bluuebunny/crossref_metadata_2025 huggingface dataset:
Interventional Treatments for Postherpetic
Neuralgia: A Systematic Review
Authors: Lin Chia-Shiang
Published: February 2021

Background: Postherpetic neuralgia, a persistent pain condition often characterized by allodynia
and hyperalgesia, is a deleterious consequence experienced by patients after an acute herpes
zoster vesicular eruption has healed. The pain associated with postherpetic neuralgia can severely
affect a patient’s quality of life, quality of sleep, and ability to participate in activities of daily living.
Currently, first-line treatments for this condition include the administration of medication therapies
such as tricyclic antidepressants, pregabalin, gabapentin, and lidocaine patches, followed by the
application of tramadol and capsaicin creams and patches as second- or third-line therapies. As not
all patients respond to such conservative options, however, interventional therapies are valuable
for those who continue to experience pain.
Objective: This review focuses on interventional therapies that have been subjected to
randomized controlled trials for the treatment of postherpetic neuralgia, including transcutaneous
electrical nerve stimulation; local botulinum toxin A, cobalamin, and triamcinolone injection;
intrathecal methylprednisolone and midazolam injection; stellate ganglion block; dorsal root
ganglion destruction; and pulsed radiofrequency therapy.
Study Design: Systematic review
Setting: Hospital department in Taiwan
Methods: Search of PubMed database for all randomized controlled trials regarding postherpetic
neuralgia that were published before the end of May 2017.
Results: The current evidence is insufficient for determining the single best interventional
treatment. Considering invasiveness, price, and safety, the subcutaneous injection of botulinum
toxin A or triamcinolone, transcutaneous electrical nerve stimulation, peripheral nerve stimulation,
and stellate ganglion block are recommended first, followed by paravertebral block and pulsed
radiofrequency. If severe pain persists, spinal cord stimulation could be considered. Given the
destructiveness of dorsal root ganglion and adverse events of intrathecal methylprednisolone
injection, these interventions should be carried out with great care and only following
comprehensive discussion.
Limitations: Although few adverse effects were reported, these procedures are invasive, and a
careful assessment of the risk-benefit ratio should be conducted prior to administration.
Conclusion: With the exception of intrathecal methylprednisolone injection for postherpetic
neuralgia, the evidence for most interventional procedures used to treat postherpetic neuralgia is
Level 2, according to “The Oxford Levels of Evidence 2”. Therefore, these modalities have received
only grade B recommendations. Despite the lack of a high level of evidence, spinal cord stimulation
and peripheral nerve stimulation are possibly useful for the treatment of postherpetic neuralgia.
Key words: Interventional treatment, postherpetic neuralgia, botulinum toxin, steroid, stellate
ganglion block, peripheral nerve stimulation, paravertebral block, radiofrequency, spinal cord
stimulation
Effectiveness of Percutaneous Adhesiolysis in
Post Lumbar Surgery Syndrome: A Systematic
Analysis of Findings of Systematic Reviews
Authors: Manchikant Laxmaiah
Published: February 2021

Background: Post lumbar surgery syndrome is common and often results in chronic, persistent
pain and disability, which can lead to multiple interventions. After failure of conservative treatment,
either surgical treatment or a nonsurgical modality of treatment such as epidural injections,
percutaneous adhesiolysis are often contemplated in managing post lumbar surgery syndrome.
Multiple previous systematic reviews have reached discordant conclusions about the level of
evidence for the effectiveness of percutaneous adhesiolysis in managing post lumbar surgery
syndrome and other conditions.
Study Design: A systematic review of previously published systematic reviews assessing efficacy
of percutaneous adhesiolysis in managing post lumbar surgery syndrome.
Objective: To evaluate the value and validity of previous systematic reviews performed after 2015
on effectiveness of percutaneous adhesiolysis in managing chronic refractory low back and lower
extremity pain secondary to post lumbar surgery syndrome.
Methods: Previous systematic reviews on percutaneous adhesiolysis were evaluated. The quality
of each systematic review was assessed by Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) and A Measurement Tool to Assess Systematic Reviews (AMSTAR).
The randomized trials included in the available systematic reviews were assessed by Cochrane
review criteria and Interventional Pain Management techniques - Quality Appraisal of Reliability
and Risk of Bias Assessment (IPM-QRB) for methodologic quality.
Data sources included relevant systematic reviews and the randomized trials included in those
systematic reviews published since 2015 with searches of PubMed, Cochrane reviews, and Google
Scholar through February 2019.
Outcome Measures: Outcome measures were significant improvement defined as 50% pain
relief and improvement in functional status. Short-term efficacy was defined as improvement of 6
months or less, whereas long-term efficacy was defined as more than 6 months.
Results: Three systematic reviews and 4 randomized controlled trials (RCTs) of post lumbar surgery
syndrome with chronic refractory low back and lower extremity pain showed notable evidence of
significant pain relief. Only one systematic review, which was of low quality with inappropriate
analysis, showed lack of evidence.
Conclusion: Overall, the present analysis shows Level I evidence for percutaneous adhesiolysis
based on significant evidence from published RCTs and 3 of the 4 systematic reviews.
Key words: Post lumbar surgery syndrome, epidural fibrosis, percutaneous adhesiolysis,
systematic reviews, randomized controlled trials
Neurostimulation for the Treatment of Chronic
Head and Facial Pain: A Literature Review
Authors: Antony Ajay
Published: February 2021

