James D. Sigler

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.

The Rate of Detection of Intravascular Injection in Cervical Transforaminal Epidural Steroid Injections With and Without Digital Subtraction Angiography

To determine whether digital subtraction angiography (DSA) combined with real‐time fluoroscopic imaging improves the detection rate of intravascular injection during cervical transforaminal epidural steroid injections (CTFESIs).

The behavior of the gas film formed upon drop impact with a liquid surface

Abstract In nucleate boiling the sources of vapor nuclei are important. One source arises when a drop of liquid resulting from bursting vapor bubbles strikes the liquid surface and entrains bubbles. This is called secondary nucleation. This research studied differences in bubble entrainment, even for successive drops for water drops falling through air. Close-up photographs were taken soon after impact of the breakup of an air film trapped upon drop impact. They show two distinct patterns. In one pattern, an uniform distribution of small bubbles marks the interface. In the other pattern, bubbles penetrate both the drop and pool at one location on the interface. The interpretation from many photographs is that the first pattern results from a surface disturbance due to a Rayleigh-Taylor instability. The second pattern results from the air film being pinched to a point and then the confined air squirts into both the drop and pool.

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 …

Multi-center Randomized Controlled Trial Comparing Particulate versus Non-Particulate Corticosteroids via Lumbar Transforaminal Epidural Injection for Acute Unilateral, Uni-level Radicular Pain due to Herniated Nucleus Pulposus

home from the EC the same day or kept overnight in the EC observation unit. A difference in length of stay between the two groups was identified in the upper quartile of patients, which included the patients admitted to the hospital for more than one day. There were 338 patients in the Control group who were admitted longer than one day for a total of 2033 hospital days. There were 51 patients in the PM&R Consult group admitted for more than one day for a total of 243 hospital days. The mean LOS for patients admitted more than one day was 6.01 days for the Control group and 4.76 days for the PM&R Consult group. When the mean LOS for the PM&R Consult group was applied to the Control group it equated to a savings of 424 hospital days. A Wilcoxon two-sample test was performed to compare the similarity of the length of stay data in the two groups. The Wilcoxon twosample test results indicated that for patients admitted longer than one day the LOS was significantly lower in the PM&R Consult group (p< .0001). Conclusions: The length of stay for patients admitted to the hospital for more than one day with back pain was significantly less for patients who received a PM&R consultation in the EC.

Poster 65: Segmental Zoster Paresis Following Spinal Surgery: A Case Report

Disclosures: M. Darwish, Cephalon, Stock options or bond holdings; Cephalon, Employment. Objective: Explore the efficacy of once-daily cyclobenzaprine extended-release (CER) and its relation to plasma concentration-vs-time profile. Design: Retrospective analysis of i) pooled efficacy assessments from 2 randomized, controlled, double-blind clinical studies and ii) systemic exposure data from a pharmacokinetic study (simulated for multiple dosing). Setting: i) outpatient clinics and ii) study sites. Participants: i) Patients with acute muscle spasm (n 504) and ii) healthy volunteers. Interventions: CER 15 mg, 30 mg, placebo. Main Outcome Measures: i) Patient’s daily rating of medication helpfulness, relief from local pain, and restriction of movement and ii) average steady-state concentrations (CavSS) of cyclobenzaprine. Results: At day 2, more patients treated with CER 15 mg rated medication helpfulness as “good” to “excellent” than those given placebo (26% vs 21%). This difference was statistically significant at day 4 (CER 15 mg 51%, placebo 36%; P .014) and maintained through day 8 (CER 15 mg 62%, placebo 48%). For relief of local pain, “some” to “complete” ratings for CER 15 mg vs placebo were 30% vs 27% at day 2, 58% vs 47% at day 4 (P .041), and 75% vs 59% at day 8 (P .012). For relief from restriction of movement, “some” to “complete” ratings for CER 15 mg were 29% vs 28% at day 2, 58% vs 47% at day 4, and 72% vs 63% at day 8. Onset and maintenance of efficacy corresponded with cyclobenzaprine steady-state concentrations; 62.5% of CavSS was achieved by day 2, 90.4% by day 4, and 100% by day 8, following CER 15 mg. A similar correspondence was seen between the CER 30 mg efficacy and pharmacokinetic data. Conclusions: The efficacy profile of CER over the first 8 days seems to correspond with its plasma concentration-vstime profile.