bluuebunny/crossref_metadata_2025 huggingface dataset:
Systematic Review of the Effectiveness of
Thermal Annular Procedures in Treating
Discogenic Low Back Pain
Authors: Helm II Standiford
Published: March 2021

Background: Chronic discogenic low back pain is a common problem with significant personal
and societal costs. Thermal annular procedures (TAPs) have been developed in an effort to provide
a minimally invasive treatment for this disorder. Multiple techniques utilized are intradiscal electrothermal therapy (IDET), radiofrequency annuloplasty, and intradiscal biacuplasty (IDB). However,
these treatments continue to be controversial, coupled with a paucity of evidence.
Study Design: A systematic review of the literature evaluating the efficacy or effectiveness of
TAPs.
Objective: To determine the effectiveness of TAPs in reducing low back pain in patients with intradiscal disorders.
Methods: A comprehensive evaluation of the literature relating to TAPs was performed. The
literature was evaluated according to Cochrane Review criteria for randomized controlled trials
(RCTs) and according to the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies.
The level of evidence was classified as Level I, II, or III based on the quality of evidence developed
by the U.S. Preventive Services Task Force (USPSTF). Pain relief was the primary outcome measure.
Other outcome measures were functional improvement, improvement of psychological status,
and return to work.
Data sources included relevant literature of the English language identified through searches of
PubMed, EMBASE, the Cochrane Library, and the Database of Reviews of Effectiveness (DARE).
Outcome Measures: Short-term effectiveness was defined as one-year or less and long-term
effectiveness was defined as greater than one-year.
Results: Systematic review of IDET identified 2 RCTs and 16 observational studies with an indicated evidence of Level II-2.
Systematic review of radiofrequency annuloplasty identified no RCTs but 2 observational studies
with an uncertain evidence of Level II-3.
Systematic review of IDB identified one pilot study. The level of evidence is lacking with Level III.
Limitations: The limitations of this review include paucity of the literature and lack of evidence
with internal validity and generalizability.
Conclusion: IDET offers functionally significant relief in approximately one-half of appropriately
chosen chronic discogenic low back pain patients. There is minimal evidence supporting the use
of radiofrequency annuloplasty and IDB.
Key words: Chronic low back pain, degenerative disc disease, internal disc disruption, intervertebral disc, thermal annular procedures, intradiscal electrothermal therapy, radiofrequency ablation, intradiscal biacuplasty, radiofrequency annuloplasty
Evidence-Based Medicine, Systematic Reviews,
and Guidelines in Interventional Pain
Management: Part 3: Systematic Reviews and
Meta-Analyses of Randomized Trials
Authors: Manchikanti Laxmaiah
Published: March 2021

In recent years, progress and innovations in healthcare are measured by evidencebased medicine (EBM), systematic reviews, and meta-analyses. A systematic review
is defined as, “the application of scientific strategies that limit bias by the systematic
assembly, critical appraisal, and synthesis of all relevant studies on a specific topic.”
In contrast, meta-analysis is the statistical pooling of data across studies to generate
pooled estimates of effects. Meta-analysis usually is the final step in a systematic review.
Systematic reviews and meta-analyses are labor intensive, requiring expertise in both
the subject matter and review methodology, and also must follow the rules of EBM
which suggest that a formal set of rules must complement medical training and common sense for clinicians to interpret the results of clinical research effectively. While
expertise in the subject matter is crucial, expertise in review methods is also particularly important.
Despite an explosion of systematic reviews and meta-analyses, the empiric research
on the quality of systematic reviews has shown that not all systematic reviews are truly systematic, having highly variable quality, deficiencies in methodologic assessment
of the quality of the included manuscripts, and bias. Even then, systematic review of
the literature is currently the best, least biased, and most rational way to organize,
cull, evaluate, and integrate the research evidence from among the expanding medical and healthcare literature. However, a dangerous discrepancy between the experts
and the evidence continues to persist in part because multiple instruments are available to assess the quality of systematic reviews or meta-analyses.
Steps in conducting systematic reviews include planning, conducting, reporting,
and disseminating the results. The Quality of Reporting of Meta-analysis (QUOROM)
statement provides a checklist and a flow diagram. The checklist describes the preferred way to present the abstract, introduction, methods, results, and discussion sections of the report of an analysis. This review describes various aspects of systematic
reviews and meta-analyses of randomized trials with a special focus on interventional pain management.
Key words: Randomized trials, pragmatic trials, evidence-based medicine, systematic reviews, meta-analyses, guidelines, bias, interventional pain management, Quality of Reporting of Meta-analysis (QUOROM), Cochrane reviews
Physician Impairment: Is Recovery Feasible?
Authors: Christo Paul J.
Published: March 2021

