Current Trends in Steroid Dose Choice and Frequency of Administration of Epidural Steroid Injections: A Survey Study.

BACKGROUND: Epidural steroid injections (ESI) are commonly used to treat refractory radicular spinal pain. Although evidence suggests that an increasing cumulative dose of exogenous corticosteroid may be harmful, knowledge of current practice patterns is limited regarding the choice of dose and frequency of epidural steroid injections (ESIs). OBJECTIVE: Describe current practice trends in the dose selection and frequency of administration of transforaminal ESIs (TFESIs) and interlaminar ESIs (ILESIs). DESIGN: Cross-sectional survey study. SETTING: Not applicable. PARTICIPANTS: Three hundred fourteen physician members of the Spine Intervention Society (SIS). From May to June 2018, an online survey was distributed to 5907 physician members of the SIS. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Corticosteroid dose used by practitioners and the number of annual ESIs administered per patient. RESULTS: Three hundred fourteen physicians responded to the survey. For single cervical or lumbar injections of dexamethasone, most physicians (56.0%) reported using 10 mg; 17% of physicians reported use of doses greater than 10 mg, with 6% using a dose of 20 mg per injection level. The most common particulate corticosteroid dose used during both cervical and lumbar ILESIs was 80 mg (cervical = 55.4%, lumbar = 54.7%). During cervical and lumbar ILESIs, 17% and 12.7% of physicians reported using doses greater than 80 mg, respectively. Almost 10% of physicians reported performing cervical TFESIs with particulate steroids. Forty percent of physicians reported allowing four ESIs at a given spinal segmental level per year (cervical/thoracic/lumbosacral). A small percentage of physicians reported allowing more than six ESIs annually (6%) and >10 injections annually (1%). CONCLUSIONS: There is considerable variability among this large cohort of interventionists with regard to corticosteroid dose selection and epidural steroid injection frequency. A small proportion of respondents reported Mulitsociety Pain Workgroup guideline-discordant use of particulate steroids during cervical TFESIs. These findings demonstrate a need for additional research regarding both the reasons for such variation in care and the reasons for guideline-discordant practice in a subset of physicians. LEVEL OF EVIDENCE: IV.

Presentation and Rehabilitation in a Patient With Toxoplasmosis Encephalitis: A Case Study and Review.

Toxoplasma gondii is an opportunistic infection that often presents in the setting of acquired immunodeficiency syndrome. The infection can cause severe and potentially fatal encephalitis because of the reactivation of latent infections in the setting of immune suppression. Diagnosing toxoplasmosis encephalitis (TE) in immunocompromised patients often is difficult because the signs and symptoms can be nonspecific, but making a diagnosis of TE is even more challenging in a patient who is not known to have human immunodeficiency virus/acquired immunodeficiency syndrome and shows no other signs of being immunocompromised. Early diagnosis and treatment can result in rapid radiologic and clinical improvement; however, no studies exist that evaluate the utility of functional rehabilitation for patients diagnosed with TE. Although previous studies report a good prognosis for patients who receive antibiotic treatment, they do not discuss the extent to which functional abilities lost during the infection are returned after their treatment. We discuss a case of stroke-like presentation of cerebral TE in a patient whose human immunodeficiency virus status was previously unknown and report the functional improvements that were made during acute inpatient rehabilitation.

Is Hip Abduction Strength Asymmetry Present in Female Runners in the Early Stages of Patellofemoral Pain Syndrome?

BACKGROUND: The current literature indicates that hip abduction weakness in female patients is associated with ipsilateral patellofemoral pain syndrome (PFPS) as part of the weaker hip abductor complex. Thus, it has been suggested that clinicians should consider screening female athletes for hip strength asymmetry to identify those at risk of developing PFPS to prevent the condition. However, no study to date has demonstrated that hip strength asymmetry exists in the early stages of PFPS. PURPOSE: To determine whether hip abduction strength asymmetry exists in female runners with early unilateral PFPS, defined as symptoms of PFPS not significant enough to cause patients to seek medical attention or prevent them from running at least 10 miles per week. STUDY DESIGN: Controlled laboratory study. METHODS: This study consisted of 21 female runners (mean age, 30.5 years; range, 18-45 years) with early unilateral PFPS, who had not yet sought medical care and who were able to run at least 10 miles per week, and 36 healthy controls comparably balanced for age, height, weight, and weekly running mileage (mean, 18.5 mi/wk). Study volunteers were recruited using flyers and from various local running events in the metropolitan area. Bilateral hip abduction strength in both a neutral and extended hip position was measured using a handheld dynamometer in each participant by an examiner blinded to group assignment. RESULTS: Patients with early unilateral PFPS demonstrated no significant side-to-side difference in hip abduction strength, according to the Hip Strength Asymmetry Index, in both a neutral (mean, 83.5 ± 10.2; P = .2272) and extended hip position (mean, 96.3 ± 21.9; P = .6671) compared with controls (mean, 87.0 ± 8.3 [P = .2272] and 96.6 ± 16.2 [P = .6671], respectively). Hip abduction strength of the affected limb in patients with early unilateral PFPS (mean, 9.9 ± 2.2; P = .0305) was significantly stronger than that of the weaker limb of control participants (mean, 8.9 ± 1.4; P = .0305) when testing strength in a neutral hip position; however, no significant difference was found when testing the hip in an extended position (mean, 7.0 ± 1.4 [P = .1406] and 6.6 ± 1.5 [P =.1406], respectively). CONCLUSION: The study data show that early stages of unilateral PFPS in female runners is not associated with hip abduction strength asymmetry and that hip abduction strength tested in neutral is significantly greater in the affected limb in the early stages of PFPS compared with the unaffected limb. However, when tested in extension, no difference exists. Further studies investigating the early stages of PFPS are warranted. CLINICAL RELEVANCE: Unlike patients with PFPS seeking medical care, early PFPS does not appear to be significantly associated with hip abduction strength asymmetry.

