Atul L. Bhat

Transforaminal epidural steroid injections in lumbosacral radiculopathy: A prospective randomized study

Study Design. A prospective study randomized by patient choice from the private practice of a single physician affiliated with a major teaching hospital was conducted. Objectives. To compare transforaminal epidural steroid injections with saline trigger-point injections used in the treatment of lumbosacral radiculopathy secondary to a herniated nucleus pulposus. Summary of Background Data. Epidural steroid injections have been used for more than half a century in the management of lumbosacral radicular pain. At this writing, however, there have been no controlled prospective trials of transforaminal epidural steroid injections in the treatment of lumbar radiculopathy secondary to a herniated nucleus pulposus. Methods. Randomized by patient choice, patients received either a transforaminal epidural steroid injection or a saline trigger-point injection. Treatment outcome was measured using a patient satisfaction scale with choice options of 0 (poor), 1 (fair), 2 (good), 3 (very good), and 4 (excellent); a Roland-Morris low back pain questionnaire that showed improvement by an increase in score; a measurement of finger-to-floor distance with the patient in fully tolerated hip flexion; and a visual numeric pain scale ranging from 0 to 10. A successful outcome required a patient satisfaction score of 2 (good) or 3 (very good), improvement on the Roland-Morris score of 5 or more, and pain reduction greater than 50% at least 1 year after treatment. The final analysis included 48 patients with an average follow-up period of 16 months (range, 12–21 months). Results. After an average follow-up period of 1.4 years, the group receiving transforaminal epidural steroid injections had a success rate of 84%, as compared with 48% for the group receiving trigger-point injections (P < 0.005). Conclusion. Fluoroscopically guided transforaminal injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus.

Low Back Pain in Professional Golfers The Role of Associated Hip and Low Back Range-of-Motion Deficits

Background Low back pain is fairly prevalent among golfers; however, its precise biomechanical mechanism is often debated. Hypothesis There is a positive correlation between decreased lead hip rotation and lumbar range of motion with a prior history of low back pain in professional golfers. Study Design A cross-sectional study. Methods Forty-two consecutive professional male golfers were categorized as group 1 (history of low back pain greater than 2 weeks affecting quality of play within past 1 year) and group 2 (no previous such history). All underwent measurements of hip and lumbar range of motion, FABEREs distance, and finger-to-floor distance. Differences in measurements were analyzed using the Wilcoxon signed rank test. Results 33% of golfers had previously experienced low back pain. A statistically significant correlation (P < .05) was observed between a history of low back pain with decreased lead hip internal rotation, FABEREs distance, and lumbar extension. No statistically significant difference was noted in nonlead hip range of motion or finger-to-floor distance with history of low back pain. Conclusions Range-of-motion deficits in the lead hip rotation and lumbar spine extension correlated with a history of low back pain in golfers.

A critical review of the evidence for the use of zygapophysial injections and radiofrequency denervation in the treatment of low back pain.

BACKGROUND CONTEXT Lumbar zygapophysial joints are currently believed to be a cause of axial low back pain. Once this diagnosis is made, decisions about when to institute a particular intervention and which treatment to offer is regionally and specialty dependent. PURPOSE To perform a critical review of prior published studies assessing the use of interventional treatment options for the treatment of lumbar zygapophysial joint syndrome. STUDY DESIGN Evidence-based medicine analysis of current literature. METHODS A database search of Medline (PubMed, Ovid and MDConsult), Embase and the Cochrane database was conducted. The keywords used were low back pain, lumbar zygapophysial joint, lumbar facet joint, radiofrequency denervation, medial branch block, and intraarticular injection. After identifying all relevant literature, each article was reviewed. Data from the following categories were compiled: inclusion criteria, randomization of subjects, total number of subjects involved at enrollment and at final analysis. statistical analysis used, intervention performed, outcome measures, follow-up intervals and results. Guidelines described by the Agency for Health Care Policy and Research were then applied to these data. RESULTS This review determined that the evidence for the treatment of lumbar zygapophysial joint syndrome with intraarticular injections should be rated as level III (moderate) to IV (limited) evidence, whereas that for radiofrequency denervation is at a level III. CONCLUSIONS Current studies fail to give more than sparse evidence to support the use of interventional techniques in the treatment of lumbar zygapophysial joint-mediated low back pain. This review emphasizes the need for larger, prospective, randomized controlled trials with uniform inclusion and exclusion criteria, standardized treatment, uniform outcome measures and an adequate duration of follow-up period so that definitive recommendations for the treatment of lumbar zygapophysial joint-mediated pain can be made.

Management of Knee Osteoarthritis: Knee Lavage Combined With Hylan Versus Hylan Alone

OBJECTIVE To assess the difference in efficacy between knee lavage plus the standard hylan G-F 20 (a derivative of hyaluronan) protocol and the standard hylan G-F 20 as per standard usage protocol alone for the treatment of knee osteoarthritis (OA). DESIGN Nonrandomized prospective study in which patients chose their treatment group. Follow-up averaged 1.1 years. SETTING Faculty practice of a single physician at a major teaching hospital. PARTICIPANTS Eighty-one patients with documented knee OA on magnetic resonance imaging. INTERVENTIONS Group 1 (n=44) received a single-needle lavage 1 week before the standard hylan G-F 20 protocol; group 2 (n=37) received the standard hylan G-F 20 protocol alone. MAIN OUTCOME MEASURES Pre- and posttreatment scores on the Lysholm-II Questionnaire and a visual analog scale (VAS) were documented for each patient. The Wilcoxon signed-rank test was used for statistical analysis. RESULTS A successful outcome was noted in 79.5% of group 1 patients and in 54% of group 2 patients (P<.05). CONCLUSIONS In the management of knee OA, the use of knee lavage before viscosupplementation with hylan G-F 20 yields better results than using hylan G-F 20 alone. The presence of radiologic grade IV knee OA or moderate to severe patellofemoral arthritis are negative prognostic factors.

Abdominal pain secondary to a sacral perineural cyst

BACKGROUND CONTEXT Perineural cysts are commonly found in the sacral region and are incidently discovered on imaging studies performed for the evaluation of low back and/or leg pain. PURPOSE To report on a patient presenting with abdominal pain secondary to a large sacral perineural cyst. STUDY DESIGN/SETTING Case report. METHODS/PATIENT SAMPLE: A 47-year-old woman was referred to a specialized multidisciplinary spine center with complaints of left lower quadrant abdominal pain and left leg pain. Of significant note was the presence of constipation and urinary frequency over the preceding 8 months. Physical examination was normal. Magnetic resonance imaging of the lumbosacral spine revealed large perineural cysts eroding the sacrum and extending to the pelvis. The presence of abdominal symptoms prompted a neurosurgical consultation. However, after considering the possible risks associated with the surgical procedure, the patient opted to follow the nonsurgical route. RESULT AND CONCLUSIONS Although commonly visualized, sacral perineural cysts are rarely symptomatic. When symptomatic, it may be secondary to its size and location. Presence of abdominal pain in a patient with back and/or leg pain should prompt the evaluation of the lumbosacral spine.