bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical Benefits of Femoroplasty: A
Nonsurgical Alternative for the Management
of Femoral Metastases
Authors: Plancarte Ricardo
Published: February 2021

Background: Bone metastases occur frequently in advanced cancer. The spine, pelvis, ribs, skull
and femur are the most affected sites. It is reported that up to 83% of the patients develop pain
at some point of the disease. The patient can also develop fractures and disability, particularly in
the femur..
Objectives: To evaluate the effectiveness of percutaneous femoroplasty in patients with
metastatic osseous disease located in the proximal femur (trochanter, neck, and femoral head).
Study Design: A retrospective clinical review, comparing pain status “before vs after”
intervention.
Setting: National Cancer Institute in Mexico.
Methods: We included patients over 18 years old, with mild to severe pain due to metastasis in
the proximal femur (trochanter, neck, or head), or with a high risk of fracture according to Mirels
scale (> 8 points) or severe osteoporosis according to the World Health Organization (a Karnofsky
score more than 50%). Exclusion criteria were femoral fracture. We recorded the following
variables age, sex, type of neoplasm, concomitant therapy,
We used the Karnofsky functionality scale, the VAS pain intensity assessment, the “Mayo Clinic”
scale to measure improved functionality, and the European Organisation for Research and Treatment
of Cancer Quality of Life Questionnaire Core 15 Palliative (EORTC QLQ-C15-PAL) (Spanish version)
questionnaires. Follow-up was performed at 7 days, one month after femoroplasty, and during the
individual outpatient that lasted one year on average.
Results: Eighty subjects were enrolled. Seventy-three percent were women. The most frequent
tumors were breast (46.3%), followed by multiple myeloma (18.7%). All patients had a decrease
in the intensity of pain, analgesic consumption, and improved quality of life, at 7 and 30 days
after the intervention. There were no complications with serious consequences. Two participants
experienced polymethylmetacrylate (PMMA) leakage, without clinical or functional impact. In 4
patients, the needle was occluded during the filling process and we had to place another biopsy
needle through the same entry site to finish the injection process.
Limitations: The sample was a single group of patients evaluated before and after the
femoroplasty. We did not include a control group.
Conclusion: The results of the current report suggest that femoroplasty, a percutaneous
cement placement analogous to a vertebroplasty, might be a therapeutic option for patients with
metastatic bone disease of the proximal femur, providing the patient an analgesic reduction and
a better quality of life.
Key words: Femoroplasty, bone metastases, cancer, pain, bone pain
Concordant Provocation as a Prognostic
Indicator During Interlaminar Lumbosacral
Epidural Steroid Injections
Authors: Sinofsky Alexander H.
Published: February 2021

Background: Interlaminar epidural steroid injection is a well-established intervention for the
treatment of radicular pain. Pain is commonly reported during the injection into the epidural space;
this provocation is typically either concordant or discordant with the patient’s baseline pain. It is not
well known how this provocation pain relates to treatment outcomes.
Objective: To determine the relationship between concordant versus discordant provocation
during interlaminar epidural steroid injection and its effects on pain reduction at follow-up.
Study Design: Secondary analysis of a single center, prospective randomized double-blind study.
Methods: Interlaminar epidural steroid injections under fluoroscopic guidance were performed
on 48 patients with radicular lumbosacral pain. After injection with 80 mg methylprednisolone
and 2 mL of normal saline at a single level, patients were asked to report if pain was provoked,
and whether the pain was concordant or discordant with their baseline pain. The primary outcome
measure was self-rated percentage of pain reduction from baseline at 2-week follow-up. Secondary
outcomes included improvement in activity level and decreased analgesic consumption.
Results: Provocation was observed in 37 out of 48 patients (77%). This was further classified
as concordant (22/37, 60%) or discordant (15/37, 40%) pain. The concordant group achieved a
significant decrease in self-reported pain as compared to the discordant group at 2-week followup (61%, t = 2.45, P < 0.01). There were also significantly more patients in the concordant group
who reported 75% pain reduction as compared to the discordant group (X = 6.44, df(1), P < 0.05).
There were no significant differences between concordant and discordant groups in regard to
improvements in activity level (X = 2.56) and decreased analgesic use (X = 3.28).
Limitations: The secondary analysis did not examine long-term outcomes.
Conclusions: The concordant group demonstrated significantly higher pain reduction as
compared to the discordant group. There were no significant differences between the 2 groups
in terms of improved function or reduced analgesic requirements. Concordant provocation during
interlaminar epidural injection may be a predictor of outcome.
Key words: Lumbar epidural steroid injection, steroids, interlaminar injection, lumbar,
lumbosacral, provocation, pressure paresthesia, low back pain
Cervical Radiofrequency Neurotomy Reduces
Psychological Features in Individuals with
Chronic Whiplash Symptoms
Authors: Smith Ashley
Published: February 2021