Background: Physician impairment is a serious public health issue affecting not only
physicians, but also their families, colleagues, and patients. Physician impairment is
used most often to refer to substance use disorders, which involve both substance
abuse and substance dependence and/or addiction.
Objective: This article aims to describe the problem of physician impairment within
the context of substance use disorders. The concept of recovery and several strategies
for effective recovery are explored.
Discussion: Experts now define impairment as an enduring condition that if left untreated is not amenable to remission and cure. In terms of functional capacity, impairment renders the physician unable to provide competent medical services, with serious
flaws in professional judgment. Herein, we define the scope of the problem, consider
several theories to explain the reason physicians may be prone to develop substance
use disorders, discuss diagnosis and reporting, as well as treatment and prognosis, and
identify several relapse prevention strategies.
Conclusion: Physician impairment is a real and significant public health concern;
however, recovery is feasible and the data support favorable odds of recovery and a return to clinical practice among those seeking appropriate treatment, counseling, and
relapse prevention strategies.
Key words: Physician impairment, substance use disorder, prevention, relapse, recovery, dependence, substance abuse, Physician Health Programs (PHPs).
The Marginalization of Chronic Pain Patients on
Chronic Opioid Therapy
Authors: Peppin John F.
Published: March 2021

The realities of treating chronic pain do not reflect the attention that marginalization of patients taking opioids has received. Physicians continue the same prejudices and biases that were present decades ago. One theory proposed to explain
this poor treatment has been titled, the “barriers to pain management.” The
barriers are not treated as moral issues, but rather as clinical aberrations and do
not explain continued poor treatment. However, the barriers do not explain certain types of cases where there appears to be specific unfounded concerns related to a specific class of medications, e.g, opioids. Four cases are presented, from
the authors experience, illustrating the marginalization of chronic pain patients
on chronic opioid therapy admitted to a tertiary care hospital. These types of
cases have not been presented in the literature previously and illustrate the failure of the barriers to explain marginalization. In each of these cases mental status changes was the presenting problem. However, in each of these cases, these
changes were not related to their opioids, but were explained by clear reasons,
other than opioids. Regardless, in each case, the attending physician blamed the
opioids, without further workup and stopped them reflexively. It is proposed that
there may be more complex psychosocial issues involved in the marginalization of
chronic pain patients. This case series illustrates a ubiquitous problem demanding
further examination and discussion. It is hoped that this case series will create interest in further research in this area.
Key words: Chronic pain, opioids, marginalization, bias, barriers
A Systematic Review of Mechanical Lumbar
Disc Decompression with Nucleoplasty
Authors: Manchikanti Laxmaiah
Published: March 2021

Background: Lumbar disc prolapse, protrusion, or extrusion account for less than 5% of all low
back problems, but are the most common causes of nerve root pain and surgical interventions.
The primary rationale for any form of surgery for disc prolapse is to relieve nerve root irritation
or compression due to herniated disc material. The primary modality of treatment continues to
be either open or microdiscectomy, but several alternative techniques including nucleoplasty,
automated percutaneous discectomy, and laser discectomy have been described. There is a
paucity of evidence for all decompression techniques, specifically alternative techniques including
nucleoplasty.
Study Design: A systematic review of the literature.
Objective: To determine the effectiveness of mechanical lumbar disc decompression with
nucleoplasty.
Methods: A comprehensive evaluation of the literature relating to mechanical lumbar disc
decompression with nucleoplasty was performed. The literature was evaluated according to
Cochrane review criteria for randomized controlled trials (RCTs), and Agency for Healthcare
Research and Quality (AHRQ) criteria was utilized for observational studies.
The level of evidence was classified as Level I, II, or III with 3 subcategories in Level II based on the
quality of evidence developed by the United States Preventive Services Task Force (USPSTF).
A literature search was conducted using only English language literature through PubMed,
EMBASE, the Cochrane library, systematic reviews, and cross-references from reviews and
systematic reviews.
Outcome Measures: Pain relief was the primary outcome measure. Other outcome measures
were functional improvement, improvement of psychological status, opioid intake, and return
to work.
Short-term effectiveness was defined as one year or less, whereas, long-term effectiveness was
defined as greater than one year.
Results: Based on USPSTF criteria the level of evidence for nucleoplasty is Level II-3 in managing
predominantly lower extremity pain due to contained disc herniation.
Limitations: Paucity of literature, both observational and randomized.
Conclusion: This systematic review illustrates Level II-3 evidence for mechanical lumbar
percutaneous disc decompression with nucleoplasty in treatment of leg pain. However, there is
no evidence available in managing axial low back pain.
Key words: Intervertebral disc disease, chronic low back pain, disc herniation, disc protrusion,
radiculitis, contained disc herniation, mechanical disc decompression, nucleoplasty, coblation
technology, nucleotomy
Percutaneous Lumbar Laser Disc
Decompression: A Systematic Review of
Current Evidence
Authors: Singh Vijay
Published: March 2021

