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AAPM&R
Best Pain and Spine Papers
What will help my practice?
David E. Fish, MD, MPH
Professor, Department of Orthopaedics
Physical Medicine and Rehabilitation, The UCLA Spine Center
UCLA School of Medicine
David E. Fish, MD, MPH
Physical Medicine and Rehabilitation
Department of Orthopeadic Surgery
Influence Of Low Back Pain And
Prognostic Value Of MRI In
Sciatica Patients In Relation To
Back Pain
Study # 1
• Influence of low back pain and
prognostic value of MRI in sciatica
patients in relation to back pain.
• el Barzouhi A
• PLoS One. 2014 Mar 17;9(3):e90800. doi:
10.1371/journal.pone.0090800.
eCollection 2014.
Purpose
It is not known whether there are
prognostic relevant differences in Magnetic
Resonance Imaging (MRI) findings
between sciatica patients with and without
disabling back pain.
Methods
The MRI findings were compared between sciatica
patients with and without disabling back pain
Two neuroradiologists and one neurosurgeon
independently evaluated all MR images.
The presence of disabling back pain at baseline was
correlated with perceived recovery at one year.
Results
379 sciatica patients, 158 (42%) had
disabling back pain.
Of the patients with both sciatica and
disabling back pain 68% did reveal a
herniated disc with nerve root
compression on MRI.
Results
The existence of disabling back pain in
sciatica at baseline was negatively
associated with perceived recovery at one
year
(Odds ratio [OR] 0.32
95% Confidence Interval 0.18-0.56, P<0.001).
Results
Sciatica patients with disabling back pain
in absence of nerve root compression on
MRI
at baseline reported less perceived
recovery at one year
compared to those with predominantly
sciatica and nerve root compression on
MRI.
(50% vs 91%, P<0.001)
Is this good science?
Hells Yeah it is!!!
Is it important to PMR?
Without a doubt !!!
How will it change me and my
practice with patients?
You can’t judge a person’s emotional state with perceived
pain and what is seen on an MRI.
One must methodically go through the work up and
conservative treatment
Give a person time to recover with therapy, medications,
epidurals, and time.
Have the surgical option for a neurological deficit.
Consider more psychological screening and treatment in
an individual with a ‘normal’ MRI.
PAIN AS A DISEASE
Diagnostic Accuracy Of History
Taking To Assess Lumbosacral
Nerve Root Compression
Study # 2
• Diagnostic accuracy of history
taking to assess lumbosacral nerve
root compression
• Verwoerd AJ
• Spine J. 2014 Sep 1;14(9):202837. doi:
10.1016/j.spinee.2013.11.049.
Epub 2013 Dec 8.
Purpose
To assess the diagnostic accuracy of history
taking
for the presence of lumbosacral nerve root
compression or disc herniation
on magnetic resonance imaging in patients
with sciatica.
Methods
395 adult patients with severe disabling
radicular leg pain of 6 to 12 weeks duration
were included
History was broken out to a standardized
protocol of 20 questions to find what
contributed in diagnosing nerve root
compression
Examples:
"male sex,"
"pain worse in leg than in back,"
"a non-sudden onset."
"body mass index <30,"
"sensory loss."
Methods
Age > 40 years
Male sex
BMI >30
Intellectual job
Physically heavy job
Smoking
Duration of pain for > 9 weeks
Leg pain duration in weeks
Pain worse in leg than back
Back pain > 12 weeks
Sudden Onset
Previous leg pain
Subjective sensory loss
Subjective muscle weakness
Results
Conclusion
Few history items used in isolation have a
diagnostic value to predict MRI disk
herniation and nerve root compression.
Diagnostic accuracy of history taking is
limited.
The evidence to base diagnostic history and
physical exam with sciatica remains limited
Is this good science?
Unfortunately.
Is it important to PMR?
Absolutely
How will it change me and my
practice with patients?
You got me…
Thoracic interlaminar epidural injections
in managing chronic thoracic pain: a
randomized, double-blind, controlled trial
with a 2-year follow-up.
Study # 3
• Manchikanti L
• Pain Physician. 2014 MayJun;17(3):E327-38.
Background
The prevalence of thoracic pain in
approximately 13% of the general population
compared to 32% of the population with neck
pain and 43% of the population with low back
pain
Interventions in managing chronic thoracic pain
are also less frequent, leading to the paucity of
literature about various interventions in
managing chronic thoracic pain
Interventions in managing chronic thoracic pain
are also less frequent, leading to the paucity of
literature about various interventions in
managing chronic thoracic pain
Purpose
Assess the effectiveness of thoracic
interlaminar epidural injections
in providing effective pain relief and
improving function
in patients with chronic mid and/or upper
back pain.
