A pragmatic randomized prospective trial of cooled radiofrequency ablation of the medial branch nerves versus facet joint injection of corticosteroid for the treatment of lumbar facet syndrome: 12 month outcomes.

BACKGROUND: Lumbar medial branch radiofrequency ablation (LRFA) and intraarticular facet steroid injections (FJI) are commonly performed for recalcitrant facet joint-mediated pain. However, no study has compared clinical outcomes of the two treatments in patients selected using dual medial branch blocks (MBBs) with an 80% relief threshold. OBJECTIVE: Compare the effectiveness of cooled LRFA (C-LRFA) to FIJ as assessed by pain and functional improvements. DESIGN: Prospective randomized comparative trial. METHODS: Patients with dual MBB-confirmed facet joint-mediated pain were randomized to receive C-LRFA or FIJ. Outcomes were assessed at 1, 3, 6, and 12 months. The primary outcome was ≥50% improvement in numerical pain rating scale (NPRS) score at 3 months. Secondary outcomes included ≥30% Oswestry Disability Index (ODI) improvement and Patient Global Impression of Chance (PGIC) ≥6 points, among others. Data were analyzed using contingency tables and mixed-effects logistic regression models. RESULTS: Of 1128 patients screened, 32 met eligibility criteria, were randomized, and received their allocated study treatment. In total, 20 (62.5%) and 12 (37.5%) participants received C-LRFA and FIJ, respectively. In the C-LRFA group, 70% (95% CI 48-85), 55% (95% CI 34-74), and 45% (95% CI 26-66) of participants met the NPRS responder definition, compared to 25% (95%CI 9-53), 25% (95% CI 9-53), and 17% (95% CI 5-45) in the FJI group at 3, 6, and 12 months, respectively (P = .014 at 3 months). The PGIC responder proportion was higher in the C-LRFA compared to FJI group at 3 and 6 months (P < .05). CONCLUSIONS: C-LRFA demonstrated superior success rates compared to FJI across pain and functional outcome domains. TRIAL REGISTRATION DETAILS: ClinicalTrials.gov (NCT03614793); August 3, 2018.

Hip aspiration: A comparison of ultrasound and fluoroscopic guidance.

Introduction: Hip aspirations are commonly performed for diagnostic purposes using either fluoroscopic or ultrasound guidance. The superiority of one type of image guidance over another for aspiration of a native or replaced hip remains a matter of debate. The questions to be evaluated in this study include 1) to determine if hip aspiration using fluoroscopy or ultrasound guidance more often obtains fluid from native and post-arthroplasty hip joints, and 2) to identify patient-related factors associated with the ability to obtain fluid. Material and methods: A retrospective analysis of all hip aspirations (433) performed at a single institution was undertaken, with the primary outcome variable being successful attainment of joint fluid. Age, body mass index (BMI), sex, presence of a trainee, presence of an arthroplasty at the time of aspiration on the affected side, amount of fluid collected, and type of image guidance were used as independent variables in regression models. Results: 1) The likelihood of obtaining fluid was approximately 2.1 times greater with ultrasound guidance than fluoroscopy guidance (95% CI = 1.382, 3.117; p < 0.001). 2) Ultrasound guidance and lower BMI were independently associated with a significantly higher likelihood of obtaining fluid. Additionally, one unit decrease in BMI was associated with about a 3% increase in the odds of obtaining fluid (95% CI = 0.950, 0.998; p = 0.033). Conclusion: This study demonstrates that the use of ultrasound guidance for hip joint aspiration, when compared to fluoroscopic guidance, is more likely to result in a successful aspiration and the acquisition of a greater volume of fluid. Therefore, ultrasound guidance is the preferred method for hip aspiration in both native and replaced hips.

Cervical and Thoracic Spondylotic Myelopathies.

Spondylotic myelopathies are among the most common disorders of the spine, yet the clinical and treatment approach is far from standardized. This article discusses our current understanding of the epidemiology, pathophysiology, clinical assessment, natural history, and treatment options in degenerative myelopathies of the cervical and thoracic spine. We additionally review diagnostic modalities including imaging modalities of the spine and neurophysiological tools such as electromyography/nerve conduction studies, somatosensory-evoked potentials, and motor-evoked potentials. Assessment instruments that can be used for the assessment of myelopathies are reviewed, including the Japanese Orthopedic Association (JOA) score, modified-JOA scale, Nurick scale, nine-hole peg test, and 30-m walking test. We also review common disorders that mimic spondylotic myelopathies, as well as helpful diagnostic clues in differentiating spondylotic and nonspondylotic myelopathies.

One-year results from a randomized comparative trial of targeted steroid injection via epidural catheter versus standard transforaminal epidural injection for the treatment of unilateral cervical radicular pain.

