bluuebunny/crossref_metadata_2025 huggingface dataset:
Use of Targeted Transversus Abdominus Plane
Blocks in Pediatric Patients with Anterior
Cutaneous Nerve Entrapment Syndrome
Authors: Gulur Padma
Published: February 2021

Anterior cutaneous nerve entrapment syndrome (ACNES) is a commonly overlooked
source of chronic abdominal wall pain. A diagnosis of ACNES should be considered
in cases of severe, localized abdominal pain that is accentuated by physical activity.
Providers should consider diagnosing ACNES once a patient has both a positive result
from a Carnett’s test and precise localization of pain. We describe the use of transversus
abdominus plane (TAP) blocks to treat ACNES in the pediatric patient population. TAP
blocks are a treatment modality which have been described less frequently in the
management of this syndrome, with rectus sheath blocks being used more commonly.
TAP blocks can be used effectively for ACNES by targeting the site of maximal
tenderness, which was identified using ultrasound guidance. Moreover, TAP blocks are
an attractive procedure option for ACNES as they are less invasive than other commonly
used techniques. We present 3 case series reports of pediatric patients evaluated at our
institution for severe abdominal pain to describe the clinical manifestations, sequelae,
and outcome of ACNES. Though the exact incidence of ACNES in the pediatric
population is unknown, this condition has significant implications from chronic pain.
Chronic pain can lead to significant emotional and social impacts on these pediatric
patients, as well as their on their families. Further, the extensive utilization of health
care resources is impacted when children with undiagnosed ACNES undergo invasive
treatments when ACNES is not in the early differential. The purpose of this case series
report is to prompt better recognition of the condition ACNES, and to highlight the
efficacy of TAP blocks as a management strategy.
Key words: TAP block, pediatric patients, abdominal pain, ACNES
Sacral Neuromodulation as a Treatment for
Pudendal Neuralgia
Authors: Valovska Assia
Published: February 2021

Pudendal neuralgia is a debilitating pain syndrome, and finding long-lasting
treatment modalities has been challenging in pain management. The pudendal
nerve has sensory and motor functions, and influences autonomic functions.
Thus, entrapment or damage of this nerve can have multiple serious implications.
The constellation of symptoms which result from injury to this nerve is commonly
referred to as pudendal neuralgia. When conservative therapy does not provide
adequate pain relief and surgical procedures fail or are not viable options, central
and peripheral nerve stimulation can be effective treatment modalities. More
recent approaches to treatment include the use of peripheral nerve stimulation
through the use of an electrical lead placed next to the pudendal nerve in the
ischioanal fossa. Also, epidural stimulation of the conus medullaris and pulsed
radiofrequency ablation of the pudendal nerve have been shown to be effective
in small patient populations. We present the case of a 36-year-old woman
who sustained pudendal nerve injury during a hysterectomy and subsequently
developed intractable pelvic pain and pudendal neuralgia. Conservative
treatment measures failed, but she obtained excellent results from peripheral
nerve stimulator therapy. Permanent implantation consisted of 4 tined Interstim
leads, individually placed into the bilateral S3 and S4 foramina. The patient has
been followed for approximately 4 years since her procedure, demonstrating
increased function as she is able to stand and sit for prolonged periods of time.
She has returned to her usual daily activities, including horseback riding. This
is the first reported case of transforminal sacral neurostimulation providing
excellent relief of pudendal neuralgia related symptoms.
Key words: Pudendal neuralgia, sacral neurostimulation, peripheral nerve
stimulator, pelvic pain, nerve stimulation, interventional pain procedures, surgical
management of pain
Transforaminal Endoscopic Discectomy
with Foraminoplasty for the Treatment of
Spondylolisthesis
Authors: Telfeian Albert E.
Published: February 2021

Background: Lumbar degenerative spondylolisthesis is a common entity and occurs mainly in
elderly patients. The trend in surgery has been to offer decompression with instrumented fusion
based on patient-based outcome data and the inherent instability of the condition.
Objectives: Transforaminal endoscopic discectomy and foraminotomy is an ultra-minimally
invasive outpatient surgical option available to patients that does not require general anesthesia and
does not involve the same amount of destabilizing facet joint removal as a traditional laminectomy
and medial facetectomy. The purpose of this study was to assess the benefit of tranforaminal
endoscopic discectomy and foraminotomy in patients with lumbar 4-5 (L4-L5) and lumbar 5-sacral
1 (L5-S1) spondylolisthesis and lumbar radiculopathy.
Methods: After Institutional Review Board Approval, charts from 21 consecutive patients with
L4-L5 or L5-S1 spondylolisthesis and complaints of lower back and radicular pain who underwent
endoscopic procedures between 2007 and 2012 were reviewed.
Results: The average pain relief one year postoperatively was reported to be 71.9%, good
results as defined by MacNab. The average pre-operative VAS score was 8.48, indicated in our
questionnaire as severe and constant pain. The average one year postoperative VAS score was
2.30, 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 spondylolisthesis undergoing endoscopic spine surgery for treatment of lumbar radiculopathy.
Conclusions: Endoscopic discectomy is a safe and effective alternative to open back surgery.
The one year follow-up data presented here appears to indicate that an ultra-minimally invasive
approach to the treatment of lumbar radiculopathy in the setting of spondylolisthesis that has a
low complication rate, avoids general anesthesia, and is outpatient might be worth studying in a
prospective, longer term way.
IRB approval: Meridian Health: IRB Study # 201206071J
Key words: Endoscopic discectomy, minimally-invasive, transforaminal, spondylolisthesis
Etiologic Factors of Ice Hockey Injuries in
Korean High School Players
Authors: Lee Chang-Hyung
Published: February 2021