Background: Since the descriptions by Mixter and Barr of open surgical treatment for rupture
of the intervertebral disc in 1934, open surgical procedures have become a common practice.
Disc herniations have been reported as being contained and non-contained. The results of open
surgical discectomy for contained disc herniation have been poor. Consequently, several alternative techniques have been developed which are minimally invasive including percutaneous laser
disc decompression.
Study Design: A systematic review of the literature.
Objective: The objective of this systematic review is to evaluate the clinical effectiveness of percutaneous laser discectomy in managing radicular pain secondary to contained disc herniation.
Methods: A comprehensive evaluation of the literature relating to mechanical disc decompression was performed. The literature was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs), and Agency for Healthcare Research and Quality (AHRQ) criteria
was utilized for observational studies.
A literature search was conducted by using only the English language literature through PubMed,
EMBASE, the Cochrane library, systematic reviews, and cross references from reviews and systematic reviews.
The level of evidence was classified as Level I, II, or III with 3 subcategories in Level II based on the
quality of evidence developed by the United States Preventive Services Task Force (USPSTF).
Outcome Measures: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, opioid intake, and return to work.
Short-term effectiveness was defined as one year or less, whereas, long-term effectiveness was
defined as greater than one year.
Results: Based on USPSTF criteria the indicated level of evidence for percutaneous lumbar laser
discectomy (PLLD) is II-2 for short- and long-term relief.
Limitations: Even though laser discectomy has been in utilization for a number of years and
numerous procedures have been performed there continues to be a paucity of literature of randomized clinical trials.
Conclusion: This systematic review illustrates Level II-2 evidence for percutaneous laser disc decompression which is equivalent to automated percutaneous lumbar disc decompression.
Key words: Intervertebral disc disease, chronic low back pain, disc herniation, disc protrusion,
radiculitis, contained disc herniation, mechanical disc decompression, percutaneous lumbar laser
discectomy, laser assisted spinal endoscopy
Automated Percutaneous Lumbar Discectomy
for the Contained Herniated Lumbar Disc: A
Systematic Assessment of Evidence
Authors: Hirsch Joshua
Published: March 2021

Background: Lumbar disc prolapse, protrusion, and extrusion account for less than 5%
of all low back problems, but are the most common causes of nerve root pain and surgical
interventions. The typical rationale for traditional surgery is an effort to provide more rapid
relief of pain and disability. It should be noted that the majority of patients will recover with
conservative management. The primary rationale for any form of surgery for disc prolapse
associated with radicular pain is to relieve nerve root irritation or compression due to herniated
disc material. The primary modality of treatment continues to be either open or microdiscectomy,
but several alternative techniques including automated percutaneous lumbar discectomy (APLD)
have been described. However, there is a paucity of evidence for all decompression techniques,
specifically alternative techniques including automated and laser discectomy.
Study Design: A systematic review of the literature.
Objective: To determine the effectiveness of APLD.
Methods: A comprehensive evaluation of the literature relating to automated lumbar disc
decompression was performed. The literature was evaluated according to Cochrane review
criteria for randomized controlled trials (RCTs), and Agency for Healthcare Research and Quality
(AHRQ) criteria was utilized for observational studies.
A literature search was conducted of English language literature through PubMed, EMBASE,
the Cochrane library, systematic reviews, and cross references from reviews and systematic
reviews.
The level of evidence was classified as Level I, II, or III with 3 subcategories in Level II based on the
quality of evidence developed by the United States Preventive Services Task Force (USPSTF).
Outcome Measures: Pain relief was the primary outcome measure. Other outcome measures
were functional improvement, improvement of psychological status, opioid intake, and return
to work.
Short-term effectiveness was defined as one-year or less, whereas, long-term effectiveness was
defined as greater than one-year.
Results: Based on USPSTF criteria, the indicated evidence for APLD is Level II-2 for short- and
long-term relief.
Limitations: Paucity of RCTs in the literature.
Conclusion: This systematic review indicated Level II-2 evidence for APLD. APLD may provide
appropriate relief in properly selected patients with contained lumbar disc prolapse.
Key words: Intervertebral disc disease, chronic low back pain, mechanical disc decompression,
automated percutaneous lumbar discectomy, internal disc disruption, radiculitis.
Greater Occipital Nerve Stimulation via the
Bion® Microstimulator: Implantation Technique
and Stimulation Parameters
Clinical Trial: NCT00205894
Authors: Trentman Terrence L.
Published: March 2021

Background: Millions of patients suffer from medically refractory and disabling
primary headache disorders. This problem has led to a search for new and innovative
treatment modalities, including neuromodulation of the occipital nerves.
Objectives: The primary aim of this study is to describe an implantation technique
for the Bion® microstimulator and document stimulation parameters and stimulation
maps after Bion placement adjacent to the greater occipital nerve. The secondary aim
is to document outcome measures one year post-implant.
Design: Prospective, observational feasibility study.
Methods: Nine patients with medically refractory primary headache disorders
participated in this study. Approximately 6 months after Bion insertion, stimulation
parameters and maps were documented for all patients. At one year, outcome
measures were collected including the Migraine Disability Assessment Score.
Results: At 6 months, the mean perception threshold was 0.47 mA, while the
mean discomfort threshold was 6.8 mA (stimulation range 0.47 – 6.8 mA). The mean
paresthesia threshold was 1.64 mA and the mean usage range was 16.0. There were
no major complications reported such as device migration, infection, or erosion. One
patient stopped using her Bion before the 12-month follow-up visit. At one year, 7
of the 8 patients were judged as having obtained fair or better results in terms of
reduction of disability; 5 patients had greater than a 90% reduction in disability.
Limitations: Small, heterogeneous patient population without control group. Not
blinded or randomized.
Conclusion: The Bion can be successfully inserted adjacent to the greater occipital
nerve in an effort to treat refractory primary headache disorders. This microstimulator
may provide effective occipital stimulation and headache control while minimizing the
risks associated with percutaneous or paddle leads implanted subcutaneously in the
occipital region.
Key words: Chronic headache, migraine, cluster headache, peripheral nerve
stimulation
The Role of the Internet in Doctor
Performance Rating
Authors: Segal Jeffrey
Published: March 2021

