bluuebunny/crossref_metadata_2025 huggingface dataset:
Randomized Controlled Study of Percutaneous
Epidural Neuroplasty Using Racz Catheter and
Epidural Steroid Injection in Cervical Disc Disease
Authors: Shin Dong Ah
Published: February 2021

Background: The efficacy of lumbar percutaneous epidural neuroplasty (PEN) as a minimally
invasive technique has been relatively well investigated, but the clinical effectiveness of cervical
PEN (C-PEN) has yet to be established.
Objective: The purpose of this study was to compare clinical outcomes between C-PEN and
cervical epidural steroid injection (C-ESI).
Study Design: Randomized control study.
Setting: University hospital center.
Methods: Eighty patients with neck pain from single level cervical disease with and without
radiculopathy were included in this study. Patients were randomly assigned into 2 groups: C-PEN
or C-ESI. Clinical outcomes were assessed according to Neck Disability Index (NDI) score and Visual
Analog Scale (VAS) score for arm pain until 12 months after treatment.
Results: All C-PEN and C-ESI groups showed better NDI recovery and greater reduction in VAS
score at postoperative 6 months (P < 0.001). The C-PEN group demonstrated better NDI score at
postoperative 6 months than the C-ESI group (P = 0.014), while there were no differences at 2, 4,
and 12 months. Additionally, the C-PEN group showed lower VAS scores at all follow-up intervals
compared to the C-ESI group (P < 0.050). Symptom relief was sustained for a significantly longer
duration in the C-PEN group than in the C-ESI group (23.4 vs. 20.5 weeks, P < 0.001).
Limitations: The follow-up period was relatively short with a small sample size, and the grade
of cervical disc disease, root compression, and disc degeneration grade were could not considered
in this study.
Conclusions: C-PEN was superior to C-ESI in terms of better NDI recovery (at 6 months) and
greater reduction in VAS score (until 12 months) in treating single level cervical disc herniation.
Better outcomes with C-PEN may have been achieved via a more localized selective block in the
epidural space closer to the dorsal root ganglion and ventral aspect of the nerve root.
Key words: Cervical, cervical disc disease, pain management, percutaneous epidural neuroplasty,
percutaneous adhesiolysis, epidural steroid injection
The Clinical Results of Percutaneous Endoscopic
Interlaminar Discectomy (PEID) in the
Treatment of Calcified Lumbar Disc Herniation:
A Case-Control Study
Authors: Qiang Fu
Published: February 2021

Background: Percutaneous endoscopic interlaminar discectomy (PEID), which poses advantages
for certain types of herniated disc, is gaining wider acceptance in clinical practice. We retrospectively
analyzed the efficacy of the PEID technique in treatment of calcified lumbar disc herniation.
Study Design: A retrospective case-control study.
Setting: University hospital in China.
Objective: To evaluate the efficacy of the PEID technique in treatment of calcified lumbar disc
herniation, and a comparison between calcified and noncalcified disc herniation was drawn to
analyze the causes of herniated disc calcification.
Methods: Data from patients who underwent full-endoscopic lumbar discectomy in our
department between March 2011 and May 2013 were collected. Thirty cases with calcified lumbar
disc herniation were included in the study group, and 30 age-, gender-, and body mass index
(BMI)-matched cases with noncalcified lumbar disc herniation served as controls. Perioperative
data, preoperative and postoperative Visual Analog Scale (VAS) scores, Oswestry Disability Index
(ODI) values, MacNab scores, and postoperative low-extremity dysesthesia among patients in the
2 groups were collected.
Results: The values of computed tomography (CT) in the calcified group were significantly
higher than those in the noncalcified group (P < 0.01). The preoperative disease courses in the
2 groups were similar. However, there was a statistically significant difference in the duration of
traditional Chinese medicines (TCM) administration (P < 0.01). VAS and ODI scores improved
significantly after surgery, but there were no significant differences between the 2 groups (P >
0.05). Three months after surgery, the rate of low-extremity dysesthesia in the calcified group was
significantly higher than that in the control group (P = 0.03) but became similar at 6 months. By
applying MacNab criteria the proportions of good and excellent were greater than 90% in both
groups, and there was no difference between groups (P > 0.05).
Limitations: The sample size was small in this retrospective study.
Conclusion: The PEID technique is an effective method in the treatment of calcified lumber
disc herniation, although the rate of postoperative dysesthesia is higher in this group during the
early postoperative period. Long-term TCM administration may be related to the calcification of
herniated lumbar discs.
Key words: Lumbar disc herniation, percutaneous endoscopic lumbar discectomy, interlaminar
approach, calcification
Treatment of Osteoporotic Vertebral
Compression Fractures: Applicability of
Appropriateness Criteria in Clinical Practice
Authors: Stoevelaar Herman
Published: February 2021