Background: Head and facial pain is a common and often difficult to treat disorder.
Routine treatments sometimes fail to provide acceptable relief, leaving the patient searching
for something else, including narcotics and surgery. Recently, neuromodulation has been
expanding to provide another option. Secondary to its potentially temporary nature and
relatively manageable risk profile, several reviews have suggested trialing neuromodulation
prior to starting narcotics or invasive permanent surgeries. There is evidence that
neuromodulation can make a difference in those patients with intractable severe craniofacial
pain.
Objectives: To provide a basic overview of the anatomy, epidemiology, pathophysiology
and common treatments of several common head and facial disorders. Furthermore, to
demonstrate the suggested mechanisms of neuromodulation and the evidence currently
existing for the use of neuromodulation.
Methods: A comprehensive review was performed regarding the available literature
through targeting articles reporting on the use of neuromodulation to treat pain of the head
and face.
Results: We compiled and discuss the current evidence available in treating head and facial
pain. The strongest evidence currently for neuromodulation is for occipital nerve stimulation
for migraine, transcutaneous vagal nerve stimulation for migraine and cluster headache,
sphenopalatine ganglion microstimulation for cluster headache, and transcutaneous
supraorbital and supratrochlear nerve stimulation for migraine. In addition, there is moderate
evidence for occipital nerve stimulation in treating occipital neuralgia.
Limitations: Neuromodulation has been trialed and is promising in several craniofacial pain
disorders; however, there remains a need for large-scale, randomized, placebo-controlled
clinical trials to further evaluate the efficacy and safety of most treatments. Much of the
current data relies on case reports without randomization or placebo controls.
Conclusions: With advancing techniques and technology, neuromodulation can be
promising in treating intractable pain of the head and face. Although more randomized
controlled trials are warranted, the current literature supports the use of neuromodulation in
intractable craniofacial pain.
Key words: Neuromodulation, headache, facial pain, craniofacial pain, migraine, cluster
headache, trigeminal neuralgia, occipital neuralgia, peripheral nerve stimulator, high cervical
spinal cord stimulator, peripheral nerve field stimulator
The Associations Between Cognitive
Dysfunction, Stress Biomarkers, and
Administered Anesthesia Type in Total Knee
Arthroplasties: Prospective, Randomized Trial
Authors: Edipoglu Ipek Saadet
Published: February 2021

Background: Postoperative cognitive dysfunction (POCD) is a serious complication associated
with total knee arthroplasty (TKA) and has been shown to increase the length of hospital stay,
cause functional impairment, and morbidity.
Objectives: We aimed to determine whether POCD is associated with the use of general or
regional anesthesia in patients undergoing TKA. Our hypothesis was that POCD would be reduced
in the group that received regional analgesia without any sedations. Our secondary hypothesis was
POCD would be associated with biomarkers of surgical stress.
Study Design: Randomized controlled study between general and spinal anesthesia.
Setting: Single-centered, university hospital, from January to October 2017.
Methods: A total of 112 patients were assessed for eligibility, and a total of 57 patients completed
the study. We divided the patients into general and regional anesthesia groups. Blood samples
were obtained preoperatively at the first intraoperative, the third and the 24th postoperative
hour. C-reactive protein (CRP), cortisol, insulin, and blood glucose levels were tested. We used
4 neurocognitive tests that were administered 1 day before operation, 7 days and 30 days after
operation. Main outcome measures were neurocognitive tests scores for regional anesthesia
without sedation and general anesthesia groups. Cortisol, glucose, insulin, and CRP levels.
Results: Patients who received regional anesthesia showed significantly higher Mini-Mental
State Examination (MMSE) scored compared with the general anesthesia at the seventh day (P
= 0.037). In the general anesthesia group, patients showed significantly higher variations for the
Stroop number difference. There were negative correlations between MMSE scores measured at
postoperative day 7 and the 1-hour intraoperative cortisol measurements (r = –0.302; P = 0.022)
and 3-hour postoperative cortisol measurements (r = –0.295; P = 0.026).
Limitations: A limitation was the small number of patients.
Conclusions: We demonstrate that regional anesthesia results in better neurocognitive test
scores than general anesthesia in patients undergoing TKA. Patients who received regional
anesthesia showed lower cortisol, higher insulin, and lower glucose levels. We recommend that
patients who undergo arthroplasty surgeries should receive regional anesthesia to avoid POCD at
the early stages of the postoperative period.
Key words: Cognitive dysfunction, stress biomarkers, acute pain, regional anesthesia, spinal
anesthesia
Analgesic and Respiratory Effects of Two Doses
of Morphine as an Adjunct to Bupivacaine in
Ultrasound-Guided Transversus Abdominis
Plane Block in Upper Abdominal Surgery
Authors: Abdel-Ghaffar Hala S.
Published: February 2021

