bluuebunny/crossref_metadata_2025 huggingface dataset:
A Perfect Storm in Interventional Pain
Management: Regulated, but Unbalanced
Authors: Benyamin Ramsin M.
Published: March 2021

Interventional pain management now stands at the crossroads at what is described as
“the perfect storm.” The confluence of several factors has led to devastating results for
interventional pain management. This article seeks to provide a perspective to various issues
producing conditions conducive to creating a “perfect storm” such as use and abuse of
interventional pain management techniques, and in the same context, use and abuse of
various non-interventional techniques. The rapid increase in opioid drug prescribing, costs
to health care, large increases in death rates, and random and rampant drug testing, can
also lead to increases in health care utilization. Other important aspects that are seldom
discussed include medico-legal and ethical perspectives of individual and professional
societal opinions and the interpretation of diagnostic accuracy of controlled diagnostic
blocks.
The aim of this article is to discuss the impact of several factors on interventional pain
management and overuse, abuse, waste, and fraud; inappropriate application without
evidence-based literature support (sometimes leading to selective use or non-use of
randomized or observational studies for proving biased viewpoints — post priori rather
than a priori), and issues related to multiple professional societies having their own agendas
to push rather than promulgating the science of interventional pain management.
This perspective is based on a review of articles published in this issue of Pain Physician,
information in the public domain, and other relevant articles. Based on the results of this
review, various issues of relevance to modern interventional pain management are discussed
and the viewpoints of several experts debated.
In conclusion, supporters of interventional pain management disagree on multiple aspects
for various reasons while detractors claim that interventional pain management should
not exist as a speciality. Issues to be addressed include appropriate use of evidence-based
medicine (EBM), overuse, overutilization, and abuse.
Key words: Interventional pain management, interventional techniques, physician
payment reform, fraud, abuse, evidence-based medicine, health care costs, comparative
effectiveness research, bias
Analysis of the Growth of Epidural Injections
and Costs in the Medicare Population: A
Comparative Evaluation of 1997, 2002, and
2006 Data
Authors: Manchikanti Laxmaiah
Published: March 2021

Background: Interventional techniques for the treatment of spinal techniques are commonly
used and are increasing exponentially. Epidural injections and facet joint interventions are
the 2 most commonly utilized procedures in interventional pain management. The current
literature regarding the effectiveness of epidural injections is sparse with highly variable
outcomes based on the technique, outcome measures, patient selection, and methodology.
Multiple reports have illustrated the exponential growth of lumbosacral injections with
significant geographic variations in the administration of epidural injections in Medicare
patients. However, an analysis of the growth of epidural injections and costs in the Medicare
population has not been performed with recent data and has not been looked at from an
interventional pain management perspective.
Study Design: Analysis of epidural injection growth and costs in Medicare’s population
1997, 2002, and 2006.
Objectives: The primary purpose of this study was to evaluate the use of all types of
epidural injections (i.e. caudal, interlaminar, and transforaminal in lumbar, cervical and
thoracic regions), and other epidural procedures, including epidural adhesiolysis. In addition,
the purpose was to identify trends in the number of procedures, reimbursement, specialty
involvement, fluoroscopy use, and indications from 1997 to 2006.
Methods: The Centers for Medicare and Medicaid Services (CMS) 5% national sample
carrier claim record data from 1997, 2002, and 2006 was utilized.
Outcomes Assessment: Outcome measures included Medicare beneficiaries’
characteristics receiving epidural injections, epidural injections by place of service, type of
specialty, reimbursement characteristics, and other variables.
Results: Epidural injections increased significantly in Medicare beneficiaries from 1997
to 2006. Patients receiving epidurals increased by 106.3%; visits per 100,000 population
increased 102.7%.
Hospital outpatient department (HOPD) payments increased significantly; ASC average
payments decreased; overall payments increased. The increase in procedures performed by
general physicians outpaced that of interventional pain management (IPM) physicians.
Limitations: Study limitations include no Medicare Advantage patients; potential
documentation, coding, and billing errors.
Conclusions: Epidural injections grew significantly. This growth appears to coincide with
chronic low back pain growth and other treatments for low back pain. Since many procedures
are performed without fluoroscopy, continued growth and inappropriate provision of services
might reduce access.
Key words: Epidural injections, interventional techniques, interventional pain management,
chronic pain, ambulatory surgery center (ASC), hospital outpatient department (HOPD)
Considerations and Methodology for Trialing
Ziconotide
Authors: Burton Allen W.
Published: March 2021

