A multicenter randomized controlled trial on the efficacy of intradiscal methylene blue injection for chronic discogenic low back pain: the IMBI study

Radiofrequency ablation of basivertebral and sinuvertebral nerves for chronic discogenic low back pain: a systematic review and meta-analysis

Radiofrequency ablation (RFA) of the basivertebral and sinuvertebral nerve is a relatively new intervention for patients with chronic discogenic low back pain. It aims to ablate the irritated nerve endings to improve pain control and disability. This meta-analysis includes prospective single and double-arm studies that determine if RFA is effective in improving chronic low back pain and disability for patients with degenerative spinal discs who have not yet required surgical decompression. The outcomes of interest were comprised of commonly used patient-reported outcomes, which included the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) scores. Forest plots were generated to report associations as well as funnel plots to report the risk of publication bias. The meta-analysis included 429 patients from five eligible studies, comprising two randomized controlled trials and three prospective single-arm trials. A total of 280 patients underwent RFA whereas 149 served as controls. The baseline scores in the single-arm trials served as the outcomes of their control group. The RFA group (n = 280) had significantly lower ODI scores (mean difference = - 28.08; 95% CI: [- 43.53, - 12.63]) than the control group (n = 240). Similarly, the RFA group (n = 279) had significantly lower VAS scores (mean difference = - 3.16; 95% CI: [- 5.02, - 1.31]) than the control group (n = 238). Our study demonstrates RFA as a promising intervention for chronic discogenic low back pain, noting significant improvements in pain control and disability. Although not intended to substitute surgical decompression, it can serve as a better alternative to other non-operative therapies in patients who do not require surgical management. Clinical trial number: not applicable.

Discogenic Low Back Pain: Anatomic and Pathophysiologic Characterization, Clinical Evaluation, Biomarkers, AI, and Treatment Options

Discogenic low back pain (LBP) is a significant clinical condition arising from degeneration of the intervertebral disc, a common yet complex cause of chronic pain, defined by fissuring in the annulus fibrosus resulting in vascularization of growing granulation tissue and growth of nociceptive nerve fibers along the laceration area. This paper delves into the anatomical and pathophysiological underpinnings of discogenic LBP, emphasizing the role of intervertebral disc degeneration in the onset of pain. The pathogenesis is multifactorial, involving processes like mitochondrial dysfunction, accumulation of advanced glycation end products, and pyroptosis, all contributing to disc degeneration and subsequent pain. Despite its prevalence, diagnosing discogenic LBP is challenging due to the overlapping symptoms with other forms of LBP and the absence of definitive diagnostic criteria. Current diagnostic approaches include clinical evaluations, imaging techniques, and the exploration of potential biomarkers. Treatment strategies range from conservative management, such as physical therapy and pharmacological interventions, to more invasive procedures such as spinal injections and surgery. Emerging therapies targeting molecular pathways involved in disc degeneration are under investigation and hold potential for future clinical application. This paper highlights the necessity of a multidisciplinary approach combining clinical, imaging, and molecular data to enhance the accuracy of diagnosis and the effectiveness of treatment for discogenic LBP, ultimately aiming to improve patient outcomes.

Methylene Blue, a Unique Topical Analgesic: A Case Report

Background: Rectal prolapse is a circumferential, full-thickness protrusion of the rectum through the anus, which, if not properly managed, may become incarcerated and pose a risk of strangulation. This pathology is rarely a medical emergency unless a complication is encountered. Such complications include infection, necrosis, perforation, incarceration, and uncontrolled pain. Case Presentation: We report a case of an elderly patient with pain associated with chronic rectal prolapse. Surgical intervention had been ruled out, and there had been no pain relief after using systemic analgesics. Case Management: Based on increasing reports of analgesic properties, topical methylene blue (MB) 0.1% was applied externally at the prolapsed organ, obtaining pain relief. Case Outcome: The patient experienced immediate and long-lasting pain relief; MB applications were continued every 12 hours as needed. After this therapy, the patient was no longer in need of systemic analgesics. No side effects were reported. Conclusion: Topical MB may be an effective analgesic for the management of pain associated with chronic rectal prolapse. This treatment might be extrapolated to other clinical scenarios of tegumentary pain. Similar use has been shown to be safe and effective in other pathologies, including pain in oral mucositis associated with cancer therapy.

Chronic Low Back Pain: History, Symptoms, Pain Mechanisms, and Treatment

Chronic low back pain (cLBP) is the most frequently reported cause of years lived with disability. Identifying the anatomical structures or dysfunction contributing to patients' symptoms is critical to guiding treatment. The etiology of back pain and differential diagnosis is often broad, ranging from non-degenerative cLBP (trauma, tumor, inflammation, infection, etc.) to degenerative (also described as nonspecific) cLBP. After eliminating suspicion for more insidious causes of cLBP, a thorough investigation can be conducted in an attempt to identify a source of degenerative cLBP. Degenerative cLBP can originate from many sources, and a detailed understanding of the structures potentially involved is invaluable for an accurate diagnosis. This review article aims to provide a broad overview of the utility of clinical history, physical exam findings, imaging findings, and diagnostic procedures in identifying the cause of patients' cLBP. We provide a framework to help guide clinicians by dividing the structures into groups as follows: anterior vertebral column, posterior vertebral column, and extra-vertebral pain. For each condition listed, we touch on the treatment options that can be considered.

