 4-category system with a lower hypertension threshold of ≥130/80 mmHg: 

[2-4]

• Normal: SBP <120 and DBP <80 mmHg

• Elevated BP: SBP 120–129 and DBP <80 mmHg

• Stage 1 HTN: SBP 130–139 or DBP 80–89 mmHg

• Stage 2 HTN: SBP ≥140 or DBP ≥90 mmHg

Pharmacotherapy is recommended for Stage 1 HTN only in patients with CVD, diabetes, CKD, or 10-year ASCVD risk ≥7.5% (updated from ≥10% in 2017 to ≥7.5% using PREVENT equations in 2025). 

[3][5]

 All others with Stage 1 HTN receive lifestyle modification alone. Stage 2 HTN warrants pharmacotherapy regardless of risk. 

[4]

 The 2025 update maintains this classification and further encourages targeting SBP <120 mmHg in high-risk patients. 

[6]

2024 ESC

The ESC introduced a simplified 3-category system: 

[7]

• Non-elevated: Office BP <120/70 mmHg — no treatment

• Elevated BP: 120–139/70–89 mmHg — treatment based on CVD risk and follow-up BP

• Hypertension: ≥140/90 mmHg — prompt confirmation and drug treatment in most

The default SBP treatment target is 120–129 mmHg, with relaxed targets for patients ≥85 years, frailty, or treatment intolerance. 

[7]

2018 ESC/ESH (prior European framework)

Used a more granular system with Grade 1 (140–159/90–99), Grade 2 (160–179/100–109), Grade 3 (≥180/≥110), and isolated systolic HTN (≥140/<90). 

[8]

The American College of Cardiology/American Heart Association (2024 Perioperative Guideline) recommends the following regarding hypertension and blood pressure management in the perioperative setting:

Preoperative BP Management

• It is reasonable to continue antihypertensive medical therapy throughout the perioperative period in most patients with hypertension planned for elective noncardiac surgery (NCS) (Class 2a, C-EO). 

• [1]

• Deferring surgery may be considered in patients undergoing elective elevated-risk surgery who have cardiovascular risk factors (≥1 RCRI component: CAD, CHF, CVA, creatinine >2.0, or preoperative insulin) and a recent history of poorly controlled hypertension (SBP ≥180 mmHg or DBP ≥110 mmHg before the day of surgery) (Class 2b, C-LD). 

• [1]

• In the absence of RCRI components, there is little evidence for increased risk of perioperative complications in patients with preoperative BP <180/110 mmHg, or at any preinduction BP. 

• [1]

• An elevated BP on the day of surgery may represent "white coat hypertension" — referring to patients' baseline ambulatory BP is recommended to guide management. 

• [1]

Intraoperative BP Management

• Maintaining an intraoperative MAP ≥60–65 mmHg or SBP ≥90 mmHg is recommended (Class 1, B-NR) to reduce the risk of myocardial injury. 

• [1]

• The harm threshold in observational analyses appears to be roughly MAP <65 mmHg or SBP <90 mmHg maintained for ~15 minutes. 

• [1]

Postoperative BP Management

• Treatment of postoperative hypotension (MAP <60–65 or SBP <90 mmHg) is recommended to limit cardiovascular, cerebrovascular, renal events, and mortality (Class 1, B-NR). 

• [1]

• Preoperative antihypertensive medications should be restarted as soon as clinically reasonable to avoid complications from postoperative hypertension (Class 1, C-EO). 

• [1]

Key Context

Uncontrolled hypertension is associated with a 35% increase in cardiovascular complications in a meta-analysis of 30 observational studies. 

[1]

 Induction of anesthesia in patients with untreated or uncontrolled hypertension can trigger sympathetic activity, resulting in labile BP and heart rate. 

[1]

 The 2025 ACC/AHA HTN guideline adds that patients with DBP >110 mmHg immediately before surgery have increased cardiovascular, cerebrovascular, and renal complications, whereas those with DBP <110 mmHg do not appear to be at significantly increased risk. 

[2]

Unlike Type 1 diabetes, Type 2 diabetes does not have a formally adopted staging system from the ADA. However, the pathophysiology is well described as a progressive continuum from insulin resistance through β-cell failure, and several models have been proposed to stage this progression.

Weir's Multistage Model of T2D Development

The most widely cited staging framework was proposed by Weir and Bonner-Weir and is referenced in major reviews. It describes five stages of glycemic deterioration: 

[1]

1. Stage 1 — Compensation: A prolonged period of insulin resistance accompanied by compensatory increased insulin secretion and increased β-cell mass. Glucose levels remain normal.

