Bipolar Radiofrequency Neurotomy of the Genicular Nerves for Chronic Pain Due to Knee Osteoarthritis.

Background: The current treatments for chronic knee osteoarthritis (OA), a disabling and costly healthcare condition in the United States, vary in their level of supporting evidence. Although total knee replacement is one of the best-supported interventions, its associated risks should not be taken lightly, especially in older patients with comorbidities. Genicular nerve block with subsequent genicular nerve radiofrequency neurotomy (GN-RFN) has emerged as a promising intervention for refractory pain in knee OA. Purposes/Questions: We sought to assess the pain and functional outcomes of genicular nerve bipolar radiofrequency neurotomy (B-RFN) for the treatment of chronic pain due to knee OA. Methods: A total of 21 patients who underwent unilateral genicular nerve B-RFN after positive diagnostic genicular nerve block (50% or greater pain relief) treated between July 2018 to December 2018 were included. Pain numeric rating scale (NRS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were collected at baseline, 3 months, and 6 months post-B-RFN. Changes at each time point were compared to baseline scores using paired sample t tests. Results: At 3 months, 62% of patients had a greater than 50% improvement in NRS scores and 57% of patients had a greater than 50% improvement in WOMAC scores. At 6 months, 81% of patients had a greater than 50% improvement in NRS scores and 67% had a greater than 50% improvement in WOMAC scores. The absolute change in mean NRS (± standard deviation) at 6 months went from 7.5 ± 1.9 to 2.5 ± 1.2. The absolute change in mean WOMAC scores at 6 months went from 46.9 ± 8.0 to 19.0 ± 6.2. Conclusion: Of 21 patients, 14 (67%) saw greater than 50% improvements in both NRS and WOMAC scores at 6 months after genicular nerve B-RFN. Further prospective studies are needed to determine the selection criteria of patients most likely to benefit from this procedure.

Dexamethasone Effectively Reduces the Incidence of Post-neurotomy Neuropathic Pain: A Randomized Controlled Pilot Study.

BACKGROUND: Radiofrequency neurotomy (RFN) of facet or sacroiliac joints is widely used for the treatment of chronic axial pain and can provide long-term pain relief in well-selected patients. The most common side effect is transient neuropathic pain at the paravertebral level of interest. Pain physicians commonly administer corticosteroid post-neurotomy to reduce the risk of post-neurotomy neuropathic pain, yet it remains unclear if this provides a true reduction in incidence. OBJECTIVES: To determine the efficacy of corticosteroid administration post-lesion in preventing the development of post-neurotomy neuropathic pain after cervical, thoracic, lumbar, and sacroiliac joint radiofrequency denervation. STUDY DESIGN: Randomized, placebo-controlled, double-blind prospective study. SETTING: Ambulatory Surgical Center within a Tertiary Hospital System. METHODS: This trial is registered on ClinicalTrials.gov (NCT03247413). Permission to conduct human research was obtained from the Institutional Review Board. Eligible patients included those with cervical, thoracic, or lumbar facet or sacroiliac joint pain who had positive concordant medial branch blocks (thus scheduled for bilateral RFN), at least 18 years of age, and English-speaking. Patients received dexamethasone vs saline (control) at each lesion site, serving as their own control (with laterality). Follow-ups were completed at 4- and 8-weeks post-intervention to evaluate the incidence of post-procedure pain (questionnaire) and function using the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI). RESULTS: At the time of data analysis, 35/63 patients completed the study protocol. There was a statistically significant reduction in the incidence of post-neurotomy pain in the steroid group vs the control group (20/35 control group vs 3/35 steroid group, P < 0.001). ODI/NDI scores changed differently over time depending on the spinal level of neurotomy, showing statistically significant improvement in ODI/NDI in the cervical subgroup and lumbar subgroup at 4-week (P = 0.05) and 8-week time points (P < 0.01), respectively. There was no improvement of ODI scores in the sacral subgroup. The incidence of post-neurotomy neuropathic pain was not significantly different among patients with different spinal levels of neurotomy. Patients who developed post-neurotomy neuropathic pain did not differ in ODI/NDI scores at any time point. LIMITATIONS: This study has several limitations, most notably the number of patients lost to follow-up, the use of a single corticosteroid, and the use of laterality for incidence reporting. Additionally, all procedures were performed by a single interventionalist using one neurotomy system. CONCLUSIONS: A statistically significant reduction in post-neurotomy pain was observed in the steroid group. This protocol can be feasibly conducted in an effective and resource-efficient manner. Additional research is needed to increase the power of the study.