Background: Ice hockey is a competitive sport and ice hockey injuries can be influenced
by many physical and psychological factors. Young ice hockey players are especially
vulnerable to injury due to their relative lack of experience and rapid physical growth during
their juvenile years. Up to now there has been no survey of the physical, psychological,
and environmental etiological factors based on the Korean high school ice hockey players
population.
Purpose: The purpose of our study was to evaluate, through a comprehensive survey, the
incidence of ice hockey injuries according to age and the relationship between etiological
factors and injuries in high school students.
Study Design: A cross-sectional study.
Methods: One hundred nineteen ice hockey players in Korean high schools were
recruited for this study. The study was conducted by a self-administered questionnaire
survey. The researcher explained the purpose of the survey and how to fill it out. Individual
questionnaires were distributed to participants. Chi-squared tests were used to evaluate
the relationship between the independent and dependent values. There was a significant
difference between a player’s age and injury incidence (P = .018). The injury level of each
position showed a significant tendency (P = .055). Age was highly correlated with the
number of total injuries (P = .019).
Results: The average demographic characteristics of those surveyed were age (16.7
years), play line (2.2), height (174.8 cm), weight (69.6 kg), and body mass index (23.4). The
shoulder was the most frequent injury area and the knee was the most common cause of
hospital visits. There was a higher injury incidence in older groups; however, there was no
correlation with body mass index, position, and play line. The causative factors were divided
into physical factors, psychological factors, and environmental factors. Generally, 3 factors
were not closely regarded as etiologic factors of ice hockey injury. However, deficiency of
fitness in the physical factor, aggressiveness in the psychological factor, and injury by other
players in the environmental factor showed a high etiological correlation for ice hockey
injury.
Conclusion: The multiple aspects of this etiological factor analysis showed modest results.
However, based on our results, in order to reduce the long-term implications of youth
ice hockey injuries and associated public health costs, comprehensive efforts, including
psychological and environmental factor modification, should be put in place.
Key terms: Ice hockey, etiologic factor, high school player
Adjuvant Hyaluronidase to Epidural Steroid
Improves the Quality of Analgesia in Failed Back
Surgery Syndrome: A Prospective Randomized
Clinical Trial
Authors: Nader Nader Djalal
Published: February 2021

Background: Management of low back pain after spinal surgeries is one of the most
challenging problems in pain medicine. Transforaminal lumbar epidural steroid injection has
been used with inconsistent response. Most patients require multiple and frequent injections
due to high recurrence of back pain.
Objective: To find out whether the addition of hyaluronidase to the epidural injectate affects
the quality and duration of analgesia in patients with low back pain secondary to failed back
surgery syndrome.
Study Design: Prospective randomized trial.
Methods: The study was registered in the Government Clinical Trial registry and the protocol
was reviewed and approved by the institutional review board. After obtaining an informed
consent, 25 patients with low back pain due to failed back syndrome were randomly assigned
to receive a transforaminal epidural injection of hyaluronidase 1500 IU (HYL) or normal saline
(NSL) to a mixture of bupivacaine 0.5% (1 mL) and triamcinolone 40mg (1 mL) in a doubleblind fashion. An interventional pain specialist using fluoroscopic guidance performed all
epidural injections. The patients received a comprehensive neurological examination by a
non-interventional pain specialist who was blinded to the treatment during their follow-up
visits, scheduled one, 2, and 4 weeks after the intervention. Numerical pain scores, analgesic
requirement, and satisfaction scores were recorded during every visit.
Results: There was no difference in demographic data between the 2 groups. Pain scores and
total analgesic requirement were significantly lower in the HYL group at 2 and 4 weeks after
blockade (P < 0.01). Patient satisfaction was higher in the HYL group.
Limitations: The study was limited by a relatively small sample size.
Conclusion: We conclude that adding hyaluronidase to the epidural injectate was effective
in the management of chronic low back pain in patients with failed back surgery syndrome
demonstrated over a period of 4 weeks.
Key words: Low back pain, lumbar epidural injection, steroid, hyalorunidase, bupivacaine
Neuromodulation of the Suprascapular Nerve
Authors: Elahi Foad
Published: February 2021

