Raj Mitra

Adverse Effects of Corticosteroids on Bone Metabolism: A Review

Glucocorticoid (GC) exposure is the most common etiology of drug‐induced (secondary) osteoporosis. Twenty percent of all cases of osteoporosis have been attributed to GC exposure. Significant risk factors for the development of fractures after GC exposure include age older than 65 years, prolonged GC exposure (>3 months), positive family history of osteoporosis, and low calcium intake. GCs are known to inhibit bone remodeling and to increase fracture risk. GC exposure alters the fragile balance between osteoclast and osteoblast activity in bone metabolism. GC stimulates osteoclast‐mediated bone resorption and reduces osteoblast‐mediated bone formation, which results in increased overall net bone resorption. Specifically, the 2 main effects of GCs on bone metabolism are (1) inducing apoptosis in osteoblasts and osteocytes, thereby decreasing bone formation, and (2) prolonging the lifespan of osteoclasts and increasing bone resorption. The risk of fracture decreases 3 months after cessation of GC therapy; thus, a 3‐month period may be ideal between GC exposures in patients at high risk for the development of osteoporosis. Patients managed with GCs who are at high risk for the development of secondary osteoporosis should have appropriate diagnostic testing; pre‐GC exposure medication management (ie, use of bisphosphonates, human parathyroid hormone); and a limitation of GC therapy, with a wait period of 3 months between GC exposures if possible.

Cervical Facet Joint Dysfunction: A Review

OBJECTIVE To review the relevant literature on cervical facet joint dysfunction and determine findings regarding its anatomy, etiology, prevalence, clinical features, diagnosis, and treatment. DATA SOURCES A computer-aided search of several databases was performed, including Medline (1966 to present), Ovid (1966 to present), and the Cochrane database (1993 to present). STUDY SELECTION Selected articles had the following criteria: (1) all articles analyzed cervical facet joint pain-anatomy, prevalence, etiology, diagnosis, treatment; (2) only full, published articles were studied, not abstracts; and (3) all articles were published in English. DATA EXTRACTION All articles were critically evaluated and included the following categories: randomized controlled trials, meta-analyses, uncontrolled clinical trials, uncontrolled comparison studies, nonquantitative systematic reviews, and literature-based reviews. DATA SYNTHESIS We examined 45 references that consisted of 44 journal articles and relevant sections from 1 textbook. Cervical facet joints have been well established in the literature as a common nociceptive pain generator, with an estimated prevalence that ranges from 25% to 66% of chronic axial neck pain. No studies have reported clinical examination findings that are diagnostic for cervical facet mediated pain. CONCLUSIONS Overall the literature provides very limited information regarding the treatment of this condition, with only radiofrequency neurotomy showing evidence of effectively reducing pain from cervical facet joint dysfunction.

Osteitis Condensans Ilii

Osteitis Condensans Ilii (OCI) is a benign cause of axial low back pain. Although no clear etiology has been identified, the prevailing theory is that mechanical strain affects the auricular portion of the ilium and causes premature arthritis. The location of the sclerosis has been traditionally confined to the ilium and may give the false impression of sacro-iliac joint involvement. Clinicians must be guided by history, radiographic findings, and laboratory studies in differentiating OCI with other disorders; furthermore additional causes of low back pain including metastatic disease and ankylosing spondylitis must be ruled out. Treatments for the condition are primarily conservative (therapies, non-steroidal anti-inflammatory medications, and steroid injections), with surgical resection being reserved for refractory cases.

Adjuvant Analgesics in Cancer Pain: A Review

Adjuvant analgesics (co-analgesics) are medications whose primary indication is the management of a medical condition with secondary effects of analgesia. Cancer pain is multifactorial and often involves inflammatory, nociceptive, and neuropathic pain subtypes. Adjuvant analgesics used in conjunction with opioids have been found to be beneficial in the management of many cancer pain syndromes; however, they are currently underutilized. Antidepressants, anticonvulsants, local anesthetics, topical agents, steroids, bisphosphonates, and calcitonin are all adjuvants which have been shown to be effective in the management of cancer pain syndromes. When utilizing analgesic adjuvants in the treatment of cancer pain, providers must take into account the particular side effect profile of the medication. Ideally, adjuvant analgesics will be initiated at lower dosages and escalated as tolerated until efficacy or adverse effects are encountered.

