Bipolar Radiofrequency Neurotomy of the Genicular Nerves for Chronic Pain Due to Knee Osteoarthritis.

Background: The current treatments for chronic knee osteoarthritis (OA), a disabling and costly healthcare condition in the United States, vary in their level of supporting evidence. Although total knee replacement is one of the best-supported interventions, its associated risks should not be taken lightly, especially in older patients with comorbidities. Genicular nerve block with subsequent genicular nerve radiofrequency neurotomy (GN-RFN) has emerged as a promising intervention for refractory pain in knee OA. Purposes/Questions: We sought to assess the pain and functional outcomes of genicular nerve bipolar radiofrequency neurotomy (B-RFN) for the treatment of chronic pain due to knee OA. Methods: A total of 21 patients who underwent unilateral genicular nerve B-RFN after positive diagnostic genicular nerve block (50% or greater pain relief) treated between July 2018 to December 2018 were included. Pain numeric rating scale (NRS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were collected at baseline, 3 months, and 6 months post-B-RFN. Changes at each time point were compared to baseline scores using paired sample t tests. Results: At 3 months, 62% of patients had a greater than 50% improvement in NRS scores and 57% of patients had a greater than 50% improvement in WOMAC scores. At 6 months, 81% of patients had a greater than 50% improvement in NRS scores and 67% had a greater than 50% improvement in WOMAC scores. The absolute change in mean NRS (± standard deviation) at 6 months went from 7.5 ± 1.9 to 2.5 ± 1.2. The absolute change in mean WOMAC scores at 6 months went from 46.9 ± 8.0 to 19.0 ± 6.2. Conclusion: Of 21 patients, 14 (67%) saw greater than 50% improvements in both NRS and WOMAC scores at 6 months after genicular nerve B-RFN. Further prospective studies are needed to determine the selection criteria of patients most likely to benefit from this procedure.

Dexamethasone Effectively Reduces the Incidence of Post-neurotomy Neuropathic Pain: A Randomized Controlled Pilot Study.

BACKGROUND: Radiofrequency neurotomy (RFN) of facet or sacroiliac joints is widely used for the treatment of chronic axial pain and can provide long-term pain relief in well-selected patients. The most common side effect is transient neuropathic pain at the paravertebral level of interest. Pain physicians commonly administer corticosteroid post-neurotomy to reduce the risk of post-neurotomy neuropathic pain, yet it remains unclear if this provides a true reduction in incidence. OBJECTIVES: To determine the efficacy of corticosteroid administration post-lesion in preventing the development of post-neurotomy neuropathic pain after cervical, thoracic, lumbar, and sacroiliac joint radiofrequency denervation. STUDY DESIGN: Randomized, placebo-controlled, double-blind prospective study. SETTING: Ambulatory Surgical Center within a Tertiary Hospital System. METHODS: This trial is registered on ClinicalTrials.gov (NCT03247413). Permission to conduct human research was obtained from the Institutional Review Board. Eligible patients included those with cervical, thoracic, or lumbar facet or sacroiliac joint pain who had positive concordant medial branch blocks (thus scheduled for bilateral RFN), at least 18 years of age, and English-speaking. Patients received dexamethasone vs saline (control) at each lesion site, serving as their own control (with laterality). Follow-ups were completed at 4- and 8-weeks post-intervention to evaluate the incidence of post-procedure pain (questionnaire) and function using the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI). RESULTS: At the time of data analysis, 35/63 patients completed the study protocol. There was a statistically significant reduction in the incidence of post-neurotomy pain in the steroid group vs the control group (20/35 control group vs 3/35 steroid group, P < 0.001). ODI/NDI scores changed differently over time depending on the spinal level of neurotomy, showing statistically significant improvement in ODI/NDI in the cervical subgroup and lumbar subgroup at 4-week (P = 0.05) and 8-week time points (P < 0.01), respectively. There was no improvement of ODI scores in the sacral subgroup. The incidence of post-neurotomy neuropathic pain was not significantly different among patients with different spinal levels of neurotomy. Patients who developed post-neurotomy neuropathic pain did not differ in ODI/NDI scores at any time point. LIMITATIONS: This study has several limitations, most notably the number of patients lost to follow-up, the use of a single corticosteroid, and the use of laterality for incidence reporting. Additionally, all procedures were performed by a single interventionalist using one neurotomy system. CONCLUSIONS: A statistically significant reduction in post-neurotomy pain was observed in the steroid group. This protocol can be feasibly conducted in an effective and resource-efficient manner. Additional research is needed to increase the power of the study.

Intervertebral Disc Degeneration: The Role and Evidence for Non-Stem-Cell-Based Regenerative Therapies.

The use of non-stem-cell-based regenerative medicine therapies for lumbar discogenic pain is an area of growing interest. Although the intervertebral disc is a largely avascular structure, cells located within the nucleus pulposus as well as annulus fibrosis could be targeted for regenerative and restorative treatments. Degenerative disc disease is caused by an imbalance of catabolic and anabolic events within the nucleus pulposus. As catabolic processes overwhelm the environment within the nucleus pulposus, proinflammatory cytokines increase in concentration and lead to further disc degeneration. Non-stem-cell-based therapies, which include growth factor therapy and other proteins, can lead to an increased production of collagen and proteoglycans within the disc.

Aromatherapy for Procedural Anxiety in Pain Management and Interventional Spine Procedures: A Randomized Trial.

OBJECTIVE: The aim of this study was to evaluate a nonsedating agent, lavender aromatherapy, to reduce anxiety before interventional spinal procedures. DESIGN: In this prospective, single-blind study performed at a tertiary care center for an academic institution, 144 patients undergoing spinal procedures (epidural steroid injection, medial branch block, or radiofrequency ablation) were randomized into two groups of 72 patients. The experimental group was exposed to a tablet formulation of lavender aromatherapy, while the control group was exposed to tablets devoid of any scent. The exposure duration for each group was 5 mins. The primary outcome measurement was patients' anxiety state before the spinal procedure using the six-item State-Trait Anxiety Inventory. Secondary outcomes quantified the rate of vasovagal events and aborted procedures because of patient intolerance. RESULTS: Compared with the control group, the posttreatment anxiety score of those exposed to lavender aromatherapy revealed a statistically significant difference as measured by the six-item State-Trait Anxiety Inventory (12.15 ± 2.67 and 10.67 ± 2.81, P < 0.05). Within group, the experimental group's anxiety level decreased from 12.26 ± 2.75 to 10.67 ± 2.81 (P < 0.05). There were two vasovagal episodes and one aborted procedure in the control group, whereas there was one vasovagal episode and no aborted procedures in the aromatherapy group. CONCLUSIONS: Lavender-based aromatherapy is effective in reducing preprocedural anxiety before interventional spine procedures for pain management.

Telemedicine During COVID-19 and Beyond: A Practical Guide and Best Practices Multidisciplinary Approach for the Orthopedic and Neurologic Pain Physical Examination.

BACKGROUND: The COVID pandemic has impacted almost every aspect of human interaction, causing global changes in financial, health care, and social environments for the foreseeable future. More than 1.3 million of the 4 million cases of COVID-19 confirmed globally as of May 2020 have been identified in the United States, testing the capacity and resilience of our hospitals and health care workers. The impacts of the ongoing pandemic, caused by a novel strain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have far-reaching implications for the future of our health care system and how we deliver routine care to patients. The adoption of social distancing during this pandemic has demonstrated efficacy in controlling the spread of this virus and has been the only proven means of infection control thus far. Social distancing has prompted hospital closures and the reduction of all non-COVID clinical visits, causing widespread financial despair to many outpatient centers. However, the need to treat patients for non-COVID problems remains important despite this pandemic, as care must continue to be delivered to patients despite their ability or desire to report to outpatient centers for their general care. Our national health care system has realized this need and has incentivized providers to adopt distance-based care in the form of telemedicine and video medicine visits. Many institutions have since incorporated these into their practices without financial penalty because of Medicare's 1135 waiver, which currently reimburses telemedicine at the same rate as evaluation and management codes (E/M Codes). Although the financial burden has been alleviated by this policy, the practitioner remains accountable for providing proper assessment with this new modality of health care delivery. This is a challenge for most physicians, so our team of national experts has created a reference guide for musculoskeletal and neurologic examination selection to retrofit into the telemedicine experience. OBJECTIVES: To describe and illustrate musculoskeletal and neurologic examination techniques that can be used effectively in telemedicine. STUDY DESIGN: Consensus-based multispecialty guidelines. SETTING: Tertiary care center. METHODS: Literature review of the neck, shoulder, elbow, wrist, hand, lumbar, hip, and knee physical examinations were performed. A multidisciplinary team comprised of physical medicine and rehabilitation, orthopedics, rheumatology, neurology, and anesthesia experts evaluated each examination and provided consensus opinion to select the examinations most appropriate for telemedicine evaluation. The team also provided consensus opinion on how to modify some examinations to incorporate into a nonhealth care office setting. RESULTS: Sixty-nine examinations were selected by the consensus team. Household objects were identified that modified standard and validated examinations, which could facilitate the examinations.The consensus review team did not believe that the modified tests altered the validity of the standardized tests. LIMITATIONS: Examinations selected are not validated for telemedicine. Qualitative and quantitative analyses were not performed. CONCLUSIONS: The physical examination is an essential component for sound clinical judgment and patient care planning. The physical examinations described in this manuscript provide a comprehensive framework for the musculoskeletal and neurologic examination, which has been vetted by a committee of national experts for incorporation into the telemedicine evaluation.

The Impact of Local Steroid Administration on the Incidence of Neuritis following Lumbar Facet Radiofrequency Neurotomy.

BACKGROUND: Pain arising from the lumbar facet joints is a common cause of axial back pain in adults. Radiofrequency neurotomy (RFN) of the medial branches of the spinal dorsal rami has been used as a treatment option. The most common side effect is transient, localized, burning, neuritic-type pain, termed post-neurotomy neuritis (PNN). Corticosteroids have been administered through the radiofrequency cannula after neurotomy to prevent PNN, but no study has examined the effects of this on PNN. OBJECTIVES: We investigated the incidence of PNN in patients who received corticosteroids after RFN and in those patients who did not receive corticosteroids. STUDY DESIGN: Retrospective evaluation. SETTING: Single-site interventional pain management practice in an urban tertiary academic medical center. METHODS: One hundred and sixty-four patients were included in this study and were categorized into non-steroid (n = 87) and steroid (n = 77) groups. Patient's age, gender, body mass index (BMI), laterality of procedure, use of neuropathic pain medications, baseline pain, and duration of pain were all recorded. PNN was determined if the patient self-reported transient burning or neuropathic pain at the site prior to or at the 6-week routine follow-up encounter. RESULTS: There was no significant difference in demographic characteristics between the 2 groups in age, gender, baseline pain, and duration of pain. The proportion of patients in the steroid treated group with PNN was 5 out of 77 (6.4%) and the non-steroid group was 6 out of 87 (6.9%). There was no statistically significant difference between the groups. There was no statistically significant difference in the incidence in neuritis between individuals taking neuropathic agents and individuals not taking neuropathic agents. LIMITATIONS: This study has several limitations including small sample size, patients' self-reported neuropathic symptoms, and inability to draw strong conclusions due to the retrospective study design. A single interventionalist performed all the procedures in this retrospective study and variations in technique amongst others are inevitable. CONCLUSION: Administration of steroids after RFN does not reduce the incidence of post-neurotomy neuritis. Concurrently administering neuropathic medications does not protect against neuritis. KEY WORDS: Radiofrequency neurotomy, radiofrequency ablation, neuritis, corticosteroid, lumbar facet pain, post neurotomy neuritis.

Percutaneous CT-guided facet joint synovial cyst rupture: Success with refractory cases and technical considerations.

Percutaneous image-guided rupture of lumbar facet synovial cysts can improve clinical outcomes and obviate the need for open surgery. This series describes eleven patients who had successful CT-guided lumbar facet synovial cyst ruptures, 82% of which experienced excellent pain relief at a minimum of one-year follow-up. Of the five patients who failed prior fluoroscopic-guided synovial cyst rupture, 80% had a successful CT-guided rupture and one-year sustained pain relief. These findings reinforce minimally invasive CT-guided treatment as an excellent option to improve patient symptoms and potentially avoid open surgery.

The Clinical Efficacy for Two-Level Transforaminal Epidural Steroid Injections.

BACKGROUND: Epidural steroid injections have been used in combination with other modalities for the treatment of lumbar radicular pain. The literature has shown that 1-level lumbar fluoroscopically guided transforaminal epidural steroid injections (TFESIs) are effective in decreasing pain and morbidity; however, the efficacy of 2-level TFESIs has not been investigated, although they are performed by many practitioners in the treatment of lumbar radicular pain. OBJECTIVES: To assess the clinical effectiveness of 2-level TFESIs in patients with unilateral, single-level lumbar radicular pain. In addition, a subgroup analysis was performed based on disk herniation location. STUDY DESIGN: Retrospective cohort. SETTING: Outpatient physiatry pain practice. PATIENTS: A total of 721 patients were included in this study having undergone a two-level transforaminal epidural steroid injection. METHODS: The study group included patients who underwent a 2-level lumbar TFESI. Patients presented for lumbar radicular pain as the result of disk herniation with or without radiculopathy and were scheduled to receive a lumbar TFESI at L3 or below. Of this group, only those that underwent a 2-level TFESIs were included in the study, and data analysis was carried out on this group. MAIN OUTCOME MEASURES: Subjects were assessed with a pain numerical rating scale (NRS 0-10) and Oswestry Disability Index (ODI) before TFESI and at 2-week and 2-month follow-up. Responders were defined as greater that 50% reduction in NRS or greater than 40% reduction in ODI. RESULTS: A total of 57.7% of patients were responders in terms of NRS (P < .05, confidence interval 53.6%-61.9%) and 51.7% responded in ODI at 2-month follow-up (P < .05 [confidence interval 47.5%-55.9%]). In addition, patients with complete pain relief (defined as 0/10 on NRS) were noted at both 2-week (n = 239, 33%) and 2-month (n = 130, 18%) follow-up. In subgroup analysis, the paracentral/subarticular disk group had an increased number of responders, 66.0% in NRS and 64.0% in ODI at 2-month follow-up (P < .05). CONCLUSIONS: Two-level TFESIs are effective in the management of radicular pain, but more research is needed to evaluate the utility of this treatment compared with single-level TFESI. Our study showed a greater improvement in pain and function as a result of 2-level TFESIs in the setting of paracentral/subarticular disk herniations. LEVEL OF EVIDENCE: IV.

Soleus Muscle Herniation With Magnetic Resonance Imaging and Ultrasound Correlation in a Female Long-Distance Runner: A Case Report.

This is a case of a 40-year-old female endurance athlete with right leg pain while running. A comprehensive workup revealed a fascial defect with soleus muscle herniation. Although historically in many practice settings magnetic resonance imaging is the diagnostic imaging modality of choice for suspected muscle herniation through the fascia, the use of ultrasound is increasing because of lower cost, ease of access, and dynamic evaluation. To the authors' knowledge, there has not been a direct comparison between the accuracy of magnetic resonance imaging versus ultrasound in determining the size or location of a soleus muscle herniation. LEVEL OF EVIDENCE: Not applicable.

Short-term efficacy of sacroiliac joint corticosteroid injection based on arthrographic contrast patterns.

OBJECTIVE: To determine the relationship between sacroiliac joint (SIJ) contrast dispersal patterns during SIJ corticosteroid injection and pain relief at 2 and 8 weeks after the procedure. The association between the number of positive provocative SIJ physical examination maneuvers (minimum of one in all patients undergoing SIJ injection) and the patient's response to the intervention was also assessed. DESIGN: Retrospective chart review. SETTING: Academic outpatient musculoskeletal practice. PATIENTS: Fifty-four subjects who underwent therapeutic SIJ corticosteroid injection were screened for inclusion; 49 subjects were included in the final analysis. METHODS: A retrospective review of electronic medical records identified patients who underwent SIJ corticosteroid injection. Fluoroscopic contrast flow patterns were categorized as type I (intra-articular injection with cephalad extension within the SIJ) or type II (intra-articular injection with poor cephalad extension). Self-reported numeric pain rating scale (NPRS) values at the time of injection and 2 and 8 weeks after the procedure were recorded. The number of positive provocative SIJ physical examination maneuvers at the time of the initial evaluation was also recorded. MAIN OUTCOME MEASURES: The primary outcome measure was the effect of contrast patterns (type I or type II) on change in NPRS values at 2 weeks and 8 weeks after the injection. The secondary outcome measure was the association between the number of positive provocative SIJ physical examination maneuvers and decrease in the level of pain after the procedure. RESULTS: At 2 weeks after the procedure, type I subjects demonstrated a significantly lower mean NPRS value compared with type II subjects (2.8 ± 1.4 versus 3.8 ± 1.6, respectively, P = .02). No statistically significant difference was observed at 8 weeks after the procedure. NPRS values were significantly reduced both at 2 weeks and 8 weeks, compared with baseline, in both subjects identified as having type I flow and those with type II flow (P < .0001 for all within-group comparisons). CONCLUSIONS: Fluoroscopically guided corticosteroid injections into the SIJ joint are effective in decreasing NPRS values in patients with SIJ-mediated pain. Delivery of corticosteroid to the superior portion of the SIJ leads to a greater reduction in pain at 2 weeks, but not at 8 weeks. Patients with at least one positive provocative maneuver should benefit from an intra-articular corticosteroid injection.

