Omar El Abd

Discography in practice: a clinical and historical review

Chronic low back pain is the most common cause of disability in individuals between the ages of 45 and 65. Given the variety of anatomic and pathophysiologic causes of persistent low back pain, it is a difficult diagnosis for clinicians to treat. Discography is a diagnostic option that may link a patient’s subjective complaints of spinal pain to symptomatic disk disease when non-invasive imaging, such as magnetic resonance imaging (MRI), does not find structural abnormalities. A controversial procedure, discography is only necessary to assess painful discs prior to surgical interventions. For accurate discogram interpretation an experienced spine interventionalist must be careful to exclude false positive results and be aware of the patient’s underlying psychological state. This literature review will discuss the following: anatomy and function of the spine and intervertebral disc, intervertebral disc degeneration and discogenic pain, history of discography, indications and contraindications, a description of the procedure, complications, and the current debate regarding its outcomes.

When should a cervical collar be used to treat neck pain

Neck pain is one of the most prevalent and costly health problems in the United States. It remains a complex, subjective experience with a variety of musculoskeletal causes. Although, cervical collars are a seemingly benign intervention, they can have adverse effects, especially when used for longer periods of time. It is feared that a long period of immobilization, can result in atrophy-related secondary damage. Many physicians cite anecdotal evidence of their clinical utility and soft cervical collars are often prescribed by convention for patients complaining of neck pain. The use of cervical collars to treat neck pain is an area of controversy. This review article examines the current evidence and studies related to recommending cervical collars for neck pain of a variety of etiologies.

Coccidioidomycosis Infection Presenting With Thoracic Spinal Pain

Thoracic pain that originates from thoracic spine pathology is uncommon, and it is reported to represent not more than 5% of all common spinal pain symptoms [1]. Presentations of thoracic spinal pain include “band-like” chest pain, focal pain in the mid back, and pain on deep breathing [1]. Given the paucity of primary thoracic spine pathologies, persistent thoracic pain should prompt consideration of serious conditions such as spinal infection; malignant neoplasm; traumatic or nontraumatic vertebral compression fractures; and extraspinal pathologies, such as rib fractures, peptic ulcer disease, pancreatitis, cholecystitis, pleuritis, and aortic aneurysms [1]. The incidence of infectious spondylodiskitis in developed countries is 4-24 per million each year [2]. Spondylodiskitis in adults is considered very rare; it usually follows surgical interventions or presents in cases of generalized septicemia [3]. In this report, we present a patient who described a new onset of thoracic pain that progressed without improvement, the evaluation that led to the diagnosis of coccidioidomycosis diskitis and vertebral osteomyelitis, and the course of treatment. We also discuss the diagnostic and therapeutic options and previous reports of this pathology.

The lateral atlanto-axial joint as a source of headache in congenital atlanto-occipital fusion.

El Abd OH, Rosenberg D, Gomba L, Isaac Z: The lateral atlanto–axial joint as a source of headache in congenital atlanto–occipital fusion. Am J Phys Med Rehabil 2008;87:232–237.A 47-yr-old woman presented with severe right-sided neck pain and headache, predominantly in the right-occipital region, for 3 yrs. The symptoms persisted despite using nonsteroidal antiinflammatory medications and undergoing physical therapy. The patients examination was unremarkable except for reduced neck motion and prominent right-occipital tenderness. Imaging showed congenital fusion of the atlanto–occipital joints bilaterally. A fluoroscopically guided diagnostic right-lateral atlanto–axial joint injection was positive. We are reporting the first case of clinically proven lateral atlanto–axial joint arthropathy with neck pain and headache in a patient with congenital atlanto–occipital joint fusion. Subsequently, the patient received a set of two therapeutic lateral atlanto–axial joint injections. She had remarkable improvement of her headache and neck pain. At 1-yr follow-up, the patient continued to have significant improvement of the right-sided neck pain and headache.

