Jeremy Simon

Discogenic Low Back Pain

Most lumbar disk herniations improve over time with or without medical treatment. Disk herniations and annular tears may not be symptomatic and are shown to exist in patients without any symptoms. In some patients, chronic low back pain may result from the syndrome of internal disk disruption. Treatment of chronic pain of diskal cause can be challenging and have varying results in terms of success. The diagnosis, cause, and treatment options are reviewed in this article.

Injectate volumes needed to reach specific landmarks in lumbar transforaminal epidural injections.

To identify the volumes of contrast material needed to reach specific landmarks during lumbar transforaminal epidural injections (L‐TFEIs).

Injectate Volumes Needed to Reach Specific Landmarks in S1 Transforaminal Epidural Injections

OBJECTIVES   We identify the contrast volumes needed to reach specific landmarks during S1 transforaminal epidural injections (S1-TFEIs). DESIGN   Prospective, nonrandomized, observational human study. Setting.  Academic/private pain management practice. Subjects.  Forty-two patients undergoing S1-TFEIs were investigated. Thirty-seven patients were included in this study. Interventions.  S1-TFEIs were performed using contrast-enhanced fluoroscopic visualization. MAIN OUTCOME MEASUREMENTS   After confirming appropriate spinal needle position, up to 5 mL of nonionic contrast was slowly injected. Under biplanar fluoroscopic guidance, contrast volumes were recorded as flow reached specific anatomic landmarks: the ipsilateral S1 pedicle, the superior aspect of the L5-S1 disc space, and across the midline of the spinous process. RESULTS   After injecting 2 mL of contrast, 100% of S1-TFEIs spread to the medial aspect of the ipsilateral superior pedicle of S1. After injecting 3.0 mL of contrast, 92% of S1-TFEIs spread to the superior aspect of the L5-S1 intervertebral disc. After injecting 4 mL of contrast, 27% of S1-TFEIs spread beyond the midline of the spinous process, but by only a few millimeters. CONCLUSIONS   This study demonstrates injectate volumes needed to reach specific anatomic landmarks in S1-TFEIs. A volume of 3.0 mL of contrast reaches the superior aspect of the L5-S1 intervertebral disc 92% of the time.

Intravascular Penetration Following Lumbar Transforaminal Epidural Injections Using the Infraneural Technique

Dear Editor, Lumbar transforaminal epidural steroid injections (L-TFESIs) are commonly used to treat painful lumbar radiculopathy ⇓. While generally accepted as a low-risk procedure, major complications including spinal cord infarction with resultant paraplegia are reported ⇓. These catastrophic events are largely thought to be due to the inadvertent injection of particulate steroid into a radiculomedullary artery, homologous to the Artery of Adamkewicz ⇓, which supplies the lower portion of the spinal cord. This has led to studies of the vascular anatomy in this region ⇓, suggestions of using nonparticulate steroids ⇓, and alternative techniques in performing this procedure ⇓. Recent publications suggest using an infraneural injection technique as opposed to the traditional superior-posterior placement referred to as the region of the “safe triangle.” …

Electrodiagnostic Evaluation of Compressive Nerve Injuries of the Upper Extremities

Electrodiagnostic testing includes electromyography and nerve conduction studies that are physiologic tests used in the diagnosis of peripheral nerve injuries. It is a supplement rather than a replacement for a physical examination. This article reviews the terminology as well as the findings seen and used in electrodiagnostic studies. Common compression nerve injuries including the median, ulnar, radial, axillary, and suprascapular nerves and their electrical findings are reviewed.

Musculocutaneous Neuropathy Following Insertion of Cosmetic Silicone Biceps Implants: A Case Report

This is a case report of a 40-year-old man who underwent bilateral cosmetic biceps implantation, developed pain, and had the implants removed. He then developed weakness and numbness in the left arm and was subsequently found to have musculocutaneous neuropathy by electromyography and ultrasound. After failing to respond to conservative care and having ongoing weakness, the patient underwent a neurolysis and debridement of the musculocutaneous nerve. Subsequently, he regained full function and use of the left upper limb. This case report brings attention to musculocutaneous neuropathy as a potential complication of cosmetic bicipital implantation surgery.

