bluuebunny/crossref_metadata_2025 huggingface dataset:
Percutaneous Tibial Nerve Stimulation (PTNS ) in Iatrogenic
Chronic Vulvar Pain
Authors: Carvaljo Moreira Pedro
Published: May 2021

Chronic vulvar pain (CVP), although being fairly
prevalent, in most cases is not attributable to a
specified disorder, i.e., presents as vulvodynia.
There are, however, many disorders known to
cause CVP, such as radiotherapy and surgery.
There have been, so far, no reports in the literature
of effective treatment options for Iatrogenic
CVP.
Percutaneous tibial nerve stimulation (PTNS) is
a neurostimulation technique used in the treatment
of urinary urgency, frequency, urge incontinence,
and urinary retention. There has been
increasing evidence of its benefits in improving
other conditions, such as chronic pelvic pain or
sexual dysfunction.
We report a case of a 62 year-old woman with
iatrogenic chronic vulvar pain (CVP) submitted
to PTNS. The patient reported a consistent and
dramatic decrease in both frequency and intensity
of pain, assessed by the Brief Pain Inventory
(BPI). A decrease in the pain interference with
mood, normal work, and walking/mobility was also
noted, as evaluated by BPI and EQ-5D questionnaires.
Even though a relapse of symptoms was
seen after the end of the treatment protocol, it was
possible to achieve more permanent benefits after
a maintenance scheme of PTNS, with the patient
becoming almost asymptomatic.
Neuromodulation treatments have been reported
as effective in cases of vulvodynia, however
reports using PTNS are rare. The tibial nerve is
easily accessible and provides an optimal site for
neurostimulation without the need of an operating
room or anesthesia. The overall improvement
registered in this case of CVP elicits a new area
of research for PTNS. {Need key words.}
Key words: Chronic pain, pelvic pain, vulvar
diseases, neuromodulation, percutaneous electric
nerve stimulation, tibial nerve
Perioperative Ketamine Infusion is Effective in Reversing
Opioid-Induced Hyperalgesia
Authors: Candido Kenneth
Published: May 2021

Opioid-induced hyperalgesia (OIH) is a condition
of nociceptive sensitization caused by exposure
to opioids, which is characterized by a paradoxical
response whereby patients receiving opioids
for the treatment of pain actually become more
sensitive to pain as a direct result of opioid therapy.
There is increasing evidence showing OIH
presents a clinical challenge in acute, chronic,
and cancer pain settings. Both clinical and animal
studies have shown that glutamate N-methyl-Daspartate
(NMDA) receptors may play a key role
in OIH and pre-application of ketamine, an NMDA
receptor antagonist, or co-administration of ketamine
and opioids, can prevent OIH. However,
no reports have shown if ketamine can reverse
OIH once it occurs.
We present a case of a 56-year-old male with
past medical history of DM-2 with severe peripheral
neuropathy, recurrent osteomyelitis of the left
foot, hypertension, dyslipidemia, chronic neck
and right arm pain due to cervical spondylosis,
status post four times of cervical discectomy
and fusion surgeries for cervical radiculopathy.
He was on high doses of opioids (MS Contin 60
mg po q8 hour and hydrocodone/acetaminophen
10/325 prn- up to 4 times daily) for approximately
10 years. He underwent left below knee amputation
due to uncontrolled osteomyelitis. The patient
had worsening stump pain with increasing dose of
opioids and phantom pain on post-operative day
1, and he developed OIH, diagnosed as escalating
pain reports with every opioid dose increase.
A ketamine infusion (loading dose 10 mg IV bolus,
then 20 mg/hour IV infusion) was used after
total cessation of opioid use for postoperative
analgesia for 3 consecutive days and the patient
recovered from his obvious OIH, with his stump
pain and phantom pain well-controlled by opioid
administration on post-operative day 5.
In our case, blockage of NMDA receptors by
ketamine might quickly restore the balance between
opioid-dependent analgesic systems and
NMDA-dependent pronociceptive systems by deactivation
of the latter, which may help the patient
recover from OIH rapidly. While it is possible that
ketamine may help facilitate patients’ recovery
from OIH in addition to its ability to prevent OIH,
this clinical observation has to be tested in future
prospective studies.
Key words: Ketamin, opioid-induced hyperalgesia
NEEDLE TIP DEPTH ASSESSMENT ON FORAMINAL OBLIQUE FLUOROSCOPIC
VIEWS DURING CERVICAL RADIOFREQUENCY NEUROTOMY. A TECHNICAL NOTE
Authors: Raju Robin
Published: May 2021

Background: Precise needle tip visualization
using fluoroscopy is critical to avoid injury to
nearby neurovascular structures during cervical
radiofrequency neurotomy (RFN). The contralateral
oblique (CLO) view has been shown to
be superior to the lateral view for needle tip visualization
during cervical interlaminar epidural
injection (CESI). It has been demonstrated that
increasing the angle of obliquity during CESI
causes the needle tip to appear to move dorsal
and superficial on contralateral oblique views.
Needle tip visualization for cervical RFN has been
described using a foraminal oblique (FO) view,
but the technique and effect of angle on needle
tip depth have not been studied.
Objective: To analyze how the needle tip depth
changes with varying oblique angles of FO views
during cervical RFN.
Methods: Fluoroscopic views during cervical
RFN between lateral and 50 degrees FO in a
single subject were analyzed.
Results: The needle tip appears to move ventral
and deeper with increasing angle of obliquity with
respect to the lamina.
Conclusion: Contrary to the phenomenon noticed
with contralateral oblique views in CESI, in this
case the needle tip appears to move ventral and
deeper with increasing angle of obliquity on foraminal
oblique views during cervical RFN. It becomes
crucial for practitioners to understand that during
cervical RFN, with inadequate foraminal oblique
angle, needle tip looks artificially superficial, which
in turn may cause one to advance the needle to
a dangerous depth.
Limitation: This is an observational study in a
single subject; hence further larger studies are
needed to confirm the findings in this technical
report.
Key words: contralateral oblique, needle depth
assessment, cervical radiofrequency neurotomy,
cervical radiofrequency ablation, foraminal
oblique, fluoroscopy views, fluoroscopy angles
DIAGRAMMATIC ANALYSIS OF SUBARACHNOID CONTRAST SPREAD IN THE
CONTRALATERAL OBLIQUE VIEW: A TECHNICAL REPORT
Authors: Urits Ivan
Published: May 2021

