BACKGROUND: Percutaneous microballoon compression (PMC) is a safe and effective method (1) for treating trigeminal neuralgia (TN). Though many surgeons have carried out this kind of surgery, practitioners who lack sufficient surgical experience may be unaware of this method of improving the clinical effectiveness of PMC for aged patients. OBJECTIVE: To investigate the relationship among the success of the PMC method, the size of a patient’s Meckel’s cave (MC), and the iohexol dosage in a pear-shaped balloon and form a mathematical model for the effectiveness of the treatment. STUDY DESIGN: Retrospective study. SETTING: Neurosurgery Department of Tongling People’s Hospital, China. METHODS: One hundred eighteen patients (34 men and 84 women) undergoing PMC, aged 72.07 ± 7.10 years old, were collected retrospectively in the study. Fifteen of the patients were in Tongling People’s Hospital from September 2022 to March 2024, and 103 were in Nanjing Drum Tower Hospital from January 2023 to October 2023, The sizes of all the patients’ MCs were measured by 3D-Slicer software with preoperative cranial magnetic resonance imaging (MRI); all balloons were of the standardized pear shape, and intraoperative iohexol dosages were recorded. The patient’s score on the Barrow Neurological Institute pain scale (BNI-P) was recorded at 3 time points: before the surgery (Pre_BNI), the first day after the surgery (BNI_1), and the seventh day after the surgery (BNI_7). Correlation analysis was carried out to determine the association between the intraoperative iohexol dosage and MC size. RESULTS: The overall effective rate of PMC was 97.46% (115/118). During the first postoperative day, 3 patients reported feeling pain scores of V on the BNI-P scale. None of the other patients reported an experience of pain. At the 7th day of post-operation, those 3 patients still felt no pain relief, whereas the others continue not to experience pain. There was a significant correlation between iohexol dosage (unit: mL) and MC size (expressed as MC volume, unit: mm3): iohexol dosage (mL) = 0.54336 + 0.00060286 x MC Volume (mm3) - 0.05654 x BNI_1*. ( *The scores from 1 to 5 are equivalent to I to V on the BNI-P.) LIMITATIONS: The study was retrospective, so we could not validate the accuracy of the model by analyzing the iohexol dosage used in the operation; additionally, the duration of the follow-up was short, and the sample size was relatively small. CONCLUSIONS: The equation (iohexol dosage = 0.54336 + 0.00060286 x MC Volume - 0.05654 x BNI_1) yields a value at which operations have a very high success rate, regardless of whether the patients have received previous TN treatment. The equation can be used to guide the intraoperative usage of iohexol and to help surgeons without sufficient surgical experience for predicting patients’ prognoses. KEY WORDS: Trigeminal neuralgia, percutaneous microballoon compression, iohexol dosage, 3D Slicer, Meckel’s cave

BACKGROUND: Chronic low back pain (CLBP) is prevalent, with lumbar spondylolisthesis a common cause of the condition. Spondylolisthesis, the displacement of one vertebra over another, can have various causes. Isthmic and degenerative forms are the most common. Clinicians need to evaluate whether the condition is fixed or dynamic, since dynamic cases may cause vertebral instability and nerve compression, necessitating surgery. Traditional flexion-extension x-rays have been the standard diagnostic tool, but recent studies suggest that alternative imaging methods, such as magnetic resonance imaging or computed tomography, may offer more accurate detection. OBJECTIVE: Spondylolisthesis, often described as the slipping forward of one of the vertebrae, is a common etiology for CLBP. Generally, spondylolisthesis can be categorized as either stable or unstable. Unstable or dynamic spondylolisthesis is usually diagnosed based on the visualization of sagittal translation of the vertebral body on flexion-extension x-rays. However, it has been reported that flexion-extension x-rays may not be the most reliable method for determining the presence of an unstable spondylolisthesis. The present investigation aimed to identify the extent of the literature that discussed alternative imaging techniques for diagnosing dynamic spondylolisthesis. STUDY DESIGN: A retrospective systematic review of original research done on spondylolisthesis from 2000 to 2023. METHODS: A review protocol was followed based on PRISMA guidelines and conducted across 3 databases for relevant articles published between the years 2000 and 2023. Two reviewers screened and characterized the articles independently, and 3 additional reviewers performed full-text analysis and data extraction. RESULTS: The search yielded 13 articles with differences in origin, study design, sample size, and outcomes. Most of the articles were retrospective studies. Of the 13 articles, 11 showed promising results in utilizing alternative imaging to diagnose dynamic spondylolisthesis. LIMITATIONS: The lack of a formally registered protocol and potential publication bias were the limitations for this review. CONCLUSION: The present investigation analyzed the current literature and determined that alternative imaging techniques could adequately diagnose the dynamic instability of the spine. Further research is warranted to establish an in-depth analysis that elucidates the most reliable and sensitive imaging sequence for diagnosing dynamic spondylolisthesis. KEY WORDS: Spondylolisthesis, dynamic spondylolisthesis, unstable spondylolisthesis, vertebrae

BACKGROUND: Genicular nerve blocks (GNBs) are commonly performed prior to performing radiofrequency ablation (RFA) to assess RFA’s potential efficacy. Typically, GNBs are commonly performed with local anesthetic only. The duration of efficacy of GNBs has not been investigated much in the literature. OBJECTIVES: The primary goals of this study were to evaluate for any differences in response to GNBs between using local anesthetic only versus local anesthetic and corticosteroid, and assess for the potential therapeutic benefit of GNBs by examining pain relief percentage, pain relief duration, and change in pain scores. STUDY DESIGN: Randomized prospective trial. SETTING: Fluoroscopy suite at an urban academic teaching hospital. METHODS: Fifty patients with chronic knee osteoarthritis were randomly assigned to undergo a GNB done under fluoroscopic guidance with either bupivacaine only (n = 24, the control group) or bupivacaine and triamcinolone (n = 26, the experimental group). Baseline and postprocedure pain scores were collected on the day of the procedure. Patients were then called at postprocedure 24 hours, 2 weeks, and 6 weeks and asked their maximum percentage of pain relief, duration of pain relief, and Numeric Rating Scale (NRS-11) scores, which were compared between the 2 groups. Associations between these factors and Kellgren-Lawrence Classification of Osteoarthritis scores, body mass index, age, gender, race, and baseline pain scores were also assessed. RESULTS: The mean duration of pain relief was significantly higher in the group administered a corticosteroid (0.87; SD, 0.29 days) compared to the group not administered a corticosteroid (0.64; SD, 0.43 days) at 24 hours postprocedure. No significant differences were found between the 2 groups in pain relief percent, pain relief duration, or NRS-11 scores at any of the 3 time points. No significant difference in changes from baseline NRS-11 scores over time were found between the 2 groups. No significant associations were found between pain relief percent, pain relief duration, and NRS-11 scores regarding age, gender, body mass index, race, Kellgren-Lawrence scores, and baseline pain scores at postprocedure days one, 14, and 42. LIMITATIONS: This was a single-blind, single-center study. It lacked a follow-up at 6 weeks postprocedure, lacked a placebo group, and had a small sample size. CONCLUSION: The addition of a corticosteroid to local anesthetic for GNB may prolong initial analgesic effects within the first postprocedure 24 hours. However, there is no analgesic difference in the weeks following a GNB between procedures done with local anesthetic only or local anesthetic and corticosteroid. These findings suggest that there is a lack of therapeutic benefit and effect on relief duration with using corticosteroids in GNBs. KEY WORDS: Genicular nerve block, radiofrequency ablation, corticosteroid, triamcinolone, local anesthetic, bupivacaine, osteoarthritis

