Radiofrequency Ablation for Chronic Hip Pain: A Comprehensive, Narrative Review.

Chronic hip pain can be treated with physical therapy, oral medications, injections, and, definitively, total hip arthroplasty. Enough patients have contraindications to and refractory pain even after total hip arthroplasty, that there is a need to develop alternative managements for this disabling condition. This article examines the state of hip radiofrequency ablation literature including relevant anatomy, patient selection, and treatment outcomes.

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.

The Reliability of a Grading System for Digital Subtraction Imaging Quality During Cervical Transforaminal Epidural Steroid Injection.

OBJECTIVE: Digital subtraction imaging (DSI) decreases the risk of intravascular injection during cervical transforaminal epidural steroid injection (CTFESI); however, sequence acquisition and interpretation are operator-dependent skills. This study tests the reliability of a grading system to determine adequate DSI during CTFESI. SETTING: Academic tertiary medical center. METHODS: A grading scheme for adequate DSI quality during CTFESI was created by the study authors based on patient positioning, mask image, and volume of contrast injected. The inter-rater and intrarater reliability values of this grading scheme were tested using 50 DSI images evaluated by three raters during two distinct sessions separated by four weeks. Based on a power analysis, a sample of 50 scans was sufficient to detect significant correlations. Inter-rater reliability was determined by percent agreement between graders for dichotomized categories of "quality of DSI is adequate for safe C-TFESI" vs "quality of DSI is inadequate for safe C-TFESI." The percentage of agreement was reported, along with Gwet's agreement coefficient (AC). The intrarater (pre/post) correlation was assessed using Yule's Q statistics. RESULTS: Correlation coefficients were interpreted as follows: 0.00-0.19 "very weak," 0.20-0.39 "weak," 0.40-0.59 "moderate," 0.60-0.79 "strong," and 0.80-1.00 "very strong." Inter-rater reliability analyses demonstrated that the patient position category had "very strong" agreement, contrast volume had "strong" agreement, and mask image had "moderate" agreement. The overall inter-rater reliability was "moderate." All of the raters demonstrated "very strong" intrarater reliability. CONCLUSIONS: The proposed grading system for adequate-quality DSI during CTFESI showed overall "moderate" and "very strong" inter- and intrarater reliability, respectively. This scheme provides an objective measure of DSI quality for CTFESI. Refinement is needed to improve the reliability of this scheme.

Cooled Radiofrequency Ablation of the Genicular Nerves for Chronic Pain due to Knee Osteoarthritis: Six-Month Outcomes.

OBJECTIVE: Determine outcomes of cooled radiofrequency ablation (C-RFA) of the genicular nerves for treatment of chronic knee pain due to osteoarthritis (OA). DESIGN: Cross-sectional survey. SETTING: Academic pain medicine center. SUBJECTS: Consecutive patients with knee OA and 50% or greater pain relief following genicular nerve blocks who underwent genicular nerve C-RFA. METHODS: Survey administration six or more months after C-RFA. Pain numeric rating scale (NRS), Medication Quantification Scale III (MQSIII), Patient Global Impression of Change (PGIC), and total knee arthroplasty (TKA) data were collected. Logistic regression was used to identify factors that predicted treatment success. RESULTS: Thirty-three patients (52 discrete knees) met inclusion criteria. Thirty-five percent (95% confidence interval [CI] = 22-48) of procedures resulted in the combined outcome of 50% or greater reduction in NRS score, reduction of 3.4 or more points in MQSIII score, and PGIC score consistent with "very much improved/improved." Nineteen percent (95% CI = 10-33) of procedures resulted in complete pain relief. Greater duration of pain and greater than 80% pain relief from diagnostic blocks were identified as predictors of treatment success. The accuracy of the model was 0.88 (95% CI = 0.78-0.97, P < 0.001). CONCLUSIONS: Genicular C-RFA demonstrated a success rate of 35% based on a robust combination of outcome measures, and 19% of procedures resulted in complete relief of pain at a minimum of six months of follow-up. Report of 80% or greater relief from diagnostic blocks and duration of pain of less than five years are associated with high accuracy in predicting treatment success. Further prospective study is needed to optimize the patient selection protocol and success rate of this procedure.