Interlaminar epidural steroid injections are commonly
used in clinical practice for the relief of low
back pain. Reliable deposition of medication
in the epidural space is important in producing
significant results. Pathological conditions,
including vertebral osteoarthritis, degenerative
disc disease, and spinal stenosis, are frequently
treated with epidural steroid injections. Associated
degenerative features such as ligamentum
flavum hypertrophy, facet joint hypertrophy, and
osteophyte formation can lead to significant alterations
in the anatomy of the epidural space.
Epidurograms, prior to steroid injection, aid the
physician in identifying the epidural space, as a
false loss of resistance can occur. Extradural,
subdural, intradural, and subarachnoid contrast
spread has been demonstrated in the anteroposterior
and lateral views; but, has not previously
been demonstrated in the contralateral oblique
(CLO) view. This technical report is the first to
demonstrate concomitant epidural and subarachnoid
spread in the contralateral oblique view after
inadvertent low volume subarachnoid injection,
as might happen in clinical practice.
In this technical report, we demonstrate both
epidural and subarachnoid contrast spread in the
contralateral oblique view and compare it to the
anteroposterior view.
In an oblique view, epidural contrast spread is
observed to approximate the ventral margin of the
superior aspect of the lamina while subarachnoid
contrast spread has a distinct demarcation at the
ventral laminar margin. In an anteroposterior view,
epidural spread is confirmed by spread of the dye
along the nerve roots and beyond the margins of
the pedicles.
The CLO view provides an accurate and consistent
visualization of the epidural space; irrespective
of the obliquity, epidural contrast is observed
to approximate the ventral margin of the superior
aspect of the lamina. In the CLO view, if contrast
spread does not approximate the lamina, then
intrathecal injection must be considered.
Key words: Epidural steroid injection, epidurogram,
epidural spread, subarachnoid injection,
intrathecal spread, fluoroscopy, contralateral
oblique view
RADIOFREQUENCY FACILITATED MANUAL SEMI-ENDOSCOPIC DISCECTOMY
UTILIZING THE DISC FX® SYSTEM IN THE TREATMENT OF DISC-PREDOMINATE
LUMBAR SPINAL STENOSIS
Authors: Arcos George J.
Published: May 2021

Background: Lumbar spinal stenosis (LSS)
occurs with increasing prevalence in the elderly
population. The American Academy of Orthopedic
Surgeons has estimated that by 2021,
2.4 million adults in the United States (8-11% of
the population) will be affected by this condition.
Surgical options for LSS are being performed
with increased frequency, high cost, and substantial
risk of life-threatening complications.
While nonsurgical treatment options for LSS are
available, they are limited by patient selection
(ligamentum flavum hypertrophy) or high rates
of reoperation (Interspinous process spacer
devices).
This study is the first to suggest a minimally
invasive treatment option for disc-predominate
lumbar central canal stenosis.
Objectives: To evaluate the clinical efficacy of
radiofrequency facilitated manual semi-endoscopic
discectomy utilizing the Disc FX® system
in the treatment of disc-predominate lumbar
spinal stenosis.
Study Design: Single center, prospective, observational
study.
Setting: Multi-specialty private practice clinic.
The Medical Group of South Florida, Jupiter, FL.
Methods: This study involved 6 patients with
disc-predominant lumbar central spinal stenosis.
All patients were treated with the Disc FX®
system. Radiographic evidence of central lumbar
stenosis was confirmed by measurement of minimum
AP canal diameter (mm) performed by 1
board-certified neuroradiologist. Inclusion criteria
included absence of lumbar surgery, physical
therapy within the previous 6 months, failure of
epidural steroid injections (3) within the previous
8 months, spondylolisthesis limited to Grade I,
disc height > 50%, presence of low back axial
pain + leg pain exacerbated by walking, and
relieved with sitting or forward flexion, absence
of dermatomal radicular leg pain, radiographic
evidence of disc displacement > 4 mm from disc
endplate. Zurich claudication (symptom severity
and physical function scale was administered 1
week preoperatively, and again 6 months postoperatively.
There were no patients lost to follow up.
Results: All patients in the study demonstrated
moderate-severe or severe central canal stenosis,
with an average AP canal diameter of 6.63
mm for all treated disc levels and 5.5 mm for the
most severe levels. There was a mean improvement
of 57% in a symptom severity scale and
56% in the physical function scale at 6 months.
This exceeds the improvement reported with
interspinous spacer devices.
Limitations: Limitations include very small
sample size, observational design, non-randomization,
absence of share controls, short
follow-up period.
Conclusion: For patients suffering from discpredominant
lumbar spinal stenosis, The Disc
FX® System provides an effective, low-cost
alternative to surgical intervention.
Key words: Spinal, stenosis, claudication, disc,
Disc FX®, operative, minimally invasive, Zürich
claudication score
Ultrasound Guided Transverse Carpal Ligament Fenestration for
Carpal Tunnel Syndrome: A Case Series
Authors: Chiu Yu M.
Published: May 2021

