bluuebunny/crossref_metadata_2025 huggingface dataset:
An Ethical Analysis of Crisis in Chronic Pain
Care: Facts, Issues and Problems in Pain
Medicine; Part I
Authors: Giordano James
Published: March 2021

We posit that in order to realistically, fully, and most positively affect the capability of implementing a more comprehensive paradigm of pain care it is necessary to: 1) recognize
the complexity of chronic pain; 2) account for economic factors imposed upon the healthcare system, and 3) enable articulation of any paradigmatic revision within the contemporary medico-legal environment.
Three primary ethical problems arise from the interaction(s) of these contingencies —
namely 1) the under-treatment of pain, 2) the inappropriate over-utilization of pharmacologic agents and techniques, and 3) tensions and conflicts that develop within the relationships of pain medicine. All can lead to a failure of technically apt and ethically sound
pain care.
This essay — the first in a 3-part series — employs the method of ethical analysis to approach the circumstances, issues, questions, and problems of contemporary practice of
pain medicine, to allow insight(s) to the facts, define the agents involved, appreciate how
problems are generated, and develop more thorough evaluation and articulation of potential resolutions. We contend that resolution of these problems must offer practical responses to the circumstances and issues. Such practicality entails affording “good” in ways
that are grounded to the facts and realities of situations, and are not merely theoretical or
conceptual.
Determining the “good” is the work of ethics — as systems and analyses of the moral decisional process. Ethics establishes norms and articulates their use in practice, and we opine
that the distinction between the normative and applied is more of a continuum that is dependent upon case and circumstance(s). Given the variety of circumstances in the practice
of pain medicine, no single ethical system would be totally adequate, and we believe a discursive approach to be most effective.
Subsequent papers in this series will describe the systems, structure, and function of a putative ethical infrastructure of pain medicine, and will attempt to illustrate how these could
be articulated within an integrative paradigm of pain care.
Key words: Pain medicine, crisis, ethics, philosophy, sociology, humanities, chronic pain
Sacral Vertebral Augmentation:
Confirmation of Fluoroscopic Landmarks
by Open Dissection
Authors: Betts Andres
Published: March 2021

Sacral insufficiency fractures are a more commonly recognized cause of spine pain
among osteoporotic patients, and are now treatable by sacroplasty using percutaneous instillation of PMMA cement. Sacroplasty may be performed using only fluoroscopic landmarks; however, the bony anatomy of the sacrum is complex and the cement deposition based on these landmarks has not been specifically confirmed. In
this report we determined the precise fluoroscopic landmarks for cannula placement
in a specially prepared excised sacral cadaveric specimen with metal surface markers.
The cannulas were placed using the usual dorsal approach, and where the tip was visually seen to breach the cortical surface, fluoroscopic images were obtained and the
boundaries of the sacrum were carefully determined. A fluoroscopic cortical “breach”
area emerged where a cannula tip would likely be outside the cortical boundaries of
the sacrum.
With simple sacral vertebroplasty there is no direct control of cement deposition after
the PMMA leaves the tip of the cannula. The use of vertebral augmentation devices
may be of use to help control cement delivery in performing sacroplasty. We evaluated 2 such devices in cadaver specimens to determine their suitability in performing a
sacral vertebral augmentation.
Using these same landmarks, a sacral balloon Kyphoplasty was performed and the cadaveric specimen was subsequently bivalved to visually confirm the deposition of cement. On direct inspection the PMMA cement was found to be confined within the
sacral cortical boundaries and there was no extravasation near or into the sacral foramen.
Based on these fluoroscopic landmarks, the Arcuplasty device was tested in an intact
cadaver to determine the optimal cannula placement and locations for creating osteotomies within the sacral trabecular bone prior to PMMA cement deposition. The cement deposition was observed to remain closely confined to the areas where the osteotomies were performed. In the balloon Kyphoplasty specimen the cement deposition
was visually confirmed to be confined within the cortical boundaries by open dissection, and both devices have been found successful in creating a more controlled deposition of PMMA cement for performing sacral vertebral augmentation under fluoroscopic imaging.
Key words: Sacroplasty, vertebroplasty vertebral augmentation, kyphoplasty, sacral
insufficiency fractures, osteoporosis.
A Crisis in Chronic Pain Care: An Ethical
Analysis
Part Two: Proposed Structure and Function of
an Ethics of Pain Medicine
Authors: Giordano James
Published: March 2021

