Curtis W. Slipman

Sacroiliac joint pain referral zones

OBJECTIVE To determine the patterns of pain referral from the sacroiliac joint. STUDY DESIGN Retrospective. PARTICIPANTS/METHODS Fifty consecutive patients who satisfied clinical criteria and demonstrated a positive diagnostic response to a fluoroscopically guided sacroiliac joint injection were included. Each patients preinjection pain description was used to determine areas of pain referral, and 18 potential pain-referral zones were established. OUTCOME MEASURES Observed areas of pain referral. RESULTS Eighteen men (36.0%) and 32 women (64.0%) were included with a mean age of 42.5 years (range, 20 to 75 yrs) and a mean symptom duration of 18.2 months (range, 1 to 72 mo). Forty-seven patients (94.0%) described buttock pain, and 36 patients (72.0%) described lower lumbar pain. Groin pain was described in 7 patients (14.0%). Twenty-five patients (50.0%) described associated lower-extremity pain. Fourteen patients (28.0%) described leg pain distal to the knee, and 6 patients (14.0%) reported foot pain. Eighteen patterns of pain referral were observed. A statistically significant relationship was identified between pain location and age, with younger patients more likely to describe pain distal to the knee. CONCLUSIONS Pain referral from the sacroiliac joint does not appear to be limited to the lumbar region and buttock. The variable patterns of pain referral observed may arise for several reasons, including the joints complex innervation, sclerotomal pain referral, irritation of adjacent structures, and varying locations of injury with the sacroiliac joint.

The predictive value of provocative sacroiliac joint stress maneuvers in the diagnosis of sacroiliac joint syndrome

OBJECTIVE To determine the clinical validity of provocative sacroiliac joint (SIJ) maneuvers in making the diagnosis of sacroiliac joint syndrome (SIJS). DESIGN Prospective constructive cohort study using sacroiliac joint block (SIJB) as the diagnostic gold standard. SETTING Tertiary care center. PATIENTS Consecutive patients describing low back pain including the region of the sacral sulcus. Physical examination revealed a positive response to three provocative SIJ maneuvers, two of which had to be Patricks test and pain with palpation over the ipsilateral sacral sulcus. INTERVENTIONS All subjects underwent fluoroscopically guided SIJB. MAIN OUTCOME MEASURES Response to SIJB was assessed with visual analog scale (VAS) ratings before and after the block. A reduction of the VAS rating by at least 80% was considered a positive response to SIJB. RESULTS Fifty consecutive patients met our criteria and underwent SIJB. Thirty patients had positive response to SIJB, making up the positive SIJS group. Twenty patients had less than 80% pain reduction with SIJB and thus comprised the negative SIJS group. The positive predictive value of provocative SIJ maneuvers in determining the presence of SIJS is therefore 60%. CONCLUSIONS Our results do not support the use of provocative SIJ maneuvers to confirm a diagnosis of SIJS. Rather, these physical examination techniques can, at best, enter SIJS into the differential diagnosis.

Therapeutic selective nerve root block in the nonsurgical treatment of atraumatic cervical spondylotic radicular pain: A retrospective analysis with independent clinical review

OBJECTIVE To investigate the outcomes resulting from the use of fluoroscopically guided therapeutic selective nerve root block (SNRB) in the nonsurgical treatment of atraumatic cervical spondylotic radicular pain. STUDY DESIGN Retrospective study with independent clinical review. PARTICIPANTS Twenty subjects (10 men, 10 women) with mean age 56.6 years. METHODS Each patient met specific physical examination, radiographic, and electrodiagnostic criteria to confirm a level of cervical involvement. Those patients whose root level remained indeterminate were required to demonstrate a positive response to a fluoroscopically guided diagnostic SNRB prior to the initiation of treatment. Therapeutic injections were administered in conjunction with physical therapy. Data collection and analysis were performed by an independent clinical reviewer. MAIN OUTCOME MEASURES Pain score, work status, medication usage, and patient satisfaction. RESULTS Twenty patients with an average symptom duration of 5.8 months were included. An average of 2.2 therapeutic injections was administered. Follow-up data collection transpired at an average of 21.2 months following discharge from treatment. A significant reduction (p = .001) in pain score was observed at the time of follow-up. Medication usage was also significantly improved (p = .005) at the time of follow-up. An overall good or excellent result was observed in 60%. Thirty percent of patients required surgery. Younger patients were more likely (p = .0047) to report the highest patient satisfaction rating following treatment. CONCLUSIONS This study suggests that fluoroscopically guided therapeutic SNRB is a clinically effective intervention in the treatment of atraumatic cervical spondylotic radicular pain.

