bluuebunny/crossref_metadata_2025 huggingface dataset:
Real-Time Maintenance Optimization Considering Health Monitoring and Additive Manufacturing
Authors: Cubillo Adrian , Perinpanayagam Suresh , Esperon-Miguez Manuel , John Philip
Published: March 2021

Prognostics Health Management (PHM) and Integrated Vehicle Health Management (IVHM) are extensive areas of research. Whereas a lot of work has been done in diagnostics and prognostics, economic viability is an important consideration. The availability of aircraft in the aerospace sector is a critical factor. Thus, cost and downtime are the main parameters to assess the impact of IVHM. Additionally, new repair technologies, such as additive manufacturing (AM), have the potential to become standard repair procedures, complementing IVHM, and its viability also has to be assessed. However, to accurately study the impact of these factors, the characteristics of aerospace maintenance have to be taken into account. Several approaches are followed in aircraft maintenance, depending on cost, downtime and aircraft availability constraints. For instance, some parts can be repaired on the ground and assembled again on the same aircraft, while single Line Replaceable Units (LRUs) need to be removed, replaced and later repaired in the workshop without affecting the availability of the aircraft. With the gradual introduction of IVHM, the viability of any new IVHM technology needs to be assessed.This paper describes an extensive cost and downtime model to take into account all these scenarios, including the impact of using different types of IVHM systems. The impact of IVHM and new repair technologies is discussed comparing maintenance cost and downtime of parts of LRUs and parts repaired when the aircraft is on the ground.Secondly, a real-time maintenance case study based on IVHM, a cost and downtime model and additive manufacturing is presented. This application allows the optimization of maintenance activities by updating the available resources and their corresponding cost and time, along with the actual prediction of the Remaining Useful Life (RUL) using a health monitoring system, instead of depending on historical component/sub-system failure probabilities.
Characterization of Friction and Wear Behavior of Friction Modifiers used in Wheel-Rail Contacts
Authors: Oomen M. A. , Bosman R. , Lugt P.M.
Published: March 2021

Reliable traction between wheel and rail is an important issue in the railway industry. To reduce variations in the coefficient of friction, so-called “friction modifiers” (carrier with particles) are used. Twin-disk tests were done with three commercial friction modifiers, based on different compositions of carrier and particles, to characterize their friction and wear behavior. It is shown experimentally that the influence of the carrier cannot be neglected just after application and very low (0.01-0.05) frictional values are observed in a fully flooded situation. However, starvation occurs quickly and friction values will become relatively stable at an intermediate level around μ=0.2 until the friction modifier is consumed and a new dose is required. After the carrier is pushed out of the running track the particles in the contact dominate the tribological performance. The level of friction is a function of total rolling distance, effective sliding length and sum velocity. The most dominant factor depends on the friction modifier and the working mechanism for friction stabilization. It is also shown that the wear rates during tests do not depend significantly on slip, which makes it possible to predict wear behavior. Wear rates are dependent on the type of friction modifier used.
Hierarchical Reasoning about Faults in Cyber-Physical Energy Systems using Temporal Causal Diagrams
Authors: D Chhokra Ajay , Mahadevan Nagabhushan , Dubey Abhishek , Hasan Saqib , Balasubramanian Daniel , Karsai Gabor
Published: March 2021

fault management systems that observe the state of the system, decide if there is an anomaly and then take automated actions to isolate faults. For example, in electrical networks relays and breaks isolate faults in order to arrest failure propagation and protect the healthy parts of the system. However, due to the limited situational awareness and hidden failures the protection devices themselves, through their operation (or mis-operation) may cause overloading and the disconnection of parts of an otherwise healthy system. Additionally, often there can be faults in the management system itself leading to situations where it is difficult to isolate failures. Our work presented in this paper is geared towards solution of this problem by describing the formalism of Temporal Causal Diagrams (TCD-s) that augment the failure models for the physical systems with discrete time models of protection elements, accounting for the complex interactions between the protection devices and the physical plants. We use the case study of the standard Western System Coordinating Council (WSCC) 9 bus system to describe four different fault scenarios and illustrate how our approach can help isolate these failures. Though, we use power networks as exemplars in this paper our approach can be applied to other distributed cyberphysical systems, for example water networks.
Selecting Suitable Candidates for Predictive Maintenance
Authors: Tiddens W. W. , Braaksma A.J.J. , Tinga T.
Published: March 2021

Predictive maintenance (PdM) or Prognostics and Health Management (PHM) assists in better predicting the future state of physical assets and making timely and better-informed maintenance decisions. Many companies nowadays desire the implementation of such an advanced maintenance policy. However, the first step in any implementation of PdM is identifying the most suitable candidates (i.e. systems, components). This is to assess where PdM would provide the greatest benefit in performance and costs of downtime. Although multiple selection methods are available, these methods do not always lead to the most suitable candidates for PdM. The main reason is that these methods mainly focus on critical components without considering the clustering of maintenance, and the technical, economic, and organizational feasibility.This paper proposes a three-stage funnel-based selection method to enhance this process. The first step of the funnel helps to significantly reduce the number of suitable systems or components by a traditional filtering on failure frequency and impact on the firm. In the second and third step, a more in-depth analysis on the remaining candidates is conducted. These steps help to filter potential showstoppers and study the technical and economic feasibility of developing a specific PdM approach for the selected candidates. Finally, the proposed method is successfully demonstrated using two distinct cases: a vessel propulsion system and a canal lock.
Prognostics Health Estimation of Lithium-ion Batteries in Charge-Decay Estimation Uncertainties – A Comparative Analysis
Authors: I. Ossai Chinedu
Published: March 2021

