bluuebunny/crossref_metadata_2025 huggingface dataset:
Intravascular Flow Detection During
Transforaminal Epidural Injections:
A Prospective Assessment
Authors: Abd Omar El
Published: February 2021

Background: Transforaminal epidural steroid injections (TFESI) are a mainstay in the treatment
of spine pain. Though this commonly performed procedure is generally felt to be safe, devastating
complications following inadvertent intra-arterial injections of particulate steroid have been
reported. The use of digital subtraction angiography (DSA) has been suggested as a means of
detecting intra-arterial needle placements prior to medication injection.
Objective: To examine the efficacy of DSA in detecting intra-arterial needle placements during
TFESI.
Study Design: Prospective cohort study evaluating the impact of DSA on detecting intra-arterial
needle placements during TFESI.
Methods: We enrolled 150 consecutive patients presenting to a university-affiliated spine center
with discogenic and/or radicular symptoms affecting the cervical, lumbar, and sacral regions. For
each injection, prior to imaging with DSA, traditional methods for vascular penetration detection
were employed, including the identification of blood in the needle hub (flash), negative aspiration
of blood prior to injection, and live fluoroscopic injection of contrast. Once these tests were
performed and negative for signs of intra-arterial needle placement, DSA imaging was utilized
prior to medication administration for identification of vascular flow.
Results: A total number of 222 TFESI were performed, 41 injections at the cervical levels
(18.47%), 113 at the lumbar levels (50.9%), and 68 at the sacral levels (30.36%). Flash was
observed in 13 injections performed (5.85% of the total number of injections): one (0.45%) in the
cervical, 2 (0.9%) in the lumbar, and 10 (4.5%) in the sacral levels. In 11 TFESI blood aspiration was
obtained (4.95% of all injections): 3 (1.3%) in cervical, 4 (1.8%) in lumbar, and 4 (1.8%) in sacral
injections. Live fluoroscopy during contrast injection detected 46 (20.72%) intravascular flow
patterns: 7 (3.1%) cervical, 17 (7.6%) lumbar, and 22 (9.9%) sacral. DSA identified an additional 5
intravascular injections after all previous steps had resulted in negative vascular penetration signs,
which accounted for 2.25% of all injections.
Limitations: This is a prospective, single-center study with a relatively small number of patients
and no control group.
Conclusion: DSA detected additional 5.26% intravascular needle placements following
traditional methods. Our findings also support other studies that conclude TFESI are generally a
safe procedure. We recommend that special attention should be paid to the sacral injections as
vascular penetration was statistically higher than at other levels.
Key words: Digital subtraction angiography, transforaminal epidural steroid injections
Treatment of Metastatic Spinal Lesions with a
Navigational Bipolar Radiofrequency Ablation
Device: A Multicenter Retrospective Study
Authors: Jennings Jack W
Published: February 2021

Background: Spinal metastatic lesions are a common occurrence among oncology patients
and contribute to significant morbidity. Treatment options have been limited in their effectiveness
and scope to this point.
Objective: This study aims to report the safety and efficacy of radiofrequency ablation (RFA)
of malignant spinal lesions using a novel RFA bipolar tumor ablation system which includes a
navigational electrode containing 2 active thermocouples.
Study Design: IRB approved multicenter retrospective review of patients receiving RFA as a
treatment of metastatic osseous lesions between March 2012 and March 2013.
Setting: This study consists of patients from 5 large academic centers.
Method: One hundred twenty-eight metastatic lesions were identified in 92 patients who
underwent a total of 96 procedures. Cement augmentation was performed when the vertebral
body was at risk or had a pathological fracture. Visual analogue scale (VAS) scores were obtained
preoperatively as well as postoperatively at the one week, one month, and 6 month time points.
Interval change in the patients’ pain medications was recorded. Postoperative imaging was used
to assess tumor burden at the treated level when available.
Results: RFA was technically successful in all of the lesions without complication or thermal
injury. Our study demonstrated significant (P < 0.01) decreases in the VAS scores at one
week, one month, and 6 months postoperatively. In our largest center, 54% of our patients
experienced a decrease and 30% had no change in their pain medications postoperatively. Sixtytwo percent of the spinal lesions in this largest institution were located in the posterior vertebral
body. Post-ablation imaging confirmed size of ablation zones consistent with that measured by
the thermocouples.
Limitations: The main limitations of this study are the heterogeneous patient population,
data set, and potential confounding variable of concurrent cement augmentation.
Conclusion: The STAR System is an RFA device that was safely and effectively used in the
treatment of spine metastatic osseous lesions. This new device allows RFA treatment of previously
untreatable lesions with resultant reduction in pain that was not controlled by systemic or
radiation therapy.
Key words: Radiofrquency ablation, pain, osseous metastasis, spine, interventional oncology,
oncology, pain management, tumor, vertebral augmentation
Effect of a Fixed-Dose Opioid Agonist/
Antagonist on Constipation in Patients on
Long-term Opioids for Non-Malignant Pain
Unable to Tolerate Laxatives
Authors: Mehta Dr Vivek
Published: February 2021

