Ray Baker

Cervical transforaminal injection of corticosteroids into a radicular artery: a possible mechanism for spinal cord injury.

Spinal cord injury has been recognized as a complication of cervical transforaminal injections, but the mechanism of injury is uncertain. In the course of a transforaminal injection, an observation was made after the initial injection of contrast medium. The contrast medium filled a radicular artery that passed to the spinal cord. The procedure was summarily abandoned, and the patient suffered no ill effects. This case demonstrates that despite using careful and accurate technique, it is possible for material to be injected into a radicular artery. Consequently, inadvertent injection of corticosteroids into a radicular artery may be the mechanism for spinal cord injury following transforaminal injections. This observation warns operators to always perform a test injection of contrast medium, and carefully check for arterial filling using real-time fluoroscopy with digital subtraction.

Safeguards to Prevent Neurologic Complications after Epidural Steroid Injections: Consensus Opinions from a Multidisciplinary Working Group and National Organizations

Background: Epidural corticosteroid injections are a common treatment for radicular pain caused by intervertebral disc herniations, spinal stenosis, and other disorders. Although rare, catastrophic neurologic injuries, including stroke and spinal cord injury, have occurred with these injections. Methods: A collaboration was undertaken between the U.S. Food and Drug Administration Safe Use Initiative, an expert multidisciplinary working group, and 13 specialty stakeholder societies. The goal of this collaboration was to review the existing evidence regarding neurologic complications associated with epidural corticosteroid injections and produce consensus procedural clinical considerations aimed at enhancing the safety of these injections. U.S. Food and Drug Administration Safe Use Initiative representatives helped convene and facilitate meetings without actively participating in the deliberations or decision-making process. Results: Seventeen clinical considerations aimed at improving safety were produced by the stakeholder societies. Specific clinical considerations for performing transforaminal and interlaminar injections, including the use of nonparticulate steroid, anatomic considerations, and use of radiographic guidance are given along with the existing scientific evidence for each clinical consideration. Conclusion: Adherence to specific recommended practices when performing epidural corticosteroid injections should lead to a reduction in the incidence of neurologic injuries.

Evidence-informed management of chronic low back pain with intradiscal electrothermal therapy.

The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Evidence-informed management of chronic low back pain with minimally invasive nuclear decompression

The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

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.

Use of Spinal Injections for Low Back Pain

Use of Spinal Injections for Low Back Pain To the Editor Dr Staal and colleagues1 highlighted the overuse of spinal injections for back pain and pointed out “heterogeneity regarding purpose and content of injection therapy has to be considered when evaluating studies of the effects of injection therapy in patients with low back pain.” Unfortunately, they ignored this heterogeneity in concluding, “... injection therapy for low back pain and sciatica can be regarded as having limited clinical benefit.” Back pain is a symptom, not a diagnosis. Predictably, studies of treatments for nonspecific back pain yield poor results, whereas studies of treatments for a specific diagnosis demonstrate high success rates.2 Imagine a systematic review of prescription medications to treat cough. Pooled data from heterogeneous groups (bacterial pneumonia, viral bronchitis, chemical pneumonitis, asthma) might demonstrate poor overall effects. Should antibiotics for bacterial pneumonia then be abandoned? In addition, the authors make a number of inaccurate statements. In their 2008 Cochrane review,3 the Viewpoint authors excluded studies of patients with radiculopathy because of disk herniation. However, they cited this same review in their Viewpoint as evidence that epidural injections are not indicated for radicular pain. The authors also claimed that among published international guidelines “... only 1 guideline, from Belgium, recommends injection therapy.” In fact, the review they cited references multiple guidelines recommending injection therapy.4 The authors used a review by Pinto et al5 to suggest a lack of value for all spinal injections when these authors actually found high-quality evidence “for the short-term effect of epidural corticosteroid injections ... for leg pain, back pain, and disability outcomes.” Spinal injections are useful when specific injections are targeted toward specific disorders. Using epidural steroid injections to treat radiculopathy from disk herniation and radiofrequency neurotomy to treat confirmed facet joint pain are 2 examples in which targeted spinal injections have proven benefits for patients with specific anatomic diagnoses.2 Like Staal and colleagues, we decry the overuse of spinal injections and agree that injections should be reserved for those patients most likely to derive benefit. We welcome an evidencebased review of target-specific treatments.

