bluuebunny/crossref_metadata_2025 huggingface dataset:
Permanent Lesion of the Lateral Femoral
Cutaneous Nerve after Low-Volume Ethanol 96%
Application on the Lumbar Sympathetic Chain
Authors: Pennekamp Dr. Werner
Published: March 2021

Lumbar sympathetic blocks and chemical sympathectomies are used for the pain treatment
of peripheral arterial occlusive disease or sympathetically maintained pain syndrome after
nerve injury or complex regional pain syndrome (CRPS). A 30-year-old patient was referred
to the pain department with all the clinical signs and symptoms of a CRPS of the right
foot one and a half years after being surgically treated for rupture of the achilles tendon.
An inpatient admission was necessary due to insufficient pain reduction upon the current
treatment, strong allodynia in the medial distal right lower leg and decreased load-bearing
capacity of the right foot. A computed tomography (CT)-guided lumbar sympathetic block
at the right L3 (Bupivacaine 0.5%, 4 mL) led to a skin temperature increase from 21°C before
block to > 34°C for about 5 hours after the intervention. The patient experienced significant
pain relief, indicating sympathetically maintained pain. Thus, we performed a CT-guided
lumbar sympathetic neurolysis at the same level (ethanol 96%, 2 mL) 5 days later, achieving
again a significant skin temperature increase of the right foot and a slight reduction of his
pain intensity from numeric rating scale (NRS) 7 prior to the intervention to NRS 4 after 8
hours (NRS, 0 = no pain, 10 = strongest pain imaginable). Eight months later a repeated
inpatient admission was necessary due to considerable pain relapse and decreased loadbearing capacity of his right foot. A CT-guided lumbar sympathetic neurolysis was repeated
at the L4 level on the right side and was successful, inducing a significant skin temperature
increase. Despite a temporary irritation of the genitofemoral nerve 8 hours after the
intervention, a delayed irritation of the lateral femoral cutaneous nerve occurred. This was
a long-lasting lesion of the lateral femoral cutaneous nerve following a CT-guided chemical
sympathectomy with a low-volume ethanol 96% application - a complication which has not
been described in literature until now. This is probably caused by broad dissemination of
the neurolytic agent along the psoas muscle despite a correct needle position and spread of
contrast agent. The development of this nerve injury even after injection of a small volume
of ethanol (2 mL) may be delayed.
Key words: Complex regional pain syndrome, CRPS; sympathetically maintained
pain syndrome, sympathectomy, neurolysis, lateral femoral cutaneous nerve, ethanol,
complication, genitofemoral nerve
Unilateral Versus Bilateral Balloon Kyphoplasty
for Osteoporotic Vertebral Compression
Fractures
Authors: Yang Huilin
Published: March 2021

Background: Osteoporotic vertebral compression fractures (VCFs) commonly occur in aged people.
Balloon kyphoplasty (KP) has been proven to be efficacious for pain relief and reduction of vertebral
height for patients with osteoporotic VCFs. However, very little is known about the comparison of
clinical and radiographic outcomes between unilateral and bilateral balloon KP in treating this kind
of patients.
Objective: To compare the safety and long-term radiographic and clinical outcomes of unilateral or
bilateral balloon KP to treat patients with osteoporotic VCFs.
Study Design: A systemic review and meta-analysis of all randomized controlled trials (RCTs)
comparing the analgesic efficacy, radiographic outcomes, and complications between unilateral and
bilateral balloon KP in patients with osteoporotic VCFs.
Setting: The MEDLINE, EMBASE, Pubmed, CINAHL databases, Bandolier, and the Cochrane
Controlled Trials Register were systematically searched for evidence from their inception to July 2012
by 2 of the authors (J.L. and L.Z.).
Methods: Relevant reports were reviewed by 2 assessors independently and the reference lists of
retrieved papers were scrutinized to identify further studies for inclusion, using guidelines set by
PRISMA statement criteria.
Results: Three RCTs were enrolled in this study. The VAS scores showed no statistical difference
between the groups before surgery and either at short-term or long-term follow-up. There was no
statistical significance in polymethylmethacrylate (PMMA) leakage between the groups. Analysis of 2
studies showed statistical significance in surgery time (WMD -23.77 [-27.83, -19.71]; P < 0.00001)
and PMMA (WMD -1.65 [-2.28, -1.02]; P < 0.00001) consumption between the groups.
Limitations: There were few data sources from which to extract abstracted data or published studies.
There were only 3 RCTs that met criteria enrollment in this meta-analysis. The quality of these trials
was quite low (Jadad score: 1-2). Variable reporting of end points and inconsistent definitions meant
that we were not able to include every study for each outcome. There was also clinical heterogeneity
among the studies.
Conclusion: The efficacy of both unilateral and bilateral balloon KP to provide rapid, significant,
and sustained pain relief for patients with osteoporotic VCFs is validated. Unilateral balloon KP is a
reasonable treatment for patients with osteoporotic VCFs considering that it could achieve equivalent
pain relief with less surgery time and PMMA consumption compared to bilateral balloon KP. There
was no evidence to prove that unilateral balloon KP results in higher incidence of PMMA leakage than
bilateral balloon KP. Although unilateral balloon KP was less efficacious in the reduction of fractured
vertebral body, it is still unclear if the clinical results of balloon KP were positively correlated with the
restoration of vertebral height and amount.
Key words: Kyphoplasty, unilateral approach, bilateral approach, , postoperative pain, osteoporotic
fractures
Indications for Repeat Diagnostic Medial
Branch Nerve Blocks Following a Failed First
Medial Branch Nerve Block
Authors: Derby Richard
Published: March 2021

