bluuebunny/crossref_metadata_2025 huggingface dataset:
Efficacy of Intradiscal Ozone Therapy with or
without Periforaminal Steroid Injection on
Lumbar Disc Herniation: A Double-Blinded
Controlled Study
Authors: Ercalik Tulay
Published: February 2021

Background: Intradiscal ozone therapy, a minimally invasive technique, is used in patients that do
not respond to standard conservative therapies for low back pain due to degenerative disc-induced
lumbar disc herniation (LDH). Many studies on clinical efficacy lack a standardized injection method
and are limited by inadequate study design.
Objective: This study aimed to determine the efficacy of periforaminal steroid injection together
with intradiscal ozone therapy.
Study Design: A prospective, double-blinded, randomized controlled trial.
Setting: A tertiary care center.
Methods: This study was conducted in 65 patients with low back and leg pain caused by LDH.
Group 1 received intradiscal ozone therapy (n = 35) and Group 2 received intradiscal ozone therapy
with periforaminal steroid injection (n = 30). Patients were evaluated for pain using the visual
analogue scale (VAS), for disability using Oswestry Disability Index (ODI), and for quality of life
using the short form 36 health survey administered pre-injection and at one and 6 months postinjection. All procedures were performed under sterile conditions using C-arm fluoroscopy.
Results: Significant improvements were observed in pain, disability, and quality of life in both
groups post-treatment compared to pre-injection. Mean pre-injection VAS was not significantly
different between the groups (VAS: 7.8 ± 1.1 for Group 1, 7.8 ± 1.2 for Group 2). VAS values
at 6 months for Group 1 and Group 2 were as follows: 3.6 ± 2.4, 4.1 ± 1.6, respectively) (P <
0.001). Mean pre-injection ODI was not significantly different between the groups (ODI: 20.9
± 9.6 for Group 1, 25.2 ± 10.3 for Group 2). ODI values at 6 months for Group 1 and Group
2 were as follows: 12.8 ± 9.2, 14.3 ± 7.2, respectively) (P < 0.001). However, there were no
significant differences between the groups. Similarly, there was no significant difference between
the 2 groups on any of these parameters.
Limitations: A limited number of patients and limited follow-up time.
Conclusion: This study showed that intradiscal ozone injection alone was sufficient to treat
low back and leg pain caused by LDH and that periforaminal steroid injection does not provide
additional benefit, which is contrary to the literature.
Key words: Low back pain, intradiscal ozone, steroid, lumbar disc herniation, lumbar disc
degeneration
The Analgesic Efficacy of Pecto-Intercostal Fascial
Block Combined with Pectoral Nerve Block in
Modified Radical Mastectomy: A Prospective
Randomized Trial
Authors: Mostafa Shaimaa F.
Published: February 2021

Background: Pectoral nerve (Pecs) block is one of the most promising regional analgesic
techniques for breast surgery. However, Pecs II block may not provide analgesia of the medial
aspect of the breast or the entire nipple-areolar complex.
Objectives: The aim of the present study was to investigate the efficacy of combining the pectointercostal fascial block (PIFB) and Pecs II block for perioperative analgesia following modified
radical mastectomy (MRM).
Study Design: A prospective randomized study.
Setting: An academic medical center.
Methods: Sixty women undergoing unilateral MRM were randomly divided into 2 groups. The
Pecs II group received Pecs II block using 20 mL bupivacaine 0.25% between the serratus anterior
and the external intercostal muscles, and 10 mL bupivacaine 0.25% between the pectoralis major
and minor muscles, together with sham PIFB using 15 mL normal saline solution in the interfascial
plane between the pectoralis major muscle and the external intercostal muscle. PIFB-Pecs II group
received the same Pecs II block combined with PIFB using 15 mL bupivacaine 0.25%.
Results: The median (interquartile range [IQR]) time to the first morphine dose was significantly
longer in the PIFB-Pecs II group (327.5 [266.3–360.0] minutes) than the Pecs II group (196 [163.8–
248.8] minutes) (P < 0.001, 95% confidence interval [CI] 79.98, 150.00).The median (IQR)
cumulative morphine consumption was higher in the Pecs II group (14.0 [11.0–18.0] mg) than
the PIFB-Pecs II group (8.0 [7.0–9.0] mg) (P < 0.001; CI, 4.0–8.0). Intraoperative consumption of
fentanyl was significantly lower in PIFB-Pecs II group with a median (IQR) of 0 (0–15 μg) than the
Pecs II group median 57.5 (0–75 μg) (P = 0.022, CI; 0–60). The Visual Analog Scale scores for the
first 12 postoperative hours were lower in the PIFB-Pecs II group than the Pecs II group at rest and
on moving the ipsilateral arm (P < 0.001). The dermatomal block on the lateral chest wall was
comparable between the 2 studied groups. PIFB-Pecs II provided extensive sensory block on the
anterior chest wall, whereas Pecs II block failed to achieve any sensory block.
Limitations: This study was limited by its small sample size.
Conclusions: The combination of Pecs II and PIFB provide better perioperative analgesia for
MRM than Pecs II alone.
Key Words: Pectoral nerves, postoperative pain, modified radical mastectomy
Ashi Acupuncture Versus Local Anesthetic Trigger
Point Injections in the Treatment of Abdominal
Myofascial Pain Syndrome: A Randomized
Clinical Trial
Authors: Rosa e Silva Júlio Cesar
Published: February 2021

