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Kang HJ, Subramanian SA, Song SY, Hwang J, Lee C, Kim SJ. Epigallocatechin-3-Gallate (EGCG)-Loaded Hyaluronic Acid Hydrogel Seems to Be Effective in a Rat Model of Collagenase-Induced Achilles Tendinopathy. J Funct Biomater 2025; 16:55. [PMID: 39997589 PMCID: PMC11856759 DOI: 10.3390/jfb16020055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2024] [Revised: 02/04/2025] [Accepted: 02/07/2025] [Indexed: 02/26/2025] Open
Abstract
Tendon injuries account for 45% of musculoskeletal injuries. However, research on the occurrence and pathogenesis of tendinopathy is insufficient, and there is still much debate regarding treatment methods. It is important to understand the molecular mechanisms of oxidative stress and inflammatory responses because oxidative stress in tendon tissue is induced by various factors, including inflammatory cytokines, drug exposure, and metabolic abnormalities. In this study, 28 rats were divided into four groups (7 rats assigned to each group): control group (CON), collagenase injection group (CL), collagenase injection and hyaluronic acid injection group (CL + HA), and collagenase injection and EGCG-loaded hyaluronic acid injection group (CL + HA + EGCG). Seven weeks after the start of the study, all rats underwent histochemical analysis, immunofluorescence staining, and Western blot. The results showed increased inflammatory cells, disarray of collagen matrix, and degradation of the collagen matrix in the CL group. However, in the EGCG-treated group, there was a significant increase in type I collagen expression and a significant decrease in type III collagen expression, compared to the CL group. Additionally, there was an increase in the expression of antioxidant markers SOD (Superoxide Dismutase) and CAT (Catalase), tenogenic markers COLL-1 (collagen type I), and SCX (Scleraxis), and a downregulated expression of apoptosis markers cas-3 and cas-7. Our findings suggest that EGCG-loaded hyaluronic acid hydrogel exhibits potential in preventing tendon damage and promoting the regeneration process in a rat model of Achilles tendinopathy. The insights gained from our histological and molecular investigations highlight the future potential for testing novel tendinopathy treatments in human subjects.
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Affiliation(s)
- Hwa Jun Kang
- Department of Orthopedic Surgery, Dongtan Sacred Hospital, Hallym University College of Medicine, Hwaseoung 18450, Republic of Korea; (H.J.K.); (S.A.S.); (S.Y.S.)
| | - Sivakumar Allur Subramanian
- Department of Orthopedic Surgery, Dongtan Sacred Hospital, Hallym University College of Medicine, Hwaseoung 18450, Republic of Korea; (H.J.K.); (S.A.S.); (S.Y.S.)
| | - Si Young Song
- Department of Orthopedic Surgery, Dongtan Sacred Hospital, Hallym University College of Medicine, Hwaseoung 18450, Republic of Korea; (H.J.K.); (S.A.S.); (S.Y.S.)
| | - Jihyun Hwang
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Collin Lee
- Department of Biology, University of Maryland—College Park, College Park, MD 20742, USA;
| | - Sung Jae Kim
- Department of Orthopedic Surgery, Dongtan Sacred Hospital, Hallym University College of Medicine, Hwaseoung 18450, Republic of Korea; (H.J.K.); (S.A.S.); (S.Y.S.)
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Hsu W, Turk R, Spector L. Lumbar Spine Injuries in Recreational Athletes: A Review. J Am Acad Orthop Surg 2025:00124635-990000000-01238. [PMID: 39888643 DOI: 10.5435/jaaos-d-24-00979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2024] [Accepted: 12/15/2024] [Indexed: 02/01/2025] Open
Abstract
Back pain that is associated with lumbar spine pathology is a growing issue in the athlete population. As an aging population continues to remain active, it is essential for primary care physicians, general orthopaedic surgeons, and spine surgeons alike to understand the nuances of diagnosis and management in the recreational athlete population. This is a unique population due to the increased importance placed on returning to high levels of activity, but, by definition, they enjoy less resources and financial incentive to optimize their rehabilitation and return to sport compared with professional athletes. Lumbar disk herniation, spondylolysis, and disk degeneration are common pathologies in this population. Most the time, these pathologies in recreational athletes can be managed nonsurgically with excellent outcomes. In recreational athletes who have failed nonsurgical treatment and/or have risk of neurological injury, surgical treatment is a viable option with good outcomes. Evidence suggests that most athletes can return to sport after both nonsurgical or surgical management. A rapidly expanding number of easily accessible, minimally invasive, surgical options continue to gain popularity and may gain further indication in this population. Future studies focused on the return to activity for the unique population of recreational athletes is warranted.
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Affiliation(s)
- Wellington Hsu
- From the Department of Orthopaedic Surgery (Dr. Hsu), Northwestern University Feinberg School of Medicine, Chicago, IL, the Department of Orthopaedic Surgery, Atrium Health (Dr. Turk), Carolinas Medical Center, Charlotte, NC, and the OrthoCarolina Spine Center (Dr. Spector), Charlotte, NC
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Kim A, Sanchez JG, Abdou MA, Buser Z, Cheng D, Pickering T, Tekmyster G. Evaluating the Effectiveness of Epidural Steroid Injections in Relieving Pain in a Single-Center Retrospective Cohort. Cureus 2025; 17:e76916. [PMID: 39906458 PMCID: PMC11790416 DOI: 10.7759/cureus.76916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2025] [Indexed: 02/06/2025] Open
Abstract
Background Epidural steroid injections (ESIs) are a common conservative treatment for mitigating radicular pain and are often used to relieve pain, increase function, and improve mobility. However, their efficacy and duration of pain relief are relatively unclear because of the variability in clinical indications, injection techniques, injection mixtures, the number of allowable injections, and the lack of standard and objective outcome measures in the literature. Objectives This study aimed to characterize the effectiveness of ESIs in improving pain, measured with numerical rating scale (NRS) scores, and their relationship with subsequent lumbar spine surgery within a one-year period. Methods Patients who received a lumbar ESI from January 2018 to March 2022 in the Keck Medical Center of the University of Southern California were identified. Only patients with a one-year follow-up and no traumatic injuries were included. Exclusion criteria included a prior lumbar ESI within five years prior to January 2018. Demographics, comorbidities, injection information, and NRS scores were extracted. NRS score comparisons were analyzed with the Wilcoxon signed-rank test. Significance was defined at p ≤ 0.05. Results A total of 143 ESI patients were identified. The patient population consisted of 62 (43.36%) male, 81 (56.64%) female, and a median age of 63 years (IQR: 51,73). Patients who were one- and five-months post-ESI had the greatest median change in NRS of -3 (IQR: -7,0) (p < 0.05 for all). At one year post-ESI, there was a median decrease in NRS scores by 2 (IQR: 0,5). Of the cohort, only 28 (27.20%) patients went on to have lumbar spine surgery within a year. Conclusion The data suggests ESIs may be effective at relieving pain for at least one year. The data provides some evidence that ESIs are most reliable at relieving pain up to the five-month mark, after which their efficacy decreases.
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Affiliation(s)
- Annabel Kim
- Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, USA
| | | | - Marc A Abdou
- Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Zorica Buser
- Orthopaedic Surgery, New York University Grossman School of Medicine, New York, USA
| | - David Cheng
- Orthopaedics and Rehabilitation, Veteran Affairs Long Beach Healthcare System, Long Beach, USA
| | - Trevor Pickering
- Public Health Sciences, University of Southern California, Los Angeles, USA
| | - Gene Tekmyster
- Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, USA
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Hagger G, Guest S, Birchall S, Bradley A, Brindley C, Corbett D, Cummings PJ, Freire C, Harris J, Wise A, Wood M, Czaplewski LG. Preclinical development and characterisation of PP353, a formulation of linezolid for intradiscal administration. JOR Spine 2024; 7:e70010. [PMID: 39544355 PMCID: PMC11561648 DOI: 10.1002/jsp2.70010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 07/15/2024] [Accepted: 10/10/2024] [Indexed: 11/17/2024] Open
Abstract
Introduction Bacterial infection of the intervertebral disc can lead to vertebral endplate edema known as Modic changes, with associated chronic low back pain. Oral antimicrobial therapy has shown efficacy but relies on prolonged dosing and may not be optimal in terms of patient outcome, side effects, or antibiotic stewardship. There is no antibiotic formulation approved for intradiscal administration. Here, we describe the development and preclinical characterization of a formulation of linezolid, a suspension of 50 mg/mL micronized powder, for intradiscal administration. Methods Micronization, particle size analysis, Franz cell diffusion assays, ex vivo bioassay, and estimates of gelling temperature were used to optimize the composition and properties of the formulation. Performance of the formulation was assessed using sheep to characterize the pharmacokinetics and a model of intradiscal infection was developed to demonstrate efficacy. Suitability for human administration was demonstrated in a Good Laboratory Practice (GLP) local tolerance study. Results Micronized linezolid, formulated as a powder suspension using a vehicle containing poloxamer 407 and iohexol, provided a temperature-dependent radio-opaque gel that was suitable for image-guided percutaneous intradiscal administration. Efficacy in a sheep model of intradiscal Staphylococcus aureus infection was demonstrated. The formulation provides a high level of sheep disc tissue exposure, with Cmax of 6500 μg/g and limited systemic exposure, with a plasma Cmax of 0.04 μg/mL per 0.1 mL dose (5 mg of linezolid). Deconvolution of plasma linezolid pharmacokinetics correlated with linezolid remaining in the disc over time. Observations from a GLP local tolerance study with the linezolid formulation were of a minor nature and related to the intradiscal administration procedure. Conclusions Linezolid can be formulated for image-guided percutaneous intradiscal administration. The formulation is now in a Phase 1b clinical trial to evaluate safety, pharmacokinetics, and efficacy in patients with CLBP and suspected bacterial infection.
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Anwar N, Wei X, Jie Y, Hongbo Z, Jin H, Zhu Z. Current advances in the treatment of myofascial pain syndrome with trigger point injections: A review. Medicine (Baltimore) 2024; 103:e39885. [PMID: 39465697 PMCID: PMC11460881 DOI: 10.1097/md.0000000000039885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Indexed: 10/29/2024] Open
Abstract
Myofascial pain syndrome (MPS) caused by trigger points in muscles is a common cause of local or generalized pain, which is clinically common, has a high incidence, and has no specific cure. The most popular and widely used clinical method mainly targets the trigger point for treatment, i.e. trigger point injection (TPI) therapy. The injectable drugs mainly include glucose, saline, local anesthetics, botulinum toxin type A, platelet-rich plasma, platelet-poor plasma, steroid preparations, etc. This method is low cost and less invasive, and early clinical applications have shown good efficacy. In this paper, we have reviewed clinical research progress in treating MPS with TPI therapy.
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Affiliation(s)
- Nadia Anwar
- Department of Anaesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Rehabilitation Medicine, Zunyi Medical University, Zunyi, China
| | - Xiong Wei
- Department of Rehabilitation Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yuan Jie
- Department of Anaesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Zhao Hongbo
- Department of Rehabilitation Medicine, Zunyi Medical University, Zunyi, China
| | - Hao Jin
- Department of Rehabilitation Medicine, Zunyi Medical University, Zunyi, China
| | - Zhaoqiong Zhu
- Department of Anaesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
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Padilla-Lichtenberger F, Saavedra-Azcona T, Taboada N, Landriel F, Hem S, Guiroy A. Understanding the Landscape of Spinal Injections: Insights and Challenges from Latin America. World Neurosurg 2024; 190:e230-e236. [PMID: 39059723 DOI: 10.1016/j.wneu.2024.07.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 07/10/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Low back pain and neck pain are primary causes of disability, with low back pain being a frequent reason for medical consultations. After conservative and pharmacological treatments, spinal injections are considered the next option. Despite multiple guidelines, spinal blocks remain controversial in terms of indication, technique, and operator, leading to considerable interinstitutional variability. The absence of regional studies in Latin America on how spinal surgeons handle spinal injections prompts the objectives of this study: to evaluate spinal surgeons' knowledge and experience, analyze techniques, and identify barriers and challenges in implementing spinal injections, including resource limitations, technology access, and training. METHODS A cross-sectional survey was performed using a questionnaire specifically designed by the authors. RESULTS Two hundred sixty spinal surgeons from Latin America participated and answered a 17-question questionnaire; 75% performed their own spinal blocks and they are willing to keep on learning new techniques on the field. The most frequent block, was the lumbar facet injection (80%). And the great majority (76%) used fluoroscopy in their practice. CONCLUSIONS The study addresses a critical gap in the literature by focusing on spinal interventions in Latin America, where there is a notable lack of regional studies. The majority of the surgeons enrolled perform their own spinal injections, and they are interested in keep on learning. The findings not only contribute to the global discourse on spinal care but also offer a basis for the development of region-specific guidelines and educational initiatives.
