bluuebunny/crossref_metadata_2025 huggingface dataset:
Cooled Radiofrequency Neurotomy of the Articular
Sensory Branches of the Obturator and Femoral
Nerves – Combined Approach Using Fluoroscopy
and Ultrasound Guidance: Technical Report, and
Observational Study on Safety and Efficacy
Authors: Kapural Leonardo
Published: October 2019

Background Chronic hip joint pain is a common condition with an estimated prevalence of 7%
in men and 10% in women, in a population sample aged over 45. Conservative treatment can
include physical therapy, weight loss, a variety of pharmacologic agents ranging from nonsteroidal
antiinflammatory drugs (NSAIDS) to opioids, and intraarticular injections with various substances.
Definitive treatment of hip pain, however, has primarily centered on hip arthroplasty.
Objective: We describe a novel anterior approach to cooled radiofrequency (RF) hip denervation
under combined ultrasound (US) and fluoroscopy guidance to avoid the neurovascular femoral
bundle and reach proper landmarks.
Study Design: Retrospective chart review of consecutive cases.
Setting: Interventional Pain Management urban private practice.
Methods: Data on 52 RF ablations of the hip in 23 patients were retrospectively collected. RF
ablation was conducted with patient supine and under guidance of fluoroscopy and US. While
fluoroscopy was used to place RF probes to appropriate landmarks, sole purpose of using US was
to avoid femoral neurovascular bundle. Data were collected on needle placement, stimulation
parameters, and short- and long-term complications.
Results: A total of 62 patients underwent 2 diagnostic blocks. Fifty-two of them had greater
than 50% relief and agreed to RF ablation. Until now, the ablation was conducted in 23 patients.
There were no adverse events, except one case of neuritis. Expectedly, the needle approach to the
lateral articular branches of the femoral nerve was easily achieved with more than a 1 cm passage
distance from the femoral nerve in all 52 RF cases (median 2.5 range 1-3.5 cm). Placement of the
second trocar to the incisura acetabuli was more challenging; in 21 RF cases the passing distance
was less than 1 cm (range 0.5 to 1.9 cm, median 0.8). Motor stimulation (2 Hz) at less than 1 V was
positive for the obturator nerve in 26 cases, which resulted in electrode repositioning more laterally
(2-5 mm). Change in the pain scores was from the baseline 7.61 ± 1.2 to 2.25 ± 1.4 after the RF
ablation (P < 0.01). The time interval of pain relief was much longer for RF ablation.
Limitations: Limitations of this retrospective, observational study include lack of blinding and
absence of a comparator group. We did not attempt to wean opioids in our patient population.
Conclusions: An anterior needle approach to the lateral articular branches of the femoral and
obturator nerves, and subsequently RF denervation of these nerves, is a safe procedure when US
needle guidance is combined with identification of landmarks using fluoroscopy.
Key words: Chronic hip pain, radiofrequency ablation, hip denervation
Improving Fluoroscopic Visualization for Lower
Cervical Medial Branch Blocks with a Modified
Swimmer’s View: A Technical Report
Authors: Stolzenberg David
Published: October 2019

Background: Neural blockade of the cervical medial branches is a validated procedure in the
diagnosis and treatment of cervical zygapophyseal joint pain. Fluoroscopic visualization of the
lower cervical medial branch target zones (CMBTZs) in lateral view is sometimes challenging or not
possible due to the patient’s shoulders obscuring the target. Large shoulders and short necks often
exacerbate the problem. Clear visualization is critical to accuracy and safety.
Objective: We aim to describe a method for optimal fluoroscopic visualization of the lower
CMBTZs using a modified swimmer’s view.
Study Design: A technical report.
Setting: A private practice.
Methods: Discussion with accompanying fluoroscopic images of the cervical spine, focusing on
the lateral aspects of the lower cervical articular pillars in both the traditional lateral view and
modified swimmer’s view. Four authors served as volunteers for undergoing fluoroscopic x-rays in
both views. Visualization of each lower CMBTZ was attempted and stored. The most caudal, clearly
visualized levels were compared in both views for each participant.
Results: Visualization of the lower CMBTZs can be successfully obtained with the modified
swimmer’s view and in select patients is superior to a lateral view.
Limitations: A limitation to this study is the design as a technical report. A future prospective
study is warranted.
Conclusions: Modified swimmer’s view can serve as a primary method of visualizing the lower
CMBTZs or an alternate view when a lateral view is unable to clearly demonstrate target landmarks.
This can improve the ease, accuracy, and safety of performing diagnostic cervical medial branch
blocks (CMBBs).
Key words: Swimmer’s view, cervical medial branch block, facet joint, fluoroscopy
Functional Connectivity Alterations: Novel
Therapy and Future Implications in Chronic
Pain Management
Authors: Thorp Dr. Stephen
Published: October 2019