OBJECTIVES: The objective of this study was to evaluate the long-term effectiveness of catheter-directed cervical interlaminar epidural steroid injection with triamcinolone compared with cervical transforaminal steroid injection with dexamethasone for the treatment of refractory unilateral radicular pain. DESIGN: Prospective, randomized, comparative trial. METHODS: The primary outcome was the proportion of participants with ≥50% Numeric Rating Scale 'dominant pain' (the greater of arm vs neck) reduction from baseline. Secondary outcomes included ≥30% Neck Disability Index reduction and Patient Global Impression of Change response indicating 'much improved' or 'very much improved'. RESULTS: Data from 117 participants (55.6% women; 52.3±12.5 years of age; body mass index, 28.2±6.5 kg/m2) were analyzed. The proportion of participants who experienced ≥50% pain reduction at 1 month, 3 months, and 6 months has been previously reported. At 1 year, 61.2% (95% CI, 46.9% to 73.9%) of the catheter group compared with 51.9% (95% CI, 38.4% to 65.2%) of the transforaminal group reported ≥50% 'dominant' pain reduction (p=0.35). The proportion of participants who experienced ≥30% improvement in Neck Disability Index score was 60.4% (95% CI, 45.9% to 73.3%) and 47.1% (95% CI, 33.7% to 60.8%) in the catheter and transforaminal groups (p=0.18). Patient Global Impression of Change improvement was similar in both groups: 60.5% (95% CI, 44.2% to 74.8%) and 57.5% (95% CI, 41.7% to 71.9%) of the catheter and transforaminal groups reported being 'much improved' or 'very much improved', respectively (p=0.79). CONCLUSION: Both cervical catheter-directed interlaminar epidural injection and cervical transforaminal steroid injection were effective in reducing pain and disability in the majority of participants with refractory unilateral cervical radiculopathy for up to 1 year.

Does the Contrast Dispersion Pattern During Fluoroscopically Guided Cervical Transforaminal Epidural Steroid Injection Predict Short-Term Pain and Functional Outcomes? An Exploratory Analysis of Prospective Cohort Data.

SUMMARY OF BACKGROUND DATA: No study has evaluated the relationship between contrast dispersion patterns and outcomes after fluoroscopically guided cervical transforaminal epidural steroid injection (CTFESI). OBJECTIVES: Determine whether contrast dispersion patterns predict pain and functional outcomes after CTFESI. METHODS: Secondary analysis of data collected during two prospective studies of CTFESI for the treatment of refractory radicular pain. Contrast dispersion patterns visualized by true anteroposterior (AP) projections during CTFESIs were categorized by flow: 1) completely external to the lateral border of the neuroforamen (zone 1); 2) within the neuroforamen but without entry into the lateral epidural space (zone 2); and 3) with extension into the lateral epidural space (zone 3). At baseline and at 1 month post-CTFESI, neck pain, arm pain, and "dominant index pain" (the greater of arm or neck pain) were evaluated using a numeric rating scale (NRS); physical function was assessed using the Five-Item Version of the Neck Disability Index (NDI-5). RESULTS: One-month post-CTFESI, neck pain, arm pain, and "dominant index pain" reductions of ≥50% were observed in 39.4% (95% confidence interval [CI], 28.2-51.8), 55.6% (95% CI, 43.0-67.5), and 44.1% (95% CI, 32.7-56.2) of participants, respectively. Regarding "dominant index pain," 72.7% (95% CI, 40.8-91.2), 39.4% (95% CI, 24.2-57.0), and 37.5% (95% CI, 20.5-58.2) of participants reported ≥50% pain reduction when zone 1, zone 2, and zone 3 contrast flow patterns were observed. Contrast dispersion zone was not significantly associated with subgroup differences in neck pain, arm pain, or NDI-5 scores (P>0.05). CONCLUSION: Improvements in pain and function 1 month after treatment with CTFESI did not differ significantly based on the contrast dispersion pattern. Future study is needed to confirm or refute these findings in other procedural settings, in broader patient populations, and with longer-term outcome assessment.

Descriptive Epidemiology, Medical Evaluation, and Outcomes of Rock Climbing Injuries.

OBJECTIVE: To gather epidemiologic data on injury type, treatment, and recovery from rock climbing injuries. METHODS: Design: retrospective cross-sectional study. SETTING: web-based survey. PARTICIPANTS: rock climbers who sustained a climbing-related injury during the prior 24 months. Criteria for inclusion: aged ≥18 years; participation in rock climbing at least 4 times per year in the United States. INTERVENTIONS: none. MAIN OUTCOME MEASURES: percentage of injured climbers seeking medical care, providers seen, subspecialty referral, development of chronic problems, factors affecting return to climbing, injuries by climbing type, body region, and injury type. RESULTS: Data were collected over a 60-day period using the Research Electronic Data Capture (REDCap) survey system. Seven hundred and eight surveys were collected from 553 male and 155 female climbers. Thirteen hundred ninety seven injuries were reported, and 975 injuries were suitable for analysis. The most common provider initially seen was a primary care provider. Subspecialty referral was commonly obtained. Injury patterns differed by climbing type. The percentage of respondents that returned to climbing before their injury was fully healed was 51.1%, and 44.9% of respondents developed chronic problems related to their climbing injury. Twenty-eight percent of respondents were unable to return to their previous level of climbing performance. Several factors were associated with delayed recovery from climbing injury. CONCLUSIONS: A significant number of climbers sought healthcare after injury. A majority of climbers who sought treatment were referred to subspecialist providers. About one-half of climbers were symptomatic when they returned to climbing and developed chronic problems after injury. Factors associated with slower return to climbing included increasing age, smoking, fractures, and surgery.