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Affiliation(s)
| | - Tomás Saavedra-Azcona
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Buenos Aires City, Argentina
| | - Nestor Taboada
- Department of Neurosurgery, Clinica Portoazul, Barranquilla, Colombia
| | - Federico Landriel
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Buenos Aires City, Argentina
| | - Santiago Hem
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Buenos Aires City, Argentina
| | - Alfredo Guiroy
- Spine Surgery Department, Elite Spine Health and Wellness, Fort Lauderdale, Florida, USA
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Schubiner H, Lowry WJ, Heule M, Ashar YK, Lim M, Mekaru S, Kitts T, Lumley MA. Application of a Clinical Approach to Diagnosing Primary Pain: Prevalence and Correlates of Primary Back and Neck Pain in a Community Physiatry Clinic. THE JOURNAL OF PAIN 2024; 25:672-681. [PMID: 37777033 DOI: 10.1016/j.jpain.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/17/2023] [Accepted: 09/24/2023] [Indexed: 10/02/2023]
Abstract
Chronic back or neck pain (CBNP) can be primary (nociplastic or neuroplastic; without clear peripheral etiology) or secondary (to nociceptive or neuropathic causes). Expanding on available models of nociplastic pain, we developed a clinic-ready approach to diagnose primary/nociplastic pain: first, a standard physical exam and review of imaging to rule out secondary pain; and second, a detailed history of symptom presentation to rule in primary pain. We trained a physician who evaluated 222 patients (73.9% female, age M = 59.6) with CBNP; patients separately completed pain and psychosocial questionnaires. We estimated the prevalence of primary CBNP and explored biomedical, imaging, and psychological correlates of primary CBNP. Although almost all patients (97.7%) had at least 1 spinal anomaly on imaging, the diagnostic approach estimated that 88.3% of patients had primary pain, 5.0% had secondary pain, and 6.8% had mixed pain. Patients with primary pain were more likely than the other 2 groups of patients (combined as "non-primary pain") to report certain functional conditions, central sensitization, and features such as sensitivity to light touch, spreading pain, and pain worsening with stress; however, no difference was detected in depression, anxiety, and pain catastrophizing between those with primary and nonprimary pain. These findings are consistent with prior estimates that 85 to 90% of CBNP is "nonspecific." Further research is needed to validate and perhaps refine this diagnostic approach, which holds the potential for better outcomes if patients are offered treatments targeted to primary pain, such as pain neuroscience education and several emerging psychological therapies. PERSPECTIVE: We developed an approach to diagnose chronic primary pain, which was applied in a physiatry clinic to 222 patients with CBNP. Most patients (88.3%) had primary pain, despite almost universal anomalies on spinal imaging. This diagnostic approach can guide educational and psychological treatments tailored for primary pain.
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Affiliation(s)
- Howard Schubiner
- Department of Internal Medicine, Michigan State University College of Human Medicine, East Lansing, Michigan
| | | | - Marjorie Heule
- Department of Psychology, Wayne State University, Detroit, Michigan
| | - Yoni K Ashar
- Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Michael Lim
- Department of Psychiatry, Michigan State University College of Human Medicine, East Lansing, Michigan
| | - Steven Mekaru
- School of Medicine, Wayne State University, Detroit, Michigan
| | - Torran Kitts
- Department of Psychology, Wayne State University, Detroit, Michigan
| | - Mark A Lumley
- Department of Psychology, Wayne State University, Detroit, Michigan
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Ussing K, Smith A, O'Sullivan P. The relationship between changes in pain intensity and functional disability in persistent disabling low back pain during a course of cognitive functional therapy. Scand J Pain 2024; 24:sjpain-2024-0040. [PMID: 39361965 DOI: 10.1515/sjpain-2024-0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 09/09/2024] [Indexed: 10/05/2024]
Abstract
OBJECTIVES Pain relief and reduced disability are both common treatment targets for persistent disabling low back pain (LBP). Cross-sectional studies show a moderate relationship between functional disability and pain intensity, but little is known about the relationship between changes in pain intensity and functional disability over multiple time points. The objective of this study was to investigate the associations between changes in functional disability and pain intensity and whether changes occurred simultaneously or differentially during a course of cognitive functional therapy for people with persistent disabling LBP. METHODS Self-reported measures of pain intensity and patient-specific functional disability were collected prior to each treatment session from 40 participants during a 12-week intervention period. Linear mixed modeling was used to assess simultaneous and lagged associations between pain intensity and functional disability over time. Sensitivity analysis using nonparametric subject-specific methods (simulation modeling analysis) was also performed. RESULTS Thirty-five participants had sufficient data for analysis. Using the linear mixed-model approach, there was evidence of a moderate and simultaneous association between pain intensity and functional disability over time (regression coefficient = 0.56, 95% confidence interval: 0.44-0.68, p < 0.001). Simulation modeling analysis supported weak to mostly strong associations and supported for simultaneous change in pain and disability for the majority of participants (22 of 35, 64%). CONCLUSION Changes in pain intensity and functional disability were moderately related across the intervention. Visual inspection of graphs indicated a very close relationship in some individuals and a decoupling of pain intensity and functional disability in others. The changes in pain intensity and functional disability seem to occur simultaneously in most individuals.
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Affiliation(s)
- Kasper Ussing
- Spine Centre of Southern Denmark, Region of Southern Denmark: Region Syddanmark, Münstervej 21, Strib, Middelfart, 5500, Fyn, Denmark
| | - Anne Smith
- School of Allied Health, Faculty of Health Science, Curtin University, Perth, WA, Australia
| | - Peter O'Sullivan
- School of Allied Health, Faculty of Health Science, Curtin University, Perth, WA, Australia
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Deer TR, Chafin TB, Costandi SJ, Qu H, Kim C, Jassal N, Patel K, Calodney A. The MOTION study: Two-year results of a real-world randomized controlled trial of the mild® procedure for treatment of lumbar spinal stenosis. Pain Pract 2024; 24:109-119. [PMID: 37661347 DOI: 10.1111/papr.13293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
OBJECTIVE The MOTION study is designed to measure the impact of percutaneous image-guided lumbar decompression as a first-line therapy on patients otherwise receiving real-world conventional medical management for lumbar spinal stenosis with neurogenic claudication secondary to hypertrophic ligamentum flavum. This prospective, multicenter randomized controlled trial uses objective and patient-reported outcome measures to compare the combination of the mild® percutaneous treatment and nonsurgical conventional medical management (CMM) to CMM-Alone. METHODS Test group patients received the mild procedure after study enrollment. Test and control groups were allowed conventional conservative therapies and low-risk interventional therapies as recommended by their physicians. Subjective outcomes included the Oswestry Disability Index, Numeric Pain Rating Scale, and Zurich Claudication Questionnaire. Objective outcomes included a validated Walking Tolerance Test, the rate of subsequent lumbar spine interventions, and safety data. RESULTS Two-year follow-up included 64 mild + CMM and 67 CMM-Alone patients. All outcome measures showed significant improvement from baseline for mild + CMM, whereas the majority of CMM-Alone patients had elected to receive mild treatment or other lumbar spine interventions by 2 years, precluding valid 2-year between-group comparisons. Neither group reported any device- or procedure-related adverse events. CONCLUSIONS The durability of mild + CMM for this patient population was demonstrated for all efficacy outcomes through 2 years. Improvements in walking time from baseline to 2 years for patients treated with mild + CMM were significant and substantial. The lack of reported device or procedure-related adverse events reinforces the strong safety profile of the mild procedure. These results provide support for early interventional treatment of symptomatic LSS with the mild procedure.
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Affiliation(s)
- Timothy R Deer
- The Spine & Nerve Centers of the Virginias, Charleston, West Virginia, USA
| | | | | | - Huaguang Qu
- Pennsylvania Pain& Spine Institute, Chalfont, Pennsylvania, USA
| | - Christopher Kim
- The Spine & Nerve Centers of the Virginias, Charleston, West Virginia, USA
| | | | - Kiran Patel
- The Spine & Pain Institute of New York, New Hyde Park, New York, USA
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Kozak M, Hallan DR, Rizk E. Epidural Steroid Injection Prior to Spinal Surgery: A Step-Wise and Wise Approach. Cureus 2023; 15:e45125. [PMID: 37842405 PMCID: PMC10569744 DOI: 10.7759/cureus.45125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/12/2023] [Indexed: 10/17/2023] Open
Abstract
BACKGROUND An epidural steroid injection (ESI) is used to treat a number of morbid central nervous system pathologies and is considered a reasonably safe procedure. This study aimed to determine the relative infection risk after spinal surgery by comparing outcomes in spinal surgery patients who received an ESI shortly prior to the surgery against those who did not receive an ESI shortly prior to the surgery. METHODS The present study is a retrospective cohort study using a multi-institutional healthcare database, TriNetX, to collect data on patients who received spinal surgery with and without having had ESIs six months before surgery. Two cohorts were generated: Cohort 1 included patients who had received an ESI in the six months prior to spinal surgery, and cohort 2 included patients who did not have an ESI in the six months prior to spinal surgery. The patients in cohort 2 had propensity scores matched 1:1 to those in cohort 1 using common baseline demographics, comorbidities and spinal procedure indications. The spinal procedures and surgeries considered for the analysis included open procedures for any purpose, including exploration, decompression, resection, revision or biopsy. Multiple outcomes were compared across these two cohorts in the three months following the spinal procedure/surgery, including the occurrence of death, surgical site infection, epidural and/or spinal abscess, and dural tear. RESULTS An ESI in the six months prior to spinal surgery was associated with a significant decrease in the likelihood epidural/spinal abscess in the three months after surgery. There was no change in mortality, wound infection or identification of dural tear in the three months after spinal surgery for those who received an ESI six months before spinal surgery. CONCLUSION This data suggests that epidural steroid injections' anti-inflammatory effects provide benefits before surgery beyond symptomatic relief. Given that the degeneration of spinal pathologies is typically advanced rather than corrected by the body's inflammatory response, it is likely that preventing hyperactivation of the body's immune system in the months preceding surgical intervention, a traumatic insult, is protective compared to no intervention and, importantly, without major adverse effects.
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Affiliation(s)
- Michael Kozak
- Neurosurgery, Penn State College of Medicine, Hershey, USA
| | - David R Hallan
- Neurosurgery, Penn State College of Medicine, Hershey, USA
| | - Elias Rizk
- Neurological Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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Çetin E, Şah V, Zengin I, Arabacı Ö, Akyol ME, Yücel M. Comparative Effectiveness of Epidural Steroid İnjections in Patients With Disc Bulging and Disc Protrusion. Cureus 2023; 15:e45994. [PMID: 37900516 PMCID: PMC10601978 DOI: 10.7759/cureus.45994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2023] [Indexed: 10/31/2023] Open
Abstract
Purpose Discogenic low back pain is a widespread disorder in the world. Many methods have been developed and continue to be developed in the treatment of discogenic low back pain. We aimed to examine the effect of epidural steroid administration on disc bulging and disc protrusion in patients with discogenic low back pain. Design The clinical effects of interlaminar epidural steroids administered to 71 patients who were admitted to our clinic and whose treatment did not require surgery were radiologically divided into two groups disc bulging and disc protrusion. Patients were followed up for six months and clinical results were recorded. Methods The scores of the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were measured before the procedure, one week after the procedure, one month after the procedure, and six months after the procedure. The normal distribution of continuous variables was evaluated using the Kolmogorov-Smirnov test. Continuous variables were compared with the Mann-Whitney U test and categorical variables were compared using the Chi-square test or Fisher's exact test. Results There was no significant difference in demographic data in patients with disc bulging and disc protrusion. In the disc protrusion group, the VAS scores in the first week after, the first month after and the sixth month after the procedure showed a significant decrease compared to the pre-procedure. There was no significant difference between the disc bulging and protrusion groups in the first week of post-procedure VAS score reduction. In the Disc Bulging group, the ODI score one week after, one month after, and six months after the procedure showed a significant decrease compared to the pre-procedure. In the Disc Protrusion group, the ODI score one week after, one month after, and six months after the procedure showed a significant decrease compared to the pre-procedure. Conclusion There was strong evidence that lumbar interlaminar steroid injection is an effective treatment for disc bulging and discogenic pain due to protrusion. When the ODI and VAS scores of patients with both disc bulging and disc protrusion were evaluated, it was seen that they benefited from epidural steroid injection. In the disc protrusion group, except for the first week of injection, relief due to the use of epidural steroids was observed to be greater compared to disc bulging.
