Facets of facet joint interventions.

Facet joint (FJ) disease is a common cause of axial low back pain with many minimally invasive image-guided treatment options. This article discusses fluoroscopic and CT-guided intraarticular FJ injections, medial branch (MB) radiofrequency ablation (RFA), and lumbar facet synovial cyst (LFSC) aspiration, rupture, or fenestration. Additionally, the article will highlight medial branch blocks (MBBs) utilized to diagnose facet-mediated pain and to predict outcomes to RFA.

The Effectiveness of Intraosseous Basivertebral Nerve Radiofrequency Neurotomy for the Treatment of Chronic Low Back Pain in Patients with Modic Changes: A Systematic Review.

OBJECTIVE: Determine the effectiveness of intraosseous basivertebral nerve radiofrequency neurotomy for the treatment of chronic low back pain with type 1 or 2 Modic changes. DESIGN: Systematic review. POPULATION: Persons aged ≥18 years with chronic low back pain with type 1 or 2 Modic changes. INTERVENTION: Intraosseous basivertebral nerve radiofrequency neurotomy. COMPARISON: Sham, placebo procedure, active standard care treatment, or none. OUTCOMES: The primary outcome of interest was the proportion of individuals with ≥50% pain reduction. Secondary outcomes included ≥10-point improvement in function as measured by Oswestry Disability Index as well as ≥2-point reduction in pain score on the Visual Analog Scale or Numeric Rating Scale, and decreased use of pain medication. METHODS: Three reviewers independently assessed publications before May 15, 2020, in MEDLINE and Embase and the quality of evidence was evaluated using the Grades of Recommendation, Assessment, Development, and Evaluation framework. RESULTS: Of the 725 publications screened, seven publications with 321 participants were ultimately included. The reported 3-month success rate for ≥50% pain reduction ranged from 45% to 63%. Rates of functional improvement (≥10-point Oswestry Disability Index improvement threshold) ranged from 75% to 93%. For comparison to sham treatment, the relative risk of treatment success defined by ≥50% pain reduction and ≥10-point Oswestry Disability Index improvement was 1.25 (95% confidence interval [CI]: .88-1.77) and 1.38 (95% CI: 1.10-1.73), respectively. For comparison to continued standard care treatment the relative risk of treatment success defined by ≥50% pain reduction and ≥10-point Oswestry Disability Index improvement was 4.16 (95% CI: 2.12-8.14) and 2.32 (95% CI: 1.52-3.55), respectively. CONCLUSIONS: There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings.

Housing structure including the surrounding environment as a risk factor for visceral leishmaniasis transmission in Nepal.

Visceral leishmaniasis (VL) in Nepal is found in 61 out of 75 districts including areas previously listed as non- endemic. This study focused on the role of housing conditions and its immediate environment in VL transmission, to limit future transmissions, ensure sustainable vector control and support the VL elimination program. The objective was to explore the risk factors in rural housing-and land lot typologies contributing to clinical VL occurrence and transmission. Housing structures and land lots were examined based on characteristics as risk factors of VL transmission in a case-control analysis. VL cases from 2013-2017 were identified based on the existing database from the Epidemiology and Disease Control Division and District Public Health Office from the plain Terai area (Morang, and Saptari districts) and hilly area (Palpa district) of Nepal. Two hundred and three built environments were analyzed (66 cases and 137 controls). Inferential statistics and logistic regression analysis were performed to determine the association of risk factors with VL. The risk factors with the highest odds of VL were: bamboo walls (adjusted odds ratio (AOR)- 8.1, 95% CI 2.40-27.63, p = 0.001), walls made of leaves/branches (AOR- 3.0, 95% CI 0.84-10.93, p = 0.090), cracks in bedroom walls (AOR- 2.9, 95% CI 0.93-9.19, p = 0.065), and placing sacks near sleeping areas (AOR- 19.2, 95% CI 4.06-90.46, p <0.001). Significant outdoor factors were: lots with Kadam trees (AOR- 12.7, 95% CI 3.28-49.09, p <0.001), open ground-outdoor toilets (AOR- 9.3, 95% CI 2.14-369.85, p = 0.003), moisture in outdoor toilet sheds (AOR- 18.09, 95% CI 7.25-451.01, p = 0.002), nearby- open land (AOR- 36.8, 95% CI 3.14-430.98, p = 0.004), moisture inside animal sheds (AOR- 6.9, 95% CI 1.82-26.66, p = 0.005), and surrounding animals/animals wastes particularly goats (AOR- 3.5, 95% CI 1.09-10.94, p = 0.036). Certain housing and surrounding environmental conditions and characteristics are risk factors for VL. Hence, elimination and educational programs should include the focus on housing improvement and avoidance of risk factors. Longitudinal interventional studies are required to document temporal relationships and whether interventions on these factors will have an impact on Leishmania transmission or burden.