Carpal tunnel syndrome is caused by compression of
the median nerve under the transverse carpal ligament.
We present a description of an ultrasound-guided
(USG) percutaneous technique of the transcarpal tunnel
and provide a discussion to the evidence in utilizing
a minimally invasive technique as an alternative
to open and endoscopic carpal tunnel release.
USG percutaneous transverse carpal ligament fenestration
is a quick, and relatively simple office based
treatment for carpal tunnel syndrome. The use of
ultrasound provides satisfactory visualization for the
procedure and requires very little time and effort for
setup. Here, in this case series, we detail the procedure
and the results from our follow-up.
This report details a case series of 2 patients with
confirmed electrodiagnostic findings of mild to severe
median neuropathy at the wrist in a university
hospital outpatient pain management center. USG
percutaneous fenestration of the transcarpal ligament
was performed under local anesthesia. Patients were
followed up from 4 to 20 weeks.
It was found in patient 1, a greater than 60% reduction
in pain at 20 weeks follow-up, and patient 2 had
at least 50% reduction in pain at 8 weeks follow-up.
Both patients had a minimum of 50% improvement in
pain and sensory disturbance and without any adverse
events.
The main advantage of USG transverse carpal ligament
fenestration is that it is an office based procedure,
requiring local anesthesia only. Minimally invasive
USG transcarpal ligament fenestration, in select patients,
may be an appropriate tool and even prove to
be a surgery-sparing modality. The limitations of this
study includes no case-control, small sample size, and
the short term follow-up. In conclusion, this case series
presents an alternative to a more invasive and costlier
procedure including open and endoscopic carpal tunnel
release, usually performed in a surgical suite. USG
percutaneous transverse carpal ligament fenestration is
a quick, and relatively simple office based treatment for
carpal tunnel syndrome. The use of ultrasound provides
satisfactory visualization for the procedure and requires
very little time and effort for setup.
Key words: Ultrasound guided, transverse carpal ligament,
fenestration, carpal tunnel syndrome
A REPORT ON USE OF 10% LIDOCAINE NEUROLYSIS FOR CHRONIC
REFRACTORY SUPRAORBITAL NEURALGIA
Authors: Chauhan Gaurav
Published: May 2021

We present a case report of a 50-year-old female
with a past medical history of chronic headaches
diagnosed as supraorbital neuralgia. Her
headaches had been refractory to conventional
analgesic medications and she had received
multiple supraorbital nerve blocks which gave
her temporary relief of the headaches lasting up
to 2 weeks. The patient also received chemical
neurolysis of the supraorbital nerve bilaterally
with 10% Lidocaine bilaterally, under fluoroscopic
guidance in the pain clinic. The patient reported
positive outcome following the block with significant
pain control for up to 6-7 months postprocedure.
The authors conclude that in a patient
with a refractory headache due to supraorbital
neuralgia, a 10% lidocaine,injection can be an
efficacious alternative to radiofrequency ablation
as it yields optimum symptom control for up to
6 - 7 months and is a relatively easy procedure
to perform. Furthermore, the procedure is not
associated with significant side effects and with
reversibility of induced sensory functional deficits,
offering an advantage over radiofrequency
ablation.
Key words: Lidocaine, supraorbital neuralgia,
neurolysis, nerve blocks, flouroscopy
Diagnosis and Spontaneous Resolution of an Epidural Hematoma in
a Patient Presenting after Cervical Epidural Steroid Injection
Authors: Urits Ivan
Published: May 2021

While not a cure for the underlying spinal pathology,
cervical epidural steroid injections (CESI)
are an important minimally invasive treatment
for neck pain with radiculopathy. Although CESIs
are considered safe, cervical epidural hematoma
(CEH) is a major complication and has previously
been reported. Patients, who develop CEH, present
with acute neck pain and upper extremity
radiculopathy. A prolonged time to treatment
may lead to worsened neurological outcome.
Diagnostic magnetic resonance imaging and
surgical decompression is the mainstay of treatment.
This report presents a patient with a history
of chronic neck pain and repeat cervical injections,
who presented with increased neck pain
and upper extremity weakness after undergoing
a CESI. Initial radiographic findings were complicated
and inconclusive of a definitive epidural
hematoma. With conservative management, the
patient showed signs of clinical improvement and
ultimately had spontaneous resolution of his CEH.
Though CEH are frequently rapidly progressing
and most often surgically decompressed, some
acutely presenting cases may be approached conservatively.
Though MRI is an important diagnostic
tool for CEH, interpretation of radiographic findings,
following a recent CESI, may be challenging
due to distortion of the epidural space anatomy.
Patients with a history of multiple cervical epidural
injections may have an increased risk for the development
of CEH.
Key words: Cervical epidural steroid injection,
cervical epidural hematoma, spontaneous resolution,
conservative management, magnetic resonance
imaging, complication
The Long Term Effectiveness of Genicular Nerve Blocks for Chronic
Knee Pain: A Retrospective Study
Authors: Lynem Laura Anne
Published: May 2021