Background: Chronic pelvic pain (CPP) is defined as recurrent or continuous pain in the lower
abdomen or pelvis, non-menstrual or non-cyclic, lasting at least 6 months. There is strong evidence
that up to 85% of patients with CPP have serious dysfunction of the musculoskeletal system,
including abdominal myofascial syndrome (AMPS). AMPS is characterized as deep abdominal pain,
originating from hyperirritable trigger points, usually located within a musculoskeletal range or its
fascia of coating. In the literature, there are few studies that address AMPS.
Objective: This study aimed to compare the responses of ashi acupuncture treatment and local
anesthetic injection in the treatment of chronic pelvic pain secondary to abdominal myofascial pain
syndrome in women.
Study Design: Randomized controlled clinical trial.
Setting: Tertiary University Hospital.
Methods: Women with a clinical diagnosis of CPP secondary to AMPS were randomized and
evaluated using instruments to assess clinical pain, namely, the visual analogue scale (VAS),
numerical categorial scale (NCS), and the McGill Questionnaire, after receiving treatment with
ashi acupuncture (group A, n = 16) or local anesthetic injections (group B, n = 19). They were
reevaluated after one week and one, 3, and 6 months after each treatment, in addition to
assessments of pain and adverse events performed during the sessions.
Results: Ashi acupuncture and local anesthetic injections were both effective in reducing clinical
pain assessed through the analyzed variables among study participants. There was no difference
between the groups and there was a strong correlation between these pain assessment instruments.
Limitations: The absence of blinding to the different forms of treatment among the patients
and the researcher directly involved in the treatment, the absence of a placebo group, the selective
exclusion of women with comorbidities and other causes of CPP, and the difference between the
number of sessions used for each technique.
Conclusion: Treatments with ashi acupuncture and local anesthetic injections were effective in
reducing clinical pain in women with abdominal myofascial pain syndrome.
Key words: Chronic pelvic pain, abdominal myofascial pain syndrome, trigger points,
acupuncture, topical injectable anesthetic
Ultrasound-Guided Peripheral Nerve Stimulation
for Shoulder Pain: Anatomic Review and
Assessment of the Current Clinical Evidence
Authors: Mazzola Anthony
Published: February 2021

Background: The shoulder region is a common area for pain. The shoulder has the largest range
of motion and the most complex mechanical anatomy. The shoulder girdle and related tendons
allow for numerous painful disorders to occur. Also, given the overall use of the shoulder, arthritic
deformities are all too common. Finally, pain from more complex states such as poststroke shoulder
pain and status post total shoulder arthroplasty pain have always been a difficult diagnosis to treat
with effectiveness. The innervation to the shoulder predominantly comes from the suprascapular
and axillary nerves. Both nerves relatively follow an expected anatomic course and whereby they
can be targeted with ultrasound or fluoroscopy. Recently, there has been an increase in evidence
that suggests peripheral nerve stimulation can make a difference in these patients with shoulder
pain.
Objectives: To provide a basic overview of peripheral nerve stimulator placement targeting the
axillary and suprascapular nerves. Furthermore, to demonstrate the suggested implantation and
current evidence of peripheral nerve stimulation for the treatment of shoulder pain.
Study Design: Anatomic clinical review.
Methods: A comprehensive review was performed regarding the available literature through
targeting articles reporting on the use of peripheral nerve stimulation to treat pain of the shoulder
region.
Results: We compiled and discuss the current evidence available in treating shoulder pain
utilizing peripheral stimulation. The strongest evidence currently is for peripheral nerve stimulation
targeting either the axillary or suprascapular nerve, as well as placement targeting the motor points
of the deltoid. The most common treated pathology is poststroke shoulder pain.
Limitations: Peripheral nerve stimulation has been trialed and is promising for several shoulder
pain pathologies; however, there remains a need for large-scale, randomized, placebo-controlled
clinical trials to further evaluate the efficacy of most treatments. Much of the current data relies on
case reports without randomization or placebo controls.
Conclusions: Overall there is fair to moderate evidence for peripheral nerve stimulation to treat
shoulder pain in hemiplegic poststroke patients. There is limited evidence when treating other
shoulder pain etiologies. Utilizing ultrasound or fluoroscopic guidance, the procedure has proven
to be safe allowing proper placement of the electrodes near the target nerves. Considering the
high prevalence of shoulder pain from degenerative conditions and overuse, future studies are
undoubtedly warranted to evaluate whether peripheral nerve stimulation can modify our treatment
algorithm for management of these conditions.
Key words: Shoulder pain, suprascapular nerve, axillary nerve, ultrasonography, peripheral nerve
stimulation, post stroke shoulder, osteoarthritis, rotator cuff, hemiplegic shoulder pain, adhesive
capsulitis
Interventional Management of Refractory
Trigeminal Neuropathic Pain: A Prospective Audit
of a Novel Management Pathway in 70 Patients
Authors: Niraj G.
Published: February 2021