The shoulder joint is an enarthrodial or ball-and-socket joint. A complex network of anatomic
structures endows the human shoulder with tremendous mobility, greater than any other joint
in the body. Many pathologies can been found in those patients with chronic shoulder pain.
The painful limitation of shoulder motion affects hand and arm motion as well; therefore, it
significantly influences work performance and everyday activities as well as the quality of life.
Therefore, the treatment of patients with chronic shoulder pain has major social and health
economic implications.
In this article we present a patient with a complex history of shoulder pathology including 7
surgeries that left the patient with chronic debilitating shoulder pain.
She was suffering from chronic pain and limited mobility of the shoulder joint due to adhesive
shoulder capsulitis. She was treated with a multimodality approach with the goals of increasing
shoulder range of motion and decreasing her pain. This did not provide significant improvement.
The suprascapular nerve supplies motor and sensory innervation to the shoulder, and can be
easily accessible in the supraspinatus fossa. A suprascapular nerve block dramatically decreased
her pain. This clinical observation along with confirmatory nerve block play an important role
during the decision-making process for a trial period of electrical neuromodulation.
She was followed for 3 months after the permanent implantation of a suprascapular nerve
stimulator. Her pain and shoulder range of motion in all planes improved dramatically.
Peripheral nerve stimulation (PNS) of the suprascapular nerve, in addition to multimodality
pain management, is one approach to the difficult task of treating adhesive capsulitis with
accompanying pain and the inability to move the shoulder.
We conducted a literature review on PubMed and found no case describing a similar patient
to our knowledge.
Key words: Suprascapular nerve, neuromodulation, peripheral nerve stimulation, adhesive
capsulitis, chronic shoulder pain
Greater Trochanteric Pain Syndrome Due to
Tumoral Calcinosis in a Patient with Chronic
Kidney Disease
Authors: Lee Sang Eun
Published: February 2021

Tumoral calcinosis is a rare syndrome characterized by massive subcutaneous soft tissue
deposits of calcium phosphate near the large joints. It is more prevalent in patients with
chronic kidney disease undergoing dialysis.
A 57-year-old woman was referred to our pain clinic with the complaint of severe pain
in the left buttock and lateral hip. The patient had been suffering from chronic kidney
disease for 10 years and had been undergoing peritoneal dialysis over the past 5 years.
The patient’s symptom was initially suspected to be of lumbar origin at the L5 level
and a left L5 transforaminal epidural block was performed, but without success. Reevaluation of the physical examination revealed severe tenderness over the left greater
trochanter and piriformis muscle. On ultrasonographic evaluation, multiple mass-like
lesions in the left buttock were observed. About 30 mL of fluid was aspirated from the
cystic lesions, followed by 30 mL mixture of 0.08% levobupivacaine and triamcinolone
40 mg injected into the bursa under ultrasound guidance, which brought pain relief.
Trochanteric bursitis was thought of as the cause of the symptoms. The patient was
diagnosed with tumoral calcinosis based on the past medical history, simple plain
radiographs, and hip magnetic resonance imaging (MRI).
We diagnosed a case of greater trochanteric pain syndrome due to tumoral calcinosis
related to chronic kidney disease in a patient whose symptoms had initially been
considered to be radiating leg pain caused by lumbar spinal disease. We report our
experience of symptomatic improvement following the repeated ultrasound-guided
aspiration of calcific fluid and the injection of a mixture of local anesthetic and steroid.
Key words: Trochanteric bursitis, greater trochanteric pain syndrome, tumoral
calcinosis
Resolution of Long Standing Tinnitus Following
Radiofrequency Ablation of C2-C3 Medial
Branches – A Case Report
Authors: Gritsenko Karina
Published: February 2021

Tinnitus is described as an auditory phantom perception analogous to central neuropathic pain.
Despite the high prevalence of this debilitating symptom, no intervention is recognized that reliably
eliminates tinnitus symptoms; a cause has yet to be determined.
A 65-year-old healthy man presented with a 3 year history of left-sided tinnitus. Full workup
performed by the primary care physician including blood tests for electrolyte imbalance,
consultations by 2 independent otholaryngologists, and imaging did not reveal abnormalities to
provide etiology of the tinnitus. No other complaints were noted except for occasional minimal left
sided neck pain. Cervical spine x-ray showed degenerative changes with facet hypertrophy more
pronounced on the left side.
Subsequently, the patient underwent diagnostic left-sided C2-C3 medial branch block, resulting
in complete resolution of tinnitus for more than 6 hours. After successful radiofrequency ablation
of left C2-C3 medial branches, the patient became asymptomatic. At one year follow-up, he
continued to be symptom free.
Sparce studies have shown interaction between the somatosensory and auditory system at dorsal
cochlear nucleus (DCN), inferior colliculus, and parietal association areas. Upper cervical nerve
(C2) electrical stimulation evokes potentials in the DCN, eliciting strong patterns of inhibition and
weak excitation of the DCN principal cells. New evidence demonstrated successful transcutaneous
electrical nerve stimulation (TENS) of upper cervical nerve (C2) for treatment of somatic tinnitus in
240 patients. This case indicates that C2-C3 facet arthropathy may cause tinnitus and radiofrequency
ablation of C2-C3 medial branches can provide an effective approach not previously considered.
Key words: Radiofrequency ablation, tinnitus, neuropathic pain, cervical medial branch block,
cervical pain, auditory phantom perception
Effect of Individually Tailored Biopsychosocial
Workplace Interventions on Chronic
Musculoskeletal Pain and Stress Among Laboratory
Technicians: Randomized Controlled Trial
Authors: Jay Kenneth
Published: February 2021