Historically, if a patient was dissatisfied with care, he or she could tell his or her friends
and family. The criticism was limited to a small circle of people. If the patient was injured
negligently, he or she could hire an attorney to prosecute a lawsuit. The threshold for finding
an attorney and prevailing posed a significant barrier for the patient achieving redress. With
the Internet, if a patient is unhappy he or she needs do little more than access a growing
number of Internet physician rating sites. Such criticism can be rendered anonymously. The
posts are disseminated worldwide, and once posted, the criticism rarely comes down. While
transparency is a laudable goal, such sites often lack accountability. More formal sites run by
authoritative bodies, such as medical licensing boards, also provide data about physicians, but
such data is often unfiltered, making it difficult for the public to properly interpret.
Given how important reputation is to physicians, the traditional remedy of suing for
defamation because of libelous posts is ordinarily ineffective. First, many patients who post
libelous comments, do so anonymously. Next, the Internet Service Providers (ISPs) hosting
such sites are generally immune from liability for defamation. Finally, the law has a very formal
definition for libel, and a negative rating does not necessarily equate to “defamation.”
A novel method of addressing un-policed physician rating sites in the Internet age is described.
The system embraces the use of mutual privacy contracts to provide physicians a viable remedy
to anonymous posts. In exchange, patients receive additional privacy protections above and
beyond that mandated by law.
Key words: Defamation, libel, Internet, physician, rating sites, Section 230, Communication
Decency Act, anonymous
Evidence-Based Medicine, Systematic Reviews,
and Guidelines in Interventional Pain
Management: Part 4: Observational Studies
Authors: Manchikanti Laxmaiah
Published: March 2021

Evidence-based medicine (EBM) stresses the examination of evidence from clinical research and describes it as a shift in medical paradigms, in contrast to intuition, unsystematic clinical experience, and pathophysiologic rationale. While the importance of
randomized trials has been created by the concept of the hierarchy of evidence in guiding therapy, much of the medical research is observational. There is competition, contrast, and a feeling of inferiority and uselessness for observational studies, created by a
lack of understanding of medical research. However, observational studies and randomized clinical trials (RCTs) can be viewed as the steps of observation and experimentation
that form the basis of the scientific methodology. Further, rational healthcare practices require knowledge about the etiology and pathogenesis, diagnosis, prognosis, and
treatment of disorders.
The reporting of observational research is often not detailed and clear enough with insufficient quality and poor reporting, which hampers the assessment of strengths and
weaknesses of the study and the generalizability of the mixed results. Thus, design, implementation, and reporting of observational studies is crucial. The biased interpretation of results from observational studies, either in favor of or opposed to a treatment,
and lack of proper understanding of observational studies, leads to a poor appraisal of the quality. Similar to the Consolidated Standards of Reporting Trials (CONSORT)
statement for the reporting of randomized trials, the Strengthening of the Reporting
of Observational Studies in Epidemiology (STROBE) statement was developed with recommendations to improve the quality of reporting observational studies. The STROBE
statement consists of a checklist of 22 items, which relate to the title, abstract, introduction, methods, results, and discussion sections of articles.
Multiple types of observational studies are conducted; however, 3 types have been
highlighted in the STROBE document and also in the present review, which include cohort studies, case-controlled studies, and cross-sectional studies.
This comprehensive review provides an introduction and rationale, types, design, and
reporting of observational studies; outcomes assessment and data presentation and
analysis; statistical analysis, results, and a discussion of observational studies.
Key words: Observational studies, cohort studies, case control studies, cross-sectional studies, allocation bias, sample size, Strengthening of the Reporting of Observational
Studies in Epidemiology (STROBE)
Independent Medical Examinations:
Facts and Fallacies
Authors: Ky Paul
Published: March 2021

Background: Independent Medical Examinations (IMEs) have protected the rights of
workers in the United States since the first laws protecting employees were established
in the early 1900s. There have been many social advancements and a great collective
struggle over the last 100 years that have ultimately lead to justice for the injured or
disabled worker.
Objective: We describe the origins of the IME as well as the evolution of both medical
and social processes that have provided the legal framework for the correct practice
of IMEs. This article will summarize the current medical principles, legal process, and
social controversy embodying the modern IME.
Discussion: Medical professionals must adhere to the same principles of impartial
and ethical conduct that they uphold in general patient care when dealing with IMEs.
Although previously controversial, it is now clear following successful litigation of
many physician examiners that at least a ‘limited doctor-patient relationship’ is created
during an IME.
Limitations: The limitations of this manuscript include a paucity of the literature,
lack of IME updates, and certain conflicts with guidelines by various organizations.
Conclusion: IMEs represent a valuable mechanism for determining alleged impairment
and/or disability. In the current economic environment of declining reimbursement to
physicians, IMEs exist outside the scope of traditional payment methods and offer
competitive compensation.
Key words: Independent Medical Examination, disability, impairment, worker’s
compensation, injured worker, disabled worker, doctor-patient relationship
Herpes Zoster Radiculopathy Treated with
Fluoroscopically-Guided Selective Nerve Root
Injection
Authors: Conliffe Theodore
Published: March 2021