In this paper, we propose a constructive approach to an ethics of pain medicine that is animated by a core philosophy of medicine as specific and focal to the uniqueness of pain, the
pain patient, and the pain clinician. This philosophy of pain medicine 1) defines the nature
of pain, 2) recognizes the variability and subjectivity of its expression in the pain patient, 3)
acknowledges and explicates the vulnerabilities rendered by pain, 4) describes the inherent characteristics and asymmetries of the patient-clinician relationship, and 5) defines the
ends of pain care. That these ends entail the provision of “good” care links the epistemic
domains of pain medicine to its anthropologic focus and ethically sound conduct.
We posit that an ethics of pain medicine should define the profession and sustain the practice. Facts establish (the need for) certain duties and rules of pain medicine. These emphasize the duty to self and others, and an appreciation for relational asymmetries, and dictates that those who enter the profession of pain medicine should be generally aligned
with this set of core practical and ethical affirmations and duties.
To maintain contemporary relevance, rules, duties, and moral reasoning must adjust to
changing conditions. Applied ethics shape the practice within the infrastructure of core
rules and duties of the profession. An applied ethics of pain medicine must be pragmatic,
and therefore, cannot rely upon, or be reduced to, a single principle or ethical system. A
number of ethical systems (such as the use of principles, utilitarianism, casuistry, feminist/
care orientations) all have relative merit and potential limitations. We argue that the obligation to recognize ethical issues, and utilize knowledge to best reflect appropriate moral
values rests upon the clinician as a moral agent, and therefore advocate the relevance and
importance of an agent-based virtue ethics, recognizing that virtue ethics cannot stand
alone, but must be employed within a larger system of ethical intuition. Yet, if such a structure of normative and applied ethics is to be realized, moral consideration must guide evaluation of the current system of pain care, and provide direction for the development and
implementation of therapeutically and ethically integrative pain medicine for the future.
Key words: Pain medicine, normative ethics, applied ethics, deontology, virtue ethics,
humanities
CNS or Classic Drugs for the Treatment of Pain
in Functional Dyspepsia? A Systematic Review
and Meta-Analysis of the Literature
Authors: Fregni Felipe
Published: March 2021

Background: Recent evidence has suggested that pain in functional dyspepsia (FD) is associated with nervous system dysfunction; indicating that therapies
aimed at nervous system modulation might be associated with pain relief in FD
Objective: To conduct a systematic review and meta-analysis to quantify the
efficacy of drugs targeting the central nervous system (antidepressants and antianxiety agents — referred as “CNS drugs”) and drugs targeting gastric modulation (antisecretory and prokinetic — referred as “classic drugs”) for the treatment of pain in FD and, in an exploratory way, compare these 2 modalities of
treatment.
Methods: MEDLINE and reference lists were examined for relevant articles. We
included prospective studies that evaluated the effects of either CNS drugs or
classic drugs (subdivided in prokinetic and antisecretory drugs) on the symptoms
of FD.
Results: Seven studies for CNS drugs and 11 studies for gastric drugs met our
inclusion criteria. The analyses of these drugs showed that the 2 groups of drugs
are associated with a significant reduction in dyspeptic symptoms. The pooled effect size (standardized mean difference between pre-treatment versus post-treatment means) from the random effects model was 1.25 (95% C.I., 0.83, 1.67) for
CNS; 1.63 (95% C.I., 1.28, 1.97) for prokinetic, and 0.93 (95% C.I., 0.57, 1.29)
for antisecretory drugs. The exploratory comparison between classes of drugs revealed no significant difference in dyspeptic symptoms reduction between CNS
and prokinetic drugs; however CNS drugs were associated with a larger reduction in symptoms as compared with antisecretory drugs.
Conclusions: The results show that both CNS and classic drugs are associated
with a significant pain reduction in functional dyspepsia.
Key words: antidepressants, antianxiety, prokinetics, antisecretory agents,
brain activity, functional dyspepsia, epigastric pain
An Assessment of the Association Between
Smoking Status, Pain Intensity, and Functional
Interference in Patients with Chronic Pain
Authors: Weingarten Toby N.
Published: March 2021

Background: This article examines the association between smoking and
pain intensity and functional interference in a heterogeneous group of patients evaluated at a tertiary outpatient pain clinic. Current smoking is associated with less favorable clinical presentations.
Objective: This study was conducted to determine if the smoking status
of patients seen in an outpatient pain clinic is associated with differences in
pain intensity and interference.
Methods: Surveys were mailed to 500 consecutive new patients evaluated at an outpatient pain clinic. Measures included the Brief Pain Inventory
(BPI) and the Fagerström Test for Nicotine Dependence (FTND). Univariate
analyses compared BPI scores between smokers and non-smokers. Mean BPI
scores were compared between smoking status via analysis of covariance
(adjusted for demographic variables which differed significantly by smoking
status). A p value ≤ 0.05 was accepted as significant.
Results: Survey completion rate was 46%, and 14.7% were current smokers. Smokers were younger, and more likely to be male and unemployed.
Smokers had higher scores on all the pain intensity BPI scales (p < 0.01), and
higher scores (indicating greater functional impairment) on the general activity (p = 0.007), mood (p = 0.003), normal work (p = 0.02), relationships
(p = 0.04), sleep (p < 0.001), and life enjoyment (p = 0.03) BPI functional
impairment scales. Severe nicotine dependence was associated with greater pain now, (p = 0.05), and greater functional interference on mood (p =
0.005), normal work (p = 0.02) and life enjoyment (p = 0.04) BPI scales.
Conclusion: In patients who completed evaluation in an outpatient pain
clinic, current cigarette smokers reported significantly greater pain intensity
and pain interference with functioning. Symptoms were more pronounced
in smokers with more severe nicotine dependence.
Key words: smoking status; outpatient pain management; brief pain inventory; Fagerström test for nicotine dependence
Age-Related Prevalence of Facet-Joint
Involvement in Chronic Neck and Low Back
Pain
Authors: Manchikanti Laxmaiah
Published: March 2021

