Michael J. DePalma

Multivariable Analyses of the Relationships Between Age, Gender, and Body Mass Index and the Source of Chronic Low Back Pain

OBJECTIVE To examine the combined relationships between age, gender, and body mass index (BMI) and the specific source of chronic low back pain. DESIGN Retrospective chart review. SETTING University spine center. PATIENTS Charts from 378 cases from 358 consecutive patients were reviewed and 157 independent cases from 153 patients who underwent definitive diagnostic injections were analyzed. INTERVENTIONS Discography, dual diagnostic facet joint blocks, sacroiliac joint injections, anesthetic interspinous ligaments/opposing spinous processes/posterior fusion hardware injections, percutaneous augmentation. OUTCOME MEASURES Chronic low back pain source was the primary outcome variable. Predictor variables included age at initial presentation, gender, and BMI. RESULTS Age, gender, and BMI were each significantly associated with the source of chronic low back pain, after controlling for the effects of each other. Increases in age were associated with significant decreases in the odds of internal disc disruption (IDD) vs facet joint pain (FJP), sacroiliac joint pain (SIJP), and other sources and decreases in the odds of FJP and SIJP vs other sources. Being female was associated with significant increases in the odds of SIJP vs IDD, FJP, and other sources. Increased BMI was associated with significant increases in the odds of FJP vs SIJP. CONCLUSIONS These findings suggest a significant relationship among gender, age, and BMI and structural causes of chronic low back pain. Lumbar IDD is more prevalent in young males while FJP is more prevalent in females with increased BMI. Female gender and low BMI are associated with SIJP.

Efficacy and safety of percutaneous sacroplasty for painful osteoporotic sacral insufficiency fractures: a prospective, multicenter trial.

Study Design. A prospective observational cohort study of consecutive osteoporotic patients with sacral insufficiency fractures (SIFs). Objective. Assess the safety and efficacy of sacroplasty in treating osteoporotic SIFs. Summary of Background Data. SIFs can cause low back pain in osteoporotic patients. Symptomatic improvement may require up to 12 months. Treatment includes limited weight-bearing and bed rest, oral analgesics, and sacral corsets. Significant mortality and morbidity are associated with pelvic insufficiency fractures. Percutaneous sacroplasty is an alternative treatment for SIF patients, and initial reports have documented its safe and effective performance. Yet, follow-up intervals have been short, and study cohorts small precluding definitive assessment of sacroplasty’s safety and efficacy. Methods. Baseline Visual Analogue Scale (VAS), analgesic usage, and duration of symptoms were recorded. Subsequent VAS ratings were assessed at 30 minutes and at 2, 4, 12, 24, and 52 weeks postprocedure. Analgesic usage and patient satisfaction were assessed at final follow-up. Each procedure was performed under intravenous conscious sedation using fluoroscopy. Two bone trochars were inserted between the sacral foramen and sacroiliac joint through which 2 to 3 mL of polymethylmethacrylate was injected. Results. Thirty-seven patients, 27 females, were treated. Mean age was 76.6 years, and mean symptom duration was 34.4 days. All patients were available at each follow-up interval except 1 patient who died due to unrelated pulmonary disease before the 4-week follow-up. The mean VAS score at baseline was 7.7 and 3.2 within 30 minutes, and 2.1 at 2, 1.7 at 4, 1.3 at 12, 1.0 at 24, and 0.7 at 52 weeks postprocedure. Improvement at each interval and overall was statistically significant using the Wilcoxon Rank Sum Test. One case of transient S1 radiculitis was encountered. Conclusions. Sacroplasty appears to be a safe and effective treatment for painful SIF. The rate of improvement is rapid and sustained through 1 year.

Interspinous bursitis in an athlete

We present a case of L2/3 interspinous bursitis treated with extraspinal injections. No previous investigations have used fluoroscopically guided spinal injections to confirm the clinical relevance of the MRI features of this type of bursae. Autopsy studies have revealed an increased incidence of interspinous lumbar bursal cavities with advancing age. Afflicted patients present with localised, midline lower lumbar pain exacerbated by extension. In young athletes these symptoms can mimic spondylolysis. MRI is useful in detecting soft-tissue injury of the posterior elements. Fluoroscopically guided diagnostic and therapeutic extraspinal injections can be used for confirmation and treatment of pain from such bursae.

Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fractures in the Nonagenarians : A Prospective Study Evaluating Pain Reduction and New Symptomatic Fracture Rate

Study Design. A prospective observational cohort study of consecutive osteoporotic vertebral compression fractures (VCFs) in ≥90-year-old patients evaluated at a multidisciplinary, university spine center. Objective. Assess efficacy, safety, and new fracture occurrence after percutaneous vertebroplasty (PV) in a large uncontrolled cohort of ultra elderly VCF patients. Summary of Background Data. VCFs are associated with increased morbidity and mortality. Percutaneous injection of polymethylmethacrylate into the fractured vertebral body, vertebroplasty, has been extensively performed as an effective minimally-invasive treatment option for VCF patients. The patient sample included consecutive, osteoporotic patients with symptomatic VCFs electing to enter the study. Methods. Baseline visual analogue scale rating, analgesic usage, duration of symptoms. Subsequent VAS ratings, analgesic utilization, and new fractures were assessed within 30 minutes after the procedure, at 2 weeks, 1 month, 3 months, 6 months, 1 year, and 2 years postprocedure. Outcome measures: Visual Analogue Scale score, analgesic utilization, patient satisfaction, cement extravasation, and new fractures. Results. A total of 123 (74% female) underwent PV for 163 VCFs. Eleven patients did not complete final follow-up at 2 years due to death unrelated to the PV procedure. The mean VAS score was 7.6 at baseline and 3.1 at 30 minutes after the procedure, and 2.3, 1.2, 1.1, 0.9, 0.8, and 0.5 at 2 weeks, 1 month, 3 months, 6 months, 1 year, and 2 years, respectively. Improvement over time was statistically significant using repeated measures analysis of variance (P < 0.05). No complications were encountered during the follow-up intervals. Thirteen new fractures were observed (10.6%) at a mean 20.8 weeks (1–52 weeks) after PV with 6 new fractures (4.9%) involving an adjacent level in 5 patients (4.1%). Conclusion. Vertebroplasty for VCFs in the very elderly appears effective and safe without increased risk of adjacent level fracture.

Structural Etiology of Chronic Low Back Pain Due to Motor Vehicle Collision

OBJECTIVE To estimate prevalence rates of discogenic, facet, and sacroiliac joint pain, and describe clinical features of chronic low back pain patients whose symptoms were initiated by motor vehicle collisions. DESIGN Retrospective chart review. SETTING Academic spine center. PATIENTS Twenty-seven motor vehicle collision-induced chronic low back pain patients were included after undergoing diagnostic procedures. INTERVENTIONS Lumbar provocation discography, dual diagnostic facet joint blocks, and intra-articular sacroiliac joint injections. METHODS Enrolled patients underwent diagnostic procedures based on clinical presentation until the pain source was identified. The prevalence of each source of low back pain was estimated. Clinical, categorical, and continuous characteristics within the source groups were calculated with SAS v.9.2 (SAS Institute Inc., Cary, NC). OUTCOME MEASURES Etiology and prevalence were analyzed for each diagnosis group. RESULTS Of the 27 patients, 15/27 (56%) were diagnosed with discogenic pain, 7/27 (26%) with sacroiliac joint pain, and 5/27 (19%) with facet joint pain. Seventy-eight percent were female. Mean age was 42.5 years (standard deviation = 10.4) with median duration of symptoms of 24 months (interquartile range = 6-48). CONCLUSIONS Our study is the first to demonstrate that diagnostic spinal injections can identify particular spinal structures, namely the intervertebral disc, facet joint, and sacroiliac joint, as the specific source of chronic low back pain due to inciting motor vehicle collisions. The most common source of motor vehicle collision-induced chronic low back pain appears to be the disc followed by the sacroiliac and facet joints.

Epidemiology/pathophysiologyOsteoarthritis supplementSpine Osteoarthritis

Osteoarthritis of the spine develops as a consequence of the natural aging process and is associated with significant morbidity and health care expenditures. Effective diagnosis and treatment of the resultant pathologic conditions can be clinically challenging. Recent evidence has emerged to aid the investigating clinician in formulating an accurate diagnosis and in implementing a successful treatment algorithm. This article details the degenerative cascade that results in the osteoarthritic spine, reviews prevalence data for common painful spinal disorders, and discusses evidence‐based treatment options for management of zygapophysial and sacroiliac joint arthrosis.