Intervertebral Disc Degeneration: The Role and Evidence for Non-Stem-Cell-Based Regenerative Therapies.

The use of non-stem-cell-based regenerative medicine therapies for lumbar discogenic pain is an area of growing interest. Although the intervertebral disc is a largely avascular structure, cells located within the nucleus pulposus as well as annulus fibrosis could be targeted for regenerative and restorative treatments. Degenerative disc disease is caused by an imbalance of catabolic and anabolic events within the nucleus pulposus. As catabolic processes overwhelm the environment within the nucleus pulposus, proinflammatory cytokines increase in concentration and lead to further disc degeneration. Non-stem-cell-based therapies, which include growth factor therapy and other proteins, can lead to an increased production of collagen and proteoglycans within the disc.

Fifty Shades of Darkness: A Socio-Cognitive Information-Processing Framework Applied to Narcissism and Psychopathy.

Existing trait-based and cognitive models of psychopathy and narcissism fail to provide a comprehensive framework that explains the continuum between sub-clinical and clinical presentations of those personalities and to predict associated maladaptive behavior in different social and cultural contexts. In this article, a socio-cognitive information-processing framework for narcissism and psychopathy (SCIPNP) is proposed to explain how psychopathic and narcissistic schemata influence the activation of psychological processes that interact with social and cultural contexts to display those personalities at a sub-clinical level. The proposed framework enables us to predict maladaptive behavior and to explain how sub-clinical narcissists and psychopaths develop personality disorders. The SCIPNP emphasizes the role of culture in shaping motives, appraisals, behavior and affect. Recommendations for future research are provided.

Aromatherapy for Procedural Anxiety in Pain Management and Interventional Spine Procedures: A Randomized Trial.

OBJECTIVE: The aim of this study was to evaluate a nonsedating agent, lavender aromatherapy, to reduce anxiety before interventional spinal procedures. DESIGN: In this prospective, single-blind study performed at a tertiary care center for an academic institution, 144 patients undergoing spinal procedures (epidural steroid injection, medial branch block, or radiofrequency ablation) were randomized into two groups of 72 patients. The experimental group was exposed to a tablet formulation of lavender aromatherapy, while the control group was exposed to tablets devoid of any scent. The exposure duration for each group was 5 mins. The primary outcome measurement was patients' anxiety state before the spinal procedure using the six-item State-Trait Anxiety Inventory. Secondary outcomes quantified the rate of vasovagal events and aborted procedures because of patient intolerance. RESULTS: Compared with the control group, the posttreatment anxiety score of those exposed to lavender aromatherapy revealed a statistically significant difference as measured by the six-item State-Trait Anxiety Inventory (12.15 ± 2.67 and 10.67 ± 2.81, P < 0.05). Within group, the experimental group's anxiety level decreased from 12.26 ± 2.75 to 10.67 ± 2.81 (P < 0.05). There were two vasovagal episodes and one aborted procedure in the control group, whereas there was one vasovagal episode and no aborted procedures in the aromatherapy group. CONCLUSIONS: Lavender-based aromatherapy is effective in reducing preprocedural anxiety before interventional spine procedures for pain management.

Paranoia, hallucinations and compulsive buying during the early phase of the COVID-19 outbreak in the United Kingdom: A preliminary experimental study.