Image-Guided Minimally Invasive Treatment Options for Degenerative Lumbar Spine Disease: A Practical Overview of Current Possibilities

Lumbar back pain is one of the main causes of disability around the world. Most patients will complain of back pain at least once in their lifetime. The degenerative spine is considered the main cause and is extremely common in the elderly population. Consequently, treatment-related costs are a major burden to the healthcare system in developed and undeveloped countries. After the failure of conservative treatments or to avoid daily chronic drug intake, invasive treatments should be suggested. In a world where many patients reject surgery and prefer minimally invasive procedures, interventional radiology is pivotal in pain management and could represent a bridge between medical therapy and surgical treatment. We herein report the different image-guided procedures that can be used to manage degenerative spine-related low back pain. Particularly, we will focus on indications, different techniques, and treatment outcomes reported in the literature. This literature review focuses on the different minimally invasive percutaneous treatments currently available, underlining the central role of radiologists having the capability to use high-end imaging technology for diagnosis and subsequent treatment, allowing a global approach, reducing unnecessary surgeries and prolonged pain-reliever drug intake with their consequent related complications, improving patients' quality of life, and reducing the economic burden.

The effectiveness of intradiscal corticosteroid injection for the treatment of chronic discovertebral low back pain: a systematic review

OBJECTIVE

Determine the effectiveness of intradiscal corticosteroid injection (IDCI) for the treatment of discovertebral low back pain.

DESIGN

Systematic review.

POPULATION

Adults with chronic low back pain attributed to disc or vertebral end plate pain, as evidenced by positive provocation discography or Modic 1 or 2 changes on magnetic resonance imaging.

INTERVENTION

Fluoroscopically guided or computed tomography-guided IDCI.

COMPARISON

Sham/placebo procedure including intradiscal saline, anesthetic, discography alone, or other active treatment.

OUTCOMES

Reduction in chronic low back pain reported on a visual analog scale or numeric rating scale and reduction in disability reported by a validated scale such as the Oswestry Disability Index.

METHODS

Four reviewers independently assessed articles published before January 31, 2023, in Medline, Embase, CENTRAL, and CINAHL. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The risk of bias in randomized trials was evaluated with the Cochrane Risk of Bias tool (version 2).

RESULTS

Of the 7806 unique records screened, 6 randomized controlled trials featuring 603 total participants ultimately met the inclusion criteria. In multiple randomized controlled trials, IDCI was found to reduce pain and disability for 1-6 months in those with Modic 1 and 2 changes but not in those selected by provocation discography.

CONCLUSION

According to GRADE, there is low-quality evidence that IDCI reduces pain and disability for up to 6 months in individuals with chronic discovertebral low back pain as evidenced by Modic 1 and 2 changes but not in individuals selected by provocation discography.

STUDY REGISTRATION

PROSPERO (CRD42021287421).

Efficacy of stepped care treatment for chronic discogenic low back pain patients with Modic I and II changes

Objective

This study investigated whether patients with Modic changes (MC) of types I, I/II, and II would respond to an anti-inflammatory-based, stepped care treatment with three treatment steps: first, oral administration of NSAIDs, 2 × 200 mg celecoxib daily for two weeks; second, an intradiscal steroid injection (ID) with dexamethasone and cefazolin; and third, oral treatment with antibiotics (AB), 3 × 1 g amoxicillin daily for 100 days.

Design

This was an observational clinical study based on analyses of categorical data of patient-reported outcome measurements.

Subjects

Subjects were consecutive patients with chronic low back pain (CLBP), diagnosed by assessment of anamnestic signs of inflammation; a pain score ≥6 on the Numeric Pain Rating Scale (NPRS); a mechanical assessment; MC I, I/II, or II based on MRI; and lack of response to conservative treatment.

Methods

From January 1, 2015, to December 31, 2021, 833 eligible patients were selected for the stepped care treatment. A total of 332 patients completed requested follow-up questionnaires at baseline and 12 months (optional at 3 and 6 months). Primary outcomes were pain (at least 50 % pain relief) and/or a minimum of 40 % improvement in functionality as measured by the Roland Morris Disability Questionnaire (RMDQ) or the Oswestry Disability Questionnaire (ODI). Secondary outcome measures were use of pain medication and return to work.

Results

At 1 year of follow-up, 179 (53.6 %) of 332 patients reported improvement according to the responder criteria. Of the 138 patients that had received only NSAIDs, 88 (63.8 %) had improved. In addition, 50 (56.8 %) of the 183 patients that had received ID had improved, and 41 (38.7 %) of the 106 patients treated with AB had improved. None of the patients reported complications. 12.0 % of patients using AB stopped preterm due to undesirable side effects.

Conclusion

Treatment with a stepped care model for inflammatory pain produced clinically relevant, positive reported outcomes on pain and/or function. Our stepped care model appears to be a useful, safe, and cost-saving treatment option that is easily reproducible. Further studies, including randomized controlled trials and analyses of subgroups, may help to develop a more patient-tailored approach and further avoidance of less-effective treatments and costs.

