Is a history of episodic low back pain an indicator of Modic changes?

Background: Prior work demonstrated that a history of episodic low back pain was highly indicative of discogenic pain. Recently, there has been more focus on vertebrogenic pain, however little is known about the clinical features of this condition. Purpose: To determine if a history of severe episodic low back pain correlates with Modic endplate changes on lumbar spine magnetic resonance imaging (MRI), presumed to be a marker of vertebrogenic pain. Study design: /setting: Retrospective, observational, in vivo study of consecutive patients at outpatient Physical Medicine & Rehabilitation clinics at a single academic spine center. Patient sample: Consecutive patients who received a lumbar spine MRI between January 1, 2020, and December 31, 2020. Methods: A retrospective chart review identified patients who received a lumbar spine MRI in 2020. Chart review then determined if patients had a history of episodes of low back pain lasting at least 2 days, or if they had non-episodic low back pain (pain beginning with a gradual onset or after a specific event with continuous symptoms for >3 months). Patients were excluded if they had prior lumbar spine surgery, radicular leg pain without low back pain, indeterminate presentations based on chart review, acute spine fractures, or metastatic spine lesions. For the primary analysis, the MRIs were reviewed and were dichotomized into positive (having for either type 1 or type 2 Modic changes at any level) or negative (no Modic changes at any level). Results: A total of 111 patients were analyzed. Inter-rater reliability for determining whether a patient's low back pain was episodic was strong (kappa â€‹= â€‹0.83), as was inter-rater reliability for determining if a patient had any levels with type 1 or type 2 Modic changes (kappa â€‹= â€‹0.81). Seventy-one out of 111 patients had type 1 and/or type 2 Modic changes at one or more spinal levels. The sensitivity of the test (episodic vs non-episodic low back pain) in finding patients with Modic changes was 20% and the specificity was 70%. The diagnostic confidence odds were 1.2, with a diagnostic confidence of 55%. Subgroup analyses for type 1 Modic changes, and for type 2 Modic changes, showed similar values. Conclusions: A history of episodic low back pain is not a strong indicator for a vertebrogenic etiology.

Treatment pattern trends of medications for type 2 diabetes in British Columbia, Canada.

INTRODUCTION: Several new oral drug classes for type 2 diabetes (T2DM) have been introduced in the last 20 years accompanied by developments in clinical evidence and guidelines. The uptake of new therapies and contemporary use of blood glucose-lowering drugs has not been closely examined in Canada. The objective of this project was to describe these treatment patterns and relate them to changes in provincial practice guidelines. RESEARCH DESIGN AND METHODS: We conducted a longitudinal drug utilization study among persons with T2DM aged ≥18 years from 2001 to 2020 in British Columbia (BC), Canada. We used dispensing data from community pharmacies with linkable physician billing and hospital admission records. Laboratory results were available from 2011 onwards. We identified incident users of blood glucose-lowering drugs, then determined sequence patterns of medications dispensed, with stratification by age group, and subgroup analysis for patients with a history of cardiovascular disease. RESULTS: Among a cohort of 362 391 patients (mean age 57.7 years old, 53.5% male) treated for non-insulin-dependent diabetes, the proportion who received metformin monotherapy as first-line treatment reached a maximum of 90% in 2009, decreasing to 73% in 2020. The proportion of patients starting two-drug combinations nearly doubled from 3.3% to 6.4%. Sulfonylureas were the preferred class of second-line agents over the course of the study period. In 2020, sodium-glucose cotransporter type 2 inhibitors and glucagon-like peptide-1 receptor agonists accounted for 21% and 10% of second-line prescribing, respectively. For patients with baseline glycated hemoglobin (A1C) results prior to initiating diabetic treatment, 41% had a value ≤7.0% and 27% had a value over 8.5%. CONCLUSIONS: Oral diabetic medication patterns have changed significantly over the last 20 years in BC, primarily in terms of medications used as second-line therapy. Over 40% of patients with available laboratory results initiated T2DM treatment with an A1C value ≤7.0%, with the average A1C value trending lower over the last decade.

Extensor digitorum brevis bulk and associations with fibular motor nerve conduction amplitude.

INTRODUCTION: Prior work demonstrates that fibular compound motor action potential (CMAP) amplitude <4.0 mV predicts impairment of ankle proprioceptive precision and increased fall risk. Extensor digitorum brevis (EDB) inspection may present a simple clinical surrogate for CMAP amplitude. OBJECTIVE: (1) To estimate the inter-rater reliability of assessment of EDB bulk. (2) To determine whether inspection of EDB bulk is associated with fibular CMAP amplitude. DESIGN: Prospective inter-rater reliability study. SETTING: Academic center outpatient Physical Medicine & Rehabilitation electromyography (EMG) clinics. PARTICIPANTS: Fifty-two adult participants (102 feet). MAIN OUTCOME MEASURES: (1) Inter-rater reliability of assessment of EDB bulk. (2) Mean fibular CMAP amplitude. (3) A binary measure of fibular CMAP amplitude at/above or below a 4.0 mV threshold. RESULTS: Inter-rater reliability of EDB bulk grading was moderate (kappa: 0.65 [95% confidence interval (CI) 0.48-0.82]). The mean CMAP value was 5.9 ± 2.2 mV when bulk was normal, 3.4 ± 2.1 mV when diminished, and 0.6 ± 0.9 mV when atrophied. A multivariable analysis demonstrated that EDB bulk, distal symmetric polyneuropathy (DSP), and lumbar radiculopathy were all associated with CMAP amplitude. The sensitivity and specificity of grading muscle bulk as normal versus abnormal in detecting CMAP amplitude above or below 4.0 mV were 0.86 (95% CI 0.78-0.94) and 0.71 (95% CI 0.54-0.88), respectively. An atrophied EDB was a highly specific indicator that CMAP amplitude was abnormal (<4.0 mV) in 100% of cases (8/8). CONCLUSIONS: EDB bulk was associated with fibular CMAP amplitude. Atrophy was a highly specific indicator for CMAP amplitude below 4.0 mV. Evaluation of EDB bulk may represent a quick and easy clinical surrogate marker for CMAP amplitude and distal neuromuscular impairment.

Contrast flow patterns based on needle tip position during cervical transforaminal epidural injections.

BACKGROUND: Few studies have evaluated the effect of final needle position on contrast flow patterns during the performance of cervical transforaminal epidural steroid injections (TFESIs). OBJECTIVE: To analyze fluoroscopically guided cervical TFESI contrast flow patterns based upon final needle tip position. DESIGN: Retrospective, observational in vivo study. SETTING: Outpatient private practice physical medicine and rehabilitation spine clinic. PARTICIPANTS: One hundred consecutive patients undergoing cervical TFESIs. INTERVENTIONS: Cervical TFESIs. MAIN OUTCOME MEASURES: Categories of contrast flow patterns including epidural, intraforaminal, "sufficient to inject," and "predominantly epidural and/or intraforaminal," based upon final needle tip position. RESULTS: Two independent observers reviewed images from 100 consecutive patients and classified injectate flow patterns stratified by needle tip position. The interrater reliability for all categories of interest was moderate, with kappa values from 0.61 to 0.76. More medially placed needles (middle third and lateral third of the articular pillars) resulted in higher rates of epidural contrast flow (75%; 95% confidence interval [CI]: 56%-94%; and 60%; 95% CI: 47%-73%) compared to needles placed lateral to the articular pillars (26%; 95% CI: 8%-44%), and higher rates of "predominantly epidural and/or intraforaminal" flow patterns with needles placed in the middle one third (75%; 95% CI: 56%-94%) and lateral one third of the articular pillars (47%; 95% CI: 34%-60%) compared to flow patterns when needles were placed lateral to the articular pillars (17%; 95% CI: 2%-32%). No needles were placed in the medial third of the articular pillars. CONCLUSIONS: More medially placed needle tips result in more optimal flow patterns during cervical TFESIs. The importance of this finding is unknown as clinical outcomes were not measured.

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.

Retrospective analysis of cervical transforaminal versus interlaminar epidural steroid injections.

Background: Several studies have compared outcomes from lumbar epidural steroid injections (ESIs) based upon technique (transforaminal (TF) vs interlaminar (IL) vs caudal). However, little on this topic has been reported in the cervical spine, and results have been conflicting. Purpose: To compare success rates of fluoroscopically-guided cervical TFESIs vs ILESIs. Study design/setting: Retrospective, observational, in vivo study of consecutive patients at outpatient Physical Medicine & Rehabilitation clinics at a single academic spine center. Patient sample: Consecutive patients who received a cervical TF or IL ESI between January 2010 and October 2018. Outcome measures: NRS pain scores within 60 days of the ESI. Methods: Current procedural terminology (CPT) codes were used to search all consecutive patients at a single outpatient academic spine center who received a cervical TF or IL ESI between January 2010 October 2018. 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 178 â€‹TF and 185 ILESIs were analyzed. Success was defined as ≥ 50% improvement in NRS pain score. 52% [95% CI: 47 - 57%] of all patients receiving a cervical ESI achieved a successful outcome. There was a strong trend towards better results in the ILESI group with 59% [95% CI: 52 - 66%] of patients achieving at least 50% pain relief compared to 46% [95% CI: 39 - 53%] in the TF group. A higher proportion of patients in the IL group obtained at least 80% pain relief (37% [95% CI: 30 - 44%]) compared to those in the TF group (17% [95% CI: 11 - 23%]). Post-procedure median NRS pain scores, and improvement in median NRS pain scores were better in the ILESI group compared to the TFESI group (p<0.001). Conclusion: This retrospective study demonstrated better results in the cervical ILESI group compared to the cervical TFESI group.

Modification of the Cervical Transforaminal Epidural Steroid Injection Technique Based Upon the Anatomic Angle of the Superior Articular Process on MRI.

OBJECTIVE: A modification of the conventional technique for cervical transforaminal epidural steroid injection (CTFESI) has been developed. This technique may, theoretically, decrease the likelihood of the needle encountering the vertebral artery and spinal nerve. The approach uses angle measurements of the superior articular process ventral surface from the patient's axial MRI as a guide for fluoroscopic set-up and needle trajectory. This report aims to compare contrast flow patterns of the modified approach with those of the conventional technique. DESIGN: Retrospective chart review and prospective blinded analysis of contrast flow patterns. Setting. Outpatient interventional physiatry practice. METHODS: A retrospective blinded qualitative review of fluoroscopic images was performed to compare contrast flow patterns of CTFESIs performed using the modified approach with those using the conventional technique. A detailed description of the modified approach is provided in this report. RESULTS: Ninety-seven CTFESI procedures were used for flow analysis. The modified approach resulted in a statistically significant greater percentage of injections with epidural flow: 69% [95% CI = 57-82%] modified approach vs. 42% [95% CI = 28-56%] conventional approach. The modified technique also showed a statistically significant higher percent of injections categorized as having an ideal flow pattern, that of predominate epidural and/or intraforaminal flow: 65% [95% CI = 52-78%] vs. 27% [95% CI = 14-40%]. CONCLUSIONS: A modification of the conventional CTFESI technique, developed for the purpose of improved safety, may provide superior contrast flow patterns when compared to the conventional approach.

Validity of Physical Exam Maneuvers in the Diagnosis of Sacroiliac Joint Pathology.

BACKGROUND: A combination of physical examination maneuvers is currently considered necessary to help predict who will respond to injections in the sacroiliac joint. However, the literature on this topic currently consists of conflicting studies, with one showing the value of a combination of exam maneuvers and the other showing no real value. OBJECTIVE: To determine the diagnostic validity of sacroiliac joint (SIJ) physical exam maneuvers using anesthetic intra-articular injection as a reference standard. DESIGN: A single institution prospective study. PARTICIPANTS: Patients with the clinical diagnosis of SIJ pain and referred for SIJ injection were enrolled. MAIN OUTCOME MEASURE: Numeric rating scale (NRS) to assess pain intensity. RESULTS: Participants underwent fluoroscopically guided SIJ intra-articular injection with 1 cc of 2% lidocaine and 1 cc of triamcinolone 40 mg. Patients' pain was assessed via 0-10 NRS pre-injection and immediately postinjection to determine positive anesthetic response to the injection. Six physical exam maneuvers (thigh thrust, Geanslen's test, FABER test, distraction test, compression test, and sacral thrust) were performed pre-injection and 15 minutes postinjection. The results of these SIJ physical exam maneuvers were evaluated singly and in combinations for diagnostic power in relation to a positive anesthetic response (>80% relief) to the injection. No association was found between a single SIJ physical exam maneuver or combination of maneuvers and anesthetic response to the injection. CONCLUSIONS: In this cohort, patient physical exam maneuvers to identify intra-articular SIJ pain did not demonstrate diagnostic value when compared with the reference standard of an intra-articular anesthetic block.

Pain and Functional Outcomes After Sacroiliac Joint Injection with Anesthetic and Corticosteroid at Six Months, Stratified by Anesthetic Response and Physical Exam Maneuvers.

OBJECTIVE: To evaluate sacroiliac joint (SIJ) injection outcomes with local anesthetic and corticosteroid. DESIGN: Prospective cohort. SETTING: Single academic medical center. METHODS: Thirty-four patients referred for SIJ injection with a clinical diagnosis of SIJ pain underwent injections with 1:1 mixture of 2% lidocaine and triamcinolone 40 mg/mL. Pain provocation physical exam (PE) maneuvers were recorded immediately before and after injection. Outcome measures at two to four weeks and six months included pain numeric rating scale (NRS) and Oswestry Disability Index (ODI). RESULTS: For the analysis of outcomes by the overall group (not stratified by PE and/or anesthetic block), a 58.8% (95% confidence interval [CI] = +/-16.5%) ≥2 NRS reduction, a 32.4% (95% CI = +/-15.7%) ≥50% NRS reduction, and a 38.2% (95% CI = +/-16.3%) ≥30% ODI reduction were observed at two to four weeks, with similar improvements at six months. Outcomes stratified based on pre-injection PE did not reveal significant differences at either time point. The stratification based on the presence of 100% postinjection anesthetic response demonstrated a significant difference at two to four weeks for ≥50% NRS improvement. The true positive/true negative group (TP/TN) stratification demonstrated a significant difference for ≥50% NRS improvement at two to four weeks, whereas six-month outcomes for TP/TN demonstrated significant differences for ≥50% NRS and ≥30% ODI improvement. An increased injection response was observed with stratification of patients more likely to have true SIJ pain (i.e., TP), with TP/TN stratification demonstrating a 75% (95% CI = +/-30.0%) ≥2 NRS improvement and a 62.5% (95% CI = +/-33.5%) improvement of ≥50% NRS and ≥30% ODI for the TP group at two to four weeks, with similar results at six months. CONCLUSIONS: SIJ steroid injection based on referral clinical diagnosis is unlikely to demonstrate true injection efficacy, and more specific selection criteria are warranted.

Corticosteroid Injections Into Lumbar Facet Joints: A Prospective, Randomized, Double-Blind Placebo-Controlled Trial.

BACKGROUND: Corticosteroid injections into the intra-articular zygapophysial (z-joints) are frequently used to treat this cause of low back pain. No studies have been done on the efficacy of intra-articular corticosteroids in those with z-joint pain confirmed by dual comparative medial branch blocks. OBJECTIVE: The aim of the study was to determine whether an injection of a corticosteroid into lumbar z-joints is effective in reducing pain and the need for radiofrequency neurotomy. METHODS: This is a double-blind, prospective, randomized, placebo-controlled trial. The study was conducted in Academic Medical Center. Twenty-eight subjects with z-joint pain confirmed by medial branch blocks were included in the study. Subjects with confirmed z-joint pain via dual comparative medial branch block were randomized to receive either intra-articular corticosteroid (triamcinolone 20 mg) or saline via fluoroscopic guided injection. RESULTS: No statistically significant difference in the need for radiofrequency neurotomy (radiofrequency neurotomy) between the groups, with 75% (95% confidence interval = 50.5%-99.5%) of the saline group vs. 91% (95% confidence interval = 62.3%-100%) of the corticosteroid group receiving radiofrequency neurotomy. There is no difference in mean time to radiofrequency neurotomy between saline (6.1 wks) and corticosteroid (6.5 wks) groups. There is a need for radiofrequency neurotomy. CONCLUSIONS: Corticosteroid injections into the lumbar z-joints were not effective in reducing the need for radiofrequency neurotomy of the medial branches in those with z-joint pain confirmed by dual comparative medial branch blocks.

Does Immediate Pain Relief After an Injection into the Sacroiliac Joint with Anesthetic and Corticosteroid Predict Subsequent Pain Relief?

Objectives: To determine if immediate pain response following an injection with local anesthetic and corticosteroid predicts subsequent relief. Design: Prospective observational cohort. Setting: An institutional review board-approved prospective study from a single academic medical center. Methods: Patients with clinical diagnosis of sacroiliac (SIJ) pain and referred for SIJ injection were enrolled; 1 cc of 2% lidocaine and 1 cc of triamcinolone 40 mg/mL were injected into the SIJ. Pain score on 0-10 numeric rating scale (NRS) during provocation maneuvers was recorded immediately before injection, immediately after injection, and at two and four weeks of follow-up. Oswestry Disability Index (ODI) was also recorded. Results: Various cutoffs were identified to establish positive anesthetic response and successful outcomes at follow-up. These were used to calculated likelihood ratios. Of those with 100% anesthetic response, six of 11 (54.5%, 95% confidence interval [CI]+/-29.4%, +LR 2.6, 95% CI = 1.1-5.9) demonstrated 50% or greater pain relief at follow-up, and four of 11 (36.5%, 95% CI+/-28.4%, +LR 3.00, 95% CI = 1.4-5.1) had 100% relief at two to four weeks. Fourteen of 14 (100%, 95% CI+/-21.5%, -LR 0.0, 95% CI = 0.0-2.1) with an initial negative block failed to achieve 100% relief at follow-up. Conclusions: Patients who fail to achieve initial relief after SIJ injection with anesthetic and steroid are very unlikely to achieve significant pain relief at follow-up; negative likelihood ratios (LR) in this study, based on how success is defined, range between 0 and 0.9. Clinically significant positive likelihood ratios of anesthetic response to SIJ injection are more limited and less robust, but are valuable in predicting 50% relief or 100% relief at two to four weeks.

Is a History of Severe Episodic Low Back Pain an Indicator of a Discogenic Etiology?

Objective: To determine if a history of severe episodic low back pain (LBP) correlates with positive discography. Methods: A retrospective chart review identified patients undergoing discography from January 2012 through February 2016. The review determined if the patient's LBP began or continued with severe disabling episodes (lasting a minimum of two days). A gradual onset or initiating event with continuous symptoms was considered a nonepisodic history. Patients were excluded for unclear record, workers' compensation, litigation, prior lumbar surgery, radiologic instability, or indeterminate discography. Results: Seventy-eight patients underwent discography. Thirty-nine patients were included, 31 of which had positive discograms. Eight had negative discograms. Nineteen patients had a history of episodic LBP, and 20 had no history of episodic LBP. Of those 19 with a history of episodic LBP, 18 had positive discography and one had negative discography. Of those with no history of episodic LBP, 13 had positive discography and seven had negative discography. Using the historical finding of severe episodic LBP as a test for discogenic source of LBP, the sensitivity is 58% (95% confidence interval [CI] = 41-75%) and the specificity is 88% (95% CI = 65-100%). The likelihood ratio is 4.7 (95% CI = 0.72-30). The positive predictive value (PPV) is 95% (95% CI = 72-100%). The PPV is based upon a prevalence of 79% (discogram positive) in our sample of patients considering fusion surgery. The diagnostic confidence odds are 18.2, with a diagnostic confidence of 95%. Conclusions: A positive history of severe episodic LBP may be a strong indicator for a discogenic etiology.