This study uses nonlinear mixed effect-based degradation modeling that considers the influence of uncertainties on the state-of-charge of lithium-ion batteries to determine the State-of-Health (SOH) of the batteries at different End-of-Life (EOL) failure thresholds. The results of the analysis obtained with lithium-ion batteries data from NASA Ames Centre repository, confirms that the SOH of the batteries is influenced by the uncertainties. This is because the random effects models show a better correlation with the experimental data than the fixed effects models that have not considered uncertainty. It is important therefore that battery prognosis is done in consideration of these parametric uncertainties, to forestall poor estimation of the SOH of the lithium-ion batteries at various stages of the lifecycle. Seeing that the presence of uncertainties could result in unwarranted failures of assets powered by the batteries, due to over-estimation of the remaining useful life (RUL) or capital loss, due to early decommissioning of efficient batteries when the RUL is under-estimated.
Systematic Review of Effectiveness and
Complications of Adhesiolysis in the
Management of Chronic Spinal Pain: An
Update
Authors: Trescot Andrea M
Published: March 2021

Background: Percutaneous epidural adhesiolysis and spinal endoscopic adhesiolysis are interventional pain management techniques used to treat patients with refractory low back pain due
to epidural scarring. Standard epidural steroid injections are often ineffective, especially in patients with prior back surgery. Adhesions in the epidural space can prevent the flow of medicine
to the target area; lysis of these adhesions can improve the delivery of medication to the affected areas, potentially improving the therapeutic efficacy of the injected medications.
Study Design: A systematic review utilizing the methodologic quality criteria of the Cochrane
Musculoskeletal Review Group for randomized trials and the criteria established by the Agency for
Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials.
Objective: To evaluate and update the effectiveness of percutaneous adhesiolysis and spinal endoscopic adhesiolysis in managing chronic low back and lower extremity pain due to
radiculopathy, with or without prior lumbar surgery, since the 2005 systematic review.
Methods: Basic search identified the relevant literature, in the MEDLINE, EMBASE, and BioMed
databases (November 2004 to September 2006). Manual searches of bibliographies of known primary and review articles, and abstracts from scientific meetings within the last 2 years were reviewed. Randomized and non-randomized studies are included in the review based on criteria established. Percutaneous adhesiolysis and endoscopic adhesiolysis are analyzed separately.
Outcome Measures: The primary outcome measure was significant pain relief (50% or greater). Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term relief was defined as less than 3 months, and long-term relief was defined as 3 months or longer.
Results: Studies regarding the treatment of epidural adhesions for the treatment of low back
and lower extremity pain were sought and reviewed. The evidence from the previous systematic review was combined with new studies since November 2004. There is strong evidence for
short term and moderate evidence for long term effectiveness of percutaneous adhesiolysis and
spinal endoscopy.
Conclusion: Percutaneous adhesiolysis and spinal endoscopy may be effective interventions to
treat low back and lower extremity pain caused by epidural adhesions.
Key Words: Spinal pain, chronic low back pain, percutaneous adhesiolysis, spinal endoscopic
adhesiolysis, spinal stenosis, post lumbar laminectomy syndrome, epidural fibrosis, epidural adhesions, caudal neuroplasty.
Systematic Review of Discography as a
Diagnostic Test for Spinal Pain: An Update
Authors: Buenaventura Ricardo M.
Published: March 2021

Background: The intervertebral disc has been implicated as an etiology of chronic spine
pain based on clinical, basic science, and epidemiological research. There is currently no way
to determine with absolute certainty whether or not the disc is a spinal pain generator. At our
current level of understanding, discography is thought of as the best tool to evaluate disc-related
pain.
Study Design: A systematic review.
Objective: To systematically assess the diagnostic accuracy of discography with respect to
chronic spinal pain.
Methods: A systematic review of the literature was performed to assess the diagnostic accuracy
of discography with respect to chronic spinal pain. Study inclusion/exclusion criteria were based
on the modern practice of discography. Selected studies were then subjected to two rating
instruments for diagnostic accuracy studies (AHRQ and QUADAS). Specific data were then culled
from these studies and tabulated. Evidence was then classified into five levels: conclusive, strong,
moderate, limited, or indeterminate.
Results: Evidence is strong for the diagnostic accuracy of discography as an imaging tool.
Evidence is also strong for the ability of discography to evoke pain. There is strong evidence
supporting the role of discography in identifying that subset of patients with lumbar discogenic
pain. There is moderate evidence supporting the role of discography in identifying a subset of
patients with cervical discogenic pain. There is limited evidence supporting the role of discography
in identifying a subset of patients with thoracic discogenic pain.
Conclusion: Discography is a useful imaging and pain evaluation tool in identifying a subset of
patients with chronic spinal pain secondary to intervertebral disc disorders.
Key words: Spinal pain, intervertebral disc, discography, pain generator, false-positives,
diagnostic accuracy
Issues in Health Care: Interventional Pain
Management at the Crossroads
Authors: Manchikanti Laxmaiah
Published: March 2021