Interventional Therapy and Surgical Management of Lumbar Disc Herniation in Spine Surgery: A Narrative Review

Significant advancements in lumbar disc herniation (LDH) management have been made in interventional pain therapy, operative therapy, peri-operative management, and cost analysis of various procedures. The present review aims to provide a concise narrative of all these topics, current trends, and possible future directions in the management of LDH. Interventional pain management using intradiscal injections often serves as a minimally invasive non-surgical approach. Surgical modalities vary, including traditional open laminectomy, microdiscectomy, endoscopic discectomy, tubular discectomy, percutaneous laser disc decompression, and transforaminal foraminotomy. Prevention of infections during surgery is paramount and is often done via a single-dose preoperative antibiotic prophylaxis. Recurrence of LDH post-surgery is commonly observed and thus mitigative strategies for prevention have been proposed including the use of annular closure devices. Finally, all treatments are well-associated with clear as well as hidden costs to the health system and society as described by billing codes and loss of patients' quality-adjusted life-years. Our summary of recent literature regarding LDH may allow physicians to employ up-to-date evidence-based practice in clinical settings and can help drive future advancements in LDH management. Future longitudinal and comprehensive studies elucidating how each type of treatments fare against different types of herniations are warranted.

Patent blue versus methylene blue and indigo carmine as a better dye for chromodiscography: in vitro staining efficacy and cytotoxicity study using bovine coccygeal intervertebral discs

BACKGROUND CONTEXT

Chromodiscography is an integral part of full-endoscopic discectomy (FED), comprising ordinary discography with radiopacity produced by contrast medium and intradiscal stain for visualizing annular defects in the endoscopic field. Nevertheless, concerns remain about the cytotoxicity of the stains used. The study of their staining efficacy is also lacking.

PURPOSE

To evaluate the feasibility of methylene blue, patent blue, and indigo carmine for intradiscal injection, investigate the effectiveness of each dye, and define critical concentration with adequate staining efficacy and tolerable cytotoxicity for use in chromodiscography during FED.

STUDY DESIGN

An experimental in vitro study.

METHODS

Dye stock solutions were prepared from powder. The stock was diluted with culture medium or balanced saline and used for cytotoxicity or intervertebral disc staining assays, respectively. Bovine tails were obtained from the local slaughterhouse and functional spine units of intervertebral discs were acquired by transverse incision at the disc level. Each disc was punctured over the posterolateral aspect using a surgical knife to simulate an annular defect. The intradiscal injection was performed with each dye at different concentrations using a 22G needle from the contralateral aspect of the punctured site. Staining efficacy was quantified using ImageJ software. Primary cells of bovine tails were cultivated in each dye at different concentrations. Cytotoxicity was assessed 24 hours after stain exposure using the CCK-8 toxicity assay.

RESULTS

Staining efficacy and cytotoxicity were proportional to the concentration of tested dyes. Lower limits of concentration producing significant staining efficacy of indigo carmine, methylene blue, and patent blue were 0.25 mg/mL, 0.25 mg/mL, and 0.05 mg/mL, respectively. Compared with controls, concentrations showing significant toxicity for indigo carmine, methylene blue, and patient blue were 1 mg/mL, 0.5 mg/mL, and 2.5 mg/mL, respectively.

CONCLUSIONS

Patent blue can serve as a more suitable tissue stain than either indigo carmine or methylene blue due to the widest range of tradeoff concentration within 0.05 to 2.5 mg/mL.

CLINICAL SIGNIFICANCE

Patent blue with the characteristic of good staining efficacy and lower cytotoxicity may be a promising option for chromodiscography during FED.

SIRT5-related desuccinylation modification of AIFM1 protects against compression-induced intervertebral disc degeneration by regulating mitochondrial homeostasis

Mitochondrial dysfunction plays a major role in the development of intervertebral disc degeneration (IDD). Sirtuin 5 (SIRT5) participates in the maintenance of mitochondrial homeostasis through its desuccinylase activity. However, it is still unclear whether succinylation or SIRT5 is involved in the impairment of mitochondria and development of IDD induced by excessive mechanical stress. Our 4D label-free quantitative proteomic results showed decreased expression of the desuccinylase SIRT5 in rat nucleus pulposus (NP) tissues under mechanical loading. Overexpression of Sirt5 effectively alleviated, whereas knockdown of Sirt5 aggravated, the apoptosis and dysfunction of NP cells under mechanical stress, consistent with the more severe IDD phenotype of Sirt5 KO mice than wild-type mice that underwent lumbar spine instability (LSI) surgery. Moreover, immunoprecipitation-coupled mass spectrometry (IP-MS) results suggested that AIFM1 was a downstream target of SIRT5, which was verified by a Co-IP assay. We further demonstrated that reduced SIRT5 expression resulted in the increased succinylation of AIFM1, which in turn abolished the interaction between AIFM1 and CHCHD4 and thus led to the reduced electron transfer chain (ETC) complex subunits in NP cells. Reduced ETC complex subunits resulted in mitochondrial dysfunction and the subsequent occurrence of IDD under mechanical stress. Finally, we validated the efficacy of treatments targeting disrupted mitochondrial protein importation by upregulating SIRT5 expression or methylene blue (MB) administration in the compression-induced rat IDD model. In conclusion, our study provides new insights into the occurrence and development of IDD and offers promising therapeutic approaches for IDD.