Poster 212: EMG Findings Consistent with Axillary Nerve Entrapment at Teres Minor Relieved with Axillary Nerve Decompression

tenderness, restricted active and passive left hip movements and truncal extension due to pain, and a circumducted gait pattern. Initial radiographs showed 6 lumbar vertebrae with left rudimentary rib on L1 and partial sacralization of L6. Pain and radicular symptoms did not improve initially with relative rest and passive stretching. Lumbar MRI revealed multilevel degenerative changes with L4-5 central disc herniation and mild spinal stenosis. Setting: Academic-affiliated outpatient sports medicine clinic Results: Office based education and exercise programming regarding core strengthening, neutral spine emphasis, and self-mobilization techniques were prescribed for pain and movement control. Supplemental physical therapy using manual techniques, progressive impact loading, and a Pilates reformer program was also requested. Stabilization in neutral movements resulted in significantly decreased pain. Timeframe was limited to return to full performance for an upcoming international competition, however, rapid functional and symptomfree recovery was achieved by follow-up after 5 weeks. Discussion: Bertolotti syndrome is an uncommon cause of lower pack pain in pediatric patients. Although evidence suggests increased incidence of disc herniation above lumbosacral transitional vertebrae due to altered biomechanics and hypermobility, it is still debated whether these structural abnormalities predispose patients to injury. We present this case as an example of conservative rehabilitation involving a team approach with use of corrective exercises and multiple modalities as mentioned to alleviate soft tissue injury and promote return to full competitive function despite underlying structural anomalies. Conclusions: Young athletes with back pain and Bertolotti syndrome may have corresponding intervertebral disc pathology that can be managed with a comprehensive functional rehabilitation approach. Level of Evidence: Level V

Concomitant use of opioids and benzodiazepines in the outpatient setting: A retrospective study

BACKGROUND Benzodiazepines have been identified as a concurrent factor in opioid-related deaths. Although the dangers of concomitant administration of opioids and benzodiazepines are well documented, implementation of this knowledge into practice may be lagging behind. OBJECTIVE To examine the concomitant use of opioids and benzodiazepines in the outpatient setting. DESIGN Retrospective study. SETTING Academic outpatient multispecialty practice. PARTICIPANTS Over 2000 outpatient clinic visits from January 2018 to April 2018 among four physiatrists were analyzed. METHODS All patients were reviewed in the Prescription Drug Monitoring Program (PDMP) website to identify whether they have filled either opioid or benzodiazepine prescription(s) in the last 12 months. MAIN OUTCOME MEASUREMENTS Number of opioid and benzodiazepine prescriptions, discrepancies in reporting of medications, providers prescribing medications, and cigarette/alcohol use. RESULTS A total of 353 patients were identified to have filled either opioid or benzodiazepine prescription(s) in last 12 months. 49.4% of patients prescribed opioids were found to be taking benzodiazepines concurrently. Reporting discrepancies were noted between the outpatient electronic medical record and PDMP in 17.2% of patients. Among patients taking both opioids and benzodiazepines, 38.9% had multiple providers prescribing these medications, 41.9% were over 65 years old, and 11.9% were daily cigarette/alcohol users. Patients taking both types of drugs (opioids and benzodiazepines) were significantly more likely to use different providers (38.9%) compared to patients taking one type of drug (9.8%, P < .001). The former group was also noted to fill significantly more prescriptions than the latter group (P < .001). CONCLUSION The study results emphasize that clinicians may not be aware that some of their patients are concurrently taking opioids and benzodiazepines. These results highlight the importance of routinely checking the PDMP and using that information to make fully informed decisions to minimize risks in use of these controlled substances. LEVEL OF EVIDENCE III.Benzodiazepines have been identified as a concurrent factor in opioid‐related deaths. Although the dangers of concomitant administration of opioids and benzodiazepines are well documented, implementation of this knowledge into practice may be lagging behind.

Successful Repeat Sacroplasty in a Patient With a Recurrent Sacral Insufficiency Fracture: A Case Presentation

The standard of care for treatment of sacral insufficiency fracture (SIF) remains conservative management with limited weight‐bearing and analgesics, as most fractures heal within 12 weeks. For those who fail to respond to conservative therapy, are immobile, or cannot tolerate the pain despite analgesic therapy, as well as those who do not improve with time, rest, or activity modification, minimally invasive surgery with percutaneous transverse screw fixation across the fracture is effective. However, a less invasive procedure, percutaneous sacroplasty, may be an option for potential rapid pain reduction. This is a novel report of repeat sacroplasty in a patient with a recurrent SIF to the same anatomical area as a previously treated SIF. To our knowledge, this is the first report of such an occurrence.

Interventional Spine Procedures: A Case-based Approach

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