Systematic review of diagnostic accuracy of patient history, clinical findings, and physical tests in the diagnosis of lumbar spinal stenosis.

PURPOSE: To update evidence of diagnostic potential for identification of lumbar spinal stenosis (LSS) based on demographic and patient history, clinical findings, and physical tests, and report posttest probabilities associated with test findings. METHODS: An electronic search of PubMed, CINAHL and Embase was conducted combining terms related to low back pain, stenosis and diagnostic accuracy. Prospective or retrospective studies investigating diagnostic accuracy of LSS using patient history, clinical findings and/or physical tests were included. The risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS 2) tool. Diagnostic accuracy including sensitivities (SN), specificities (SP), likelihood ratios (+LR and -LR) and posttest probabilities (+PTP and -PTP) with 95% confidence intervals were summarized. RESULTS: Nine studies were included (pooled n = 36,228 participants) investigating 49 different index tests (30 demographic and patient history and 19 clinical findings/physical tests). Of the nine studies included, only two exhibited a low risk of bias and seven exhibited good applicability according to QUADAS 2. The demographic and patient history measures (self-reported history questionnaire, no pain when seated, numbness of perineal region) and the clinical findings/physical tests (two-stage treadmill test, symptoms after a March test and abnormal Romberg test) highly improved positive posttest probability by > 25% to diagnose LSS. CONCLUSION: Outside of one study that was able to completely rule out LSS with no functional neurological changes none of the stand-alone findings were strong enough to rule in or rule out LSS. These slides can be retrieved under Electronic Supplementary Material.

Degenerative Disc Disease: What is in a Name?

STUDY DESIGN: A systematic search and review OBJECTIVE.: The aim of this study was to investigate the term, degenerative disc disease, to elucidate its current usage and inform clinical, research, and policy recommendations. SUMMARY OF BACKGROUND DATA: Degenerative disc disease has long been a dominant concept in common, painful spinal disorders. Yet, despite its pervasiveness and important clinical consequences and controversies, there has not been a systematic examination of its use and meaning in the scientific literature. METHODS: We conducted a systematic search of publications using the term degenerative disc disease from 2007 through 2016 in Ovid MEDLINE (R), Embase, CINAHL, and Scopus. Two investigators independently reviewed all publications in the primary sample. Publication and author identifiers, and qualitative study descriptors were extracted. Finally, the definition of degenerative disc disease was placed in one of eight categories. Data were summarized using descriptive statistics. RESULTS: Degenerative disc disease appeared in the titles of 402 publications in the primary sample and increased in frequency by 189% from the first to the last 3 years of the decade. No single definition was used in the majority of publications, and most frequently, the term was used without any definition provided (30.1%). In other cases, degenerative disc disease specifically included radiculopathy or myelopathy (14.4%), or only back or neck pain (5.5%), or was equated with disc degeneration regardless of the presence of symptoms (15.4%), or with discogenic pain or disc degeneration as a presumed cause of axial pain (12.7%). Another 7.2% comprised a mix of broad ranging findings and diagnoses. The most notable differences in definitions occurred between surgeons and other disciplines, and when applied to cervical versus lumbar regions. CONCLUSION: Despite longstanding use and important consequences, degenerative disc disease represents an underdeveloped concept, with greatly varying, disparate definitions documented. Such inconsistencies challenge clear, accurate communication in medicine and science, create confusion and misconceptions among clinicians, patients and others, and hinder the advancement of related knowledge. LEVEL OF EVIDENCE: 4.