Methods
A randomized, double-blind, active
controlled trial.
110 participants divided into 2 groups
1. ESI with local anesthetic alone
2. ESI with steroid (Bethamethasone 6mg)
Outcome Measures
Oswestry Disability Index
Employment status
Opioid Intake (morphine equivalents)
Greater than 3 weeks of ‘significant’ improvement
with first 2 procedures were considered success
Significant = > 50% decrease in scores at 3, 6, 12, 18,
and 24 months
Methods
Inclusion Criteria
no facet joint pain based on blocks
18 years or older
pain duration for more than 6 months
failed conservative care
Exclusion Criteria
facet joint pain
unstable or uncontrolled opioid use
uncontrolled psychiatric issues
uncontrolled medial illness
large disc herniation with spinal cord compression
active infection
Methods
Injection done as an interlaminar approach
facet blocks done to determine pain generator
sedation for the injection
pain complaint pattern with clinical and imaging
repeated ESI only when pain increased
The level of success reduced to below 50%
Results
Groups 1 and 2 :
71% and 81% significantly improved
2 year follow up
Characteristics
5 to 6 ESI over 2 years
Relief in weeks
Group 1: 80 weeks
Group 2: 78 weeks
Results
ESI levels
T9-T10
30%
T10-T11 31%
T8-T9
17%
Others
6%
Results
Results
Is this good science?
I don’t know… I must be
doing something wrong
based on these results…
Is This Good Science?
High success rate
Significant number of opiate reductions
I don’t see that much thoracic pain
No indication of compression fractures
The steroid group did as well as local only
Is This Good Science?
Authors admit that mechanism of efficacy
is unclear.
Authors indicate that the results are
similar to cervical and lumbar result in
literature
The success is based on first two injections
and if no success, ESI were not continued.
No Placebo group… is local a placebo?
Is it important to PMR?
Definitely because I am
inadequate.
Transforaminal Thoracic
How will it change me and my
practice with patients?
I may stop doing bilateral TFESI
I may stop using steroids.
I am sending all patients to Kentucky
for shots!
Does the presence of the fibronectinaggrecan complex predict outcomes
from lumbar discectomy for disc
herniation?
Study # 4
•
•
•
Does the presence of the fibronectin-aggrecan
complex predict outcomes from lumbar
discectomy for disc herniation?
Smith MW
Spine J. 2013 Nov 13. pii: S15299430(13)00767-5. doi:
10.1016/j.spinee.2013.06.064.
Background
•
•
Protein biomarkers associated with lumbar
disc disease have been studied as diagnostic
indicators and therapeutic targets.
A cartilage degradation product, the
fibronectin-aggrecan complex (FAC) identified
in the epidural space, has been shown to
predict response to lumbar epidural steroid
injection.
Background
•
•
Protein biomarkers associated with lumbar
disc disease have been studied as diagnostic
indicators and therapeutic targets.
Numerous disease-modifying therapies have
been proposed to intervene in this cascade,
including antibody therapies, stem cell and
cellular therapies, and gene therapies
Background
•
A complex molecular and cellular cascade of disc
degeneration has been elucidated, which involves
inflammatory mediators



cytokines, nitric oxide, and signal transduction pathways
structural proteins and their degradation fragments (e.g.,
fibronectin, aggrecan, and collagens)
proteases/protease inhibitors (e.g., matrix metalloproteinases
[MMPs] and aggrecanases).1–6
Purpose
Determine the ability of FAC to predict
response to microdiscectomy for patients
with radiculopathy due to lumbar disc
herniation
Methods
Intraoperative sampling was done via lavage of
the excised fragment by ELISA for presence of
FAC.
92 consecutive patients who opted for
microdiscectomy to treat lumbar or
lumbosacral radiculopathy caused by a lumbar
disc herniation.
Methods
excluded criteria:
plain radiography demonstrating severe loss of disc height
high-grade degenerative disc disease
spondylolisthesis greater than grade I
Prior lumbar surgery or trauma
physical examination revealing weakness in a distribution
inconsistent with the MRI
Diagnosis of inflammatory arthritides
crystalline arthropathies or other rheumatologic diseases
red flags:
progressive weakness
bowel or bladder complaints
unknown radiographic mass
unexpected weight loss
Results
75 individuals
At 3-month follow-up, 57 (76%) patents were
"better."