Conservative Management of Perineural Cysts

Study Design. A case series and literature review are presented. Objective. To review relevant data for the management of perineural cysts, and present a case series of 2 patient with symptomatic perineural cysts treated by steroid therapy. Summary of Background Data. Perineural cysts are usually an incidental finding, but rarely may cause mechanical nerve root compression. Surgical treatments for perineural cysts are complicated by postoperative pseudomeningocoele and intracranial hypotension, and reoccurrence of the cyst. There are no reported nonsurgical treatments for perineural cysts. Methods. We present a case series symptomatic perineural cysts. Results. Patients with lumbar and cervical perineural cysts were treated successfully with oral and epidural steroid therapy. Conclusion. Steroid therapy may offer a nonsurgical alternative for the treatment of symptomatic perineural cysts.

Trends in Ambulatory Physician Opioid Prescription in the United States, 1997-2009

To describe the changing practice pattern of opioid medication prescription by health care providers and its relationship to shifts in the incidence of back pain, demographics, and health care access.

Functional assessment of the acute local and distal transplantation of human neural stem cells after spinal cord injury

BACKGROUND CONTEXT Spinal cord injury can lead to severe functional impairments secondary to axonal damage, neuronal loss, and demyelination. The injured spinal cord has limited regrowth of damaged axons. Treatment remains controversial, given inconsistent functional improvement. Previous studies demonstrated functional recovery of rats with spinal cord contusion after transplantation of rat fetal neural stem cells. PURPOSE We hypothesized that acute transplantation of human fetal neural stem cells (hNSCs) both locally at the injury site as well as distally via intrathecal injection would lead to improved functional recovery compared with controls. STUDY DESIGN/SETTING Twenty-four adult female Long-Evans hooded rats were randomized into four groups with six animals in each group: two experimental and two control. Functional assessment was measured after injury and then weekly for 6 weeks using the Basso, Beattie, and Bresnahan Locomotor Rating Score. Data were analyzed using two-sample t test and linear mixed-effects model analysis. METHODS Posterior exposure and laminectomy at T10 level was used. Moderate spinal cord contusion was induced by the Multicenter Animal Spinal Cord Injury Study Impactor with 10-g weight dropped from a height of 25 mm. Experimental subjects received either a subdural injection of hNSCs locally at the injury site or intrathecal injection of hNSCs through a separate distal laminotomy. Controls received control media injection either locally or distally. RESULTS Statistically significant functional improvement was observed in local or distal hNSCs subjects versus controls (p=.034 and 0.016, respectively). No significant difference was seen between local or distal hNSC subjects (p=.66). CONCLUSIONS Acute local and distal transplantation of hNSCs into the contused spinal cord led to significant functional recovery in the rat model. No statistical difference was found between the two techniques.

Facet Pain in Thoracic Compression Fractures

OBJECTIVE To determine if thoracic facet joints may be a significant secondary pain generator in patients with compression fractures. Traditionally, pain from vertebral compression fractures has been attributed to vertebral body itself. Compression fractures have been shown to increase thoracic kyphosis and thereby increase the thoracic flexion moment; these changes eventually increase the shear stress on the posterior elements. DESIGN We present a small case series of patients with thoracic compression fractures managed with intra-articular facet injections. SETTING Tertiary care academic medical center. PARTICIPANTS Two patients with thoracic compression fractures. INTERVENTIONS The subjects received fluoroscopically guided thoracic facet steroid injections for pain management. MAIN OUTCOME Change in verbal analog pain score. RESULTS Patients with thoracic compression fractures received significant long-lasting relief after receiving fluoroscopically guided intra-articular injections. CONCLUSION Facet joints may be abnormally stressed due to the increasing thoracic flexion moment in anterior compression fractures, which may serve as a secondary pain generator; intra-articular facet blocks may be an alternative to vertebroplasty.

Bertolotti's Syndrome: A Case Report

Study Design:  A case report and literature review is presented.

Pulmonary Cement Embolism after Kyphoplasty

Abstract:  An 80‐year‐old female with a history of osteoporosis was evaluated for sudden onset axial low back pain with bilateral lower extremity weakness, hyperreflexia, pain, urinary retention, and decreased rectal tone. Computed tomography of the lumbar spine revealed L1 compression fracture, retropulsion of bone causing spinal canal compromise with associated severe central canal stenosis. Following cement kyphoplasty of L1 with polymethyl methacrylate, the patient developed tachycardia and dyspnea. Chest radiograph and computed tomographic pulmonary angiogram revealed a large collection of hyperdense material within the right lower lobe pulmonary artery, consistent with pulmonary cement emboli. Management and imaging are discussed.