Rehabilitation management of low back pain - it's time to pull it all together!

In the past, rehabilitation research initiatives for low back pain (LBP) have targeted outcome enhancement through personalized treatment approaches, namely through classification systems (CS). Although the use of CS has enhanced outcomes, common management practices have not changed, the prevalence of LBP is still high, and only selected patients meet the CS profile, namely those with a nociceptive context. Similarly, although practice guidelines propose some level of organization and occasionally a timeline of care provision, each mainly provides best practice for isolated treatment approaches. Moreover, there is no theoretical framework that has been proposed that guides the rehabilitation management process of mechanical LBP. In this commentary, we propose a model constituted of five domains (nociceptive drivers, nervous system dysfunction drivers, comorbidities drivers, cognitive-emotional drivers, and contextual drivers) grounded as mechanisms driving pain and/or disability in LBP. Each domain is linked to the International Classification of Functioning, Disability and Health, where once a patient is deemed suitable for rehabilitation, the clinician assesses elements of each domain in order to identify where the relative treatment efforts should be focused. This theoretical model is designed to provide a more comprehensive management overview, by appreciating the relative contribution of each domain driving pain and disability. Considering that the multiple domains driving pain and disability, and their interaction, requires a model that is comprehensive enough to identify and address each related issue, we consider that the proposed model has several positive implications for rehabilitation of this painful and highly prevalent musculoskeletal disorder.

Technique for CT Fluoroscopy-Guided Lumbar Medial Branch Blocks and Radiofrequency Ablation.

OBJECTIVE: The purpose of this study is to describe the procedure for CT fluoroscopy-guided lumbar medial branch blocks and facet radiofrequency ablation. CONCLUSION: CT fluoroscopic guidance allows more-precise needle tip positioning and is an alternative method for performing medial branch blocks and facet radiofrequency ablation.

Factors That Predict Satisfaction With Medical Care: Data From 27,212 Injured Workers Surveyed for 14 Years.

OBJECTIVE: the aim of this study is to report satisfaction rates and identify factors predicting satisfaction in the Pennsylvania Workers' Compensation (WC) system. METHODS: Cross-sectional survey data on satisfaction and care experience of injured workers were collected annually for 14 years with 27,712 injured workers responding. RESULTS: The overall response rate was 19.44%. The overall proportion of satisfied workers was 83.97% with a range of 80.43% to 88.13%. Obtaining a correct initial diagnosis [odds ratio (OR) = 4.26], explanation of WC rights (OR = 2.58), and physician explanation of treatment options (OR = 1.83) most strongly predicted satisfaction. CONCLUSIONS: Injured worker satisfaction with their medical care exceeded 80% in all years surveyed. Patient perception of a correct initial diagnosis, explanation of WC rights, and explanation of treatment options were the strongest predictors of satisfaction during the 14-year study period.

Adverse events associated with fluoroscopically guided sacroiliac joint injections.

