Vijay B. Vad

Transforaminal epidural steroid injections in lumbosacral radiculopathy: A prospective randomized study

Study Design. A prospective study randomized by patient choice from the private practice of a single physician affiliated with a major teaching hospital was conducted. Objectives. To compare transforaminal epidural steroid injections with saline trigger-point injections used in the treatment of lumbosacral radiculopathy secondary to a herniated nucleus pulposus. Summary of Background Data. Epidural steroid injections have been used for more than half a century in the management of lumbosacral radicular pain. At this writing, however, there have been no controlled prospective trials of transforaminal epidural steroid injections in the treatment of lumbar radiculopathy secondary to a herniated nucleus pulposus. Methods. Randomized by patient choice, patients received either a transforaminal epidural steroid injection or a saline trigger-point injection. Treatment outcome was measured using a patient satisfaction scale with choice options of 0 (poor), 1 (fair), 2 (good), 3 (very good), and 4 (excellent); a Roland-Morris low back pain questionnaire that showed improvement by an increase in score; a measurement of finger-to-floor distance with the patient in fully tolerated hip flexion; and a visual numeric pain scale ranging from 0 to 10. A successful outcome required a patient satisfaction score of 2 (good) or 3 (very good), improvement on the Roland-Morris score of 5 or more, and pain reduction greater than 50% at least 1 year after treatment. The final analysis included 48 patients with an average follow-up period of 16 months (range, 12–21 months). Results. After an average follow-up period of 1.4 years, the group receiving transforaminal epidural steroid injections had a success rate of 84%, as compared with 48% for the group receiving trigger-point injections (P < 0.005). Conclusion. Fluoroscopically guided transforaminal injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus.

Fluoroscopic transforaminal lumbar epidural steroids: An outcome study☆

OBJECTIVES To determine the therapeutic value and long-term effects of fluoroscopic transforaminal epidural steroid injections in patients with refractory radicular leg pain. BACKGROUND DATA Although numerous studies have evaluated the efficacy of traditional transsacral (caudal) or translaminar (lumbar) administration of epidural steroids, to our knowledge no studies have assessed specifically the therapeutic value of fluoroscopic transforaminal epidural steroids. STUDY DESIGN A prospective case series that investigated the outcome of patients with lumbar herniated nucleus pulposus and radiculopathy who received fluoroscopic transforaminal epidural steroid injections. METHODS Patients who met our inclusion criteria received fluoroscopically guided, contrast-enhanced transforaminal epidural administration of anesthetic and steroid directly at the level and side of their documented pathology. Patients were evaluated by an independent observer and received sequential questionnaires before and after injection, documenting pain level, activity level, and patient satisfaction. RESULTS Sixty-nine patients met our inclusion criteria and were followed for an average period of 80 weeks (range, 28 to 144 weeks); 75.4% of patients had a successful long-term outcome, reporting at least a >50% reduction between preinjection and postinjection pain scores, as well as an ability to return to or near their previous levels of functioning after only 1.8 injections per patient (range, 1 to 4 injections). Of our patients, 78.3% were satisfied with their final outcomes. CONCLUSIONS Fluoroscopic transforminal epidural steroids are an effective nonsurgical treatment option for patients with lumbar herniated nucleus pulposus and radiculopathy in whom more conservative treatments are not effective and should be considered before surgical intervention.

Low Back Pain in Professional Golfers The Role of Associated Hip and Low Back Range-of-Motion Deficits

Background Low back pain is fairly prevalent among golfers; however, its precise biomechanical mechanism is often debated. Hypothesis There is a positive correlation between decreased lead hip rotation and lumbar range of motion with a prior history of low back pain in professional golfers. Study Design A cross-sectional study. Methods Forty-two consecutive professional male golfers were categorized as group 1 (history of low back pain greater than 2 weeks affecting quality of play within past 1 year) and group 2 (no previous such history). All underwent measurements of hip and lumbar range of motion, FABEREs distance, and finger-to-floor distance. Differences in measurements were analyzed using the Wilcoxon signed rank test. Results 33% of golfers had previously experienced low back pain. A statistically significant correlation (P < .05) was observed between a history of low back pain with decreased lead hip internal rotation, FABEREs distance, and lumbar extension. No statistically significant difference was noted in nonlead hip range of motion or finger-to-floor distance with history of low back pain. Conclusions Range-of-motion deficits in the lead hip rotation and lumbar spine extension correlated with a history of low back pain in golfers.

Hip and shoulder internal rotation range of motion deficits in professional tennis players.