No studies have directly measured the false negative rate of medial branch block (MBB) with
correlation to medial branch neurotomy (MBN) outcome. We investigated the potential false
negative MBB rate and the subsequent MBN outcome on a consecutive audit of all patients
undergoing a double MBB protocol.
We prospectively collected audit data and retrospectively collected data by phone on 229
consecutive patients undergoing diagnostic MBB. One-hundred-twenty-two patients reporting
greater than 50% of subjective pain relief subsequently underwent either MBN or a confirmatory
block followed by MBN. A total of 55 patients underwent a second confirmatory MBB and within
that group 27.3% (15/55) reported less than 50% relief post initial MBB and 30.9% (17/55)
between 50% and 69% relief. We performed an in-depth analysis of these 2 subgroups focusing
on the reason a second MBB was performed despite a “negative” or “indeterminant” first MBB.
We divided the “negative” responders to the first MBB into those reporting < 50% relief (Group
1) and those reporting between 50% and 69% relief (Group 2). We calculated a potential 46.7%
false negative rate in Group 1 and 47.1% false negative in Group 2; however, the false negative
results in Group 1 were predominately in those patients reporting delayed relief of pain and those
re-blocked greater than 2 years after the first MBB. The success rate in all patients undergoing
MBN was 87% compared to the 75% relief in the false negative groups with no statistically
significant difference.
In summary, the false negative rate for patients reporting less than 50% relief post MBB is probably
less than 20% although there is a high “apparent negative” responds in patients reporting delayed
relief or in those who had a second block 2 or more years post initial MBB. Patients reporting
between 50 and 69% pain relief have a false negative response rate of 47.1% and should be
considered for a confirmatory block.
Key words: Facet rhizotomy, zygapophyseal joint, low back pain, chronic pain, facet joint,
radiofrequency neurotomy, medial branch block, medial branch neurotomy
Evaluation of Interaction between a Spinal
Cord Stimulator and Implanted CardioverterDefibrillator in a Swine Model
Authors: Chaiban Gassan M.
Published: March 2021

Background: Spinal cord stimulators (SCS) have been used for many years to treat a myriad of
chronic pain conditions using electrical signals to diminish the perception of a painful stimulus.
Because of the electrical nature of the devices, there is a concern about the potential for
electromagnetic interaction between the device and lifesaving cardiac implantable cardiovertersdefibrillators (ICVD).
Objective: The purpose of this study was to use a swine model to evaluate the potential for
interaction between an implanted SCS and ICVD using the closest possible proximity, highest
stimulation settings, and most sensitive ICVD settings.
Methods: A pig was anesthetized and subsequently an ICVD and ICVD lead (Cogni 100-D and
Endotak Reliance®, Boston Scientific, Natick, MA) were placed into the right prepectoral region and
the right ventricle, respectively. An SCS (50 cm linear ST Precision Plu octad electrode lead [Boston
Scientific, Valencia, CA] with 3 mm wide contacts spaced one mm apart) was implanted using
fluoroscopic guidance into the posterior epidural space. Remote interrogation and programming
of the ICVD were performed while the SCS lead was placed in as close proximity as possible, using
fluoroscopy to guide the final position of the SCS electrode. After confirming that both systems
were working, appropriately 9 stimulating configurations of varying current, pulse width, and
frequency, including maximal settings, were delivered through the SCS. The effects on the ICVD
were recorded at 2 sensitivity settings.
Results: None of the tested SCS configurations caused interference with the proper functioning
of the ICVD.
Limitations: The anatomical proximity of the posterior epidural space and right ventricle of the
swine is different from humans. While the entire pacer, including generator, was imbedded in
a subcutaneous pocket, an implantable pulse generator for the SCS was not implanted, which
did not allow us to study if any damage or a resetting of settings had occurred to the generator.
Only one manufacturer was used in this study. Also, this study was performed in an anesthetized
pig and the anatomical positions remained static. Realistically, changes in position of the devices
would occur in patients who perform activities of daily living, and this can potentially shorten the
distance between the 2 leads causing adverse interaction.
Conclusion: This study clearly demonstrated the feasibility of the 2 devices coexisting and
functioning appropriately in an animal model using an ICVD and SCS donated by Boston Scientific.
Further studies are needed to elucidate restrictions, optimal settings and parameters in a human
setting.
Key words: Spinal cord stimulator, interaction, implantable cardioverter defibrillator, pacemaker,
swine model, cross-talk.
Anatomical Basis of Ulnar Approach in Carpal
Tunnel Injection
Authors: Kim Dr. Dong Hwee
Published: March 2021