This study examines the impact of COVID-19 (in the early phase of the outbreak) on symptoms of psychosis, namely paranoia and hallucinations. Three hundred and sixty-one people in the United Kingdom participated in a 2 (self-isolation vs. no self-isolation) x 2 (perceived COVID-19 symptomatology vs. no perceived COVID-19 symptomatology) x 2 (exposure to COVID-19 news vs. control) experiment online. Participants completed measures of political trust, social network, fear of COVID-19, current paranoid thoughts, hallucinatory experiences and compulsive buying. Kruskal-Wallis results showed that employed people and students are more prone to paranoia and hallucinatory experiences in response to COVID-19 news. A multigroup model showed a moderation effect of the news conditions - in the COVID-19 news condition, fear of COVID-19 and political trust significantly predict the variance of paranoia, hallucinatory experiences and compulsive buying and these co-vary with each other but not in the control condition. In line with cognitive and social theories of paranoia, results suggest that negative affect and low political trust are linked to the presence of paranoid thoughts and hallucinatory experiences and compulsive buying amid COVID-19. Digitized and Tailored Cognitive and Behavioral Therapy are proposed to address the psychiatric impact of COVID-19.

Telemedicine During COVID-19 and Beyond: A Practical Guide and Best Practices Multidisciplinary Approach for the Orthopedic and Neurologic Pain Physical Examination.

BACKGROUND: The COVID pandemic has impacted almost every aspect of human interaction, causing global changes in financial, health care, and social environments for the foreseeable future. More than 1.3 million of the 4 million cases of COVID-19 confirmed globally as of May 2020 have been identified in the United States, testing the capacity and resilience of our hospitals and health care workers. The impacts of the ongoing pandemic, caused by a novel strain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have far-reaching implications for the future of our health care system and how we deliver routine care to patients. The adoption of social distancing during this pandemic has demonstrated efficacy in controlling the spread of this virus and has been the only proven means of infection control thus far. Social distancing has prompted hospital closures and the reduction of all non-COVID clinical visits, causing widespread financial despair to many outpatient centers. However, the need to treat patients for non-COVID problems remains important despite this pandemic, as care must continue to be delivered to patients despite their ability or desire to report to outpatient centers for their general care. Our national health care system has realized this need and has incentivized providers to adopt distance-based care in the form of telemedicine and video medicine visits. Many institutions have since incorporated these into their practices without financial penalty because of Medicare's 1135 waiver, which currently reimburses telemedicine at the same rate as evaluation and management codes (E/M Codes). Although the financial burden has been alleviated by this policy, the practitioner remains accountable for providing proper assessment with this new modality of health care delivery. This is a challenge for most physicians, so our team of national experts has created a reference guide for musculoskeletal and neurologic examination selection to retrofit into the telemedicine experience. OBJECTIVES: To describe and illustrate musculoskeletal and neurologic examination techniques that can be used effectively in telemedicine. STUDY DESIGN: Consensus-based multispecialty guidelines. SETTING: Tertiary care center. METHODS: Literature review of the neck, shoulder, elbow, wrist, hand, lumbar, hip, and knee physical examinations were performed. A multidisciplinary team comprised of physical medicine and rehabilitation, orthopedics, rheumatology, neurology, and anesthesia experts evaluated each examination and provided consensus opinion to select the examinations most appropriate for telemedicine evaluation. The team also provided consensus opinion on how to modify some examinations to incorporate into a nonhealth care office setting. RESULTS: Sixty-nine examinations were selected by the consensus team. Household objects were identified that modified standard and validated examinations, which could facilitate the examinations.The consensus review team did not believe that the modified tests altered the validity of the standardized tests. LIMITATIONS: Examinations selected are not validated for telemedicine. Qualitative and quantitative analyses were not performed. CONCLUSIONS: The physical examination is an essential component for sound clinical judgment and patient care planning. The physical examinations described in this manuscript provide a comprehensive framework for the musculoskeletal and neurologic examination, which has been vetted by a committee of national experts for incorporation into the telemedicine evaluation.

The Impact of Local Steroid Administration on the Incidence of Neuritis following Lumbar Facet Radiofrequency Neurotomy.

