Joshua D. Rittenberg

Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review.

To critically review the best available studies evaluating the efficacy of lumbosacral transforaminal epidural steroid injections (TFESIs) in the treatment of radicular pain.

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.

Complications of Fluoroscopically Guided Caudal Epidural Injections

Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Hanna A, Rittenberg J, Thomas SA: Complications of fluoroscopically guided caudal epidural injections. Am J Phys Med Rehabil 2001;80:416–424. ObjectivesTo assess the incidence of complications of fluoroscopically guided caudal epidural injections. DesignA retrospective cohort design study in which chart review was performed on patients, who presented with radiculopathy and received fluoroscopically guided caudal epidural steroid injections. All injections were performed consecutively over a 12-mo period. An independent observer reviewed medical charts, which included a 24-hr post procedure telephone call by an ambulatory surgery center nurse, who asked a standardized questionnaire about complications after the injections. Physician follow-up office notes 1 to 3 wk after injection along with epidurograms were reviewed. ResultsThe charts of 139 patients, who received 257 injections, were reviewed. Complications per injection included 12 episodes of insomnia the night of the injection (4.7%), 9 transient nonpositional headaches that resolved within 24 hr (3.5%), 8 increased back pain (3.1%), 6 facial flushing (2.3%), 2 vasovagal reactions (0.8%), 2 episodes of nausea (0.8%), and 1 increased leg pain (0.4%). No dural punctures occurred. ConclusionsNo major complications occurred. The incidence of minor complications was 15.6% per injection. All reactions resolved without morbidity and no patient required hospitalization.

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 practical management of Achilles tendinopathy.

The Achilles tendon, named after the legendary warrior and hero of Homer’s Iliad, is the strongest and thickest tendon in the human body. Despite this fact, Achilles tendinopathy is a common overuse injury, particularly in runners and other athletes. Kujala et al showed a 10-fold increase in Achilles injuries in runners compared with age-matched controls. Another study reported the incidence of Achilles tendinopathy in top-level runners as 7% to 9%. The specific factors linking this injury with running include excessive mileage, sudden increase in training intensity, decrease in recovery time, change of running surface, and poor footwear. This injury also is common in athletes who compete in racquet sports, track and field, volleyball, and soccer. Other factors that have been associated with Achilles tendinopathy include various biomechanical deficits, older age, male gender, increased body weight and height, and fluoroquinolone exposure.

Utility of the anesthetic test dose to avoid catastrophic injury during cervical transforaminal epidural injections

BACKGROUND CONTEXT Reports of serious complications from cervical transforaminal epidural corticosteroid injections often consider accidental intra-arterial injection the most likely mechanism of injury. As a result, many physicians have instituted methods to prevent intravascular injections. Routine use of the anesthetic test dose is one such method. The utility of the anesthetic test dose in this function has not been characterized in the current literature. PURPOSE The aim of this study was to determine the utility of injecting an anesthetic test dose before cervical transforaminal epidural corticosteroid injection and estimate the rate of false-negative intravascular contrast injection using live fluoroscopy and digital subtraction angiography (DSA). STUDY DESIGN Two-center retrospective study. PATIENT SAMPLE A consecutive cohort of men and women, ages of 23 to 83, who underwent cervical transforaminal epidural injection and received the anesthetic test dose after contrast injection was negative for vascular uptake, observed using live fluoroscopy or DSA. OUTCOME MEASURES Response to the anesthetic test dose was documented in each procedure note and recorded as either positive or negative. METHODS Records of three physiatrists at two academic spine centers (Center A and Center B) were reviewed to identify all patients who received a cervical transforaminal epidural injection during the preceding 5 years, resulting in a cohort of consecutively treated patients at each center. Each patient record was reviewed for demographics, indication for injection, procedure level and side, needle gauge, use of DSA, volume and type of anesthetic test dose used, and result of test dose injection. The test dose was considered positive if the following occurred: agitation or other sudden central nervous system change; gross motor deficits and/or paresthesias in the trunk, legs, or contralateral arm; systemic symptoms of anesthetic toxicity including cardiac arrhythmia, perioral numbness, metallic taste, dizziness, and/or ringing in the ear. For analysis, injections were separated into groups to compare results at Center A to Center B and to compare injections that used DSA to those that did not. The incidence of a positive response was calculated as a percentage from the total number of injections in the group. Differences between groups were analyzed for statistical significance using the Fisher exact test. RESULTS Six hundred seventy-eight injections were included. Of these, 349 were performed at Center A with test doses given after contrast injection under live fluoroscopy. The remaining 329 were performed at Center B, 183 also using live fluoroscopy, and 146 using DSA. The overall incidence of a positive anesthetic test dose was 0.59% (4/678). There was no significant difference between the incidence at each of the two centers (0.86% [3/349] vs. 0.30% [1/329]; p=.63). The overall incidence after live fluoroscopy was 0.75% (4/532) and after DSA was 0% (0/146), but this difference was not statistically significant (p=.58). Positive symptoms elicited by test dose administration included midneck and contralateral arm pain, metallic taste, dizziness, tachycardia, full body paresthesias, auditory changes, slurred speech, and motor ataxia. In all four cases with a positive response, the procedure was immediately terminated, symptoms resolved, and no lasting complications were observed. CONCLUSIONS The routine use of an anesthetic test dose appears to be safe and capable of detecting potentially dangerous intravascular injections undetected by conventional techniques. Positive responses occur in a small portion of those who receive the test dose injection. Further studies are required to determine the optimal dose and concentration of anesthetic to be used and the time required for observation after test dose administration.