Background: Trigeminal neuropathic pain (TNP) can present as a constant, unremitting unilateral
facial pain. Current management is based on expert recommendation that includes pharmacologic
agents and psychological therapy. However, treatment success with pharmacologic management is
poor. We adopted a novel strategy that proved to be effective in providing durable relief.
Objectives: Prospectively audit a novel strategy in the management of refractory TNP.
Study Design: The authors present a prospective audit of a novel structured management
pathway in the treatment of refractory TNP.
Setting: Multidisciplinary facial pain clinic at a University Teaching Hospital.
Methods: Over a 4-year period, 70 patients with unilateral TNP were prospectively audited at a
tertiary care university hospital. Initial treatment was based on pharmacologic therapy while the
patient awaited psychological therapy. Patients who failed to respond were offered a novel set of
interventions that included ultrasound-guided trigeminal nerve block with depot steroids.
Results: Patient satisfaction with the novel pathway was high. Only 13 patients (13/70, 18%)
responded to standard treatment. Of the 57 patients who were offered the novel intervention, 50
patients consented to undergo the intervention. Forty-two patients (42/50, 84%) reported clinically
significant pain relief at 3 months, and 27 patients (27/50, 54%) reported on-going durable relief
at 6 months. Treatment failure with the novel intervention was 16%. Out of 54 patients in the
employable age, 45 patients (45/54, 83%) were able to maintain gainful employment.
Limitations: Open-label, nonrandomized observational design.
Conclusions: Standard treatment of TNP is ineffective. The novel set of interventions based on
empirical evidence may have a role in managing patients with refractory TNP.
Key words: Trigeminal neuropathic pain, ultrasound-guided trigeminal nerve block, intermediate
cervical plexus block :
High-Voltage Intraarticular Pulsed
Radiofrequency for Chronic Knee Pain Treatment:
A Single-Center Retrospective Study
Authors: Yao Peng
Published: February 2021

Background: Intraarticular pulsed radiofrequency (IAPRF) for the treatment of painful knee
osteoarthritis (KOA) is a less invasive treatment method. It has fewer adverse effects and can
quickly reduce KOA-related pain and improve knee joint dysfunction.
Objectives: We compared the effectiveness of high- and low-voltage IAPRF for the treatment
of chronic knee pain.
Study Design: Retrospective comparative study design.
Setting: This study took place at Shengjing Hospital of China Medical University.
Methods: A total of 57 patients with KOA who were hospitalized between July 2018 and July
2019 were randomly allocated into the high-voltage (n = 29) and low-voltage (n = 28) IAPRF
groups. IAPRF was performed under the guidance of computed tomography (CT). Numeric
Rating Scale (NRS-11), Oxford Knee Score (OKS), degree of pain relief, global perceived effect,
and side effects at baseline and 1 week, 2 weeks, 1 month, 3 months, and 6 months after the
procedure were recorded and analyzed.
Results: NRS-11 scores decreased significantly in both groups after the procedure, but
gradually increased after the 6-month follow-up period. There was a significant difference in
NRS-11 scores between the 2 groups at all follow-up periods postprocedure. OKS were similar
between the 2 groups. Patients with pain relief rate 50% or greater at 1, 3, and 6 months after
the procedure accounted for 72.41%, 72.41%, and 55.17% in the high-voltage group, and
46.43%, 46.43%, and 28.57% in the low-voltage group, respectively. The difference between
the 2 groups was statistically significant. No significant adverse reactions were observed in
the 2 groups, however, patient satisfaction in the high-voltage group was significantly higher
compared with patients in the low-voltage group.
Limitations: This study was a single-center retrospective study with a relatively small sample
cohort and short follow-up period.
Conclusions: CT-guided high-voltage IAPRF is more beneficial in reducing knee pain and
improving knee function compared with low-voltage IAPRF. In addition, patients who received
high-voltage IAPRF were more satisfied with their treatment.
Key words: Pulsed radiofrequency, knee osteoarthritis, intraarticular, high voltage, Oxford
Knee Score, Numeric Rating Scale
Impact of Urine Drug Screening on No Shows
and Dropouts among Chronic Pain Patients: A
Propensity-Matched Cohort Study
Authors: Krishnamurthy Parthasarathy
Published: February 2021

Background: The last 2 decades have seen a substantial increase in both the prescription of
opioids for managing chronic pain, and an increase in opioid-related deaths in the US. Urine
drug screening (UDS) is the de facto monitoring tool aimed at detecting and deterring opioid
misuse.
Objective: We study whether administering UDS on pain patients influences post-screening
behavior of no-shows and dropouts.
Study Design: Observational cohort study of electronic medical records.
Setting: Single urban academic pain-clinic.
Methods: A retrospective cohort comparison of patients receiving UDS versus those not
receiving UDS was conducted on the entire sample as well as in the propensity score-matched
samples in which matching was based on age, gender, pain-score, procedure-scheduled, systolic
and diastolic blood pressure (BP), pulse, temperature, physician ID, year of visit, psychology
referral, and opioid prescription in the first visit. In addition, we conducted within-subjects
logistic-regression to study no-shows and non-proportional hazards survival modeling to study
dropout.
Results: Analyses of 4,448 clinic visits by 723 pain patients indicated that UDS exposure in
the first visit is associated with increased risk of no-show in the second visit (OR = 2.73, P <
.0001); no-show rate was 10.24% for those without UDS compared to 23.75% for those with
a UDS. Among those tested, the no-show rate was higher for those testing positive for illicit
substances (34.57%) than for those testing negative (21.74%). These findings were replicated
in 8 different propensity-score matched subsamples aimed at addressing potential nonrandom selection, as well as in within-subject analysis accounting for individual-level no-show
propensity. Non-proportional hazards survival analysis shows that risk of dropout increased by
100.3% with every additional UDS (HR 95% CI: 1.54 to 2.61).
Limitations: Retrospective design, non-randomized sample, single-setting.
Conclusions: The results indicate that UDS is associated with increased no-shows and dropout
from clinic subject to limitations of observational studies such as selection bias and confound by
unobserved variables. These results serve as a call for additional prospective randomized studies
to understand the impact of UDS, and where the patients might go when they dropout from
the clinic.
Key words: Chronic pain, opioid monitoring, UDS, urine-drug screening, no-show, dropout,
adherence, propensity-score matching
Clinical Outcome Following Radiofrequency
Denervation for Refractory Sacroiliac Joint
Dysfunction Using the Simplicity III Probe: A
12-Month Retrospective Evaluation
Authors: Hegarty Dominic
Published: February 2021

