Kutay Tezel

The effectiveness of transforaminal epidural steroid injection in patients with radicular low back pain due to lumbar disc herniation two years after treatment

BACKGROUND AND AIM The aim of this retrospective study was to investigate the therapeutic effect of transforaminal epidural steroid injection in patients with chronic low back pain and radicular leg pain due to lumbar disc herniation. MATERIALS AND METHODS This study included 80 patients (32 female and 48 male; mean age: 45.8 years [range: 25-65 years]) that received fluoroscopically guided transforaminal epidural steroid injections for chronic radicular low back pain due to lumbar disc herniation. All of the patients had diagnostic MRI findings and did not respond to conservative treatment. All injections were performed by the same physician at the interventional pain unit of a tertiary hospital. The effectiveness of transforaminal epidural steroid injections was assessed via a standardized telephone questionnaire administered 2 years after the first injection. RESULTS Mean duration of radicular low back pain was 24.50 ± 18.25 months. Most of the epidural injections were administered at the L5 and S1 levels. The most effective post-injection period was the first 5.11 ± 3.07 months. Mean duration of injection effect was 12.46 ± 7.24 months. The response rate to the epidural steroid injections was 72%. CONCLUSIONS There was negative correlation between the duration of treatment effect and the duration of pre-treatment symptoms. Additionally, clinical improvement of radicular low back pain increased significantly as the duration of pre-treatment symptoms decreased. Based on the present findings, we think that transforaminal epidural steroid injections can be used as an alternative treatment for managing chronic radicular low back pain.

A Different Approach to the Management of Osteoarthritis in the Knee: Ultrasound Guided Genicular Nerve Block

Dear Editor, A 61-year-old female was referred to our tertiary physical medicine and rehabilitation outpatient clinic with a 7-year history of severe left knee pain. The patient was a nonsmoker and obese, with no comorbidities, and reported that the left knee pain worsened when walking and descending stairs and particularly when climbing stairs. Radiography of the left knee revealed Kellgren-Lawrence grade 3 osteoarthritis (OA) with multiple osteophytes and definite joint space narrowing. The pain and functional disability were nonresponsive to conservative treatment methods including weight loss, exercise, analgesics (paracetamol or diclofenac sodium once or twice a day), intra-articular steroid and hyaluronic acid injections, and physical therapy. The patient was finally offered knee replacement surgery by an orthopedic surgeon, but she did not accept surgery. The sensory and motor nerves supplying all the structures around the knee are the saphenous, tibial, and common peroneal nerves together with the subsartorial, peripatellar, and popliteal plexuses [1,2]. Vas et al. [2] targeted both the sensory and motor nerves supplying all the structures around the knee and succeeded in relieving the pain. Choi et al. [3] reported successful pain relief by ablation of the three branches of the genicular nerve [superior lateral (SL), superior medial (SM), and inferior medial (IM) genicular nerves]. These three nerves were selected because they pass the periosteal areas connecting the shaft of the femur to the bilateral epicondyles and the shaft of …

Multiple Sclerosis Presenting with Parsonage–Turner Syndrome: A Case Report

Abstract Background: A case of Parsonage–Turner syndrome [PTS] with typical sudden onset of shoulder pain and weakness in shoulder girdle was presented. Findings: Electrodiagnostic testing revealed an upper trunk lesion. Further diagnostic steps were pursued because of medical history and additional clinical findings. Hyperintense plaques typical of multiple sclerosis [MS] were revealed by cranial magnetic resonance imaging. Diagnosis of clinically definite MS was establised according to the McDonald criteria. Conclusions: A variety of peripheral nervous system pathologies might coexist with MS with unknown binding pathogenesis. This is an unusual case of PTS coexisting with MS as the presenting symptom.

The Anterior Cervical Triangle: An Unusual Site for Iatrogenic Accessory Nerve Palsy – A Case Report

Background Injury to the spinal accessory nerve [SAN] results in a debilitating shoulder dysfunction. Iatrogenic injury is common during radical neck dissection, cervical lymph node biopsy, and other surgical procedures; thus the superficial course of the nerve in posterior cervical triangle [PCT] makes it susceptible. The anterior cervical triangle [ACT] is an unusual location for iatrogenic SAN injury. Findings We present a case that outlines the risk of SAN injury following a surgical operation in the ACT. Conclusions Prevention of inadvertent injury to the SAN is also critical in the ACT, as well as in the PCT section.

Ultrasound Findings of Young and Traumatic Amputees With Lower Extremity Residual Limb Pain in Turkey.