Chronic knee pain is a leading cause of chronic
disability and its symptoms have a profound
impact on the lives of those suffering from it. Current
treatment modalities for chronic knee pain
include pharmacologic and nonpharmacologic
interventions. Genicular nerve blocks are a new
therapeutic alternative that have been shown
to relieve chronic knee pain and may provide
significant relief in patients who are either poor
surgical candidates or are unwilling to accept the
risks associated with surgery. Genicular nerve
blocks may provide long term pain relief for
chronic knee pain and radiofrequency ablation
(RFA) may not be necessary. This Institutional
Review Board (IRB) approved retrospective study
conducted at a single center university hospital
involved 44 patients aged 43 to 87 who received
genicular nerve blocks for chronic knee pain. The
primary purpose of this study was to determine if
genicular nerve blocks provide effective long term
pain relief for patients with chronic knee pain.
The numeric rating scale was used to measure
the patient’s knee pain at baseline, 30, 90, and
120 days post procedure. Patients experienced
a mean pain level of 7.43 out of 10 before the genicular
nerve block and 4.02 afterward representing
an average improvement of 42.6% in pain relief
overall post procedure follow-up. A t-test revealed
a statistically significant difference between the
mean pain score before and after the blocks (t =
8.534, P < 0.01). Overall, the patients experienced
significant pain relief of an average of 111.9 days
resulting in an average of 42.6 percent pain relief
post procedure follow-up. Out of the 44 patients,
15 (34.1%) underwent a RFA after receiving a
genicular nerve block procedure to further manage
their chronic knee pain symptoms. In conclusion,
we have found statistically significant evidence
that genicular nerve blocks provide effective
long-term pain relief for patients with chronic knee
pain. Therefore, for patients who are not surgical
candidates, genicular nerve blocks represent a
viable alternative treatment for knee pain.
Key words: Genicular nerve blocks, chronic knee
pain, genicular nerves, genicular nerve radiofrequency
ablation
Pulsed Radiofrequency Ablation after One Block for the Treatment
of Meralgia Paresthetica
Authors: Dua Anterpreet
Published: May 2021

Meralgia paresthetica describes a condition
in which impingement of the lateral femoral
cutaneous nerve (LFCN) causes anterolateral
thigh numbness, and often pain. Treatment options
include conservative care with nonsteroidal
anti-inflammatories, local anesthetic nerve blocks
with corticosteroids, radiofrequency ablation of
the LFCN, and surgical interventions, such as
neurolysis and neurectomy. When a left femoral
cutaneous nerve block is used to treat meralgia
paresthetica, it is typically repeated before
advancing to pulsed radiofrequency ablation
(pRFA). We hypothesized that a single trial of a
LFCN block, which relieved pain, but for only a
short duration was sufficient to advance to pRFA .
Our patient was a 55-year-old woman with right
anterior lateral thigh pain for 1 year, which made
activities of daily living difficult and was resistant
to conservative treatment which included nonsteroidal
anti-inflammatories, an antidepressant,
and an anticonvulsant. Diagnosis of meralgia
paresthetica was established by physical exam,
nerve conduction study, and electromyography.
A LFCN block under ultrasound guidance was
successful in resolving 100 percent of the pain
for approximately 2 weeks duration, at which
time the pain and paresthesia returned to original
intensity. The patient was deemed an appropriate
candidate for pRFA of the LFCN, which resulted
in complete resolution of symptoms as of her 9
month follow-up visit.
To our knowledge, this is the first report of the
use of pRFA after a single LFCN block providing
faster resolution of symptoms and return to activities
of daily living.
Key words: Pulsed radiofrequency ablation,
RFA, pRFA, meralgia paresthetica, lateral femoral
cutaneous nerve, LFCN
Management of Refractory Intracranial Hypotension Using
Percutaneous Fibrin Sealant Patch – A Case Series and Review
of the Literature
Authors: Wong Kevin
Published: May 2021

Background: Intracranial hypotension (IH) among
patients with persistent cerebrospinal fluid (CSF)
leakage remains a challenging problem. The majority
of these cases resolve spontaneously with
conservative measures. The customary treatment
for IH is epidural blood patch (EBP). In some
cases, CSF leaks can persist for months or even
years despite multiple trials of EBP. To date, there
are only a limited number of published studies
documenting the percutaneous injection of fibrin
sealant for treatment of IH refractory to conservative
measures and EBP.
Objective: Our objective was to perform a literature
review and retrospective case series regarding
patients who underwent percutaneous injection of
fibrin sealant for treatment of refractory IH at our
institution.
Study Design: This case series used a singlecentered
retrospective observational study design
and literature review.
Setting: Patients in this case series were treated
at a community-based tertiary care medical center.
Methods: Five consecutive patients with the diagnosis
of IH refractory to conservative measures
and EBP who underwent percutaneous patching
with fibrin sealant were identified at our institution
between January 1, 2000 and January 1, 2016. A
retrospective chart review was performed and data
including demographics, characteristics, interventions,
clinical outcomes, and complications were
collected. A critical review of the current literature
regarding the percutaneous use of fibrin sealant for
treatment of IH was conducted.
Results: Four of the 5 patients (80%) experienced
no further symptoms of IH and no adverse events
were noted. One patient (20%) ultimately required
surgical duroplasty. Review of the current literature
showed a total of 2 prospective case series,
4 retrospective case series, and 11 case reports.
Our present case series and literature review demonstrated
that fibrin sealants were well-tolerated by
most patients and associated with low incidences
of complications and recurrence.
Limitations: This study is limited by the small retrospective
case series of 5 patients.
Conclusions: Percutaneous injection of fibrin sealant
may be considered in refractory cases of IH
when repeated trials of EBP have persistently failed.
It appears to be a highly effective, safe, and easy-touse
alternative therapy for patients with refractory IH
in an ambulatory setting. Our review of the literature
revealed only studies with low quality of evidence,
including case series and case reports. There is a
substantial need for high-quality studies and clinical
evidence to corroborate the efficacy and safety of
this percutaneous technique. However, this ideal is
very challenging because of the relative rarity and
heterogeneous etiologies of cases.
Keywords: Fibrin sealant, intracranial hypotension,
CSF leak, epidural blood patch, orthostatic
headache, refractory, quality of life, percutaneous
Preoperative Surveillance Thoracic MRI for Thoracic Dorsal
Column Stimulation: Case Series
Authors: Carayannopoulos Alexios
Published: May 2021