Background: Chronic pain is a major public health problem resulting in physical and
emotional pain for individuals and families, loss of productivity, and an annual cost of billions
of dollars. The lack of objective measures available to aid in diagnosis and evaluation of
therapies for chronic pain continues to be a challenge for the clinician.
Objectives: Functional magnetic resonance imaging (fMRI) is an imaging technique that can
establish regional areas of interest and examine synchronous neuronal activity in functionally
related but anatomically distinct regions of the brain, known as functional connectivity.
Study Design: The present investigation examines changes in functional connectivity in 4
common pain syndromes: chronic back pain (CBP), fibromyalgia, diabetic neuropathy, and
complex regional pain syndrome (CRPS).
Setting: This is a review of the current understanding of functional connectivity.
Methods: Utilizing functional imaging, patients with these conditions have been shown
to have significant structural and functional differences when compared to healthy controls.
Results: Functional connectivity, therefore, has the potential to assist in diagnostic
classification of different pain conditions, predict individual responses to specific therapeutic
interventions, and serve as a gateway for personalized medicine. Indirect activation of brain
activity can be seen by the blood flow to the brain at specific sites, with chronic pain patients
having increased brain activity.
Limitations: The present investigation is limited in that few studies have examined this
relatively new modality.
Conclusions: Knowing and observing the brain’s activity as related to pain gives pain
patients an opportunity to decrease pain-related brain activity and decrease severe chronic
pain. This modality can be used along with interventional pain management techniques in
order to provide optimum pain relief.
Key words: Functional connectivity, fMRI, chronic pain, chronic back pain, fibromyalgia,
diabetic neuropathy, chronic regional pain syndrome
Efficacy of Pulsed Radiofrequency Stimulation
in Patients with Peripheral Neuropathic Pain: A
Narrative Review
Authors: Chang Min Cheol
Published: October 2019

Background: Recently, clinicians have been applying pulsed radiofrequency (PRF) stimulation on
various peripheral nerves to manage patients’ peripheral neuropathic pain.
Objectives: To review the literature on the use and efficacy of PRF for controlling peripheral
neuropathic pain.
Study Design: This is a narrative review of relevant articles on the effectiveness of PRF for
peripheral neuropathic pain.
Methods: A PubMed search was conducted for papers published from January 1, 1980 to August
31, 2017 that used PRF to treat peripheral neuropathic pain. The key search phrase for identifying
potentially relevant articles was [PRF AND pain]. The following inclusion criteria were applied for
the selection of articles: 1) patients’ pain was caused by peripheral nervous system disorders; 2) PRF
stimulation was applied on the peripheral nerve; and 3) after PRF stimulation, follow-up evaluation
was performed to assess the reduction in pain. Review articles were excluded.
Results: A total of 468 articles were found to be potentially relevant. After reading the titles
and abstracts of the papers and assessing them for eligibility based on the full-text articles, 63
publications were finally included in this review. For radicular pain from spinal diseases, the
evidence supports that PRF is an effective treatment. Similarly, PRF appears to be effective for
postherpetic neuralgia and occipital neuralgia. On the other hand, for trigeminal neuralgia, the
results of previous studies indicate that PRF is not appropriate for managing trigeminal neuralgia
and less effective than conventional RF. However, data on the use of PRF for pudendal neuralgia,
meralgia paresthetica, carpal tunnel syndrome, tarsal tunnel syndrome, and Morton’s neuroma, is
lacking and thus the efficacy of PRF in these peripheral nerve disorders cannot be determined at
this time.
Limitations: This review did not include studies indexed in databases other than PubMed.
Conclusions: This review will help guide clinicians in making informed decisions regarding
whether PRF is the appropriate option for managing the various peripheral neuropathic pain
conditions in their patients.
Key words: Pulsed radiofrequency, peripheral neuropathic pain, radicular pain, postherpetic
neuralgia, trigeminal neuralgia, occipital neuralgia, pudendal neuralgia, meralgia, carpal tunnel
syndrome, review
Medical Device Related Pressure Injury in the
Treatment of Chronic Pain: An Early Sign of
Explantation in Suspected Infection
Authors: Sanchis-López Nerea
Published: October 2019

Background Chronic back pain is a prevalent disease and has a high impact in daily life.
Implantable devices (IDs) for chronic pain management include spinal cord stimulation (SCS)
systems and intrathecal drug delivery (ITDD) pumps. The number of ITDD implants have increased
exponentially in the last decade. The number of complications, such as infections, are also more
prevalent. Infection management guidelines are needed to standarize our clinical practice and
define protocols of explantation.
Objectives: The primary outcome is to define the likelihood of device explantation regarding
some covariates related to the patient, antibiotic therapy or surgerical procedures. The secondary
outcome is to evaluate performance compared to the results published in the literature.
Study Design: Retrospective study.
Setting: Hospital General of Valencia. Valencia. Spain.
Methods: A retrospective study of 288 implantable device surgeries was conducted at the Hospital
General Universitary of Valencia (Spain) from 1994 to 2015. Demographical and infection data
were collected. We have followed the “guidelines for the diagnosis, prevention and management
of implantable electronic cardiac device infection” due to the lack of a specific guideline in our
field.
Results: Forty-three out of 288 procedures were identified as suspected device-infected
interventions. Half of the patients had microbiologically confirmed infection after wound, blood or
lumbar fluid culture. The odds ratio (OR) for explantation of the device was 19 for the presence of
decubitus, a sign of medical device related pressure injury (P < 0.0005) and 5 for positive wound
culture (P < 0.0452). Medical indication leading to device implantation and the antibiotics on
discharge also played a role in the decision of device explantation.
Limitations: Lack of external validity and others.
Conclusion: In this study, presence of decubitus is the defining variable for device explantation
when a infection is suspected rather than waiting to culture results. Due to a high variability in
infection rates, multidisciplinary guidelines are needed to provide an approach that focuses on
accurate data monitoring, rigurous implantation technique and standardized protocols.
Key Words: Chronic pain, spinal cord stimulation infection, neurostimulator, intrathecal drug
delivery pump, complication, infection, explantation
Prevalence of Recurrent Herniation Following
Percutaneous Endoscopic Lumbar Discectomy:
A Meta-Analysis
Authors: Tao Huiren
Published: October 2019