Emerging strategies in health care are extremely important for interventional pain physicians, as well as with the payors in various categories. While most Americans, including
the US Congress and Administration, are looking for ways to provide affordable health
care, the process of transformation and emerging health care strategies are troubling for
physicians in general, and interventional pain physicians in particular. With the new Congress, only new issues rather than absolute solutions seem to emerge. Interventional pain
physicians will continue to face the very same issues in the coming years that they have
faced in previous years including increasing national health care spending, physician payment reform, ambulatory surgery center reform, and pay for performance.
The national health expenditure data continue to extend the spending pattern that has
characterized the 21st century, with US health spending continuing to outpace inflation
and accounting for a growing share of the national economy. Health care spending in
2005 was $2.0 trillion or $6,697 per person and represented 16% of the gross domestic product. In 2005, Medicare spending reached $342 billion, while Medicaid spending
was $315 billion. Physician and clinical services occupied approximately 21% of all US
health care spending in 2005, reaching $421.2 billion. Overall, health spending in the
US is expected to double to $4.1 trillion by 2016, then consuming 20% of the nation’s
gross domestic product, up from the current 16%. It is predicted that by 2016 the government will be paying 48.7% of the nation’s health care bill, up from 38% in 1970 and
40% in 1990.
The Medicare Physician Payment system based on the Sustainable Growth Rate (SGR)
formula continues to be a major issue for physicians. The Congressional Budget Office
has projected budget implications of change in the SGR mechanism, with consideration
for allowing payment rates to increase by the amount of medical inflation, costing Medicare an estimated $218 billion from 2007 to 2016. Changes in the physician fee schedule in 2006 using the bottom-up methodology have resulted in significant cuts for interventional pain physicians performing procedures in an office setting. Medicaid physician
payments and ambulatory surgery center payments for interventional techniques are proposed to be reduced substantially by Medicare and Medicaid, while hospital payments remain at stable levels with increases.
Key words: Interventional pain management, physician payment reform, national
health spending, sustainable growth rate formula, ambulatory surgery center reform,
pay for performance
Outcomes of Percutaneous Disc
Decompression Utilizing Nucleoplasty for the
Treatment of Chronic Discogenic Pain
Authors: Yakovlev Alexander
Published: March 2021

Background: Percutaneous disc decompression utilizing Nucleoplasty has emerged as one
of the minimally invasive techniques for treatment of low back pain and lower extremity pain
due to contained herniated discs. Only 1 study to date has examined its effect on functional activity and pain medication use; however, results were not analyzed over time, and recall
bias was a limitation.
Objective: Evaluation of the effect of Nucleoplasty on pain and opioid use in improving
functional activity in patients with radicular or axial low back pain secondary to contained
herniated discs.
Design: Retrospective, non-randomized case series.
Methods: Twenty-two patients who had undergone Nucleoplasty were included in the analysis. Patients were evaluated at 1, 3, 6, and 12 months postoperatively, and were asked to
quantify their pain using a visual analog scale ranging from 0 to 10. Patients were also surveyed in regards to their pain medication use, and functional status was quantified by a physical therapist who also used patient reports of ability to perform activities of daily living to
assess status. Data were compared between baseline and at 1, 3, 6, and 12 months posttreatment.
Results: Reported pain and medication use were significantly decreased and functional status was improved at 1, 3, 6, and 12 months following Nucleoplasty (P values ≤ 0.0010 for all
outcome measures at all time periods). There were no complications associated with the procedure and we found continued improvements over time.
Conclusion: Nucleoplasty appears to be safe and effective. Randomized, controlled studies
are required to further evaluate its long-term efficacy.
Key words: Discectomy, disc herniation, low back pain, minimally invasive, Nucleoplasty,
percutaneous disc decompression.
Evidence-Based Interventional Pain
Management: Principles, Problems,
Potential and Applications
Authors: Manchikanti Laxmaiah
Published: March 2021

