bluuebunny/crossref_metadata_2025 huggingface dataset:
Pulsed Dose Radiofrequency Before Ablation
of Medial Branch of the Lumbar Dorsal Ramus
for Zygapophyseal Joint Pain Reduces Postprocedural Pain
Authors: Arsanious David
Published: February 2021

Background: One of the potential side effects with radiofrequency ablation (RFA) includes painful
cutaneous dysesthesias and increased pain due to neuritis or neurogenic inflammation. This pain
may require the prescription of opioids or non-opioid analgesics to control post-procedural pain and
discomfort.
Objectives: The goal of this study is to compare post-procedural pain scores and post-procedural
oral analgesic use in patients receiving continuous thermal radiofrequency ablation versus patients
receiving pulsed dose radiofrequency immediately followed by continuous thermal radiofrequency
ablation for zygopophaseal joint disease.
Study Design: This is a prospective, double-blinded, randomized, controlled trial. Patients who met
all the inclusion criteria and were not subject to any of the exclusion criteria were required to have two
positive diagnostic medial branch blocks prior to undergoing randomization, intervention, and analysis.
Setting: University hospital.
Methods: Eligible patients were randomized in a 1:1 ratio to either receive thermal radiofrequency
ablation alone (standard group) or pulsed dose radiofrequency (PDRF) immediately followed by
thermal radiofrequency ablation (investigational group), all of which were performed by a single
Board Certified Pain Medicine physician. Post-procedural pain levels between the two groups were
assessed using the numerical pain Scale (NPS), and patients were contacted by phone on postprocedural days 1 and 2 in the morning and afternoon regarding the amount of oral analgesic
medications used in the first 48 hours following the procedure.
Results: Patients who received pulsed dose radiofrequency followed by continuous radiofrequency
neurotomy reported statistically significantly lower post-procedural pain scores in the first 24 hours
compared to patients who received thermal radiofrequency neurotomy alone. These patients also
used less oral analgesic medication in the post-procedural period.
Limitations: These interventions were carried out by one board accredited pain physician at one
center. The procedures were exclusively performed using one model of radiofrequency generator,
at one setting for the PDRF and RFA. The difference in the number of levels of ablation was not
considered in the analysis of the results.
Conclusion: Treating patients with pulsed dose radiofrequency prior to continuous thermal
radiofrequency ablation can provide patients with less post-procedural pain during the first 24 hours
and also reduce analgesic requirements. Furthermore, the addition of PDRF to standard thermal
RFA did not prolong the time of standard thermal radiofrequency ablation procedures, as it was
performed during the typically allotted time for local anesthetic action.
Key words: Low back pain, facet joint disease, medial branch block, Radiofrequency ablation,
thermal radiofrequency, pulsed dose radiofrequency, PDRF, zygapophyseal joint
Polyunsaturated Fatty Acids and Chronic Pain:
A Systematic Review and Meta-analysis
Authors: Takkouche Bahi
Published: February 2021

Background: Chronic pain is one of the most frequent disease symptoms and represents a
global health problem with a considerable economic burden. The role of polyunsaturated fatty
acids (PUFA) in chronic pain conditions was debated during the last decade with conflicting results.
Objective: To assess whether polyunsaturated fatty acids intake is useful as a preventive or
curative tool in chronic pain.
Study Design: Systematic review and meta-analysis.
Setting: This study examined all published studies, either preventive or curative, on PUFA
supplementation and chronic pain.
Methods: We retrieved studies published in any language by searching systematically Medline,
Embase, Conference Proceedings Citation Index, dissertations databases, and the 5 regional
bibliographic databases of the World Health Organization until May 2015.
We included both observational and intervention studies reporting effect measures and their
confidence intervals of polyunsaturated fatty acids intake in the regular diet or supplementation
and pain.
Two investigators selected studies; extracted data independently on baseline characteristics,
exposure, and outcomes; and rated the quality of interventional studies using Jadad score.
We calculated pooled standardized mean differences (SMDs) of pain indexes such as the Visual
Analogue Score. We further carried out subgroup analyses by disease, type of PUFA, outcome
scale, quality index, dose, and time of supplementation.
Results: We retrieved 5 observational and 46 intervention studies. Only one observational study
showed a protective effect of PUFA. On the contrary, the interventional studies yielded a pooled
random effects SMD of -0.40 (95% CI -0.58, -0.22), which indicates improvement, as 0 is the value
that indicates absence of effect. The largest effect was found for dysmenorrhea (SMD -0.82, 95%
CI -1.21, -0.43), Ω-3 supplementation (-0.47, 95% CI -0.68, -0.26) and composite scores (-0.58,
95% CI -1.07, -0.09). Mitigation of pain was stronger for low doses (-0.55, 95% CI -0.79, -0.30)
and short supplementation periods (-0.56, 95% CI -0.86, -0.25).
Limitations: While the number of curative studies was large, that of preventive studies available
was limited.
Conclusion: Our results suggest that Ω-3 PUFA supplementation moderately improves chronic
pain, mainly that due to dysmenorrhea. Further investigation on the preventive potential of PUFA
supplementation is needed, as the amount of evidence is scarce.
Key words: Meta-analysis, systematic review, chronic pain, PUFA, supplementation, Ω-3,
dysmenorrhea
Technical Strategies and Anatomic
Considerations for an Extrapedicular Modified
Inferior Endplate Access to Thoracic and Lumbar
Vertebral Bodies
Authors: Burner Scott
Published: February 2021