Background: Chronic pain affects a large number of patients throughout the world and impacts
greatly on their quality of life, including the ability of a patient to sleep, go to work, and socialize.
Guidance on the use of opioids in chronic pain patients is available from the British Pain Society;
however, patients receiving opioid treatment for their pain often suffer from symptoms associated
with opioid-induced bowel dysfunction (OIBD), including constipation. The usual treatment of
constipation in these patients is laxatives; however, one study has shown that 54% of patients do
not receive the desired results from this approach. Oxycodone/naloxone tablets have been shown
to provide analgesia to chronic pain patients, while improving the symptoms of OIBD, as the
naloxone component blocks the effects of oxycodone at opioid receptors in the gut.
Objectives: The objective of the present study was to assess improvements in quality of life and
bowel function in patients receiving oxycodone/naloxone tablets for their chronic non-malignant
pain.
Study Design: This was a 12-week observational follow-up study that included 28 outpatients
with chronic non-malignant pain attending the Pain Clinic at St. Bartholomew’s Hospital in London.
All patients had recently been prescribed oxycodone/naloxone tablets as treatment for their pain.
Methods: Patients were assessed at baseline, week 1, week 4, and week 12 for functioning and
well-being using the Patient Assessment of Constipation Quality of Life questionnaire (PAC-QOL),
and for bowel function using the Bowel Function Index (BFI).
Results: Mean PAC-QOL scores, as well as scores for each of the subscales (worries and concerns,
physical discomfort, psychosocial discomfort, and satisfaction) significantly improved from baseline
to week 12. Mean BFI scores significantly decreased from baseline to all time-points during the
study. Subscale analysis of the BFI scores showed that mean scores for ease of defecation and
judgment regarding constipation had significantly decreased at week 12; however, mean scores
for feeling of incomplete bowel evacuation had not.
Limitations: The results of the current study should be interpreted in relation to the study design.
However, the results are consistent with previous studies that included a comparator group, had a
longer duration of treatment, and included larger patient numbers.
Conclusions: The results of this study indicate that patients receiving oxycodone/naloxone
tablets achieved statistically and clinically significant improvements in bowel function as well as
quality of life after 12 weeks of treatment.
Key words: Non-malignant pain, opioid, opioid-induced constipation, laxatives, oxycodone,
naloxone, audit
New Insights from Immunohistochemistry for
the Characterization of Epidural Scar Tissue
Authors: Pereira Paulo
Published: February 2021

Background: The association between epidural fibrosis and recurrent symptoms after
lumbar spine surgery remains a matter of debate in scientific literature and the underlying
pathophysiological mechanism has not been clearly elucidated.
Objective: To investigate the presence of nerve fibers and the expression of osteopontin
in epidural fibrous tissue after lumbar surgery in humans.
Study Design: Laboratory study of human tissue samples.
Methods: Twenty-four patients with persistent or recurrent low back and/or leg pain after
lumbar spine surgery, in whom no relevant findings were present on magnetic resonance
imaging (MRI) besides epidural scar tissue, were submitted to epiduroscopy. Biopsy
samples of epidural scar tissue resting in the posterior epidural and periradicular space
were obtained from 15 patients, using an endoscopic grasping forceps, in locations where
the stimulation with the tip of a Fogarty consistently reproduced pain. Biopsy samples
were processed for examination under optical and transmission electron microscopes and
under a fluorescence microscope after incubation in primary antibodies against beta3-
tubulin or against osteopontin.
Results: Optical and transmission electron microscopy revealed a homogeneous fibrous
tissue rich in collagen and lacking nerve fibers. No immunofluorescence was present in
any of the samples immunoreacted against beta3-tubulin. In the samples immunoreacted
against osteopontin, a punctate signal was detected around the collagen fibers.
Limitations: Being a human study, there was no control group, so it is not possible to
determine the contribution of osteopontin in the formation of epidural fibrosis and its
relation to the patients’ symptoms. Additional animal studies are needed to investigate
these issues.
Conclusion: Rather than direct stimulation of nociceptors in the epidural scar tissue,
other factors should relate epidural fibrosis and recurrent symptoms after lumbar spine
surgery. Osteopontin seems to play a role in the formation of epidural fibrosis.
Key words: Osteopontin, failed back surgery syndrome, epidural fibrosis,
immunofluorescence, beta3-tubulin, epiduroscopy, nerve fibers, lumbar surgery
Contrast Dispersion Pattern and Efficacy
of Computed Tomography-Guided Cervical
Transforaminal Epidural Steroid Injection
Authors: Park Chan Hong
Published: February 2021

Background: The causes of upper extremity radicular pain or neck pain are varied, often involving
disc herniation, spinal stenosis, or spondylosis. Cervical transformaminal epidural steroid injection
(C-TFESI) is a common treatment for such pain. However, its efficacy conceivably may depend on
needle-tip placement, linking the degree of pain reduction achieved to the pattern of contrast
dispersion.
Objective: The current study explores this relationship, evaluating contrast dispersion patterns of
C-TFESI in conjunction with short-term patient outcomes.
Study Design: Prospective evaluation.
Methods: A total of 67 patients with cervical radicular pain were enrolled, each of whom
underwent computed tomography (CT)-guided C-TFESI. Procedural contrast dispersion was
judged as either intraforaminal or extraforaminal. Using the Roland 5-point pain scale, outcomes
were scored 2 weeks after injection and then grouped as improvement (scores, 0 – 2) or no
improvement (scores, 3 – 5).
Results: Contrast dispersion was largely intraforaminal (50 patients), as opposed to extraforaminal
(17 patients), with no statistically significant difference in short-term pain relief by contrast pattern
(intraforaminal: 56%, 28/50; extraforaminal: 53%, 9/17; P = 0.459). Of the 50 procedures where
dispersion of contrast was intraforaminal, 44% (22/50) were scored as unfavorable outcomes.
Limitations: Small sample size, brief follow-up, and secondary outcomes were not measured.
Authors also did not analyze other variables impacting C-TFESI, and classifying patterns of contrast
spread anatomically as epidural or epiradicular (one, both, or neither as applicable) is simply not
feasible by CT.
Conclusion: C-TFESI is an effective treatment for cervical radicular pain that is refractory to
conventional conservative remedies. However, therapeutic response to C-TFESI and dispersion
pattern of injected contrast failed to correlate in this study.
Key words: Cervical, epidural, contrast, CT-guided, TFESI
Comparative Efficacy of Levobupivacaine and
Ropivacaine for Epidural Block in Outpatients
with Degenerative Spinal Disease
Authors: Egashira Takashi
Published: February 2021

