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.

Changes in Interventional Pain Physician Decision-Making, Practice Patterns, and Mental Health During the Early Phase of the SARS-CoV-2 Global Pandemic.

BACKGROUND AND OBJECTIVES: The novel coronavirus outbreak (SARS-CoV-2) began in late 2019 and dramatically impacted health care systems. This study aimed to describe the impact of the early phase of the pandemic on physician decision-making, practice patterns, and mental health. METHODS: An anonymous survey was distributed to physician members of the Spine Intervention Society (SIS) on March 24 and April 7, 2020. Respondents provided information regarding changes in clinical volume, treatment, and mental health (Patient Health Questionnaire [PHQ-4]) before April 10, 2020. RESULTS: Of the 1,430 individuals who opened the survey, 260 completed it (18.2%). Overall clinical and procedural volume decreased to 69.6% and 13.0% of prepandemic volume, respectively. Mean in-person clinic visits were reduced to 17.7% of total prepandemic clinic volume. Ongoing clinical visits were predominantly completed via telemedicine (video) or telephone (74.5%), rather than in-person (25.5%). Telemedicine and telephone visits represented 24.6% and 27.3% of prepandemic clinical volume, respectively. Respondents decreased in-person visits of select groups of high-risk patients by 85.8-94.6%. Significantly more providers reported increasing rather than decreasing prescriptions of the following medications: opioids (28.8% vs 6.2% of providers, P < 0.001), muscle relaxants (22.3% vs 5.4%, P < 0.001), neuropathic pain medications (29.6% vs 3.8%, P < 0.001), and acetaminophen (26.2% vs 4.2%, P < 0.001). Respondents' mean PHQ-4 score was 3.1, with 19% reporting moderate or severe psychological distress. Several demographic factors were significantly associated with practice changes. CONCLUSIONS: The novel coronavirus pandemic dramatically altered the practice and prescribing patterns of interventional pain physicians.

Effect of low-dose lidocaine on objective upper extremity strength and immediate pain relief following cervical interlaminar epidural injections: a double-blinded randomized controlled trial.

BACKGROUND: Low-dose lidocaine is a common diluent for analgesia following cervical interlaminar epidural steroid injection (CIESI). Concerns with this practice exist. A single-arm cohort reported that 20% of patients develop postprocedural upper extremity weakness when using lidocaine as a diluent. Furthermore, a high-cervical spinal block with unintended intrathecal or subdural administration is possible. OBJECTIVE: Determine if low-dose lidocaine as a diluent during CIESI causes clinically meaningful (1) upper extremity weakness and (2) immediate pain relief when compared with saline. DESIGN: Double-blinded randomized control trial. METHODS: Patients with cervical radicular pain scheduled for CIESI were enrolled. Participants received lidocaine (CIESI-L) or saline (CIESI-S) as a diluent for the epidural injectate. Myotomal strength was measured with dynamometry before and between 20 and 30 min after CIESI. Pre-pain and post-pain scores were obtained. Primary and secondary outcomes were post-CIESI weakness of ≥20% (minimal clinically important difference (MCID)) in >1 myotome and ≥50% pain reduction on the numerical scale. RESULTS: 120 participants (64 females (53%), mean age, 56 (SD 13.7) years) completed the study and were analyzed (CIESI-L n=60; CIESI-S n=60). There was no significant between-group difference in the proportion of participants with postprocedural weakness, CIESI-L 41.7% (95% CI, 29.8% to 54.5%), CIESL-S 50% (95% CI, 37.5% to 62.5%). Between-group comparison showed no significant difference in pain reduction, relative risk 1.53 (95% CI, 0.82 to 2.86). CONCLUSION: Low-dose lidocaine as a diluent in CIESI does not significantly increase the risk of post-CIESI myotomal weakness when compared with saline, but also does not substantially increase the likelihood of immediate, meaningful pain relief. TRIAL REGISTRATION DETAILS: ClinicalTrials.gov (NCT03127137); December 26, 2017.

Psychometric properties of the PROMIS physical function item bank in patients with spinal disorders.

STUDY DESIGN: Patient-reported outcomes provide vital information when assessing effectiveness of clinical care. Yet, most patient-reported outcome instruments are limited by lack of validation and reliability to measure PF adequately. As part of the Patient-Reported Outcomes Measurement Information System (PROMIS), a PF item bank consisting of 124 items has been developed. OBJECTIVE: There is validation evidence for the PROMIS PF item bank in the general orthopedic patient population in general, but has yet to be validated in the patient with spinal disorders. This study aims to evaluate the psychometric properties of the PROMIS PF item bank specifically for patients presenting with spine-related complaints. SUMMARY OF BACKGROUND DATA: Data were collected from adult patients visiting a university spine clinic for back and neck problems. All patients older than 18 years were eligible to participate. A total of 438 patients (49% male) were enrolled in this prospective study. Patients were 18- to 89-year old and presented with back problems (n = 286) and neck problems (n = 152). All patients were administered a 131 item questionnaire. METHODS: Conventional descriptive statistics such as means, standard deviations, and proportions were conducted to examine patient characteristics. A Rasch model was used to examine the psychometric properties of the instrument including dimensionality, floor/ceiling effects, reliabilities, and item bias. RESULTS: Results showed that a single PF dimension was supported by the data (i.e., unexplained variance was 2.9%). The instrument had 1.7% ceiling effect and 0.2% floor effect. Item reliability was 1.00 and person reliability was 0.99. We found evidence of item response bias associated with sex, age, and education in some items. CONCLUSION: The PROMIS PF item bank adequately addressed outcomes of patients with spinal disorders as reliabilities were excellent, minimal ceiling/floor effect existed, and item bias was limited. Future effort should be focused on eliminating, rescaling, or modifying those items that had item bias. LEVEL OF EVIDENCE: 2.