Symptom provocation of fluoroscopically guided cervical nerve root stimulation. Are dynatomal maps identical to dermatomal maps

Study Design. This prospective study consisted of mechanical stimulation of cervical nerve roots C4 to C8 in patients with cervical radicular symptoms undergoing diagnostic selective nerve root block. Objectives. To document the distribution of pain and paresthesias that result from stimulation of specific cervical nerve roots and compare that distribution to documented sensory dermatomal maps. Summary of Background Data. Cervical dermatomes were first studied in the late 19th century. The results of those studies underpin current clinical decision making for patients with neck and arm pain. However, it has been observed that patients with radicular symptoms may have cervical pathology by radiographic imaging that is not corroborative, or have imaging studies that suggest a lesion at a level other than the one suggested by the patients dermatomal symptoms. These observations may suggest that cervical dermatomal mapping is inaccurate or the distribution of referred symptoms (dynatome) from cervical root irritation is different than the sensory deficit outlined by dermatomal maps. Methods. Inclusion criteria consisted of consecutive patients undergoing fluoroscopically guided diagnostic cervical selective nerve root blocks from C4 to C8. Immediately preceding contrast injection, mechanical stimulation of the root was performed. An independent observer interviewed and recorded the location of provoked symptoms on a pain diagram. Visual data was subsequently compiled using a 793 body sector bit map. Forty‐three clinically relevant body regions were defined on this bit map. Frequencies of symptom provocation and likelihood of symptom location from C4 to C8 stimulation of each nerve root were generated. Results. One hundred thirty‐four cervical nerve root stimulations were performed on 87 subjects. There were 4 nerve root stimulations at C4, 14 at C5, 43 at C6, 52 at C7, and 21 at C8. Analyzing the frequency of involvement of the predetermined clinically relevant body regions either individually or in various combinations yielded more than 1,000 bits of data. Although the distribution of symptom provocation resembled the classic dermatomal maps for cervical nerve roots, symptoms were frequently provoked outside of the distribution of classic dermatomal maps. Conclusion. The current study demonstrates a distinct difference between dynatomal and dermatomal maps.

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.

Fluoroscopically guided therapeutic sacroiliac joint injections for sacroiliac joint syndrome.

Slipman CW, Lipetz JS, Plastaras CT, Jackson HB, Vresilovic EJ, Lenrow DA, Debra L. Braverman DL: Fluoroscopically guided therapeutic sacroiliac joint injections for sacroiliac joint syndrome. Am J Phys Med Rehabil 2001;80:425–432. ObjectiveTo investigate the outcomes resulting from the use of fluoroscopically guided therapeutic sacroiliac joint injections in patients with sacroiliac joint syndrome. DesignA retrospective study design with independent clinical review was utilized. Thirty-one patients were included; each patient met specific physical examination criteria and failed to improve clinically after at least 4 wk of physical therapy. Each patient demonstrated a positive response to a fluoroscopically guided diagnostic sacroiliac joint injection. Therapeutic sacroiliac joint injections were administered in conjunction with physical therapy. Outcome measures included Oswestry scores, Visual Analog Scale pain scores, work status, and medication usage. ResultsPatients’ symptom duration before diagnostic injection averaged 20.6 mo. An average of 2.1 therapeutic injections was administered. Follow-up data collection was obtained at an average of 94.4 wk. A significant reduction (P = 0.0014) in Oswestry disability score was observed at the time of follow-up. Visual Analog Scale pain scores were reduced (P < 0.0001) at the time of discharge and at follow-up. Work status was also significantly improved at the time of discharge (P = 0.0313) and at follow-up (P = 0.0010). A trend (P = 0.0645) toward less drug usage was observed. ConclusionsThese initial findings suggest that fluoroscopically guided therapeutic sacroiliac joint injections are a clinically effective intervention in the treatment of patients with sacroiliac joint syndrome. Controlled, prospective studies are necessary to further clarify the role of therapeutic injections in this patient population.