Background: Opioid receptors are present at the terminals of afferent peripheral nerves;
therefore, administration of opioids peripherally might provide a significant analgesic effect.
Objectives: We investigated the analgesic efficacy of 2 different doses of morphine in bilateral
subcostal single-injection ultrasound-guided transversus abdominis plane (TAP) block in abdominal
surgery.
Study Design: Randomized, controlled, double-blind trial.
Setting: University hospital.
Methods: We enrolled 90 patients (aged 18-60 years) who were scheduled for elective upper
abdominal surgeries and received TAP block for postoperative analgesia. Patients received 20 mL
bupivacaine 0.5% (group B) only or combined with 10 mg morphine (group BM10) or 15 mg
morphine (group BM15). Study drugs were diluted with saline solution 0.9% to 40 mL volume and
bupivacaine concentration of 0.25% and injected 20 mL on each side. Primary outcome was the
verbal rating pain scale (VRS) over the first 24 hours postoperatively. Secondary outcomes were
time to first request for analgesics, total analgesic consumption, lung spirometry, and adverse
effects.
Results: Compared with group B, patients in BM10 and BM15 groups showed significantly lower
postoperative VRS scores at rest and during cough. Patients in BM15 group had lower VRS scores
at the 24th hour postoperatively at rest (P = 0.034) and during cough (P = 0.040), compared with
group BM10, with no significant difference at other timepoints. The median time to first request
for intravenous patient controlled analgesia (PCA) nalbuphine was 10 hours (range, 6-12 hours) in
group B versus 15 hours (8-18 hours; P = 0.000) and 16 hours (10-23 hours; P = 0.000) in BM10
and BM15 groups, respectively. Total consumption of nalbuphine PCA in BM15 group was 12
mg (6-18 mg) compared with 26 mg (20-34 mg; P = 0.000) and 18 mg (12-24 mg; P = 0.000] in
groups B and BM10, respectively, with a significant difference between BM10 and BM15 groups (P
= 0.000) and without significant adverse effects.
Limitations: A limitation was a small sample size.
Conclusions: Addition of morphine to bupivacaine in single-injection subcostal TAP block
controlled pain and reduced opioid requirements after abdominal surgery in a dose–dependent
manner.
Key words: Abdominal surgery, analgesia, transversus abdominis plane block, morphine
Update on Reversal and Decline of Growth
of Utilization of Interventional Techniques
In Managing Chronic Pain in the Medicare
Population from 2000 to 2018
Authors: Manchikanti Laxmaiah
Published: February 2021

Background: The cost of US health care continues to increase, with treatments related to
low back and neck pain and other musculoskeletal disorders accounting for the third highest
amount of various disease categories. Interventional techniques for managing pain apart from
conservative modalities and surgical interventions, have generally been thought to be growing
rapidly. However, a recent analysis of utilization of interventional techniques from 2000 to
2016 has shown a modest decline from 2009 to 2016, compared to 2000 to 2009.
Objectives: The objectives of this analysis include providing an update on utilization of
interventional techniques in managing chronic pain in the Medicare population from 2009 to
2018 in the fee-for-service (FFS) Medicare population of the United States.
Study Design: Utilization patterns and variables of interventional techniques in managing
chronic pain were assessed from 2000 to 2009 and from 2009 to 2018 in the FFS Medicare
population of the United States.
Methods: The data for the analysis was obtained from the master database from the Centers for
Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2018.
Results: The analysis of data showed that there was a decline in utilization of interventional
techniques from 2009 to 2018 of 6.7%, with an annual decline of 0.8% per 100,000 FFS
Medicare population, despite an increase of 0.7% per year of population growth (3.2% of
those 65 years or older) and a 3% annual increase in Medicare participation from 2009 to
2018. Medicare data from 2000 to 2009 showed an increase of 11.8% per year per 100,000
individuals of the Medicare population. The 2009 to 2018 data also showed a 2.6% annual
decrease in the rate of utilization of epidural and adhesiolysis procedures per 100,000
population of FFS Medicare, and a 1% decrease for disc procedures and other types of nerve
blocks, while there was an increase of 0.9% annually for facet joint interventions and sacroiliac
joint blocks.
Limitations: Limitations of this analysis include: only the Medicare population was utilized,
and among the Medicare population, only the FFS population was evaluated; utilization
patterns in Medicare Advantage Plans, which constitutes almost 30% of the population were
not considered. Further, the utilization data for individual states was sparse and may not be
accurate.
Conclusion: The decline in utilization of interventional techniques continued from 2009 to
2018 with 6.7% per 100,000 Medicare population, with an annual decline of 0.8%, despite an
increase in the population rate and Medicare enrollees of 0.7% and 3% annually.
Key words: Interventional pain management, chronic spinal pain, interventional techniques,
epidural injections, adhesiolysis, facet joint interventions, sacroiliac joint injections, disc
procedures, other types of nerve blocks
Transforaminal Epiduroscopy in Patients with
Failed Back Surgery Syndrome
Authors: Avellanal Martín
Published: February 2021