Background: Percutaneous access to the vertebral bodies is commonly done via the transpedicular
approach for both diagnoses and treatment of spinal pathology. While this approach is effective
in most cases, it is difficult in certain situations such as a patient with obstructing hardware from
prior surgery.
Objectives: To investigate and illustrate an alternative to the typical percutaneous access to the
vertebral body via an extrapedicular approach and to determine the complications associated with
this approach.
Study Design: Description of a novel percutaneous vertebral body access technique developed
during cadaver dissection and a report of complication rates in cases that were performed using
this technique.
Setting: Radiology department at a private institution.
Methods: An effective extrapedicular access technique that could safely and consistently allow
the needle tip to be placed in the center of the vertebral body was developed from cadaver
dissection observations for the purpose of clinical use. A total of 96 vertebral compression fractures
from T5 to L5 were treated via the extrapedicular technique at our institution between July 2008
and August 2012. There were 72 patients between ages 27 and 98 (mean age 73.2 years) who
underwent treatment.
Results: Cadaver dissection revealed a relatively avascular and aneural portion of the inferior
vertebral body just anterior to the pedicle. A total of 96 vertebral fractures were treated using the
extrapedicular technique without any recognized clinical complications from the needle access or
the instrumentation.
Limitations: The trial included a relatively small sample size, representing 7.4 percent of total
patients treated at our institution. This was likely the result of a smaller patient population with
contraindications to typical transpedicular access.
Conclusions: The thoracic and lumbar vertebral bodies may be accessed using a percutaneous
extrapedicular access technique which represents a relatively avascular and aneural approach to
the vertebral body. The technique presented allows access to the vertebral body around existing
hardware and can accommodate the placement of large instruments. This technique was not
associated with any known complications in our series of patients.
Key words: Vertebral body, spine, extrapedicular, kyphoplasty, vertebroplasty, paraspinal,
thoracic, lumbar
A New Radiofrequency Ablation Procedure to
Treat Sacroiliac Joint Pain
Authors: Cheng Jianguo
Published: February 2021

Background: Low back pain may arise from disorders of the sacroiliac joint in up to 30% of
patients. Radiofrequency ablation (RFA) of the nerves innervating the sacroiliac joint has been
shown to be a safe and efficacious strategy.
Objectives: We aimed to develop a new RFA technique to relieve low back pain secondary to
sacroiliac joint disorders.
Study Design: Methodology development with validation through prospective observational
non-randomized trial (PONRT).
Setting: Academic multidisciplinary health care system, Ohio, USA.
Methods: We devised a guide-block to facilitate accurate placement of multiple electrodes to
simultaneously ablate the L5 dorsal ramus and lateral branches of the S1, S2, and S3 dorsal rami.
This was achieved by bipolar radiofrequency ablation (b-RFA) to create a strip lesion from the lateral
border of the base of the sacral superior articular process (L5-S1 facet joint) to the lateral border
of the S3 sacral foramen. We applied this technique in 31 consecutive patients and compared
the operating time, x-ray exposure time and dose, and clinical outcomes with patients (n = 62)
who have been treated with the cooled radiofrequency technique. Patients’ level of pain relief
was reported as < 50%, 50 – 80%, and > 80% pain relief at one, 3, 6, and 12 months after the
procedure. The relationship between RFA technique and duration of pain relief was evaluated
using interval-censored multivariable Cox regression.
Results: The new technique allowed reduction of operating time by more than 50%, x-ray
exposure time and dose by more than 80%, and cost by more than $1,000 per case. The percent
of patients who achieved > 50% pain reduction was significantly higher in the b-RFA group at 3, 6,
and 12 months follow-up, compared to the cooled radiofrequency group. No complications were
observed in either group.
Limitations: Although the major confounding factors were taken into account in the analysis,
use of historical controls does not balance observed and unobserved potential confounding
variables between groups so that the reported results are potentially confounded.
Conclusion: Compared to the cooled radiofrequency ablation (c-RFA) technique, the new b-RFA
technique reduced operating time by more than 50%, decreased x-ray exposure by more than
80%, and cut the cost by more than $1000 per case. The new method was associated with
significantly improved clinical outcomes despite the limitations of the study design. Thus this new
technique appeared to be safe, efficacious, and cost-effective.
Key words: Sacroiliac joint pain, sacroiliac joint, low back pain, radiofrequency ablation (RFA),
bipolar radiofrequency ablation (b-RFA), cooled radiofrequency ablation (c-RFA), cost-effectiveness
A New Technique for the Treatment of Lumbar
Facet Joint Syndrome Using Intra-articular
Injection with Autologous Platelet Rich Plasma
Authors: Liu Qinyi
Published: February 2021