OBJECTIVE: To describe the type, incidence, and factors that contribute to adverse events associated with fluoroscopically guided intra-articular sacroiliac joint injections (IASIJ). DESIGN: A retrospective cohort study. SETTING: Tertiary, academic, outpatient physical medicine and rehabilitation interventional spine clinic. PARTICIPANTS: English-speaking adults aged 18-90 years who underwent fluoroscopically guided IASIJ injections between March 8, 2004, and April 19, 2007. INTERVENTIONS: After IASIJ injections, 3 senior researchers recorded the presence and types of adverse events. The relationship of adverse events with age, gender, fluoroscopy time, vital signs, and trainee presence was analyzed with the Fisher exact or the Wilcoxon rank sum 2-sided tests. MAIN OUTCOME MEASURES: The frequency of immediate (during or immediately after the procedure) or delayed (within 24-72 hours after the procedure) adverse events. RESULTS: A total of 162 patients (133 women) underwent 191 procedures. The range of subject age was from 20 to 90 years (15.8 years, standard deviation [SD]). The range (SD) of the preprocedure 11-point Likert Pain Scale was from 1.0 to 10.0 (2.0) and for the postprocedure 11-point Likert Pain Scale was from 0.0 to 9.0 (2.5). Trainees were involved in 57% of the procedures. Reported immediate adverse events were vasovagal reaction (2.1% [n = 4]) and steroid-clogged needle (0.5% [n = 1]). Follow-up data were available for 132 of 191 procedures (69%). There were 32 adverse events reported at a mean follow-up interval of 2 days, of which, the most frequent adverse events were injection-site soreness (12.9% [n = 17]), pain exacerbation (5.3% [n = 7]), and facial flushing and/or sweating (2.3% [n = 3]). Delayed adverse events decreased with older age (P = .0029). The patients who underwent bilateral procedures experienced more delayed adverse events than the patients who underwent unilateral procedures (P = .024). CONCLUSIONS: Fluoroscopically guided IASIJ injection is associated with minimal adverse effects. The most common immediate adverse event was vasovagal reaction, and the most common delayed adverse event was injection-site soreness. Younger age is significantly related to reported delayed adverse events.

The electrodiagnostic evaluation of neck pain.

Electrodiagnostic studies play an important role in the evaluation of radiculopathy. This article reviews the use of standard nerve conduction studies, late responses, evoked potentials, and needle electrode examination in the electrodiagnostic evaluation of neck pain.

Factors associated with regional bias of pfcrt (plasmodium falciparum chloroquine resistance transporter) haplotypes in Nepal.

Evidences of reappearance of chloroquine sensitive Plasmodium falciparum haplotypes after cessation of chloroquine in many countries provide a rationale for the search of chloroquine sensitive haplotypes in P. falciparum isolates in Nepal where the use of chloroquine for falciparum malaria treatment has been ceased since 1988. P. falciparum chloroquine resistant transporter gene (pfcrt) haplotypes were determined and the factors associated with pfcrt haplotypes in the Eastern and Central regions of Nepal were identified. Blood samples from 106 microscopy-positive falciparum malaria patients (62 from the Eastern and 44 from the Central region) were collected on filter paper. Pfcrt region covering codons 72-76 was amplified by PCR and sequenced. SVMNT haplotype was predominant in the Central region, whereas CVIET haplotype significantly more common in the Eastern region. In multivariable analysis of factors associated with CVIET haplotype, the Eastern region and parasite isolates from patients visiting India within one month are significant at 5% level of significance. These findings suggest that antimalarial pressure is different between Eastern and Central regions of Nepal and there is a need of an effective malaria control program in the border areas between India and Nepal.

The electrodiagnostic evaluation of radiculopathy.

Electrodiagnostic studies play an important role in the evaluation of radiculopathy. This article reviews the use of standard nerve conduction studies, late responses, evoked potentials, and needle electrode examination in the work-up of lumbosacral and cervical radiculopathy.

Correlates of sharing injection equipment among male injecting drug users in Kathmandu, Nepal.

BACKGROUND: HIV prevalence is high and risky injection practices occur frequently among injecting drug users (IDUs) in Nepal. We explored the correlates of sharing injection equipment (having injected with a needle or syringe previously used by another) among male IDUs in Kathmandu, Nepal. METHODS: From August to September 2007, we anonymously interviewed 296 male IDUs in Kathmandu, Nepal, using a structured questionnaire. We performed bivariate and multivariable logistic regression analysis and identified variables associated with sharing injection equipment. RESULTS: Over half (n=152) of the participants reported injecting drugs with a needle or syringe previously used by another in the past year. Of these, 70% reported engaging in sharing injection equipment with multiple persons. The unavailability of new needles and drinking alcohol were independently associated with sharing injection equipment among the study participants. CONCLUSIONS: IDUs who drank alcohol or who could not obtain new needles when needed were more likely to share injection equipment. Our results suggest that reducing alcohol use and increasing the availability of new needles and syringes might improve safer injection practices among male IDUs in Kathmandu, Nepal.

