Jose Mena

Use of Glucosamine and Chondroitin in Persons With Osteoarthritis

Glucosamine and chondroitin are members of a group of dietary supplements often termed “complementary agents,” “disease‐modifying agents,” or “disease‐modifying osteoarthritis drugs” (DMOADs). They are among the best‐selling dietary supplements in the United States. DMOADs are thought to act by affecting cytokine‐mediated pathways regulating inflammation, cartilage degradation, and immune responses. Given the results of recent studies, investigators have begun to question whether the popular combination of glucosamine and chondroitin alleviates disease progression or pain in people with mild to moderate knee osteoarthritis. Reasons proposed for the lack of benefit include incorrect dosing, suboptimal compound manufacture, and a lack of complete understanding of when and how to apply the compounds. In addition, adjuvant medications also could augment the therapeutic potential of these agents. Although these agents are considered safe, some uncommon and minor adverse effects have been reported, including epigastric pain or tenderness (3.5%), heartburn (2.7%), diarrhea (2.5%), and nausea (1%). In conclusion, although some questions have arisen about whether DMOADs are as effective as has been claimed, a trial should be considered in in selected patients with sustained refractory cases of osteoarthritis.

Imaging in Radiculopathy

All patients presenting with signs and symptoms of lumbar radiculopathy must undergo a thorough history taking and physical examination. Often, however, the diagnosis remains unclear; it is accurate anatomically, but the underlying cause of the lesion is not confirmed, or the symptoms are so severe that more information on the anatomy is required. Therefore, the next step in the diagnostic process is imaging studies. This article discusses imaging modalities, including plain radiographs, magnetic resonance imaging, computed tomography (CT), CT myelogram, selective nerve root block, and bone scan.

Not All Conditions Respond Equally to Spine Injections: A Review of the Outcome Literature for Common Spine Pathologies

A variety of spinal pathologies can result in symptoms including low back and radicular pain. These different diagnostic etiologies have different natural histories and may have varying responses to treatment. Unfortunately, this is not often accounted for in the literature, and the outcomes from treatment of these various diseases are lumped together based on their symptomology. This is an inappropriate way to examine the literature given the different pathologies. This article will therefore offer a narrative review of the outcomes of injection therapy for common disease processes including zygapophyseal (facet) joint pain, sacroiliac joint pain, discogenic pain, disk herniation with radicular pain, and spinal stenosis.

Radiographic Evidence of Lumbar Zygapophysial Joint Arthritis on MRI at Initial Zygapophysial Joint Injection or Medial Branch Block

Disclosures: A. Miciano, No Disclosures: I Have Nothing To Disclose. Objective: 1) To adapt the PROMIS item banks to spine medicine by administering it in individuals with chronic spine pain (CSP) and comparing the outcomes of different spine intervention groups (non-invasive vs. invasive procedures); and, 2) To correlate the PROMIS scores with clinician-derived tests. Design: Retrospective study Setting: Outpatient rehabilitation clinic Participants: Records of 100 patients were reviewed after being referred for CSP; 17 had previously undergone no invasive interventions (NII), 15 with therapeutic spinal injections (TSI), and 17 with a spinal reconstruction intervention (SRI). Interventions: N/A Main Outcome Measures: All study participants had completed the PROMIS global health item banks: physical function, anxiety, depression, fatigue, sleep disturbance, satisfaction with social roles, and pain impact. Also, clinician-derived tests had been administered: skeletal muscle mass (SM) and skeletal muscle index (SMI) by Bioelectric Impedance Analysis; spinal flexor and extensor strength by the 1-Repetition Maximum Method; and, physical performance tests Dynamic Gait Index (DGI), Berg Balance Scale, and 6-Minute Walk Test. Results or Clinical Course: Age was a significant covariate only for PROMIS-Fatigue, wherein there was a negative correlation between fatigue and age in all three treatments. Gender differences were present for DGI, flexor strength, SM, and PROMIS-Physical Function; in all cases, male scores were significantly higher than females. Intervention differences were significant in PROMISFatigue (both NII and SRI had higher mean scores than did TSI); PROMIS-Sleep disturbance (SRI had a higher mean score than did TSI); PROMIS-Pain impact (SRI had a higher mean score than did TSI). Conclusions: This study had differentiated the global health outcomes in individuals with chronic spine pain and who have undergone varied interventions. It also showed that the PROMIS item banks can provide efficient and precise dimensional estimates of comparative outcomes that can be utilized to monitor patient progress in individuals with CSP. Measurement practice in busy outpatient spine clinics and in research can be advanced by using the PROMIS. Further evaluation in clinical populations on a larger scale is warranted before the PROMIS item banks can be used for spine clinical trials. Poster 474 Radiographic Evidence of Lumbar Zygapophysial Joint Arthritis on MRI at Initial Zygapophysial Joint Injection or Medial Branch Block. Jackson Cohen, MD (University of Miami Miller School of Medicine, Miami, FL, United States); Daniel Rivera, MD; Douglas Johnson-Greene, PHD; Jose Mena, MD; Andrew L. Sherman, MD.