Background and Objectives: Lumbar facet joint syndrome is currently suggested to be
a main source of axial low back pain, and a large portion of axial low back pain is caused by
disorders in lumbar facet joints. Intra-articular injection is one of the most common treatment
methods in the early clinical application. Therefore, we attempt to seek a new injectable
material, autologous platelet rich plasma (PRP), to treat lumbar facet syndrome, as well as to
assess its therapeutic effectiveness and safety.
Study Design: A prospective clinic evaluation.
Setting: The outpatient clinic of a single academic medical center.
Methods: Total 19 patients with lumbar facet joint syndrome (8 men, 11 women; mean
ages: 52.53 ± 6.79 years, range: 38 – 62 years) were enrolled to receive lumbar facet joint
injection with autologous PRP under x-ray fluoroscopic control. Patients were followed up
immediately, at one week, one month, 2 months, and 3 months following treatment, and
the elements of this analysis included low back pain visual analogue scale (VAS) at rest and
during flexion, Roland-Morris Disability Questionnaire (RMQ), Oswestry Disability Index (ODI),
and modified MacNab criteria for the pain relief.
Results: All the 19 patients completed the intra-articular injections with autologous PRP
successfully. At one week after treatment, low back pain reduced significantly compared with
prior to treatment both at rest and during flexion. The outcomes were assessed as “good”
or “excellent” for 9 patients (47.37%) immediately after treatment, 14 patients (73.68%) at
one week, 15 patients (78.95%) at one month, 15 patients (78.95%) at 2 months, and 15
patients (78.95%) at 3 months. Statistically significant differences were observed based on
RMQ and a more than 10% improvement in lumbar functional capacity was observed based
on ODI between pre-treatment and post-treatment. In addition, there were no severe relevant
complications during the whole process of injection and follow-up period.
Limitations: A control group and the curative effect observations with longer follow-up
may lead to a more convincing result for our study.
Conclusions: In the short-term period of 3 months, the new technique of lumbar facet
joint injection with autologous PRP is effective and safe for patients with lumbar facet joint
syndrome.
Key words: Low back pain, lumbar facet joint syndrome, autologous platelet rich plasma,
intra-articular injection
The Effectiveness and Safety of
Thermocoagulation Radiofrequency Treatment
of the Ophthalmic Division (V1) and/or Maxillary
(V2) and Mandibular (V3) Division in Idiopathic
Trigeminal Neuralgia: An Observational Study
Authors: Wan Li
Published: February 2021

Background: Trigeminal neuralgia (TN) is a pain appearing in the ophthalmic (V1), maxillary (V2),
and mandibular (V3) trigeminal branches. Pharmacologic treatment is the first line for TN; however,
many patients prefer to receive minimally invasive treatment rather than medicine because of
intolerable side effects. Thermocoagulation radiofrequency (TRF) is a minimally invasive treatment
that has been shown to effectively treat the maxillary (V2) and mandibular (V3) divisions, but the
safety of TRF treatment of the ophthalmic (V1) division has been controversial.
Objective: This study was to observe the effectiveness and safety of TRF treatment of the
ophthalmic (V1) division of trigeminal branches in idiopathic TN patients.
Study Design: An observational study.
Setting: All of patients received temperature controlled TRF, the effectiveness and safety of TRF
was assessed by VAS and complications.
Methods: Eighty patients with ophthalmic division (V1) or ophthalmic division (V1) combined
with maxillary (V2) or mandibular (V3) divisions of idiopathic TN were treated with step-increased
temperature TRF for 6 minutes. At a pulse width of 20 ms, the temperature was titrated up 2
degrees from 60 degrees to 66 degrees every 60 seconds, and then another 66 degrees or 68
degrees for 2 minutes. Meanwhile, the tip of the cannula was turned 180 degrees with each
temperature titration. Patients were assessed for pain relief and corneal reflex, numbness, and
masticatory muscle weakness at one week, one month, and 3 months after the procedure.
Results: Eighty patients were successfully treated with temperature controlled TRF for ophthalmic
(V1) division. Excellent pain relief was achieved in 79 of 80 patients (98.75%) after one week, one
month, and 3 months, and 78 of 80 patients (97.5%) patients experienced tolerable numbness.
Only one patient lost the corneal reflex, 14 experienced a corneal reflex that was mildly decreased,
and 2 patients felt a foreign body sensation in the ipsilateral eye after TRF, but there were no
corneal ulcers, incidences of blindness, or other complications.
Limitations: This study is limited by being an observation study and a non-prospective trial with
a short-term follow-up period.
Conclusion: Temperature controlled TRF to the ophthalmic division (V1) of the semilular ganglion
is effectiveness and safe in TN.
Key words: Thermocoagulation radiofrequency, pulsed radiofrequency, trigeminal neuralgia,
ophthalmic division, trigeminal ganglion, pain, numbness, corneal reflex
Timing of Platelet Rich Plasma Injections
During Antithrombotic Therapy
Authors: Ramsook Ryan Ravi
Published: February 2021

The use of platelet rich plasma (PRP) spans across many fields owing to its role in
healing and as a natural alternative to surgery. PRP continues to grow however much
of the literature is anecdotal or case report based and there is a lack of controlled
trials to evaluate standards for PRP. The International Cellular Medical Society (ICMS)
has developed guidelines to help with the safe advancement of PRP; however there
remains a gap in literature concerning the timing of PRP injections in patients who are on
antithrombotic therapy. The importance of an intact platelet surface membrane allows
for the appropriate release of the healing bioproteins and growth factors granting PRP
therapy its efficacy. This along with the proliferation of differentiated cells, enhancement
of collagen synthesis, early angiogenesis and revascularization help promote the benefits
of regeneration. The intrinsic and extrinsic pathways of the coagulation cascade are
valuable in that disruption of this mechanism or prematurely activated platelets may
result in limited efficacy. Anticoagulants and antiplatelet drugs are commonly used in
patients who are candidates for PRP. As antithrombotic agents affect platelet stability,
they will have an effect on PRP efficacy and must be discontinued at an appropriate
time frame prior to injection therapy. Understanding the pharmacokinetics and platelet
effects can help guide discussion on the proper timing of discontinuation and resumption
of a particular antithrombotic agent. With future research, the establishment of clinical
practice guidelines concerning PRP and antithrombotic therapy can help structure safe
and efficacious means in which to promote healing and regeneration in a growing patient
population.
Key words: Platelet rich plasma, antithrombotic therapy, coagulation, platelet activation,
regenerative medicine, growth factors
Repeal and Replace of Affordable Care: A
Complex, but Not an Impossible Task
Authors: Manchikanti Laxmaiah
Published: February 2021

