bluuebunny/crossref_metadata_2025 huggingface dataset:
Pathogenesis, Diagnosis, and Treatment of
Cervical Vertigo
Authors: Peng Baogan
Published: February 2021

Cervical vertigo is characterized by vertigo from the cervical spine. However, whether cervical
vertigo is an independent entity still remains controversial. In this narrative review, we
outline the basic science and clinical evidence for cervical vertigo according to the current
literature. So far, there are 4 different hypotheses explaining the vertigo of a cervical origin,
including proprioceptive cervical vertigo, Barré-Lieou syndrome, rotational vertebral artery
vertigo, and migraine-associated cervicogenic vertigo. Proprioceptive cervical vertigo and
rotational vertebral artery vertigo have survived with time. Barré-Lieou syndrome once was
discredited, but it has been resurrected recently by increased scientific evidence. Diagnosis
depends mostly on patients’ subjective feelings, lacking positive signs, specific laboratory
examinations and clinical trials, and often relies on limited clinical experiences of clinicians.
Neurological, vestibular, and psychosomatic disorders must first be excluded before the
dizziness and unsteadiness in cervical pain syndromes can be attributed to a cervical origin.
Treatment for cervical vertigo is challenging. Manual therapy is recommended for treatment
of proprioceptive cervical vertigo. Anterior cervical surgery and percutaneous laser disc
decompression are effective for the cervical spondylosis patients accompanied with BarréLiéou syndrome. As to rotational vertebral artery vertigo, a rare entity, when the exact area of
the arterial compression is identified through appropriate tests such as magnetic resonance
angiography (MRA), computed tomography angiography (CTA) or digital subtraction
angiography (DSA) decompressive surgery should be the chosen treatment.
Key words: Cervical vertigo, dizziness, whiplash injury, neck pain, cervical spondylosis,
manual therapy, vestibular rehabilitation, vertebrobasilar insufficiency
The Use of Spinal Cord Neuromodulation in the
Management of HIV-Related Polyneuropathy
Authors: Candido Kenneth D.
Published: February 2021

Background: The prevalence of HIV-related neuropathy may rise nationwide as Highly Active
Antiretroviral Therapy (HAART) usage and HIV-survival rates increase, resulting in higher referral
rates to pain practitioners for analgesic strategies. However, if patients’ symptoms are refractory
to conservative measures, an advanced interventional approach may be indicated.
Objective: We present 2 cases of successful use of spinal cord neuromodulation in the treatment
of HIV-related neuropathy.
Study Design: Case Report
Methods: One patient experienced severe lower extremity burning pain, progressively
worsening over the past 6 years. He had trouble ambulating, and pain was refractory to
conservative treatments. The other patient suffered from low back pain and distal symmetrical
polyneuropathy. A remote lumbar discectomy prior to his development of HIV disease resulted in
marked improvement in lumbar spinal pain, but subsequent later development of neuropathic
pain remained refractory to different treatment modalities.
Results: Both patients reported more than 90% improvement in pain during the spinal cord
stimulator (SCS) trial, which led to permanent SCS implantation with equivalent success rates.
One of them was followed up for 3 years, and another one for 14 months before he moved
overseas. Both of them reported an improved quality of life, reductions in the use of oral opioid
analgesics, and increased ability to participate in daily activities without limitations. Neither patient
sustained any infectious complications, lead migration, or required battery changes.
Limitations: Controlled double blinded studies with a higher number of patients are needed to
prove efficacy in these patients.
Conclusion: These 2 cases demonstrate that SCS neuromodulation is a safe, viable, and
efficacious option for patients whose HIV-related neuropathic type pain is refractory to
conventional treatment modalities. Our patients appear to be the first case reports that show a
remarkable efficacy of SCS in the management of HIV-related polyneuropathy.
Key words: HIV neuropathy, spinal cord stimulation, lower extremity pain, chronic pain,
neuropathic pain
Peripheral and Neuraxial Chemical Neurolysis
for the Management of Intractable Lower
Extremity Pain in a Patient with Terminal
Cancer
Authors: Pinto Mario De
Published: February 2021

We present the case of a 74-year-old man with Stage IV metastatic, multifocal, malignant fibrous
histiocytoma (T2b, N1, M1, G4) invading the proximal area of the left lower extremity and resulting
in intractable neuropathic pain along the distribution of the femoral nerve. He described the pain
as being so severe to cause inability to ambulate without assistance or to sleep in a supine or
prone position. After a spinal cord stimulation trial and a trial of intrathecal (IT) hydromorphone,
both performed at an outside institution, had failed to achieve adequate pain relief, we decided
to perform a femoral nerve chemical neurolysis with phenol under ultrasound (US) guidance. The
intervention provided 6 months of almost complete pain relief.
With the tumor spreading in girth distally and proximally to the scrotal and pelvic areas as well
as to the lungs, and pain returning back to baseline, we proceeded with a second femoral nerve
chemical neurolysis. Unfortunately we were not able to achieve adequate pain relief. Therefore
we opted to proceed with a diagnostic injection of local anesthetic under fluoroscopic guidance
at the left L2, L3, and L4 nerve roots level. This intervention provided 100% pain relief and was
followed, a few days later, by chemical neurolysis with phenol 3%. The patient reported complete
pain relief with the procedure and no sensory-motor related side effects or complications. He was
able to enjoy the last 6 weeks of life with his wife and family, pain-free.
With this report we add to the limited literature available regarding the management of intractable
cancer pain with chemical neurolysis in and around the epidural space.
Key words: Cancer, pain, chemical neurolysis, peripheral, neuraxial
Perineural Dexamethasone Added to Local
Anesthesia for Brachial Plexus Block Improves
Pain but Delays Block Onset and Motor Blockade
Recovery
Authors: Candido Kenneth D.
Published: February 2021