Background: The past decade has been marked by unprecedented interest in evidencebased medicine (EBM) and a focus upon the use of innovative methods and protocols to
provide valid and reliable information for and about healthcare. Thus (it is at least purported that), healthcare decisions are increasingly being based upon research-derived evidence,
rather than on expert opinion or clinical experience alone. But this quest for evidence to support clinical practice also compels the question of whether the methods employed to acquire
information, the ranking of information that is acquired, and the prudent use of this information are sound enough to actually sustain the validity of an evidence-based paradigm in
practice. Moreover, it is becoming apparent that the scope, depth, and applicability of available evidence to effectively and ethically guide the myriad of situational decisions in clinical
practice is not uniform across all medical fields or disciplines. In particular, comprehensive
evidence synthesis or complete guidelines for clinical decision-making in interventional pain
management remain relatively scarce.
EBM is defined as the conscientious, explicit, and judicious use of the current best evidence
in making decisions about the care of individual patients. Thus, the practice of EBM requires
the integration of individual clinical expertise with the best available external evidence from
systematic research. To arrive at evidence-based medical decisions all valid and relevant evidence should be considered alongside randomized controlled trials, patient preferences, and
resources.
Objective: To describe principles of EBM, and the methods and relative utility of evidence
synthesis in interventional pain management.
Description: This review provides 1) an understanding of evidence-based medicine, 2) an
overview of issues related to evaluating the quality of individual studies, analyses, narrative,
and systematic reviews, 3) discussion of factors affecting the strength and value(s) of evidence, 4) analysis of specific reviews of interventional techniques, and finally, 5) the utility and
purpose of guidelines in interventional pain management.
Conclusion: Interpreting and understanding evidence synthesis, systematic reviews and
other analytic literature is a difficult task. It is crucial for pain physicians to understand the
goals, principles, and process(es) of EBM so as to meaningfully improve its application(s). This
knowledge affords better insight into not only the analytic reviews in interventional pain management provided herein, but ultimately allows future information to be selected, evaluated,
and used with prudence in technically competent, ethically sound medical practice.
Key words: Interventional pain management, interventional techniques, evidence-based
medicine, evidence synthesis, pragmatic or practical clinical trials, randomized trials, observational studies, non-randomized trials, systematic reviews, quality of evidence
Vertebroplasty: A Systematic Approach
Authors: Syed Mubin I.
Published: March 2021

Background: Though vertebroplasty is a well-known and extremely effective procedure in experienced hands, it is a much more difficult procedure to learn than standard
spinal pain injection procedures. We therefore present a simplified, methodical approach
to vertebroplasty that can be adopted by trained interventionalists. Many practitioners
who attend hands-on cadaver workshops lack confidence to apply this technique in live
patients.
Objectives: To present a methodical, reproducible, and proven technique. To provide
strategies on pre-procedure and post-procedure care in order to optimize outcomes in
vertebroplasty patients.
Study Design: A step-by-step tutorial is presented outlining the steps in the vertebroplasty procedure. A discussion of anatomic considerations, pre-procedure patient selection issues, and post-procedure management is also presented.
Methods: Sections are presented on anatomy, patient selection, a 10-step technique
on performance of vertebroplasty, a discussion of how this technique is advantageous,
and post-procedure management.
Results: This technique has been proven in clinical practice for over 1,500 vertebroplasties and has been well-received the past 4 years by hundreds of trainees taught at numerous hands-on courses (Stryker Interventional Pain, Arthrocare, and Society of Interventional Radiology).
Conclusion: A basic tutorial is presented for the beginner who is interested in vertebroplasty. This safe and reproducible technique has been proven in clinical practice. The anatomic considerations, patient selection issues, technique, and post-procedure management has been taught and well received by hundreds of physicians at numerous hands
on courses within the United States and Canada.
Key words: vertebroplasty, fluoroscopic anatomy, PMMA
Hydrocodone Use and Sensorineural
Hearing Loss
Authors: Vrabec Jeffrey T.
Published: March 2021

Background: The hydrocodone/acetaminophen combination is one of the most commonly used analgesic preparations. Isolated incidences of suspected association between hydrocodone abuse and rapidly progressive hearing loss have been reported. In
this study, we describe the clinical characteristics of 5 patients presenting with progressive hearing loss and a history of hydrocodone use.
Methods: Patients presenting with rapidly progressive bilateral hearing loss who had a
documented history of hydrocodone use were selected for the study. The presentation,
audiologic findings, associated comorbidities, and treatment outcomes were reviewed
Results: All patients displayed rapidly progressive sensorineural hearing loss without
vestibular symptoms. Hearing loss was asymmetric in 3 patients at initial presentation,
but progressed to profound loss, usually within months. Steroid treatment has no effect on the progression of the hearing loss. The admitted quantity of hydrocodone consumed ranged from 10 to 300 mg per day. Hepatitis C was the most common comorbidity, present in 60% of the patients. All patients underwent cochlear implantation with
satisfactory results.
Conclusions: The chronic use of hydrocodone can be associated with progressive sensorineural hearing loss. Successful auditory rehabilitation can be achieved with cochlear
implantation. Genetic polymorphisms of drug metabolizing enzymes as well as associated comorbidities such as hepatitis C infection may be significant in the development of
hydrocodone ototoxicity, though additional investigations are necessary.
Key words: hydrocodone, sensorineural hearing loss, cochlear implant
Opioid Analgesia: Perspectives on
Right Use and Utility
Authors: Ballantyne Jane C.
Published: March 2021