The Affordable Care Act (ACA), signature legislation of President Obama, was arguably the most
consequential and comprehensive health care reform since Medicare was introduced as part of
President Lyndon B. Johnson’s great society. It has been claimed that many of the law’s reforms are
now so integrated in the health system that full repeal would be impractical, while others including
President Elect Trump have rejected that idea and called for full repeal and replacement claiming
ACA law cannot be fixed. A tsunami of increasing regulatory burden over the past 8 years, the
current health care milieu has moved independent practitioners towards hospital employment
in great numbers. In addition, public opinion has been slowly climbing against ObamaCare with
54% of Americans now opposing the law.
President Obama has indicated that the law has accomplished many of its goals, including
increasing accessibility, affordability, and quality of health care. However, others have contradicted
these assertions and described the ACA as “insurance for many with coverage for few.” Some
believe that the ACA might be more appropriately labeled the “Medicaid Expansion Act.”
There are multiple plans developed over the years by republican members of the congress;
however, of significant consequence and importance are President-elect Trump’s proposals and
the plan developed by Speaker Paul Ryan to repeal and replace the ACA. The President-elect
has described the problems he perceives with the ACA; rapidly rising premiums and deductibles,
narrow networks, and limits of coverage imposed by health insurance companies. The Presidentelect has indicated that his goal will be to create a patient-centered health care system that
promotes choice, quality, and affordability with health insurance and health care, and take any
needed action to alleviate the burdens imposed on American families and businesses by law.
Key words: Affordable Care Act, ObamaCare, Medicaid, exchanges, Trump plan, repeal, replace
The Safety of CT-Guided Epidural Steroid
Injections in an Older Patient Cohort
Authors: Fenster Andrew J.
Published: February 2021

Background: Epidural steroid injections (ESIs) are a common method for treating lower back
pain, which is one of the most prevalent health-related complaints in the adult U.S. population.
Although the safety of CT-guided ESIs has been extensively studied in adults, there is limited data
concerning the procedure’s safety profile in an older patient population.
Objective: This retrospective study analyzed safety data among a single-center cohort of patients
> 65 years-old who received one or more CT-guided interlaminar ESIs from 2012 to 2015.
Study Design: An Institutional Review Board (IRB)-approved retrospective chart review.
Setting: University hospital center.
Methods: A total of 688 CT-guided ESI procedures were evaluated and a linear regression analysis
was conducted to examine the relationship between dose length product (DLP), body mass index
(BMI), procedure duration, and kVp/mA settings. Further analysis was performed on a sample of
long procedure time, average-DLP and high-DLP procedures.
Results: Average age was 75.77 years, with 44% having a BMI > 30. The mean DLP was 55.58
mGy x cm and the mean procedure duration was 5.94 minutes. All procedures were technically
successful and no complications were observed during or after any of the procedures, including at
one-month follow-up office visits. The kVp and mA settings were the strongest predictors of DLP,
followed by procedure time. The high-DLP cases had a greater number of needle placement series,
more intervertebral disc spaces included in each planning series and higher machine settings (kVp
120; mA 87.5) than the average-DLP cases (kVp 100; mA 49.9).
Limitations: This study is limited by its retrospective design.
Conclusion: CT-guided interlaminar ESIs can be performed safely, with low procedure times,
relatively low DLP’s and without complications in an older patient population.
Key words: Epidural steroid injection, interlaminar approach, CT-guidance, older adults, back
pain, lumbar spine, thoracic spine, cervical spine, dose length product, radiation exposure
Ganglion Cyst at the Proximal Tibiofibular Joint
in a Patient with Painless Foot Drop
Authors: Renno Waleed M.
Published: February 2021

Entrapment neuropathies of the fibular nerve and its branches are often underdiagnosed
due to the lack of reliable diagnosis using clinical examination and electrophysiologic
evaluation. Most fibular nerve compressions may be classified into 2 broad categories:
(a) mechanical causes, which occur at fibrous or fibro-osseous tunnels, and (b) dynamic
causes related to nerve injury during specific limb positioning. Foot drop resulting from
weakness of the dorsiflexor muscles of the foot is a relatively uncommon presentation
and closely related to L5 neuropathy caused by a disc herniation. However, we herein
describe a rare case of usually painless foot drop triggered by a cyst at the proximal
tibiofibular joint compressing the deep fibular nerve. The presence of multilevel disc
diseases made the diagnosis more difficult. Foot drop is highly troubling, and health
care providers need to broaden their search for the imperative and overlapping causes
especially in patients with painless drop foot, and the treatment is variable and should
be directed at the specific cause. The magnetic resonance imaging (MRI), including
high-resolution and 3D MR neurography, allows detailed assessment of the course and
anatomy of peripheral nerves, as well as accurate delineation of surrounding soft-tissue
and osseous structures that may contribute to nerve entrapment. Knowledge of normal
MRI anatomy of the nerves in the knee and leg is essential for the precise assessment of
the presence of peripheral entrapment conditions that may produce painless or painful
drop foot. In conclusion, we stress the importance of preoperative anatomic mapping of
entrapment neuropathies to minimize neurological complications.
Key words: Foot drop, fibular nerve, ganglion cyst, proximal tibiofibular joint
Long-term Follow-up Results of Percutaneous
Endoscopic Lumbar Discectomy
Authors: Sabal Luigi Andrew
Published: February 2021