Background: Multiple studies have shown that perineural dexamethasone improves
postoperative analgesia. However, some studies have shown minimal benefit, and have raised
concerns regarding adverse physio-chemical effects of perineural dexamethasone. Furthermore,
there is a paucity of studies wherein control (IV) dexamethasone was considered.
Objective: The purpose of this meta-analysis was to evaluate the effectiveness of different
concentrations of perineural dexamethasone injection on postoperative analgesia, as well as
complications from its use for brachial plexus blocks.
Methods: A systematic literature search was conducted using the Cochrane Central Registry
of Controlled Trials, PubMed, and Scopus. Trials comparing control and local dexamethasonetreated groups, and those which reported duration of analgesia and/or pain scores/opioid
consumptions were selected. Meta-analysis was performed using the Review Manager (RevMan)
software 5.1.
Results: Fourteen studies consisting of a total of 1,022 patients were included. Perineural
dexamethasone significantly prolonged the duration of postoperative analgesia in patients
receiving both low-dose (4 – 5 mg) [SMD 2.41 (95% CI: 1.47, 3.35 P = 0<0.00001) I2
= 82%],
and higher-doses (8 – 10 mg) [SMD 4.46 (95% CI 3.54, 5.38 P < 0.00001) I2
= 94%]. However,
the duration of motor block was also prolonged [SMD 2.52 (95% CI: 1.06, 3.98 P = 0.0007) I2
= 97%] and dexamethasone delayed latency of onset of sensory [SMD -0.49 (95% CI: -0.89,
-0.09 P = 0.02) I2
= 76%] and motor [SMD -0.56 (95% CI: -1.13, 0.00 P = 0.05) I2
= 87%]
blocks. Postoperative pain scores were improved at both 24 hours [SMD -1.46 (95% CI: -2.43,
-0.50 P = 0.003) I2
= 95%] and 48 hours [SMD -1.20 (95% CI: -2.26, -0.13 P = 0.03) I2
= 95%]
in dexamethasone-treated groups, whereas opioid consumption was reduced only at 48 hours
[SMD -2.97 (95% CI: -4.17, -1.76 P < 0.00001) I2
= 88%]. Complications were comparable
between control and dexamethasone-adjuvant groups, except for the excessively prolonged
nerve block that was observed predominantly in the dexamethasone-adjuvant group.
Limitations: The limitations include different definitions used for the measurements of certain
parameters such as the duration of analgesia and duration of motor block, number of studies
assessing certain parameters having high heterogeneity, and varying types of local anesthetics
used in various studies.
Conclusions: Perineural dexamethasone addition to local anesthetic solutions significantly
improved postoperative pain in brachial plexus block without increasing complications.
However, perineural adjuvant dexamethasone delayed the onset of sensory and motor block,
and prolonged the duration of motor block. Smaller doses of dexamethasone (4 – 5 mg) were
as effective as higher doses (8 – 10 mg).
Key words: Dexamethasone, perineural, brachial plexus block, postoperative pain, metaanalysis, systematic review
Linear Accelerator Stereotactic Radiosurgery
for Trigeminal Neuralgia
Authors: Varela-Lema Leonor
Published: February 2021

Background: Stereotactic radiosurgery is accepted as an alternative for patients with refractory
trigeminal neuralgia, but existing evidence is fundamentally based on the Gamma Knife, which
is a specific device for intracranial neurosurgery, available in few facilities. Over the last decade it
has been shown that the use of linear accelerators can achieve similar diagnostic accuracy and
equivalent dose distribution.
Objectives: To assess the effectiveness and safety of linear-accelerator stereotactic radiosurgery
for the treatment of patients with refractory trigeminal neuralgia.
Methods: We carried out a systematic search of the literature in the main electronic databases
(PubMed, Embase, ISI Web of Knowledge, Cochrane, Biomed Central, IBECS, IME, CRD) and
reviewed grey literature. All original studies on the subject published in Spanish, French, English,
and Portuguese were eligible for inclusion. The selection and critical assessment was carried out
by 2 independent reviewers based on pre-defined criteria. In view of the impossibility of carrying
out a pooled analysis, data were analyzed in a qualitative way.
Results: Eleven case series were included. In these, satisfactory pain relief (BIN I-IIIb or reduction
in pain ≥ 50) was achieved in 75% to 95.7% of the patients treated. The mean time to relief
from pain ranged from 8.5 days to 3.8 months. The percentage of patients who presented
with recurrences after one year of follow-up ranged from 5% to 28.8%. Facial swelling or
hypoesthesia, mostly of a mild-moderate grade appeared in 7.5% – 51.9% of the patients.
Complete anaesthesia dolorosa was registered in only study (5.3%). Cases of hearing loss
(2.5%), brainstem edema (5.8%), and neurotrophic keratoplasty (3.5%) were also isolated.
Conclusions: The results suggest that stereotactic radiosurgery with linear accelerators could
constitute an effective and safe therapeutic alternative for drug-resistant trigeminal neuralgia.
However, existing studies leave important doubts as to optimal treatment doses or the therapeutic
target, long-term recurrence, and do not help identify which subgroups of patients could most
benefit from this technique.
Limitations: Paucity of literature and clear lack of clarification for clinical utilization of this
technique.
Key words: Radiosurgery, trigeminal neuralgia, functional radiosurgery, radiation therapy of
benign diseases, stereotactic radiotherapy
Piriformis Syndrome: Comparison of the
Effectiveness of Local Anesthetic and
Corticosteroid Injections: A Double-Blinded,
Randomized Controlled Study
Authors: Misirlioglu Tugce Ozekli
Published: February 2021

