Earticle

Sarcopenia is a progressive and generalized skeletal muscle disorder characterized by the accelerated loss of muscle mass and function. It is associated with increased morbidity and mortality, particularly in older adults. According to the World Health Organization (WHO), the global population aged 60 years and older has doubled since 1980 and is projected to reach 2 billion by 2050, with more than 400 million individuals aged 80 years or older. As aging progresses, older adults experience a decline in mTORC1 (mammalian target of rapamycin complex 1) signaling activity, which plays a crucial role in protein synthesis and muscle maintenance. This leads to reduced anabolic response and impaired muscle protein synthesis. Therefore, adequate intake of essential amino acids, particularly those containing leucine, is important for preventing and managing sarcopenia in the elderly. Livact®, a branched-chain amino acid (BCAA) formulation containing leucine, isoleucine, and valine, has gained attention as a potential therapeutic option for sarcopenia. Studies suggest that combining Livact® supplementation with resistance exercise can significantly improve physical function, increase muscle mass, and enhance muscle strength in older adults. This evidence supports the clinical utility of BCAA supplementation, particularly Livact®, in the management of sarcopenia among the elderly population.

Failed Back Surgery Syndrome (FBSS) is a condition where persistent neuropathic pain continues despite spinal surgery, often resistant to conventional treatments such as transforaminal epidural block (TFEB). This report presents a 63-year-old female patient who underwent posterolateral fusion (PLF) and interbody fusion (IF) at L4-5 but continued to experience severe low back pain (Numeric rating scale, NRS 7) and radiating pain (NRS 9), along with motor weakness and claudication. MRI revealed foraminal disc extrusion at L5-S1 compressing the left L5 nerve and moderate central spinal stenosis at L3-4. Despite multiple TFEBs, pain relief was only temporary, leading to the decision to perform retrodiscal approach percutaneous epidural adhesiolysis (PEA) using the WHIP catheter® in January 2025. The procedure combined hydraulic force via high-pressure injection of saline and medications with mechanical force through catheter manipulation to disrupt adhesions. Following the procedure, NRS decreased from 7 to 1, and the effect was sustained at one month, with significant improvement in paresthesia, calf pain, and leg swelling. The Patient’s Global Impression of Change (PGIC) score indicated "greatly improved," reflecting high patient satisfaction. This case suggests that retrodiscal approach PEA using the WHIP catheter® may be an effective alternative for FBSS patients unresponsive to TFEB, offering substantial and sustained pain relief. Further studies are needed to establish long-term efficacy and patient selection criteria.

Cervical epidural steroid injection (C-ESI) is often performed as a treatment for cervical radicular pain. However, stellate ganglion block (SGB) may be effective in improving cervical radiculopathy. We present two cases of patients with unilateral cervical radicular pain who showed significant symptom relief following ultrasound-guided SGB. Pain severity was evaluated using NRS. Both patients demonstrated marked improvement in pain after SGB without complication. The outcomes were comparable to these of fluoroscopy-guided C-ESI. C-ESI and SGB may have similar effectiveness in managing patients with cervical radicular pain. Ultrasound-guided SGB may be effectively used when avoiding the risk of radiation and adverse effects of steroids associated with C-ESI.

The Intrathecal Drug Administration System (ITDAS) can be an effective treatment option for patients with chronic pain. However, as with all medical interventions, it is not without potential complications. Since ITDAS involves implanting a device within the patient’s body and requires drug refills at least every three months, it carries the risk of iatrogenic adverse events. One such complication arises when the reservoir fill port is not accurately located during the refill procedure. In such cases, the medication may not be properly delivered into the device and can instead accumulate in the subcutaneous tissue. This misadministration, particularly involving opioids, can lead to various adverse effects depending on the specific drug used. Morphine, the most commonly used opioid, may cause overdose symptoms such as nausea, vomiting, pruritus, urinary retention, constipation, and edema. Less commonly, it may result in serious complications like respiratory depression. To avoid these risks, the use of ultrasound during the ITDAS refill procedure is essential. Ultrasound guidance ensures that the needle is correctly inserted into the reservoir fill port and allows verification of residual drug aspiration. If aspiration cannot be confirmed, the refill process should be halted and the needle position should be reassessed to ensure patient safety.

