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Plastaras CT, Marciniak CM, Sipple DP, D'Amore KG, Garvan C, Zaman SM: Effect of interelectrode distance on sural nerve action potential parameters. Am J Phys Med Rehabil 2008;87:183-188. OBJECTIVE:: To assess differences in amplitude, latency, and duration, using a 3-cm vs. 4-cm distance between the active and reference electrodes when performing sural nerve conduction studies (NCS). Current normative data in lower-limb studies are generally based on 3-cm interelectrode differences, although 4-cm differences have been reported to be optimal in the upper limb. DESIGN:: Prospective study comparing the onset latency, peak latency, duration, and amplitude for the sural sensory nerve action potential (SNAP) recording at two interelectrode distances in adult volunteers. RESULTS:: Forty-three sural nerves were studied in 22 normal subjects. Peak latencies recorded with a 4-cm interelectrode distance were significantly longer than those recorded with a 3-cm distance (mean difference = 0.06 msecs [SD = 0.09, P = 0.0073]). Duration was significantly longer (mean difference = 0.03 msecs [SD = 0.07, P = 0.0270]), conduction velocities were significantly slower (mean difference = -0.7 msecs [SD 1.0, P = 0.0012]), and onset latency and amplitude were not found to differ significantly. Average differences in peak latencies, duration, velocity, onset latency, and amplitude were not correlated with gender, age, or BMI. CONCLUSIONS:: In contrast to studies of upper-limb sensory NCS, sural SNAP parameters obtained with 3- and 4-cm interelectrode distances did not differ for onset latencies and amplitude. Peak latencies, duration, and conduction velocity differences, though statistically significant, were of insufficient magnitude to be clinically meaningful. By using a 4-cm instead of a 3-cm interelectrode difference for sural nerve studies, the small prolongation of 0.06 msecs in peak latency and tiny increment of 0.27 muV observed in our investigation is unlikely to influence the electrodiagnostician's interpretation of the study. [ABSTRACT FROM AUTHOR]

Objective: Epidural steroid injections (ESIs) are widely used in clinical practice for the treatment of low back radicular pain. Anecdotally it has been conveyed that the reproduction of a patient's usual pain during ESI was of prognostic value as to which patients would show favorable results from the procedure, however, there is no data available to support this supposition. Design: Retrospective. Setting: Outpatient Spine and Sports Medicine Clinic. Patients: Patients with lumbosacral radicular pain treated with fluoroscopically guided contrast enhanced lumbosacral transforaminal ESI. Outcome Measures: 11-point pain intensity numeric rating scale (PI-NRS). Results: Overall the procedure provided statistically significant pain relief in both groups A (typical radicular pain reproduced) and B (typical radicular pain not reproduced) immediately and significant pain reduction was maintained until the time of the follow-up No reduction in pain was seen in group A vs. B, although in group B there was a strong trend toward having higher pain scores at all times. Conclusion: The reproduction of a patient's typical radicular pain during a fluoroscopically guided contrast enhanced lumbosacral transforaminal ESI does not predict a significant decrease in pain scores immediately after the procedure or at follow up. [ABSTRACT FROM AUTHOR]

Persons with back, neck, and limb symptoms constitute a major referral population to specialists in electrodiagnostic (EDX) medicine. The evaluation of these patients involves consideration of both the common and less common disorders. The EDX examination with needle electromyography (EMG) is the most important means of testing for radiculopathy. This test has modest sensitivity but high specificity and well complements imaging of the spine. Needle EMG in combination with nerve conduction testing is valuable in excluding entrapment neuropathies and polyneuropathy-conditions that frequently mimic radicular symptoms. In this first of a two-part review, the optimal EDX evaluation of persons with suspected radiculopathy is presented. In part two, the implications of EDX findings for diagnosis and clinical management of persons with radiculopathy are reviewed., (© 2020 by the American Association of Neuromuscular & Electrodiagnostic Medicine, Inc. All rights reserved.)

