bluuebunny/crossref_metadata_2025 huggingface dataset:
Conus Medullaris Infarction After a Right L4
Transforaminal Epidural Steroid Injection Using
Dexamethasone
Authors: Fakhry Michael
Published: February 2021

Background: For decades, epidural steroid injections have been an effective tool in the
management of many pain related conditions, including lumbar radiculopathy. Transforaminal
epidural steroid injections in particular have been reported to potentially result in central nervous
system infarctions which have not been reported with interlaminar epidural steroid injections, while
providing comparable efficacy. This rare, catastrophic complication has been attributed by some
authors to be due to vascular injury secondary to vasospasm, thrombus formation, dissection, as
well as concerns with placing the needle at the so-called “safe triangle.” Others, however, have
proposed it to be secondary to embolization of the vessel by particulate steroids. This has led to the
recommendation of the use of soluble steroids such as dexamethasone when performing TFESI’s,
despite concerns over its efficacy and potential for neurotoxicity in the literature. Furthermore,
there have also been multiple studies which have revealed that IV dexamethasone is analgesic and
that peri-neural dexamethasone is no more effective than IV dexamethasone.
Case History: The present case involves a 60-year-old patient with right back and radicular
leg pain for 3 years. Two right L4 TFESI’s had been performed with betamethasone several years
prior with satisfactory results, until the patient presented to the physician with a pain recurrence
of 6 weeks of duration. The patient again underwent a right L4 TFESI with dexamethasone,
which provided good relief after 2 weeks. The patient underwent a repeat right L4 TFESI with
dexamethasone which was followed by a prompt onset of lower extremity numbness, weakness,
and incontinence that was discovered to be related to a conus infarction. While this is the
first publicly reported case of a conus medullaris infarction following a lumbar transforaminal
injection utilizing dexamethasone, the incidence of these reports may rise as the prevalence of
dexamethasone use increases in clinical practice.
Conclusion: The spinal cord infarction with TFESI’s may occur related to various mechanisms,
regardless of the type of particulate or non-particulate steroid used during these procedures.
Key words: Dexamethasone, particulate steroids, non-particulate steroids, conus medullaris
infarction, cauda equina syndrome, transforaminal epidural steroid injection, epidural steroid
injection, safe triangle, methylprednisolone, paralysis
Finite Element Analysis of the Effect of
Epidural Adhesions
Authors: Shin Dong Ah
Published: February 2021

Background: It is well documented that epidural adhesion is associated with spinal pain.
However, the underlying mechanism of spinal pain generation by epidural adhesion has not yet
been elucidated.
Objectives: To elucidate the underlying mechanism of spinal pain generation by epidural
adhesion using a two-dimensional (2D) non-linear finite element (FE) analysis.
Study design: A finite element analysis.
Setting: A two-dimensional nonlinear FE model of the herniated lumbar disc on L4/5 with
epidural adhesion.
Methods: A two-dimensional nonlinear FE model of the lumbar spine was developed, consisting
of intervertebral discs, dura, spinal nerve, and lamina. The annulus fibrosus and nucleus pulpous
were modeled as hyperelastic using the Mooney-Rivlin equation. The FE mesh was generated and
analyzed using Abaqus (ABAQUS 6.13.; Hibbitt, Karlsson & Sorenson, Inc., Providence, RI, USA).
Epidural adhesion was simulated as rough contact, in which no slip occurred once two surfaces
were in contact, between the dura mater and posterior annulus fibrosus.
Results: The FE model of adhesion showed significant stress concentration in the spinal nerves,
especially on the dorsal root ganglion (DRG). The stress concentration was caused by the lack of
adaptive displacement between the dura mater and posterior annulus fibrosus. The peak von
Mises stress was higher in the epidural adhesion model (Adhesion, 0.67 vs. Control, 0.46). In the
control model, adaptive displacement was observed with decreased stress in the spinal nerve and
DRG (with adhesion, 2.59 vs. without adhesion, 3.58, P < 0.00).
Limitations: This study used a 2D non-linear FE model, which simplifies the 3D nature of the
human intervertebral disc. In addition, this 2D non-linear FE model has not yet been validated.
Conclusion: The current study clearly demonstrated that epidural adhesion causes significantly
increased stress in the spinal nerves, especially at the DRG. We believe that the increased stress on
the spinal nerve might elicit more pain under similar magnitudes of lumbar disc protrusion.
Key words: Finite element, epidural adhesion, spinal pain, adhesiolysis
Elastoplasty: A Silicon Polymer as a New Filling
Material for Kyphoplasty in Comparison to PMMA
Authors: Bornemann Rahel
Published: February 2021