Background: Epiduroscopy is a useful diagnostic and therapeutic tool for managing failed
back surgery syndrome (FBSS). The conventional approach is via either the sacral hiatus or the
interlaminar. Major causes of FBSS include epidural fibrosis, disc herniation, and stenosis. When
these problems are located at the intervertebral foramen level, it can be difficult to reach the lateral
recess and the foramen with the epiduroscope. Transforaminal epiduroscopy could be a useful
alternative approach in patients with FBSS located at the foraminal level.
Objective: We present a new procedure for lumbar epiduroscopy via a transforaminal approach
and its application in patients with FBSS. The technique is described and long-term results are
reported.
Study Design: This study used a single-arm prospective observational design.
Setting: The research took place at the University Hospital in Spain.
Methods: Patients with FBSS suffering severe chronic radicular pain (Numeric Rating Scale [NRS11] > 7) who had not responded to other treatments were included. Selective root stimulation
during a pulsed radiofrequency procedure confirmed the origin of pain by means of an exact
reproduction of typical pain. Transforaminal epiduroscopy was performed at the affected level.
The severity of fibrosis observed was recorded. The NRS-11 score was reevaluated at 1, 6, and 12
months after the procedure. Any complications related to the treatment were recorded.
Results: Twenty-four patients were included. The mean number of back surgeries was 1.66
(range, 1-5). The basal NRS-11 score was 7.83 (0.14); at 1 month, 3.66 (0.38) (P < 0.001); at 6
months, 4.46 (0.48) (P < 0.01); and at 1 year after treatment, 4.17 (0.51) (P < 0.01). Most patients
(54%; 95% CI, 34%-74%) obtained > 50% pain reduction on the NRS-11, maintained during a
1-year follow-up period. No major complications were registered.
Limitations: The research was limited by the lack of a control group.
Conclusions: We have described a new procedure for epiduroscopy via the transforaminal
approach. It is a useful and safe approach to managing FBSS at the foraminal level and shows
better long-term results than other endoscopic procedures.
Key words: Epidural, epiduroscopy, chronic pain, spinal cord, back surgery
OPRM1 Gene Interaction with Sleep in Chronic
Pain Patients Treated with Opioids
Authors: Peiró Ana M
Published: February 2021

Background: The experience of chronic non-cancer pain (CNCP) is one of the most
common reasons individuals seek medical attention. Patients with CNCP frequently experience
concomitant sleep-related problems.
Objectives: The aim was to evaluate sleep problems in opioid naïve CNCP patients, before
and after opioid titration, analyzing the influence of OPRM1 gene variants.
Study Design: A prospective, cohort, observational study.
Setting: This study was performed at the Pain Unit of the Alicante University General Hospital.
Methods: Pain and Medical Outcomes Study Sleep questionnaire (MOS-Sleep) were assessed
at baseline and 3 months after opioid titration in 231 opioid naïve CNCP patients. Sleep
data was compared with a matched-control group (n = 64). Morphine equivalent daily doses,
adverse events, and drugs prescribed for pain were also registered. OPRM1 polymorphism
rs1799971 was analyzed by RT-PCR. Ethics Committee approved the study and results were
analyzed by R software.
Results: After 3 months of opioid titration, patients with CNCP (63 ± 14 years, 64% female,
VAS 74 ± 17 mm) significantly decreased pain intensity, anxiety and depression, and increased
quality of life. Sleep problems were significantly more frequent in females (P = 0.002). Age,
quality of life, anxiety, and depression all influenced sleep disturbances and problems indices,
which were significantly different from the control group. Furthermore, the OPRM1 118-
GG genotype was also associated with significantly lower sleep adequacy, and more sleep
problems.
Limitations: Total number of subjects studied was relatively small and most patients were on
other non-opioid centrally-acting medications.
Conclusions: Opioids decreased CNCP severity, improving patients’ psychological areas, and
quality of life. However, patients with OPRM1 118-GG genotype indicated an increase in sleep
problems and worsening sleep pattern while taking opioids.
Key words: OPRM1, pharmacogenetics, MOS-Sleep, opioids, chronic noncancer pain, sleep
related problems, sleep problem index SLP-6 and SLP-9
Nerve Entrapment Headaches at the Temple:
Zygomaticotemporal and/or Auriculotemporal
Nerve?
Authors: Trescot Andrea
Published: February 2021

Background: Temple headaches are common, yet the anatomic etiology of headaches in
this region is often confusing. One possible cause of temple headaches is dysfunction of the
auriculotemporal nerve (ATN), a branch of the third division of the trigeminal nerve. However,
the site of pain is often anterior to the described path of the ATN, and corresponds more
closely to a portion of the path of a small branch of the second division of the trigeminal
nerve called the zygomaticotemporal nerve (ZTN)
Objectives: We present the anatomic and clinical differences between these 2 nerves and
describe treatment approaches. Diagnosis is made by physical examination of the temporal
fossa and the temporomandibular joint, and injection of local anesthetic over the tenderest
nerve.
Results: In general, treatments of headaches that generated from the peripheral nerve
attempt to neutralize the pain origin using surgical or interventional pain techniques to
reduce nerve irritation and subsequently deactivate stimulated migraine centers.
Conclusions: Treatment of temporal nerve entrapment includes medications, nerve
injections, dental appliances, cryoneuroablation, chemical neurolysis, neuromodulation, and
surgical decompression.
Key Words: Headache, migraine, trigeminal nerve, Frey’s syndrome, zygomaticotemporal
nerve, auriculotemporal nerve, temple pain, jaw pain, ear pain, tooth pain
The Effectiveness and Safety of 42°C Pulsed
Radiofrequency Combined with 60°C
Continuous Radiofrequency for Refractory
Infraorbital Neuralgia: A Prospective Study
Authors: Fang Luo
Published: February 2021