Background: Chronic musculoskeletal pain is prevalent among laboratory technicians and
work-related stress may aggravate the problem.
Objectives: This study investigated the effect of a multifaceted worksite intervention on pain
and stress among laboratory technicians with chronic musculoskeletal pain using individually
tailored physical and cognitive elements.
Study Design: This trial uses a single-blind randomized controlled design with allocation
concealment in a 2-armed parallel group format among laboratory technicians. The trial
“Implementation of physical exercise at the Workplace (IRMA09) – Laboratory technicians“
was registered at ClinicalTrials.gov prior to participant enrolment.
Setting: The study was conducted at the head division of a large private pharmaceutical
company’s research and development department in Denmark. The study duration was March
2014 (baseline) to July 2014 (follow-up).
Methods: Participants (n = 112) were allocated to receive either physical, cognitive, and
mindfulness group-based training (PCMT group) or a reference group (REF) for 10 weeks at the
worksite. PCMT consisted of 4 major elements: 1) resistance training individually tailored to the
pain affected area, 2) motor control training, 3) mindfulness, and 4) cognitive and behavioral
therapy/education. Participants of the REF group were encouraged to follow ongoing company
health initiatives. The predefined primary outcome measure was pain intensity (VAS scale 0 –
10) in average of the regions: neck, shoulder, lower and upper back, elbow, and hand at 10
week follow-up. The secondary outcome measure was stress assessed by Cohen´s perceived
stress questionnaire. In addition, an explorative dose-response analysis was performed on the
adherence to PCMT with pain and stress, respectively, as outcome measures.
Results: A significant (P < 0.0001) treatment by time interaction in pain intensity was observed
with a between-group difference at follow-up of -1.0 (95%CI: -1.4 to -0.6). No significant
effect on stress was observed (treatment by time P = 0.16). Exploratory analyses for each body
region separately showed significant pain reductions of the neck, shoulders, upper back and
lower back, as well as a tendency for hand pain.
Within the PCMT group, general linear models adjusted for age, baseline pain, and stress levels
showed significant associations for the change in pain with the number of physical-cognitive
training sessions per week (-0.60 [95%CI -0.95 to -0.25]) and the number of mindfulness
sessions (0.15 [95%CI 0.02 to 0.18]). No such associations were found with the change in stress
as outcome.
Limitations: Limitations of behavioral interventions include the inability to blind participants
to which intervention they receive. Self-reported outcomes are a limitation as they may be
influenced by placebo effects and outcome expectations
Acupuncture-Analgesia Following a Single
Treatment Session in Chronic Whiplash is
Unrelated to Autonomic Nervous System
Changes: A Randomized Cross-over Trial
Authors: Nijs Jo
Published: February 2021

Background: An acupuncture treatment can reduce pain sensitivity in patients with
chronic whiplash associated disorders (WAD). But it has been hypothesized that many of
the experimental results in acupuncture research could be interpreted as stress-induced
analgesia.
Objective: The present study aimed at examining whether acupuncture has an effect on
the autonomic nervous system response in patients with chronic WAD and if this response is
related to the pain inhibition after an acupuncture session.
Study Design: Randomized crossover trial with blinded assessor.
Setting: Two private practices.
Methods: Thirty-nine patients with chronic WAD received 2 treatment sessions of identical
duration, with acupuncture and relaxation therapy randomly crossed over in the 2 visits.
The primary outcome measurement was the registration of autonomic nervous system
parameters (heart rate, skin conductance, and heart rate variability parameters) during the
administration of experimental pain. Endogenous analgesia was the secondary outcome.
Results: Following one acupuncture treatment session, there was a significant change for
2 parameters: the heart rate was slightly reduced and the skin conductance was raised.
Comparing the effects of acupuncture and relaxation, no differences were found with
respect to the change in any of the autonomic parameters. Further, the reduction in pain
sensitivity in response to acupuncture treatment was unrelated to any of the changes in
autonomic measurements.
Limitations: The results were observed after only one session of acupuncture.
Conclusion: In patients with chronic WAD, in response to a single treatment session, no
acupuncture specific effects on the autonomic response to pain assessment were present
and the analgesia after one session of acupuncture is not caused by stress-induced analgesia
but is more likely the result of an acupuncture specific reaction.
Key Words: Acupuncture, chronic whiplash, autonomic nervous system, pain analgesia,
heart rate variability, acupuncture analgesia
Combined Ablation and Radiation Therapy
of Spinal Metastases: A Novel Multimodality
Treatment Approach
Authors: Greenwood Taylor J.
Published: February 2021