2. Stage 2 — Stable Adaptation: β-cells are no longer fully compensating for insulin resistance. Fasting and postload glucose values begin to drift upward but may still be within the normal range. Loss of acute (first-phase) insulin secretion begins at FPG ~100 mg/dL. Much of Stages 1 and 2 occur before the prediabetic phase.

3. Stage 3 — Unstable Early Decompensation: β-cells become unable to compensate, and glucose concentrations rise rapidly. This period extends from prediabetes into early manifest diabetes.

4. Stage 4 — Stable Decompensation: Established diabetes with significant β-cell loss but relatively stable (though elevated) glucose levels.

5. Stage 5 — Severe Decompensation: Marked β-cell failure with severe hyperglycemia, often requiring insulin therapy.

Pathophysiologic Continuum (DeFronzo / Kahn)

The classic DeFronzo model describes the natural history as a sequence of pathophysiologic events: 

[2-3]

• Earliest abnormality: Insulin resistance (hepatic and peripheral/muscle), often driven by obesity and visceral adiposity. Glucose tolerance remains normal because β-cells compensate with increased insulin output.

• Progressive β-cell decline: Over time, β-cells fail to maintain the high rate of insulin secretion needed to overcome resistance. This relative insulinopenia leads first to impaired glucose tolerance (IGT), then to overt diabetes.

• β-cell dysfunction is already present in at-risk groups (first-degree relatives, women with prior GDM, PCOS) even before glucose levels become abnormal. 

• [3]

• Rises in glucose — even within the normal range — reflect a continuous fall in β-cell function, not a sudden threshold event. 

• [3]

The IMI DIRECT study confirmed that faster HbA1c progression in recently diagnosed T2D is independently driven by deterioration in insulin sensitivity, β-cell glucose sensitivity, and increasing insulin clearance, along with visceral/liver fat and worsening lipid profiles. 

[4]

Emerging: Diabetes Severity Classification (DSC) Framework (2026)

A recently proposed framework reconceptualizes diabetes (including T2D) as a multiaxial disease continuum with five severity stages defined by four interrelated axes: β-cell function, insulin resistance, glycemic regulation, and complication burden: 

[5]

• Stage 0 — Predisposition: Genetic/metabolic risk factors present, no dysglycemia

• Stage 1 — Early Dysregulation: Mild insulin resistance and/or early β-cell dysfunction

• Stage 2 — Pathophysiologic Polarization: Dominant pathophysiology emerges (insulin resistance vs. β-cell failure predominant)

• Stage 3 — Metabolic Decompensation: Significant hyperglycemia with progressive β-cell loss

• Stage 4 — Complication-Dominant: Advanced disease with established micro/macrovascular complications

====

The American Diabetes Association (ADA) 2026 Standards of Care recommends the following for perioperative management of patients with diabetes: 

[1]

Preoperative Glycemic Optimization

• A1C goal <8% within 3 months of elective surgery, with individualized risk-to-benefit assessment. A 14-day glucose management indicator <8% and/or time in range >50% (from CGM) may also be used. 

• [1-2]

• However, postponing surgery based on A1C alone is not recommended, as it may lead to unnecessary delay of required surgery. 

• [1]

• Severe hyperglycemia (glucose >250 mg/dL) with metabolic decompensation warrants postponement of elective surgery. 

• [1]

Perioperative Glucose Targets

• Blood glucose should be monitored and maintained between 100–180 mg/dL before, during, and after surgery. 

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• For critically ill patients, a target of 140–180 mg/dL is recommended once insulin therapy is initiated. More stringent goals (110–140 mg/dL) may be appropriate for selected patients (e.g., cardiac surgery) if achievable without significant hypoglycemia. 

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• Stricter targets are not advised — the NICE-SUGAR trial demonstrated that intensive glycemic management (80–110 mg/dL) resulted in 10- to 15-fold greater rates of hypoglycemia and slightly higher mortality compared with moderate targets. 

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Medication Management

• Metformin and other oral agents: Hold on the day of surgery. 

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• SGLT2 inhibitors: Stop 3 days before scheduled surgery (4 days for ertugliflozin) due to risk of euglycemic DKA. 

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• GLP-1 receptor agonists: Should be held for acutely ill hospitalized individuals; data on perioperative use remain limited. 

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• Insulin is the only recommended glucose-lowering medication in the perioperative period. 

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Insulin Adjustments

• A 25% reduction of basal insulin dose the evening before surgery is more likely to achieve perioperative glucose goals with lower hypoglycemia risk. 

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• NPH insulin: Reduce to one-half the dose. 

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• Long-acting basal analogs (glargine, degludec): Reduce to 75–80% of the dose. 

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• All prandial (short/rapid-acting) insulin should be held while NPO. 

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• Basal-bolus insulin is preferred over correction-only sliding-scale insulin, which is associated with worse glycemic outcomes and higher complication rates. 

