Gary P. Chimes

Adverse Events Associated With Fluoroscopically Guided Sacroiliac Joint Injections

To describe the type, incidence, and factors that contribute to adverse events associated with fluoroscopically guided intra‐articular sacroiliac joint injections (IASIJ).

Patient satisfaction surveys: tools to enhance patient care or flawed outcome measures?

David J. Kennedy, MD Department of Orthopaedics, Stanford J.F. is a 38-year-old physiatrist who has been in a small group practice since she completed her fellowship 6 years ago. Her practice is a general physiatric practice. She does rounds daily on an inpatient service of 9 patients and has a mixed outpatient clinic that consists of follow-ups from her inpatient service, electromyograms, and amputee care. Her group was recently acquired by a larger medical institution in the area, and she became an employee of the hospital system. In recognition that medicine is changing and outcomes may be tied to future reimbursement, her new hospital business administrator implemented the random utilization of Press Ganey patient satisfaction surveys (Press Ganey Associated Inc, South Bend, IN). She was told that high patient satisfaction is imperative and that her bonus salary will be correlated with the results of these satisfaction surveys. Brian F. White, DO, and Gary Chimes, MD, PhD, will argue that satisfaction surveys do not enhance medical care. Peter Esselman, MD, will argue that satisfaction surveys are an integral part of a modern medical practice and facilitate better patient care.

Adverse events associated with fluoroscopically guided lumbosacral transforaminal epidural steroid injections.

BACKGROUND CONTEXT Although the types and incidence of adverse events (AEs) associated with transforaminal epidural steroid injection (TFESI) have been described, no study has used a systematic standardized questionnaire to solicit AEs from patients to capture an accurate range and incidence of complications. PURPOSE The aim was to systematically identify the types and incidence of AEs associated with TFESI. Additionally, this study evaluated demographic and clinical factors that may predict a higher risk of an AE. STUDY DESIGN/SETTING This was a retrospective cohort study from a multiphysician academic PM&R clinic. PATIENT SAMPLE Patients, aged 19 to 89, who underwent a fluoroscopically guided TFESI for lumbosacral radicular pain between 2004 and 2007 were included. OUTCOME MEASURES The relationship of AEs with gender, age, trainee presence, steroid type, preprocedure visual analog scale (VAS) pain score, systolic blood pressure, fluoroscopy time, and corticosteroid injectate volume was analyzed. METHODS Adverse event data were collected using a survey both immediately and at 24 to 72 hours after TFESI. Statistical analysis was performed using the chi-square, Fisher exact, or Wilcoxon rank sum two-sided tests. Logistic regression analysis was also performed. C.P. is the owner of Rehabilitation Institute of Chicago Physiatric Log & Analysis System computer software. RESULTS In 1,295 consecutive patients undergoing 2,025 TFESI procedures, immediate AEs and delayed AEs occurred after 182 (9.2%) and 305 (20.0%) injections, respectively. The most common immediate AEs were: vasovagal reaction (4.2%) and interrupted procedure from intravascular flow (1.7%). Common delayed AEs included: pain exacerbation (5.0%), injection site soreness (3.9%), headache (3.9%), facial flushing/sweating (1.8%), and insomnia (1.6%). Significant associations were identified between AEs and gender, age, preprocedure VAS, steroid type, and fluoroscopy time. Trainee involvement in the procedure did not impact the complication rate. CONCLUSIONS Fluoroscopically guided lumbosacral TFESI is associated with a similar rate of minor AEs both immediately and 24 to 72 hours after procedure that are typical of other axial corticosteroid injections. Permanent AEs were not found in this sample. The most common AEs associated with TFESI include vasovagal episodes, procedure interruption from intravascular flow, pain exacerbation, injection site soreness, headache, and insomnia.