Background: Radiation therapy (RT) is the current gold standard for palliation of painful
vertebral metastases. However, other percutaneous modalities such as radiofrequency ablation
(RFA), cryoablation, and vertebral augmentation have also been shown to be effective in alleviating
symptoms. Combined RT and ablation may be more effective than either therapy alone in palliating
painful metastatic disease to the spine.
Objective: To evaluate the safety and efficacy of combined ablation, either RFA or cryoablation,
and RT in the treatment of spinal metastases.
Study Design: Retrospective study.
Setting: This is a retrospective study at a single institution.
Methods: Medical records of all patients who underwent ablation of spine lesions at a single
institution between March 2012 and June 2014 were reviewed; patients treated with both RT
and either RFA or cryoablation concurrently were identified. Pain scores before and after RFA were
measured with the numerical rating scale (NRS) (0 – 10 point scale) and compared. Procedural
complications, changes in general activity level, and pain medication usage after ablation were also
recorded. When available, follow-up imaging was evaluated for evidence of residual or recurrent
disease.
Results: Twenty-one patients with 36 spine metastases were treated with RT and percutaneous
ablation concurrently; either RFA (21/22) or cryoablation (1/22). One patient received 2 separate
RFA treatments. Overall, mean worst pain score (8.0, SD = 2.3) significantly decreased at both
one week (4.3, SD = 3.1; P < .02) and 4 weeks (2.9, SD = 3.3; P < .0003). Temporary postprocedural radicular pain occurred after one RFA treatment (4.5%; 1/22). Seven patients had
radiation resistant tumors (renal cell, melanoma, or sarcoma). Post-procedural imaging (median
6 months; range 2 – 27 months) showed stable treated disease in 12/13 treatments at 3 months
and 10/10 at 6 months.
Limitations: The therapeutic effect of vertebral augmentation versus percutaneous ablation
cannot be separated in this retrospective study. Radiation treatment protocols were variable and
included both stereotactic body and conventional RT which may have different safety and efficacy
profiles.
Conclusion: Percutaneous ablation and concurrent RT is safe and effective in palliating painful
spinal metastases and can be effective in those who have radiation resistant tumor histology.
Key words: Interventional spine oncology, pain, percuataneous ablation, radiofrequency
ablation, cryoablation, radiation therapy, spine metastases, vertebroplasty
Factors Associated with Increased Risk for
Clinical Insomnia in Patients with Chronic
Neck Pain
Authors: Yoon Duck Mi
Published: February 2021

Background: Insomnia is highly prevalent among people with chronic pain conditions. Because
insomnia has been shown to worsen pain, mood, and physical functioning, it could negatively
impact the clinical outcomes of patients with chronic pain.
Objective: To determine the risk factors associated with clinical insomnia in chronic neck pain
(CNP) patients.
Study Design: Retrospective analysis.
Setting: Outpatient department for interventional pain management at a university hospital.
Methods: Data from 218 CNP patients were analyzed in this study. The Insomnia Severity Index
(ISI) was used to determine the presence of clinical insomnia (ISI score ≥ 15). Patient demographics
and pain-related factors were evaluated with logistic regression analysis to identify risk factors of
clinical insomnia in CNP.
Results: In total, 53.7% of patients reported mild to severe insomnia after neck pain development;
22.9% of patients met the criteria for clinically significant insomnia (ISI score ≥ 15). In multivariate
analysis, high pain intensity, the presence of comorbid musculoskeletal pain, and a high level of
depression were strongly associated with clinical insomnia in patients with CNP. Among these
factors, a greater level of depression was the strongest predictor of clinical insomnia, with the
highest odds ratio of 3.689 (95% CI 1.570 – 8.667).
Limitations: This study was conducted in a single clinical setting including a selected study
population with a homogeneous racial background. The ISI does not include several sleep-related
variables, the roles of which are unknown in determining insomnia severity.
Conclusions: Insomnia should be addressed as an indispensable part of pain management in
CNP patients with these risk factors, especially depression.
Key words: Chronic neck pain, insomnia, risk factors, pain severity, neuropathic pain,
musculoskeletal pain, depression
Invasive Management for Pediatric Complex
Regional Pain Syndrome: Literature Review of
Evidence
Authors: Barroso Alex
Published: February 2021

Background: Complex regional pain syndrome (CRPS) is a multifactorial condition with complex
pathogenesis characterized by spontaneous or stimulus-induced pain that is disproportionate
to the inciting event. It is also commonly accompanied by a myriad of autonomic and motor
disturbances in highly variable combinations. This condition has been underreported in children
until recently. Consequently, the management of CRPS in the pediatric population presents an
even greater challenge than in adults, partly because there is a lack of clinical data concerning the
efficacy of the diverse treatment methods available, and partly because successful treatment of
CRPS involves a multidisciplinary approach. There is a variety of invasive methods to the treatment
of CRPS, but scarce pediatric-focused trials have been published to date.
Objective: To examine and analyze the data currently existing for the invasive management of
CRPS in children. It further suggests a management algorithm based in the evidence reviewed and
our team experience.
Study Design: A comprehensive review of invasive management for pediatric CRPS.
Setting: Academic hospital in Spain.
Methods: A comprehensive review of all the evidence published to date was conducted. Four
databases (PubMed, Medline, Web of Science, Embase, and Cochrane databases) were searched
for articles published from 1980 to 2014. The eligibility criteria were any paper published in
English or Spanish where a non-conventional approach was used to manage pediatric CRPS. Two
independent reviewers extracted the data.
Results: Many case series have reported the use of interventional management with positive
results; however, there is not a single randomized control trial to date comparing the conservative
and the invasive management in children. The largest series of pediatric cases showed that
between 29% to 35% of children with CRPS needed interventional measures to manage this
condition successfully. Sympathetic blocks and spinal drug infusion emerge as the most reported
techniques; the spinal infusion of drugs together with the spinal cord stimulation being the most
successfully employed. Based upon the available evidence with regard to effect and complications,
we recommend an algorithm for the management of pediatric CRPS.
Limitations: The limitations of this study include the paucity of literature, lack of randomized
trials, and lack of quality evidence.
Conclusions: Invasive techniques have been used to treat CRPS over the last few decades;
however, the evidence for their use is still very weak. Invasive management should be contemplated
only when high-standard conservative management has failed to work.
Key words: Pediatric pain, complex regional pain syndrome, CRPS, invasive treatment, pain
management, multidisciplinary management, neurostimulation
Manual Therapy for Hip Osteoarthritis: A
Systematic Review and Meta-analysis
Authors: Liang Qian-qian
Published: February 2021