Background: Appropriate treatment choice for osteoporotic vertebral compression fractures
(OVCF) is challenging due to patient heterogeneity. Using the RAND/UCLA method, an
international multidisciplinary expert panel established patient-specific criteria for the choice
between non-surgical management (NSM), vertebroplasty (VP), and balloon kyphoplasty (BKP).
Objectives: To assess the applicability of the appropriateness criteria in real-life practice.
Study Design: Prospective observational study.
Setting: Eight practices of experts who participated in the panel study, including 2
interventional radiologists, one internal medicine specialist, 2 neurosurgeons, and 3 orthopedic/
trauma surgeons. Practices were located in Belgium, Germany, Italy, Switzerland, and the
United Kingdom.
Methods: Using an online data capture program, participants documented the clinical profile
(age, gender, previous VCFs, time since fracture, magnetic resonance imaging (MRI) findings,
evolution of symptoms, impact of symptoms on quality of life, spinal deformity, ongoing
fracture process, and presence of pulmonary dysfunction) and treatment choice for consecutive
patients who consulted them for OVCF.
Results: In total 426 patients were included. BKP was the most frequently chosen treatment
option (49%), followed by VP (34%) and NSM (14%). When compared with the panel
recommendations, inappropriate treatment choices were rare (5% for NSM, 2% for VP, none
for BKP). Treatment choice was strongly associated with the clinical variables used in the panel
study.
Differences in treatment decisions between interventional radiologists and surgeons were
largely determined by differences in patient characteristics, with time of clinical presentation
being the dominant factor.
Limitation: The study population was restricted to the practices of the participants of the
panel study.
Conclusion: This international, multi-specialty utilization review showed excellent applicability
of, and good adherence with RAND/UCLA-based recommendations on treatment choice in
OVCF.
Key words: Appropriateness criteria, utilization review, RAND/UCLA Appropriateness
Method, balloon kyphoplasty, non-surgical management, osteoporosis, vertebral compression
fractures, vertebroplasty
A Novel Mini-invasive Approach to the
Treatment of Neuropathic Pain: The PENS Study
Authors: Iemma Domenico
Published: February 2021

Background: Peripheral neuromodulation is often used as chronic neuropathic pain
treatment. Percutaneous electrical nerve stimulation (PENS) is generally utilized with several
probes at the same time and repeated treatments.
Objectives: Evaluate the short- and long-term efficacy of a single probe and single shot PENS
approach.
Study Design: Multicenter, prospective, observational study.
Setting: Four Italian pain therapy centers.
Methods: Inclusion criteria were age ≥ 18 and ≤ 80 years, presence of severe peripheral
neuropathic pain lasting more than 3 months, localized and refractory to pharmacological
therapies. Patients with infection, coagulopathies, psychiatric disorders, pacemakers, or
implantable cardiac defibrillators were excluded.
Patients: Seventy-six patients (47 women, 29 men), mean age 62 ± 14 years, affected by
neuralgia (21 herpes zoster infection, 31 causalgia, 24 postoperative pain) were enrolled in the
study.
Intervention: After localization of trigger point and/or allodynic/hyperalgesic area, PENS
therapy was achieved with a single 21 gauge conductive probe tunneled percutaneously and
a neurostimulator device.
Measurement: Numerical Rating Scale (NRS) and Neuropathic Pain Scale (NPS) were assessed
at baseline, 60 minutes after PENS, at one week, after one, 3, and 6 months; perceived health
outcome was measured with Euroqol-5 dimension (EQ-5D) questionnaire at baseline and at 6
months. Adverse events and patient satisfaction were reported.
Results: NRS and NPS decreased significantly after 60 minutes and the reduction remained
constant over time at follow-up. EQ-5D increased significantly with respect to the baseline.
Two nonclinically significant adverse events (one contralateral dysestesia and one self-resolving
hematoma) were observed.
Limitations: Small sample size and non-randomized observational study; high prevalence of
post-herpetic and occipital neuralgias.
Conclusion: PENS therapy produced significant and long-lasting pain relief in chronic
peripheral neuropathic pains of different etiology. The present study confirms the feasibility,
safety, and repeatability of this minimally invasive technique.
Key words: Neuropathic pain, neuromodulator, peripheral nerve, percutaneous stimulation
Musculoskeletal Ultrasonography in CRPS:
Assessment of Muscles Before and After Motor
Function Recovery with Dry Needling as the
Sole Treatment
Authors: Vas Lakshmi
Published: February 2021

Background: Motor impairment is an important criterion in the Clinical Diagnostic Criteria
(CDC) of Complex Regional Pain Syndrome type-1 (CRPS-1) as defined by International
Association for Study of Pain (IASP).
Objective: To describe the changes in musculoskeletal ultrasonography (MSKUSG) in CRPS-1
before and after treatment with ultrasound-guided dry needling (USGDN) in retrospective data
from 44 patients.
Study Design: Patients irrespective of age, gender, or cause of CRPS were included in this
retrospective data analysis; the Budapest criteria for the diagnosis of CRPS were stringently
adhered to.
Setting: The analysis was done at Ashirvad Institute for Pain Management and Research with
the database of CRPS patients who were treated between December 2005 and December
2014.
Methods: The CDC, range of motion at upper extremity joints, dynamometry, Disability of
arm, shoulder and hand score (DASH) and ultrasonography were documented on days one, 15,
and 45. MSKUSG demonstrated loss of myoarchitecture and reduced bulk.
Results: All 44 patients received USGDN as the sole intervention with medications and
physiotherapy. MSKUSG at 15 and 45 days after starting USGDN showed a return of normalcy
to the myoarchitecture and muscle bulk increase that coincided with the disappearance of CDC
and a progressive and predictable improvement of the DASH scores in all the 44 patients.
Limitation: The analysis focuses on only 2 parameters: the musculoskeletal changes of the
forearm flexors and extensors on ultrasound guidance and the efficacy of the dry needling
treatment. It is not a comparative study with another accepted form of treatment or intervention.
We have not looked into the age and gender predilection of the condition owing to the small
sample size of the study. Analysis of long term maintenance of relief and rehabilitation of the
disability were limited to one year.
Conclusion: Myofascial pathology of co-contraction appears to cause CDC of CRPS and
probable ischemic loss of myoarchitecture. Relief of co-contraction with USGDN allowed
resolution of tenosynovitis causing the CDC and return of normal myoarchitecture.
Key words: CRPS-1, co-contraction, motor impairment, disability, dry needling,
musculoskeletal ultrasonography
Neuromodulation of the Suprascapular Nerve
Authors: Kurt Erkan
Published: February 2021

