Earticle

Chronic back pain is a prevalent condition often refractory to conventional medical therapies, prompting the use of spinal cord stimulation (SCS) for intractable cases such as chronic pain after spinal surgery. Traditional SCS, however, demonstrates limitations, including inconsistent relief for axial back pain and potential loss of efficacy over time. This narrative review synthesizes the conceptual foundations, neurophysiological mechanisms, and emerging clinical evidence supporting differential target multiplexed (DTM) SCS in chronic back pain management. DTM SCS employs multiplexed electrical stimulation, integrating a low-frequency base signal with multiple high-frequency prime signals to concurrently target neurons and glial cells—whose dysregulated interplay drives chronic pain persistence and neuroinflammation—unlike conventional SCS, which predominantly modulates neuronal activity. Preclinical investigations reveal DTM’s superiority over traditional and high-frequency SCS in altering neural cell-specific transcriptomes and enhancing mechanical withdrawal thresholds in neuropathic pain models. Clinically, DTM SCS yields substantially greater therapeutic efficacy, offering a promising advancement for refractory back pain.

We report a case of sternoclavicular joint infection with chest wall abscess in a 54-year-old female with right shoulder pain for one month. The patient had hypertension and newly diagnosed diabetes. Laboratory findings showed elevated inflammatory markers. Chest MRI confirmed infectious arthritis with abscess, and blood cultures isolated Methicillin-sensitive Staphylococcus aureus. After surgical drainage and 7-week antibiotic therapy, the patient improved. This case emphasizes considering sternoclavicular joint infection in persistent shoulder pain, especially with risk factors like diabetes.

The transverse abdominis plane (TAP) block is a regional anesthetic technique that provides analgesia to the anterolateral abdominal wall. Performing the block under ultrasound guidance improves accuracy, increases success rates, and reduces the risk of complications. Although the TAP block is generally considered to have a low complication rate, this case report describes the development of an abdominal wall hematoma following a TAP block performed for chronic abdominal pain management in an outpatient setting.

Spinal infection is a rare but potentially life-threatening condition that may occur spontaneously or following spinal interventions. Early diagnosis and treatment are critical for favorable outcomes, and clinical suspicion followed by appropriate imaging is crucial. We report a rare case of suspected spontaneous hematogenous spinal infection that developed shortly after lumbar transforaminal epidural neuroplasty. A 77-year-old male patient underwent lumbar transforaminal epidural neuroplasty for recurrent radicular pain. He developed worsening leg pain the following evening, later accompanied by fever. Laboratory tests revealed elevated inflammatory markers. Initial MRI on post-procedure day 5 showed nonspecific findings; however, a follow-up MRI on day 12 demonstrated spontaneous hematogenous spondylitis with an epidural abscess. Conservative management with prolonged intravenous antibiotics was performed, and the patient’s symptoms and laboratory markers gradually improved. This case highlights the importance of early suspicion, repeated MRI when initial imaging is inconclusive, and consideration of spontaneous hematogenous spinal infection as a potential etiology, even after interventional procedures.

Epidural steroid injection (ESI) is one of the most common interventional procedures for the management of lumbar radicular or axial pain. Although generally safe, rare but devastating complications such as paraplegia can occur. We present two cases of irreversible lower extremity paralysis after ESI, in which previously unrecognized thoracic ligamentum flavum hypertrophy was identified as the underlying cause. Both patients developed acute motor weakness within hours after the procedure—one after interlaminar and the other after caudal ESI. Subsequent MRI revealed severe thoracic spinal cord compression caused by ligamentum flavum hypertrophy at T10–T12. Despite emergent decompressive laminectomy, both patients had persistent neurological deficits. These cases highlight that preexisting thoracic spinal pathology, such as ligamentum flavum hypertrophy, may predispose patients to irreversible spinal cord injury following ESI. Preprocedural neurological assessment and consideration of thoracic imaging in selected high-risk patients may help prevent such catastrophic outcomes.

Chronic pain after spinal surgery, which is called failed back syndrome, is known as chronic pain developing or increasing in intensity after surgery that persists or recurs for longer than 3 months following spinal surgery. This type of pain remains challenging to treat with medications and interventions including conventional spinal cord stimulation (SCS) particularly when it involves intractable axial pain. Recently, Differential Target Multiplexed (DTM) SCS has been introduced, which is a new stimulation paradigm with the aim of modulating glial cells and neurons to rebalance their interactions. DTM SCS has been mainly applied to patients with low back and lower extremity pain, and its use in cervical or upper extremity pain has been rarely reported. In this report, we present a case of DTM SCS, which successfully treat the patient with intractable chronic cervical axial pain after cervical spinal surgery.