Background: Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive
surgery for the treatment of lumbar disc herniation (LDH) with a smaller incision, decreased
damage to soft tissues, faster recovery, and fewer postoperative complications. However, the
exactly epidemiological prevalence of recurrent herniation after PELD remains unclear.
Objectives: To investigate the epidemiological prevalence of recurrent herniation in patients
following PELD and to analyze the potentially related risk factors.
Study Design: Meta-analysis and systematic review of prospective and retrospective studies.
Methods: We conducted a comprehensive search in MEDLINE, EMBASE, and Cochrane Central
Register of Controlled Trials that mentioned the incidence of recurrent herniation after PELD.
The overall prevalence estimate was calculated by an appropriate meta-analysis. Subgroup
analysis, sensitivity analysis, and publication bias assessment were also performed in our study,
respectively.
Results: Our results showed the overall prevalence of recurrent herniation after PELD was
3.6% (95% CI 3.0-4.3%). The prevalence estimates after percutaneous endoscopic interlaminar
discectomy (PEID) and percutaneous endoscopic transforaminal discectomy (PETD) were 4.2%
and 3.4%, respectively. Individuals with older age (≥ 50 years) and higher BMI (≥ 25) had
increased recurrence rates after PELD than those with younger age (4.3% vs. 2.7%) and normal
body mass index (BMI) (4.8% vs. 1.5%). The prevalence was significantly higher at upper discs
(5.4%) than that at L4-5 (2.7%) and L5-S1 (3.1%) level. The incidence of recurrent herniation at
lateral disc was 4.7%, and the recurrence rate of migrated herniation was 3.8%. In most cases,
the recurrent herniation occurred within 6 months postoperatively (accounting for 61.7%).
Limitations: A majority of the included articles were relatively low quality retrospective
studies with significant heterogeneity among them. Furthermore, owing to the paucity of data
focused on recurrence, many potentially predictive factors related to subgroup analyses could
not be conducted, which might have influenced the accuracy and comprehensiveness of our
meta-analysis.
Conclusions: PELD is associated with a certain rate of recurrence (3.6%), which usually
occurred within 6 months postoperatively. Older age (≥ 50 years), obesity (BMI ≥ 25), upper
lumbar disc and central disc herniation might be independent risk factors for recurrence after
PELD; however, different surgical approaches (PETD or PEID), lateral discs, migrated discs and
foraminoplasty did not affect the incidence. These factors could be useful in preoperative
evaluation, appropriate patient selection and informed consent before PELD.
Key words: Percutaneous endoscopic lumbar discectomy, prevalence, recurrent herniation,
meta-analysis
Pulsed Radiofrequency on Dorsal Root
Ganglion Relieved Neuropathic Pain Associated
with Downregulation of the Spinal Interferon
Regulatory Factor 8, Microglia, p38MAPK
Expression in a CCI Rat Model
Authors: Liu Ronggue
Published: October 2019

Background: Interferon regulatory factor 8 (IRF8), which is induced by peripheral nerve injury
(PNI), plays a key role in activating spinal microglia to release inflammatory cytokines in a p38-
dependent way, thereafter results in formation of central sensitization. Pulsed radiofrequency (PRF)
on dorsal root ganglion (DRG) alleviates neuropathic pain and inhibits the microglial activation in
chronic constriction injury (CCI) rats. However, the consequences of PRF on spinal IRF8 of CCI rats
remains unknown.
Objectives: We explore if PRF on DRG of rats with CCI could restrain IRF8, microglia, and p38
hyperactivity in the spinal cord to alleviate neuropathic pain.
Study Design: A randomized, controlled animal study.
Setting: Department of Pain Management, Fujian Provincial Hospital, Fujian Key Laboratory of
Geriatrics, Provincial Clinic College of Fujian Medical University.
Methods: The changes in pain behaviors and the expressions of IRF8, Iba1 and p-p38 in the spinal
cord of CCI rats which were administrated with antisense/ mismatch oligodeoxynucleotide of IRF8
were studied. Rats in CCI+AS ODN group, CCI+MM ODN group or CCI+NS group were intrathecally
treated with antisense oligodeoxynucleotide of IRF8, mismatch oligodeoxynucleotide of IRF8 or same
volume 0.9% NaCl once daily respectively, beginning from the day after nerve transection 12 hours
and lasting for 7 days. The effects of PRF on L4-5 DRG of rats with CCI were investigated. PRF was
applied adjacent to the L4-5 DRG at an intensity of 45 V for 6 minutes after CCI, whereas the control
rats were treated without radiofrequency current. The withdrawal thresholds were studied and the
spinal levels of IRF8, ionized calcium-binding adapter molecule 1 (Iba1, microglia characteristic marker)
and p-p38 were calculated by ELISA, western blot, RT-PCR, and immunofluorescence.
Results: Intrathecal administration of antisense oligodeoxynucleotide of IRF8 led to the reversal
of CCI-induced allodynia, lower activation of spinal microglia and p-p38. Withdrawal thresholds
were partially recovered after a single PRF treatment for 14 days. CCI-induced IRF8 upregulation,
microglia hyperactivity, and p38 phosphorylation in the spinal cord were reduced due to PRF
treatment. However, PRF did not alter pain behaviors and pain signals in normal rats.
Limitations: In our study, one time point was selected just to assess the levels of microglia, and
p-p38. The changes of IRF8, microglia, p-p38 in the ipsilateral DRG were not investigated. A more
detailed study on how PRF on the DRG could further relieve NP is needed.
Conclusions: Restraining IRF8, microglia and p38 hyperactivity in the spinal cord of CCI rats
involved in the contribution to the long-lasting analgesia of PRF.
Keywords: Neuropathic pain, pulsed radiofrequency, dorsal root ganglion,
Operation of Soft or Calcified Thoracic Disc
Herniations in the Full-Endoscopic Uniportal
Extraforaminal Technique
Authors: Ruetten Sebastian
Published: October 2019