Treatment Options in Knee Osteoarthritis: Total Knee Arthroplasty Versus Platelet-Rich Plasma

A 63-year-old man presents to your office with 10 years of left knee pain. He is an active skier but finds that knee pain prevents him from skiing. He is still able to walk long distances with only some limitation, but climbing up stairs is still painful. He has had 5 courses of corticosteroid injections and 3 courses of viscosupplementation in the past, with only transient relief. He also has been through 3 courses of physical therapy, which has included both openand closed-kinetic chain strengthening of the quadriceps, gluteus maximus, and gluteus medius, as well as a trial with body-weight-supported treadmill training, electrical stimulation, and several trials with different braces, taping techniques, and foot wedges. The patient is concerned that he may have to stop skiing. His knee radiographs and magnetic resonance images both confirm that he has tricompartmental osteoarthritis of the knee, severe in the medial compartment, moderate in the patellofemoral compartment, and mild in the lateral compartment. He is seeking your recommendation for a best next step. He is considering both knee replacement and platelet-rich plasma regenerative injection therapy. What would you recommend? Arguing for the motion that this patient would best be managed by a total knee replacement is Brian A. Klatt, MD. Dr Klatt is an assistant professor of orthopaedic surgery at the University of Pittsburgh Medical Center, with a special interest in joint reconstruction. Arguing for the motion that this patient would best be managed by platelet-rich plasma regenerative injection therapy is Hector H. Lopez, MD, MS. Dr Lopez is the founder and director of Physicians Pioneering Performance, LLC, a multidisciplinary physical medicine and rehabilitation based clinic designed for optimizing human performance. Guest Discussants:

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.

The Role of Core Strengthening for Chronic Low Back Pain

A 39-year-old female runner presents with episodic low back pain that is becomingmorefrequent.Inthepast,shehasusedchiropracticcarewithsomelimitedtemporarysuccess. She experiences pain in her lower lumbar region and denies any leg pain.Results of her physical examination reveal pain with forward flexion. Results of herneurologicexaminationarenormal.Shehasnegativeduraltensiontestsinallpositions.Her sacroiliac provocation maneuvers are also negative. However, she has a positiveprone instability test. (Posterior to anterior pressure is exerted in the prone position. Ifpainiselicitedinthispositionandthenlesspainwithspinalextensormuscleactivation,this would be considered a positive test). Physical therapy has been recommended toher,butsheremainsconfusedastothepropercourseoftherapy.Shehasheardtheterm

Carpal Tunnel Injection: With or Without Ultrasound Guidance?

A.H. is a 44-year-old woman with a 2-year history of numbness and tingling in her dominant right hand. She reports that the symptoms are primarily in her third digit but also into her thumb and index finger. She works as a secretary and notes that she occasionally drops things, although she is not sure if this is because of true weakness or difficulty feeling things in her hand. She was diagnosed by her primary care physician with carpal tunnel syndrome and had a course of hand therapy with some improvement, but she still has persistent symptoms. She wears a custom splint made by her therapist, which does help with night pain, but she is frustrated with her symptoms at work. She has had electrodiagnostic testing, which demonstrated moderate median mononeuropathy at the wrist, with prolonged distal latency of both the motor and sensory studies but no evidence of axonal involvement. She would like to avoid surgery if possible and asked her primary care physician to refer her to someone with expertise in carpal tunnel injections. She presents to your office today, with the goal of having a carpal tunnel injection. She did some research on carpal tunnel injections, and although she is already committed to having the injection, she is unsure whether she would like this performed with ultrasound guidance. She is soliciting your advice: should the injection be performed with ultrasound guidance? Arguingforthepositionthatyes,theinjectionshouldbeperformedwithultrasound guidance, is Gary Goldberg, MD. Dr Goldberg is a professor of physical medicine and rehabilitation at Virginia Commonwealth University, with expertise in brain injury, electrodiagnostic medicine, and therapeutic use of diagnostic ultrasound and ultrasound-guidedprocedures.Arguingforthepositionthat,no,theinjectiondoesnotneed to performed with ultrasound guidance is Ronit Wollstein, MD. Dr Wollstein is an associate professor of orthopedic surgery and plastic surgery at the University of Pittsburgh, with special expertise in hand surgery.