Gluteus maximus calcific tendonosis: a rare cause of sciatic pain.

Extraspinal causes of radicular pain are rare and are in danger of being overlooked. Here, we present a patient with pain radiating into the posterior thigh and lateral calf. Although initial differential diagnosis included lumbar herniated nucleus pulposus, further imaging revealed the presence of gluteus maximus calcific tendonosis. After physical therapy and a potent oral steroid regimen, the pain gradually resolved and the patient was able to return to full activity.

Atypical clinical presentation of periprosthetic femur fracture after revision total hip arthroplasty.

A common complication after revision total hip arthroplasty is periprosthetic fracture. These injuries tend to occur in bones that have undergone repeated reaming during surgery, thereby compromising the intramedullary integrity of the bone. The clinical presentation of this complication varies among patients, and practitioners must use clinical suspicion and imaging studies to make the diagnosis early. This case study presents a patient who sustained a periprosthetic femur fracture and reported isolated knee pain. This obscure clinical presentation delayed the patient's diagnosis, which could have potentially led to further mobility. This report stressed the importance of taking an accurate history and physical examination as well as using diagnostic modalities when appropriate.

Utility of pathologic evaluation following removal of explanted orthopaedic internal fixation hardware.

This report questions the cost and effectiveness of routinely sending explanted hardware to pathology for evaluation. Forty-six consecutive patients who had symptomatic hardware removed were enrolled in this study. Pathology reports following hardware removal were obtained, and charts were reviewed for these patients. The pathology department was contacted for related departmental procedure codes, and hospital billing records were obtained regarding the cost of the procedure. In all cases, the pathology reports gave the gross diagnosis of "hardware" and the gross description included the measurements of the internal fixation hardware removed. In no case did the report alter the plan of the attending physician. The healthcare system may benefit by subspecialty review of the current practice of sending internal fixation devices to pathology for evaluation. We recommend a single radiographic view along with proper documentation in the postoperative report to confirm the removal of internal fixation hardware in lieu of pathologic evaluation.

Functional outcome in patients treated for chronic posttraumatic osteomyelitis.

BACKGROUND: Management of chronic posttraumatic osteomyelitis remains an important challenge in orthopaedics. In this investigation, 43 patients at a large university hospital were retrospectively identified who had been diagnosed with chronic osteomyelitis at 44 sites. METHODS: Diagnosis was based on the patient's history and physical examination, laboratory values, radiological evaluation, and intraoperative specimens. Patients' charts were reviewed and follow-up was obtained on 33 patients in whom Short Musculoskeletal Functional Assessment (SMFA) questionnaires were obtained. RESULTS: The mean follow-up of the cohort was 21.1 months (range, 10 to 54 months). Sites involved included: tibia (55%) and femur (36%), with the remainder involving the pelvis, radius/ulna, and calcaneus. Blood, bone, or wound aspirate cultures were positive in 85%, most commonly for Staphylococcus aureus. 84% of the patients in this investigation were completely cured after a single surgical intervention, removal of hardware and a course of intravenous antibiotics. Three patients required additional surgical intervention and two remained infected. Ultimately, the cohort reached a cure rate of 94%. SMFA data revealed that patients had a dysfunction score of 53.8 and bother index of 51.5, with 50 being the normal for the general population. CONCLUSION: The patients in this cohort functioned at a level less than one standard deviation below the general population. These results suggest that patients with chronic posttraumatic osteomyelitis do not function significantly below that of the normal population following eradication of their infections.