Michael B. Furman

Injectate volumes needed to reach specific landmarks in lumbar transforaminal epidural injections.

To identify the volumes of contrast material needed to reach specific landmarks during lumbar transforaminal epidural injections (L‐TFEIs).

Should Antiplatelet Medications Be Held Before Cervical Epidural Injections

Christopher T. Plastaras, MD Department of Physical Medicine & Rehabilitation, Perelman School of Medicine Penn Spine Center, University of Pennsylvania, Philadelphia, PA Disclosures related to this publication: consulting fee/honorarium, National Council on Strength and Fitness (NCSF), Elite Rehabilitation Solutions, LLC, CMEInfo, Pennsylvania Neurosurgical Society Speaker, AAPM&R, North American Spine Society; support for travel to meetings for study or other purposes, AAPM&R, North American Spine Society; other, TLG Associates Disclosures outside this publication: board membership, NCSF (money to author); consultancy, TLG Associates; grants/grants pending, ISIS; payment for lectures/service on speakers bureaus, Elite Rehabilitation Solutions, LLC; patents/royalties, ownership of copyright, RICPLAS computer software for outpatient musculoskeletal pain practice; travel/accommodations/meeting expenses unrelated to activities listed, NCSF, Elite Rehabilitation Solutions, LLC, CMEInfo, Pennsylvania Neurosurgical Society, AAPM&R, North American Spine Society, 18th European congress of Physical & Rehabilitation Medicine: Science & Art in Physical & Rehabilitation Medicine; other, TLG Associates (money to author) CASE SCENARIO

Provocative cervical discographic symptom mapping

Abstract Purpose of study: This was a prospective visual and statistical descriptive study of pain provocation of a cohort of subjects undergoing cervical discography. In a prospective study assessing 10 subjects, Schellhas compared cervical discography with magnetic resonance imaging. Within that study he reported on the distribution of pain for the C3–4 to C6–7 levels. Four years later, Grubb reported on his 12-year experience using cervical discography. The results concerning the regions of provoked pain by specific disc levels raised many interesting questions. When there is chest pain, is the C6–7 disc the only level implicated? Does head or facial pain emanate only from the C2–3 or C3–4 discs? Does cervical discogenic pain equally refer pain unilaterally as it does bilaterally? The objective of this study was to answer the aforementioned questions by formally mapping concordant pain referral patterns provoked during cervical discography. Methods used: Prospective multicenter design in which pain referral maps were generated of each disc level from patients undergoing a minimum of two-level cervical discography. If concordant pain was reproduced in a morphologically abnormal disc, the subject immediately completed a pain diagram. An independent observer interviewed the subject and recorded the location of provoked symptoms. Visual data were compiled using a body sector bit map, which consisted of 48 clinically relevant bodies. Visual maps with graduated color codes and frequencies of symptom location at each cervical disk level were generated. of findings: A total of 101 symptom provocation maps were recorded during cervical discography on 41 subjects. There were 10 at C2–3, 19 at C3–4, 27 at C4–5, 27 at C5–6, 16 at C6–7 and 2 at C7–T1. Predominantly unilateral symptoms were provoked just as often as bilateral symptoms. C2–3 discography provoked pain in the posterior neck 90% and suboccipital area 60% of the time. C3–4 discography provoked posterior neck pain 90% of the time, posterior inferior neck pain 79% of the time and suboccipital pain 26% of the time. C4–5 discography provoked pain in the face, anterior neck and chest; pain was provoked in each location 15% of the time. C5–6 discography provoked pain in the posterior neck (74%) and chest (19%). C6–7 provocation never resulted in anterior chest wall pain. Relationship between findings and existing knowledge: Our findings corroborated those reported by Grubb. Cervical discography provokes pain unilaterally just as often as Grubb reported that only C2–3 or C3–4 refers pain to head whereas Schellhas found that the C3–4 through C5–6 discs levels can refer pain to the head. In contrast, we observed that the C2–3, C3–4 and C4–5 discs provoked pain in the head. Interestingly the results of chest pain symptom reproduction were quite different than reported by Grubb and more consistent with that of Schellhas. We found that mid-cervical levels (C4–5 and C5–6) provoked pain in the chest, whereas the C6–7 disc provoked pain only in the interscapular, periscapular and upper arm regions. Finally, when upper extremity symptoms are described, the potentially involved disc levels include C3–4 through C6–7, which does not correlate with the results obtained from either Grubb or Schellhas. Overall significance of findings: The results of this study allow the spine clinician to make accurate assumptions about probable disc level involvement by considering the location of symptom manifestation. For example, the patient who describes only upper neck and occipital pain requires at maximum a four-level discogram; C2–3, C3–4, C4–5 and control level. Disclosures: No disclosures. Conflict of interest: No conflicts.