Chronic intractable shoulder pain (CISP) is defined as shoulder pain which is present for longer than 6
months and does not respond to standard treatments like medication, physical therapy, rehabilitation,
selective nerve blocks and local infiltrations, or orthopedic procedures. The etiology of CISP may
be very diverse, varying from many orthopedic conditions to non-orthopedic conditions. The fact
that the suprascapular nerve is one of the most important nerves supplying the shoulder region
makes this nerve an interesting target in treating patients suffering shoulder pain. Invasive treatment
options are peripheral nerve blocks, temporary electrical stimulation, and neurostimulation. To
our best knowledge, thus far there are only a few reports describing the technique of permanent
neurostimulation of the suprascapular nerve. In this article we present a patient suffering shoulder
pain after she underwent surgery for cervical stenosis. After a step by step treatment protocol was
done, we finally offered her trial stimulation of the suprascapular nerve. A single quad lead was
implanted via a posterior approach under fluoroscopic and ultrasound guidance. Two weeks after
successful stimulation, we implanted a permanent neuromodulation system.
Permanent neurostimulation of the suprascapular nerve and its end branches may be a new interesting
target in treating patients suffering shoulder pain due to various etiologies. In our patient the followup period is 9 months with an excellent result in pain relief, we observed no complications thus far,
especially no dislocation or breakage of the lead. In this report, literature on this subject is reviewed, and
our technique is well documented with additional anatomical illustrations.
Key words: Suprascapular nerve, shoulder pain, peripheral nerve stimulation, neuromodulation,
neurostimulation, chronic pain
Percutaneous Endoscopic Lumbar Discectomy as
an Alternative to Open Lumbar Microdiscectomy
for Large Lumbar Disc Herniation
Authors: Kim Jin-Sung
Published: February 2021

Background: Remarkable advancements in endoscopic spinal surgery have led to successful
outcomes comparable to those of conventional open surgery. Large lumbar disc herniation (LLDH)
is a serious condition, resulting in higher surgical failure when accessing the herniated disc.
Objectives: This study compared the outcomes of LLDH treated with percutaneous endoscopic
lumbar discectomy (PELD) and open lumbar microdiscectomy (OLM).
Study Design: Retrospective assessment.
Methods: This retrospective observational study was conducted from January 2011 to June
2012. Forty-four consecutive patients diagnosed with LLDH without cauda equina syndrome who
were scheduled to undergo spinal surgery were included. LLDH was defined as herniated disc
fragment occupying > 50% of the spinal canal. Clinical outcomes were evaluated using a visual
analogue scale (VAS, 0 – 10), functional status was assessed using the Oswestry Disability Index
(ODI, 0 – 100%) at 1, 6, and 24 months postoperatively and surgical satisfaction rate (0 – 100%)
at final follow up. Radiological variables were assessed by plain radiography.
Results: Forty-three patients were included; 20 and 23 patients underwent PELD and OLM,
respectively. Both groups exhibited significant improvements in leg and back pain postoperatively
(P < 0.001). Although there was no significant difference in leg pain improvement between the
groups, improvement in back pain was significantly higher in the PELD group than in the OLM
group (4.9 ± 1.5 vs. 2.5 ± 1.0, P < 0.001). The surgical satisfaction rate of the PELD group was
significantly higher than that of the OLM group (91.3% ± 6.5 vs. 84.3% ± 5.2, P < 0.001). Mean
operating time, hospital stay, and time until return to work were significantly shorter in the PELD
group than in the OLM group (67.8 vs. 136.7 minutes, 1.5 vs. 7.2 days, and 4.2 vs. 8.6 weeks;
P < 0.001). Disc height (%) decreased significantly from 23.7 ± 3.3 to 19.1 ± 3.7 after OLM (P
< 0.001), but did not change significantly after PELD (23.6 ± 3.2 to 23.4 ± 4.2; P = 0.703). The
segmental angle of the operated level increased from 10.3° to 15.4° in the PELD group, which was
significantly higher than that in the OLM group (9.6° to 11.6°; P = 0.038). In the OLM group, there
was one case of fusion due to instability. In the PELD group, one case required revision surgery and
another case experienced recurrence. There were no perioperative complications in either group.
Limitation: The study was retrospective with a small sample size and short follow-up period.
Conclusion: PELD can be an effective treatment for LLDH, and it is associated with potential
advantages, including a rapid recovery, improvements in back pain, and disc height preservation.
Key words: Large lumbar disc herniation, percutaneous endoscopic lumbar discectomy,
microdiscectomy, back pain, disc height
Endoscopic Retrieval of a Broken Guidewire
During Spinal Surgery
Authors: Gu Xin
Published: February 2021