Background: To date, there have been no
guidelines, studies, or consensus statements
regarding the use of advanced imaging studies
as a preoperative screening tool prior to patients
undergoing spinal cord stimulation (SCS).
Objectives: The purpose of this case series is to
highlight the importance of obtaining thoracic imaging
studies as part of a thorough initial clinical
assessment prior to percutaneously or surgically
placing an SCS electrode.
Methods: We undertook a 3-year retrospective
review of patients undergoing evaluation for
SCS therapy in an academic interventional pain
management and neurosurgery practice. Patients
with chronic neuropathic pain underwent a trial
with percutaneous dorsal column stimulation,
and if response to the trial was > 50% reduction
in pain and improvement in function, the patient
was implanted using either a percutaneous approach
or placement of a paddle electrode with
an internal pulse generator (IPG). All patients had
advanced thoracic imaging performed (magnetic
resonance imaging [MRI] if possible, or computed
tomography [CT] if contraindicated) prior to percutaneous
trial or paddle electrode implantation.
Results: In 3 years, 88 patients underwent a trial
of SCS, of which 75 patients (85%) were referred
for implantation of a permanent percutaneous or
paddle stimulator with IPG. Two patients (1.2%)
treated by trial and implant were found to have
a thoracic lesion on surveillance imaging, which
contraindicated SCS implantation. One patient
had thoracic imaging prior to undergoing the
trial and one patient had thoracic surveillance
imaging after the trial, but before surgical paddle
placement.
Limitations: The retrospective nature and lack of
a control group in this case series are limitations
of this study.
Conclusion: This case series outlines the importance
of considering advanced thoracic imaging
studies for screening/surveillance purposes prior
to SCS therapy. Placement of SCS electrodes
in the thoracic epidural space without prior understanding
of spinal anatomy potentially puts
patients at unnecessary risk. In the cases presented,
had patients undergone SCS trial and
subsequent implant without screening imaging,
thoracic lesions would have been missed, increasing
the likelihood of diagnostic and therapeutic
complications. Our incidental findings of lesions on
MRI prior to SCS trial or implant support the use
of a screening protocol for other centers providing
thoracic SCS therapies.
Key words: Thoracic, dorsal column stimulation,
chronic pain, surveillance MRI, patient selection
COMMON PERONEAL NERVE PALSY AND LONG-LASTING ROPIVACAINE
DURATION AFTER INFEROLATERAL GENICULAR NERVE BLOCK: A CASE REPORT
Authors: Rahimzadeh Poupak
Published: May 2021

This case report introduces a 43-year-old woman
who presented with left knee pain due to knee
osteoarthritis. She developed a long-lasting nerve
block with ropivacaine, plus common peroneal
nerve palsy and foot drop following a genicular
nerve block.
Key words: Ropivacaine, knee osteoarthritis,
genicular nerve block, foot drop
CHRONIC NON-CANCER ABDOMINAL WALL PAIN AMELIORATION VIA PHENOL
NEUROLYSIS BY TRANVERSUS ABDOMINIS PLANE APPROACH: A CASE REPORT
Authors: McAnally Heath
Published: May 2021

Abdominal pain is common and has multiple etiologies.
We present a case of chronic abdominal
wall pain that was treated with phenol neurolysis
via a tranversus abdominis plane (TAP). To
date, only 4 case reports utilizing TAP neurolysis
have been reported and all were performed
in the context of malignancy-related pain. The
TAP block has become an integral component
of the regional anesthesiologist’s perioperative
anesthesia and analgesia arsenal. In summary,
chemical denervation of the anterior abdominal
wall is feasible and efficacious in palliating chronic
non-cancer pain via a TAP block technique.
Key words: TAP, transversus abdominal plane,
phenol, abdominal wall pain, neurolytic, noncancer
pain
An Approach to Psychological Assessment of Chronic Pain Patient
Evaluated for Implantable Devices
Authors: Javed Saba
Published: May 2021

Chronic pain is a multidimensional field in which
a patient’s physical, environmental, and psychological
state must be fully understood to further
assess their problem. These variables form a
complex interaction with each other and play
a critical role in the treatment of chronic pain.
The clinical interview is the cornerstone of the
psychological evaluation. An important purpose
of the interview is to identify any psychiatric
conditions that might exacerbate pain or complicate
treatment, such as psychosis, substance
dependence, or a personality disorder.
The patient was seen in the chronic pain clinic
and assessed by the pain clinical psychologist.
We present the case of a patient who presented
to the chronic pain clinic and underwent evaluation
for spinal cord stimulator trial placement. As part of
this evaluation, the patient underwent psychological
assessment by the pain clinical psychologist;
we discuss the approach to psychological assessment
using observational narrative.
Psychological evaluation can help guide a physician’s
treatment plan to better meet the patient’s
needs. Psychological assessment prior to interventional
management should be used as a tool
to give the patient the best chance for success.
Key words: Psychological assessment, psychological
evaluation, spinal cord stimulation,
intrathecal pump
Conventional Thermal versus Water-Cooled Genicular Nerve
Radiofrequency Lesioning: A Retrospective Chart Review
Authors: Shea Cristina
Published: May 2021