Background: Painful vertebral compression fractures (VCF) caused by osteoporosis are a
common health problem in the elderly population. If conservative treatments are unsuccessful,
surgical treatments like vertebroplasty or kyphoplasty are recommended. But the use of
Polymethylmethacrylat (PMMA) bone cement for augmentation surgery is associated with risks.
Objectives: Evaluation of the effectiveness and safety of a newly developed silicon polymer
(VK100) that can be used instead of PMMA bone cement for kyphoplasty treatments.
Study Design: A retrospective study of 30 patients comparing the outcomes of kyphoplasty
treatments conducted with PMMA and VK100.
Setting: Clinic for Orthopedics and Trauma Surgery Bonn, Germany.
Methods: Thirty patients with one to 3 VCF were treated either with balloon kyphoplasty using
VK100 or balloon kyphoplasty using PMMA bone cement. Data from both groups was compared
by a matched pair analysis. The medial vertebral height was measured at each examination
radiologically. The patients stated their pain intensity using the Visual Analogue Scale (VAS) and
the patient’s functional impairment was evaluated with the Oswestry-Disability-Index (ODI).
All data were assessed before surgery, and 3 days, 3 months, 6 months, and 12 months after
surgery. Intraoperative and postoperative adverse events were documented.
Results: The patients’ functional impairment and pain improved significantly after surgery. The
course of ODI and VAS was comparable in both treatment groups, but the improvement in the
VK group was significantly ongoing until the 12 month follow-up. Vertebral height improvement
was significant in both groups, but the PMMA group achieved a better absolute restoration. The
vertebral height stayed constant during the follow-up in the VK group and worsened significantly
in the PMMA group. There was no significant difference between groups concerning the
occurrence of additional fractures; and no other types of complications or surgery-related adverse
events were observed in either the PMMA group or in the VK group.
Limitations: The study is only a matched pair analysis of 15 patients for each procedure and the
amount of injected filling material was not recorded.
Conclusion(s): The study results demonstrate that the clinical outcome of VAS and ODI of
using the silicon polymer VK100 is comparable or slightly better than using PMMA. VK 100 shows
a trend to minor additional fractures during the follow-up. However, height restoration is not
satisfactory in comparison to PMMA, although vertebral height stayed more or less constant in the
VK group. To address the augmentation success further, it would be necessary to study a larger
patient group over a longer study period and to assess additional parameters such as bone density
and injected amount of filling material.
Key words: Vertebral compression fracture, kyphoplasty, augmentation, osteoporosis, back
pain, VK 100, elastoplasty
Anatomical Basis for Injection around First
Dorsal Compartment of the Wrist: A Fresh
Cadaveric Study
Authors: Kim Dong Hwee
Published: February 2021

Background: It is important to understand the anatomical relationship between the medial
and lateral branches of superficial radial nerve (SRN) and the first dorsal compartment to
prevent and minimize possible injury to these nerves during various procedures around the tip
of radial styloid process (RSP).
Objective: To delineate the anatomical location of the SRN in relation to the extensor pollicis
brevis (EPB) and abductor pollicis longus (APL) tendons.
Study Design: Observational study.
Setting: Academic medical center.
Methods: The width of the first dorsal compartment, distance between the EPB tendon and
the closest medial branch of the SRN, and distance between the APL tendon and the closest
lateral branch of the SRN were measured. The distances were measured at the RSP (the tip of
the RSP) and RSP+1 (1 cm proximal to the tip of the RSP) levels.
Results: The median distances between the EPB tendon and the closest medial branch of the
SRN at the RSP and RSP+1 were 6.0 mm (range: 1.6 − 11.0 mm) and 3.2 mm (range: -2.0 −
9.4 mm), respectively. The median distances from the APL tendon to the closest lateral branch
of the SRN at the RSP and RSP+1 were -2.0 mm (range: -9.0 − 8.4 mm) and 1.0 mm (range:
-7.2 − 8.0 mm), respectively. A high percentage of overlap (up to 59%) was observed between
the lateral branch of the SRN and the APL tendon.
Limitation: This study is limited by its small sample size.
Conclusion: Due to the anatomical proximity of the branches of the SRN and the first
dorsal compartment around the RSP, physicians must be cautious during procedures near this
location. It is important to approach from above the EPB, rather than from above the APL,
when performing blind procedures, although ultrasound guidance is preferable.
Key words: Superficial radial nerve, abductor pollicis longus, extensor pollicis brevis, cadaver;
wrist, first dorsal compartment
Complex Regional Pain Syndrome Caused by
Lumbar Herniated Intervertebral Disc Disease
Authors: Choi Sang Sik
Published: February 2021

Most cases of complex regional pain syndrome (CRPS) occur after some inciting injury. There are
a few cases of CRPS after an operation for disc disease. CRPS from a mild herniated intervertebral
disc (HIVD) without surgical intervention is even rarer than CRPS after an operation for disc
disease.
A 22-year-old man was transferred to a pain clinic. He had continuously complained about back
and right leg pain. He presented with a skin color change in the right lower leg, intermittent
resting tremor, stiffness, and swelling in the right leg. He complained of a pulling sensation
and numbness in his right buttock, posterior thigh, lateral calf, and ankle. This symptom was in
accordance with L4/5 radiculopathy. Magnetic resonance imaging (MRI) also showed L4/5 HIVD
that was central to the bilateral subarticular protrusion.
He was diagnosed as having CRPS, which fits the revised International Association for the Study
of Pain (IASP) criteria. He fulfilled 4 symptom categories (allodynia, temperature asymmetry and
skin color change, sweating changes, decreased range of motion and motor dysfunction) and
3 of 4 sign categories (allodynia, temperature asymmetry and skin color changes, decreased
range of motion and motor dysfunction). The bone scan and thermography also revealed CRPS.
For the past 2 months, we have performed intensive treatments. But, he never became painfree and walking for 5 minutes led to persistent leg pain. We decided to perform percutaneous
nucleoplasty, which can directly decompress a HIVD. On the next day, he achieved dramatic
symptom relief. The visual analog scale (VAS) score improved to 3, compared to the VAS score
of 9 at the first visit. The skin color change, allodynia, and tremor in the right leg disappeared,
and the temperature asymmetry normalized. Motor weakness of the right leg also recovered.
We report an unusual case of CRPS that was caused by L4/5 HIVD without a history of trauma
or surgery. It has a clear causal relationship between HIVD and CRPS and definitively fits in the
newly revised IASP criteria. In conclusion, mild HIVD can cause CRPS without any trauma. And
percutaneous nucleoplasty can be considered as a treatment option.
Key words: Complex regional pain syndrome, diagnosis, herniated intervertebral disc,
nucleoplasty, radiculopathy, sign, symptom, treatment
Facility Payments for Interventional Pain
Management Procedures: Impact of Proposed
Rules
Authors: Manchikanti Laxmaiah
Published: February 2021