One hundred tennis players were recruited from the professional mens tennis tour to investigate the correlation between hip internal rotation deficits and low back pain (LBP), as well as shoulder internal rotation deficits and shoulder pain. A statistically significant correlation was observed between dominant shoulder internal rotation deficits and shoulder pain. Also observed was a statistically significant correlation between lead hip internal rotation deficits and lumbar extension deficits with LBP. We conclude that due to repetitive demands on the dominant shoulder and repetitive pivoting at the lead hip, the cycle of microtrauma and scar formation leads to capsular contracture and subsequent reduction in internal range of motion. It is likely that the limitation in lumbar extension in the symptomatic group is not only due to decreased flexibility from an increased load on the spine, but also due to a protective mechanism to prevent further exacerbation of the LBP. Physical conditioning that includes shoulder as well as hip internal rotation stretching programs should therefore be essential aspects in the treatment of tennis players with shoulder pain and LBP respectively.

Prevalence of peripheral neurologic injuries in rotator cuff tears with atrophy.

The purpose of this study is to define the prevalence of peripheral nerve injury associated with full-thickness tears of the rotator cuff presenting with shoulder muscle atrophy. Twenty-five patients with the diagnosis of full-thickness rotator cuff tear were included. Electrodiagnostic testing, including nerve conduction studies and needle examination, was performed on all patients. There were 7 abnormal electromyographic examinations. The most common diagnosis was upper trunk brachial plexopathy severely affecting the axillary nerve (4/7), followed by suprascapular neuropathy (2/7) and cervical radiculopathy (1/7). The prevalence of associated peripheral neuropathy was found to be 28%. Greater degrees of atrophy were significantly associated with the presence of neuropathy in these patients. Careful neurologic screening in all patients and electromyographic examination in clinically suspicious groups are recommended in patients with full-thickness cuff tears before surgical repair.

Role of hylan G-F 20 in treatment of osteoarthritis of the hip joint.

OBJECTIVE To study the efficacy of hylan G-F 20 in the treatment of osteoarthritis (OA) of the hip joint. DESIGN Prospective within-group study. SETTING Musculoskeletal rehabilitation clinic. PARTICIPANTS Twenty-two patients (25 hips) with hip joint OA who had failed to find pain relief from conservative methods such as physical therapy, exercises, and steroid injections. Demographics included 14 men and 11 women (mean age, 56.4y), 21 of whom had mild to moderate OA and 4 of whom had severe OA of the hips. INTERVENTION Each hip joint was injected with 2mL of hylan G-F 20 at 2, 3, and 4 weeks and fluoroscopic lavage with 100mL of normal saline at week 1. All patients had standard hip exercise regimen after the injection. MAIN OUTCOME MEASURES American Academy of Orthopaedic Surgeons (AAOS) Lower Limb Core Scale score and visual numeric pain score. RESULTS At 1-year follow-up, the AAOS Lower Limb Core Scale score improved from a preinjection mean of 44.2 to a follow-up mean of 86.1 (P<.05). The mean visual numeric pain score improved from a preinjection mean of 8.7 (range, 6.4-10) to a follow-up mean of 2.3 (range, 0-7.2). The overall success rate was 84%. In patients with mild to moderate OA, the mean pain score decreased from a preinjection value of 7.8 to a follow-up value of 1.7. The success rate was 90.5% in that subgroup. In patients with severe OA, the mean pain score decreased from a preinjection value of 9.1 to a follow-up value of 3.8. The success rate was 50% in that subgroup. There were no complications related to the injection. CONCLUSION Use of hylan G-F 20 injection is a viable option for treatment of mild to moderate OA of the hip joint.

Negative prognostic factors in managing massive rotator cuff tears.

ObjectiveTo investigate the negative prognostic factors in the management of massive rotator cuff tears. DesignRetrospective nonrandomized study. SettingFaculty Practice associated with a major orthopedic teaching hospital. Patients108 patients who were treated for massive rotator cuff tears were evaluated for an average of 3.2 years posttreatment. There were 58 females and 50 males, with a mean age of 61.3 years. Interventions40 patients underwent conservative nonsurgical management (Group 1), 32 patients underwent arthroscopic debridement (Group 2), and 36 patients underwent primary repair of the rotator cuff (Group 3). Main Outcome MeasuresA detailed Shoulder Rating Questionnaire was filled out by patients pretreatment and minimal 2 years posttreatment. ResultsOverall, Group 1 had 65% excellent or good outcomes, Group 2 had 81%, and Group 3 had 86%. The subgroup of patients in Group 1 who had cortisone injections had a 75% success rate. ConclusionsNegative prognostic factors evaluated are presence of glenohumeral arthritis, decreased passive range of motion, superior migration of the humeral head, presence of atrophy, and external rotation/abduction strength less than 3. The presence of 3 or more of these negative prognostic factors are correlated with poor outcomes in the treatment of massive rotator cuff tears.

Exercise recommendations in athletes with early osteoarthritis of the knee.