Background: Piriformis syndrome (PS), which is characterized by pain radiating to the gluteal
region and posterior leg, is accepted as one of the causes of sciatalgia. Although the importance
of local piriformis muscle injections whenever PS is clinically suspected has been shown in many
studies, there are not enough studies considering the clinical efficacy of these injections.
Objective: To investigate the differences between local anesthetic (LA) and LA + corticosteroid
(CS) injections in the treatment of PS.
Study Design: A prospective, double-blinded, randomized controlled trial.
Setting: Physical medicine and rehabilitation department of a university hospital.
Methods: Fifty-seven patients having unilateral hip and/or leg pain with positive FAIR test and
tenderness and/or trigger point at the piriformis muscle were evaluated. Out of 50 patients
randomly assigned to 2 groups, 47 patients whose pain resolved at least 50% from the baseline
after the injection were diagnosed as having PS. The first group (n = 22) received 5 mL of lidocaine
2% while the second group (n = 25) received 4 mL of lidocaine 2% + 1 mL of betametazone under
the guidance of ultrasound.
Outcome Assessment: Numeric Rating Scale (NRS) and Likert Analogue Scale (LAS).
Results: No statistically significant difference (P > 0.05) was detected between the groups in
NRS score values at resting (P = 0.814), night (P = 0.830), and in motion (P = 0.145), and LAS
values with long duration of sitting (P = 0.547), standing (P = 0.898), and lying (P = 0.326) with
evaluations at baseline, first week, and first and third months after the injection. A statistically
highly significant (P < 0.005) reduction of pain was evaluated through NRS scores at resting (P =
0.001), in motion (P = 0.001), and at night (P = 0.001) and LAS values with long duration of sitting
(P = 0.001), standing (P = 0.001), and lying (P = 0.001) in both of the groups.
Limitations: Presumed limitations of this study include having a relatively small sample.
Conclusion: LA injections for the PS were found to be clinically effective. However, addition of
CS to LA did not give an additional benefit. This gives us the idea that PS is mostly muscular in
origin and responds well to both LA and LA+CS injections.
Key words: Piriformis muscle syndrome, injection, ultrasound, pain, local anesthetics, steroids,
rehabilitation
Effects of Stellate Ganglion Block on Sedation
as Assessed by Bispectral Index in Normal
Healthy Volunteers
Authors: Jeon Younghoon
Published: February 2021

Background: The sympathetic nervous system plays an important role in the arousal response.
Recently, the stellate ganglion block (SGB) was found to effectively treat anxiety and night
awakening in humans and decrease electroencephalogram (EEG) indices of arousal responses in
rat. But, the role of the sympathetic block in human arousal responses has not yet been studied.
Objective: We performed this prospective, double-blinded, controlled volunteer study to
investigate the sedative effects and bispectral index (BIS) changes of SGB.
Study Design: A randomized, double-blind trial.
Setting: Single academic medical center.
Methods: This study was approved by the Ethics Committee of Kyungpook National University
Hospital (ref: KNUH_10-1081) and registered with CRiS (Clinical Research Information Service,
http://cris.cdc.go.kr, ref: KCT0000036, 2010. 9.24). Twenty healthy volunteers were enrolled in
this study. The volunteers were randomly assigned to one of 2 groups: the SGB group (n = 10) and
the sham group (n =10). Volunteers in SGB group received SGB and volunteers in the sham group
received a sham procedure. BIS value, heart rate, and blood pressure were measured before and 5,
10, 20, and 30 minutes after the procedure. Observer’s Assessment of Alertness/Sedation (OAA/S)
scores were assessed before and 10 and 30 minutes after the intervention.
Results: In the SGB group, BIS values and OAA/S scores significantly decreased after the
intervention as compared to baseline (P < 0.05). The values were also significantly decreased in the
SGB group when compared to the values in sham group after the intervention (P < 0.05). There
was a significant change of mean blood pressure 10 to 30 minutes after SGB (P < 0.05). There were
no differences in heart rate during study period between groups.
Limitations: This study is limited by a relatively small sample size.
Conclusions: This study showed that SGB has a sedative effect in normal healthy volunteers, as
evidenced by decreased OAA/S scores and BIS values.
Key words: Stellate ganglion, sympathetic block, sedation, bisepctral index, EEG, volunteers
Transforaminal Endoscopic Treatment of
Lumbar Radiculopathy after Instrumented
Lumbar Spine Fusion
Authors: Telfeian Albert E.
Published: February 2021