Since the percutaneous posterolateral approach in treating lumbar disc herniation was
introduced in 1973, percutaneous endoscopic lumbar discectomy (PELD) has become a
routine minimally invasive spinal procedure. However, as clinical evidence accumulated,
several complications of PELD have raised our concerns, including the intraoperative injury
to neural, vascular structures and failure of surgery. Herein, we present 2 patients who
experienced guidewire breakage during PELD procedure to demonstrate the details.
The 2 patients, who are 28 and 33 years old, were diagnosed with lumbar disc herniation
with or without intervertebral foreman stenosis by magnetic resonance imaging. Following
a preoperative evaluation, a PELD procedure was performed with the help of local
anesthesia. During the advancement of the obturator and foraminotomy under fluoroscopy,
the guidewire was found broken. With the patients’ permission, the operator inserted the
working cannula to the broken end of the guidewire and retrieved it by straight grasping
forceps under endoscopy. The patients were reported to recover from their back pain
immediately after the operation and hence the postoperative course was stable.
In conclusion, the guidewire breakage in PELD procedures is a rare but severe complication,
which requires immediate removal. An appropriate manner and fluoroscopic control are
recommended to forestall such problems. It is possible to retrieve the broken guidewire
under endoscopy with skillful experience.
Key words: Endoscopic discectomy, intraoperative complication, instrument breakage,
minimally invasive surgery
Ultrasound-Guided Diagnosis and Treatment of
Morton’s Neuroma
Authors: Ata Ayse Merve
Published: February 2021

Morton’s neuroma is the fibrous enlargement of the interdigital nerve branches, usually
in the second and third interspace between the metatarsal heads where the lateral and
medial plantar nerves often join. Specific symptoms are dull or sharp pain, numbness
and/or tingling in the third and fourth digits, burning sensation, cramping, and a
feeling of “walking on a stone” around the metatarsal heads. Numerous clinical tests
for Morton’s neuroma have been described, such as thumb index finger squeeze, and
Mulder’s click and foot squeeze tests. Ultrasound and magnetic resonance imaging can
be used for confirmation, especially for differential diagnosis, exact localization, and
number of neuromas. Further, performing dynamic imaging during the aforementioned
tests is paramount and can readily be carried out with ultrasound. The treatment mainly
comprises footwear modifications, radiofrequency ablation, physical therapy, local
(corticosteroid and anesthetic) injections into the affected webspace, and surgery. Again
the use of real-time ultrasound guidance during such interventions is noteworthy.
Key words: Morton’s neuroma, ultrasound, diagnosis, treatment
Pneumogastric (Vagus) Nerve Activity Indexed
by Heart Rate Variability in Chronic Pain
Patients Compared to Healthy Controls: A
Systematic Review and Meta-Analysis
Authors: Koenig Julian
Published: February 2021

Background: A large body of scientific literature derived from experimental studies emphasizes
the vital role of vagal-nociceptive networks in acute pain processing. However, research on
vagal activity, indexed by vagally-mediated heart rate variability (vmHRV) in chronic pain patients
(CPPs), has not yet been summarized.
Objectives: To systematically investigate differences in vagus nerve activity indexed by timeand frequency-domain measures of vmHRV in CPPs compared to healthy controls (HCs).
Study Design: A systematic review and meta-analysis, including meta-regression on a variety
of populations (i.e., clinical etiology) and study-level (i.e., length of HRV recording) covariates.
Setting: Not applicable (variety of studies included in the meta-analysis)
Methods: Eight computerized databases (PubMed via MEDLINE, PsycNET, PsycINFO, Embase,
CINAHL, Web of Science, PSYNDEX, and the Cochrane Library) in addition to a hand search
were systematically screened for eligible studies based on pre-defined inclusion criteria. A metaanalysis on all empirical investigations reporting short- and long-term recordings of continuous
time- (root-mean-square of successive R-R-interval differences [RMSSD]) and frequency-domain
measures (high-frequency [HF] HRV) of vmHRV in CPPs and HCs was performed. True effect
estimates as adjusted standardized mean differences (SMD; Hedges g) combined with inverse
variance weights using a random effects model were computed.
Results: CPPs show lower vmHRV than HCs indexed by RMSSD (Z = 5.47, P < .0001; g =
-0.24;95% CI [-0.33, -0.16]; k = 25) and HF (Z = 4.54, P < .0001; g = -0.30; 95% CI [-0.44,
-0.17]; k = 61).Meta-regression on covariates revealed significant differences by clinical etiology,
age, gender, and length of HRV recording.
Limitations: We did not control for other potential covariates (i.e., duration of chronic pain,
medication intake) which may carry potential risk of bias.
Conclusion(s): The present meta-analysis is the most extensive review of the current evidence
on vagal activity indexed by vmHRV in CPPs. CPPs were shown to have lower vagal activity,
indexed by vmHRV, compared to HCs. Several covariates in this relationship have been identified.
Further research is needed to investigate vagal activity in CPPs, in particular prospective and
longitudinal follow-up studies are encouraged.
Key words: Vagus nerve, heart rate variability, chronic pain, irritable bowel syndrome,
fibromyalgia, primary headache disorders, meta-analysis, systematic review
Effects of Intravenous and Oral Magnesium
on Reducing Migraine: A Meta-analysis of
Randomized Controlled Trials
Authors: Chen Pin-Yuan
Published: February 2021

