Vertebral Augmentation of Cancer-Related Spinal Compression Fractures: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: To compare the magnitude and duration of pain relief with vertebral augmentation to any other therapy for the treatment of cancer-related vertebral compression fractures through meta-analysis of randomized controlled trials. SUMMARY OF BACKGROUND DATA: Derived from search on PubMed, EMBASE, CINAHL, Scopus, Central, Scopus, and Web of Science databases in May 2020. Studies selected were limited to randomized controlled trials comparing vertebral augmentation, either Balloon Kyphoplasty or Percutaneous Vertebroplasty (PVP) with or without additional therapy to any other intervention or placebo/sham. METHODS: The methodological quality of each included study was assessed according to the Cochrane Collaboration's domain-based framework. Random effects model, Q test, and I2 statistics were implemented. RESULTS: Of 180 records identified, 7 were considered relevant, and included 476 participants. The risk of bias was considered "Low" in all studies. In five of the studies, vertebral augmentation alone (either PVP or Balloon Kyphoplasty) comprised one group, while comparative treatments included nonsurgical management, Kiva implantation, PVP and radiofrequency therapy, PVP and chemotherapy, PVP and intrasomatic injection of steroid, and PVP with 125I seeds. Two studies compared PVP with an additional therapy against the standard of care. With regard to changes in pain severity, the effect sizes varied from 0.0 (95% -1.7 to 1.7) to -5.1 (95% -5.3 to -4.9). Most studies demonstrated a positive and statistically significant effect associated with PVP. Four of the seven studies demonstrated a clinically significant effect as well. Other than cement leakage, with an event rate of 0.24 (95% CI 0.11-0.44) or 24% (95% CI 11%-44%), there were no major adverse events consistently observed across multiple studies. CONCLUSIONS: The included randomized controlled trials demonstrated an overall positive and statistically significant effect of vertebral augmentation surgeries, such as vertebroplasty and kyphoplasty, for the treatment of cancer-related vertebral compression fractures, especially when compared with nonsurgical management, radiofrequency ablation, or chemotherapy alone.Level of Evidence: 1.

The Effectiveness of Lumbar Transforaminal Injection of Steroid for the Treatment of Radicular Pain: A Comprehensive Review of the Published Data.

OBJECTIVE: To determine the effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain. DESIGN: Comprehensive systematic review. OUTCOME MEASURES: The primary outcome of interest was the proportion of individuals with reduction of pain by ≥50%. Additional outcomes of interest were a more-than-two-point reduction in pain score, patient satisfaction, functional improvement, decreased use of pain medication, and avoidance of spinal surgery. RESULTS: For patients with disc herniations, using the criterion of ≥50% reduction in pain, success rates across included studies (range) were 63% (58-68%) at one month, 74% (68-80%) at three months, 64% (59-69%) at six months, and 64% (57-71%) at one year. For patients with lumbar spinal stenosis, success rates across included studies (range) were 49% (43-55%) at one month, 48% (35-61%) at three months, 43% (33-53%) at six months, and 59% (45-73%) at one year, but there was a lack of corroboration from appropriately controlled studies. CONCLUSIONS: There is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. There is a lack of high-quality evidence demonstrating their effectiveness for the treatment of radicular pain due to spinal stenosis, though small studies suggest a possible benefit. Lumbar transforaminal injection of nonparticulate steroids is as effective as injections with particulate steroids.

Use of pain medication before and after lumbar discectomy: longitudinal analysis of a nation-wide cohort.

BACKGROUND: Previous studies have suggested that variation in results of lumbar discectomy depends on careful selection of patients. Numerous factors have been suggested to explain this variation with no direct examinations on this issue. The objective was to examine the use of pain medication before and after lumbar discectomy in patients with back pain. METHODS: Prospective occupational cohort study (N.=151,618) with linkage to national registers. Of the cohort members, 1538 (age 44 years) underwent discectomy. Records from purchases of pain medication were obtained during a 3-year period before and after hospital discharge. RESULTS: Purchases of pain medication increased during the follow-up period from 9.7±28.7 to 17.3±17.3 defined daily doses. Three groups were identified: 1) with constant, relatively low pain medication use; 2) with high use combined with further increases in purchases until the time of surgery and only a slight decrease thereafter; and 3) with a sharp rise in medication use before surgery and a return to no pain medication use approximately six months after the discharge. Non-manual profession (OR=1.34, 95% CI: 1.06 to 1.69) and open surgery technique increased (OR=1.32, 95% CI: 1.04 to 1.67) the probability of being included into the third group. CONCLUSIONS: The greater decline in the use of pain medication after discectomy was associated with a sharp rise of that use within six months before surgery. This suggests that lumbar discectomy may benefit especially those with acute or subacute pain within the six-month window.

