Intra-Articular Platelet Rich Plasma vs Corticosteroid Injections for Sacroiliac Joint Pain: A Double-Blinded, Randomized Clinical Trial.

OBJECTIVE: Using stringent inclusion criteria, a double-blinded study protocol, and fluoroscopically guided injections, we compare intra-articular sacroiliac joint platelet-rich plasma injections with intra-articular steroids. DESIGN: Double-blind, randomized controlled trial. SETTING: Two large university-based interdisciplinary spine centers. SUBJECTS: A total of 26 patients with a positive diagnostic block (>80% relief). METHODS: Subjects who had a positive diagnostic block were randomized to undergo either a fluoroscopically guided intra-articular injection of steroid or a platelet-rich plasma injection. Follow-up was at 1 month, 3 months, and 6 months. Outcomes included level of pain, as indicated on a 0- to 100-mm numeric pain rating scale, and functional disability score, obtained via the Oswestry Disability Index (ODI). RESULTS: At 1, 3, and 6 months, both groups improved; however, subjects who received steroid injections reported lower pain scores than did subjects who received platelet-rich plasma. Using categorical data, we observed significantly more responders (defined as pain scores that improved by 50% or more from baseline) at 1 and 3 months in the group who received steroids than in the group who received platelet-rich plasma. CONCLUSION: Although both groups showed improvements in pain and function, the steroid group had significantly greater response and significantly more responders than did the platelet-rich plasma group.

Pain and functional outcomes of the sacroiliac joint after platelet-rich plasma injection: a descriptive review.

The purpose of this manuscript is to highlight and review the status of literature regarding efficacy of platelet-rich plasma (PRP) in the treatment of sacroiliac joint (SIJ) dysfunction. A review of the literature on PRP interventions on the SIJ or ligaments was performed. Seven studies had improvements in their respective primary end point and demonstrated a strong safety profile without any serious adverse events. Only five articles demonstrated clinical efficacy of >50% in their primary outcome measures. There appears to be inconsistent and insufficient evidence for a conclusive recommendation for or against SIJ PRP. There is a need for adequately powered well-designed, standardized, double-blinded randomized clinical trials to determine the effectiveness of PRP in SIJ-mediated pain.

Cannabis Use and Low-Back Pain: A Systematic Review.

Introduction: The potential use of cannabis and cannabinoid products for the treatment of low-back pain is an important area for investigation. As one of the leading reasons to visit a primary care provider, low-back pain results in a significant burden of disease in both the United States' economic and health care systems. Given the current opioid epidemic, it is important to seek novel analgesics and understand their efficacy for myriad pain conditions, including low-back pain. Materials and Methods: A systematic review was performed using multiple online databases to assess the association of cannabis use and low-back pain in the literature. Results: A total of 124 articles were produced via our search methods, 73 abstracts in total were screened, 16 articles underwent full-text review, and 6 articles were included in qualitative synthesis. Discussion: This systematic literature review reveals a lack of primary research investigating cannabis as a potential treatment of low-back pain and highlights the need for further investigation with well-designed clinical trials. There remain substantial political and legal barriers to performing such research. Conclusion: Although there is a considerable body of work on the usage of cannabinoid products for many medical conditions, including the treatment of chronic pain, more directed clinical research into their utility as an analgesic for low-back pain and related symptoms needs to be addressed.

Running with Femoral Acetabular Impingement: Operative Vs Nonoperative Treatment.

A 31-year-old female lawyer presents with right hip pain starting approximately 3 years ago and worsening over the past 2 to 3 months. She is an avid runner, running 20 to 30 miles weekly, and noticed that her pain started after a running program training for the marathon. Her pain is primarily over the lateral aspect of her hip with some radiation into the groin. The pain is made worse with impact exercises such as running and made better with walking and cycling. She has done physical therapy for the past 3 months without any significant improvement. She has not had any injections or taken anti-inflammatories because of a history of gastric ulcer disease. On physical examination she has mild tenderness over her right greater trochanter and her range of motion tests are full in terms of flexion, internal rotation, and external rotation. She has a positive FADIR (flexion-adduction-internal rotation) impingement that causes both groin and lateral hip pain. Radiograph of the right hip revealed preservation of the joint space and an anterior cam lesion with reduced offset at the femoral head neck junction. Magnetic resonance imaging (MRI) of the right hip revealed a tear at the anterior superior labrum at the 1 to 2 o'clock position along with subjacent bone marrow edema in the femoral head that is likely reactive. Computed tomography (CT) scan of the right hip confirmed a combined cam and pincer type femoral acetabular impingement of the right hip with overcoverage of the femoral head. There was 15° of femoral anteversion and the coronal lateral center of edge angle (LCEA) is 34°. Dr. Peter Moley argues that a focused rehabilitation program to restore strength and motor control of the deep hip stabilizers will provide optimal functional recovery. Dr. Jakub Tatka argues that right hip arthroscopy with labral repair and possible osteochondralplasty are indicated in order to prevent early hip arthritis and prevent long-term sequela of femoral acetabular impingement.

