Acute Cervical Radiculopathy Outcomes: Soft Disc Herniations vs Osteophytes.

OBJECTIVE: Prospectively evaluate the clinical outcomes of acute cervical radiculopathy with respect to soft disc herniations vs osteophytes. METHODS: Sixty consecutive patients who had had cervical radiculopathy for ≤1 month were enrolled in the study. Inclusion criteria were radicular pain greater than axial pain and a pain score ≥4 out of 10 on a numerical rating scale. Patients had at least one positive clinical finding: motor, sensory, or reflex changes. Plain films and magnetic resonance imaging were ordered. Follow-up was at 6 weeks and 3, 6, and 12 months. Outcomes included pain scores (neck and upper limb), neck disability index, medication use, opioid use, and need for surgery. Two attending musculoskeletal radiologists reviewed imaging findings for osteophytes vs soft disc herniations at the symptomatic level. RESULTS: More than 75% reduction in pain was seen in 77% of patients with soft disc herniations and 66% of patients with osteophytes (P > 0.05) at 12 months. A pain score ≤2 out of 10 within 6 to 12 months was seen in 86% of patients with soft disc herniations and 81% of patients with osteophytes (P > 0.05). Moderate or marked improvement at 12 months was seen in 85% of patients with soft discs and 77% of patients with osteophytes (P > 0.05). Baseline-to-12-month numerical rating scale pain scores of patients with soft discs vs osteophytes had overlapping confidence intervals at each follow-up. At 12 months, very few had undergone surgery (7% of patients with soft discs, 11% of patients with osteophytes; P > 0.05) or were on opioids (7% of patients with soft discs, 9% of patients with osteophytes; P > 0.05). CONCLUSIONS: The majority of patients, but not all patients, with acute radiculopathies improved with time. This was seen with both soft disc herniations and osteophytes.

Anomalous location of the vertebral artery in relation to the neural foramen. Implications for cervical transforaminal epidural steroid injections.

OBJECTIVES: Evaluate the prevalence of an anomalous posterior vertebral artery (VA) in the neural foramen and to see if any factors might correlate with proximity of the VA to needle location in a cervical transforaminal epidural steroid injection (CTFESI). METHODS: A radiologist with subspecialty training in neuroradiology documented VA location in relation to the neural foramen on axial views of 198 consecutive computed tomography angiograms done for various reasons, 11 were excluded because of poor imaging or occluded VA. The levels of C2-3 through C6-7 were evaluated, where the VA courses within the foramen. The distance was measured from VA to ideal needle location for a CTFESI. Other data were collected including severity of foraminal stenosis, loss of disc height, and medical history. Analysis was done to see if any factor correlated with anomalous VA location. RESULTS: The VA was in the posterior foramen and within 2 mm of ideal needle location in at least one location in 29% of patients. When looking at the more commonly injected levels of C4-5 through C6-7, the prevalence was 18%. Severity of foraminal stenosis and loss of disc height correlated with VA proximity to typical needle location (both with P < 0.0001). CONCLUSION: The VA can sometimes be in close proximity to the typical target location of a CTFESI. This proximity correlates with severity of foraminal stenosis and loss of disc height. Physicians should be mindful of this and evaluate the T2 axial magnetic resonance imaging before doing CFTESIs.

Facet injection trends in the Medicare population and the impact of bundling codes.

BACKGROUND CONTEXT: Interventional spine procedures have seen a steady increase in utilization over the last 10 to 20 years. In 2010, the Current Procedural Terminology (CPT) codes for facet injections were bundled with image guidance (fluoroscopic or computed tomography) and limited billing to a maximum of three levels. This was done in part because of increased utilization and to ensure that procedures were done appropriately with image guidance. PURPOSE: The study aimed to evaluate if the CPT code changes correlated with a decreased utilization of facet injections. STUDY DESIGN: This is a retrospective time series study. PATIENT SAMPLE: The sample was composed of 100% Medicare Part B claims submitted for facet joint injections from 2000 to 2012, as documented in the Centers for Medicare & Medicaid Services (CMS) Physician Supplier Procedure Summary (PSPS) master files. OUTCOME MEASURES: Procedure numbers and trends were the outcome measures. METHODS: The trends of facet injections were analyzed from 2000 to 2012 using the CMS PSPS master files. The total number of lumbosacral and cervical-thoracic facet injections was noted. Changes over those years were calculated with specific attention to 2010, when CPT were bundled with image guidance and injections were limited to no more than three levels. Also, to account for the growth in the Medicare population, a calculation was done of injections per 100,000 Medicare enrollees. No funding was used for this study. RESULTS: Facet injection utilization increased from 2000 to 2012, with an average growth rate of 11% per year for lumbosacral facet injections and 15% for cervical-thoracic facet injections (per 100,000 Medicare enrollees). The largest growth occurred from 2000 to 2006 (25% growth per year for lumbosacral and 32% for cervical-thoracic injections per 100,000 Medicare enrollees) and this leveled off from 2007 to 2012 (-3% growth per year for lumbosacral and -2% for cervical-thoracic injections per 100,000 Medicare enrollees). The biggest drop in these procedures was in 2010, when there was a drop of 14% for lumbosacral facet injections and 15% drop for cervical-thoracic facet injections (per 100,000 Medicare beneficiaries). CONCLUSIONS: Facet injection utilization notably increased from 2000 to 2006 but began to level off from 2007 to 2012. The most notable drop was in 2010, which correlated with the release of new CPT codes that bundled image guidance and limited procedures to three levels or less.