Application of methylene blue combined with ropivacaine intercostal nerve block in postoperative analgesia of autologous costal cartilage augmentation rhinoplasty

OBJECTIVE

To observe the effect of methylene blue combined with ropivacaine intercostal nerve block on postoperative analgesia after autologous costal cartilage augmentation rhinoplasty.

METHODS

In this study 100 female patients who underwent autologous costal cartilage comprehensive augmentation rhinoplasty in Chongqing Huamei Plastic Surgery Hospital from April to November 2021 were randomly divided into an experimental group and a control group, with 50 cases in each group. In the experimental group methylene blue was combined with ropivacaine intercostal nerve block as patient controlled intravenous analgesia (PCIA), and the control group was ropivacaine intercostal nerve block combined with PCIA. The visual analogue scale (VAS) scores of resting and coughing at 6 h (T1), 24 h (T2), 48 h (T3), 72 h (T4) after surgery were recorded and evaluated. At the same time, the number and times of oral analgesics were recorded as well as nausea, vomiting, burning pain and paresthesia.

RESULTS

The VAS scores of the experimental group were lower than those of the control group at all time points. At 6 h, 24 h and 48 h after surgery, the VAS score of the experimental group was lower than that in the control group, but the difference was not statistically significant (P > 0.05). The VAS score of calm 72 h after surgery in the experimental group was significantly lower than that in the control group (P < 0.05). The analgesic effect of the two groups was better when they coughed after surgery. At 6 h after surgery, the VAS score of coughing in the experimental group was lower than that in the control group, but the difference was not statistically significant (P > 0.05); At 24 h, 48 h and 72 h after surgery, the VAS score of the coughing state in the experimental group was significantly lower than that in the control group (P < 0.05).

CONCLUSION

Intercostal nerve block with methylene blue combined with ropivacaine can achieve good postoperative analgesic effects in augmentation rhinoplasty with autologous costal cartilage.

Methylene blue for intractable pain from oral mucositis related to cancer treatment: a randomized phase 2 clinical trial

BACKGROUND

Oral mucositis (OM) in patients receiving cancer therapy is thus far not well managed with standard approaches. We aimed to assess the safety and effectiveness of methylene blue (MB) oral rinse for OM pain in patients receiving cancer therapy.

METHODS

In this randomized, single-blind phase 2 clinical trial, patients were randomized to one of four arms: MB 0.025%+conventional therapy (CTx) (n = 15), MB 0.05%+CTx (n = 14), MB 0.1%+CTx (n = 15), or CTx alone (n = 16). Intervention groups received MB oral rinse every 6 h for 2 days with outcomes measured at days 1-2; safety was evaluated up to 30 days. The primary outcome measured change in the pain numeric rating scale (0-10) from baseline to day 2. Secondary outcome measured change in oral function burden scores from baseline to day 2, World Health Organization OM grades, morphine equivalent daily doses, and adverse events. The trial was registered with ClinicalTrials.gov ID: NCT03469284.

RESULTS

Sixty patients (mean age 43, range 22-62 years) completed the study. Compared with those who received CTx alone, those who received MB had a significant reduction of pain scores at day 2 of treatment (mean ± SD); 0.025%: 5.2 ± 2.9, 0.05%: 4.5 ± 2.9, 0.1%: 5.15 ± 2.6) and reduction of oral function burden scores (0.025%: 2.5 ± 1.55, 0.05%: 2.8 ± 1.7, 0.1%: 2.9 ± 1.60). No serious adverse events were noted, but eight patients reported burning sensation of the oral cavity with the first dose, and this caused one patient to discontinue therapy.

CONCLUSIONS

MB oral rinse showed significant pain reduction and improved oral functioning with minimal adverse effects.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03469284.

The Effectiveness of Intraosseous Basivertebral Nerve Radiofrequency Ablation for the Treatment of Vertebrogenic Low Back Pain: An Updated Systematic Review with Single-Arm Meta-analysis

OBJECTIVE

To provide an estimate of the effectiveness of basivertebral nerve (BVN) radiofrequency ablation (RFA) to treat vertebrogenic low back pain (LBP).

DESIGN

Systematic review with single-arm meta-analysis.

POPULATION

Persons ≥18 years of age with chronic LBP associated with type 1 or 2 Modic changes.

INTERVENTION

Intraosseous BVN RFA.

COMPARISON

Sham, placebo procedure, active standard care treatment, or none.

OUTCOMES

The proportion of patients treated with BVN RFA who reported ≥50% pain score improvement on a visual analog scale or numeric rating scale. The main secondary outcome was ≥15-point improvement in Oswestry Disability Index score.

METHODS

Three reviewers independently assessed articles published before December 6, 2021, in MEDLINE and Embase. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was used to evaluate the overall quality of evidence.