Background: Migraine attack has been associated with magnesium deficiency. Previous
studies investigating the effect of intravenous and oral magnesium on acute migraine attacks
and the prevention of migraine have produced equivocal findings.
Objective: To evaluate the effects of intravenous magnesium on acute migraine attacks and
oral magnesium supplements on migraine prophylaxis.
Study Design: A meta-analysis of randomized controlled trials (RCTs).
Setting: Electronic databases, namely EMBASE, PubMed, the Wanfang Data Chinese
Database, and the China Knowledge Resource Integrated Database were searched from
inception to February 24, 2015.
Methods: This review was conducted according to the guidelines of the PRISMA. Only RCTs
evaluating the effects of intravenous or oral magnesium on migraine compared with a control
group were included.
Results: A total of 21 studies were included. Of which, 11 studies investigated the effects
of intravenous magnesium on acute migraine (948 participants) and 10 examined the effects
of oral magnesium on migraine prophylaxis (789 participants). Intravenous magnesium
significantly relieved acute migraine within 15 – 45 minutes, 120 minutes, and 24 hours after
the initial infusion (Odd ratios [ORs] = 0.23, 0.20, and 0.25, respectively). Oral magnesium
significantly alleviated the frequency and intensity of migraine (ORs = 0.20 and 0.27).
Limitations: Some of the included studies did not adopt adequate randomization methods.
Conclusions: Intravenous magnesium reduces acute migraine attacks within 15 – 45 minutes,
120 minuts, and 24 hours after the initial infusion and oral magnesium alleviates the frequency
and intensity of migraine. Intravenous and oral magnesium should be adapted as parts of
multimodal approach to reduce migraine.
Key words: Magnesium, migraine, meta-analysis
Optimization of Postoperative Intravenous
Patient-Controlled Analgesia with OpioidDexmedetomidine Combinations: An Updated
Meta-Analysis with Trial Sequential Analysis of
Randomized Controlled Trials
Authors: Ji Fu-hai
Published: February 2021

Background: It is still a challenge to optimize postoperative pain management. The effects of
adding dexmedetomidine (DEX) to opioid-based postoperative intravenous patient-controlled
analgesia (PCA) are not fully understood.
Objectives: The aim of this study is to assess the efficacy and safety of opioid-DEX combinations
for postoperative PCA, and a trial sequential analysis (TSA) is utilized to evaluate the robustness of
the current evidence.
Study Design: A systematic review and meta-analysis.
Setting: Randomized controlled trials that compared opioid-DEX combinations with opioid-only
for PCA in adult surgical patients.
Methods: MEDLINE, EMBASE, and CENTRAL databases were searched for relevant articles. The
main outcomes analyzed were postoperative pain intensity, opioid requirement, and opioid-related
adverse events. The random-effects model was used to estimate mean differences (MDs) or relative
risks (RRs) with 95% confidence intervals (CIs). A TSA was performed to test whether the evidence
was reliable and significant. The quality of evidence for the main outcomes was assessed using the
Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.
Results: Eighteen studies involving 1,284 patients were included. The meta-analysis indicated
that opioid-DEX combinations were associated with lower postoperative pain intensity (at rest: MD
[24 hours] = -0.48, 95% CI [-0.75, -0.21], P = 0.0005), lower morphine-equivalent requirement
(MD [0 – 24 hours] = -12.16 mg [-16.12, -8.21], P < 0.00001), and lower adverse events (nausea:
RR = 0.66 [0.52, 0.83]; vomiting: RR = 0.65 [0.49, 0.87]; and pruritus: RR = 0.57 [0.40, 0.81]).
For the above results, the TSA revealed that the cumulative Z-curve exceeded both the traditional
boundary and the trial sequential monitoring boundary for benefit. DEX had no effect on the
incidence of hypotension or bradycardia, which was also confirmed by the TSA. The GRADE
level of evidence was high for postoperative nausea, moderate for pain intensity at rest at 24
hours postoperatively, morphine-equivalent requirement during 0 – 24 hours postoperatively, and
postoperative vomiting, pruritus, and bradycardia, and low for postoperative hypotension.
Limitations: The risk of introducing potentially significant heterogeneity exists, and this study
did not evaluate the effects of DEX combined with opioids on long-term outcomes including
chronic pain and patients’ satisfaction after hospital discharge.
Conclusions: Postoperative PCA strategies with opioid-DEX combinations decreased
postoperative pain, opioid requirement, and opioid-related adverse events. DEX is a useful adjuvant
to opioid-based PCA.
Key words: Dexmedetomidine, pain, postoperative analgesia, opioid, patient-controlled
Endoscopic Epidural Laser Decompression
Versus Transforaminal Epiduroscopic Laser
Annuloplasty for Lumbar Disc Herniation: A
Prospective, Randomized Trial
Authors: Park Chang Hong
Published: February 2021