Background: Transforaminal endoscopic discectomy and foraminotomy is a well-described
minimally invasive technique for surgically treating lumbar radiculopathy caused by a herniated
disc and foraminal narrowing.
Objective: To describe the technique and feasibility of transforaminal foraminoplasty for the
treatment of lumbar radiculopathy in patients who have already undergone instrumented spinal
fusion.
Study Design: Retrospective study.
Setting: Hospital and ambulatory surgery center
Methods: After Institutional Review Board approval, charts from 18 consecutive patients with
lumbar radiculopathy and instrumented spinal fusions who underwent endoscopic procedures
between 2008 and 2013 were reviewed.
Results: The average pain relief one year postoperatively was reported to be 67.0%, good
results as defined by MacNab. The average preoperative VAS score was 9.14, indicated in our
questionnaire as severe and constant pain. The average one year postoperative VAS score was
3.00, indicated in our questionnaire as mild and intermittent pain.
Limitations: This is a retrospective study and only offers one year follow-up data for patients
with instrumented fusions who have undergone endoscopic spine surgery.
Conclusion: Transforaminal endoscopic discectomy and foraminotomy could be used as a safe,
yet, minimally invasive and innovative technique for the treatment of lumbar radiculopathy in the
setting of previous instrumented lumbar fusion.
IRB approval: Meridian Health: IRB Study # 201206071J
Key words: Endoscopic siscectomy, minimally-invasive, transforaminal, fusion
Different Analgesic Effects of Intrathecal
Endomorphin-2 on Thermal Hyperalgesia and
Evoked Inflammatory Pain in Ovariectomized Rats
Authors: Wang Wen
Published: February 2021

Hormone replacement remains one of the common therapies for menopause-related
pain but is associated with risk of orofacial or back pain. Spinal endomorphin-2 (EM-2) is
involved in varied pain and its release is steroid-dependent, but whether increasing spinal
EM-2 can inhibit thermal hyperalgesia and inflammatory pain in ovariectomized (OVX)
female rats, an animal model mimicking menopause, is not clear, nor is the potential
involvement of spinal mu-opioid receptor (MOR). In the current study, we revealed
that the temporal decrease of spinal EM-2 is accompanied with OVX-induced thermal
hyperalgesia that was dose-dependently attenuated by intrathecal (IT) delivery of EM2. The subcutaneous injection of formalin-induced inflammatory pain in OVX rats was
exacerbated and IT delivery of EM-2 dose-dependently inhibited the inflammatory pain.
However, the ED50 for IT delivery of EM-2 on thermal hyperalgesia is smaller than that
on inflammatory pain in OVX rats, suggesting different contributions of the EM-2 system
to these 2 pain modalities in OVX rats. IT pretreatment with MOR antagonist, betafunaltrexamine (β-FNA), attenuated IT EM-2 analgesia on both thermal hyperalgesia
and inflammatory pain in OVX rats. Furthermore, IT delivery of EM-2 did not affect the
animals’ locomotion or anxiety status. Our findings suggested that IT EM-2 might be a
safer analgesia strategy than hormone replacement therapy in reducing risk of orofacial
or back pain. However, a long-lasting form of EM-2 with less tolerance is needed to
induce sustained analgesia.
Key words: analgesia, intrathecal, endomorphin, ovariectomize, rat
Medical Journal Peer Review: Process and Bias
Authors: Manchikanti Laxmaiah
Published: February 2021

Scientific peer review is pivotal in health care research in that it facilitates the evaluation
of findings for competence, significance, and originality by qualified experts. While the
origins of peer review can be traced to the societies of the eighteenth century, it became an
institutionalized part of the scholarly process in the latter half of the twentieth century. This
was a response to the growth of research and greater subject specialization. With the current
increase in the number of specialty journals, the peer review process continues to evolve to
meet the needs of patients, clinicians, and policy makers.
The peer review process itself faces challenges. Unblinded peer review might suffer from
positive or negative bias towards certain authors, specialties, and institutions. Peer review can
also suffer when editors and/or reviewers might be unable to understand the contents of the
submitted manuscript. This can result in an inability to detect major flaws, or revelations of
major flaws after acceptance of publication by the editors. Other concerns include potentially
long delays in publication and challenges uncovering plagiarism, duplication, corruption and
scientific misconduct. Conversely, a multitude of these challenges have led to claims of scientific
misconduct and an erosion of faith. These challenges have invited criticism of the peer review
process itself. However, despite its imperfections, the peer review process enjoys widespread
support in the scientific community.
Peer review bias is one of the major focuses of today’s scientific assessment of the literature.
Various types of peer review bias include content-based bias, confirmation bias, bias due to
conservatism, bias against interdisciplinary research, publication bias, and the bias of conflicts
of interest. Consequently, peer review would benefit from various changes and improvements
with appropriate training of reviewers to provide quality reviews to maintain the quality and
integrity of research without bias. Thus, an appropriate, transparent peer review is not only
ideal, but necessary for the future to facilitate scientific progress.
Key words: Scientific research, peer review process, scientific publications, peer review bias,
blinded peer review, scientific misconduct.
Perioperative Lidocaine Infusion Reduces the
Incidence of Post-Mastectomy Chronic Pain: A
Double-Blind, Placebo-Controlled Randomized
Trial
Authors: Tiouririne Mohamed
Published: February 2021

