bluuebunny/crossref_metadata_2025 huggingface dataset:
High-Voltage, Long-Duration Pulsed
Radiofrequency on Gasserian Ganglion Improves
Acute/Subacute Zoster-Related Trigeminal
Neuralgia: A Randomized, Double-Blinded,
Controlled Trial
Authors: Song Tao
Published: February 2021

Background: Trigeminal postherpetic neuralgia is a severe neuropathic pain and often refractory
to existing treatment, it develops secondary to herpes zoster-infected Gasserian ganglion.
Therefore, it is important to prevent the transition of acute/subacute zoster-related pain to
trigeminal postherpetic neuralgia. Despite numerous studies, the optimal intervention that reduces
trigeminal postherpetic neuralgia incidence is still unknown.
Objectives: This study aimed to evaluate the efficacy and safety of high-voltage, long-duration
pulsed radiofrequency (PRF) on the Gasserian ganglion in patients with acute/subacute zosterrelated trigeminal neuralgia.
Study Design: Prospective, randomized, double-blinded study.
Setting: Department of Pain Medicine, the First Affiliated Hospital of China Medical University.
Methods: Ninety-six patients with acute/subacute zoster-related trigeminal neuralgia were
equally randomly assigned into 2 groups. The electrode needle punctured the Gasserian ganglion
guided by computed tomography in every patient. High-voltage, long-duration PRF at 42°C for
900 seconds was applied in the PRF group (n = 48). It was also applied in the sham group (n =
48) without radiofrequency energy output. The therapeutic effects were evaluated using a visual
analog scale (VAS) and the 36-Item Short Form Health Survey (SF-36) at different time points. The
average dosage of pregabalin (mg/d) administrated within the first month after treatment was also
recorded.
Results: The postprocedure VAS scores in the PRF group were significantly lower than those in the
sham group at different time points after treatment (P < 0.01). The SF-36 scores, which included
physical functioning, physical role, bodily pain, general health perceptions, vitality, social function,
emotional role, and the mental health index, were significantly improved at the sixth month
after treatment in the PRF group compared with the sham group (P < 0.01). The average dosage
of pregabalin administered (mg/d) within the first month after treatment was also significantly
reduced in the PRF group compared with the sham group (P < 0.01). There were no bleeding,
infection, or other severe side effects in both groups.
Limitations: Single center study, relatively small number of patients.
Conclusions: High-voltage, long-duration PRF on the Gasserian ganglion is an effective and safe
therapeutic alternative for patients with acute/subacute zoster-related trigeminal neuralgia.
Key words: Pulsed radiofrequency, zoster-related trigeminal neuralgia, visual analog scale, 36-
Item Short Form Health Survey
Posterior Cervical Foraminotomy Via
Full-Endoscopic Versus Microendoscopic
Approach for Radiculopathy: A Systematic
Review and Meta-analysis
Authors: Wang Bing
Published: February 2021

Background: Recently posterior cervical foraminotomy (PCF) performed using a minimally-invasive
surgery (MIS) approach for cervical radiculopathy due to lateral disc herniation or osseous foraminal
stenosis has gained popularity. As 2 dominating MIS techniques, whether FE-PCF or MI-PCF provides
superior clinical outcomes remains controversial.
Objectives: To compare clinical success rate, overall incidence of complications and reoperation
rate between full-endoscopic posterior cervical foraminotomy (FE-PCF) and microendoscopic posterior
cervical foraminotomy (MI-PCF) for cervical radiculopathy.
Study Design: A systematic review and meta-analysis.
Methods: A literature search of Pubmed, Embase and Web of Science was conducted to identify
comparative or single-arm studies concerning FE-PCF or MI-PCF. The pooled results were performed by
calculating the effect size based on the logit event rate and reported with 95% confidence intervals
(CI).
Results: A total of 26 articles with 2003 patients (FE-PCF, 377; MI-PCF, 1626) were included. The pooled
clinical success rate was 93.6% (CI: 90.0%~95.9%) for the FE group and 89.9% (CI: 86.6%~92.5%)
for the MI group, which was not statistically significant (P = 0.908). Overall complication rates were
6.1% (CI: 3.2%~11.3%) and 3.5% (CI: 2.7%~4.6%) for the FE group and the MI group, respectively,
with no significant difference (P = 0.128). Nevertheless, the specific constituents showed apparent
disparity, with transient nerve root palsy in the FE group (12/16, 75.0%) and dural tear in the MI group
(20/47, 42.6%) being the most commonly reported. the pooled reoperation rate, the FE group (4.8%,
CI: 2.9%~7.8%) and the MI group (5.3%, CI: 3.4%~8.2%), also demonstrated no statistical difference
(P = 0.741).
Limitations: The indirect comparison eroded the reliability of results inevitably due to the paucity of
randomized clinical trials or high quality prospective cohort studies.
Conclusions: Both FE-PCF and MI-PCF can offer an effective and relatively secure treatment for
cervical radiculopathy. There was no significant difference in the pooled outcomes of clinical success
rate, complication rate and reoperation rate between the 2 approaches.
Key words: Cervical radiculopathy, full-endoscopic, microendoscopic, posterior cervical foraminotomy,
clinical outcome, complication, reoperation, meta-analysis
Transition from Acute to Chronic Pain:
Evaluating Risk for Chronic Postsurgical Pain
Authors: Wang Jingping
Published: February 2021