Background: Infraorbital neuralgia, one of the rare causes of facial pain, lacks systematic
treatment guidelines because few studies on the topic have been published. We previously found
that 42°C percutaneous nondestructive pulsed radiofrequency (PRF) treatment could achieve
satisfactory pain relief for infraorbital neuralgia patients. However, patients who responded poorly
to PRF had no other ideal treatment options until now. Recently, standard PRF combined with 60°C
continuous radiofrequency (CRF) was successfully performed on trigeminal neuralgia patients and
achieved a promising effective rate with mild complications. However, the efficacy of the combined
therapy in the treatment of infraorbital neuralgia has not yet been reported.
Objectives: To evaluate the effectiveness and safety of 42°C PRF combined with 60°C CRF in
infraorbital neuralgia patients who responded poorly to 42°C PRF and were reluctant to receive
destructive therapies or nerve decompression surgery.
Study Design: Prospective, single-center, observational clinical trial.
Setting: The interventional pain management center in Beijing Tiantan Hospital.
Methods: We prospectively investigated the effects of 10 minutes of 3-dimensional computer
tomography-guided 42°C PRF combined with 270 seconds of 60°C CRF in the treatment of 28
patients with refractory infraorbital neuralgia. The response criterion was a postoperative verbal
pain numeric rating scale score reduction of > 50%. The response rates at different time points
during a 2-year follow-up were calculated.
Results: The effective rates of combined PRF and CRF treatment were 95.5%, 86.4%, 81.8%,
72.7%, 72.7%, and 72.7% postoperative at 1 month, 3 months, 6 months, 1 year, 18 months,
and 2 years, respectively. Except for 16 patients (72.7%) experiencing mild numbness that
gradually disappeared within 1 week to 2 months after the operation, no obvious complications
were observed.
Limitations: This study examined the therapeutic effectiveness over a period of only 2 years;
no further follow-up was conducted. In addition, this study is a single-center observational clinical
study with small sample sizes.
Conclusions: For patients with intractable infraorbital neuralgia, 42°C PRF combined with 60°C
CRF is an effective and safe treatment. Prospective, double-blind randomized controlled trials with
longer follow-up periods are needed to evaluate whether the combined treatment could become
an alternative option for those who do not respond to conservative treatment, sparing those
patients from destructive therapies or more invasive nerve decompression surgery.
Key words: Infraorbital neuralgia, effectiveness, safety, pulsed radiofrequency, continuous
radiofrequency, combined therapy
Gender Differences in the Association of Brain
Gray Matter and Pain-Related Psychosocial
Characteristic
Authors: Malfliet Anneleen
Published: February 2021

Background: Although the association of gray matter morphology alterations and pain-related
psychosocial characteristics with pain intensity and chronification in people with chronic spinal
pain is evident, research on their mutual interaction is scarce and does not account for possible
gender differences. Gender-based differences are, however, of utmost importance to consider
when examining pain neurobiology.
Objectives: To look for gender differences in the association between magnetic resonance
imaging- (MRI) derived brain gray matter morphology and self-reported psychosocial characteristics.
Study Design: An explorative, observational study.
Setting: University Hospitals Ghent and Brussels, Belgium.
Methods: Brain gray matter morphology (using MRI) and self-reported psychosocial characteristics
were examined in women and men with nonspecific chronic spinal pain. Statistical analyses were
performed in SPSS and R to identify differences between men and women regarding brain gray
matter, self-reported psychosocial characteristics, as well as gender differences in the association
between those outcome measures.
Results: A total of 94 people with chronic spinal pain were studied, including 32 men (15 suffering
from neck pain, 17 suffering from low back pain; demographics [mean ± SD] age: 45.00 ± 12.02
years; pain duration: 128.37 ± 110.45 months), and 62 women (36 suffering from neck pain, 26
suffering from low back pain; demographics [mean ± SD] age: 38.78 ± 12.69 years; pain duration:
114.27 ± 92.45 months). Woman showed larger (positive) associations of several central brain areas
(paracentral, precentral, postcentral, etc.) with perceived consequences (P < 0.001), emotional
representations (P < 0.001), chronicity (P < 0.001), and pain catastrophizing (P< 0.001). Men showed
larger (both positive and negative) associations of the precuneus cortex, the precentral gyrus, and the
insula with perceived personal control (P < 0.001) and kinesiophobia (P < 0.001).
Limitations: Other factors, such as menstrual cycle and medication can have a certain influence,
and were only partly taken into consideration in the present investigation to obtain sufficient
power. Another limitation is the observational study design, which hampers the possibility to look
for causal or temporal interactions.
Conclusions: Gray matter morphology relates differently to psychosocial characteristics in
women and men. These explorative findings provide ideas for further research to investigate if
targeting perceived negative consequences of the illness, perceived emotional representations,
perceived chronicity, and pain catastrophizing in women, and perceived personal control of the
illness and kinesiophobia in men, could contribute to the normalization of brain alterations in
people with nonspecific chronic spinal pain.
Key words: Gray matter, brain morphology, central nervous system, illness perceptions, central
sensitization
Efficacy and Safety of Surgical Interventions
for Treating Multilevel Cervical Spondylotic
Myelopathy via Anterior Approach: A Network
Meta-Analysis
Authors: Li Bo
Published: February 2021