Background: Chronic post-surgical pain (CPSP) is a not uncommon complication after
mastectomy, with a reported incidence between 20% and 68%. Careful dissection, the use of
minimally invasive surgical techniques, and attempts to reduce the associated inflammatory and
hyperalgesic responses are suggested methods to prevent CPSP.
Objective: To determine if the use of perioperative lidocaine infusion is associated with decreased
incidence of CPSP after mastectomy.
Study Design: Double-blind, placebo-controlled randomized trial.
Methods: This is a secondary analysis of data from 61 out of 71 patients who underwent
mastectomy for breast cancer. Patients were randomized to either placebo (Group P; n = 27) or
intravenous lidocaine (Group L; n = 34, bolus 1.5 mg/kg at induction, then infusion at 2 mg/kg/hr,
up to 2 hours after the end of surgery) in a prospective double-blind design. CPSP was assessed at
6 months after surgery. Stepwise logistic regression analysis was performed to assess the efficacy
of lidocaine.
Results: Overall 12 (20%) patients developed CPSP, 8 (30%) in the placebo group and 4 (12%)
in the lidocaine group. Predictive factors for CPSP that remained significant after multivariate
analysis included lidocaine (associated with a 20-fold decrease in CPSP, P = 0.013), breast implant
placement (associated with a 16-fold increase in CPSP, P = 0.034), and radiotherapy (associated
with a 29-fold increase in CPSP, P = 0.008).
Limitations: Small sample size.
Conclusion: Perioperative lidocaine administration was associated with a decreased incidence
of CPSP, while breast implant placement and radiotherapy were associated with an increased
incidence. These findings suggest a protective effect of lidocaine on CPSP development in
mastectomy patients.
Key words: Lidocaine, chronic pain, breast surgery, radiotherapy, breast implant
Patients with Refractory Back Pain Treated
in the Emergency Department: Is Immediate
Interlaminar Epidural Steroid Injection Superior
to Hospital Admission and Standard Medical
Pain Management?
Authors: Todd Miller Todd Miller
Published: February 2021

Background: Hospital admissions for back pain are prolonged, costly, and common. Epidural
steroid injections are frequently performed in an outpatient setting with an excellent safety and
efficacy profile.
Objectives: The purpose was to review data from patients with severe pain that did not respond
to aggressive medical treatment in the emergency department (ED) and determine the effectiveness
of an interlaminar epidural steroid injection (ESI) in this patient population.
Study Design: Retrospective matched cohort design.
Setting: Single urban emergency department at a tertiary referral center.
Methods: A retrospective cohort comparison pairing 2 groups that both failed aggressive pain
control in the ED was performed. The epidural injection group (1ESI) received an interlaminar ESI
while in the ED. The standard therapy group (2ST) was admitted for medical pain management.
Groups were matched for pain intensity, age, and symptom duration.
Results: Thirty-five patients in 1ESI (NRS 8.8, 5 – 10, 0.35), and 28 patients in 2ST (NRS 8.9, 4 –
10, 1.7). Pain score after ESI 0.33 (0 – 2, 0.6); all were discharged. Pain score on day 1 of hospital
admission for 2ST was 8.7 (7 – 10, 1.5). Total ED time was 8 hours for 1ESI and 13 hours for 2ST
(P < 0.002). 1ESI patients received less narcotics while in the ED (P < 0.002) and were discharged
home with less narcotics than 2ST (< 0.002). Average inpatient length of stay (LOS) for 2ST was
5 (1.5 – 15, 3.3) days. Cost of care was over 6 times greater for those patients admitted for pain
management (P < 0.001).
Limitations: Retrospective design, non-randomized sample, and a small patient population.
Conclusion: An ED patient cohort with severe refractory pain was treated with an interlaminar
ESI after failing maximal medical pain management while in the ED. Complete pain relief was
achieved safely and rapidly. The need for inpatient admission was eliminated after injection. Costs
were lower in the group that received an epidural injection. Narcotic requirements upon discharge
were decreased as well.
Key words: Low back pain, epidural steroid injection, emergency department, hospital admission
Clinical Evaluation of Transforaminal Epidural
Steroid Injection in Patients with Gadolinium
Enhancing Spinal Nerves Associated with Disc
Herniation
Authors: Ahn Sang-Ho
Published: February 2021

Background: Transforaminal epidural steroid injection (TFESI) of corticosteroid is
frequently employed to mitigate the painful and disabling symptoms of lumbar disc
herniation. However, the treatment outcome of TFESI in patients with radicular pain and
inflamed neural structures as assessed by contrast-enhanced magnetic resonance imaging
(MRI) has not been forthcoming.
Objectives: To investigate functional improvement and pain reduction following TFESI in
patients found to have nerve inflammation as evidenced by gadolinium-enhanced (MRI).
Study Design: Retrospective assessment.
Setting: Tertiary spinal intervention center, Daegu, Korea.
Methods: Thirty-seven patients were selected by strict inclusion criteria. Patients were
classified into enhancing and non-enhancing groups as evidenced by gadolinium-enhanced
MRI. The enhancing group was further divided into pre-dorsal roog ganglion (DRG) only
enhanced group and pre-DRG and post-DRG enhanced group. Clinical outcomes were
evidenced by numeric rating scale (NRS) and Oswestry disability index (ODI) at pretreatment,
one week, and 4 weeks after treatment.
Results: The improvement of NRS and ODI in the enhanced group was greater than those
of the non-enhanced group, at one week and 4 weeks after TFESI (P < 0.05). However
there was no significant difference in improvement of NRS and ODI between pre-DRG only
enhanced group and pre-DRG and post-DRG enhanced group at one week and 4 weeks
after TFESI.
Limitations: Retrospective chart review with a small sample size.
Conclusion: The improvement of NRS and ODI in the enhanced group was significantly
greater than those of the non-enhanced group after TFESI. Radicular pain and functional
impairment in the presence of gadolinium enhancing spinal neural structures and lumbar
disc herniation may be more responsive to TFESI than patients without enhancing neural
structures.
Key words: Transforaminal epidural steroid injection, radicular pain, herniated lumbar
disc, spinal nerve enhancement, contrast enhanced MRI
Spontaneous Muscle Contraction with Extreme
Pain after Thoracotomy Treated by Pulsed
Radiofrequency
Authors: Ke Ma
Published: February 2021

