Lisa Huynh

Does Immediate Pain Relief After an Injection into the Sacroiliac Joint with Anesthetic and Corticosteroid Predict Subsequent Pain Relief

Objectives To determine if immediate pain response following an injection with local anesthetic and corticosteroid predicts subsequent relief. Design Prospective observational cohort. Setting An institutional review board-approved prospective study from a single academic medical center. Methods Patients with clinical diagnosis of sacroiliac (SIJ) pain and referred for SIJ injection were enrolled; 1 cc of 2% lidocaine and 1 cc of triamcinolone 40 mg/mL were injected into the SIJ. Pain score on 0-10 numeric rating scale (NRS) during provocation maneuvers was recorded immediately before injection, immediately after injection, and at two and four weeks of follow-up. Oswestry Disability Index (ODI) was also recorded. Results Various cutoffs were identified to establish positive anesthetic response and successful outcomes at follow-up. These were used to calculated likelihood ratios. Of those with 100% anesthetic response, six of 11 (54.5%, 95% confidence interval [CI]+/-29.4%, +LR 2.6, 95% CI = 1.1-5.9) demonstrated 50% or greater pain relief at follow-up, and four of 11 (36.5%, 95% CI+/-28.4%, +LR 3.00, 95% CI = 1.4-5.1) had 100% relief at two to four weeks. Fourteen of 14 (100%, 95% CI+/-21.5%, -LR 0.0, 95% CI = 0.0-2.1) with an initial negative block failed to achieve 100% relief at follow-up. Conclusions Patients who fail to achieve initial relief after SIJ injection with anesthetic and steroid are very unlikely to achieve significant pain relief at follow-up; negative likelihood ratios (LR) in this study, based on how success is defined, range between 0 and 0.9. Clinically significant positive likelihood ratios of anesthetic response to SIJ injection are more limited and less robust, but are valuable in predicting 50% relief or 100% relief at two to four weeks.

Poster 450: Unexpected Motor Responses with Motor Stimulus Testing during Lumbar Radiofrequency Neurotomy: A Case Series

ligaments. This reduced his pain significantly and allowed him to return to function. Discussion: Interspinous ligament injury is an under recognized etiology of back pain. Cadaveric studies have demonstrated that interspinous ligaments are the weakest of the spinal ligaments and are subjected to the greatest strain during flexion and extension of the spine. The diagnosis is largely clinical as imaging modalities such as MRI have shown varying reliability. Prolotherapy, or proliferative therapy, is gaining recognition as a treatment modality for tendinopathy as well as ligamentous laxity but its use for the treatment of interspinous ligament injury is poorly described. Further studies are warranted to explore the presentation and diagnosis of interspinous ligament injury and the use of dextrose prolotherapy in its treatment. Conclusions: Physiatrists should recognize interspinous ligament injury as a potential source of chronic back pain in conjunction with or separate from other diagnoses, such as degenerative disc disease or radiculopathy. Prolotherapy injections may be beneficial as both an adjuvant and primary treatment modality. Level of Evidence: Level V

Poster 483: Immediate vs. Prolonged Pain Relief After Sacroiliac Joint Injection with Anesthetic and Corticosteroid: A Prospective Study

discharge. Among those with a reported psychosocial health related quality of life score, 135 had a score at baseline, 130 at admission, and 64 reported post-discharge. The cohort was between ages 4-21, primarily Caucasian, male, and English speaking. Patient and familyreported physical HRQOL improved significantly from the time of rehabilitation admission to outpatient follow-up (mean score 20.2 to 59.7, P<.001). Psychosocial HRQOL improved, though to a lesser extent (mean score 55.8 to 71.2, P<.001). Conclusions: Patient and family-reported physical and psychosocial HRQOL, which are impacted significantly by new functional impairment, are seen to improve significantly through a course of inpatient rehabilitation. Despite significant loss to follow-up, we were able to determine the magnitude of change was greater than the 10-point decrement previously clinically correlated with an increase in 30-day readmissions and emergency department return visits. Inpatient rehabilitation is associated with important benefits for perceived HRQOL. Level of Evidence: Level III

Poster 487: A Minimum of 5-Year Follow-Up after Lumbar Transforaminal Epidural Steroid Injections in Patients with Lumbar Radicular Pain due to Intervertebral Disc Herniation