Background: The pathophysiology of pain involves complex nervous system interactions
after initial noxious stimuli. When stimuli persist, biochemical and structural changes occur
in the nociceptive pathways of the central and peripheral nervous systems, leading to pain
sensitization. Peripheral and central sensitization are key in the transition from acute to chronic
pain. This development of chronic pain is particularly common following various surgical
procedures, with many postsurgical patients experiencing persistent pain for significant periods.
Chronic pain is a common and severe complication of surgery, and preventing its development
is tantamount in improving patient outcomes.
Objectives: To understand underlying pathophysiology of chronic postsurgical pain (CPSP)
and the underlying risk factors predisposing the transition from acute to CPSP. To review our
ability to identify patients at highest risk for the development CPSP. To identify evidence-based
multimodal approaches that can aid in the prevention of CPSP.
Study Design: Narrative review of peer-reviewed literature.
Setting: Inpatient surgical centers.
Methods: Medline and Cochrane databases were reviewed to identify publications relevant
to CPSP pathophysiology, risk factors, predictive models, and prevention. Publications were
selected based on author expertise to summarize our current understanding of CPSP.
Results: This review presents our current understanding of CPSP in the following domains:
underlying pathophysiology, predisposing risk factors, predictive models of CPSP, and
preventative strategies. Each section provides a structured review of key evidence base to
understand the complex topic of CPSP.
Limitations: This narrative review is a nonsystematic review of relevant publications aimed at
presenting succinct overview of CPSP.
Conclusions: The incidence of CPSP can potentially be reduced through early identification of
perioperative, genetic, physiologic, and psychologic factors. Models predicting the development
of CPSP continue to improve and may help focus preventative efforts in patients at highest risk.
There is a growing body of evidence supporting the use of multimodal analgesia and anesthetic
techniques in the reducing rates of CPSP development.
Key words: Acute pain, chronic postsurgical pain, pain sensitization, chronic pain prevention,
regional anesthesia, pain adjuncts, neuraxial anesthesia, chronic pain risk factors
Transforaminal Versus Lateral Parasagittal
Versus Midline Interlaminar Lumbar Epidural
Steroid Injection for Management of Unilateral
Radicular Lumbar Pain: A Randomized DoubleBlind Trial
Authors: Makkar Jeetinder Kaur
Published: February 2021

Background: Epidural steroid injections (ESIs) are commonly used for management of lumbosacral
radicular pain. Midline interlaminar (MIL) or transforaminal (TF) routes are commonly used. The
TF route, although associated with higher delivery of drug to the ventral epidural space, has
serious complications including spinal cord injury and permanent paralysis reported in literature.
Therefore, there is a search for a technically better route with fewer complications and greater
drug delivery into the ventral epidural space. Recently, a parasagittal interlaminar (PIL) approach
has been defined.
Objectives: We conducted this study to compare therapeutic effectiveness of 3 techniques of
ESIs in patients having unilateral lumbar radiculopathy. Further, effect of ESI on bone mineral
density (BMD) and serum osteocalcin levels were studied.
Study Design: Randomized double-blind trial.
Setting: Pain clinic of a tertiary care hospital.
Methods: Sixty-five patients were randomly allocated into group MIL, group PIL, and group TF to
receive epidural injection with 80 mg of methylprednisolone and 2 mL of 2% lidocaine. Effective
pain relief and improvement in disability were assessed using Visual Analog Scale (VAS) and
Modified Oswestry Disability Questionnaire (MODQ) scores at 2 weeks, 4 weeks, 3 months, and
6 months, respectively. Patients with < 50% relief received additional injection. Primary outcome
of study was effective pain relief at 6 months. Mean change in VAS and MODQ scores, BMD, and
serum osteocalcin levels were secondary outcome assessed.
Results: Patients having effective pain relief were significantly higher in group PIL (16 of 20
[80%]) and group TF (15 of 20 [75%]) compared with group MIL. Patients receiving ESI in group
PIL and group TF showed significantly lower VAS scores than group MIL (P = 0.02, P = 0.50 at
3 months and P = 0.00, P = 0.02 at 6 months, respectively). Mean MODQ scores in group PIL
and group TF were significantly lower than group MIL. However, group PIL and group TF did not
significantly differ in MODQ scores. There was no significant change in serum osteocalcin and
BMD, as assessed by dual energy x-ray absorptiometry scan at 3 months.
Limitations: The absence of a placebo control group, small sample size, and relatively short
follow-up of 6 months were limitations.
Conclusions: PIL approach is equivalent to TF and superior to MIL approach in terms of effective
pain relief and decrease in disability in patients with unilateral lumbar radiculopathy. This study
showed no deleterious effect on BMD.
Key words: Epidural steroid, technique, efficacy, bone marrow density, serum osteocalcin
Effect of Dry Needling Injection and
Kinesiotaping on Pain and Quality of Life in
Patients with Mechanical Neck Pain
Authors: Polat Cemile Sevgi
Published: February 2021