In the face of the progressive implementation of the Affordable Care Act (ACA), a significant
regulatory regime, and the Merit-Based Incentive Payment System (MIPS), the Centers for
Medicare and Medicaid Services (CMS) released its proposed 2017 hospital outpatient
department (HOPD) and ambulatory surgery center (ASC) payment rules on July 14, 2016,
and the physician payment schedule was released July 15, 2016. U.S. health care costs
continue to increase, occupying 17.5% of the gross domestic product (GDP) in 2014 and
surpassing $3 trillion in overall health care expenditure. Solo and independent practices face
unique challenges and many are being acquired by hospitals or larger groups. This transfer
of services to hospital settings is indisputably leading to an increase in the net cost to the
system.
Comparison of facility payments for interventional techniques in HOPD, ASC, and in-office
settings shows wide variation for multiple interventional techniques. Major discrepancies in
payment schedules are related to higher payments for hospitals than comparable treatments
in in-office settings and ASCs. In-office procedures, which have been converted to ASC
procedures, are reimbursed at as high as 1,366% higher than ASCs and 2,156% higher
than in-office settings. The Medicare Payment Advisory Commission (MedPAC) has made
recommendations on avoiding the discrepancies and site-of-service differentials in in-office
settings, hospital outpatient settings, and ASCs. These have not been implemented by CMS.
In addition, there have been slow reductions in reimbursements over the recent years, which
continue to accumulate, leading to significant reductions in payments
In conclusion, equalization of site-of-service differentials will simultaneously improve
reimbursement patterns for interventional pain management procedures, increase access
and quality of care, and finally, reduce costs for CMS, extending Medicare solvency.
Key words: Hospital outpatient departments, ambulatory surgery centers, physician inoffice services, interventional pain management, interventional techniques
Intrathecal Dexmedetomidine, Ketamine, and
their Combination Added to Bupivacaine for
Postoperative Analgesia in Major Abdominal
Cancer Surgery
Authors: El-Rahman Ahmad MA
Published: February 2021

Background: Intrathecal ketamine has been studied extensively in animals, but rarely in
humans. Intrathecal dexmedetomidine prolongs the duration of spinal anesthesia.
Objective: To investigate the efficacy and safety of intrathecal dexmedetomidine, ketamine,
or both when added to bupivacaine for postoperative analgesia in major abdominal cancer
surgery.
Design: Double-blinded, randomized, controlled trial.
Setting: Academic medical center.
Methods: Ninety patients were randomly allocated to receive either intrathecal 10 mg of
hyperbaric bupivacaine 0.5% and 5 µg of dexmedetomidine (group I, n = 30), 10 mg of
hyperbaric bupivacaine 0.5% and 0.1 mg/kg ketamine (group II, n = 30), or 10 mg of hyperbaric
bupivacaine 0.5% and 5 µg of dexmedetomidine plus 0.1 mg/kg of ketamine (group III, n = 30).
Hemodynamics, pain score, time to first request of analgesia, total PCA morphine consumption,
sedation score, and adverse effects in the first 24 hours postoperatively were recorded.
Results: Time to first request of analgesia was longer in group II (7.42 ± 1.43 h) and group
III (13.00 ± 7.31h) compared to group I (3.50 ± 1.57 h). PCA morphine consumption was less
in group III (6.67 ± 2.8 mg) compared to group I (9.16 ± 3.63 mg) and group II (8.66 ± 3.49
mg). Group III showed lower postoperative pain scores, and a higher incidence of postoperative
sedation (P < 0.03).
Limitations: This study is limited by its relatively small sample size.
Conclusion: In conclusion, the combination of intrathecal dexmedetomidine and ketamine
provided superior postoperative analgesia, prolonged the time to first request of rescue
analgesia, and reduced the total consumption of PCA morphine, without serious side effects
compared to either drug alone.
Key words: Intrathecal, ketamine, dexmedetomidine, lower abdominal cancer surgery
Pain Pressure Threshold in the Region of the
Sacroiliac Joint in Patients Diagnosed with
Sacroiliac Joint Pain
Authors: Leeuwen RJH van
Published: February 2021