Investigation of genicular neurotomy of the knee: MRI characterization of anatomy and implications for intervention.

BACKGROUND: Genicular nerve block and subsequent radiofrequency neurotomy (RFN) has emerged as a novel intervention and alternative for total knee arthroplasty in patients with refractory pain from knee osteoarthritis (OA). To our knowledge, there is no cited report correlating the accuracy of localizing the genicular nerves using bony landmarks on magnetic resonance imaging (MRI). OBJECTIVES: To quantify the proximity of superomedial genicular nerve (SMGN), superolateral genicular nerve (SLGN), and inferomedial genicular nerve (IMGN) from a target point. The target point was an intersection marked by a line parallel to the diaphysis and a separate line parallel to the metaphyseal flare along the cortical surfaces of both the femur and tibia. DESIGN: Retrospective chart review. PATIENTS: A total of 25 de-identified knee MRIs were reviewed. METHODS: The coronal proton density fat suppressed sequence was used for identification and localization of the SLGN, SMGN, and IMGN. The neurovascular bundles were traced from posterior location along their origin as they wrap around the distal diaphysis. The nerve locations were determined by consensus measurements performed by two board-certified radiologists with certificates of added qualification in neuroradiology and interventional radiology. The proximity of each respective genicular nerves was measured by drawing a perpendicular line from each genicular nerve to the height of the target point. All measurements were taken on the mid-coronal view at the point of maximal epiphyseal flare. MAIN OUTCOME MEASUREMENTS: Positive values indicated the location of the neurovascular bundle to be superior to the target point. Negative values indicated the location of the neurovascular bundle to be inferior to the target point. RESULTS: The distance between our target point and the inferior border of SLGN ranged from -3 mm to 6 mm. Twenty-three out of 25 (92%) SLGN lied exactly at or above our target intersection. The distance between our target point and the inferior border of SMGN ranged from -1 mm to 2 mm with twenty-two out of 25 (88%) SMGN lied exactly at or above our target point. The distance between our target point and the superior border of IMGN ranged from 0 mm to 3 mm with all (100%) IMGN lying exactly at or above the target point. CONCLUSION: The intersection of the femoral diaphyseal shaft to a line along the metaphyseal flare and the intersection of the tibial diaphyseal shaft to a line along the medial metaphyseal can be used as a target point to localize the genicular nerves with close proximity.

The utility of magnetic resonance imaging results in physician decision-making before initial lumbar spinal injection.

BACKGROUND CONTEXT: The need for advanced imaging before spinal intervention is an area of ongoing debate. Many studies have demonstrated the accuracy of magnetic resonance imaging (MRI) results in evaluating structural pathology in the lumbar spine, but few have addressed how frequently MRI findings change clinical management. A randomized controlled trial showed that viewing MRI results did not impact outcomes in patients with radiculopathy undergoing epidural steroid injection (ESI). The results suggested ESIs that correlated with both imaging and clinical findings experienced slightly more benefit than the blinded cohort, although statistically insignificantly. PURPOSE: Three related studies were conducted to (1) increase understanding of the opinions of interventional spine physicians regarding the utility of viewing imaging before injection and (2) evaluate the impact of viewing MRI results on injection planning (retrospective and prospective analyses). STUDY DESIGN: Survey, prospective, and retrospective analysis. PATIENT SAMPLE: Patients presenting to a university-based spine center for initial evaluation of back or leg pain who were candidates for spinal intervention. OUTCOME MEASURES: Self-reported measures from a clinical practice questionnaire distributed to interventional spine physicians to determine rates and rationale for utilization of MRI before spine injection, physiologic measures including MRI results, functional measures including physician decision-making regarding type and location of injection performed. METHODS: This study was funded by the University of Colorado Health and Welfare Trust. A survey was sent to interventional spine physicians to assess their utilization of MRI results before spine procedures. A retrospective analysis of patients who were candidates for ESI was conducted to evaluate how initial injection plan compared with the postviewing of MRI results on injection performed. In a prospective analysis, injection plans pre- and post-MRI were compared among patients presenting for initial evaluation of low back or leg pain. RESULTS: Survey responses showed that specialists order MRI studies to correlate with physical exam (91%) and to detect the presence of synovial cysts (68%), whereas tumor/infection (93%) was most likely to cause a change in their approach. In the retrospective review, the physician's planned approach before viewing the MRI was concordant with the actual procedure 49% of the time. A different type of procedure was performed in 15% of planned injections. In such cases, the initial treatment plan was altered (ie, same procedure at a different or additional level or side) in 35% of planned injections. In the prospective data collection, 43% of injections were different from the initial physician decision. The most common reasons for altering the injection was different level affected (36%), facet pathology (22%), and different nerve root affected (16%). CONCLUSIONS: In clinical practice, MRI before injection frequently changes management decisions in the planning and delivery of lumbar spine injections.