Background: Individuals with chronic whiplash associated disorder (WAD) demonstrate various
psychological features. It has previously been demonstrated that cervical radiofrequency neurotomy
(cRFN) resolves psychological distress and anxiety. It is unknown if cRFN also improves or reduces a
broader spectrum of psychological substrates now commonly identified in chronic whiplash, such
as post-traumatic stress disorder (PTSD) and pain catastrophizing.
Objectives: To determine if reducing pain in the cervical spine (following cRFN) significantly
reduces psychological features (distress, pain catastrophizing and post-traumatic stress symptoms)
in individuals with chronic WAD.
Setting: Tertiary spinal intervention centre in Calgary, Alberta, Canada.
Study Design: Prospective observational study of consecutive patients.
Methods: Patients: Fifty-three individuals with chronic whiplash associated disorder symptoms
(Grade 2). Intervention: Cervical RFN following successful response to cervical facet joint blockade.
Measures were made at 4 time points: 2 prior to RFN, and 1-month and 3-months post-RFN.
Psychological measures included the General Health Questionnaire (GHQ-28); Pain Catastrophizing
Scale (PCS) and the Post Traumatic Stress Diagnostic Scale (PDS). Self-reported pain (VAS) and
disability (NDI) measures were also collected.
Results: Pain, disability, psychological distress and pain catastrophization significantly decreased
at both 1-month and 3 months following cervical RFN. There was no significant change in
post-traumatic stress symptom severity (P = 0.39). Reducing pain via cRFN was associated with
significant improvement in psychological distress and pain catastrophizing, but not posttraumatic
stress symptoms.
Limitations: Individual administering questionnaires was not blinded to aim(s) of the study.
Other psychological features possibly present in WAD were not measured.
Conclusion: Effective pain relief would seem a crucial element in the management of
psychological features associated with chronic WAD.
IRB Approval: University of Calgary Conjoint Health Research Ethics Board ID#: E-22082.
Key words: Whiplash, radiofrequency neurotomy, cervical facet joints, psychology, psychological
distress, pain catastrophizing, post traumatic stress disorder
Fluoroscopically Guided Infiltration of the
Cervical Nerve Root: An Indirect Approach
Through the Ipsilateral Facet Joint
Authors: Kelekis Alexios
Published: February 2021

Transforaminal infiltrations in the cervical spine are governed by a higher rate of vascular
puncture than in the lumbar spine. The purpose of our study is to assess the safety and
efficacy of percutaneous, fluoroscopically guided nerve root infiltrations in cases of cervical
radiculopathy. An indirect postero-lateral approach was performed through the ipsilateral
facet joint.
During the last 2 years, 25 patients experiencing cervical radiculopathy underwent
percutaneous, fluoroscopically guided nerve root infiltrations by means of an indirect
postero-lateral approach through the ipsilateral facet joint. The intra-articular position
of the needle (22-gauge spinal needle) was fluoroscopically verified after injection of a
small amount of contrast medium which also verified dispersion of the contrast medium
periradicularly and in the epidural space. Then a mixture of long-acting glucocorticosteroid
diluted in normal saline (1.5/1 mL) was injected intra-articularly. A questionnaire with
a Numeric Visual Scale (NVS) scale helped assess pain relief, life quality, and mobility
improvement.
A mean of 2.3 sessions was performed in the patients of our study. In the vast majority
of our patients 19/25 (76%), the second infiltration was performed within 7 – 10 days of
the first one.
Comparing the pain scores prior (mean value 8.80 ± 1.080 NVS units) and after (mean
value 1.84 ± 1.405 NVS units), there was a mean decrease of 6.96 ± 1.695 NVS units
[median value 7 NVS units (P < 0.001) in terms of pain reduction, effect upon mobility, and
life quality. There were no clinically significant complications noted in our study.
Fluoroscopically guided transforaminal infiltrations through the ipsilateral facet joint
seem to be a feasible, efficacious, and safe approach for the treatment of patients with
cervical radiculopathy. This approach facilitates needle placement and minimizes risk of
complications.
Key words: Infiltrations, cervical spine, facet joint, transforaminal, pain, mobility,
corticosteroid, fluoroscopy
Adverse Events Associated with
Fluoroscopically Guided Zygapophyseal
Joint Injections
Authors: McCormick Zack
Published: February 2021

Background: In spite of the widespread performance of intra-articular zygapophyseal joint
(IAZJ) injections, we know of no systematic analysis to date that examines the risks and types
of adverse events when IAZJ injections are performed.
Objective: To describe the type, incidence, and factors contributing to adverse events
associated with fluoroscopically guided IAZJ injections.
Study Design: A retrospective, cohort study of English-speaking adults aged 18 – 90 years
who underwent fluoroscopically guided IAZJ injections between March 8, 2004, and April
19, 2007. Following IAZJ injections, 3 senior researchers recorded the presence and type of
adverse events. The relationship of adverse events with age, gender, fluoroscopy time, vital
signs, and trainee presence was analyzed with Fisher’s exact or Wilcoxon rank sum 2-sided
tests. Frequency of immediate (during or immediately after the procedure) or delayed (within
24 – 72 hours following the procedure) adverse events.
Setting: Tertiary, academic, outpatient physical medicine and rehabilitation interventional
spine clinic.
Results: One hundred ninety-one patients (111 men) underwent 239 procedures. The mean
and standard deviation (SD) of subject age was 56.4 (16.6) years ranging from 20 to 89. The
mean and SD of pre-procedure 11-point Visual Analog Pain Scale was 5.5 (2.2) ranging from
0 to 10, and for post-procedure was 2.6 (2.6) ranging from 0 to 10. Trainees were involved
in 52.3% of procedures. Reported immediate adverse events were vasovagal reaction (3.8%,
n = 9) and steroid clogged needle (0.4%, n = 1). Follow-up data were available for 185/239
procedures (77.4%). There were 35 adverse events reported at mean follow-up interval
of 1.8 days, of which the most frequent were injection site soreness (6.0%, n = 11), pain
exacerbation (4.3%, n = 8), sleeplessness (2.2%, n = 4), and transient headache (1.6%, n =
3). Patient gender, age, trainee involvement, pre-procedural pain score, systolic or diastolic
blood pressure, pulse, hemoglobin saturation as measured by pulse oximetry, volume of
corticosteroid injected, and duration of fluoroscopy were not found to have a significant effect
on immediate or delayed adverse events.
Limitations: This study is limited by a 24- to 72-hour follow-up window, which may have
also been too small to capture more delayed complications, and a sample size too small to
accurately define the incidence of rare complications.
Conclusion: Fluoroscopically guided IAZJ injections have minimal adverse effects. The most
common immediate adverse event was vasovagal reaction and most common delayed adverse
event was injection site soreness.
Key words: Fluoroscopic injection, facet joint, zygapophyseal joint, complications, adverse
effects, steroid injection
Effects of Movement and Postural Positions
in Spinal Cord Stimulation in the New
Rechargeable Systems
Authors: Abejón David
Published: February 2021