Background: Although the prevalence of sacroiliac joint (SIJ) pain is relatively
high (15 – 30%), there is no unambiguous reference standard to diagnose SIJ pain.
Pressure tenderness in the SIJ region is used for diagnostic purposes, but the clinimetric
properties of this procedure remain to be determined.
Objectives: The aim of this study is to determine the reliability of pain pressure
threshold (PPT) measurements in the SIJ region and the difference in PPTs in the SIJ
region between healthy volunteers and PPTs in patients with SIJ pain.
Study Design: Prospective cohort study.
Setting: Outpatient pain clinic VU University Medical Center.
Methods: Forty-one healthy volunteers and 31 patients diagnosed with SIJ pain were
included. PPTs were obtained from 5 measurement points in the region of the SIJ with
a pressure pain algometer using a standardized protocol. The inter-rater reliability of
this method was calculated by means of the Intraclass Correlation Coefficients (ICC)
of individual assessment performed by 2 individual raters of SIJs of healthy volunteers
on both sides. PPTs of healthy volunteers were compared to those of the affected side
in patients with SIJ pain.
Results: PPT measurement showed moderate to good inter-rater reliability (ICC 0.6 –
0.82).The median PPTs of 5 points was comparable for both sides in healthy volunteers
(right: 8.5 kg/cm2
[IQR 6.0 – 10.0]; left 8.3 kg/cm2
(5.8 – 10.0]). Median PPTs for the
affected sides of patients with SIJ pain were significantly lower compared to the same
side of healthy volunteers (right: 2.4 kg/cm2
[IQR 2.2 – 3.2, n = 15]; left: 2.5 kg/cm2
[2.3 – 3.2, n = 16]; P < 0.001 for both sides).
Limitations: Only the SIJ on one side of was measured in patients with SIJ pain,
where both sides would be desirable.
Conclusions: Pressure pain algometry appears to be a reliable method to establish
differences in PPTs between healthy volunteers and patients with SIJ pain. The
diagnostic accuracy of this test should be investigated further.
Key words: Sacroiliac joint pain, pain pressure threshold, pressure algometry
What is the Correlation Between Facet Joint
Radiofrequency Outcome and Response to
Comparative Medial Branch Blocks?
Authors: Holz Sara Christensen
Published: February 2021

Background: Facet joint pain is a common cause of low back pain. There are no physical exam
findings that provide a reliable diagnosis. Diagnosis is made by medial branch block injections
(MBB). Once the source of pain has been determined, radiofrequency neurotomy (RFN) can be
performed. Previous studies have shown that RFN reduces level of pain and improves function. No
study has tried to correlate MBB results with outcomes after RFN.
Objectives: (1) Estimate percentage decrease in pain, decrease in analgesic use, and increase in
activity tolerance after facet joint radiofrequency neurotomy (2) Determine correlation between
percentage pain relief or duration of pain relief after MBB and RFN outcomes.
Study Design: Retrospective review of patients undergoing RFN, who had ≥ 70% pain relief
on 2 sets of MBB with 0.5 – 1 mL of 2% lidocaine (MBB 1) and 0.75% bupivacaine (MBB 2). IRB
approval was obtained before data collection began.
Setting: All patients undergoing RFN between 12/06-1/10 at University Spine and Pain clinics.
Methods: Subgroup analysis was performed based on response to MBB, a)100% pain relief
and <100% pain relief after MBB 1 and 2 and a) those with > 8 hours and ≤ 8 hours pain relief
after MBB 1 and 2. Correlational analysis was conducted to determine the correlation between
a) percent pain relief after MBB1 and 2 and percent change in pain after RFN and b) duration of
pain relief after MBB 1 and 2 and percent change in pain relief after RFN. Outcome measures: Pain
intensity, disability index, analgesic use, and patient perception of benefit.
Results: Mean improvement of Disability scores at 3 months was 12.63 (P = 0.001), percent
pain relief was 47.68% (P = 0.001). Patients with 100% pain relief after MBB 1 had greater
improvement of disability scores (P = 0.008). Those with > 8 hours pain relief after MBB 1 had
greater reduction in pain (P = 0.014). Pearson correlation analysis showed no correlation between
percent pain relief or duration of pain relief after MBB and percent pain relief after RFN.
Limitations: This was a small observational study with short-term follow up.
Conclusion: Patients had improved disability scores and decreased pain after RFN. No correlation
was seen between results on MBB and pain relief after RFN. It is still unclear how many medial
branch blocks are needed and the criteria for MBB results before proceeding to RFN.
Key words: Facet, medial branch blocks, radiofrequency ablation, chronic low back pain,
interventional spine procedures, functional improvement
Clinical Efficacy of Pulsed Radiofrequency
Neuromodulation for Intractable Meralgia
Paresthetica
Authors: Choi Hyuk Jai
Published: February 2021

Background: Meralgia paresthetica (MP) is a neurologic disorder of the lateral femoral
cutaneous nerve (LFCN), which is characterized by a localized area of paresthesia and
numbness on the anterolateral aspect of the thigh. In most patients with MP, symptoms
can be successfully managed with conservative treatment. However, in a small group of MP
patients who are refractory to medical treatment, more aggressive low-risk treatment should
be considered.
Objective: The objective of this study was to evaluate clinical outcomes of pulsed
radiofrequency (PRF) neuromodulation of the LFCN in MP patients refractory to conservative
treatment.
Study Design: Retrospective evaluation.
Methods: We retrospectively reviewed the clinical data of 11 patients with medically
intractable MP who underwent PRF neuromodulation of the LFCN. These patients with MP
underwent a diagnostic LFCN block using 2.0% lidocaine. Temporary pain relief > 50%
was considered to be a positive response to the diagnostic nerve block. Following a positive
response to the diagnostic nerve block, patients underwent PRF neuromodulation at 420
for 2 minutes. Patient pain was evaluated using a 10-cm visual analog scale (VAS). In MP
patients who received PRF, we statistically evaluated VAS scores and the presence of any
complications for 6 or more months after the procedure.
Results: The mean initial patient VAS score was 6.4 ± 0.97 cm. This score was decreased to
0.91 ± 0.70 cm, 0.82 ± 0.75 cm, and 0.63 ± 0.90 cm at the one-, 3-, and 6- month followups, respectively (P < 0.001). Sixty-three point six percent of patients achieved complete pain
relief (pain-free) in the last follow-up, whereas 27.3% of patients achieved successful pain
relief (≥ 50% reduction in pain as determined by the VAS score). Furthermore, we did not
observe any complications after the procedure.
Conclusion: PRF neuromodulation of the LFCN provides immediate and long-lasting
pain relief without complications. Therefore, PRF of the LCFN can be used as an alternative
treatment in patients with MP who are refractory to conservative medical treatment.
Key words: Diagnosis; lateral femoral cutaneous nerve, meralgia paresthetica, magnetic
resonance imaging, neurosurgery, pain, intractable, pulsed radiofrequency, visual analog
scale
Safety and Efficacy of Dexmedetomidine in
Treating Post Spinal Anesthesia Shivering: A
Randomized Clinically Controlled Dose-Finding
Trial
Authors: Abdel-Ghaffar Hala S.
Published: February 2021