Background: Before long-term intrathecal analgesic therapy is initiated, patients
often undergo a spinal analgesia trial. Ziconotide is a nonopioid intrathecal analgesic
used to manage severe chronic pain, and a variety of methods have been used to trial
ziconotide.
Objectives: The purpose of this review is to compare and discuss the different methods
of ziconotide trialing.
Methods: Various databases (i.e., PubMed, Excerpta Medica, Cumulative Index
to Nursing and Allied Health Literature, Biological Abstracts, Cochrane Database of
Systematic Reviews, EMBASE, International Pharmaceutical Abstracts, and Google
Scholar) and association meeting abstracts were searched with the use of the terms
ziconotide, Prialt, trial, and trialing. In addition, a search was conducted for abstracts/
posters presented at a variety of association meetings.
Results: Nine sources, including one expert opinion piece, were identified. Three
methods of ziconotide trialing were discovered: continuous infusion, limited-duration
infusion, and bolus injection. Results indicate that patients often achieve analgesia during
trialing, regardless of the trialing method. Adverse events reported during ziconotide
trialing studies were similar to those reported during ziconotide clinical trials. Preliminary
evidence suggests that both effectiveness and safety may be dose-related. In 3 studies
the value of ziconotide trialing in predicting long-term patient response to ziconotide
therapy was investigated; however, the results were preliminary. The expert opinion piece
from 2008 recommended trialing ziconotide via continuous infusion, using a starting
dose of 1.2 mcg/d and dose increases of 1.2 mcg/d every 12 to 24 hours, for up to 3 days;
the trial may be extended in some cases.
Limitations: Given the small samples size and lack of controlled ziconotide trialing
studies, it is currently not possible to determine the relative safety and effectiveness
of different methods of ziconotide trialing, nor is it possible to determine if trialing is
predictive of patient response to long-term ziconotide therapy.
Conclusions: All 3 methods of ziconotide trialing appear to be viable options, and no
method can be considered superior on the basis of the evidence presented in this review.
Controlled studies comparing ziconotide trialing methods may be warranted.
Key words: Ziconotide, trialing, trial, review, intrathecal, chronic pain, Prialt, analgesic
Multi-Day Low Dose Ketamine Infusion as
Adjuvant to Oral Gabapentin in Spinal Cord
Injury Related Chronic Pain: A Prospective,
Randomized, Double Blind Trial
Authors: Amr Yasser Mohamed
Published: March 2021

Background: Severe, intractable, chronic pain is a significant management problem for those
involved in the long-term care of spinal cord injury (SCI) patients . Gabapentin, an anticonvulsant,
is widely used for treating chronic pain. Ketamine, an NMDA receptor antagonist, has been
available in clinical practice for 35 years. Its usefulness in pathological pain states is known.
Despite this, no formal research on its effectiveness in treating neuropathic SCI pain exists.
Objectives: This double-blind study sought to determine the safety and efficacy of adding a
multi-day low dose ketamine infusion to oral gabapentin for treating chronic pain related to post
spinal cord injury.
Study Design: Randomized, controlled, double blind trial
Setting: Hospital, in-patient setting.
Methods: Forty patients diagnosed with neuropathic pain secondary to spinal cord injury were
randomized into 2 equal groups. Group I received an 80 mg intravenous ketamine infusion
diluted in 500 cc normal saline over a 5 hour period daily for one week and 300 mg of gabapentin
3 times daily. Group II received a placebo infusion and 300 mg of gabapentin 3 times daily
(continued) after 300 mg of gabapentin 3 times daily. Using the visual analogue scale, pain
was assessed prior to treatment, daily following ketamine or placebo infusions for 7 days, and
then weekly for one month after infusion termination. Side effects, specifically those related to
ketamine or gabapentin, were reported.
Results: Both groups demonstrated significantly reduced pain scores compared with pretreatment values (P < 0.05). Group I showed significant pain score improvements over Group II at
all measurements (P < 0.0001) during infusion and 2 weeks after infusion termination. There was
no statistical difference between the groups at 3 weeks and 4 weeks after infusion termination
(P = 0.54 and P = 0.25 respectively). Both drugs were tolerated by all patients; no side effects
required intervention.
Conclusion: Multi-day low dose ketamine infusion as adjuvant to gabapentin in post-spinal
cord injury related chronic pain is safe and efficacious in reducing pain, but the effect compared
to placebo ceased 2 weeks after infusion termination.
Limitations: Study size limited to 40 patients.
Key words: Ketamine, Gabapentin, Spinal, Pain, injury, chronic
Spinal Cord Stimulation for the Treatment
of Chronic Knee Pain Following Total Knee
Replacement
Authors: Simopoulos Thomas T.
Published: March 2021

Background: Chronic pain after total knee replacement is common but remains
poorly understood. Management options for patients with this condition are
traditionally limited to pharmacological approaches.
Objective: This article presents a case of using spinal cord stimulation in the
management of chronic knee pain following total knee replacement.
Design: Case report
Setting: Pain management clinic
Methods: A 68-year old patient presented with a 3-year history of persistent knee
pain following total knee replacement. After failing to respond to medications and
nerve blocks, a trial of spinal cord stimulation and subsequent permanent implantation
of a spinal cord stimulator (SCS) were performed. The Oxford knee score (OKS) was
used to assess her pain and functionality before and after SCS implantation.
Results: The patient reported improvement in her pain and function. Her baseline
OKS was 39 and fell to 26 one year post implantation of an SCS representing a
reduction of pain and disability from severe to moderate.
Limitations: A case report.
Conclusion: Spinal cord stimulation might be an option in the management of
refractory knee pain following total knee replacement.
Key Words: total knee replacement, knee pain, spinal cord stimulation
New Image-Guided Ultra-Minimally Invasive
Lumbar Decompression Method: The mild®
Procedure
Authors: Deer Timothy R.
Published: March 2021

