The role of the Back Rx exercise program in diskogenic low back pain: a prospective randomized trial.

OBJECTIVE: To determine the efficacy of the Back Rx program in patients with diskogenic low back pain (LBP). DESIGN: Prospective, randomized study. SETTING: Outpatient setting of a major university teaching hospital. PARTICIPANTS: Subjects with LBP greater than leg pain for at least 3 months duration and magnetic resonance imaging evidence of disk pathology. Fifty of 87 eligible patients consented and were randomized into age- and sex-matched groups. INTERVENTIONS: Group I participated in the Back Rx program for 15 minutes a day, 3 times a week. All patients, from both groups, received celecoxib (200 mg) and hydrocodone (5 mg) with acetaminophen (500 mg) as needed, and wore a lumbar cryobrace for 15 minutes before bedtime. MAIN OUTCOME MEASURES: Roland-Morris Disability Questionnaire score, numeric pain rating score, patient satisfaction score, measured forward flexion, use of celecoxib, hydrocodone, and acetaminophen, time off work, and rate of symptom recurrence. RESULTS: At minimal 12-month follow-up, 70% of group I reported over 50% pain reduction with good or better patient satisfaction, compared with 33% in group II (P=.001). Average daily hydrocodone and acetaminophen use and time off work were less for group I (all, P<.05). Recurrence of symptoms at the end of the year was less for group I (P=.001). CONCLUSIONS: Back Rx exercises, combined with use of a lumbar cryobrace and oral medications, yielded superior therapeutic results than with use of medications and cryobrace alone. Also significant was the reduced rate of recurrence in these patients.

Incidence of vocal cord dysfunction after fluoroscopically guided steroid injections in the axial skeleton.

OBJECTIVE: To report on the incidence of dysphonia and/or associated throat symptoms after steroid injections in the axial skeleton. DESIGN: A prospective cohort study. SETTING: Academic spine center. PARTICIPANTS: Patients (N = 100) undergoing a diagnostic injection followed by a therapeutic injection in the axial skeleton. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Presence or absence of dysphonia and/or associated throat symptoms, as determined by completion of a predetermined 10-item questionnaire. This questionnaire was administered before participation in the study and at specific intervals after a diagnostic injection and, again, after a therapeutic spinal injection. RESULTS: There was a 12% incidence of transient dysphonia and/or associated throat symptoms in this study population after a therapeutic injection. CONCLUSIONS: Throat symptoms are a potential, albeit transient side effect, after an epidural space corticosteroid injection. The mechanism through which dysphonia or other throat symptoms develop is unknown but appears to be mediated by a systemic steroid effect.

Inciting events initiating injection-proven sacroiliac joint syndrome.

OBJECTIVE: To determine the inciting events leading to the development of sacroiliac joint syndrome (SIJS). METHODS: This was a retrospective descriptive cohort series from an academic interdisciplinary spine center. Consecutive patients presenting with low back or buttock pain with or without leg symptoms who met specific inclusion and exclusion criteria for the diagnosis of SIJS were included in the study. Inciting events leading to the development of SIJS in these patients were categorized into traumatic, cumulative, and idiopathic events. RESULTS: Of 194 patients who were included in the study, 54 patients had symptom resolution with one or more therapeutic intraarticular sacroiliac joint injections, following a positive diagnostic injection. Those patients were given the diagnosis of SIJS. Of these, 24 (44%) had had a traumatic event (13 motor vehicle accidents, six falls onto the buttock, three immediately postpartum, one severe football tackle, and one pelvis fracture). Eleven (21%) patients were considered to have a cumulative injury (four lifting, two running, three altered gait due to lower extremity disorder, one crew training injury, and one forceful hip extension injury). Nineteen (35%) patients had spontaneous or idiopathic onset of sacroiliac joint pain. CONCLUSION: SIJS can occur following a traumatic event or cumulative shear events, or can occur spontaneously.

Low back pain in professional golfers: the role of associated hip and low back range-of-motion deficits.

BACKGROUND: Low back pain is fairly prevalent among golfers; however, its precise biomechanical mechanism is often debated. HYPOTHESIS: There is a positive correlation between decreased lead hip rotation and lumbar range of motion with a prior history of low back pain in professional golfers. STUDY DESIGN: A cross-sectional study. METHODS: Forty-two consecutive professional male golfers were categorized as group 1 (history of low back pain greater than 2 weeks affecting quality of play within past 1 year) and group 2 (no previous such history). All underwent measurements of hip and lumbar range of motion, FABERE's distance, and finger-to-floor distance. Differences in measurements were analyzed using the Wilcoxon signed rank test. RESULTS: 33% of golfers had previously experienced low back pain. A statistically significant correlation (P <.05) was observed between a history of low back pain with decreased lead hip internal rotation, FABERE's distance, and lumbar extension. No statistically significant difference was noted in nonlead hip range of motion or finger-to-floor distance with history of low back pain. CONCLUSIONS: Range-of-motion deficits in the lead hip rotation and lumbar spine extension correlated with a history of low back pain in golfers.

