Sacroiliac Joint Interventions.

The sacroiliac joint complex (SIJC) is composed of complex anatomy of numerous potential pain generators that demonstrate varying pathophysiology and differing innervations. This heterogeneity has been a challenge to advancing research and clinical care. Moving forward, individualized approaches taking these factors into account may be a path forward to improved outcomes. Thus, as we move toward precision medicine in interventional spine care, it is imperative to investigate more targeted diagnostic and therapeutic approaches to the SIJC.

Radiofrequency Ablation for Chronic Posterior Sacroiliac Joint Complex Pain: A Comprehensive Review.

Radiofrequency ablation of the sacral lateral branches targets the innervation of the posterior sacroiliac ligaments and posterior portion of the sacroiliac joint. These structures are also collectively referred to as the posterior sacroiliac joint complex. This review will discuss current diagnostic block paradigms and selection criteria for sacral lateral branch radiofrequency ablation, varying techniques and technologies utilized for sacral lateral branch radiofrequency ablation, and updates on the clinical outcome literature. The current evidence suggests that sacral lateral branch radiofrequency ablation can provide relief for posterior sacroiliac joint complex pain, but the literature is limited by variability in selection criteria, the specific nerves targeted by radiofrequency ablation, and the types of radiofrequency ablation technology and techniques utilized in clinical outcome studies.

Low-profile elastic exosuit reduces back muscle fatigue.

We investigated the extent to which an un-motorized, low-profile, elastic exosuit reduced the rate of fatigue for six lumbar extensor muscles during leaning. Six healthy subjects participated in an A-B-A (withdrawal design) study protocol, which involved leaning at 45º for up to 90 s without exosuit assistance (A1), then with assistance (B), then again without assistance (A2). The exosuit provided approximately 12-16 Nm of lumbar extension torque. We measured lumbar muscle activity (via surface electromyography) and assessed fatigue rate via median frequency slope. We found that five of the six subjects showed consistent reductions in fatigue rate (ranging from 26% to 87%) for a subset of lumbar muscles (ranging from one to all six lumbar muscles measured). These findings objectively demonstrate the ability of a low-profile elastic exosuit to reduce back muscle fatigue during leaning, which may improve endurance for various occupations.

Complications Associated With Electromyography: A Systematic Review.

OBJECTIVES: The aims of the study were to systematically review the available literature concerning complications due to electromyography and to review those associated with nerve conduction studies. DESIGN: A systematic review was undertaken of Medline and Cochrane Central Register of Controlled Trials. Any complication related to clinical electromyography written in English was included, and all bibliographies were scanned for missed articles. RESULTS: A total of 27 articles fit the inclusion criteria, with two observational studies, and the rest case series or case studies; 42 patients were reported. Of these, 28 patients required hospitalization and 22 required surgery or a procedure, with zero deaths reported. Needle-related complications were the most prevalent (18 patients reported), with 17 related to pneumothoraces. Disorders of hemostasis were identified in 13 patients (many were asymptomatic) and cutaneous disorders were identified in 11 patients. Only one complication was identified in the narrative review related to nerve conduction studies. CONCLUSIONS: This systematic review identified a variety of complications related to electromyography. Although the incidence of these occurrences cannot be elucidated from the case series and case study-predominant literature, adverse events seem to be rare but can cause significant morbidity. Electromyographers should be aware of all reported complications; this review outlines all reported occurrences that fit the inclusion criteria.

Radiofrequency Ablation for Posterior Sacroiliac Joint Complex Pain: A Narrative Review.

Radiofrequency ablation (RFA) of the sacral lateral branches targets the innervation of the posterior sacroiliac ligaments and posterior portion of the sacroiliac joint, also referred to as the posterior sacroiliac joint complex. This review assesses the published evidence on local anesthetic blocks for the diagnosis of posterior sacroiliac joint complex pain and the efficacy of RFA of the sacral lateral branches as a treatment. The current evidence suggests that RFA can provide relief of pain that originates from the posterior sacroiliac joint complex, but interpretation of this literature is limited by variability in patient selection criteria, the specific nerves targeted for ablation, and the types of RFA technology and technique utilized.

Effect of pre-injection opioid use on post-injection patient-reported outcomes following epidural steroid injections for radicular pain.

BACKGROUND CONTEXT: Chronic opioid therapy is associated with worse patient-reported outcomes (PROs) following spine surgery. However, little literature exists on the relationship between opioid use and PROs following epidural steroid injections for radicular pain. PURPOSE: We evaluated the association between pre-injection opioid use and PROs following spine epidural steroid injection. STUDY DESIGN: This study is a retrospective analysis of a prospective longitudinal registry database. PATIENT SAMPLE: A total of 392 patients within our database who were undergoing epidural steroid injections (ESIs) at our institution for degenerative structural spine diagnoses and met our inclusion criteria were included in this study. OUTCOME MEASURES: Patient-reported outcomes for disability (Oswestry Disability Index/Neck Disability Index [ODI/NDI)]), quality of life (EuroQol-5D [EQ-5D]), and pain (Numerical Rating Scale scores for back pain, neck pain, leg pain, and arm pain [NRS-BP/NP/LP/AP]) were assessed at baseline and at 3 and 12 months post-injection. METHODS: Multivariable proportional odds logistic regression models were created to examine the relationship between pre-injection opioid use and post-injection PROs. A logistic regression with Bayesian Markov chain Monte Carlo parameter estimation was used to investigate a possible cutoff value of pre-injection opioid use above which the effectiveness of ESI (as measured by minimum clinically important difference [MCID] for ODI/NDI) decreases. RESULTS: A total of 276 patients with complete 12-month follow-up following ESI were analyzed. The mean pre-injection daily morphine equivalent amount (MEA) was 14.7 mg (95% confidence interval [CI] 12.4 mg-19.1 mg) for the cohort. Pre-injection opioid use was associated with slightly higher odds of worse disability (odds ratio [OR] 1.03, p=.03) and leg/arm pain (OR 1.01, p=.04) scores at 3 months post-injection only. No significant association between pre-injection opioid use and MCID for ODI/NDI was found, although a cutoff of 55.5 mg/day might serve as a significant threshold. CONCLUSION: Increased pre-injection opioid use does not impact long-term outcomes after ESIs for degenerative spine diseases. A pre-injection MEA around 50 mg/day may represent a threshold above which the 3-month effectiveness of ESI for back- and neck-related disability decreases. Epidural steroid injection is an effective treatment modality for pain in patients using opioids, and can be part of a multimodal strategy for opioid independence.