Study Design: Retrospective matched cohort study., Objective: To determine if low-pressure lumbar provocation discography (PD) results in long-term accelerated disc degeneration, internal disc disruption, or disc herniation in patients with symptomatic low back pain (LBP)., Summary of Background Data: Study of subjects without clinically-significant LBP suggests that high-pressure PD may accelerate disc degeneration., Methods: Consecutive patients with symptomatic LBP who underwent magnetic resonance imaging (MRI), PD, and repeat MRI more than 7 years later, but did not undergo subsequent spinal fusion surgery, were included. Punctured discs were matched (1:2 to 1:4) to corresponding discs in a control cohort by age, BMI, Pfirrmann score (±2), and presence of disc herniation; control cohort inclusion required MRIs for symptomatic LBP, separated by more than 7 years. The primary outcome of the study was a progression in Pfirrmann score category (I-II, III-IV, V). MRI disc-to-CSF T2 signal-intensity ratio, disc height, disc herniations, high intensity zones (HIZs), and Modic changes were assessed., Results: Baseline and follow-up MRIs were available for 77 discs exposed to PD, and for 260 discs in the matched control cohort. There was no difference in the proportion of punctured discs that advanced in Pfirrmann score category in the PD group (17%, 95% CI 9-27%) compared with corresponding discs in the Control group (21%, 95% CI 17-27%), P = 0.3578, or in non-punctured discs in the PD group (35%, 95% CI 21-51%) compared with corresponding discs in the Control group (34%, 95% CI 27-42%), P = 0.1169. There were no differences in disc-to-CSF T2 signal-intensity ratio, presence of disc herniations, HIZs, or Modic changes following puncture in the PD versus matched cohort discs or in the non-punctured PD cohort discs versus corresponding control cohort discs (P > 0.05)., Conclusion: Patients with symptomatic LBP who underwent low-pressure PD, but who did not undergo a subsequent spinal fusion surgery, developed disc degeneration and new disc herniations at a similar rate to corresponding discs in matched control patients., Level of Evidence: 3.

Background: The clinical course of motor deficits from lumbosacral radiculopathy appears to improve with or without surgery. Strength measurements have been confined to manual muscle testing (MMT) and have not been extensively followed and quantified in prior studies., Objective: To determine if motor weakness and patient-reported outcomes related to lumbosacral radiculopathy improve without surgical intervention over the course of 12 months., Design: Prospective observational cohort., Setting: Outpatient academic spine practice., Participants: Adults with acute radicular weakness due to disk herniation., Methods: Forty patients with radiculopathy and strength deficit were followed over a 12-month period. Objective strength and performance tests as well as survey-based measurements were collected at baseline and then every 3 months. Patients underwent comprehensive pain management and rehabilitation and/or surgical approaches as determined in coordination with the treating specialist. This study was approved by the institutional review board of Colorado., Main Outcome Measurements: Testing of strength was through MMT, handheld dynamometer, and performance-based testing. Furthermore, visual analog scale, modified Oswestry Disability Index, and 36-Item Short Form Health Survey (SF-36) were used to measure pain and disability outcomes., Results: Of the 40 patients, 33 (82.5%) did not have surgery; 7 (17.5%) had surgery. Twenty-four of the 33 patients (60%) did not undergo surgery and were followed for 12 months (Comprehensive Pain Management and Rehabilitation, Complete [CPM&R-C]), and 9 (22%) did not have surgery and lacked at least one follow-up evaluation (Comprehensive Pain Management and Rehabilitation, Incomplete [CPM&R-I]). No statistically significant differences were found on baseline measures of strength deficits and SF-36 domains between the CPM&R-C, Surgery, and CPM&R-I groups. Pain and disability scores in the Surgery group were significantly higher than in the CPM&R-C at baseline. There were statistically significant improvements in all areas of strength, pain, and function when comparing measurements at the 12-month follow-up to baseline in the CPM&R-C group., Conclusions: Individuals with motor deficits due to lumbosacral radiculopathy improve over time regardless of treatment choice. Most did not choose surgery, and almost all of these patients regained full strength at 1 year. Strength recovery typically occurred in the first 3 months, but there was ongoing recovery over the course of a year., Level of Evidence: II., (© 2019 American Academy of Physical Medicine and Rehabilitation.)