BACKGROUND: Pain arising from the lumbar facet joints is a common cause of axial back pain in adults. Radiofrequency neurotomy (RFN) of the medial branches of the spinal dorsal rami has been used as a treatment option. The most common side effect is transient, localized, burning, neuritic-type pain, termed post-neurotomy neuritis (PNN). Corticosteroids have been administered through the radiofrequency cannula after neurotomy to prevent PNN, but no study has examined the effects of this on PNN. OBJECTIVES: We investigated the incidence of PNN in patients who received corticosteroids after RFN and in those patients who did not receive corticosteroids. STUDY DESIGN: Retrospective evaluation. SETTING: Single-site interventional pain management practice in an urban tertiary academic medical center. METHODS: One hundred and sixty-four patients were included in this study and were categorized into non-steroid (n = 87) and steroid (n = 77) groups. Patient's age, gender, body mass index (BMI), laterality of procedure, use of neuropathic pain medications, baseline pain, and duration of pain were all recorded. PNN was determined if the patient self-reported transient burning or neuropathic pain at the site prior to or at the 6-week routine follow-up encounter. RESULTS: There was no significant difference in demographic characteristics between the 2 groups in age, gender, baseline pain, and duration of pain. The proportion of patients in the steroid treated group with PNN was 5 out of 77 (6.4%) and the non-steroid group was 6 out of 87 (6.9%). There was no statistically significant difference between the groups. There was no statistically significant difference in the incidence in neuritis between individuals taking neuropathic agents and individuals not taking neuropathic agents. LIMITATIONS: This study has several limitations including small sample size, patients' self-reported neuropathic symptoms, and inability to draw strong conclusions due to the retrospective study design. A single interventionalist performed all the procedures in this retrospective study and variations in technique amongst others are inevitable. CONCLUSION: Administration of steroids after RFN does not reduce the incidence of post-neurotomy neuritis. Concurrently administering neuropathic medications does not protect against neuritis. KEY WORDS: Radiofrequency neurotomy, radiofrequency ablation, neuritis, corticosteroid, lumbar facet pain, post neurotomy neuritis.

A structural equation model to predict pre-exposure prophylaxis acceptability in men who have sex with men in Leicester, UK.

OBJECTIVES: Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool for high-risk men who have sex with men (MSM). However, acceptability and uptake have been variable. This study explored the factors that predict PrEP acceptability in MSM in Leicester, where HIV prevalence is double the national average. METHODS: A total of 191 HIV-negative MSM completed a cross-sectional survey. Participants provided demographic information, and completed measures of HIV knowledge, perceived HIV risk, engagement in sexual risk behaviour, acquisition of a sexually transmitted infection (STI) in the last 12 months, frequency of HIV testing and PrEP acceptability. RESULTS: Kruskal-Wallis tests showed statistically significant effects of sexual orientation, education level and income, respectively, on HIV knowledge. Gay-identified individuals possessed greater HIV knowledge than bisexuals. Respondents with General Certificate of Secondary Education (GCSE)-level education had significantly less HIV knowledge than those educated to postgraduate level. Respondents with income of < £10 000 possessed significantly less HIV knowledge than higher income groups. Structural equation modelling showed that the relationship between HIV knowledge and PrEP acceptability was mediated by perceived HIV risk, engagement in sexual risk behaviour, acquisition of an STI in the past 12 months and frequency of HIV testing. CONCLUSIONS: The results reveal socio-economic inequalities in HIV knowledge and HIV testing, and suggest that MSM who have high levels of HIV knowledge and perceived HIV risk and who regularly test for HIV are most likely to endorse PrEP as personally beneficial. HIV knowledge and accurate risk appraisal should be promoted in MSM. The HIV testing context constitutes an ideal context for promoting PrEP to high-risk MSM.

The Roles of Socioeconomic Status, Occupational Health and Job Rank on the Epidemiology of Different Psychiatric Symptoms in a Sample of UK Workers.

There is a considerable gap in epidemiological literature about community mental health showing how psychiatric symptoms are associated with job rank, socioeconomic status, and occupational health. We examine data from 4596 employees collected in the United Kingdom's Psychiatric Morbidity among Adults Living in Private Households Survey. There were 939 workers in managerial jobs, 739 in supervisory jobs and 2918 employees in lower ranking jobs. Of the 4596 workers, 2463 had depressive symptoms and 2133 no depressive symptoms. Job rank, household gross income, social class, personal gross income and socio-economic group were significantly associated with general health, occupational health and depressive and avoidant symptoms. Job rank, occupational and physical health also explained the variance in paranoid and avoidant symptoms among the employees. This study shows that severe psychopathology is related to workers' job rank.