International Spine Intervention Society (ISIS) Presidential Address

It is fitting, at this 20th Annual Scientific Meeting of our society, that we reflect on how far we have come. Our founding fathers, Charles Aprill, Nikolai Bogduk, and Rick Derby, probably never imagined that their small study group formed in San Antonio, Texas, in 1989 out of a handful of self-proclaimed “Needle Jockeys” would become the ISIS of today. And yet, reading from the 1991 ISIS Statement of Purpose, I was struck by how true we have remained to their original mission and purpose. I quote, “ISIS is an association of physicians interested in the development, implementation and standardization of percutaneous techniques for the precision diagnosis of spinal pain. By constituting a forum for the exchange of ideas, by undertaking research, and by holding public lectures, the association seeks to consolidate developments in diagnostic needle procedures, to identify and resolve persisting controversies, to publicize developments, and to recommend guidelines of practice based on scientific data.” That small group of dedicated individuals has since grown to nearly 3,000 members. Our continued success, despite an economic downturn and a proliferation of specialty societies, is a tribute to our founding fathers and to their hard work, alongside that of previous ISIS leaders, the ISIS board of directors, the staff, and, of course, the life-blood of any organization, our member volunteers. You should all congratulate yourselves on the tremendous ongoing success of ISIS. Yet, challenges abound. Health care in the United States is undergoing an unprecedented transformation. We are transitioning from a fee-for-service system toward an outcome, value-based system where doing less is often seen as doing more. Yet, we still live in an eat-what-you-kill, fee-for-service world. Private practice has changed dramatically, as well. In fact, physician employment has risen over 32% since 2000 in the United States. We are facing more challenges …

Commentary on Classification of patients with incident non-specific low back pain: implications for research

COMMENTARY ON Norton G, McDonough CM, Cabral HJ, Shwartz M, Burgess JF Jr. Classification of patients with incident non-specific low back pain: implications for research. Spine J 2016;16:567-76 (in this issue).

Déjà vu all over again

COMMENTARY ON: Kapoor SG, Huff J, Cohen SP. Systematic review of the incidence of discitis after cervical discography. Spine J 2010;10:739–45 ( in this issue ).

Demystifying Lumbar Transforaminal Epidural Steroids: A Seminal Efficacy Study of a Specific Spinal Injection

Medical research and health care delivery is in a state of transition—and uncertainty. The initial disquiet following the introduction of evidence-based decision making almost two decades ago [1,2] has given rise to a more profound angst as researchers, health care analysts, and insurers all struggle with the imperative of defining which treatments are simultaneously efficacious, effective, and efficient. Vaguely defined terms such as health utility indices, together with a dazzling array of initialisms—ICER (incremental cost-effectiveness ratio), HRQoL (health-related quality-of-life), SCB (substantial clinical benefit), and CEACs (cost-effectiveness acceptability curves)—leave most of us numb. Meanwhile, the cry for evidence grows louder. Traditionally, placebo randomized controlled trials (P-RCTs) have been held as the gold standard for determining if a particular treatment is efficacious . However, by necessity, placebo controlled trials often involve short-term follow-up, and are costly and difficult to perform, particularly with invasive treatments. RCTs are also criticized as representing an idealized patient population—one that is rarely, if ever, seen in routine clinical practice. On the other hand, despite being currently fashionable, comparative effectiveness research (CER) is far from ideal. Comparative effectiveness research attempts to prove whether or not a particular treatment is effective in the “real world.” But CER is heterogeneous, running the spectrum from data mining of existing databases (Medicare, Ingenix, and others) to observational studies to formal registries. The most legitimate method involves using large registries; however, collecting registry data is particularly difficult and expensive, and the resulting datasets are often incomplete [3]. Most recently, the concept of value in spine care has been touted [4–6]. Commonly defined as quality/cost, value attempts to go beyond mere proof of efficacy and effectiveness, to examine the efficiency of a treatment. Despite being discussed for decades, this field is still …