Background: Local steroid injection may be an effective conservative treatment for carpal
tunnel syndrome; however, the use of a blind injection technique can increase the chance of
median nerve or ulnar artery injury due to median nerve swelling or the close proximity of the
median nerve and ulnar artery around the distal wrist crease.
Objectives: The purpose of this study is to investigate the relative location of the median nerve
and ulnar artery to the palmaris longus (PL) tendon around the wrist in carpal tunnel syndrome.
Study Design: An observational study.
Setting: A university outpatient interventional pain management practice in the Republic of
Korea.
Methods: Thirty hands of 15 patients with carpal tunnel syndrome and 30 hands of 15 healthy
subjects were studied. Ultrasonography was performed to determine the relative relationship of
the ulnar artery and median nerve to the PL tendon around the wrist.
Results: There were statistically significant differences both in the distance from the medial
margin of the PL to the medial end of the median nerve and the distance from the medial end
of the median nerve to the lateral end of the ulnar artery at all levels of scanning between the
2 groups.
Limitations: Limitations include the inclusion of a small number of patients with carpal tunnel
syndrome.
Conclusion: It is important to recognize the risk of blind local steroid injection for carpal
tunnel syndrome, which is most likely a result of swelling and/or flattening of the median nerve
around the distal wrist crease. A real time, ultrasound-guided local steroid injection is preferred
as a safe and accurate technique in carpal tunnel syndrome treatment.
Key Words: Carpal tunnel syndrome, median nerve, ulnar artery, injection, steroid, injury,
ultrasonography, risk, cross-sectional area
Animal Models of Disc Degeneration and Major
Genetic Strategies
Authors: Zhang Yin-gang
Published: March 2021

The establishment of a reliable animal model of lumbar disc degeneration (AMDD)
is important for studying pathogenesis and evaluating treatment effectiveness.
However, an ideal AMDD for use in laboratory studies has not yet been produced.
This retrospective study reviews and compares several common AMDD and
discusses their strengths and weaknesses. We also suggest a new method for
establishing future AMDD. The identified genes associated with disc degeneration
are susceptibility genes, which elevate risk but do not necessarily lead to disease
occurrence. We propose to identify families with hereditary disc degeneration,
find major casual genes with exome sequencing, and establish transgenic animal
models. This approach may help us to build an improved AMDD.
Key words: Disc degeneration, animal model, major gene strategy, exome
sequencing
Common Anatomical Variation in Patients
with Idiopathic Meralgia Paresthetica: A High
Resolution Ultrasound Case-Control Study
Authors: Moritz Thomas
Published: March 2021

Background: Meralgia paresthetica (MP) is a mononeuropathy of the lateral femoral cutaneous
nerve (LFCN) characterized by pain, numbness or paresthesia on the anterolateral aspect of the
thigh. Though several contributing factors have been identified, the cause of its idiopathic form still
remains unclear. Anatomic and clinical studies have demonstrated a variable course for the LFCN
and have suggested a contribution to the pathogenesis of MP.
Objective: It was the aim of the present case-control study to assess the anatomical course and
compression site of the LFCN using high resolution ultrasound (HRUS) in patients suffering from
idiopathic MP, and compare the anatomical course in these patients to an asymptomatic control
group.
Study Design: Case-control study.
Setting: Nerve imaging center at a large university hospital in Austria.
Methods: Twenty-eight patients with a diagnosis of MP were included in this study (20 men, 8
women; mean age 54 years). The diagnosis was established by clinical history, physical examination,
and diagnostic anesthetic block. Fifteen age- and gender-matched healthy volunteers served as the
control group.
Standardized HRUS examinations were performed by one experienced radiologist from June 2004
through April 2012. Two experienced radiologists reviewed the patients’ standardized HRUS
examinations and performed examinations in the control group to measure the minimal distance
between the LFCN and the anterior superior iliac spine (ASIS).
Outcomes: The minimal distance between the ASIS and the LFCN was measured using HRUS.
Results: The LFCN could be seen in all patients and volunteers. In MP patients, the mean distance
between the LFCN and the ASIS was 0.52 cm (SD 0.46 cm), compared to a mean distance of 1.79
cm (SD 1.48 cm) in the control group (P < 0.001).
Limitations: Limited sample size, retrospective design.
Conclusions: The results of this study demonstrate a significantly different course of the LFCN,
closer to the ASIS in patients with idiopathic MP.
Key words: Ultrasound, meralgia paresthetica, entrapment neuropathy, assessment
Assessment of the Growth of Epidural
Injections in the Medicare Population from
2000 to 2011
Authors: Manchikanti Laxmaiah
Published: March 2021