Background: Surgery for thoracic disc herniation and stenosis is comparatively rare and often
demanding. The goal is to achieve sufficient decompression without manipulating the spinal
cord and to minimize surgical trauma and its consequences. Individual planning and various
surgical techniques and approaches are required. The key factors for selecting the technique
are anatomical location, consistency of the pathology, general condition of the patient, and
the surgeon’s experience.
Objectives: The objective of the study was the evaluation of the technical implementation
and outcomes of a full-endoscopic uniportal technique via the extraforaminal approach in
patients with symptomatic soft or calcified disc herniation of the thoracic spine, taking specific
advantages and disadvantages and literature into consideration.
Study Design: Retrospective study
Setting: A center for spine surgery and pain medicine.
Methods: Between 2009 and 2015, decompression was performed on 26 patients with
thoracic disc herniation or stenosis with radicular or myelopathic symptoms in a full-endoscopic
uniportal technique with an extraforaminal approach. No patients underwent additional
posterior stabilization. Imaging and clinical data were collected in follow-up examinations for
18 months.
Results: Sufficient decompression was achieved in the full-endoscopic uniportal technique
in all cases. The individual selection of the respective approach made it possible to reach the
target area without manipulating the spinal cord. One patient experienced deterioration
of a myelopathy. No other serious complications were observed. All patients, except one,
experienced regression or improvement of symptoms. No evidence of increasing instability was
found in imaging.
Limitations: This is a retrospective study. The limited number of cases must be considered.
Conclusions: The full-endoscopic uniportal technique with an extraforaminal approach
was found to be a sufficient and minimally invasive method with the known advantages of
an endoscopic procedure under continuous irrigation for monosegmental disc herniations.
The inclusion criteria must be taken into consideration. If they are not met, an alternative
full-endoscopic approach (interlaminar, transthoracic retropleural) or decompression in a
conventional method must be selected. Additional stabilization does not appear to be necessary
due to the low level of trauma.
Key Words: Extraforaminal approach, thoracic disc herniation, giant disc herniation, Fullendoscopic, minimally invasive, thoracic spine
High Prevalence of Hypovitaminosis D in
Patients with Low Back Pain: Evidence from
Meta-Analysis
Authors: Bansal Dipika
Published: October 2019

Background: Emerging evidence suggests an association between vitamin D deficiency and low
back pain (LBP).
Objective: To pool evidence on the prevalence of hypovitaminosis D in patients with LBP.
Study Design: Meta-analysis.
Methods: A comprehensive literature search was done in PubMed, Cochrane Database, and
Google scholar for observational studies including cohort, cross sectional (CS), and case control (CC)
evaluating the prevalence of hypovitaminosis D in LBP patients. The primary outcome assessed was
a prevalence of hypovitaminosis D in patients with LBP, presented as weighted pooled prevalence
ratio (WPPR) with 95% confidence interval (CI) using the random effects model. Heterogeneity and
inconsistency of the measurements were identified through Cochran’s Q statistic and I2
statistic.
We also performed sensitivity analysis, publication bias (using funnel plot and Begg’s test), and
subgroup analysis.
Results: Fourteen studies (6 were CC, 6 CS, and 2 cohort) involving 2602 patients were included
in the final analysis. The WPPR (95% CI) of hypovitaminosis D in patients with LBP was found to
be 0.72 (0.60–0.83). Marked heterogeneity was observed, median quality score of all studies was
7.5 interquartile range (IQR) (6.2 - 8.7) on a scale of 0 to 11. Sensitivity analysis showed robustness
of the results. The WPPR of hypovitaminosis D was lower in CS at 0.60 (0.35–0.85) as compared
to CC studies at 0.81 (0.72–0.90) (P < 0.01). The WPPR was lower in men at 0.74 (0.63–0.86) as
compared to women at 0.84 (0.78–0.89) (P < 0.01). No publication bias was observed.
Limitations: Heterogeneity in the cut off level of vitamin D to classify the included patients as
vitamin D deficient.
Conclusions: The high prevalence of hypovitaminosis D was observed in patients with LBP.
This provides a chance to screen the deficiency and correct it by supplementation, which can be
therapeutic adjunct in the management of LBP patients.
Key words: Low back pain, hypovitaminosis D, meta-analysis, pooled prevalence, systematic
review
Percutaneous Endoscopic Lumbar Discectomy
for All Types of Lumbar Disc Herniations (LDH)
Including Severely Difficult and Extremely
Difficult LDH Cases
Authors: Paudel Byapak
Published: October 2019