Setting: Interventional procedures directed toward sources of pain in the axial and appendicular musculoskeletal system are performed with increasing frequency. Despite the presence of evidence-based guidelines for such procedures, there are wide variations in practice. Case reports of serious complications such as spinal cord infarction or infection from spine injections lack appropriate context and create a misleading view of the risks of appropriately performed interventional pain procedures., Objective: To evaluate adverse event rate for interventional spine procedures performed at three academic interventional spine practices., Methods: Quality assurance databases at three academic interventional pain management practices that utilize evidence-based guidelines [1] were interrogated for immediate complications from interventional pain procedures. Review of the electronic medical record verified or refuted the occurrence of a complication. Same-day emergency department transfers or visits were also identified by a records search., Results: Immediate complication data were available for 26,061 consecutive procedures. A radiology practice performed 19,170 epidural steroid (primarily transforaminal), facet, sacroiliac, and trigger point injections (2006-2013). A physiatry practice performed 6,190 spine interventions (2004-2009). A second physiatry practice performed 701 spine procedures (2009-2010). There were no major complications (permanent neurologic deficit or clinically significant bleeding [e.g., epidural hematoma]) with any procedure. Overall complication rate was 1.9% (493/26,061). Vasovagal reactions were the most frequent event (1.1%). Nineteen patients (<0.1%) were transferred to emergency departments for: allergic reactions, chest pain, symptomatic hypertension, and a vasovagal reaction., Conclusion: This study demonstrates that interventional pain procedures are safely performed with extremely low immediate adverse event rates when evidence-based guidelines are observed., (© 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To examine the link between cytokines in intervertebral disc (IVD) tissues and axial back pain., Design: In vitro study with human IVD cells cultured from cadaveric donors and annulus fibrosus (AF) tissues from patients., Results: Cultured nucleus pulposus (NP) and AF cells were stimulated with interleukin (IL)-1β. IL-8 and IL-7 gene expression was analyzed using real-time polymerase chain reaction. IL-8 protein was quantified by enzyme-linked immunosorbent assay. After IL-1β stimulation, IL-8 gene expression increased 26,541 fold in NP cells and 22,429 fold in AF cells, whereas protein released by the NP and AF cells increased 2,389- and 1,784-fold, respectively. IL-7 gene expression increased 3.3-fold in NP cells (P < 0.05).Cytokine profiles in AF tissues collected from patients undergoing surgery for back pain (painful group) or scoliosis (controls) were compared by cytokine array. IL-8 protein in the AF tissues from patients with back pain was 1.81-fold of that in controls. IL-7 and IL-10 in AF tissues from the painful group were 6.87 and 4.63 times greater than the corresponding values in controls, respectively (P < 0.05)., Conclusion: Inflammatory mediators found in AF tissues from patients with discogenic back pain are likely produced by IVD cells and may play a key role in back pain.

Background Data: Minimizing fluoroscopy time in spine interventions is critical for time of procedure as well as radiation safety of the patient and medical personnel. Specific fluoroscopy angle settings for fluoroscopically guided L4-S1 transforaminal epidural injections (TFEIs) have not been described., Objectives: To describe the most common encountered settings for the C-arm fluoroscope angles for fluoroscopically guided L4-S1 (TFEI)., Methods: Each subject was placed in prone position on a flat fluoroscopy table without utilizing any device to alter innate lumbar spine curvature. The data from 246 consecutive patients at their first encounter in the fluoroscopy suite for a single level subpedicular lumbosacral TFEI was retrospectively analyzed. Most procedures occurred at the L4-5, L5-S1, and S1 levels (227 subjects). The C-arm angles including the oblique, cephalad/caudal were recorded for each subject upon observing final needle positioning for successful completion of the procedure according to ISIS Guidelines., Results: For the L4-5 level, 71% of cases had oblique angle of 30°±5° and 94% of cases had neutral cephalad/caudal tilt (0°±5°) observed. For the L5-S1, 72% of cases had oblique angle of 30°±5° and 62% of cases had cephalad tilt angle of 15°±5° observed. For the S1 level, 73% of cases had oblique angle of 5°±5° and 69% of cases had cephalad tilt angle of 15°±5° observed., Discussion/conclusion: This retrospective descriptive study suggests fluoroscope angles for L4-S1 TFEI as a starting point before fine tuning views accounting for individual anatomy. Angles suggested for each level (oblique/cephalad tilt angles) are as follows: L4-5 (30/0°), L5-S1 (30/15°), and S1 (5/15°). Prospective studies using these guidelines would need to be undertaken to prove reproducibility between interventionalists, time efficiency, and radiation exposure reduction., (© 2015 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Pharmacologic treatment of radicular pain with oral medications is limited by adverse effects and concern for dependence. While topical formulations have been explored in pain research, there is no published literature evaluating the efficacy in radicular pain. We present the first three cases of radicular pain successfully treated with a topical formulation of diclofenac, ibuprofen, baclofen, cyclobenzaprine, bupivacaine, gabapentin, and pentoxifylline (T7)., Case Presentation: Case series evaluating T7 for treatment of radicular pain in a single, outpatient pain center. Pain was rated on the numeric rating scale (NRS) on initial evaluation and follow up after a trial of T7. One to two grams of T7 was applied to the affected area 3 - 4 times daily in addition to the patient's baseline pharmacologic management. Three patients with median age of 50 (range, 39 to 65) and diagnosis of cervical and/or lumbosacral radicular pain participated. Two of the three had chronic radicular pain despite use of analgesic agents, spinal injections and failed spinal surgery syndrome. Each reported subjective improvement in radicular pain, function and sleep. There was an average decrease in NRS score consistent with 30% - 40% global improvement in symptoms, clinically significant based on the minimal clinically important difference for radicular pain. T7 was well tolerated without adverse reactions. Surgery was prevented or delayed in all cases., Conclusions: This is the first report of the successful treatment of radicular pain with a topical agent. This highlights the need for randomized, prospective study of both single and compounded topical agents for treatment of radicular pain.