The Effectiveness of Autologous Platelet-Rich Plasma for Osteoarthritis of the Hip: A Retrospective Analysis.

BACKGROUND: Platelet-rich plasma (PRP) is a minimally invasive treatment option to reduce pain and promote tissue healing. At the time this study was performed, there was limited published literature analyzing outcomes for patients treated with PRP for hip osteoarthritis. METHODS: Thirty-six patients aged 49-85 (66.0 ± 12.1) years with chronic hip pain who met inclusion criteria underwent image-guided intra-articular hip PRP injection. Outcomes were measured at baseline, two weeks, three months, and up to six months using the visual analog scale (VAS) for pain and the Hip Disability and Osteoarthritis Outcome Score (HOOS). The proportion of responders, as defined by a ≥50% reduction in VAS pain score, was assessed at three and six months. RESULTS: At two weeks, there was a significant improvement (P < 0.05) of function in two HOOS subscales: Symptoms and Activities of Daily Living. There was a significant improvement in all HOOS categories at six months. A significant improvement in VAS was observed at six months (baseline VAS = 6.9 ± 0.7 &→ 4.3 ± 1.8, 95% confidence interval = 2.0 to 3.2, P < 0.05). Sixty-seven percent (24/36) of the patients reported a ≥50% improvement in pain at three months; 58% (21/36) reported a ≥50% improvement in pain at six months. Stratification by Kellgren-Lawrence grades revealed that 86% and 82% of the KL grades 1 and 2 were responders at six months, respectively. CONCLUSIONS: In patients with mild/moderate hip osteoarthritis, PRP may provide pain relief and functional improvement for up to six months.

Systematic Review of the Efficacy of Particulate Versus Nonparticulate Corticosteroids in Epidural Injections.

OBJECTIVE: To systematically analyze published studies in regard to the comparative efficacy of particulate versus nonparticulate corticosteroids for cervical and lumbosacral epidural steroid injections (ESI) in reducing pain and improving function. TYPE: Systematic review. LITERATURE SURVEY: MEDLINE (Ovid), EMBASE, and Cochrane databases were searched from the period of 1950 to December 2015. METHODOLOGY: Criteria for inclusion in this review were (1) randomized controlled trials and (2) retrospective studies that compared particulate versus nonparticulate medication in fluoroscopically guided injections via a transforaminal (TF) or interlaminar (IL) approach. Each study was assigned a level of evidence (I-V) based on criteria for therapeutic studies. A grade of recommendation (A, B, C, or I) was assigned to each statement. Categorical analysis of the data was reported when available, with success defined by the minimal clinically important difference for appendicular radicular pain-a reduction of at least 2 on the visual analog scale. When data were available, additional categorical analysis included the proportion of individuals with a reduction in pain of at least 50%, 70%, or 75%. Follow-up was included at all reported intervals from 2 weeks to 6 months. SYNTHESIS: Three cervical ESI and 6 lumbar ESI studies were found to be suitable for review. Of the 3 cervical ESI studies, 2 were retrospective studies with grade III level of evidence and 1 was a randomized controlled trial with grade II evidence. Of 4 lumbar ESI studies that used a TF approach, the 2 randomized double-blinded controlled trials were grade I evidence and 2 retrospective studies were grade II and III level of evidence. One randomized controlled trial using the lumbar IL approach was level II evidence. One retrospective cohort study using the lumbar TF, IL and caudal approach was level III evidence. CONCLUSIONS: There is no statistically significant difference in terms of pain reduction or improved functional outcome between particulate and nonparticulate preparations in cervical ESI and, therefore, the authors recommend using nonparticulate steroid when performing cervical TFESI (Grade of Recommendation: B). In patients with lumbar radiculopathy due to stenosis or disk herniation, TFESI using particulate versus non-particulate is equivocal in reducing pain (Grade of Recommendation: B) and improving function (Grade of Recommendation: C) and therefore the authors recommend the use of nonparticulate steroids for lumbar TFESI in patients with lumbar radicular pain (Grade of Recommendation: B). There is insufficient information to make a recommendation of one steroid preparation over the other in lumbar ILESI (Grade of Recommendation: I). Given the lack of strong data favoring the efficacy of one steroid preparation over the other, and the potential risk of catastrophic complications, all of which have been reported with particulate steroids, nonparticulate steroids should be considered as first line agents when performing ESIs. LEVEL OF EVIDENCE: III.

Treatment of postherpetic neuralgia using a thoracic transforaminal epidural steroid injection.

A 64-year-old male patient with a history of herpes zoster exposure presented with severe, constant, burning pain in the left T10 dermatome consistent with postherpetic neuralgia. Previous treatment included oral and topical medications as well as an intercostal nerve block; however, these treatment options did not provide significant relief. The patient was treated with a single-level T10 thoracic transforaminal epidural steroid injection for refractory postherpetic neuralgia. He reported complete resolution of his symptoms at 2- and 12-week follow-ups. This case illustrates transforaminal epidural steroid injections may be a successful treatment option for postherpetic neuralgia.