Christopher J. Visco

Comparative Effectiveness of Lumbar Transforaminal Epidural Steroid Injections with Particulate Versus Nonparticulate Corticosteroids for Lumbar Radicular Pain due to Intervertebral Disc Herniation: A Prospective, Randomized, Double-Blind Trial

BACKGROUND Lumbar transforaminal epidural injections are commonly utilized to treat radicular pain due to intervertebral disc herniation. OBJECTIVE This study aims to determine if there was a major difference in effectiveness between particulate and nonparticulate corticosteroids for acute radicular pain due to lumbar disc herniation. DESIGN A multicenter, double blind, prospective, randomized trial on 78 consecutive subjects with acute uni-level disc herniation resulting in unilateral radicular pain. All subjects received a single level transforaminal epidural steroid injection with either dexamethasone or triamcinolone. Repeat injections were allowed as determined by the blinded physician and subjects. Primary outcomes included: number of injections received, surgical rates, and categorical pain scores at 2 weeks, 3 months, and 6 months. Secondary outcomes included mean Oswestry Disability Index. RESULTS Both triamcinolone and dexamethasone resulted in statically significant improvements in pain and function at 2 weeks, 3 months, and 6 months, without clear differences between groups. The surgical rates were comparable with 14.6% of the dexamethasone group and 18.9% of the triamcinolone group receiving surgery. There was a statistically significant difference in the number of injections received, with 17.1% of the dexamethasone group receiving three injections vs only 2.7% of the triamcinolone group. CONCLUSIONS Transforaminal epidural corticosteroid injections are an effective treatment for acute radicular pain due to disc herniation, and frequently only require 1 or 2 injections for symptomatic relief. Dexamethasone appears to possess reasonably similar effectiveness when compared with triamcinolone. However, the dexamethasone group received slightly more injections than the triamcinolone group to achieve the same outcomes.

Sacroiliac joint and lumbar zygapophysial joint corticosteroid injections.

The sacroiliac joint and the lumbar zygapophysial joints are both known pain generators with demonstrated pain-referral patterns. They are both amenable to image-guided intraarticular injection of corticosteroids, a procedure that is commonly performed for pain. The literature on the efficacy of intraarticular corticosteroid injections for these joints is currently limited. This article covers the diagnostic dilemmas associated with these joints, the utility of anesthetic blocks, and the literature on the efficacy of intraarticular corticosteroid injections.

Current concepts for shoulder training in the overhead athlete.

Nontraumatic shoulder pain in the adult overhead athlete is a common problem. The exact biomechanical adaptations that predispose the overhead athlete to injury can be multifactorial in nature, including range of motion deficits, muscular imbalances, and scapular dyskinesis. It is imperative that the rehabilitation professional not only correctly identify and treat the direct cause of the pain, but also initiate a rehabilitation program aimed at improvement of the underlying biomechanical deficits that predispose the overhead athlete to shoulder injury. This only can be accomplished through a better understanding of the most common biomechanical deficits that the overhead athlete develops and how to treat them. This article focuses primarily upon shoulder training in the adult baseball pitcher as a classic example of an overhead athlete.

Programmatic design for teaching the introductory skills and concepts of lumbar spine procedures to physiatry residents: a prospective multiyear study.

ObjectiveThe objective of this study was to determine the effectiveness of a 2-day course teaching the introductory skills and concepts of lumbar spine procedures to physiatry residents. DesignThis is a 3-yr prospective study of a 2-day musculoskeletal course teaching the introductory skills and concepts of lumbar spinal procedures to the residents at a large academic physical medicine and rehabilitation program. The residents attending the course took multiple-choice pretests and posttests as well as participated in a procedural skills competency demonstration. ResultsForty-two residents participated. The results were stratified according to the level of training and repetition of the material and revealed gains of medical knowledge at each level of residency training (P < 0.001). The postgraduate year 2 residents seemed to have the greatest overall improvement (P = 0.04). Half of the residents scored lower than 65% on the pretest, and these residents ultimately had the largest posttest gains. Forty (95.2%) residents achieved a grade of pass in the skills-based test. The residents felt that the course was valuable or extremely valuable. ConclusionsThe comprehensive 2-day course teaching the skills and concepts of spinal interventions for physiatry residents enhances medical knowledge as an introduction to interventional spine care. Those who benefited the most were the residents who had the greatest deficit of medical knowledge on this topic before the course. This course curriculum does not replace fellowship training or closely monitored mentorship in the performance of spinal procedures.

Pharmaceutical Therapy for Radiculopathy

Pharmaceutical treatments for radiculopathy include opioid, antiinflammatory (steroidal and nonsteroidal), neuromodulating, topical, and adjuvant treatments. These medications act locally, peripherally, or centrally on the neural axis. This article reviews the history of medication use for radiculopathy and the available literature along with the breadth of current treatment and indications.

Comparison of Spinal Needle Deflection in a Ballistic Gel Model.