Background: Transforaminal epidural steroid injections (TFESI) have demonstrated efficacy and effectiveness in treatment of radicular pain. Despite little evidence of efficacy/effectiveness, interlaminar epidural steroid injections (ILESI) are advocated by some as primary therapy for radicular pain due to purported greater safety., Objective: To assess immediate and delayed adverse event rates of TFESI and ILESI injections at three academic medical centers utilizing International Spine Intervention Society practice guidelines., Methods: Quality assurance databases from a Radiology and two physical medicine and rehabilitation (PM&R) practices were interrogated. Medical records were reviewed, verifying immediate and delayed adverse events., Results: There were no immediate major adverse events of neurologic injury or hemorrhage in 16,638 consecutive procedures in all spine segments (14,956 TFESI; 1,682 ILESI). Vasovagal reactions occurred in 1.2% of procedures, more frequently (P = 0.004) in TFESI (1.3%) than ILESI (0.5%). Dural punctures occurred in 0.06% of procedures, more commonly after ILESI (0.2% vs 0.04%, P = 0.006). Delayed follow up on PM&R patients (92.5% and 78.5, next business day) and radiology patients (63.1%, 2 weeks) identified no major adverse events of neurologic injury, hemorrhage, or infection. There were no significant differences in delayed minor adverse event rates. Central steroid response (sleeplessness, flushing, nonpositional headache) was seen in 2.6% of both TFESI and ILESI patients. 2.1% of TFESI and 1.8% of ILESI patients reported increased pain. No long-term sequelae were seen from any immediate or delayed minor adverse event., Conclusions: Both transforaminal and ILESI are safely performed with low immediate and delayed adverse event rates when informed by evidence-based procedural guidelines. By demonstrating comparable safety, this study suggests that the choice between ILESI and TFESIs can be based on documented efficacy and effectiveness and not driven by safety concerns.

Objective: the aim of this study is to report satisfaction rates and identify factors predicting satisfaction in the Pennsylvania Workers' Compensation (WC) system., Methods: Cross-sectional survey data on satisfaction and care experience of injured workers were collected annually for 14 years with 27,712 injured workers responding., Results: The overall response rate was 19.44%. The overall proportion of satisfied workers was 83.97% with a range of 80.43% to 88.13%. Obtaining a correct initial diagnosis [odds ratio (OR) = 4.26], explanation of WC rights (OR = 2.58), and physician explanation of treatment options (OR = 1.83) most strongly predicted satisfaction., Conclusions: Injured worker satisfaction with their medical care exceeded 80% in all years surveyed. Patient perception of a correct initial diagnosis, explanation of WC rights, and explanation of treatment options were the strongest predictors of satisfaction during the 14-year study period.

Objective: Pain intensity is commonly rated on an 11-point Numerical Pain Rating Scale which can be expressed as a calculated percentage pain reduction (CPPR), or by patient-reported percentage pain reduction (PRPPR). We aimed to determine the agreement between CPPR and PRPPR in quantifying musculoskeletal pain improvement at short-term follow-up after a corticosteroid injection., Design: Retrospective cohort study., Setting: Urban, academic, physical medicine, and rehabilitation outpatient interventional musculoskeletal and spine center., Methods: The agreement between CPPR and PRPPR was determined by concordance correlation coefficient (CCC) in subjects who had experienced improvement in musculoskeletal or radicular pain 3 weeks after a first-time injection at our clinic. Subjects who experienced unchanged pain (PRPPR = 0) were compared to CPPR with paired t-test., Results: We examined 197 subjects with greater than 3/10 pain who underwent first-time fluoroscopic-guided corticosteroid injections. Ninety-three subjects reported higher PRPPR than CPPR values, and 41 subjects reported higher CPPR values. The CCC between CPPR and PRPPR was 0.44 (95% CI 0.35-0.54), with a precision of 0.54 and an accuracy of 0.81, and 95% limits of agreement ranging between -41% and +73%. Values for CCC, precision, and accuracy were higher for males compared to females and were highest in the youngest age group (18-40) and lowest in the middle age group (41-60)., Conclusions: PRPPR may not agree with CPPR at 3 week follow-up, as these individuals tend to report a higher estimated percentage improvement compared to the value calculated from their pain scores., (Wiley Periodicals, Inc.)