Background: Dry needling (DN) is a commonly used technique by clinicians for the treatment of
mechanical neck pain (MNP) by targeting trigger points and nontrigger point structures. It is a skilled
intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying trigger points,
muscular and connective tissues without the use of injectate. Another popular treatment technique used
in the management of musculoskeletal pathologies is kinesiotaping (KT). Although its popular, there is
minimal scientific evidence supporting KT for neck pain. Although there are a few studies regarding KT
for neck pain in literature, there is a lack of randomized, controlled studies evaluating KT for neck pain.
Objectives: To evaluate the effect of KT on posterior cervical spine and DN into a posterior paracervical
muscle of patients with MNP.
Study Design: Randomized clinical study.
Setting: Physical medicine and rehabilitation center.
Methods: Seventy-two patients (17 men, 55 women) were randomly assigned to DN or KT treatment
groups. Numeric Rating Scale (NPS-11), Neck Disability Index (NDI), range of motion (ROM), Short Form36 Quality of Life Scale, and Beck Depression Inventory (BDI) were assessed before the intervention and
one month postintervention.
Results: Before treatment, there was no difference between groups in NPS-11, NDI, and BDI scores;
however, ROM of the DN group was greater than ROM of the KT group (P < 0.05). After treatment,
significant improvement was observed in all variables for both of the groups, except ROM in the DN
group (P < 0.05). The KT group showed greater ROM compared with the DN group (P < 0.05). The preand posttreatment results showed that the KT group was significantly superior for the differences on
ROM and NDI (P < 0.05); however, each group showed better results after treatment (P < 0.05).
Limitations: First, we did not include a control or placebo group. Second, patients were followed up for
only 4 weeks. Third, we used a sample of convenience from one clinic, which may not be representative
of the entire population of individuals with MNP.
Conclusions: In this study, both methods were found to be effective on pain, mood, and quality of
life, and KT was found to be superior to DN in MNP in terms of increasing ROM and decreasing disability
Effectiveness of “Transgrade” Epidural
Technique for Dorsal Root Ganglion
Stimulation. A Retrospective, Single-Center,
Case Series for Chronic Focal Neuropathic Pain
Authors: Al-Kaisy Adnan
Published: February 2021

Background: The recent interest in targeting the dorsal root ganglion (DRG) has led to the
development of new techniques of electrode placement. In this article, we describe a new
“Transgrade” approach to the DRG, accessing the contralateral interlaminar space and steering
the lead out the opposite foramen.
Objectives: The purpose of this study was to evaluate the Transgrade technique to the DRG in
the management of focal neuropathic pain, predominately complex regional pain syndrome in
terms of efficacy and safety.
Study Design: A retrospective, observational review of all patients selected for DRG stimulation
using the Transgrade technique to the DRG.
Setting: Pain Management and Neuromodulation Centre, Guys and St. Thomas NHS Foundation
Trust, London, United Kingdom.
Methods: Data were taken from a hospital password-protected database. All patients were
contacted by telephone for Numeric Rating Scale (NRS-11) score, Patient Global Impression of
Change (PGIC) score, and complications. A patient responder was defined as having a PGIC score
of 6 or 7, and a 2-point reduction from baseline NRS-11.
Results: A total of 39 patients (46% women) with a mean age of 46 years (± 2) underwent a trial
of DRG stimulation that resulted in an implantation rate of 82% (32 of 39). The responder rates,
according to NRS-11 and PGIC results, were 87% (28 of 32) at 6 weeks and 66% (21 of 32) at a
mean of 18 months (± 1.8) follow-up. Pocket pain was the most common complication, occurring
in 7 of 32 (22%) patients, and the lead migration rate was 3 out of 57 leads placed (5.2%). A
burst protocol was the favored method of stimulation in the majority of patients, 25 of 32 (78%).
Limitations: Retrospective nature of design, small sample size.
Conclusions: The Transgrade technique of placing DRG leads offers an alternative method that
is safe and effective. New methods of stimulation to the DRG offer more choice and potentially
better efficacy for patients with chronic neuropathic pain.
Uncinate Process Area as a New Sensitive
Morphological Parameter to Predict Cervical
Neural Foraminal Stenosis
Authors: Kim Young Uk
Published: February 2021

Background: Hypertrophy of the uncovertebral joint has been considered as a major cause
of cervical neural foraminal stenosis (CNFS). The cross-sectional area of the uncinate process
is a key morphologic parameter in the identification of uncovertebral joint hypertrophy.
To evaluate the connection between CNFS and the uncinate process, we devised a new
morphological parameter, the uncinate process area (UPA).
Objective: We hypothesized that the UPA is an important morphologic parameter in the
diagnosis of CNFS.
Study Design: Retrospective observational study.
Setting: The single center study in Incheon, Republic of Korea.
Methods: UPA data were collected from 146 patients with CNFS and 197 control subjects
who underwent neck computed tomography (CT) as part of a routine medical examination.
Neck CT images were obtained from all subjects. The whole cross-sectional area of the bone
margin of the uncinate process was measured at the C5-6 intervertebral disc level on CT scans
using a picture archiving and communications system.
Results: The average UPA was 15.52 mm2
in the control group and 29.97 mm2
in the CNFS
group. The CNFS group displayed significantly greater UPA levels (P < 0.001). Regarding the
validity of the UPA as a predictor of CNFS, the receiver operating characteristic curve analysis
revealed an optimal cut-off point for the UPA of 21.15 mm2
, with 91.8% sensitivity, 93.4%
specificity, and an area under the curve of 0.972 (95% CI,0.956-0.989) in the CNFS group.
Limitations: Anatomically, the UP is located on the superior lateral surfaces of the C3-7
cervical vertebral bodies. However, we focused on the C5-6 uncovertebral joint level,
because many previous studies revealed C6 UP has the greatest height among UP and C5-6
uncovertebral joint hypertrophy is a primary cause of CNFS.
Conclusions: The newly devised UPA is a sensitive parameter for assessing CNFS. A
hypertrophied UPA is associated with an increased risk of CNFS. We think that this result will
be helpful for diagnostic radiology in evaluating patients with CNFS.
Institutional Review Board (IRB) approval number: IS16RISI0002
Key words: Uncinate process area, cervical neural foraminal stenosis, Uncovertebral joint
hypertrophy, optimal cut-off point, cross- sectional area
Endoscopic Radiofrequency Treatment of the
Sacroiliac Joint Complex for Low Back Pain: A
Prospective Study with a 2-Year Follow-Up
Authors: Telfeian Albert E.
Published: February 2021