Single Versus Two-Level Transforaminal Epidural Steroid Injection for Treating Lumbosacral Radicular Pain: What is the Evidence?

M.S. is a 58-year-old man presenting for evaluation of a 12-week history of low back and right leg pain radiating to the right buttocks, groin, anterolateral thigh, posterolateral calf, lateral ankle, and dorsal foot with paresthesias. His physical examination demonstrates that a right straight leg raise at 50 reproduces concordant right lower limb symptoms. Results of a hip examination are negative, including pain-free full range of motion. Findings of a sensory and motor examination are normal, and the patient has slightly diminished, symmetrical patellar and Achilles reflexes bilaterally. A recent lumbar magnetic resonance imaging (MRI) study demonstrates multilevel degenerative abnormalities, including mild to moderate foraminal stenosis at L4-L5 and L5-S1 bilaterally and a right paracentral disk protrusion at L5-S1 that is mildly compressing the right S1 nerve. Electromyography (EMG) of the right lower extremity was normal with no objective evidence of radiculopathy or neuropathy. After a trial of physical therapy and oral anti-inflammatory medications, the patient underwent an L5-S1 interlaminar epidural steroid injection (ESI) that provided 85% improvement for 4-5 days. The patient is frustrated and has requested one more injection before considering surgery. Drs Michael B. Furman and Nicholas H. Weber will advocate for a 2-level transforaminal (TF) ESI (TFESI), whereas Dr Steven P. Cohen suggests that a 1-level TFESI is sufficient to produce a therapeutic effect.

Do physiatric procedures represent a value or liability

David J. Kennedy, MD Department of Orthopaedics, Stanford University, 450 Broadway St, MC 6342, Redwood City, CA 94063. Address correspondence to: D.J.K.; e-mail:djkenned@ stanford.edu Disclosure: nothing to disclose than 10,000 physicians having ever been board certified and only approximately 350-400 new certificates issues annually. Despite being a relatively small field, PMR this leads to 2 fundamental issues:

Induced lumbosacral radicular symptom referral patterns: a descriptive study

BACKGROUND CONTEXTnLumbosacral radicular symptoms are commonly evaluated in clinical practice. Level-specific diagnosis is crucial for management. Clinical decisions are often made by correlating a patients symptom distribution and imaging with sensory dermatomal maps. It is common for patients to describe non-dermatomal symptom patterns and for imaging to demonstrate pathology at levels not predicted by a dermatomal map. These observations suggest that the referred symptom distribution from lumbosacral nerve root provocation is different from dermatomal maps. This phenomenon has been demonstrated in the cervical spine but not in the lumbosacral spine.nnnPURPOSEnThe objective of this study was to characterize potential lumbosacral radicular symptom referral patterns induced during transforaminal epidural injections.nnnSTUDY DESIGN/SETTINGnThis is an observational descriptive study.nnnPATIENT SAMPLEnThe patient sample included 71 consecutive patients with lumbosacral radicular pain undergoing lumbosacral transforaminal epidural injections at an outpatient interventional spine practice.nnnOUTCOME MEASURESnEach subject drew the location of provoked lumbosacral radicular symptoms on a pain diagram.nnnMATERIALS AND METHODSnSeventy-one consecutive patients undergoing 125 fluoroscopically guided lumbosacral transforaminal epidural injections at an outpatient interventional spine practice were included in the study. The described location of provoked symptoms was recorded (1) after final needle positioning, (2) after injection of up to 0.5u2009mL of contrast solution, and (3) after injection of up to a 1u2009mL test dose of 1% lidocaine. Each subject drew the location of provoked symptoms on a diagram. The provoked symptom diagrams for each lumbosacral segmental level were combined to create composite nerve root, level-specific, symptom referral pattern maps.nnnRESULTSnOf the 125 injections, 87 provoked referred symptoms and were included in the analysis. Thirty-eight injections did not provoke referred pain symptoms and were excluded from further analysis. Four nerve roots were tested at L1 and eight were tested at L2. Because of the small number of subjects, composite diagrams and statistical analysis were not completed for these levels. Eleven nerve roots were analyzed at L3, 28 at L4, 34 at L5, and 11 at S1. Composite symptom referral pattern maps were created for levels L3, L4, L5, and S1. Although the symptom distribution occasionally followed the expected dermatomal maps, most often the referral was outside of the patterns expected for each level. The most common symptom referral pattern for levels L3-S1 was the buttock, the posterior thigh, and the posterior calf.nnnCONCLUSIONSnThe level-specific provoked symptom distribution during lumbosacral transforaminal epidural injections is frequently different from that predicted by classic lumbosacral dermatomal maps. Referred pain to the buttock, the posterior thigh, or the posterior calf may come from L3, L4, L5, or S1 nerve root segmental irritation.

