Purpose
This study aimed to compare the clinical effectiveness and potential benefits of ultrasound (US)-guided versus fluoroscopy (FL)-guided cervical retrolaminar block (RLB) in patients with cervical facet joint pain.
Materials and Methods
A total of 27 patients aged 40 years or older who were diagnosed with cervical facet joint syndrome based on physical examination and imaging modalities were included. 12 patients of group I treated with US-guided RLB and 15 patients of group II treated with FL-guided RLB. The position of the needle and the distribution of contrast agent were confirmed using fluoroscopic images, and the changes in numeric rating scale (NRS) and neck disability index (NDI) before and 2 weeks after the procedure were compared in the two groups.
Results
Radiologically, the target agreement of needle placement in group I was 75%. There was no difference in contrast medium spread between the two groups. Clinically, the mean NRS improved from 7.08±0.52 to 3.08±0.90 in group I (p=0.01) and from 7.20±0.56 to 3.33±0.72 in group II (p=0.01). The mean NDI decreased from 41.67±2.27 before the procedure to 20.83±2.33 after the procedure in group I (p=0.01), and from 40.87±2.61 before the procedure to 21.67±2.02 after the procedure in group II (p=0.01), with no difference between the two groups.
Conclusions
US-guided cervical RLB is an effective, radiation-free alternative to FL-guided RLB for managing cervical facet joint pain, offering comparable pain relief and functional improvement.

In modern society, chronic low back pain is a common disease and is the most common cause of limiting social and economic activities in the population over the age of 45. Unlike general chronic low back pain patients, there may be cases of complaining of non-specific symptoms. However, it is difficult to diagnose or treat neuropathic chronic low back pain patients because they have a more complex pathophysiology than simple low back pain. Neuropathic chronic low back pain is caused by abnormal pain inducing mechanisms due to damage and dysfunction of the nervous system from the peripheral to the brain. Symptoms can occur anywhere in the vertebral or paravertebral structures where nociceptors are distributed. It is difficult to diagnose neuropathic back pain. Early and appropriate treatment can prevent the nervous system from being improperly adapted to become chronic pain syndrome, so it is very important as a clinician to access and diagnose neuropathic pain as easily as possible and apply general treatment early. Therefore, in this review article, based on literatures and research results on chronic low back pain with neuropathic component, we understand diseases and suggest directions for clinical applications.

Purpose
This study examined the utility of PainVision (Nipro, Osaka, Japan) calculating the degree of lower back pain, as compared with conventional pain assessment (Numeric Rating Scale [NRS], McGill Pain Questionnaire [MPQ]).
Materials and Methods
A retrospective study was conducted from March 2021 to July 2021 on 40 patients with low back pain. NRS score, MPQ score and the degree of pain calculated by PainVision were measured before and after facet joint block in each patient. An electrode was patched on opposite side of lower back surface at which the patients complain of pain and the degree of pain was automatically calculated (degree of pain=100×[current producing pain comparable with low back pain–current at perception threshold/current at perception threshold]). Correlations between NRS and MPQ scores and the degree of pain were determined using Spearman’s rank correlation test.
Results
There was a strong correlation between the NRS and MPQ scores at each time point (before: rs=0.67, p<0.0001, after: rs=0.78, p<0.0001). The degree of pain before facet joint block also showed a moderate correlation with NRS and MPQ scores at each time point (NRS: rs=0.60, p<0.0001, MPQ: rs=0.343, p<0.03). The change in the degree of pain after facet joint block showed a moderate correlation with changes in the NRS and MPQ scores (NRS: rs=0.509, p<0.0001, MPQ: rs=0.581, p<0.0001).
Conclusions
The Pain vision can evaluate lower back pain well and quantify it in the form of pain degree, which is helpful for objective quantitative analysis of lower back pain.

Among the complex causes of chronic low back pain, suboptimal injury of ligament in the lumbosacral spine is common. Injured ligaments can become a primary pain source and raise secondary pain with referred pain pattern. Due to the low blood supply to the ligaments, ligaments are notoriously poor healer. In order to compensate the poor healing of ligament, prolotherapy has been introduced and used for more 60 years. To date, no definite recommendations have not been made based on literature available. However, if conventional treatment modalities have failed in patient with chronic back pain in lumbosacral spine, prolotherapy targeted on ligaments around lumbosacral spine should be considered in appropriate patients.

Objective
The aim of this study was to analyze significant motion predictors in patients with discogenic and facetogenic back pain confirmed by diagnostic injections and to see confounders which influence motion predictors.
Methods
Medial branch block and epidural steroid injection were used for facetogenic and discogenic midline pain. Transforaminal epidural steroid injection was selected for discogenic lateralized back pain. Positive response was defined as over 75% pain relief. Sixty-four patients (facetogenic pain, 45 bilateral or 9 unilateral, 82% pain relief ), Sixty-three patients (discogenic midline pain, 83%), and twenty-three patients (discogenic lateralized pain, 85%) had been enrolled prospectively in one institution between June 2010 and October 2013. Motion provocation tests were conducted during standing, sitting, flexion, extension, lateral bending, rotation, and extension with rotation for the detection of motion predictors. A self-weighted grade system was applied for pain provocation. Confounders such as age, sex, facet joint degeneration, flexion pain, grade of protrusion, circumferential annular tear, transverse annular tear, and spino-pelvic parameters were assessed to find the influence on motion predictors.
Results
In patients with facetogenic pain, pain provocation was prominent during standing (p=0.006), extension (p=0.052), rotation (p=0.000), and extension with rotation (p=0.000). In those with discogenic midline pain, more pain generated during flexion (p=0.000) and sitting (p=0.044). The difference in spino-pelvic parameters between two pain groups was not observed. The difference between discogenic midline and lateralized pain occurred during flexion (midline, p=0.046) and lateral bending (lateralized, p=0.057). Similarly, flexion (p=0.068) and lateral bending (p=0.067) might be also insignificant but helpful predictors to differentiate discogenic lateralized pain from facetogenic lateralized pain. For facetogenic pain, there were significant confounders as follows; standing (facet capsule enhancement, pelvic incidence), sitting (sex), extension (spino-pelvic parameters), lateral bending (pelvic tilt), rotation (age, sex, arthritis, facet capsule enhancement, pelvic tilt). Extension with rotation showed relatively less changes. For discogenic pain, a lake type circumferential tear generated less flexion pain and more extension pain. A superior transverse tear influenced sitting, extension, and lateral bending. A protrusion without a transverse tear increase flexion pain. Higher pelvic incidence and pelvic tilt generated more extension and extension with rotation pain. Among motions, sitting was not influenced by most probable confounders.
Conclusion
Predictors of facetogenic pain were extension with rotation, rotation, standing, extension, and lateral bending in order of probability. Flexion and sitting may be predictors of discogenic midline pain. Flexion and lateral bending may be predictors favoring discogenic lateralized pain compared with facetogenic pain. However, these motions may be vulnerable to parameters such as age, sex, facet arthritis, facet enhancement, circumferential or transverse tear, and spino-pelvic parameters. Considering the confounders’ effect, predictors were likely to be extension with rotation for facetogenic pain, sitting for discogenic midline pain, flexion and lateral bending for discogenic lateralized pain compared with facetogenic pain. These points should be considered in making a diagnosis during the physical examination in the outpatient clinic.

Thirty-four-year old female patient visited our clinic for posterior neck pain for 3 days. She had no medical history or traumatic injury. On physical examination, posterior neck pain aggravating with neck motion was seen, there was no neurologic symptom. WBC, ESR and CRP were slightly increased. There was no specific finding on simple cervical radiologic study but, on cervical CT, calcified lesion was seen on the right lateral side of dens. The symptom got better after medication with NSAIDs, oral and intra venous steroid drugs for 2 days, disappeared after 4 days with NSAIDs and intra venous steroid drug. In following lab study, inflammatory marker decreased. Crowned Dens Syndrome could be misdiagnosed with meningitis, so cervical CT study is essential for differential diagnosis. Symptoms can be treated with NSAIDs and steroid drug.

Epiduroscopy which is the latest development in clinical application of the endoscopy in human body is gaining more popularity in recent days. As the interest in the percutaneous neuroplasty in the non-surgical treatment of spinal pain is increasing among the physicians dealing chronic pain from spinal origin, the interest about epiduroscopic pain treatment is increasing also. The epiduroscopic pain treatment has an inherent advantage of observing the offending pathology directly. In line with this, small, but continuous reports regarding the effectiveness of the epiduroscopic pain treatment has been reported in the literature against for chronic pain from post-spinal surgery syndrome, lumbosacral radiculopathy from herniated lumbar disc and spinal stenosis, and chronic low back pain. However, epiduroscopic pain treatment has disadvantages of furnishing the complex equipments, more detailed procedures, and demanding more time in the procedure. The risks of ophthalmological complications associated with injudicious use of the irrigation saline during the procedure has been stressed several times. Other complications related to the techiniques of epidural anesthesia have already been reported. More thoughtful application of the epiduroscopy for the chronic pain of benign spinal pathology is warranted.

Discectomy or fusion have been a gold standard of the treatment for discogenic back pain. Since mid 1950s, spine surgeons have introduced the concept of arthroplasty for the management of low back pain. The current technologies are total disc replacement (TDR), posterior dynamic stabilization (PDS), interspinous process. Although many studies have reported their efficacy and safety, there are still lacking high-quality evidence. It is also not proven that these technologies are superior to spinal fusion in preventing the adjacent segment disease. Second generation TDR is newly developed technology. The current TDR could allow the motion of flexionextension and lateral bending, but it did not have the capacity to bear the axial compressive force. Second generation TDR placed the shock-absorption materials that can endure the compressive force. The current TDR was performed through the anterior approach, which is invasive and necessitates the removal of anterior longitudinal ligament. To overcome these disadvantages, TDR through lateral approach was developed. Various type of nucleus replacement technologies have been introduced with theoretical advantages over TDR such as less invasiveness, stable segmental motion and preservation of disc height. However, some of them had critical problems such as the migration and subsidence of implanted prosthesis. Total facet replacement arthroplasty was developed to overcome both the adjacent segment disease after fusion and the instability after posterior decompression. Because most of reports about total facet replacement arthroplasty are based on the results from the animal or cadaveric study, the long-term human trial is required. New technologies regarding motion preservation spinal surgery have been introduced, shifting paradigm in spinal care. Even though various attempts have been made in the field of spine surgery, the fact is that all of these attempts do not succeed due to paucity of better clinical outcomes. Thus, well designed long-term studies are required to prove their safety and efficacy, showing “superiority”, not just “no inferiority” to the traditional treatments.