The potential contributing effect of ketorolac and fluoxetine to a spinal epidural hematoma following a cervical interlaminar epidural steroid injection: a case report and narrative review.

Cervical interlaminar epidural steroid injections (ESIs) are commonly performed as one part of a multi-modal analgesic regimen in the management of upper extremity radicular pain. Spinal epidural hematoma (SEH) is a rare complication with a reported incidence ranging from 1.38 in 10,000 to 1 in 190,000 epidurals. Current American Society of Regional Anesthesia (ASRA), American Society of Interventional Pain Physicians (ASIPP), and the International Spine Intervention Society (ISIS) recommendations are that non-steroidal anti-inflammatory drugs (NSAIDs) do not need to be withheld prior to epidural anesthesia. We report a case wherein intramuscular ketorolac and oral fluoxetine contributed to a SEH and tetraplegia following a cervical interlaminar (ESI). A 66 year-old woman with chronic renal insufficiency and neck pain radiating into her right upper extremity presented for evaluation and was deemed an appropriate CESI candidate. Cervical magnetic resonance imaging (MRI) revealed multi-level neuroforaminal stenosis and degenerative intervertebral discs. Utilizing a loss of resistance to saline technique, an 18-gauge Tuohy-type needle entered the epidural space at C6-7. After negative aspiration, 4 mL of saline with 80 mg of methyl-prednisolone was injected. Immediately thereafter, the patient reported significant spasmodic-type localized neck pain with no neurologic status changes. A decision was made to administer 30 mg intramuscular ketorolac as treatment for the spasmodic-type pain. En route home, she developed a sudden onset of acute tetraplegia. She was brought to the emergency department for evaluation including platelet and coagulation studies which were normal. MRI demonstrated an epidural hematoma extending from C5 to T7. She underwent a bilateral C5-T6 laminectomy with epidural hematoma evacuation and was discharged to an acute inpatient rehabilitation hospital. Chronic renal insufficiency, spinal stenosis, female gender, and increasing age have been identified as risk factors for SEH following epidural anesthesia. In the present case, it is postulated that after the spinal vascular system was penetrated, hemostasis was compromised by the combined antiplatelet effects of ketorolac, fluoxetine, fish oil, and vitamin E. Although generally well tolerated, the role of ketorolac, a potent anti-platelet medication used for pain relief in the peri-neuraxial intervention period, should be seriously scrutinized when other analgesic options are readily available. Although the increased risk of bleeding for the alternative medications are minimal, they are nevertheless well documented. Additionally, their additive impairment on hemostasis has not been well characterized. Withholding NSAIDs, fluoxetine, fish oil, and vitamin E in the peri-procedural period is relatively low risk and should be considered for all patients with multiple risk factors for SEH.

A mediastinal mass presenting with unilateral periscapular and arm pain.

We describe a case of a patient with mediastinal lymphoma who presented with arm and scapular pain, which is an atypical referral pattern for pain originating from the mediastinum. We use this case as a platform to discuss mediastinal pain referral patterns and the importance of maintaining a broad differential diagnosis of arm and scapular pain, especially when symptoms atypical of pure neuromusculoskeletal structural disease are present.

Long-term intrathecal baclofen: outcomes after more than 10 years of treatment.