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.

Confirmatory factor analysis of 12-Item World Health Organization Disability Assessment Schedule in patients with musculoskeletal pain conditions.

OBJECTIVE: To investigate the factor structure of the 12 item World Health Organization Disability Assessment Schedule (WHODAS) 2.0. DESIGN: Cross-sectional cohort survey study. SETTING: Physical and Rehabilitation Medicine outpatient university clinic. SUBJECTS: The 408 consecutive patients with chronic musculoskeletal pain. MAIN MEASURES: Exploratory and confirmatory factor analysis. RESULTS: A two-factor model most accurately fit the observed data of musculoskeletal pain patients (root mean square error of approximation 0.049, relative Chi square value 1.99). Twelve WHODAS 2.0 items were distributed between two factors with covariance between them of 0.8. The first factor contained domains related mostly to physical functioning, while another was associated mostly with social and cognitive functioning. There were a few differences between single items in their importance in defining the variance within these two factors. Of the six International Classification of Functioning, Disability and Health domains belonging to the first construct, the ability to carry out household responsibilities explained most, 84% of the total variance in this construct. For the second factor, the ability to participate in community activities seemed to be the most important, explaining 85% of the total variance in this construct. CONCLUSIONS: In this study, the two-factor structure model of the 12-item WODAS 2.0 demonstrated the most accurate fit within patients with musculoskeletal pain conditions.

A study of the psychometric properties of 12-item World Health Organization Disability Assessment Schedule 2.0 in a large population of people with chronic musculoskeletal pain.

OBJECTIVE: To assess the validity of the Finnish translation of the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0). DESIGN: Cross-sectional cohort survey study. SETTING: Physical and Rehabilitation Medicine outpatient university clinic. SUBJECTS: The 501 consecutive patients with chronic musculoskeletal pain. MAIN MEASURES: Exploratory factor analysis and a graded response model using item response theory analysis were used to assess the constructs and discrimination ability of WHODAS 2.0. RESULTS: The exploratory factor analysis revealed two retained factors with eigenvalues 5.15 and 1.04. Discrimination ability of all items was high or perfect, varying from 1.2 to 2.5. The difficulty levels of seven out of 12 items were shifted towards the elevated disability level. As a result, the entire test characteristic curve showed a shift towards higher levels of disability, placing it at the point of disability level of +1 (where 0 indicates the average level of disability within the sample). CONCLUSIONS: The present data indicate that the Finnish translation of the 12-item WHODAS 2.0 is a valid instrument for measuring restrictions of activity and participation among patients with chronic musculoskeletal pain.

Detection of Intravascular Injection During Lumbar Medial Branch Blocks: A Comparison of Aspiration, Live Fluoroscopy, and Digital Subtraction Technology.

BACKGROUND CONTEXT: Medial branch blocks may have unrecognized vascular uptake potentially resulting in false- negative results. PURPOSE: To determine the rate of unintended vascular injection of contrast medium during medial branch blocks (MBB) with digital subtraction (DS) technology in the context of negative vascular uptake as determined by live fluoroscopy. STUDY DESIGN/SETTING: Prospective Study in an academic medical center. PATIENT SAMPLE: 344 consecutive MBBs in 80 subjects. OUTCOME MEASURES: The presence of vascular flow as determined by live fluoroscopy and DS technology. METHODS: Unintended vascular injection of contrast medium was determined on 344 consecutive MBBs in 84 subjects, first using live fluoroscopy followed by DS. If live fluoroscopy initially detected vascular uptake, the needle was repositioned until no vascular flow was detected. Once no vascular uptake was confirmed by live fluoroscopy, a contrast medium was then injected while being visualized with DS to again assess the presence or absence of vascular flow undetected by live fluoroscopy. RESULTS: Live fluoroscopy revealed inadvertent vascular uptake in 38 of the 344 blocks [11% (95% CI 8.0-15%)]. DS uncovered an additional 27 of the 344 blocks [7.8% (95% CI 5.3-11.4%)] with evidence of vascular uptake that were not detected with conventional live fluoroscopy. CONCLUSION: DS enhances the ability to detect inadvertent vascular flow during medial branch blocks. This study demonstrates that standard live fluoroscopy can miss a small percentage of cases with unintentional vascular uptake during MBB when compared with DS and may contribute to occasional false-negative responses.