Background: Sacroiliac joint syndrome (SIJ) is diagnosed in 10% to 25% of cases of lower
back pain. The response to traditional radiofrequency (RF) denervation of the SIJ has being
inconsistent. The Simplicity III RF probe (Neruotherm. Inc.) offers a novel treatment option.
Objective: To evaluate the long-term clinical outcome (12 months) refractory SIJ syndrome in
terms of pain intensity and functional improvement. A 50% reduction in intensity pain intensity
(VAS) at 12 months was deemed clinically significant.
Study Design: A 12-month retrospective observational evaluation all of adults treated with
RF for refractory SIJ.
Setting: Chronic pain management center.
Methods: The medical records of all adults treated with this technique was retrospectively
reviewed. The primary outcome was pain intensity scores (VAS) over a 12 months period;
Secondary outcomes included Roland-Morris Functional scores (RMF), Brief Pain Inventory (BPI),
general health assessment (Sf12), and patient satisfaction scores (GPI), which were recorded
pre and post denervation.
Results: Pain Intensity improved by 4.7 points compared to pre-treatment representing a 61%
reduction in pain at 12 months (n=11, P < 0.001). Significant improvements in (a) RMF (P <
0.01, W2
= 0.63 (large effect size); (b) BPI (P < 0.001, W2
= 0.72 (strong effect size); and (c)
Sf12 (P < 0.01) were noted. Overall patients were satisfied with the outcome (GPI = 77.7%).
Limitations: The retrospective in nature of the study and the small sample size are limitations.
As it was our policy to monitor the progress of the individuals since the introduction of this
technique a reliable method of recording the baseline and outcome variables at each point of
contact was in place. Access to a complete set of variables in all individuals over a 12-month
period was therefore possible, which we feel contributes to the quality of the dataset.
Conclusion: By creating a consistent radiofrequency lesion between the sacral foramen
and the SIJ will reliably capture the innervation to the SIJ with significant long-term clinical
improvement. This technique should be considered earlier in the treatment algorithm of
individuals suffering from SIJ symptoms.
Key words: Sacroiliac Joint syndrome, radiofreqency denervation, Simplicity III probe, chronic
pain, long-term clinical outcome, Roland-Morris Functional scores (RMF), Brief Pain Inventory
(BPI), general health assessment (Sf12), patient satisfaction scores (GPI)
Subjective Cognitive Symptoms During a
Migraine Attack: A Prospective Study of a
Clinic-Based Sample
Authors: Gil-Gouveia Raquel
Published: February 2021

Background: A migraine attack aggregates a range of different symptoms, besides pain, that
contribute to attack-related disability. Cognitive dysfunction is an unacknowledged part of the
migraine attack.
Objective: To provide a profile of the frequency and character of migraine attack-related
cognitive symptoms occurring during the headache phase of the attack.
Study Design: Cross-sectional survey.
Setting: Clinical-based sample of episodic migraine patients.
Methods: Sequential patients were screened about the occurrence of cognitive symptoms
during migraine attacks using an open-ended question followed by a self-fulfilled symptom
checklist.
Results: Of 165 migraine patients (15 men, age average 37.3 ± 10.7 years), 89.7% described
cognitive symptoms during the headache phase of the migraine attack. On average 2.5 ± 1.6
symptoms were reported per patient, uninfluenced by demographic or disease-related variables.
The most common spontaneous symptoms related to executive functions, such as poor ability to
concentrate (37%), difficulty in reasoning (25%), and thinking (23%). The pattern of responses
on the symptoms checklist corroborated with those reported spontaneously and quantitative
scores of the checklist were higher in patients with spontaneous symptoms.
Limitations: Open-ended questions tend to overestimate frequency; data accuracy may be
influenced by the population chosen (clinical-based, some using prophylactic treatment).
Conclusions: This study detailed the frequency and characteristics of migraine attackrelated subjective cognitive symptoms and found its frequency to be similar to reports of other
migraine defining symptoms (ex. nausea, photophobia) in recent clinical series. Patients’ reports
were consistent and dominated by complaints of attention difficulties, diminished cognitive
efficiency, and processing speed impairment.
Key Words: Migraine, cognitive symptoms, executive dysfunction, disease impact
The Extent of Tissue Damage in the Epidural
Space by Ho / YAG Laser During Epiduroscopic
Laser Neural Decompression
Authors: Jo Daehyun
Published: February 2021