Background: Lumbar disc herniation (LDH) is being treated with limited indication by percutaneous
full endoscopic lumbar discectomy. However, microscopic lumbar discectomy (MLD) is still considered
as a gold standard.
Objective: With the advances in spinal endoscopic instruments and surgical techniques, all LDHs
have now become operable with percutaneous full endoscopic lumbar discectomy procedure.
We report the results of percutaneous full endoscopic lumbar discectomy (PELD) for all patients
diagnosed with LDH, including severely difficult and extremely difficult LDH cases who visited our
clinic with leg pain and lower back pain.
Study Design: Retrospective study of consecutive prospective patients.
Setting: Spine center, Nanoori Suwon Hospital, Suwon, Korea.
Methods: Electronic medical records of 98 consecutive patients (104 levels) who underwent
surgery from October 2015 to May 2016, by PELD for different LDHs either by percutaneous
endoscopic transforaminal lumbar discectomy (PETLD) or percutaneous endoscopic interlaminar
lumbar discectomy (PEILD) approach were reviewed retrospectively. The L5-S1 level was accessed
with PEILD approach and the other levels were accessed with PETLD approach. Outcomes were
analyzed utilizing the visual analog scale (VAS), Oswestry disability index (ODI), Mac Nab Criteria and
endoscopic surgical success grade/score.
Results: There were 75 (72.1%) men and 29 (27.9%) women patients with a mean age of 48.12
± 15.88 years. Follow-up range from a minimum of 10 to 15 months (mean 12.77 ± 1.84 months).
Most of the LDHs were located at L4-5 level. There were 76% severely difficult and extremely difficult
cases. PETLD was the choice of approach in most of the cases (78 cases, 75%). VAS decreased
significantly. ODI improved from preoperative 54.67 ± 7.52 to 24.50 ± 6.45 at last follow-up. 96.1%
good to excellent result was obtained as per Mac Nab criteria. 98.1% of patients were managed with
a successful to completely successful grade according to the endoscopic surgical success grading/
scoring. Two cases (1.9%) developed transient motor weakness.
Limitation: Retrospective analysis of consecutive prospective patients.
Conclusion: With more than 96% success (98.1% as per endoscopic success grading/scoring) all
kinds of LDHs, including severely difficult and extremely difficult LDHs, are accessible by the PELD
(PETLD and PEILD) technique. PELD can now be considered an alternative to microscopic lumbar
discectomy (MLD) in the treatment of all kinds of disc herniations with the added benefits of keyhole
surgery even for severely difficult and extremely difficult LDH cases.
Key words: Lumbar disc herniation (LDH), percutaneous endoscopic lumbar discectomy (PELD),
percutaneous endoscopic transforaminal lumbar discectomy (PETLD), percutaneous endoscopic
interlaminar discectomy (PEILD), evolution of PELD, difficult LDH, highly migrated LDH, high canal
compromised LDH, revision LDH, LDH with discal cyst, calcified LDH
Effects of Epidural Steroid Injections on Bone
Mineral Density and Bone Turnover Markers in
Patients Taking Anti-Osteoporotic Medications
Authors: Lee Jae Hyup
Published: October 2019

Background: Glucocorticoids adversely affect bone mineral density (BMD) and increase the
risk of fracture. Yet, the cause-and-effect relationship between epidural steroid injection (ESI)
and BMD has not been thoroughly investigated, and available results are inconsistent. This is
probably a consequence of differences in the dose of steroids and follow-up duration.
Objective: This study aimed to evaluate changes in BMD and the risk of fracture according
to duration of the follow-up and amount of steroids used for ESI.
Setting: Department of Orthopedic Surgery at Seoul Metropolitan Government Seoul
National University (SMG-SNU) Boramae Medical Center, Korea.
Methods: We retrospectively reviewed the medical records of postmenopausal patients
who underwent dual-energy x-ray absorptiometry (DEXA) at least 3 times in 5 years. Patients
were divided into 2 groups. Group 1 consisted of 73 patients who received ESI, whereas
Group 2 consisted of 294 patients who did not receive ESI. All patients took anti-osteoporotic
medications. BMD measurements were performed in 4 different regions, and levels of bone
turnover markers (BTMs) were measured. In Group 1, BMD and BTMs levels were measured
before the last ESI and 1 and 2 years after. A sub-analysis was conducted in Group 1 to
compare BMD values in sub-groups with different doses of steroids.
Results: In Group 1, the absolute values of BMD of the spine were decreased at the 1-year
follow-up, but by the 2-year follow-up they recovered and approached the values in Group
2. In Group 2, BMD increased both at the 1- and 2-year follow-ups. There was an increase in
occurrence of osteoporosis during the first year after ESI, but the prevalence of osteoporosis
declined remarkably during the second year. The levels of BTMs increased at the 1-year followup and decreased at the 2-year follow-up in Group 1. Higher cumulative doses of steroids
induced greater decreases in BMD. However, the changes in spine BMD in the sub-analysis
were insignificant.
Limitations: This was a retrospective study. Additionally, administration of anti-osteoporotic
medication might have prevented accurate evaluation of the effects of ESI.
Conclusions: ESI adversely affects BMD in postmenopausal women, especially that of the
spine, and the adverse effects increase with the dose of steroids. Gradual reduction of the
effect of steroids one year after the cessation of ESI resulted in recovery of BMD to a level
similar to that in the control group.
Key words: Epidural steroid injection, bone mineral density, osteoporosis, postmenopausal
women, glucocorticoids, bone turnover markers, osteoporotic fracture
Preemptive Analgesia with Parecoxib in Total
Hip Arthroplasty: A Randomized, Double-Blind,
Placebo-Controlled Trial
Authors: Weng Xi-sheng
Published: October 2019