Background: Anterior cervical discectomy, with or without interbody fusion, is a common
technique to treat cervical spondylotic myelopathy (CSM). To date, controversy still exists
among spine surgeons regarding the anterior surgical approach to be used for the treatment
of multilevel CSM.
Objectives: To evaluate the effectiveness and safety of anterior cervical discectomy and
fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), cervical total disc replacement
(CTDR), and hybrid surgery (HS) in the treatment of multilevel CSM.
Study Design: Network meta-analysis (NMA) of randomized or nonrandomized controlled
studies for the treatment of multilevel CSM.
Methods: The databases such as PubMed, CENTRAL, and EMBASE were used to search and
identify the clinical trials involving the evaluations for the treatment of multilevel CSM. The
Newcastle-Ottawa Scale was used for the assessment of methodological qualities, whereas
the Cochrane Collaboration tool was used for assessing the risk of bias. Outcome assessments
included duration of surgery, Neck Disability Index (NDI) scores, and complications. Odds
ratio was used to express dichotomous outcomes, whereas mean difference with a 95%
confidence interval was used to express continuous outcomes.
Results: Sixteen relevant studies were identified, and 1,639 patients were included in this
analysis. CTDR demonstrated a prominently decreased NDI score and total incidence of
complications compared with ACDF, ACCF, and HS. In addition, ACDF resulted in shorter
operation times compared with ACCF, CTDR, and HS. The ranked order of NDI score
improvement in decreasing order was: CTDR, HS, ACDF, followed by ACCF. The rank order
for reduction in operation time increased progressively from ACDF, HS, ACCF to CTDR. The
total incidence of complications also showed a decreasing trend in the decreasing order—
CTDR, ACDF, HS, ACCF, and finally CTDR with the lowest complication rate.
Limitations: The limitations of this NMA include inconformity of the follow-up times and
surgical skill, and implants of different treatment centers vary.
Conclusions: The analysis of this study has shown that the best method for improvement
of functional outcome and reduction in total incidence of complications for multilevel CSM
is CTDR.
Key words: Multilevel cervical spondylotic myelopathy, anterior cervical discectomy and
fusion, anterior cervical corpectomy and fusion, cervical total disc replacement, hybrid surgery,
effectiveness, safety, network meta-analysis
Does Coadministration of Transforaminal
Epidural Steroid Injection with Sedation
Improve Patient Satisfaction? A Prospective
Randomized Clinical Study
Authors: Edipoglu Ipek Saadet
Published: February 2021

Background: Transforaminal epidural steroid injection (TFESI) can be administered with or without
sedation in clinical practice.
Objectives: The aim of this study was to compare both procedures in terms of patient and physician
satisfaction, preoperative anxiety level, procedural pain level, and complications.
Study Design: A prospective randomized trial.
Setting: A university hospital interventional pain management center.
Methods: The study included patients scheduled for single-level unilateral TFESI. The patients
were randomized into 2 groups. The first group underwent TFESI without sedation, whereas the
second group underwent TFESI with sedation. The Likert scale was used to determine the patient and
physician satisfaction, and the Numeric Rating Scale (NRS-11) was used to determine the procedural
pain level. Cases in which the procedure was to be repeated, the patient was questioned if they
desired to undergo the procedure with the same technique.
Results: A total of 64 patients, (31 [48.4%] in the sedation group) were included. In the sedation
group, the patient and physician satisfaction were significantly higher (P = 0.0001), the periprocedural
NRS-11 scores were significantly lower (P = 0.0001), and the rate of desire to have the intervention
with the same technique was higher (P = 0.001). After the regression analysis, we reported that there
was a significant correlation between being in the sedation group and NRS-11 procedure scores, the
desire to have the same technique, and patient and physician satisfaction (odds ratio [OR], 0.341;
OR, 0.648; OR, 0.329; OR, 0.514; P = 0.0001).
Limitations: Both patients and physicians were unblinded.
Conclusions: Coadministration of TFESI with sedation improves patient and physician satisfaction.
Additionally, the low periprocedural pain level results in patients’ demand for the intervention to be
performed with sedation in the event of repetition of the procedure.
Key words: Patient satisfaction, transforaminal epidural steroid injection, sedation, physician
satisfaction
β-blocker Use is Associated with a Reduction
in Opioid Use 30 Days After Total Knee
Arthroplasty
Authors: Starr Jordan
Published: February 2021

Background: Total knee arthroplasty (TKA) can lead to chronic pain and prolonged postoperative
opioid use. There are few evidence-based interventions to prevent these outcomes. Recently,
β-blockers have emerged as possible novel analgesics.
Objectives: The objective of this study was to determine whether perioperative β-blocker use is
associated with reduced prolonged postoperative opioid use after TKA.
Study Design: This study used a retrospective cohort design.
Setting: The research took place within Department of Veterans Affairs hospitals in the United
States between April 2012 and April 2016.
Methods: Patients: IRB approval was obtained to examine the records of Veterans Affairs (VA)
patients undergoing TKA. Patients using opioids 60 days before surgery were excluded.
Intervention: The intervention being investigated was perioperative β-blocker use, overall and
by class.
Measurement: Oral morphine equivalent usage through postoperative day 1 and prescription
opioid refills through 30, 90, and 365 days after TKA were recorded. Adjusted models were created
controlling for relevant demographic and comorbidity covariates. A secondary analysis examined
the same outcomes separated by β-blocker class.
Results: The cohort was 93.8% male with a mean age of 66 years. Among the 11,614 TKAs
that comprised the cohort, 2,604 (22.4%) were performed on patients using β-blockers. After
adjustment, β-blocker use was associated with reduced opioid use through 30 days after surgery
(odds ratio [OR] 0.89 [95% confidence interval (CI), 0.80-0.99], P = .026). Selective β-blockers
were associated with reduced opioid use at 30 days (OR 0.88 [95% CI, 0.78-0.98], P = .021), and
nonselective β-blockers were associated with reduced oral morphine equivalent usage through
postoperative day 1 (β = -17.9 [95% CI, -29.9 to -5.8], P = .004).
Limitations: Generalizability of these findings is uncertain, because this study was performed
on a cohort of predominantly white, male VA patients. This study also measured opioid use,
but opioid use is not a perfect surrogate for pain. Nevertheless, opioid use offers value as an
objective measure of pain persistence in a national cohort for which patient-reported outcomes
are otherwise unavailable.
Conclusions: Perioperative β-blocker use was associated with reduced prescription opioid use
at 30 days after surgery. Both selective and nonselective β-blockers were associated with reduced
opioid use when analyzed individually.
Key words: Analgesics, opioid, arthroplasty, replacement, knee, adrenergic beta-antagonists,
pain management
Variations of Technique in Transforaminal
Epidural Steroid Injections and Periprocedural
Practices by Interventional Pain Medicine
Physicians in the United States
Authors: Doan Lisa
Published: February 2021