Background: The optimum dose of dexmedetomidine for shivering control with the least
hemodynamic derangements is still under research.
Objective: To compare the efficacy, hemodynamic and side effects of dexmedetomidine in 3
different doses with those of meperidine for the treatment of shivering in patients undergoing
spinal anesthesia for minor elective lower abdominal surgery.
Study Design: Prospective double-blind randomized clinically controlled study.
Setting: University hospital.
Methods: One hundred twenty patients who developed shivering under spinal anesthesia.
On shivering, patients were randomly allocated to receive an intravenous 2 mL bolus dose
of meperidine 0.4 mg/kg (meperidine group, n = 30), dexmedetomidine 0.5 µg/kg (DEX I
group, n = 30), 0.3 µg/kg (DEX II group, n = 30), or 0.2µg/kg (DEX III group, n = 30). Control
of shivering, time taken for cessation of shivering, response rate, recurrence, hemodynamic
changes, sedation score, tympanic temperature, and side effects were noted and compared
between groups.
Results: The groups were comparable regarding demographic profile, tympanic temperature
decline, and shivering onset time (P > 0.05). Lower shivering cessation time (P < 0.001) and
higher response rate (P < 0.01) were observed in DEX I and II groups compared with DEX III and
meperidine groups, with a nonsignificant difference between DEX I and II groups. Recurrence
of shivering activity was higher in DEX III group (36.7%, P < 0.01) compared with DEX I (10%),
DEX II (6.7%) and meperidine (16.7%) groups. Lower heart rates, systolic and diastolic blood
pressure mean values were recorded in DEX I group (P < 0.05). Nine patients (30%) in DEX I
group were in levels 3 – 5 of sedation (P < 0.02) compared with 5 (16.66%), 2 (6.66%), and 4
(13.3) patients in DEX II, DEX III, and meperidine groups, respectively.
Limitations: This study is limited by its small sample size.
Conclusions: Among the 3 doses investigated, dexmedetomidine 0.3µg/kg effectively
treated shivering associated with spinal anesthesia with modest hemodynamic and sedation
effects.
Trial Registration: ClinicalTrials.gov Identifier: NCT02382432.
Key words: Dexmedetomidine, hypothermia, shivering, spinal anesthesia
High Frequency Spinal Cord Stimulation at 10
kHz for the Treatment of Chronic Pain: 6-Month
Australian Clinical Experience
Authors: Russo Dr Marc A.
Published: February 2021

Background: High frequency spinal cord stimulation at 10 kHz (HF10 therapy) represents a
prominent advance in spinal cord stimulation (SCS) therapy, having demonstrated enhanced
efficacy in patients with back and leg pain and pain relief without paresthesia that is sustained at
24 months post implant.
Objective: To report on the effectiveness HF10 SCS therapy for a wide range of intractable pain
conditions in clinical practice.
Study Design: Retrospective investigation of 256 patients who trialed HF10 SCS for chronic
intractable pain of various etiologies.
Setting: Three Australian pain clinics.
Methods: Two hundred fifty-six patients trialed HF10 SCS with view of a permanent implant
if successful. Pain distributions included back + leg, back only, head ± neck, and neck ± arm/
shoulder. About 30% of patients had previously failed traditional low-frequency paresthesiabased stimulation, while the remaining cohort were either highly refractory to treatment or not
recommended by the pain physician for traditional SCS. Pain scores (numerical pain rating scale
– NPRS) and functional outcome measures (Oswestry Disability Index – ODI; and activity tolerance
times) were assessed at baseline, post-trial, and at 3 and 6 months post-implant as available in the
medical records.
Results: Of the 256 patients, 189 (73%) reported a positive trial and were implanted. Patients
with back + leg pain demonstrated the highest trial success rate (81%). A mean reduction in
pain, among those for whom data were available, of 50% was sustained up to 6 months postimplant across the entire patient population. Sixty-eight percent of patients who failed traditional
SCS reported a positive trial and mean pain relief at 6 months was 49% (P < 0.001). An 8.6 point
reduction in ODI (21%) at 6 months and improved sitting, standing, and walking tolerances were
also reported.
Limitations: As data was collected retrospectively, missing data points were unavoidable; this
was primarily due to inconsistent data collection and patients being lost to follow-up. Patient
populations were diverse and a control group was not appropriate in this setting.
Conclusions: These retrospective results demonstrate a significant advancement for patients
suffering with chronic intractable pain and are consistent with recently published clinical results for
HF10 SCS. HF10 SCS appears to be a viable, paresthesia-free alternative to traditional SCS, with
high trial success rates, demonstrated effectiveness in a range of pain distributions including those
typically difficult to treat with traditional SCS, and the possibility to restore pain control in patients
who have previously failed traditional SCS.
Key words: Spinal cord stimulation, high frequency stimulation, HF10, paresthesia-free
stimulation, back pain, leg pain, cervical pain, neuromodulation
Combined Spinal Cord Stimulation and
Peripheral Nerve Stimulation for Brachial
Plexopathy: A Case Report
Authors: Moon Ho Sik
Published: February 2021