Failed back surgery syndrome has been defined as persistent low back pain with or without radiating pain despite previous spine surgery, and it has various etiologies. Given the high probability that the pain would be chronic and intractable, it is essential to employ a broad range of therapeutic strategies. Radiofrequency ablation (RFA) may serve as one of the treatment options. A 64-year-old woman who had undergone lumbar fixation (L4–5) surgery five years ago visited our multidisciplinary pain center, complaining of back pain with radiating pain to both lower extremities (NRS 8) despite receiving medications at a local clinic. Following a positive diagnostic medial branch block, we decided to perform RFA using a novel multitined (Diros TridentTM) radiofrequency needle device, which has been reported to be more effective than conventional single-tined needles. Heat RFA was conducted on the right L3, L4, and L5 medial branches of the patient after nerve stimulation for localization. One month after the procedure, the patient reported a reduction in pain intensity (NRS 5 from 8). The patient is being followed up to evaluate the long-term effects. Additional comparative research is required to validate the therapeutic and side effects of multitined needles.

VR simulation enables realistic and repetitive training through three-dimensional modeling based on real patient imaging data. It addresses the limitations of traditional training methods such as phantom models, cadaver labs, and patient-based procedural instruction. This study introduces the VR simulation technology currently under development for the lumbar transforaminal epidural block training and discusses its potential for future expansion and educational effectiveness.

Stellate ganglion block (SGB) may be of benefit for relieving symptoms of complex regional pain syndrome (CRPS), involving upper extremities. Typically, SGB induces vasodilation and hypotension due to sympathetic block. Hypertension after SGB has been documented in very few cases. We report a case of 16- year -old girl who developed hypertension after SGB. She was diagnosed with CRPS type I in her right arm 7 months ago, and was under outpatient observation. However, as the symptoms such as pain and edema relapsed, she was admitted to the pediatrics and referred to the pain clinic for interventional treatment. Her right pupil has been dilated for months after cimetropium bromide administration of pretreatment to gastrointestinal endoscopy, and she was taking a selective serotonin reuptake inhibitor. An ultrasoundguided SGB was performed using 5 mL of 2% lidocaine at C7 level. There were no acute complications after SGB. Two hours later, the patient exhibited acute hypertension, along with symptoms of chills and sweats. After taking a calcium channel blocker with acetaminophen administration, blood pressure normalized within hours. We postulate that diffusion of the local anesthetic along the carotid sheath may produce vagal block causing unopposed sympathetic activity as a result of attenuation of the baroreceptor reflex. Therefore, close hemodynamic monitoring is recommended in all cases of SGB.

경피적 경막외신경성형술(percutaneous epidural neuroplasty, PEN)은 요추 추간판 탈출증이나 척추관 협착 증과 같은 병변에 의해 발생하는 하지 방사통(radiculopathy)에 대해 효과적인 중재적 치료법으로 널리 사용되 고 있다. 그러나 일부 환자에서는 시술 직후 일시적인 통증 완화에도 불구하고 기능적으로 의미 있는 통증이 잔 존하며, 이는 PEN 단독으로는 해결되지 않는 병태생리적 원인이 존재함을 시사한다. 본 증례보고에서는 PEN 이후에도 하지 통증이 지속되는 두 명의 환자에 대해 초음파 유도하 근막 수압박리술(fascial hydrodissection, FHD)을 적용하여 임상적으로 유의한 통증 경감 및 기능 회복을 이끌어낸 사례를 기술한다. 특히 본 증례는 Luigi Stecco의 근막 해부학(fascial anatomy) 및 근막 도수치료(fascial manipulation, FM) 이론에 근거하여, 근막의 병리적 긴장 및 활주 장애(glide dysfunction)가 PEN 이후에도 지속되는 통증의 기전 중 하나일 수 있음을 전제로 하였다. 이에 따라 CC(Center of coordination) 및 CF(Center of fusion) 포인트를 치료 대상으로 설정 하고, 초음파를 이용하여 정확히 타겟팅된 부위에 FHD를 시행하였다. 시술 후 두 증례 모두에서 통증의 현저한 감소뿐 아니라 일상생활 기능의 개선이 관찰되었으며, 이는 하지 통증에 있어 근막 병변이 신경병증성 통증의 잔 존 원인으로 작용할 수 있음을 시사한다. 본 증례는 PEN 이후에도 완전히 소실되지 않는 하지 통증에 대해 근막 을 치료 타깃으로 설정한 FHD의 적용이 효과적인 치료 전략이 될 수 있음을 보여주는 임상적 근거로서 의의가 있다.