Background: Vasovagal reactions can occur with spine procedures and may result in premature procedure termination or other adverse events., Objective: To evaluate if moderate sedation is an effective means of secondary prevention for vasovagal reactions., Methods: Prospectively collected data on 6,364 consecutive spine injections., Results: Of the 6,364 spine injections, 6,150 spine injections were done without moderate sedation and resulted in 205 vasovagal reactions (3.3% [95% confidence interval {CI} 2.9-3.8%]). One hundred thirty-four spine procedures were performed on patients that had a history of prior vasovagal reaction during a spine procedure. Of these, 90 procedures were performed without moderate sedation, and 21/90 (23.3% [95% CI 15.2-32.1%]) were complicated by a repeat vasovagal reaction. None of 44 repeat injections that utilized moderate sedation experienced a repeat vasovagal reaction (0% [95% CI 0-9.6%]) (χ(2)  = 12.17, P < 0.00048). The rate of vasovagal reaction in patients with a history of prior reaction undergoing repeat injection without conscious sedation was significantly higher (23.3% [95% CI 15.2-32.1%]) than the rate in patients with no such history (3.0% [95% CI 2.6-3.5%] [χ(2)  = 113.4, P < 1.78E-26])., Conclusions: A history of vasovagal reaction is a strong predictor of experiencing a vasovagal reaction on subsequent procedures. No vasovagal reactions occurred with the use of moderate sedation, including in the 44 injections in patients that had a history of vasovagal reaction during spine procedures. The overall low rate of vasovagal reactions is low, and greater benefits of moderate sedation were observed when utilized as secondary prevention of repeat vasovagal reactions., (Wiley Periodicals, Inc.)

Peripheral nerve traction injuries may occur after surgical care and can involve any of the upper extremity large peripheral nerves. In this review, injuries after shoulder or elbow surgical intervention are discussed. Understanding the varying mechanisms of injury as well as classification is imperative for preoperative risk stratification as well as management., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Peripheral nerve traction injuries may occur after surgical care and can involve any of the lower extremity large peripheral nerves. In this review, the authors discuss injuries after knee or hip surgical intervention. The diagnosis, including electrodiagnostic studies, is time sensitive and also relies on a detailed history and physical examination. Successful prevention and treatment involve familiarity with risk and predisposing factors as well as prophylactic measures., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To determine the rate of vasovagal (vv) complications in fluoroscopically guided interventional procedures., Design: Retrospective case series analysis of prospectively collected data from March 8, 2004 to January 30, 2009., Setting: A single academic medical center., Subjects: Four thousand one hundred eighty-three subjects undergoing 8,010 consecutive injections., Outcome Measures: Pearson's chi-square test was used to determine the relationship between categorical variables., Results: A total of 8,010 injections, including epidural steroid injections, radiofrequency nerve ablations, medial branch blocks, hip injections, knee injections, and glenohumeral injections were performed. Overall vv reaction rate was 2.6%, with 0.8% of procedures resulting in early terminated due to vv reaction. Peripheral joint injections had a vv rate of 0.2%, all occurring in hip injections. Transforaminal epidural steroid injections had a vv rate of 3.5%. Diagnostic blocks of the medial branches had the highest rate of vv (5.1%). Other predictors of vv reactions were identified including preprocedure pain score visual analog scale <5 (P = 0.004), male gender (P < 0.001), and age less than 65 years old (P < 0.001)., Conclusions: vv reactions have an overall low occurrence rate (2.6%) in interventional procedures ranging from 0% in peripheral knee and shoulder injections to 5.1% in medial branch blocks. Conservative treatment of vv reaction and willingness to terminate procedures resulted in no serious adverse events related to vv reaction in 8,010 procedures., (Wiley Periodicals, Inc.)