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.

Glenohumeral Joint Pain Referral Patterns: A Descriptive Study.

BACKGROUND: Pain diagrams are a useful tool to help physicians understand the varying presentation patterns of specific pain generators. This study is the first to describe the potential pain patterns of the glenohumeral joint (GHJ) based on responses to diagnostic image-guided GHJ injections. PURPOSE: To determine potential GHJ pain referral patterns. METHODS: 162 consecutive patients undergoing 168 GHJ injections recorded their preprocedure pain scores and drew accurate pain diagrams prior to undergoing fluoroscopically guided GHJ injections with local anesthetic. Postprocedure pain scores were recorded and those with complete relief were considered responders. Pain diagrams were overlaid via computer software to facilitate analysis and a composite pain map. A responder composite was also compared with a nonresponder composite. RESULTS: The GHJ was shown to cause pain in traditionally localized areas of the anterior and/or posterior shoulder and upper arm regions in 100% of patients who experienced complete pain relief after injection. Among 100% responders, 18% had neck pain and 6% had scapular pain. Pain was shown to radiate distally, with anterior forearm pain in 9%, posterior forearm pain in 8%, and hand pain in 9%. No patients with pain both in the medial neck and below the elbow were found to be 100% responders. Similarly, no patients were 100% responders if they had pain in the medial scapula and below the elbow, or medial scapula and medial neck. CONCLUSIONS: Anterior or posterior shoulder and upper arm pain, or a combination of the two, is the most common pain referral area from a symptomatic shoulder joint. Referral to the lateral neck, in combination with shoulder pain, was occasionally seen. Pain referral to the forearm and hand was less common. Rarely did a symptomatic shoulder joint refer pain to the scapula or to the medial neck.

Pacific Spine and Pain Society (PSPS) Evidence Review of Surgical Treatments for Lumbar Degenerative Spinal Disease: A Narrative Review.

INTRODUCTION: Interventional treatment options for the lumbar degenerative spine have undergone a significant amount of innovation over the last decade. As new technologies emerge, along with the surgical specialty expansion, there is no manuscript that utilizes a review of surgical treatments with evidence rankings from multiple specialties, namely, the interventional pain and spine communities. Through the Pacific Spine and Pain Society (PSPS), the purpose of this manuscript is to provide a balanced evidence review of available surgical treatments. METHODS: The PSPS Research Committee created a working group that performed a comprehensive literature search on available surgical technologies for the treatment of the degenerative spine, utilizing the ranking assessment based on USPSTF (United States Preventative Services Taskforce) and NASS (North American Spine Society) criteria. RESULTS: The surgical treatments were separated based on disease process, including treatments for degenerative disc disease, spondylolisthesis, and spinal stenosis. CONCLUSIONS: There is emerging and significant evidence to support multiple approaches to treat the symptomatic lumbar degenerative spine. As new technologies become available, training, education, credentialing, and peer review are essential for optimizing patient safety and successful outcomes.

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.

Are there gender-related differences in the psychometric properties of the Oswestry Disability Index?

BACKGROUND: Despite the wide body of research on the properties of the Oswestry Disability Index (ODI), only a few studies have investigated whether ODI scores can be interpreted similarly in both genders. A few previous studies suggested that the ODI may behave differently in different populations, e.g. in different age groups. AIM: The objective was to investigate gender-related differences in the psychometric properties of the ODI amongst patients with chronic low back pain. DESIGN: Observational cross-sectional cohort study. SETTING: University outpatient Physical and Rehabilitation Medicine clinic. POPULATION: Consecutive patients seen in an outpatient Physical and Rehabilitation Medicine clinic at a university hospital between April 2014 and February 2017. METHODS: Internal consistency was evaluated using Cronbach's alpha. Factor structure was investigated using exploratory factor analysis. Gender-related differences in psychometric properties of ODI items were assessed using item response theory analysis. RESULTS: The study included 912 patients, 579 women (63%), with an average age of 45.8 (SD 14.2) years old. The Cronbach's alpha for both genders was good at 0.88. The discrimination abilities of all 10 ODI items were mostly high to perfect for both men and women with only small fluctuations. The item information function curves were similar for most of the items. Exploratory factor analysis resulted in a unidimensional one-factor structure for both genders. CONCLUSIONS: The ODI appears to be a similarly unidimensional and internally consistent questionnaire in both genders without any substantial variability in the items' difficulty and discrimination. CLINICAL REHABILITATION IMPACT: The ODI produces psychometrically similar results in both genders. Small and clinically hardly significant gender-related differences in the properties of ODI can be neglected.

The Magnitude and Duration of the Effect of Intra-articular Corticosteroid Injections on Pain Severity in Knee Osteoarthritis: A Systematic Review and Meta-Analysis.

OBJECTIVES: The aims of the study were to clarify the evidence on the magnitude and duration of treatment effect of intra-articular corticosteroid injections for knee osteoarthritis compared with placebo, to evaluate a treatment effect by steroid type, and to describe the reported adverse effects. DESIGN: Cochrane Controlled Trials Register, Medline, Embase, CINAHL, Scopus, and Web of Science databases were searched. The risk of systematic bias was assessed according to the Cochrane Collaboration's domain-based evaluation framework. RESULTS: The final sample included eight randomized controlled studies with follow-ups from 1 to 26 wks. The risk of systematic bias was considered low in five and high in three studies. The pooled standardized mean difference was -0.58 (95% confidence interval = -0.88 to -0.27) and number needed to treat 5.1 (95% confidence interval = 10.0 to 3.7). The heterogeneity was considerable. The pooled effect size approached the level of statistical insignificance at 4 mos. The pooled risk ratio of adverse effects was insignificant 0.95 (95% confidence interval = 0.34 to 2.55). CONCLUSIONS: The intra-articular corticosteroid had a mild to moderate effect on pain severity up to 3 mos after the injection-much longer than it had previously been reported. The effect may vary substantially in different patient groups and appropriate patient selection is important. The risk of adverse effects was low.

Factors associated with willingness to work among unemployed persons with a disability in a large urban area: A short communication.

BACKGROUND: One of the reasons for the high unemployment amongst people with disability is a lack of knowledge on factors determining their employment. Factors associated with willingness and attitudes towards work have not been studied sufficiently amongst the general population of people with impaired functioning. Recognizing and improving attitudes to work and vocational rehabilitation may increase the employment rate of persons with disabilities. OBJECTIVE: To investigate the influence of some demographic factors on a willingness to work and an interest in vocational rehabilitation amongst unemployed persons with confirmed disability. METHODS: Cross-sectional survey-based study amongst unemployed persons with disabilities in a large urban area. The sample consisted of 1 547 respondents with mostly mild or moderate disabilities. The multinomial logistic regression was used to obtain relative risk ratios (RRs) for different demographic characteristics of the sample. RESULTS: An interest in vocational rehabilitation was significantly associated with older age (RR 1.36, 95% CI 1.2 to 1.5), lower disability grade (RR 1.30, 95% CI 1.06 to 1.60), and lower expectation of a desired salary (RR 0.77, 95% CI 0.67 to 0.88). Older age (RR 1.31, 95% CI 1.14 to 1.51) and more severe disability (reversed figure - RR 0.75, 95% CI 0.60 to 0.93) were associated with a delayed willingness to work. CONCLUSIONS: Amongst unemployed persons with severe or moderate disabilities, a better willingness to work was mostly associated with younger age and milder disability severity. Older persons with less disabilities and realistic expectations of salary rate reported an interest in vocational rehabilitation more often.