BACKGROUND: The optimal dosing and delivery strategies for intrathecal ziconotide are debated. Previous research suggests that high volume, low concentration dosing techniques may decrease side effects and enhance analgesic effect. Previous studies that have investigated the effects of diluting ziconotide have examined continuous infusions of the medication through an intrathecal pump. OBJECTIVES: This study investigates the trial phase to determine if diluting the bolus dose leads to improved outcomes. The hypothesis of the authors is that the dilution of ziconotide will improve the trial outcomes. STUDY DESIGN: This single-center, retrospective, case-control study included 62 patients with chronic pain refractory to conservative therapy who received a one-time intrathecal bolus dose of ziconotide. METHODS: The study included 62 patients who received a single outpatient trial dose of ziconotide. The study was approved by an institutional review board. Data were collected from electronic medical records. Doses ranged from a total of 2.5 µg–5 µg in a volume of 0.5 mL–5 mL. The primary endpoints were the number of patients that achieved significant pain relief (>= 50%) and the presence or absence of side effects. Statistical analysis was performed using a c2 test to evaluate side effects and meaningful pain relief and an unpaired, 2-tailed t test to evaluate pain relief percentage. RESULTS: There were no differences in side effects experienced by the patients in the Undiluted Group compared to the patients in the Diluted Group (21% vs 25%; P = 0.679). There were no differences in pain relief in the Undiluted Group compared to the Diluted Group (59% vs 61%; P = 0.880). The mean (SD) pain relief in the Undiluted Group was 46% (± 40%) compared to 51% (± 41%) in the Diluted Group (P = 0.645). A power analysis revealed a 68% power to detect a difference between the groups. LIMITATIONS: These results are limited by the accuracy of the chart review and sample size; therefore, additional investigation may be warranted. CONCLUSION: This study demonstrates there is no substantial difference between diluted and undiluted bolus doses of intrathecal ziconotide in regard to analgesic effect or side effects. KEY WORDS: Ziconotide, analgesic, chronic pain, calcium channel, spinal cord

This commentary explores the tragic case of Luigi Mangione, as detailed in Melanie Thernstrom’s Wall Street Journal article, to address the complex interplay between chronic pain, psychological distress, and systemic inadequacies in healthcare. Chronic pain, as a biopsychosocial phenomenon, profoundly impacts not only physical functionality but also identity, cognition, and behavior, often leading to psychological destabilization and despair. Neurobiological evidence illustrates how chronic pain alters neural structures and functions, amplifying emotional reactivity and impairing judgment. Mangione’s descent into violence exemplifies the detrimental cycle of pain, frustration, and alienation, exacerbated by systemic barriers such as inequitable healthcare access and insurance inadequacies. The discussion highlights the broader ethical implications for pain management, emphasizing the necessity of empathetic engagement, equitable care, and individualized therapeutic approaches. While advances in neurotechnology offer new diagnostic and interventional possibilities, their accessibility and integration into practice raise critical ethical concerns. Additionally, responsible opioid prescribing, informed by nuanced understanding of chronic pain, remains essential to addressing the dual challenges of effective pain relief and the opioid epidemic. This analysis calls for a comprehensive paradigm shift in pain care, integrating biopsychosocial methodologies, healthcare reforms, and ethical innovation. By addressing systemic inequities and prioritizing both high- and low-technology solutions, researchers, clinicians, and policymakers can better support patients and mitigate the far-reaching consequences of unaddressed chronic pain. Ultimately, this tragedy underscores the urgent need for actionable reform to prevent further individual and societal harm. KEY WORDS: Chronic pain, psychology, healthcare inequity, neurotechnology, neuroethics