RESULTS

Of the 856 unique records screened, 12 publications met the inclusion criteria, representing six unique study populations, with 414 participants allocated to receive BVN RFA. Single-arm meta-analysis showed a success rate of 65% (95% confidence interval [CI] 51-78%) and 64% (95% CI 43-82%) for ≥50% pain relief at 6 and 12 months, respectively. Rates of ≥15-point Oswestry Disability Index score improvement were 75% (95% CI 63-86%) and 75% (95% CI 63-85%) at 6 and 12 months, respectively.

CONCLUSION

According to GRADE, there is moderate-quality evidence that BVN RFA effectively reduces pain and disability in most patients with vertebrogenic LBP. Further high-quality studies will likely improve our understanding of the effectiveness of this procedure.

Efficacy of the Gelstix nucleus augmentation device for the treatment of chronic discogenic low back pain: protocol for a randomised, sham-controlled, double-blind, multicentre trial

INTRODUCTION

Discogenic pain is the cause of pain in 26%-40% of patients with for low back pain. Consensus about treatment of chronic discogenic low back pain is lacking and most treatment alternatives are supported by limited evidence. The percutaneous implantation of hydrogels into the nucleus pulposus represents a promising regenerative intradiscal therapy. The hydrogel 'GelStix' is composed primarily of hydrolyzed polyacrylonitrile and acts as a reservoir of hydration, producing increased pressure and improved pH balance, potentially leading to disc preservation. We hypothesise that treatment with GelStix will lead to greater reduction in pain intensity at 6 months post-treatment compared with patients receiving sham treatment.

METHODS AND ANALYSIS

This is a parallel group, randomised sham-controlled double-blind, multicentre trial to assess whether the GelStix device is superior to sham in reducing pain intensity in patients with chronic discogenic low back pain. The study will be conducted in two regional hospitals in Europe. Seventy-two participants will be randomised in a 1:1 ratio. The primary outcome will be the change in pain intensity between preoperative baseline and at 6 months postintervention. Secondary outcomes were disability, quality of life, the patient's global impression of change scale, the use of pain medication and the disc degeneration process assessed by means of MRI. For change in pain intensity, disability, health-related quality of life and disc height, mean values will be compared between groups using linear regression analysis, adjusted for treatment centre.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of the Canton Ticino, Switzerland (CE2982) and by the Medical Ethical Committee Arnhem-Nijmegen, the Netherlands (2016-2944). All patients that agree to participate will be asked to sign an informed consent form. Results will be disseminated through international publications in peer-reviewed journals, in addition to international conference presentations.

TRIAL REGISTRATION NUMBER

NCT02763956.

PROTOCOL VERSION

7.1, 18 November 2020.

Intradiscal injection for the management of low back pain

Low back pain (LBP) is a common clinical problem and a major cause of physical disability, imposing a prominent socioeconomic burden. Intervertebral disc degeneration (IDD) has been considered the main cause of LBP. The current treatments have limited efficacy because they cannot address the underlying degeneration. With an increased understanding of the complex pathological mechanism of IDD, various medications and biological reagents have been used for intradiscal injection for the treatment of LBP. There is increasing clinical evidence showing the benefits of these therapies on symptomatic relief and their potential for disc repair and regeneration by targeting the disrupted pathways underlying the cause of the disease. A brief overview of the potential and limitations for these therapies are provided in this review, based on the recent and available data from clinical trials and systematic reviews. Finally, future perspectives are discussed.

Effectiveness of intradiscal platelet rich plasma for discogenic low back pain without Modic changes: A randomized controlled trial

Objective

To determine if autologous platelet-rich plasma (PRP) injection into a degenerative intervertebral disc, without Modic changes on magnetic resonance imaging (MRI), improve pain and function.

Design

Prospective, randomized controlled study.

Setting

Outpatient spine practice (Stichting Rugpoli, Netherlands).

Participants

Adults with chronic low back pain referred to Stichting Rugpoli, according to the Dutch General Practitioners Guidelines, unresponsive to conservative treatment, without Modic changes on MRI.

Methods

Provocation discography was performed to confirm the suspected disc was the source of pain. Participants were randomized to receive 1.0 ​cc intradiscal PRP (intervention) or 1.0 ​cc Saline with 0.2g Kefzol (control). Data on pain (Numeric Rating Scale), physical function (Roland Morris Disabilty Questionnaire, RMDQ), and participants' general perceived health (SF-12) were collected at 1 week, 4 weeks, 2 months, 6 months, 9 months and 1 year. A repeated-measures analysis (mixed model) was used for comparing the outcomes of the groups.

Results

Of the initial 98 (49 intervention, 49 control) patients randomized, 89 (91%) (44 intervention, 45 control) with complete outcome data were analyzed. Groups were balanced at baseline. After twelve months no differences between groups were found in the average pain (improved 21/44 in intervention vs 16/45 in control, p ​= ​0.244), the disability scores (RMDQ minimal 3 points improvement 22/44 in intervention vs 24/45 in control, p ​= ​0.753) and the SF-12 (mean difference physical health -1.19, 95% CI -5.39 to 2.99, p ​= ​0.721, and mental health -0.34, 95% CI -3.99 to 3.29, p ​= ​0.834). One serious adverse event occurred (spondylodiscitis) after intervention.