Background: Open lumbar microdiscectomy (OLM) has been considered the gold standard
in the management of lumbar disc herniation (LDH) for its favorable outcomes in longterm follow-up. Nowadays, percutaneous endoscopic lumbar discectomy (PELD) is gaining
recognition. However, greatest limitation of studies of PELD is the lack of long-term followup outcomes.
Objective: To investigate the long-term outcomes of PELD in terms of clinical and radiographic
findings and revision surgery rate.
Study Design: Retrospective study.
Setting: Spine hospital.
Methods: Sixty-two patients who underwent PELD 10 years previously were contacted for
follow-up. Clinical parameters such as the visual analog scale scores for the back and legs
(VAS-B and VAS-L, respectively), the Oswestry disability index (ODI), and radiographic findings
such as the disc-height ratio and change in the difference between flexion and extension were
recorded and compared to the preoperative values.
Results: For 62 followed patients, 38 met our inclusion criteria (35 transforaminal, 3
interlaminar). Excluded were 6 patients (9.4%) who underwent revision OLM at same level and
17 patients (26.6%) who underwent lumbar spine surgery at other levels. The average followup period was 11.22 (± 0.83) years. For the remaining 38 patients who had no further surgery,
the postoperative VAS-B (2.53 ± 1.98), VAS-L (1.82 ± 1.92), and ODI (12.69 ± 11.26) were
significantly different from the pre-operative values (8.45 ± 1.52, 7.40 ± 3.04, and 55.33 ±
24.63, respectively; all P = 0.01). The average disc-height ratio was 81.54% of the original disc
height. There was no evidence of instability after long-term postoperative follow-up.
Limitation: Retrospective nature of data collection.
Conclusion: PELD has favorable long-term outcomes.
Key words: Long-term, PELD, endoscopic lumbar discectomy, revision rate, disc height,
instability
Clinical Evaluation and Magnetic Resonance
Imaging Assessment of Intradiscal Methylene
Blue Injection for the Treatment of Discogenic
Low Back Pain
Authors: Hu ZhenMing
Published: February 2021

Background: Low back pain is a common worldwide health problem and has a significant
socioeconomic impact on public health. Internal disc disruption has been considered as the
most common cause of low back pain. Various therapies, including interbody fusion, disc
replacement, injection therapies, and thermal annular procedures have been utilized for the
treatment of discogenic low back pain. Recently, a new method of intradiscal methylene blue
injection has been introduced to treat discogenic low back pain, but the clinical outcomes are
controversial.
Objectives: To investigate the clinical outcomes and magnetic resonance imaging changes
of intradiscal methylene blue injection for the treatment of discogenic low back pain.
Study Design: Observational study.
Setting: An interventional low back pain management practice in a university hospital.
Methods: A total of 33 patients were selected to be treated with intradiscal methylene blue
injection. The clinical outcomes were evaluated by numeric rating scale and Oswestry Disability
Index at pretreatment, one month, 3, 6, and 12 months after treatment. The magnetic
resonance imaging changes of involved intervertebral discs were assessed by apparent
diffusion coefficient and T2 values at pretreatment, 3, 6, and 12 months after treatment.
Results: All of the patients got a follow-up period up to 12 months. The mean numeric
rating scale scores at pretreatment, one month, 3, 6, and 12 months after treatment were
6.54, 2.98, 3.23, 3.66, and 4.72, respectively. There was a minimum of 2 points reduction at
one month, 3, and 6 months after treatment, but less than 2 points reduction at 12 months.
There was at least 50% improvement on the Oswestry Disability Index at one month, 3, and 6
months after treatment, but not at 12 months. The mean apparent diffusion coefficient and T2
value were significantly higher at 6 and12 months after treatment compared to pretreatment,
but there was no significant difference between pretreatment and 3 months after treatment.
Limitations: This is an observational study with a relatively small sample size and short-term
follow-up.
Conclusions: The intradiscal methylene blue injection might be an effective therapy for
discogenic low back pain for the short-term and could improve disc degeneration condition
to some extent.
Key words: Low back pain, discogenic pain, internal disc disruption, provocation discography,
methylene blue, intradiscal injection, disc degeneration, magnetic resonance, imaging
What’s Tramadol Got to Do with It? A
Case Report of Rebound Hypoglycemia,
a Reappraisal and Review of Potential
Mechanisms
Authors: Odonkor Charles A.
Published: February 2021