Background: Levobupivacaine has less toxic potential on both the cardiovascular and
central nervous system and has been widely used for postoperative epidural analgesia in
surgical patients. However, there are few reports on the efficacy of epidural levobupivacaine
in outpatients with lumbosacral radiculopathy. This study was carried out to evaluate the
comparative efficacy of levobupivacaine and ropivacaine for epidural block in outpatients with
degenerative spinal disease and sciatica.
Objective: We studied 32 patients (19 men and 13 women) with degenerative spinal
disease and sciatica.
Study Design: The study was performed in a prospective, randomized, double blind, and
crossover fashion.
Setting: University medical facility.
Methods: The epidural block was produced with a caudal approach (0.125% levobupivacaine
or 0.2% ropivacaine, 15 mL). The upper level of analgesia, lumbosacral pain, motor blockade,
and hemodynamic changes were evaluated by pin prick, visual analogue scale (VAS), Bromage
scale, and arterial blood pressure and heart rate at 15, 30, 60, and 90 minutes after epidural
block, respectively. The recovery time to mobilization, ambulation, and spontaneous micturition
were measured.
Results: There were no significant differences (P < 0.05) in the upper level of analgesia,
VAS, and Bromage scale between 0.125% levobupivacaine and 0.2% ropivacaine throughout
the time course. There were no significant differences in the recovery times to mobilization,
ambulation, and spontaneous micturition between 0.125% levobupivacaine and 0.2%
ropivacaine. There were no significant differences in arterial blood pressure and heart rate
between the 2 trials throughout the time course.
Conclusion: The results showed that 0.125% levobupivacaine and 0.2% ropivacaine for
epidural block by a caudal approach provide similar lumbosacral pain relief, hemodynamic
effects, and the degree and the recovery of motor blockade in outpatients with degenerative
spinal disease and sciatica.
Key words: Levobupivacaine, ropivacaine, outpatients, epidural block, degenerative
spinal disease with sciatica
Examination of Symptom Clusters in Acute and
Chronic Pain Patients
Authors: Fishbain David
Published: February 2021

Background: Symptom clusters have not been previously explored in acute pain patients
(APPs) and chronic pain patients (CPPs) with non-cancer pain.
Objectives: The objectives of this study were to determine in CPPs and APPs which somatic and
non-somatic symptoms cluster with each other, the number of clusters, and if cluster number
and cluster symptom makeup differ by pain level.
Study Design: Study sample was 326 APPs and 341 CPPs who had completed a pool of
questions that had included current symptom questions other than pain. Symptom cluster
analyses were performed on 15 somatic and non-somatic symptoms for APPs and CPPs and for
2 CPP subgroups with moderate and severe pain.
Setting: APPs and CPPs were from rehabilitation facilities located in 30 states in all geographical
regions of the United States.
Results: APPs had 4 symptom clusters and CPPs had 5. For CPPs, the clusters represented
memory, neurological, behavioral, somatic, and autonomic problems. CPPs with moderate
and severe pain had 3 and 4 symptom clusters, respectively, and differed in cluster symptom
constitution.
Limitations: Patients selected themselves for study inclusion and were paid for their
participation. This could have affected random selection. Lastly, we used the current time
definitions of acute pain versus chronic pain (90 days) to separate our patients into these groups.
Currently, no consensus exists regarding the optimal time duration to divide acute from chronic.
Conclusions: APPs and CPPs are characterized by symptom comorbidities that form clusters.
In CPPs, cluster number and cluster symptom makeup are affected by pain level. This has
implications for clinical practice and future research.
Key words: Comorbidity, somatic symptoms, comorbid symptoms, chronic pain patients,
acute pain patients, community patients without pain, clusters, symptom clusters
Mental Nerve Neuropathy Following Dental
Extraction
Authors: Elahi Foad
Published: February 2021

Mental nerve neuropathy (MNN), colloquially referred to as numb chin syndrome, is an
uncommon neurologic condition that may arise secondary to multiple local and systemic
etiologies, and may mimic other pain conditions affecting the mandible. Early recognition
of mental nerve neuropathy in conjunction with accurate etiologic identification is crucial,
as early pain management may prevent the transition from an acute to a chronic pain
condition.
In this article, we will describe the clinical courses of 2 patients who presented to the pain
clinic with chronic painful numbness in the mental nerve sensory distribution following
dental extraction. After a period of failed conservative medical management and repetitive
successful nerve blocks at the mental foramen, we decided to proceed with radiofrequency
nerve ablation. In both cases, performance of radiofrequency nerve ablation demonstrated
a significant decrease in pain.
Within interventional pain medicine, nerve blocks are often utilized to assist with pain
generator identification, and resultantly also play an integral role in treatment planning.
For instance, nerve blocks are often utilized to establish accurate identification of nerve
tissue viability, a preliminary role essential for the determination of whether to proceed
with an ablative peripheral nerve procedure. In this article, we will additionally review these
important usages of nerve blocks within interventional pain medicine.
The objective of our article is to help clinicians identify and properly manage early stage
mental nerve neuropathy. Moreover, we aim to advance general medical knowledge of this
important pain medicine topic. During the process of preparing this article we reviewed all
existing pertinent medical literature related to MNN.
Key words: Mental nerve, neuropathy, radiofrequency, nerve ablation, chronic pain
Epidural Steroid Warning Controversy Still
Dogging FDA
Authors: Manchikanti Laxmaiah
Published: February 2021