Background: Total hip arthroplasty (THA) is a well-accepted surgical treatment for terminal hip
diseases.
Objective: To evaluate the effect of preemptive analgesia with parecoxib in patients undergoing
primary unilateral THA.
Study Design: A randomized, double-blind, placebo-controlled study.
Setting: This study was conducted at Peking Union Medical College Hospital and Beijing Jishuitan
Hospital in Beijing, China.
Methods: A total of 94 patients scheduled for primary unilateral THA in 2 centers (Peking Union
Medical College Hospital and Beijing Jishuitan Hospital) were randomly assigned to receive 40
mg parecoxib (n = 48) or 0.9% normal saline solution (n = 46) 30 minutes before incision. All
patients received standardized intravenous patient-controlled analgesia (PCA) postoperatively.
Preoperative baseline data, surgery-related conditions, postoperative Visual Analog Scale (VAS)
pain score, cumulative narcotic consumption of PCA, and complications were compared between
the parecoxib group and the placebo group.
Results: There were no significant differences in postoperative VAS pain score, cumulative narcotic
consumption of PCA, proportion of analgesic remedy, and complications between the 2 groups.
Limitations: Only a single dose of parecoxib was used without including a dose-dependent
control group.
Conclusion: A single dose of parecoxib 30 minutes before incision did not provide effective
preemptive analgesia for the management of postoperative pain after primary unilateral THA. The
possible effect of preemptive analgesia with parecoxib needs further investigation.
Key words: Total hip arthroplasty, pain, parecoxib, COX-2 selective inhibitor, preemptive
analgesia, clinical trial, patient-controlled analgesia, analgesics
Comparison of Efficacy of Lateral Branch Pulsed
Radiofrequency Denervation and Intraarticular
Depot Methylprednisolone Injection for
Sacroiliac Joint Pain
Authors: Dey Samarjit
Published: October 2019

Background: Sacroiliac joint dysfunctional pain has always been an enigma to the pain physician,
whether it be the diagnosis or the treatment. Diagnostic blocks are the gold standard way to diagnose
this condition. Radiofrequency neurotomy of the nerves supplying the sacroiliac joint has shown equivocal
results due to anatomical variation. Intraarticular depo-steroid injection is a traditional approach to
treating sacroiliac joint pain. For long-term pain relief, however, lesioning the sacral lateral branches may
be a better approach.
Objective: This study compared the efficacy of intraarticular depo-methylprednisolone injection to that
of pulsed radiofrequency ablation for sacroiliac joint pain.
Study Design: This study used a randomized, prospective design.
Setting: Thirty patients with diagnostic block-confirmed sacroiliac joint dysfunctional pain were
randomly assigned to 2 groups. One group received intraarticular methylprednisolone and another group
underwent pulsed radiofrequency of the L4 medial branch, the L5 dorsal rami, and the lateral sacral
branches.
Results: Reduction in Numeric Rating Scale (NRS) for pain at 1 month post-procedure remained similar in
Group A, while in Group B few patients reported a further decrease in the NRS score (3.333 ± 0.4880 and
2.933 ± 0.5936, respectively). At 3 months post-procedure, the NRS score began to rise in most patients in
group A, while in Group B, the NRS score remained the same since the last visit (4.400 ± 0.9856 and 3.067
± 0.8837, respectively). At 6 months post-procedure, the NRS score began to rise further in most patients
in group A. In Group B, the NRS score remained the same in most of the patients since the last visit (5.400
± 1.549 and 3.200 ± 1.207). There was a marked difference between the 2 groups in Oswestry Disability
Index (ODI) scores at 3 months post-procedure (Group A, 12.133 ± 4.486 vs Group B, 9.133 ± 3.523) and
at 6 months post-procedure there was a significant (P = 0.0017) difference in ODI scores between Group A
and Group B (13.067 ± 4.284 and 8.000 ± 3.703, respectively). Global Perceived Effect (GPE) was assessed
in both groups at 3 months post-procedure Only 33.3% (Confidence Interval (CI) of 11.8- 61.6 ) of patients
in Group A had positive GPE responses whereas in Group B, 86.67% (CI of 59.5- 98.3 ) of patients had
positive GPE responses. At 6 months post-procedure, the proportion of patients with positive GPE declined
further in Group A, while in Group B, positive GPE responses remained the same (20% with a CI of 4.30-
48.10 and 86.67% with a CI of 59.5- 98.3, respectively ).
Limitations: Small sample size.
Conclusion: This comparative study shows that pulsed radiofrequency denervation of the L4 and L5
primary dorsal rami and S1-3 lateral branches provide significant pain relief and functional improvement
in patients with sacroiliac joint pain.
Key words: Low back pain, sacroiliac joint dysfunctional pain, radiofrequency, intraarticular injection
Low Volume Neurolytic Retrocrural Celiac Plexus
Block for Visceral Cancer Pain: Retrospective
Review of 507 Patients with Severe Malignancy
Related Pain Due to Primary Abdominal Cancer
or Metastatic Disease
Authors: Rahman Abed
Published: October 2019