The effect of body mass index on fluoroscopy time and radiation dose in intra-articular glenohumeral joint injections.

PURPOSE: To determine the relationship between body mass index (BMI) and fluoroscopy time and radiation dose during fluoroscopy-guided glenohumeral joint injections. METHODS: This was a retrospective analysis of prospectively collected data. Physicians with board certification in Physical Medicine and Rehabilitation and/or Sports Medicine performed or supervised all injections. BMI was calculated within three months of the injection. Fluoroscopy time and radiation dose data were recorded by the fluoroscopy system and transcribed into the clinical database after each procedure. RESULTS: A total of 335 intra-articular GHJ injections were performed, 230 on the right shoulder and 105 on the left shoulder; none were bilateral. The mean fluoroscopy time for all injections was 18.8±12.6s, and the mean radiation DAP was 656±1190mGy-cm2. There was no significant difference in fluoroscopy time or dose between first-time and repeat injections (P=.405; P=.011) and no significant differences in fluoroscopy time or radiation dose when a trainee was involved (P=.756 for time and P=.149 for dose). Needle lengths of 1.5, 2.5, or 3.5in. were used during the injection, and there was no significant difference in needle length selection between BMI groups (P=.319). CONCLUSIONS: Intra-articular glenohumeral joint injection fluoroscopy time and radiation dose are not affected by body mass index, age, gender, trainee-involvement, first versus repeat injection, or needle length. This procedure is associated with a dose of radiation that likely has minimal to no clinical significance.

Percutaneous Needle Tenotomy for the Treatment of Lateral Epicondylitis: A Systematic Review of the Literature.

OBJECTIVE: To analyze the literature to determine whether controlled studies on percutaneous tenotomy have been published, and if so, to systematically assess the efficacy of percutaneous tenotomy for the treatment of tendinosis at the lateral epicondyle of the elbow. DESIGN: Systematic review of the available literature. METHODS: Cochrane Controlled Trials Register (CENTRAL), MEDLINE, EMBASE, CINAHL, and Web of Science databases were searched in November 2015, unrestricted by date. After the initial search, we excluded conference proceedings, theses, reviews, expert opinions, and publications written in languages other than English. Next, 2 independent reviewers screened all of the remaining records with regard to their titles and abstracts, and subsequently, the full texts of identified publications potentially relevant to the present study. RESULTS: Six articles focused on percutaneous tenotomy, none of which were controlled against a placebo or conservative treatment group. The absence of true randomized controlled trials created a great deal of heterogeneity between the studies; thus we could not include any of our studies in the intended final quantitative analysis with meta-analysis tools. We describe all 6 studies identified by this systematic review with a detailed analysis of the procedural methods, outcome measures, and conclusions of each study. CONCLUSIONS: Percutaneous tenotomy presents an alternative to surgical release of the common extensor tendon for the treatment of chronic tendinosis at the lateral epicondyle of the elbow. Current research supporting the efficacy of this procedure, however, is of low quality (level II to level IV). LEVEL OF EVIDENCE: III.

Is There a Relationship Between Body Mass Index and Fluoroscopy Time During Cervical Interlaminar Epidural Steroid Injections?