On April 23, 2014, the Food and Drug Administration (FDA) issued a letter of warning
that injection of corticosteroids into the epidural space of the spine may result in rare,
but serious adverse events, including “loss of vision, stroke, paralysis, and death.” The
advisory also advocated that patients should discuss the benefits and risks of epidural
corticosteroid injections with their health care professionals, along with the benefits
and risks associated with other possible treatments. In addition, the FDA stated that the
effectiveness and safety of the corticosteroids for epidural use have not been established,
and the FDA has not approved corticosteroids for such use.
To raise awareness of the risks of epidural corticosteroid injections in the medical
community, the FDA’s Safe Use Initiative convened a panel of experts including pain
management experts to help define the techniques for such injections with the aim of
reducing preventable harm. The panel was unable to reach an agreement on 20 proposed
items related to technical aspects of performing epidural injections. Subsequently, the
FDA issued the above referenced warning and a notice that a panel will be convened in
November 2014.
This review assesses the inaccuracies of the warning and critically analyzes the available
literature. The literature has been assessed in reference to alternate techniques and an
understanding of the risk factors when performing transforaminal epidural injections in
the cervical, thoracic, and lumbar regions, ultimately resulting in improved safety.
The results of this review show the efficacy of epidural injections, with or without steroids,
in a multitude of spinal ailments utilizing caudal, cervical, thoracic, and lumbar interlaminar
approaches as well as lumbar transforaminal epidural injections . The evidence also shows
the superiority of steroids in managing lumbar disc herniation utilizing caudal and lumbar
interlaminar approaches without any significant difference as compared to transforaminal
approaches, either with local anesthetic alone or local anesthetic and steroids combined.
In conclusion, the authors request that the FDA modify the warning based on the
evidence.
Key words: Chronic pain, epidural injections, epidural steroids, local anesthetic,
radicular artery, complication.
Dexmedetomidine as an Adjunctive Analgesic
with Bupivacaine in Paravertebral Analgesia
for Breast Cancer Surgery
Authors: Mohamed Sahar A.
Published: February 2021

Background: There is little systematic research on the efficacy and tolerability of the addition
of adjunctive analgesic agents in paravertebral analgesia. The addition of adjunctive analgesics,
such as fentanyl and clonidine, to local anesthetics has been shown to enhance the quality and
duration of sensory neural blockades, and decrease the dose of local anesthetic and supplemental
analgesia.
Objectives: Investigation of the safety and the analgesic efficacy of adding 1 µg/kg
dexmedetomidine to bupivacaine 0.25% in thoracic paravertebral blocks (PVB) in patients
undergoing modified radical mastectomy.
Study Design: A randomized, double-blind trial.
Setting: Academic medical center.
Methods: Sixty American Society of Anesthesiologists physical status –I – III patients were
randomly assigned to receive thoracicPVB with either 20 mL of bupivacaine 0.25% (Group B, n =
30), or 20 mL of bupivacaine 0.25% + 1 µg/kg dexmedetomidine (Group BD, n= 30). Assessment
parameters included hemodynamics, sedation score, pain severity, time of first analgesics request,
total analgesic consumption, and side effects in the first 48 hours.
Results: There was a significant reduction in pulse rate and diastolic blood pressure starting at 30
minutes in both groups, but more evidenced in group BD (P < 0.001). Intraoperative Systolic blood
pressure showed a significant reduction at 30 minutes in both groups (P < 0.001) then returned to
baseline level at 120 minutes in both groups. There was a significant increase in pulse rate starting
2 hours postoperative until 48 hours postoperatively in group B but only after 12 hours until 48
hours in group BD (P < 0.001). The time of the first rescue analgesic requirement was significantly
prolonged in the group BD (8.16 ± 42 hours) in comparison to group B (6.48 ± 5.24 hours) (P =
0.04). The mean total consumption of intravenous tramadol rescue analgesia in the postanesthesia
care unit in the firtst 48 hours postoperatively was significantly decreased in group BD (150.19 ±
76.98 mg) compared to group B (194.44 ± 63.91 mg) (P = 0.03). No significant serious adverse
effects were recorded during the study.
Limitations: This study is limited by its sample size.
Conclusion: The addition of dexmedetomidine 1 µg/kg to bupivacaine 0.25% in thoracic PVB
in patients undergoing modified radical mastectomy improves the quality and the duration of
analgesia and also provides an analgesic sparing effect with no serious side effects.
Key words: Dexmedetomidine, paravertebral block, postoperative analgesia, breast cancer
surgery
The Catheter Tip Position and Effects of
Percutaneous Epidural Neuroplasty in Patients
with Lumbar Disc Disease During 6-Months of
Follow-up
Authors: Shin Prof. Dong Ah
Published: February 2021