Percutaneous CT-guided facet joint synovial cyst rupture: Success with refractory cases and technical considerations.

Percutaneous image-guided rupture of lumbar facet synovial cysts can improve clinical outcomes and obviate the need for open surgery. This series describes eleven patients who had successful CT-guided lumbar facet synovial cyst ruptures, 82% of which experienced excellent pain relief at a minimum of one-year follow-up. Of the five patients who failed prior fluoroscopic-guided synovial cyst rupture, 80% had a successful CT-guided rupture and one-year sustained pain relief. These findings reinforce minimally invasive CT-guided treatment as an excellent option to improve patient symptoms and potentially avoid open surgery.

Soleus Muscle Herniation With Magnetic Resonance Imaging and Ultrasound Correlation in a Female Long-Distance Runner: A Case Report.

This is a case of a 40-year-old female endurance athlete with right leg pain while running. A comprehensive workup revealed a fascial defect with soleus muscle herniation. Although historically in many practice settings magnetic resonance imaging is the diagnostic imaging modality of choice for suspected muscle herniation through the fascia, the use of ultrasound is increasing because of lower cost, ease of access, and dynamic evaluation. To the authors' knowledge, there has not been a direct comparison between the accuracy of magnetic resonance imaging versus ultrasound in determining the size or location of a soleus muscle herniation. LEVEL OF EVIDENCE: Not applicable.

The Clinical Efficacy for Two-Level Transforaminal Epidural Steroid Injections.

BACKGROUND: Epidural steroid injections have been used in combination with other modalities for the treatment of lumbar radicular pain. The literature has shown that 1-level lumbar fluoroscopically guided transforaminal epidural steroid injections (TFESIs) are effective in decreasing pain and morbidity; however, the efficacy of 2-level TFESIs has not been investigated, although they are performed by many practitioners in the treatment of lumbar radicular pain. OBJECTIVES: To assess the clinical effectiveness of 2-level TFESIs in patients with unilateral, single-level lumbar radicular pain. In addition, a subgroup analysis was performed based on disk herniation location. STUDY DESIGN: Retrospective cohort. SETTING: Outpatient physiatry pain practice. PATIENTS: A total of 721 patients were included in this study having undergone a two-level transforaminal epidural steroid injection. METHODS: The study group included patients who underwent a 2-level lumbar TFESI. Patients presented for lumbar radicular pain as the result of disk herniation with or without radiculopathy and were scheduled to receive a lumbar TFESI at L3 or below. Of this group, only those that underwent a 2-level TFESIs were included in the study, and data analysis was carried out on this group. MAIN OUTCOME MEASURES: Subjects were assessed with a pain numerical rating scale (NRS 0-10) and Oswestry Disability Index (ODI) before TFESI and at 2-week and 2-month follow-up. Responders were defined as greater that 50% reduction in NRS or greater than 40% reduction in ODI. RESULTS: A total of 57.7% of patients were responders in terms of NRS (P < .05, confidence interval 53.6%-61.9%) and 51.7% responded in ODI at 2-month follow-up (P < .05 [confidence interval 47.5%-55.9%]). In addition, patients with complete pain relief (defined as 0/10 on NRS) were noted at both 2-week (n = 239, 33%) and 2-month (n = 130, 18%) follow-up. In subgroup analysis, the paracentral/subarticular disk group had an increased number of responders, 66.0% in NRS and 64.0% in ODI at 2-month follow-up (P < .05). CONCLUSIONS: Two-level TFESIs are effective in the management of radicular pain, but more research is needed to evaluate the utility of this treatment compared with single-level TFESI. Our study showed a greater improvement in pain and function as a result of 2-level TFESIs in the setting of paracentral/subarticular disk herniations. LEVEL OF EVIDENCE: IV.

Gluteus maximus calcific tendonosis: a rare cause of sciatic pain.

Extraspinal causes of radicular pain are rare and are in danger of being overlooked. Here, we present a patient with pain radiating into the posterior thigh and lateral calf. Although initial differential diagnosis included lumbar herniated nucleus pulposus, further imaging revealed the presence of gluteus maximus calcific tendonosis. After physical therapy and a potent oral steroid regimen, the pain gradually resolved and the patient was able to return to full activity.