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Insulin Pump Use

• Patients may continue insulin pump use during surgery if consistent with institutional policies and the patient can self-manage. If the pump cannot be used, an alternative plan (IV insulin infusion or basal + correctional SC insulin) should be initiated before surgery. 

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Monitoring

• Blood glucose should be checked at least every 2–4 hours while NPO. 

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• CGM should not be used alone for glucose monitoring during surgery. 

Stages of Type 1 Diabetes

A formal staging system for T1D was established by a joint scientific statement from JDRF, the Endocrine Society, and the ADA, and is now incorporated into the ADA Standards of Care: 

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• Stage 1 (Presymptomatic, Normoglycemia): ≥2 islet autoantibodies (GAD65, insulin, IA-2, ZnT8) with normal glucose (FPG <100, 2h OGTT <140, A1C <5.7%). The 5-year risk of progressing to symptomatic T1D is ~44%, with lifetime risk approaching 100%. 

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• Stage 2 (Presymptomatic, Dysglycemia): ≥2 islet autoantibodies with dysglycemia not yet meeting diabetes criteria — defined as FPG 100–125 mg/dL, 2h OGTT 140–199 mg/dL, A1C 5.7–6.4%, or stimulated glucose ≥200 mg/dL at 30/60/90 min on OGTT. Risk of Stage 3 is ~60% within 2 years and ~75% within 5 years. Teplizumab is FDA-approved for Stage 2 T1D to delay progression to Stage 3. 

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• Stage 3 (Clinical Diabetes): Overt hyperglycemia meeting standard diabetes diagnostic criteria (FPG ≥126, 2h OGTT ≥200, A1C ≥6.5%, or random glucose ≥200 with symptoms). This is when clinical diagnosis is traditionally made and insulin therapy is required. 

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Frequently Asked Questions: Understanding Herniated Discs & Your Treatment

What is a herniated disc?

Your spinal discs act as shock absorbers between your vertebrae. They consist of a tough outer layer and a jelly-like center. A herniation occurs when a tear in the outer layer (annulus) allows that inner material (nucleus) to push out, which can irritate or compress nearby nerves.

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How are herniation sizes categorized? [ NOTE VERY SIMILAR TO PAIN MILD-MODERATE-SEVERE .... SMALL/MODERATE/LARGE ]

While the impact of a herniation depends on the size of your specific spinal canal, physicians generally use the following measurements to describe the protrusion:

• Small (1–3 mm): These are often contained and may only cause localized aching or no symptoms at all.

• Moderate (4–6 mm): These are more likely to make contact with nerve roots, often resulting in radiating pain, tingling, or numbness. 

• Large (Over 6 mm): These represent significant displacement. A large herniation has a higher likelihood of causing mechanical compression of the nerves.

Cervical vs. Lumbar Herniations

The symptoms you experience depend on where the disc is located:

• Cervical (Neck): Pain typically radiates into the shoulders, arms, or hands. You may feel "electric shocks" down your arm or weakness in your grip.

• Lumbar (Lower Back): This is the most common site for herniations. Pain usually travels into the buttocks and down the leg (often called Sciatica). It may also cause numbness or tingling in the feet.

Does a herniated disc require surgery?

In the vast majority of cases, the answer is no. Most herniated discs resolve with conservative, non-surgical interventional care. As board-certified pain physicians, our goal is to reduce the inflammation around the nerve and manage your pain while your body naturally heals.

What to Expect: Your First Epidural Steroid Injection (ESI)

If conservative treatments like physical therapy haven't provided enough relief, an ESI is often the next step. This procedure delivers powerful anti-inflammatory medication directly to the source of your pain.

How is the procedure performed?

The procedure is performed in our clinic and typically takes 15–30 minutes. You will lie on your stomach, and the physician will use Fluoroscopy (Live X-ray) to ensure the needle is placed with millimeter precision. A local anesthetic is used to numb the skin, so you should feel pressure rather than sharp pain.

Does it hurt?

Most patients describe a "fullness" or a temporary replication of their typical leg or arm pain as the medication is injected. This is normal and usually subsides within a few minutes.

How soon will I feel better?

Some patients feel immediate relief from the local anesthetic, but the steroid itself typically takes 2 to 7 days to begin reducing inflammation. You may feel slightly sore at the injection site for a day or two.

What are the activity restrictions?

We generally recommend "taking it easy" for the remainder of the day. Most patients can return to their normal daily routine and work the following day.

When should I seek emergency care?

While most herniations are managed in an office setting, you should seek immediate emergency medical attention if you experience:

• Sudden loss of bowel or bladder control.

• Numbness in the "saddle area" (groin, buttocks, inner thighs).

• Sudden, severe weakness that makes it impossible to stand or walk.