Background: Hip osteoarthritis (HOA) is one of the major causes of disability in seniors and is
costly to society. Manual therapy is one therapeutic approach to treating HOA.
Objectives: To assess the effect of manual therapy compared to the placebo or wait-list/no
treatment or a minimal intervention control for HOA at post-treatment and short-, intermediateand long-term follow-ups.
Study Design: A systematic review and meta-analysis of randomized controlled trials (RCTs).
Setting: Hospital outpatient clinic in China.
Methods: We searched PubMed, EMBASE, the Cochrane Library, CINAHL, ISI web of knowledge,
and Chinese databases from the inception to October 2014 without language restrictions.
References of systematic reviews and other related reviews, files in our department, and conference
proceedings as grey literature were also screened by hand.
RCTs compared manual therapy to the placebo, wait-list/no treatment or a minimal intervention
control with an appropriate and precise description of randomization. Two reviewers independently
conducted the search results identification, data extraction, and methodological quality assessment.
We calculated the risk difference (RD) for dichotomous data and the mean difference (MD) or
standardized mean difference (SMD) for continuous data in a fixed or random effect model.
Outcome Measures: The primary outcomes were self-reported pain in the past week and
physical function. The secondary outcomes were the quality of life, global perceived effect,
patients’ satisfaction, cost, and adverse events.
Results: Six studies involving 515 HOA patients were included. Five of the 6 studies ranked
as high quality in the methodological assessment. Immediately post-treatment, there was lowquality evidence that manual therapy could not statistically significantly relieve pain (SMD: -0.07
[95%CI -0.38 to 0.24]); for physical function, a moderate quality of evidence showed that manual
therapy could not improve the physical function significantly (SMD: 0.14 [95%CI -0.08 to 0.37]).
We still found low-quality evidence that manual therapy did not benefit the patients in the global
perceived effect (RD: 0.12 [95%CI -0.12 to 0.36]), and in terms of quality of life. In addition, the
risks of patients in the manual therapy group was 0.13 times higher than that in the controls (RD:
0.13 [95%CI -0.05 to 0.31]) in the low-quality evidence studies. We could not find any evidence
that manual therapy benefits the patients at short-, intermediate- or long-term follow-up. There
were no studies reporting patients’ satisfaction or cost.
Limitations: The limitations of this systematic review include the paucity of literature and
inevitable heterogeneity between included studies.
Conclusion: This review did not suggest there was enough evidence for manual therapy for the
management of HOA. However, we are not confident in making such a conclusion due to the
limitations listed above.
Key words: Manual therapy, hip osteoarthritis, efficacy, systematic review, meta-analysis
High Frequency Repetitive Transcranial
Magnetic Stimulation Therapy For Chronic
Neuropathic Pain: A Meta-analysis
Authors: Mu Qiwen
Published: February 2021

Background: Increasing evidence supports an analgesic effect of repetitive transcranial magnetic
stimulation (rTMS) for neuropathic pain (NP). However, the optimal parameters of rTMS (stimulation
frequency and treatment sessions) for achieving long-term analgesic effects remain unknown. This
study analyzed the current findings in the literature.
Objective: The aim of this study was to assess the optimal parameters of rTMS for NP, including
the rTMS sessions needed for inducing acute as well as long-term analgesic effects.
Study Design: A meta-analysis of the analgesic effect of high frequency rTMS (HF- rTMS) for
neuropathic patients.
Setting: This meta-analysis examined all studies involving the analgesic efficacy of HF-rTMS for
NP.
Methods: PubMed, Embase, and the Cochrane library were searched for clinical studies of rTMS
treatment on NP published before December 31, 2014. Crude standardized mean differences
(SMD) with 95% confidence interval (CI) were calculated for pain intensity after different treatment
sessions (from 1 to 10) and follow-up of one or 2 months after rTMS treatment using random
effect models.
Results: Twenty-five studies (including 32 trials and 589 patients) were selected for the metaanalysis according to the inclusion and exclusion criteria. All 3 HF-rTMS treatments (5, 10, and 20
Hz) produced pain reduction, while there were no differences between them, with the maximal
pain reduction found after one and 5 sessions of rTMS treatment. Further, this significant analgesic
effect remained forone month after 5 sessions of rTMS treatment.
Limitations: There are limitations of this meta-analysis. For example, the long-term analgesic
effects of different HF-rTMS and low frequency (LF) rTMS sessions, including the single session of
rTMS on different NP of varying origins have yet not been evaluated; the full degree of pain relief
is still unclear for many rTMS studies.
Conclusions: HF-rTMS stimulation on primary motor cortex is effective in relieving pain in NP
patients. Although 5 sessions of rTMS treatment produced a maximal analgesic effect and may
be maintained for at least one month, further large-scale and well-controlled trials are needed
to determine if this enhanced effect is specific to certain types of NP such as post-stroke related
central NP.
Key words: High frequency, repetitive transcranial magnetic stimulation, neuropathic pain,
single stimulation, multiple stimulation, meta-analysis
Extracellular Signal-Regulated Kinase 5 in
the Cerebrospinal Fluid-Contacting Nucleus
Contributes to Neuropathic Pain in Rats
Authors: Zhang Li-Cai
Published: February 2021