Background: Among the many diagnostic and therapeutic interventions available for the
management of chronic pain, epidural steroid injections are one of the most commonly used
modalities. The explosive growth of this technique is relevant in light of the high cost of
health care in the United States and abroad, the previous literature assessing the effectiveness
of epidural injections has been sparse with highly variable outcomes based on technique,
outcome measures, patient selection, and methodology. However, the recent assessment of
fluoroscopically directed epidural injections has shown improved evidence with proper inclusion
criteria, methodology, and outcome measures.
The exponential growth of epidural injections is illustrated in multiple reports. The present report
is an update of the analysis of the growth of epidural injections in the Medicare population from
2000 to 2011 in the United States.
Study Design: Analysis of utilization patterns of epidural procedures in the Medicare
population in the United States from 2000 to 2011.
Objectives: The primary purpose of this assessment was to evaluate the use of all types of
epidural injections (i.e., caudal, interlaminar, and transforaminal in the lumbar, cervical, and
thoracic regions) with an assessment of specialty and regional characteristics.
Methods: This assessment was performed utilizing the Centers for Medicare and Medicaid
Services (CMS) Physician/Supplier Procedure Summary (PSPS) Master data from 2000 to 2011.
Results: Epidural injections in Medicare beneficiaries increased significantly from 2000 to
2011. Overall, epidural injections increased 130% per 100,000 Medicare beneficiaries with an
annual increase of 7.5%. The increases per 100,000 Medicare recipients were 123% for cervical/
thoracic interlaminar epidural injections; 25% for lumbar/sacral interlaminar, or caudal epidural
injections; 142% for cervical/thoracic transforaminal epidural injections; and 665% for lumbar/
sacral transforaminal epidural injections. The use of epidurals increased 224% in the radiologic
specialties (interventional radiology and diagnostic radiology) and 145% in psychiatric settings,
whereas and physical medicine and rehabilitation physicians’ use of epidurals increased 520%.
Limitations: Study limitations include lack of inclusion of Medicare Advantage patients. In
addition, the statewide data is based on claims which may include the contiguous or other
states.
Conclusions: Epidural injections in Medicare recipients increased significantly. The growth was
significant for some specialties (radiology, physical medicine and rehabilitation, and psychiatry)
and for certain procedures (lumbosacral transforaminal epidural injections).
Key words: Spinal pain, interventional pain management, epidural injections, caudal epidural,
lumbar epidural, cervical epidural, cervical transforaminal, lumbar transforaminal
Assessment of the Escalating Growth of Facet
Joint Interventions in the Medicare Population
in the United States from 2000 to 2011
Authors: Manchikanti Laxmaiah
Published: March 2021

Background: Both the Office of Inspector General (OIG) and reports from studies of the
utilization of facet joint interventions have expressed that explosive increases in facet joint
interventions provided to spinal pain patients are a major concern.
Study Design: The study is designed to assess the growth of facet joint interventions in
managing spinal chronic pain in Medicare beneficiaries from 2000 to 2011.
Objective: To assess the use of facet joint interventions in chronic pain management.
Methods: The study was performed utilizing the Centers for Medicare and Medicaid Services
(CMS) physician supplier procedure summary master data from 2000 to 2011.
Results: The utilization of all types of facet joint interventions increased enormously from
2000 to 2011, with an overall increase of 308% per 100,000 Medicare beneficiaries and
a 13.6% average annual increase. In addition, the highest increases were seen for cervical/
thoracic radiofrequency neurotomy with 836%, followed by an increase of 662% for lumbar/
sacral radiofrequency neurotomy, a 359% increase in cervical/thoracic facet joint injections, and
228% increase in lumbosacral facet joint injections. In reference to the number of procedures
performed, however, the highest numbers were in the lumbosacral region with 990,449 total
procedures of lumbar facet joint blocks and 406,378 lumbosacral radiofreqency neurotomies in
2011. Cervical and thoracic facet joint nerve blocks were 317,220, whereas cervical and thoracic
radiofrequency neurotomies were 97,526 in 2011.
The data also showed that there were enormous increases in the proportion of procedures
performed by the specialty of physical medicine and rehabilitation, with an increase of 781%
and an annual increase of 21.9% excluding physicians of physical medicine and rehabilitation
enrolled as interventional pain management or pain management. Even though the numbers
were very low for nurse anesthetists, nurse practitioners, and physician assistants, the increases
were from 143 in 2000 to 21,263 in 2011, providing an annual increase of 55.2%, an overall
increase of 12,460%.
Limitations: The limitations of this study included a lack of inclusion of Medicare participants
in Medicare Advantage plans, as well as potential documentation, coding, and billing errors.
Furthermore, the data provided for state utilizations is based on claims data for that state which
also may include patients from contiguous or other states receiving services in those states.
Conclusions: The explosive increase in the number of lumbar facet joint interventions
performed began to wane in 2008. From 2008 to 2010, the utilization of facet joint interventions
declined by 6%.
Key Words: Chronic spinal pain, interventional pain management, interventional techniques,
facet joint injections, medial branch blocks, radiofrequency neurotomy
Vertebroplasty for Treatment of Osteolytic
Metastases at C2 Using an Anterolateral
Approach
Authors: Sun Gang
Published: March 2021