Background: The sacroiliac joint complex (SIJC) is considered a major sources of chronic low
back pain. Interventional procedures for sacroiliac (SI) joint pain tend to be short-lived and surgical
treatment usually involves a fusion procedure.
Objectives: To determine the clinical efficacy of endoscopically visualized radiofrequency
treatment of the SIJC in the treatment of low back pain.
Study Design: Retrospective chart review.
Setting: This study took place in a single-center, orthopedic specialty hospital.
Methods: Patients received general anesthesia and under endoscopic visualization, radiofrequency
ablation was performed on 1) the perforating branches that innervate the posterior capsule of the
SI joint capsule, 2) along the course of the long posterior SI ligament, 3) the lateral edges of the
S1, S2, and S3 foramen, and 4) the L4, L5, and S1 medial marginal nerve branches along the lateral
facet margins.
Results: From January 2015 to June 2016, a total of 30 patients who met the precise inclusion
criteria were treated with the endoscopic SIJC radiofrequency treatment for low back pain. The
average patient was aged 56 years (19 women and 11 men), the average preoperative visual
analog scale (VAS) score was 7.23, and the average Oswestry disability index (ODI) score was 44.8.
VAS and ODI were measured at 3, 6, 9, 12, 15, 21 and 24 months: VAS was reduced from 7.23 at
baseline to 2.82 at 24 months (61% reduction), and ODI was improved from 44.8 at baseline to
22.2 at 24 months (50% reduction).
Limitations: Small retrospective case series.
Conclusions: Full-endoscopic radiofrequency ablation of the large sensory SI joint innervation
complex, that includes the sensory nerve branches along the lateral S1-3 foramina and the L4-S1
medial branches, is perhaps a minimally invasive surgical procedure that could provide significant
relief of lumbar back pain in the carefully selected patient.
Key words: Endoscopic spine surgery, minimally invasive, low back pain, sacroiliac joint,
radiofrequency treatment
Clinical Anatomy and Possible Clinical
Significance of the Intervertebral Vein in the
Lumbar Intervertebral Foramina
Authors: Lu Hai
Published: February 2021

Background: The detailed structure of the lumbar intervertebral foramina has been wellstudied. Nevertheless, detailed descriptions of branches of the intervertebral vein (IV) through
the lumbar intervertebral foramina are lacking.
Objectives: This study aimed to provide an anatomical basis for invasive treatment targeting
the branches of the IV using an approach through the lumbar intervertebral foramina,
particularly for the purposes of transforaminal epidural steroid injection.
Study Design: This research involved a dissection-based study of 10 embalmed human
cadavers.
Setting: The research took place at The Third Affiliated Hospital of Southern Medical University.
Methods: One hundred lumbar intervertebral foramina from 10 embalmed cadavers were
studied. Branches of the IV in the intervertebral foramina were observed. The length and
diameter of the veins were measured using a Vernier caliper.
Results: At a rate of 100%, branches of the IV were observed in the 100 lumbar foramina
examined in our study. The following 4 types of branches of the IV were routinely found: Type
I in 27 (27%) of the IV foramina, in which a superior branch of the IV ran along the inferior
margin of the vertebral pedicle; Type II in 18 (18%) of the intervertebral foramina, in which an
inferior branch of the IV ran along the superior margin of the inferior vertebral pedicle; Type
III in 41 (41%) of the intervertebral foramina, in which the IV was divided into a superior and
inferior branch; and Type IV in 14 (14%) of the intervertebral foramina, in which the IV was
divided into 2 superior branches and an inferior branch.
Limitations: The greatest weakness of this study is that it lacks actual clinical verification.
Future clinical trials are expected to contribute more objective data concerning the IV branches.
Due to the relative changes in vascular position during dissection, the relevant data warrant
improvement.
Conclusions: The lumbar IVs are an important part of the anatomical structure of the
intervertebral foramina. Adequate knowledge of the IV may be of clinical importance to
physicians performing transforaminal epidural steroid injection.
Key words: Clinical anatomy, intervertebral veins, lumbar vertebra, Kambin’s triangle, safe
triangle, intervertebral foramina, vertebral venous system, inadvertent injection, transforaminal
epidural steroid injection
Role of 3 Tesla MR Neurography and CT-guided
Injections for Pudendal Neuralgia: Analysis of
Pain Response
Authors: Chhabra Avneesh
Published: February 2021