BACKGROUND: Lumbar epidural steroid injections (ESIs) are commonly used to alleviate pain associated with lumbar disorders. However, administering steroids to patients with osteoporosis may lead to a decline in bone mineral density (BMD) and increase fracture risk. While various steroids are utilized in ESIs, limited research exists on their effect on BMD. OBJECTIVES: This study aimed to analyze the effect of dexamethasone-based ESI therapy on osteoporosis in patients receiving or not receiving denosumab, utilizing real-world clinical data. STUDY DESIGN: Retrospective analysis. SETTING: A university hospital orthopedic department. METHODS: A retrospective review was conducted, incorporating patients who underwent denosumab therapy alongside ESIs for pain alleviation from January 2018 through April 2022. Eligibility criteria included patients with a minimum follow-up period of 12 months. Forty patients who had received an ESI and denosumab treatment were enrolled in Group One. Similarly, 35 patients who had only received an ESI (Group 2) and 33 patients who underwent denosumab treatment alone (Group 3) were enrolled and analyzed. Statistical analysis was performed using analysis of variance (ANOVA) to compare patient age, gender, lumbar and hip BMD, difference in lumbar and hip BMD at postinjection one year, serum vitamin D, calcium, phosphorus levels, and one-year cumulative steroid dosage. RESULTS: In terms of patient demographics, the mean age of Group One was 71.73 (± 9.59) years, Group 2 was 70.00 (± 9.82) years, and Group 3 was 71.18 (± 5.64) years. The ANOVA analysis revealed no significant differences among groups. The BMD analysis showed that the lumbar BMD in Group One was 0.811 g/cm2, Group 2 was 0.831 g/cm2, and Group 3 was 0.822 g/cm2. Hip BMD in Group One was 0.696 g/cm2, Group 2 was 0.711 g/cm2, and Group 3 was 0.668 g/cm2. The change in BMD values showed that in Group One, lumbar BMD increased by 0.0411 g/cm2 compared to baseline, a 5.06% increase, while hip BMD increased by 0.0047 g/cm2, a 0.68% increase. In Group 2, lumbar BMD decreased by -0.0307 g/cm2, a 3.7% decrease, and hip BMD decreased by -0.036 g/cm2, a 5.02% decrease. In Group 3, lumbar BMD increased by 0.056 g/cm2, a 6.77% increase, while hip BMD increased by 0.005 g/cm2, a 0.69% increase. LIMITATIONS: The number of patients recruited was relatively small and limited to specific age groups. Study design was retrospective. CONCLUSION: Lumbar ESIs with dexamethasone reduce BMD in elderly patients with osteoporosis. However, when denosumab is administered alongside dexamethasone-based ESIs, the steroid does not significantly affect the decline of BMD. KEY WORDS: Steroid, epidural injection, osteoporosis, antiresorptive agent, denosumab, bone mineral density, lumbar spine

BACKGROUND: Post-COVID pain (PCP) is a condition that ensues from an infection of coronavirus disease 2019 (COVID-19). Some researchers have explored the prevalence of PCP and its characteristics in the individuals who experience it. However, most individuals involved in the previous studies were middle-aged, and those studies focused mainly on hospital patients and musculoskeletal PCP. Existing data on PCP and its subtypes among older adults and outpatients are scanty. OBJECTIVE: Our study aims to identify PCP’s prevalence and associated risk factors and to compare the quality of life (QoL), sleep quality, and anxiety and depression levels in nonhospitalized elderly COVID-19 survivors with different PCP subtypes. STUDY DESIGN: A cross-sectional study. SETTING: The study was conducted from April 2023 to June 2023 after the first outbreak of the Omicron variant of SARS-CoV-2 in the Taikang Yanyuan Continuing Care Retirement Community (CCRC) in China. METHODS: Eligible participants were surveyed using the Numeric Rating Scale (NRS), Douleur Neuropathique-4 questionnaire (DN4), EuroQol 5D-5L questionnaire (EQ-5D-5L), Pittsburgh Sleep Quality Index (PSQI), Generalized Anxiety Disorder 7 (GAD-7) scale, and Patient Health Questionnaire-9 (PHQ-9) scale. COVID-19 symptoms and laboratory parameters were obtained through an electronic healthcare system. Descriptive analysis was performed based on the presence of PCP and PCP subtypes. Multivariable logistic regression analysis and multiple linear regression were used for risk-factor analysis and adjustment of confounding factors. RESULTS: A total of 668 individuals (female: 59.3%, median age: 84 years) who had been