Objective: To describe the type, incidence, and factors that contribute to adverse events associated with fluoroscopically guided intra-articular sacroiliac joint injections (IASIJ)., Design: A retrospective cohort study., Setting: Tertiary, academic, outpatient physical medicine and rehabilitation interventional spine clinic., Participants: English-speaking adults aged 18-90 years who underwent fluoroscopically guided IASIJ injections between March 8, 2004, and April 19, 2007., Interventions: After IASIJ injections, 3 senior researchers recorded the presence and types of adverse events. The relationship of adverse events with age, gender, fluoroscopy time, vital signs, and trainee presence was analyzed with the Fisher exact or the Wilcoxon rank sum 2-sided tests., Main Outcome Measures: The frequency of immediate (during or immediately after the procedure) or delayed (within 24-72 hours after the procedure) adverse events., Results: A total of 162 patients (133 women) underwent 191 procedures. The range of subject age was from 20 to 90 years (15.8 years, standard deviation [SD]). The range (SD) of the preprocedure 11-point Likert Pain Scale was from 1.0 to 10.0 (2.0) and for the postprocedure 11-point Likert Pain Scale was from 0.0 to 9.0 (2.5). Trainees were involved in 57% of the procedures. Reported immediate adverse events were vasovagal reaction (2.1% [n = 4]) and steroid-clogged needle (0.5% [n = 1]). Follow-up data were available for 132 of 191 procedures (69%). There were 32 adverse events reported at a mean follow-up interval of 2 days, of which, the most frequent adverse events were injection-site soreness (12.9% [n = 17]), pain exacerbation (5.3% [n = 7]), and facial flushing and/or sweating (2.3% [n = 3]). Delayed adverse events decreased with older age (P = .0029). The patients who underwent bilateral procedures experienced more delayed adverse events than the patients who underwent unilateral procedures (P = .024)., Conclusions: Fluoroscopically guided IASIJ injection is associated with minimal adverse effects. The most common immediate adverse event was vasovagal reaction, and the most common delayed adverse event was injection-site soreness. Younger age is significantly related to reported delayed adverse events., (Copyright © 2012 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Electrodiagnostic studies play an important role in the evaluation of radiculopathy. This article reviews the use of standard nerve conduction studies, late responses, evoked potentials, and needle electrode examination in the electrodiagnostic evaluation of neck pain., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Of the multitude of treatment options for the management of neck pain, no obvious single treatment modality has been shown to be most efficacious. As such, the clinician should consider alternative treatment modalities if a modality is engaging, available, financially feasible, potentially efficacious, and is low risk for the patient. As evidence-based medicine for neck pain develops, the clinician is faced with the challenge of which treatments to encourage patients to pursue. Treatment modalities explored in this article, including chiropractic, acupuncture, TENS, massage, yoga, Tai Chi, and Feldenkrais, represent reasonable complementary and alternative medicine methods for patients with neck pain., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Electrodiagnostic studies play an important role in the evaluation of radiculopathy. This article reviews the use of standard nerve conduction studies, late responses, evoked potentials, and needle electrode examination in the work-up of lumbosacral and cervical radiculopathy., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objectives: The primary aim was to evaluate the prevalence of inadvertent intradiscal injection during fluoroscopically guided contrast-enhanced lumbar transforaminal epidural steroid injections. The secondary aim was to determine if there are any risk factors for or adverse events as a result of inadvertent intradiscal contrast injection., Design: The study was a retrospective case series., Setting: The study was set in three outpatient spine care centers., Patients: A search was conducted in a database of spinal injection procedures from July 2000-May 2008. Fifteen cases of inadvertent intradiscal contrast flow were identified. These cases were matched with one control case with the same age, gender, level, and side of injection., Interventions: The prevalence of intradiscal contrast flow with lumbar transforaminal epidural steroid injection was calculated. Chart review of the cases and controls was performed. An independent, blinded examiner evaluated needle tip placement., Outcome Measures: Frequency of intradiscal contrast flow during lumbar transforaminal epidural steroid injections and the relationship between the occurrence of intradiscal contrast flow with potential risk factors., Results: The prevalence of inadvertent intradiscal injection during lumbar transforaminal epidural steroid injections was 0.17%. All of the patients received prophylactic antibiotics after inadvertent disk injection, and there were no infectious or other complications identified., Conclusions: Intradiscal contrast injection is an infrequently reported event during lumbar transforaminal epidural steroid injections. Our data support that the prevalence is very low and there might be an association with ipsilateral foraminal stenosis. Although there is potential for significant adverse complications with intradiscal injection, our data set did not show serious sequelae., (Wiley Periodicals, Inc.)