The ability of opioids to effectively and safely control acute and cancer pain has been
one of several arguments used to support extending opioid treatment to patients with
chronic pain, against a backdrop of considerable caution that has been based upon fears
of addiction. Of course, opioids may cause addiction, but the “principle of balance”
may justify that “…efforts to address abuse should not interfere with legitimate medical practice and patient care.” Yet, situations are increasingly encountered in which opioid-maintained patients are refractory to analgesia during periods of pain, or even during the course of chronic treatment. The real question is whether analgesic efficacy of
opioids can be maintained over time. Overall, the evidence supporting long-term analgesic efficacy is weak.
The putative mechanisms for failed opioid analgesia may be related to tolerance or opioid-induced hyperalgesia. Advances in basic sciences may help in understanding these
phenomena, but the question of whether long-term opioid treatment can improve patients’ function or quality of life remains a broader issue.
Opioid side effects are well known, but with chronic use, most (except constipation) subside. Still, side effects can negatively affect the outcomes and continuity of therapy. This
paper addresses 1) what evidence supports the long-term utility of opioids for chronic
pain; 2) how side effects may alter quality of life; 3) the nature of addiction and why it
is different in pain patients, and 4) on what grounds could pain medication be denied?
These questions are discussed in light of patients’ rights, and warrant balancing particular responsibilities with risks. These are framed within the Hippocratic tradition of “producing good for the patient and protecting from harm,” so as to enable 1) more informed clinical decision making, and 2) progress towards right use and utility of opioid
treatment for chronic pain.
Key Words: Opioids, chronic pain, addiction, side effects, utility, ethics
Combining Ultrasonography and
Electromyography for Botulinum
Chemodenervation Treatment of Thoracic
Outlet Syndrome: Comparison with
Fluoroscopy and Electromyography Guidance
Authors: Jordan Sheldon E
Published: March 2021

Background: Botulinum chemodenervation has been increasingly used for treating conditions characterized by muscular pain and dystonia. Complication rates commonly exceed 10
percent in published accounts due to an inadvertent spread of toxin. Various techniques of
precision targeting have been described to minimize undesirable toxin effects. The present
study reports on a clinical experience combining ultrasonography and electromyography in
order to demonstrate how favorably this approach compares to previously described techniques in terms of minimizing complications while maintaining efficacy.
Design: Retrospective case series
Methods: The present study is a retrospective clinical analysis of patients treated with
botulinum toxin using 2 different combined targeting techniques; one using ultrasonography and electromyography and the other using fluoroscopy and electromyography.
Results: Combined ultrasonography and electromyography was used in 77 of 245 procedures; in 168 procedures, fluoroscopy and electromyography was used. There were
no complications with ultrasonography guided procedures; the complication rate for
combined fluoroscopy and electromyography was 1.8 percent (3/168; Fisher exact p =
0.3206). For combined ultrasonography and electromyography, after 70 out of 77 procedures (91%) there was a good outcome compared to 136 out of 168 (81%) after procedures utilizing a combination of fluoroscopy and electromyography (Fisher exact p=
0.331).
Conclusions: There was no significant difference in complication rate or successful outcomes comparing the 2 forms of imaging guidance when targeting muscles for botulinum
injection. Since outcomes are comparable, other factors such as cost and radiation exposure may be considered in choosing which imaging modality to use.
Key words: thoracic outlet syndrome, brachial plexus, botulinum toxin, ultrasound
Fluoroscopically Guided Caudal Epidural
Steroid Injections in Degenerative Lumbar
Spinal Stenosis
Authors: Botwin Kenneth P.
Published: March 2021

Background: Caudal epidural steroid injections are commonly utilized to help reduce
radicular pain in lumbar spinal stenosis. There have been studies done to evaluate the effectiveness of this procedure non-fluoroscopically guided. Search revealed no prospective
studies evaluating the effectiveness of fluoroscopically guided caudal epidural injections
on patients with bilateral radicular pain from degenerative lumbar spinal stenosis.
Objective: To evaluate the therapeutic benefit of fluoroscopically guided caudal epidural steroid injections in the treatment of bilateral radicular pain from symptomatic Degenerative Lumbar Spinal Stenosis (DLSS).
Design: This prospective cohort study was performed on 34 patients with bilateral radicular pain from lumbar spinal stenosis who received fluoroscopically guided caudal epidural injections at a multidisciplinary spine center as they did not improve with conservative
care. The patients’ degenerative lumbar spinal stenosis was confirmed by magnetic resonance imaging and classified as mild, moderate, or severe. The patients were evaluated
by an independent observer and completed questionnaires, prior to initial injection, at 6
weeks, 6 months and 12 months after the injections.
Outcome Measures: Visual analog scale, patient satisfaction scale, standing/walking
tolerance scale and Oswestry low back pain disability questionnaire.
Results: A total of 34 patients met our inclusion criteria and were followed at 6 weeks,
6 months, and 12 months. Sixty-five percent of patients at 6 weeks, 62% at 6 months,
and 54% at 12 months had a successful outcome, reporting at least a >50% reduction
between pre-injection and post injection visual analog pain scores. Fifty nine percent of
patients had an improved walking tolerance at 6 weeks (P <0.0001), 56% at 6 months (P
<0.0001), and 51% at 12 months (P=0.0005). Fifty percent of patients had an improved
standing tolerance at 6 weeks (P= 0.0002), 54% at 6 months (P < 0.0001), and 51% at
12 months (P=0.0005). The patient satisfaction scale revealed 64% of patients felt completely or somewhat better at 6 weeks, 59% at 6 months and 52% at 12 months. Owestry low back pain disability questionnaire scores showed statistically significant improvement from initial scores to 6 weeks (P < 0.0001), initial to 6 months (P= 0.0095), and
initial to 12 months (P=0.00015). The outcome was statistically significant even in severe
stenotic patients when comparing initial mean scores to 12 month mean scores in standing tolerance (P =0.2956), walking tolerance (P=0.0250), and VAS (P= 0.0199).
Conclusion: Fluoroscopically guided caudal epidural steroid injections may help reduce bilateral radicular pain and improve standing and walking tolerance in patients with DLSS.
Key words: Injections, epidural radiculopathy, lumbar spinal stenosis, rehabilitation
Treatment of Iliopsoas Tendinitis
after a Left Total Hip Arthroplasty
with Botulinum Toxin Type A
Authors: Fish David E
Published: March 2021