Background: Spinal pain is common in all age groups. While the research has focused primarily on incidence and prevalence in younger working adults, there is evidence that spinal pain is one of the most frequent complaints in older persons and is
responsible for functional limitations. While facet arthrosis is a common radiographic finding, which has been suggested to be a potential cause of spinal pain, nearly
10% of all adults show signs of degeneration by the time they reach age 30. Radiographic changes of osteoarthritis have been shown to be equally common in patients
with and without low back or neck pain. The studies of low back pain have shown
the prevalence of facet joint involvement to be approximately 15% to 45%. However,
age related prevalence of facet joint neck pain has not been studied.
Objective: To assess age-related prevalence and false-positive rates of facet-joint
involvement in chronic spinal pain using controlled comparative local anesthetic
blocks.
Design: Retrospective analysis of 424 patients, divided into 6 groups based upon
age (Group I: aged 18 – 30 years, Group II: aged 31 – 40 years, Group III: aged 41 –
50 years, Group IV: aged 51 – 60, Group V: 61 – 70 years, and Group VI: greater than
70 years of age).
Results: The prevalence of cervical facet joint-related pain was the lowest (33%)
in Group VI and highest (42%) in Group I. False-positive rates for cervical facet joint
blocks ranged from 39% (Group III) to 58% (Group V) with an overall false-positive
rate of 45%. The prevalence of facet joint involvement in lumbar spinal pain ranged
from 18% (in Group II) to 44% (in Group IV), with significant differences noted when
Group II and Group III were compared to other groups and with higher rates in Group
V.
Conclusion: This study demonstrated a variable age-related prevalence of facet joint
pain in chronic low back pain, whereas in the cervical spine it was similar among all
the age groups.
Key Words: Prevalence, facet arthrosis, facet joint pain, cervical spine, lumbar spine,
controlled comparative local anesthetic blocks, false-positive rate.
Acute Renal Failure During a Trial of Spinal
Cord Stimulation: Theories as to a Possible
Connection
Authors: Larkin Thomas M.
Published: March 2021

Objective: This is the first case describing an episode of acute renal failure occurring during a spinal cord stimulation trial.
Clinical Presentation: A 48-year-old male with a history of hypertension and 3
prior failed spine surgeries underwent a trial of spinal cord stimulation for uncontrolled bilateral lower extremity neuropathic pain. Two days after the placement of
the percutaneous stimulator lead the patient returned complaining of 3 syncopal
episodes. He was found to be hypotensive and in acute renal failure with a creatinine of 8.1 and a BUN of 83.
Intervention: The stimulator lead was immediately removed. The patient was admitted to the intensive care unit and responded promptly to rehydration and placement of a urinary catheter. His renal and urological work-ups revealed no significant abnormalities.
Conclusion: The development of the episode of acute renal failure may have
been influenced by the secondary effects of spinal cord stimulation. Since acute renal failure has never been associated with the use of spinal cord stimulation, this
singular example does not by itself demonstrate a relationship. However, if future
episodes are seen, a link between the 2 events could be drawn. For now, it is not
clear if the development of this patient’s acute renal failure could, in part, be attributed to the use of the spinal cord stimulator or if it was merely coincidental in
nature. We do feel it is useful for the clinician to understand the pathophysiologic
changes associated with spinal cord stimulation and to see how, at least in theory,
there could be a connection.
Key words: acute renal failure, spinal cord stimulation
Deep Cervical Plexus Block for the Treatment of
Cervicogenic Headache
Authors: Goldberg Michael E.
Published: March 2021

Background: Cervicogenic headache descriptors include its unilateral nature, “signs
and symptoms linking it to the neck,” and trauma of the neck. Since the pain often occurs over the C2 or C3 nerve root, we used a modification of the deep cervical block
technique for treatment of this refractory type headache.
Objective: To determine the efficacy of a modified deep cervical block for treatment
of cervicogenic headache.
Design: Prospective case study.
Methods: Thirty-nine patients referred to our pain clinic participated in this study. All
patients had undergone extensive screening/diagnostic testing. The blocks were performed unilaterally, without inducing a risk of invading the neural foramen, and repeat
injection of the contra-lateral side occurred at >1 week after initial injection. Patients
were followed for a 6-month period using a pain diary and questionnaire. Pain was assessed pre- and post-injection and 3 and 6 months post treatments.
Results: The mean treatment period was 59 ± 61 days. The mean values for pre- and
post-injection series pain scores (0–10 pain scale) were 9.54 ± 1.53 and 6.75 ± 3.23 respectively (p < 0.001). Thirty-three percent (33%) of the patients reported pain scores
of ≤ 4 on the 0-10 pain scale after their last treatment. Effectiveness of the therapy following the injection procedure was rated to be 42% effective for all first injections and
40% effective for last injections (p =NS). Six months evaluations showed that return of
moderate to severe pain took 6.62 ± 8.1 weeks. At the 3 and 6 months follow up evaluations, mean pain scores had returned to 8.41 ± 2.96 and 8.83 ± 2.78, respectively. Ten
patients (24%) had pain scores ≤ 4 at the 3-month evaluation while 7 of the patients
(18%) had pain scores ≤ 4 at the 6-month evaluation.
Conclusions: These results showed that for some patients this series of blocks provided effective pain relief for 3 months post treatment but by 6 months the pain had returned to pre-treatment levels. This block technique significantly diminished pain after
the initial as well as the last treatment. These clinically significant changes in pain relief
suggest that more aggressive selective therapy targeting these nerve routes might provide longer lasting relief.
Key words: Cervicogenic headache, deep cervical block, chronic pain
Experimental Evaluation of Hyaluronidase
Activity in Combination with Specific Drugs
Applied in Clinical Techniques of Interventional
Pain Management and Local Anaesthesia
Authors: Bittorf Thomas
Published: March 2021