Background: Magnetic resonance neurography (MRN) has an increasing role in the diagnosis
and management of pudendal neuralgia, a neurogenic cause of chronic pelvic pain.
Objective: The objective of this research was to determine the role of MRN in predicting improved
pain outcomes following computed tomography (CT)-guided perineural injections in patients with
pudendal neuralgia.
Study Design: This study used a retrospective cross-sectional study design.
Setting: The research was conducted at a large academic hospital.
Methods:
Patients: Ninety-one patients (139 injections) who received MRN and CT-guided pudendal blocks
were analyzed.
Intervention: A 3Tesla (T) scanner was used to evaluate the lumbosacral plexus for pudendal
neuropathy. Prior to receiving a CT-guided pudendal perineural injection, patients were given pain
logs and asked to record pain on a visual analog scale.
Measurement: MRN findings for pudendal neuropathy were compared to the results of the CTguided pudendal nerve blocks. Injection pain responses were categorized into 3 groups – positive
block, possible positive block, and negative block.
Statistical Tests: A chi-square test was used to test any association, and a Cochran-Armitage trend
test was used to test any trend. Significance level was set at .05. All analyses were done in SAS
Version 9.4 (SAS Institute, Inc., Cary, NC).
Results: Ninety-one patients (139 injections) who received MRN were analyzed. Of these 139
injections, 41 were considered positive (29.5%), 52 of 139 were possible positives (37.4%), and
46 of 139 were negative blocks (33.1%). Of the patients who had a positive pudendal block, no
significant difference was found between the MRN result and the pudendal perineural injection
response (P = .57). Women had better overall response to pudendal blocks, but this response was
not associated with MRN findings (P = .34). However, positive MRN results were associated with
better pain response in men (P = .005). Patients who reported bowel dysfunction also had a better
response to pudendal perineural injection (P = .02).
Limitations: Some limitations include subjectivity of pain reporting, reporting consistency,
absence of a control group, and the retrospective nature of the chart review.
Conclusion: Pudendal perineural injections improve pain in patients with pudendal neuralgia
and positive MRN results are associated with better response in men.
Key words: MRI, MRN, CT injection, pudendal neuralgia, pudendal nerve, pelvic pain, chronic
pelvic pain, pudendal neuropathy
Vitamin B12 as a Treatment for Pain
Authors: Buesing Scott
Published: February 2021

Background: First isolated as cyanocobalamin in 1948, vitamin B12 has been explored
for pain treatment almost since its discovery. With the advent of the opioid epidemic, safer
treatments for pain are needed.
Objectives: Our objective was to compile the latest information on potential mechanisms
from animal studies and clinical trial data on vitamin B12 for the treatment of pain conditions.
Study Design: We conducted a narrative review.
Methods: PubMed was searched using the terms “methylcobalamin pain”, “hydroxycobalamin
pain”, “cyanocobalamin pain”, and “vitamin B12 pain.” Animal studies that identified
mechanisms of action for the effects of pain were collected. Clinical trials utilizing larger,
pharmaceutical doses of vitamin B12 (> 100 µg/dose) in pain treatment were identified and
reviewed.
Results: Animal studies support multiple beneficial effects of vitamin B12 including the
regeneration of nerves and the inhibition of cyclooxygenase enzymes and other pain-signaling
pathways. In addition, animal studies have demonstrated synergistic benefits of vitamin B12
combined with other pain medications, including nonsteroidal anti-inflammatory drugs and
opiates. Clinical trials provide evidence for the effectiveness of vitamin B12 for the treatment of
low back pain and neuralgia, although data is still fairly limited and optimal treatment regimens
have not been identified.
Limitations: More large, double-blind placebo-controlled trials are needed to fully establish
efficacy and best dosing parameters.
Conclusion: Vitamin B12 may prove to be an adjunctive or integrative treatment for pain
conditions. While more research is needed, considering the low incidence of side effects and
overall safety, B12 may be an additional tool to consider for pain treatment.
Key words: Vitamin B12, cyanocobalamin, methylcobalamin, hydroxycobalamin, pain,
chronic pain, neuropathy, low back pain
Sciatic Scoliosis Evolution after Lumbar
Discectomy: A Comparison Between Adolescents
and Young Adults
Authors: Zhu Zezhang
Published: February 2021

Background: Scoliosis secondary to lumbar disc herniation (LDH) may occur in both
adolescents and adults. As the spine is more flexible in adolescents than in adults, the curve
features and curve evolution could be different between these 2 cohorts, which were unclear.
Objectives: To compare the radiologic features of scoliosis secondary to LDH between adolescents
and adults, and to further characterize the curve evolution after lumbar discectomy in 2 cohorts.
Study Design: A retrospective study.
Setting: An inpatient surgery center.
Methods: Patients with scoliosis secondary to LDH who underwent surgical intervention between
2010 and 2016 were reviewed. Radiographic parameters were measured on standing whole spine
radiographs. The apical vertebral translation was measured on serial radiographs taken before
surgery, one month and 6 months after surgery, and at last follow-up to evaluate the curve evolution.
Meanwhile, the patients’ reported outcomes were evaluated. According to age, patients were divided
into adolescent and adult group. Comparisons between the 2 groups were made with regards to the
preoperative and postoperative radiographic parameters and clinical outcomes.
Results: A total of 42 adolescent and 41 adult patients were included in this study. The incidence
of scoliosis secondary to LDH in the adolescents was significantly higher than that in the adults.
Adolescent patients present remarkably higher incidence of coronal balance as compared with
the adult patients preoperatively. No significant difference was observed between the 2 groups in
terms of preoperative radiographic parameters. A total of 85.7% of the adolescent patients and
92.7% of the adult patients achieved resolution of scoliosis within 6 months after surgery.
Limitations: This was a retrospective study with a small series of cases and relatively short-term
follow-up.
Conclusions: The incidence of scoliosis secondary to LDH in adolescents is significantly higher
than in adults. Moreover, adolescent patients are more likely to present coronal balance before
surgery. The 2 cohorts could have comparable curve evolution, and resolution of scoliosis generally
occurred within 6 months after surgery.
Key words: Sciatic scoliosis, lumbar disc herniation, adolescent, adult, resolution, lumbar
discectomy
Causes of Residual Back Pain at Early Stage
After Percutaneous Vertebroplasty: A
Retrospective Analysis of 1,316 Cases
Authors: Hao Ding-Jun
Published: February 2021