Clinical impression versus standardized questionnaire: the spinal surgeon's ability to assess psychological distress.

BACKGROUND: Psychological distress can affect spine surgery outcomes. A majority of spinal surgeons do not use standardized questionnaires to assess for psychological distress and instead rely on their clinical impressions. The ability of spinal surgeons to properly assess patients with psychological distress has not been adequately evaluated. Our hypothesis was that the clinical impressions of spinal surgeons were not as accurate as a standardized questionnaire in assessing for psychological distress. METHODS: A prospective study was performed with eight physicians, four spinal surgeons and four nonoperative spine specialists, who evaluated 400 patients. All patients completed the Distress and Risk Assessment Method (DRAM) questionnaire for the evaluation of psychological distress. The eight physician subjects, blinded to the results of this questionnaire, performed their routine clinical evaluation and categorized the patients' psychological distress level. The results of the Distress and Risk Assessment Method questionnaire and the surgeons' assessments were compared. RESULTS: In the study population of 400 patients, 64% (254 of 400) were found to have some level of psychological distress. Twenty-two percent (eighty-seven of 400) of the patients were found to have high levels of distress. Overall, the physicians' rate of sensitivity when assessing patients with high levels of distress was 28.7% (95% confidence interval: 19.5%, 39.4%) with a positive predictive value of 47.2% (95% confidence interval: 33.3%, 61.4%). Nonoperative spine specialists had a significantly higher sensitivity rate when assessing highly distressed patients (41.7% [95% confidence interval: 25.5%, 59.2%]) than surgeons (19.6% [95% confidence interval: 9.8%, 33.1%]) (p = 0.03). The sensitivity rates between experienced (greater than ten years in practice) (14.7% [95% confidence interval: 5.0%, 31.1%]) and less experienced (less than two years in practice) (29.4% [95% confidence interval: 10.3%, 56.0%]) spinal surgeons was not significant (p = 0.27). CONCLUSIONS: A large percentage of patients (64%) presenting for spine evaluation have some level of psychological distress. When compared with a standardized questionnaire designed to screen for psychological distress, spinal surgeons had low sensitivity rates to detect this distress. The routine use of a standardized questionnaire to screen for psychological distress should be considered.

Lumbar facet syndromes.

Low back pain is a common presenting complaint to sports medicine providers. The lumbar spine is a complex anatomic structure with multiple potential pain generators. Epidemiologic studies have shown that the intervertebral disc is the most common pain generator in all patients with low back pain. The facet joints may account for 15%-40% of low back pain. It can be challenging at times to establish a firm diagnosis of facet pain. Facet pain can have different presentations, and pain emanating from other lumbopelvic structures can present similarly as facet joint pain. This article reviews the anatomy and biomechanics of the lumbar facet joints, presenting symptoms and physical examination findings seen with facet pain. We also will discuss diagnostic and treatment paradigms that are helpful to the clinician treating low back pain in athletes.

Creatine supplementation for weak muscles in persons with chronic tetraplegia: a randomized double-blind placebo-controlled crossover trial.

BACKGROUND AND OBJECTIVES: Creatine supplementation improves muscle strength in some patient populations with neurologic disorders. The purpose of this study was to determine whether creatine supplementation improves muscle strength and endurance in weak upper limb muscles in persons with tetraplegia, and whether it improves function. METHODS: Outpatients with tetraplegia and mild wrist extensor weakness were randomized to receive either creatine or placebo in a double-blind crossover design. During creatine supplementation, participants were loaded with 10 g orally twice per day for 6 days, then maintained on 5 g daily until undergoing testing. Main outcome measures, performed at baseline, after placebo, and after creatine supplementation, included maximal voluntary wrist extensor isometric contraction strength (MVC), endurance times for 5 submaximal wrist extensor contractions, and the Grasp and Release Test for hand function. RESULTS: Eight individuals (7 men, 1 woman) with tetraplegia met inclusion criteria and completed all study phases. The mean age of participants was 48 years, and 7 of 8 had C6 motor level injuries. There were no significant differences in MVC, endurance times, or hand function for creatine vs placebo. CONCLUSION: Creatine does not improve MVC and endurance of weak wrist extensors and does not improve hand function in individuals with tetraplegia.