Antiplatelet and Anticoagulant Risk for Select Spine Interventions: A Retrospective Cohort.

OBJECTIVES: To identify significant bleeding complications following spinal interventions in patients taking medications with antiplatelet or anticoagulation effect. DESIGN: Retrospective chart review of a 12-month period. SETTING: Outpatient academic medical practice. INTERVENTIONS: Injections during outpatient interventional spine clinical encounters, including 14 cervical transforaminal epidural steroid injections, 26 cervical medial branch blocks, seven cervical radiofrequency neurotomies, three cervical facet joint injections, 88 lumbar transforaminal epidural steroid injections, 66 lumbosacral medial branch blocks, 18 lumbosacral radiofrequency neurotomies, 13 lumbar facet joint injections, one caudal epidural steroid injection, 11 sacral transforaminal epidural steroid injections, and 32 sacroiliac joint injections. MAIN OUTCOME MEASURE: Epidural hematoma or other serious bleeding. RESULTS: In this cohort of 275 consecutive encounters with available records in which patients underwent a spinal injection while continuing medications with antiplatelet or anticoagulant effect, zero of the 275 clinical encounters (0%, 95% confidence interval = 0-1.4%) resulted in epidural hematoma or other serious bleeding. For antiplatelet medication, nonsteroidal anti-inflammatory drugs were continued in 102 procedures, aspirin in 142, clopidogrel in 21, and meloxicam and/or Celebrex in 81; for anticoagulation medication, warfarin was continued in four procedures, apixaban in six, dabigatran in one, and fondaparinux in two. Of note, one patient suffered a deep vein thrombosis, which was identified at two-week follow-up despite continuing aspirin therapy. CONCLUSIONS: This cohort adds to the growing evidence that the risk of serious bleeding complications from select spine interventions while continuing medications with antiplatelet or anticoagulant effect appears low.

Validity of Physical Exam Maneuvers in the Diagnosis of Sacroiliac Joint Pathology.

BACKGROUND: A combination of physical examination maneuvers is currently considered necessary to help predict who will respond to injections in the sacroiliac joint. However, the literature on this topic currently consists of conflicting studies, with one showing the value of a combination of exam maneuvers and the other showing no real value. OBJECTIVE: To determine the diagnostic validity of sacroiliac joint (SIJ) physical exam maneuvers using anesthetic intra-articular injection as a reference standard. DESIGN: A single institution prospective study. PARTICIPANTS: Patients with the clinical diagnosis of SIJ pain and referred for SIJ injection were enrolled. MAIN OUTCOME MEASURE: Numeric rating scale (NRS) to assess pain intensity. RESULTS: Participants underwent fluoroscopically guided SIJ intra-articular injection with 1 cc of 2% lidocaine and 1 cc of triamcinolone 40 mg. Patients' pain was assessed via 0-10 NRS pre-injection and immediately postinjection to determine positive anesthetic response to the injection. Six physical exam maneuvers (thigh thrust, Geanslen's test, FABER test, distraction test, compression test, and sacral thrust) were performed pre-injection and 15 minutes postinjection. The results of these SIJ physical exam maneuvers were evaluated singly and in combinations for diagnostic power in relation to a positive anesthetic response (>80% relief) to the injection. No association was found between a single SIJ physical exam maneuver or combination of maneuvers and anesthetic response to the injection. CONCLUSIONS: In this cohort, patient physical exam maneuvers to identify intra-articular SIJ pain did not demonstrate diagnostic value when compared with the reference standard of an intra-articular anesthetic block.

Challenges in Diagnosing Sacroiliac Joint Pain: A Narrative Review.

Accurate diagnosis of sacroiliac joint (SIJ) pain is challenging. Diagnosis can be aided by pain referral patterns, historical features, physical examination maneuvers, and imaging. However, all of these diagnostic tools have limitations. The most reliable clinical tools may be a combination of three or more positive physical exam maneuvers, although the evidence is inconsistent even for this strategy. Intra-articular diagnostic SIJ injections are often used as the reference standard for "true" sacroiliac pain. However, such injections do not consider extra-articular sources of pain that may also exist as part of the sacroiliac joint complex. Research has established the posterior sacral ligaments as a possible source of pain, and the innervation of these ligaments has been anatomically defined. It is possible that by expanding our focus from the articular portion of the sacroiliac complex structure to both the joint and extra-capsular ligaments, advancements in clinical diagnosis and treatment will be possible.

Improving Diabetic Retinopathy in an Indigent Population.

Diabetic retinopathy is the leading cause of preventable blindness in working-age American adults. This study hypothesized that patients with diabetes types I and II at St.Luke's Free Medical Clinic in Spartanburg, South Carolina were not being systematically referred for annual diabetic retinopathy screening. We evaluated the number of patients referred for screening, those patients who actually went for the screening, and the rate at which retinopathy was found in those who went. Of the 111 charts reviewed, only 49.5% of the patients were referred to an eye care professional between January 1, 2013 and December 31, 2014. Of those referred, 21.1% were found to have vision-threatening pathology. The median number of days to have an eye exam was 28.5. A standardized method to screen for diabetic retinopathy in the clinic would alleviate the referral burden and ultimately allow for detection of ocular pathology earlier in the course of disease.