Savas Sencan

Pain Relief due to Transsacrococcygeal Ganglion Impar Block in Chronic Coccygodynia: A Pilot Study.

OBJECTIVE Coccygodynia is a distressing condition that presents with pain around the coccyx. Impar (Walther) ganglion is a sympathetic ganglion located at the end of lumbosacral sympathetic chain. The objective of this study is to share our results and follow up of 34 ganglion impar blocks in 22 patients. DESIGN Retrospective pilot study. SETTING Interventional Pain Clinic in the Department of Physical Medicine and Rehabilitation in a university hospital. SUBJECTS Twenty-two patients with coccygodynia who did not respond to conservative treatment and then presented to interventional pain clinic of a PM&R department in a university hospital METHODS Pain was evaluated via 10-cm visual analog scale (VAS). VAS values were obtained before, 1 hour and 3 weeks after injection and during this study was conducted. RESULTS For achieving at least 50% relief of pain, the success rate of a first injection was 82%, but accounted for three technical failures. In patients with a successful outcome, relief lasted for a median duration of 6 months. Relief was reinstated for a median period of 17 months by a second injection in nine patients who presented for repeat treatment. No relief was achieved in two of these patients when they presented for a third treatment. CONCLUSIONS Ganglion impar block appears to be effective in patients who have coccygodynia resistant to conservative therapy, with high success rates and prolonged duration of effect. Controlled studies are required to reveal the mechanism of this effect.

A Rare Cause of Lumbar Radiculopathy: Perineural Cyst

Dear Editor, Lumbosacral perineural cysts are formed by the arachnoid membrane of the nerve root at the lumbosacral level. Sacral perineural cysts called Tarlov cysts were identified by Tarlov for the first time in 1938 [1]. Langdown et al. reported that Tarlov cysts, which are a relatively common finding on lumbosacral magnetic resonance imaging (MRI) scans, have a prevalence of 1–2%, and only 13% of these cysts are symptomatic [2]. Symptomatic perineural cysts, which are relatively less common when compared with Tarlov cysts, are found in the lumbar region where they cause nerve root compression, which then leads to radiculopathy mimicking disc herniation [3]. Herein, we report a case with lumbosacral radiculopathy due to a perineural cyst that responded well to a transforaminal epidural steroid injection. A 19-year-old male patient was admitted to the Physical Medicine and …

Fluoroscopy-guided intra-articular steroid injection for sternoclavicular joint arthritis secondary to limited cutaneous systemic sclerosis: a case report

We report a case of fluoroscopy-guided intraarticular steroid injection for sternoclavicular joint (SCJ) arthritis caused by limited cutaneous systemic sclerosis (SSc). A 50-year-old woman diagnosed with limited cutaneous SSc presented with swelling and pain in the right SCJ. MRI revealed signs of inflammation consistent with right-sided sternoclavicular joint arthritis. After the failure of oral medications, we performed fluoroscopy-guided injection in this region. She reported complete resolution of her symptoms at 4 and 12-week follow-ups. This outcome suggests that a fluoroscopy-guided SCJ injection might be a safe and successful treatment option for sternoclavicular joint arthritis.

Cutaneous silent period in myofascial pain syndrome

Introduction: An increased response to painful stimuli without spontaneous pain suggests a role of central hyperexcitability of pain pathways in the pathogenesis of myofascial pain syndrome (MPS). In this study we aimed to test the hypothesis that spinal pain pathways are affected in MPS. We used cutaneous silent period (CSP) parameters to demonstrate the hyperexcitability of spinal pain pathways in MPS. Methods: Twenty‐nine patients diagnosed with MPS and 30 healthy volunteers were included in the study. The CSP recordings were performed in the right upper and left lower extremities. Results: In both upper and lower extremities, patients had prolonged CSP latencies (P = 0.034 and P = 0.049 respectively) and shortened CSP durations (P = 0.009 and P = 0.008, respectively). Discussion: Delayed and shortened CSP in MPS patients implies dysfunction in the inhibitory mechanism of the spinal/supraspinal pain pathways, suggesting central sensitization in the pathogenesis of MPS and supporting our research hypothesis. Muscle Nerve 57: E24–E28, 2018

The influence of coccygeal dynamic patterns on ganglion impar block treatment results in chronic coccygodynia