Background: Varicella-zoster virus, a member of the herpes virus family, is a neurotrophic virus
that primarily affects afferent sensory neurons. Reactivation of latent virus within the dorsal root
ganglion and axoplasmic transport to epithelial nerve terminals causes the segmental cutaneous
rash and neuralgic pain characteristic of herpes zoster.
Setting: Outpatient orthopedic practice.
Case Description: A 75-year-old male developed a herpetic rash followed by burning pain in the
right L5 distribution. The pain was exacerbated by standing or walking. Six weeks later, the rash had
improved, but the patient developed a right foot drop requiring use of a molded ankle-foot orthosis.
MRI of the lumbar spine revealed mild degenerative changes without evidence of significant spinal
stenosis or disc disease. Electrodiagnostic studies confirmed the diagnosis of right L5 radiculopathy.
Results: The patient had dramatic improvement of pain and weakness after undergoing a
fluoroscopically guided right L5 selective nerve root block with Depo-Medrol and Lidocaine. He
then began a course of physical therapy and, 6 weeks later, had only trace weakness of the ankle
dorsiflexor group on the right side. The patient has continued without significant weakness or pain
since the procedure and has returned to normal functioning.
Discussion: This case demonstrates apparent treatment of a relatively uncommon phenomenon,
herpes zoster radiculopathy, using selective nerve root block.
Limitations: There is a limited amount of data regarding this disorder presently available
regarding Herpes Zoster Radiculopathy. A second limitation would be an inability to exclude spinal
pathology as an alternative etiology of this patient’s condition.
Conclusion: Cases of herpes zoster-induced radiculopathy may become more frequent,
as evidenced by the increasing number of cases of herpes zoster in the United States noted
epidemiologically.
Key words: Herpes zoster, shingles, lumbar radiculopathy, lumbar stenosis, dermatome,
electrodiagnosis, selective nerve, root injection
Polymethylmethacrylate and Radioisotopes in
Vertebral Augmentation: An Explanation of
Underlying Principles
Authors: Hirsch Ariel E.
Published: March 2021

We recently reported a novel concept for combining radioactive isotope technology with
polymethylmethacrylate (PMMA) cement used for vertebral augmentation and have
advocated that pain physicians become aware of this new concept when treating malignant
compression fractures. The use of vertebral augmentation for malignant compression
fractures is steadily increasing, and the goal of this novel approach would be to stabilize
the fractured vertebral body while also controlling proliferation of the tumor cells in the
vertebral body that caused the vertebral fracture. This approach would therefore provide
mechanical stabilization of the fractured vertebral body at the same time as direct targeting
of the cancer cells causing the fracture. For our analysis, we investigated six specific
radioisotopes with regard to physical and biologic properties as they would interact with
PMMA and local bone metastatic disease, taking into consideration anatomical, biological
and physical characteristics. The radioisotopes investigated include beta emitting (plus and
minus) sources, as well as low energy and mid-energy photon sources and are: P-32, Ho166, Y-90, I-125, F-18, and Tc-99m.
We review the advantages and disadvantages of each radioisotope. In addition, this paper
serves to provide pain physicians with a basic background of the biologic principles (Biologically
Effective Dose) and statistical modeling (Monte Carlo method) used in that analysis. We
also review the potential complications when using radioactive sources in a clinical setting.
Understanding the methodologies employed in determining isotope selection empowers
the practitioner by fostering understanding of this presently theoretical treatment option.
We believe that embedding radioisotopes in PMMA is merely a first step in the road of local
treatment for symptomatic local lesions in the setting of systemic disease.
Key words: polymethylmethacrylate, radioisotopes, vertebral, augmentation, Monte
Carlo, biologically, effective, dose
Hydrogen Sulfide’s Involvement in Modulating
Nociception
Authors: Smith Howard
Published: March 2021