Background: Percutaneous epidural neuroplasty (PEN) is a minimally invasive intervention
designed to treat neck, back, and low back pain. The efficacy of lumbar PEN has been relatively
well investigated, but clinical effectiveness according to catheter position has not yet been
established.
Objective: The purpose of this study was to compare clinical outcomes between the ventral and
dorsal positions of the catheter tip during lumbar PEN procedures using a retrospective review
series.
Methods: A total of 303 patients with back pain from single-level lumbar disc disease with and
without radiculopathy were included in this study. In all patients, an attempt was made to place
the catheter tip in the ventral position to maximize theoretical clinical improvement; however,
several catheters failed to reach the desired position. Patients were assigned to 2 groups after
lumbar PEN procedures were completed: those with catheters in the ventral position (Ventral
group) and those with catheters in the dorsal position (Dorsal group). Clinical outcomes were
assessed according to the Visual Analog Scale (VAS) score for back pain and leg pain at 0, 1, 3,
and 6 months after treatment.
Results: The only demographic difference observed between the 2 groups (Ventral and Dorsal
groups) was an elongated symptom duration in the Dorsal group compared to the Ventral group
(16.1 vs. 9.4 months, P = 0.013). The VAS (back) scores during the follow-up period (1, 3, and
6 months) were similar between the 2 groups. In one area of the VAS scoring (leg), the Ventral
group showed a similar effect at postoperative one month compared to the Dorsal group, but
significantly improved at postoperative 3 and 6 months (1.3 and 0.9 in ventral group, and 1.9
and 1.4 in dorsal group, respectively; P = 0.002 and 0.010). Odom’s criteria were also significantly
improved over 6 months in the Ventral group compared to the Dorsal group.
Limitations: This study was a retrospective analysis with a relatively short follow-up duration
was not a randomized, controlled study. Therefore, the clinical effects of the catheter position
could be confounded by other variables.
Conclusion: In this short-term follow-up study, the effects of lumbar PEN on VAS scores were
different according to the position of the catheter tip in patients with single-level lumbar disc
herniation. Better outcomes in the Ventral group may have been achieved by more localized
treatment with a selective block in the epidural space closer to the dorsal root ganglion and
ventral aspect of the nerve root.
Key words: Lumbar disc disease, pain management, percutaneous epidural neuroplasty,
catheter position, dorsal, ventral
Lumbar Interlaminar Epidural Injections Are
Superior to Caudal Epidural Injections in
Managing Lumbar Central Spinal Stenosis
Authors: Manchikanti Laxmaiah
Published: February 2021

Background: Epidural injections are performed to manage lumbar central spinal
stenosis pain utilizing caudal, interlaminar, and transforaminal approaches. The
literature on the efficacy of epidural injections in managing lumbar central spinal
stenosis pain is sparse; lacking multiple, high quality randomized trials with long-term
follow-up.
Methods: Two randomized controlled trials of the caudal and lumbar interlaminar
approaches that assessed 220 patients with lumbar central spinal stenosis were
analyzed.
Results: The analysis found efficacy for both caudal and interlaminar approaches in
managing chronic pain and disability from central spinal stenosis was demonstrated.
In the patients responsive to treatment, those with at least 3 weeks of improvement
with the first 2 procedures, 51% reported significant improvement with caudal
epidural injections, whereas it was 84% with local anesthetic only with interlaminar
epidurals, 57% with caudal and 83% with lumbar interlaminar with local anesthetic
with steroid. The response rate was 38% with caudal and 72% with lumbar
interlaminar with local anesthetic only and 44% with caudal and 73% with lumbar
interlaminar with local anesthetic with steroid when all patients were considered. In
the interlaminar approach, results were superior for pain relief and functional status
with fewer nonresponsive patients compared to the caudal approach.
Limitations: The data was derived from 2 previously published randomized,
controlled trials rather than comparing 2 techniques in one randomized controlled
trial. Further, the randomized controlled trials were active control trials without a
placebo.
Conclusions: The results of this assessment showed significant improvement in
patients suffering with chronic lumbar spinal stenosis with caudal and interlaminar
epidural approaches with local anesthetic only, or with steroids in a long-term followup of up to 2 years, in contemporary interventional pain management setting, with
the interlaminar approach providing significantly better results.
Key Words: Caudal epidural, lumbar interlaminar, transforaminal epidural, steroids,
local anesthetic, central spinal stenosis, radiculitis
The Incorporation of Platelet-rich Plasma into
Calcium Phosphate Cement Enhances Bone
Regeneration in Osteoporosis
Authors: Kim Kyung-Hoon
Published: February 2021