Background: Lasers have recently become very useful for epiduroscopy. As the use of lasers
increases, the potential for unwanted complications with direct application of laser energy to nerve
tissue has also increased. Even using the lowest laser power to test for nerve stimulation, there are
still risks of laser ablation. However, there are no studies investigating tissue damage from laser
procedures in the epidural space.
Objective: This is a study on the risks of Ho/YAG laser usage during epiduroscopy.
Study Design: Observatory cadaver study.
Setting: Department of anatomy and clinical research institute at the University Hospital.
Methods: We used 5 cadavers for this study. After removing the dura and nerve root from the
spinal column, laser energy from a Ho/YAG laser was applied directly to the dura and nerve root
as well as in the virtual epidural space, which mimicked the conditions of epiduroscopy with the
dura folded. Tissue destruction at all laser ablation sites was observed with the naked eye as well
as with a microscope. Specimens were collected from each site of laser exposure, fixed in 10%
neutral formalin, and dyed with H/E staining.
Results: Tissue destruction was observed in all laser ablation sites, regardless of the length of
exposure and the power of the laser beam.
Limitations: A cadaver is not exactly the same as a living human because dura characteristics
change and tissue damage can be influenced by dura thickness according to the spinal level.
Conclusion: Even with low power and short duration, a laser can destroy tissue if the laser beam
makes direct contact with the tissue.
Key words: Epiduroscopic laser neural decompression, epiduroscopy, Ho/YAG laser, laser
damage, neural decompression, dura histology
Effectiveness of Spinal Cord Stimulation in
Chronic Spinal Pain: A Systematic Review
Authors: Grider Jay
Published: February 2021

Background: Chronic neuropathic pain has been recognized as contributing to a significant
proportion of chronic pain globally. Among these, spinal pain is of significance with failed back
surgery syndrome (FBSS), generating considerable expense for the health care systems with increasing
prevalence and health impact.
Objective: To assess the role and effectiveness of spinal cord stimulation (SCS) in chronic spinal
pain.
Study Design: A systematic review of randomized controlled trials (RCTs) of SCS in chronic spinal
pain.
Methods: The available literature on SCS was reviewed. The quality assessment criteria utilized
were Cochrane review criteria to assess sources of risk of bias and Interventional Pain Management
Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment (IPM – QRB) criteria for
randomized trials.
The level of evidence was based on a best evidence synthesis with modified grading of qualitative
evidence from Level I to Level V.
Data sources included relevant literature published from 1966 through March 2015 that were
identified through searches of PubMed and EMBASE, manual searches of the bibliographies of
known primary and review articles, and all other sources.
Outcome Measures: RCTs of efficacy with a minimum 12-month follow-up were considered
for inclusion. For trials of adaptive stimulation, high frequency stimulation, and burst stimulation,
shorter follow-up periods were considered.
Results: Results showed 6 RCTs with 3 efficacy trials and 3 stimulation trials. There were also 2
cost effectiveness studies available. Based on a best evidence synthesis with 3 high quality RCTs, the
evidence of efficacy for SCS in lumbar FBSS is Level I to II. The evidence for high frequency stimulation
based on one high quality RCT is Level II to III. Based on a lack of high quality studies demonstrating
the efficacy of adaptive stimulation or burst stimulation, evidence is limited for these 2 modalities.
Limitations: The limitations of this systematic review continue to require future studies illustrating
effectiveness and also the superiority of high frequency stimulation and potentially burst stimulation.
Conclusion: There is significant (Level I to II) evidence of the efficacy of spinal cord stimulation in
lumbar FBSS; whereas, there is moderate (Level II to III) evidence for high frequency stimulation; there
is limited evidence for adaptive stimulation and burst stimulation.
Key words: Neuropathic pain, chronic spinal pain, failed back surgery syndrome, spinal cord
stimulation, high frequency stimulation, burst stimulation, adaptive stimulation
Music-Induced Analgesia in Chronic Pain
Conditions: A Systematic Review and MetaAnalysis
Authors: Garza-Villarreal Eduardo A.
Published: February 2021

Background: Music is increasingly used as an adjuvant for the management of chronic pain (CP),
as it is non-invasive, inexpensive, and patients usually report positive experiences with it. However,
little is known about its clinical efficacy in chronic pain patients.
Objectives: We aimed to determine the effect of music as an adjuvant for chronic pain, as well as
to identify characteristics of music interventions associated with positive clinical outcomes.
Study Design: In this systematic review and meta-analysis, we investigated randomized
controlled trials (RCTs) of adult patients that reported any type of music intervention for chronic
pain, chosen by the researcher or patient, lasting for any duration. Searches were performed
using PsycINFO, Scopus, and PubMed for RCTs published until the end of May 2016. The primary
outcome was reduction in self-reported pain using a standardized pain measurement instrument,
reported post-intervention. The secondary outcomes were: quality of life measures, depression,
anxiety, and related measures.
Methods: The study was pre-registered with PROSPERO (CRD42016039837), and the metaanalysis was performed using RevMan 5.3 (The Nordic Cochrane Centre for The Cochrane
Collaboration, Copenhagen, Denmark). We identified 768 titles and abstracts, and we included 14
RTCs that fulfilled our criteria. The sample size of the studies varied between 25 and 200 patients.
Results: We found that music reduced self-reported chronic pain and depressive symptoms. We
also found that music had a greater effect when the patient chose the music, compared to when
the researcher chose it.
Limitations: The sample size of RCTs was small and sometimes with different outcome measures.
There was high heterogeneity associated with pooled estimates.
Conclusions: Our analysis suggests that music may be beneficial as an adjuvant for chronic pain
patients, as it reduces self-reported pain and its common comorbidities. Importantly, the analgesic
effect of music appears higher with self-chosen over researcher-chosen music.
Key Words: Pain, music, analgesia, music-induced analgesia, chronic pain, meta-analysis,
systematic review, therapy
Pain Physician 201
Decreased Regional Grey Matter Volume in
Women with Chronic Whiplash-Associated
Disorders: Relationships with Cognitive Deficits
and Disturbed Pain Processing
Authors: Coppieters Iris
Published: February 2021