Background: Despite recent developments in implantable neurostimulation devices,
the adjustment of stimulation levels to the patient’s postural changes has remained a
problem so far.
Objective: This study was conducted with the newest rechargeable devices, in order
to compare its results with the ones published from conventional systems.
Study Design: It is a prospective study.
Setting: In 46 patients implanted with rechargeable constant current stimulation
systems we measured impedance, stimulation thresholds, therapeutic range, as well
patients’ satisfaction and sensation in 7 different body postures.
Results: Data analysis was performed in 46 patients, whose most frequent pathologies
were failed back surgery syndrome (FBSS) and complex regional pain syndrome (CRPS).
The lowest amplitude needed to reach the different thresholds was always scored in
the supine decubitus position, with no significant changes in the therapeutic range
and impedance. For all stimulation thresholds, there is always a difference between the
supine position and all other postures. No statistically significant differences with regard
to patients’ satisfaction and sensation were found for the different postures.
Limitations: Sample sample size.
Conclusion: The findings of the present work are similar to those described in previous
publications that showed the relationship between postural changes and several
stimulation thresholds and pulse energy. The posture which requires lower energy —
and whose corresponding therapeutic range (TR) is narrower — is supine decubitus.
Key words: Spinal cord stimulation, change posture, rechargeable systems, sensor
generation, threshold perception, threshold discomfort
The Anatomy of the Lateral Branches of
the Sacral Dorsal Rami: Implications for
Radiofrequency Ablation
Authors: Fortin Joseph
Published: February 2021

Background: The sacroiliac joint (SIJ) is a major source of pain in patients with chronic low
back pain. Radiofrequency ablation (RFA) of the lateral branches of the dorsal sacral rami that
supply the joint is a treatment option gaining considerable attention. However, the position of
the lateral branches (commonly targeted with RFA) is variable and the segmental innervation to
the SIJ is not well understood.
Objectives: Our objective was to clarify the lateral branches’ innervation of the SIJ and their
specific locations in relation to the dorsal sacral foramina, which are the standard RFA landmark.
Methods: Dissections and photography of the L5 to S4 sacral dorsal rami were performed on
12 hemipelves from 9 donated cadaveric specimens.
Results: There was a broad range of exit points from the dorsal sacral foramina: ranging from
12:00 – 6:00 position on the right side and 6:00 – 12:00 on the left positions. Nine of 12 of the
hemipelves showed anastomosing branches from L5 dorsal rami to the S1 lateral plexus.
Limitations: The limitations of this study include the use of a posterior approach to the pelvic
dissection only, thus discounting any possible nerve contribution to the anterior aspect of the SIJ,
as well as the possible destruction of some L5 or sacral dorsal rami branches with the removal of
the ligaments and muscles of the low back.
Conclusion: Widespread variability of lateral branch exit points from the dorsal sacral foramen
and possible contributions from L5 dorsal rami and superior gluteal nerve were disclosed by
the current study. Hence, SIJ RFA treatment approaches need to incorporate techniques which
address the diverse SIJ innervation.
Key words: Sacroiliac joint pain, radiofrequency ablation, dorsal sacral rami, low back pain
Effectiveness of Pulsed Radiofrequency with
Multifunctional Epidural Electrode in Chronic
Lumbosacral Radicular Pain with Neuropathic
Features
Authors: Vigneri Simone
Published: February 2021