Background: Percutaneous vertebroplasty (PVP) is now well accepted in the treatment of
painful osteopathic vertebral compression fractures (OVCF), providing early pain relief and
strengthening of the bone of the vertebrae. However, some patients still experienced severe
back pain after PVP.
Objectives: To analyze the possible reason for unsatisfactory back pain relief (UBPR) after
PVP at early stage.
Study Design: Retrospective analysis.
Setting: Hong-Hui Hospital in Xi’an.
Methods: Between March 2013 and January 2015, a total of 1,316 patients with OVCF
were treated by PVP at our Hospital. Demographics, clinical data, and surgical data were
collected to analyze the factors associated with UBPR after PVP.
Results: Sixty cases complained of UBPR, and the prevalence was 4.6%. Univariate
analyses showed that preoperative bone mineral density (BMD), number of fractures,
cement distribution and volume injected per level, lumbodorsal fascia contusion, and
depression were associated with UBPR after PVP (P < 0.001). Multivariate analysis revealed
that preoperative BMD (odds ratio [OR], 3.577; P = 0.029), lumbodorsal fascia contusion
(OR, 3.805; P = 0.002), number of fractures (OR, 3.440; P < 0.001), cement volume injected
per level (OR, 0.079; P < 0.001), cement distribution (OR, 3.009; P = 0.013), and depression
(OR, 3.426; P = 0.028) were independently associated with UBPR after PVP at the early
postoperative stage.
Limitations: A further prospective controlled study is needed to explore the association
between the different degrees of the aforementioned factors and UBPR after PVP.
Conclusions: Preoperative low BMD, lumbodorsal fascial injury, multiple segment PVP,
insufficient cement injected volume, unsatisfactory cement distribution, and depression
were strong risk factors associated with UBPR after PVP in patients with OVCF.
Key words: Unsatisfactory back pain relief, residual back pain, percutaneous vertebroplasty
Prescriber Education Interventions to Optimize
Opioid Prescribing in Acute Care: A Systematic
Review
Authors: Hopkins Ria E.
Published: February 2021

Background: Opioid medications are frequently used effectively for analgesia in acute settings,
however, they are associated with dependence and addiction, and were implicated in 47,600
American fatalities in 2017. Evidence suggests that despite guidelines and professional body
recommendations, acute prescribing remains highly variable. Educational interventions targeting
prescribers have potential to optimize prescribing in-line with evidence-based best practice.
Objectives: To identify the objective impacts of education interventions on opioid prescribing in
the acute care setting.
Study Design: A systematic literature review.
Setting: The electronic databases MEDLINE, Embase, and Cochrane for works published until
December 31, 2018. Bibliographies of relevant studies and the gray literature were also searched.
Methods: Databases were searched for interventional studies (clinical trials and pre- and
poststudies). Studies describing an educational intervention delivered to clinicians and reporting at
least one objective measure of opioid use in the acute care setting were included. Studies reporting
only subjective outcomes and those focused on chronic pain or set in primary care were excluded.
Two reviewers (RB, TB) extracted data and assessed the quality of included studies using the Downs
and Black Tool.
Results: Nine studies met inclusion criteria; all used pre- and postdesigns. Three studies described
stand-alone education, and the others described multifaceted interventions. All 9 interventions
significantly reduced at least one of the following: high-risk agent use including meperidine
use by up to 71%; total or daily dosage of opioids at discharge, including median morphine
milligram equivalence (MME) from 90 mg to 45 mg per patient; and quantity of medications such
as oxycodone supplied to patients, halved in one study from 6,170 expected to 2,932 supplied
tablets. No increase in pain complaints or prescription refill requests were reported in those studies
assessing these outcomes. The longest study examined prescribing 15 months after education
delivery, reporting sustained practice changes.
Limitations: Overall study quality was fair to poor. Significant heterogeneity in settings,
patient groups, methodologies, and outcomes prevented pooled quantitative analysis. No studies
examined all available opioid agents or formulations.
Conclusions: These findings support prescriber education as an effective strategy to reduce
opioid use and optimize prescribing in acute settings. Further research, particularly high quality
randomized studies, describing the impact of education on all available opioid formulations and
total MME is required. Reviewing the existing literature has offered useful models that can be
implemented to improve care with opioid prescribing in acute settings.
Key words: Opioids, education, physician education, prescriber education, opioid education,
opioid prescribing, systematic review, prescriptions, prevention
Hyaluronidase in Neuroplasty: A Review
Authors: Helm II Standiford
Published: February 2021