Background Percutaneous diagnostic and therapeutic procedures are commonly used in the treatment of spinal pain. The success of these procedures depends on the accuracy of needle placement, which is influenced by needle size and shape. Objectives The purpose of this study is to examine and quantify the deviation of commonly used spinal needles based on needle tip design and gauge, using a ballistic gel tissue simulant. Materials and Methods Six needles commonly used in spinal procedures (Quincke, Short Bevel, Chiba, Tuohy, Hustead, Whitacre) were selected for use in this study. Ballistic gel samples were made in molds of two depths, 40mm and 80 mm. Each needle was mounted in a drill press to ensure an accurate needle trajectory. Distance of deflection was recorded for each needle. Results In comparing the mean deflection of 22 gauge needles of all types at 80 mm of depth, deflection was greatest among beveled needles [Short Bevel (9.96 ± 0.77 mm), Quincke (8.89 ± 0.17 mm), Chiba (7.71 ± 1.16 mm)], moderate among epidural needles [Tuohy (7.64 ± 0.16 mm) and least among the pencil-point needles [Whitacre (0.73 ± 0.34 mm)]. Increased gauge (25 g) led to a significant increase in deflection among beveled needles. The direction of deflection was away from the bevel with Quincke, Chiba and Short Beveled needles and toward the bevel of the Tuohy and Hustead needles. Deflection of the Whitacre pencil-point needle was minimal. Conclusions There is clinical utility in knowing the relative deflection of various needle tips. When a procedure requires a needle to be steered around obstacles, or along non-collinear targets, the predictable and large amount of deflection obtained through use of a beveled spinal needle may prove beneficial.

Poster 370 Deep Motor Branch Radial Neuropathy after a Distal Biceps Repair: A Case Report

on standard ankle radiographs (AP and lateral) in the acute setting and have been shown to have an error rate of 4.2% including missed fractures and improper classifications of old injuries as acute. Conclusion: The astute physician should never abandon a detailed and thorough history and physical examination. A high index of suspicion and avoidance of the pitfall of being swayed by prior reports or testing should be maintained when examining orthopedic injuries.

Revolutionizing Sports Medicine With Ultrasound

Finally, we have a road map to a more thoughtful and comprehensive approach in the education and clinical application of sports ultrasound. Dr Finnoff and his team have articulated the path with 2 new well-thought-out pieces. One is in this issue of PM&R: the American Medical Society for Sports Medicine (AMSSM) Position Statement on Interventional Musculoskeletal Ultrasound in Sports Medicine [1]. Seven authors of this position statement, including 3 physiatrists, comprise representative constituents from the field of sports medicine. The second piece is an online publication for PM&R, “AMSSM Recommended Sports Ultrasound Curriculum for Sports Medicine Fellowships” [2]. The position statement takes aim at giving a complete review and grading of current evidence for providing ultrasound-guided injections, whereas the curriculum provides training guidance for teaching sports ultrasound. These 2 important documents consolidate the best practices for teaching and optimizing the application of this technology. This is a true interdisciplinary effort, resulting in mandatory reading for anyone applying ultrasound in his or her practice. Most practitioners apply ultrasound guidance to their interventions because it is an extremely safe and effective method of providing an injection. It makes patients more comfortable, greatly reduces the complications of neurovascular injury, and is extremely accurate. When the first injection has been placed accurately, it can result in improved efficacy and save patients from a repeat injection. This position statement supports that methodology and also challenges us to think hard about how we look at efficacy and the future direction of ultrasound guidance. After all, as the authors suggest, the future of injections will likely be more than just needles and corticosteroids. Novel tools and methodologies for tissue manipulation and regeneration already exist and are becoming a growing share of the interventional part of a sports medicine practice. In learning ultrasound, one of the first milestones is to understand the concept of anisotropy, which is when something looks different from different angles or different perspectives. Indeed, ultrasound itself may be

Lateral epicondylosis: emerging management options.

Lateral epicondylosis is one of the most prevalent disorders of the arm and results in significantly decreased function among the workforce and athletes. Historically, the disorder has been diagnosed clinically and treated as an inflammatory entity. Management strategies have included anti-inflammatory medications and techniques, including oral nonsteroidal anti-inflammatories, injected corticosteroid, and physical therapy with modalities. More recent literature postulates a degenerative or compressive etiology, directing some clinicians to try new, more regenerative management strategies such as platelet-rich plasma and stem cell injections. To date, literature evaluating these new treatment methods has shown positive results, although no definitive conclusions can be drawn. More research is needed to evaluate these new treatment methods, and a new look at the diagnosis of the disorder with ultrasound imaging may be reasonable to consider.

Response to Dr. Candido et al

Dear Editor, We concur with Doctors Knezevic, Lissounov, and Candido that pain relief resulting in the prevention of spinal surgery is one goal of interventional spine procedures. While this effect has been documented [1,2], it is a capricious outcome measure. It was serendipitous that we mentioned the avoidance of surgery as an outcome measure in our study. Our study was not designed to control for the numerous psychosocial and pathophysiologic and pathoanatomical factors that affect this particular outcome. Given the number of factors …