The value of radionuclide imaging in the diagnosis of sacroiliac joint syndrome

Study Design A prospective study was done to assess the diagnostic value of radionuclide imaging (bone scan) in the evaluation of sacroiliac joint syndrome. Objectives To determine the sensitivity and specificity of radionuclide imaging in establishing a diagnosis of sacroiliac joint syndrome in patients with low back pain. Summary of Background Data There is no pathognomonic symptom or sign to establish the diagnosis of sacroiliac joint syndrome. It has been accepted that confirmation of sacroiliac joint syndrome requires relief of pain, a positive response to a sacroiliac joint block. Bone scanning has been proposed as a useful imaging technique to evaluate for sacroiliac joint syndrome. The authors explored the use of nuclear imaging as a cost‐effective and noninvasive technique in the diagnostic algorithm of sacroiliac joint syndrome. Methods Patients presenting to the authors Spine Center with complaints of low back pain including the region of the sacral sulcus were screened for inclusion into this study. Positive response to three provocative sacroiliac joint maneuvers was requisite, two of which had to be Patricks test and pain with palpation over the sacral sulcus. Patients who met these criteria were entered into a physical therapy program comprised of lumbar spine stabilization techniques and excluded any interventions considered specific for sacroiliac joint syndrome. Those whose symptoms failed to improve with this program underwent bone scan and fluoroscopically guided sacroiliac joint block. Response to sacroiliac joint block was assessed with pre‐ and post‐block visual analog scale scores completed by the patient. A reduction of the VAS rating by at least 80% was considered a positive response to sacroiliac joint block. Results Fifty consecutive patients met the authors criteria and underwent bone scan and sacroiliac joint block. Thirty‐one patients who had positive responses to sacroiliac joint block comprised the positive sacroiliac joint block group. Nineteen patients had less than 80% pain reduction with sacroiliac joint block and were labeled the negative sacroiliac joint block group. Four patients had positive bone scans, all of whom were in the positive sacroiliac joint group. Conclusions The results demonstrated very low sensitivity and high specificity of nuclear imaging in the evaluation of sacroiliac joint syndrome. The authors do not recommend bone scan in the diagnostic algorithm for sacroiliac joint syndrome.

Therapeutic spinal corticosteroid injections for the management of radiculopathies

Current literature and a recent meta-analysis suggest a favorable role for corticosteroid injections in the nonoperative treatment of radiculopathy [70]. The superior results reported in recent literature may be attributable to precise fluoroscopically guided transforaminal placement of injectate close to the disc-nerve root interface and near the dorsal root ganglia, maximizing the therapeutic effect. The favorable results of corticosteroid injections in the treatment of radiculopathy caused by a focal disc herniation are consistent with the biochemical construct of radicular pain. The preliminary unfavorable results of therapeutic SNRB for radicular pain caused by epidural or intraneural fibrosis or occurring after trauma may relate to a biomechanical rather than a biochemical etiology. Outcomes for acquired cervical or lumbar spinal stenosis are intermediate compared with those observed for herniated discs and scarring or trauma. Such results may stem from the multifactorial origin of stenosis symptoms; they may develop from impaired venous flow, restricted neural glide, inflammation, or structural root injury. Better-designed studies that use strict inclusion criteria that stratify patients into categories according to the mechanism of injury (atraumatic versus traumatic), the presence or absence of neurologic deficits or imaging abnormalities, and prior treatment will provide the basis for evidence-based treatment decisions. Such an emphasis is just beginning and inevitably will occur. Until then, decisions have to be predicated on the limited and flawed work conducted to date [71]. Nevertheless, the information gleaned from these published reports provides valuable insight not available just a decade ago.

Evidence-informed management of chronic low back pain with epidural steroid injections

The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing amongst available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to chronic low back pain, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Side effects and complications after percutaneous disc decompression using coblation technology.

Bhagia SM, Slipman CW, Nirschl M, Isaac Z, El-Abd O, Sharps LS, Garvin C: Side effects and complications after percutaneous disc decompression using coblation technology. Am J Phys Med Rehabil 2006;85:6–13. Objective:To report the short-term side effects and complications after percutaneous disc decompression utilizing coblation technology. Design:Following institutional review board approval, consecutive patients who were to undergo percutaneous disc decompression using coblation technology (nucleoplasty) were prospectively enrolled. Patients were questioned preoperatively, postoperatively, and 24 hrs, 72 hrs, 1 wk, and 2 wks postprocedure by an independent reviewer regarding 17 possible symptom complications, which included bowel or bladder symptoms, muscle spasm, new pain, numbness/tingling or weakness, fevers/chills, rash/pruritus, headaches, nausea/vomiting, bleeding, and needle insertion site soreness. Statistical analysis was performed using Wilcoxon’s signed-rank test. Results:A total of 53 patients enrolled, of whom four patients dropped out. Two patients had increased symptoms and opted for surgery. Two patients could not be contacted. The most common side effects at 24 hrs postprocedure was soreness at the needle insertion site (76%), new numbness and tingling (26%), increased intensity of preprocedure back pain (15%), and new areas of back pain (15%). At 2 wks, no patient had soreness at the needle insertion site or new areas of back pain; however, new numbness and tingling was present in 15% of patients. Two patients (4%) had increased intensity of preprocedure back pain. There were statistically significant reductions in visual analog scale score for back pain and leg pain (P < 0.05). Conclusions:Based on this preliminary data, nucleoplasty seems to be associated with short-term increased pain at the needle insertion site and increased preprocedure back pain and tingling numbness but without other side effects.