Background: Lumbar radicular pain often results from lumbar disc herniation, spinal stenosis, or
degenerative spondylolisthesis. Minimally invasive disc decompression procedures, such as nucleoannuloplasty or epiduroscopic neural decompression by laser, have been devised to treat such pain.
Objective: The short-term outcomes of disc decompression by endoscopic epidural laser decompression
(EELD) or transforaminal epiduroscopic laser annuloplasty (TELA) were compared in patients with lumbar
radicular pain due to disc herniation.
Study Design: A randomized, prospective trial.
Setting: The Department of Anesthesiology and Pain Medicine at Spine Health Wooridul Hospital in
Daegu, Korea.
Methods: A total of 97 patients were enrolled in this study; 48 patients underwent EELD and 49
underwent TELA. The pain relief was evaluated at baseline and at 1, 3, and 6 months post-procedure
via the numeric rating scale (NRS). The Oswestry Disability Index (ODI) was recorded at baseline and at
the final follow-up. Postoperative wound pain was assessed over a 24-hour period. Complications and
side effects were also recorded, as were operative times (from local anesthetic infiltration at entry sites
to suturing of skin).
Results: At post-treatment months 1, 3, and 6 the mean pain scores of patients were significantly lower
(relative to pre-treatment baseline) regardless of the procedure used. However, the mean pain scores
did not differ significantly by procedure (EELD vs TELA). As well, the number of patients who obtained
relief from their pain and needed analgesics was not statistically significant. The irrigation volume was
significantly higher in the TELA group. Two patients undergoing TELA procedures experienced headache
during the procedures; however, no serious complications such as bleeding, dural/neural injuries, or
infection were recorded for either group.
Limitation: The observed significant reductions in pain (from baseline) lacked secondary outcome
substantiation and given the mid follow-up period, no long-term follow-up results were monitored.
Conclusion: Both EELD and TELA provide similar outcomes and are reasonable treatment options for
carefully selected patients with lower back or radicular pain.
Key words: Epiduroscopy, laser, annuloplasty, disc, herniation, TELA
Dexamethasone and Dexmedetomidine as
an Adjuvant to Intraarticular Bupivacaine for
Postoperative Pain Relief in Knee Arthroscopic
Surgery: A Randomized Trial
Authors: Moeen Seham M.
Published: February 2021

Background: Knee arthroscopy causes minimal trauma, however, good analgesia is required for
early rehabilitation and return to normal life in the patients.
Objective: We aimed to compare the analgesic effects of intraarticular dexamethasone and
dexmedetomidine added to bupivacaine with those of bupivacaine alone.
Study Design: This study uses a double-blind, randomized, controlled design with allocation
concealment in a 3-armed parallel group format among patients undergoing arthroscopic meniscal
surgery.
Setting: The study was conducted at Assiut University Hospital in Asyut, Egypt. The study duration
was from July 2016 to February 2017.
Methods: After the ethics committee approval, 60 patients, with the American Society of
Anesthesiologists (ASA) physical status of I or II, 20 – 50 years old, and scheduled for arthroscopic
meniscal surgery were randomized in a double-blind manner to receive 18mL intraarticular
bupivacaine 0.25% with either dexamethasone 8 mg (group I), dexmedetomidine 1 μg/kg (group
II), or 2 mL of normal saline (group III). The total volume of injectate used in each group was 20 mL.
All of the patients received spinal anesthesia. Postoperatively, oral paracetamol 1000 mg was given
every 8 hours, and oral tramadol 50 mg was administered, as needed, for rescue analgesia. The
visual analog scale (VAS) pain scores, time to first analgesic request, and total dose of postoperative
analgesics were recorded for 3 days postoperatively.
Results: The VAS scores were lower in groups I and II compared with group III. The time to the
first analgesic was significantly shorter in group III compared with groups I and II (P = 0.001).
The total dose of rescue paracetamol was higher in group III compared with groups I and II (P =
0.001). No need for tramadol rescue analgesia was recorded in any of the groups. No significant
differences between groups I and II were noticed.
Limitations: The limitations of this study include the lack of previous research to compare the
effect of both intraarticular dexamethasone and dexmedetomidine added to bupivacaine for
postoperative analgesia in arthroscopic knee surgery. Additionally, there was a short observation
period for the detection of chondrotoxicity, if occurred.
Conclusion: The addition of dexamethasone or dexmedetomidine to a solution of bupivacaine
0.25% provided better analgesia than using bupivacaine alone.
Clinical trial registration: NCT02818985.
Key words: Intraarticular, knee arthroscopy, bupivacaine, dexmedetomidine, dexamethasone,
postoperative pain
Current Impact and Application of AbuseDeterrent Opioid Formulations in Clinical
Practice
Authors: Chen Hsiang-Yin
Published: February 2021

Background: Abuse-deterrent formulations (ADFs) represent one novel strategy for curbing the
potential of opioid abuse.
Objective: We aim to compare and contrast the characteristics and applications of current abusedeterrent opioid products in clinical practice.
Methods: Literature searches were conducted in databases (Pubmed Medline, International
Pharmaceutical Abstracts, Google Scholar) and official reports. Relevant data were screened and
organized into: 1) epidemiology of opioid abuse, 2) mitigation strategies for reducing opioid abuse,
3) development of ADFs, and 4) clinical experience with these formulations.
Results: Increasing trends of opioid abuse and misuse have been reported globally. There are 5
types of abuse-deterrent opioid products: physical chemical barrier, combined agonist/antagonist,
sequestered aversive agent, prodrug, and novel delivery system. The advantages and disadvantages
of the 5 options are discussed in this review. A total of 9 products with abuse-deterrent labels have
been approved by the Food and Drug Administration (FDA). The rates of abuse, diversion, and
overdose deaths of these new products are also discussed. A framework for collecting in-time data
on the efficacy, benefit and risk ratio, and cost-effectiveness of these new products is suggested to
facilitate their optimal use.
Limitations: The present review did not utilize systematic review standards or meta-analytic
techniques, given the large heterogeneity of data and outcomes reviewed.
Conclusions: ADFs provide an option for inhibiting the abuse or misuse of oral opioid products
by hindering extraction of the active ingredient, preventing alternative routes of administration,
or causing aversion. Their relatively high costs, uncertain insurance policies, and limited data on
pharmacoeconomics warrant collaborative monitoring and assessment by government agencies,
pharmaceutical manufacturers, and data analysis services to define their therapeutic role in the
future.
Key words: Opioid abuse, abuse-deterrent formulations, ADF, post-marketing, FDA guidance, cost
impact, abuse liking, physician attitude, generic abuse-deterrent formulation, clinical application
Hypothalamic Pituitary Adrenocortical Axis
Suppression following a Single Epidural
Injection of Methylprednisolone Acetate
Authors: Ghai Babita
Published: February 2021