Objective: Treatment of iliopsoas tendinitis after a left total hip arthroplasty with botulinum toxin type A (BTX-A).
Design: Case study.
Setting: Outpatient musculoskeletal clinic.
Participants: Single patient subject with left iliopsoas tendinitis after a left total hip arthroplasty.
Interventions: Fluoroscopically guided injection of 100 units of BTX-A into the left iliopsoas muscle.
Main Outcome Measures: Functional improvement with Oswestry Disability Index
(ODI) and scores using a 0–10 point pain intensity numerical rating scale (PI-NRS) at one
and 6 months follow up.
Results: A 71-year-old female with 4 months of left groin pain after successful total hip
arthroplasty. Work up did not reveal any infection or malpositioning of the left hip prosthetic components. Attempts at aspiration revealed no fluid in the joint space. A positive
xylocaine muscle block confirmed a diagnosis of iliopsoas tendinitis. The BTX-A injection
resulted in an improved left groin pain rating from a baseline of 7 to 1 and improved ability to flex her left hip at one month follow up. Pain was rated 8 at six months follow up.
ODI improved from a baseline of 26% to 22% at one month follow up and 18% at 6
months follow up.
Conclusions: Iliopsoas tendinitis is an uncommon cause of groin pain but has been described after a total hip arthroplasty in several case reports. Non-operative management
has not been well established but includes anesthetic and corticosteroid injection into the
muscle. The use of botulinum toxin A provided significant pain relief, functional improvement, and may represent an alternative to the surgical management of iliopsoas tendinitis.
Key words: Rehabilitation, iliopsoas tendinitis, iliopsoas bursitis, total hip arthroplasty,
groin pain, botulinum toxin.
Treatment of CRPS with ECT
Authors: Schwartzman Robert J.
Published: March 2021

Background: Electroconvulsive therapy (ECT) is a well-established treatment method
for medically refractory depression. ECT has also been used in the treatment of pain for
over 50 years. The mechanism of action of ECT is still unknown, although several observations have been made regarding the effect of ECT on pain processes. It has been reported that several patients with medically refractory depression and Complex Regional
Pain Syndrome who were treated with ECT for their depression were also cured of their
CRPS symptoms.
Objective: We report a case of CRPS in a patient who also suffered from medically refractory depression. She was treated with ECT for her depression and subsequently was
relieved of all her CRPS symptoms.
Case Report: A 42 year-old female patient underwent a series of 12 standard bitemporal electroconvulsive therapy treatments for medically refractory depression. Physical examination and Quantitative Sensory Testing was done before and after the patient’s treatment with ECT. This standard treatment procedure for refractory depression completely
resolved the patient’s depressive symptoms. In addition, the patient’s CRPS symptoms
were also reversed. Physical examination as well as Quantitative Sensory Testing done before and after the ECT treatment correlated with her CRPS symptom improvement.
Conclusion: ECT was effective in the treatment of severe refractory CRPS in this patient.
Key words: Iimpedance, posture change, spinal cord stimulation
Transforaminal Epidural Blood Patch
Authors: Weil Lawrence
Published: March 2021

Spinal headache is an occasional, but painful complication of epidural injection
procedures due to dural puncture that allows leakage of CSF from the thecal sac,
thereby reducing intracranial pressure. In the event of failure of conservative management, (e.g. abdominal binder, fluids, acetaminophen), an epidural blood patch
is often used.
This case report describes a patient with spinal headache after a transforaminal
selective epidural injection in a post laminectomy patient that was treated with a
transforaminal epidural blood patch after the failure of conservative management.
The patient underwent left transforaminal epidural injections at L5 and S1 for
management of chronic low back pain secondary to post laminectomy syndrome.
Three days later, the patient presented with a severe post lumbar puncture headache and failed to respond to conservative management. Interlaminar epidural approach for blood patch was not feasible secondary to prior laminectomy. Transforaminal epidural blood patch was performed utilizing 2 mL of autologous blood at
each of the two sites. The patient recovered well without headache.
In cases, with inability to perform interlaminar blood patch, a transforaminal approach may be considered.
Key words: blood patch, epidural, spinal headache, transforaminal
Prevalence of Low Back Pain in Greek Public
Office Workers
Authors: Spyropoulos Dr. Panagiotis
Published: March 2021