Background: Hyaluronidase is an enzyme additive used in local anaesthesia and
interventional pain reducing procedures such as adhesiolysis of epidural scar tissue
after spinal surgery. Only a limited number of studies describe the influence of drugs
on hyaluronidase activity. Postulated effects and effectiveness of hyaluronidase are
only based on clinical observations.
Objective: The aim of this study is to investigate the influence of the combined
drugs on the activity of hyaluronidase under standardized conditions and to verify
the effectiveness of the enzyme.
Design: An ELISA-based microtiter-technique is used to evaluate the activity of hyaluronidase in combination with local anaesthetics, corticosteroids, NaCl 10%, and
iodinated contrast media.
Methods: Microtiter plates were coated with biotinylated hyaluronate and incubated with hyaluronidase in combination with the above-mentioned drugs. The activity of hyaluronidase was determined by an avidin-peroxidase-based procedure using an ELISA reader. Incubations were carried out at room temperature as well as
at 37°C.
Results: The data show that drugs affect the activity of hyaluronidase in different ways. Iodinated contrast media, NaCl (10%), and the absence of corticosteroids
reduce hyaluronidase activity. In contrast, higher activities were detected at a lower NaCl concentration (0.9%). We cannot attribute a significant influence to local
anaesthetics.
Conclusions: Hyaluronidase is effective in all combinations with drugs. To get the
maximum effect calculated use of accompanying drugs is necessary.
Key words: Hyaluronidase, enzymatic activity, adhesiolysis, local anaesthesia, pain
management
Ultrasound-Guided Trigger Point Injections in
the Cervicothoracic Musculature: A New and
Unreported Technique
Authors: Botwin Kenneth P.
Published: March 2021

Background: Myofascial pain is defined as pain that originates from myofascial trigger points
in skeletal muscle. It is prevalent in regional musculoskeletal pain syndromes, either alone or in
combination with other pain generators. The myofascial pain syndrome is one of the largest
groups of under diagnosed and under treated medical problems encountered in clinical practice.
Trigger points are commonly seen in patients with myofascial pain which is responsible for localized pain in the affected muscles as well as referred pain patterns. Correct needle placement in a
myofascial trigger point is vital to prevent complications and improve efficacy of the trigger point
injection to help reduce or relieve myofascial pain. In obese patients, these injections may not
reach the target tissue. In the cervicothoracic spine, a misguided or misplaced injection can result
in a pneumothorax. Here, we describe an ultrasound-guided trigger point injection technique
to avoid this potential pitfall. Office based ultrasound-guided injection techniques for musculoskeletal disorders have been described in the literature with regard to tendon, bursa, cystic, and
joint pathologies. For the interventionalist, utilizing ultrasound yields multiple advantages technically and practically, including observation of needle placement in real-time, ability to perform
dynamic studies, the possibility of diagnosing musculoskeletal pathologies, avoidance of radiation exposure, reduced overall cost, and portability of equipment within the office setting. To our
knowledge, the use of ultrasound guidance in performing trigger point injection in the cervicothoracic area, particularly in obese patients, has not been previously reported.
Methods: A palpable trigger point in the cervicothoracic musculature was localized and marked
by indenting the skin with the tip of a plastic needle cover. The skin was then sterile prepped.
Then, using an ultrasound machine with sterile coupling gel and a sterile latex free transducer cover, the musculature in the cervicothoracic spine where the palpable trigger point was detected was visualized. Then utilizing direct live ultrasound guidance, a 25-gauge 1.5 inch needle
connected to a 3 mL syringe was placed into the muscle at the exact location of the presumed
trigger point. This guidance helps confirm needle placement in muscle tissue and not in an adipose tissue or any other non-musculature structure.
Results: The technique is simple to be performed by a pain management specialist who has ultrasound system training.
Conclusion: Ultrasound-guided trigger point injections may help confirm proper needle placement within the cervicothoracic musculature. The use of ultrasound-guided trigger point injections in the cervicothoracic musculature may also reduce the potential for a pneumothorax by
an improperly placed injection.
Key words: Trigger point injection, myofascial pain, ultrasound
Anti-inflammatory Effects of Electronic
Signal Treatment
Authors: Odell Robert H.
Published: March 2021