Background: Patients with chronic whiplash-associated disorders (CWAD) are characterized by
pain of traumatic origin, cognitive deficits, and central sensitization (CS). Previous neuroimaging
studies revealed altered grey matter volume (GMV) in mild traumatic brain injury patients and
chronic pain conditions also characterized by CS. It can therefore be hypothesized that GMV
alterations also play a role in the persistent complaints of CWAD. However, brain alterations remain
poorly investigated in these patients.
Objectives: This study examined regional GMV alterations in patients with CWAD compared to
patients with non-traumatic chronic idiopathic neck pain (CINP), who normally do not show CS
at a group level, and healthy controls. Additionally, in both patient groups, relationships between
regional GMV and measures of cognition as well as pain processing were assessed.
Study Design: A cross-sectional case-control study.
Setting: This study was performed at the Department of Rehabilitation Sciences and Physiotherapy
of Ghent University in cooperation with the Ghent Institute for Functional and Metabolic Imaging.
Methods: Ninety-three women (28 healthy controls, 34 CINP patients, and 31 CWAD patients)
were enrolled. First, T1-weighted magnetic resonance images (MRIs) were acquired to examine
GMV alterations in the brain regions involved in processing cognition and pain. Next, cognitive
performance, pain cognitions, and CS symptoms were assessed. Finally, hyperalgesia and
conditioned pain modulation efficacy were examined.
Results: Regional GMV of the right lateral orbitofrontal cortex, left supramarginal cortex, and
left posterior cingulate cortex was decreased in CWAD patients compared to healthy controls (P =
0.023; P = 0.012; P = 0.047, respectively). Additionally, GMV of the right superior parietal cortex
and left posterior cingulate cortex was decreased in CWAD patients compared to CINP patients
(P = 0.008; P = 0.035, respectively). Decreased regional GMV correlated with worse cognitive
performance, higher maladapted pain cognitions, CS symptoms, and hyperalgesia in CWAD
patients (rs
= -0.515 to -0.657; P < 0.01). In CINP patients, decreased regional GMV correlated
only with worse cognitive performance (rs
= -0.499 to -0.619; P < 0.01), and no GMV differences
compared with the controls could be revealed.
Limitations: No conclusions about the causality of the observed relationships can be drawn.
Conclusions: These results provide the first evidence for reduced GMV in cortical regions
involved in processing cognition and pain in patients with CWAD. Accordingly, it is recommended
that therapy approaches for CWAD patients should address the brain and take into account
neuroplasticity of the central nervous system (CNS).
Key words: Whiplash injuries, neck pain, magnetic resonance imaging, grey matter, cognitive
dysfunction, pain catastrophizing, central sensitization
Loss of Efficacy to Spinal Cord Stimulator
Therapy: Clinical Evidence and Possible Causes
Authors: Aiudi Christopher M.
Published: February 2021

Background: Although spinal cord stimulation (SCS) therapy has been shown to be efficacious
in various pain conditions, the ability for SCS therapy to maintain long-term efficacy has been
questioned.
Objective: The purpose of this study was to investigate whether a loss of efficacy (LOE)
phenomenon exists with SCS therapy and to investigate if this phenomenon is more apparent in
any specific patient population.
Study Design: A retrospective, observation chart review was conducted to evaluate the patient
response to SCS therapy over time.
Setting: Massachusetts General Hospital, Boston, Massachusetts.
Methods: Patients who received a SCS at the Massachusetts General Hospital, between January
1, 2002 and December 31, 2012, were invited to participate. A total of 62 patients were included
in this study. Various models were created to analyze pain score changes over time using 2-tailed
statistical analysis. Additionally, one-way ANOVA and Pearson’s chi-square tests were used to
determine if certain patient characteristics were associated with LOE.
Results: Compared to the visual analog scale (VAS) score at one month after device implantation,
pain scores increased 1.95 points after 2 years (95% CI: 1.06 to 2.84, P = < 0.001). There were
no significant differences in baseline characteristics between the groups of patients who did and
did not lose efficacy of their therapy. However, those who experienced LOE had a baseline SCS
therapy VAS score 3.09 points lower than those who did not (95% CI: 1.69 to 4.48, P = < 0.001).
Limitations: This study had several limitations including the retrospective nature of its design,
confounders to VAS scores, small sample size, missing data points, and the evaluation of only
conventional, low-frequency SCS therapy.
Conclusions: Patients who received a SCS had a significant increase in VAS scores over time. Our
data did not show any baseline patient characteristic that helped predict LOE. However, patients
who have significant baseline response to therapy may be more likely to experience LOE.
Key words: Spinal cord stimulation, chronic pain, retrospective study, low frequency electrical
stimulation, efficacy, chronic pain therapy
Philosophical Issues and Psychological
Variables that Influence the Determination of
Opioid Effectiveness: A Narrative Review
Authors: Doleys Daniel Michael
Published: February 2021