Background: Lumbosacral radicular pain is a common clinical finding with a statistical prevalence
ranging from 9.9% to 25% in the general population.
Objective: To investigate the effectiveness of dorsal root ganglion pulsed radiofrequency (PRF)
in patients with chronic lumbosacral radicular pain and neuropathic features.
Study Design: Prospective case series clinical outcome study.
Methods: We evaluated 34 patients with lumbosacral neuropathic pain who underwent PRF at
the corresponding level of radicular symptoms distribution (ranging from L3 to S1). Each patient
suffered a single leg-radiating pain with probable neuropathic features (assessed with clinical
grading) lasting for > 6 months and unresponsive to previous treatments. A multifunctional
PASHA-electrode® was introduced with trans-sacral access through a hollow needle, placed under
fluoroscopic guidance into the lumbosacral epidural space and its active tip moved close to the
dorsal root ganglion responsible of the clinical symptoms. After connecting the electrode to a
generator, stimulation tests were performed and PRF was started and applied for 240 seconds
at a frequency of 2Hz, amplitude of 45 V and a tip temperature between 40 – 42°C. If the pain
involved more than a single nerve root, the electrode was placed at a different segment and the
procedure repeated. Outcome measures included the pain intensity score on a 0 – 10 numeric
rating scale (NRS) and the Italian Pain Questionnaire (QUID) at pre-treatment, one and 6 months
post-treatment. P values < 0.05 were considered statistically significant.
Results: In comparison with pre-treatment, a significant reduction in pain score was observed in
mean NRS either at one and 6 months (P < 0.001). The QUID - Pain Rating Index rank displayed a
parallel trend at the first (P < 0.001) and last follow-up (P = 0.01). Moreover, a direct correlation
between the 2 scales occurred, showing a parallel score decreasing (P < 0.001). Eighteen (52.9%)
and 17 (50%) of 34 patients showed pain reduction in NRS > 2 points and > 30%, at one and 6
months, respectively.
Limitations: The non-controlled design of the study, the patients were heterogeneous, the
small number of patients, and the duration of follow-up was limited to 6 months.
Conclusions: PRF of dorsal root ganglion performed with a multifunctional electrode for > 240
seconds appears to be safe and might be more effective than the classic 120 seconds needlemediated approach. Therefore, it may be considered as a valuable tool for the treatment of
lumbosacral radicular pain with neuropathic features.
Key words: PRF, radicular pain, neuropathic pain, DRG, NRS, PRIr-T, multifunctional electrode
Pulsed Radiofrequency of the Composite Nerve
Supply to the Knee Joint as a New Technique
for Relieving Osteoarthritic Pain: A Preliminary
Report
Authors: Vas Dr. Lakshmi
Published: February 2021

We report a new technique for pulsed radiofrequency (PRF) of the entire nerve supply
of the knee as an option in treating osteoarthritis (OA) of knee. We targeted both
sensory and motor nerves supplying all the structures around the knee: joint, muscles,
and skin to address the entire nociception and stiffness leading to peripheral and central
sensitization in osteoarthritis. Ten patients with pain, stiffness, and loss of function in
both knees were treated with ultrasonography (USG) guided PRF of saphenous, tibial,
and common peroneal nerves along with subsartorial, peripatellar, and popliteal plexuses.
USG guided PRF of the femoral nerve was also done to address the innervation of the
quadriceps muscle. Assessment of pain (Numerical Rating Scale [NRS], pain DETECT, knee
function [Western Ontario and McMaster Universities Osteoarthritis Index- WOMAC])
were documented pre and post PRF at 3 and 6 months. Knee radiographs (KellgrenLawrence [K-L] grading) were done before PRF and one week later. All the patients showed
a sustained improvement of NRS, pain DETECT, and WOMAC at 3 and 6 months. The
significant improvement of patellar position and tibio-femoral joint space was concordant
with the patient’s reporting of improvement in stiffness and pain. The sustained pain relief
and muscle relaxation enabled the patients to optimize physiotherapy thereby improving
endurance training to include the daily activities of life. We conclude that OA knee pain is
a product of neuromyopathy and that PRF of the sensory and motor nerves appeared to
be a safe, effective, and minimally invasive technique. The reduction of pain and stiffness
improved the knee function and probably reduced the peripheral and central sensitization.
Key words: Osteoarthritis, knee pain, stiffness, knee innervation, femoral nerve supply,
Hilton’s law, peripheral sensitization, pulsed radiofrequency treatment of nerves to knee
joint
The Role of Pain Catastrophizing in the
Provision of Rescue Analgesia by Health Care
Providers Following Major Joint Arthroplasty
Authors: Pinto Patrícia R.
Published: February 2021

Background: After surgery, patient reports or health care professional evaluations of heightened
acute pain intensity should lead to extra analgesia provision, which is designated by rescue
analgesia (RA). Whether RA is administered or not, it is not directly dependent on the patient but
rather on clinical decisions, which should be based on pain management guidelines. There is a
general lack of studies focusing on pain-related decision-making regarding RA provision.
Objectives: This study aimed to examine which pre and post-surgical factors, beyond acute postsurgical pain intensity, might influence clinical decisions on RA administration after major joint
arthroplasties (MJA).
Methods: A consecutive sample of 110 patients undergoing MJA was fully assessed 24 hours
before (T1) and 48 hours after (T2) surgery. Before surgery, baseline demographic, clinical, and
psychological variables were evaluated and after surgery the main outcome was RA provision, with
acute post-surgical pain intensity being also registered.
Study Design: Prospective observational cohort study.
Setting: Central hospital in northern Portugal.
Results: Logistic regression analysis revealed that RA provision, after MJA, is influenced by a
patient-related psychological factor, pain catastrophizing (OR = 1.143; 95% CI 1.044 – 1.253, P =
0.004), above and beyond acute post-surgical pain intensity. Additionally, the type of arthroplasty
(OR = 2.806; 95% CI 1.002 – 7.857, P = 0.050) also affected RA provision. Other patient-related
factors such as gender, previous pain states, pre-surgical optimism, and post-surgical anxiety did
not reveal any predictive role in RA administration.
Limitations: This is a single-site study, only confined to MJA patients.
Conclusions: The findings of this study shed light on the importance of psychological factors
in determining RA provision following MJA. This encourages further reflection on acute postsurgical pain management by health care providers, namely by raising clinicians’ awareness about
the factors that influence patient-provider interactions, as well as their impact on decision-making
regarding RA provision. A global assessment of patients, wherein psychological variables are taken
into account, is warranted in order to improve the quality of surgical pain management. Finally,
these findings provide support for the design of acute post-surgical pain management interventions
directed at clinicians, in order to augment professionals’ awareness about the potential influence
of patient-related psychological factors on RA decisions.
Key words: Rescue analgesia, major joint arthroplasty, post-surgical pain intensity, psychological
factors, pre-surgical pain catastrophizing, patient-provider interactions, pain-related decisionmaking, predictive analysis
Thermal Pain in Complex Regional Pain
Syndrome Type I
Authors: Grothusen John R.
Published: February 2021