Background Context: Reports of serious complications from cervical transforaminal epidural corticosteroid injections often consider accidental intra-arterial injection the most likely mechanism of injury. As a result, many physicians have instituted methods to prevent intravascular injections. Routine use of the anesthetic test dose is one such method. The utility of the anesthetic test dose in this function has not been characterized in the current literature., Purpose: The aim of this study was to determine the utility of injecting an anesthetic test dose before cervical transforaminal epidural corticosteroid injection and estimate the rate of false-negative intravascular contrast injection using live fluoroscopy and digital subtraction angiography (DSA)., Study Design: Two-center retrospective study., Patient Sample: A consecutive cohort of men and women, ages of 23 to 83, who underwent cervical transforaminal epidural injection and received the anesthetic test dose after contrast injection was negative for vascular uptake, observed using live fluoroscopy or DSA., Outcome Measures: Response to the anesthetic test dose was documented in each procedure note and recorded as either positive or negative., Methods: Records of three physiatrists at two academic spine centers (Center A and Center B) were reviewed to identify all patients who received a cervical transforaminal epidural injection during the preceding 5 years, resulting in a cohort of consecutively treated patients at each center. Each patient record was reviewed for demographics, indication for injection, procedure level and side, needle gauge, use of DSA, volume and type of anesthetic test dose used, and result of test dose injection. The test dose was considered positive if the following occurred: agitation or other sudden central nervous system change; gross motor deficits and/or paresthesias in the trunk, legs, or contralateral arm; systemic symptoms of anesthetic toxicity including cardiac arrhythmia, perioral numbness, metallic taste, dizziness, and/or ringing in the ear. For analysis, injections were separated into groups to compare results at Center A to Center B and to compare injections that used DSA to those that did not. The incidence of a positive response was calculated as a percentage from the total number of injections in the group. Differences between groups were analyzed for statistical significance using the Fisher exact test., Results: Six hundred seventy-eight injections were included. Of these, 349 were performed at Center A with test doses given after contrast injection under live fluoroscopy. The remaining 329 were performed at Center B, 183 also using live fluoroscopy, and 146 using DSA. The overall incidence of a positive anesthetic test dose was 0.59% (4/678). There was no significant difference between the incidence at each of the two centers (0.86% [3/349] vs. 0.30% [1/329]; p=.63). The overall incidence after live fluoroscopy was 0.75% (4/532) and after DSA was 0% (0/146), but this difference was not statistically significant (p=.58). Positive symptoms elicited by test dose administration included midneck and contralateral arm pain, metallic taste, dizziness, tachycardia, full body paresthesias, auditory changes, slurred speech, and motor ataxia. In all four cases with a positive response, the procedure was immediately terminated, symptoms resolved, and no lasting complications were observed., Conclusions: The routine use of an anesthetic test dose appears to be safe and capable of detecting potentially dangerous intravascular injections undetected by conventional techniques. Positive responses occur in a small portion of those who receive the test dose injection. Further studies are required to determine the optimal dose and concentration of anesthetic to be used and the time required for observation after test dose administration., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Objective: To determine whether digital subtraction angiography (DSA) combined with real-time fluoroscopic imaging improves the detection rate of intravascular injection during cervical transforaminal epidural steroid injections (CTFESIs)., Design: Retrospective analysis., Setting: Outpatient surgery center., Participants: A total of 134 subjects with cervical radicular pain who had CTFESIs performed by a single physician between June 9, 2004, and April 23, 2007., Interventions: One hundred seventy-seven CTFESIs performed at one or more cervical spinal levels either unilaterally or bilaterally. Procedures performed before September 12, 2005, used fluoroscopic guidance with contrast injection and live imaging to identify intravascular injection. All procedures performed after September 12, 2005, also included DSA., Main Outcome Measures: Intravascular injection detected during CTFESIs with and without DSA., Results: Intravascular injection was detected in 17.9% of CTFESIs performed without DSA. By adding DSA technology to the real-time fluoroscopic imaging procedure, the detection of vascular injection nearly doubled to 32.8%, which was statistically significant (P = .0471)., Conclusions: The use of DSA improves the detection rate of intravascular injection during CTFESIs.

This study compared the efficacy of 4 different hamstring-stretching techniques. Flexibility can be achieved by a variety of stretching techniques, yet little research has been performed on the most effective method. The 2 basic types include active stretching, in which range of motion is increased through voluntary contraction, and passive stretching, in which range of motion is increased through external assistance. The 2 types of active stretching include neuromobilization and proprioceptive neuromuscular facilitation (PNF). Our study aims to determine which type of stretching technique is most effective in improving hamstring length. One hundred subjects between the ages of 21 and 57 were enrolled in the study. Intrarater reliability of hamstring length measurement was performed using 10 subjects. All 100 subjects were included in a randomized controlled trial of 5 different groups comparing different hamstring-stretching techniques. Outcome measures, including hamstring length and perceived level of hamstring tightness, were recorded on all subjects initially, at 4 weeks, and at 8 weeks. After 4 weeks of stretching, there was a statistically significant improvement in hamstring length (p < 0.05) using active stretches as compared with passive stretches. From weeks 4 through 8, hamstring length for the active stretching groups decreased. After 8 weeks of stretching, the straight leg raise (SLR) passive stretch group had the greatest improvement in hamstring length. There was no correlation between hamstring flexibility and age, initial tightness, or frequency of exercise per week. Improvement in hamstring flexibility was greatest for the SLR passive stretch. Also, using PNF in the 90/90 active stretch provided better knee range-of-motion improvements than the 90/90 passive methods did.

In most cases, a detailed history provides the information that is necessary for the clinician to diagnose the injured runner correctly; however, to treat the injury and guide a successful rehabilitation program, the physical examination must go beyond the standard regional musculoskeletal examination. The victims (tissue injury) and the culprits (biomechanical deficits) must be identified to facilitate treatment (Table 3). Gait and other dynamic assessments help to reveal underlying deficits in function that may have contributed to injury. In short, the entire functional kinetic chain must be considered and weak links identified.

Taken together, the most common electromyographic finding in lumbar spinal stenosis is bilateral multilevel radiculopathy. The sensitivity of electrodiagnostic testing for radiculopathy is difficult to quantify because there is no criterion standard. Differentiating peripheral neuropathy and lumbar spinal stenosis on electromyography and routine nerve-conduction studies can be clinically challenging, especially when the two entities may be present simultaneously in older patients.

Objective: To determine whether a simple educational intervention can influence use of prescription medications at an institution., Design: Cost-effectiveness analysis of prescribing behavior before and after an educational intervention., Setting: A large, urban, free-standing academic rehabilitation hospital., Participants: Physicians, residents, and physician extenders., Interventions: The hospital's pharmacy department provided simple written educational material about cost differences of various prescription medications to attending and resident physicians, nurse leaders, and case managers. Telephoned reminders were given when targeted medications were prescribed., Main Outcome Measures: Total prescription medication use was recorded monthly for 12 months before and after the intervention. Pharmaceuticals monitored were subcutaneously administered anticoagulants, histamine type 2 (H2) blockers, and nonsteroidal anti-inflammatory drugs (NSAIDs)., Results: A 32% decrease in use of the more costly anticoagulant and a 20% increase in use of the less costly anticoagulant (p <.0001), representing an estimated annual savings of nearly $66,000. Use of more costly H2 antagonist decreased 50% and use of less costly H2 antagonist increased 128% (p <.0001). With written intervention only, use of more costly NSAIDs declined 28%, whereas use of less costly NSAIDs increased 58% (p <.0020)., Conclusion: Providing physicians with simple pharmaceutical cost information and telephone reminders decreased the use of targeted more costly medications.

This study was designed to investigate the clinical efficacy of fluoroscopically guided therapeutic cervical selective nerve root blocks (SNRBs) in patients with whiplash induced cervical radicular pain. Study design was restrospective with independent clinical review. Twenty two patients were included. Each patient met specific physical examination criteria and failed to improve clinically after at least four weeks of physical therapy and the use of oral analgesics. Each patient demonstrated a positive response to a fluoroscopically guided diagnostic cervical SNRB. Patients were excluded for radiographic evidence of a focal disc protrusion or foraminal stenosis at the symptomatic level. Therapeutic cervical SNRBs were administered in conjunction with physical therapy. Data collection and analysis were performed by an independent clinical reviewer. Outcome measures included VAS pain scores, work status, medication usage, and Oswestry disability scores. Results showed the patients' symptom duration prior to diagnostic injection averaged 6 months. An average of 2.1 therapeutic injections was administered. Follow up data collection transpired at an average of 33.3 weeks following the final therapeutic injection. Good or excellent results were observed in 14% of patients. In higher functioning individuals a significantly greater (F=.0427) improvement in pain of 48.9% was observed. In these initial findings suggest that fluoroscopically guided therapeutic SNRBs, except possibly for higher functioning individuals, are not effective in the treatment of whiplash induced cervical radicular pain.

Study Design: This prospective study consisted of mechanical stimulation of cervical nerve roots C4 to C8 in patients with cervical radicular symptoms undergoing diagnostic selective nerve root block., Objectives: To document the distribution of pain and paresthesias that result from stimulation of specific cervical nerve roots and compare that distribution to documented sensory dermatomal maps., Summary of Background Data: Cervical dermatomes were first studied in the late 19th century. The results of those studies underpin current clinical decision making for patients with neck and arm pain. However, it has been observed that patients with radicular symptoms may have cervical pathology by radiographic imaging that is not corroborative, or have imaging studies that suggest a lesion at a level other than the one suggested by the patient's dermatomal symptoms. These observations may suggest that cervical dermatomal mapping is inaccurate or the distribution of referred symptoms (dynatome) from cervical root irritation is different than the sensory deficit outlined by dermatomal maps., Methods: Inclusion criteria consisted of consecutive patients undergoing fluoroscopically guided diagnostic cervical selective nerve root blocks from C4 to C8. Immediately preceding contrast injection, mechanical stimulation of the root was performed. An independent observer interviewed and recorded the location of provoked symptoms on a pain diagram. Visual data was subsequently compiled using a 793 body sector bit map. Forty-three clinically relevant body regions were defined on this bit map. Frequencies of symptom provocation and likelihood of symptom location from C4 to C8 stimulation of each nerve root were generated., Results: One hundred thirty-four cervical nerve root stimulations were performed on 87 subjects. There were 4 nerve root stimulations at C4, 14 at C5, 43 at C6, 52 at C7, and 21 at C8. Analyzing the frequency of involvement of the predetermined clinically relevant body regions either individually or in various combinations yielded more than 1,000 bits of data. Although the distribution of symptom provocation resembled the classic dermatomal maps for cervical nerve roots, symptoms were frequently provoked outside of the distribution of classic dermatomal maps., Conclusion: The current study demonstrates a distinct difference between dynatomal and dermatomal maps.