Brachial plexopathy usually results from an iatrogenic brachial plexus injury and can sometimes
cause severe chronic pain and disability. There are a number of possible treatments for this
condition, including medication, physical therapy, nerve blocks, and neuromodulation, but they
are not always successful. Recently, combined spinal cord stimulation (SCS) and peripheral
nerve stimulation (PNS) have been tried for various chronic pain diseases because of their
different mechanisms of action.
Here, we describe the case of a 54-year-old man who was diagnosed with brachial plexopathy 8
years ago. He underwent video-assisted thoracoscopic surgery to remove a superior mediastinal
mass. However, his brachial plexus was damaged during the surgery. Although he had received
various treatments, the pain did not improve. For the management of intractable severe pain,
he underwent SCS 2 years ago, which initially reduced his pain from numeric rating scale
(NRS) 10/10 to NRS 4 – 5/10, but the pain then gradually increased, reaching NRS 8/10, 6
months ago. At that time, he was refractory to other treatments, and we therefore applied
PNS in combination with SCS. The PNS electrode was positioned on the radial nerve under
ultrasound guidance. After combined PNS and SCS, his background pain disappeared, although
a breakthrough pain (NRS 3 – 4/10) was caused intermittently by light touch. Furthermore,
the patient’s need for analgesics decreased, and he was satisfied with the outcome of this
combined treatment.
We concluded that combined SCS and PNS is a very useful treatment modality, which can
stimulate the target nerve both directly and indirectly, and hence, relieve pain from brachial
plexopathy.
Key words: Brachial plexopathy, spinal cord, peripheral nerve, stimulation, ultrasound,
neuropathic
Multi-Modal Treatment Approach to Painful
Rib Syndrome: Case Series and Review of the
Literature
Authors: Germanovich Andrew
Published: February 2021

Background: Mechanical chest wall pain is a common presenting complaint in the primary
care office, emergency room, and specialty clinic. Diagnostic testing is often expensive due
to similar presenting symptoms that may involve the heart or lungs. Since the chest wall
biomechanics are poorly understood by many clinicians, few effective treatments are offered to
patients with rib-related acute pain, which may lead to chronic pain.
Objective: This case series and literature review illustrates biomechanics involved in the
pathogenesis of rib-related chest wall pain and suggests an effective multi-modal treatment
plan using interventional techniques with emphasis on manual manipulative techniques.
Study Design: Case series and literature review.
Setting: Pain clinic in an academic medical center.
Results: This is a case series of 3 patients diagnosed with painful rib syndrome using osteopathic
palpatory physical examination techniques. Ultrasound-guided intercostal nerve blocks were
followed by manual manipulation of mechanically displaced ribs as a part of our multi-modal
treatment plan. A review of the literature was undertaken to clarify nomenclature used in the
description of rib-related pain, to describe the biomechanics involved in the pathogenesis of
mechanical rib pain, and to illustrate the use of effective manual manipulation techniques.
Limitation: This review is introductory and not a complete review of all manual or
interventional pain management techniques applicable to the treatment of mechanical ribrelated pain.
Conclusions: Manual diagnostic and therapeutic skills can be learned by physicians to treat
biomechanically complex rib-related chest wall pain in combination with interventional imageguided techniques. Pain physicians should learn certain basic manual manipulation skills both
for diagnostic and therapeutic purposes.:
Key words: Chest wall pain, rib pain, intercostal neuralgia, slipping rib syndrome, chest pain,
intercostal nerve block, chest trauma
Fluoroscopically Guided C2 Percutaneous
Vertebroplasty: A Surgical Technique Note on
an Anterior Ascending Approach
Authors: Liliang Po-Chou
Published: February 2021

Background: C2 vertebroplasty is more challenging than transpedicular percutaneous
vertebroplasty in the thoracic and lumbar spine.
Objective: We report an anterior ascending approach for C2 percutaneous vertebroplasty to
avoid potential injury to vital structures surrounding the C2 vertebra.
Study Design: A technique note with 5 consecutive cases.
Setting: Neurosurgery department of a university hospital.
Methods: Fluoroscopically guided manual compression was applied using 3 fingers at the C5
level between the muscle and trachea. The larynx and trachea were displaced medially and the
carotid artery laterally. The anterior cervical spine was palpated, and a 15-gauge 4-inch bone
marrow biopsy needle was introduced through an anterior ascending approach. When the tip
touched the intervertebral disc between C2 and C3, the needle was pushed through the disc
until it penetrated into the C2 vertebral body. After confirming adequate needle insertion,
vertebroplasty was performed.
Results: Pain relief was achieved in 4/5 (80%) patients. One patient possibly did not benefit
from percutaneous vertebroplasty, and asymptomatic cement extravasation was detected in 2
patients.
Limitations: Sample size; impossibility of placebo control.
Conclusion: An anterior ascending approach for C2 percutaneous vertebroplasty is a valuable
alternative for relieving pain caused by metastatic spinal tumors. This approach is familiar to
surgeons performing anterior cervical discectomies, percutaneous nucleoplasty, or odontoid
screw placement surgeries.
Key words: Vertebroplasty, pain, axis, cement leak, metastases, palliative medicine, spine,
fracture
Chronic Bilateral Sphenopalatine Ganglion
Stimulation for Intractable Bilateral Chronic
Cluster Headache: A Case Reportlkmjn
Authors: Zhang Kai
Published: February 2021