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Affiliation(s)
- Eyup Çetin
- Department of Neurosurgery, Haydarpaşa Numune Education and Research Hospital, Istanbul, TUR
| | - Volkan Şah
- Department of Sports Medicine, Van Yuzuncu Yıl University, Van, TUR
| | - Irfan Zengin
- Department of Neurosurgery, Faculty of Medicine, Yuzuncu Yil University, Van, TUR
| | - Özkan Arabacı
- Department of Neurosurgery, Van Yuzuncu Yıl University, Van, TUR
| | - Mehmet E Akyol
- Department of Neurosurgery, Faculty of Medicine, Yuzuncu Yil University, Van, TUR
| | - Murat Yücel
- Department of Neurosurgery, Yalova University, Yalova, TUR
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Nourbakhsh A, Harrison K. Use of Steroids in Spine Surgery. J Am Acad Orthop Surg 2023:00124635-990000000-00692. [PMID: 37184471 DOI: 10.5435/jaaos-d-22-00971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/01/2023] [Indexed: 05/16/2023] Open
Abstract
Steroids are commonly used in spine pathologies. A broad range of providers from different specialties such as primary care, emergency medicine, and spine surgeons use steroids. The indications and controversies of steroid use are discussed in this article. A literature review was conducted on the use of steroids in spine pathologies. Steroids have been successfully used in anterior cervical discectomy and fusion (ACDF) to prevent dysphagia, in spinal cord injuries to improve neurological function, in acute back and neck pain for pain control, and in spinal metastasis. Steroid injections have been used for axial as well as radicular pain. Techniques and complications are further discussed. Local and systemic steroids have been successful in preventing dysphagia after anterior cervical diskectomy and fusion. Steroids failed to improve the neurologic outcomes after spinal cord injuries, and they were associated with multiple complications. Systemic steroids have not been proven to provide better clinical outcomes for acute low back pain. Steroid injections are more effective in radicular pain rather than axial pain. There are not enough high-quality studies on the use of steroids for metastatic spinal cord compression.
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Papalia GF, Russo F, Vadalà G, Pascarella G, De Salvatore S, Ambrosio L, Di Martino S, Sammartini D, Sammartini E, Carassiti M, Papalia R, Denaro V. Non-Invasive Treatments for Failed Back Surgery Syndrome: A Systematic Review. Global Spine J 2023; 13:1153-1162. [PMID: 36412047 PMCID: PMC10189334 DOI: 10.1177/21925682221141385] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Systematic Review. OBJECTIVES The aim of this systematic review is to evaluate the efficacy of non-invasive procedures in relieving chronic pain due to Failed Back Surgery Syndrome (FBSS). METHODS Since patients who suffered from FBBS are often non-responders to analgesics, we compared Visual Analogical Scale for low back and leg pain, Oswestry Disability Index, trial success rate, adverse events and complications between conservative treatment groups and control groups. RESULTS The included studies were 15. Spinal Cord Stimulation (SCS) was performed in 11 trials; 4 studies assessed the efficacy of different epidural injections; one study evaluated repetitive Transcranial Magnetic Stimulation. All the studies reported back and leg pain relief after treatment with SCS, with a significant superiority in high frequences (HFS) group, compared to low frequences (LFS) group. Moreover, disability decreased with each non-invasive treatment evaluated. Epidural injections of steroids and hyaluronidase have shown controversial results. Adverse events were described in 7 studies: lead migration, hardware-related events, infection and incisional pain were the most reported. Finally, trial success rate showed better outcomes for HFS. CONCLUSIONS Our systematic review highlights the efficacy of conservative treatments in FBSS patients, with an improvement in pain scores and a decrease in disability index, especially after SCS with HFS. However, due to the lack of homogeneity among trials and population characteristics, further studies are needed to confirm the effectiveness of non-invasive interventions in patients affected by FBSS.
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Affiliation(s)
| | - Fabrizio Russo
- Department of Orthopaedic and
Trauma Surgery, Campus Bio-Medico University of
Rome, Rome, Italy
| | - Gianluca Vadalà
- Department of Orthopaedic and
Trauma Surgery, Campus Bio-Medico University of
Rome, Rome, Italy
| | - Giuseppe Pascarella
- Unit of Anaesthesia, Intensive Care
and Pain Management, Department of Medicine, Campus Bio-Medico University of
Rome, Rome, Italy
| | - Sergio De Salvatore
- Department of Orthopaedic and
Trauma Surgery, Campus Bio-Medico University of
Rome, Rome, Italy
| | - Luca Ambrosio
- Department of Orthopaedic and
Trauma Surgery, Campus Bio-Medico University of
Rome, Rome, Italy
| | - Sara Di Martino
- Unit of Anaesthesia, Intensive Care
and Pain Management, Department of Medicine, Campus Bio-Medico University of
Rome, Rome, Italy
| | - Davide Sammartini
- Unit of Anaesthesia, Intensive Care
and Pain Management, Department of Medicine, Campus Bio-Medico University of
Rome, Rome, Italy
| | - Emanuele Sammartini
- Unit of Anaesthesia, Intensive Care
and Pain Management, Department of Medicine, Campus Bio-Medico University of
Rome, Rome, Italy
| | - Massimiliano Carassiti
- Unit of Anaesthesia, Intensive Care
and Pain Management, Department of Medicine, Campus Bio-Medico University of
Rome, Rome, Italy
| | - Rocco Papalia
- Department of Orthopaedic and
Trauma Surgery, Campus Bio-Medico University of
Rome, Rome, Italy
| | - Vincenzo Denaro
- Department of Orthopaedic and
Trauma Surgery, Campus Bio-Medico University of
Rome, Rome, Italy
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Mariadoss AVA, Subramanian SA, Kwon YM, Shin S, Kim SJ. Epigallocatechin gallate protects the hydrogen peroxide-induced cytotoxicity and oxidative stress in tenocytes. Process Biochem 2023. [DOI: 10.1016/j.procbio.2023.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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15
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Use of injections for chronic pain from 2010 to 2019 in Ontario, Canada. Can J Anaesth 2023; 70:100-105. [PMID: 36450946 DOI: 10.1007/s12630-022-02357-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/08/2022] [Accepted: 09/05/2022] [Indexed: 12/02/2022] Open
Abstract
PURPOSE The management of chronic pain often involves interventional procedures such as injections. Nevertheless, there have been concerns raised regarding the frequency with which these injections are being performed. We conducted a descriptive study to examine trends in the use of pain injections over a ten-year time period in Ontario, Canada. METHODS We used provincial administrative data to conduct a retrospective observational study of the most common pain injections performed from 2010 to 2019 in Ontario. We determined the frequency of pain injections and their associated physician billings from physician billing data. RESULTS A total of 18,050,058 pain injections were included in this study with an associated total cost of CAD 865,431,605. There was a threefold increase in the number of blocks performed annually and associated costs, rising from 1,009,324 blocks (CAD 50,026,678) in 2010 to 3,198,679 blocks (CAD 156,809,081) in 2019. The majority of injections were performed by general practioners (70.8%), followed by anesthesiologists (8.3%). CONCLUSION This descriptive study revealed a rapid increase in the frequency of pain injections performed in Ontario from 2010 to 2019. Given the associated costs and potential risks, this warrants further investigation to ensure that these interventions are being administered appropriately.
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Zouch J, Comachio J, Bussières A, Ashton-James CE, dos Reis AHS, Chen Y, Ferreira M, Ferreira P. Influence of Initial Health Care Provider on Subsequent Health Care Utilization for Patients With a New Onset of Low Back Pain: A Scoping Review. Phys Ther 2022; 102:pzac150. [PMID: 36317766 PMCID: PMC10071499 DOI: 10.1093/ptj/pzac150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 05/05/2022] [Accepted: 08/08/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The aim of this research was to examine the scope of evidence for the influence of a nonmedical initial provider on health care utilization and outcomes in people with low back pain (LBP). METHODS Using scoping review methodology, we conducted an electronic search of 4 databases from inception to June 2021. Studies investigating the management of patients with a new onset of LBP by a nonmedical initial health care provider were identified. Pairs of reviewers screened titles, abstracts, and eligible full-text studies. We extracted health care utilization and patient outcomes and assessed the methodological quality of the included studies using the Joanna Briggs Institute checklist. Two reviewers descriptively analyzed the data and categorized findings by outcome measure. RESULTS A total of 26,462 citations were screened, and 11 studies were eligible. Studies were primarily retrospective cohort designs using claims-based data. Four studies had a low risk of bias. Five health care outcomes were identified: medication, imaging, care seeking, cost of care, and health care procedures. Patient outcomes included patient satisfaction and functional recovery. Compared with patients initiating care with medical providers, those initiating care with a nonmedical provider showed associations with reduced opioid prescribing and imaging ordering rates but increased rates of care seeking. Results for cost of care, health care procedures, and patient outcomes were inconsistent. CONCLUSIONS Prioritizing nonmedical providers at the first point of care may decrease the use of low-value care, such as opioid prescribing and imaging referral, but may lead to an increased number of health care visits in the care of people with LBP. High-quality randomized controlled trials are needed to confirm our findings. IMPACT This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, may help reduce opioid prescription and selective imaging in people with LBP. The trend observed in this scoping review has important implications for pathways of care and the role of nonmedical providers, such as physical therapists, within primary health care systems. LAY SUMMARY This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, might help reduce opioid prescription and selective imaging in people with LBP. High-quality randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- James Zouch
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Josielli Comachio
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - André Bussières
- Department de Chiropractique, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - Claire E Ashton-James
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Yanyu Chen
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Manuela Ferreira
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Paulo Ferreira
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Tossolini Goulart L, Matsunaga FT, Belloti JC, Faloppa F, Paim TS, Tamaoki MJS. Effectiveness of subacromial injections in rotator cuff lesions: systematic review and meta-analysis protocol. BMJ Open 2022; 12:e062114. [PMID: 36323483 PMCID: PMC9639075 DOI: 10.1136/bmjopen-2022-062114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Subacromial injections are therapeutic options for rotator cuff injuries, with consistent results not well established yet for each drug applied. The objective of this systematic review and meta-analysis is to analyse the effectiveness of the substances used in subacromial injections for the treatment of rotator cuff injuries and shoulder impingement syndrome, considering the functional gain and pain improvement of the shoulder. METHODS AND ANALYSIS Beginning in November 2022, we will perform a detailed search using the MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials and LILACS databases. Relevant grey literature (reference lists, conference abstracts and academic papers) will also be included.Two reviewers will independently screen and extract the information from the literature. Bias and quality of the included studies will be evaluated using the risk of bias assessment tool provided by the Cochrane Collaboration. Statistical analyses will be performed using Review Manager V.5.4 software. ETHICS AND DISSEMINATION Approval and patient informed consent are not required because we will only include published literature. The results of this research will be disseminated in a peer-reviewed journal and likely through other scientific events. PROSPERO REGISTRATION NUMBER CRD42020199292.