Conclusion

Participants who received intradiscal PRP showed no significant improvement in pain or functionality compared to the control group at 1 year follow up.

Efficacy Analysis of Percutaneous Endoscopic Spinal Surgery for Young Patients with Discogenic Low Back Pain

Purpose

To evaluate the application value of percutaneous endoscopic spinal surgery for young patients with discogenic low back pain (DLBP) and to judge its clinical efficacy.

Methods

We retrospectively analyzed young patients with single-segment discogenic lumbago from July 2018 to June 2020 in our department who underwent percutaneous endoscopic surgery according to the inclusion and exclusion criteria. We finally enrolled 20 patients. The follow-up time was 6–30 months. In all patients, we recorded the visual analog scale (VAS) score for waist pain and the Oswestry Disability Index (ODI) preoperatively, immediately postoperatively and at the last follow-up. We used the modified MacNab criteria to assess the curative effect at the last follow-up.

Results

All 20 patients underwent successful operations without complications. No recurrence was observed during follow-up. The VAS score of low back pain was 5.05±1.19 points before surgery, 1.50±051 points immediately after surgery, and 1.10±0.72 points at the last follow-up (P < 0.05 preoperative vs both postoperative). At the last follow-up, the VAS scores of all 20 patients were ≤2, and 4 patients had no pain. The ODI was 46.66±7.03% before surgery, 9.78±4.05% immediately after surgery, and 4.11±3.18% at the last (P < 0.05, preoperative vs both postoperative). According to the evaluation under the modified MacNab standard, the good–excellent rate of clinical efficacy at the last follow-up was 95%.

Conclusion

Percutaneous endoscopic spinal surgery can significantly improve the symptoms and dysfunction of young patients with DLBP and has little effect on the biomechanical stability of the lumbar spine. This surgery has great clinical application value.

Clinical important improvement of chronic pain patients in randomized controlled trials and the DATAPAIN cohort

BACKGROUND

Change on the Numeric Rating Scale (NRS) is based on subjective pain experience, hampering the establishment of clinically important improvement. An anchor-based method, the Patients' Global Impression of Change (PGIC), is often added to determine whether a patient has improved. A two-point change on the NRS has been shown to be equivalent to a moderate clinically important improvement in randomized controlled trials (RCT's) on medication effects. We contemplated whether these findings could be reproduced in cohort and data and in non-drug interventional RCT's.

METHODS

The NRS change was quantified by subtracting the NRS of baseline from the NRS at 6-month follow-up. Categorization of success/nonsuccess was applied on the PGIC, and their average NRS raw changes were calculated. The Spearman correlation coefficient quantified the overall relationship, while the discriminative ability was explored through the receiver operating characteristic curve. Data were stratified on design, sex, and pain intensity at baseline. Besides, the cohort evaluated treatment status at follow-up.

RESULTS

The records of 1661 patients were examined. Overall, the observed NRS change needed for moderate clinically important improvement was larger than the average two points. Yet, the changes in the cohort were smaller compared with the RCT's. Moreover, it modified with pain intensity at baseline and treatment statuses indicated differences in mean clinical importance of -4.15 (2.70) when finalized at 6 months and -2.16 (2.48) when treatment was ongoing.

CONCLUSION

The moderate clinically important improvement varied substantially, representing heterogeneity in pain relief and its relation to treatment success in chronic pain patients.

Effects of a BMI1008 mixture on postoperative pain in a rat model of incisional pain

Background

The purpose of this study was to evaluate the analgesic effect of BMI1008 (a new drug containing lidocaine, methylene blue, dexamethasone and vitamin B complex) and to investigate the analgesic effect of lidocaine and BMI-L (other components of BMI1008 except lidocaine) at different concentrations in a rat model of incisional pain.

Methods

Male Sprague-Dawley rats (250–300 g) were used for the incisional pain model simulating postoperative pain. After the operation, normal saline, various concentrations of BMI1008, lidocaine with a fixed concentration of BMI-L, and BMI-L with a fixed concentration of lidocaine were injected at the incision site. The preventive analgesic effect was evaluated using BMI1008 administered 30 min before and immediately after the operation. In addition, BMI1008 was compared with positive controls using intraperitoneal ketorolac 30 mg/kg and fentanyl 0.5 μg/kg. The mechanical withdrawal threshold was measured with a von Frey filament.

Results

The analgesic effect according to the concentration of BMI1008, lidocaine with a fixed concentration of BMI-L, and BMI-L with a fixed concentration of lidocaine showed a concentration-dependent response and statistically significant difference among the groups (P <0.001, P <0.001, and P <0.001, respectively). The analgesic effect according to the time point of administration (before and after the operation) showed no evidence of a statistically significant difference between the groups (P = 0.170). Compared with the positive control groups, the results showed a statistically significant difference between the groups (P = 0.024).

Conclusion

BMI1008 showed its analgesic effect in a rat model of incisional pain in a concentration-dependent manner. Moreover, BMI-L showed an additive effect on the analgesic effect of lidocaine.