Background: Neuroplasty, also known as percutaneous adhesiolysis, is an effective treatment for
persistent axial and radicular pain.
Objectives: One issue of concern is whether hyaluronidase should be used when performing
neuroplasty. The objective of this narrative review is to evaluate the current literature relating to
hyaluronidase and its role in neuroplasty.
Methods: The literature relating to hyaluronidase was examined via a search of PubMed and
Google Scholar until April 2019, review of the citations of relevant literature, and the authors’
knowledge of the literature and activity in the field. The literature was reviewed in light of
hyaluronidase’s physiologic role, allergenicity, medical uses, and evaluation specifically for
neuroplasty.
Results: Hyaluronidase facilitates the spread of medications in the extracellular matrix by breaking
down polysaccharides in the interstitial space. While allergic reactions to hyaluronidase have
been reported, these reactions occurred with animal-derived preparations. The current human
recombinant hyaluronidase does not have any reports of allergic reactions. Laboratory studies
show that it does not evoke an immune response. Hyaluronidase has been extensively used in a
variety of medical applications, including intrathecal treatment of arachnoiditis.
There have been multiple studies reporting benefit from the use of hyaluronidase in interventional
procedures. One randomized trial specifically looking at the use of hyaluronidase in neuroplasty
found that the addition of hyaluronidase improved pain ratings at 12 months compared to other
techniques and decreased the number of procedures needed to gain effect.
Limitations: There have been limited studies examining the enhanced efficacy of neuroplasty
when hyaluronidase is added.
Conclusions: Because of enhanced efficacy and safety, and because of the decrease in the
number of procedures needed to be performed, hyaluronidase should be considered when
deciding which medications to use when performing neuroplasty.
Key words: Neuroplasty, adhesiolysis, hyaluronidase, spinal stenosis, failed back surgery
synderome, post lumbar surgery syndrome
Sacroiliac Joint Ligaments and Sacroiliac
Pain: A Case–Control Study on Micro- and
Ultrastructural Findings on Morphologic
Alterations
Authors: Hammer Niels
Published: February 2021

Background: The sacroiliac joint (SIJ) is a common source of low back pain. SIJ pain has
shown to have negative impact on patients’ quality of life. Although clinically there is an
increasing interest to treat SIJ-related pain both conservatively and surgically, the underlying
mechanisms related to pathology in that region are poorly understood. One hypothesis is that
the SIJ ligaments are structurally altered in SIJ pain.
Objectives: The given study investigated patient cases with different pain durations
undergoing posterior distraction arthrodesis of the SIJ, with subsequent micro- and
ultrastructural assessment of the interosseous and posterior SIJ ligaments compared with
autopsy controls without known history of low back pain.
Study Design: Case–control study. Morphologic-pathological analysis of tissue samples
obtained during surgery with controls from legal medicine.
Setting: Rural hospital setting in Halberstadt, Germany.
Methods: SIJ ligaments were removed from 6 patients undergoing SIJ arthrodesis for
histological and ultrastructural assessment in scanning and transmission electron microscopy,
and compared with 6 controls without known history of SIJ pathology.
Results: A number of alterations were observed in the ligaments of patients with SIJ, namely
ligament disruption, collagen loosening and coiling, vascularization, and hemorrhage. In
some areas, these changes were observed in proximity to healthy (structurally unaltered and
intact tissues), indicative of a potential disease progression. Comparison to controls yielded
a significant correlation between SIJ pathology and the level of collagen degeneration (φ ≥
0.82; P < 0.001).
Limitations: Small sample size, method of tissue removal from patients may have influenced
tissue integrity.
Conclusions: The combined clinical, histological, and ultrastructural analysis provided, to
our knowledge, first-time evidence of morphologic SIJ ligament alteration of a nontraumatic
and noninflammatory cause. Further research is necessary to elucidate these structural
changes and to substantiate pain duration and patient-history-dependent changes at the
ligaments of the posterior pelvis
Percutaneous Endoscopic Interlaminar Lumbar
Discectomy with Local Anesthesia for L5-S1
Disc Herniation: A Feasibility Study
Authors: Wang Yansong
Published: February 2021