Inflammation often plays a key role in the perpetuation of pain. Chronic inflammatory conditions (e.g. osteoarthritis, immune system dysfunction, micro-circulatory disease, painful neuritis, and even heart disease) have increased as baby boomers age. Medicine’s current antiinflammatory choices are NSAIDs and steroids; the value in promoting cure and side effect
risks of these medications are unclear and controversial, especially considering individual patient variations.
Electricity has continuously been a powerful tool in medicine for thousands of years. All medical professionals are, to some degree, aware of electrotherapy; those who directly use electricity for treatment know of its anti-inflammatory effects. Electronic signal treatment (EST),
as an extension of presently available technology, may reasonably have even more anti-inflammatory effects.
EST is a digitally produced alternating current sinusoidal electronic signal with associated harmonics to produce theoretically reasonable and/or scientifically documented physiological effects when applied to the human body. These signals are produced by advanced electronics
not possible even 10 to 15 years ago.
The potential long-lasting anti-inflammatory effects of some electrical currents are based on
basic physical and biochemical facts listed in the text below, namely that of stimulating and
signaling effective and long-lasting anti-inflammatory effects in nerve and muscle cells. The
safety of electrotherapeutic treatments in general and EST in particular has been established
through extensive clinical use.
The principles of physics have been largely de-emphasized in modern medicine in favor of
chemistry. These electrical treatments, a familiar application of physics, thus represent powerful and appropriate elements of physicians’ pain care armamentaria in the clinic and possibly for prescription for use at home to improve overall patient care and maintenance of quality of life via low-risk and potentially curative treatments.
Key words: Electroanalgesia, electronic signal treatment (EST), inflammation, anti-inflammatory effects, immune system, neurogenic inflammation, chronic pain, steroids, NSAIDs, oscillo/torsional effect, cAMP, membrane repair and stabilization, pain care/management
Successful Treatment of Digital Ulcers in
a Scleroderma Patient with Continuous
Bilateral Thoracic Sympathetic Block
Authors: Kim Chan
Published: March 2021

Background: Raynaud’s phenomenon (RP) associated with connective tissue disease (secondary RP) may be difficult to manage with conservative therapy. A combination of sympathetically mediated vasospasm and vaso-occlusion has been implicated as the etiology
of digital ischemic phenomenon. Thoracic sympathetic outflow blocking has been performed with various techniques. However, there have been some limitations in all treatment options.
Objective: We report on a patient with medically refractory digital ulceration and gangrene caused by scleroderma who was successfully treated with a continuous infusion
of mepivacaine into the thoracic sympathetic ganglions as a means to improve finger
circulation.
Case Report: We are reporting on a 32-year-old female patient suffering from a medically intractable gangrenous ulcer in the right third finger and the left second and third fingers, accompanied by aching pain (VAS, visual analogue scale, 5 – 6/10) and numbness in
both forearms. She underwent continuous infusion of mepivacaine through the thoracic
sympathetic catheter placed in T2 vertebral segment for 13 days on the right and for 11
days on the left and cervical epidural infusion of mepivcaine with fentanyl for 10 days after the medical treatment failed. Her finger temperature increased 2o
C – 5o
C during the
thoracic sympathetic block with continuous infusion of mepivacine. Her finger wounds
healed completely with 13 days of the continuous thoracic sympathetic block without any
complications.
Conclusions: Continuous infusion of mepivacaine into the thoracic sympathetic ganglionic space led to the healing of the medically refractory gangrenous ulcer of the fingers in
the patient with scleroderma.
Key words: Scleroderma, Raynaud’s phenomenon, thoracic sympathetic catheter
Corticosteroid Induced Psychosis in the
Pain Management Setting
Authors: Benyamin Ramsin
Published: March 2021

Background: Synthetic corticosteroids are commonly utilized in interventional pain
management procedures. These substances have potential side-effects including psychological adverse events.
Objective: We describe a case of substance-induced psychotic disorder resulting from
corticosteroids administration.
Design: Case Report
Methods: We describe a 67-year-old male that, six months prior to being consulted
at our center, received a cervical epidural, 4 level medial branch blocks, 4 trigger point
injections and a tendon injection in the shoulder all including corticosteroids all in one
treatment session.
Results: Approximately 7 days following the multiple injections, the patient developed psychotic episodes including racing thoughts, anger, agitation, pressured hyperverbal speech and paranoia. The symptoms spontaneously resolved in approximately
7-10 days.
Discussion: Although well known as a potential complication, corticosteroid induced
psychosis secondary to interventional pain procedures have never been reported. We
further discuss this potential side effect of utilizing corticosteroids and emphasize the
need for guidelines regarding steroid utilization.
Key words: Steroid, corticosteroid, psychosis, psychotic disorder
Subdural Hematoma Following Spinal Cord
Stimulator Implant
Authors: Chiravuri Srinivas
Published: March 2021

Headache following interventional procedures is a diagnostic challenge
due to the multitude of possible etiologies involved. Presentation can be
simple (PDPH alone) or complex (exacerbation of pre-existing chronic headache along with PDPH) or headache associated with a new onset intracranial process. Subdural hematoma is a rare complication of cranio-spinal trauma.
Cranial subdural hematoma may present in an acute, sub-acute, or chronic
fashion. Diagnosis of a subdural hematoma in the wake of a PDPH is difficult, requiring a high level of suspicion. Delayed diagnosis of subdural hematoma is usually related to failure to consider it in the differential diagnosis. Thorough history, assessment of the evolution of symptoms, and
imaging studies may identify the possible cause and help direct treatment.
Change in the character of initial presenting symptoms may be a sign of
resolution of the headache or the onset of a secondary process.
We report a case of acute intracranial subdural hematoma secondary to
unintentional dural puncture during placement of a permanent spinal cord
stimulator lead for refractory angina. There is need for careful follow-up of
patients with a known post-dural tear. Failure to identify uncommon adverse events in patients with complicated spinal cord stimulator implantation may lead to permanent injury.
Key words: Subdural, post-dural puncture, headache, spinal cord stimulation
Opioid Pharmacology
Authors: Trescot Andrea M.
Published: March 2021