Background: Chronic post thoracotomy pain (CPTP) was a common complication after
thoracotomy, while spontaneous muscle contraction (SMC) was very rare. Neuropathic pain
components appeared in some CPTP patients. The patients with neuropathic pain (NPP) often
suffered from more severe pain.
Objective: We presented a case of a 57 year- old Chinese male, suffering from SMC with extreme
chronic pain after thoracotomy for 2 years. The patient was treated by pulsed radiofrequency
(PRF). Then we reviewed the related progresses including recent view on NPP in CPTP, the possible
mechanism of SMC, treatments for CTPT, and peripheral nerve treatments in NPP.
Study Design: Case report and review of the literature.
Methods: The patient was diagnosed as CPTP with SMC. After the experimental intercostal nerve
block provided short-term analgesia, we performed PRF through the angulus costae on intercostal
nerves under x-ray guidance. We performed PRF for 3 times in all, at an interval of 2 weeks. Then
we had followed up the pain intensity, frequency and amplitude of SMC of this patient during the
2 years.
Results: The pain intensity decreased from 8 to 2 on the visual analogue scale (VAS). The frequency
of muscle contraction was decreased by 90%, and the amplitude was decreased by 60%. The
treatment also improved the patient’s sleep quality. These improvements were stable in 2 years’
follow-up. In our review of the literature, the SMC may be based on the pain-spasm-pain model.
Limitation: Single case report.
Conclusion: Pulsed radiofrequency provided good efficacy in CPTP with SMC in this case.
Key words: Chronic post-thoracotomy pain, pulsed radiofrequency, intercostal nerve, angulus
costae, neuropathic pain, muscle spasm
Effect of Buprenorphine on Total Intravenous
Anesthetic Requirements During Spine Surgery
Authors: Khelemsky Yury
Published: February 2021

Buprenorphine is a partial mu receptor agonist and kappa/delta antagonist commonly
used for the treatment of opioid dependence or as an analgesic. It has a long plasma halflife and a high binding affinity for opioid receptors. This affinity is so high, that the effects
are not easily antagonized by competitive antagonists, such as naloxone. The high affinity
also prevents binding of other opioids, at commonly used clinical doses, to receptor sites
– preventing their analgesic and likely minimum alveolar concentration (MAC) reducing
benefits.
This case report contrasts the anesthetic requirements of a patient undergoing emergency
cervical spine surgery while taking buprenorphine with anesthetic requirements of the
same patient undergoing a similar procedure after weaning of buprenorphine. Use of
intraoperative neurophysiological monitoring prevented use of paralytics and inhalational
anesthetics during both cases, therefore total intravenous anesthesia (TIVA) was maintained
with propofol and remifentanil infusions. During the initial surgery, intraoperative patient
movement could not be controlled with very high doses of propofol and remifentanil. The
patient stopped moving in response to surgical stimulation only after the addition of a
ketamine. Buprenorphine-naloxone was discontinued postoperatively. Five days later the
patient underwent a similar cervical spine surgery. She had drastically reduced anesthetic
requirements during this case, suggesting buprenorphine’s profound effect on anesthetic
dosing. This case report elegantly illustrates that discontinuation of buprenorphine is
likely warranted for patients who present for major spine surgery, which necessitates
the avoidance of volatile anesthetic and paralytic agents. The addition of ketamine may
be necessary in patients maintained on buprenorphine in order to ensure a motionless
surgical field.
Key words: Buprenorphine, anesthesiology, intraoperative, total intravenous anesthesia,
pharmacology
Analysis of the Carrot and Stick Policy of
Repeal of the Sustainable Growth Rate
Formula: The Good, The Bad, and The Ugly
Authors: Manchikanti Laxmaiah
Published: February 2021

The Balanced Budget Act which became law in 1997 was designed to help stem the
increasing in costs of healthcare. The Sustainable Growth Rate (SGR) formula was
incorporated into that law as a method of helping balance the budget through a
complex formula tying reimbursement to the growth in the economy. Soon after its
inception, the flawed nature of the formula, linking the balancing of the federal budget
to physician professional fees was realized. Congress has provided multiple short-term
fixes known as SGR patches over the years so as to avoid generally progressively larger
negative corrections to professional reimbursement. The near annual SGR correction
requirement has been compared to Groundhog Day in the legislative arena. Over the
years, physician and other providers faced numerous looming, large cuts. Most recently,
on April 1, 2015 physicians faced a 21.2% cut in provider payments. To the surprise of
many, in April 2015 a bipartisan bicameral effort permanently repealed the Medicare
SGR formula for controlling provider payment.
The repeal of SGR means the temporary measures to override the growth rate formula
will no longer dominate Medicare policy discussions and now the focus turns to continue
payment reforms. The MACRA provides physicians and other health care professionals
with stable fee update for 5 years and it follows with a new incentive program, termed
the Merit-based Incentive Payment System (MIPS) replacing and consolidating preexisting incentive payment programs: meaningful use of electronic health records
(EHR), physician quality reporting system, and the value-based payment modified.
Thus, payments to clinicians will be subjected to adjustments based on participation in
MIPS or other approved alternative payment mechanisms. This legislation also creates
numerous other regulations.
The MACRA has been criticized for providing insufficient statutory updates, enacting
a flawed quality and performance improvement program associated with MIPS and
inappropriate use of utilization and payment data. Thus, the MACRA offers physicians a
predictable schedule for Medicare rates – a carrot, and controls the physician behaviors
with payment reforms analogous to a stick. Thus, it could be said that this legislation
embodies some good, bad, and ugly aspects.
Key words: Balanced Budget Act, sustainable growth rate, alternative payment
models, Medicare Access and CHIP Reauthorization Act of 2015, Merit-based Incentive
Payment System, payment reform, payment modernization, health information
technology
Ultrasound Guided Peripheral Nerve
Stimulation Implant for Management of
Intractable Pain after Inguinal Herniorrhaphy
Authors: Elahi Foad
Published: February 2021