Background: The clinical management of osteolytic metastases involving C2 is unique,
because it is challenging to approach these lesions. Symptoms may vary from local pain to
progressive neurological deficit. Surgery or radiotherapy have been the treatments of choice
for several years; however, surgery may not be an option for patients with multiple metastases
and poor general medical status, and radiotherapy carries the risk of vertebral collapse and
consequent neural compression due to delayed bone reconstruction. Through different
approaches, vertebroplasty has been introduced into clinical practice as an alternative to
traditional surgical and radiotherapy treatments of osteolytic metastases at C2.
Objective: This study aimed to evaluate the safety and efficacy of vertebroplasty with an
anterolateral approach for osteolytic metastases at C2 under fluoroscopic guidance.
Study Design: Vertebroplasty in 13 patients with osteolytic metastases at C2 and its clinical
effects were evaluated.
Setting: This study was conducted in an interventional therapy group at a medical center in
a major Chinese city.
Methods: Thirteen consecutive patients were treated with vertebroplasty via an anterolateral
approach. The researchers followed up with the patients for 3 to 12 months, with an average
of 9.2 months. The clinical effects were evaluated with the visual analog scale (VAS) preoperatively and at 3 days, one month, 3 months, 6 months, and 12 months post-operatively.
Results: Thirteen consecutive patients were successfully treated with a satisfying resolution
of painful symptoms. Extraosseous cement leakages were found in 5 cases without any clinical
complications. VAS scores decreased from 7.6 ± 0.9 pre-operatively to 2.1 ± 1.9 by the 3-day
post-operative time point, and were 1.8 ± 1.7 at one month, 1.7 ± 1.8 at 3 months, 0.9 ± 0.8
at 6 months, and 0.6 ± 0.5 at 12 months after the procedure. There was a significant difference
between the mean pre-operative baseline score and the mean score at all of the post-operative
follow-up points (P < 0.001).
Limitations: This was an observational study with a relatively small sample size.
Conclusions: Vertebroplasty via an anterolateral approach is an effective technique to treat
osteolytic metastases involving C2. It is a valuable, minimally invasive, and efficient method that
allows quick and lasting resolution of painful symptoms.
Key words: Vertebroplasty, C2, anterolateral approach, osteolytic metastasis, pain
Vertebroplasty Augmentation Procedures:
Examining the Controversy
Authors: Hussain Arif
Published: March 2021

Background: Vertebral compression fractures are a common pathology affecting primarily
the elderly, postmenopausal women, and those with metastatic vertebral disease. Vertebral
augmentation procedures are popular treatment options for stability and pain relief. Preliminary
studies have suggested that such procedures are adequately efficacious. However, the first
randomized controlled trials (RCTs) published in the New England Journal of Medicine in 2009
showed that these procedures were not significantly different than placebo with regards to
pain relief and quality of life. These studies were met with considerable criticism. The matter
was further complicated when The Lancet published an RCT of its own that demonstrated
the superiority of vertebroplasty over conservative management. The conflicting evidence
has sparked ongoing debate in the medical community. All sides have provided arguments
supported by evidence of varying strength and validity.
Objective: To provide a concise and comprehensive presentation of the controversy
surrounding vertebral augmentation procedures and the evidence cited by proponents on
both sides of the debate.
Methods: We began by researching the major randomized controlled trials both for and
against vertebroplasty. These articles were already known to us, and were used as a starting
point. We then performed a literature search in PubMed for articles dated from 2000 through
2012. The bibliographies of major articles and reviews were also cross-referenced for additional
sources.
Results: A number of articles that included comprehensive and systematic reviews, metaanalyses, and commentaries about noted studies were found. These provided a broad, detailed
overview of the subject. Many of the common themes of these articles included limitations in
the design, methods, and patient selection with regard to the RCTs and other available studies.
Limitations: This review does not analyze the quality of evidence available nor does it
provide an opinion in this regard. The conclusions of the present article are, therefore, general
and descriptive in nature.
Conclusions: The arguments presented by proponents of both sides of the debate appear to
have validity. All of the major studies cited as evidence for or against vertebral augmentation
procedures have limitations in their quality. Consequently, the debate cannot be concluded,
convincingly, until more elaborate studies are conducted involving larger numbers of patients
with clear procedure methods agreed upon by the major authorities in the field.
Key words: Vertebroplasty, kyphoplasty, vertebral augmentation procedures, controversy of
vertebroplasty, vertebral cancer, vertebral pain, compression fractures, back pain, vertebral
fractures.
A Randomized, Double-Blind, Active-Controlled
Trial of Fluoroscopic Lumbar Interlaminar
Epidural Injections in Chronic Axial or Discogenic
Low Back Pain: Results of 2-Year Follow-Up
Authors: Manchikanti Laxmaiah
Published: March 2021

Background: Chronic low back with or without lower extremity pain is extremely
common, expensive, and disabling. Although it is responsible for a very small proportion
of patients, disc herniation is the primary focus of modalities of treatments. In fact, chronic
low back pain without disc herniation is common. Multiple modalities of treatments are
utilized in managing axial or discogenic pain without disc herniation including surgery,
intradiscal therapies, and epidural injections. There is, however, continued debate on the
effectiveness, indications, and medical necessity of all modalities of treatments in managing
axial or discogenic pain in the lumbar spine.
Objectives: To assess the effectiveness of lumbar interlaminar epidural injections in
managing chronic axial or discogenic low back pain with epidural injections of local
anesthetic with or without steroids.
Study Design: A randomized, double-blind, active-controlled trial.
Setting: A private practice, specialty referral, interventional pain management practice in
the United States.
Methods: In this study, a total of 120 patients were randomly allocated to one of 2 groups
of 60 patients receiving either local anesthetic alone or local anesthetic with steroids. The
primary outcome measure was at least a 50% improvement in the numeric rating scale
(NRS) and Oswestry Disability Index (ODI). Outcomes were assessed at 3, 6, 12, 18, and 24
months post treatment.
Results: Significant pain relief and functional status improvement, defined as a reduction
in scores from baseline of at least 50% or more, were observed in 72% of patients receiving
local anesthetic alone and 67% of patients receiving local anesthetic with steroids. Opioid
intake was reduced from the baseline in each group for 2 years.
Limitations: The results of the study are limited by the lack of a placebo group.
Conclusion: Lumbar interlaminar epidural injections of local anesthetic with or without
steroids are effective in patients with chronic axial low back pain of discogenic origin without
facet joint pain, disc herniation, and/or radiculitis.
Key words: Lumbar disc herniation, axial or discogenic pain, lumbar interlaminar epidural
injections, local anesthetic, steroids, controlled comparative local anesthetic blocks
Evaluation of Prognostic Predictors of
Percutaneous Adhesiolysis Using a Racz
Catheter for Post Lumbar Surgery Syndrome or
Spinal Stenosis
Authors: Lee Pyung-Bok
Published: March 2021