Hydrogen sulfide (H2S) is a malodorous gas which functions as an endogenous gasotransmitter
in humans. It is becoming appreciated that H2S may be involved in a wide variety of processes including nociceptive processes. The molecular mechanisms responsible for many of the activities
of H2S remain uncertain, however, H2S increases cAMP levels in neuronal and glial cell lines and
primary neuron cultures with hyperpolarization. H2S may be involved in multiple signaling pathways and produce various effects on ion channels (e.g. T-type calcium channel currents, ATP-sensitive K+ (KATP) channels) which may inhibit or promote nociception. It is also conceivable that
H2S may affect the n-methyl-d aspartate (NMDA) receptor complex and/or TRPA1 ion channels
which may modulate nociceptive processes. It appears that H2S may regulate key neuronal functions, including the induction of hippocampal long-term potentiation, a synaptic model of learning and memory thought to involve the NMDA receptor as well as the release of corticotrophinreleasing hormone from the hypothalamus. It seems that the primary role of H2S in nociceptive
processes is the activation of T-type calcium channels leading to facilitation of pronociceptive processes. A secondary contribution to the facilitation of pronociceptive processes may come from
H2S-induced activation. It would appear that much like other gasotransmitters (e.g. nitric oxide),
endogenous H2S may be involved in multiple physiologic processes and its effects remain complex, difficult to predict, and may vary depending on the specific environment/circumstances/location where it is generated.
A greater understanding of the clinically significant human physiology of H2S and hydrogen sulfide’s effects on modulating nociceptive processes may potentially lead to novel targets for improving analgesia.
Key words: Pain, nociception, hydrogen sulfide, calcium channels, analgesia, potassium
channels
Sacral Nerve Stimulation as a Treatment
Modality for Intractable Neuropathic
Testicular Pain
Authors: McJunkin Tory L.
Published: March 2021

Background: Chronic testicular pain, or “chronic orchalgia,” is defined as testicular pain
3 months or longer in duration that significantly interferes with the daily activities of the
patient. For patients failing to respond to conservative treatment, microsurgical denervation
of the spermatic cord, epididymectomy, and vasovasostomy have all shown a degree of relief.
However, these are all invasive procedures and no treatment has proven efficacy when these
options fail.
We present a case of a male who presented with over a decade of chronic right-sided
testicular pain secondary to recurrent epididymitis. Before arriving at our clinic the patient
had an epididymectomy performed with no appreciable improvement in pain. Initially
ilioinguinal, iliohypogastric, and genetofemoral nerve blocks; right-sided S1, S2, and S3
transforaminal epidural steroid injections (TFESIs) with inferior hypogastric blocks; and rightsided T12-L1, L1-L2, and L2-L3 TFESIs all failed to provide pain relief. After conservative
therapies had failed, a sacral nerve stimulation trial was done via a caudal epidural approach.
The permanent implant has provided the patient with sustained 80% decrease in pain at 4
months status post permanent sacral nerve stimulation implant.
The above case demonstrates the potential benefit of sacral nerve stimulation with neuropathic
intractable testicular pain in a patient that failed conservative treatment. In this case, the
patient had exhausted medical and surgical management, including advanced interventional
pain options. We were unable to find any previous published cases of neurostimulation used
as a modality of treatment for testicular pain, and further studies are needed to gain a better
understanding of the efficacy in this setting.
Key words: Sacral nerve stimulation, spinal cord stimulation, neuromodulation, testicular
pain, orchalgia, intractable, chronic
Calcineurin as a Nociceptor Modulator
Authors: Smith Howard
Published: March 2021

Calcineurin may be involved in affecting nociceptive processes in multiple circumstances.
It is conceivable that interfering with calcineurin’s normal role in contributing to glial resting membrane potential, via its effects on the ion channel (TRESK) [tandem-pore-domain
weakly inward rectifying potassium channels (TWIK)-related spinal cord potassium channels] may facilitate nociception. Another aspect of calcineurin function may be its role in
the pronociceptive signaling of nuclear factor of activated T-cells (NFAT). NFAT activation
via mediators (e.g. Substance P, brain-derived neurotrophic factor, nerve growth factor, bradykinin) appears to be dependent on calcineurin function. This calcineurin-regulated NFAT
signaling may subsequently lead to transcription of pronociceptive genes as well as upregulation of pronociceptive chemokine receptors in the dorsal root ganglion. In fact, multiple
articles have described the clinical use of calcineurin-inhibitors leading to pain, a phenomenon referred to as calcineurin inhibitor-induced pain syndrome (CIPS). Thus, it appears
that calcineurin functions may encompass actions which promote or dampen nociceptive
processes. A greater understanding of the physiology of calcineurin, especially as it relates
to modulating nociception may lead to the development of novel analgesic targets in attempts to optimally alleviate patient discomfort.
Key words: Pain, neuropathic, calcineurin, NFAT, TRESK-[Tandem-pore-domain weakly
inward rectifying potassium channels (TWIK)-related spinal cord potassium channels], CIPS
(calcineurin-induced pain syndrome)
Comprehensive Review of Neurophysiologic
Basis and Diagnostic Interventions in Managing
Chronic Spinal Pain
Authors: Manchikanti Laxmaiah
Published: March 2021