Background: Mu agonists have been an important component of pain
treatment for thousands of years. The usual pharmacokinetic parameters
(half-life, clearance, volume of distribution) of opioids have been known for
some time. However, the metabolism has, until recently, been poorly understood, and there has been recent interest in the role of metabolites in modifying the pharmacodynamic response in patients, in both analgesia and adverse effects. A number of opioids are available for clinical use, including
morphine, hydromorphone, levorphanol, oxycodone, and fentanyl. Advantages and disadvantages of various opioids in the management of chronic
pain are discussed.
Objective: This review looks at the structure, chemistry, and metabolism of
opioids in an effort to better understand the side effects, drug interactions,
and the individual responses of patients receiving opioids for the treatment
of intractable pain.
Conclusion: Mu receptor agonists and agonist-antagonists have been used
throughout recent medical history for the control of pain and for the treatment of opiate induced side effects and even opiate withdrawal syndromes.
Key words: Opioid metabolism, opioid interactions, morphine, codeine,
hydrocodone, oxycodone, hydromorphone, methadone, intractable pain, endorphins, enkephalins, dynorphins, narcotics, pharmacology, propoxyphene,
fentanyl, oxymorphone, tramadol
Effectiveness of Opioids in the Treatment of
Chronic Non-Cancer Pain
Authors: Trescot Andrea M.
Published: March 2021

For thousands of years, opioids have been used to treat pain, and they continue to be one
of the most commonly prescribed medications for pain. It is estimated that 90% of patients presenting to pain centers and receiving treatment in such facilities are on opioids.
Opioids can be considered broad-spectrum analgesics that act at multiple points along
the pain pathway. Unfortunately, opioids also have the potential for great harm, with
multiple side effects and potential complications, some of which are lethal. They are also
uniquely addictive, which can lead to misuse and diversion.
We reviewed the relevant English literature and did thorough manual searches of the bibliographies of known primary and review articles. We utilized pain relief as the primary
outcome measure. Other outcome measures were functional improvement, improvement
of psychological status, improvement in work status, and evidence of addiction. Shortterm use and improvement was defined as less than 6 months and long-term relief was
defined as 6 months or longer.
The 3 systematic reviews evaluating long-term effectiveness of opioids for chronic noncancer pain provided unclear and weak evidence. The results of this review showed that
many patients in the included studies were dissatisfied with adverse events or insufficient pain relief from opioids and withdrew from the studies. For patients able to continue on opioids, evidence was weak suggesting that their pain scores were lower than before therapy and that this relief could be maintained long-term (> 6 months). There was
also weak evidence that long-term opioid therapy with morphine and transdermal fentanyl not only decreases pain but also improves functioning. Limited evidence was available for the most commonly used opioids, oxycodone and hydrocodone. Evidence for
the ability to drive on chronic opioid therapy was moderate without major side effects or
complications.
It is concluded that, for long-term opioid therapy of 6 months or longer in managing
chronic non-cancer pain, with improvement in function and reduction in pain, there is
weak evidence for morphine and transdermal fentanyl. However, there is limited or lack
of evidence for all other controlled substances, including the most commonly used drugs,
oxycodone and hydrocodone.
Key words: Opioids, opioid effectiveness, pain relief, functional improvement, adverse
effects, codeine, morphine, hydrocodone, hydromorphone, fentanyl, methadone.
Therapeutic Opioids: A Ten-Year Perspective
on the Complexities and Complications of
the Escalating Use, Abuse, and Nonmedical
Use of Opioids
Authors: Manchikanti Laxmaiah
Published: March 2021

Therapeutic opioid use and abuse coupled with the nonmedical use of other psychotherapeutic drugs has shown an explosive growth in recent years and has been a topic of great
concern and controversy. Americans, constituting only 4.6% of the world’s population,
have been consuming 80% of the global opioid supply, and 99% of the global hydrocodone supply, as well as two-thirds of the world’s illegal drugs. With the increasing therapeutic use of opioids, the supply and retail sales of opioids are mirrored by increasing
abuse in patients receiving opioids, nonmedical use of other psychotherapeutic drugs (in
this article the category of psychotherapeutics includes pain relievers, tranquilizers, stimulants, and sedatives, but does not include over-the-counter drugs), emergency department visits for prescription controlled drugs, exploding costs, increasing incidence of side
effects, and unintentional deaths.
However, all these ills of illicit drug use and opioid use, abuse, and non-medical use do
not stop with adults. It has been shown that 80% of America’s high school students, or
11 million teens, and 44% of middle school students, or 5 million teens, have personally witnessed, on the grounds of their schools, illegal drug use, illegal drug dealing, illegal
drug possession, and other activities related to drug abuse.
The results of the 2006 National Survey on Drug Use and Health showed that 7.0 million or 2.8% of all persons aged 12 or older had used prescription type psychotherapeutic drugs nonmedically in the past month, 16.387 million, or 6.6% of the population, had
used in the past year, and 20.3%, or almost 49.8 million, had used prescription psychotherapeutic drugs nonmedically during their lifetime. Sadly, the initiates of psychotherapeutic drugs used for nonmedical purposes were highest for opioids.
Therapeutic opioid use has increased substantially, specifically of Schedule II drugs. Apart
from lack of effectiveness (except for short-term, acute pain) there are multiple adverse
consequences including hormonal and immune system effects, abuse and addiction, tolerance, and hyperalgesia. Patients on long-term opioid use have been shown to increase
the overall cost of healthcare, disability, rates of surgery, and late opioid use.
Key words: Controlled prescription drug abuse, opioid abuse, opioid misuse, nonmedical
use of psychotherapeutic drugs, nonmedical use of opioids, National Survey on Drug Use
and Health, National Center on Addiction and Substance Abuse at Columbia University
Spinal Cord Stimulation for Patients with Failed
Back Surgery Syndrome: A Systematic Review
Authors: Frey Michael E.
Published: March 2021