Background: Genicular nerve radiofrequency
lesioning (RFL) is an interventional approach to
chronic knee pain. It is currently unknown whether
conventional thermal RFL (CT-RFL) or watercooled
RFL (WC-RFL) yields better outcomes.
Objective: The objective of this research was
to analyze and compare outcomes of genicular
nerve conventional thermal radiofrequency lesioning
(CT-RFL) vs water-cooled radiofrequency
lesioning (WC-RFL) for the treatment of chronic
knee pain.
Study Design: We used retrospective chart
review.
Setting: The research took place in an outpatient
pain clinic at a large academic medical center.
Methods: Patients who participated in the study
were those aged 18 and older who received genicular
nerve RFL for chronic knee pain between
January 1, 2014 and December 31, 2016. Random
intercepts models were used to examine Visual
Analog Scale (VAS) pain scores across the first
year of follow-up, adjusting for age, gender, and
prior history of knee surgery.
Results: Overall, VAS scores were significantly
reduced from baseline (mean = 6.66, standard
deviation [SD] = 1.36) by 1.46 points during the
first follow-up month (95% confidence interval [CI],
0.6-2.3, P = .001), 2.22 points during the second
follow-up month (95% CI, 1.4-3.1, P = < .001), and
1.24 points during the sixth follow-up month (95%
CI, 0.1-2.4, P = .035) but were not significantly
reduced at other months during the one-year followup
time period. There was no statistically significant
difference in follow-up pain scores (mean difference
= 0.73, 95% CI, -0.14-1.59, P = .116) or rates of
complications (P = .10, 2-tailed Fisher exact test)
between RFL types.
Limitations: Study shortcomings include patient
loss to follow-up, heterogeneity of CT-RFL techniques,
and heterogeneity of study patients.
Conclusions: Genicular RFL is a promising strategy
for long-term management of treatment-resistant
chronic knee pain. In this study, no significant difference
in outcomes was detected between CT-RFL
and WC-RFL techniques. Larger prospective studies
are warranted to compare outcomes of these
techniques and guide future care.
Key words: Radiofrequency lesioning, knee pain,
chronic pain, osteoarthritis, genicular, cooled radiofrequency
lesioning, water-cooled radiofrequency
lesioning, conventional radiofrequency lesioning
SPINAL CORD STIMULATION IN BUERGER’S DISEASE – A CASE REPORT
Authors: Santos Olga
Published: May 2021

Buerger’s disease (BD) or thromboangeitis obliterants
is a nonatherosclerotic segmental inflammation
of the medium- and small-size arteries
and vessels of the extremities. The pathogenesis
of this process remains unclear. This disease is
typically seen in male smokers under 45 years
of age, and successful therapy is possible only
with abstinence from tobacco. Methods to control
ischemic pain include nonpharmacological and
pharmacological options, such as prostanoids, or
surgical intervention (sympathectomy or revascularization).
This case report describes an unusual
case of Buerger’s disease in a 60-year-old
woman with a moderate smoking habit. Despite
apparent tobacco abstinence and therapeutic
optimization, there was no clinical improvement
in this patient with pharmacological treatment.
Attending to the imminent risk of amputation of
her fingers, spinal cord stimulation (SCS) system
implantation was the chosen therapeutic option.
Transcutaneous oxygen pressure (TcPO2) was
measured at different points in time after implantation
and there was a significant increment of
TcPO2 in both hands. In fact, the patient reported
no pain after the first month of spinal stimulation;
analgesics were progressively reduced and complete
healing of ulcers was achieved. Furthermore,
the patient reported a substantial improvement
in her quality of life and total functional recovery
in her hands mobilization after 6 months of treatment.
The Brief Pain Inventory Scale and EuroQol-
5D scale were used to evaluate disease progression
and its impact on quality of life. SCS system
implantation is considered a safe procedure and
cost-effective in the long term. The mechanisms
behind these effects are still unknown, but SCS
is a promising treatment option. More studies that
include larger numbers of patients are needed.
Key words: Buerger, tobacco, ischemia, amputation,
electrical spinal cord stimulation, transcutaneous
oxygen pressure
Stability and Compatibility of Drug Mixtures from Intrathecal Pump Using High Performance Liquid Chromatography
Authors: Javed Saba
Published: May 2021

Although management of intractable pain using
long-term intrathecal analgesic administration by
implantable infusion systems has become acceptable
clinical practice, this method presents
unique challenges regarding the stability of the
pharmaceutical agent(s) delivered. The stability
and compatibility of a single drug such as hydromorphone
or bupivacaine, as well as mixtures
of morphine-clonidine, have previously been
reported, but only using implantable infusion systems
and syringes under simulated clinical use
conditions, not from implanted intrathecal pumps.
The objective of this study was to assess the
compatibility and stability of drug mixtures from
intrathecal pumps placed in patients.
For this case-series, 5 patients with intrathecal
pumps who presented to the pain clinic for refill
were randomly selected. An aliquot of sample
extracted from the pump and an aliquot of new
medicine used for pump refill were collected. High
performance liquid chromatography (HPLC) was
used to compare the 2 samples.
Drug samples used were as follows: (A) hydromorphone
only, (B) morphine and bupivacaine,
(C) hydromorphone and ziconotide, (D)
ziconotide and baclofen; and (E) hydromorphone,
ziconotide, and baclofen. Samples B and E appeared
to be stable when placed in situ in the
SynchroMed II intrathecal pump based on the
HPLC analysis. However, samples A, C, and D
appeared to have undergone some degradation
and/or byproduct formation as noted in the graphical
display on HPLC.
While sample A was a single-drug combination,
the sample was in the pump for over 3 months;
likewise, sample E was a 3-drug combination,
however it was in the pump for only 30 days.
Based on these results, it appears as though
(a) when the length of time the drug stays in
the intrathecal pump increases, or (b) when a
combination of drugs is used in the intrathecal
pump (as opposed to a single drug), some drug
degradation and/or byproduct formation happens
as seen on HPLC.
This is the first reported study assessing the
compatibility and stability of drug mixtures from intrathecal
pumps. While the above reported HPLC
data reveals quantitative differences, further
qualitative analysis is required for confirmation
and possible identification of possible degradation
and/or byproducts.
Key words: Degradation, high performance liquid
chromatography, intrathecal pump
Pre-Contrast Injection Multiple
Needle Placement Technique: An
Alternative Method for Performing
Challenging Transforaminal
Epidural Steroid Injections for
Radicular Pain
Authors: Gupta Sanjeeva
Published: May 2021