Background: Understanding the neurophysiological basis of chronic spinal pain and
diagnostic interventional techniques is crucial in the proper diagnosis and management
of chronic spinal pain.Central to the understanding of the structural basis of chronic spinal pain is the provision of physical diagnosis and validation of patient symptomatology. It
has been shown that history, physical examination, imaging, and nerve conduction studies in non-radicular or discogenic pain are unable to diagnose the precise cause in 85%
of the patients. In contrast, controlled diagnostic blocks have been shown to determine
the cause of pain in as many as 85% of the patients.
Objective: To provide evidence-based clinical practice guidelines for diagnostic interventional techniques.
Design: Best evidence synthesis.
Methods: Strength of evidence was assessed by the U.S. Preventive Services Task Force
(USPSTF) criteria utilizing 5 levels of evidence ranging from Level I to III with 3 subcategories in Level II.
Diagnostic Criteria: Diagnostic criteria established by systematic reviews were utilized with controlled diagnostic blocks. Diagnostic criteria included at least 80% pain relief with controlled local anesthetic blocks with the ability to perform multiple maneuvers
which were painful prior to the diagnostic blocks for facet joint and sacroiliac joint blocks,
whereas for provocation discography, the criteria included concordant pain upon stimulation of the target disc with 2 adjacent discs producing no pain at all.
Results: The indicated level of evidence for diagnostic lumbar, cervical, and thoracic facet joint nerve blocks is Level I or II-1. The indicated evidence is Level II-2 for lumbar and
cervical discography, whereas it is Level II-3 for thoracic provocation discography. The evidence for diagnostic sacroiliac joint nerve blocks is Level II-2. Level of evidence for selective nerve root blocks for diagnostic purposes is Level II-3.
Limitations: Limitations of this guideline preparation include a continued paucity of literature and conflicts in preparation of systematic reviews and guidelines.
Conclusion: These guidelines include the evaluation of evidence for diagnostic interventional procedures in managing chronic spinal pain and recommendations. However,
these guidelines do not constitute inflexible treatment recommendations. These guidelines also do not represent a “standard of care.”
Key words: Diagnostic interventional techniques, chronic spinal pain, facet joint interventions, epidural procedures, provocation discography, sacroiliac joint blocks, post lumbar surgery syndrome, spinal stenosis, provocation discography
Comprehensive Review of Therapeutic
Interventions in Managing Chronic Spinal Pain
Authors: Manchikanti Laxmaiah
Published: March 2021

Background: Available evidence documents a wide degree of variance in the definition and
practice of interventional pain management.
Objective: To provide evidence-based clinical practice guidelines for interventional techniques
in the treatment of chronic spinal pain.
Design: Best evidence synthesis.
Methods: Strength of evidence was assessed by the U.S. Preventive Services Task Force (USPSTF) criteria utilizing 5 levels of evidence ranging from Level I to III with 3 subcategories in Level II.
Outcomes: Short-term pain relief was defined as relief lasting 6 months or less and long-term
relief as longer than 6 months, except ≤ one year and > one year for intradiscal therapies, mechanical disc decompression, spinal cord stimulation, and intrathecal infusion systems.
Results: The indicated evidence for therapeutic interventions is Level I for caudal epidural steroid injections in managing disc herniation or radiculitis, and discogenic pain without disc herniation or radiculitis. The evidence is Level I to II-1 for percutaneous adhesiolysis in management
of pain secondary to post-lumbar surgery syndrome. The evidence is Level II-1 or II-2 for therapeutic cervical, thoracic, and lumbar facet joint nerve blocks; for caudal epidural injections in
managing pain of post-lumbar surgery syndrome, and lumbar spinal stenosis, for cervical interlaminar epidural injections in managing cervical pain (Level II-1); for lumbar transforaminal epidural injections; and spinal cord stimulation for post-lumbar surgery syndrome.
Limitations: The limitations of this guideline preparation included a paucity of literature, lack
of updates, and lack of conflicts in preparation of systematic reviews and guidelines by various
organizations.
Conclusion: The indicated evidence for therapeutic interventions is variable from Level I to
III. This comprehensive review includes the evaluation of evidence for therapeutic procedures in
managing chronic spinal pain and recommendations. However, this review and recommendations do not constitute inflexible treatment recommendations or “standard of care.”
Key words: Interventional techniques, chronic spinal pain, therapeutic interventions, facet
joint interventions, epidural procedures, epidural adhesiolysis, radiofrequency, mechanical disc
decompression, spinal cord stimulation, intrathecal implantable systems
Ethical Insights to Rapprochement in Pain Care:
Bringing Stakeholders Together in the Best
Interest(s) of the Patient
Authors: Giordano James
Published: March 2021

Advances in medicine have produced an elongated lifespan often burdened
by chronic disorders. Throughout the lifespan and at end of life such disorders can give rise to intractable pain. Although clear distinctions about
the respective role(s) for pain therapeutics and palliative medicine remain
debatable, both are involved in chronic pain care. Such care has reached
a point of crisis fueled by tensions within and between clinical, administrative, and economic factors. We call for a strategy of rapprochement to
reconcile these tensions as a means to facilitate more effective and ethically sound pain care. We describe roles and values of principal stakeholders: palliative- and pain-care physicians, chronic pain patients, insurance
providers, and hospital administrators and elucidate how dissonances between these groups may contribute to inefficacy of the pain care system
and sustain chronic, maldynic pain. We discuss how such values affect use
of evidence and resources and explicate frameworks for an ameliorative
rapprochement model that acknowledges and balances relative needs and
values of all stakeholders. While we have tried to depict why rapprochement is necessary, and possible, the more difficult task is to determine how
this process should be articulated and what shape a profession of total pain
care might assume.
Key words: Pain medicine, palliative care, ethics, policy, collaboration,
rapprochement
Ultrasound-Guided Placement of a Permanent
Percutaneous Femoral Nerve Stimulator Leads
for the Treatment of Intractable Femoral
Neuropathy
Authors: Narouze Samer N
Published: March 2021