Comparison of Four Different Analgesic Discogram Protocols Comparing the Incidence of Reported Pain Relief Following Local Anesthetic Injection into Concordantly Painful Lumbar Intervertebral Discs

OBJECTIVE To compare the incidence of pain relief following injection of local anesthetic (LA) into lumbar discs that caused concordant pain during provocation testing. DESIGN Prospective collected data review from two centers and compare with published results. OUTCOME MEASURES We compared subjective reported pain relief following provocative testing using the following protocols at three separate facilities: 23 patients undergoing routine provocative discography using contrast alone (PD); 47 patients undergoing provocative discography performed using an equal combination of LA and contrast (CPD); 120 patients injected with LA following routine PD (ADPD); 33 patients undergoing stand-alone analgesic discography (SAAD); and 28 patients injected with LA through a catheter (FAD) placed during provocative discogaphy testing. RESULTS Pressure-controlled PD showed a positive response rate of 34% per disc in patients with a clinical diagnosis of discogenic pain. None of the PD group without LA had pain relief and less than 10% of the CPD group reported pain relief. Forty percent of the SAAD group with positive pain reproduction reported ≥50% relief and 20% reporting ≥80% relief. Forty-six percent of the ADPD group reported ≥50% relief and 30% reporting ≥80% relief. The FAD group had a greater 80% patients reporting ≥50% pain relief although fewer 26% reporting more convincing ≥80% relief. CONCLUSIONS If the criterion standard to confirm painful annular tears is concordant pain provocation and 80% or greater pain relief following LA injected into lumbar discs, the SAAD, ADPD, and FAD protocols show statistically similar 20% to 30% prevelance.

Cellular Supplementation Technologies for Painful Spine Disorders

Low back pain affects more than 80% of adults. A proportion of these adults develops chronic low back pain (CLBP) and becomes disabled by their condition. CLBP is expensive to diagnose and treat and in terms of associated loss of productivity in the work place setting by affected individuals. Although challenging, the source of CLBP can be identified. Contemporary literature contains several studies that have established prevalence estimates for various structural sources of CLBP. In young adults, the intervertebral disk is a common source of CLBP, once it incurs annular injury that heals incompletely. Effective treatment for painful disks currently is an unmet clinical need. In older adults, the facet and sacroiliac joints are more commonly responsible for CLBP. Although certain minimally invasive techniques do exist for these painful joints, an effective restorative intervention has yet to be established. Annular injury precipitates a physiologic response that can lead to a catabolic state within the disk that impairs disk restoration. Cell loss is a feature of this process as well as the pathophysiology associated with painful facet and sacroiliac joints. Cellular supplementation is an attractive treatment strategy to initiate the repair of an injured lumbosacral structure. The introduction of exogenous cells may lead to increased extracelluar matrix production and reduced pain and disability in diskogenic CLBP. Compelling data in animal studies have been produced, stimulating Food and Drug Administration−regulated trials in humans. Numerous questions remain regarding cell viability and sufficient native nutrients to support these cells. Clinical research protocols have focused predominantly on diskogenic CLBP, and very few have addressed painful facet and/or sacroiliac joints.

Diagnostic Nihilism Toward Low Back Pain: What Once Was Accepted, Should No Longer Be

A postulate that low back pain cannot be diagnosed was published 50 years ago ⇓. This assumption was perpetuated for nearly 3 decades ⇓ before more rigorous studies identified the sources of low back pain (LBP) ⇓. The medical communitys initial impression that LBP cannot be determined is not correct. Published prevalence estimates with reasonable confidence intervals from three different continents have presented accurate accounts of different structural sources of LBP. The confidence intervals of these published prevalence estimates overlap. Indeed it is now factual that approximately 40%, 30%, and 20% of adults with chronic LBP are suffering from disc, facet joint, and sacroiliac joint related pain, respectively. These …

Does BMI weigh in on spine matters

Dear Editor, We thank Drs. Alexiou and Voulgaris for responding to our article entitled, “Multivariable analyses of the relationships between age, gender, and body mass index and the source of chronic low back pain.” We appreciate the opportunity to reply. Alexiou et al. are in the process of conducting a pilot study examining the association between body mass index (BMI), lumbar disc degeneration, and clinical outcome in patients undergoing lumbar disc herniation surgery. I commend Alexiou and his cohorts for applying their investigation to symptomatic patients seeking treatment. However, neither the clinical presentation of their surgical patients—e.g., axial low back only …