Background: Percutaneous adhesiolysis (PA) is considered to be a reasonable nonoperative
treatment for herniation of intervertebral disc (HIVD), spinal stenosis, and post-lumbar-surgery
syndrome (PLSS). The success of PA depends on the removal of epidural fibrosis and drug
delivery to the target region. However, prognostic predictors of the effects of PA are not well
known.
Objective: The aim of this study was to evaluate prognostic predictors of PA using a Racz
catheter for patients with PLSS or spinal stenosis.
Study Design: Retrospective assessment.
Methods: PA using a Racz catheter was performed on 78 patients. We assessed the
effectiveness of PA at pretreatment, 2 weeks, 3 months, and 6 months following the procedure.
Effectiveness was defined as a 50% or more reduction of the Numeric Rating Scale (NRS) for
back and leg pain or a 40% or more reduction of the Oswestry Disability Index (ODI) following
the procedure. Data collected for each patient included age, gender, BMI, grade and location
of stenosis in magnetic resonance imaging (MRI), symptom durations, and history of previous
lumbar surgery. The adjusted odds ratios (OR) and 95% confidence intervals (CI) for each
variable were analyzed by logistic regression.
Results: PA using a Racz catheter was more effective in patients with no previous lumbar
surgery (OR, 7.426; 95% CI, 1.820–30.302; P = 0.005) or root compression with HIVD or
foraminal stenosis (OR, 5.479; 95% CI, 1.137–26.391; P = 0.036). Other included factors were
not related to PA effectiveness.
Limitations: The number of patients examined in this study was relatively small.
Conclusion: Good prognostic predictors were identified as no previous lumbar surgery or root
compression with HIVD or foraminal stenosis. These results are expected to contribute to the
establishment of indications for PA.
Key words: Percutaneous adhesiolysis, post lumbar surgery syndrome, spinal stenosis
Pulsed Radiofrequency Modulates Pain
Regulatory Gene Expression Along the
Nociceptive Pathway
Authors: Vallejo Ricardo
Published: March 2021

Background: Pulsed radiofrequency (PRF) therapy is a clinical treatment utilizing electromagnetic
energy aimed to relieve neuropathic pain. This is the first study examining the modulated expression
of pain regulatory genes following the induction of the spared nerve injury (SNI) pain model and
subsequently treated with PRF therapy.
Objectives: The present study investigated the behavioral efficacy of PRF therapy in rats exhibiting
sciatic nerve injury and examined gene expression changes in the sciatic nerve, ipsilateral L5 dorsal
root ganglia (DRG), and spinal cord.
Study Design: A randomized, experimental trial.
Setting: Department of Biological Sciences, Illinois State University and Department of Psychology,
Illinois Wesleyan University.
Methods: An SNI model was used in male Sprague-Dawley rats (weight 260-310 g). A sham
surgery was also performed as a control group. After 3 days development of the SNI model, an
RF electrode was applied to the sciatic nerve proximal to the site of injury and stimulated for 3
minutes. The response to mechanical stimuli was assessed throughout the duration of the study.
Furthermore, changes in gene expression along the nociceptive tract (sciatic nerve, DRG, and spinal
cord) were assessed 24 hours post-PRF therapy.
Results: It was observed that the mechanical allodynia, induced by SNI model, was reversed
to control values within 24 hours post-PRF therapy. Additionally, modulated expression of pain
regulatory genes was observed after induction of the SNI model. Following PRF therapy, expression
of many of these genes returned to control values (sham) in each of the tissues tested. Increased
proinflammatory gene expression, such as TNF-α and IL-6, observed in the sciatic nerve (site of
injury) in the SNI group was returned to baseline values following PRF therapy. Up-regulation of
GABAB-R1, Na/K ATPase, and 5-HT3r as well as down regulation of TNF-α and IL-6 were also
observed in the DRG in the SNI-PRF group relative to the SNI group. Up-regulation of Na/K ATPase
and c-Fos was found in the spinal cord following PRF treatment relative to the SNI group.
Limitations: Immediate changes in gene expression were observed at 24 hours to better
determine the mechanism with no long-term data at this time. Protein expression was not assessed
in addition to gene expression changes.
Conclusion: These results indicate that the electromagnetic energy applied via PRF therapy
influences the reversal of behavioral and molecular effects of hypersensitivity developed from a
peripheral nerve injury.
Key words: Pulsed radiofrequency, PRF; spared nerve injury, SNI; electromagnetic stimulation;
Sprague-Dawley, rat; withdrawal threshold; mechanical allodynia, Von Frey; gene expression;
nociceptive pathway; electroneuromodulation; cytokines
False Positive Radiographical Evidence of Pump
Catheter Migration into the Spinal Cord
Authors: Dardashti Simon
Published: March 2021