Background: Interlaminar and transforaminal epidural steroid injections (ILESI and TFESI) are
commonly performed procedures. However, the United States Food and Drug Administration has
required the addition of drug warning labels for injectable corticosteroids. Updated evidence and
scrutiny from regulatory agencies may affect practice patterns.
Objective: To characterize TFESI practices as well as to provide an update on periprocedural
practices for any type of epidural steroid injection (ESI), we surveyed pain medicine physicians in
the United States.
Study Design and Setting: This was a cross-sectional survey of pain medicine physicians in
the United States.
Methods: A web-based survey was distributed to pain medicine physicians in the United
States selected from the Accreditation Council for Graduate Medical Education accredited pain
medicine fellowship program list as well as the American Society of Interventional Pain Physicians
membership database. Physicians were queried about TFESI practices, including needle size, use of
image guidance, methods to detect vascular uptake, and preference for injectate.
Results: A total of 249 responses were analyzed. Only a minority of respondents reported
performing cervical TFESI. There were variations in needle size, methods to detect vascular uptake,
and choice of injectate. There were also variations in monitoring practices.
Limitations: The response rate is a limitation. Thus the results may not be representative of all
US pain medicine physicians.
Conclusions: Though all respondents used image guidance for TFESI, variations in other TFESI
practices exist. There are also differences in periprocedural practices. Since the closure of this
survey, a multisociety pain workgroup published recommendations regarding ESI practices. Our
survey findings support the need for more evidence-based guidelines regarding ESI.
Key words: Epidural steroid injections, transforaminal epidural steroid injection, steroids, local
anesthetic, survey, interventional pain
A Staged Treatment of Symptomatic Lumbar
Intraspinal Synovial Cysts
Authors: Kim Kyung-Hoon
Published: February 2021

Background: Lumbar intraspinal synovial cyst (LISC) refers to a cyst that arises from the
zygapophyseal joint capsule of the lumbar spine and contains serous or gelatinous fluid. In cases
of LISCs resistant to conservative treatments, various minimally invasive percutaneous spinal
techniques (MIPSTs) may be applied prior to open surgery.
Objectives: The outcomes of 3-staged MIPSTs for the treatment of symptomatic LISCs resistant
to conservative treatments were evaluated.
Study Design: An institutional review board approved retrospective chart review.
Setting: University hospital inpatients referred to our pain clinic.
Methods: Review of charts of all patients who underwent MIPSTs for symptomatic LISCs resistant
to conservative treatments during a time period of 13 years at a university hospital pain clinic.
Patients with symptomatic LISCs resistant to conservative treatments were treated with 3-staged
MIPSTs, including image-guided intraarticular aspiration, cyst distention and rupture, and injection
of corticosteroids (ARI), endoscopic cyst enucleation (ECE), and endoscopic superior facetectomy
(ESF) by a single pain specialist. A symptom-free period after each intervention was evaluated.
Recurrence was defined as the same recurrent symptomatic radicular pain with confirmation of
the LISC on magnetic resonance imaging. All patients with a minimum follow-up time of 3 years
were included.
Results: Of the 40 patients who underwent ARI, 3 patients failed to complete a follow-up and
19 patients (51.4%) who had recurring symptoms received ECE. Ten patients (52.6%) who had rerecurring symptoms after ECE received ESF. There was no recurrence after ESF.
Limitations: This retrospective and observational study with a limited number of patients does
not represent a high level of evidence.
Conclusions: This information provided the recurrence rate after each intervention. Half of the
patients who went on to receive ARI experienced recurrence, whereas half of the patients with
recurrence who received ECE experienced re-recurrence. ESF treatment resulted in no recurrence
within the 3-year study period.
Key words: Conservative treatment, endoscopic surgical procedures, facet joint, intraarticular
injection, minimally invasive surgical procedures, needle biopsy, nerve root compression,
radiculopathy, synovial cysts
The Long-Term Outcome of 3-Dimensional
CT-Guided Percutaneous Radiofrequency
Thermocoagulation for Tumor-Related
Trigeminal Neuralgia
Authors: Fang Luo
Published: February 2021