Background: The activation of mitogen-activated protein kinases (MAPKs) have been observed
in synaptic plasticity processes of learning and memory in neuropathic pain. Cerebrospinal fluidcontacting nucleus (CSF-CN) has been identified with the onset and persistence of neuropathic
pain. However, whether extracellular signal-regulated protein kinase 5 (ERK5), a member of
MAPKs, in CSF-CN participates in neuropathic pain has not been studied yet.
Objective: The aim of the present study was to identify the role of ERK5 in CSF-CN on the
formation and development of neuropathic pain, and to investigate its possible mechanism.
Study Design: Controlled animal study.
Setting: University laboratory.
Methods: After a chronic constriction injury (CCI) model was produced, BIX02188 was
dissolved in 1% DMSO and injected into the lateral ventricles LV in a volume of 3 μl with different
doses (0.1 μg, 1 μg, 10 μg). Mechanical allodynia and thermal hypersensitivity behavioral test,
immunofluorescence, and western blot technique were used in this research.
Result: Following CCI, mechanical allodynia and thermal hypersensitivity were developed within
a day, peaked at 14 days, and persisted for 21 days. ERK5 was remarkably activated by CCI in CSFCN. Moreover, selective inhibiting of p-ERK5 expression in CSF-CN by BIX02188 could significantly
relieve CCI-induced mechanical allodynia and thermal hypersensitivity, accompanying with the
decreased phosphorylation of cAMP response-element binding protein (CREB) in CSF-CN.
Limitations: More underlying mechanism(s) of the role of ERK5 in CSF-CN on the formation and
development of neuropathic pain will be needed to explore in future research.
Conclusion: These findings suggest activation of ERK5 in CSF-CN might contribute to the onset
and development of neuropathic pain and its role might be partly accomplished by p-CREB.
Key words: Neuropathic pain, extracellular signal-regulated kinase 5, distal cerebrospinal fluidcontacting neurons, cerebrospinal fluid-contacting nucleus, chronic constriction injury, cAMP
response-element binding protein
Effect of Augmentation Material Stiffness
on Adjacent Vertebrae after Osteoporotic
Vertebroplasty Using Finite Element Analysis
with Different Loading Methods
Authors: Cho Ah-Reum
Published: February 2021

Background: Vertebroplasty is an effective treatment for osteoporotic vertebral fractures,
which are one of the most common fractures associated with osteoporosis. However, clinical
observation has shown that the risk of adjacent vertebral body fractures may increase after
vertebroplasty. The mechanism underlying adjacent vertebral body fracture after vertebroplasty
is not clear; excessive stiffness resulting from polymethyl methacrylate has been suspected as
an important mechanism.
Objectives: The aim of our study was to compare the effects of bone cement stiffness on
adjacent vertebrae after osteoporotic vertebroplasty under load-controlled versus displacementcontrolled conditions.
Study Design: An experimental computer study using a finite element analysis.
Setting: Medical research institute, university hospital, Korea.
Methods: A three-dimensional digital anatomic model of L1/2 bone structure was reconstructed
from human computed tomographic images. The reconstructed three-dimensional geometry
was processed for finite element analysis such as meshing elements and applying material
properties. Two boundary conditions, load-controlled and displacement-controlled methods,
were applied to each of 5 deformation modes: compression, flexion, extension, lateral bending,
and torsion.
Results: The adjacent L1 vertebra, irrespective of augmentation, revealed nearly similar
maximum von Mises stresses under the load-controlled condition. However, for the displacementcontrolled condition, the maximum von Mises stresses in the cortical bone and inferior endplate
of the adjacent L1 vertebra increased significantly after cement augmentation. This increase was
more significant than that with stiffer bone cement under all modes, except the torsion mode.
Limitations: The finite element model was simplified, excluding muscular forces and
incorporating a large volume of bone cement, to more clearly demonstrate effects of bone
cement stiffness on adjacent vertebrae after vertebroplasty.
Conclusion: Excessive stiffness of augmented bone cement increases the risk of adjacent
vertebral fractures after vertebroplasty in an osteoporotic finite element model. This result was
most prominently observed using the displacement-controlled method.
Key words: Bone cements, displacement-controlled method, finite element analysis, loadcontrolled method, osteoporosis, osteoporotic fracture, polymethyl methacrylate, vertebroplasty
Ultrasound-Guided Injection of the Adductor
Longus and Pectineus in a Cadaver Model
Authors: Lee Sang Chul
Published: February 2021