Objective Ganglion impar block (GIB) can be performed in patients with chronic coccygodynia who do not respond to conservative treatments. We investigated the effect of coccygeal dynamic patterns on the treatment outcome in patients with chronic coccygodynia treated with GIB. Materials and methods We retrospectively analyzed the data for patients diagnosed with chronic coccygodynia who underwent GIB only once by a transsacrococcygeal method under fluoroscopy guidance in our Pain Medicine Clinic. Patients were assessed with standard and dynamic coccyx radiographs and classified according to coccygeal mobility. Pain scores were assessed with a numerical rating scale (NRS) before and after the intervention (at 1 hour and 4, 12 and 24 weeks). A 50% or more reduction in the NRS score was accepted as significant pain relief. Results Of the 37 patients included in the study, 14 had normal coccyx (Group I) and 23 had immobile coccyx (Group II) based on the radiological evaluation. The NRS scores were significantly reduced in both groups on each follow-up visit but there was no significant difference between the two groups in terms of pre- and post-intervention NRS scores. Significant pain relief was achieved in 42.9% and 61.9% of patients in Group I and II at the last examination, respectively. Conclusion GIB administered by transsacrococcygeal method in patients with chronic coccygodynia is a safe and alternative treatment approach with reduced pain scores and low complication rates. In patients with chronic coccygodynia, having a normal or immobile coccyx does not appear to affect treatment outcomes.

Pregnancy-related low back pain in women in Turkey: Prevalence and risk factors

OBJECTIVES To investigate the prevalence of pregnancy-related low back pain (PRLBP) in women in Turkey, identify the factors associated with PRLBP and predict the risk of PRLBP. MATERIALS AND METHODS This cross-sectional study included a total of 1500 pregnant women admitted to a prenatal care clinic in a secondary care hospital in Turkey between August 2011 and September 2014. All participants were asked to complete a survey questionnaire. The pregnant women who reported recurrent or continuous pain in the lumbar spine or pelvis for more than 1 week were offered a clinical examination for PRLBP by the spine physiatrist. The main outcome measure was the presence of PRLBP. We collected data on sociodemographic factors, previous obstetric history, daily habits, history of LBP, and functional disability scores as assessed by the Oswestry Disability Index (ODI). RESULTS The mean age of the 1500 women was 26.5±5.5 years. The prevalence of PRLBP was 53.9%, mostly in the third trimester. Women with PRLBP in the third trimester were more disabled than those in the first and second trimesters (mean ODI 40.0±16.7 vs. 34.9±19.2 and 37.4±15.3, respectively). Risk factors of PRLBP were history of LBP, PRLBP, and menstruation-related LBP as well as no housework assistance (OR=5.394, 95% CI: 3.128-9.300, P<0.001; 3.692, 2.745-4.964, P<0.001; 2.141, 1.563-2.932, P<0.001; 1.300, 1.029-1.64, P=0.028, respectively). CONCLUSION This cross-sectional study is the largest study of PRLBP in the literature and showed that about 1 in 2 women have PRLBP in any stage of pregnancy. History of LBP related and unrelated to previous pregnancy and menstruation are strong risk factors for PRLBP. Receiving no housework assistance is another risk factor.

Recovery of H-Reflex with Transforaminal Epidural Steroid Injection in S1 Radiculopathy

Transforaminal epidural steroid injection (TFESI) is a recognized nonsurgical management of radicular back pain through its effects on neural inflammation and edema [1]. Electrodiagnostic changes of the compressed nerve root such as Hoffmann reflex (H-reflex) are apparent within days following injury and persist throughout nerve compression [2], with sensitivity and specificity of 50% and 91%, respectively, making the detection of H-reflex abnormality an option to identify early radiculopathy [3]. Despite its prevalent diagnostic use, to our knowledge there is limited information in the current literature regarding changes of an abnormal H-reflex following treatment of radiculopathy. We have investigated the changes of the H-reflex profile following fluoroscopyguided epidural steroid injections in three patients with S1 radiculopathy secondary to disc herniation.

The effect of transforaminal epidural steroid injections in patients with spondylolisthesis

BACKGROUND Transforaminal epidural steroid injection (TFE) is a widely accepted non-surgical treatment for pain in patients with spondylolisthesis. However, the effectiveness of TFE has not been compared in patients with degenerative (DS) and isthmic spondylolisthesis (IS). OBJECTIVE To compare the effectiveness of bilateral TFEs in DS and IS. METHODS Patients who underwent bilateral TFEs for spondylolisthesis at University of California San Francisco Orthopaedic Institute from 2009 to 2014 were evaluated retrospectively. RESULTS DS patients (120 female, 51 male) were significantly older and had higher comorbidity than those with IS (18 female, 14 male). They had better pain relief after TFE than patients with IS (72.11 ± 27.46% vs 54.39 ± 34.31%; p = 0.009). The number of TFEs, the mean duration of pain relief after TFE, follow-up periods, translation and facet joint widening were similar in DS and IS groups (p > 0.05). DS group had higher successful treatment rate (66.1% vs 46.9%, p = 0.009) and longer duration of pain relief (181.29 ± 241.37 vs 140.07 ± 183.62 days, p = 0.065) compared to IS group. CONCLUSIONS Bilateral TFEs at the level of spondylolisthesis effectively decreased pain in patients. TFEs provided better pain relief for longer duration in patients with DS than for those with IS.