Lumbar Sympathetic Block

Sympathetic nerve blocks are used to help with the diagnosis and treatment of sympathetically maintained pain. The lumbar sympathetic chain typically overlies the anterolateral aspect of the first through fourth lumbar vertebrae. The axons of the lumbar sympathetic preganglionic neurons exit the spinal cord through the ventral roots of the first four lumbar spinal nerves and send fibers through the white rami communicantes to the corresponding lumbar sympathetic ganglia. Postganglionic fibers then exit the chain to join a vascular plexus or the spinal nerves via the gray rami communicantes. The largest portion of lumbar sympathetic ganglia is located in the area of the second and third lumbar vertebrae. Therefore, a single-level block along the lower third of L2 or the upper third of L3 is usually sufficient as long as there is adequate medication spread. This chapter describes an injection at the L3 level.

Chapter 16 – Lumbar Sympathetic Block

Sympathetic nerve blocks are used to help with the diagnosis and treatment of sympathetically maintained pain. The lumbar sympathetic chain typically overlies the anterolateral aspect of the first through fourth lumbar vertebrae. The axons of the lumbar sympathetic preganglionic neurons exit the spinal cord through the ventral roots of the first four lumbar spinal nerves and send fibers through the white rami communicantes to the corresponding lumbar sympathetic ganglia. Postganglionic fibers then exit the chain to join a vascular plexus or the spinal nerves via the gray rami communicantes. The largest portion of lumbar sympathetic ganglia is located in the area of the second and third lumbar vertebrae. Therefore, a single-level block along the lower third of L2 or the upper third of L3 is usually sufficient as long as there is adequate medication spread. This chapter describes an injection at the L3 level.

On Contrast Dispersal Patterns as a Predictor of Clinical Outcome With Transforaminal Epidural Steroid Injection For Lumbar Radiculopathy

Paidin et al [1] have identified 2 important clinical questions regarding transforaminal epidural steroid injections (TF-ESI) in the management of radicular pain: (1) do TF-ESI contrast patterns correlate with clinical outcomes, and (2) does the degree of neural compression predict the anticipated contrast pattern and associated clinical outcome. If so, this information could greatly contribute to improving clinical course and associated quality of life for our patients. We could potentially extrapolate from these data support for the theory that repositioning our needle tip to achieve an improved contrast pattern can result in improved clinical patient outcomes. The researchers have taken on a difficult task. They have attempted to answer both questions using limited retrospective data. Retrospective studies themselves can be difficult to interpret because they can be prone to confounding and bias errors, and many variables may not be controlled. Prospective randomized control trials have not investigated the role of contrast patterns in determining patient outcomes. It is likely that, because of so many other important issues, such as volume of injectate, particulate versus nonor lowparticulate steroid, interlaminar versus transforaminal, and so forth, formally assessing contrast patterns has unfortunately not yet garnered much attention. Although these 2 questions do have significant clinical implications, the limitations created by the data, analysis and study design unfortunately do not allow the researchers to definitively evaluate them, which suggests that further study should be considered. Contrast patterns represent a 3-dimensional volume that surrounds specific anatomic structures. The researchers use a 2-dimensional analysis of anteroposterior (AP) contrast patterns based on a study by Pfirrmann et al [2]. Although there are limited options for grading contrast patterns, the Pfirrmann system itself has flaws; it relates the contrast pattern to the “nerve root sheath” itself, with type 1 presumed to be within it, type 2 presumably surrounding it, and type 3 being cloudlike and not identifying the “nerve root” at all [2]. Without multiplanar imaging, including a lateral view, it is difficult for the reader to determine exactly where the contrast extends, that is, dorsal, middle, or ventral in the canal or foramen. There is still controversy about whether one needs to treat the area of compression and/or abutment versus simply the involved dorsal root ganglia (DRG). An ideal grading system would utilize a 3-dimensional view and actually be related to a true anatomic location in relation to the neural structure being treated, such as the medial epidural space, disk-nerve root interface, nerve root sheath, DRG (intraforamen), or lateral exiting spinal nerve. To be more clinically relevant, the 3 “types” of contrast patterns should ideally be evaluated relative to not only the “nerve root sheath” but also to the above surrounding anatomy [3-5]. The analysis by Paidin et al is limited by the available retrospective imaging and NRPS ata [1]. Within their chosen grading system, contrast patterns 1 and 3 had both statistically cceptable decreases in mean Numeric Pain Rating Scale (NPRS) and a positive correlation ith outcome. The contrast pattern group 2 (contrast surrounds the nerve root with the ppearance of a filling defect) had a small total number (N), a statistically insufficient mean RPS decrease, as well as negative outcomes. In the future, adequately powered studies may ndeed support such conclusions. The analysis of compression grade effect on outcomes is lso not ideal. Because the retrospective analysis was limited in number, it is difficult to