Background: Inguinal hernia repair is one of the most common operations performed
worldwide. Intractable pain following this operation is a potential debilitating complication.
The exact etiology of this complex pain is unknown and the treatment of chronic pain after
inguinal herniorrhaphy can be a difficult task for both the patient and the clinician.
Objectives: The objectives of this study are to identify the ability of peripheral nerve electrical
stimulation to decrease post inguinal herniorrhaphy pain, increase patients’ functionality, and
decrease pain medication use.
Study Design: Three patients with intractable pain after inguinal herniorrhaphy were
included in this case series. Two patients had right-sided inguinal repair and one had a leftsided repair. Pain in these patients all began after the inguinal repair and had an average
pain duration of 3.4 years after surgery. All 3 patients had been treated with multiple pain
management modalities without significant pain improvement. We will describe the clinical
course of these patients who presented with chronic intractable pain. After a period of failed
conservative medical management and repetitive successful nerve blocks, we decided to
proceed with utilizing electrical nerve stimulation as a treatment modality.
Setting: This retrospective study was done at the university hospital and has an IRB assigned
number.
Results: After careful consideration of the patients’ history and physical examination
and a thorough psychological assessment, we proceeded with a temporary percutaneous
electrical neurostimulation that provided significant pain relief. Ultrasound guided permanent
percutaneous electrical neurostimulation implant was shown to provide significant pain relief
at 12-month follow-ups. We reviewed all existing pertinent medical literature related to the
management of post herniorrhaphy pain. This case series adds to our current knowledge for
chronic intractable post herniorrhaphy pain management.
Limitations: This study is a retrospective assessment of a new technique that was applied to
a limited number of cases. It remains to be determined whether this technique is superior to
the classical open surgical technique in the future. Our findings warrant further studies on the
utilization of peripheral nerve stimulation with chronic post herniorrhaphy pain.
Key words: Peripheral nerve stimulation, ilioinguinal nerve, iliohypogastric nerve, nerve
block, inguinal hernia repair, ultrasound guided procedure
The Continuance Time of Pressure Effect in
the Rat Model of Complete Freund’s Adjuvant
Induced Arthritis
Authors: Lee Chang-Hyung
Published: February 2021

Background: We previously published on the pressure effect using a rheumatoid
animal model (Pain Physician in 2013 and 2014). However, we do not know how long
the pressure effect lasts after exposure to high pressure.
Objective: We evaluated the duration of the pressure effect in a day for a given study
period.
Study Design: Laboratory animal study.
Methods: Following injection of Complete Freund’s Adjuvant (CFA) into one side of the
knee joint, 8 rats were assigned to 1.5 atmospheres absolute (ATA) hyperbaric chamber
3 hours per day for one or 2 weeks (1WPG or 2WPG). Pain levels were assessed daily
for 2 weeks according to weight bearing force (WBF) of the affected limb. In addition,
the levels of gelatinase, MMP-2, and MMP-9 expression in synovial fluids of the knees
were analyzed.
Results: The reduction of WBF was high at one day after injection and then increased
spontaneously up to 2 weeks in 1WPG and 2WPG. The pressure effects lasted for a
given day and did not exceed the pressure effects of the next day in all study periods.
Improvement of WBF in 2WPG was significantly greater than that of 1WPG during
8~14 days. The gelatinase expression ratio was significantly reduced in 1WPG and
2WPG, and 2WPG showed the lowest gelatinase ratio at 2 weeks.
Limitation: Although enough samples were used for the study, more samples will be
needed to raise the reliability.
Conclusion: The 3 hours of 1.5 ATA pressure effect lasted for more than a day. Longer
pressure exposure time appears to yield a greater therapeutic effect in an RA animal
model up to a given study period. Continuous application of high pressure might be
beneficial for achievement of a better therapeutic effect in clinical application.
Key words: Pressure effect, arthritic knee, arthritic pain, long-term effect of pressure,
biophysiologic assessment, pain behavior assessment, arthritis treatment
Synergistic Effect of Intravenous Ibuprofen
and Hydromorphone for Postoperative Pain:
Prospective Randomized Controlled Trial
Authors: Ahn Hyun Joo
Published: February 2021