Background: Abdominal pain from primary cancer or metastatic disease is a significant cause
of pain for patients undergoing treatment for the disease. Patient’s pain may be resistant to
conventional analgesics. The need for timely pain relief in order to facilitate further care in the
cancer treatment plan should be a priority.
Objectives: The aim of this retrospective observational review was to assess the relief given with
a low volume neurolytic retrocrural celiac plexus nerve block, the duration of the procedure, the
duration of relief, the reduction in daily opioid consumption, and the improvement of quality of life
in a patient suffering from incapacitating abdominal pain due to primary abdominal malignancy or
abdominal metastatic disease. Patients were given a neurolytic celiac plexus block without previous
diagnostic block due to multiple comorbidities.
Study Design: This is a retrospective, observational study.
Methods: Five hundred and seven patients were studied and data at 5 months for 455 patients
were retained at the end of the review. They were evaluated in the pain center prior to and after the
neurolytic retrocrural celiac plexus nerve block under fluoroscopic guidance. They were assessed on
duration of procedure, pain scores (numeric rating scale 0-10), daily opioid consumption, quality of
life improvement (simple yes or no question at 3 months) and routine follow-up during treatment
for the cancer for 6 months or end of life. All data was gathered by extensive chart review and
placed on a spreadsheet for analysis.
Results: Follow-up was completed 6 months after the procedure. Pain scores, daily opioid
consumption, and quality of life showed improvement for the duration of the study. There
was some return in pain during the fourth to sixth month due to disease progression and the
anticipated duration of the neurolytic agent. Some short duration known side effects did occur.
An initial vascular contrast uptake of 6.7% was noted during the procedure while utilizing digital
subtraction angiography with fluoroscopy.
Limitations: A larger sample size would be ideal, as well as, a prospective trial with a control
group, but this is unrealistic in our patient population. A proven quality of life questionnaire
would be beneficial. Comparing alcohol, phenol and radiofrequency thermocoagulation would be
interesting to equate duration, effect, and side effects.
Conclusion: Low volume neurolytic retrocrural celiac plexus nerve block with phenol is a safe
procedure providing up to 6 months of pain relief and is an effective, well-established, minimally
time-consuming procedure for abdominal pain due to primary malignancy or metastatic spread.
Key words: Celiac plexus, neurolytic, abdominal cancer pain, pain, retrocrural, cancer pain
Efficacy Assessment of Radiofrequency Ablation
as a Palliative Pain Treatment in Patients with
Painful Metastatic Spinal Lesions: A Systematic
Review
Authors: Rosian Katharina
Published: October 2019

Background: Metastatic spinal lesions are difficult-to-treat entities that are most commonly
associated with pain and severely reduced health-related quality of life (HRQoL). Within the last 5
to 10 years, radiofrequency ablation (RFA) has emerged as an option in the palliative treatment of
vertebral metastases.
Objectives: Our review aims to evaluate the clinical effectiveness and safety of RFA, mostly in
combination with vertebroplasty, in patients with painful vertebral metastases.
Study Design: The design of this study is a systematic review.
Methods: We conducted a systematic literature search and a manual search of 5 databases
in December 2016. The review applied a methodological framework based on the HTA Core
Model®. Data on each selected outcome category were synthesized according to the Grading of
Recommendations, Assessment, Development and Evaluation (GRADE) scheme. Risk of bias was
assessed using the Institute of Health Economics (IHE) Risk of Bias checklist for case series.
Results: We identified 299 citations. After applying the inclusion criteria, a total of 9 studies (4
prospective and 5 retrospective studies) were determined to be eligible. These studies included a total
of 583 patients with vertebral metastases who were treated with RFA and, in most cases, received
an additional vertebroplasty treatment (n = 437). The studies were categorized as having a moderate
to high risk of bias. The strength of evidence was found to be “very low” for safety outcomes and
could not be assessed for efficacy outcomes. Current evidence suggests that RFA leads to significant
pain reduction. Furthermore, no major complications occurred when using RFA.
Limitations: A major concern is the low number of included patients and heterogeneity of study
characteristics in most of the studies. The low number of patients also impeded comparison of the
effectiveness of RFA alone to RFA in combination with vertebroplasty.
Conclusion: According to the available evidence, RFA may be safe and effective, especially for
patients with painful vertebral metastases who show contraindications or unresponsiveness to
conventional therapies (e.g., radiation) or for those who are at risk of tumor progression.
Key words: Radiofrequency ablation, vertebral metastases, metastatic spinal lesions, pain, clinical
effectiveness, safety, palliative pain treatment
A Retrospective Review of Spinal Radiofrequency
Neurotomy Procedures in Patients with Metallic
Posterior Spinal Instrumentation – Is it Safe?
Authors: Ellwood Stephen
Published: October 2019