Background: Percutaneous radiofrequency thermocoagulation (PRFT) has been widely
used to treat trigeminal neuralgia. By querying MEDLINE, EMBASE, and the Cochrane Library,
no study has reported the long-term outcome of PRFT for tumor-related trigeminal neuralgia
(TRTN).
Objectives: In this study, we aimed to evaluate the long-term efficacy and safety of PRFT
as an alternative treatment for TRTN.
Study Design: A retrospective study.
Setting: The interventional pain management center in Beijing Tiantan hospital.
Methods: We retrospectively analyzed data of all patients who underwent PRFT applied
to the Gasserian ganglion under computed tomography guidance for TRTN through a
combination of available institutional electronic medical records, patient notes, and radiologic
images.
Results: Among 38 patients with PRFT treated between March 2007 and February 2018,
13 patients were men and 25 were women. All patients were evaluated as modified Barrow
Neurological Institute (BNI) IV-V before the operation and had a total symptom duration
of 45.55 ± 23.31 months. The mean operation duration was 59.63 ± 16.89 minutes. All
patients experienced satisfactory pain relief defined as a classification of BNI I-IIIb within 3
days after PRFT. The median remission length with satisfactory pain relief was 33 (range,
4-132) months. No serious intraoperative complications, except bradycardia in 6 patients,
were recorded. Postprocedure complications, including masticatory muscle weakness, were
reported in 5 patients. Although all 38 patients experienced facial dysesthesia, the patients’
Likert scale rating represented that quality of life significantly increased after the procedure.
Limitations: The small sample size may have unavoidably caused selection bias in our study.
Larger prospective, randomized, multicenter trials are necessary to validate our outcomes.
Conclusions: PRFT is an effective and safe treatment that should be considered as an
alternative for pain control in the treatment of TRTN.
Key words: Pain, secondary trigeminal neuralgia, radiofrequency thermocoagulation,
trigeminal neuralgia
Fibromyalgia Impact Score in Women with
Fibromyalgia Across Southern, Central, and
Northern Areas of Europe
Authors: Segura-Jimenez Victor
Published: February 2021

Background: The Fibromyalgia Impact Questionnaire (FIQ) is the most used
questionnaire worldwide to measure the health status of patients with fibromyalgia. The
questionnaire has been subjected to several studies to analyze psychometric properties.
However, norm scores and cultural differences have not been presented.
Objectives: To obtain and present norm scores for the FIQ in patients with fibromyalgia
in different cultures, namely Southern, Central, and Northern areas of Europe.
Study Design: This observational study consisted of women with fibromyalgia from 4
countries (Spain, Belgium, the Netherlands, and Sweden) classified in 3 areas (Southern,
Central, and Northern) in Europe.
Setting: Women with fibromyalgia from Spain, Belgium, the Netherlands, and Sweden.
Methods: The impact of fibromyalgia was assessed by the FIQ. A total of 1,478 women
with fibromyalgia were asked to fill out the FIQ in the Spanish (n = 531), Dutch and
Belgian (n = 629), or Swedish (n = 318) versions.
Results: The norm scores and percentiles score of the FIQ are presented. Norm scores
differed between European areas (Southern area = 64.8 ± 15.9; Central area = 60.9 ±
15.7; Northern area = 62.8 ± 16.7). Perceived physical impairment, overall well-being
(all, P < 0.001), FIQ total (P < 0.01), and morning tiredness (P < 0.05) in women with
fibromyalgia from the Central area of Europe reported lower impact than Southern and
Northern areas. The Northern area of Europe showed the lowest score of job difficulty,
anxiety, depression (all, P < 0.001), and pain (P < 0.01), whereas the Southern area of
Europe showed the lowest score of work missed subscale (P < 0.001) with regard to the
rest of the areas studied.
Limitations: The selection of patients was conducted with just women because of
the scarce prevalence of fibromyalgia among men. Moreover, sociodemographic status,
socioeconomic status, and clinical characteristics were not measured. Similar research
should be conducted with adequate representation of populations from other parts of
the world.
Conclusions: Pairwise comparisons showed significant differences mainly between the
Southern area versus Northern and Central areas of Europe. The impact of fibromyalgia
showed mainly higher scores in women with fibromyalgia from the Southern area of
Europe.
Key words: Symptom, psychometric, norm scores, European comparison
Hydraulic Distension with Pumping Technique
for Treating Frozen Shoulder: A CaseControlled, Retrospective, Comparative Study
with 6-Month Follow-Up
Authors: Lee Sang Chul
Published: February 2021

Background: We have applied a new method called “the pumping technique” to the capsulepreserving hydraulic distension for frozen shoulder. With this technique, the stretching effect can
be directly applied to the joint capsule of the affected shoulder.
Objectives: We attempted to evaluate the effect of capsule-preserving hydraulic distension
using the pumping technique by comparing capsule-preserving hydraulic distension without it.
Study Design: A case-controlled, retrospective, comparative study.
Setting: Outpatient clinic of department of rehabilitation medicine in a single university hospital.
Methods: Patients (n = 47) with frozen shoulder who were treated with hydraulic distension
were assigned into the pumping group (n = 24) and the nonpumping group (n = 23). Range of
motion (ROM), Shoulder Pain and Disability Index (SPADI), and Visual Analog Scale (VAS) scores
were assessed.
Results: Significant improvement of VAS, ROM, and SPADI scores was observed after the
second injection in each group (P < 0.05). There were significant differences in total passive
ROM, abduction, and flexion after the fifth injection between the 2 groups (P < 0.05). There was
a significant difference in the disability domain of SPADI after the second injection between the
2 groups (P < 0.05). However, there was no significant interaction between time and group with
respect to VAS scores. There were no serious complications after procedures.
Limitations: This was a retrospective study. There might be some limitations in gathering
comprehensive records of outcome measurements. In addition, because the objective of this
study was to determine the effect of the new pumping technique, included patients range was
very narrow. This study only included patients who were treated 5 times with capsule-preserving
hydraulic distensions with or without the pumping technique.
Conclusions: Although the effect on pain was excellent in both groups, the superiority of the
new pumping technique was demonstrated by reduction of SPADI disability subscale score and
improvement of ROM of the shoulder compared with the nonpumping technique.