A critical review of the evidence for the use of zygapophysial injections and radiofrequency denervation in the treatment of low back pain.

BACKGROUND CONTEXT: Lumbar zygapophysial joints are currently believed to be a cause of axial low back pain. Once this diagnosis is made, decisions about when to institute a particular intervention and which treatment to offer is regionally and specialty dependent. PURPOSE: To perform a critical review of prior published studies assessing the use of interventional treatment options for the treatment of lumbar zygapophysial joint syndrome. STUDY DESIGN: Evidence-based medicine analysis of current literature. METHODS: A database search of Medline (PubMed, Ovid and MDConsult), Embase and the Cochrane database was conducted. The keywords used were low back pain, lumbar zygapophysial joint, lumbar facet joint, radiofrequency denervation, medial branch block, and intraarticular injection. After identifying all relevant literature, each article was reviewed. Data from the following categories were compiled: inclusion criteria, randomization of subjects, total number of subjects involved at enrollment and at final analysis. statistical analysis used, intervention performed, outcome measures, follow-up intervals and results. Guidelines described by the Agency for Health Care Policy and Research were then applied to these data. RESULTS: This review determined that the evidence for the treatment of lumbar zygapophysial joint syndrome with intraarticular injections should be rated as level III (moderate) to IV (limited) evidence, whereas that for radiofrequency denervation is at a level III. CONCLUSIONS: Current studies fail to give more than sparse evidence to support the use of interventional techniques in the treatment of lumbar zygapophysial joint-mediated low back pain. This review emphasizes the need for larger, prospective, randomized controlled trials with uniform inclusion and exclusion criteria, standardized treatment, uniform outcome measures and an adequate duration of follow-up period so that definitive recommendations for the treatment of lumbar zygapophysial joint-mediated pain can be made.

Abdominal pain secondary to a sacral perineural cyst.

BACKGROUND CONTEXT: Perineural cysts are commonly found in the sacral region and are incidently discovered on imaging studies performed for the evaluation of low back and/or leg pain. PURPOSE: To report on a patient presenting with abdominal pain secondary to a large sacral perineural cyst. STUDY DESIGN/SETTING: Case report. METHODS/PATIENT SAMPLE: A 47-year-old woman was referred to a specialized multidisciplinary spine center with complaints of left lower quadrant abdominal pain and left leg pain. Of significant note was the presence of constipation and urinary frequency over the preceding 8 months. Physical examination was normal. Magnetic resonance imaging of the lumbosacral spine revealed large perineural cysts eroding the sacrum and extending to the pelvis. The presence of abdominal symptoms prompted a neurosurgical consultation. However, after considering the possible risks associated with the surgical procedure, the patient opted to follow the nonsurgical route. RESULT AND CONCLUSIONS: Although commonly visualized, sacral perineural cysts are rarely symptomatic. When symptomatic, it may be secondary to its size and location. Presence of abdominal pain in a patient with back and/or leg pain should prompt the evaluation of the lumbosacral spine.

Management of knee osteoarthritis: knee lavage combined with hylan versus hylan alone.

OBJECTIVE: To assess the difference in efficacy between knee lavage plus the standard hylan G-F 20 (a derivative of hyaluronan) protocol and the standard hylan G-F 20 as per standard usage protocol alone for the treatment of knee osteoarthritis (OA). DESIGN: Nonrandomized prospective study in which patients chose their treatment group. Follow-up averaged 1.1 years. SETTING: Faculty practice of a single physician at a major teaching hospital. PARTICIPANTS: Eighty-one patients with documented knee OA on magnetic resonance imaging. INTERVENTIONS: Group 1 (n=44) received a single-needle lavage 1 week before the standard hylan G-F 20 protocol; group 2 (n=37) received the standard hylan G-F 20 protocol alone. MAIN OUTCOME MEASURES: Pre- and posttreatment scores on the Lysholm-II Questionnaire and a visual analog scale (VAS) were documented for each patient. The Wilcoxon signed-rank test was used for statistical analysis. RESULTS: A successful outcome was noted in 79.5% of group 1 patients and in 54% of group 2 patients (P<.05). CONCLUSIONS: In the management of knee OA, the use of knee lavage before viscosupplementation with hylan G-F 20 yields better results than using hylan G-F 20 alone. The presence of radiologic grade IV knee OA or moderate to severe patellofemoral arthritis are negative prognostic factors.