Background: Failed back surgery syndrome is common in the United States. Management of post lumbar surgery syndrome with multiple modalities includes interventional
techniques, resulting in moderate improvement, leaving a proportion of patients in intractable pain. The systematic reviews of long-term benefits and risks of spinal cord stimulation
(SCS) for patients with failed back surgery syndrome showed limited to moderate evidence
and cost effectiveness. However, with the exponential increase in surgery in the United
States, spinal cord implants are also increasing. Thus, the discussion continues with claims
of lack of evidence on one hand and escalating increases in utilization on the other hand.
Study Design: A systematic review of SCS in patients with failed back surgery
syndrome.
Objectives: This systematic review is undertaken to examine the evidence from randomized controlled trials (RCTs) and observational studies to evaluate the effectiveness of SCS
in post lumbar surgery syndrome and to demonstrate clinical and cost effectiveness.
Methods: Review of the literature was performed according to the Cochrane Musculoskeletal Review Group Criteria as utilized for interventional techniques for randomized trials and the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies.
The 5 levels of evidence were classified as Level I, II, or III with 3 subcategories in Level
II based on the quality of evidence developed by the U.S. Preventive Services Task Force
(USPSTF).
Data sources included relevant literature of the English language identified through
searches of PubMed and EMBASE from 1966 to December 2008, and manual searches
of bibliographies of known primary and review articles.
Outcome Measures: The primary outcome measure was pain relief (short-term relief
≤ one-year and long-term > one-year). Secondary outcome measures of improvement in
functional status, psychological status, return to work, and reduction in opioid intake were
utilized.
Results: The indicated evidence is Level II-1 or II-2 for long-term relief in managing patients with failed back surgery syndrome.
Limitations: The limitations of this review included the paucity and heterogeneity of
the literature.
Conclusion: This systematic review evaluating the effectiveness of SCS in relieving
chronic intractable pain of failed back surgery syndrome indicated the evidence to be
Level II-1 or II-2 for clinical use on a long-term basis.
Key words: Chronic low back pain, neuropathic pain, failed back surgery syndrome,
FBSS, post lumbar surgery syndrome, electrical stimulation, spinal cord stimulation
Ultrasound-Guided Cryoablation of
Genitofemoral Nerve for Chronic Inguinal Pain
Authors: Plunkett Anthony R.
Published: March 2021

Background: Cryotechnology is a modality of renewed interest in pain management. It is safe
and effective when used to treat neuropathies of sensory and mixed nerves. Cryoablation, in
general, is devoid of the risk of neuroma formation and can provide several weeks to months of
adequate pain relief. Traditionally, cryoablation was applied blindly to the target area. The use
of ultrasound guidance may improve the efficacy and reduce morbidity. We report a case of a
successful cryoablation of the femoral component of the genitofemoral nerve using ultrasound
guidance in a patient with chronic inguinal pain.
A 47 year-old male (ASA Classification II for obesity, HLD, and OSA, 125kg, 69 in) presented
to the Walter Reed Pain Clinic with the complaint of 4/10 VAS left sided groin pain of 3 month
duration. The patient was diagnosed with a neuropathy of the femoral component of the
left genitofemoral nerve. He received a diagnostic block with local anesthetic and reported
immediate pain relief that lasted one week. The patient was counseled on the risks and benefits
of cryoablation. The skin was anesthetized with 1% lidocaine and a 14 gauge angiocatheter
needle was introduced using an in-plane technique to the target area. A Westco Cryoablation
machine (San Diego, California) with a 14 gauge Lloyd Neurostat cryoprobe was then passed
via the angiocatheter. The area was treated for two 3-minute intervals while the cryo probe was
visualized under ultrasound.
Ultrasound is increasingly utilized for both acute and chronic pain procedures. Ultrasound offered
several advantages in this case. It allowed a smaller gauge introducer and cryoablation probe
to be used since there was better visualization of the target area. Ultrasound helped identify
important vascular structures, allowing safe introduction of the introducer and cryoablation
probe. The patient remains pain free at 2-month follow-up.
Key words: Chronic pain, ultrasound, cryoablation, pain management, neuropathic pain,
nerve block
The Preliminary Results of a Comparative
Effectiveness Evaluation of Adhesiolysis and
Caudal Epidural Injections in Managing Chronic
Low Back Pain Secondary to Spinal Stenosis: A
Randomized, Equivalence Controlled Trial
Authors: Manchikanti Laxmaiah
Published: March 2021