There was a statistically significant association
of the presence of FAC and clinical
improvement (p=.017) with an 85% positive
predictive value.
Results
Conclusions
Patients who are "FAC+" are more likely to
demonstrate clinical improvement following
microdiscectomy.
The data suggest that the inflammatory milieu
plays a significant role regarding improvement
in patients undergoing discectomy for
radiculopathy in lumbar HNP
The FAC represents a potential target for
treatment in HNP.
Is this good science?
Maybe…
The results of the subset analysis suggest that
patients with preoperative weakness have a very
strong association between presence of FAC and
clinical improvement.
This is an intriguing finding that the removal of the
inflammatory component may be more related to
outcomes, not necessarily the mechanical
compression. (Chemical Radiculitis)
Is it important to PMR?
For Spine specialists it
maybe the reason why
patients don’t respond to
injections.
How will it change me and my
practice with patients?
Do we do assays on all patients for
presence of FAC?
The relative contribution of inflammatory
processes versus mechanical processes is
evolving
Outcomes of Fluoroscopically Guided
Lumbar Transforaminal Epidural
Steroid Injections in Degenerative
Lumbar Spondylolisthesis Patients
Study # 5
•Outcomes of Fluoroscopically Guided Lumbar
Transforaminal Epidural Steroid Injections in
Degenerative Lumbar Spondylolisthesis Patients
• Kraiwattanapong, C
• Asian Spine J 2014;8(2):119-128 •
http://dx.doi.org/10.4184/asj.2014.8.2.119 .
Background
•
•
Fluoroscopically guided TFESI is frequently being
used for treatment of radicular pains in lumbar
disc herniation, spinal stenosis and degenerative
disc disease patients with various results.
There has been no study which has exclusively
evaluated the effectiveness of epidural steroid
injections in patients with Degenerative Lumbar
Spondylolisthesis (DLS).
Purpose
• Report the short- and long-term outcomes
of fluoroscopically guided lumbar TFESI in
DLS patients.
Methods
38 DLS patients who underwent
fluoroscopically guided lumbar TFESI
during April 2009 to March 2010
Methods
22 gauge spinal needles at spondylolisthesis
level
1% lidocaine 2mls
Depomedrol 80mg
Methods
Inclusion criteria
1) Patients with history of low back pain
and unilateral radiating pain at least
below the knee joint
2) Patients with slip grade 1 degenerative
lumbar spondylolisthesis, visible on plain
radiographs and one or two levels of
neural compression found from the
magnetic resonance imaging (MRI)
3) Failures of conservative treatment by
physiatrists for at least 6 weeks.
Methods
The patients were evaluated by an
independent observer before the initial
injection (pre-injection)
2 weeks, 6 weeks, 3 months, 12 months
Visual analog scale (VAS)
Roland 5-point pain scale
Standing tolerance,
Walking tolerance
Patient satisfaction scale
Methods
Results
Results
Results
Results
Conclusion
TFESI significantly reduced VAS and Roland 5point pain scores for both short term and long
term follow ups.
Standing tolerance and walking tolerance only
significantly improved in the short term (for 2
weeks), but in the long term there was no
significant difference.
The patient satisfaction scale for this procedure
was highest at 2 weeks and declined with time.
Conclusion
All parameters indicated better outcome in one
level of spinal stenosis patients than in two levels
of spinal stenosis patients.
These findings may be explained by the poor
neural structures and physiology caused by
double compression sites in neural elements.
Conclusion
The fluoroscopically guided lumbar TFESI is
able to reduce VAS and Roland 5-point pain
scale and improves standing tolerance and
walking tolerance in the short term for DLS
patients.
For long term results, it reduces VAS but the
improvement in standing tolerance and walking
tolerance are limited. In addition, DLS patients
with one level of spinal stenosis showed
significantly better outcomes than DLS patients
with two levels of spinal stenosis.
Is this good science?
Interesting…
Not sure why ODI or
SF36 was not used…
Small sample size
Is it important to PMR?
Yes!
If spondylolisthesis chose
TFESI or facets?
Another option besides
surgery.
How will it change me and my
practice with patients?
Reinforces the TFESI for
spondylolisthesis
Just Because We Have A
Treatment…
Doesn’t Mean Use it!!!!
David E. Fish, MD, MPH
Physical Medicine and Rehabilitation
Department of Orthopeadic Surgery