Background and Objectives: Lumbar canal stenosis is a common source of chronic low
back and leg pain. Minimally Invasive Lumbar Decompression (mild®) is a new minimally
invasive treatment for pain relief from symptomatic central lumbar canal stenosis. The
procedure involves limited percutaneous laminotomy and thinning of the ligamentum
flavum in order to increase the critical diameter of the stenosed spinal canal. The objective
of this technical report is to evaluate the acute safety of the mild procedure.
Methods: Manual and electronic chart survey was conducted by 14 treating physicians
located in 9 U.S. states on 90 consecutive patients who underwent the mild procedure.
Patients within local geographical practice areas were selected in keeping with product
Instructions For Use. Those patients requiring lumbar decompression via tissue resection
at the perilaminar space, within the interlaminar space and at the ventral aspect of the
lamina were treated. Data collected included any complications and/or adverse events
occurring during or immediately following the procedure prior to discharge.
Results: Of 90 procedures reviewed, there were no major adverse events or complications
related to the devices or procedure. No incidents of dural puncture or tear, blood
transfusion, nerve injury, epidural bleeding, or hematoma were observed.
Limitations: Data were not specifically collected; however, regardless of difficulty, in this
series none of the procedures were aborted and none resulted in adverse events. Efficacy
parameters were not collected in this safety survey.
Conclusions: This review demonstrates the acute safety of the mild procedure with no
report of significant or unusual patient complications. To establish complication frequency
and longer-term safety profile associated with the treatment, additional studies are
currently being conducted. Survey data on file at Vertos Medical, Inc.
Key words: Spine, decompression, fluoroscopy, mild, stenosis, ligamentum
Preliminary Results of a Randomized, DoubleBlind, Controlled Trial of Fluoroscopic Lumbar
Interlaminar Epidural Injections in Managing
Chronic Lumbar Discogenic Pain Without Disc
Herniation or Radiculitis
Authors: Manchikanti Laxmaiah
Published: March 2021

Background: Low back pain without disc herniation is the most common problem among chronic
pain disorders. Epidural injections are commonly used interventions in managing chronic low back
pain without disc herniation. However, little evidence exists regarding the effectiveness, indications,
and medical necessity of lumbar epidural injections in managing axial low back pain without disc
herniation or radiculitis.
Study Design: A randomized, double-blind, controlled trial.
Setting: An interventional pain management practice, a specialty referral center, a private practice
setting in the United States.
Objectives: To evaluate the ability to provide effective and long-lasting pain relief with lumbar
interlaminar epidural injections with local anesthetic with or without steroids in managing chronic
low back pain not caused by disc herniation or radiculitis.
Methods: Patients were randomly assigned to one of 2 groups with Group I patients receiving
local anesthetic only, whereas Group II patients received local anesthetic mixed with non-particulate
betamethasone. Seventy patients were included in this analysis. Randomization was performed by
computer-generated random allocation sequence by simple randomization.
Outcomes Assessment: Outcome measures included the Numeric Rating Scale (NRS), the
Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake. The assessments were
done at baseline, 3 months, 6 months, and 12 months post-treatment.
Significant pain relief and/or improvement in disability were defined as at least 50% improvement.
Results: Significant pain relief (≥ 50%) was demonstrated in 74% of patients in Group I and 63%
in Group II. Functional status improvement (reduction of ≥ 50%) in the ODI scores was seen in 71%
of patients in Group I and 60% of patients in Group II. The overall average procedures per year were
approximately 4.
Limitations: The results of this study are limited by the lack of a placebo group and that it is a
preliminary report of 35 patients in each group with a total of 70 patients.
Conclusion: Lumbar interlaminar epidural injections of local anesthetic with or without steroids
was effective in 63% and 74% of patients with chronic function-limiting low back pain without
facet joint pain, disc herniation, and/or radiculitis.
Key words: Chronic low back pain, lumbar interlaminar epidural injections, discogenic pain, disc
herniation, radiculitis, local anesthetic, steroids, controlled comparative local anesthetic blocks
Peripherally Acting Opioids and Clinical
Implications for Pain Control
Authors: Sehgal Nalini
Published: March 2021