Background: The prescribing of opioids in the chronic pain setting is often based on the
pharmacodynamics, pharmacokinetics, and pharmacogenetics of the drug obtained during
development and clinical trials. However, the effectiveness of opioids varies widely and often
appears to bear no relationship to the aforementioned variables. The impact of philosophical issues
and psychological factors on determining how clinically effective opioid therapy is has often been
over looked.
Objectives: This manuscript provides a selective review and narrative summary of the philosophical
issues and psychological factors which can influence opioid effectiveness.
Study Design: A selective review and narrative analysis of the literature.
Methods: Experimental and clinical-based studies examining the impact of psychological factors
on the effectiveness of opioids were extracted from the literature. Studies in which psychological
factors were used as an independent variable were given preference.
Results: The philosophical issues reviewed include: (a) one’s understanding of the nature of
chronic pain, (b) the meaning of the score on the pain numerical rating scale (NRS), and (c) the
selection of outcome measures. The psychological factors found to influence the effectiveness
of opioids include: (a) role conditioning and learning, especially as they relate to conditioned
analgesia, non-associative tolerance, and the nocebo effect, (b) dosing pattern, (c) patient specific
factors, e.g., mood, overall psychological and neurocognitive status, (d) social variables, e.g.,
personal environment and the media, and (e) the dysfunctional endogenous opioid system and its
relationship to various psychological disorders.
Limitations: This is a selective review of the literature. Some of the hypotheses presented have
not been experimentally validated. The review includes animal, human, experimental, and clinical
studies.
Conclusions: In general, the effectiveness of opioids may be influenced as much by the overall
context in which they are used, including the physician-patient relationship as well as their
pharmacological properties. Data obtained from short-term and well-controlled trials may not
generalize to the clinical setting, which is often more complex and dynamic. Appreciating the
impact of psychological factors may assist the clinician in proper patient selection, monitoring, and
improved outcomes.
Key words: Psychological factors, philosophical issues, chronic pain, opioid therapy, effectiveness,
conditioning, placebo, cognitive dysfunction
A Prospective Randomized Comparison of
the Efficacy of Ultrasound- vs FluoroscopyGuided Genicular Nerve Block for Chronic Knee
Osteoarthritis
Authors: Choi Seong-Soo
Published: February 2021

Background: Recently, genicular nerve block and radiofrequency ablation were introduced to
alleviate knee pain in patients with chronic knee osteoarthritis. Both ultrasound- and fluoroscopyguided genicular nerve blocks have been used. However, whether one is superior to the other
remains unknown.
Objectives: The present study compares the efficacy of ultrasound- vs fluoroscopy-guided
genicular nerve blocks.
Study Design: This research used a prospective randomized comparison design.
Setting: The study took place at a single pain clinic within a tertiary medical center in Seoul,
Republic of Korea.
Methods: From July 2015 to September 2017, a randomized controlled study was performed
to analyze the difference in the efficacy of ultrasound- vs fluoroscopy-guided genicular nerve
blocks. The Numeric Rating Scale (NRS-11), Western Ontario and McMaster Universities Arthritis
Index (WOMAC), Global Perceived Effect Scales (GPES), and complications were evaluated preprocedure, and 1 and 3 months after genicular nerve block.
Results: A total of 80 patients were enrolled and randomly distributed to groups U (ultrasoundguided, n = 40) and F (fluoroscopy-guided, n = 40). Those who were lost to follow-up or had
undergone other interventions were excluded, resulting in 31 and 30 patients in groups U and
F, respectively. No differences in NRS-11 or WOMAC were observed between the 2 groups at
baseline or during the follow-up period. GPES and complication rates were also similar between
both groups.
Limitations: We were unable to perform double-blind randomization and did not evaluate
patients’ baseline emotional states.
Conclusions: Pain relief, functional improvement, and safety were similar between groups
receiving ultrasound- and fluoroscopy-guided genicular nerve blocks. Therefore, either of the
2 imaging devices may be utilized during a genicular nerve block for chronic knee pain relief.
However, considering radiation exposure, ultrasound guidance may be superior to fluoroscopic
guidance.
The study protocol was approved by our institutional review board (2015-0369), and written
informed consent was obtained from all patients. The trial was registered with the Clinical Research
Information Service (KCT 0002846). This work was presented in part as D-H Kim’s MS thesis at the
University of Ulsan College of Medicine (2018).
Key words: Genicular nerve block, ultrasound, fluoroscopy, knee osteoarthritis, Numeric Rating
Scale, The Western Ontario and McMaster Universities Osteoarthritis Index
Unilateral Versus Bilateral Balloon Kyphoplasty
for Osteoporotic Vertebral Compression
Fractures: A Systematic Review of Overlapping
Meta-analyses
Authors: Yun Tian
Published: February 2021