BACKGROUND: The challenge of obtaining medical imaging in individuals with higher body mass index (BMI) is described, but there is minimal data regarding the relationship between BMI and fluoroscopy time during cervical interlaminar epidural steroid injection (CIESI). OBJECTIVE: To determine the relationship between BMI and fluoroscopy time during CIESI. METHODS: Retrospective cohort study of patients who underwent fluoroscopically guided CIESI between January 2014 and February 2015 at an academic pain medicine center. Fluoroscopy time data were collected. Comparisons based on analysis of variance were made between patients with normal (<25.0 kg/m 2 ), overweight (25.0-29.9 kg/m 2 ), and obese (≥30.0 kg/m 2 ) BMI. RESULTS: Of 399 procedure encounters, 366 had documented BMI and fluoroscopy time data and were included for analysis. Mean age (± SD) in this cohort was 53 ± 13 years, including 189 females (52%) and 205 first-time injections. Mean fluoroscopy time for all injections was 18 ± 10 seconds. Separated by categorical BMI class, the mean fluoroscopy time was 18 ± 9 seconds for normal weight patients, 17 ± 10 seconds for overweight patients, and 20 ± 11 seconds for obese patients, respectively. Post hoc analysis showed that fluoroscopy time was significantly longer only in obese compared with overweight patients ( P = 0.02). Trainee involvement and first-time vs repeat injection did not significantly alter fluoroscopy time ( P = 0.17 and P = 0.12, respectively). CONCLUSIONS: The findings of this study indicate that BMI does not appear to have a clinically significant impact on fluoroscopy time during cervical interlaminar epidural steroid injection procedures. Future study is needed to directly quantify radiation exposure in patients and practitioners, as well as the associated health risk.

Novel Treatment of Radicular Pain With a Multi-Mechanistic Combination Topical Agent: A Case Series and Literature Review.

INTRODUCTION: Pharmacologic treatment of radicular pain with oral medications is limited by adverse effects and concern for dependence. While topical formulations have been explored in pain research, there is no published literature evaluating the efficacy in radicular pain. We present the first three cases of radicular pain successfully treated with a topical formulation of diclofenac, ibuprofen, baclofen, cyclobenzaprine, bupivacaine, gabapentin, and pentoxifylline (T7). CASE PRESENTATION: Case series evaluating T7 for treatment of radicular pain in a single, outpatient pain center. Pain was rated on the numeric rating scale (NRS) on initial evaluation and follow up after a trial of T7. One to two grams of T7 was applied to the affected area 3 - 4 times daily in addition to the patient's baseline pharmacologic management. Three patients with median age of 50 (range, 39 to 65) and diagnosis of cervical and/or lumbosacral radicular pain participated. Two of the three had chronic radicular pain despite use of analgesic agents, spinal injections and failed spinal surgery syndrome. Each reported subjective improvement in radicular pain, function and sleep. There was an average decrease in NRS score consistent with 30% - 40% global improvement in symptoms, clinically significant based on the minimal clinically important difference for radicular pain. T7 was well tolerated without adverse reactions. Surgery was prevented or delayed in all cases. CONCLUSIONS: This is the first report of the successful treatment of radicular pain with a topical agent. This highlights the need for randomized, prospective study of both single and compounded topical agents for treatment of radicular pain.

Comparing Percutaneous Vertebroplasty and Conservative Therapy for Treating Osteoporotic Compression Fractures in the Thoracic and Lumbar Spine: A Systematic Review and Meta-Analysis.

BACKGROUND: Vertebral compression fractures are a common complication of osteoporosis and are often treated by percutaneous vertebroplasty (PVP). The ability of this procedure to relieve pain better than conservative treatment is still debated. The purpose of this study was to compare the degree and duration of pain relief following PVP with that following conservative treatment for osteoporotic compression fractures by means of meta-analysis of randomized controlled trials. METHODS: The CENTRAL (Cochrane Central Register of Controlled Trials), MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Web of Science databases were queried for randomized controlled trials comparing PVP with conservative treatment or placebo/sham. The methodological quality was assessed according to the Cochrane Collaboration's domain-based evaluation framework. Random-effects meta-analysis of the raw mean difference between groups in change in pain level was performed, with sensitivity analyses and the Egger test for potential publication bias. RESULTS: Of 209 records found, 11 were considered relevant, involving 1,048 participants. The risk of bias was considered low in 10 studies and high in 1. The 531 patients treated with PVP had a significantly lower pain level compared with the control group at 1 to 2 weeks, 2 to 3 months, and 12 months. The 95% CI (confidence interval) of the pooled effect size at every time interval included the score of 1.5, considered to be the minimal clinically important difference. The largest pooled effect size of -1.4 (95% CI, -2.3 to -0.5) was found during the first 1 to 2 weeks. The heterogeneity was high at all 3 time points (I(2), 71% to 96%). No significant publication bias was detected. CONCLUSIONS: Up to 1 year postoperatively, the effect of PVP exceeded the effect of conservative therapy with respect to pain relief in patients with osteoporotic compression fractures. The effect size was significant and close to the minimal clinically important difference.