Opioid receptors are widely expressed in the central and peripheral nervous system
and in the non-neuronal tissues. Data from animal and human clinical studies support
the involvement of peripheral opioid receptors in analgesia, especially in the presence
of inflammation. Inflammation has been shown to increase the synthesis of opioid
receptors in the dorsal root ganglion neurons and enhance transport and accumulation
of opioid receptors in the peripheral terminals of sensory neurons. Under the influence
of chemokines and adhesion molecules, opioid peptide-containing immune cells
extravasate and accumulate in the injured tissues.
Stress, chemokines, cytokines, and other releasing factors in inflamed tissues stimulate
these granulocytes to release opioid peptides. Once secreted, opioid peptides bind
to and activate peripheral opioid receptors on sensory nerve fibers and produce
analgesia by decreasing the excitability of sensory nerves and/or inhibiting release of
pro-inflammatory neuropeptides.
Research has revealed that local application of exogenous opioid agonists produces a
potent analgesic effect by activating peripheral opioid receptors in inflamed tissues.
The analgesic activity occurs without activation of opioid receptors in the central
nervous system (CNS), and therefore centrally mediated side effects, such as respiratory
depression, mental clouding, altered consciousness, or addiction, are not associated
with peripheral opioid activity. This discovery has stimulated research on developing
peripherally restricted opioid agonists that lack CNS effects. In addition, it has been
recognized that opioid receptors modulate inflammation, and that opioids have antiinflammatory effects. The anti-inflammatory actions of opioids are not well known
or understood. Conflicting reports on mu-opioids suggest both anti-inflammatory
and pro-inflammatory effects. This article will present the basis for peripheral opioid
analgesia and describe current research directed at developing novel treatments for
pain with improved side effect profiles.
Key words: Opioids, opioid receptors, opioid agonists, peripheral nervous system,
peripheral opioid receptors
Retrospective Review of the Efficacy and Safety of
Repeated Pulsed and Continuous Radiofrequency
Lesioning of the Dorsal Root Ganglion/Segmental
Nerve for Lumbar Radicular Pain
Authors: Nagda Jyotsna V.
Published: March 2021

Background: Chronic lumbosacral radicular pain is a common source of radiating leg pain
seen in pain management patients. These patients are frequently managed conservatively with
multiple modalities including medications, physical therapy, and epidural steroid injections.
Radiofrequency has been used to treat chronic radicular pain for over 30 years; however,
there is a paucity of literature about the safety and efficacy of repeat radiofrequency lesioning.
Objectives: To determine the safety, success rate, and duration of pain relief of repeat
pulsed radiofrequency (PRF) and continuous radiofrequency (CRF) lesioning of the dorsal root
ganglion (DRG)/ sacral segmental nerves (SN) in patients with chronic lumbosacral radicular
pain.
Study Design: Retrospective chart review
Setting: Outpatient multidisciplinary pain center
Methods: Medical record review of patients who were treated with pulsed and continuous
radiofrequency lesioning of the lumbar dorsal root ganglia and segmental nerves and who
reported initial success were evaluated for recurrence of pain and repeat radiofrequency
treatment. Responses to subsequent treatments were compared to initial treatments for
success rates, average duration of relief, and adverse neurologic side-effects.
Limitations: Retrospective chart review without a control group.
Results: Twenty-six women and 24 men were identified who received 50% pain relief or better
after PRF and CRF of the lumbar DRG/ sacral SN for lumbosacral radicular pain. The mean
age was 62 years (range, 25-86). The mean duration of relief for the 40 patients who had 2
treatments was 4.7 months (range 0-24; Se [standard error] 0.74). Twenty-eight patients had
3 treatments with an average duration of relief of 4.5 months (range 0-19 months; Se 0.74).
Twenty patients had 4 treatments with a mean duration of relief of 4.4 months (range 0.5-18;
Se 0.95) and 18 patients who had 5 or more treatments received an average duration of relief
of 4.3 months (range 0.5-18; Se 1.03). The average duration of relief and success frequency
remained constant after each subsequent radiofrequency treatment. Of the 50 total patients,
there was only 1 reported complication, specifically, transient thigh numbness which resolved
after one week.
Conclusions: Repeated pulsed and continuous radiofrequency ablation of the lumbar dorsal
root ganglion/segmental nerve shows promise to be a safe and effective long-term palliative
management for lumbosacral radicular pain in some patients.
Key words: Pulsed radiofrequency lesioning, dorsal root ganglion, segmental nerve,
continuous radiofrquency elsioning, chronic lumbosacral radicular pain
Prevalence and Characteristics of Headache in
Khoramabad, Iran
Authors: Bahrami Parviz
Published: March 2021

Background: Headache is a prevalent and disabling condition affecting people in all age groups
worldwide, leading to low job performance and quality of life with a significant economic burden
on societies.
Objective: We evaluated headache prevalence and characteristics and some probable associated
factors in patients referring to neurology specialist clinics.
Study Design: Cross sectional study
Setting: Clinics of Khoramabad and also those referring to the emergency department of
Khoramabad University Hospital.
Methods: One thousand patients with a chief concern of headache were assigned to the study.
All patients filled out a structured questionnaire to gather demographic information and data on
headache characteristics and associated factors, including past medical and psychiatric history,
history of oral contraceptive pill (OCP) use, nonsteroidal anti-inflammatory drug (NSAID) overuse,
and menstruation.
Results: The total prevalence of primary headaches was 78.2%, with migraine (with and without
aura) being the most prevalent type with a prevalence of 41.6% followed by tension type headache
found in 31.6% of the study population. Primary headaches were significantly more common in
women and younger age groups. Factors found associated with a significantly higher prevalence of
primary headaches were lower economic level, higher educational level, occupation, OCP use and
NSAIDs overuse. Secondary headaches, with a total prevalence of 20.1%, significantly increased
in older age groups and higher economic levels and were significantly less prevalent in higher
educational levels.
Limitations: The study population is not quite representative of the general population of Iran.
Conclusion:‍‍ Results highlight the impact of socioeconomic factors on headache epidemiology in
a developing country and demonstrate that OCPs and NSAIDs overuse might have an effect on the
distribution of primary headaches. Further multicenter studies are needed to evaluate headache
epidemiology in the whole country.
Key words: headache, prevalance, migraine, tension-type headache
Low Bone Mineral Density, But Not Epidural
Steroid Injection, Is Associated with Fracture in
Postmenopausal Women with Low Back Pain
Authors: Hwang Byeongmun
Published: March 2021