Background: The close anatomic and functional relationship between the proximal parts of
the adductor longus and pectineus muscles produce considerable overlap in symptoms and
signs in the inguinal region. To our knowledge, there have been no publications of ultrasound
(US)-guided injection techniques into the 2 muscles.
Objective: This study sought to describe US-guided injection techniques in the proximal
part of the adductor longus and pectineus muscles and to validate whether these techniques
deliver injections appropriately to their target muscles in unembalmed cadavers.
Study Design: Cadaveric study.
Methods: A preliminary trial with 2 unembalmed cadavers provided information on the
target sonographic structures of proximal adductor longus and pectineus muscles. Bilateral
US-guided intramuscular injections in the proximal adductor longus and pectineus were
performed using the remaining 5 unembalmed male cadavers. To avoid confusion of dye
location, we did not inject into both the adductor longus and pectineus muscle in the same
side. After injections, each specimen was dissected to evaluate the accuracy of injection.
Results: Ten injections (5 for the adductor longus muscle and 5 for the pectineus muscle)
were performed targeting the proximal parts of muscles in 5 cadaveric specimens. All injections
were successful and blue dye was injected accurately at the target area within the adductor
longus and the pectineus muscles. No other muscles were injected unintentionally. There were
no accidental penetrations and/or injuries at adjacent neurovascular structures as well.
Limitation: Despite successful injection of the proximal parts of adductor longus and
pectineus, this study did not verify the usefulness of this technique in clinical practice.
Conclusions: The results of this study may play a role in the diagnosis and management of
patients presenting with chronic pelvic pain syndrome and sports hernia.
Key words: Inguinal, injections, ultrasonography, pain, cadaver, pectineus, adductor, pelvis
Carbamazepine Withdrawal-induced
Hyperalgesia in Chronic Neuropathic Pain
Authors: Zhai Suodi
Published: February 2021

Combined pharmacological treatments are the most used approach for neuropathic pain.
Carbamazepine, an antiepileptic agent, is generally used as a third-line treatment for
neuropathic pain and can be considered an option only when patients have not responded
to the first- and second-line medications. In the case presented herein, a patient with
neuropathic pain was treated using a combined pharmacological regimen. The patient’s
pain deteriorated, despite increasing the doses of opioids, when carbamazepine was
discontinued, potentially because carbamazepine withdrawal disrupted the balance that
was achieved by the multifaceted pharmacological regimen, thus inducing hyperalgesia.
Interestingly, when carbamazepine was prescribed again, the patient’s pain was successfully
managed. Animal research has reported that carbamazepine can potentiate the analgesic
effectiveness of morphine in rodent models of neuropathic pain and postoperative
pain. This clinical case demonstrates that carbamazepine may have a synergistic effect
on the analgesic effectiveness of morphine and may inhibit or postpone opioid-induced
hyperalgesia. We postulate that a probable mechanism of action of carbamazepine
may involve -aminobutyric acid-ergic potentiation and the interruption of glutamatergic
function via N-methyl-D-aspartate receptors. Further research is warranted to clarify the
analgesic action of carbamazepine and its potential use for the prevention of opioidinduced hyperalgesia in chronic neuropathic pain patients.
Key words: Analgesia, hyperalgesia, carbamazepine, opioids, neuropathic pain,
pharmacologic treatment
Human Serum Modifies Aggregation Properties
of Commonly Used Epidural Steroids
Authors: Wahez Sayed E
Published: February 2021

Background: Case reports of catastrophic neurological sequelae during ESIs have questioned
the safety of this procedure. A proposed mechanism is particulate steroid embolization resulting
in neuralischemia. Previous reports have described steroid clumping in common epidural injection
mixtures. We demonstrate that physiologic medium can also modify aggregation.
Objective: To inspect and compare aggregative properties of steroid preparations with and
without human serum.
Setting: Academic tertiary care center.
Hypothesis: Particulate steroids display different aggregation characteristics in serum compared
to non-physiologic solutions.
Design: Solutions were inspected under light microscopy: betamethasone sodium phosphate/
betamethasone acetate, methylprednisolone, and dexamethasone were each mixed in lidocaine
1%, bupivacaine 0.5%, or sterile water in a 1:1 ratio. All preparations were inspected under
light microscopy with 100x and 400x magnifications by a pathologist blinded to our expectations
and hypothesis. Five random viewing fields were selected within each slide and the number of
aggregates per field and the number of particles per aggregate was evaluated.
Results: The addition of serum had a significant effect on steroid particle aggregation and
number of particles per aggregate.
Limitations: This study was limited by sample size as only 2 sets of human serum samples were
tested with each preparation against one non-serum control. Additionally, as steroid preparations
were evaluated under light microscopy, the ex vivo setting must be considered in the interpretation
of results. Finally, mixing preparations with human serum as opposed to whole blood was necessary
to allow for improved visibility on light microscopy despite the fact that whole blood may be
necessary to more closely emulate in vivo coagulation setting.
Conclusions: Overall, the presence of serum resulted in fewer large steroid particle aggregates
when compared to non-serum control samples. Amongst particulate steroids, betamethasone with
bupivacaine 0.5% demonstrated the fewest and smallest particle aggregates, suggesting that
preparation may reduce the risk of embolic infarction. Methylprednisolone formed significantly
larger particles in bupivicaine 0.5% with serum compared to non-serum controls.
Key words: Corticosteroid, particulate aggregate, epidural injection, embolic infarction, serum