Ranges of motion after reverse shoulder arthroplasty improve significantly the first year after surgery in patients with rheumatoid arthritis.

OBJECTIVES: To evaluate the trajectory of the change in range of motion after reverse shoulder joint replacement during 3-year follow-up among patients with rheumatoid arthritis. METHODS: Retrospective cohort longitudinal study of 76 shoulder replacements performed in a university clinic. The range of shoulder motion was assessed by a physiotherapist using a manual goniometer with 5-degree precision before the surgery and 1, 3, 6, 12, and 36 months postoperatively. RESULTS: The shapes of the regression curves suggest that the improvement or decline observed in joint motion was happening mostly during the first year after surgery. After 1 year, the trajectories become flat and they remained unchanged until the end of follow-up. CONCLUSIONS: After shoulder joint replacement, the range of shoulder motion showed substantial changes during the first year only. This should be taken into account when scheduling control visits, planning rehabilitation, and predicting the use of community services after the surgery.

The effect of body mass index on fluoroscopic time and radiation dose during lumbar transforaminal epidural steroid injections.

OBJECTIVE: Transforaminal epidural steroid injections (TFESIs) are a commonly used, effective treatment for radicular pain. Accurate delivery of the injected medication helps to ensure maximum therapeutic efficacy and to decrease possible adverse events, and fluoroscopy is the preferred and most common image-guidance modality used to ensure accurate needle placement during lumbar TFESIs. However, fluoroscopic-guided lumbar TFESIs put patients at risk because of radiation exposure. The purpose of this study was to determine the relationship between body mass index (BMI) and fluoroscopy time and radiation dose during lumbar TFESIs. DESIGN: A retrospective study design was used. SETTING: The study was conducted at an academic orthopedic center. All procedures were performed by physicians board-certified in Physical Medicine and Rehabilitation (PM&R) and with subspecialty certification in sports medicine, or by a trainee under close supervision from an attending physician. PARTICIPANTS: Participants were patients who underwent fluoroscopic-guided lumbar TFESIs between February 2013 and March 2015 with a documented height/weight, fluoroscopy time, and radiation dose. INTERVENTIONS: All patients received unilateral or bilateral lumbar TFESIs with fluoroscopic guidance. Fluoroscopy time and dose were recorded. MAIN OUTCOME MEASURES: The main outcome measures were fluoroscopy time and radiation dose. A Bonferroni correction was implemented for multiple comparisons, defining statistical significance at p<.01. RESULTS: A total of 2,443 injections were performed on 1,548 patients. There were 419 normal, 572 overweight, and 557 obese patients, respectively. There were 1,426 first-time injections and 1,017 repeat injections. Sixty-nine percent (1,681) were unilateral injections, and 26.4% (645) were single level injections. A trainee was involved in 1,361 (55.7%) of the injections performed. The mean fluoroscopy time for all injections was 30.0±17.5 seconds, and the mean radiation dose was 2,164±1,484 mGy-cm(2). The mean fluoroscopy time was 27.7±15.2 seconds for normal weight patients, 30.0±21.0 seconds for overweight patients, and 32.2±15.1 seconds for obese patients, showing a significant difference between groups (p<.001). The mean radiation doses for each group were 1,376±450, 1,911±653, and 3,029±640 mGy-cm(2), respectively, with a significant increase in radiation dose with increasing BMI (p<.001). CONCLUSIONS: The findings of this study demonstrate that fluoroscopy radiation dose and fluoroscopy time during lumbar TFESIs are increased in patients with an elevated BMI, and in patients of greater age, but the presence of a trainee had no effect on fluoroscopy time.