Background: Tramadol has gained traction as an analgesic of choice among pain practicing
physicians. However some concerns regarding a previously unlabeled adverse reaction
– hypoglycemia – have cast it in a dim light. Prior reports have noted an associated risk of
hospitalization for hypoglycemia after tramadol use, but whether tramadol is the main causal
agent is poorly understood and the underlying mechanisms are not well delineated.
We present a unique case of rebound hypoglycemia as a variation of the theme of tramadol’s
adverse effect profile in a patient with type 1 diabetes mellitus, and reappraise potential
mechanisms underlying this underappreciated phenomenon.
Case Presentation: A 71-year-old woman presented with right buttock pain and right
lateral leg discomfort of 9-month duration. Her physical exam suggested sacroiliac joint (SIJ)
etiology, confirmed by magnetic resonance imaging (MRI). She was scheduled for an SIJdiagnostic and therapeutic block and started on tramadol 50 mg 3 times daily on as needed
basis. The patient subsequently developed severe hypoglycemia initially resistant to euglycemia
restorative interventions with a rebound episode. Hypoglycemia resolved with oral ingestion of
high levels of glucose and the patient was taken off tramadol. Fortunately, she did not require
hospitalization.
Discussion: The clinical scenario described is a case of rebound hypoglycemia after tramadol
use in a patient with type-1 diabetes naïve to opioid analgesics. The episodes of hypoglycemia
aligned perfectly with the anticipated pharmacodynamic and pharmacokinetic properties of
tramadol. The specificity and temporality of events after tramadol use in this patient fulfilled
causality criteria. Tramadol may cause rebound hypoglycemia in patients via interference of
the intrinsic euglycemia-restoration pathways and a blunted autonomic counter-regulatory
response to antecedent hypoglycemia. Its use must be tempered by this underappreciated
adverse effect profile.
Key words: Tramadol, hypoglycemia, sacroiliac joint arthritis, type 1 diabetes mellitus,
serotonin uptake inhibitors, glutamate receptor 4
CT-Guided Percutaneous Femoroplasty for the
Treatment of Proximal Femoral Metastases
Authors: Zhang Yingze
Published: February 2021

Background: The spine, pelvis, skull, and femur are the most common sites of bone metastases,
and pain is the main symptom of metastatic tumors. Percutaneous femoroplasty (PFP) is becoming
increasingly popular for treating proximal femoral metastases.
Objectives: To assess the clinical value and feasibility of PFP performed under the guidance of
computed tomography (CT).
Study Design: A retrospective clinical review comparing pain intensity and the ability to perform
activities of daily living before and after treatment with PFP.
Setting: Single academic medical center.
Methods: Sixteen patients with proximal femoral metastasis were treated with PFP under CT
guidance and followed up for 6 – 12 months. Pain intensity was evaluated using the visual analog
scale (VAS) and patients’ quality of life was evaluated using the Barthel Index of Activities of Daily
Living (BIADL) preoperatively and at both 7 days and 6 months after PFP.
Results: The mean VAS score decreased from 7.44 ± 0.81 preoperatively to 2.69 ± 0.79 at 7
days postoperatively and 1.25 ± 0.93 at 6 months postoperatively. The BIADL score increased
from 44.06 ± 9.53 preoperatively to 69.06 ± 8.61 at 7 days postoperatively and 83.13 ± 6.55 at
6 months postoperatively. No patients suffered from pulmonary embolism or complications such
as pathologic fracture of the proximal femur. The median overall survival was 12 months. One
patient experienced cement leakage into the hip, and the injection was immediately stopped. Then
dexamethasone was injected intravenously to prevent potential pulmonary fat embolism caused
by localized high pressure.
Limitations: The study evaluated a single group of patients before and after CT-guided PFP and
did not include a comparison with conventional fluoroscopic approaches in a large patient sample.
Conclusion: Use of CT-guided PFP was associated with a low risk of complications and
improvement in patients’ quality of life. CT guidance made the operation easy and safe, and
thus, this approach represents a potential treatment option for proximal femoral metastases if
indications are observed closely.
Key words: CT guidance, percutaneous femoroplasty, proximal femoral metastasis, pain relief,
cementoplasty
High-Resolution Three-Dimensional Computed
Tomography for Assessing Complications
Related to Intrathecal Drug Delivery
Authors: Morgalla Matthias
Published: February 2021

Background: The assessment of the functionality of intrathecal drug delivery (IDD) systems
remains difficult and time-consuming. Catheter-related problems are still very common, and
sometimes difficult to diagnose.
Objectives: The aim of the present study is to investigate the accuracy of high-resolution
three-dimensional computed tomography (CT) in order to detect catheter-related pump
dysfunction.
Study Design: An observational, retrospective investigation.
Setting: Academic medical center in Germany.
Methods: We used high-resolution three dimensional (3D) computed tomography with
volume rendering technique (VRT) or fluoroscopy and conventional axial-CT to assess IDDrelated complications in 51 patients from our institution who had IDD systems implanted for
the treatment of chronic pain or spasticity.
Results: Twelve patients (23.5%) presented a total of 22 complications. The main type of
complication in our series was catheter-related (50%), followed by pump failure, infection, and
inappropriate refilling. Fluoroscopy and conventional CT were used in 12 cases. High-resolution
3D CT VRT scan was used in 35 instances with suspected yet unclear complications.
Using 3D-CT (VRT) the sensitivity was 58.93% – 100% (CI 95%) and the specificity 87.54% –
100% (CI 95%).The positive predictive value was 58.93% – 100% (CI 95%) and the negative
predictive value: 87.54% – 100% (CI 95%).
Fluoroscopy and axial CT as a combined diagnostic tool had a sensitivity of 8.3% – 91.7% (CI
95%) and a specificity of 62.9% – 100% (CI 95%). The positive predictive value was 19.29% –
100% (CI 95%) and the negative predictive value: 44.43% – 96.89% (CI 95%).
Limitations: This study is limited by its observational design and the small number of cases.
Conclusion: High-resolution 3D CT VRT is a non- invasive method that can identify IDDrelated complications with more precision than axial CT and fluoroscopy.
Key words: Volume rendering technique (VRT), intrathecal drug delivery systems, highresolution 3D computed tomography, complications, spasticity, chronic pain, cost effectiveness,
fluoroscopy
Post Dural Puncture Headache in Fibromyalgia
after Cesarean Section: A Comparative Cohort
Study
Authors: Morsy Khalid M.
Published: February 2021