OBJECTIVE: To report outcomes of intrathecal baclofen (ITB) therapy for spasticity management in a cohort of patients who had received this treatment for at least 10 years. DESIGN: A cross-sectional survey and retrospective chart review. SETTING: An academic rehabilitation outpatient clinic. PARTICIPANTS: Adult patients with spasticity treated with ITB for at least 10 years. MAIN OUTCOME MEASUREMENTS: Surveys included the Brief Pain Inventory, Penn Spasm Frequency Scale, Epworth Sleepiness Scale, Fatigue Severity Scale, Diener Satisfaction with Life, Life Satisfaction Questionnaire, and Intrathecal Baclofen Survey. RESULTS: Twenty-four subjects completed the surveys. The subjects had been treated with ITB from 10.0-28.4 years, with a mean (standard deviation) of 14.7 ± 4.2 years. The mean (standard deviation) dose of ITB was 627.9 ± 306.7 µg/d, with only 6 subjects averaging daily dose changes of more than 10% compared with 3 years earlier. The mean (standard deviation) scores on outcomes surveys were the following: 2.6 ± 2.3 for pain severity on the Brief Pain Inventory, 1.4 ± 0.7 for spasm severity on the Penn Spasm Frequency Scale, 7.9 ± 5.4 on the Epworth Sleepiness Scale, 4.1 ± 1.6 on the Fatigue Severity Scale, 19.4 ± 8.1 on the Diener Satisfaction with Life, 3.9 ± 0.9 on the Life Satisfaction Questionnaire, and 8.8 ± 1.9 for overall satisfaction with ITB on the Intrathecal Baclofen Survey. On the Brief Pain Inventory, the mean scores for pain severity and interference of pain with life showed moderate inverse correlations with ITB dose (r = -0.386, P = .115; and r = -0.447, P = .062, respectively). On the Life Satisfaction Questionnaire, the mean scores for life satisfaction showed statistically significant positive correlation with ITB dose (r = 0.549, P = .021). CONCLUSIONS: The subjects reported low levels of pain, moderate levels of life satisfaction, normal levels of sleepiness, low-to-moderate levels of fatigue, infrequent spasms at mild-to-moderate severity, and high levels of satisfaction. The efficacy and favorable adverse effect profile of ITB therapy was sustained in this cohort of subjects with more than a decade of treatment.

Transforaminal epidural steroid injection in the treatment of lumbosacral radicular pain caused by epidural lipomatosis: a case series and review.

BACKGROUND: Spinal epidural lipomatosis (SEL) can cause radicular pain due to spinal nerve root impingement. While SEL decompression surgery can provide symptom relief, these patients are often poor surgical candidates due to elevated BMI or immunosuppression. Transforaminal epidural steroid injection (TFESI) has been attempted as an alternative treatment for patients with SEL who are unable to tolerate conservative medical treatment. To date, only two such cases have been reported in the literature. OBJECTIVES: We report three additional cases of radicular pain associated with SEL, review the current literature on this condition, and describe the risks and benefits of using TFESI to treat radicular pain due to SEL. METHODS: We measured changes on the pain visual analogue scale (VAS) and pain disability index (PDI) from presentation to 1-5 weeks after treatment with sequential TFESIs. RESULTS: Pain VAS scores improved by 50-75% and PDI scores improved 13-44 points. CONCLUSIONS: This case series suggests that TFESI can provide modest short-term symptom relief of lumbosacral radicular pain and improvement in disability caused by SEL. Further study of non-operative management of SEL is warranted, given the high risk associated with surgery in this population.

Fever after traumatic spinal cord injury: a case of Brucella sepsis.

Fever during acute rehabilitation in patients with a spinal cord injury is a common problem. Infection, typically of the urinary or respiratory tract, is the most frequent cause of fever in these circumstances. We report a case of Brucella sepsis as a cause of fever in a patient with a spinal cord injury who was undergoing acute rehabilitation. We discuss the epidemiology, differential diagnosis, and evaluation of fever in persons with Brucella infection, as well as fever in patients with a spinal cord injury in the acute rehabilitation setting.

Lumbosacral transforaminal epidural steroid injections are equally effective for treatment of lumbosacral radicular pain in the obese compared to non-obese population: a pilot study.

BACKGROUND AND OBJECTIVES: Current evidence suggests that lumbosacral transforaminal epidural steroid injection (TFESI) is an effective treatment for lumbosacral radicular pain. However, practitioners may be reluctant to attempt this intervention in obese patients because of a perceived reduction in the chance of providing pain relief due to the increased technical difficulty of TFESI in individuals with a larger body habitus. No study to date has compared the effectiveness of TFESI in groups stratified by BMI. We report pilot data addressing whether lumbosacral transforaminal epidural steroid injection is as effective in treating lumbosacral radicular pain in the obese and overweight population as it is in the non-overweight population. MATERIAL AND METHODS: This study consisted of 9 normal weight (18.5 < BMI < 25), 9 overweight (25 < BMI < 30), and 6 obese (BMI > 30) patients who presented with lumbosacral radicular pain and received a TFESI. For each group, percent reduction in pain and the proportion of individuals with a 50% or greater reduction in pain 2-4 weeks after TFESI was determined. RESULTS: Comparing the overweight and obese groups to the normal weight group, no significant differences were found in the percent improvement in pain after TFESI (p=0.7154, p=0.4566) or in the proportion of each group with a 50% or greater reduction in lower back pain after TFESI (p=0.2968). CONCLUSION: Our pilot data indicates that lumbosacral TFESI is as effective in providing short-term relief of lumbosacral radicular pain in obese and overweight patients as it is in non-overweight patients. However, our sample size was not large enough to find a significant difference at a power of 80%. We plan to perform a larger prospective study to confirm the findings of this study. LEVEL OF EVIDENCE: Case-control study, Level II-2.