Pseudosubarachnoid hemorrhage (pseudoSAH) is a radiologic finding that resembles true subarachnoid hemorrhage on computed tomography, even though there is no actual bleeding. It can occur in various conditions, such as intracranial hypotension, brain edema, or abnormal spread of contrast material, and may be mistaken for real hemorrhage. We experienced a rare case of pseudoSAH that appeared after a cervical epidural block. The finding was likely caused by unintentional dural puncture and temporary diffusion of contrast medium into the subarachnoid space. Recognizing pseudoSAH is important because its imaging features can mimic true hemorrhage, but its clinical course and management are very different. This case emphasizes the need to interpret radiologic findings together with clinical features and cerebrospinal fluid analysis, and to be aware that pseudoSAH may occur as a transient and benign phenomenon after cervical spine procedures.

Background : Estimating the contribution of endplate oedema known as Modic changes to lower back pain (LBP) has been the subject of multiple observational studies and reviews, some of which conclude that the evidence for an association of Modic change with LBP is uncertain while others demonstrate a clear link. The clinical trials demonstrating the benefit of basivertebral nerve ablation, a therapeutic intervention, in a tightly defined homogenous patient group with chronic LBP and Modic changes type 1 or type 2, provides further evidence for the contribution of Modic changes to LBP and shows that in these subjects, nerve ablation substantially reduces pain and disability. These interventional studies provide direct evidence that Modic changes can be associated with lower back pain and disability. This review set out to explore why the literature to date has been conflicting. Methods : A narrative, forensic, non-systematic literature review of selected articles to investigate why the published literature investigating the association between Modic imaging changes and chronic low back pain is inconsistent. Results : This review found that previous systematic reviews and meta-analyses included both heterogeneous study designs and diverse patient syndromes resulting in an inconsistent association between Modic changes and nonspecific chronic lower back pain. Re-analysis of literature data focussing on more homogenous patient populations provides clearer evidence that Modic changes are associated with nonspecific chronic lower back pain and that type 1 Modic changes are more painful than type 2. Conclusions : Studies using tightly defined homogenous patient groups may provide the best test for association between MRI-findings and pain and disability. Clinical benefit of basivertebral nerve ablation observed in randomised controlled trials further supports the association between type 1 and type 2 Modic changes with pain and disability.

Importance : An unhealthy lifestyle is believed to increase the development and persistence of low back pain, but there is uncertainty about whether integrating support for lifestyle risks in low back pain management improves patients' outcomes. Objective : To assess the effectiveness of the Healthy Lifestyle Program (HeLP) compared with guidelinebased care for low back pain disability. Design, Setting, and Participants : This superiority, assessor-blinded randomized clinical trial was conducted in Australia from September 8, 2017, to December 30, 2020, among 346 participants who had activity-limiting chronic low back pain and at least 1 lifestyle risk (overweight, poor diet, physical inactivity, and/or smoking), referred from hospital, general practice, and community settings. Statistical analysis was performed from January to December 2021. Main Outcomes and Measures : The primary outcome was low back pain disability (Roland Morris Disability Questionnaire [RMDQ] score; 0-24 scale, where higher scores indicate greater disability) at 26 weeks. Secondary outcomes were weight, pain intensity, quality of life, and smoking. Analyses were performed by intention to treat. We estimated the complier average causal effect (CACE) as sensitivity analyses. Results : The sample of 346 individuals (mean [SD] age, 50.2 [14.4] years; 190 female participants [55%]) had a baseline mean (SD) RMDQ score of 14.7 (5.4) in the intervention group and 14.0 (5.5) in the control group. At 26 weeks, the between-group difference in disability was −1.3 points (95% CI, −2.5 to −0.2 points; P = .03) favoring HeLP. CACE analysis revealed clinically meaningful benefits in disability among compliers, favoring HeLP (−5.4 points; 95% CI, −9.7 to −1.2 points; P = .01). HeLP participants lost more weight (−1.6 kg; 95% CI, −3.2 to −0.0 kg; P = .049) and had greater improvement in quality of life (physical functioning score; 1.8, 95% CI, 0.1-3.4; P = .04) than control participants. Conclusions and Relevance : Combining healthy lifestyle management with guideline-based care for chronic low back pain led to small improvements in disability, weight, and quality of life compared with guidelinebased care alone, without additional harm. Targeting lifestyle risks in the management of chronic low back pain may be considered safe and may offer small additional health benefits beyond current guideline-based care.