Inadvertent intradiscal contrast flow during lumbar transforaminal epidural steroid injections: a case series examining the prevalence of intradiscal injection as well as potential associated factors and adverse events.

OBJECTIVES The primary aim was to evaluate the prevalence of inadvertent intradiscal injection during fluoroscopically guided contrast-enhanced lumbar transforaminal epidural steroid injections. The secondary aim was to determine if there are any risk factors for or adverse events as a result of inadvertent intradiscal contrast injection. DESIGN The study was a retrospective case series. SETTING The study was set in three outpatient spine care centers. PATIENTS A search was conducted in a database of spinal injection procedures from July 2000-May 2008. Fifteen cases of inadvertent intradiscal contrast flow were identified. These cases were matched with one control case with the same age, gender, level, and side of injection. INTERVENTIONS The prevalence of intradiscal contrast flow with lumbar transforaminal epidural steroid injection was calculated. Chart review of the cases and controls was performed. An independent, blinded examiner evaluated needle tip placement. OUTCOME MEASURES Frequency of intradiscal contrast flow during lumbar transforaminal epidural steroid injections and the relationship between the occurrence of intradiscal contrast flow with potential risk factors. RESULTS The prevalence of inadvertent intradiscal injection during lumbar transforaminal epidural steroid injections was 0.17%. All of the patients received prophylactic antibiotics after inadvertent disk injection, and there were no infectious or other complications identified. CONCLUSIONS Intradiscal contrast injection is an infrequently reported event during lumbar transforaminal epidural steroid injections. Our data support that the prevalence is very low and there might be an association with ipsilateral foraminal stenosis. Although there is potential for significant adverse complications with intradiscal injection, our data set did not show serious sequelae.

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).

Functional rehabilitation for degenerative lumbar spinal stenosis.

Nonoperative treatment for lumbar spinal stenosis must address anatomic and biomechanical factors. The entire functional kinetic chain and patient specific goals must be considered. In addition to passive modalities, manual therapy, and patient education, an active program consisting of flexion-based lumbar stabilization exercises, hip mobilization, proprioceptive training, and general conditioning should be initiated. More studies are needed to establish the benefit of a comprehensive, multifaceted treatment approach and to prove its clear benefit over the natural history of lumbar spinal stenosis.

Cost-effectiveness of the X-STOP® interspinous spacer for lumbar spinal stenosis.

Lumbar spinal stenosis is defined as a narrowing of the spinal canal and peripheral neural pathways, resulting in compression of neural elements. Treatment initially consists of conservative care (CC), with nonsteroidal anti-inflammatory medication, oral steroids, analgesics, epidural steroid inject