Background: Lumbar surgery and epidural injections for spinal stenosis are the most commonly
performed interventions in the United States. However, there is only moderate evidence to the
effectiveness of surgery and caudal epidural injections. The next sequential step is adhesiolysis
and hypertonic neurolysis with targeted delivery. There have not been any randomized trials
evaluating the effectiveness of percutaneous adhesiolysis and targeted delivery of local
anesthetic, steroid and hypertonic sodium chloride solution in lumbar spinal stenosis.
Study Design: A randomized, equivalence, controlled trial.
Setting: An interventional pain management practice, a specialty referral center, a private
practice setting in the United States.
Objectives: To evaluate the effectiveness of percutaneous epidural adhesiolysis in patients
with chronic low back and lower extremity pain with lumbar central spinal stenosis and
compare with fluoroscopically directed caudal epidural injections.
Methods: Patients were randomly assigned to one of 2 groups with 25 patients in each
group. Group I patients received caudal epidural injections with catheterization up to S3 with
local anesthetic, 0.9% sodium chloride solution, non-particulate betamethasone and served as
the control group. Group II patients received percutaneous adhesiolysis with targeted delivery
and injection of lidocaine, 10% hypertonic sodium chloride solution, and non-particulate
Betamethasone and formed the intervention group. Randomization was performed by
computer-generated random allocation sequence by simple randomization.
Outcomes Assessment:
Multiple outcome measures were utilized including the Numeric Rating Scale (NRS), the
Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at
3, 6, and 12 months post treatment.
Significant pain relief was described as 50% or more, whereas significant improvement in the
disability score was defined as a reduction of 40% or more.
Results: This evaluation showed significant pain relief (> 50%) in 76% of the patients at one
year follow-up in the adhesiolysis group compared to 4% of the patients in the control group.
Limitations: The results of this study are limited by the lack of a placebo group, the fact that
it is a preliminary report, and there are only 25 patients in each group.
Conclusions: With significant pain relief in 76% of patients, percutaneous adhesiolysis utilizing
local anesthetic, steroids and hypertonic sodium chloride solution may be effective in patients
with chronic function-limiting low back and lower extremity pain with spinal stenosis.
Key words: Spinal stenosis, percutaneous adhesiolysis, steroids, local anesthetics, hypertonic
sodium chloride solution, randomized equivalence controlled trial, pragmatic trial
Comprehensive Review of Epidemiology, Scope,
and Impact of Spinal Pain
Authors: Manchikanti Laxmaiah
Published: March 2021

Persistent pain interfering with daily activities is common. Chronic pain has been
defined in many ways. Chronic pain syndrome is a separate entity from chronic pain.
Chronic pain is defined as, “pain that persists 6 months after an injury and beyond
the usual course of an acute disease or a reasonable time for a comparable injury to
heal, that is associated with chronic pathologic processes that cause continuous or
intermittent pain for months or years, that may continue in the presence or absence of
demonstrable pathologies; may not be amenable to routine pain control methods; and
healing may never occur.” In contrast, chronic pain syndrome has been defined as a
complex condition with physical, psychological, emotional, and social components.
The prevalence of chronic pain in the adult population ranges from 2% to 40%, with
a median point prevalence of 15%. Among chronic pain disorders, pain arising from
various structures of the spine constitutes the majority of the problems. The lifetime
prevalence of spinal pain has been reported as 54% to 80%. Studies of the prevalence
of low back pain and neck pain and its impact in general have shown 23% of patients
reporting Grade II to IV low back pain (high pain intensity with disability) versus 15%
with neck pain. Further, age related prevalence of persistent pain appears to be much
more common in the elderly associated with functional limitations and difficulty in
performing daily life activities. Chronic persistent low back and neck pain is seen in
25% to 60% of patients, one-year or longer after the initial episode.
Spinal pain is associated with significant economic, societal, and health impact.
Estimates and patterns of productivity losses and direct health care expenditures among
individuals with back and neck pain in the United States continue to escalate. Recent
studies have shown significant increases in the prevalence of various pain problems
including low back pain.
Frequent use of opioids in managing chronic non-cancer pain has been a major issue
for health care in the United States placing a significant strain on the economy with
the majority of patients receiving opioids for chronic pain necessitating an increased
production of opioids, and escalating costs of opioid use, even with normal intake. The
additional costs of misuse, abuse, and addiction are enormous. Comorbidities including
psychological and physical conditions and numerous other risk factors are common in
spinal pain and add significant complexities to the interventionalist’s clinical task.
This section of the American Society of Interventional Pain Physicians (ASIPP)/EvidenceBased Medicine (EBM) guidelines evaluates the epidemiology, scope, and impact of
spinal pain and its relevance to health care interventions.
Key words: Chronic pain, chronic spinal pain, chronic low back pain, chronic neck
pain, chronic thoracic pain, prevalence, health care utilization, loss of productivity,
interventional techniques, surgery, comorbid factors, socioeconomic effects, health
care impact