Feasibility of a Biomechanically-Assistive Garment to Reduce Low Back Loading During Leaning and Lifting.

GOAL: The purpose of this study was: 1) to design and fabricate a biomechanically-assistive garment which was sufficiently lightweight and low-profile to be worn underneath, or as, clothing, and then 2) to perform human subject testing to assess the ability of the garment to offload the low back muscles during leaning and lifting. METHODS: We designed a prototype garment which acts in parallel with the low back extensor muscles to reduce forces borne by the lumbar musculature. We then tested eight healthy subjects while they performed common leaning and lifting tasks with and without the garment. We recorded muscle activity, body kinematics, and assistive forces. RESULTS: The biomechanically-assistive garment offloaded the low back muscles, reducing erector spinae muscle activity by an average of 23-43% during leaning tasks, and 14-16% during lifting tasks. CONCLUSION: Experimental findings in this study support the feasibility of using biomechanically-assistive garments to reduce low back muscle loading, which may help reduce injury risks or fatigue due to high or repetitive forces. SIGNIFICANCE: Biomechanically-assistive garments may have broad societal appeal as a lightweight, unobtrusive, and cost-effective means to mitigate low back loading in daily life.

Conservative Care in Lumbar Spine Surgery Trials: A Descriptive Literature Review.

OBJECTIVE: To evaluate the degree to which conservative care and failure were specifically defined in studies comparing nonoperative treatment versus surgery for low back pain (LBP) conditions in adults. DATA SOURCES: A comprehensive literature search was conducted by an experienced librarian using MEDLINE (PubMed), Embase, Google Scholar, and CENTRAL from January 2003 to June 2014. Endnote bibliographic management application was used to remove duplicates and organize the citations. STUDY SELECTION: Prospective, randomized, or cohort trials comparing surgery versus conservative intervention for patients with LBP conditions. Study selection was conducted by 2 independent reviewers. DATA EXTRACTION: Three independent reviewers extracted data from each article using a structured data extraction form. Data extracted included type of study, participant characteristics, sample size, description, and duration of conservative care and whether failed conservative care criterion was defined. DATA SYNTHESIS: A total of 852 unique records were screened for eligibility; of those, 72 articles were identified for further full-text review. Thirty-four full texts were excluded based on the exclusion criteria, and 38 articles, representing 20 unique studies, were included for qualitative synthesis. Fifteen of the 20 studies defined the duration of conservative care. Only 3 studies defined the dosage of physical therapy sessions, including total number of visits and visit duration. Two studies described medication usage, including the duration and type. No studies specifically defined what constituted failed conservative therapy. CONCLUSIONS: This literature review suggests conservative care is poorly defined in randomized trials, which can lead to ambiguity of research procedures and unclear guidelines for clinicians. Future studies should increase transparency and explicitly define conservative care.

Effects of Off-Axis Elliptical Training on Reducing Pain and Improving Knee Function in Individuals With Patellofemoral Pain.

OBJECTIVE: To examine whether an off-axis elliptical training program reduces pain and improves knee function in individuals with patellofemoral pain (PFP). DESIGN: Controlled laboratory study, pretest-posttest. SETTING: University rehabilitation center. PARTICIPANTS: Twelve adult subjects with PFP. INTERVENTIONS: Subjects with PFP completed an exercise program consisting of 18 sessions of lower extremity off-axis training using a custom-made elliptical trainer that allows frontal plane sliding and transverse plane pivoting of the footplates. MAIN OUTCOME MEASURES: Changes in knee pain and function posttraining and 6 weeks after training were evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) scores. Lower extremity off-axis control was assessed by pivoting and sliding instability, calculated as the root mean square (RMS) of the footplate pivoting angle and sliding distance during elliptical exercise. Subjects' single-leg hop distance and proprioception in detecting lower extremity pivoting motion were also evaluated. RESULTS: Subjects reported significantly greater KOOS and IKDC scores (increased by 12-18 points) and hop distance (increased by 0.2 m) after training. A significant decrease in the pivoting and sliding RMS was also observed after training. Additionally, subjects with PFP demonstrated improved pivoting proprioception when tested under a minimum weight-bearing position. CONCLUSIONS: An off-axis elliptical training program was effective in enhancing lower extremity neuromuscular control on the frontal and transverse planes, reducing pain, and improving knee function in persons with PFP. CLINICAL RELEVANCE: This study provides a novel intervention approach to enhance the control of the frontal and transverse plane motions of the lower extremities during functional weight-bearing activities. This novel off-axis elliptical training may be incorporated with other common treatment options currently available for PFP to augment the effects of musculoskeletal rehabilitation for the PFP population.