Intervertebral disc therapies for non-specific chronic low back pain: a systematic review and meta-analysis

Objectives

We aim to evaluate the benefits and harms of intervertebral disc therapies (IDTs) in people with non-specific chronic low back pain (NScLBP).

Methods

We conducted a systematic review and meta-analysis of randomized trials of IDTs versus placebo interventions, active comparators or usual care. EMBASE, MEDLINE, CENTRAL and CINHAL databases and conference abstracts were searched from inception to June 2020. Two independent investigators extracted data. The primary outcome was LBP intensity at short term (1 week-3 months), intermediate term (3-6 months) and long term (after 6 months).

Results

Of 18 eligible trials (among 1396 citations), five assessed glucocorticoids (GCs) IDTs and were included in a quantitative synthesis; 13 assessed other products including etanercept (n = 2), tocilizumab (n = 1), methylene blue (n = 2), ozone (n = 2), chymopapaine (n = 1), glycerol (n = 1), stem cells (n = 1), platelet-rich plasma (n = 1) and recombinant human growth and differentiation factor-5 (n = 2), and were included in a narrative synthesis. Standardized mean differences (95% CI) for GC IDTs for LBP intensity and activity limitations were -1.33 (-2.34; -0.32) and -0.76 (-1.85; 0.34) at short term, -2.22 (-5.34; 0.90) and -1.60 (-3.51; 0.32) at intermediate term and -1.11 (-2.91; 0.70) and -0.63 (-1.68; 0.42) at long term, respectively. Odds ratios (95% CI) for serious and minor adverse events with GC IDTs were 1.09 (0.25; 4.65) and 0.97 (0.49; 1.91).

Conclusion

GC IDTs are associated with a reduction in LBP intensity at short term in people with NScLBP. Positive effects are not sustained. IDTs have no effect on activity limitations. Our conclusions are limited by high heterogeneity and a limited methodological quality across studies.

Registration

PROSPERO: CRD42019106336.

The Effectiveness of Intraosseous Basivertebral Nerve Radiofrequency Neurotomy for the Treatment of Chronic Low Back Pain in Patients with Modic Changes: A Systematic Review

OBJECTIVE

Determine the effectiveness of intraosseous basivertebral nerve radiofrequency neurotomy for the treatment of chronic low back pain with type 1 or 2 Modic changes.

DESIGN

Systematic review.

POPULATION

Persons aged ≥18 years with chronic low back pain with type 1 or 2 Modic changes.

INTERVENTION

Intraosseous basivertebral nerve radiofrequency neurotomy.

COMPARISON

Sham, placebo procedure, active standard care treatment, or none.

OUTCOMES

The primary outcome of interest was the proportion of individuals with ≥50% pain reduction. Secondary outcomes included ≥10-point improvement in function as measured by Oswestry Disability Index as well as ≥2-point reduction in pain score on the Visual Analog Scale or Numeric Rating Scale, and decreased use of pain medication.

METHODS

Three reviewers independently assessed publications before May 15, 2020, in MEDLINE and Embase and the quality of evidence was evaluated using the Grades of Recommendation, Assessment, Development, and Evaluation framework.

RESULTS

Of the 725 publications screened, seven publications with 321 participants were ultimately included. The reported 3-month success rate for ≥50% pain reduction ranged from 45% to 63%. Rates of functional improvement (≥10-point Oswestry Disability Index improvement threshold) ranged from 75% to 93%. For comparison to sham treatment, the relative risk of treatment success defined by ≥50% pain reduction and ≥10-point Oswestry Disability Index improvement was 1.25 (95% confidence interval [CI]: .88-1.77) and 1.38 (95% CI: 1.10-1.73), respectively. For comparison to continued standard care treatment the relative risk of treatment success defined by ≥50% pain reduction and ≥10-point Oswestry Disability Index improvement was 4.16 (95% CI: 2.12-8.14) and 2.32 (95% CI: 1.52-3.55), respectively.

CONCLUSIONS

There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings.

Methylene Blue Application to Lessen Pain: Its Analgesic Effect and Mechanism

Methylene blue (MB) is a cationic thiazine dye, widely used as a biological stain and chemical indicator. Growing evidence have revealed that MB functions to restore abnormal vasodilation and notably it is implicated even in pain relief. Physicians began to inject MB into degenerated disks to relieve pain in patients with chronic discogenic low back pain (CDLBP), and some of them achieved remarkable outcomes. For osteoarthritis and colitis, MB abates inflammation by suppressing nitric oxide production, and ultimately relieves pain. However, despite this clinical efficacy, MB has not attracted much public attention in terms of pain relief. Accordingly, this review focuses on how MB lessens pain, noting three major actions of this dye: anti-inflammation, sodium current reduction, and denervation. Moreover, we showed controversies over the efficacy of MB on CDLBP and raised also toxicity issues to look into the limitation of MB application. This analysis is the first attempt to illustrate its analgesic effects, which may offer a novel insight into MB as a pain-relief dye.

Intradiskal Injection of Methylene Blue for Discogenic Back Pain: A Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

 Intradiskal injection of methylene blue has some potential in alleviating discogenic back pain. This meta-analysis aims to explore the impact of intradiskal injection of methylene blue for discogenic back pain.