Role of radiofrequency denervation in lumbar zygapophyseal joint synovitis in baseball pitchers: a clinical experience.

Lumbar zygapophyseal joints have long been considered a source of low back pain with or without leg pain. The objective of this prospective study was to investigate the therapeutic effectiveness of lumbar zygapophyseal joint radiofrequency denervation (RFD) followed by physical therapy, for the treatment of refractory lumbar zygapophyseal joint mediated low back pain secondary to lumbar zygapophyseal joint synovitis, in baseball pitchers. Participants included twelve male baseball pitchers with a diagnosis of lumbar zygapophyseal joint synovitis mediated low back pain and a subsequent difficulty in pitching. These athletes underwent a trial of treatment, including oral anti-inflammatory medication, physical therapy, osteopathic manipulations, and fluoroscopically guided intra-articular zygapophyseal joint injection utilizing steroid and local anesthetic agent. Failure to progress led to these athletes receiving percutaneous, fluoroscopically-guided, radiofrequency denervation of the bilateral L 4-L5 and L5-S1 zygapophyseal joints. A good response to a diagnostic medial branch block was a prerequisite for RFD treatment. In all cases, the medial branch above and below the involved level was treated. Post procedure, all athletes participated in a phased physical therapy program followed by a progressive return to pitching. Success was defined as the ability to return to pre-procedure level of baseball pitching combined with greater than 50% low back pain reduction. Pre- and post-RFD, Visual Analog (Numeric) Scale (VAS) and Roland-Morris (R-M) tests were administered. Ten out of 12 (83%) athletes were able to return to pitching at a level attained prior to RFD. All 12 patients, experienced statistically significant low back pain relief, with a mean pre-RFD VAS of 8.4; mean post-RFD VAS of 1.7; mean pre-RFD R-M score of 12.3; and mean post-RFD R-M score of 22.3. In conclusion, athletes, experiencing lumbar zygapophyseal joint mediated low back pain secondary to zygapophyseal joint synovitis and have failed more conservative management may benefit from radiofrequency zygapophyseal joint denervation followed by a formal rehabilitation program.

Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study.

STUDY DESIGN: A prospective study randomized by patient choice from the private practice of a single physician affiliated with a major teaching hospital was conducted. OBJECTIVES: To compare transforaminal epidural steroid injections with saline trigger-point injections used in the treatment of lumbosacral radiculopathy secondary to a herniated nucleus pulposus. SUMMARY OF BACKGROUND DATA: Epidural steroid injections have been used for more than half a century in the management of lumbosacral radicular pain. At this writing, however, there have been no controlled prospective trials of transforaminal epidural steroid injections in the treatment of lumbar radiculopathy secondary to a herniated nucleus pulposus. METHODS: Randomized by patient choice, patients received either a transforaminal epidural steroid injection or a saline trigger-point injection. Treatment outcome was measured using a patient satisfaction scale with choice options of 0 (poor), 1 (fair), 2 (good), 3 (very good), and 4 (excellent); a Roland-Morris low back pain questionnaire that showed improvement by an increase in score; a measurement of finger-to-floor distance with the patient in fully tolerated hip flexion; and a visual numeric pain scale ranging from 0 to 10. A successful outcome required a patient satisfaction score of 2 (good) or 3 (very good), improvement on the Roland-Morris score of 5 or more, and pain reduction greater than 50% at least 1 year after treatment. The final analysis included 48 patients with an average follow-up period of 16 months (range, 12-21 months). RESULTS: After an average follow-up period of 1.4 years, the group receiving transforaminal epidural steroid injections had a success rate of 84%, as compared with 48% for the group receiving trigger-point injections (P < 0.005). CONCLUSION: Fluoroscopically guided transforaminal injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus.

Innervation of the anterior spinal canal: an update.

Understanding the innervation of the lumbar spine can be a daunting task. Until recently, only macroscopic visualization and crude histological techniques were available to document the presence of nerve fibers in the anterior spinal canal. Using newer immunohistochemical techniques, studies have been able to more thoroughly investigate the innervation of the anterior spinal canal. The presence of sensory nerve fibers has been definitively identified in all anterior spinal structures. These sensory fibers enable any of the spinal structures the capability of being a pain generator. These sensory nerve fibers tend to form dense interwoven plexuses on the posterior longitudinal ligament and ventral surface of the dura mater. The plexuses allow for anastamoses to take place between nerve fibers from multiple segmental levels. This polysegmental formation causes the expression of low back pain to be diffuse, rather than focal. It is these diffuse pain symptoms that create great difficulty in diagnosing and treating spinal canal structures.