Ryan Mattie

Comparing Percutaneous Vertebroplasty and Conservative Therapy for Treating Osteoporotic Compression Fractures in the Thoracic and Lumbar Spine: A Systematic Review and Meta-Analysis.

BACKGROUND Vertebral compression fractures are a common complication of osteoporosis and are often treated by percutaneous vertebroplasty (PVP). The ability of this procedure to relieve pain better than conservative treatment is still debated. The purpose of this study was to compare the degree and duration of pain relief following PVP with that following conservative treatment for osteoporotic compression fractures by means of meta-analysis of randomized controlled trials. METHODS The CENTRAL (Cochrane Central Register of Controlled Trials), MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Web of Science databases were queried for randomized controlled trials comparing PVP with conservative treatment or placebo/sham. The methodological quality was assessed according to the Cochrane Collaborations domain-based evaluation framework. Random-effects meta-analysis of the raw mean difference between groups in change in pain level was performed, with sensitivity analyses and the Egger test for potential publication bias. RESULTS Of 209 records found, 11 were considered relevant, involving 1,048 participants. The risk of bias was considered low in 10 studies and high in 1. The 531 patients treated with PVP had a significantly lower pain level compared with the control group at 1 to 2 weeks, 2 to 3 months, and 12 months. The 95% CI (confidence interval) of the pooled effect size at every time interval included the score of 1.5, considered to be the minimal clinically important difference. The largest pooled effect size of -1.4 (95% CI, -2.3 to -0.5) was found during the first 1 to 2 weeks. The heterogeneity was high at all 3 time points (I(2), 71% to 96%). No significant publication bias was detected. CONCLUSIONS Up to 1 year postoperatively, the effect of PVP exceeded the effect of conservative therapy with respect to pain relief in patients with osteoporotic compression fractures. The effect size was significant and close to the minimal clinically important difference.

Safety of epidural steroid injections

ABSTRACT Introduction: Epidural steroid injections (ESI) are a commonly utilized treatment for cervical and lumbar radicular pain. All medical procedures and medications carry an inherent level of risk, that must be balanced with the effectiveness of the treatment to determine the risk to benefit ratio for a patient. Areas covered: This article will outline the risks of ESIs and in doing so help shed light on the procedural risks versus the risks of the medication. Additionally, it will help differentiate minor adverse events from significant permanent complications. Expert Opinion: Catastrophic complications of ESI such as paralysis and stroke unquestionably warrant the recent increased attention given to the safety of these injections. While a single major complication is unacceptable, the relative rate of these major complications must be put in prospective. The true rate is small enough that it is impossible to calculate. All cases are limited to case reports and not detected in even the largest published cohorts of ESI. Moreover, recent advances in medication selection and technique have further reduced the incidence of these very rare complications. Conversely, the more common adverse events are rather minor, generally transient, and mostly occur at incidences of less than 1%.

The effect of body mass index on fluoroscopic time and radiation dose during lumbar transforaminal epidural steroid injections