Poster 402 Comparison of Radiation Exposure Using Two Types of Shield Protection During Spinal Interventions

detection during needle positioning of transforaminal epidural steroid injections (TFESI) with dexamethasone and the occurrence of perineal pruritus. Design: A prospective, single-arm, observational epidemiological study. Setting: Spine center affiliated with a rehabilitation hospital. Participants: 150 consecutive subjects who underwent 284 TFESIs for management of radicular and axial spinal pain. Interventions: Cervical, lumbar and sacral TFESI with dexamethasone. Main Outcome Measures: Signs of vascular penetration during needle positioning at the neural foramen were observed using 4 different methods: the presence of blood at the needle hub after stylet removal (flash); blood aspiration; visualization of intravascular flow with contrast injection under live fluoroscopy; and visualization of intravascular flow using digital subtraction technology. Subsequently, the needle was repositioned and dexamethasone injection was performed after no sign of vascular penetration was noted. Within 5 minutes of the injection, the development of perineal pruritus was observed and correlated with any sign of vascular penetration during positioning. Results: Two hundred eighty four procedures were performed, 53 (18.66%) cervical, 144 (50.7%) lumbar and 87 (30.63%) sacral. Sixty eight procedures (23.94%) had signs of intravascular needle placement, and 216 procedures (76.06%) had no signs of vascular flow detection. For the subjects who had signs of vascular penetration during needle positioning, 10.29% had perineal pruritus, while for subjects who didn’t have any sign of vascular penetration only 1.39% had pruritus (P .0022) OR: 8.14 (CI: 2.04-32.45). Pruritus was observed in 2.08% of lumbar and 8.05% of sacral procedures OR 4.11 (CI: 1.03-16.34). In our sample no subjects who underwent cervical TFESI reported pruritis. Conclusions: The occurrence of signs of vascular penetration during needle introduction correlates with a higher chance of perineal pruritus after TFESI. This might be related to unrecognized intravascular injection leading to systemic absorption of dexamethasone.

Poster 401 Correlation Between Vascular Penetration During Needle Positioning and Perineal Pruritus in Transforaminal Epidural Injections With Dexamethasone

50Hz. Motor stimulation confirmed appropriate muscle twitch (2Hz). pRFA was performed at 42 degrees C for 120 seconds. 20 mg of triamcinolone acetate and 3mL of 1% lidocaine was then injected at both sites. Setting: Tertiary care VA hospital. Results or Clinical Course: The patient reported reduction in pain (90 mm to 20 mm on visual analog scale) for 12 days after procedure. He underwent 3 additional sessions, one month apart, with prolonged relief after each treatment. By the fourth procedure, he reported 90% pain relief for greater than 3 months. Discussion: Previous trials using pRFA for chronic shoulder pain have included treatment of the suprascapular nerve alone. This approach includes pRFA of both nerves as well as ultrasound guidance to improve chronic shoulder pain. Conclusions: pRFA of axillary and suprascapular nerves may offer improved pain relief in comparison to suprascapular technique alone. Further studies are indicated to compare differences between these two approaches.

Poster 400 Immediate and Acute Complications Following Transforaminal Epidural Steroid Injections With Dexamethasone

50Hz. Motor stimulation confirmed appropriate muscle twitch (2Hz). pRFA was performed at 42 degrees C for 120 seconds. 20 mg of triamcinolone acetate and 3mL of 1% lidocaine was then injected at both sites. Setting: Tertiary care VA hospital. Results or Clinical Course: The patient reported reduction in pain (90 mm to 20 mm on visual analog scale) for 12 days after procedure. He underwent 3 additional sessions, one month apart, with prolonged relief after each treatment. By the fourth procedure, he reported 90% pain relief for greater than 3 months. Discussion: Previous trials using pRFA for chronic shoulder pain have included treatment of the suprascapular nerve alone. This approach includes pRFA of both nerves as well as ultrasound guidance to improve chronic shoulder pain. Conclusions: pRFA of axillary and suprascapular nerves may offer improved pain relief in comparison to suprascapular technique alone. Further studies are indicated to compare differences between these two approaches.