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Affiliation(s)
- Luana Tossolini Goulart
- Orthopaedics and Traumatology - Division of Hand Surgery and Upper Limb, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
| | - Fabio Teruo Matsunaga
- Orthopaedics and Traumatology - Division of Hand Surgery and Upper Limb, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
| | - João Carlos Belloti
- Orthopaedics and Traumatology - Division of Hand Surgery and Upper Limb, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
| | - Flavio Faloppa
- Orthopaedics and Traumatology - Division of Hand Surgery and Upper Limb, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
| | - Thays Sellan Paim
- Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
| | - Marcel Jun Sugawara Tamaoki
- Orthopaedics and Traumatology - Division of Hand Surgery and Upper Limb, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
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Wentz K, Chung YC, Patel A. The clinical impact of lumbar epidural steroid injections prior to spine surgery for lumbar spinal stenosis. INTERVENTIONAL PAIN MEDICINE 2022; 1:100104. [PMID: 39239369 PMCID: PMC11373000 DOI: 10.1016/j.inpm.2022.100104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 09/07/2024]
Abstract
Introduction Lumbar spinal stenosis is a common finding in the adult population. Lumbar Epidural Steroid Injections (ESIs) are often used in management of this condition, with conflicting evidence regarding their efficacy. Previous research has suggested a negative impact of ESIs on the postoperative outcomes when ESIs are administered preoperatively prior to spine surgery in this population. Our retrospective study was performed to gain greater insight into the impact of preoperative ESIs on postoperative outcomes following spine surgery in management of lumbar stenosis. Objective Our objective is to determine how preoperative ESIs impact postoperative outcomes following spine surgery in management of lumbar stenosis. Design Retrospective cohort involving 95 patients (39 patients who received ESI in the preoperative timeframe and 56 patients who did not) who underwent surgical management of lumbar stenosis. Data for patients with preoperative ESI was compared to those without preoperative ESI administration. Setting Institutional. Interventions Not Applicable. Main outcome measures PROMIS (Patient-Reported Outcomes Measurement Information System) scores, VAS (Visual Analog Scale) pain scores, ODI (Oswestry Disability Index), NDI (Neck Disability Index). Results At baseline (time of surgery), the ESI group had significantly higher ODI, PROMIS pain, PROMIS pain interference, VAS leg and lower PROMIS physical function, but no significant difference in PROMIS satisfaction, VAS back and NDI, compared to the Non-ESI group. At 3 months after surgery, both the ESI and Non-ESI groups demonstrated a significant decrease in VAS back, VAS leg, PROMIS pain and ODI from baseline scores. The improvement in PROMIS pain at 3 months after surgery was larger in the ESI group than the Non-ESI group. Conclusions Preoperative ESI administration did not lead to worsening of disability, function, or pain symptoms in the short-term postoperative period following surgical management of lumbar stenosis. Patients had short term improvements in radicular pain following surgical management of lumbar stenosis, regardless of preoperative ESI administration.
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Affiliation(s)
- Kyle Wentz
- UT Southwestern Medical Center, United States
| | | | - Ankit Patel
- UT Southwestern Medical Center, United States
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19
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Won SJ, Kim DY, Kim JM. Effect of platelet-rich plasma injections for chronic nonspecific low back pain: A randomized controlled study. Medicine (Baltimore) 2022; 101:e28935. [PMID: 35212300 PMCID: PMC8878905 DOI: 10.1097/md.0000000000028935] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/08/2022] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND Patient with chronic nonspecific low back pain is weakened ligament, and prolotherapy is the effective treatment but their use remains controversial. These ligaments can be strengthened by platelet-rich plasma injection. We hypothesized that the effectiveness of platelet-rich plasma injection and prolotherapy may decrease pain and improved disability of patient with chronic low back pain. METHODS This study was a prospective, double-blind, randomized controlled trial and was conducted for 3 years for patient enroll and follow-up. Thirty-four patients with chronic nonspecific low back pain (duration of at least 3 months) refectory to conventional management were randomized to platelet-rich plasma injection and lidocaine injection. Patients were treated with weekly platelet-rich plasma or lidocaine injections at the lumbopelvic ligaments for 2 weeks and then weekly prolotherapy with 15% glucose for 2 weeks and followed up 6 months. Visual analog scale, Oswestry Disability Index, and Roland-Morris Disability Questionnaire were evaluated at initial, 4 weeks, 3 months, and 6 months. Four patients did not complete this trial. Three were in the platelet-rich plasma injection and 1 was in the lidocaine injection. RESULTS The intensity of pain was significantly decreased in platelet-rich plasma injections at 6 months as compared lidocaine injections; between-group differences were 0.9 (95% confidence interval 0.10-1.75 [P = .027]). All participants were significantly decreased pain and disability index at 4 weeks, 3 months, and 6 months but there were no significant differences between groups except for visual analog scale at 6 months. The baseline parameters were no significant differences in both groups. CONCLUSIONS In chronic nonspecific low back pain, the platelet-rich plasma injection in combination with prolotherapy is an effective intervention and either lidocaine or platelet-rich plasma injection significantly reduced disability. And injection at the lumbopelvic ligaments using the platelet-rich plasma and prolotherapy is also an effective treatment for pain.
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Affiliation(s)
- Sun Jae Won
- Department of Rehabilitation Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Da-ye Kim
- Department of Rehabilitation Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae Min Kim
- Department of Rehabilitation Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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20
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Braeuninger-Weimer K, Anjarwalla N, McGregor A, Roberts L, Sell P, Pincus T. Improving consultations for persistent musculoskeletal low back pain in orthopaedic spine settings: an intervention development. BMC Musculoskelet Disord 2021; 22:896. [PMID: 34674677 PMCID: PMC8532354 DOI: 10.1186/s12891-021-04783-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/07/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND There is a need to improve consultations between patients with persistent musculoskeletal low back pain and orthopaedic spine clinicians when surgery is not indicated. Poor communication and lack of education about self- management in these consultations have been shown to be associated with increased distress and higher subsequent health care seeking. AIM To develop a standardised intervention to improve spine care consultations for patients for whom surgery is not beneficial. METHOD The intervention was developed in six stages. The first three stages included: interviews with patients, an interactive workshop with clinicians from a mix of disciplines, and interviews with spine clinicians about their perspective of the recommendations, their perceived difficulties and potential improvements. Information from these stages was synthesised by an expert panel, creating a draft intervention structure and content. The main features of the intervention and the materials developed were then reviewed by patients and spine clinicians. Finally, the research team incorporated the recommended amendments to produce the intervention. RESULTS In total, 36 patients and 79 clinicians contributed to the development of the intervention. The final intervention includes three components: a pre-consultation letter with information suggesting that surgery is one possible intervention amongst many, introducing the staff, and alerting patients to bring with them a potted history of interventions tried previously. The intervention includes short online training sessions to improve clinicians' communication skills, during the consultation, in reference to listening skills, validation of patients' pain, and use of appropriate language. Clinicians are also supplied with a list of evidence-based sources for advice and further information to share with patients. Finally, post consultation, a follow up letter includes a short summary of the patients' clinical journey, the results of their examination and tests, and a reminder of recommendations for self-management. CONCLUSION The intervention includes aspects around patient education and enhanced clinician skills. It was developed with input from a multitude of stakeholders and is based on patients' perceptions of what they would find reassuring and empowering when surgery is excluded. The intervention has the potential to improve the patients care journey and might lead to changes in practice in spine clinicians.
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Affiliation(s)
| | - Naffis Anjarwalla
- Department of Orthopaedics, Wexham Park Hospital, Slough, Berkshire, UK
| | - Alison McGregor
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Lisa Roberts
- School of Health Sciences, University of Southampton & University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Philip Sell
- Department of Orthopaedics, Leicester University Hospitals, Leicester, UK
| | - Tamar Pincus
- Department of Psychology, Royal Holloway, University of London, Egham, Surrey, UK.
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21
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Jindal R, Rudol G, Okafor B, Rambani R. Role of psychological distress screening in predicting the outcomes of epidural steroid injection in chronic low back pain. J Clin Orthop Trauma 2021; 19:26-33. [PMID: 34046297 PMCID: PMC8141939 DOI: 10.1016/j.jcot.2021.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/14/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND There is a paucity of studies investigating relationship between psychological distress and effectiveness of epidural steroid injection in patients with chronic lower back pain (CLBP). AIMS This prospective cohort study assessed whether the outcome can be predicted in CLBP patients undergoing epidural injection by pre-treatment psychological stress stratification using objective screening methods. METHODS 96 patients with CLBP were recruited to this prospective cohort study. Preoperative level of psychological distress was measured using Modified Zung Index (MZI) and Modified Somatic Perception Questionnaire (MSPQ); pain with Visual Analogue Score (VAS) and McGill Pain Questionnaire (MPQ) and back pain related disability with Oswestry Disability Index (ODI). Fluoroscopic caudal epidural steroid injection comprising 80 mg methylprednisolone and 8 mg of lignocaine was performed. Scores were repeated at 6, 12, and 26 weeks. Successful outcome was Minimal Clinically Important Change (MCIC) in any given measure. RESULTS There were 60 (62.5%) not-distressed patients, 3(3.1%) purely somatising, 15(15.6%) depressed and 18(18.8%) with mixed distress. Preoperative VAS was 82.4, MPQ 18.2 and ODI 51.6. Average VAS and MPQ improved significantly at 6 and 26 weeks. Average magnitude of change of VAS and ODI did not differ between distressed and not-distressed. MPQ improved significantly more in the distressed. MZI was negatively associated with VAS MCIC at 6 weeks and 6 months but it failed to predict the outcome independently. MSPQ was the only individual predictor of MPQ-MCIC at any time; MSPQ≥8 could predict MPQ-MCIC at 6 months with 53%-sensitivity and 78%-specificity. None of psychological measures used showed a significant predictive value of ODI at any follow-up point. CONCLUSIONS Psychological distress may predict response only in certain outcome measures in patients suffering from nonspecific CLBP. If the interest lied primarily in pain and functional improvement, the psychological distress failed to discriminate the results at 6 months.
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Affiliation(s)
| | - Greg Rudol
- Leeds Teaching Hospital NHS Trust, Leeds, UK
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22
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Paul G, Meißner A, Neuneier J, Neuschmelting V, Grau S, Yagdiran A, Scheyerer MJ, Malin JJ, Suárez I, Lehmann C, Exner M, Wiesmüller GA, Higgins PG, Seifert H, Fätkenheuer G, Zweigner J, Jung N. Outbreak of Pseudomonas aeruginosa infections after CT-guided spinal injections. J Hosp Infect 2021; 116:1-9. [PMID: 34298033 DOI: 10.1016/j.jhin.2021.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Meningitis and spinal infections with Gram-negative bacteria after local injections for treatment of chronic back pain are rare. This study investigated an outbreak of Pseudomonas aeruginosa infections following computed tomography (CT)-guided spinal injections (SI). METHODS A case was defined as a spinal infection or meningitis with P. aeruginosa after SI between 10th January and 1st March 2019 in the same outpatient clinic. Patients without microbiological evidence of P. aeruginosa but with a favourable response to antimicrobial therapy active against P. aeruginosa were defined as probable cases. FINDINGS Twenty-eight of 297 patients receiving CT-guided SI during the study period developed meningitis or spinal infections. Medical records were available for 19 patients. In 15 patients, there was microbiological evidence of P. aeruginosa, and four patients were defined as probable cases. Two of 19 patients developed meningitis, while the remaining 17 patients developed spinal infections. The median time from SI to hospital admission was 8 days (interquartile range 2-23 days). Patients mainly presented with back pain (N=18; 95%), and rarely developed fever (N=3; 16%). Most patients required surgery (N=16; 84%). Seven patients (37%) relapsed and one patient died. Although the source of infection was not identified microbiologically, documented failures in asepsis when performing SI probably contributed to these infections. CONCLUSIONS SI is generally considered safe, but non-adherence to asepsis can lead to deleterious effects. Spinal infections caused by P. aeruginosa are difficult to treat and have a high relapse rate.