Objective The current study was designed to document clinical and ultrasound (US) findings of patients with residual limb pain (RLP) after amputation and to investigate the relationship between these findings. Materials and Methods A chart review was performed to identify demographic and clinical data including the age (current and at the time of injury), time since amputation, gender, reason for amputation, affected limb number, side and level of limb loss, and ultrasonographic findings of young and traumatic amputees with RLP. Results The study included a total of 147 patients. Inflammation and neuroma were the leading pathologies in 20–29 years and 30–39 years age groups, respectively. Inflammation/edema were detected significantly more in patients with <1 year since amputation (P = 0.001). Neuroma was found at a significantly high rate in patients at 1–5 years (P = 0.029) and infection/abscess was more common in patients at >5 years since amputation (P = 0.051). The percentage of neuromas in below-the-knee amputees was significantly higher than in non–below-the-knee amputees (45.8% vs. 28.6%). Neuroma formation was detected in 50% of the patients with land mine–related amputation and at 27% in patients with amputation secondary to other traumatic reasons. Regression analysis showed below-the-knee-level amputation to be an associated factor for US abnormality. Conclusion The leading US findings were inflammation/edema, neuroma, and infection/abscess in traumatic amputees with RLP. The US findings might be different in patients according to the time since amputation. Patient with land mine–related amputations may have different US findings.

Poster 174 Overlooked Diagnosis of Stress Fractures of the Pubic Ramus

Case/Program Description: A 52-year-old woman with right gluteal pain for 1 year. Patient presents after exhausting multiple treatment approaches such as physical therapy, right hip and right ischial bursa corticosteroid injections. MRI and EMG findings were not helpful in identifying cause. Physical exam noted tenderness at the right middle lower gluteal region, but otherwise normal. In a prone position, ultrasound imaging the maximal local tender point demonstrated imaging of right obturator internus (OI) and its underlying bursa. Identification of the tendon of OI muscle and OI bursa transtendinosus injection technique was based on the detailed description by J Smith. A 22-gauge 3.5-inch needle was then inserted through the sterilized skin using in-plane to transducer and longitudinal to the OI from lateral to medial direction until the tip of needle touching the ischium just underneath the tendon of obturator internus muscle. The patient reported severe pain when needle was advanced to this location where a mixture of 2.5cc 0.5% lidocaine mixed with 20mg kenalog was injected. Patient reported immediate complete relief of pain following the injection. Results: Patient returned to office at 3 months after the injection. She continued to report significant pain relief in the right gluteal region. She reported sleeping much better and no longer took pain medications. Discussion: This case report is to stress the success of US guided injection of obturator internus bursa at the ischial region. To our knowledge, there has no been prior documented case report utilizing this approach. Conclusions: Ultrasound guided injection of obturator internus bursa utilizing the OI bursa trans-tendinosus technique as described by J Smith may be an effective approach for successful treatment for patients with gluteal pain from OI bursitis. Setting: Outpatient Clinic Level of Evidence: Level V

Poster 269: Results of Transforaminal Epidural Steroid Injections in Patients With an Extruded Disk Herniation

Objective: To evaluate the outcomes of radiofrequency neurotomy for chronic facet mediated pain. Design: Retrospective review. Setting: University pain and rehabilitation clinics. Participants: All adult patients who underwent radiofrequency neurotomy between 12/2006-1/2010 (n 50). Interventions: Records were reviewed for patients who were considered candidates for radiofrequency neurotomy based on response to 2 sets of medial branch blocks (MBB) with 2% lidocaine and .75% bupivacaine separated in time. Main Outcome Measures: Oswestry or Neck Disability Index, LASA pain score, Brief Pain Inventory, percentage of pain decrease on 1-10 scale, medication change and patient perception of benefit at baseline, 3 and 6 months. Results: Disability Index was significantly lower in the group with less than 100% pain relief and the group with 24 pain relief on MBB1 at baseline. At 3 months, those with 100% pain relief on MBB1 had a significantly reduced disability index compared with those with 100% pain relief on MBB1. There was significantly more pain reduction at 3 months in the group with 24 hours pain relief from MBB1. When combining all groups, the average Disability Index was 12.63 points lower at 3 months, and 7.29 points lower at 6 months after the radiofrequency neurotomy, both of which were statistically significant. Conclusions: The study suggests that those with 100% pain relief and those with greater than 24 hours of pain relief after MBB have a better outcome after radiofrequency neurotomy as measured by disability index and pain reduction. Disability scores were significantly lower at 3 and 6 months, suggesting improved function after radiofrequency neurotomy.