Chemical and environmental vector control as a contribution to the elimination of visceral leishmaniasis on the Indian subcontinent: cluster randomized controlled trials in Bangladesh, India and Nepal.

BACKGROUND: Bangladesh, India and Nepal are working towards the elimination of visceral leishmaniasis (VL) by 2015. In 2005 the World Health Organization/Training in Tropical Diseases launched an implementation research programme to support integrated vector management for the elimination of VL from Bangladesh, India and Nepal. The programme is conducted in different phases, from proof-of-concept to scaling up intervention. This study was designed in order to evaluate the efficacy of the three different interventions for VL vector management: indoor residual spraying (IRS); long-lasting insecticide treated nets (LLIN); and environmental modification (EVM) through plastering of walls with lime or mud. METHODS: Using a cluster randomized controlled trial we compared three vector control interventions with a control arm in 96 clusters (hamlets or neighbourhoods) in each of the 4 study sites: Bangladesh (one), India (one) and Nepal (two). In each site four villages with high reported VL incidences were included. In each village six clusters and in each cluster five households were randomly selected for sand fly collection on two consecutive nights. Control and intervention clusters were matched with average pre-intervention vector densities.In each site six clusters were randomly assigned to each of the following interventions: indoor residual spraying (IRS); long-lasting insecticide treated nets (LLIN); environmental management (EVM) or control. All the houses (50-100) in each intervention cluster underwent the intervention measures. A reduction of intra-domestic sand fly densities measured in the study households by overnight US Centres for Disease Prevention and Control light trap captures (that is the number of sand flies per trap per night) was the main outcome measure. RESULTS: IRS, and to a lesser extent EVM and LLINs, significantly reduced sand fly densities for at least 5 months in the study households irrespective of type of walls or whether or not people shared their house with cattle. IRS was effective in all sites but LLINs were only effective in Bangladesh and India. Mud plastering did not reduce sand fly density (Bangladesh study); lime plastering in India and one Nepali site, resulted in a significant reduction of sand fly density but not in the second Nepali site. CONCLUSION: Sand fly control can contribute to the regional VL elimination programme; IRS should be strengthened in India and Nepal but in Bangladesh, where vector control has largely been abandoned during the last decades, the insecticide treatment of existing bed nets (coverage above 90% in VL endemic districts) could bring about an immediate reduction of vector populations; operational research to inform policy makers about the efficacious options for VL vector control and programme performance should be strengthened in the three countries.

Measles deaths in Nepal: estimating the national case-fatality ratio.

OBJECTIVE: To estimate the case-fatality ratio (CFR) for measles in Nepal, determine the role of risk factors, such as political instability, for measles mortality, and compare the use of a nationally representative sample of outbreaks versus routine surveillance or a localized study to establish the national CFR (nCFR). METHODS: This was a retrospective study of measles cases and deaths in Nepal. Through two-stage random sampling, we selected 37 districts with selection probability proportional to the number of districts in each region, and then randomly selected within each district one outbreak among all those that had occurred between 1 March and 1 September 2004. Cases were identified by interviewing a member of each and every household and tracing contacts. Bivariate analyses were performed to assess the risk factors for a high CFR and determine the time from rash onset until death. Each factor's contribution to the CFR was determined through multivariate logistic regression. From the number of measles cases and deaths found in the study we calculated the total number of measles cases and deaths for all of Nepal during the study period and in 2004. FINDINGS: We identified 4657 measles cases and 64 deaths in the study period and area. This yielded a total of about 82 000 cases and 900 deaths for all outbreaks in 2004 and a national CFR of 1.1% (95% confidence interval, CI: 0.5-2.3). CFR ranged from 0.1% in the eastern region to 3.4% in the mid-western region and was highest in politically insecure areas, in the Ganges plains and among cases < 5 years of age. Vitamin A treatment and measles immunization were protective. Most deaths occurred during the first week of illness. CONCLUSION: To our knowledge, this is the first CFR study based on a nationally representative sample of measles outbreaks. Routine surveillance and studies of a single outbreak may not yield an accurate nCFR. Increased fatalities associated with political insecurity are a challenge for health-care service delivery. The short period from disease onset to death and reduced mortality from treatment with vitamin A suggest the need for rapid, field-based treatment early in the outbreak.

