Jason S. Lipetz

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.

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.

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.

Therapeutic zygapophyseal joint injections for headaches emanating from the C2-3 joint.

Slipman CW, Lipetz JS, Plastaras CT, Jackson HB, Yang ST, Meyer AM: Therapeutic zygapophyseal joint injections for headaches emanating from the C2-3 joint. Am J Phys Med Rehabil 2001;80:182–188. ObjectiveTo report our experience using fluoroscopically guided therapeutic intra-articular C2-3 zygapophyseal joint injections in patients with chronic headaches after a whiplash event. DesignRestrospective study (n = 18 patients) with independent clinical review. Each patient experienced persistent daily headache symptoms which failed to improve after at least 3 mo of physical therapy, activity restriction, and the use of oral analgesics. Each patient demonstrated initially a positive response to a diagnostic intra-articular C2-3 joint injection. Data collection and analysis were performed by an independent clinical reviewer. Outcome measures included headache frequency, medication usage, symptom response to medication, and employment status. ResultsPatients’ symptom duration before diagnostic injection averaged 34 mo. Follow-up data collection transpired at an average of 19 mo after the final therapeutic injection. In 61% of patients, fewer than three headaches were experienced each week; these headaches were relieved with the use of oral analgesics. ConclusionsAlthough the inherent limitations of this study preclude a definitive statement regarding the efficacy of C2-3 injections, these initial findings suggest that therapeutic intra-articular zygapophyseal joint injections are effective in the treatment of headaches emanating from the C2-3 joint after a whiplash event. Future controlled, prospective studies are necessary to clarify the role of such injections in this challenging patient population.

Deep venous thrombosis and pulmonary embolism as a complication of bed rest for low back pain

A case of bilateral lower extremity deep venous thrombosis and pulmonary embolism as a complication of bed rest prescribed for an acute low back pain episode is presented. A 29-year-old woman with low back pain was prescribed more than 2 weeks of bed rest, during which she developed progressive bilateral lower extremity complaints that were ascribed to nerve root irritation. Her symptoms were initially treated with physical therapy and epidural steroid injections. A Doppler examination and ventilation-perfusion scan revealed extensive deep venous thromboses and mismatches consistent with pulmonary embolism. This case illustrates an unusual extraspinal source of lower extremity symptoms associated with low back pain and further supports the role of early mobilization in the treatment of back pain.

Nonsurgical treatment for radicular of pain of zygoapophyseal joint cyst origin: Therapeutic selective nerve root block

We report the first case of zygoapophyseal joint cyst-induced radicular pain successfully treated with therapeutic selective nerve root block. A 56-year-old dentist presented with pain involving the lateral thigh, lateral calf, and foot dorsum that worsened with standing and walking. Magnetic resonance imaging of the lumbar spine showed a cyst emanating from the right L4-L5 zygoapophyseal joint, resulting in central canal and lateral recess stenosis. The patient was treated with two fluorscopically guided therapeutic L5 selective nerve root blocks. The patient remained pain free at 18-month follow-up.

Resolution of pronounced painless weakness arising from radiculopathy and disk extrusion.

Lipetz JS, Misra N, Silber JS: Resolution of pronounced painless weakness arising from radiculopathy and disk extrusion. Am J Phys Med Rehabil 2005;84:528–537. In this retrospective, consecutive case series, we report the nonsurgical and rehabilitation outcomes of consecutive patients who presented with pronounced painless weakness arising from disk extrusion. Seven consecutive patients who chose physiatric care were followed clinically, and strength return was monitored. Each presented with predominantly painless radiculopathy, functionally significant strength loss, and radiographic evidence of disk extrusion or sequestration. Each patient participated in a targeted strengthening program, and in some cases, transforaminal injection therapy was employed. Each patient demonstrated an eventual full functional recovery. In most cases, electrodiagnostic studies were performed and included a needle examination of the affected limb and compound muscle action potentials from the most clinically relevant and weakened limb muscle. The electrodiagnostic findings and, in particular, the quantitative compound muscle action potential data seemed to correlate with the timing of motor recovery. Patients with predominantly painless and significant weakness arising from disk extrusion can demonstrate successful rehabilitation outcomes. Despite a relative absence of pain, such patients can present with a more rapidly reversible neurapraxic type of weakness. The more quantitative compound muscle action potential data obtained through electrodiagnostic studies may offer the treating physician an additional means of characterizing the type of neuronal injury at play and the likelihood and timing of strength return.

Severe Coronary Artery Disease Presenting with a Chief Complaint of Cervical Pain

We present the case of a 49-yr-old man with cervical pain of 14 wk of duration. Physical examination and magnetic resonance imaging of the cervical spine demonstrated no neurologic abnormality or corroborative pathology. Cardiac catheterization demonstrated advanced multivessel disease. The patient underwent successful coronary bypass grafting and was symptom free 12 mo later. Spine practitioners are often consulted by the medical community to determine if a patients limb or chest complaints might be caused by a spinal pain generator. This atypical case reminds us of the overlap between cardiac and cervical symptom referral. A patient with critical cardiac ischemia can present with predominant cervical complaints.

An unusual extraspinal cause of bilateral leg pain

Low back pain with pain radiating to the lower extremities is common in patients referred to a spine center. Lumbar spine pathology is commonly the etiology of such symptoms, but extraspinal causes of back and leg pain can manifest as a radicular disorder. Extraspinal etiologies must be considered in the workup of back and leg pain. This report describes an unusual case of spontaneously occurring bilateral femoral neck stress fractures presenting as low back pain with seemingly bilateral L4 radicular symptoms.

Poster 85: Severe aortoiliac occlusive disease presenting as suspected symptomatic high lumbar stenosis: a report of 2 cases1

Abstract Setting: Outpatient physiatric spine center. Patients: 2 patients with the chief complaint of proximal thigh pain. Case Descriptions: 2 middle-aged female smokers were referred by their primary care physician with bilateral thigh pain that had persisted for several years. Each presented with a lumbar magnetic resonance imaging, which demonstrated upper lumbar stenosis. In each case, bilateral and circumferential thigh pain was described, which prohibited the patient from ambulating extended distances and was relieved through quiet standing. A detailed history and radiographic review were not convincing for a corroborative radicular stressor. Each patient was neurologically intact and had diminished lower-extremity pulses. Segmental arterial Doppler studies were performed. Assessment/Results: In each case, a markedly diminished ankle-brachial index was observed. Although a focal drop in pressure was not observed between lower-limb segments, a significant reduction was appreciated when comparing the high thigh to brachial pressure measurements. Computed tomography (CT) angiograms confirmed severe aortoiliac atherosclerotic disease. Each patient was treated with an antiplatelet agent prior to further considering aortofemoral bypass. One patient’s carotid Doppler image revealed severe bilateral occlusion that led to a prompt endarterectomy. Discussion: Neurogenic claudication can present with proximal and anterior lower-extremity pain arising from a high lumbar and stenotic radicular stressor. Vascular claudication most commonly arises from atherosclerosis obliterans, and smoking remains a primary risk factor. Isolated proximal limb pain with ambulation, Leriche’s syndrome, can arise from aortoiliac occlusive disease. Conclusions: Spine practitioners are often consulted to determine if a patient’s limb complaints are arising from a spinal pain generator. These atypical cases highlight a less common pain distribution in the vascular patient, the symptomatic overlap between neurogenic and vascular claudication, and the challenges that arise when evaluating the patient with combined disease.