Rehabilitation of a Patient with Proteus Syndrome: A Case Report

Case Description: Interscalene brachial plexus block (ISBPB) has been widely used in surgical shoulder procedures. Nerve block anesthesia provides superior same-day recovery over general anesthesia and allows reducing costs. It has been stated that ISBPB is safe. We report the case of a long-term neurological deficit after a nerve stimulator-guided ISBPB. Setting: Neurological Rehabilitation Results or Clinical Course: Surgery was advised for a 55-yearold right-handed man, with right shoulder impingement syndrome who did not improve after 12 months of conservative treatment. Diazepam 10 mg was administered p.o. 15 minutes before performing nerve stimulator assisted ISBPB, without ultrasonography guide. During nerve stimulation, the patient felt a sharp pain but he was immediately sedated. After discharge, 24 hours later, he began to complain about severe shoulder and right arm burning pain. He required a progressive increase in analgesic medication, even requiring oxycodone to partially minimize the pain. Severe periscapular atrophy developed in some days. Electromyography showed an upper trunk plexus injury (C5, C6 partially C7), with severe denervation of supraspinatus, infraspinatus, deltoid, and moderate denervation in biceps brachii. Pulmonary function (forced vital capacity, FVC, 60%) was also affected due to partial diaphragmatic palsy, visible on radiological exam. At one year follow-up, only partial improvement was observed since functional disability persists with inability to flex, abduct and externally rotate the shoulder. FVC is still 60%. Conclusions: Severe brachial plexus plexopathy is an uncommon but catastrophic ISBPB complication, probably associated to intraneural local anesthetic administration. The use of multiple monitoring like ultrasound, nerve stimulation and opening-pressure control minimize the risk of intraneural injection in ISBPB.

Poster 391 Steroid Psychosis After Cervical Transforaminal Epidural Steroid Injection: A Case Report and Literature Review

ment for lumbar radiculopathy. When it is used, to our knowledge, most practitioners combine it with steroid administration to the nerve root for additive therapeutic effect. This case illustrates the potential utility of steroid-free PRF for patients who are unable to tolerate steroid side effects. PRF’s mechanism of action is still unclear. Theories include electromagnetic field alteration of celluluar protein expression and heat-induced modulation of neural transmission that selectively affects pain fibers. Conclusions: PRF may be an alternative to ESI for patients with lumbar radiculopathy who are unable to tolerate steroids.

Poster 395 Neuropathic Pain Improvement in Incomplete Spinal Cord Injury After Spinal Cord Stimulator Trial: A Case Series

activity in the PAIS intervals (described elsewhere in this Conference), PSE (1-190), PL1 (191-350), PL2 (351-800), PL3 (8012,500), and PMI (2,000-30,000), stratified by gender and BMI, described as a function of age. Results: Pain-free subjects are stratified by gender and BMI. Within each stratum, physical activity profiles are summarized using PAIS cut-points, and the 10%, 50%, and 90% (percentile) reference values are constructed. Two types of reference values are constructed: 1) age-agnostic, and 2) cubic-B spline quantile regression in age. PAIS cut-points are designed to detect physical activity alterations in pain. Indeed, we show that in all 6 gender-BMI strata, subjects with low back pain demonstrate statistically significant (P .01) deviations in one or more of the PAIS intervals. We in addition demonstrate modeling the non-linear age effect improves sensitivity by 20%. Conclusions: We introduce “pain-free PARC”, a reference chart for physical activity research in pain in the United States. Based on physical activity intensity signature (PAIS) intervals, PARC is tailored for the study of musculoskeletal pain. Compared to widelyused cut-points based on VO2, PAIS intervals are designed to maximally detect alterations in physical activity in pain. Indeed in this large-scale analysis, we demonstrate its superior test characteristics. By statistically describing the physical activity profiles of the non-institutionalized pain-free population in the United States, PARC should provide a reliable and exogenous reference standard for future studies in pain. PARC is available via download and via API (http://quantifiedus.com).

Poster 360 Epidural Hematoma and Paraplegia After Spinal Cord Stimulator Removal: A Case Report