A challenge for monitoring iodine deficiency disorders in rural Nepal.

Developing a strategy for monitoring iodine deficiency disorders (IDD) remains a big challenge in rural Nepal where great variations could exist in IDD status. To explore the possibility of variation in urinary iodine excretion (UIE) level in rural settings, we carried out a detailed study of UIE among 586 school children of 20 schools in five villages. Our data revealed statisitically significant differences in UIE values among rural villages and schools in the same villages. The policy-makers should keep such variations in mind for a successful monitoring of IDD in Nepal and other countries where such variations may exist.

Retention and effectiveness of HIV/AIDS training of traditional healers in far western Nepal.

OBJECTIVE: To evaluate HIV/AIDS training for traditional healers (THs) in far western Nepal. METHODS: We collected data using a structured questionnaire and assessed THs' knowledge of HIV transmission, misconceptions and preventive measures immediately prior to the initial training conducted from June to December 1999, and then 9-12 months after the training in 2000. We also conducted six focus group discussions (FGD) and assessed THs' performances after the training. We interviewed 12 key informants about their perceptions towards the trained THs. RESULTS: THs significantly improved their knowledge of HIV transmission, misconceptions and preventive measures after the training. The FGD and key informant interview results showed that the trained THs provided culturally acceptable HIV/AIDS education to the local people, distributed condoms and played a role in reducing the HIV/AIDS-related stigma. CONCLUSIONS: THs have a potential to work as key players in HIV/AIDS programmes in Nepal.

2002 survey of the American Glaucoma Society: practice preferences for glaucoma surgery and antifibrotic use.

PURPOSE: To determine the preference of members of the American Glaucoma Society for the use of antifibrotic agents (mitomycin C or 5-fluorouracil or both) and glaucoma drainage devices in ten clinical settings. MATERIALS AND METHODS: Voluntary written survey of the American Glaucoma Society. RESULTS: American Glaucoma Society (AGS) members continue to report preference for mitomycin C use in ten clinical settings. The percent usage for glaucoma drainage devices has increased in poor prognosis scenarios including the following: neovascular glaucoma, previous failed trabeculectomy, previous ECCE/ICCE, previous PKP, previous scleral buckling surgery, and uveitic glaucoma. However, trabeculectomy and MMC continue to be more likely employed for surgical management. CONCLUSION: Despite the long-term complications of bleb-related infections, no statistically significant shift in preference away from MMC use or reduction in the concentration of drug delivery was observed since the 1996 survey.

Migrants' risky sexual behaviours in India and at home in far western Nepal.

OBJECTIVE: To examine Nepali migrants' vulnerability to HIV/sexually transmitted infections (STIs) and their possible role in causing the epidemic in far western Nepal. METHODS: From August to October 2000, we conducted six focus group discussions among 53 returned migrants from India, mainly from Mumbai. Data were analysed by interpretative thematic analysis. RESULTS: Migrants commonly had multiple sexual encounters, changed partners, and used condoms infrequently both in India and at home. Several factors influenced them to practice high-risk sexual behaviours. In India, these included peer norms and pressures, cheaper sex, lack of family restraint, drinking alcohol, and low perceived vulnerability to HIV/STIs. In Nepal, these factors included the migrants' new status, frequent local festivals, and low perceived vulnerability to HIV/STIs. Participants displayed substantial deficits in their knowledge of HIV/STIs. CONCLUSIONS: This study revealed Nepali migrants' high-risk sexual behaviours both abroad and at home. Understanding these realities will assist in the development of culturally appropriate HIV/STI interventions necessary to halt the spread of HIV/STIs in Nepal.