Background: Patients of chronic pain syndromes like fibromyalgia (FMS) when subjected to
spinal anesthesia are theoretically more liable to post dural puncture headache (PDPH) as they
have enhanced central nervous system sensitization and decreased descending inhibition.
Objective: The current study aims to verify the incidence and chronicity of PDPH in FMS
patients.
Study Design: Case control study.
Methods: In a comparative control study, 70 fibromyalgia patients were scheduled for
an elective cesarean delivery fibromyalgia group or Group 1. Group 2 included 70 women
scheduled for elective cesarean delivery who had no history of chronic pain and is used as a
control group. Both groups were compared regarding the incidence of development of PDPH in
the first postoperative 48 hours and the persistence of PDPH for 7 days or more.
Settings: Women’s Health Hospital, Assiut University, antenatal Clinic.
Results: The fibromyalgia group reported more PDPH (18 patients, 25.7%) as compared to the
control group (10 patients, 14.3%), P < 0.01. PDPH persisted for 7 or more days in 8 patients
in the fibromyalgia group (11.4%) while, it persisted in 2.86% of the control patients. PDPH
continued for more than 3 months in 2 patients in the fibromyalgia group (2.86%)
Limitations: Difficulty in calculating the dose of analgesics as patients with fibromyalgia may
use other analgesics due to musculoskeletal pain.
Conclusion: Dural puncture increases the incidence of PDPH in fibromyalgia patients in
comparison with normal controls without increasing other postoperative side effects.
Key Words: Fibromyalgia, cesarean section, post dural puncture headache, spinal anesthesia
Clinical Effectiveness and Prognostic Indicators
of Parasagittal Interlaminar Epidural Injection
Authors: Hong JiHee
Published: February 2021

Background: Interlaminar epidural steroid injection (ESI) is a well-established intervention to
improve radicular leg pain. However, few studies have demonstrated the prognostic factors for
interlaminar ESI.
Objective: To investigate the clinical effectiveness and prognostic indicators of parasagittal
interlaminar ESI during a 2-week follow-up.
Study Design: Prospective evaluation.
Setting: An interventional pain management practice in South Korea.
Methods: After Institutional Review Board approval, parasagittal interlaminar ESI under
fluoroscopic guidance was performed in 55 patients with central spinal stenosis. The numerical
rating scale (NRS) and the Oswestry Disability Index (ODI) (%) were used to evaluate clinical efficacy
and prognostic indicators. To determine the prognostic indicators, treatment outcomes were
classified as successful (decreased NRS ≥ 50%, decreased ODI ≥ 40%) and unsuccessful (decreased
NRS < 50%, decreased ODI < 40%) results.
Results: Parasagittal interlaminar ESI significantly improved the NRS and ODI (%) scores after
2 weeks compared to those measured pretreatment. Paresthesia provocation (P = 0.006) was
a significant prognostic factor on the NRS, whereas the Beck Depression Inventory (BDI) score
(P = 0.007), paresthesia provocation (P = 0.035), and epidurography finding (P = 0.038) were
significant on the ODI (%) score between patients with successful and unsuccessful outcomes.
Limitations: We included the method of parasagittal interlaminar ESI only, therefore, direct
comparison with other techniques was not available.
Conclusion: Parasagittal interlaminar ESI significantly improved the NRS and ODI (%) scores.
Paresthesia provocation was a prognostic indicator on the NRS and ODI (%) scores, and BDI scores
and epidurography findings were prognostic indicators for the ODI (%) score.
Key words: Parasagittal interlaminar epidural steroid injection, spinal stenosis, radicular leg pain,
prognostic indicator, paresthesia provocation, epidurography, Beck Depression Inventory
Intracerebroventricular Pain Treatment with
Analgesic Mixtures including Ziconotide for
Intractable Pain
Authors: Staquet Hélène
Published: February 2021

Intracerebroventricular (ICV) administration of opioids for control of intractable cancer pain has
been used since 1982. We present here our experience of intracerebroventricular administration
of pain treatments including ziconotide associated with morphine and ropivacaine for patients
resistant to a conventional approach, with nociceptive, neuropathic, or mixed pain.
These clinical cases were conducted with patients suffering from refractory pain, more than
6/10 on a numerical pain rating scale (NPRS) while on high-dose medical treatment and/
or intolerance with significant side effects from oral medication. The baseline study visit
included a physical examination and an assessment of pain intensity on a NPRS. Under general
anesthesia, a neuronavigation device was used to place the catheter on the floor of the third
ventricle, supported by an endoscope. Then, drugs were injected in the cerebroventricular
system, through a pump (external or subcutaneous). The primary objective was to measure
pain evaluation with ICV treatment after a complete withdrawal of other medications.
Four patients were enrolled: 3 with intractable cancer pain and one with central neuropathic
pain. The median NPRS at baseline was 9.5 [8.5; 19]. The mean NPRS after one month was
3.5 [3; 4.5]. Ziconotide was initiated at 0.48 µg/dy and up to a median of 1.2 µg/dy [1.0;
1.56]. The median dose of morphine and ropivacaine used initially was respectively 0.36 mg/dy
[0.24; 0.66] up to 0.6 mg/dy [0.45; 4.63] and 1.2 mg/dy [0; 2.4] up to 2.23 mg/dy [1.2; 3.35].
Minor side effects were initially observed but transiently. One psychiatric agitation required
discontinuation of ziconotide infusion.
For intractable pain, using ziconotide by intracerebroventricular infusion seems safe and
efficient, specifically for chronic neoplastic pain of cervicocephalic, thoracic, or diffuse origin
and also for pain arising from a central neuropathic mechanism.
Key words: Intracerebroventricular infusion, ziconotide, intractable pain, nociceptive and
neuropathic pain
Merit-Based Incentive Payment System
(MIPS): Harsh Choices For Interventional Pain
Management Physicians
Authors: Manchikanti Laxmaiah
Published: February 2021