Abstract: A subpedicular transforaminal epidural steroid injection (TFESI) at the L5-S1 level can be technically challenging
due to lumbar spondylosis. As described in the cases below, in challenging cases, placing multiple
needles (normally 2 needles, occasionally 3 needles) before injecting the radiocontrast dye can improve the
chances of depositing the steroid in the area of pathology responsible for pain. This will, of course, add
to the risk of the procedure due to multiple needles being close to the nerve root. On balance, however,
it may be less risky than not placing the steroid at the appropriate pathological site, which may fail to
provide pain relief leading to unnecessary suffering and, in some cases, surgical intervention. However, if
the spread of contrast medium and the subsequent steroid injection through the first needle is satisfactory,
then the other needles can be removed without injecting. The “pre-contrast injection multiple needle
placement” technique has been used by the author on multiple occasions and 3 cases are described
below.
Key words: Epidural steroid injection, transforaminal epidural injection, sciatica, radicular pain, multiple needle technique
Survey of Interventional Pain Physicians on Bending Spinal
Needles for Chronic Pain Procedures
Authors: Panjeton Geoffrey D.
Published: May 2021

Background: Interventional pain procedures
involve placement of fine-gauge spinal needles,
which practitioners will frequently bend to facilitate
both driving the needle through tissue, and
to increase accuracy of placement at a specific
spinal structure or nerve target. This bend is commonly
performed by hand, leaving the proceduralist
at risk for fingerstick injury, and the patient
at risk of site contamination. However, few case
studies have been published, and there are almost
no data on physician preference or practice.
Objectives: The purpose of this study was to
survey interventional pain physicians on their
practice of spinal needle manipulation before
performing lumbar medial branch nerve blocks.
Specific aims were to assess the prevalence of
manual needle bending, and to determine possible
associations with practitioner experience,
clinical environment, and fingerstick injury.
Study Design: A survey.
Setting: Annual 2018 American Society for
Interventional Pain Physicians conference in
Orlando, Florida.
Methods: A convenience sample of participants
were screened for eligibility and asked to voluntarily
participate in a de-identified IRB-approved
survey (IRB201703055). The survey consisted of
5 questions, 2 with binary answer choices and the
remaining 3 with multiple answer choices. Data
were collected on an iPad via Qualtrics software.
Data were analyzed by descriptive statistics
(counts, percentages).
Results: Of 480 interventional pain physician attendees
at the conference, 154 (32.1%) completed
the survey. The majority (114/154; 74%) reported
‘always’ bending the distal tip of spinal needles,
and a further 21 (14%) reported ‘sometimes’; 19
(12%) said they do not bend their needles. Only
25 (18%) respondents used an instrument to bend
their needles; 112 (82%) bend their needles by
hand. Eight respondents (6%) reported a fingerstick
injury while bending a spinal needle, one
while using an instrument, and 7 during a manual
bend. Approximately half of respondents had been
practicing for greater than 15 years; 78% work in
a private practice environment.
Limitations: Due to the setting, the recruitment
method presents the possibility of selection bias.
Furthermore, although the response rate may
appear low, it is higher than similarly performed
studies.
Conclusions: Spinal needle manipulation is common
prior to performing interventional pain procedures,
and most spinal needle manipulations are
performed by hand. Rate of fingerstick injury was
low in this sample, but cannot be evaluated without
comparative data. Factors to be considered in a
subsequent study are the effects of needle bend
variability relative to practitioner experience and
alternative means of needle manipulation.
Key words: Interventional pain procedures, spinal
needles, facet joint injections, needle bending,
fingerstick injuries
Efficacy of Erector Spinae Plane
Block for Back Pain Referred from
Visceral Pain in the Palliative Care
Setting
Authors: Takimoto Kayo
Published: May 2021