The Effect of Body Mass Index on Fluoroscopic Time and Radiation Dose During Intra-articular Hip Injections.

BACKGROUND: Intra-articular hip injections are commonly performed for both diagnostic and therapeutic interventions. Because of the risk of damage to neurovascular structures, fluoroscopic guidance with injection of contrast material has been established as the gold standard to ensure proper needle placement into the intra-articular space. However, fluoroscopically guided intra-articular hip injections put patients at risk due to radiation exposure. OBJECTIVE: To examine the relationship between body mass index (BMI) and fluoroscopy time and radiation dose during intra-articular hip injections. DESIGN: Retrospective study. SETTING: The study was conducted at an academic orthopedic center. All procedures were performed by physicians board-certified in PM&R and/or with subspecialty certification in sports medicine, or by a trainee under close supervision from an attending physician. PARTICIPANTS: All patients who underwent fluoroscopically guided intra-articular hip injections between the years 2003-2014 with a documented height/weight, fluoroscopy time, and radiation dose. INTERVENTIONS: All patients received unilateral or bilateral intra-articular hip injections with fluoroscopic guidance. Fluoroscopy time and dose were recorded. MAIN OUTCOME MEASURES: The main outcome measures were fluoroscopy time and radiation dose. A Bonferroni correction was implemented for multiple comparisons, defining statistical significance at P < .01. RESULTS: A total of 438 subjects (446 injections) were included. Mean fluoroscopy times were 17.4 ± 9.9, 17.5 ± 11.4, and 19.1 ± 13.4 seconds for normal, overweight, and obese body mass (BMI) index groups, respectively, with no significant difference between groups (P = .148). The mean radiation doses were 601 ± 690, 678 ± 558, and 1049 ± 812 mGy-cm(2), respectively (P < .001, r = 0.29). There was no association of age (P = .03), needle length (P = .34) or trainee involvement (P = .159) with fluoroscopy time. CONCLUSION: This study demonstrates that increasing BMI leads to elevated radiation dose during fluoroscopically guided intra-articular hip injections. The increased radiation experienced by patients with a larger BMI, however, is likely negligible.

Cooled Radiofrequency Ablation of Genicular Nerves for Knee Osteoarthritis Pain: A Protocol for Patient Selection and Case Series.

BACKGROUND: Chronic knee pain from osteoarthritis (OA) is common in the aging and the obese population. Radiofrequency ablation of the genicular nerves has been introduced as a potential surgery-sparing treatment for chronic knee pain from OA, yet only two outcome studies have been published and optimal patient selection for this procedure has not been established. OBJECTIVES: We describe a standardized protocol for selecting patients for cooled radiofrequency ablation (C-RFA) of the genicular nerves, as well as the clinical outcomes of four patients ages 63-65 years. METHODS: The threshold for selection based on diagnostic genicular nerve block was ≥ 80% pain reduction. Following successful block, C-RFA of the genicular nerves was performed. Outcomes included pain, function, analgesic medication use, opioid use, and progression to total knee arthroplasty at a minimum of 6 month follow up. RESULTS: C-RFA of the genicular nerves after using the described selection protocol resulted in > 90% pain reduction, improved function and avoidance of surgery at 6 months in all four cases. All opioid and analgesic medication use decreased or was unchanged in all cases. No serious adverse events occurred. CONCLUSIONS: The accompanying case series suggests that this protocol is deserving of randomized, prospective study.

Neurosarcoidosis presenting as mononeuritis multiplex.

Sarcoidosis is a multisystem granulomatous disease of unknown etiology, with prevalence ranging from 1 to 50 per 100,000. Neurologic involvement occurs in up to 5% of patients but can be the initial presentation of sarcoidosis in 50% of those affected by neurosarcoidosis. The authors report a case of mononeuritis multiplex of the ulnar and then the radial nerve that subsequently led to a diagnosis of sarcoidosis in a patient 8 mos after initial presentation. It is important that neurosarcoidosis be in the differential diagnosis of mononeuritis multiplex when other causes cannot be found because early treatment could help prevent progression to other nerves.