Background: Therapy with glucocorticoids often results in bone loss and glucocorticoidinduced osteoporosis. However, the relationship between epidural steroid injection (ESI), bone
mineral density (BMD), and vertebral fracture remains to be determined.
Objective: To establish a relationship between ESI, BMD, and vertebral fracture in
postmenopausal women with low back pain.
Study Design: This study was a retrospective, nonblinded, cross-sectional clinical study.
Setting: University-based pain management center.
Methods: We reviewed the medical records of postmenopausal women with low back
pain who were treated with ESI. A total of 352 postmenopausal women were divided into 2
groups. Group 1 consisted of patients without fracture and Group 2 consisted of those with
fractures. The results of BMD measurements, as well as any fragility fractures, the anatomical
site involved, and the treatment administered, were also recorded. BMD was measured in the
lumbar spine, femoral neck, and total femur after the treatment.
Results: Of the 352 patients, 218 (62%) had no fractures while 134 (38%) sustained a
fracture. The age was significantly higher among patients who sustained fractures, and
BMD at the lumbar spine, total femur, and femoral neck regions was significantly lower
among patients who sustained fractures. In each region, the prevalence of osteoporosis
was significantly higher in patients with fracture than in patients without fracture (all P <
0.05). Age, height, and weight were associated with low BMD. However, our study showed
no consistent correlation between BMD and the mean number of ESIs, mean total dose of
glucocorticoids, or mean duration of ESIs.
Limitations: First, this study is limited by the fact that it was retrospective. Second, the
number of cases receiving very frequent, high-dose glucocorticoid injections was very small.
Conclusions: Older age and lower BMD were associated with osteoporotic fracture in
postmenopausal women treated for low back pain with ESI. The ESIs were not associated
with low BMD or fracture.
Key words: Bone mineral density, epidural steroid injection, fracture, glucocorticoids, low
back pain, postmenopause.
Iatrogenic Hypercortisolism Complicating
Triamcinolone Acetonide Injections in Patients
with HIV on Ritonavir-Boosted Protease
Inhibitors
Authors: Fessler David
Published: March 2021

Epidural corticosteroid injection is a commonly used approach for managing back pain of several
etiologies. The risk of clinical complications from systemic absorption is felt to be rare. Ritonavir is
a protease inhibitor whose potent cytochrome P450 3A4 inhibition is exploited for pharmacologic
boosting in human immunodeficiency virus (HIV) infection. It has been associated with systemic
hypercortisolism when used in combination with nasal and inhaled corticosteroids. This is a case
series describing 2 patients with HIV on ritonavir-containing regimens who developed iatrogenic
hypercortisolism following epidural injection of triamcinolone acetonide. The 2 patients developed
cushingoid symptoms, with detectable serum triamcinolone acetonide levels weeks after their
epidural injections. Their symptoms took several weeks to resolve, in one case necessitating a
change to an HIV regimen that did not contain ritonavir.
Iatrogenic hypercortisolism is a rarely reported, but potentially devastating complication of injectable
corticosteroids. Individuals receiving ritonavir-based therapy appear to be at increased risk for this
process due to pharmacologic boosting of the corticosteroid. The preponderance of reported
cases of iatrogenic hypercortisolism following injectable corticosteroids has involved triamcinolone
acetonide, which may be due to the relatively rapid absorption characteristics and high serum levels
of this compound compared with other preparations. For individuals on ritonavir-containing HIV
therapy, we recommend close coordination with the involved HIV clinicians prior to use of injectable
corticosteroids, and avoidance of injections with triamcinolone acetonide whenever possible.
Choosing an alternative corticosteroid preparation to triamcinolone acetonide may reduce the risk
of systemic absorption, though more research is needed to confirm this hypothesis.
Key words: Epidural steroid injection, ritonavir, hypercortisolism, Cushing syndrome, HIV,
injectable corticosteroids, P450 3A4, drug interaction.
Spinal Cord Stimulation for Chronic Pain
Originating from Lyme Disease
Authors: Li Yongjie
Published: March 2021