Background: Epidemiological studies have provided information on the prevalence and
risk factors of low back pain (LBP) in white collar workers in industrialized countries. Little
information has related individual, work ergonomic, and psychosocial factors to the incidence of LBP in low income countries.
Objectives: To assess the prevalence of LBP among Greek public office workers. To identify
and relate the individual, work ergonomic, and psychosocial factors to the occurrence of LBP.
Design: Cross-sectional study of Greek office workers in the public sector.
Methods: A self-reported standardized questionnaire was constructed to record risk factors associated with the occurrence of LBP. Personal characteristics, work ergonomics, and
psychosocial traits were collected and related to LBP prevalence.
Results: Of the 771 office workers, 648 responded (84% return rate). The majority of
the participants were women (75.8%). Among all responders, 33%, 37.8%, 41.8%,
and 61.6% presented with point, one-year, two-year, and lifetime prevalence respectively. Sleep disturbances due to pain were reported in 37% of the office clerks with chronic
low back pain. Multiple logistic regression models have revealed that significant determinants for predicting LBP occurrence are age, gender, body mass index, body distance from
computer screen, adjustable back support, clerk body position while sitting, sitting time
of greater than 6 hours, job satisfaction, repetitive work, and anger during last 30 days.
Conclusion: High proportions of Greek office workers suffer from LBP which might affect
the Greek economy. The incidence of LBP status is significantly associated with some anthropometric, ergonomic, and psychosocial factors.
Key words: Office workers, risk factors, low back pain, epidemiology
Total Cervical Translation as a Function
of Impact Vector as Measured by FlexionExtension Radiography
Authors: Centeno Christopher J
Published: March 2021

Background: Clinical and cadaveric studies have implicated that sub-failure cervical
instability likely occurs in a subset of whiplash injury patients. Cadaveric studies have
suggested that female specimens suffer from more ligamentous stretch injury than
males when exposed to simulated rear end crash vectors. However, these findings
have never been tested in an in-vivo clinical setting.
Design: A prospective evaluation of total cervical translation on sagittal flexion radiographs versus impact vector in a late whiplash population.
Objectives: To determine if total cervical translation on radiographs is correlated
with impact crash vector.
Methods: Consecutive late whiplash patients in a subspecialty pain clinic setting
were sent for radiographs using a strict stress flexion-extension protocol. Information
concerning crash vector and damage was recorded. Vertebral translation was read by
a blinded reader and recorded.
Results: Males did not significantly differ in total translation in flexion-extension radiographs when involved in sagittal plane crashes (n=75) compared to coronal plane
crashes (n=10). In a front end collision, males (n=16) and females (n=26) did not differ in total translation in flexion-extension radiographs. In a rear end collision, females
(mean translation 4.61 mm, n=103) did differ significantly in total translation in flexion-extension radiographs from their male counterparts (mean translation 3.29, n=48)
(P<0.001).
Conclusion: This investigation suggests that specific crash vectors lead to particular
patterns of radiographic translation in female subjects. A realization that sub-failure
cervical instability occurs in whiplash may help design more effective treatments.
Key words: Cervical translation, impact vector, radiograph, flexion, extension, whiplash
Interventional Techniques in Managing
Persistent Pain After Vertebral Augmentation
Procedures: A Retrospective Evaluation
Authors: Georgy Bassem
Published: March 2021

Background: Based on systematic reviews, it appears that at least 10% of patients may
continue to suffer with residual or persistent pain after successful vertebral or sacral augmentation procedures.
Objective: To report and evaluate the incidence and prevalence of different spinal injections in patients who received vertebroplasty, kyphoplasty, and sacroplasty procedures for
both benign and malignant compression fractures.
Design: A retrospective case review.
Methods: Retrospective review of all cases of vertebroplasty, sacroplasty, and kyphoplasty performed in a 12-month period in a single outpatient setting of interventional radiology was conducted.
Results: In a 12-month period starting from October 2005 to September 2006, 144 patients underwent cement augmentation procedures. Of the 144, 34 patients required a spinal injection procedure for residual or persistent pain within a 1-year period after the augmentation procedure.
Twenty-four patients required epidural steroid injections, 6 patients required intercostal
nerve blocks, 5 patients required trigger point injections, 5 patients required sacroiliac joint
injections, and 1 patient required facet joint injections. Nine patients who required lumbar
epidural steroid injections and all patients who required intercostal nerve blocks and had
underwent a thoracic cement augmentation procedure.
Conclusion: A small proportion of patients undergoing percutaneous cement augmentation for vertebral compression fractures or sacral insufficiency fractures potentially require
spinal injections to treat residual pain after the procedure.
Key words: Kyphoplasty, vertebroplasty, sacroplasty, residual pain, vertebral compression
fractures, epidural steroid injections, facet joint pain, sacroiliac joint injections, facet joint
injections.
Ultrasound-guided Stellate Ganglion Block
Successfully Prevented Esophageal Puncture
Authors: Narouze Samer
Published: March 2021