Setting: Urban, academic physical medicine and rehabilitation residency program. Participants: Physical medicine and rehabilitation residents (n 17), control group (n 8) and treatment group (n 9). Interventions: All residents were given an examination of neuroanatomy that included a multiple choice portion (written) and a plexus labeling portion (drawing) at baseline and at 5 weeks. Residents in the control group received only lecture notes. Residents in treatment group received lecture notes as well as four interactive neuroanatomy lectures including visual aids, such as plexus drawings, supplemented with pneumonic devices given over a 5-week period. Main Outcome Measures: Post-test performance on the total exam score (max 80), written exam score (max 20), and drawing exam score (max 60) adjusted for baseline scores. Results: Both the treatment and control groups improved in the total exam score (32.6 11.0 and 22.4 20.6, respectively) and drawing exam score (30.7 10.7 and 23.1 19.1, respectively). The treatment group improved in the written exam (1.9 2.6) whereas the control group performed worse at follow-up ( 0.8 3.3). At 5 weeks, there was no significant difference between treatment group verses control group in the total exam score (P .2) or the drawing exam score (P .6), but there was a significant difference in the written exam score (P .03). Conclusions: The interactive neuroanatomy lecture series was associated with higher written exam scores at 5 weeks than those for residents who received lecture notes only. The interactive neuroanatomy lectures were associated with non-significantly higher scores in drawing exam score and the total exam score.

Poster 396 Variant for Transforaminal Epidural Injection: Retrodiscal Approach for Severe Neuroforaminal Stenosis: A Case Series

Disclosures: M. Delille, No Disclosures. Case Description: This case series reports on 15 patients who presented with radicular pain symptoms. Initial rehabilitation treatment consisting of medications and physical therapy failed to alleviate their symptoms. In all cases, magnetic resonance imaging (MRI) revealed severe neuroforaminal stenosis causing ipsilateral radicular symptoms consistent with the affected level. All patients then underwent a single ipsilateral retrodiscal transforaminal epidural steroid injection. Setting: University hospital-based spine center. Results or Clinical Course: The retrodiscal approach for injection with ropivacaine and betamethasone for radicular symptoms in a disc herniation resulted in complete or nearly complete pain relief after 1-2 injections. Utilizing fluoroscopy, no difficulty was encountered to enter the retrodiscal space. Pain relief in the patients started 24 hours to 1 week postinjection and persisted for at least 6 months in most of the patients. Functionally, the patients improved or returned to their previous level of activity. Discussion: The retrodiscal approach (RDA) was used in this series of 25 patients as an alternative to the classical approach of performing a transforaminal epidural steroid injection (TFESI) or selective nerve root block (SNRB). The RDA technique consists of approaching the site of pathology as one would for a discogram in the inferior aspect of the neural foramen. The anterior advancement of the needle is monitored by fluoroscopy in multiple planes so as to not puncture the annulus. This approach has been reported only sporadically in the literature, but has been found safe in all cases. An advantage of this approach is fewer intravascular injections and delivery of medication even closer to the site of the herniation. Its use in cases of severe neuroforaminal stenosis, which prevents an adequate entry of the needle into the affected neuroforamen, is advocated. We have consistently seen that with the use of contrast, it spreads and exits the neuroforamen of the same target level. Conclusions: Cases with severe neuroforaminal stenosis prevent a safe needle entry subpedicularly; however, they may still benefit from a retrodiscal trasforaminal epidural injection. Future studies comparing the traditional subpedicular transforaminal injection technique with the RDA technique should be considered.

Poster 270 Baclofen Overdose Following Missed Diagnosis of Intrathecal Catheter Tip Occlusion: A Case Report

Disclosures: D. Rivera, No Disclosures. Case Description: A 26-year-old woman whose spasticity had been managed with intrathecal baclofen (ITB) presents to the Spasticity Clinic for routine pump refill. Of note, her dose had been increased consistently over the past due to poor spasticity control. The leftover baclofen volume was noted to be almost the same as what was placed on the previous visit. The patient was taken to the procedure room for pump dye and roller studies. During the dye study, after an unusual amount of initial resistance, the contrast solution was visualized exiting the catheter tip into the intrathecal space. The roller study was found to be normal. The pump was then re-programmed at the most recent rate. Setting: Tertiary academic hospital. Results or Clinical Course: The evening after the procedure the patient began experiencing lightheadedness and somnolence. Upon evaluation at the ER she was found to be hypotensive and flaccid. She was thought to be suffering from baclofen overdose so the pump’s reservoir was immediately evacuated. After resolution of her symptoms the pump was refilled and programmed at a lower dose. She was seen at the clinic 1 week afterward with better-controlled spasticity and no signs of baclofen overdose or withdrawal. Discussion: Given the unusual initial resistance noted during the dye study, we suspect that the catheter was being mechanically obstructed but got unclogged during contrast injection. This would explain the high residual baclofen and the patient’s progressive dose requirement, as well as the overdose symptoms while on the same dose following the dye study. There have been numerous cases reported in the literature regarding intrathecal catheter obstruction, most notably due to catheter-tip granulomas. To our knowledge, the occurrence of baclofen overdose related to failure of recognition of this problem has not been reported yet in the literature. Conclusions: The idea of a catheter-tip associated mass was not entertained until after the resolution of the apparent mechanical problem. However, this problem should be considered in all patients receiving intrathecal baclofen presenting with a relatively rapid increase in dose requirement and persistent high residuals. These patients might deserve more specific investigation, such as MRI or CT myelogram to confirm the associated abnormality.