Objective: To evaluate parental satisfaction in patients who were treated with a pharmaceutical grade of tetra-hydro cannabinol (THC): Marinol (Dronabinol), for neuro-irritability and agitation not responding to traditional medications. Design: Convenience cohort study using structured phone interviews to assess parental perceptions of benefit in their child’s agitation, sleep duration, muscle tone, muscle spasticity, attention span, and displays of physical violence. A standardized agitation scale was also used in a small subset. Setting: Tertiary Children’s hospital in Rocky Mountain Region. Participants: 15 subjects mean age of 13.9 years (range 7-40) with a secondary diagnosis of agitation. Primary diagnoses were cerebral palsy (n1⁄49), developmental delays (n1⁄43), brain injury (n1⁄42), and Angelmen Syndrome (n1⁄41). Majority of the population were white (86.7%) non-Hispanics (80.0%). Interventions: Not applicable. Main Outcome Measures: Qualitative and quantitative assessment of agitation and other symptoms. Results: Overall 73.3% of parents felt that Marinol was effective in treating their child’s agitation. 13% of families reported that taking Marinol helped their child sleep more. 20% of families felt there was a positive change in muscle tone and muscle spasticity and attention span. 20% of families felt their child displayed less physical violence while being treated. 73.3% of families decided to stay on Marinol and in total 86.7% of families continued medical TCH treatment. Conclusions: Marinol may be a promising option for treatment of agitation as well as other secondary sequelae of pediatric brain damage from various causes. These preliminary results suggest that further work is warranted on the use of Marinol in treating symptoms resistant to other treatment paradigms. Level of Evidence: Level III

Poster 484: A Multi-Institutional Randomized, Double-Blind, Placebo-Controlled, Prospective Study of Intra-Articular Lumbar Zygapophysial Joint Corticosteroid Injection(s) as Treatment of Chronic Low Back Pain in a Selected Population

Design: Prospective study on consecutive patients undergoing a fluoroscopically guided injection into the SIJ. Setting: Academic institution. Participants: Patients suspected given history and physical examination to have SIJ mediated pain. Interventions: 2 cc mixture of 1cc of 2% lidocaine and 1 cc of triamcinolone 40mg/mL was injected into the SIJ after correct needle placement was confirmed using contrast dye and real time fluoroscopy. Main Outcome Measures: An independent physician assessed pain score on 0-10 scale immediately before and after the injection, and at 2-4 weeks and 6 months after the injection. Results: 100% immediate pain relief was considered a positive anesthetic response, while 50% pain relief at follow-up was considered positive. 14/34 (41.0%, 95% CI 26.4-57.8%) obtained 100% immediate relief. 8/14 (57.1%, 95% CI 32.6-78.6%) that had 100% initial relief reported 50% relief at 2-4 weeks, and 5/8 (62.5%, 95% CI 30.6-86.3%) had 50% relief at 6 months. Of the 6/14 (42.9%, 95% CI 21.4-67.4%) that had an initial 100% pain relief, but did not achieve 50% pain relief at 2 weeks, 0/6 (0%, 95% CI 0-39.0%) had 50% pain relief at 6 months. Of those with a negative initial block, only 3/20 (15%, 95% CI 5.2-36.0%) had 50% pain relief at 2 weeks or 6 months. Conclusions: This study illustrates a high negative predictive value of the immediate response at predicting pain relief at 2-4 weeks, but a much stronger positive predictive value of pain at 2-4 weeks for predicting continued pain relief at 6 months. Level of Evidence: Level II

Current Treatments for Coccydynia

Purpose of ReviewRefractory cases of coccydynia can be functionally debilitating. Here, we summarize the latest advances in interventional options for coccydynia.Recent FindingsThe literature on treatments of coccydynia is sparse, and mostly limited to low-quality studies. Although some of these studies have demonstrated benefit from various treatment options, the lack of high-quality, prospective, controlled trials limits the ability to draw conclusions about efficacy.SummaryConservative treatment remains the mainstay of coccydynia. In refractory cases, invasive treatments may be considered, although larger, randomized studies are needed to establish clear efficacy.

Poster 380 Immediate Relief After Sacroiliac Joint Injection as a Predictor of Subsequent Relief to Steroid at 2-4 Weeks

the immune system may play a role through humoral or cellmediated immunity. Symptomatic PND is rare, affecting 0.01% of cancer patients. Neurological symptoms are the initial manifestations of underlying malignancy in 70% of PND. Conclusions: In patients with myelitis of unknown etiology, physicians should consider PND as a differential and search for a source of underlying malignancy. Recognition and aggressive treatment of the malignancy, along with early rehabilitation can slow disease progression and improve functional outcomes. Level of Evidence: Level V

Ideal Cervical Epidural Injection Route: Interlaminar or Transforaminal

Cervical epidural steroid injections are commonly used to treat cervical radicular pain, but not without some controversy. Opinions differ about the relative safety and effectiveness of the two available routes, interlaminar verses transforaminal. The purpose of this review article is to compare the risks and risk reduction profiles associated with both cervical epidural routes, and to make practical recommendations based on the current literature.