Background: Quantitative sensory testing (QST), with thermal threshold determinations,
is a routine part of the comprehensive clinical workup of patients suffering from chronic pain,
especially those with Complex Regional Pain Syndrome seen at our outpatient pain clinic. This is
done to quantitatively assess each patient’s small fiber and sensory function in a controlled manner.
Most patients have normal sensory detection thresholds, but there are large differences in thermal
pain thresholds. Some patients display no thermal hyperalgesia, while other patients display severe
thermal hyperalgesia when tested in all 4 limbs.
Objectives: To ascertain the prevalence of thermal hyperalgesia in patients with complex regional
pain syndrome type 1 (CRPS-I).
Study Design: This was a retrospective review of the results of QST performed on 105 patients
as part of their clinical workup.
Setting: The outpatient clinic of the Department of Neurology at Drexel University College of
Medicine.
Methods: All patients had a diagnosis of CRPS-I. Thermal quantitative sensory testing, including
cool detection, warm detection, cold pain, and heat pain, was performed on 8 distal sites on each
patient as part of a comprehensive clinical examination.
Results: With regards to thermal hyperalgesia, patients with CPRS-I appear to fall into distinct
groups. One subgroup displays evidence of generalized cold and heat hyperalgesia, one subgroup
displays evidence of generalized cold hyperalgesia only, one displays evidence of heat hyperalgesia
only, and one subgroup does not display evidence of cold or heat hyperalgesia.
Limitations: This study is based on retrospective information on a relatively small (105 patient
records) number of patients. Since only patients with CRPS-I were included, the results are only
applicable to this group.
Conclusions: Thermal QST provides useful information about the sensory phenotype of individual
patients. Subgrouping based on thermal hyperalgesia may be useful for future studies regarding
prognosis, treatment selection, and efficacy.
Key words: Complex regional pain syndrome, CRPS, quantitative sensory testing, QST, cold pain,
heat pain, thermal hyperalgesia
Percutaneous Adhesiolysis Procedures in the
Medicare Population: Analysis of Utilization
and Growth Patterns from 2000 to 2011
Authors: Manchikanti Laxmaiah
Published: February 2021

Background: Multiple reviews have shown that interventional techniques for chronic pain have
increased dramatically over the years. Of these interventional techniques, both sacroiliac joint
injections and facet joint interventions showed explosive growth, followed by epidural procedures.
Percutaneous adhesiolysis procedures have not been assessed for their utilization patterns
separately from epidural injections.
Study Design: An analysis of the utilization patterns of percutaneous adhesiolysis procedures in
managing chronic low back pain in the Medicare population from 2000 to 2011.
Objective: To assess the utilization and growth patterns of percutaneous adhesiolysis in
managing chronic low back pain.
Methods: The study was performed utilizing the Centers for Medicare and Medicaid Services
(CMS) Physician Supplier Procedure Summary Master of Fee-For-Service (FFS) Data from 2000 to
2011.
Results: Percutaneous adhesiolysis procedures increased 47% with an annual growth rate of
3.6% in the FFS Medicare population from 2000 to 2011. These growth rates are significantly
lower than the growth rates for sacroiliac joint injections (331%), facet joint interventions (308%),
and epidural injections (130%), but substantially lower than lumbar transforaminal injections
(665%) and lumbar facet joint neurolysis (544%).
Limitations: Study limitations include lack of inclusion of Medicare Advantage patients. In
addition, the statewide data is based on claims which may include the contiguous or other states.
Conclusion: Percutaneous adhesiolysis utilization increased moderately in Medicare beneficiaries
from 2000 to 2011. Overall, there was an increase of 47% in the utilization of adhesiolysis
procedures per 100,000 Medicare beneficiaries, with an annual geometric average increase of
3.6%.
Key words: Interventional techniques, chronic spinal pain, epidural steroid injections,
percutaneous adhesiolysis, post surgery syndrome, spinal stenosis
Spinal Cord Injury from Fluoroscopically Guided
Intercostal Blocks with Phenol
Authors: Laughlin Ruple S.
Published: February 2021