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Affiliation(s)
- G Paul
- Department I of Internal Medicine, Division of Infectious Diseases, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany; Department of Gastroenterology, Hepatology, Pneumology and Infectious Diseases, Katharinenhospital, Klinikum Stuttgart, Stuttgart, Germany.
| | - A Meißner
- Department of Hospital Hygiene and Infection Control, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - J Neuneier
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - V Neuschmelting
- Centre for Neurosurgery, Department of General Neurosurgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - S Grau
- Centre for Neurosurgery, Department of General Neurosurgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - A Yagdiran
- Department of Orthopaedics and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - M J Scheyerer
- Department of Orthopaedics and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - J J Malin
- Department I of Internal Medicine, Division of Infectious Diseases, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany; German Centre for Infection Research, Partner Site Cologne-Bonn, Cologne, Germany
| | - I Suárez
- Department I of Internal Medicine, Division of Infectious Diseases, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany; German Centre for Infection Research, Partner Site Cologne-Bonn, Cologne, Germany
| | - C Lehmann
- Department I of Internal Medicine, Division of Infectious Diseases, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany; German Centre for Infection Research, Partner Site Cologne-Bonn, Cologne, Germany
| | - M Exner
- Institute of Hygiene and Public Health, Bonn University, Bonn, Germany
| | - G A Wiesmüller
- Abteilung Infektions- and Umwelthygiene, Gesundheitsamt der Stadt Köln, Germany
| | - P G Higgins
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany; German Centre for Infection Research, Partner Site Cologne-Bonn, Cologne, Germany
| | - H Seifert
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany; German Centre for Infection Research, Partner Site Cologne-Bonn, Cologne, Germany
| | - G Fätkenheuer
- Department I of Internal Medicine, Division of Infectious Diseases, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany; German Centre for Infection Research, Partner Site Cologne-Bonn, Cologne, Germany
| | - J Zweigner
- Department of Hospital Hygiene and Infection Control, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - N Jung
- Department I of Internal Medicine, Division of Infectious Diseases, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
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Liang CL, Wang SW, Chen HJ, Tsai YD, Chen JS, Wang HK, Wang KW. Optimal Cut-Off Points of Sagittal Spinopelvic Parameters as a Morphological Parameter to Predict Efficiency in Nerve Block and Pulsed Radiofrequency for Lumbar Facet Joint Pain: A Retrospective Study. J Pain Res 2021; 14:1949-1957. [PMID: 34234541 PMCID: PMC8253931 DOI: 10.2147/jpr.s303979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/16/2021] [Indexed: 11/23/2022] Open
Abstract
Background After proper patient selection, anatomically correct pulsed radiofrequency of the lumbar facet joints provide long-term pain relief in a routine clinical setting. In the study, we performed an analysis of clinical and radiological predictive factors and provide the scientific basis for this promising modality. Methods The study included 198 patients with lower back pain due to lumbar facet joint disease who underwent medial branch block and pulsed radiofrequency during the period 2015–2019. According to the improvement in pain score, the patients were divided into good and poor outcome groups. Clinical and radiological data were collected and analyzed. Results The multivariable analysis revealed the predictive factors, including lumbar lordosis, lower lumbar lordosis, pelvic tilt, the number of facet joints, old compression fracture with/without vertebroplasty, and post lumbar fusion procedures. Conclusion With the results of this study, we demonstrated that the improved outcome after the surgery was related to lumbar lordosis, lower lumbar lordosis, pelvic tilt, the number of facet joints, old compression fracture with/without vertebroplasty, and the lumbar fusion procedures. Old compression fractures and lumbar fusion would change the radiological factors and cause refractory lumbar facet joint pain.
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Affiliation(s)
- Cheng-Loong Liang
- Department of Neurosurgery, E-DA Hospital, Kaohsiung, Taiwan.,School of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Shih-Wei Wang
- Department of Neurosurgery, E-DA Hospital, Kaohsiung, Taiwan.,Department of Rheumatology, E-DA Hospital, Kaohsiung, Taiwan
| | - Han-Jung Chen
- Department of Neurosurgery, E-DA Hospital, Kaohsiung, Taiwan.,School of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Yu-Duan Tsai
- Department of Neurosurgery, E-DA Hospital, Kaohsiung, Taiwan.,School of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Jui-Sheng Chen
- Department of Neurosurgery, E-DA Hospital, Kaohsiung, Taiwan.,School of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Hao-Kuang Wang
- Department of Neurosurgery, E-DA Hospital, Kaohsiung, Taiwan.,School of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Kuo-Wei Wang
- School of Medicine, I-Shou University, Kaohsiung, Taiwan.,Department of Neurosurgery, E-Da Cancer Hospital, Kaohsiung, Taiwan
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Peterson E, Finkel J. Trigger point injections for axial back pain in adolescents. BMJ Case Rep 2021; 14:e242727. [PMID: 34167984 PMCID: PMC8231043 DOI: 10.1136/bcr-2021-242727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 11/04/2022] Open
Abstract
Adolescents who participate in athletics or have abnormal musculoskeletal anatomy have higher incidences of back pain than non-athletic peers with normal anatomy. Significant time and money spent in diagnostic evaluations for axial back pain can result in treatment delay causing a subsequent decrease in quality of life. Myofascial trigger points are a commonly overlooked reason for axial back pain. They develop due to an abnormal myoneural connection in the setting of muscle overuse. Trigger point injections are a technically simple intervention that is both diagnostic and therapeutic in alleviating trigger point-mediated back pain. There are few complications from these injections, and they should be considered prior to surgical referral or fluoroscopic-guided interventions.
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Affiliation(s)
- Elisha Peterson
- School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA
- Division of Anesthesiology, Pain, and Perioperative Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Julia Finkel
- Pain Medicine, The Sheikh Zayed Institute for Pediatric Surgical Innovation; Children's National Hospital, Pediatrics and Critical Care Medicine, The George Washington University, Washington, District of Columbia, USA
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Baschera D, Syrianos S, Samel C, Alfieri A, Westermann L. Current patterns of practice in spinal fusion for chronic low back pain-results from a survey at the German Spine Societies' Annual Congress 2018. Acta Neurochir (Wien) 2021; 163:853-861. [PMID: 33404879 DOI: 10.1007/s00701-020-04691-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 12/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is debate regarding criteria to select patients for lumbar fusion surgery who have chronic low back pain (CLBP) and corresponding degenerative changes, but without nerve root compression or neurogenic claudication. The aim of this study was to compare patterns in current practice. METHOD A total of 143 printed questionnaires containing 51 questions were distributed at the German Spine Societies' (DWG) annual congress, 6-8 December 2018. RESULTS We received 127 (89%) surveys (64 orthopedic surgeons and 63 neurosurgeons). Excluding the 22% who do not perform lumbar fusion for CLBP, 41.4% reported performing 1-10 lumbar fusion procedures for patients with CLBP per year, 20.2% reported 11-20, 10.1% reported 21-30 and 17.2% reported performing more than 50. A total of 44.9% of surgeons reported treating patients for at least 6-12 months conservatively before considering surgery; 65.6% considered postoperative pain reduction of 50-70% a treatment success; 32.6% of respondents believe that <50% of patients showed good outcomes after fusion in CLBP and only 15.5% believed that 70% or more showed good outcomes. Orthopedic surgeons perform more lumbar fusion surgeries than neurosurgeons (p = 0.05), fuse more lumbar segments than neurosurgeons (p = 0.02) and are more likely to suggest that their patients with CLBP cease smoking preoperatively (p = 0.02). CONCLUSIONS Despite discouraging evidence in the literature, the majority of respondents still perform fusion surgery in patients with CLBP. The use of preoperative diagnostics and tests vary widely among spine surgeons.
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Affiliation(s)
- Dominik Baschera
- Department of Neurosurgery, Kantonsspital Winterthur, Brauerstrasse 15, 8401, Winterthur, Switzerland.
- Department of Neurosurgery, Luzerner Kantonsspital, Spitalstrasse, 6004, Luzern, Switzerland.
| | - Sofia Syrianos
- Center of Orthopedic and Trauma Surgery, University Hospital, Kerpener Str. 62, 50937, Cologne, Germany
| | - Christina Samel
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Bachemer Str. 86, 50931, Cologne, Germany
| | - Alex Alfieri
- Department of Neurosurgery, Kantonsspital Winterthur, Brauerstrasse 15, 8401, Winterthur, Switzerland
- Brandenburg Medical School, Fehrbellinerstrasse, 38, 16816, Neuruppin, Germany
| | - Leonard Westermann
- Center of Orthopedic and Trauma Surgery, University Hospital, Kerpener Str. 62, 50937, Cologne, Germany
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26
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Almalki MAO, Almatroudi NSA, Almutairi RNS, Alshareef YA, Alkhuwaylidi HM, Alruwaili RZA, Alnuayr MAMA, Alamri SAS, Alruwaili MTM, Alenezı ATF, Mayouf SJAA, Hanash AA. Review on Chronic Low Back Pain Management Approach in Primary Care. ARCHIVES OF PHARMACY PRACTICE 2021. [DOI: 10.51847/j26v7yozmb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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27
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Kennedy DJ, Schneider B. Lies, Damn Lies, and Statistic: A Commentary. PAIN MEDICINE 2020; 21:2052-2054. [PMID: 32918475 DOI: 10.1093/pm/pnaa287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- David J Kennedy
- Vanderbilt University Medical Center, Physical Medicine and Rehabilitation, Nashville, Tennessee, USA
| | - Byron Schneider
- Vanderbilt University Medical Center, Physical Medicine and Rehabilitation, Nashville, Tennessee, USA
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28
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Does ultrasound-guided facet joint injection reduce pain and improve mobility in patients with failed back surgery syndrome? Jt Dis Relat Surg 2020; 31:564-570. [PMID: 32962590 PMCID: PMC7607942 DOI: 10.5606/ehc.2020.75727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES This study aims to evaluate whether ultrasound (US)-guided facet joint injection reduces pain and improves mobility in patients with failed back surgery syndrome (FBSS). PATIENTS AND METHODS This retrospective study included 27 patients (8 males, 19 females; mean age 43.6±11.5 years; range, 31 to 54 years) who underwent US-guided facet injections for FBSS between January 2017 and January 2019. Patients' medial records were assessed. Pain rating scores were evaluated with the Numeric Rating Scale (NRS). Functional status was assessed with Oswestry Disability Index (ODI) version 2.0. Lumbar flexion degree was noted. After injection (lidocaine-betamethasone mixture), patients were reevaluated at first and sixth months. The study data were analyzed with Wilcoxon signed-rank test. RESULTS Successful facet joint injections were achieved without any complications in all patients. The median duration of time after surgery was 7.8±1.3 months. Mean duration of pain was 6.7±5.7 months. There was a significant decrease in NRS values between baseline and sixth month comparison (7.0 at baseline and 6.0 at sixth month, p=0.006). Baseline-first month and first-sixth months comparisons were not significant (p=0.165 and p=0.106, respectively). For ODI, no significant change was observed between baseline-first month, first-sixth months, and baseline-sixth month comparisons (p=0.109, p=0.857, and p=0.095, respectively). For lumbar flexion, all comparisons resulted in significant increase (50.0° for baseline, 60.0° at first month, and 70.0° at sixth month; p<0.001 for baseline-first month comparison, p<0.001 for baseline-sixth month comparison, and p<0.001 for first-sixth months comparison). CONCLUSION Our results show that pain is reduced and mobility is improved with US-guided facet joint injections in patients with FBSS.
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Retrospective Study on Ganglionic and Nerve Block Series as Therapeutic Option for Chronic Pain Patients with Refractory Neuropathic Pain. Pain Res Manag 2020; 2020:6042941. [PMID: 32774567 PMCID: PMC7399767 DOI: 10.1155/2020/6042941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/03/2020] [Accepted: 06/13/2020] [Indexed: 11/18/2022]
Abstract
Objective Current recommendations controversially discuss local infiltration techniques as specific treatment for refractory pain syndromes. Evidence of effectiveness remains inconclusive and local infiltration series are discussed as a therapeutic option in patients not responding to standard therapy. The aim of this study was to investigate the effectiveness of infiltration series with techniques such as sphenopalatine ganglion (SPG) block and ganglionic local opioid analgesia (GLOA) for the treatment of neuropathic pain in the head and neck area in a selected patient group. Methods In a retrospective clinical study, 4960 cases presenting to our university hospital outpatient pain clinic between 2009 and 2016 were screened. Altogether, 83 patients with neuropathic pain syndromes receiving local infiltration series were included. Numeric rating scale (NRS) scores before, during, and after infiltration series, comorbidity, and psychological assessment were evaluated. Results Maximum NRS before infiltration series was median 9 (IQR 8–10). During infiltration series, maximum NRS was reduced by mean 3.2 points (SD 3.3, p < 0.001) equaling a pain reduction of 41.0% (SD 40.4%). With infiltration series, mean pain reduction of at least 30% or 50% NRS was achieved in 54.2% or 44.6% of cases, respectively. In six percent of patients, increased pain intensity was noted. Initial improvement after the first infiltration was strongly associated with overall improvement throughout the series. Conclusion This study suggests a beneficial effect of local infiltration series as a treatment option for refractory neuropathic pain syndromes in the context of a multimodal approach. This effect is both significant and clinically relevant and therefore highlights the need for further randomized controlled trials.