Cervical Manipulation for Neck Pain

K.L. is a 48-year-old man with an acute episode of neck pain. He presents with sharp neck pain in the upper right side. He had neck pain before, but this is significantly more intense than what he has felt in the past. The pain radiates into the posterior aspect of his head. On examination, he has brisk 3 reflexes throughout both his upper and lower limbs, and reports “I’ve always had strong reflexes.” He has a positive Hoffmann sign bilaterally but no ankle clonus, and downgoing toes to a Babinski stimulus. He is stable when performing both a Romberg and tandem Romberg maneuver. No focal weakness was noted within his upper or lower limb myotomes. Both the Sharp-Purser test and the modified lateral shear test were negative for segmental cervical instability. Manual cervical traction provided some relief of symptoms, and manual cervical palpation demonstrated hypomobility of the C1-2 and C2-3 segments on the right side, with concordant reproduction of symptoms. Results of the patient’s vascular examination reveal no evidence of carotid bruits and strong distal pulses in the upper and lower limbs. The patient has no vascular history but notes that his father, older brother, and paternal uncle have significant vascular histories, with his father dying from a ruptured abdominal aortic aneurysm, and his older brother had a 5-vessel coronary artery bypass graft when in his 40s. K.L. has worked with a chiropractor in the past for his low back and has responded well to high-velocity manipulations for his lumbar symptoms. He is interested in a trial of high-velocity manipulations for his neck as well, but, because of his family history of vascular complications, wants to know if it would be safe to have neck manipulations. Michael Schneider, DC, PhD, will argue that cervical manipulations should be performed. Stuart Weinstein, MD, will argue that cervical manipulations should be avoided. Guest Discussants:

Recommendations for Routine Sickle Cell Trait Screening for NCAA Division I Athletes

You are part of a panel determining recommendations for routine sickle cell trait screening for National Collegiate Athletic Association (NCAA) Division I athletes. In particular, the panel would like your informed opinion whether all Division I athletes should be screened for sickle cell trait. The panel would like your opinion on how you anticipate screening will impact the morbidity and mortality of athletes as well as the impact on cost and time for appropriate administration of testing. Arguing for the motion that NCAA Division I athletes should be screened for sickle cell trait is Scott A. Anderson, head athletic trainer for the University of Oklahoma and president of the College Athletic Trainers Society. Arguing against the motion, that sickle cell trait testing should not be part of the routine screening for Division I Athletes, is Jeanne Doperak, DO, fellowship director for the Primary Care Sports Medicine Fellowship at the University of Pittsburgh, head team physician for Seton Hill University and St Vincent College, assistant team physician at Carnegie Mellon University, and physician representative on the board of directors of the Big East Sports Medicine Society. Guest Discussants:

Performance-Enhancing Drugs

You are the head team physician for a major international professional cycling team. A 30-year-old elite professional cyclist presents with concerns regarding his performance. He has been finishing in the top 10 of major international stage races, but he has struggled to break into the top 5. If he were able to improve his performance by as little as 3%, he could potentially win these races. He has worked with a host of well-known coaches during the past 3 years to modify his training regimen, yet his results have not improved, and he expresses significant frustration with this lack of improvement. He states that the best years of his career are probably going to take place during the next 5 years and that he needs to maximize his athletic abilities to increase his income potential and enhance the recognition he receives from his peers and the public. In addition, he believes that his competitors are using performance-enhancing drugs (PEDs) and that this is the reason he is unable to compete with them. He would like to know what you think about athletes using PEDs, what the risks and benefits are related to their use, and whether you would consider prescribing him PEDs. His inquiry is serendipitous because the management of the cycling team recently approached you to revisit the team’s antidoping policies. They are concerned with the bad press surrounding athletes who have been suspended for using PEDs and the public perception that many of the athletes within their sport are “cheaters.” Please advise the athlete and cycling team accordingly. Guest Discussants: