The effectiveness of intradiscal corticosteroid injection for the treatment of chronic discovertebral low back pain: a systematic review.

OBJECTIVE: Determine the effectiveness of intradiscal corticosteroid injection (IDCI) for the treatment of discovertebral low back pain. DESIGN: Systematic review. POPULATION: Adults with chronic low back pain attributed to disc or vertebral end plate pain, as evidenced by positive provocation discography or Modic 1 or 2 changes on magnetic resonance imaging. INTERVENTION: Fluoroscopically guided or computed tomography-guided IDCI. COMPARISON: Sham/placebo procedure including intradiscal saline, anesthetic, discography alone, or other active treatment. OUTCOMES: Reduction in chronic low back pain reported on a visual analog scale or numeric rating scale and reduction in disability reported by a validated scale such as the Oswestry Disability Index. METHODS: Four reviewers independently assessed articles published before January 31, 2023, in Medline, Embase, CENTRAL, and CINAHL. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The risk of bias in randomized trials was evaluated with the Cochrane Risk of Bias tool (version 2). RESULTS: Of the 7806 unique records screened, 6 randomized controlled trials featuring 603 total participants ultimately met the inclusion criteria. In multiple randomized controlled trials, IDCI was found to reduce pain and disability for 1-6 months in those with Modic 1 and 2 changes but not in those selected by provocation discography. CONCLUSION: According to GRADE, there is low-quality evidence that IDCI reduces pain and disability for up to 6 months in individuals with chronic discovertebral low back pain as evidenced by Modic 1 and 2 changes but not in individuals selected by provocation discography. STUDY REGISTRATION: PROSPERO (CRD42021287421).

Sonographic peripheral nerve cross-sectional area in adults, excluding median and ulnar nerves: A systematic review and meta-analysis.

INTRODUCTION/AIMS: Although electromyography remains the "gold standard" for assessing and diagnosing peripheral nerve disorders, ultrasound has emerged as a useful adjunct, providing valuable anatomic information. The objective of this study was to conduct a systematic review and meta-analysis evaluating the normative sonographic values for adult peripheral nerve cross-sectional area (CSA). METHODS: Medline and Cochrane Library databases were systematically searched for healthy adult peripheral nerve CSA, excluding the median and ulnar nerves. Data were meta-analyzed, using a random-effects model, to calculate the mean nerve CSA and its 95% confidence interval (CI) for each nerve at a specific anatomical location (= group). RESULTS: Thirty groups were identified and meta-analyzed, which comprised 16 from the upper extremity and 15 from the lower extremity. The tibial nerve (n = 2916 nerves) was reported most commonly, followed by the common fibular nerve (n = 2580 nerves) and the radial nerve (n = 2326 nerves). Means and 95% confidence interval (CIs) of nerve CSA for the largest number of combined nerves were: radial nerve assessed at the spiral groove (n = 1810; mean, 5.14 mm2 ; 95% CI, 4.33 to 5.96); common fibular nerve assessed at the fibular head (n = 1460; mean, 10.18 mm2 ; 95% CI, 8.91 to 11.45); and common fibular nerve assessed at the popliteal fossa (n = 1120; mean, 12.90 mm2 ; 95% CI, 9.12 to 16.68). Publication bias was suspected, but its influence on the results was minimal. DISCUSSION: Two hundred thirty mean CSAs from 15 857 adult nerves are included in the meta-analysis. These are further categorized into 30 groups, based on anatomical location, providing a comprehensive reference for the clinician and researcher investigating adult peripheral nerve anatomy.

Genicular nerve radiofrequency ablation for the treatment of chronic knee joint pain: a real-world cohort study with evaluation of prognostic factors.

BACKGROUND: Genicular nerve radiofrequency ablation (GNRFA) is an effective treatment for chronic knee pain. However, there has been minimal investigation of real-world, long-term outcomes and factors that predict treatment success after GNRFA. OBJECTIVES: To evaluate the effectiveness of GNRFA for chronic knee pain in a real-world population and identify predictive factors. METHODS: Consecutive patients who underwent GNRFA at a tertiary academic center were identified. Demographic, clinical, and procedural characteristics were collected from the medical record. Outcome data were numeric rating scale (NRS) pain reduction and Patient Global Impression of Change (PGIC). Data were collected by standardized telephone survey. Predictors of success were evaluated with logistic and Poisson regression analyses. RESULTS: Of the 226 total patients identified, 134 (65.6 ± 12.7; 59.7% female) were successfully contacted and analyzed, with a mean follow-up time of 23.3 ± 11.0 months. Of those, 47.8% (n = 64; 95% CI: 39.5%-56.2%) and 61.2% (n = 82; 95% CI: 52.7%-69.0%) reported ≥50% NRS score reduction and ≥2-point NRS score reduction, respectively, and 59.0% (n = 79; 95% CI: 50.5%-66.9%) reported "much improved" on the PGIC questionnaire. Factors associated with a greater likelihood of treatment success (P < .05) were higher Kellgren-Lawrence osteoarthritis grade (2-4 vs 0-1); no baseline opioid, antidepressant, or anxiolytic medication use; and >3 nerves targeted. CONCLUSION: In this real-world cohort, approximately half of the participants experienced clinically meaningful improvements in knee pain after GNRFA at an average follow-up time of nearly 2 years. Factors associated with higher likelihood of treatment success were more advanced osteoarthritis (Kellgren-Lawrence Grade 2-4); no opioid, antidepressant, or anxiolytic medication use; and >3 nerves targeted.

The effect of lumbar medial branch radiofrequency neurotomy on cobb angle progression in individuals with adult scoliosis compared to natural history: A cross-sectional study.

Background: Lumbar radiofrequency neurotomy (LRFN) effectively alleviates zygapophyseal joint-mediated pain by coagulating medial branch nerves to disrupt nociceptive signaling pathways. The concomitant denervation of multifidus fibers has led to concern that LRFN may increase segmental instability and accelerate degenerative changes in patients with certain pre-existing spinal pathologies. There is a paucity of literature evaluating whether LRFN increases the progression of spinal curvature in patients with adult scoliosis. Objective: Compare the lumbosacral Cobb angle progression rate in patients with adult scoliosis who underwent LRFN to the annual progression rate of 0.83 ± 1.1° expected by natural history. Design: Cross-sectional study. Methods: Consecutive patients diagnosed with adult scoliosis who underwent LRFN to treat zygapophyseal joint-related low back pain were identified. Patient demographics, LRFN procedure details, and radiographs confirming scoliosis were collected from electronic medical records. Pre- and post-LRFN radiographs were used to calculate the average annual rate of Cobb angle progression. Data were analyzed using a Wilcoxon signed-rank test and a linear regression model. Results: Sixty patients (mean age 69.2 ± 11.6 years; 70.0 % female) met the criteria and were included in the analyses. The mean time to radiographic follow-up was 35.0 ± 22.7 months post-LRFN. The average Cobb angle progression was 0.54 ± 3.03° per year and did not differ significantly from the known natural progression rate of 0.83 ± 1.1° per year. None of the included covariates (body mass index, LRFN laterality, and number of levels denervated) were significantly associated with the average annual Cobb angle progression rate. Conclusions: Our results suggest that LRFN has no appreciable effect on the rate of Cobb angle progression in patients with adult scoliosis.

The association of payer type on genicular radiofrequency neurotomy treatment outcomes: Results of a cross-sectional study.

Background: Genicular radiofrequency neurotomy (GRFN) is an effective treatment for a subset of individuals with chronic knee pain. Previous studies demonstrate that Medicare and Medicaid beneficiaries report worse outcomes following various interventional procedures compared with commercially insured patients. Objective: Evaluate the association of payer type on GRFN treatment outcomes. Methods: Consecutive patients who underwent GRFN at a tertiary academic center were contacted for participation. Demographic, clinical, and procedural characteristics were collected from electronic medical records. Outcome data were collected by standardized telephone survey at 6-12 months, 12-24 months and ≥24 months. Treatment success was defined as ≥50% numerical pain rating scale (NPRS) score reduction from baseline. Data were analyzed using descriptive statistics for demographic, clinical, and procedural characteristics. Logistic and Poisson regression analyses were performed to examine the association of variables of interest and pain reduction. Results: One hundred thirty-four patients treated with GRFN (mean 65.6 ± 12.7 years of age, 59.7% female) with a mean follow-up time of 23.3 ± 11.3 months were included. Payer type composition was 48.5% commercial (n = 65), 45.5% Medicare (n = 61), 3.7% Medicaid (n = 5), 1.5% government (n = 2), and 0.8% self-pay (n = 1). Overall, 47.8% of patients (n = 64) reported ≥50% NPRS score reduction after GRFN. After adjusting for age, follow-up duration, Kellgren-Lawrence osteoarthritis grade, baseline opioid use, antidepressant/antianxiety medication use, history of knee replacement, and number of RFN lesions placed, the logistic regression model showed no statically significant association between payer type and treatment outcome (OR = 2.11; 95% CI = 0.87, 5.11; p = 0.098). Discussion/conclusion: In this study, after adjusting for demographic, clinical, and procedural characteristics, we found no association between payer type and treatment success following GRFN. This observation contrasts findings from other interventional studies reporting an association between payer category and treatment success.

Does medial branch radiofrequency neurotomy accelerate degenerative lumbar spondylolisthesis compared to natural progression? A cross-sectional cohort study.

Background: Lumbar radiofrequency neurotomy (LRFN) effectively treats lumbar zygapophyseal joint pain by coagulating medial branch nerves (MBNs) carrying nociceptive signals. MBNs also innervate deep paraspinal muscles. There is a paucity of literature on whether LRFN accelerates the progression of vertebral displacement in patients with degenerative lumbar spondylolisthesis (DLS). Objective: Compare the rate of spondylolisthesis progression in adults with DLS who underwent LRFN to the 2% annual rate of progression expected by natural history. Design: Cross-sectional cohort study. Methods: Consecutive patients with pre-existing DLS who underwent LRFN for zygapophyseal joint-mediated low back pain were identified. Patient demographics, LRFN procedure details, and radiographic images confirming Meyerding Grade (I-II) spondylolisthesis were collected from electronic medical records. The quantitative magnitude of spondylolisthesis progression and the annualized rate were calculated from pre-and post-LRFN radiographs. Data were analyzed using Wilcoxon signed-rank tests and a linear regression model. Results: 152 patients (mean age 65.9 ± 12.3 years; 59.2% female) met eligibility criteria and were included in the analyses. Average time to radiographic follow-up was 35.6 ± 24.7 months post-LRFN. The average spondylolisthesis progression rate of 1.63 ± 2.91% per year calculated for the LRFN cohort was significantly lower than the 2% annual rate of progression associated with natural history (p < 0.001). None of the included covariates, such as age, BMI, LRFN laterality, number of levels denervated, or history of prior lumbar spinal surgery, were significantly associated with the average annual rate of progression. Conclusions: Our results suggest that spondylolisthesis progression rate is no different or worse than the expected natural progression rate in patients with pre-existing DLS who have undergone LRFN.

Results of lumbar transforaminal epidural steroid injections based on the physician referral source.

Background: Many patients who receive lumbosacral transforaminal epidural steroid injections (TFESIs) are referred for the injection from a physician who does not perform the procedure. Purpose: To compare success rates of fluoroscopically guided lumbosacral TFESIs in patients who had a clinical evaluation and recommendation for the injection by a fellowship-trained spine specialist who routinely performs ESIs (Group A), vs those who had a clinical evaluation by a fellowship-trained spine specialist who referred the patient for the procedure to be done by a different physician (Group B). Study design/setting: Retrospective, observational, in vivo study of consecutive patients. Patient. Sample: Patients undergoing lumbosacral TFESIs at a single outpatient academic spine center. Outcome. Measures: Numeric Rating Scale (NRS) pain score improvement. Methods: Current procedural terminology (CPT) codes were used to search all consecutive patients who received a lumbosacral TFESI between September 2019 and September 2020. All patients with pre- and post-injection NRS pain scores within 60 days of the injection were included in the analysis. Results: A total of 230 TFESIs were analyzed, 151 in Group A, and 79 in Group B. The primary outcome was defined as > 50% improvement in the NRS pain score. 39% [95% CI: 33, 45%] of all patients who received a lumbosacral TFESI achieved a successful outcome. There were better results in Group A with a 47% [95% CI: 39, 55%] success rate compared to a 23% [95% CI: 14, 32%] success rate in Group B. Group A also had a higher proportion of patients who achieved at least 80% pain relief (26% [95% CI: 19, 33%]) compared to Group B (10% [95% CI: 3, 17%]). History of prior surgery did not significantly affect outcomes. Conclusion: This retrospective study demonstrated a higher success rate from lumbosacral TFESIs when patients were referred for the injection by a physician who performs ESIs.

The association of payer type and opioid use on functional improvement at short-term follow-up after lumbosacral transforaminal epidural steroid injection: Results of a large registry study.

Background: Lumbosacral transforaminal epidural steroid injection (LTFESI) is a commonly performed intervention for treating radicular pain. While factors that predict pain improvement after LTFESI have been evaluated, minimal literature exists regarding predictors of functional improvement. Purpose: To identify factors that are associated with functional improvement at short-term follow-up after LTFESI. Study design: Retrospective review of prospectively collected registry data. Patient sample: Patients undergoing LTFESI at an academic spine center who completed an Oswestry Disability Index (ODI) questionnaire both pre-procedure and one to three weeks post-procedure. Outcome measures: The outcomes of interest were the proportions of patients who experienced a minimal clinically important difference (MCID) in function defined as â€‹≥ â€‹30% improvement in ODI score, as well as â€‹≥ â€‹10-point and ≥15-point improvement in ODI score. Methods: Logistic regression analysis was performed to examine the associations of predictor variables to the ODI responder/non-responder outcome variable. The predictor variables for the analysis included: age, baseline ODI score, Charleston Comorbidity Index (CCI), payer type, prior lumbosacral spine surgery, pre-injection opioid use, two-level injections, bilateral injections, repeat injection, trainee presence during injection, immediate numerical rating scale (NRS) change post-injection. An odds ratio (OR) and its 95% confidence intervals (CIs) were calculated. Results: A total of 606 patients were included in the analysis. More than half of the patients (56.8%) reported a ≥7.1% improvement in ODI score, and about 30% reported a ≥30% improvement in ODI score. Approximately 36% and 20% of the patients reported ≥10-point and ≥15-point reductions in ODI score, respectively. Medicaid and Medicare payer type and pre-injection opioid use were significantly associated with a lower likelihood of ≥30%, and ≥15-point improvements in ODI, after adjusting for the other factors (p â€‹< â€‹0.05). Conclusions: When using various common definitions of MCID for ODI score improvement, Medicaid, Medicare, and pre-injection opioid use were identified as factors that are negatively associated with functional improvement at short-term follow-up after LTFESIs.

A comparison of the effectiveness of cervical medial branch radiofrequency ablation for chronic facet joint syndrome in patients selected by two common medial branch block paradigms.

