Spinal region corticosteroid injections are not associated with increased risk for influenza.

BACKGROUND CONTEXT: Spinal region corticosteroid injections (CSI) are intended to act locally to relieve radicular or axial back pain, however some systemic absorption occurs, potentially placing recipients at risk for immunosuppressive effects of corticosteroids. No previous studies examine whether patients undergoing spinal region CSI are at increased risk for viral infections, particularly influenza-a common viral illness with potentially serious consequences, especially for patients with multimorbidity. PURPOSE: To examine odds of influenza in patients who received spinal region CSI compared to matched controls. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Adults (n=9,196) who received a spinal CSI (epidural, facet, sacroiliac, paravertebral block) during influenza seasons occurring from 2000 to 2020 were 1:1 matched to controls without spinal CSI. OUTCOME MEASURES: The primary outcome was odds of influenza diagnosis in spinal CSI patients compared to matched controls. Predetermined subgroup analyses examined odds of influenza diagnosis based on vaccination status and injection location. METHODS: An institutional database was queried to identify patients that received spinal CSI during influenza season (September 1 to April 30) from 2000 to 2020. Patients were matched by age, sex, and influenza vaccination status to controls without spinal CSI within the specified influenza season. Influenza diagnosis was ascertained using International Classification of Disease codes and data was analyzed using multiple logistic regression adjusted for comorbidities associated with increased risk for influenza. RESULTS: A total of 9,196 adults (mean age 60.8 years, 60.4% female) received a spinal CSI and were matched to a control. There were no increased odds of influenza for spinal CSI patients as compared to matched controls (OR 1.13, [95% CI, 0.86-1.48]). When subgroups were examined, there were also no increased odds of influenza for spinal CSI patients based on immunization status (unvaccinated or vaccinated) or spinal injection location (epidural or non-epidural). CONCLUSIONS: Spinal region CSI was not associated with increased odds of influenza or reduced vaccine efficacy. This is reassuring given the analgesic and functional restoration benefits of these injections. Assessing risk of viral infection associated with spinal CSI is particularly relevant in the era of the COVID-19 pandemic, and further work is needed to address this issue.

Spinal corticosteroid injections are not associated with increased influenza risk.

BACKGROUND CONTEXT: Spinal corticosteroid injections (CSI) are often used to treat radicular and axial pain arising from the spine. Systemic corticosteroids are well known to cause immunosuppression, and locally injected spinal CSI are known to have some systemic absorption. However, it is unknown whether spinal CSI increases the risk of systemic viral infections, such as influenza. PURPOSE: To determine whether spinal CSI causes an increased risk for influenza infection and whether they reduce the protective effect of vaccination STUDY DESIGN/SETTING: A retrospective cohort study was performed at Kaiser Permanente Northern California, a large healthcare system with a diverse population. PATIENT SAMPLE: Adults (n=60,880) who received a spinal CSI during influenza seasons from 2016 to 2019. A comparison was made with 121,760 case-matched individuals who did not receive a spinal CSI. OUTCOME MEASURES: The primary outcome was odds of influenza diagnosis following spinal CSI compared with case-matched controls. Secondary analysis examined odds of influenza diagnosis based on vaccination status, multiple same-day injections, and epidural versus non-epidural route of injection. METHODS: The electronic health record and associated research databases were analyzed to identify patients who received a spinal CSI during three consecutive flu seasons, 2016 through 2019. Injections were stratified into epidural versus non-epidural CSI and single injections versus multiple same-day injections. Additionally, the rate of influenza in vaccinated versus non-vaccinated individuals was examined. Inpatient flu diagnosis was used as a proxy for severe disease. After case matching was completed, odds ratios for flu diagnosis were calculated using a logistical regression model. RESULTS: The odds of flu diagnosis following spinal CSI were not increased compared with controls (OR 0.93 [0.87-1.01, 95% Wald CL]). For epidural CSI the OR was 0.91 (0.83-1.00, 95% Wald CL), and non-epidural it was 1.00 (0.89-1.13, 95% Wald CL). There were similar findings for multiple same-day injections and when looking at inpatient flu diagnosis. For vaccinated individuals, the OR for flu following spinal CSI was 0.86 (0.80-0.92, 95% Wald CL), which indicates a protective effect in these patients. CONCLUSIONS: Spinal CSI did not increase the odds of subsequently receiving a diagnosis of influenza, regardless of vaccination status, location of injection, single versus multiple same-day injection, or co-morbidity. Vaccination had a protective effect against influenza, and this was not adversely affected by receiving spinal CSI during the flu season.

Correlation of Measurements of the Prearthritic Hip Between Plain Radiography and Computed Tomography.

BACKGROUND: Previous studies have compared radiographic and computed tomography (CT) imaging for the evaluation of prearthritic hip pain. However, the intermodality, interrater, and intrarater consistencies of those parameters have not been investigated. OBJECTIVE: To determine whether radiographs with an anteroposterior pelvis view and 45°-Dunn lateral view reliably correlate with CT in the context of lateral center edge (LCE), Tonnis, alpha, and beta angle measurements for femoroacetabular impingement or hip dysplasia diagnosis. DESIGN: Retrospective study. SETTING: Academic orthopedic institution. PATIENTS: Fifty consecutive participants with hip pain in the institutional hip registry with radiographs and CT imaging on file were evaluated between 2013 and 2014. MATERIALS AND METHODS: Radiologic data (50 CTs and 50 radiographs) were evaluated by 3 physicians. LCE, Tonnis, alpha, and beta angles were measured on radiographs and CTs in 2 rounds of readings. In round 1, the center of rotation on CT imaging was standardized by 1 rater. In round 2, individual raters chose CT images using a quadrant method, and reproducibility was assessed. Reliability statistics were operationalized with intraclass correlation coefficients (ICCs). MAIN OUTCOME MEASUREMENTS: Intermodality, intrarater, and interrater reliability of CT vs radiographic measurements. RESULTS: The intermodality reliability for all raters was excellent (ICC [95% CI]: 0.84 [0.76-0.90] to 0.97 [0.96-0.98]). Intrarater reliability for both modalities showed excellent reliability (ICC = 0.75-0.96). Interrater reliability of CT measures of LCE, Tonnis, and alpha angles demonstrated excellent agreement (ICC ≥ 0.88). Beta angle measures demonstrated good agreement (ICC [95% CI] = 0.68 [0.49-0.81]). Interrater reliability of radiographic measures showed excellent agreement (ICC = 0.82-0.94). CONCLUSION: Equivalent angle measurement readings on CT and radiographs were consistent among physicians. CT measurements correlated well with radiographic measurements. This suggests that if a standardized procedure is used to find the center of the femoral head, a positive correlation among LCE, alpha, beta, and Tonnis angles measured on CT can be obtained between multiple readers. LEVEL OF EVIDENCE: III.

Utilization of Routine Primary Care Services Among Dancers.

This study examines the current utilization of primary and preventive health care services among dancers in order to assess their self-reported primary care needs. Participants were 37 dancers from a variety of dance backgrounds who presented for a free dancer health screening in a large US metropolitan area (30 females, 7 males; mean age: 27.5 ± 7.4 years; age range: 19 to 49 years; mean years of professional dancing: 6.4 ± 5.4 years). Dancers were screened for use of primary care, mental health, and women's health resources using the Health Screen for Professional Dancers developed by the Task Force on Dancer Health. Most dancers had health insurance (62.2%), but within the last 2 years, only approximately half of them (54.1%) reported having a physical examination by a physician. Within the last year, 54.1% of dancers had had a dental check-up, and 56.7% of female dancers received gynecologic care. Thirty percent of female participants indicated irregular menstrual cycles, 16.7% had never been to a gynecologist, and 16.7% were taking birth control. Utilization of calcium and vitamin D supplementation was 27.0% and 29.7%, respectively, and 73.0% were interested in nutritional counseling. A high rate of psychological fatigue and sleep deprivation was found (35.1%), along with a concomitant high rate of self-reported need for mental health counseling (29.7%). Cigarette and recreational drug use was low (5.4% and 5.4%); however, 32.4% engaged in binge drinking within the last year (based on the CDC definition). These findings indicate that dancers infrequently access primary care services, despite high self-reported need for nutritional, mental, and menstrual health counseling and treatment. More studies are warranted to understand dancers' primary health care seeking behavior.

Trust, Satisfaction, and Confidence in Health Care Providers Among Student and Professional Dancers in France.

BACKGROUND: Patients who trust their physicians are more likely to communicate about medical problems, adhere to medical advice, and be satisfied with care. Dancers have demonstrated low utilization of physician services for both preventive care and dance injuries. The purpose of this cross-sectional study was to examine trust in physicians as a variable influencing dancers' health care-seeking behavior. METHODS: The validated Trust in Physician Scale was administered to 45 professional and 34 student ballet/contemporary dancers in France (36.7% male, 63.3% female) to evaluate their trust in medical doctors (MDs) vs physical therapists (PTs). Dancers were also asked about satisfaction and confidence in medical treatment for dance injuries. RESULTS: Dancers indicated greater trust in PTs than MDs (70.61±10.57 vs 65.38±10.79, t=-3.499, p=0.001). Students exhibited significantly less trust in MDs than professional dancers (62.04±9.96 vs 67.65±10.42, t=-2.381, p=0.020). Trust scale scores for PTs did not differ between students and professionals (69.53±8.30 vs 71.68±12.09, t=-0.866, p=0.389). Students were less confident than professional dancers in their physician's ability to treat their most severe injury (6.7% of students vs 35.7% of professionals "very confident, " X2=9.402, p=0.052). CONCLUSIONS: Dancer patients exhibit lower trust in physicians compared to previously studied non-dancer populations. Our results suggest that reduced trust in physicians and factors related to professional status may influence dancers' health care-seeking behavior. Student dancers may comprise a unique subpopulation of dancers with distinctive health care needs.

Dissecting the doctor-dancer relationship: health care decision making among American collegiate dancers.

OBJECTIVE: To examine perceptual influences on dancers' health care-seeking decisions and whether dancers' beliefs correlate with actual use of provider services when they are injured. Secondary aims were to understand how dancers may select physicians and what they consider to be the most important features of the medical consultation. DESIGN: Prospective cohort study. SETTING: University and conservatory dance departments. PARTICIPANTS: Forty American collegiate dancers. ASSESSMENT OF RISK FACTORS: Before the start of the dance semester, all participants completed a retrospective survey that included baseline demographic data, dance experience, a dance-related injury (DRI) inventory, previous health care exposures, and perceptions regarding health care treatment providers. Data regarding new DRIs and health care exposures were then prospectively collected every 2 weeks for 6 months. MAIN OUTCOME MEASUREMENTS: A DRI was defined as any neuromusculoskeletal condition sustained as the result of dancing activity that caused a dancer to stop or modify his or her dancing for more than 3 consecutive days. RESULTS: Dancers perceived dance teachers to be first-line treatment providers (47.5%), followed by physical therapists (PTs; 30%). Physicians were ranked third (12.5%) and only marginally higher than a dance colleague (10%). The dancers expressed a strong preference for nonsurgical rather than surgical physicians (87.5% versus 5.0%), and among physicians, the majority of dancers preferred subspecialists (60%), namely nonsurgical sports medicine doctors and physiatrists. During the 6-month prospective data-collection period, 25 dancers (69.4%) sustained 55 unique injuries, with 22 dancers (88%) and 34 injuries (61.8%) undergoing evaluation. Only 17.7% of injuries were evaluated by a physician. Dancers showed greater incongruity between their preinjury perceptions and postinjury use of physicians than they did with PTs (P = .0002). CONCLUSIONS: Although dancers did not perceive physicians to be first-line treatment providers for DRIs, these perceptions about physicians were poorly correlated with use. Instead, injured dancers' health care-seeking behaviors were more likely related to relatively decreased barriers to other nonphysician providers, as well as pre-existing referral pathways to PTs.

Use and effectiveness of orthotics in hyperpronated dancers.

Hyperpronation is a common foot problem in dancers. The aim of this study was to investigate the usage and effectiveness of orthotics in the management of symptomatic hyperpronation among dancers. A prospective cohort study of all dancer-patients in the investigators' practice who were prescribed orthotics for new symptoms related to hyperpronation between July 2008 and January 2009 was conducted. In this group, the longitudinal medial arch angle of the foot was measured by the foot build registration system (FBRS), both barefoot and while wearing the orthotics. In addition, patients filled out questionnaires addressing perceived effectiveness of the orthotics for pain reduction and dance ability, among other items. A second retrospective study was conducted in order to obtain longitudinal data regarding dancers' compliance with, and subjective evaluation of, wearing orthotics over the preceding 6 years. Among participating dancers who met criteria for the prospective (N = 24) or retrospective (N = 81) aspects of the study (total N = 105), 67% wore orthotics at the time of follow-up. The average compliance in usage was 6.0 (± 1.5 ) days per week and 7.5 (± 3) hours per day. The average rate of satisfaction was 67.9 (± 26.5), average degree of relief in symptoms was 58.3 (± 28.3), and self-reported degree of improvement in dance ability was 45.7 (± 27.9) on a 100 mm Visual Analogue Scale (VAS). There was a significant decrease in pain from the day of orthotics prescription to follow-up (25.9%, or 18.9 mm decrease on the VAS, CI 6.6-30.9, p = 0.005) in the prospective group (N = 24). Orthotics were found to decrease the medial longitudinal arch angle significantly during static stance with the orthotic in place (CI 0.08-1.65, p = 0.03). It is concluded that the dancers in this study demonstrated a high rate of compliance in obtaining and wearing their orthotics and experienced a significant decrease in pain.

Chylothorax complicating inpatient rehabilitation after thoracic spinal cord injury: a review of risk factors and anatomy for the physiatrist.

After malignancy, traumatic and surgical injuries to the upper abdomen and chest are the leading causes of chylothorax. Thoracic spine extension injury, blunt or penetrating chest trauma, anterior thoracic spine surgery, and increased intra-abdominal pressure have all been implicated in the development of chylothorax. Despite the physiatrist's frequent exposure to polytrauma and postsurgical patients, there are no case reports of chylothorax complicating inpatient rehabilitation or occurring in a patient fitted in a thoracic or lumbar orthosis. We present the case of a patient with traumatic spinal cord injury from a high-speed motor vehicle accident who was diagnosed with a left-sided chylothorax while wearing a thoracolumbosacral orthosis 4 wks into her inpatient rehabilitation stay. Knowledge of the anatomy of the thoracic duct can be useful for diagnosing chylothorax in patients with thoracic spine fractures, upper abdomen/chest injury, or thoracic surgery, as the trajectory of the duct often determines the location of pleural effusion.

Hyperpronation in Dancers Incidence and Relation to Calcaneal Angle.

Hyperpronation is a common finding when examining the dancer-patient and is thought to be implicated in several dance-related injuries. Little is known about the incidence of hyperpronation-related symptoms in dancers. Additionally, there is no current easy method for estimating the degree of hyperpronation. This study was designed to investigate the incidence of symptoms related to foot hyperpronation in dancer-patients and to evaluate the potential correlation between the patient's calcaneal angle and severity of hyperpronation. A retrospective study of 2,427 dancers' charts over the past 6 years was undertaken to identify dancers who presented with musculoskeletal complaints or problems related to hyperpronation. Physical exam data and diagnoses were collected. Among 24 new dancer-patients presenting to clinic with hyperpronation-related symptoms, the calcaneal angle was measured and correlated with a clinical grading scale based on the Hübscher maneuver. Per chart review, the incidence of symptomatic hyperpronation resulting in prescription for orthotics was 30% (739 dancers out of 2,427). The most common related diagnosis was retropatellar chondropathy (10%). Clinical severity of hyperpronation was linearly related to the calcaneal angle (95% CI [1.25, 4.14], p = 0.0006; Pearson's r(2) = 0.97). The calcaneal angles among mild, moderate, and severe hyperpronators differed significantly (H = 13.45, p = 0.0012). It was concluded that measuring the calcaneal angle may be a useful adjunct to the Hübscher maneuver for grading the clinical severity of a dancer's hyperpronation. Healthcare providers working with dancers should be aware of the presence of hyperpronation, its relation to compensatory turnout techniques, and association with injuries in the foot, ankle, knee, hip, and low back. A standard, time-efficient method of measuring and grading hyperpronation is still needed.

Freiberg's disease as a rare cause of limited and painful relevé in dancers.

Freiberg's disease, or osteonecrosis of the second metatarsal head, is an uncommon cause of forefoot pain that can severely limit a dancer's relevé. Dancers may be predisposed to the condition due to repetitive microtrauma to the ball of the foot during routine dance movements. Freiberg's disease is diagnosed by history, physical examination, and plain film radiographs. Conservative treatment in dancers is disappointing, and surgical options fail to produce uniformly good results. Previously published reports of successful surgical outcomes would, for a dancer, result in an unacceptable loss of dorsiflexion of the MTP joint. This first case report of Freiberg's disease in a dancer serves to discuss the orthopaedic and artistic implications of managing the disease in a young, active, adolescent dancer. A new surgical treatment involving modification of Mann's cheilectomy, normally used for hallux rigidus, is presented. The operation corrected the patient's pain, completely normalized the aberrant relevé, allowed her to resume dance training within three weeks, and return to full dance activity within three months.