Background: Polymethyl methacrylate (PMMA) bone cement is widely used for osteoplasty.
However, previous studies have demonstrated the adverse effects of PMMA due to its excessive
stiffness and heat production. Recently, calcium phosphate cement (CPC) that overcomes those
negative effects has been successfully applied in osteoplasty. The potential problem of CPC is
markedly less initial stiffness. It leads to progressive, repeated collapse in the treated vertebra
before CPC has been replaced by new bone that would provide substantial improvement in
compressive strength and stiffness. The activated platelets in platelet-rich plasma (PRP) release a
high concentration of growth factors which play an important role in bone healing.
Objective: To investigate whether PRP could accelerate the osteoconduction of CPC and enhance
the bone strength of the treated vertebra in an animal model.
Study Design: Controlled animal study.
Setting: Laboratory animal study,
Methods: Thirty-two female Sprague-Dawley rats were ovariectomized at 8 weeks of age. After 3
months, they were randomly divided into 4 groups and received cement augmentation in the fifth
caudal spine with different filler materials; sham-operated rats (S), PMMA (P), CPC (C), and CPC +
PRP (CP). Bone mineral density (BMD) and trabecular type-associated morphological parameters,
including trabecular bone volume fraction and trabecular thickness in the augmented caudal spine,
were evaluated by micro-computed tomography (mirco-CT) 2 weeks after the cementoplasty.
Histological analysis was also performed to compare the bone regeneration.
Results: The trabecular bone volume fraction in the CP group was significantly greater than those
of all the other groups. Trabecular thickness was higher in the CP group than the S and P groups.
This augmented trabecular structure in the CP group accordingly showed higher BMD. Histological
evaluations showed significantly more bone regeneration in the CP group.
Limitations: There has been a concern that the effect of PRP would be dependent on the
species, and might show different results in humans. Baseline values of micro-CT analysis were
not measured, which could have provided exact evidence of the changes in trabecular microarchitecture parameters and cement resorption profiles. Finally, caudal vertebrae with filler
materials used in biological study should have been compared by their mechanical properties using
biomechanical evaluations for a more coherent study, which was not possible due to technical
problems.
Conclusions: Incorporating PRP into CPC could accelerate osteoconduction in the augmented
vertebra leading to improvement of trabecular bone microarchitecture and BMD in rats.
Key words: Bone mineral density, calcium phosphates, cementoplasty, histology, osteoconduction,
osteoporosis, platelet-rich plasma, polymethyl methacrylate, vertebra
Hemiparesis and Facial Sensory Loss following
Cervical Epidural Steroid Injection
Authors: Wahezi Sayed E.
Published: February 2021

Interlaminar cervical epidural steroid injections (ic-ESI) are safe and effective treatment options
for the management of acute and chronic radiculopathy, spinal stenosis, and other causes of
neck pain not responding to more conservative measures. However, the procedure inherently
lends itself to possible spinal cord injury (SCI). Though reports of such events have been
documented, the clinical presentation of patients with needle puncture SCI varies. In part, this
may be due to anatomic considerations, as symptoms may be dependent on the cervical level
intruded, as well as the volume and type of injectate used.
Many cases go unreported and therefore the true incidence of cord injections during ic-ESI
is not known. Cervical epidurals can be performed by the transforaminal or interlaminar
approach. It is generally accepted that ic-ESI is safer than transforaminal epidurals. There are
numerous reports of arterial invasion or irritation with the latter despite an inherently greater
risk of cord puncture with the former. The likelihood of cord interruption rises when ic-ESIs are
performed above C6-C7 as there is a relatively slim epidural layer compared to lower cervical
epidural zones. Though most cases of devastating outcomes, such as hemiplegia and death,
have been reported during cervical transforaminal epidural injections and rarely with ic-ESI,
it is important to understand the symptoms and potential pitfalls of performing any cervical
epidural injection. Cervical epidural malpractice claims are uncommon, but exceed those of
steroid blocks at all the levels combined, demonstrating the need for improved awareness of
potential complications in ic-ESI. Here, we will describe an unusual presentation of a spinal cord
injection during an ic-ESI procedure.
Key words: Cervical epidural, spinal cord, hemiparesis
Radioisotope Cisternography: A Potentially
Useful Tool for Headache Diagnosis in Patients
with an IDD Pump
Authors: Andres Dr. Jose De
Published: February 2021

Background: Spontaneous intracranial hypotension (SIH) and related headache
after intrathecal pump implantation is a possibility. Knowing the exact location of the
cerebrospinal fluid (CSF) leak is mandatory for managing with interventional therapies.
Objectives: Radioisotope cisternography (RICG) is a common procedure in nuclear
medicine and may be used as an additional procedure in the differential diagnosis of
headaches due to intracranial liquor hypotension syndrome caused by microleakage
of CSF.
Study Design: We report an imaging case of complex chronic headache in a patient
with an implanted drug delivery pump. The symptomatology of the patient was
considered typical of spontaneous intracranial hypotension (SIH). Therefore, the initial
suspicion was the loss of CSF due to the implanted pump catheter. The negativity of the
routine headache test can exclude any leakage of CSF at the site of catheter insertion.
Setting: Anesthesia, Critical Care, and Multidisciplinary Pain Management
Department, General University General Hospital, Valencia, Spain.
Results: Many patients are treated with implanted intrathecal infusion systems.
In these patients, any neurological symptoms are readily attributed to the invasive
neuroaxial system, especially severe cephalalgia. RICG was helpful in this particular case
to make a diagnosis of exclusion of the diagnosis of SIH due to CSF leakage.
Conclusion: RICG may be considered as an additional diagnostic technique in patients
with chronic pain and implanted spinal infusion devices for whom standard detection
procedures have been exhausted.
Key words: Intrathecal drug delivery (IDD), chronic headache (CH), radiosotope
cisternography (RICG), cerebrospinal fluid leakage, spontaneous intracranial
hypotension (SIH)
Radiologic Analysis and Clinical Study of
the Upper One-third Joint Technique for
Fluoroscopically Guided Sacroiliac Joint Injection
Authors: Kim Young Hoon
Published: February 2021

Background: Sacroiliac intraarticular injection by the traditional technique can be challenging
to perform when the joint is covered with osteophytes or is extremely narrow.
Objective: To examine whether there is enough space for the needle to be advanced from
the L5-S1 interspinous space to the upper one-third sacroiliac joint (SIJ) by magnetic resonance
image (MRI) analysis as an alternative to fluoroscopically guided SIJ injection with the lower
one-third joint technique, and to determine the feasibility of this novel technique in clinical
practice.
Study Design: MRI analysis and observational study.
Setting: An interventional pain management practice at a university hospital.
Methods: We analyzed 200 axial T2-weighted MRIs between the L5 and S1 vertebrae of
100 consecutive patients. The following measurements were obtained on both sides: 1) the
thickness of fat in the midline; 2) the distance between the midline (Point C) and the junction
(Point A) of the skin and the imaginary line that connects the SIJ and the most medial cortex
of the ilium; 3) the distance between the midline (Point C) and the junction (Point B) of the
skin and the imaginary line that connects the SIJ and the L5 spinous process; 4) the distance
between the SIJ and midline (Point C) on the skin, or between the SIJ and the midpoint
(Point C’) of the line from Point A to Point B; and 5) the angle between the sagittal line and
the imaginary line that connects the SIJ and the midline on the skin. The upper one-third
joint technique was performed to establish the feasibility of the alternative technique in 20
patients who had unsuccessful sacroiliac intraarticular injections using the lower one-third
joint technique.
Results: The mean distances from the midline to Point A and to Point B were 21.9 ± 13.7 mm
and 27.8 ± 13.6 mm, respectively. The mean distance between the SIJ and Point C (or Point C’)
was 81.0 ± 13.3 mm. The angle between the sagittal line and the imaginary line that connects
the SIJ and the midline on the skin was 42.8 ± 5.1°. The success rate of sacroiliac intraarticular
injections with the upper one-third joint technique was 90% (18/20).
Limitations: This was an observational study and lacked a control group.
Conclusions: Sacroiliac intraarticular injections with the upper one-third joint technique are
advisable when it is hard to perform them with the lower one-third joint technique.
Key words: Buttock pain, fluoroscopy, low back pain, sacroiliac joint, sacroiliac joint pain
Percutaneous Kyphoplasty for Kummell Disease
with Severe Spinal Canal Stenosis
Authors: Yang Yan
Published: February 2021

Background: Percutaneous kyphoplasty (PKP) has been proven as an effective, minimally
invasive procedure for the treatment of Kummell’s disease in the early stages. However, a risk
of cement leakage and further neurological damage remains during and after PKP, especially in
chronic osteoporotic stage III Kummell’s disease with severe spinal canal stenosis.
Objective: To evaluate the feasibility and efficacy of PKP for the treatment of chronic
osteoporotic stage III Kummell’s disease with severe spinal canal stenosis.
Study Design: A retrospective evaluation of postoperative radiographs.
Setting: Pain management clinic.
Methods: A retrospective study was performed on 9 patients with 11 levels managed with PKP
for chronic osteoporotic stage III Kummell’s disease with severe spinal canal stenosis. Clinical and
radiological outcomes were assessed.
Results: Substantial pain relief was attained in all the patients. Both visual analogue scale (VAS)
and Oswestry Disability Index (ODI) scores improved significantly from pre- to post-operation (P
< 0.05), and remained unchanged at every follow-up. No neurological deterioration was found.
Postoperatively, the anterior and midline vertebral body heights were significantly corrected (P
< 0.05), and were sustained at the final follow-up. Similar results were seen in the correction
of kyphotic angle. Neither cement leakage into the spinal canal nor further dislodging of the
posterior vertebral fragments occurred. Two cases experienced subsequent fractures with one
having a second PKP and the other being treated conservatively.
Limitations: Retrospective study of 9 cases with 11 levels due partly to the rarity of the disorder.
Conclusions: PKP is an effective, minimally invasive procedure for the treatment of chronic
osteoporotic stage III Kummell’s disease with severe spinal stenosis, leading to a significant relief
of symptoms and improvement of functional status.
Institutional Review: This study was approved by the Institutional Review Board.
Key words: Kummell’s disease, kyphoplasty, spine, osteoporosis, cement leakage,
polymethylmethacrylate, neurological deficits, burst fractures
ANVCFV Score System: Assessment for
Probability of New Vertebral Compression
Fractures after Percutaneous Vertebroplasty in
Patients with Vertebral Compression Fractures
Authors: Teng Gao-Jun
Published: February 2021