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Hadzimuratovic B, Mittelbach A, Bahrami A, Zwerina J, Kocijan R. Confluent abscesses in autochthonous back muscles after spinal injections : A case report and narrative review of the literature on low back pain and spinal injections. Wien Med Wochenschr 2020; 172:247-255. [PMID: 32748365 DOI: 10.1007/s10354-020-00773-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/01/2020] [Indexed: 12/13/2022]
Abstract
Injection therapy is a frequently used method for the treatment of subacute and chronic low back pain (LBP) despite scant evidence for its effectiveness. To date there are relatively few studies comparing this method with other treatments. Moreover, there are many possible side effects associated with injection therapies, some of which are potentially life threatening. We present the case of a 59-year-old woman admitted to the emergency department with confluent abscess formations of autochthonous back muscles and staphylococcal sepsis caused by injection therapy performed by a general practitioner for LBP. The findings of this case report emphasize a careful selection of patients for this type of treatment and a multidisciplinary approach to treatment of LBP.
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Affiliation(s)
- Benjamin Hadzimuratovic
- Ludwig Boltzmann Institute of Osteology, I. Medizinische Abteilung, Mein Hanusch-Krankenhaus, Heinrich Collin-Straße 30, 1140, Vienna, Austria
| | - Andreas Mittelbach
- Institut für Physikalische Medizin und Rehabilitation, Mein Hanusch-Krankenhaus, Heinrich Collin-Straße 30, 1140, Vienna, Austria
| | - Arian Bahrami
- Zentralröntgeninstitut mit Fachbereich Nuklearmedizin, I. Medizinische Abteilung, Mein Hanusch-Krankenhaus, Heinrich Collin-Straße 30, 1140, Vienna, Austria
| | - Jochen Zwerina
- Ludwig Boltzmann Institute of Osteology, I. Medizinische Abteilung, Mein Hanusch-Krankenhaus, Heinrich Collin-Straße 30, 1140, Vienna, Austria
| | - Roland Kocijan
- Ludwig Boltzmann Institute of Osteology, I. Medizinische Abteilung, Mein Hanusch-Krankenhaus, Heinrich Collin-Straße 30, 1140, Vienna, Austria.
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31
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Lin W, Ma WT, Xue Y. Low Back Pain Induced by Posterior Longitudinal Ligament Incision in Percutaneous Transforaminal Endoscopic Lumbar Discectomy. Orthop Surg 2020; 12:1230-1237. [PMID: 32700363 PMCID: PMC7454223 DOI: 10.1111/os.12747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 05/23/2020] [Accepted: 06/18/2020] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To illustrate the posterior longitudinal ligament is one of the tissue candidates who can contribute to low back pain (LBP). METHODS This is a retrospective study. A series of 72 patients who underwent single-level percutaneous endoscopic lumbar discectomy performed for lumbar disc herniation with LBP from June 2014 to June 2016 were examined. There are 42 males and 30 females. The ages of patients were 40 to 57 years, and the mean age was 49.8 years. The symptomatic disc level was at L4-5 in 43 patients and L5 S1 in 29 patients. Thirty-two patients (19 patients in L4-5 disc level, 13 patients in L5 S1 disc level) had LBP (which was limited to the lower back and buttock area) before the operation. All of the operative approaches were performed under local anesthesia. A posterior body diagram (15 cm × 10 cm) was made for this study to record the pain distribution. The centered foci of low back pain were subjectively recorded before, during, and after the operation. The transforaminal endoscopic spine system technology was used in this study. Radiological examinations (X-ray, computed tomography, and magnetic resonance imaging) were performed prior to and after surgery. The Visual Analogue Score (VAS) and Oswestry Disability Index (ODI) scores were taken before and after the surgery to observe the degree of pain. The VSA and ODI score before and after operation were expressed as mean ± SD, and compared by t-test for statistical analysis. RESULTS When inciting the posterior longitudinal ligament during the operation, all 72 patients had provoked low back pain. Forty-three patients with symptomatic discs at L4-5 had pain foci in the lower back and upper gluteal region under the L4 spinous process. Twenty-nine patients with symptomatic discs at L5 S1 had pain foci in the gluteal region under the S1 spinous process. The pain localizations of L4-5 and L5 S1 were different. After the surgery, the provoked low back pain disappeared, and had not returned in any of the patients at the 6-month follow-up. After the operation, one patient suffered from lower limb pain that he did not have before the operation, and the lower limb pain abated a few days later. Three patients had cerebrospinal fluid leakage and were treated with higher pressure applied on the incision and bed rest for 10 days. During the 6-months follow-up period, the mean VAS decreased from 5.97 ± 1.10 to 2.13 ± 0.78. The mean ODI score decreased from 23.14 ± 3.28 to 7.92 ± 1.85. CONCLUSIONS The intervertebral posterior longitudinal ligament may be one of the tissues from which low back pain originates.
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Affiliation(s)
- Wei Lin
- Department of Orthopaedic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Wen-Ting Ma
- Department of Orthopaedic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yuan Xue
- Department of Orthopaedic Surgery, Tianjin Medical University General Hospital, Tianjin, China
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32
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Fornari M, Robertson SC, Pereira P, Zileli M, Anania CD, Ferreira A, Ferrari S, Gatti R, Costa F. Conservative Treatment and Percutaneous Pain Relief Techniques in Patients with Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations. World Neurosurg X 2020; 7:100079. [PMID: 32613192 PMCID: PMC7322792 DOI: 10.1016/j.wnsx.2020.100079] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/25/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Degenerative lumbar spinal stenosis (LSS) is a progressive disease with potentially dangerous consequences that affect quality of life. Despite the detailed literature, natural history is unpredictable. This uncertainty presents a challenge making the correct management decisions, especially in patients with mild to moderate symptoms, regarding conservative or surgical treatment. This article focused on conservative treatment for degenerative LSS. METHODS To standardize clinical practice worldwide as much as possible, the World Federation of Neurosurgical Societies Spine Committee held a consensus conference on conservative treatment for degenerative LSS. A team of experts in spinal disorders reviewed the literature on conservative treatment for degenerative LSS from 2008 to 2018 and drafted and voted on a number of statements. RESULTS During 2 consensus meetings, 14 statements were voted on. The Committee agreed on the use of physical therapy for up to 3 months in cases with no neurologic symptoms. Initial conservative treatment could be applied without major complications in these cases. In patients with moderate to severe symptoms or with acute radicular deficits, surgical treatment is indicated. The efficacy of epidural injections is still debated, as it shows only limited benefit in patients with degenerative LSS. CONCLUSIONS A conservative approach based on therapeutic exercise may be the first choice in patients with LSS except in the presence of significant neurologic deficits. Treatment with instrumental modalities or epidural injections is still debated. Further studies with standardization of outcome measures are needed to reach high-level evidence conclusions.
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Affiliation(s)
- Maurizio Fornari
- Neurosurgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Scott C. Robertson
- Neurosurgery Department, Laredo Medical Center, University of the Incarnate Word School of Osteopathic Medicine, Laredo, Texas, USA
| | - Paulo Pereira
- Department of Neurosurgery, University Hospital Center of São João and Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mehmet Zileli
- Department of Neurosurgery, Ege University Faculty of Medicine, Bornova, Izmir, Turkey
| | - Carla D. Anania
- Neurosurgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ana Ferreira
- Department of Neurosurgery, University Hospital Center of São João and Faculty of Medicine of the University of Porto, Porto, Portugal
| | | | | | - Francesco Costa
- Neurosurgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
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Donado C, Spagnuolo GM, Lobo K, Berde C, Dinakar P. Effect of lumbar medial branch blocks on extension-related axial chronic low back pain in a pediatric population: a retrospective chart review and prospective follow-up. Reg Anesth Pain Med 2020; 45:1019-1020. [PMID: 32393524 DOI: 10.1136/rapm-2019-101218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Carolina Donado
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Genevieve M Spagnuolo
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kimberly Lobo
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Charles Berde
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Pradeep Dinakar
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA .,Department of Anesthesiology, Perioperative & Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Ruiz‐Lopez R, Tsai Y. A Randomized Double‐Blind Controlled Pilot Study Comparing Leucocyte‐Rich Platelet‐Rich Plasma and Corticosteroid in Caudal Epidural Injection for Complex Chronic Degenerative Spinal Pain. Pain Pract 2020; 20:639-646. [DOI: 10.1111/papr.12893] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/15/2020] [Accepted: 03/26/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Ricardo Ruiz‐Lopez
- Clinica Vertebra, Barcelona Spine and Pain Surgery Center, Unit of MISS Barcelona Spain
| | - Yu‐Chuan Tsai
- Department of Anesthesiology and Center of Pain Management E‐Da Cancer Hospital Kaohsiung Taiwan
- School of Medicine I‐Shou University College of Medicine Kaohsiung Taiwan
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[Diagnostics and therapy of back pain: what is advisable? What should be avoided and why is it still done?]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:527-534. [PMID: 32189043 DOI: 10.1007/s00103-020-03121-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Diagnostic and therapeutic procedures are popular and frequently performed for low back pain. This narrative review presents and discusses the myths and evidence related to these procedures.In most cases it is nonspecific pain, for which no underlying disease can be named. Image diagnostics using X‑rays and MRI are rarely helpful in the case of new nonspecific back pain.Evidence for chirotherapy is doubtful. Also, evidence is lacking for invasive and surgical procedures in local and regional low back pain. These procedures show superiority in radicular pain only: extraction of disc herniation in acute and subacute leg pain and segmental lumbar fusion in chronic leg pain. Nevertheless, these and other invasive methods are being used to an increasing extent. Spontaneous healing and the possibilities of the patient to become pain-relieving for themselves are neglected and increased risks are accepted.Therapeutic approaches fostering self-efficacy by reconditioning physical and mental capability and improving positive self-perception ("interdisciplinary multimodal pain therapy") effect superior and sustainable results in subacute and chronic nonspecific back pain. Patients and physicians, however, tend to prefer passive and invasive therapy strategies. The underlying mechanisms should be understood. New thinking is necessary.
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Validity, Reliability, Feasibility, and Usefulness of Pain Monitor: A Multidimensional Smartphone App for Daily Monitoring of Adults With Heterogenous Chronic Pain. Clin J Pain 2019; 34:900-908. [PMID: 29659375 DOI: 10.1097/ajp.0000000000000618] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Ecological momentary assessment has been recommended in the management of chronic pain. Smartphone apps might be a useful tool for that purpose. This goal of this study was to develop and test a multidimensional smartphone app for adults with chronic pain. A multidisciplinary team developed the app content after a series of meetings, considering clinical guidelines for pain measurement. The content included pain intensity and interference, fatigue, mood, perceived health status, activity level, side effects of the medication, use of rescue medication, and pain-related sychological constructs (catastrophizing, acceptance, fear, and coping). METHODS Thirty-eight participants (21 to 59 y) used the app, called Pain Monitor, twice a day during 30 consecutive days. Patients completed a set of well-established measures at the beginning and end of the study via paper-and-pencil. Weekly phone assessments were also made for pain intensity, pain interference, fatigue, and mood. RESULTS Construct validity was revealed by moderate-to-strong correlations between app content and traditional measures. Feasibility was supported by high compliance (between 70% and 82%) and high acceptability and ease of use. Both side effects of the medication and use of rescue medication were found to be useful tools to guide treatment. DISCUSSION The new assessment protocol in the app allows for an easy and rapid multidimensional assessment of chronic pain patients.