AbstractOsteoarthritis of the knee is a common condition that afflicts millions of individuals annually. The benefits of exercise are self evident as athletes and middle- aged individuals grow older, and the focus has centered on pain-free participation in their sports and activities. In the past, medical treatment has primarily relied on oral medications to manage symptoms, without the incorporation of therapeutic exercise. Consequently, as the osteoarthritis progresses, patients are offered surgical management and eventual joint replacement. A goal-oriented progressive rehabilitation programme that incorporates medical management in the initial stages would allow patients a greater ability to participate in sports, thereby obtaining the numerous benefits of exercise and perhaps delaying surgery.A progressive rehabilitation programme consists of five stages (I to V). Medical management is primarily reserved for stage I: protected mobilisation and pain control. It entails the use of pain medications, nonsteroidal anti-inflammatory drugs, with or without the use of chondroprotective agents such as glucosamine. Injection therapy is usually incorporated at this stage with intra-articular injections of corticosteroids or viscosupplementation, either of which may be combined with minimally invasive single-needle closed joint lavage procedure.Stages II and III introduce open kinetic-chain non-weight bearing exercises to the affected joint, with progression to closed kinetic-chain exercises. Stage IV focuses on return to sporting activities, with continued closed kinetic-chain exercises. There is also the incorporation of sport-specific exercises to improve neuromuscular coordination, timing and protect against future injury. Finally, stage V, or the maintenance phase, is primarily aimed at educating the patient on how to reduce the risk of re-injury and optimise their current exercise programme. Medical management of knee osteoarthritis within the framework of a progressive rehabilitation programme that includes active therapeutic exercise may delay the progression of this disease and allow patients years of greater pain-free activity and improved quality of life.

Management of Knee Osteoarthritis: Knee Lavage Combined With Hylan Versus Hylan Alone

OBJECTIVE To assess the difference in efficacy between knee lavage plus the standard hylan G-F 20 (a derivative of hyaluronan) protocol and the standard hylan G-F 20 as per standard usage protocol alone for the treatment of knee osteoarthritis (OA). DESIGN Nonrandomized prospective study in which patients chose their treatment group. Follow-up averaged 1.1 years. SETTING Faculty practice of a single physician at a major teaching hospital. PARTICIPANTS Eighty-one patients with documented knee OA on magnetic resonance imaging. INTERVENTIONS Group 1 (n=44) received a single-needle lavage 1 week before the standard hylan G-F 20 protocol; group 2 (n=37) received the standard hylan G-F 20 protocol alone. MAIN OUTCOME MEASURES Pre- and posttreatment scores on the Lysholm-II Questionnaire and a visual analog scale (VAS) were documented for each patient. The Wilcoxon signed-rank test was used for statistical analysis. RESULTS A successful outcome was noted in 79.5% of group 1 patients and in 54% of group 2 patients (P<.05). CONCLUSIONS In the management of knee OA, the use of knee lavage before viscosupplementation with hylan G-F 20 yields better results than using hylan G-F 20 alone. The presence of radiologic grade IV knee OA or moderate to severe patellofemoral arthritis are negative prognostic factors.

Injuries to the posterolateral structures of the knee

Abstract In recent years, injuries of the posterolateral structures of the knee are being increasingly recongnized because of improved clinical awareness and diagnostic skills, as well as technological advances in magnetic resonance imaging. The functional anatomy and biomechanical concepts of the posterolateral structures of the knee are briefly discussed to improve our understanding of the posterolateral corner injury in the clinical setting. A good history and a systematic, detailed physical examination are required to make an early, accurate diagnosis. In turn, early diagnosis is necessary so that an appropriate treatment plan can be followed to achieve optimum knee stability and function. In athletically active patients who are involved in strenuous recreational and competitive sports, surgical repair of the torn posterolateral structures should be performed when the acute inflammatory phase has subsided (usually within 7–10 days). If knee swelling is present, a judgement must be made as to the risk of stiffness versus mobility of the knee after surgery. Generally, for posterolateral corner injuries, early surgery with a greater local healing response is of value and therefore we recommend early repair even in the face of swelling and limited knee motion. If the torn posterolateral structures of the knee are not repaired acutely, a state of chronic posterolateral rotatory instability may result. Patients with such an instability may present with persistent symptoms of pain, recurrent swelling and giving-way, that interfere with a sporting lifestyle and/or activities of daily living. Therefore in patients involved with high sporting demands, our goald is to acutely repair (and augment when necessary), the torn posterolateral structures to restore knee stability and function. Prospective studies with a long-term follow-up are needed to clarify the role of various surgical procedures that are used for the management of patients with acute injuries of the posterolateral corner or chronic posterolateral rotatory instability of the knee.