OBJECTIVE Transforaminal epidural steroid injections (TFESIs) are a commonly used, effective treatment for radicular pain. Accurate delivery of the injected medication helps to ensure maximum therapeutic efficacy and to decrease possible adverse events, and fluoroscopy is the preferred and most common image-guidance modality used to ensure accurate needle placement during lumbar TFESIs. However, fluoroscopic-guided lumbar TFESIs put patients at risk because of radiation exposure. The purpose of this study was to determine the relationship between body mass index (BMI) and fluoroscopy time and radiation dose during lumbar TFESIs. DESIGN A retrospective study design was used. SETTING The study was conducted at an academic orthopedic center. All procedures were performed by physicians board-certified in Physical Medicine and Rehabilitation (PM&R) and with subspecialty certification in sports medicine, or by a trainee under close supervision from an attending physician. PARTICIPANTS Participants were patients who underwent fluoroscopic-guided lumbar TFESIs between February 2013 and March 2015 with a documented height/weight, fluoroscopy time, and radiation dose. INTERVENTIONS All patients received unilateral or bilateral lumbar TFESIs with fluoroscopic guidance. Fluoroscopy time and dose were recorded. MAIN OUTCOME MEASURES The main outcome measures were fluoroscopy time and radiation dose. A Bonferroni correction was implemented for multiple comparisons, defining statistical significance at p<.01. RESULTS A total of 2,443 injections were performed on 1,548 patients. There were 419 normal, 572 overweight, and 557 obese patients, respectively. There were 1,426 first-time injections and 1,017 repeat injections. Sixty-nine percent (1,681) were unilateral injections, and 26.4% (645) were single level injections. A trainee was involved in 1,361 (55.7%) of the injections performed. The mean fluoroscopy time for all injections was 30.0±17.5 seconds, and the mean radiation dose was 2,164±1,484 mGy-cm(2). The mean fluoroscopy time was 27.7±15.2 seconds for normal weight patients, 30.0±21.0 seconds for overweight patients, and 32.2±15.1 seconds for obese patients, showing a significant difference between groups (p<.001). The mean radiation doses for each group were 1,376±450, 1,911±653, and 3,029±640 mGy-cm(2), respectively, with a significant increase in radiation dose with increasing BMI (p<.001). CONCLUSIONS The findings of this study demonstrate that fluoroscopy radiation dose and fluoroscopy time during lumbar TFESIs are increased in patients with an elevated BMI, and in patients of greater age, but the presence of a trainee had no effect on fluoroscopy time.

The Effect of Body Mass Index on Fluoroscopic Time and Radiation Dose During Intra-articular Hip Injections

Intra‐articular hip injections are commonly performed for both diagnostic and therapeutic interventions. Because of the risk of damage to neurovascular structures, fluoroscopic guidance with injection of contrast material has been established as the gold standard to ensure proper needle placement into the intra‐articular space. However, fluoroscopically guided intra‐articular hip injections put patients at risk due to radiation exposure.

Importance of Image Guidance in Glenohumeral Joint Injections: Comparing Rates of Needle Accuracy Based on Approach and Physician Level of Training.

ObjectiveThis study compared the accuracy of blind glenohumeral joint (GHJ) injections between physical medicine and rehabilitation interventional fellows (inexperienced provider) and a sports medicine board–certified physical medicine and rehabilitation attending physician (experienced provider) using either an anterior or posterior approach. MethodsA retrospective analysis of 162 consecutive patients comprising 165 GHJ injections was performed. All GHJ injections were initially placed via anatomic landmark guidance by either an experienced or an inexperienced provider. Contrast medium using live fluoroscopy was injected to determine if intra-articular placement had been obtained. ResultsThe overall accuracy of a blind GHJ injection, regardless of the provider level of experience, was 45.5%. The inexperienced provider was accurate 37.6% of the time, and the experienced provider was accurate 64.6% of the time. The difference in provider accuracy based on level of experience was shown to be statistically significant at P less than 0.05. There was no statistically significant difference between the anterior and posterior approaches regardless of physician level of experience. ConclusionsThe results of this study suggest that image guidance is an important utility for accurate navigation into the GHJ space regardless of the level of training. Neither the anterior nor the posterior approach proved to be significantly more accurate.

Are All Epidurals Created Equally? A Systematic Review of the Literature on Caudal, Interlaminar, and Transforaminal Injections from the Last 5 Years

Abstract Spinal pathology is a common source of pain. Epidural injections are frequently utilized to treat spine-based pain. There are several routes of epidural injection including the caudal, interlaminar, and transforaminal approaches. The final needle position for these various routes of injection varies significantly, even when the same underlying pathology is targeted. This has lead to vigorous debate regarding the ideal approach for these common procedures. The goal of this article is to discuss the recent literature regarding the outcomes of the various epidural routes in the lumbar spine.

Percutaneous Needle Tenotomy for the Treatment of Lateral Epicondylitis: A Systematic Review of the Literature

To analyze the literature to determine whether controlled studies on percutaneous tenotomy have been published, and if so, to systematically assess the efficacy of percutaneous tenotomy for the treatment of tendinosis at the lateral epicondyle of the elbow.