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Kent P, O'Sullivan P, Smith A, Haines T, Campbell A, McGregor AH, Hartvigsen J, O'Sullivan K, Vickery A, Caneiro JP, Schütze R, Laird RA, Attwell S, Hancock M. RESTORE-Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain: study protocol for a randomised controlled trial. BMJ Open 2019; 9:e031133. [PMID: 31427344 PMCID: PMC6701662 DOI: 10.1136/bmjopen-2019-031133] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Low back pain (LBP) is the leading cause of disability globally and its costs exceed those of cancer and diabetes combined. Recent evidence suggests that individualised cognitive and movement rehabilitation combined with lifestyle advice (cognitive functional therapy (CFT)) may produce larger and more sustained effects than traditional approaches, and movement sensor biofeedback may enhance outcomes. Therefore, this three-arm randomised controlled trial (RCT) aims to compare the clinical effectiveness and economic efficiency of individualised CFT delivered with or without movement sensor biofeedback, with usual care for patients with chronic, disabling LBP. METHODS AND ANALYSIS Pragmatic, three-arm, randomised, parallel group, superiority RCT comparing usual care (n=164) with CFT (n=164) and CFT-plus-movement-sensor-biofeedback (n=164). Inclusion criteria include: adults with a current episode of LBP >3 months; sought primary care ≥6 weeks ago for this episode of LBP; average LBP intensity of ≥4 (0-10 scale); at least moderate pain-related interference with work or daily activities. The CFT-only and CFT-plus-movement-sensor-biofeedback participants will receive seven treatment sessions over 12 weeks plus a 'booster' session at 26 weeks. All participants will be assessed at baseline, 3, 6, 13, 26, 40 and 52 weeks. The primary outcome is pain-related physical activity limitation (Roland Morris Disability Questionnaire). Linear mixed models will be used to assess the effect of treatment on physical activity limitation across all time points, with the primary comparison being a formal test of adjusted mean differences between groups at 13 weeks. For the economic (cost-utility) analysis, the primary outcome of clinical effect will be quality-adjusted life years measured across the 12-month follow-up using the EuroQol EQ-5D-5L . ETHICS AND DISSEMINATION Approved by Curtin University Human Research Ethics Committee (HRE2018-0062, 6 Feb 2018). Study findings will be disseminated through publication in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ACTRN12618001396213).
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Affiliation(s)
- Peter Kent
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - P O'Sullivan
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Anne Smith
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Terry Haines
- Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
| | - Amity Campbell
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Alison H McGregor
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jan Hartvigsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark
| | - Kieran O'Sullivan
- Sports Spine Centre, Aspetar Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - Alistair Vickery
- General Practice, The University of Western Australia, Crawley, Western Australia, Australia
| | - J P Caneiro
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Robert Schütze
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | | | - Stephanie Attwell
- Department of Health Professions, Macquarie University, Sydney, New South Wales, Australia
| | - Mark Hancock
- Department of Health Professions, Macquarie University, Sydney, New South Wales, Australia
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Health Care Economics of SI Joint Fusion. Tech Orthop 2019. [DOI: 10.1097/bto.0000000000000370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Accuracy of the Anatomic Placement in Ultrasonography Guided Facet Joint Blockage with Supervising of C-Arm Fluoroscopy. IRANIAN JOURNAL OF RADIOLOGY 2019. [DOI: 10.5812/iranjradiol.84389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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An evaluation of contrast dispersal pattern on preganglionic epidural injection through trans-lateral recess approach in patients with lumbosacral radiculopathy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:2535-2542. [DOI: 10.1007/s00586-019-05947-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 02/01/2019] [Accepted: 03/06/2019] [Indexed: 12/12/2022]
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Bennett DS. Cryopreserved amniotic membrane and umbilical cord particulate for managing pain caused by facet joint syndrome: A case series. Medicine (Baltimore) 2019; 98:e14745. [PMID: 30855467 PMCID: PMC6417546 DOI: 10.1097/md.0000000000014745] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Treatment of back pain due to facet joint syndrome has been a challenge for physicians since its recognition ∼80 years ago. Intra-articular injections of steroids, local anesthetics, and phenol have been widely adopted despite their known shortcomings. Recently, intra-articular injection of amniotic membrane-umbilical cord (AMUC) has been utilized in various orthopedic indications, including those involving synovial joints, due to its reported anti-inflammatory properties. Herein, use of AMUC for facet joint syndrome was evaluated.A single-center case series was conducted on patients presenting with pain caused by facet joint syndrome, confirmed by single blocking anesthetic injection and treated using a single intra-articular injection of 50 mg particulate AMUC (CLARIX FLO) suspended in preservative-free saline. Patient reported back pain severity (numerical scale 0-10) and opioid use were compared between baseline and 6 months following treatment.A total of 9 patients (7 males, 2 females), average age 52.1 ± 15.9 years, were included. Five patients with cervical pain had a history of trauma, 1 patient had suffered lumbar facet injury and 3 had degenerative lumbar facet osteoarthritis. All patients had severe pain prior to injection (8.2 ± 0.8) and 4 (44%) were taking opioids (>100 morphine milligram equivalents). Six-month post-treatment, average pain had decreased to 0.4 ± 0.7 (P <.05). All patients had ceased use of prescription pain medications, including opioids. No adverse events, repeat procedures, or complications were reported.Intra-articular injection of AMUC appears to be promising for managing facet pain and mitigating opioid use. Further investigation with larger sample size is warranted.
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Abandoned techniques in spine surgery. Neurocirugia (Astur) 2019; 31:37-41. [PMID: 30792110 DOI: 10.1016/j.neucir.2019.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 01/05/2019] [Indexed: 11/20/2022]
Abstract
In spine surgery, certain surgical techniques and devices are currently in marked decline or have been completely abandoned. Although used in thousands of patients, such treatments failed to demonstrate durable and sound effectiveness, and sometimes associate inacceptable morbidity. Chemopapain injections, percutaneous discectomy, laser discectomy or antiadhesion gels are examples of abandoned therapies. Some other techniques are in frank decline like implantation of interspinous devices or lumbar disc prosthesis. In general, a technique is abandoned due to inefficacy, excessive associated morbidity, substituted by another more efficacious and less aggressive technique, end of commercialization, or usage prohibition. In the last decades, a great commercial pressure plus an increasing social demand have managed to convince many spine surgeons to indicate treatments not sufficiently supported by scientific evidence nor consolidated over time, many of which are eventually abandoned.
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Abstract
Pain significantly restricts the quality of life and well-being of older adults. With our increasingly ageing population, it is important to examine whether differing classes of biopsychosocial risk factors can predict the development of pain in older adults. Latent class analysis provides a model-based approach to identifying underlying subgroups in a population, based on some measured characteristics. In this study, latent class analysis was used to identify biopsychosocial risk classes in people aged 50 years and older, from The Irish Longitudinal Study on Ageing, who reported not often being troubled by pain at wave 1 and completed the 2-year follow-up at wave 2 (n = 4458). Four classes were identified based on 11 potential risk factors at wave 1. These classes were characterised as "Low Risk," "Physical Health Risk," "Mental Health Risk," and "High Risk." The Low-Risk class accounted for over half the sample (51.2%), whereas the High-Risk class represented 7.8% of the sample. At follow-up (wave 2), 797 (17.9%) participants reported being troubled by pain. Associations between the biopsychosocial risk classes and developing pain were examined using logistic regression, adjusting for sociodemographic variables. The High-Risk class was more likely to develop pain compared with the Low-Risk class (adjusted OR = 3.16, 95% CI = 2.40-4.16). These results add to existing data in other populations supporting the role of a range of biopsychosocial risk factors that increase the risk of developing pain. These findings have important implications for the identification, and potential moderation, of these risk factors.
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Kershen LM, Nacey NC, Patrie JT, Fox MG. Fluoroscopically Guided Facet Injections: Comparison of Intra-Articular and Periarticular Steroid and Anesthetic Injection on Immediate and Short-Term Pain Relief. AJNR Am J Neuroradiol 2018; 39:2161-2165. [PMID: 30287461 DOI: 10.3174/ajnr.a5805] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 07/30/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The effectiveness of facet injections is unclear in the literature. Our objective was to determine the immediate and short-term efficacy of intra-articular and periarticular steroid/anesthetic injections for facet-mediated lumbar pain. MATERIALS AND METHODS All outpatient fluoroscopically guided facet injections at a single institution during a 54-month period were retrospectively and independently reviewed by 2 musculoskeletal (MSK) trained radiologists. All intra-articular, all periarticular, and partial intra-/periarticular injection locations were determined. Periarticular and partial peri-/intra-articular injections were combined for analysis. Preinjection, immediate, and 1-week postinjection numeric pain scores, patient age, sex, anesthetic/steroid mixture, fluoroscopic time, and physician performing the procedure were recorded. RESULTS Seventy-seven patients (mean age, 51.1 years) had 100 procedures with 205 total facet joints injected. All intra-articular, all periarticular, and partial peri-/intra-articular injections constituted 54%, 20%, and 26% of the cases, respectively. The immediate and 1-week postprocedural change in pain was -3.7 (95% CI, -4.5 to -2.8; P < .001) and -1.4 (95% CI, -2.2 to -0.6; P = .001) for the all intra-articular and -3.6 (95% CI, -4.4 to -2.9; P < .001) and -1.2 (95% CI, -1.9 to -0.4; P = .002) for the combined group. Changes in immediate pain were significantly associated with the prepain level (P < .001) and patient age (P = .024) but not with the anesthetic used. Analyses revealed no significant difference in pain reduction between the groups either immediately or 1 week postinjection. Intra-articular injections required less fluoroscopic time (geometric mean, 39 versus 52 seconds) (P = .005). CONCLUSIONS Intra-articular and periarticular fluoroscopically guided facet injections provide statistically significant and similar pain relief both immediately and 1 week postinjection.
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Affiliation(s)
- L M Kershen
- From the Colorado Imaging Associates (L.M.K.), Golden, Colorado
| | - N C Nacey
- Departments of Radiology and Medical Imaging (N.C.N.)
| | - J T Patrie
- Public Health Sciences (J.T.P.), University of Virginia, Charlottesville Virginia
| | - M G Fox
- Department of Radiology (M.G.F.), Mayo Clinic Arizona, Phoenix, Arizona.
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Abstract
OBJECTIVE To review the literature guiding all aspects of the use of injectable corticosteroids for painful musculoskeletal conditions, with a focus on the treatment of athletes. DATA SOURCES An extensive search of the literature was completed including search terms of corticosteroid, steroid, athlete, and injection, among others. Additional articles were used after being identified from previously reviewed articles. MAIN RESULTS Injections of corticosteroids for a variety of painful conditions of the extremities and the axial spine have been described. Numerous minor and major complications have been reported, including those with a high degree of morbidity. There is a dearth of published research on the use of corticosteroid injections in athletes, with most of the research on this topic focused on older, nonathlete populations. Generally, these injections are well tolerated and can provide short-term pain improvement with little or no long-term benefits. CONCLUSIONS Corticosteroid injections should be used cautiously in athletes and only after a full consideration of the pharmacology, pathogenesis of disease, potential benefits, complications, factors specific to the athlete, and rules of athletic governing bodies. Corticosteroid injections are just one component of a comprehensive rehabilitation plan available to the physician providing care to athletes.