There is a limited understanding of risk factors and comorbidities in trigeminal neuralgia, a disease characterized by paroxysms of severe unilateral facial pain and a higher incidence in women. We aim to identify temporally associated comorbidities involving trigeminal neuralgia by analyzing nationwide disease trajectories. Using data from 7.2 million unique individuals in the Danish National Patient Register between 1994 and 2018, each individual diagnosed with trigeminal neuralgia was compared with 10,000 matched controls to identify co-occurring diseases. The sequential disease associations were identified in sexstratified disease trajectories. A Cox-regression analysis investigated whether treatment with carbamazepine or oxcarbazepine, as compared with gabapentin, pregabalin, or lamotrigine, was associated with stroke risk. Finally, we investigated the stroke polygenic risk score and its association with stroke incidence in a subset of genotyped individuals with trigeminal neuralgia. We included 7141 individuals with trigeminal neuralgia (64.2% female, mean age at diagnosis 58.7 years) and identified 18 diseases associated with subsequent trigeminal neuralgia. After diagnosis, trigeminal neuralgia was associated with 9 diseases, including ischemic stroke (relative risk 1.55). Carbamazepine or oxcarbazepine treatment increased the ischemic stroke risk (hazard ratio 1.78; 95% confidence interval 1.47-2.17); however, the polygenic risk of stroke showed no association. In the Danish population, a trigeminal neuralgia diagnosis is temporally associated with 27 diseases revealed in systematic disease trajectories. Trigeminal neuralgia itself and its first-line treatment, but not a stroke polygenic risk score, was associated with an increased risk of ischemic stroke indicating that vascular risk factors should be routinely assessed in individuals with trigeminal neuralgia.

Objectives: To investigate the efficacy of non-surgical and non-interventional treatments for adults with low back pain compared with placebo. Eligibility criteria: Randomised controlled trials evaluating non-surgical and non-interventional treatments compared with placebo or sham in adults (≥18 years) reporting non-specific low back pain. Information sources: MEDLINE, CINAHL, EMBASE, PsychInfo and Cochrane Central Register of Controlled Trials were searched from inception to 14 April 2023. Results: A total of 301 trials (377 comparisons) provided data on 56 different treatments or treatment combinations. One treatment for acute low back pain (non-steroidal anti-inflammatory drugs (NSAIDs)), and five treatments for chronic low back pain (exercise, spinal manipulative therapy, taping, antidepressants, transient receptor potential vanilloid 1 (TRPV1) agonists) were efficacious; effect sizes were small and of moderate certainty. Three treatments for acute low back pain (exercise, glucocorticoid injections, paracetamol), and two treatments for chronic low back pain (antibiotics, anaesthetics) were not efficacious and are unlikely to be suitable treatment options; moderate certainty evidence. Evidence is inconclusive for remaining treatments due to small samples, imprecision, or low and very low certainty evidence. Conclusions: The current evidence shows that one in 10 non-surgical and non-interventional treatments for low back pain are efficacious, providing only small analgesic effects beyond placebo. The efficacy for the majority of treatments is uncertain due to the limited number of randomised participants and poor study quality. Further high-quality, placebo-controlled trials are warranted to address the remaining uncertainty in treatment efficacy along with greater consideration for placebo-control design of non-surgical and non-interventional treatments.

Ultrasound (US)-guided cervical selective nerve root block (CSNRB) procedures are increasingly being performed as an alternative to conventional fluoroscopy (FL)-guided epidural injections for the treatment of cervical radicular pain. The aim of this study was to compare the effectiveness of US-guided CSNRB versus FL-guided interlaminar cervical epidural steroid injection (IL-CESI) for cervical radicular pain. A total of 60 patients with cervical radicular pain due to a single-level disc herniation were randomized into either the FL or US group. The numeric rating scale, Short Form-36, and neck disability index were evaluated before treatment at months 1, 3, and 6 after treatment. Procedure time, complications, pain medication consumption, and patient satisfaction were also recorded. Patients experienced significant improvement in pain, disability, and quality of life score up to 6 months after the procedure (p < 0.001). Treatment success rate was achieved in 56.6% of the IL-CESI group and 50% of the CSNRB group without any significant difference between the study arms (p = 0.617). US-guided CSNRB was shown to be as effective as the FL-guided IL-CESI in the treatment of cervical radicular pain, in addition to the absence of radiation exposure and requiring less procedure time.