Background: Image guided intercostal blocks are commonly performed and considered relatively
safe. Chemical denervation is commonly used in clinical practice for treatment of chronic noncancer associated pain.
Objective: To report a case of spinal cord injury resulting from fluoroscopically guided intercostal
blocks with phenol.
Study Design: Case report.
Setting: Inpatient hospital service.
Results/Case Report: A 53 year-old women was transferred from her local facility for acute
onset of lower extremity paresis beginning shortly after right intercostal nerve injections of 2 mL of
preservative-free phenol at the T7, 8, 9 levels. She had previous intercostal blocks for chronic rightsided mid thoracic/abdominal pain every 3 months for at least one year without sequelae. Within
20 minutes of the injection, she developed a sensation of right leg weakness and heaviness. Over
several hours she developed worsening right leg weakness, and then left leg weakness, followed
by urinary retention. Admission examination revealed severe right greater than left leg weakness,
right lower extremity hyperesthesia to T10, absent lower extremity reflexes, and bilateral extensor
plantar responses. Magnetic resonance imaging (MRI) of the entire spine demonstrated extensive
T2/DWI hyperintensity in the central spinal cord from T1 to L1 with mild cord enlargement and
enhancement at T7-9 (sites of injection). Extensive serum and cerebrospinal fluid (CSF) evaluation
did not show any evidence of an infectious, inflammatory, or metabolic cause to her myelopathy.
Repeat MRI of the entire spine demonstrated near complete resolution of the T2 signal abnormality.
One month after presentation, despite radiographic improvement, the patient showed some clinical
improvement, but remained walker dependent and with neurogenic bowel and bladder.
Limitations: This report describes a single case report.
Conclusion: This case offers several lessons for a pain specialist including 1) the potential for
a neurologic catastrophe (spinal cord injury) from aqueous neurolytic intercostal blocks despite
“safe” contrast spread; 2) potential mechanisms of neurogenic injury with intercostal blocks; 3)
review of modifiable factors to decrease the risk of neurogenic injury; and 4) review of potential
interventions (steroids, lumbar drain) to improve outcome in the setting of iatrogenic procedural
related spinal cord injury.
Key words: Phenol, myelopathy, paraparesis, chemical denervation, neurolysis, intercostal block,
epidural spread, chronic pain, complication, transverse myelitis
Coccyx Fractures Treated with Intranasal
Calcitonin
Authors: Foye Patrick M.
Published: February 2021

Background: Treating pain associated with acute coccyx fractures can be challenging.
Intranasal calcitonin has been used to treat acute pain after vertebral fracture, and may even
accelerate fracture healing. However, intranasal calcitonin has never previously been published
as part of the treatment of acute coccyx fractures.
Objective: To examine a series of cases in which intranasal calcitonin was used to treat
coccydynia related to coccyx fractures.
Study Design: Case series and literature review.
Setting: Outpatient university-based coccyx pain center.
Results: After use of intranasal calcitonin, pain levels decreased, adverse events were
minimal, and the medication was generally well tolerated.
Limitations: As this is not a randomized control trial, the patients treated with intranasal
calcitonin were not compared to a control group. Additionally, the sample size of 8 patients
is relatively small.
Conclusions: We propose that clinicians consider use of intranasal calcitonin for the
treatment of pain due to acute coccyx fractures.
Key words: Coccyx, fractures, calcitonin, pain
Assessment of Methodologic Quality of
Randomized Trials of Interventional Techniques:
Development of an Interventional Pain
Management Specific Instrument
Authors: Manchikanti Laxmaiah
Published: February 2021

Background: A major component of a systematic review is an assessment of the methodological quality
and bias of randomized trials. The most commonly utilized methodological quality assessment and bias
assessment for randomized trials is by the Cochrane Review Group. While this is not a “gold standard,” it is
an indication of the current state-of-the-art review methodology. There is, however, no specific instrument
to assess the methodological quality of manuscripts published for interventional techniques.
Objectives: Our objective was to develop an instrument specifically for interventional pain management,
to assess the methodological quality of randomized trials of interventional techniques.
Methods: Item generation for the instrument was based on a definition of quality, to the extent to
which the design and conduct of the trial were congruent with the objectives of the trial. Applicability
was defined as the extent to which the trial produced procedures could be applied with contemporary
interventional pain management techniques. Multiple items based on Cochrane review criteria were
utilized along with specific requirements for interventional techniques.
Results: A total of 22 items were developed which formed IPM-QRB or Interventional Pain Management
Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment tool. This included 9 of the 12
items from the Cochrane review criteria with deletion of some items that were repetitive or duplicate,
and the addition of 13 new items.
The results were compared for inter-rater reliability of Cochrane review criteria and IPM-QRB, and interinstrument reliability.
The assessment was performed in multiple stages with an initial learning curve. The final assessment was
for 4 randomized controlled trials (RCTs) utilizing both Cochrane review criteria and IPM-QRB criteria.
The inter-rater agreement for Cochrane review criteria with overall intra-class correlation coefficient was
0.407 compared to an intra-class correlation coefficient of 0.833 for IPM-QRB criteria. The inter-rater
agreement was superior for IPM-QRB criteria compared to Cochrane review criteria despite twice the
items of Cochrane review criteria as IPM-QRB criteria with the detailed nature of assessment.
Limitations: Limited validity or accuracy assessment of the instrument and the large number of items
to be scored.
Conclusion: We have developed a new comprehensive instrument to assess the methodological
quality of randomized trials of interventional techniques. This instrument is superior to Cochrane review
methodology criteria in that it provides more extensive and specific information for interventional
techniques that will be useful in assessing the methodologic quality and bias of interventional techniques.
Key words: Methodological quality assessment, evidence-based medicine, comparative effectiveness
research, Cochrane Reviews, interventional techniques, risk of bias assessment
Prevalence of Suicidal Ideation in Patients
with Chronic Non-Cancer Pain Referred to a
Behaviorally Based Pain Program
Authors: Cheatle Martin D.
Published: February 2021