A cluster headache (CH) is an excruciating pain centered on the periorbital region and is
accompanied by autonomic symptoms. Despite the best currently available medical therapy,
many patients still suffer from these headaches. Some patients also experience CH with side
shift of attacks, which makes treatment more difficult.
In light of the pathophysiological mechanism of CH, the sphenopalatine ganglion (SPG) is a
promising therapeutic target for its management. SPG ablation and non-ablation techniques
have been the preferred treatment for CH in recent decades. However, few articles have
reported the effectiveness of acute SPG stimulation for CH, and no studies have demonstrated
the safety and efficacy of bilateral continuous SPG stimulation for CH.
In this article, we report on a 59-year-old chronic cluster headache (CCH) patient who had side
shifts of attacks and was treated with bilateral continuous SPG stimulation. The patient suffered
from CCH for 9 years, and the intensity of pain and the frequency of attacks had gradually
increased over time. At the time of admission, he experienced daily attacks. Medical therapy
and SPG blocks were offered, but he only achieved transient pain relief.
After a careful preoperative examination and discussion with the patient, we provided bilateral
SPG stimulation. The electrode was implanted under C-arm fluoroscopic guidance. After
continuous stimulation, the patient experienced significant reductions in headache severity. The
frequency of attacks was reduced from daily to less than once per week. He also discontinued
all of the related drugs that he was taking.
This is the first report of bilateral continuous SPG stimulation for CCH. This report indicates that
continuous SPG stimulation is a feasible therapeutic option for CCH. However, large-scale and
long-term studies are required to elucidate the efficacy of SPG stimulation.
Key words: Cluster headache, sphenopalatine ganglion, SPG, neuromodulation, side shift,
stimulation
Late Extrusion of an Implantable Pulse
Generator of a Spinal Cord Stimulator
Authors: Rabi Joseph
Published: February 2021

The objective of this manuscript was to report a case of a patient with extruded pulse generator
3 years after implantation of a spinal cord stimulator system.
With the increasing incidence of chronic pain, spinal cord stimulation (SCS) is becoming more
commonly utilized by pain physicians. SCS is a generally safe intervention with minimal adverse
effects; however, there are risks of complications which practitioners should be aware of prior
to and after placement of the SCS.
We present a case of a patient with a late complication of extrusion of an implantable pulse
generator (IPG) of a SCS that was promptly identified and successfully removed without any
complications. A 60-year-old male truck driver with history of failed back syndrome and diabetes
underwent a SCS system implanted with excellent relief of his pain. The SCS was implanted
with 2 leads with the IPG being sutured 3 cm in depth in the superior gluteal region. Three years
after the implantation, he developed pain over the site of the generator and presented to our
clinic with extrusion of the non-rechargeable pulse generator from his gluteal region.
The pulse generator was successfully removed with the battery not being infected. This late
complication may have been related to his ongoing profession of daily driving with pressure
necrosis from prolonged sitting and constant vibration during long rides associated. Structural
size and design of the pulse generator may have had an important contribution as well. To our
knowledge this complication has not been reported in the literature.
Physicians that place or manage patients with SCSs should be aware of this rare complication
and maintain vigilance even after remote implantation of the SCS systems.
Key words: Spinal cord stimulator, complication, extrusion, implantable pulse generator,
neuromodulation, failed back syndrome, battery complication
Bipolar High-Voltage, Long-Duration Pulsed
Radiofrequency Improves Pain Relief in
Postherpetic Neuralgia
Authors: Song Tao
Published: February 2021

Background: Postherpetic neuralgia (PHN) is often refractory to existing treatments. Treatment
of the dorsal root ganglion (DRG) using monopolar pulsed radiofrequency (PRF), which is a nonor minimally neurodestructive technique, is not efficacious in all patients.
Objectives: This study aimed to determine the safety and clinical efficacy of bipolar highvoltage, long-duration PRF on the DRG in PHN patients.
Study Design: Self before-after controlled clinical trial.
Setting: Department of Pain Medicine, the First Affiliated Hospital of China Medical University.
Methods: Ninety patients diagnosed with PHN for > 3months were included. Bipolar highvoltage, long-duration PRF at 42°C for 900 seconds was applied after the induction of
paresthesias covered the regions of hyperalgesic skin. The therapeutic effects were evaluated
using a visual analog scale (VAS) and the 36-item Short Form health survey (SF-36) before
treatment and one, 4, 8, and 12 weeks after PRF.
Results: The VAS scores at one, 4, 8, and 12 weeks after PRF treatment were significantly
lower than before treatment (P < 0.001). The SF-36 scores, which included physical functioning,
physical role, bodily pain, general health perceptions, vitality, social function, emotional role,
and the mental health index, were significantly improved up to 12 weeks after PRF treatment
(P < 0.001). No serious adverse effects were identified following treatment. The main adverse
reactions included pain, tachycardia, and high blood pressure (especially when the field strength
was enhanced).
Limitations: Single center study, relatively small number of patients, lack of a control group.
Conclusion: Bipolar high-voltage, long-duration PRF on the DRG is an effective and safe
therapeutic alternative for PHN patients. This treatment could improve the quality of life of
PHN patients.
Clinical Trial Registration: NO ChiCTR-OCS-14005461
Key words: Pulsed radiofrequency, postherpetic neuralgia, VAS, SF-36
IMPACT OF PERSONALITY AND WELL-BEING ON ADJUSTMENT AMONG
PROFESSIONAL AND NON-PROFESSIONAL COLLEGE STUDENTS
Authors: Tejovathi S. , Reddy L. Kullai
Published: February 2021