Background: Neuropathic pain is a relatively common outcome of Lyme disease. Pain
management options for these patients have been limited to pharmaceutical treatments.
Objective: We present a case of chronic pain following Lyme disease treated successfully using
spinal cord stimulation (SCS).
Study Design: Case report.
Setting: Pain management clinic.
Methods: A 62-year-old patient presented with a 5-year history of bilateral foot pain following
Lyme disease that failed to respond to medication and physical therapy. The patient was treated
by a trial of SCS at the clinic and then implanted with a spinal cord stimulator. The Visual Analog
Scale (VAS) assessed pain before and after SCS.
Results: The patient reported significant pain relief and improved foot function. The 10 point VAS
score was reduced from 8−10 to 1–3.
Limitations: Single case report.
Conclusion: Spinal cord stimulation may be an effective option for relieving chronic pain
originating from Lyme disease.
Key words: Spinal cord stimulation, Lyme disease, chronic pain.
CMS Proposal for Interventional Pain
Management by Nurse Anesthetists: Evidence
by Proclamation with Poor Prognosis
Authors: Manchikanti Laxmaiah
Published: March 2021

The Office of Inspector General (OIG), Department of Health and Human Services (HHS), in a 2009
report, showed that unqualified nonphysicians performed 21% of the services. These nonphysicians
did not possess the necessary licenses, certifications, credentials, or training to perform the services.
Since the time the medical profession was founded, advances in treatments and technology, as
well as educational and training standards, have promoted a desire to go beyond the basic scope
of practice. Many have sought to broaden the scope of practice through legislative efforts and
proclamation rather than education and training.
In 2001, President Clinton signed into law a rule that permitted states to “opt out” of the Centers
for Medicare and Medicaid Services’ (CMS) requirement for nurse anesthetists to be supervised
by any physician. Since then, 17 states have adopted this rule. While it was originally intended
to help rural areas improve access to care, the opt out rule essentially supports any hospital or
organization that seeks to make a profit or cut costs by allowing nurse anesthetists to function
as physicians. With the implementation of sweeping health care regulations under the Affordable
Care Act (ACA, also popularly known as Obamacare), the future of nurses and other professionals
has been empowered. In fact, it has been proposed that medical training may be reduced by 30%,
which will in their minds equalize training between nonphysicians and physicians. In 2010, the
Federal Trade Commission (FTC) issued an opinion exerting their power to empower CRNAs with
unlimited practice, with threats to opposing parties. In the 2013 proposed physician payment rule,
CMS is proposing that CRNAs may perform interventional pain management services.
Interventional pain management is a medical discipline with defined interventional techniques
to be performed by professionals who are well trained and qualified. Without considering the
consequences of the lack of education and training qualifications for CRNAs to offer interventional
techniques, the FTC issued their opinion and CMS proposed to expand these practice patterns with
a policy of improved access and reduced cost. However, in reality, the opposite will happen and
will increase fraud, reduce access due to inappropriate procedures, and increase complications, all
as a result of privileges by legislation without education. The CMS proposal for interventional pain
management by nurse anesthetists is a proclamation with a poor prognosis.
Key words: Interventional pain management, interventional techniques, certified registered nurse
anesthetists, evidence-based medicine, fraud and abuse, education and training.
Radiocontrast Media Allergic Reactions and
Interventional Pain Practice—A Review
Authors: Newmark Jordan L.
Published: March 2021

Background: Millions of interventional pain procedures are performed each year in the United
States. Interventional pain physicians commonly administer radiocontrast media (RCM) under
fluoroscopy for these procedures. However, RCM can cause various types of hypersensitivity or
allergic type reactions, in an acute or delayed fashion. Furthermore, some patients report a prior
history of hypersensitivity reactions to RCM when presenting to the interventional pain clinic.
Both scenarios present challenges to the interventional pain physician.
Objective: To describe the various types of hypersensitivity reactions to RCM, as well as strategies
to prevent and manage these reactions, within the context of interventional pain practice.
Method: A review of the literature from 1975 through 2011 regarding allergic type reactions to
RCM, as well as iodine, and shellfish allergy, was undertaken in an effort to review and develop
recommendations on managing these patients presenting to the interventional pain clinic.
Keywords used in the literature search were: radiocontrast media, contrast allergy, contrast
reaction, iodine allergy, shellfish allergy, and fluoroscopy. The included articles were concerned
with the basic or clinical science of contrast allergy, including the physiology, epidemiology,
diagnosis, and management of such reactions. Meta-analysis, review articles, and case reports
addressing contrast media reactions were also included. Articles which discussed contrast media
reactions in a peripheral fashion were excluded.
Results: In reviewing the literature, it is apparent that the mechanisms and pathophysiology of
RCM hypersensitivity reactions are still being characterized, which should soon lead to improved
screenings, as well as prevention and treatment strategies. Many common themes are described
throughout the literature regarding patient risk factors, testing, prevention, diagnosis, and
treatment of RCM allergic-type reactions.
Limitations: The current review did not perform a meta-analysis of the available data, as most
of the available articles were trials that were randomly controlled. Therefore, the conclusions of
the present article are general, and qualitative in nature.
Conclusion: Although the mechanisms of various RCM allergic-type reactions are not entirely
understood, the interventional pain physician should have a basic understanding of patient risk
factors, prevention, diagnosis, and treatment of these reactions. The current review allowed for
prevention and treatment strategies for managing patients with RCM hypersensitivity reactions.
Key words: Radiocontrast media, contrast allergy, contrast reaction, iodine allergy, shellfish,
allergy, fluoroscopy, interventional spine practice
Radiofrequency Ablation of the SupraOrbital Nerve in the Treatment Algorithm of
Hemicrania Continua
Authors: Mathew Leena
Published: March 2021