Background: Patients with chronic pain often experience co-occurring depression and in some
cases suicidal ideation. It is critical to discover risk factors for suicide in this vulnerable patient
population.
Objective: To assess the prevalence of suicidal ideation and identify potential risk factors in
patients with chronic non-cancer pain.
Study Design: Retrospective chart review.
Setting: Four hundred and sixty-six patients with chronic non-cancer pain referred to a behaviorally
based pain program in a community health system.
Methods: Data collected included pain intensity and level of pain interference (Brief Pain
Inventory), pain duration, pain site, depression level (Beck Depression Inventory Fast Screen for
Medical Patients), anxiety (Beck Anxiety Inventory), personal and family psychiatric and substance
use disorder history, level of isolation, and demographic data. Univariate and logistic regression
analyses were performed.
Results: Results showed a high rate of suicidal ideation in this patient population (28%).
Univariate analyses stratified by level of suicide (no suicidal ideation or passive/active suicidal
ideation) revealed statistically significant group differences on pain location (extremity P = 0.046,
generalized P = 0.047), work disruption (P = 0.049), social withdrawal (P < 0.001), pre-pain history
of depression (P < 0.001), family history of depression (P < 0.001), and history of sexual/physical
abuse (P < 0.001). Logistic regression revealed that history of sexual/physical abuse (Beta = 0.825;
P = 0.020; OR = 2.657 [95% CI = 1.447 – 4.877]), family history of depression (Beta = 0.471; P =
0.006; OR = 1.985 [95% CI = 1.234 – 3.070]), and being socially withdrawn (Beta = 0.482; P <
0.001; OR = 2.226 [95% CI = 1.431 – 3.505]) were predictive of suicidal ideation.
Limitations: Measure of depression was not included in data analysis to reduce effect of colinearity. Also the study population was a specialty pain clinic allowing for possible subject selection
bias.
Conclusions: Results of this study are consistent with the prevailing literature on pain and
suicide demonstrating a high prevalence of suicidal ideation in the chronic pain population. Novel
predictive variables were also identified that will provide the basis for developing a risk stratification
model that can be further tested prospectively in chronic pain patients.
Key words: Chronic pain, suicide, depression
The Effects of Peripheral Occipital Nerve
Stimulation for the Treatment of Patients
Suffering from Chronic Migraine: A Single
Center Experience
Authors: Notaro Paolo
Published: February 2021

About 1% of patients suffering from chronic migraine do not respond to medications and
require more invasive treatments. Occipital nerve stimulation (ONS) is one of these new
therapeutic options. The aim of this data review is to evaluate the clinical impact of ONS
and whether the neuropsychological aspects of anxiety and depression can be considered as
predictors of therapeutic effects.
Seventeen migraine patients, according to the ICHD-II classification, were treated with ONS. At
baseline all patients were assessed by numeric rating scale (NRS), Migraine Disability Assessment
(MIDAS), SF-36 Health Survey (SF-36), Beck Depression Inventory II (BDI II), and Beck Anxiety
Inventory (BAI) questionnaires. MIDAS and NRS were re-assessed at 3 and 12 month follow-up
visits, while SF-36 was evaluated after 12 months of stimulation. The population was divided in 2
subgroups based on MIDAS improvement, and BDI II and BAI scores in the 2 subpopulations were
compared to investigate whether anxiety and depression can be considered as predictive factors
of clinical outcomes. MIDAS showed a significant reduction both at 3 and 12 month visits and
NRS scale showed the same trend. The SF-36 questionnaire showed a significant improvement
not only in Physical Component Summary (PCS) and Mental Component Summary (MCS) indices,
but also in sub-dimensions. Patients who reported a MIDAS improvement ≤ 40% showed a
significant difference in BDI-II test at baseline.
Significant clinical improvements were obtained already after 3 months of treatment and
stayed stable throughout the first year after the procedure. ONS seems to be an effective and
safe treatment for chronic migraine. The effects of ONS can be optimized by a multidisciplinary
diagnostic and therapeutic approach, especially for the importance of the psychological factors
in pain perception and their correlation with a good therapeutic outcome. Our experience
highlighted that a multidisciplinary team which includes psychological support and psychosocial
rehabilitation is essential for the success of this therapy.
Key words: Peripheral nerve stimulation, PNS, chronic migraine, ONS, occipital nerve
stimulation, intractable migraine, stimulation
Transforaminal Versus Interlaminar Approaches
to Epidural Steroid Injections: A Systematic
Review of Comparative Studies for Lumbosacral
Radicular Pain
Authors: Candido Kenneth D.
Published: February 2021