The study was planned to investigate the impact of personality and well-being on adjustment among professional and nonprofessional college students. Sample of the present study consists of 400 professional and non-professional college
students selected by using stratied random sampling technique and MRA. Bell's adjustment inventory Ramana (2009), The NEO Five Inventory
developed by Naumann and Soto (2008) and Well-being Scale developed by Snaith and McGufn.P.(1978). Were administered to collect the data.
Means, SD's and ANOVA used to nd out whether personality and well-being have any signicant impact on the adjustment. Results revealed that
personality and well-being on the adjustment among professional and non-professional college students.
PSYCHOSOCIAL PROBLEMS OF THE CHILDREN WITH VISUAL
IMPAIRMENT IN SALEM DISTRICT
Authors: Sowdeswari D. , Umamaheswari Mrs. K. , Little Flower F.X.Lovelina
Published: February 2021

INTRODUCTION:
A Descriptive research study had been conducted to assess the psychosocial problems of children with visual impairment
in Salem District.
objectives : To assess the psychosocial problems of children with visual impairment .
To know the association between psychosocial problems and selected socio demographic factors of children with visual impairment .
METHODS: Census method of sampling is used. Total of all 63 children with visual impairment from the age group of 11 to 18 years in Salem
district are taken as respondents.
RESULTS: Results of the study reveal that 23.8% of the respondents have mild, 15.9% of the respondents have moderate and 1.6% of the
respondents have severe level of depression, 14.3% of the respondents have mild, 6.3% of the respondents have moderate and 3.2% of the
respondents have severe level of anxiety, 11.1% of the respondents have mild and 7.9% of the respondents have moderate level of stress.
Majority 69.8% of the respondents have medium and 14.3% of the respondents have lower level of emotional adjustment
Through this study it is evident that less than half of the respondents are facing psychological problems and majority of the respondents are
facing social problems.
IMPLICATIONS FOR PRACTITIONERS: The Inclusive education of the children with visual impairment along with the normal children
reduces the numbers of children facing psychosocial problems.
The special Trainers and the school social workers are very essential for providing early assessment and intervention and to help the children
with visual impairment to get good quality of life and happiest childhood.
INVESTIGATING THE IMPACT OF AMINO-ACID SUPPLEMENTATION ON
ENHANCEMENT OF BETA CAROTENE CONTENT IN FENUGREEK PLANT.
Authors: Chauhan Shivi Singh
Published: February 2021

Plants are capable of synthesizing β-carotene but unfortunately humans are not able to do so. However, they are capable of
converting β-carotene absorbed from their diets to vitamin A. Hence, an increase in β-carotene content in plants can be an
alternative to increase the vitamin A content & prevent from certain diseases content in diet of individuals. Therefore, foliar application of amino
acid solution is a technique used for investigating the effect of amino acid supplementation on enhancement of beta carotene content in green leafy
vegetables.
In this study, fenugreek (Trigonella foenum graecum) seeds are treated with proline, tyrosine, tryptophan and proline, tyrosine, tryptophan
combination (1:1:1). It was observed that growth and beta carotene content were higher in the treated plants. Exclusive treatment with Proline,
tyrosine and the tryptophan resulted in an increase in growth and beta carotene content when compared to control which is lesser than that of
proline-tyrosine-tryptophan combination treated seeds.
Direct white noise characterization of short-channel MOSFETs
Authors: Ohmori Kenji , Amakawa Shuhei
Published: February 2021

On-wafer evaluation of white thermal and shot noise in nanoscale MOSFETs is demonstrated by directly sensing the drain current under zero- and nonzsero-drain-bias (Vd) conditions for the first time, without recourse to a hot noise source, commonly needed in noise figure measurement. The dependence of white noise intensity on the drain bias clearly shows thermal noise at Vd=0 V and shot noise at Vd>0 V with its gate-bias-dependent suppression. An empirical expression for the Fano factor (shot-noise suppression factor) that is well-behaved even at Vd=0V exactly and suitable for measurement-based evaluation is proposed. The direct measurement approach could allow more accurate and predictive noise modeling of RF MOSFETs than has conventionally been possible.
Modeling Charging Infrastructure Requirements to Achieve a Holistic E-Mobility Integration in Regional Energy Systems
Authors: Husarek Dominik , Paulus Simon , Metzger Michael , Salapic Vjekoslav , Niessen Stefan
Published: February 2021

Since E-Mobility is on the rise worldwide, large Charging Infrastructure (CI) networks are required to satisfy the upcoming Charging Demand (CD). Understanding this CD with its spatial and temporal uncertainties is important for grid operators to quantify the grid impact of Electric Vehicle integration and for Charging Station (CS) operators to assess long-term CI investments. Hence, we introduce an Agent-based E-Mobility Model assessing regional CI systems with their multi-directional interactions between CSs and vehicles. A Global Sensitivity Analysis (GSA) is applied to quantify the impact of 11 technical levers on 17 relevant charging system outputs. The GSA evaluates the E-Mobility integration in terms of grid impact, economic viability of CSs and Service Quality of the deployed Charging Infrastructure (SQCI). Based on this impact assessment we derive general guidelines for E-Mobility integration into regional systems. We found, inter alia, that CI policies should aim at allocating CSs across different types of locations to utilize cross-locational effects such as CSs at public locations affecting the charging peak in residential areas by up to 18%. Additionally, while improving the highway charging network is an effective lever to increase the SQCI in urban areas, public charging is an even stronger lever in rural areas.