Background: General anesthesia (GA), which is routinely applied in patients who undergo
percutaneous endoscopic interlaminar lumbar discectomy (PEILD) of L5-S1 disc herniation, is
closely associated with postoperative cognitive dysfunction (POCD) in the elderly. Local anesthesia
(LA) is an alternative pain control protocol that has not yet been fully evaluated.
Objectives: To evaluate the feasibility of LA in PEILD compared with GA.
Study Design: A retrospective study.
Setting: This study took place at the First Affiliated Hospital of Harbin Medical University.
Methods: A total of 120 patients (aged 60-85 years) diagnosed with L5-S1 disc herniation and
with American Society of Anesthesiologists fitness grade I or II between March 2016 and August
2017 were enrolled in the current study. Patients were randomly divided into LA group and GA
group. For LA, 0.25% lidocaine was injected layer-by-layer into skin, subcutaneous tissue, fasciae,
lumbar facet joint, muscle, and ligamentum flavum followed by injection of 1.33% lidocaine into
epidural space; for GA, propofol, sufentanil, and cisatracurium were infused intravenously at 1 to
2 mg/kg, 0.3 µg/kg, and 0.15 mg/kg, respectively. Visual Analog Scale (VAS), Oswestry Disability
Index (ODI), and MacNab Criteria (MNC) evaluated the feasibility of LA as pain control protocol
in comparison to GA before and after operation. The development of POCD was assessed by the
Mini-Mental State Examination 1 and 7 days postsurgery. Feasibility of LA as a pain control protocol
was also evaluated by patient’s willingness to receive the same surgical procedure immediately
and 24 hours after the surgery, and intraoperative fluoroscopy use, blood loss, surgery duration,
postoperative bed confinement, and duration and cost of hospital stay were also evaluated.
Results: Patients in both LA and GA groups had comparable VAS grade, ODI, and MNC preand post-PEILD, with significant pain reduction after operation. However, POCD developed only
in GA group but not in LA group. In addition, compared with GA, LA group did not require
postoperative bed confinement, had significantly shorter hospital stay, and lower hospital cost. Low
intraoperative VAS grade and willingness to receive the same procedure reflected the acceptance
of LA by patients.
Limitations: The development of POCD was examined only 7 days after operation. The followup should be extended to 3 months and 2 years postoperation.
Conclusions: LA has satisfactory pain control and low-risk of POCD in PEILD and is well accepted
by patients. The benefits of LA are no postoperative bed confinement, faster recovery, shorter
hospital stay, and lower hospital cost.
Age, Gender, Level and Side Differences in the
Anatomical Distinctions of Unilateral Percutaneous
Kyphoplasty through the Transverse ProcessPedicle Approach
Authors: Wang Hongwei
Published: February 2021

Background: Unilateral and bilateral percutaneous kyphoplasty (PKP) have been widely
adopted to treat osteoporotic vertebral compression fractures (OVCFs). Unilateral PKP
has a shorter operation time and less radiation exposure time compared with bilateral
PKP, but the anatomical distinctions of unilateral PKP are not identical in all cases.
Objective: The aim of this study was to examine the significance of age, gender, level,
and side in relation to the anatomical distinctions of unilateral PKP for lumbar OVCFs
through the transverse process-pedicle approach (TPPA).
Study Design: This was a retrospective study of 200 patients.
Setting: The research took place at General Hospital of Shenyang Military Area
Command of Chinese PLA.
Methods: Researchers examined 1000 lumbar spines (L1-L5) of 200 patients and
simulated PKP on the 3D-CT scans through unilateral TPPA. The distance between the
entry point and the midline of the vertebral body (DEM), the puncture inclination angle
(PIA), the safe range of the inner inclination angles (SRA), and the success rate (SR) of
puncture were measured and compared.
Results: There were significant differences (P < 0.05) in the mean DEM between men
and women, and between the left and right sides. The DEM was significantly larger
in men than women and in right than left. The DEM from L1 to L5 was significantly
increased (P < 0.05), from 22.4 ± 2.0 mm to 34.1 ± 4.3 mm. The right maximum PIA
was significantly larger than the left. The maximum puncture angle and SRA in men
was larger than that in women except for L5. The SRA from L1 to L5 was significantly
increased (P < 0.05), from 20.1 ± 6.0 mm to 44.2 ± 8.8 mm. The SR from L1 to L5 was
significantly increased (P < 0.05), from 88.3% to 100%. The SR in men was significantly
higher than that in women for L1 and L2.
Limitations: Sample size was relatively small.
Conclusions: The DEM was 22.4 mm to 34.1 mm according to different levels. There
were significant gender, side, and age differences in the DEM and PIA. The values of
DEM, PIA, SRA and SR were significantly increased from L1 to L5.
Key words: Lumbar, osteoporotic vertebral compression fracture, unilateral,
percutaneous kyphoplasty, transverse process.
Prognosis for Recovery of Foot Drop after
Transforaminal Endoscopic Decompression of
Far Lateral Lumbar 5-Sacral 1 Herniated Disc:
Case Series
Authors: Telfeian Albert
Published: February 2021

Background: Foot drop that results from compression of the exiting L5 nerve as a result of far
lateral disc herniation (FLDH) at L5-S1 poses a significant surgical challenge to the minimallyinvasive spine surgeon given the narrow corridor for an extraforaminal approach because of the
high iliac crest.
Objectives: Here we describe our experience with transforaminal endoscopic decompression for
the treatment of foot drop secondary to FLDH at L5-S1.
Study Design: Retrospective case review.
Setting: This study took place in a single-center, academic hospital.
Methods: A technique for the transforaminal endoscopic treatment of foot drop secondary to
L5-S1 FLDH is presented in a series of 5 consecutive patients treated over a period of 3 years.
Preoperative and postoperative clinical data with 1-year follow-up are presented.
Results: A consecutive series of 211 patients who underwent transforaminal endoscopic treatment
for lumbar radiculopathy between 2011 and 2014 are presented. Seventy-seven patients had L5-
S1 discectomies and 5 of those patients presented with foot drop and FLDH. The mean visual
analog scale score for radicular pain improved from an average pain score before surgery of 7.2 to
0.8 one year after surgery, and the mean motor score for anterior tibialis strength improved from
an average motor score before surgery of 2.6 to 4.8 one year after surgery.
Limitations: Small case series evaluated retrospectively with one year follow-up.
Conclusions: Transforaminal endoscopic surgical access to FLDH pathology may be a unique
approach to the treatment of foot drop because it allows for neural decompression of disc and
foraminal pathology without requiring significant destabilizing bone removal.
Key words: E