Stellate ganglion block is utilized in the diagnosis and management of various vascular disorders and sympathetically mediated pain in the upper extremity, head and neck. The cervical sympathetic chain is composed of superior, middle, intermediate, and inferior cervical
ganglia. However, in approximately 80% of the population, the inferior cervical ganglion is
fused with the first thoracic ganglion, forming the stellate ganglion also known as cervicothoracic ganglion.
The stellate ganglion lies medial to the scalene muscles, lateral to the longus coli muscle,
esophagus and trachea along with the recurrent laryngeal nerve, anterior to the transverse
processes and prevertebral fascia, superior to the subclavian artery and the posterior aspect
of the plura, and posterior to the vertebral vessels at C7 level. Consequently, inadvertent
placement of the needle into the vertebral artery, thyroid, neural tissues, or esophagus can
occur with the fluoroscopic or blind approach. While fluoroscopy is a reliable method for
identifying boney structures, ultrasound may identify the vertebral vessels, thyroid gland and
vessels, longus coli muscles, nerve roots and the esophagus. Thus, ultrasound may prevent
inadvertent placement of the needle into these structures as might happen with either the
blind technique or fluoroscopic technique.
A patient with complex regional pain syndrome type I of the left upper extremity was scheduled for left stellate ganglion block with the anterior paratracheal approach under fluoroscopy. Real-time ultrasound imaging prevented inadvertent injury to the esophagus as well as
the thyroid gland and vessels.
Ultrasound-guided block may improve patient safety by avoiding the soft tissue structures in
the needle path that can’t be readily seen by fluoroscopy. This may be particularly useful in
the patient with asymptomatic pharyngoesophageal diverticulum (Zenker diverticulum).
Key words: Esophageal injury, stellate ganglion block, ultrasound-guided stellate ganglion block, Zenker diverticulum
Pulsed Radiofrequency of the Median
Nerve under Ultrasound Guidance
Authors: Haider Naeem
Published: March 2021

Neuropathy of the median nerve within the carpal tunnel (carpal tunnel syndrome) has an age adjusted incidence of 105 cases per 100,000 person years.
Treatment of carpal tunnel syndrome ranges from conservative management
with medication and exercise to surgical release of the median nerve. Conservative treatment accounts for a significant portion of resources utilized and includes splinting, nerve gliding, ultrasound, and carpal bone mobilization.
Recurrent symptoms of carpal tunnel syndrome have been shown to occur in
0% to 19% of patients following carpal tunnel release, with up to 12% requiring re-exploration. Prognosis for re-exploration is not as good as for primary
carpal tunnel release, with a high recurrence rate in some populations. Ultrasound has seen increasing use in regional anesthesia and has been shown to
improve the quality of regional anesthetic blocks.
Pulsed radiofrequency was developed with the goal of providing reduction in
pain from the use of electrical fields in the absence of neural injury. The use
of ultrasound guidance for positioning radiofrequency probes over peripheral
nerves has not been reported.
This case report describes the use of ultrasound guided pulsed radiofrequency
in the treatment of recurrent carpal tunnel syndrome. Following revision carpal
tunnel surgery, the patient in this report was unable to obtain relief of pain in
either hand with medication therapy alone. After a successful diagnostic median nerve block at the cubital fossa, pulsed radiofrequency of the median nerve
was performed on the left side at the cubital fossa, under ultrasound guidance.
Radiofrequency probe adjustment around the nerve was conducted under live
ultrasound guidance and multiple pulsed treatments were applied at anatomically distinct sites over the nerve. A 70% reduction in pain was reported over
the follow up period of 12 weeks.
Key words: Pulsed radiofrequency, carpal tunnel, ultrasound, median nerve.
Health Care Reform in the United States:
Radical Surgery Needed Now More Than Ever
Authors: Manchikanti Laxmaiah
Published: March 2021

It is often claimed that American health care provides good medical care, but the system
through which that care is financed is falling apart. In 1994, Joseph A. Califano, Jr., former
Secretary of Health, Education and Welfare reported that the American health care system
was in such turmoil, that it needed radical surgery.
Health care in the United States is different from other countries. Health care costs in America have skyrocketed and in 2006 occupied 16% of the Gross Domestic Product (GDP) with a
budget of over $2 trillion. Health care expenditures per capita in the United States are higher than 13 other countries utilized in a sample by the Organisation for Economic Co-operation and Development. Estimated spending according to wealth was utilized to measure
each country’s health care spending in comparison to each other. This measure, including
various parameters (undoubtedly some have been missed), largely showed that after adjusting to its higher per capita income levels, the United States spends $477 billion - $1,645 per
capita more on health care than any other peer country.
Many health care proposals have been forwarded since 1965, when Lyndon Johnson succeeded in enacting Medicare. These come from Republicans, Democrats, Independents, physicians, insurers, non-partisan and partisan groups. However, none has been able to provide
a guaranteed proposal to fix the health care ills and also provide reasonable coverage.
This manuscript will review escalating national health care expenditures, factors contributing to health care increases, health care systems in many other countries, and various proposals.
Key words: Health care reform, Organisation for Economic Co-Operation and Development, Estimated Spending According to Wealth (ESAW), Centers for Medicare and Medicaid
(CMS), universal health care, managed health care reform