Background: An intravenous form of ibuprofen has recently been approved by the Food and
Drug Administration (FDA) and reports are rare on its co-administration with opioids.
Objectives: We researched whether an intravenous ibuprofen-hydromorphone combination is
synergistic, additive, or infra-additive on postoperative pain.
Study Design: A parallel-group, 1:1:1 allocation, randomized, double-blind controlled trial.
Setting: University teaching hospital in Korea.
Methods: Ninety patients, undergoing breast surgery, were divided into one of the 3 groups (I,
H, IH groups). Positive analgesic efficacy was defined as a numeric rating scale (NRS) ≤ 3 on a 0
– 10 NRS, 30 minutes after the drug administration. Drugs were administered by the Dixon’s upand-down method. Starting doses were ibuprofen (I) 50 mg, hydromorphone (H) 0.25 mg, or
ibuprofen 25 mg + hydromorphone 0.125 mg (IH). The maximum doses were ibuprofen 800 mg,
hydromorphone 2 mg, or ibuprofen 400 mg + hydromorphone 1 mg. Combination index (CI)
(additive: 0.9 – 1.1, synergism: < 0.9, antagonism: > 1.1), dose reduction index (DRI, a measure of
how much the dose of each drug in a combination can be reduced), and isobologram were used
to define the nature of their interaction.
Statistics: One way ANOVA, Kruskal Wallis test, and Chi square test, significance level P < 0.05.
Results: The median effective doses (ED50) of ibuprofen and hydromorphone were 1,447
mg and 1.5 mg, respectively. The median ED50 of the combination was ibuprofen 71 mg and
hydromorphone 0.3 mg. Ibuprofen and hydromorphone showed a strong synergy (CI 0.2, DRI 20
and 5 for ibuprofen and hydromorphone at ED50).
Limitation: Analgesic efficacy was observed during post-anesthesia care unit (PACU) period only.
Conclusions: The combination of intravenous ibuprofen and hydromorphone produces a strong
synergistic analgesia on postoperative pain.
Key words: Median effective dose, hydromorphone, pain, ibuprofen, postoperative
Two-Year Outcome of Percutaneous Bipolar
Radiofrequency Neurotomy of Sacral Nerves
S2 and S3 in Spinal Cord Injured Patients
with Neurogenic Detrusor Overactivity: A
Randomized Controlled Feasibility Study
Authors: Ahn Sang Oh
Published: February 2021

Background: Little research has been expended on the use of bipolar radiofrequency (RF)
lesioning of sacral nerves in spinal cord injured (SCI) patients with neurogenic detrusor overactivity
(NDO), and no study has been undertaken to demonstrate its long-term effect.
Objective: To investigated the effect of bipolar RF ablation of the second and third sacral nerves
over 2 years in SCI patients with NDO.
Study Design: A prospective, randomized controlled feasibility study.
Setting: The outpatient clinic of a single academic medical center in Korea.
Methods: Ten SCI patients with NDO were recruited. These patients were randomly assigned
to 2 groups; the intervention group (n = 5) and the control group (n = 5). Control group
members received optimized conventional treatment. International Consultation on Incontinence
Questionnaire (ICIQ), 3-day voiding diary, and the urinary incontinence quality of life scale (I-QOL)
data were obtained at baseline and at 6, 12, and 24 months after intervention. Urodynamic study
(UDS) was performed at baseline and 24 months after intervention. In the intervention group,
percutaneous bipolar RF neurotomy was performed on both S2 and S3 nerves in each patient.
Results: Frequency of urinary incontinence and ICIQ and IQOL scores showed significant effects
for time and for the group x time interaction (P < 0.05). Daily mean volume of urinary incontinence
showed only a significant group effect. In UDS parameters, comparisons of values at baseline and
at 24 months revealed all variables showed significant intergroup differences (P < 0.05).
Limitation: A small number of patients was recruited.
Conclusion: Percutaneous bipolar RF ablation of sacral nerves S2 and S3 effectively reduces
urinary incontinence and improves quality of life (QoL) in SCI patients with NDO and the effects
lasted over 2 years.
Key words: Neurogenic detrusor overactivity, bipolar RF neurotomy, sacral nerves, urinary
incontinence, maximal detrusor pressure, maximum cystometric capacity
Tanshinone IIA Exerts an Antinociceptive Effect
in Rats with Cancer-induced Bone Pain
Authors: Xu Shi-yuan
Published: February 2021

Background: Cancer-induced bone pain (CIBP) is a common chronic pain
characterized by 2 components, ongoing pain and breakthrough pain. Tanshinone IIA
(TSN IIA) is a bioactive constituent of the traditional Chinese medicine Danshen, which
has been reported to have an antinociceptive effect on neuropathic and inflammatory
pain through downregulation of the late proinflammatory cytokine high-mobility group
protein B1 (HMGB1).
Objective: To assess the antinociceptive effect of TSN IIA on CIBP.
Study Design: A randomized, double-blind, controlled animal trial was performed.
Setting: University lab in China.
Methods: A rat CIBP model was established by injecting Walker 256 mammary gland
carcinoma cells into the intramedullary cavity of the tibia. Both ongoing pain, e.g.,
flinching and guarding, and breakthrough pain, e.g., limb use and von Frey threshold,
were evaluated. The effects of intraperitoneally administered TSN IIA on pain behavior
and the expression levels of spinal HMGB1, interleukin (IL)-1β, tumor necrosis factor
(TNF)-α, and IL-6 were determined. The effect of TSN IIA on the electrically evoked
response of spinal wide-dynamic range (WDR) neurons was performed in vivo.
Results: TSN IIA dose-dependently inhibited cancer-induced ongoing pain and
breakthrough pain. The expression levels of spinal HMGB1 and other inflammatory
factors (IL-1β, TNF-α, and IL-6) were increased in the rat model, but they were
suppressed by TSN IIA in a dose-dependent manner. Moreover, TSN IIA significantly
inhibited the neuronal responses of WDR neurons in spinal deep layers.
Limitations: Further studies are warranted to ascertain how TSN IIA attenuates
cancer-induced ongoing pain.
Conclusions: Our results indicate that TSN IIA attenuates cancer-induced ongoing
pain and breakthrough pain, possibly via suppression of central sensitization in CIBP
rats. Therefore, we have provided strong evidence supporting TSN IIA as a potential and
effective therapy for relieving CIBP.
Key words: Cancer-induced bone pain, high-mobility group protein B1, Tanshinone
IIA, ongoing pain, breakthrough pain