Background: Cervical medial branch radiofrequency ablation (CMBRFA) is effective when patients are selected by dual medial branch blocks (MBBs). SIS guidelines recommend 100% pain improvement after dual comparative MBBs before CMBRFA; however, our prior investigation showed similar outcomes in those selected by a lesser strict paradigm. Objective: Compare pain and patient impression of improvement after CMBRFA in individuals stratified by a less stringent (80-99%) dual MBB response than those selected by the 100% criteria. Design: Cross-sectional study. Methods: Follow-up was conducted via standardized telephone survey at ≥6 months post-CMBRFA to obtain Numerical Rating Scale (NRS) pain and Patient Global Impression of Change (PGIC) scores. Primary and secondary outcomes were within-group and between-group differences in the proportions of patients reporting ≥50% NRS score reduction and PGIC scores. Results: Medical records of 195 consecutive patients were reviewed; 100 individuals were analyzed. 48% (95% CI 35-61%) and 52% (95% CI 37-67%) of the 80-99% and 100% MBB groups, reported ≥50% pain reduction at ≥6 months post-CMBRFA. 74% (95% CI 63-85%) and 67% (95% CI 52-81%) of the 80-99% and 100% MBB groups reported a PGIC score consistent with "improved" or "very much improved." There were no significant between-group differences in any outcome at any time point. Conclusions: We observed similar rates of pain relief and global improvement after CMBRFA in patients selected by dual MBBs with ≥80% symptom relief versus 100% relief. This provides evidence that a more practical criteria, compared to a more strict selection paradigm, may result in similar clinical outcomes.

Thoracic transforaminal epidural steroid injection for management of thoracic spine pain: A multicenter cross-sectional study of short-term outcomes.

Background: Thoracic transforaminal epidural steroid injections (TFESIs) are procedures performed for the treatment of thoracic spine pain (TSP). The literature on these interventions is sparse. Purpose: To report outcomes of thoracic TFESIs for TSP indications. Study design: Multicenter, retrospective, cross-sectional cohort study. Patient sample: Consecutive patients receiving thoracic TFESIs at three academic spine centers. Outcome measures: The primary outcome was the proportion of patients reporting at least 50% improvement in NRS pain score at short-term follow-up (>1 week, <3 months post-injection). Methods: A chart review was performed of consecutive patients who underwent a thoracic TFESI over a 4- to 10-year time period at three academic spine centers and had reported an NRS pain score at short-term follow-up. Results: Overall, 19/64 patients (30% [95% CI 20-42%]) experienced ≥50% relief following the injection at a median 22 days follow-up. 42% [95% CI 31-54%] experienced at least a 2-point improvement in NRS score. There was a slight improvement in median NRS scores from pre-to post-procedure of -1 (IQR -3, 0), from 6/10 to 5/10 (p â€‹< â€‹0.001). The success rate (≥50% pain relief) was 36% [95%CI 22-52%] in those with a disc herniation as compared to 21% [95%CI 10-40%]) in those with degenerative stenosis; however, the difference did not reach statistical significance. There was a trend towards a greater success rate in those who were employed vs. unemployed (43% [95% CI 27-61%] vs. 19% [95% CI 9-36%]). Conclusions: This is the largest series reporting outcomes from thoracic TFESI to date. Overall, the observed success rate was low compared to known success rates associated with TFESI for the treatment of pain at cervical and lumbar spinal regions.

A Systematic Review of the Efficacy of Corticosteroid Injections of Tendon Sheaths, Excluding Stenosing Tenosynovitis of the Wrist and Hand.

OBJECTIVE: Corticosteroid injections into tendon sheaths are common in clinical practice for treatment of a variety of tendon disorders. Previous systematic reviews have been performed on injections for stenosing tenosynovitis (DeQuervain tenosynovitis and trigger finger), but little high-level evidence remains for other tendon sheath injections. This systematic review analyzes the available literature on improvements in pain and function after these injections. DESIGN: This systematic review of MEDLINE and Embase databases, as well as article bibliographies, examined studies of adult tendon sheath injections, excluding DeQuervain and trigger finger injections. Studies with and without comparison groups were examined. Risk of bias assessment was additionally performed. RESULTS: Abstracts from 1293 records were screened, and 187 full-text articles were reviewed. Seven articles met final inclusion criteria, of which five were prospective trials and none were compared with a placebo. The proximal biceps, peroneal, finger flexor, and posterior tibialis tendons were explicitly examined. All articles reported at least short-term improvements in pain, and some reported improvement in function. CONCLUSIONS: Low-quality studies exist that suggest tendon sheath injections may provide at least short-term improvement in pain. Controlled studies are required to fully demonstrate efficacy.