Background: The superiority of transforaminal epidural steroid injections (TFESI) vs.
interlaminar epidural steroid injections (ILESI) for treating unilateral lumbosacral radicular
pain (LSRP) is unproven.
Objective: To assess studies comparing TFESI to ILESI for unilateral LSRP for pain relief
and functional improvement.
Study Design: Systematic review of comparative studies.
Methods: A systematic literature search was conducted using the Cochrane Central
Register of Controlled Trials, PubMed, and Scopus databases for trials reported in English.
Studies meeting the Cochrane Review criteria for randomized trials and the AHCQ
criteria for observational studies were included. Evidence was graded using the USPSTF
classification.
Results: Five (prospective) and 3 (retrospective) studies were included assessing 506
patients. Statistical analysis was calculated only utilizing the 5 prospective studies and
consisted of 249 patients with an average of 3.2 months follow-up. In the short-term (2
weeks), there was a 15% difference favoring TFESI vs. ILESI for pain relief. There was no
efficacy difference at one or 6 months. Combined pain improvements in all 5 prospective
studies revealed < 20% difference between TFESI and ILESI (54.1% vs. 42.7%). There was
slightly better functional improvement in ILESI groups (56.4%) vs. TFESI groups (49.4%)
at 2 weeks. Combined data showed slight differences (TFESI 40.1% and ILESI 44.8%).
Limitations: The limitations of this systematic review include the relative paucity of
comparative studies.
Conclusions: The findings show that both TFESI and ILESI are effective in reducing
pain and improving functional scores in unilateral LSRP. In the treatment of pain, TFESI
demonstrated non-clinically significant superiority to ILESI only at the 2-week follow-up.
Based on 2 studies, ILESI demonstrated non-clinically significant superiority to TFESI in
functional improvement.
Key words: Radiculopathy, epidural steroids, transforaminal, interlaminar, systematic
review
A Randomized, Double-Blind, Active-Control
Trial of the Effectiveness of Lumbar Interlaminar
Epidural Injections in Disc Herniation
Authors: Manchikanti Laxmaiah
Published: February 2021

Background: Among the multiple nonsurgical modalities, epidural injections are one of
the most commonly utilized treatment modalities in managing chronic low back and lower
extremity pain due to disc herniation and radiculitis. There is a paucity of randomized trials
from contemporary interventional pain management settings utilizing fluoroscopy with
long-term follow-up.
Study Design: Randomized, double-blind, active-controlled trial with 2-year follow-up.
Setting: An interventional pain management practice in the United States.
Objective: The objective was to assess the effectiveness of lumbar interlaminar epidural
injections of local anesthetic with or without steroids for managing chronic low back pain
of disc herniation or radiculitis.
Methods: Two groups of patients were studied, with 60 patients in each group receiving
either local anesthetic only or local anesthetic mixed with betamethasone.
Outcome Measures: The primary outcome measure was defined as pain relief and
functional status improvement of 50%. The outcomes were assessed by numeric rating
scale (NRS) of pain and functional status with Oswestry Disability Index (ODI). Secondary
outcome measures included employment status and opioid intake.
Results: Results showed significant improvement in 60% of patients in Group I and 70%
of patients in Group II at the end of 2 years. In addition, in the successful groups, those
with at least 3 weeks of relief (with the first 2 procedures), the improvement was 72% in
Group I and 71% in Group II. Results were somewhat superior for pain relief at 6 months
and functional status at 12 months in the steroid group. Thus, the results indicate that
a patient’s failure to respond to local anesthetic alone, may be treated with addition of
steroids.
Limitations: The results of the study are limited by the lack of a placebo group.
Conclusion: Lumbar interlaminar epidural injections of local anesthetic with or without
steroids is an effective modality, in patients with chronic function limiting low back and
lower extremity pain secondary to disc herniation after failure of conservative modalities.
Key words: Lumbar disc herniation, lumbar radiculitis, lumbar interlaminar epidural
injections, local anesthetic, steroids, randomized controlled trial, active-controlled trial
Transverse Abdominal Plane Neurostimulation
for Chronic Abdominal Pain: A Novel
Technique
Authors: Gupta Mayank
Published: February 2021

Management of chronic abdominal pain can be challenging. Sometimes patients fail to get
adequate response from multiple medications and nerve blocks. We present a patient case
report of chronic abdominal pain with a history of multiple surgeries managed successfully by
neuromodulation of the transverse abdominis plane (TAP).
The TAP block is a procedure in which local anesthetic is injected into the abdominal fascial
plane that carries sensory nerves to the abdominal wall in order to block pain sensation. It has
been shown to reduce postoperative pain and analgesic dependence after abdominal and
gynecological surgeries.
A 60-year-old woman presented to us for chronic abdominal pain for which medications
provided little relief. She had an extensive history of abdominal surgeries and was also treated
for lower back pain with surgery and less invasive procedures in the past. Under our care, she
underwent 2 TAP blocks with almost complete resolution of her abdominal pain. Her pain,
however, came back within a few of weeks of the procedures.
Since our patient found pain relief from the TAP blocks, we proceeded with neurostimulation
of the TAP for long-term pain relief. We placed a dorsal column stimulator 16 contact lead for
lower back and leg pain and 8 contact leads placed in the TAP under ultrasound guidance.
She has had multiple follow-ups since her TAP lead placement procedure with continued and
near complete resolution of her abdominal pain. The TAP lead stimulation was helping her
abdominal pain and the dorsal column lead stimulation was helping her back and leg pain.
Key words: Chronic abdominal pain, neuromodulation, transverse abdominis plane,
ultrasound, transverse abdominis plane block, multiple abdominal surgeries