Background: Percutaneous vertebroplasty (PVP) is widely used for the treatment of painful
vertebral compression fractures (VCFs). However, new VCFs occur frequently after PVP.
Objectives: We aim to establish an objective risk score system to assess the possibility of new
vertebral fractures in patients with VCFs undergoing PVP.
Study Design: This study was a retrospective study, and it was approved by the Institutional
Review Board of our 2 institutions.
Setting: This study consists of patients from 2 large academic centers.
Methods: Patients with VCFs who underwent their first PVP and met the inclusion criteria
between January 2007 and December 2013 at Hospital A (training cohort) and Hospital B
(validation cohort) were included. In the training cohort, the independent risk factors for new
VCFs after PVP were identified by multivariate stepwise backward Cox regression analysis from
the risk factors selected by univariate analysis and Harrell’s C-statistics and used to develop the
score system (assessment for new VCFs after PVP [ANVCFV]) to predict the probability of new
VCFs.
Results: In total, 397 patients (training cohort: n = 241; validation cohort: n = 156) were
included in this study. In the training cohort, the ANVCFV score was developed based on 5
independent risk factors for the new VCFs after PVP, including lower computed tomography
(CT) values, pre-existing old VCFs, intradiscal cement leakage, more than one vertebra treated,
and superior or inferior marginal cement distribution in the vertebra. The patients were divided
into 2 groups by the ANVCFV score of -1.5 to 8.5 vs. > 8.5 points in the probability of new VCFs
(median fracture-free time: 1846 vs. 732 days; P < 0.001) in the training cohort. The accuracy
of this score system was 77.4% for the training cohort and 85.3% for the validation cohort.
Limitations: The main limitations of this study are that it is a retrospective study and that
there is a significant difference of the treated vertebrae of PVP per session between the 2
cohorts.
Conclusion: Patients who underwent their first PVP with an ANVCFV score > 8.5 points may
exhibit an increased chance of suffering from new VCFs.
Key words: Vertebral compression fracture, percutaneous vertebroplasty, newly developed,
risk factors, risk score system, Cox regression model, accuracy, validation
Improving Analgesic Efficacy and Safety of
Thoracic Paravertebral Block for Breast Surgery:
A Mixed-Effects Meta-Analysis
Authors: Terkawi Abdullah S.
Published: February 2021

Background: While most trials of thoracic paravertebral nerve blocks (TPVB) for breast surgery
show benefit, their effect on postoperative pain intensity, opioid consumption, and prevention
of chronic postsurgical pain varies substantially across studies. Variability may result from use of
different drugs and techniques.
Objectives: To examine the use of TPVB in breast surgery, and to determine which method(s)
provide optimal efficacy and safety.
Study Design: Mixed-Effects Meta-Analysis.
Methods: We conducted a systematic review of randomized trials comparing TPVB to no
intervention using random-effects models. To evaluate the contributions of various techniques,
clinical approaches were included as moderators in mixed-effects models.
Results: A total of 24 randomized controlled trials (RCTs) with 1,822 patients were included. Use
of TPVB decreased postoperative pain scores at rest and movement at the first 2, 24, 48, and 72
hours. TPVB modestly decreased intraoperative and postoperative opioid consumption, reduced
nausea and vomiting, and shortened hospitalization, but to a probably clinically irrelevant degree.
Blocks also appeared to reduce the incidence of chronic postsurgical pain at 6 months. Adding
fentanyl to the TPVB improved pain at rest (at 24, 48, and 72 hours) and movement (at 24 and 72
hours). Multilevel blocks provided better postoperative pain control, but only during movement (at
2, 48, and 72 hours). Fewer procedural complications (especially hypotension, epidural spread, and
Horner’s syndrome) occurred when anatomical landmarks were supplemented with ultrasound
guidance.
Limitations: The number of studies available was limited in the meta-analytic model of incidence
of chronic post-surgical pain.
Conclusion: TPVB reduces postoperative pain and opioid consumption, and has a limited
beneficial effect on the quality of recovery. From all the techniques that were evaluated, only
the addition of fentanyl, and performing multilevel blocks were associated with improved acute
analgesia. TPVB may reduce chronic postsurgical pain at 6 months.
Key words: Thoracic paravertebral block, breast surgery, anesthesia, acute pain, chronic pain,
nausea, vomiting, length of stay, techniques, variability, meta-regression, meta-analysis, moderators
Effectiveness and Safety of Pulsed
Radiofrequency Treatment Guided by Computed
Tomography for Refractory Neuralgia of
Infraorbital Nerve: A Pilot Study
Authors: Nan Ji
Published: February 2021

Background: There is no truly optimal treatment to cure refractory neuralgia of the infraorbital
nerve. Recently, nondestructive pulsed radiofrequency (PRF) has become one of the most attractive
interventional techniques for painful disorders. However, use of the technique for infraorbital
neuralgia has been seldom reported.
Objective: The purpose of this prospective study is to observe the effectiveness and safety of PRF
treatment for neuralgia of the infraorbital nerve.
Study Design: Prospective case series clinical outcome study.
Setting: University Medical Center, Beijing, China
Methods: From January 2011 to November 2012, 36 consecutive patients, following ineffective
conservative therapy, underwent PRF treatment and completed 2-year follow-up. Numeric rating
scales (NRS), effective rate, additional carbamazepine dosage, and side effects were recorded at
postoperative day one, week one, week 2, month one, month 3, month 6, year one, and year
2. Patients were divided into effective group and ineffective group based on postoperative one
-month total pain relief or more than 50% reduction in NRS and patients were satisfied with the
effect, and possible factors affecting efficacy were compared between the 2 groups.
Results: Effective rates were 69%, 69%, 64%, 50%, and 50% at postoperative month one,
month 3, month 6, year one, and year 2, respectively. No serious side effects were observed, except
that 9 patients felt short-term (one -month duration) mild numbness. Output voltage and tissue
resistance in the effective group were significantly higher than the ineffective group (P < 0.01).
Intraoperative output voltage was negatively correlated with postoperative one -month NRS (r =
-0.332, P < 0.05).
Limitations: The non-controlled and single-centered design of the study.
Conclusions: Results demonstrated PRF treatment under computed tomography (CT) guidance
for infraorbital neuralgia is safe, effective, and is expected to become an alternative for patients
experiencing ineffective conservative therapy. Increasing the output voltage of PRF could be the
chosen method to improve the efficacy.
Key words: Infraorbital nerve, neuralgia, pulsed radiofrequency, radiofrequency
thermocoagulation