Poster 140 The Effect of Comprehensive Non-surgical Treatments in Patients with Spondylolytic Spondylolisthesis

Case Description: The patient, a 74-year-old right hand dominant woman, presented for evaluation of left wrist pain and dorsal hand numbness. 3 months prior, she had been treated for left shoulder pain by an acupuncturist. During the treatment, a needle was placed subcutaneously in the anatomic snuff box of her left wrist (corresponding to the acupuncture point Yang Xi/Large Intestine 5). She immediately experienced intense pain, and the needle was removed. Since that time, the patient noted intermittent paresthesias and shooting pain along the dorsal left wrist and hand. She presented to an orthopedic hand surgery clinic, where x-rays of the wrist revealed no acute abnormalities and no retained foreign bodies. The patient was prescribed hand therapy, a wrist brace, and gabapentin; all provided minimal relief. She was then referred for electrodiagnostic testing. On the day of electrodiagnostic evaluation, physical examination of the patient was remarkable for allodynia along the radial aspect of the dorsum of the left wrist. Nerve conduction studies revealed absent left radial superficial sensory nerve action potential at the thumb and reduced left superficial sensory nerve action potential at the wrist. Corresponding evoked potentials on the right side were normal. Needle EMG examination of the left upper limb and cervical paraspinals was normal. Setting: Academic Medical Center Electrodiagnostic Laboratory. Results or Clinical Course: Electrophysiologic testing demonstrated evidence of a left superficial radial sensory neuropathy. The acute onset of neuropathic symptoms in a corresponding distribution during acupuncture treatment suggests iatrogenic superficial radial nerve injury. Discussion: There have been rare case reports of iatrogenic peripheral nerve injury from acupuncture. To our knowledge, this is the first reported case of injury to the superficial radial nerve. Physiatrists performing or prescribing acupuncture for pain management should be aware of this possible complication. Particular care should be taken when employing acupuncture points in close proximity to peripheral nerves. Conclusion: Iatrogenic nerve injury is a potential complication of acupuncture treatment.

Contralateral lumbar radicular pain shortly after a transforaminal epidural steroid injection: an unusual sequel.

Gündüz OH, Akhlaque U, Sencan S, Celenlioglu AE, Seker A: Contralateral lumbar radicular pain shortly after a transforaminal epidural steroid injection: an unusual sequel. Am J Phys Med Rehabil 2014;93:834Y835. Lumbar transforaminal epidural steroid injections (TFESIs) are valuable techniques used in the treatment of lumbar radicular pain and other lumbosacral pain syndromes. Complications from these procedures may arise from improper or unsafe needle placement, injection of contrast, or the administration of the final injectate including corticosteroids and anesthetic. Potential risks include infection, hematoma, intravascular injection of medication, direct nerve trauma, subdural injection of medication, air embolism, disk entry, urinary retention, radiation exposure, and hypersensitivity reactions, to mention a few. In addition, selecting the correct nerve root(s) is of prime importance during a diagnostic TFESI. The purpose of this case report was to highlight the importance of considering bilateral transforaminal injections in the treatment of large-sized central lumbar disk herniations. A 43-yr-old man who presented with a history of left radicular low back pain for a 6-mo duration that did not significantly improve after physical therapy and medical treatment. On examination, there was reduced flexion of the lumbosacral spine, pain with flexion, and associated significant paraspinal muscle spasm. The result of the straight leg raise test was positive bilaterally. The left ankle jerk reflex was diminished. Manual motor testing demonstrated 4 of 5 strength in bilateral extensor hallucis longus with decreased sensations in the left L5 and S1 dermatomes. Magnetic resonance imaging of the lumbosacral spine demonstrated a central disk protrusion (Fig. 1) with central spinal stenosis at the L5/S1 level (Fig. 2). He was subsequently scheduled for a left S1 TFESI. The subject was placed in the prone position. After positioning the C-arm with 13-degree oblique tilt to optimally visualize the left S1 foramen, a 22-gauge spinal needle was introduced under fluoroscopic guidance under coaxial/trajectory view into the left S1 foramen. The placement of the needle was considered satisfactory. After negative aspiration for cerebrospinal fluid or blood, approximately 1 ml of contrast medium (iohexol) was injected. There was optimal contrast flow along the Authors: Osman Hakan Gündüz, MD Uzma Akhlaque, MD Savas Sencan, MD Alp Eren Celenlioglu, MD Askin Seker, MD