Intrathecal drug delivery systems are becoming an increasingly common modality used by
physicians to treat patients. Specifically, chronic spasticity secondary to multiple sclerosis (MS)
may be treated with intrathecal baclofen (ITB) therapy when oral antispasmodics do not provide
adequate relief. ITB therapy is effective, localizes drug delivery, and does not have the same
degree of intolerable systemic effects often seen with oral and parenteral medications. As the
use of intrathecal drug delivery systems has become more common, so has the incidence of
adverse events. ITB administration requires the surgical implantation of indwelling catheters and
a pump reservoir. Although this therapy is useful in treating spasticity, risks unique to intrathecal
drug delivery systems include medication dosing errors, pump malfunction, infection, and
catheter breakage or dislocation. To our knowledge intrathecal pump catheter migration into
the spinal cord is a very rare complication with only 2 such complications reported. We present
a case of an intrathecal baclofen pump catheter that was initially believed to have migrated into
the spinal cord and the innovative use of cinefluoroscopy and digital subtraction used to identify
catheter placement. Moreover, after confirmation of the catheter position within the spinal
cord on magnetic resonance imaging (MRI) our team elected to perform a laminectomy, which
demonstrated that the catheter was not in the spinal cord but was surrounded by arachnoid
adhesions. We hope our efforts will provide the clinician insight into the common difficulties
that arise and how best to troubleshoot them to serve this specific patient population and
prevent potentially life-threatening complications.
Key words: Intrathecal pump, intrathecal catheter, multiple sclerosis, pain medicine, spasticity,
cine mode, baclofen
Percutaneous Lumbar Mechanical Disc
Decompression Utilizing Dekompressor®: An
Update of Current Evidence
Authors: Manchikanti Laxmaiah
Published: March 2021

Background: The primary goal of the surgical treatment of nerve root compression from a disc
protrusion continues to be the relief of compression by removing the herniated nuclear material
with open discectomy. However, poor results have been reported for contained disc herniations with
open surgical interventions. In recent years, a number of minimally invasive nuclear decompression
techniques for lumbar disc prolapse, protrusion, and/or herniation have been introduced, including
the Dekompressor®. The efficacy of several alternative techniques, including the Dekompressor,
automated percutaneous discectomy, and laser discectomy, has been described, but is not
convincing. There is a continued paucity of evidence for all decompression techniques.
Objective: The objective of this systematic review is to evaluate and update the literature
describing the clinical effectiveness of Dekompressor, a high rotation per minute (RPM) device
used in mechanical lumbar disc decompression.
Study Design: A systematic review of the literature focusing on mechanical disc decompression
with Dekompressor.
Methods: The available literature on the use of percutaneous disc decompression (PDD) with
Dekompressor to manage chronic low back and lower extremity pain was reviewed using the
Cochrane Musculoskeletal Review Group criteria for randomized trials and the Newcastle-Ottawa
Scale criteria for observational studies.
The level of evidence was classified as good, fair, and limited or poor based on the US Preventive
Services Task Force (USPSTF) system for grading the quality of evidence.
Data sources included relevant literature identified through PubMed and EMBASE from 1966 through
September 2012, and manual searches of the bibliographies of known primary and review articles.
Outcome Measures: Pain relief was the primary outcome measure. Secondary outcome
measures were functional improvement, improvement of psychological status, opioid intake, and
return to work.
Short-term effectiveness was defined as one year or less. Long-term effectiveness was defined as
greater than one year.
Results: Only 5 studies were considered for inclusion. Of those, only 3 of them met inclusion
criteria.
Based on USPSTF criteria, the level of evidence for PDD with Dekompressor is limited.
Limitations: Paucity of high quality literature.
Conclusion: This systematic review found limited evidence for PDD with Dekompressor.
Key words: Intervertebral disc disease, chronic low back pain, mechanical disc decompression,
disc protrusion, disc extrusion, radiculitis, Dekompressor.
Diagnostic Utility of Selective Nerve Root Blocks
in the Diagnosis of Lumbosacral Radicular Pain:
Systematic Review and Update of Current Evidence
Authors: Manchikanti Laxmaiah
Published: March 2021

Background: Lumbosacral selective nerve root blocks and/ or transforaminal epidural injections
are used for diagnosis and treatment of different disorders causing low back and lower extremity
pain. A clear consensus on the use of selective nerve root injections as a diagnostic tool does not
currently exist. Additionally, the validity of this procedure as a diagnostic tool is not clear.
Objective: To evaluate and update the accuracy of selective nerve root injections in diagnosing
lumbar spinal disorders.
Study Design: A systematic review of selective nerve root blocks for the diagnosis of low back
and lower extremity pain.
Methods: Methodological quality assessment of included studies was performed using the
Quality Appraisal of Reliability Studies (QAREL) checklist. Only diagnostic accuracy studies meeting
at least 50% of the designated inclusion criteria were utilized for analysis. Studies scoring less
than 50% are presented descriptively and analyzed critically.
The level of evidence was classified as good, fair, or limited or poor based on the quality of
evidence grading scale developed by the United States Preventive Services Task Force (USPSTF).
Data sources included relevant literature identified through searches of PubMed and EMBASE
from 1966 to September 2012, and manual searches of the bibliographies of known primary and
review articles.
Outcome Measures: In this review, we evaluated studies in which controlled local anesthetic
blocks were performed using at least 50% pain relief as the reference standard.
Results: There is limited evidence for the accuracy of selective nerve root injections as a diagnostic
tool for lumbosacral disorders. There is limited evidence for their use in the preoperative evaluation
of patients with negative or inconclusive imaging studies.
Limitations: The limitations of this systematic review include a paucity of literature, variations in
technique, and variable criterion standards for the diagnosis of lumbar radicular pain.
Conclusions: There is limited evidence for selective nerve root injections as a diagnostic tool in
evaluating low back pain with radicular features. However, their role needs to be further clarified
by additional research and consensus.
Key words: Low back pain, lower extremity pain, selective nerve root block, transforaminal
epidural injection, discogenic pain, radiculitis, sciatica radiculopathy, nerve root pain
Neural Flip-Flops IV: Lamprey Locomotion
Authors: Yoder Lane
Published: March 2021