Background: Epidural injections (EIs) are the most commonly performed minimally invasive
intervention in managing chronic low back pain (CLBP). There is inconsistency in data
to accurately predict the degree of hypothalamic-piuitary-adrenal (HPA) axis suppression
in patients receiving exogenous steroid therapy, especially in the form of epidural steroid
injections (ESIs).
Objective: We aim to quantify the degree and duration of HPA axis suppression after a
single ESI of 80 mg methyl prednisolone acetate in patients with CLBP.
Study Design: A single open-label prospective study.
Setting: An operating room of a tertiary care hospital.
Methods: Patients with CLBP and unilateral radicular pain were included in this study.
An ESI of 80 mg of methylprednisolone acetate was administered in each patient. Blood
samples for cortisol and adrenocorticotropic hormone (ACTH) were collected before the
ESI and on days 7, 14, and 28 after the ESI. The patients’ pain levels were graded on the
numeric rating scale (NRS) at baseline and on days 7, 14, 28, and 60 after the ESI in the
pain clinic.
Results: A total of 30 patients were enrolled in this study. The median with interquartile
range (IQR) serum cortisol level at baseline and on days 7, 14, and 28 after intervention
were found to be 329.55 (208.49 – 399.48) nmol/L, 72.99 (52.95 – 119.82) nmol/L, 194.45
(73.88 – 292.52) nmol/L, and 302.56 (257.68 – 357.43) nmol/L, respectively. A significant
discrease in the serum cortisol levels was observed on days 7 (P < 0.001) and 14 (P < 0.001).
Twenty-six (87%), 13 (43%), and 2 (7%) patients had serum cortisol levels below normal
(<170 nmol/L) on days 7, 14, and 28, respectively. HPA axis suppression was observed in all
of the patients for a median (IQR) period of 14 days (range: 11–17 days).
Limitations: This study was an unblinded observational study. The effect of a single ESI
was studied and the sample collection of day 21 serum cortisol and ACTH were passed over.
Conclusions: HPA axis function was suppressed after the ESI until day 14 and returned to
the normal range by postoperative week 4.
Key words: Epidural injections, steroids, HPA, suppression, cortisol, ACTH
Adverse Outcomes Associated with Prescription
Opioids for Acute Low Back Pain: A Systematic
Review and Meta-Analysis
Authors: Samaan Zainab
Published: February 2021

Background: Acute low back pain (ALBP) is a common clinical complaint that can last
anywhere from 24 hours to 12 weeks. In recent years, there has been an opioid epidemic
which is linked to the increased availability of prescription opioids. Though guidelines
recommend that in the treatment of ALBP, opioids should be used when other treatments
fail, we have seen an increase in opioid prescriptions for ALBP. With this crisis, it is important
to examine if there are any adverse outcomes associated with prescribing opioids for ALBP.
Objective: We aim to review the published literature to examine the adverse outcomes
associated with opioid use for ALBP.
Study Design: We performed a systematic review with meta-analysis in accordance
with our published protocol and PRISMA guidelines.
Setting: The review was conducted at McMaster University.
Methods: Various electronic databases for articles published from inception to September
30, 2017, inclusive. Both randomized clinical trials and observational studies on the impact
of opioid use in ALBP in the adult population were included. Eight pairs of independent
reviewers performed screening, data extraction, and assessment of methodological
quality. The identified articles were assessed for risk of bias using sensitivity analysis. Trials
with comparative outcomes were reported in a meta-analysis using a fixed effects model.
Results: A total of 13,889 studies were initially screened for the review and a total of
4 studies were included in the full review, of which 2 studies were meta-analyzed. Our
results showed that prescribing opioids for ALBP was significantly associated with longterm continued opioid use (1.57, 95% CI, 1.06-2.33). There was no significant association
found between unemployment duration and prescribing opioids for ALBP (3.54, 95% CI,
-7.57 to 14.66).
Limitations: Due to the limited number of studies that considered unemployment,
only an unpooled analysis was conducted. Among the included studies there was both
statistical and clinical heterogeneity due to differences in methodology, study design, risk
of selection or performance bias. Most of the studies had an unclear or high risk of bias
and poorly defined side effects.
Conclusions: Due to the lack of literature examining long-term adverse outcomes
associated with prescribing opioids for ALBP, no definitive conclusions can be made.
However, with the literature available, there does seem to be risk associated with
prescribing opioids for ALBP so there is a great need to conduct further investigations
examining these adverse outcomes for ALBP patients.
Key words: Acute low back pain, opioids, prescriptions, low back pain, long-term use,
opioid use disorder
Relationship Between Decreased Subcalcaneal
Fat Pad Thickness and Plantar Heel Pain. A Case
Control Study
Authors: Iglesias Marta E. Losa
Published: February 2021