Hemicrania continua (HC) is an uncommon primary headache disorder in which the
diagnosis centers on unilaterality and its absolute responsiveness to indomethacin. We
describe 3 patients with a long standing history of headache diagnosed as hemicrania
continua. There was profound response to indomethacin which was limited by side
effects. In one patient the therapy with indomethacin was limited secondary to comorbidities. Initial diagnostic blockade provided significant relief of symptoms based
on which radio-frequency ablation of the supraorbital nerve was performed with
substantial improvement in symptoms. Traditionally, hemicrania continua has been
managed exclusively with oral analgesics and is defined by its singular response to
indomethacin. Radio-frequency ablation (RFA) has been reported in the literature for
multiple indications. This case series is unique in that it describes 3 patients diagnosed
with hemicrania continua with pain referred in the supraorbital nerve distribution, who
underwent radiofrequency ablation of the supraorbital nerve with resultant resolution
of headaches.
Traditionally, hemicrania continua has been managed exclusively with oral analgesics
and is defined by its singular response to indomethacin. This report is unique in that
it describes three patients diagnosed with hemicrania continua with pain referred in
the supraorbital nerve distribution who underwent radiofrequency ablation of the
supraorbital nerve with resultant resolution of headaches. After the RFA medical
management was minimal to none in both patients. Though the utility and cost efficacy
of RFA of peripheral nerves needs to be confirmed in well-designed trials we present
these cases as an example of how this minimally invasive technique can safely provide
analgesia in a difficult to treat cephalgia. Moreover if precise anatomical localization of
the headache is possible then diagnostic blockade of the appropriate peripheral nerve
may be performed followed by radiofrequency ablation to provide potentially more
sustained analgesia in patients where medical management is ineffective or poorly
tolerated.
Key words: Headache, hemicrania continua, radio-frequency ablation
A Minimally Invasive Surgical Technique for
the Treatment of Posttraumatic Trigeminal
Neuropathic Pain with Peripheral Nerve
Stimulation
Authors: Cohen Jackson
Published: March 2021

Background: Facial pain occurring after traumatic injury of the facial branches of the
trigeminal nerve is a medical condition that is often very difficult to treat. Patients are quite
disabled by their symptoms and most therapies are ineffective in relieving this pain. Peripheral
nerve stimulation has been used as a treatment to provide pain relief for this type of intractable
atypical facial pain.
Objective: To describe a minimally invasive peripheral nerve stimulation surgical technique
for treating posttraumatic trigeminal neuralgia.
Study Design: Case report based on a patient seen in a university setting with posttraumatic
trigeminal neuropathic pain who underwent a minimally invasive technique for the placement
of a peripheral nerve stimulator.
Setting: University-based outpatient clinic.
Methods: A patient with a clinical picture suggestive of trigeminal neuropathic pain
secondary to trauma involving the V1 and V2 branches of the trigeminal nerve was selected.
Conservative management was attempted with no improvement before peripheral nerve
stimulation was tried with a minimally invasive surgical technique. We recorded the patient’s
subjective assessment of pain and daily function before and after the procedure.
Results: Following the procedure, the patient’s pain score decreased approximately 50% and
the patient reported a better quality of life with improvement in daily function as well as a
more positive outlook on her condition. There were no complications after the procedure and
the patient reported no complaints with the device.
Limitations: Case report.
Conclusions: This surgical technique for placing peripheral nerve stimulators allows for a
minimally invasive approach for the treatment of intractable posttraumatic trigeminal neuralgia
with potentially less risk of facial nerve damage. This case confirms the need for further studies
to be done in the future to prove the safety and effectiveness of this technique.
Key Words: Peripheral nerve stimulation, posttraumatic trigeminal neuralgia, neuropathic
pain, minimally invasive technique, facial pain.
Signal Processing Techniques for Optical Transmission Based on Eigenvalue Communication
Authors: Koch Jonas , Chan Ken , Schaeffer Christian G. , Pachnicke Stephan
Published: March 2021

A minimum mean squared error (MMSE) equalizer is
a way to effectively increase transmission performance for nonlinear Fourier transform (NFT) based communication systems. Other
equalization schemes, based on nonlinear equalizer approaches or
neural networks, are interesting for NFT transmission due to their
ability to deal with nonlinear correlations of the NFTs’ eigenvalues
and their coefficients. We experimentally investigated single- and
dual-polarization long haul transmission with several modulation
schemes and compared different equalization techniques including
joint detection equalization and the use of neural networks. We observed that joint detection equalization provides range increases for
shorter transmission distances while having low numeric complexity. We could further achieve bit error rates (BER) under HD-FEC
for significant longer transmission distances in comparison to no
equalization with different equalizers.