infected with COVID-19 for a median duration of 145 (126-168) days were enrolled in our study. PCP was observed in 9.4% (63/668) of elderly COVID-19 survivors. Number of COVID-19 symptoms (aOR 1.31, 95%CI 1.05-1.64, P = 0.018) and previous chronic pain (aOR 4.24, 95%CI 1.59-11.27, P = 0.004) were risk factors associated with PCP. Individuals with neuropathic PCP exhibited higher NRS scores (5 [5-6] vs. 3 [3-4], P < 0.001) and more use of analgesic drugs (70.0%, 7/10 vs. 20.8%, 11/53, P = 0.005) for pain management. Neuropathic PCP was associated with lower scores on the EQ-5D index (B = -0.210, 95% CI -0.369 to -0.051, P = 0.011) and EQ-VAS (B = -10.808, 95% CI -21.149 to -0.468, P = 0.041) and higher PHQ-9 scores (B = 3.154, 95% CI 0.674-5.634, P = 0.014). LIMITATIONS: It is difficult to establish a strong causality between PCP and SARS-CoV-2 infection due to the study’s cross-sectional nature. Selection bias could not be eliminated, since our study relied on volunteer participation. Due to neuropathic PCP’s lower prevalence than nonneuropathic PCP, larger sample sizes and multicenter studies are crucial for a comprehensive understanding of the neuropathic PCP condition. CONCLUSION: Our study found a PCP prevalence of 9.4% in nonhospitalized older adults who had survived COVID-19. Number of COVID-19 symptoms and history of previous chronic pain seemed to be potential risk factors for PCP. Neuropathic PCP was associated with lower QoL and a more severe depression level. KEY WORDS: Post-COVID pain, elderly, prevalence, risk factor, pain subtypes

BACKGROUND: Lumbar disc herniation (LDH) occurs when the central disc material, primarily the nucleus pulposus, is displaced beyond the outer annulus, compressing the spinal nerve roots. LDH symptoms, including radicular leg pain, radiculopathy, and low back pain, are associated with considerable disease burden and the significant utilization of health care resources. OBJECTIVES: Provide overview of the current treatment landscape for LDH, identify unmet needs, and describe emerging treatments. STUDY DESIGN: Narrative literature review. METHODS: A review of literature concerning available LDH treatments and associated outcomes was conducted in PubMed to identify areas of unmet need. Some key words included “lumbar disc herniation,” “radicular leg pain,” “sciatica,” “treatment,” “therapy,” and “burden.” RESULTS: For patients who do not respond to conservative therapy, epidural steroid injections (ESIs) are widely used for persistent LDH symptoms. While ESIs provide short-term improvements in radicular pain, evidence that ESIs bestow sustained benefits is limited. ESIs are not approved by the US Food and Drug Administration (FDA) and, in rare cases, carry risks of infection and neurological injury, as well as the potential for long-term systemic effects of glucocorticoids. In cases when nonsurgical treatment fails to relieve symptoms, lumbar discectomy can provide rapid pain relief; however, in addition to the risk of intraoperative complications, the long-term consequences of lumbar discectomy may include recurrent pain or herniation, revision discectomy, loss of disc height, and Modic changes. Treatments for LDH in late-stage clinical development include sustained-release ESI formulations and a novel agent for chemonucleolysis, a nonsurgical method of minimizing the volume of the displaced nucleus pulposus. Emerging minimally invasive therapies that address the underlying pathophysiology of the disease have the potential to bridge the gap between symptomatic treatments and surgery. LIMITATIONS: Because this paper was a narrative review, literature search and selection processes were not systematic in nature. The evidence regarding the long-term efficacy of some treatments, such as discectomy, was limited by the high rates of crossover between the treatment groups. CONCLUSIONS: The lack of sustained benefits associated with ESIs and the risks associated with surgery underscore the unmet need for novel, minimally invasive interventional therapies able to address the underlying nerve root compression in LDH. KEY WORDS: Lumbar disc herniation, radicular leg pain, lumbar radiculopathy, epidural steroid injection, surgery, microdiscectomy, chemonucleolysis, condoliase, intradiscal therapy, minimally invasive treatment