Larry H. Chou

The predictive value of provocative sacroiliac joint stress maneuvers in the diagnosis of sacroiliac joint syndrome

OBJECTIVE To determine the clinical validity of provocative sacroiliac joint (SIJ) maneuvers in making the diagnosis of sacroiliac joint syndrome (SIJS). DESIGN Prospective constructive cohort study using sacroiliac joint block (SIJB) as the diagnostic gold standard. SETTING Tertiary care center. PATIENTS Consecutive patients describing low back pain including the region of the sacral sulcus. Physical examination revealed a positive response to three provocative SIJ maneuvers, two of which had to be Patricks test and pain with palpation over the ipsilateral sacral sulcus. INTERVENTIONS All subjects underwent fluoroscopically guided SIJB. MAIN OUTCOME MEASURES Response to SIJB was assessed with visual analog scale (VAS) ratings before and after the block. A reduction of the VAS rating by at least 80% was considered a positive response to SIJB. RESULTS Fifty consecutive patients met our criteria and underwent SIJB. Thirty patients had positive response to SIJB, making up the positive SIJS group. Twenty patients had less than 80% pain reduction with SIJB and thus comprised the negative SIJS group. The positive predictive value of provocative SIJ maneuvers in determining the presence of SIJS is therefore 60%. CONCLUSIONS Our results do not support the use of provocative SIJ maneuvers to confirm a diagnosis of SIJS. Rather, these physical examination techniques can, at best, enter SIJS into the differential diagnosis.

A critical review of the evidence for the use of zygapophysial injections and radiofrequency denervation in the treatment of low back pain.

BACKGROUND CONTEXT Lumbar zygapophysial joints are currently believed to be a cause of axial low back pain. Once this diagnosis is made, decisions about when to institute a particular intervention and which treatment to offer is regionally and specialty dependent. PURPOSE To perform a critical review of prior published studies assessing the use of interventional treatment options for the treatment of lumbar zygapophysial joint syndrome. STUDY DESIGN Evidence-based medicine analysis of current literature. METHODS A database search of Medline (PubMed, Ovid and MDConsult), Embase and the Cochrane database was conducted. The keywords used were low back pain, lumbar zygapophysial joint, lumbar facet joint, radiofrequency denervation, medial branch block, and intraarticular injection. After identifying all relevant literature, each article was reviewed. Data from the following categories were compiled: inclusion criteria, randomization of subjects, total number of subjects involved at enrollment and at final analysis. statistical analysis used, intervention performed, outcome measures, follow-up intervals and results. Guidelines described by the Agency for Health Care Policy and Research were then applied to these data. RESULTS This review determined that the evidence for the treatment of lumbar zygapophysial joint syndrome with intraarticular injections should be rated as level III (moderate) to IV (limited) evidence, whereas that for radiofrequency denervation is at a level III. CONCLUSIONS Current studies fail to give more than sparse evidence to support the use of interventional techniques in the treatment of lumbar zygapophysial joint-mediated low back pain. This review emphasizes the need for larger, prospective, randomized controlled trials with uniform inclusion and exclusion criteria, standardized treatment, uniform outcome measures and an adequate duration of follow-up period so that definitive recommendations for the treatment of lumbar zygapophysial joint-mediated pain can be made.