The Merit-based Incentive Payment System (MIPS) was created by the Medicare Access
and CHIP Reauthorization Act of 2015 (MACRA) to improve the health of all Americans
by providing incentives and policies to improve patient health outcomes. MIPS combines
3 existing programs, Meaningful Use (MU), now called Advancing Care Information
(ACI), contributing 25% of the composite score; Physician Quality Reporting System
(PQRS), changed to Quality, contributing 50% of the composite score; and Value-based
Payment (VBP) system to Resource Use or cost, contributing 10% of the composite
score. Additionally, Clinical Practice Improvement Activities (CPIA), contributing 15%
of the composite score, create multiple strategic goals to design incentives that drive
movement toward delivery system reform principles with inclusion of Advanced
Alternative Payment Models (APMs).
Under the present proposal, the Centers for Medicare and Medicaid Services (CMS)
has estimated approximately 30,000 to 90,000 providers from a total of over 761,000
providers will be exempt from MIPS. About 87% of solo practitioners and 70% of
practitioners in groups of less than 10 will be subjected to negative payments
or penalties ranging from 4% to 9%. In addition, MIPS also will affect a provider’s
reputation by making performance measures accessible to consumers and third-party
physician rating Web sites.
The MIPS composite performance scoring method, at least in theory, utilizes weights
for each performance category, exceptional performance factors to earn bonuses, and
incorporates the special circumstances of small practices.
In conclusion, MIPS has the potential to affect practitioners negatively. Interventional
Pain Medicine practitioners must understand the various MIPS measures and how they
might participate in order to secure a brighter future.
Key words: Medicare Access and CHIP Reauthorization Act of 2015, merit-based
incentive payment system, quality performance measures, resource use, clinical practice
improvement activities, advancing care information performance category
Structural Changes of Lumbar Muscles in
Non-Specific Low Back Pain
Authors: Danneels Lieven
Published: February 2021

Background: Lumbar muscle dysfunction due to pain might be related to altered lumbar muscle
structure. Macroscopically, muscle degeneration in low back pain (LBP) is characterized by a
decrease in cross-sectional area and an increase in fat infiltration in the lumbar paraspinal muscles.
In addition microscopic changes, such as changes in fiber distribution, might occur. Inconsistencies
in results from different studies make it difficult to draw firm conclusions on which structural
changes are present in the different types of non-specific LBP. Insights regarding structural muscle
alterations in LBP are, however, important for prevention and treatment of non-specific LBP.
Objective: The goal of this article is to review which macro- and/or microscopic structural
alterations of the lumbar muscles occur in case of non-specific chronic low back pain (CLBP),
recurrent low back pain (RLBP), and acute low back pain (ALBP).
Study Design: Systematic review.
Setting: All selected studies were case-control studies.
Methods: A systematic literature search was conducted in the databases PubMed and Web of
Science. Only full texts of original studies regarding structural alterations (atrophy, fat infiltration,
and fiber type distribution) in lumbar muscles of patients with non-specific LBP compared to
healthy controls were included. All included articles were scored on methodological quality.
Results: Fifteen studies were found eligible after screening title, abstract, and full text for inclusion
and exclusion criteria. In CLBP, moderate evidence of atrophy was found in the multifidus; whereas,
results in the paraspinal and the erector spinae muscle remain inconclusive. Also moderate evidence
occurred in RLBP and ALBP, where no atrophy was shown in any lumbar muscle. Conflicting results
were seen in undefined LBP groups. Results concerning fat infiltration were inconsistent in CLBP.
On the other hand, there is moderate evidence in RLBP that fat infiltration does not occur, although
a larger muscle fat index was found in the erector spinae, multifidus, and paraspinal muscles,
reflecting an increased relative amount of intramuscular lipids in RLBP. However, no studies were
found investigating fat infiltration in ALBP. Restricted evidence indicates no abnormalities in fiber
type in the paraspinal muscles in CLBP. No studies have examined fiber type in ALBP and RLBP.
Limitations: Lack of clarity concerning patient definitions, exact LBP symptoms, and applied
methods.
Conclusions: The results indicate atrophy in CLBP in the multifidus and paraspinal muscles but
not in the erector spinae. No atrophy was shown in RLBP and ALBP. Fat infiltration did not occur in
RLBP, but results in CLBP were inconsistent. No abnormalities in fiber type in the paraspinal muscles
were found in CLBP.
Key words: Low back pain, non-specific, chronic, recurrent, acute, muscle structure, fat
infiltration, cross-sectional area, fiber type, review