METHODS

 Several databases such as PubMed, EMbase, Web of Science, EBSCO, and Cochrane Library databases have been searched through November 2019, and randomized controlled trials (RCTs) assessing the effect of intradiskal injection of methylene blue for discogenic back pain are included.

RESULTS

 Three RCTs are included in the meta-analysis. Overall, compared with control group for discogenic back pain, intradiskal injection of methylene blue remarkably decreased pain scores at 3 months (mean difference [MD] = -0.71; 95% confidence interval [CI] = -0.96 to -0.46; p < 0.00001) and 6 months (MD = -13.92; 95% CI = -22.31 to -5.54; p = 001) and Oswestry Disability Index (ODI) at 4 to 6 weeks (MD = -10.39; 95% CI = -16.95 to -3.83; p = 0.002) and 3 months (MD = -3.66; 95% CI = -4.85 to -2.48; p < 0.00001), but demonstrated no obvious effect on ODI at 6 months (MD = -11.76; 95% CI = -33.33 to 9.80; p = 0.28).

CONCLUSIONS

 Intradiskal injection of methylene blue can substantially decrease pain scores and improve function for discogenic back pain.

Methylene blue induces an analgesic effect by significantly decreasing neural firing rates and improves pain behaviors in rats

Methylene blue (MB) is a blue cationic thiazine dye and currently used in different medical settings. Notably, there have been several attempts to introduce MB for attenuating pain in the last decade. Some clinical studies reported remarkable results, which, however, have been much debated. In addition, accumulating evidence have revealed that MB diminishes voltage-gated sodium channel currents. Accordingly, in the present study, we conducted in vivo experiments, including in vivo single nerve recording and behavioral test, to investigate whether MB dampens neural firing rates and ultimately contributes to pain relief. As a result, neural firing rates significantly decreased and finally converged to zero after MB administration. This event lasted longer than that of lidocaine and was dose-dependently modulated. Furthermore, there was a marked improvement in pain behaviors. The withdrawal threshold and latency of hind paws significantly rose post-MB administration. Therefore, these results demonstrate that MB lessens pain by significantly weakening neural excitability, which implies a strong possibility that this dye may be developed as a pain-relieving medication in the future. This is the first in vivo study to elucidate the effect of MB on nerves and pain relief.

The clinical efficacy and experience of bipedicular percutaneous vertebroplasty combined with postural reduction in the treatment of Kümmell's disease

Background

Kümmell’s disease is a special type of osteoporotic vertebral fracture that causes chronic low back pain and deformity, which seriously affects the living quality of patients. PVP is commonly used to treat osteoporotic vertebral fractures and can quickly relieve low back pain. So, the objective of this study was to analyze the clinical efficacy and experience of bipedicular percutaneous vertebroplasty combined with postural reduction for the treatment of Kümmell’s disease.

Methods

A retrospective analysis of patients with Kümmell’s disease who underwent bipedicular percutaneous vertebroplasty was conducted from February 2016 to May 2018. Operative time, VAS, bone cement injection volume, cement leakage rate, compression improvement of vertebral front edge and vertebral center, and correction degree of kyphosis were collected and analyzed meticulously.

Results

The operative time was 45.33 ± 7.64 min. The volume of bone cement injected was 5.38 ± 1.33 ml. The compression improvement of vertebral front edge was 7.31 ± 1.21%. The compression improvement of vertebral center was 10.34 ± 1.15% and the correction degree of kyphosis was − 2.73 ± 0.31゜. Bone cement leakage occurred in 6 of 39 patients (15.38%), but no clinical symptoms were observed. The VAS scores were significantly lower at 1 day after the surgery, 6 months and at the last follow-up than before the surgery (P = 0.000, respectively). The VAS score was lower at the last follow-up than at 1 day after the surgery (P = 0.001).

Conclusion

Bipedicular percutaneous vertebroplasty combined with postural reduction could achieve satisfactory analgesic effect in the treatment of Kümmell’s disease, and restore the height of the vertebral body and improve kyphosis to some extent.

Could methylene blue be used to manage burning mouth syndrome? A pilot case series

Objective: Burning mouth syndrome is a disabling condition of complex pathophysiology characterized by spontaneous pain felt in the oral mucosa in the absence of evident mucosal lesions which lacks efficient treatments to this day. The purpose of this study was to demonstrate the efficacy of methylene blue in the management of burning mouth syndrome. Methods: The study was conducted at the dental clinic of the Anta Diop University and Newtown dental clinic of Dakar, Senegal. A solution of methylene blue as a mouth-rinse (0.5%) was applied for 5 minutes in five patients satisfying the ICHD-3 diagnostic criteria for burning mouth syndrome. This procedure was repeated every 6 hours 3 times per 24h, during 7 days. Using numeric rating scale, pain severity was assessed as the mean pain felt during the last day of application. Results: After 7 days, the pain was significantly reduced by two-thirds and almost absent at 3 and 6 months follow-up. No secondary effects of the use of methylene blue were observed. Putative mechanisms of action and potential implications for treatment are discussed. Conclusion: Methylene blue is an old compound but a novel topical therapy that could prove beneficial in the management of burning mouth syndrome.