Background: Recent studies have shown that medial branch radiofrequency neurotomy (RFN)
procedures done at the level of a pedicle screw can increase pedicle screw temperature, and
it has been speculated that pedicle screw heating may cause thermal injury. There has been a
limited amount of investigation into the real-world safety profile of RFN procedures in patients
with pedicle screws.
Objectives: We aim to demonstrate that the occurrence of serious adverse events is rare for a
medial branch RFN procedure completed at a level with metallic spinal hardware when performed
according to the Spine Intervention Society practice standards.
Study Design: This study involved retrospective chart reviews of every patient who received an
RFN procedure for spinal facet joint pain during the 5-year time period from 2012-2016.
Setting: The research took place within a single university-based interventional pain management
center.
Methods: The study sample included 507 patient charts. Data collection included patient
demographics, RF denervation sites at a level with metallic hardware, and all serious RF-related
complications that could be attributable to heated metallic hardware. The research team developed
medical-chart abstraction criteria for each of the following categorized complications: a) superficial
burns, b) deep burns, c) denervation of dorsal ramus, d) denervation of ventral ramus, and e)
coagulation of a spinal vascular structure.
Results: Of the 36 patients who met the inclusion criteria for this study, 43.6% were men and
56.4% were women. The mean age was 59.5 years old, with an age range of 25 to 87 years. There
were a total of 56 ablations performed at a level with metallic spinal hardware, of which 11 were
cervical, 44 were lumbar, and 1 was thoracic . There were zero documented complications found
among our patient population in any of the 5 categories of serious complications.
Limitations: As a retrospective chart review, this study was dependent on the availability and
accuracy of medical records. Chart abstraction criteria for each outcome measure were developed
by the research team without scientific testing.
Conclusions: There have been no reported complications attributable to hardware temperature
increases when performing medial branch RFNs at the level of a pedicle screw. For safety, it is
important to use multiplanar fluoroscopic imaging techniques to ensure that the RFN cannula is
not in contact with the pedicle screw.
Key Words: Radiofrequency neurotomy, medial branch nerve ablation, safety, thermal injuries,
metallic spinal hardware, pedicle screws, lateral mass screws, cervical facet joints, severe
complications, adverse events
Variations in Interlaminar Epidural Steroid
Injection Practice Patterns by Interventional Pain
Management Physicians in the United States
Authors: Doan Lisa
Published: October 2019

Background: Previous surveys have identified variations in practice patterns related to epidural
steroid injections. Since then, the United States Food and Drug Administration (FDA) has required the
addition of drug warning labels for injectable corticosteroids. Updated evidence, as well as scrutiny
from regulatory agencies, may affect practice patterns.
Objective: To provide an update on interlaminar epidural steroid injection (ILESI) practice patterns,
we surveyed interventional pain management (IPM) physicians in the United States.
Study Design and Setting: This was a cross-sectional survey of IPM physicians in the United
States.
Methods: A web-based survey was distributed to IPM 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 ILESI practices, including needle size, use of image guidance, level of
injection, identification of the epidural space, and preference for injectate.
Results: A total of 249 responses were analyzed. All respondents used image guidance for ILESI.
There were variations in needle size, use of contrast, number of fluoroscopic views utilized, technique
for identifying the epidural space, and choice of injectate.
Limitations: The response rate is a limitation, thus the results may not be representative of all
United States IPM physicians.
Conclusions: Though all respondents used image guidance for ILESI, variations in other ILESI
practices still exist. Since the closure of this survey, a multi-society pain workgroup published
recommendations regarding ESI practices. Our survey findings support the need for more evidencebased guidelines regarding ESI.
Key words: Epidural injection, epidural steroids, survey, low back pain, neck pain, technique
Combination of Pulsed Radiofrequency with
Continuous Radiofrequency Thermocoagulation
at Low Temperature Improves Efficacy and
Safety in V2/V3 Primary Trigeminal Neuralgia
Authors: Zhou Guangyu
Published: October 2019

Background: Primary trigeminal neuralgia (TN) is a common clinical refractory neuralgia. Severe
pain is experienced during episodes, severely impacting the patient’s quality of life. Long-term
suffering from the disease can lead to anxiety, depression, and even suicide. The pathological
processes involved in TN are complex, the mechanisms of pathogenesis are unknown, and effective
treatment is lacking.
Objective: This study aimed to assess the efficacy and safety of computed tomography (CT)-
guided pulsed radiofrequency (PRF) combined with low-temperature continuous radiofrequency
(CRF) thermocoagulation in V2/V3 primary trigeminal neuralgia.
Study Design: This research used a retrospective comparative study design.
Setting: The research took place at Shengjing Hospital of China Medical University.
Methods: A total of 80 hospitalized patients with TN were selected between January 2014 and
December 2015 and randomly assigned to 2 groups differentiated by therapeutic method: CRF
(CRF group, n = 40) and PRF + CRF (PCRF group, n = 40). Radiofrequency therapy was performed
under the guidance of CT. Follow-up measures assessed preoperative conditions, pain remission,
complications and side effects, recovery time, and recurrence rate over the 2 years following the
surgery.
Results: The Visual Analog Scale (VAS) scores decreased in both groups after surgery. After one
month, the decrease in the VAS score in the PCRF group was more apparent, and this difference
was maintained for 2 years. The total efficiency rates in the CRF and PCRF groups were 85% and
97.5%, respectively, at 6 months, 1 year, and 2 years post-surgery. The differences in total efficiency
rate of pain between the 2 groups at 6 months, 1 year, and 2 years were statistically significant.
Recovery times in the PCRF group were shorter than those in the CRF group. Specifically, recovery
times for facial numbness in the CRF and PCRF groups were 3.12 ± 1.21 months and 2.23 ± 1.02
months, respectively. Recovery times for masticatory muscle weakness were 4.33 ± 1.54 months
and 3.42 ± 0.98 months, respectively.
Limitations: This study is limited by being a retrospective study, and by having a relatively small
sample size from a single center.
Conclusions: CT-guided PRF combined with low-temperature CRF thermocoagulation for
treating V2/V3 primary TN effectively relieves pain, increases late-stage pain remission rate, reduces
complications, and reduces the rate of recurrence.
Key words: Complication, continuous radiofrequency thermocoagulation, pulsed radiofrequency,
recurrence rate, trigeminal neuralgia, Visual Analog Scale