Background: Heel pain is one of the most frequent complaints in medical clinical
practice for conditions affecting the feet during weight-bearing tasks.
Objective: The goal of this study was to measure and compare the thickness of the
fat pad in a sample of patients with current unilateral heel pain and patients without
unilateral heel pain with normalized reference parameters.
Study Design: This was an observational case-control study.
Settings: The research took place in the podiatry department within a medical health
care center.
Methods: A total of 375 patients were randomly selected from a pool of patients
attending a medical health care center between the years 2008 and 2015 and diagnosed
by a single medical podiatrist without having previous treatment. Patients were categorized
in 2 groups: a heel pain group (n = 185) and a control group (asymptomatic; n = 190). The
thickness of the plantar fat pad was measured with an ultrasonic probe (BodyMetrix® BX
2000; IntelaMetrix, Inc, Livermore, CA).
Results: Initial examination of both groups indicated no significant differences in age,
height, weight, or body mass index (P > 0.01). There were, however, significant differences
in the thickness of the fat pad between those in the heel pain group and those in the control
group, when analyzed by group and by gender (P < 0.01; Cohen´s d = 0.465-1.959).
Limitations: The study was not a randomized controlled trial. Although primary
outcome data were self-reported, the assessor was not blinded.
Conclusion: This study provides further evidence that people with unilateral heel pain
showed a significantly decreased thickness of the subcalcaneal fat pad, regardless of
gender.
Key words: Heel pain, subcalcaneal fat, pain
Effectiveness of Denervation Therapy on Pain
and Joint Function for Patients with Refractory
Knee Osteoarthritis: A Systematic Review and
Meta-Analysis
Authors: Lu Lijuan
Published: February 2021

Background: Recently, denervation therapy has been applied clinically for the treatment of
intractable osteoarthritis (OA). This therapy provides an alternative for patients who are insensitive
to conservative therapies or unwilling to receive surgery and general anesthesia. However,
therapeutic effect of this method, especially the long-term efficacy, is still controversial.
Objectives: The aim of this systematic review was to examine the efficacy of denervation therapy
for the treatment of OA, especially on pain alleviation and functional recovery in the short and
long term.
Study Design: This systematic review and meta-analysis was designed to investigate whether
denervation therapy is more useful than conservative methods for achieving clinical outcomes in
patients with refractory OA.
Methods: A literature search was performed in MEDLINE, EMBASE, and the Cochrane library for
studies published from inception to August 2018. From those found meeting the search criteria,
manuscripts comparing the clinical efficacy of denervation therapy and control agents, such as
conservative therapies or sham operation, were included in this study. After reviewing the titles,
abstracts, and the full text, 6 studies were included in the quantitative synthesis. Data, including
postoperative pain scores, rate of 50% pain relief, and joint functional scores were extracted and
combined to obtain effect size and statistical significance.
Results: In terms of postoperative pain intensity, denervation therapy showed significantly better
short-term (4, 12, and 24 weeks) pain relief. The rates of 50% pain relief at 12 and 24 weeks
after operation were also higher compared with the control group. In terms of joint functional
improvement, denervation therapy showed favorable outcomes at 4 and 12 weeks after treatment,
but no significant difference was found at 24 weeks after procedure between the groups. Overall,
better results were reported in denervation therapy with a relative high-grade of evidence.
Limitation: Analyses of long-term (one year and longer) effects could not be conducted owing
to a lack of existing studies.
Conclusions: Denervation of the knee joint may become a promising therapy for patients
with knee OA who are refractory to conservative treatment. This therapy can provide short-term
therapeutic effect in pain alleviation for 6 months and joint function recovery for 3 months. The
therapeutic effect in joint function may decrease 6 months after operation. The long-term efficacy
in pain remission and function improvement is still elusive and controversial; therefore, further
research with larger sample sizes are needed in the future.
Key words: Osteoarthritis, denervation therapy, radiofrequency, chronic pain, function,
systematic review, meta-analysis
Selection of the Optimal Puncture Needle
for Induction of a Rat Intervertebral Disc
Degeneration Model
Authors: Zou Jun
Published: February 2021

Background: The incidence of intervertebral disc (IVD) degeneration has increased in recent
years. A simple, reliable, and reproducible animal model is critical for understanding the
underlying mechanisms of IVD degeneration. The caudal discs of rats have been proposed as
a common puncture model in which to induce IVD degeneration. However, there is still no
consensus on the size of needle to be used.
Objectives: The present study aimed to identify the appropriate needle size to establish an
IVD degeneration model.
Study Design: A randomized, experimental trial.
Setting: Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow
University, China.
Methods: Validity was verified by magnetic resonance imaging (MRI) and histology.
Results: From T2-weighted MRI imaging and histological examination, the IVD punctured
by the 16-gauge needle degenerated acutely one week after the operation, whereas the
26-gauge needle puncture did no harm to the IVD. An 18-gauge needle showed a progressive
degeneration in IVD.
Limitations: The observation period was not very long (4 weeks).
Conclusions: An 18-gauge needle can be used to induce IVD degeneration in rats.
Therefore, an 18-gauge needle is the optimal selection to establish the degenerative IVD
model on rats, whereas the 26-gauge needle failed to cause IVD degeneration. Thus, to
study the prevention and treatment of IVD degeneration, a 26-gauge needle can be used
for IVD injection of growth factors, plasmids, and drugs. A 16-gauge needle may be used to
induce acute disc injury, but not IVD degeneration.
Key words: Low back pain, degenerative intervertebral disc, animal model, puncture
needle, rat model, optimal choice