The
lamprey is one of the most ancient of extant vertebrate species. It has changed relatively little in 450
million years and is considered a prototype for all vertebrates. Its primitive nervous system has been studied
extensively, and the basic architecture of the central pattern generator (CPG)
that produces its anguilliform swimming motion is well known. Here
it is shown that each segmental component of the lamprey's CPG is a JK
flip-flop, with additional excitatory inputs and feedback that cause all of the
neurons' states to oscillate. The JK
flip-flop is the most widely used flip-flop design in electronic computational
systems because of its advantageous features.
This is apparently the first discovery that a known network of neurons functions
as a logic circuit. The lamprey's oscillator
can be implemented with electronic hardware, and the design is apparently
unknown in engineering. A
simulation based on simple neuron responses to excitation and inhibition illustrates
the common period, phase relationships, and burst durations of the segmental
cells' oscillations. Simulation software
for electronic logic circuits verifies the simulated neuron responses, on vastly
different time scales. The simulation
methods presented here may aid in further study of CPG neurophysiology. The architecture of the oscillating JK
flip-flop may aid in the development of artificial neural network applications
such as robotics.
PICK-UP HAFİF KAMYON UYGULAMALARI İÇİN TEK PARÇALI ALÜMİNYUM KARDAN MİLİ KONSEPT TASARIMI
Authors: KASABA Muzaffer , IŞIK Efe , TARAKÇI Sedat
Published: March 2021

Kardan milleri, motordan aldığı torku ve dönme hareketini arka akslara ileten bir aktarma organı elemanıdır. Yüksek tork taşıma gerekliliklerini karşılamak amacıyla, hafif ticari araç uygulamalarında kullanılan kardan milleri çelik malzeme kullanılarak üretilmektedir. Çelik malzeme kullanılarak üretilmiş kardan mili ve parçalarında ağırlık azaltma, geometrilerin sınır koşulları nedeniyle çoğu zaman kısıtlı olabilir. Bu nedenle alüminyum gibi düşük yoğunluklu malzemeler kullanılarak geliştirilen uygulamalar önem kazanmaktadır. Bu çalışma kapsamında pick-up tarzı hafif ticari araç uygulamalarında kullanılmak üzere alüminyum kardan mili için mühendislik hesapları gerçekleştirilmiş ve sonlu elemanlar analizleri ile hesaplar doğrulanmıştır. Doğrulmalar sonucunda iki yöntem arasında dayanım hesaplarında %1, doğal frekans hesaplarına %8 sapma hesaplanmıştır ve sapma değerlerinin kabul edilebilir olduğu belirlenmiştir. Birim parçaların, için sonlu elemanlar ile elde edilen sonuçlar kullanılan alüminyum malzemenin akma limitleri ile güvenlik katsayıları hesaplanmıştır. Elde edilen güvenlik katsayıları kardan milleri için uygun olduğu tespit edilmiştir.
PENTINGNYA KETERLIBATAN ORANG TUA DI LEMBAGA PAUD DALAM MENSTIMULASI PERKEMBANGAN SOSIAL EMOSIONAL ANAK USIA DINI
Authors: Desmariani Evi , Muzayyanah Muzayyanah , Jendriadi Jendriadi , Rahmalina Widdya
Published: March 2021

There are still many parents who take their children to go to kindergarten institutions with the aim that their children can learn to read, write, count and be good at (reading) the Koran. Like what happened in Hauriyah Halum Integrated Kindergarten. Since the learning process is implemented, parents only fulfill all the needs of the children requested by the institution for the learning process including completing school administration. After that, the parents are only tasked with taking the child to school in the morning and picking up the child from school after the learning process, and sometimes asking how many stars the child's work got. Parents do not think at all about the child's behavior while at school, such as annoying friends, making noise during the learning process, hitting friends, and saying bad words to friends. This is often conveyed by the teacher every time the child comes home from school with the hope that the parents advise the child while at home. However, every day there is no visible change and even more protracted. For this reason, it is necessary to do counseling on the importance of parental involvement in kindergarten institutions in stimulating children's socio-emotional development from an early age. Therefore, it is necessary to carry out community service in the form of counseling. The extension method is in the form of lectures and questions and answers. This community service aims to ensure that teachers always involve parents in educating children, especially in stimulating children's social-emotional development from an early age. So that children can follow the learning process and behave well to teachers and friends while they are at school. As a result of this community service, it is hoped that all parents can train themselves or get used to behaving well in front of children at all times while at home as teachers have been accustomed to while the child is in school.