Background: Erector spinae plane (ESP) block, an easy and safe interfascial plane block under ultrasound guidance,
has an analgesic effect in various surgeries for chronic pain. However, no study has described the possible
clinical efficacy of ESP block in palliative patients suffering from back pain referred from visceral pain.
Case Report: Here we report three cases of successful ESP block at the middle to lower thoracic vertebras with 5–10 mL
local anesthetic to relieve back pain referred from thoracic or abdominal visceral cancer pain. Back pain
in these cases was derived from spinal extensor muscles supplied by the dorsal rami of the spinal nerve.
Thoracic or abdominal visceral pain was suggested to stimulate the middle to lower thoracic dorsal rami
of the spinal nerve.
Conclusion: Despite the effect of ESP block on the ventral rami of the spinal nerve being uncertain, back pain accompanied
by the lateral and medial branches of the dorsal rami of the spinal nerve, similar to that in these
cases, can be relieved via ESP block. Therefore, ESP block can be easily and safely performed for relieving
back pain referred from visceral pain in the palliative care setting. Further, to establish optimal volume,
concentration of local anesthetic, and clinical efficacy, randomized control trials will be essential in the
future.
Key words: Erector spinae plane block, fascial plane block, referred pain, palliative care setting, dorsal rami of the
spinal nerve, ventral rami of the spinal nerve, visceral pain, chronic pain
A STUDY ON KNOWLEDGE, ATTITUDE AND PRACTICE REGARDING IMMUNIZATION, NEEDLE STICK INJURY AND USE OF PPE AMONG HEALTHCARE WORKERS INVOLVED IN DISPOSAL OF HOSPITAL WASTE IN A TERTIARY CARE HOSPITAL, HYDERABAD.
Authors: Nikhila B. , Uddin Mustafeed , Reddy K.V. Krishna , Mahendra R. , Satyanarayana N.
Published: May 2021

Environmentally Sound Management of Medical Waste in India
(ESMWI) has been approved by Global Environment Facility (GEF)
where the Ministry of Environment, Forests and Climate Change,
Government of India, is the national executing agency and the United
Nations Industrial Development Organization (UNIDO) is the
implementing agency. The project aims to assist the country in safe and
sound management and disposal of 180,000 tons of health care wastes
generated annually which is approximately 484 tons per day
PLACENTA PREVIA AND PLACENTA ACCRETA SPECTRUM (PAS) DISORDER: INCIDENCE, RISK FACTOR AND FETOMATERNAL OUTCOME IN A TERTIARY CARE CENTER
Authors: Perhar Ramona , Devi Rubi , Patel Ruchi , Jagriti Jagriti
Published: May 2021

Introduction: Placenta Previa is characterised by Placental implantation into the lower uterine segment covering whole
or part of the cervix . It complicates 0.4% of pregnancy at term The average incidence is 0.3% or 1 case per 300 to 400
deliveries. The presence of placenta previa can also increase a woman's risk for placenta accreta spectrum (PAS). This spectrum of conditions
includes placenta accreta, increta, and percreta. Uncontrolled postpartum hemorrhage from placenta previa or PAS may necessitate a blood
transfusion, hysterectomy thus leaving the patient infertile, admission to the ICU, or even death. Material and method: Study was conducted in
department of obstetrics & gynecology , swaroop rani hospital, Allahabad for 1 year . A total of 102 pregnant women presenting to antenatal OPD
or admitted in IPD with history of antepartum hemorrhage and conrmed case of PP or MAP in Ultrasonography were selected. The follow up till
the fetomaternal outcome was done and risk factors were evaluated for 102 cases. Result: Out of the total 2342 deliveries in one year 95 patients
had PP and the incidence was 4.04% and 7 patients had morbidily adherent Placenta which accounts to an incidence of 0.29%. Previous LSCS,
Multiparity, increase maternal age, Dialatation and curettage were risk factors in both Placenta Previa and Morbidily Adherent Placenta.
Antenatal complication were antepartum hemmorrhage , Anemia, preterm labor. Emergency LSCS is more common mode of delivery in cases of
Placenta previa. Caesarean hysterectomy were done in 3.2% cases of Placenta Previa and all cases of Morbidily adherent placenta . Most
common perinatal complications in both groups were prematurity and low birth weight. Conclusion: Now a days Placenta previa and Morbidily
adherent placenta are very common. Incidence increases as the rate of cesaerean section or abdominal surgery were increases.Earlydiagnosis and
pre plan mode of delivery will decrease the risk of prematurity and low birth weight.
EPIDEMIOLOGICAL PROFILE OF FUNGAL KERATITIS IN PATIENTS ATTENDING A TERTIARY CARE CENTRE IN BIHAR
Authors: Vikram Kumar , Bhaskar Gyan , Kumar Shailesh , Kumar Rakesh , Kumari Namrata
Published: May 2021

Introduction: Corneal blindness is a major public health problem worldwide and fungal keratitis is one of its
predominant causes. The etiological and epidemiological pattern of fungal keratitis varies signicantly with patient
population, geographical region and prevailing socioeconomic conditions.
Objectives:The objective of the study was to identify the specic pathogenic agents and to study epidemiological characteristics of fungal
keratitis presenting at a tertiary care centre in Patna, Bihar.
Materials And Methods: Corneal scrapings were obtained from clinically suspected patients of keratomycosis during the period of 18 months
from May 2015 to October 2016. The scraping material was processed and identied by standard laboratory techniques. Demographic and
clinical features of the patients were also collected.
Results: Out of total 115 suspected fungal corneal ulcers, 63(54.78%) were positive for fungal etiology. Of these, 53(84.13%) were positive on
KOH mount. 40(63.49%) and 35(55.56%) were positive in Gram stain and culture respectively. In culture, aspergillus spp (16;45.71%) were the
predominant fungal species, followed by fusarium spp (12;34.29%). Males (35/63;55.56%) were more commonly affected. 22 out of 63 patients
(34.92%) were of age group 31-45 years. Majority of patients were farmers (68.25%). Corneal trauma (50.79%) was the most common
predisposing factor in which trauma due to vegetative matter (53.13%) was most signicant.
Conclusion: Fungal keratitis continues to be a cause of concern to ophthalmologists. Agricultural activity and related ocular trauma are principal
causes of mycotic keratitis. A potassium hydroxide (KOH) wet mount preparation is a simple, and sensitive, method for diagnosis.