Background: There have been many meta-analyses and systematic reviews that have discussed
the differences between unilateral and bilateral balloon kyphoplasty. However, their conclusions
regarding the efficacy and safety of bilateral balloon kyphoplasty in the treatment of osteoporotic
vertebral compression fractures (OVCFs) are discordant.
Objective: We attempted to select the best evidence review to determine the differences
between unilateral and bilateral balloon kyphoplasty, and we wanted to determine the best
treatment approach for OVCFs.
Study Design: A systematic review of overlapping meta-analyses
Setting: The electronic databases of PubMed, Embase and The Cochrane Library were searched.
The search extended through Sept. 30, 2017. Moreover, we manually searched the last 10 years of
conference reports and papers from the Peking University Health Science Library and consulted 2
experts in the field for any additional relevant information.
Methods: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis
(PRISMA) Statement and used “A Measurement Tool to Assess Systematic Reviews” (AMTASR) and
the Oxford Levels of Evidence to assess the methodological quality of the studies. We applied the
Jadad decision algorithm to select the best evidence review.
Results: Seven meta-analyses were included in this systematic review. The AMTASR scores of the
studies ranged from 4 to 9, with an average of 6. Finally, Sun H et al was shown to represent the
best evidence study. Sun H et al proposed that the unilateral kyphoplasty required less surgical time
and consumed less cement, reduced cement leakage, and improved short-term general health
compared with that of bilateral kyphoplasty.
Limitations: The AMTASR scores indicated that some of the included studies were of low
quality. In addition, not all of the studies used the Grading of Recommendations Assessment,
Development, and Evaluation (GRADE) level. When used, the GRADE level indicated that most of
the results consisted of studies of low quality.
Conclusions: Unilateral kyphoplasty reduces the operative time, cement volume, and cement
leakage rate compared with bilateral kyphoplasty. Therefore, we conclude that unilateral
kyphoplasty is more advantageous, effective and safe, compared to bilateral kyphoplasty for the
treatment of OVCFs.
Key words: Osteoporotic vertebral compression fracture, kyphoplasty, unilateral, bilateral,
unipedicular, bipedicular, systematic review
Office-Based Kyphoplasty: A Viable Option
Using Local Anesthesia with Oral Sedation
Authors: Chandler III Gilbert S.
Published: February 2021

Background: Vertebral compression fractures (VCFs) can be conservatively treated with pain
management, bracing, and bed rest, or treated surgically with a kyphoplasty or vertebroplasty
procedure.
Objectives: The objective of this retrospective review was to assess the viability, safety, and
efficacy of using local anesthesia with oral sedation for an office-based kyphoplasty procedure.
Study Design: A retrospective review.
Setting: Private orthopedic clinic.
Methods: Ninety-nine consecutive patients (9 office-based and 90 ambulatory surgical centers
[ASC]) between January 2015 to May 2017 receiving their first percutaneous balloon kyphoplasty
(PBK) with our physician in an office-based setting or at an ASC. Clinical outcomes observed
were rates of surgical complications, 6-month re-fracture rates, adjacent fracture rates, and
postprocedure medical management.
Results: No intraoperative complications were observed during the PBK procedure. No re-fractures
occurred during the 6-month follow-up window. A total of 6% of the patients experienced an
adjacent vertebral compression fracture, but there were no significant differences between facility
type. Level-specific verbal pain score at the postoperative follow-up visit was significantly lower
than at the preoperative visit for the cohort (5.3 ± 3.1 vs.7.5 ± 2.0) (P = 0.001) and the ASC group
(5.5 ± 3.1 vs. 7.5 ± 2.0) (P = 0.002).
Limitations: Only 9 single-level office-based PBKs were performed by a single physician and
followed for at least 6 months suggesting these findings cannot be generalized to all patients,
practitioners, facilities, or vertebral augmentation procedures (VAPs).
Conclusions: To the best of our knowledge, this study of a continuous series of primary PBKs
was the first to report the safety of an office-based procedure. The cohort reported significantly
lower pain at their first postoperative follow-up visit when compared to their preoperative visit,
adding to the body of evidence that PBKs are an effective treatment for pain associated with VCFs.
The overall adjacent fracture rate in this series (6%) was slightly lower than previously reported for
VAPs performed in a hospital under local anesthesia (7%-13%).
Key words: Osteoporosis, vertebral compression fracture, kyphoplasty, local anesthesia, officebased, oral sedation:
ASIPP Guidelines for Sedation and Fasting
Status of Patients Undergoing Interventional
Pain Management Procedures
Authors: Manchikanti Laxmaiah
Published: February 2021

Many of the patients undergoing interventional procedures have daily regimens of
medications including analgesics, muscle relaxants, and other drugs that can have
significant additive/synergistic effects during the perioperative period. Further, many
patients also present with comorbid states, including obesity, cardiovascular, and
pulmonary disease. Consequently, in the perioperative period, a significant number
of patients have suffered permanent neurologic injury, hypoxic brain injury, and even
death as a result of over sedation, hypoventilation, and spinal cord injury. In addition,
physicians are concerned about aspiration, subsequent complications, and as a result,
they ask patients to fast for several hours prior to the procedures.
Based on extensive literature and consensus, a minimum fasting period is established as
2 hours before a procedure for clear liquids and 4 hours before procedure for light meals,
rather than having all patients fast for 8 hours or even fasting beginning at midnight the
night before the procedure. Gastrointestinal stimulants, gastric acid secretion blockers,
and antacids may be used, even though not routinely recommended.
Due to the nature of chronic pain and anxiety, many patients undergoing interventional
techniques may require mild to moderate sedation. Deep sedation and/or general
anesthesia for most interventional procedures is considered as unsafe, since the patient
cannot communicate acute changes in symptoms, thus, resulting in morbidity and
mortality, as well as creating compliance issues. We are adapting the published standards
of the American Society of Anesthesiologists for monitoring patients under sedation,
regardless of the location of the procedure, either office-based, in a surgery center, or a
hospital outpatient department. These standards include monitoring of blood pressure,
cardiac rhythm, temperature, pulse oximetry, and continuous quantitative end tidal CO2
monitoring. Sedation must be provided either by qualified anesthesia or non-anesthesia
providers, with appropriate understanding of the medications, drug interactions, and
resuscitative protocols.
Key words: Guidelines, sedation, fasting status, monitoring, neurological complications