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Snidvongs S, Taylor RS, Ahmad A, Thomson S, Sharma M, Farr A, Fitzsimmons D, Poulton S, Mehta V, Langford R. Facet-joint injections for non-specific low back pain: a feasibility RCT. Health Technol Assess 2018; 21:1-130. [PMID: 29231159 DOI: 10.3310/hta21740] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pain of lumbar facet-joint origin is a common cause of low back pain in adults and may lead to chronic pain and disability, with associated health and socioeconomic implications. The socioeconomic burden includes an inability to return to work resulting in loss of productivity in addition to direct and indirect health-care utilisation costs. Lumbar facet-joints are paired synovial joints between the superior and inferior articular processes of consecutive lumbar vertebrae and between the fifth lumbar vertebra and the sacrum. Facet-joint pain is defined as pain that arises from any structure that is part of the facet-joints, including the fibrous capsule, synovial membrane, hyaline cartilage and bone. This pain may be treated by intra-articular injections with local anaesthetic and steroid, although this treatment is not standardised. At present, there is no definitive research to support the use of targeted lumbar facet-joint injections to manage this pain. Because of the lack of high-quality, robust clinical evidence, the National Institute for Health and Care Excellence (NICE) guidelines on the management of chronic low back pain [NICE. Low Back Pain in Adults: Early Management. Clinical guideline (CG88). London: NICE; 2009] did not recommend the use of spinal injections despite their perceived potential to reduce pain intensity and improve rehabilitation, with NICE calling for further research to be undertaken. The updated guidelines [NICE. Low Back Pain and Sciatica in Over 16s: Assessment and Management. NICE guideline (NG59). London: NICE; 2016] again do not recommend the use of spinal injections. OBJECTIVES To assess the feasibility of carrying out a definitive study to evaluate the clinical effectiveness and cost-effectiveness of lumbar facet-joint injections compared with a sham procedure in patients with non-specific low back pain of > 3 months' duration. DESIGN Blinded parallel two-arm pilot randomised controlled trial. SETTING Initially planned as a multicentre study involving three NHS trusts in the UK, recruitment took place in the pain and spinal orthopaedic clinics at Barts Health NHS Trust only. PARTICIPANTS Adult patients referred by their GP to the specialist clinics with non-specific low back pain of at least 3 months' duration despite NICE-recommended best non-invasive care (education and one of a physical exercise programme, acupuncture or manual therapy). Patients who had already received lumbar facet-joint injections or who had had previous back surgery were excluded. INTERVENTIONS Participants who had a positive result following a diagnostic test (single medial branch nerve blocks) were randomised and blinded to receive either intra-articular lumbar facet-joint injections with steroids (intervention group) or a sham procedure (control group). All participants were invited to attend a group-based combined physical and psychological (CPP) programme. MAIN OUTCOME MEASURES In addition to the primary outcome of feasibility, questionnaires were used to assess a range of pain-related (including the Brief Pain Inventory and Short-Form McGill Pain Questionnaire version 2) and disability-related (including the EuroQol-5 Dimensions five-level version and Oswestry Low Back Pain Questionnaire) issues. Health-care utilisation and cost data were also assessed. The questionnaire visits took place at baseline and at 6 weeks, 3 months and 6 months post randomisation. The outcome assessors were blinded to the allocation groups. RESULTS Of 628 participants screened for eligibility, nine were randomised to receive the study intervention (intervention group, n = 5; sham group, n = 4), six completed the CPP programme and eight completed the study. LIMITATIONS Failure to achieve our expected recruitment targets led to early closure of the study by the funder. CONCLUSIONS Because of the small number of participants recruited to the study, we were unable to draw any conclusions about the clinical effectiveness or cost-effectiveness of intra-articular lumbar facet-joint injections in the management of non-specific low back pain. Although we did not achieve the target recruitment rate from the pain clinics, we demonstrated our ability to develop a robust study protocol and deliver the intended interventions safely to all nine randomised participants, thus addressing many of the feasibility objectives. FUTURE WORK Stronger collaborations with primary care may improve the recruitment of patients earlier in their pain trajectory who are suitable for inclusion in a future trial. TRIAL REGISTRATION EudraCT 2014-003187-20 and Current Controlled Trials ISRCTN12191542. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 74. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Saowarat Snidvongs
- Pain and Anaesthesia Research Centre, Barts Health NHS Trust, London, UK
| | - Rod S Taylor
- Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Alia Ahmad
- Pain and Anaesthesia Research Centre, Barts Health NHS Trust, London, UK
| | - Simon Thomson
- Department of Pain Management, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, UK
| | - Manohar Sharma
- Department of Pain Medicine, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Angela Farr
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Deborah Fitzsimmons
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Stephanie Poulton
- Locomotor Pain Service, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Vivek Mehta
- Pain and Anaesthesia Research Centre, Barts Health NHS Trust, London, UK
| | - Richard Langford
- Pain and Anaesthesia Research Centre, Barts Health NHS Trust, London, UK
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Van Boxem K, Rijsdijk M, Hans G, de Jong J, Kallewaard JW, Vissers K, van Kleef M, Rathmell JP, Van Zundert J. Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group. Pain Pract 2018; 19:61-92. [PMID: 29756333 PMCID: PMC7379698 DOI: 10.1111/papr.12709] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/03/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Epidural corticosteroid injections are used frequently worldwide in the treatment of radicular pain. Concerns have arisen involving rare major neurologic injuries after this treatment. Recommendations to prevent these complications have been published, but local implementation is not always feasible due to local circumstances, necessitating local recommendations based on literature review. METHODS A work group of 4 stakeholder pain societies in Belgium, The Netherlands, and Luxembourg (Benelux) has reviewed the literature involving neurological complications after epidural corticosteroid injections and possible safety measures to prevent these major neurologic injuries. RESULTS Twenty-six considerations and recommendations were selected by the work group. These involve the use of imaging, injection equipment particulate and nonparticulate corticosteroids, epidural approach, and maximal volume to be injected. CONCLUSION Raising awareness about possible neurological complications and adoption of safety measures recommended by the work group aim at reducing the risks for these devastating events.
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Affiliation(s)
- Koen Van Boxem
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
| | - Mienke Rijsdijk
- Pain Clinic, Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Guy Hans
- Multidisciplinary Pain Center, Antwerp University Hospital, Edegem, Belgium.,Laboratory for Pain Research, University of Antwerp, Wilrijk, Belgium
| | - Jasper de Jong
- Department of Pain Management, Westfriesgasthuis, Hoorn, The Netherlands
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Management, Rijnstate Ziekenhuis, Arnhem, The Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Maarten van Kleef
- Department of Anesthesiology and Pain Management, University Medical Centre Maastricht, Maastricht, The Netherlands
| | - James P Rathmell
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.,Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, U.S.A
| | - Jan Van Zundert
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium.,Department of Anesthesiology and Pain Management, University Medical Centre Maastricht, Maastricht, The Netherlands
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Cai X, Liu Y, Hu Y, Liu X, Jiang H, Yang S, Shao Z, Xia Y, Xiong L. ROS-mediated lysosomal membrane permeabilization is involved in bupivacaine-induced death of rabbit intervertebral disc cells. Redox Biol 2018; 18:65-76. [PMID: 29986210 PMCID: PMC6037912 DOI: 10.1016/j.redox.2018.06.010] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 06/20/2018] [Accepted: 06/25/2018] [Indexed: 12/15/2022] Open
Abstract
Bupivacaine is frequently administered for diagnosing and controlling spine-related pain in interventional spine procedures. However, the potential cytotoxic effects of bupivacaine on intervertebral disc (IVD) cells and the underlying molecular mechanisms have not yet been fully established. Here, we showed that bupivacaine decreased the viability of rabbit IVD cells in a dose- and time-dependent manner. Moreover, the short-term cytotoxicity of bupivacaine in IVD cells was primarily due to cell necrosis, as assessed by Annexin V-propidium iodide staining and live/dead cell staining. Necrosis was verified by observations of swollen organelles, plasma membrane rupture, and cellular lysis under transmission electronic microscopy. Interestingly, our data indicated that bupivacaine-induced primary necrosis might involve the necroptosis pathway. The key finding of this study was that bupivacaine was able to induce lysosomal membrane permeabilization (LMP) with the release of cathepsins into the cytosol, as evidenced by LysoTracker Red staining, acridine orange staining, and cathepsin D immunofluorescence staining. Consistently, inhibitors of lysosomal cathepsins, CA074-Me and pepstatin A, significantly reduced bupivacaine-induced cell death. Finally, we found that bupivacaine resulted in an increase in intracellular reactive oxygen species (ROS) and that inhibition of ROS by N-acetyl-L-cysteine effectively blocked bupivacaine-induced LMP and cell death. In summary, the results of this in vitro study reveal a novel mechanism underlying bupivacaine-induced cell death involving ROS-mediated LMP. Our findings establish a basis for the further investigation of bupivacaine cytotoxicity in an in vivo system.
Bupivacaine decreases IVD cell viability in a dose- and time-dependent manner. The short-term cytotoxicity of bupivacaine is primarily due to cell necrosis. LMP is involved in bupivacaine-induced death of IVD cells. ROS is an important mediator in bupivacaine-induced LMP and cell death.
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Affiliation(s)
- Xianyi Cai
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yunlu Liu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yiqiang Hu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Xianzhe Liu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Hongyan Jiang
- Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Shuhua Yang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Zengwu Shao
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yun Xia
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - Liming Xiong
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
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O'Leary SA, Paschos NK, Link JM, Klineberg EO, Hu JC, Athanasiou KA. Facet Joints of the Spine: Structure–Function Relationships, Problems and Treatments, and the Potential for Regeneration. Annu Rev Biomed Eng 2018; 20:145-170. [DOI: 10.1146/annurev-bioeng-062117-120924] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The zygapophysial joint, a diarthrodial joint commonly referred to as the facet joint, plays a pivotal role in back pain, a condition that has been a leading cause of global disability since 1990. Along with the intervertebral disc, the facet joint supports spinal motion and aids in spinal stability. Highly susceptible to early development of osteoarthritis, the facet is responsible for a significant amount of pain in the low-back, mid-back, and neck regions. Current noninvasive treatments cannot offer long-term pain relief, while invasive treatments can relieve pain but fail to preserve joint functionality. This review presents an overview of the facet in terms of its anatomy, functional properties, problems, and current management strategies. Furthermore, this review introduces the potential for regeneration of the facet and particular engineering strategies that could be employed as a long-term treatment.
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Affiliation(s)
- Siobhan A. O'Leary
- Department of Biomedical Engineering, University of California, Davis, California 95616, USA
| | - Nikolaos K. Paschos
- Department of Orthopedic Surgery, Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Massachusetts 02115, USA
| | - Jarrett M. Link
- Department of Biomedical Engineering, University of California, Irvine, California 92617, USA
| | - Eric O. Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California 95816, USA
| | - Jerry C. Hu
- Department of Biomedical Engineering, University of California, Irvine, California 92617, USA
| | - Kyriacos A. Athanasiou
- Department of Biomedical Engineering, University of California, Irvine, California 92617, USA
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Abstract
STUDY DESIGN Longitudinal cohort. OBJECTIVE To determine the cost per quality-adjusted life-year for lumbar epidural steroid injections (LESI). SUMMARY OF BACKGROUND DATA Despite being a widely performed procedure, there are few studies evaluating the cost-effectiveness of LESIs. METHODS Patients who had received LESI between June 2012 and July 2013 with EuroQOL-5D (EQ-5D) scores available before and after LESIs but before any surgical intervention were identified. Costs were calculated on the basis of the Medicare Fee Schedule multiplied by the number of LESIs received between the 2 clinic visits. Quality-adjusted life-years (QALYs) were calculated using the EQ-5D. RESULTS Of 421 patients who had pre-LESI EQ-5D data, 323 (77%) had post-LESI data available; 200 females, 123 males, mean age: 59.2 ± 14.2 years. Cost per LESI was $608, with most patients receiving 3 LESIs for more than 1 year (range: 1-6 yr). Mean QALY gained was 0.005. One hundred forty-five patients (45%) had a QALY gain (mean = 0.117) at a cost of $62,175 per QALY gained; 127 patients (40%) had a loss in QALY (mean = -0.120) and 51 patients (15%) had no change in QALY. Fourteen of the 145 patients who improved, and 29 of the 178 patients who did not, have medical comorbidities that precluded surgery. Thirty-two (22%) of 131 patients without medical comorbidities who improved and 57 (32%) of 149 patients without medical comorbidities who did not improve subsequently had undergone surgery (P = 0.015). CONCLUSION LESI may not be cost-effective in patients with lumbar degenerative disorders. For the 145 patients who improved, cost per QALY gained was acceptable at $62,175. However, for the 178 patients with no gain or a loss in QALY, the economics are not reportable with a cost per QALY gained being theoretically infinite. Further studies are needed to identify specific patient populations who will benefit from LESI because the economic viability of LESI requires improved patient selection. LEVEL OF EVIDENCE 2.
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