Background: Femoral nerve injury is a rare complication of cardiac catheterization and is usually caused by direct trauma during femoral artery access, compression from a hematoma, or prolonged digital pressure for post-procedural hemostasis. Peripheral nerve stimulation has been used
to treat different pain syndromes in the upper and lower extremities with variable success and it
typically requires direct vision with open surgical approach. Since the femoral nerve can be readily
seen with ultrasonography, an ultrasound-guided lead placement seemed practical.
Case Report: A 61-year-old morbidly obese male who sustained femoral nerve injury during cardiac catheterization continued to complain of intractable femoral neuropathy 18 months afterwords. He failed multiple treatment modalities and continued to complain of severe neuropathic
pains that markedly interfere with his daily activities.
Two percutaneous leads were placed under real-time ultrasonography and the placement was
confirmed with fluoroscopy. One lead was placed along the longitudinal axis of the nerve and the
patient had good coverage over the anterior thigh but not below the knee. So another lead was
placed horizontally across the femoral nerve in order to stimulate all the branches and the patient
reported good coverage along the saphenous nerve distribution down to the foot.
Results: The patient continues to be pain free 20 months after the implant.
Conclusion: Here we described a novel non-invasive percutaneous approach for femoral nerve
stimulation with ultrasound guidance which allowed precise placement of the stimulating lead
very close to the femoral nerve without the need for surgical exploration.
Key words: Femoral nerve stimulation, femoral neuropathy, ultrasound-guided lead implant,
peripheral nerve stimulation
Atypical Chest Pain: Evidence of
Intercostobrachial Nerve Sensitization in
Complex Regional Pain Syndrome
Authors: Grothusen John R.
Published: March 2021

Background: Atypical chest pain is a common complaint among Complex Regional Pain
Syndrome (CRPS) patients with brachial plexus involvement. Anatomically, the intercostobrachial
nerve (ICBN) is connected to the brachial plexus and innervates the axilla, medial arm and
anterior chest wall. By connecting to the brachial plexus, the ICBN could become sensitized by
CRPS spread and become a source of atypical chest pain.
Objective: To evaluate the sensitivity of chest areas in CRPS patients and normal controls.
Design: Prospective investigation of pressure algometry in chest areas to determine chest wall
sensitivity.
Methods: CRPS patients and normal controls volunteered to participate in our study. Each
individual was examined to meet inclusion criteria. Patients’ report of chest pain history was
collected from every participant. Pressure algometry was used to measure pressure sensitivity in
the axilla, anterior axillary line second intercostal space, mid-clavicular third rib, mid-clavicular
tenth rib, and midsternal. Each of these measurements were compared to an intra-participant
abdominal measure to control for an individuals generalized sensitivity.
The ratios of chest wall sensitivities were compared between CRPS patients and normal controls.
Results: A history of chest pain was reported by a majority (94%) of CRPS patients and a
minority (19%) of normal controls. CRPS patients reported lifting their arm as a major initiating
factor for chest pain. To pressure algometry, the ratios of CRPS patients were significantly greater
than control subjects (p< 0.02 throughout), indicating increased chest wall sensitivity.
Limitations: This study is limited by the relatively small number of patients (n=35) and controls
(n=21) used.
Conclusion: The results of this study support the idea that chest pain is greater in CRPS patients
than normal controls. The ICBN could be the source of this sensitization by CRPS spread from
the brachial plexus.
Key words: Intercostobrachial nerve (ICBN), complex regional pain syndrome (CRPS), atypical
chest pain, algometry, reflex sympathetic dystrophy (RSD), brachial plexus
Chronic Regional Pain Syndrome After
Subtalar Arthrodesis Is Not Prevented
by Early Hyperbaric Oxygen
Authors: Williams Simon TB
Published: March 2021

Subtalar arthrodesis was performed on a 48-year-old, non-insulin-dependent
diabetic with a history of chronic ankle instability and lateral ankle pain. In the
early post-operative period he presented as an emergency with an infection at
the operative site. This was treated with 2 returns to the operating theatre for
washout and debridement. His wounds were left open and at 3 weeks after
emergency admission he was referred for adjunctive hyperbaric oxygen (HBO)
therapy to aid healing by secondary intention. He received a total of 19 hyperbaric sessions, at a pressure of 2.2 ATA, one treatment per day for 5 days
a week.
Shortly after commencing HBO therapy his ankle became increasingly painful,
despite the introduction of analgesia. By 7 weeks after emergency admission
his wounds had virtually healed but hyperesthesia persisted over the dorsum
of the foot. A computerized tomography scan at 5½ months post-operatively
showed satisfactory joint fusion and revealed no evidence of infection. Symptoms and signs at this time were compatible with a diagnosis of chronic regional pain syndrome (CRPS).
There is published evidence to suggest that HBO therapy may be a useful modality in the treatment of established CRPS. Here, we seek to publicize a case in
which early treatment with HBO for another indication did not prevent the simultaneous development of CRPS Type 1.
Key words: Subtalar arthrodesis, hyperbaric oxygenation, chronic regional
pain syndrome