Novel Treatment of Radicular Pain With a Multi-Mechanistic Combination Topical Agent: A Case Series and Literature Review

Introduction Pharmacologic treatment of radicular pain with oral medications is limited by adverse effects and concern for dependence. While topical formulations have been explored in pain research, there is no published literature evaluating the efficacy in radicular pain. We present the first three cases of radicular pain successfully treated with a topical formulation of diclofenac, ibuprofen, baclofen, cyclobenzaprine, bupivacaine, gabapentin, and pentoxifylline (T7). Case Presentation Case series evaluating T7 for treatment of radicular pain in a single, outpatient pain center. Pain was rated on the numeric rating scale (NRS) on initial evaluation and follow up after a trial of T7. One to two grams of T7 was applied to the affected area 3 - 4 times daily in addition to the patient’s baseline pharmacologic management. Three patients with median age of 50 (range, 39 to 65) and diagnosis of cervical and/or lumbosacral radicular pain participated. Two of the three had chronic radicular pain despite use of analgesic agents, spinal injections and failed spinal surgery syndrome. Each reported subjective improvement in radicular pain, function and sleep. There was an average decrease in NRS score consistent with 30% - 40% global improvement in symptoms, clinically significant based on the minimal clinically important difference for radicular pain. T7 was well tolerated without adverse reactions. Surgery was prevented or delayed in all cases. Conclusions This is the first report of the successful treatment of radicular pain with a topical agent. This highlights the need for randomized, prospective study of both single and compounded topical agents for treatment of radicular pain.

Psychometric properties of the Oswestry Disability Index

The aim of this study was to investigate the psychometric properties of the Oswestry Disability Index (ODI) in a large cross-sectional cohort of individuals with chronic low back pain by defining its internal consistency, construct structure and validity, and its ability to differentiate between different degrees of functional limitation. A total of 837 consecutive outpatient patients with low back pain were studied. The internal consistency of ODI was assessed by Cronbachs &agr;, construct structure by exploratory factor analysis, construct validity by confirmatory factor analysis, and discrimination was determined by item response theory analysis. The ODI showed good internal consistency (&agr;=0.85). Explanatory factor analysis showed that ODI is a unidimensional test measuring functional level and nothing else. The confirmatory factor analysis showed that the standardized regression weights of all ODI items were relatively high, varying from 0.5 to 0.7. The item response theory analysis suggested that eight out of 10 ODI items have a close to perfect ability to measure functional limitations in accordance with the actual severity of disability experienced by the respondents. Discrimination of all the items was high to perfect (1.08–2.01). The test characteristic and test information curves showed that the discriminative ability of the ODI is superior at higher levels of disability. The present data showed that the ODI is an internally consistent, unidimensional scale with overall excellent construct validity and ability to discriminate the severity of functional disability. The analysis suggests that the ODI may better distinguish between the relative degrees of function at above-average disability levels.

Confirmatory factor analysis of 12-Item World Health Organization Disability Assessment Schedule in patients with musculoskeletal pain conditions

Objective: To investigate the factor structure of the 12 item World Health Organization Disability Assessment Schedule (WHODAS) 2.0. Design: Cross-sectional cohort survey study. Setting: Physical and Rehabilitation Medicine outpatient university clinic. Subjects: The 408 consecutive patients with chronic musculoskeletal pain. Main measures: Exploratory and confirmatory factor analysis. Results: A two-factor model most accurately fit the observed data of musculoskeletal pain patients (root mean square error of approximation 0.049, relative Chi square value 1.99). Twelve WHODAS 2.0 items were distributed between two factors with covariance between them of 0.8. The first factor contained domains related mostly to physical functioning, while another was associated mostly with social and cognitive functioning. There were a few differences between single items in their importance in defining the variance within these two factors. Of the six International Classification of Functioning, Disability and Health domains belonging to the first construct, the ability to carry out household responsibilities explained most, 84% of the total variance in this construct. For the second factor, the ability to participate in community activities seemed to be the most important, explaining 85% of the total variance in this construct. Conclusions: In this study, the two-factor structure model of the 12-item WODAS 2.0 demonstrated the most accurate fit within patients with musculoskeletal pain conditions.