Manuscript received August 6, 2020; revised November 2, 2020; accepted December 8, 2020. Date of publication December 16, 2020;
Practical activities and their theoretical background in second language and culture integrated teaching
Authors:   Tbilisi State University and University Geomedi, Georgia, Shabashvili Giuli , Gochitashvili Ketevan
Published: March 2021

The aim of the paper is to introduce some practical exercises and activities to the teachers of Georgian as a second language. These activities will help the teachers in the teaching process. In addition to this, these activities are designed to help second language learners who grow up in a Georgian environment and are more or less familiar with the realities of the dominant culture but are not fully able to establish effective and successful communication and socialisation due to language scarcity and insufficient cultural and socio-cultural competencies. The paper introduces six practical activities based on scientific research and theoretical background, and presents a table outlining each activity in terms of teaching purpose, level, language competence, outcomes, and teacher’s role. The paper employs descriptive methods, hence different activities are provided and analysed. The paper is also based on the method of observation (classroom observation), each exercise is tested by us in the classroom environment./ Keywords: Culture, teaching target culture, l2 teaching, role of language instructor, practical activities for l2 teaching
Coming together at a distance: How language researchers across the globe met for the 1st Educational Role of Language online Session “Language and Teacher Language Identity” – A report
Authors:   University of California, USA, Bailey Alison L.
Published: March 2021

The 1st Educational Role of Language online session on the theme of “Language and Teacher Language Identity” organized and hosted by the International Association for the Educational Role of Language took place on May 5, 2020 in the homes and offices of language researchers all across the globe. A total of 16 papers was presented in workshop-style over the course of a day, spanning multiple time zones. Presenters hailed from across several continents, including Europe, North America and Asia. Attendees numbered 40 and joined from all around the world. For many participants, the virtual gathering was an unexpected respite to the relentless challenges of this pandemic-stricken year. Academic conferences everywhere were being cancelled at the last minute. Where disappointment abounded, Michał Daszkiewicz (University of Gdańsk, Poland) and Dragana Božić Lenard (University of Osijek, Croatia), both part of the Educational Role of Language Network, were able to offer a unique and uplifting solution to our new “normal”. Folks came together using online communication technologies (Google Drive, Webex) to circumvent the dangers of gathering together at an in-person conference. Moreover, the virtual venue offered a much more collegial and intimate setting than can often be gleaned even from an in-person conference when attendees shift between different break-out sessions and rarely get to collectively experience a sustained set of presentations and follow-up conversations.
The creation of multimodal texts of adult English language learners in a Canadian university – A case study
Authors:   University of Windsor, Canada, Chi Chenkai , Sefton Terry ,   University of Windsor, Canada
Published: March 2021

This paper reviews the larger context of English language learning and multimodality and attempts to shed light on how multimodal texts impact adult English language learners’ social practice of second language learning and their identities. The theories of multimodality and identity texts shape this study. The data in this case study were collected through participant observation, interview, and artefact elicitation. The results show that multimodal text creation could help adult English language learners transform the learning model from competition to cooperation, from operational aspects to social aspects, and from monolingual to multimodal, as they invest their identities in the creation of these texts. Some implications and recommendations for English language teaching instructors and researchers are provided. / Keywords: multimodal texts, international education, English language learning, language and identity, artefact elicitation
Plaintiff Personal Jurisdiction and Venue Transfer
Authors: Dodson Scott
Published: March 2021

Personal jurisdiction usually focuses on the rights of the defendant. This is because a plaintiff implicitly consents to personal jurisdiction in the court where the plaintiff chooses to file. But what if the defendant seeks to transfer venue to a court in a state in which the plaintiff has no contacts and never consented to personal jurisdiction? Lower courts operate on the assumption that in both ordinary venue-transfer cases under 28 U.S.C. § 1404(a) and multidistrict-litigation cases under § 1407(a), personal-jurisdiction concerns for plaintiffs simply do not apply. I contest that assumption. Neither statute expands the statutory authorization of federal-court personal jurisdiction. And theories based on implied consent stretch that notion too far. Personal jurisdiction legitimately can treat plaintiffs and defendants differently, but those differences call for nuance and fact dependency, not a blanket exemption for plaintiffs from personal-jurisdiction protections. This Essay reestablishes plaintiff-side personal jurisdiction by articulating and justifying the standard for protecting the due process rights of plaintiffs subject to interstate venue transfer without their express consent.
Putting Accessible Expression to Bed
Authors: Odeh Jamila
Published: March 2021

In 2011, the Occupy movement began. Occupiers seized space in dozens of public parks and in the American imagination, providing a compelling illustration of an inclusive format of political expression. In the courtroom, protesters sought injunctive relief on First Amendment grounds to protect the tent encampments where Occupiers slept. In 2017, the last of the Occupy litigation ended; but the ramifications the Occupy cases hold for the First Amendment and expressive conduct remain unexamined.

This Comment takes an in-depth look at the adjudication of Occupiers’ First Amendment interest in sleeping in public parks. It analyzes the adjudication of the Occupy cases and contends that the pattern of judicial enforcement results from a desire to remove the appearance of disorder associated with houselessness. This Comment argues that the test used to set the scrutiny level for First Amendment expressive activity systematically disadvantages speech by and about houseless persons.