The value of radionuclide imaging in the diagnosis of sacroiliac joint syndrome

Study Design A prospective study was done to assess the diagnostic value of radionuclide imaging (bone scan) in the evaluation of sacroiliac joint syndrome. Objectives To determine the sensitivity and specificity of radionuclide imaging in establishing a diagnosis of sacroiliac joint syndrome in patients with low back pain. Summary of Background Data There is no pathognomonic symptom or sign to establish the diagnosis of sacroiliac joint syndrome. It has been accepted that confirmation of sacroiliac joint syndrome requires relief of pain, a positive response to a sacroiliac joint block. Bone scanning has been proposed as a useful imaging technique to evaluate for sacroiliac joint syndrome. The authors explored the use of nuclear imaging as a cost‐effective and noninvasive technique in the diagnostic algorithm of sacroiliac joint syndrome. Methods Patients presenting to the authors Spine Center with complaints of low back pain including the region of the sacral sulcus were screened for inclusion into this study. Positive response to three provocative sacroiliac joint maneuvers was requisite, two of which had to be Patricks test and pain with palpation over the sacral sulcus. Patients who met these criteria were entered into a physical therapy program comprised of lumbar spine stabilization techniques and excluded any interventions considered specific for sacroiliac joint syndrome. Those whose symptoms failed to improve with this program underwent bone scan and fluoroscopically guided sacroiliac joint block. Response to sacroiliac joint block was assessed with pre‐ and post‐block visual analog scale scores completed by the patient. A reduction of the VAS rating by at least 80% was considered a positive response to sacroiliac joint block. Results Fifty consecutive patients met the authors criteria and underwent bone scan and sacroiliac joint block. Thirty‐one patients who had positive responses to sacroiliac joint block comprised the positive sacroiliac joint block group. Nineteen patients had less than 80% pain reduction with sacroiliac joint block and were labeled the negative sacroiliac joint block group. Four patients had positive bone scans, all of whom were in the positive sacroiliac joint group. Conclusions The results demonstrated very low sensitivity and high specificity of nuclear imaging in the evaluation of sacroiliac joint syndrome. The authors do not recommend bone scan in the diagnostic algorithm for sacroiliac joint syndrome.

Idiopathic Avascular Necrosis of a Vertebral Body: Case Report and Literature Review

Study Design. Case report and literature review. Objectives. To review the English literature pertaining to idiopathic avascular necrosis of a vertebral body. As an illustrative example, the case of a 60‐year‐old woman with idiopathic avascular necrosis of L4 is presented. Summary of Background Data. Avascular necrosis of a vertebral body is an uncommon entity. Avascular necrosis has been described in the context of other underlying lesions, such as with malignancy, infection, radiation therapy, and systemic steroid treatment. The intravertebral vacuum cleft phenomenon seen on plain films has been strongly associated with vertebral body avascular necrosis. Methods. Literature and chart review was carried out. Vertebral body avascular necrosis was initially identified with imaging studies and confirmed with biopsy. A comprehensive preoperative evaluation did not identify a specific cause of avascular necrosis. The patient underwent vertebral body resection with fibula allograft struts. Conclusions. Although vertebral body collapse in an osteoporotic individual is relatively common, a case is reported of vertebral body collapse and subsequent necrosis without evidence of underlying disease at 48‐month follow‐up. The current findings support the diagnosis of idiopathic avascular necrosis of L4.

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.

Intradiscal electrothermal annuloplasty.

Chou LH, Lew HL, Coelho PC, Slipman CW: Intradiscal electrothermal annuloplasty. Am J Phys Med Rehabil 2005;84:538–549. Low back pain is a common problem, and although the majority of cases of low back pain resolve, a subset of patients will continue to have intractable pain despite appropriate conservative treatments. Intradiscal electrothermal annuloplasty is a minimally invasive spinal procedure that has been proposed to treat provocation discography–proven internal disk disruption syndrome. The early uncontrolled and nonrandomized intradiscal electrothermal annuloplasty literature suggests it may provide some relief in a small proportion of strictly defined patients; however, more recent randomized, placebo-controlled trials have not substantiated these initial findings. This article will review the published literature, indications, contraindications, safety, and efficacy of the intradiscal electrothermal annuloplasty procedure for the treatment of chronic, intractable, axial back pain.

Sacral stress fracture in a female field hockey player

Slipman CW, Gilchrist RV, Isaac Z, Lenrow DA, Chou LH: Sacral stress fracture in a female field hockey player. Am J Phys Med Rehabil 2003;82:893–896. We report a collegiate field hockey player who sustained a sacral fatigue-type stress fracture that manifested as persistent low back and leg pain. The diagnosis of sacral stress fracture was suggested by history and physical examination and confirmed by magnetic resonance imaging. Our patient experienced complete resolution of symptoms after a 3-mo interval of activity restriction. This article describes the first reported case of a sacral stress fracture in a field hockey player.